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 cartilaginous
portions of the right ribs ; 2dly, lower down in the
hypochondrium ; 3dly, in the iliac fossa ; and,
4thly, in the epigastric region. In a case of aneu
rism of the hepatic artery, which we have lately
observed, the gall-bladder formed a fluctuating
tumour very near to the right ileum, and the
biliary ducts were found in a similar state to that
described by Mr. Todd, only distended to a less
degree. We believe that in all the cases, with
the exception of that which we have recorded,
there was jaundice ; and it is probable that if the
gall-bladder had not been punctured, and that the
abscess had continued to press on the ducts, this
condition would ultimately have been induced. In
this case, also, it is very important to compare thu
appearance of the two tumours with a view to
their diagnosis. That of the gall-bladder appeared
suddenly, without being preceded by local pain
or induration, but was at once fluctuating ; tha
arising from the abscess of the left lobe was pro-
ceded by pain and induration ; and fluctuatiou

170

LIVER, (DISEASES OF THE)

did not appear until some days after its occur-
rence. This observation may be of utility in de-
termining the point in future cases.

Chronic Hepatitis* — A great number of affec-
tions of the liver have been classed under this
general term ; such as induration, scirrhus, tuber-
cle, hypertrophy, atrophy, &c, &c. In fact, we
cannot say with certainty what the condition of
the liver will be on dissection in a case where
symptoms of chronic irritation have existed. We
may, indeed, recognise an enlargement or an in-
duration, but it appears rash to go farther than
this. The liver, like other organs, however, being
subject to chronic inflammation, we may recog-
nise this condition, although we cannot say what
particular alteration it may have induced.

The disease may set in with attack of acute
hepatitis, or may from the commencement pre-
serve a slow insidious character. In some cases
there is more or less of fever, while in others the
patient is apyrexic. The principal phenomena
are various derangements of the digestive func-
tion, and it is often next to impossible to pro-
nounce on the actual condition of the gastroin-
testinal mucous membrane. In fact, chronic dis-
ease of the liver and of this surface are commonly
combined. If, in addition to pain long continued
in the region of the liver, increased by excitement,
and accompanied by tenderness and tumour, we
observe a sallow countenance, a dry skin, foul
tongue, scanty and high-coloured urine, with oc-
casional attacks of jaundice, we may safely make
the diagnosis of chronic hepatitis.

In the less acute forms of the disease the local
symptoms of an hepatic affection are often very
indistinct, and the case presents many of the usual
phenomena of a chronic gastro-enteritis. In addi-
tion to these, the pain about the right shoulder,
when it does occur, the distension and oppression
in the epigastrium and right hypochondrium, the
bitter taste in the mouth, the sallow appearance
of the countenance, the elevation of the shoulders,
and the wasted state of the body, are the circum-
stances which in warm climates are relied on as
indicative of hepatic disease.

It is stated that, when the surfaces of the liver
are the seat of disease, the pain is more decided,
and that, as the superior or inferior surface is
chiefly affected, so in the first case the symptoms
will be referred to the chest, and in the second to
the stomach and bowels. An eminent writer
says, that when the superior and exterior part of
the right lobe is the seat of disease, the patient
reclines with most ease on the right side, a drag-
ging sensation being felt on turning to the left.
From this sensation it is supposed that we may
infer the existence of. adhesions between the lobe
of the liver and the right side.

Nothing can be more various than the termi-
nations of this disease which have been observed.
In fact, every one of the known organic changes
of the liver has been found in cases where the
patient laboured under symptoms of chronic hepa-
titis. Most of these certainly may be looked on
as the results of the inflammatory action, the
modifications in their nature being probably con-
nected with the constitutional dispositions of the
patient. In fatal cases, death is induced by vari-
ous circumstances. In some cases an acute hepa-

titis supervenes upon the chronic, but in the ma-
jority the patient is cut off in consequence of dis-
ease of other organs. He may be attacked by
peritonitis, either in consequence of the rupture
of an abscess or of the gradual extension of dis-
ease to the serous surface: he may be attacked
with enteritis or dysentery, which is a common
termination in warm climates : pulmonary or cere-
bral disease may set in ; and dropsy, with or with-
out an affection of the heart, is not unfrequent.

The diseases with which chronic hepatitis has
been confounded are principally the following:
chronic gastro-duodenitis, scirrhus of the stomach,
chronic pleurisy of the right side with empyema,
and a neuralgic affection, of which the seat ap-
pears to be in the hepatic plexus.

In the articles Enteritis and Gastro-Ente-
ritis we have alluded to the great frequency of
the error of confounding the affection of the gas-
trointestinal mucous membrane with that of the
liver, and have dwelt on the injurious conse-
quences of this mistake. With respect to the
diagnosis between this disease and chronic pleurisy
with effusion, we would say that there is hardly a
case where the tact of the practitioner is more
requisite than in this. We will suppose that he is
called to see the case for the first time after con-
siderable enlargement of the organ has occurred.
He will often find that the history of the case
gives him but little assistance, as the two affec-
tions are often accompanied by very similar symp-
toms ; neither will he derive decided assistance
from the stethoscope and percussion. In both
cases we may have extensive dulness of the side,
absence of respiration, resonance of the voice, or
bronchial respiration. The side will be dilated in
both, and the decubitus generally on the affected
side. Neither will the existence of a tumour in
the abdomen be unequivocal, as in the one case
it may occur from hypertrophy of the organ, in
the other from displacement.

From our experience we should say that the
indication which is the most unequivocal is drawn
from the state of the intercostal spaces. When
the side is dilated by a fluid, as in empyema, the
spaces are raised either to a level with the ribs or
even protruded beyond them, and the side has
generally a smooth and rounded appearance. On
the other hand, when the dilatation is produced
by a solid tumour, such as an enlarged liver, the
reverse of this occurs; the pressure being exer-
cised on the ribs, these are pushed outwards, but
the intercostal spaces preserve their relative posi-
tions with them, and the side does not present any
thing of the smooth and rounded appearance
which we have described. (See Dub. Hosp. Rep.
vol. v.) There are certain cases, however, where
even this diagnosis is not applicable, such as
where the patient is fat, the integuments oedema-
tous, or the belly distended by fluid. Under such
circumstances the difficulty of diagnosis is extreme.

It appears to us that the attention of British
practitioners has not been sufficiently called to the
frequency of the neuralgic affection of the liver
which is commonly seen in hysterical subjects,
and has been noticed by Andral in his Clinique
Medicale. « We sometimes observe in the region
of the liver severe pain, which cannot be accounted
for after death by any lesion of the viscus or its

LIVER, (DISEASES OF THE)

171

excretory ducts. These are cases of hepatalgia
or hepatic colic. The circumstance just men-
tioned, and, moreover, the nature of the pains,
their intermission, and the state of good health
which often exists in the intervals, — all lead us to
believe that these pains have their site in the
numerous nervous filaments which are distributed
in the liver, and which are derived either from the
pneumogastric or the great sympathetic." (Mala-
dies de 1' Abdomen, t. ii. p. 26.)

The persons in whom we have witnessed this
affection were females. In some of these a deci-
dedly hysterical tendency existed, while in others
this disposition was scarcely if at all indicated.
In one case the condition of the spine lately deno-
minated " spinal irritation" was present. The
principal symptom in these cases was a constant
pain in the region of the liver, which lasted for
years, and was subject to occasional and violent
exacerbations from various causes, such as mental
emotion, fatigue, over-excitement, derangement of
the bowels, or the occurrence of menstruation.
During the exacerbation the pain is excruciating,
— to all appearance more violent than that in the
most intense inflammation, — and is generally ac-
companied with exquisite tenderness of the right
hypochondrium. It has been stated to have been
sometimes accompanied by a slight jaundice; but
of this we never witnessed an instance, as, in the
cases which we have observed, none of the usual
symptoms of hepatic irritation, with the exception
of the pain, existed. There was never fever, nor
tumefaction, nor a bilious state of the urine, foul-
ness of the tongue, thirst; nor were the alvine
evacuations apparently affected, although the dis-
ease had been present for months or even years.
Further intervals occurred during which the pa-
tient enjoyed a respite from pain, and presented
no local nor general symptom of hepatic derange-
ment. The diagnosis of this disease is then to
be drawn from the violence of the pain, which is
greater than that of inflammation, combined with
the absence of fever, tumour, and the other indi-
cations of structural disease of the liver. We
may also remark, that in several cases which have
occurred under our observation the patients were
subject to neuralgic affections in other situations,
as the face or extremities : in one, severe dysme-
norrhcea had long existed.

It is now some years since we were consulted
in the case of a lady of luxurious habits and
highly nervous temperament, who, while in India,
had been attacked with pain in the region of the
liver, which was supposed to arise from acute
hepatitis. For this she was largely bled, both
generally and locally, and brought under the influ-
ence of mercury, without relief. She was ordered
to return to England, and on the passage was
several times bled and twice mercurialized with
the same intention. Some time after her arrival
in this country, the pain became again severe, and
occurred with violent exacerbations. Each attack
had been treated as if it had been one of acute
hepatitis, she having been repeatedly bled, leeched,
blistered, and mercurialized. Temporary relief
used to be afforded by the bleeding, but the dis-
ease constantly recurred ; her constitution had
become shattered, and she was constantly subject
to the most violent hysterical paroxysma : the

stomach had become so irritable that every thing
was rejected, and the patient's sufferings were
indescribable. Such was the condition of this
lady when we were first called to see her ; it was
plain that the disease had resisted the most rigor-
ous and long-continued antiphlogistic treatment.
We found that there never had been any fever,
that the right hypochondrium was perfectly supple,
the lower part of the chest sounding clear, the
tongue clean, the eyes and complexion clear, and
the patient subject to neuralgic affections in other
parts of the system. Under these circumstances,
we determined on treating the affection as a neu-
ralgia. Further bleedings were inhibited, contrary
to the wish of the patient, who, as before stated,
experienced temporary relief from them. She
was put on a generous diet, sent to the country,
and directed to use free doses of the carbonate of
iron. This treatment proved perfectly successful,
and in the course of a few weeks the lady was in
the enjoyment of a state of health and comfort to
which she had been a stranger for more than two
years previously. We know of another case of a
lady who had been actively treated for supposed
hepatitis in the country without success. She
was advised to come up to town to place herself
under the care of physicians, for the purpose of
undergoing a course of mercury. On examina-
tion, her medical attendant could find no evidence
of hepatic disease except the pain. She was also
treated by the carbonate of iron with complete
success. Since then we have known several cases
where the error of confounding this affection with
inflammation has been committed, — an error
always full of danger, but in Great Britain pecu-
liarly unfortunate, from the empirical and almost
universal employment of mercury in all hepatic
affections. We have at this moment under our
care a most deplorable example of the effects of
this error, where the most profound lesions of the
nervous system have been induced by the long-
continued use of mercury.

Causes of Hepatitis. — The exciting causes
of hepatitis may be enumerated as follows : resi-
dence in a tropical climate, intermittent or con-
tinued fever, gastro-intestinal inflammation, sup-
pression of habitual fluxes, abuse of spirituous
liquors, injuries of the side, wounds of the head,
congestion from venous obstruction, suppression
of cutaneous eruptions, exposure to cold, gall-
stones, &c.

Treatment. — When a patient has been at-
tacked with symptoms of acute hepatitis, the dis-
ease being still in its early stages, and no evidence
of suppuration present, the treatment should be
commenced by a free bleeding from the arm,
which, if the subject be robust, and the inflamma-
tory fever high, should be pushed so as to produce
some effect on the circulation. It would be always
well to see the patient again in the course of from
four to six hours, when, if the pain and oppression
should have returned, and the inflammatory fever
again be lighted up, the bleeding should be re-
peated without hesitation ; a less quantity of blood,
however, will generally answer the expected pur-
pose. The bowels should be opened by a free
dose of calomel, followed by saline medicine, and
assisted by a purgative injection. The patient
will thus be brought into the state best adapted

172

LIVER, (DISEASES OF THE)

for deriving advantage from local bleeding ; and
we would impress strongly on the mind of the
practitioner, that, although the exhibition of mer-
cury is sometimes indispensable, he must place his
chief reliance on general and local bleeding, both
as the surest means of arresting the disease, and
of ensuring the beneficial action of mercury should
its exhibition become necessary. In warm climates
it has been observed that in some cases the opera-
tion of bleeding is followed by faintness before a
sufficient quantity is taken, and the blood is dark
and grumous. In this case, as has been observed
in other violent inflammations, (see Rush on the
Yellow Fever,) the bleeding is soon followed by
more violent excitement of the circulation, when
a second bleeding is indicated, and the patient
will bear the loss of a much greater quantity of
blood ; and this will then be found to present the
buffy appearance in a much higher degree. The
second bleeding also gives much greater relief to
the patient.

From our experience we would say that general
bleeding has not the same marked influence over
hepatitis that it has over peripneumony, but ap-
pears principally useful in preparing tbe patient
for local depletion, which seems to have the most
direct influence on the disease. We have seen a
case where upwards of a hundred ounces of blood
were drawn at different times, and in which no
apparent effect was produced on the inflammation
until local bleeding was performed. In a robust
adult not less than thirty leeches should be applied
after the general bleeding, to the most painful part
of the side, a measure which will be followed by
still greater advantage if the bowels have been
previously opened ; and to ensure this result, pur-
gative injections should be used to assist the action
of the medicine administered by the mouth.
When the patient can bear it, the greatest ad-
vantage will be derived from the application of a
cupping-glass, fitted with an exhausting syringe
over the leech-bites, by which means a much
greater quantity of blood is obtained, and the sub-
sequent oozing from the leech-bites generally pre-
vented. As the blood flows, the exhaustion should
be gently continued until the cup is full, when, if
it is thought necessary to obtain more, the cup
should be re-applied, and its margin surrounded
with a cloth dipped in warm water; this causes a
copious flow of blood.

In all cases it will be well to avoid, as far as
possible, the oozing hemorrhage of leech-bites, as
this exhausts the patient without any correspond-
ing influence on the disease, and keeps him in an
uncomfortable state. It is much better to make
several applications of leeches successively, and
to arrest the hemorrhage after the leeches have
fallen off, either by the cupping-glass or the appli-
cation of styptics, of which the best appear to be
the solid nitrate of silver, or the muriated tincture
of iron. In the Meath Hospital the application
of powdered alum has been found very beneficial.
After the hemorrhage has been completely arrested,
the patient will derive great advantage from the
application of warm poultices of linseed-meal or
bread and milk over the affected organ; these,
however, must be made light, as their weight in
some cases proves distressing.

It has been the practice on the continent, and

lately in Great Britain, to apply leeches to the
anus in case of hepatic irritation, on the principle
of depleting the system of the porta through the
hemorrhoidal veins. We believe that the only
cases in which this practice would be decidedly
beneficial are those where the hepatitis is compli-
cated with dysentery, or where it has supervened
on the suppression of a hemorrhoidal flux ; but
in no instance should we be content with this
mode of local depletion, as it is decidedly inferior
to the application of leeches over the affected
organ itself. In the dysenteric complication to
which we have alluded, which is frequent in India,
Mr. Annesley has found decided benefit from the
application of leeches to the os coccygis.

The circumstances which point out that the
general and local depletions have exercised a
salutary influence on the suffering organ are the
following: — the diminution of the inflammatory
heat and of the oppression in the epigastrium
and hypochondrium ; the subsidence of the pain
and tenderness ; and, lastly, of the tumefaction,
which is to be ascertained by the touch and by
percussion of the lower part of the thorax and
abdomen. (See article Abdomen, Explanation
of.) Blisters may be now employed, but their
use must never be resorted to while the inflamma-
tory fever continues high, and they must be re-
moved as soon as the patient begins to feel their
stimulus. (See Derivation.)

When the disease occurs in persons of a broken-
down constitution, and particularly in those who
have long indulged in ardent spirits, it is scarcely
necessary to observe that we must be much more
cautious in the use of the lancet, and trust prin-
cipally to local bleeding and counter-irritation.

After the employment of general and local bleed-
ing, the production of ptyalism appears to be the
most powerful means of subduing the disease;
but, as we stated before, the practitioner must
consider this treatment as secondary to that which
has now been pointed out. There can be no
doubt that the establishment of a free salivation
is commonly followed by a rapid subsidence of
the local disease, but it is also true that the ac-
complishment of this is commonly difficult, and
often impossible. The more severe the disease,
the greater will be the difficulty of inducing ptyal-
ism ; and the best mode of insuring the kindly
action of mercury will be to reduce the inflamma-
tory condition of the organ as far as possible be-
fore its exhibition. We have before stated the
remarkable fact that in cases of suppuration of
the liver it has been found nearly^ impossible to
induce salivation.

It would appear that the safest mode of using
mercury in this disease is by the exhibition of
large doses of calomel at long intervals of time,
as it is stated upon high authority that the remedy
is thus much less apt to irritate the bowels, and
that a less quantity of mercury, when thus ex-
hibited, will sooner affect the system than a greater
quantity given in divided doses. Ten grains of
calomel, combined with one or two of opium,
may be given twice in the day, or a scruple dose
at bed-time, as recommended by the East India
practitioners. It is stated that the combination of
the calomel with some antimonial, such as the
antimonial powder or James's powder, assists in

LIVER, (DISEASES OF THE)

173

the speedj production of ptyalism. But of one
fact we fee 1 certain, that if after the use of mer-
cury for three or four days free ptyalism be not
induced, the remedy should be omitted.

In the acute stage of the disease the patient
must be kept on a strict antiphlogistic regimen.
Effervescing draughts may be allowed, and will
often be found to be of great benefit when they
act en the skin or kidneys. Mild saline purges
with emollient injections should be employed ;
and the patient may drink a solution of cream of
tartar or tamarind tea ; and if there be much rest-
lessness, an anodyne draught or twelve grains of
Dover's powder should be exhibited at night.

But if, notwithstanding these means, the tume-
faction continues, and the fever assumes a remit-
tent or hectic type, the formation of abscess is to
be dreaded. Under these circumstances we can
no longer push the strict antiphlogistic treatment.
The patient's strength must be supported by fari-
naceous and gelatinous foods, and the exhibition
of wine in moderation, with vegetable tonics, will
be advisable ; poulticing must be diligently em-
ployed over the region of the liver, and we must
endeavour to bring forward the abscess towards
the surface as much as possible ; when, in the
event of a perceptible and fluctuating tumour
being formed, it will be advisable to give exit to
the matter as speedily as possible. This, how-
ever, is an operation of the greatest importance,
and must never.be undertaken without a full
knowledge of the pathological relations of this
disease.

We have already alluded to the rarity of adhe-
sions between the surfaces of the peritoneum in
cases of acute hepatic abscess. It is obvious that
for the success or safety of the operation the ad-
hesions of the peritoneum is a necessary condi-
tion ; for in the event of their not existing, the
matter will make its way into the peritoneal cavity,
defeat the object of the operation, and almost in-
evitably destroy life. To obviate these difficulties,
Dr. Graves has proposed a mode of proceeding
which has been repeatedly acted on with success
in the Meath Hospital. It is, without question,
a most important addition to the surgery of the
abdomen. In the fourth volume of the Dublin
Hospital Reports this eminent and scientific phy-
sician has published a case of hepatitis, in which,
notwithstanding the employment of active mea-
sures, evidences of suppuration occurred. There
was no distinct pointing of abscess, so that it was
judged impracticable to perform any operation
which could reach the contained matter. Under
these circumstances Dr. Graves, reflecting on the
fact that certain deep-seated collections of matter
may be induced to point towards a situation in
which the resistance of the integuments and fascia
is removed, proposed that an incision should be
made over the most prominent part of the tumour,
and carried through the abdominal muscles, so as
to reach without dividing the peritoneum. This
wound was kept open by plugs of lint, and poul-
tices were applied over it. In a few days after a
fit of sneezing by the patient, puriform matter in
great quantity broke through the wound. The
discharge continued copiously for a number of
days, and the patient recovered perfectly.

We have since witnessed two instances where

this operation proved successful. It would appear
that it not only acts on the principle of removing
resistance in a particular point, but also by indu-
cing adhesions immediately below the wound, in
all probability the result of its immediate irrita-
tion. In a case where numerous abscesses ex-
isted, and in which this operation was performed
over the most prominent part, we found on dis-
section that the only point of adhesion of the
whole peritoneal surface was that immediately
below the wound, and corresponding exactly to its
extent. Here recent coagulable lymph was ef-
fused, so that there can be no doubt that, had the
patient lived longer, the contents of this abscess
at least would have been evacuated through the
external opening. The operation has every thing
to recommend it; it is perfectly safe, productive
of no distress to the patient, prevents the chance
of effusion into the abdomen, and has been proved
to be efficacious.

In a case of extensive and chronic hepatic ab-
scess with great attenuation of the integuments,
we proposed the performance of this operation ;
but it was determined by the attending surgeon to
try the operation of a caustic issue in place of
that proposed by Dr. Graves. After the separation
of the slough, the matter did not show any dispo-
sition to escape. A small valvular incision was
then made through the ulcer, which gave exit to
a few ounces of puriform matter. This operation
was immediately followed by excruciating pain in
the abdomen and the most violent peritonitis, evi-
dently arising from the escape of matter into the
cavity, and proving that in this case the operation
of the caustic had failed in producing adhesions.
When the abscess makes its way either exter-
nally or into the lungs or digestive tube, the
strength of the patient must be carefully supported
by light and nutritous diet, wine and tonic medi-
cines, according to the circumstances of the case.
The mineral acids may also be exhibited in the
different tonic infusions, such as gentian, calumbo,
or cinchona. Attention must be paid to the
bowels; and it seems not impossible but that a
gentle and graduated pressure on the organ might
accelerate the cure by inducing a closure of the
opening after the matter had been evacuated.
The opening of the abscess into the serous cavi-
ties appears at first sight a necessarily fatal occur-
rence ; and we believe that it has been so in every
recorded case, with a single exception. In the
report of the Meath Hospital before alluded to, a
case is recorded in which death from the perito-
nitis was apparently prevented by the opiate and
stimulating treatment first proposed by Dr. Graves
in certain cases of peritonitis. In the case also
of double abscess of the liver which we have re-
corded in this article, the patient lived for eight
days after the rupture of the second abscess into
the peritoneum, and it was evident on dissection
that the process of cure had commenced, the
gelatinous effusion in many places having assumed
an appearance of layers, and presenting large
blood-vessels in its interior.

In the treatment of chronic hepatitis the first
great indication is to remove all unnecessary
stimulation of the liver or gastro-intestinal .- 1
Fermented liquors and all kinds of stimulating
food must be inhibited, and the diet of thepatien*

174

MALARIA AND MIASMA.

must consist of the simplest and most bland arti-
cles. The bowels are to be diligently but mildly
acted on by gentle laxatives combined with mer-
curials, such as the hydrargyrum cum cretii or the
blue pill. In the commencement of the treatment
we should apply every third or fourth day a dozen
of leeches to the region of the liver, until we re-
move as far as possible the pain and tenderness of
the organ. When this is effected, we should re-
sort to counter-irritation, which must be persevered
in for a considerable length of time. The best
mode of proceeding is by the repeated applications
of blisters over different parts of the organ, and
by keeping up an eruption with a mild tartar-
emetic ointment. If these means do not succeed,
and if there is no contra-indication, it will be ad-
visable to affect the system gently with mercury,
which may be done either by the exhibition of a
small dose of calomel and blue pill combined with
Dover's powder, at night, or by mercurial inunc-
tions practised over the region of the liver.

Where it is thought unadvisable to use mercu-
ry, from the constitution of the patient, the nitro-
muriatic acid and the nitrous acid have been
strongly recommended. It would appear that the
best mode of using these remedies, particularly
the first, is by the external application, either by
sponging the surface, or by the foot-bath. The
following is the mode in which this remedy is re-
commended to be used by Mr. Annesley. A mix-
ture is made of eight ounces of pure water with
four ounces of the nitric and four of the muriatic
acid, of the strength of the London Pharmacopoeia.
Of this solution from two to five ounces are to be
mixed with about three gallons of water at the
temperature of 96°, in a high and narrow vessel,
and the feet kept immersed in it for about half an
hour eveiy night before retiring to rest. If the
bath does not cause a prickling sensation in the
'parts, the next is to be increased in strength.
Advantage has also been obtained from sponging
the trunk with a similar solution every night.
The dilute nitrous acid drink has also been
strongly recommended in cases of chronic hepatic
affections. It possesses the property of producing
a slight salivation, but is much slower in its ope-
ration than mercury. Taraxacum is a favourite
remedy with many practitioners in these cases,
but we are sceptical as to its efficacy.

After the disease has been subdued, vegetable
tonics may be given to restore the digestive powers.
The patient should wear warm clothing, and care-
fully avoid any error of regimen that may cause a
return of the hepatic disease. In some obstinate
cases we have known decided benefit from the use
of the seton ; and it is scarcely necessary to ob-
serve, that where the disease has supervened in a
wTirm climate, removal to a more temperate region
will be always advisable.

William Stokes.

LUMBAGO. (See Rheumatism.)
LUMBRICI. (See Worms.)
[LUPUS. (See Noli Te Tangere.)
MAGNETISM, (ANIMAL). (See Somnam-
bulism.)]

MALARIA and MIASMA. The first of these
words, and that which is now generally employed
to designate a certain effluvium or emanation from

marshy ground, we have adopted from the Italian.
It is formed from the coalescence of the words
mala and aria (bad air.) Miasma is a Greek
word (ptaoma, from piaivu, inguino, pulluo,) signi-
fying originally contagion or pollution, but now
with the occasional adjunct, marshy, not unfre-
quently applied to the same effluvium or emana-
tion.

We infer the existence of the matter designated
by one or other of these terms, as we do that of
contagion in cases of disease which do not furnish
a material transferable by inoculation, from certain
effects on the animal economy; and we trace its
origin to marshes from its having been observed,
for a series of ages, that such effects are produced
only in the vicinity of marshes, or at least are
more abundant where vegetable matter and water
are so situated with respect to each other, that a
chemical reaction between them is possible. The
observation of centuries having rendered us well
acquainted with certain effects of malaria, we now
reason conversely; and when we perceive the more
familiar of them, particularly intermittent and re-
mittent fevers, we infer its existence, and endea-
vour to discover its sources, which may not be
very manifest.

The chemical and physical properties of malaria
are unknown to us ; the experiments which have
been hitherto performed to illustrate its nature, or
even to discover its presence, having furnished
very unsatisfactory results. The air collected
above the marshes of fort Fuentes was found by
Gattoni as pure as that at the summit of Mount
Leguone, if not more so ; and M. Deseye obtained
in the most confined marshes as on the most ex-
posed hills, 78 parts of azote, 21 of oxygen, and
one of carbonic acid, from an analysis of the air.
It is true that MM. Thenard and Dupuytren found
that the carburetted hydrogen gas disengaged from
marshes left in the water through which it was
passed a peculiar and very putrescible matter ; and
M. Julia discovered that dew gathered in the
neighbourhood of marshes contains, likewise, a
matter capable of fermentation ; but there is no
evidence that these substances are malaria ; nor,
were they proved to be so, do we know anything
of their chemical properties but their capacity of
undergoing the putrefactive process. Even the
very obvious question, whether malaria is always
one and the same, or a multiplicity of marsh poi-
sons exist, is one which the present state of our
knowledge does not enable us to answer decidedly.
It has been argued that as the existence of such a
poison is known only by its effects on the consti-
tution, a variety in these effects should be deemed
evidence of a difference in the poison. But it
may be remarked that the diseases which are re-
puted to originate from malaria pass in the same
subject into each other, — intermittents, for instance,
into remittents, and inversely; and that, of a cer-
tain number of individuals residing in or merely
visiting the same place at the same time, and con-
sequently exposed to the same morbific cause,
some are attacked with one form of fever, others
with another. And we know that diseases cer-
tainly derived from one and the same poison, such
as small-pox, exhibit great diversity of character
in different persons. These circumstances favour
the opinion that there are no differences in the

MALARIA AND MIASMA.

175

effects of thi? poison which may not be explained
by a difference in the dose, or of the constitution
on which it acts, or by the influence of certain
agents, such as temperature, which modify its ope-
ration. The fact most in favour of a multiplicity
of poisons is the occasional prevalence of one
form of malarious disease, yellow fever for example,
in the same situation for months, to the exclusion
of all others. But as this occurs only under high
temperatures, which at once promote the evolution
of the poison, and modify the individual habits on
which it operates, we would not consider it to fur-
nish conclusive evidence, that the poison acting
in this case is specifically different from the mal-
aria which produces other forms of marsh fever.

[Of late, an attempt has been made by Professor
Daniell to show, that sulphuretted hydrogen gas
is the pestiferous agent : but as the notion has
been exploded under the results of observation, it
is unnecessary to dwell upon it.]

From what we have said on this obscure branch
of our subject, it will be tolerably manifest that on
the questions of the nature and simplicity or va-
riety of malaria we possess no satisfactory infor-
mation whatsoever ; arid that the legitimate objects
of our present investigation are its sources, the
laws of its propagation, the extrinsic circumstances
which modify its influence, its effects on the ani-
mal economy, and the measures to be adopted to
guard against these effects.

Though marshes, whether salt or fresh, are pro-
lific sources of malaria, especially in a certain
stage of the drying process under a hot sun, this
poison is the product besides of various sorts of
soil, to which the term marsh is by no means ap-
plicable. In the warmer regions of the earth
these collections of low and dense brushwood, or
of reeds and grass which are called jungles, are
so familiarly known to be productive of malaria,
that jungle- fever is as common a name for mal-
arious disease in southern latitudes as marsh-fevers
in Europe; and in the warmer regions of Asia,
Africa, and America, even the larger and more
open woods generate the poison under certain cir-
cumstances. Grounds which are alternately in-
undated and drained for the cultivation of rice,
whether in India or Europe, have been found so
injurious to the health of the cultivators and the
neighbouring inhabitants, that by some govern-
ments, that of Russia for example, this species
of cultivation has been prohibited. Wet meadow
lands, especially in warm climates, and in tem-
perate ones during seasons of unusual heat, have
been proved to be sources of malaria ; at least
agues have been observed to prevail in districts
in which no assignable cause for them existed
but lands of this description. That the half-
wet ditches of fortifications may produce malaria
was shown by the result of filling up those of
Bourg-en-Bresse, by which process those fevers
ceased which had previously so affected the in-
habitants, that one half of them were incapaci-
tated from any occupation for a third of the year.
The mud which is left by the drying of extensive
ponds or marshes by the summer's heat, though
invested at the time with no growing vegetation,
but probably containing vegetable and likewise
animal recrements, is capable of furnishing this
poison. Lakes, especially if situated in flat coun-

tries, are indirectly sources of it, not by the moist-
ure of their immediate margins only, but likewise
by imparting a degree of the same quality to the
adjacent country. Considerable portions of Hun-
gary and tracts of land in France are rendered
insalubrious from this cause. The mud left by
the retiring tide in sea-ports and estuaries is pro-
ductive of malaria in hot climates, as is evinced
by the fevers with which the crews of boats are at-
tacked in such situations ; and we have seen rea-
son to think that in certain seasons they are not
perfectly salubrious in our own. The felling of
woods, by which process land previously shielded
from the sun's rays (and consequently damp) is
exposed to their influence, is often followed by the
prevalence of malarious disease in the district in
which it is performed. Turning up lands which
have long laid in pasture for the purpose of culti-
vating them is mentioned both by Volney and
Rush as productive of malaria and its 1 consequences.
In the West Indies this has been found to be a
very dangerous operation, Cassans describing it as
sometimes producing fevers which resemble an ab-
solute plague, the labourers even dying on the
spot if they attempt to remain at night on the
ground which they have broken up during the
day. (Macculloch on Malaria, p. 112.)

The decomposition of vegetable matter in other
circumstances than in connection with soil has
frequently proved a prolific source of malaria.
This is often exemplified by the pernicious effects
of steeping flax and hemp ; and Rush and others
mention examples of fevers originating from the
decomposition of coffee, potatoes, pepper, and
other vegetables. The sickliness of ships from
the leakage of sugar in a damp hold, and the oc-
currence of a fever which committed fearful ra-
vages on the crew of the Priamus frigate from the
action of bilge-water on chips and shavings left in
the hold from the repairs of the magazine, as men-
tioned by Burnett, may be referred to the same
class. Neglected sewers and drains have proved
under a high temperature to be productive of fever
by generating this poison.

If the preceding enumeration of circumstances
under which the production of malaria takes place
be examined, it will be found that vegetable mat-
ter and moisture are present in all the examples,
and that animal matter is so occasionally. It is a
proper subject of inquiry, and one which has given
rise to some controversy, which of these elements
are essential to the generation of the poison, and
under what condition those which are essential
should exist to possess the power of producing it.

With regard to water, it seems ascertained that
its presence is necessary, if not at the surface, cer-
tainly below it ; but that the quantity in the for-
mer situation should not be large. Many circum-
stances tend to prove that for the production of
malaria only a small proportion of water should
exist in any situation. It is remarked by African
travellers, that in that country the evolution of
malaria commences immediately on the falling of
rain, and that of this the inhabitants are so con-
scious that they then retire to their houses, and
endeavour to exclude even the least access of air.
As the rains continue and the ground becomes
thoroughly wetted, the sickness abates, to be re-
newed with greater violence on the retiring nf the

176

MALARIA AND MIASMA.

rains, and the ground becoming dry. In the case
of inundations, it is at their subsidence that sick-
ness prevails, as was exemplified by the mortality
among our troops under such circumstances during
the Burmese war. In temperate climates, a marsh,
the whole surface of which is thoroughly wet, is
comparatively innocuous ; but if partially or en-
tirely dried by the summer's heat, it becomes ex-
tremely pestilential in autumn. Dr. Ferguson, a
writer whose extensive opportunities have been
aided by great power of observation, has furnished
us with many instances, we cannot so justly say,
of the small degree of moisture as of the exces-
sive dryness which produces malaria in its most
intense degree. " The army," says this writer,
" advanced on to Talavera through a very dry
country, and in the hottest weather fought that
celebrated battle, which was followed by a retreat
into the plains of Estremadura, along the course
of the Guadiana river, at a time when the country
was so arid and dry for want of rain, that the
Guadiana itself and all the smaller streams had in
fact ceased to be streams, and were no more than
lines of detached pools in the courses which had
formerly been rivers ; and there they suffered from
remittent fevers of such destructive malignity, that
the enemy and all Europe believed that the British
army was extirpated. The aggravated case of
the disease differed little or nothing from the worst
yellow fevers of the West Indies ; and in all the
subsequent campaigns of the peninsula, the same
results uniformly followed, whenever, during the
hot season, any portion of the army was obliged
to occupy the arid encampments of the level
country, which at all other times were healthy, or
at least unproductive of endemic fever."* The
writer can vouch from personal observation for
the accuracy of this description ; and he has re-
peatedly observed that cases of fever and ague
abounded in parts of Estremadura so remote from
the Guadiana or any stream, that no influence
from visible water or dampness could be supposed
to have a share in their production.

The following example taken from Dr. Fer-
guson's paper is strongly illustrative of the same
facts, the effects of concealed water in producing
the poison. The approach to the town of Ciudad
Rodrigo is thro ..gh a bare, open, hollow country,
that has been likened to the dried-up bed of an
extensive lake. Upon more than one occasion,
when this low land, after having been flooded in
the rainy season, had become as dry as a brick
ground, with the vegetation utterly burnt up, there
arose fevers among our troops, which, for malig-
nity of type, could only be matched by those be-
fore mentioned on the Guadiana.

It will be readily understood, that though the
surface of the soil which produces fever may ap-
pear dry or even burnt, yet as its occurrence takes
place after rains, there is no proof that the pre-
sence of moisture is not necessary, but evidence
of the very reverse, though it is shown that the
dampness need not exist on the surface. The na-
ture of the sub-soil, — its being, for instance, a
dense clay, which by preventing percolation may
detain the water within a short distance from the

♦On the Nature and History of Marsh Poison, by
Win. Ferguson, M. D., &c. (from the Transactions of the

Koyal Society of Edinburgh), Edinburgh, 1821.

ground,— has probably some influence in engen-
dering sickness ; but there are many facts which
prove"that an impermeable subsoil is by no means
essential to the production of the poison. The lee-
ward shore of Guadaloupe, Dr. Ferguson informs
us, so far from being impermeable, is a remarka-
bly open and pure one, being mostly sand and
gravel, altogether without marsh in the most dan-
gerous places ; yet it is inconceivably pestiferous
throughout the whole tract. The soil of Walche-
ren, too, of the pestilential nature of which we
have had such melancholy experience, is sandy,
or a mixture of clay and sand.

These examples tend to confirm, so far as the
water is concerned, the law of Dr. Ferguson, that
the only condition indispensable to the production
of the marsh poison on all surfaces capable of
absorption is the paucity of water where it had
previously recently abounded ; a rule, to which he
assures us there is no exception in climates of
high temperature. It ought at the same time to
be remarked, that though the formation of ma-
laria is perfectly compatible, as the writer can tes-
tify from personal observation, with the degree of
superficial dryness described by Dr. Ferguson, it
may likewise consist with a degree of manifest
moisture.

The necessity of the presence of vegetable mat-
ter has hitherto constituted an important part of
the creed regarding malaria, but this necessity is
questioned in the paper in the Edinburgh Philo-
sophical Transactions, to which we have so often
adverted. We have already mentioned Dr. Fer-
guson's opinion, that the only essential requisite
for the formation of the poison is, that water
should be absorbed by soil and then exposed to
speedy evaporation ; and the following example is
given of the apparent absence of vegetable mat-
ter from a situation abundantly productive of mal-
aria. " In Spain, during the month of May 1809,
which was cold and wet, the army remained
healthy ; but in June, which was remarkably hot
and dry, marching through a singularly dry rocky
country of considerable elevation, several of the
regiments bivouacking in hilly ravines which had
lately been water-courses, contrary to the advice
of officers who had served in the Mediterranean,
several of the men were seized with violent remit-
tent fever, (the first that had shown itself in the
march,) before they could move from the bivouac
the next morning ; and this portion of the troops
exclusively were affected with this disorder for
some time. In this instance, the half-dried ravine
having been the stony bed of a torrent, in which
soil never could be, the very existence of vegeta-
bles, and consequently of their humid decay and
putrefaction, was impossible, and the stagnant
pools of water still left among the rocks by the
water-course, and near which these men encamped,
were perfectly pure. Yet this situation proved as
pestiferous as the bed of a fen." Even in this
situation, which furnishes the strongest argument
that could be adduced for the author's departure
from the established creed, it would perhaps be
difficult to prove the total absence of vegetable
matter, not only from the surface of the ravines,
but beneath the rocky surface ; and certainly there
exist many facts which prove that vegetable mat-
ter is in the highest degree favourable to the pro-

MALARIA AND MIASMA.

177

duction of malaria, if not essential to it. These
are, the universal presence of such matter where
the poison is generated, the cases adduced by Dr.
Ferguson and similar ones excepted, if they are
to be regarded as exceptions ; the pernicious effects
of the steeping of hemp and flax, for we presume
it will not be argued that in this case the mere
evaporation of the water, independently of the
vegetable matter, would produce the poison ; a
similar result from the leakage of sugar and the
decomposition of coffee, potatoes, pepper, &c,
and the fever which committed such ravages on
board the Priamus frigate from the action of the
bilge-water on the chips and shavings left in the
hold. A similar argument may be deduced from
the wholesomeness of peat-bogs, which seem as
well calculated as any marsh to produce malaria,
excepting that the vegetable matter they contain
being in a sub-carbonized state is not susceptible
of decomposition. Since there is no reason to
think that the evaporation of mere water will pro-
duce the poison, we are compelled to conclude
that, if there was no vegetable matter present in
the cases mentioned by Dr. Ferguson, some in-
fluence from mere terrestrial soil gave rise to the
effects, which are usually owing to the presence
of such matter.

The necessity of the putrefaction of the vege-
table matter present when malaria is produced, is
a different question from that which we have just
considered. In by far the greater number of cases
in which this poison is generated, there is no
offensive smell whatever ; it is true that a marsh
or other source of malaria may be at once noisome
to sense and pestilential, but it is frequently the
latter without being the former. Although it has
been shown that vegetable decomposition is in-
strumental in the production of the poison, if not
strictly essential to it, yet the circumstance of its
being generated in abundance without there being
any perceptible smell, and in situations so dry
that vegetable putrefaction, in the ordinary sense
of the term, seems impossible, appears to prove
that this decomposition is either in degree or kind
different from putrefaction, though the two may
coexist.

Malaria is generated in so many instances in
which animal matter does not exist, that we must
conclude that the presence of such matter is not
essential to the formation of the poison ; whether,
when present, it increases the quantity or modifies
the nature of the miasma, does not appear to be
ascertained.

[On the evidences- in regard to animal or vege-
table putrefaction, or both being the cause of mala-
ria, the writer has entered at great length in his
Human Health, p. 64, Philad. 1844. He regards
the affirmative as by no means proved.]

Heat is the extrinsic agent most influential in
favouring the production of malaria in soils and
situations capable of engendering it — an influence
attributable probably to the effect of a high tem-
perature in favouring the chemical action between
organized recrements and humidity, and likewise
to its accelerating the formation of the aqueous
vapour which appears to be the vehicle of the dif-
fusion of the poison. Hence, even the milder
forms of malarious disease are observed only in
seasons of a certain degree of warmth, rarely, for
Vol. III. — 23

instance, arising in this country before the vernal
or after the autumnal equinox ; whilst the more
intense degrees occur only in the higher latitudes,
or, if seen in climates ordinarily temperate, it is
during seasons of unwonted heat; and whereso-
ever they exist, their prevalence is terminated by
the cold of winter. It has often been observed,
that a summer of unusual warmth, especially if
occurring after a wet spring, causes intermittent
and remittent fevers to reappear in districts
whence they had long been banished by the im-
provement of agriculture, — an occurrence, of the
possibility of which medical men should be aware ;
for when the malarious disease has made its visi-
tation in the form of remittent, it has not always
been discriminated from typhus, and confusion
and controversies have thence arisen, not very
creditable to all parties concerned.

The branch of our subject now to be considered,
the propagation of the poison, is one regarding
which we possess a considerable degree of irre-
gular knowledge, consisting rather of detached
facts presenting various unexplained anomalies,
than of groups of corresponding facts from which
the medical reasoner can deduce fixed and deter-
minate laws. As might be supposed, the effect
of the poison is in general more intense in pro-
portion to the proximity to its source. This is
probably owing to the more condensed state in
which malaria exists near to the spot where it is
generated ; and it is remarked, that circumstances
which favour its condensation add to the intensity
of its effects. It appears to be on this principle
that the vicinity of swamps is so much more per-
nicious in the evening or night than during the
day. The influence of a high temperature in
favouring the production of the poison, has already
been pointed out; but it appears that during the
portion of the day when the temperature is at its
highest, the mobility of the atmosphere is so
great, and favours so much the diffusion of the
poison, that it is comparatively innocuous near
the spot where it is generated ; but in the more
quiescent state of the air in the evening, though
it is less abundantly formed, it is infinitely more
pernicious. Its effect at these times is aided pro-
bably by its finding a powerful vehicle in the
mists, which at night are observed to rest over
low and marshy grounds. The more pernicious
effect of the night-air in a pestilential country and
season, however it is to be explained, is familiarly
known, and is often exemplified by the fatality to
soldiers of certain night-guards.

But to this general law, that malaria is more
pernicious in proportion to the proximity to its
source, there are important exceptions. In some
instances it is found to affect places at some dis-
tance, especially if they are situated on an emi-
nence, with the same if not greater intensity than
those in the vicinity ; thus the neighbourhood of
Versailles is powerfully influenced by the marshes
of St. Cyr; and at Neuville-des-Dames, above
Chatillon on the Indre, fevers are more prevalent
than close to the marshes where the malaria is
produced. The stagnant water of Lake Aguano,
we learn from M. Monfalcon, exhales deleterious
effluvia, which are carried backwards to the north-
east to two or three villages, and even to the con
vent of Comaldules, a league distant, and situated

178

MALARIA AND MIASMA.

on a high mountain. But the most extraordinary
instance of this kind is mentioned by Dr. Mac-
culloch, as occurring in Malta ; the malaria which
is produced on the beach beneath a cliff producing
no effect on the spot itself, while it affects, even
to occasional abandonment, the village situated
above.

In explanation of circumstances of this nature,
of which it were easy to multiply examples, M.
Monfalcon supposes that the aqueous vapours in
which the marsh poison is dissolved, are raised
during the day by the heat and consequent ex-
pansion of the air, and are condensed and precipi-
tated on the adjacent hills during the evening ;
whilst Dr. Ferguson conceives that so far from
rising into the atmosphere, malaria has a peculiar
attraction for the earth's surface, along which it
creeps so as to concentrate and collect on the
sides of the adjacent hills. We doubt whether
either of these explanations is very satisfactory,
and think it probable that the explanation of
these facts is to be found simply in currents of
air which sweep the surface of the marsh, so as
to prevent the accumulation of the emanations
there, and convey them in a state of condensation
to the more elevated spots situated in the line of
the atmospheric movements. The situation of
certain elevated places, which have been power-
fully influenced by marsh emanations, has fre-
quently been observed to correspond with the
direction of a manifest current of air which passed
over the surface of a swamp. Chains of hills in
Corsica and Italy, very far from morasses, but
placed in their line, and in the face of a wind
which carried to them their emanations, were en-
tirely depopulated and rendered uninhabitable.
Orlandi cites an analogous example: — the south
winds passed over stagnant waters before arriving
at some hills, the air of which they infected : these
heights became salubrious only when Pope Paul
V. had caused the marshes to be drained.

The distance to which marshy emanations may
extend by gradual diffusion, has been calculated
by Monfalcon to be 1,400 or 1,600 English feet
of elevation, and from 600 to 1000 in a horizontal
direction. In Europe these limits, he supposes,
cannot be exceeded ; but in equatorial regions the
activity of the poison is much more extended ;
and in the West Indies, vessels at the distance of
9,000 feet from the marshy coast have felt their
baneful effects. But when winds are in operation,
their influence may extend to much greater dis-
tances than those mentioned. The case of the
convent of Comaldules, which was infected at the
distance of three miles, has already been quoted ;
but we know not any facts which teach us the ex-
treme limits to which the poison may be trans-
ported. The distance will probably be influenced
if the ground be such as to preserve the poison in
a state of condensation instead of allowing it to
be diffused ; thus, a current of air sweeping up a
valley, at the mouth of which the surface is
swampy, will convey the poison to a greater dis-
tance than it could reach in a more open situation.
An instance of this kind occurs in Ceylon, where
tne poison is conveyed many miles inland up a
valley, whenever the sea-breeze blows in such a
direction as to cross the swamps on the shore and
enter its mouth.

We should take but an imperfect view of
malaria did we consider intermittent and remittent
fevers its sole results. Besides these its more fa-
miliar effects, organic affections of the spleen,
liver, and mesenteric glands ; similar affections
of the stomach and intestines ; dropsy, apoplexy,
palsy, and idiocy, as manifested in the marshy
districts of Tuscany, and in the cretinism of the
valleys of Switzerland, are the effects of its long-
continued application. Cholera, dysentery, and
diarrhoea, are by many writers referred to its more
brief agency, and there is reason to think occa-
sionally with justice ; intermittent neuralgia, there
seems little doubt, is one of its effects, and to this
formidable list some are disposed to add rheuma-
tism, but the propriety of this seems doubtful. It
is observed that the natives of marshy districts,
who permanently reside in them, lose their whole
bodily and mental constitution, contaminated by
the poison they inhale. Their aspect is sallow
and prematurely senile, so that children are often
wrinkled, their muscles flaccid, the hair lank, and
frequently pale, the abdomen tumid, the stature
stunted, and the intellectual and moral character
low and degraded. They rarely attain what in
more wholesome regions would be considered old
age. In the marshy districts of certain countries,
for example Egypt, Georgia, and Virginia, the ex-
treme term of life is stated to be forty ; whilst we
learn from Dr. Jackson, that at Petersburg, in the
latter country, a native and permanent inhabitant
rarely reaches the age of twenty-eight. [Dr.
Jackson's remark must have been made, however,
on inadequate statistical evidence, and probably on
no statistical evidence whatever. If it were ever
correct, it is utterly inapplicable to the Petersburg
of the present day.] In the portions of Brittany
which adjoin the Loire, the extreme duration of
life is fifty, at which age the inhabitant wears the
aspect of one of eighty in a healthier district. It
is remarked that the inferior animals and even
vegetables partake of the general depravation;
they are stunted and short-lived.

By the progress of civilization, and conse-
quently of agriculture, the domain of malaria is
diminishing throughout the more enlightened por-
tions of the earth. This is manifest in our own
country, from many parts of which, where they
formerly prevailed, agues have been banished.
The draining of swampy lands ; preventing in
ponds or other damp situations the accumulation
of putrid or putrescible vegetable or animal mat-
ter ; and, in marshes situated near the sea, pre-
venting by embankments the mixture of salt water
with fresh, from which combination most pesti-
lential emanations have always been observed to
proceed, are the most efficient means of reclaiming
malarious tracts, and consequently of preventing
the production of the poison. But some lands
are of so incorrigible a nature, the Pontine
marshes for example, that the hand of man has
hitherto been employed upon them in vain ; and
it is desirable to know, since we cannot prevent
such districts from generating the poison, how its
diffusion and pernicious influence may be in some
degree checked. It is remarked that" malaria has
a peculiar attraction for certain surfaces, and that
it is not disengaged from those to which it adheres,
at least not in a noxious form ; in other words,

MEDICINE, (HISTORY OF)

179

they do not constitute fomites. The attraction of
the poison for trees is great ; and it has repeatedly
liee.n observed that not merely a few individuals,
but the population of whole cities, situated in the
most swampy districts in the world, have owed
ecurity to a screen of woods interposed be-
tween them and the marshes. Facts of this
nature suggest very obviously the propriety of
planting trees in the vicinity of irreclaimable
swamps. The floors of dwellings are supposed
to have a similar attractive power over the poison ;
and hence, in malarious districts, the second
stories of houses are found, to be more salubrious
than the first ; and if from circumstances the first
floor must be occupied, some security is afforded
by having the bed a few feet elevated from it.

Nutritious diet, and that kind of general regi-
men which is most conducive to good health,
should be observed by individuals exposed to the
operation of malaria ; and they should be especi-
ally careful to avoid, if possible, the vicinity of
swamps in the evening. JosEPH BrqwN-

[MANIA. (See Insanity.)
MEASLES. (See Rubeola.)]
MEDICINE, (HISTORY OF*)— CHAP-
TER I. — Introduction — Division of the his-
tory of medicine into three great chronological
periods — History of medicine previously to
its introduction into Greece — Origin of medi-
cine — State of medicine among the Egypt-
ians — Among the Assyrians — Among the
Jews — Introduction of medicine into Greece —
Chiron — Aesculapius — Machaon — Poduli-
rius — The Asclepiades — Records in the temples
of Msculapius — Ancient inscriptions — Py-
thagoras — Democritus — Heraclitus — Acron —
Herodicus — Gymnastic medicine.
Although the primary object of this treatise is
to present a view of the history and progress of
practical medicine, yet it will be impossible to
avoid entering occasionally into the consideration
of the various theories and speculations which
have so generally prevailed in the science. Medi-
cal theory and practice have been so intimately
blended together, that it would be useless to at-
tempt to separate them. The terms which are
employed, in works of the most practical nature,
are, for the most part, derived from the theory
which was current at the time of their publica-
tion, and even the narrative of facts and the direct
details of experience are, with a few exceptions,
deeply tinged with the prevailing doctrines of the
day, or with the individual speculations of the
writer. Those who are versed in medical science,
and who are acquainted with the relation which
it bears to the other physical sciences, with the
mode in which it is acquired, and the nature of
the evidence on which it rests, will easily perceive

* The writer of this Essay begs to remark that the
references inserted at the foot of the page are to be
regarded as the authorities for the facts and dates con-
tained in the text; with respect to the opinions that are
maintained, lie is to be considered as alone answerable
(or tbem. Where he has conceived it necessary to dis-
sent from, or to controvert, the doctrines of his predeces-
sors, he has endeavoured to do it without acrimony or
arrogance, and he trusts that his remarks will be received
with the same spirit of candour in which they are oflered.
He thinks it necessary to state that wherever a reference
is made to any book, the book so referred to has been
examined by him.

that, in this department, it is peculiarly difficult to
separate facts from hypothesis. It may, however,
be asserted, that until this be accomplished, medi-
cine can never be placed upon the basis of induc-
tion, and that this alone can give it that stability,
which may entitle it to be regarded as a correct
science. In its present condition it will be impos-
sible to do more than to approximate to so desira-
ble a state, but it will be a special object of atten-
tion, in the following pages, to endeavour to point
out the limits between practice and theory, between
facts, and the opinions that have been deduced
from them.

When we take an extended view of the pro-
gress of medicine, tracing it from its scanty
sources, in the most remote periods of society, and
observe its course, as gradually augmented by the
stores of Grecian and Roman learning, obscured
by the darkness of the middle ages, and again
bursting forth in the copious and almost over-
whelming streams of modern literature, we are
naturally led to separate the narrative into three di-
visions, corresponding to the three great chronologi-
cal periods. The first of these will comprehend the
history of practical medicine, from the earliest re-
cords which we possess, to the decline of Roman
literature ; the second will contain an account of
the state of the science, through what are termed the
dark ages, until the revival of letters ; the third will
commence with the establishment of the inductive
philosophy, and be continued to the present time.

In tracing the history of this science from its
earliest records, it will not be necessary to devote
much time to a subject, which was formerly dis-
cussed with great learning and acuteness, viz. the
origin of medicine. It may be sufficient to re-
mark that, in proportion to the progress of civili-
zation or refinement, attempts would be made to
remove or alleviate the diseases, and to repair the
injuries, to which the body is constantly incident.
Subject as it is, at all times, to the influence of
various noxious agents, and to a consequent de-
rangement of its functions, to painful affections
of various kinds, and to the loss or depravation of
its powers or actions, we must conceive that man-
kind would be anxious to remove or relieve these
evils. The means that would be emp^ed must
have been, in the first instance, extremely imper-
fect, and frequently ill directed. They may have
been suggested by the effects of certain kinds of
food, or by the operation of certain external
agents on the body : some analogies may have
been derived from the spontaneous actions of the
system, by observing the natural efforts of the
constitution to remove certain causes of disease,
or to relieve the patient when suffering from their
effects. Thus, in the earliest periods of society,
mankind must have been aware of the relief
which was obtained, in the derangements of the
alimentary canal, by an evacuation of its contents,
and would probably have discovered, incidentally,
that certain vegetable substances promoted this
operation. In the external injuries to which the
body is subject, more especially in a rude state of
society, means would early be had recourse to for
procuring present ease from pain, or for removing
the obvious danger to life, which would so fre-
quently follow from various causes. It would
soon be found that the nain was diminished by

160

MEDICINE, (HISTORY OF)

excluding the wounded part from the air, or from
other extraneous substances; that by certain modes
of pressure, the flow of blood might be restricted ;
and that, in some cases an increased, and in others
a diminished temperature, gave immediate ease to
the patient, and tended to promote the ultimate
cure. A rude species of medical and surgical
practice of this description has been, in all cases,
found to exist in newly-discovered countries, even
when in the most barbarous state ; while it has
been observed generally, that the improvement in
the healing art has been nearly in proportion to
the advancement of the other arts of life, and to
the gradual progress of knowledge on all subjects
intimately connected with our existence or wel-
fare.

The historical records which we possess respect-
ing the progress of practical medicine are scanty
and uncertain ; but, so far as they extend, they
coincide with the view of the subject taken above.
The writers who have investigated this point with
the greatest learning and assiduity inform us, that
Egypt was the country in which the art of medi-
cine, as well as the other arts of civilized life, was
first cultivated with any degree of success, and
that it had advanced so far as to have become a
distinct profession. We are not, however, in-
formed in what degree or to what extent that dis-
tinct appropriation was carried ; whether medicine
was made the exclusive business of certain indi-
viduals, who were regularly instructed for that
purpose ; whether it was attached to certain pub-
lic functionaries, especially to the priests ; or
whether persons in different situations applied
themselves to the practice of medicine, from a real
or supposed superiority in their skill and in their
knowledge of the treatment of diseases. The
probability, however, is that the priests of the
Egyptians were at the same time their physicians.
This appears to have been the case among the
Jews and the Greeks, who are supposed to have
borrowed from the Egyptians many of their insti-
tutions ; and indeed it seems to be the natural
progress of society in its earlier periods, when the
priests were generally the depositaries of know-
ledge of all kinds, and when they confined it as
much as possible to their own use, for the purpose
of maintaining their influence over the rest of the
community.

From some remarks which are made incident-
ally in the Mosaic writings respecting the learning
of the Egyptian priests, it would appear that it con-
sisted, in a great measure, of the employment of
magical incantations, and, so far therefore as it
effected the cure of disease, must have operated
through the medium of the imagination. This
has been, in all cases, the first step in the art of
medicine, if it may be so called, and its efficacy
must have been in exact proportion to the igno-
rance and superstition of the people on whom it
was exercised.

A circumstance respecting the practice of medi-
cine in Egypt is mentioned by Herodotus, as ex-
isting when he visited that country, and which,
it may be presumed, was transmitted from a much
earlier period, that certain individuals treated cer-
tain diseases only. (Euterpe, sec. 84.) This
division into separate branches might, at first
view, seem to indicate a considerable progress in

the practice of medicine, and it may undoubtedly
have |ed to a degree of manual dexterity and of
minute observation in certain departments. But,
independent of any other consideration, we may
rest assured, that the science must have remained
in a state of complete degradation, when we bear
in mind that it was the custom in Egypt, as it is
in the present day among many of the nations of
the east, to transmit the same occupation from
father to son, through a number of successive
generations. This practice, although it may be
favourable to the perfection of an art, or even of
a science, in some of its minute details, must fur-
nish an almost insurmountable obstacle to its
general improvement, or to the development of
the powers and faculties of the human mind.

Although we are in the habit of considering
Egypt as the parent of the arts and sciences, the
empire of Assyria has been supposed, by many
learned men, to possess a greater claim to this
distinction. Perhaps the priority of invention
may be justly awarded to the Assyrians, but the
memorials which they have left behind them are
so scanty, that the degree of excellence to which
they arrived is almost entirely conjectural. The
priests of this nation, as in all other cases, appear
to have been the depositaries of all the learning
of the times, and of that of medicine among the
rest. We have reason to suppose that their prac-
tice consisted of little more than the dexterous
application of magical arts, and such other means
as tended to impress the minds of the people with
a sense of their power over the operations of
nature, while any actual information which they
possessed was carefully concealed under the guise
of mystery and superstition. (Herodotus, Clio,
passim ; Enfield 's Hist, of Phil. v. 1. p. 25 et seq.)

In the writings of Moses there are various al-
lusions to the practice of medicine among the
Jews, and more especially with regard to the
treatment of leprosy. The priests appear in this,
as in other cases, to have been the practitioners;
the treatment consisted principally in certain re-
gulations for the purpose of promoting cleanli-
ness and preventing contagion, together with
various ceremonies, which, so far as they could
affect the patient, must have acted entirely on the
imagination. (Leviticus, chap, xiii.-xv.) So lit-
tle is known respecting the state of the arts and
sciences in the other countries of the east, at these
remote periods, that it is scarcely necessary to
allude to them in this place. . We shall only re-
mark that the imperfect and scanty notices which
we possess on this subject would lead us to con-
clude, that the practice of medicine was even in a
less advanced state than among the Egyptians, its
progress being regulated by the greater or less
degree of refinement or civilization of the respec-
tive countries, hut in no case having advanced
beyond the state of implicit credulity and gross
superstition.*

* For further information respecting the state of medi-
cine among the Egyptians and the other nations of anti-
quity, previously to Hie Greeks and Romans tilt- reader
is referred to the following works. Herodotus, Euterpe
e D , • • ° ' jVp""- Uiodorus Siculus, lib. i. sect.
ri'»t»s, lib. vn. cap. 56, lib. xxix. cap. 1. riuianhu,
De Is,de et Osinde. Josephus, Antiq. Jud. HI., viii. cap.
2, sec.o. Clemens JHexandrinus, a Potter, Stromal, lib
™' P, .»""'"'=• Ditrod. Art. Med. ran. 3 sec.2,ct

De flern.et. Med. passim. Barchu.cn, Diss! No. 1, et 7

MEDICINE, (HISTORY OF)

181

After having given an account of the state of
medicine among the ancient Egyptians and other
contemporary nations, as far as can be gleaned
from the scanty records that remain on this sub-
ject, we must follow it into Greece, and trace its
progress from the period of its first introduction
in the remote and semi-fabulous ages of their
demigods and heroes, until it acquired the rank of
a science under the genius of Hippocrates. It is
generally admitted, that although Greece cultivated
the arts and sciences with so much success, yet,
in the first instance, she borrowed them from the
neighbouring nations ; principally, as it would
appear, from Egypt, and in same cases from
Phoenicia. (Vide Bryant, ubi supra, et v. 2, p.
426 et seq. et alibi.) To certain individuals who
migrated from these countries, the Greeks them-
selves were in the habit of referring the introduc-
tion of many of the most useful inventions, and
during a considerable space of time all those who
were desirous of acquiring a larger share of know-
ledge, either theoretical or practical, than was
possessed by their countrymen, visited Egypt, as
the great storehouse of science and learning. It
is from this cause that we find so much analogy
between the divinities that were worshipped in
the two countries, as inventors or patrons of the
various arts and sciences. For although they
acquired new names on their being transferred
into Europe, yet their attributes, and even their
forms, clearly demonstrate their origin. This is
particularly the case with respect to medicine, so
that in the Orus and Thouth of the Egyptians
we may recognise the prototypes of the Apollo
and Hermes of the Greeks. (Haller, Bibl. Med.
Pract. lib. 1, sec. 7, 8. Hundertmark, in Acker-
mann, Opuscula, Exerc. No. 1.)

It is not until comparatively at a late period,
approaching to that of the Trojan war, that we
find the names of actual personages who practised
medicine in Greece ; and of these, it is probable
that some were natives of either Africa or Asia,
who brought with them the information which
they had acquired in their respective countries.
Of those whose history is better known, and who
were acknowledged to be of Grecian origin, it
was the general custom to travel into Egypt for
the purpose of obtaining a knowledge of their
art, and with this view they submitted to a sys-
tem of rigid discipline, and to a variety of irksome
and burdensome ceremonies; and after all this
laborious process, so far as the science of medicine
is concerned, the result seems to have been little
more than the knowledge of magic and incanta-
tions, with some rude notions respecting the ap-
plication of external remedies for the cure of
wounds and of cutaneous diseases, with a very
imperfect idea of the anatomy of the human body,
and a very inadequate conception of its functions.
(Herodotus, Euterpe, passim. Diodorus Siculus,
lib. 1. passim. Joscphus, Antiq. Jud. lib. viii. cap.

Oruner, Analecta, Diss. 1. De ^Egyptiorura Veterum
Anatoroe. Schuh, Hist. Med. p. I, sec. 1. Clerc, Hist, de
la Med. par. 1, liv. i. chap. 1—8. Sprengel, Hist, de la
Med. par Jourdan, sect. 2, ch. 1—3. Enfield's Hist, of
Phil. v. 1, p. 86, 7, ct alibi. Pauw, on tli« Egyptians and
Chinese, part 1, sect. 2. Bryant's Analysis, v. 2, p. 324
et seq. et in multis aliis locis. Cabanis, Revol. de la
M6d. ch. 2, sect. 1. Ackermann, Instit. Hist. Med. p. 1,
c. 1,2. Lauth, Hist, de I'Anatomic, liv. i. Blumcnbach,
Introd. in Historian! Medicina; Litter, sect. 1—3.

2, sec. 5. Odyss. xix. 656 et seq. ^Eneis, vii.
753 et seq.)

The first native of Greece who is more particu-
larly singled out, as having introduced the art of
medicine among his countrymen, is the centaur
Chiron. There is much mystery attached to his
character and to every thing connected with him,
but what we may consider as the most probable
conclusion is, that he was a prince of Thessaly,
who lived about the thirteenth century before the
Christian sera; that he was distinguished above
his contemporaries for his knowledge of the arts
of life, and that, after the manner of his country-
men, he was frequently seen on horseback, so as
to give rise to the fabulous account of his com-
pound form. He is particularly celebrated for his
skill in medicine and in music, a combination, it
may be remarked, that was said to have existed
in many other individuals. We are not informed
by what means he obtained his superior know-
ledge in medicine, but there are various circum-
stances, which lead us to conclude, that it was at
that time regarded rather as a part of the educa-
tion of all men of rank, than as attached to a
particular profession. We accordingly find that
he instructed the Argonauts in medicine, and the
heroes who were engaged in the siege of Troy,
and that all the kings and warriors of that period
were more or less acquainted with the treatment
of wounds, and even with the practices which
were adopted for the cure of internal diseases.
(Ilias, xi. 636 et seq. Sprengel, t. 1, p. 112, 13.
Ackermann, per. 1, cap. 3, sec. 25 — 40.)

But although Chiron has the reputation of
having introduced the art of medicine into Greece,
it is to his pupil ^Esculapius, that by the common
consent of antiquity, is ascribed the merit of
having first devoted himself to the cultivation of
medicine as a science, and of having made it a
distinct object of pursuit. The improvements
which he made in the art were so considerable, as
to have induced his countrymen, after his death,
to pay him divine honours, to designate him as
the god of physic, to erect temples to him in va-
rious parts of Greece,* and to derive his origin
from Apollo himself. His history, when divested
of all the fabulous appendages that were attached
to it by his contemporaries, appears to be that he
was a native of Epidaurus, that he was exposed
in his infancy, probably in consequence of his
illegitimate birth, that he was accidentally disco-
vered by a shepherd, and placed under the care
of Chiron. His death was said to have been
caused by the jealousy of Pluto, in consequence
of the number of individuals whom he rescued
from the grave ; from which tale we may at least
conclude that his reputation as a successful prac-
titioner must have been much higher than that of
any of his contemporaries.-j-

According to the custom of that age, he trans-

* Pausanias, lib. i. cap. 21; ii. 10; ii.13; iii. 22; iv.
31 ; vii. 21 ; vii. 23 ; vii. 27 ; viii. 25. Strabo, lib. viii. p.
592; ix. 668; xiii. 899; xvi. 1097, a C'asaubon, Amst
1707. Clerc, part 1, liv. i. ch. 20.

t Diodorus Siculus, lib. iv. sec. 71. Hyginus, fab. 49 el
alibi. Clerc, part i. liv. i. ch. 11—16. ' Ortelvis, Capita
Deor. lib. ii. in Gronovii Thes. Grace, t. 7, p. 278 et seq.
Monlfaucon, Antiq. v. i. book ii. chap. 1, 2. Sprengel, t.
i. p. 119 et seq. Ackermann, per. 1, cap. 3, sec. 41—59 ;
and especially the second dissertation in his Opuscula
by Gunzius and Richter.

132

MEDICINE, (HISTORY OF)

mitted his profession to his sons Machaod and
Podalirius, who accompanied the Greeks in the
Trojan expedition, and are celebrated in various
passages of the Iliad for their medical skill.* From
the incidental mention that is made by Homer and
the early Greek writers of the nature of the reme-
dies that were employed by these individuals or
their contemporaries, it will appear that their prac-
tice was principally surgical, and nearly confined
to the treatment of wounds, and that, with respect
to internal diseases, they were for the most part
conceived to be the immediate infliction of the
Deity, and were therefore abandoned as incurable,
or at least were to be obviated only by charms and
incantations, and that the arts of magic formed no
inconsiderable part even of their surgical practice.
(Ilias xi. 636 et seq. Odyss. xix. 456 et seq.)

The practice of medicine remained for a con-
siderable time hereditary in the family of iEscu-
lapius, and in a great measure confined to it. His
descendants obtained the name of Asclepiades;
they were the priests of his temples, and presided
over and directed the rites and ceremonies. —
(Sprengel, t. i. p. 168 et seq.) These temples,
indeed, became a species of hospitals, to which
patients resorted from all quarters for the relief of
the diseases with which they were affected. Under
the direction of the priests of these temples they
underwent a variety of ceremonies, the immediate
effect of which must have been principally upon
the imagination. Some, however, of the prac-
tices which were enjoined were of a dietetic na-
ture, and were directly conducive to temperance
and cleanliness; such as frequent ablution, and
the abstaining from certain kinds of food. To
these if we add that the temples were generally
erected in healthy situations, that the patients en-
joyed rest and leisure, and that the mind was in-
terested by a succession of new and pleasing im-
pressions, we may suppose that they would be
placed under circumstances, not a little resembling
those which are found so conducive to health by
the invalids who frequent the medicinal springs
and other analogous establishments of modern
times. (Clerc, part i. liv. ii. ch. 2-6. Schulz,
par. i. sect. 2, cap. 4. Sprengel, t. i. p. 153 et
seq. Cabanis, p. 59, 60.)

Although the accounts that have been transmit-
ted to us respecting ^Esculapius would lead us to
conclude that he was a real personage, who actu-
ally possessed a greater degree of medical skill
than any of his contemporaries, yet his whole
history is so involved in fable and mystery, that it
is impossible to obtain any correct idea of the de-
tails of his practice. It has been observed above
that it was probably, in a great measure, surgical,
and even confined almost exclusively to the cure
of wounds or recent injuries. The treatment of
these may be considered so far judicious as it was
simple ; it consisted in removing all extraneous
bodies, in placing the parts as much as possible in
their natural, position, in fomentations and ablu-
tions, and in the application of certain vegetables
which were supposed to be possessed of balsamic
or styptic properties. Wine and other articles of

* Clere, part 1, liv. i. chap. 17. Sprengel, t. i. p. 127
et seq. Ooulin, " Anciens Medecins," in Encyc. Method.
' Medecine ;" this article may be advantageously con-
sulted on the subject of the Greek and Roman physi-
c uns.

a more stimulating nature were also used, while
oleaginous substances were employed nearly with
the same intention as in modern times, to defend
the part from the air or other external agents, to-
gether with bandages and other means of mechani-
cal support. We have no distinct evidence how
far internal remedies wore administered ; for the
most part they relied on magical arts and incan-
tations, and although we have reason to believe
that certain vegetable products were occasionally
employed as internal remedies, we are scarcely
able to discover what was the object of the prac-
titioner, and we arc frequently unable to ascertain
what were the plants that were employed. (Cel-
sus, lib. i. praf. Plinius, lib. xxix. cap. 1. Clerc,
part 1, liv. i. ch. 15. Schulz, p. i. sect. 2, cap. 4.
Sprengel, sect. 2, ch. 4, 5. Cabanis, ch. 2, § 1.)
But scanty and imperfect as is our knowledge
of the state of medicine in the age of ^Esculapius,
after his death and that of his sons Machaon and
Podalirius, we have a long period, extending even
to several centuries, during which we have still
less information respecting the history and progress
of the science. We have not a single improve-
ment of any importance recorded as having taken
place during this long interval, nor have we the
names of any individuals transmitted to us, who
were of sufficient eminence to be distinguished
above their contemporaries. We learn that the
practice of medicine was entirely confined to the
Asclepiades, who were the guardians or superin-
tendents of the temples that were erected in
honour of iEsculapius. It may be inferred from
the very scanty materials which we possess on the
subject, consisting entirely of allusions or indirect
accounts, scattered through the works of the older
poets and historians, that they sedulously kept up
the system of rites and ceremonies, which had
been handed down to them from still more ancient
practitioners, that they carefully preserved to them-
selves the sole management of the art over which
they presided, and we cannot doubt made use of
the influence which they acquired over the minds
of their contemporaries for the purposes both of
gain and of ambition.-)- But although we regard
the general system of the priests of ^sculapiusto
be nothing more than a tissue of mystery and de-
lusion, it is very probable that the ample opportu-
nities which they possessed of witnessing the
phenomena of disease in all its forms might enable
them to obtain much valuable information respect-
ing the nature and tendency of the morbid actions
of the body, and of the effects of certain agents
upon them. Men possessed of superior talents and
sagacity would naturally profit by these advantages,
and we accordingly find that some of these tem-
ples acquired a high degree of celebrity, in conse-
quence of the supposed skill of the priests that
were attached to them. These opportunities of
acquiring experience were much facilitated by a
practice, which generally prevailed among the pa-
tients, whenever they were cured of their diseases,
of depositing in the temple a votive tablet, on
which was inscribed a narrative of the case, in-
cluding a st atement of the s ymptoms of the dis-

t Lucian in his " Philopseudos," gives an account of
various medical superstitions which prevailed at a later
period, many of which were probably transmitted from
the empirics of antiquity. See Tooke's Trans, v. i. P

c7 (?t SCQ»

MEDICINE, (HISTORY OF)

183

ease, and the means adopted for its removal. The
temples were thus converted, to a certain extent,
into schools of medicine, and as these records were
religiously preserved, they became the repositories
of much valuable information, which must have
gradually led to an improvement in the art. Of
the numerous temples that were dedicated to
„Esculapius, there were three which acquired pe-
culiar celebrity, those of Cos, of Gnidos, and
of Rhodes ; we are informed that Hippocrates
made great use of these records, and it has even
been supposed that one of the treatises which is
generally ascribed to him, " Coacae Prsenotiones,"
was composed from the records which he procured
from the temple of Cos.

Some ancient inscriptions have been discovered
by the researches of the learned antiquaries of the
last century, which would appear to consist of
memorials of this kind ; and from these specimens
we may form some idea of the nature of the in-
formation that would be conveyed by them. For
the most part they state little more than the name
of the disease, together with a very brief account
of the means adopted for its relief, which in many
cases depended entirely upon certain ceremonies,
and in others upon the application of remedies
which, we may venture to assert, could have no
physical operation. {Gruler, Corp. Inscrip. a
Gra;vio, pi. 17 et alibi. Ackermann, Opuscula,
Diss. 3. sect. 3, by Hundertmark and Carpzov.)
Still, however, some experience of the nature and
treatment of disease might have been conveyed
by their means, and of this we may presume that
an individual of a sagacious mind would have
availed himself for the improvement of his art.

Among the few circumstances that are trans-
mitted to us respecting the principles and practice
of the Asclepiades, we are informed that the
priests connected with the two rival establishments
of Cos and Gnidos devoted their attention in some
measure to different objects ; those of the former
assumed more of a philosophical cast, attempting
to unite reasoning with experience, while the
latter attached themselves solely to the observation
and collection of mere matters of fact. Hence it
would appear that a foundation was thus early laid
for the two great sects of the Dogmatists and the
Empirics, which long divided the medical world,
and the influence of which is, even at this day,
not altogether destroyed. We may remark, how-
ever, that the philosophy of the school of Cos, if
it may be so called, was founded upon such totally
incorrect principles, and upon so fallacious a basis,
that little immediate benefit was derived from it,
and that it was only useful so far as it might lead
them to exorcise their intellectual powers, and
enable them to reason more correctly on medical
subjects. By the mode in which Hippocrates
speaks of certain practices, such as bleeding and
the administration of emetics, purgatives and other
analogous medicinal agents, we may infer that
they were in common use among his contempora-
ries, and probably had been so for a long time before
him. We may in some instances obtain a know-
ledge of the vegetable substances that were employed
in these early ages, as well as of the individuals
who introduced them into practice, by the names
which were afterwards imposed upon them by the
ancients. It must indeed be obvious that the indi-

cation derived from these names is far from being
decisive as applied to any particular case, but we
derive a general inference from it as to the nature
of the articles employed, while they serve to point
out the persons who were supposed to have been
the most eminent for their skill or their science.

Some centuries had elapsed, during which the
practice of medicine continued altogether in the
hands of the priesthood, and under their control
had remained nearly stationary. It had been
exercised, for the most part, for the purpose
either of direct emolument, or for the still more
selfish purpose of maintaining their influence
over the minds of the people, when it began to be
cultivated by a different description of persons,
much more likely to produce a spirit of improve-
ment, and from whom in reality it derived its first
impulse. It was during the sixth century before
the Christian sera that the genuine principles of
philosophy first made their appearance in Greece,
and among the other topics which then became
the subject of investigation, the powers and func-
tions of the human body were examined with
considerable attention. This led to an inquiry
into the nature and cause of diseases, and to the
means of their removal ; and although a long
period elapsed before much actual advance was
made in the knowledge of pathology or of the
practice of medicine, yet we observe the effect of
a more correct mode of reasoning, and may per-
ceive that the strong-holds of mystery and super-
stition, although not destroyed, were at least in
some degree weakened. {Sprengel, sect. 3, ch. 1.)

The celebrated name of Pythagoras may be
mentioned as the first of this class respecting
whom we have any accurate information, and
even his history is enveloped in much obscurity.
We may, however, conclude with certainty that
he devoted the greatest portion of a long life to
the pursuit of natural knowledge, that he made
many considerable advances in various depart-
ments of science, and among others in the know-
ledge of the structure and actions of the human
frame. It has been supposed that he dissected the
bodies of animals, and hence acquired a certain
acquaintance with anatomy, and that he publicly
taught what he knew on this subject to a large
assembly of students, who came from all the civi-
lized parts of Greece and Italy to Crotona, where
he established his school. We are informed that,
for the purpose of acquiring knowledge, he tra-
velled into those countries which, previously to
his time, were regarded as the depositaries of
knowledge, particularly Egypt, where he is said
to have passed no less than twenty-two years, and
probably also Chaldsea and some parts of Eastern
Asia. From what has been stated above, we may
form some conception of the nature of the know-
ledge that he would obtain from these sources, and
we may conclude that he must have been pos-
sessed of a very superior mind to have been capa-
ble of extricating himself from the trammels of
superstition and bigotry in which every thing con-
nected with those countries was involved.*

* Diogenes Lacrtius, lib. viii. cap. 1-50. Cicero, de
Fin. v. 29. Valer. Maximus, viii. 7. JElianvs, Hist.
Var. iv. 17. Clemens Mexandrinus, Stromat. lib. i. p
354-7. Fabricius, Bib!. Grac. lib. ii. cap. 12. Enfield,
vol. i. p. 422 et seq. Mkermann, Instit. Per. 2, cap. 4, 5
Opuscula, diss. 4, a Kiihn.

194

MEDICINE, (HISTORY OF)

We are scarcely able to determine in what
degree he directly improved the practice of medi-
cine ; it is probable, however, that, as he did not
make it his profession, but studied it only in con-
nection with the other branches of natural philoso-
phy, the actual additions which he made to it
were not considerable. (Sprengel, t. i. p. 337 et
seq.) This we may also conclude to have been
the case with many of his pupils, who were
among the most justly celebrated philosophers of
that and the succeeding age. They may all of
them be regarded as belonging to the school of
Pythagoras, inasmuch as they cultivated natural
knowledge by means of observation, and even
occasionally of a rude kind of experiment; and
although none of them were exclusively devoted
to the study of medicine, yet they gradually and
indirectly contributed to its advancement, so as to
prepare the way for one of those great and com-
manding geniuses who occasionally make their
appearance, and by their intellectual ascendency
produce such important revolutions in the world
of science : it is unnecessary to state that we here
allude to Hippocrates.

During the interval from Pythagoras to Hippo-
crates there are few names that require any par-
ticular notice as improvers of medicine. Demo-
critus (Clerc, p. 96-101. Enfield, vol. i. p. 422
et seq. Barchusen, diss. No. 1. Sprengel, t. i.
p. 261-6) and Heraclitus (Clerc, p. 95, 6. Spren-
gel, t. p. 266-9. Enfield, vol. i. p. 436 et seq.)
were among the most illustrious followers of Py-
thagoras, but they became famous rather from the
ingenuity with which they supported their peculiar
hypotheses than from the additions which they
made to actual knowledge. They applied respec-
tively their favourite doctrine of atoms and ele-
ments to explain the phenomena of disease, and
even the operation of remedies; but, it is unne-
cessary to say, with little real advantage. The
former of these philosophers, however, deserves
honourable mention from the attention which he
paid to the study of comparative anatomy ; and it
has been conjectured that he so far rose superior
to the prejudices of his age as to venture upon the
dissection of the human subject.

The name of Acron is mentioned by Pliny
(Lib. xxix. cap. 1) as among the first who at-
tempted, upon any general principles, to apply
philosophical reasoning to the science of medicine,
but we have scarcely any knowledge of his history
or character, nor have we any memorials left of
the principles which he adopted. (Clerc, part. i.
liv. ii. ch. 7.) We may also select the name of
Herodicus as having been considered the inventor
of what was styled gymnastic medicine, (Clerc,
part. i. liv. ii. ch. 8. Mercurialis, De Arte Gym-
nastica. Schulz, p. 192 et seq. Barhier, in Diet.
Scien. Med., art. " Gymnastique." Ackermann,
per. 2, cap. 6,) which was regarded by the Greeks
as a very important branch of the art. Schools
for the practice of the gymnastic exercises were
established in various parts of Greece, and were
placed under the direction and superintendence of
persons especially trained for the purpose, who
took charge of the health of their pupils, and who
appear to have undertaken the treatment both of
the accidents which occasionally occurred in their
establishments, and also, when necessary, of in-

ternal diseases. These gymnasiarchs, as they
were styled, must in this way have acquired a
certain degree of information respecting the nature
of disease, and seem to have been considered as
among the most skilful practitioners of the age in
which they lived.*

CHAPTER II. — An account of the opinions
and practice of Hippocrates and his contempo-
raries — Remarks on the history and- education
of Hippocrates — High estimation in which he
was held — Remarks on his character and ac-
quirements — On his works — Account of Ids
principles and doctrines, his physiology, pa-
thology, anatomy, and practice.

We now enter upon the history of an individual
of very distinguished character and acquirements,
who was destined to effect a complete revolution in
his profession, and to introduce a system which may
be considered as having laid a foundation for all its
future improvements. The contemporaries and
immediate successors of Hippocrates were so sen-
sible of his merit that he acquired from them the
title, which he has since retained, of Father of
Medicine ; and it may be confidently affinned
that the science is more indebted to his genius and
ability than to that of any single individual. It
is a little remarkable that, notwithstanding the
great celebrity which he attained, we have no very
correct knowledge of his history, of the mode of
his education, or of the means by which he ac-
quired his wonderful pre-eminence. All that we
are able to learn on these points with any degree
of certainty is, that he was brought up among the
Asclepiades, who were attached to the temple of
Cos, that he studied medicine under Herodicus,
and that he embraced the philosophical hypothesis
of Heraclitus ; he is also reputed to have been a
lineal descendant, in the eighteenth degree, from
/Esculapius, and may therefore be supposed to
have been devoted to the profession from an early
period of life, and must have had access to all the
records which were accumulated in the establish-
ment to which he belonged. These circumstances
may have had the effect of originally directing
his mind to the pursuits in which he afterwards
became so eminent ; but we must suppose that he
possessed from nature a genius singularly adapted
to the advancement of medical science, by which
he was enabled so far to surpass all those who
were placed in situations equally advantageous.
We are informed that he spent a considerable
portion of his life in travelling through foreign
countries, partly for the purpose of obtaining
information, and partly from the circumstances
of his assistance being required to undertake the
cure of persons of rank, to arrest the progress of
epidemics, or to check the ravages of endemic
diseases. The works that he left behind him are
very numerous, and considering their antiquity
they may be regarded as in a tolerably perfect
state.

Unfortunately, however, to those which appear
to have a just claim to be considered as his genu-
ine productions, there are appended a number of

* Plato, De Repub. passim, et De Leg. lib. vii. Schufc
has judiciously summed up in a series of general propo-
sitions the history and progress of medicine up to the
period at which we are now arrived ; p. 201, 2.

MEDICINE, (HISTORY OF)

185

others, which it may he concluded are spurious,
cither written by his pupils or successors, or
fraudently attached to his name in consequence
of its great celebrity. Many eminent critics have
exercised their ingenuity in endeavouring to se-
parate the genuine from the spurious writings of
Hippocrates ; and in such estimation was he held,
that for many ages a main object with all writers
on medical topics was to comment on the woiks
of Hippocrates, to elucidate his principles by sub-
sequent observation, or to support their respective
doctrines by his authority. He is mentioned with
great respect by Plato, Cclsus, and Pliny, and by
others among the ancients; Galen speaks of him
with a degree of almost enthusiastic admiration,
and at the revival of letters the most learned men
of the times devoted themselves to the elucidation
of his works by glossaries, commentaries, and
criticisms of all descriptions. In Italy, Germany,
and France, where learning first began to revive,
and where the earliest universities were estab-
lished, we have, among other illustrious names,
those of Alpinus, Cornarius, Hollerius, Ballonius,
Mercurialis, Fernel, Heurnius, Sennert, Foesius,
Riolan, and Duret,* who, however they might
differ in their opinions and practice, all coincided
in regarding Hippocrates with equal respect, and
considered him as having first placed the study
of medicine on its correct basis.j-

We are hence naturally led to inquire what
were the circumstances, in the intellectual or lit-
erary character of Hippocrates, which produced
this powerful Impression, and perhaps we may as-
sign the following as among the most influential.
He appears to have had the sagacity to discover
the great and fundamental truth, that in medi-
cine, probably even more than in any other
science, the basis of all our knowledge is the ac-
curate observation of actual phenomena, and that
the correct generalization of these phenomena
should be the sole foundation of all our reasoning.
Every page of Hippocrates proves that he was
not without his speculations and hypotheses, but
at the same time we perceive that, for the most
part, they were kept in subjection to the result of
observation, and that when they appeared to be in
opposition to each other, he had the wisdom to
prefer the latter. Hence his descriptions of par-
ticular diseases, after all the revolutions of customs
and habits, both moral and physical, are still
found to be correct representations of nature,
while his indications of cure, and the treatment
derived from them, are generally rational and
practicable. When we reflect that at this period
anatomy was scarcely practised, t that physiology
was almost unknown, that the materia medica
was nearly confined to vegetable substances, and
of these to such as were indigenous to Greece and

* In designating the names of authors who flourished
after the revival of letters, it is somewhat difficult to
determine, whether we ought to employ their actual or
their latinized names; we have adopted the former,
where it could he done without ambiguity or the ap-
pearance of atTectation.

t Conrintr, Intr. cap. 3. § 8 et alibi. Holier, Bibl. Moil.
Prac lib. vi. ; it is entitled " Schola Hippocratira," and
is carried down to the beginning of the seventeenth
century.

\Gruner, Analecta. diss. 2. "Hippocrates, corpora
hiiniana insecuerit necne?" Me discusses the question
with much learning and candour, and decides in the ne-
gative.

Vol. III. — 24 a*

the neighbouring countries, our admiration of the
skill and talents of Hippocrates will be still farther
increased, and we are induced to regard him as
one of those rare geniuses, who so far outstrip
their contemporaries as to form an acra in the his-
tory of science.

With respect to the particular improvements
which he introduced into the practice of medicine,
we may remark that one of the first importance
was the narration of individual cases of disease,
a plan which may perhaps have been suggested
to him by the votive tablets deposited in the tem-
ple of iEsculapius, but upon which he so far im-
proved as to be entitled to the merit of an inventor.
The second point on which we shall remark, was
his method of endeavouring to remove particular
symptoms by carefully noticing what have been
termed the juvantia and the Isedentiu, watching
the effect of his applications, and proceeding, by
a cautious analogy, from individual facts to more
general conclusions, and hence deducing his indi-
cations of cure from the operations of remedies,
not from any preconceived or abstract principles,
which were generally either fallacious or inappli-
cable. Hence his practice may be characterized
as consisting in what has been termed a rational
empiricism, where we first ascertain the fact, and
afterwards reason upon its consequences.

In speaking of the writings of Hippocrates, it
may be proper to remark that the most complete
edition of them, in all respects, is that of Foesius,
in which every circumstance is attended to that
can illustrate them or render them more easily iiir
telligible. He has given a list of all the commen-
taries and criticisms that had been written upon
them, which at the time of Ids publication, in the
year 1595, would of themselves have formed an
extensive library. It appears from this list that
no less than one hundred and thirty-seven authors
had published on the subject of the Aphorisms
alone. It was remarked above that many of the
writings which are commonly ascribed to Hippo-
crates, or at least are published in the collection
of his works, are supposed not to have been his
genuine productions, and hence it has been an
object of interest with many eminent critics to
distinguish the one from the other. It will not be
necessary for us to enter into these discussions in
this place ; we shall only remark that the number
of treatises which are admitted to be certainly
genuine is very small compared to the whole num-
ber popularly ascribed to him. Of those which
are printed in the ordinary editions of his works,
which amount to more than sixty, Mercurialis,
Haller, Gruner, and other critics conceive that
there are a few only which were actually written
by Hippocrates, while Ackermann has reduced the
number of the genuine works to ten.*

In ascertaining what were the real opinions and
practices of Hippocrates, besides the difficulty of
discriminating the genuine from the spurious pro-
ductions, we have a farther difficulty arising from
the peculiarity of his style. This is admitted to

* Conring, cap. 3, § 8. Clerc, par. 1, liv. iii. ch. 30.
Mercurialis, Censura et Dispositio Operum Hippocratis.
Gruner, Analecta, No. 2. Kiihn, Dili. Med. p. 107-171,
for the editions of Hippocrates. Haller, Bihliotheca
Med. I'rac. lib. J. § 17-21. Eloy, Diet. hist, in loco.
Ackermann, Inst. Hist, Med. per.l, cap. 8, § 102. Blumen-
bach, Introd. § 34. Goulin, Enc. Meth. Medecine, " Hi*
pocrate," p. 202-5.

1S6

MEDICINE, (HISTORY OF)

be brief and abrupt, and to be full of ideas com-
pared with the number of words employed to con-
vey them, so that it appeared somewhat obscure
even to his contemporaries and immediate succes-
sors. Erotianus, who lived in the first century
of the Christian era, thought it necessary to write
a glossary for the express purpose of elucidating
his phraseology; and the immense number of
commentaries which have appeared, and which
continued to be published until the commencement
of the eighteenth century, must be regarded, not
only as a tribute to his extraordinary merit, but in
some measure as an indirect censure of his style.
But after making all due allowance for these pe-
culiarities, after rejecting all the doubtful works
and obscure passages, and resting more upon the
general scope and tendency of the treatises than
on particular words and phrases, we have sufficient
evidence left us of the nature of his principles,
both as regards theory and practice. Although it
is principally in the latter capacity that we are
now to regard Hippocrates, yet it will be proper
to make a few remarks upon his acquirements in
the analogous departments of science.

With respect to his philosophical tenets it ap-
pears that the father of medicine must be classed
generally among the Pythagoreans, and in the par-
ticular sect or school of Heraclitus. The leading
doctrine of this philosopher was, that fire is the
prime origin of all matter, and that by the colli-
sion and peculiar combination of its particles,
which are in perpetual motion, the four elements
are produced. (Enjield, b. 2, c. 14, v. 1. p. 436
et seq.) From this doctrine Hippocrates derived
his leading principles of pathology ; it lies at the
.'bundation of all his medical hypotheses, and is
brought forward in various parts of his works.
But although, like all his contemporaries, and in-
deed nearly all his successors up to the present
day, he assumed certain theoretical principles, yet,
as we remarked above, he had the extraordinary
sagacity to perceive the necessity of detaching
medicine from what was then styled philosophy.
He professed to examine the phenomena of disease
in the first instance, to ascertain what were the
natural powers and properties of the animal frame,
how far these were affected by external circum-
stances and by morbid causes, and hence to derive
his curative indications and his mode of treatment.
It is in the writings of Hippocrates that we ob-
serve the first traces of what is properly styled
physiology, i. e. an account of the functions and
powers of the living body. Although some of his
opinions were derived from the school of Pytha-
goras, and savour of its mysticism and obscurity,
yet others appear to have been original, and
founded upon a much more correct and philosophi-
cal view of the subject. "We owe to him the in-
vention of the hypothesis of a principle, to which
he gives the appellation of nature (4>vcis), which
influerces all parts of the corporeal frame, super-
intends and directs its motions, and which is pos-
sessed of a kind of intelligence, so as to promote
all the actions which are beneficial, and repress
those which have an injurious tendency. In ad-
dition to this general principle, he conceives of
others of a subordinate nature, which he styles
powers (<5vvafiits), which are more particularly
concerned in the action of the various functions

of the body. The body itself is supposed to con-
sist of the four elements, combined in different
proportions in different individuals, so as to pro-
duce an original difference in the constitution of
the body, giving rise to the four temperaments.
These influence both the intellectual and the cor-
poreal part of our frame, and lay a foundation for
disease independent of external circumstances,
and cause these circumstances to operate in differ-
ent modes and in different degrees in different in-
dividuals.

One of the leading pathological doctrines of
Hippocrates was, that the fluids are the primary
seat of disease, a doctrine which, under the deno-
mination of the Humoral Pathology, became the
prevailing opinion of all sects and of all theorists,
until the commencement of the eighteenth cen-
tury. The combination of the four elements with
the four states or qualities with which they were
affected, of hot, cold, moist, and dry, gave rise to
the four fluids or humours of the body ; blood,
phlegm, bile, and black bile, which originally
tended to produce the four temperaments, and
which in their turn contributed to the excess or
defect of each of the humours.

Another of the most important doctrines of
Hippocrates is that of crises, or the natural ten-
dency of disease to a cure at certain stated periods,
depending upon a natural train of actions, which,
when proceeding in their due course, terminate in
the removal of the morbid action. These sup-
posed crises were, for the most part, evacuations
of various kinds, especially by the bowels or the
skin, and hence the regulation of these evacua-
tions led to his most important indications, and
became a main part of his practice. There is no
subject on which Hippocrates showed more saga-
city and accurate observation than in watching
the effect of external agents upon the system, such
as temperature, the influence of the atmosphere,
the effect of particular situations, of the seasons,
and other analogous circumstances. In most of
these cases the causes were obscure, and he fre-
quently erred in his attempts to explain them; but
his observations were correct, and contributed
materially to the success of his practice.

The extent of knowledge which Hippocrates
possessed on the subject of anatomy has given rise
to much learned discussion. While his admirers
were unwilling to admit that he was deficient in
any of the departments of medical science, and
attempted to prove that he had acquired a correct
knowledge of the structure of the body, it has
been contended, on the other hand, that on this
point his information was very imperfect. This
may be readily supposed to be the case from the
abhorrence with which the dissection of the human
subject was regarded at that period, and from the
little attention which was paid even to compara-
tive anatomy. There are likewise other conside-
rations of an especial nature, which lead us to
conclude that he had little knowledge of the in-
ternal structure of the body, or of the relation of
its different parts to each other. Notwithstand-
ing, therefore, the claim which has been set up
for Hippocrates, by some of his devoted advocates,
to a knowledge of the circulation of the blood, and
other claims equally extravagant and unfounded,
we may conclude, with the learned and candid Le

MEDICINE, (HISTORY OF)

187

Clerc, that the knowledge which Hippocrates
possessed of anatomy was little if at all superior
to that of his contemporaries. (Clerc, part 1, liv.
liv. iii. ch. 3. Shulz, per. 1, sec. 3, cap. 2, § 1-8.
Uprengel, t. 1. p. 302 et seq. Gruner, Ana-
lecta, No. 2. Lauth, liv. iii. passim.)

After these brief observations on the theoretical
doctrines of Hippocrates, and of the knowledge
which he possessed in the various departments
of medical science, we must conclude this chap-
ter with a somewhat more minute account of his
practice. Although he has published no regular
treatise on practical medicine, nor laid down any
specific rules on this subject, he has given us in
several parts of his works a minute detail of his
treatment of various diseases, so that we are en-
abled to ascertain, with considerable minuteness,
the general principles on which he acted, as well
as the mode in which he applied them. The great
principle which directed all his indications was
the supposed operation of " nature," to which we
have referred above, in superintending and regu-
lating all the actions of the system. The chief
business of the physician is to watch these opera-
tions, to promote or suppress them according to
circumstances, and perhaps in some rare cases to
attempt to counteract them. The tendency of
this mode of practice would be to produce extreme
caution, or rather inertness, on the part of the
practitioner, and we accordingly find that Hippo-
crates seldom attempted to cut short any morbid
action, or to remove it by any decisive or vigorous
treatment. Considering the state of knowledge
on all subjects when he lived, it must be admitted
that this plan of proceeding was much more salu-
tary than the opposite extreme, and that it had
likewise the good effect of enabling the practi-
tioner to make himself better acquainted with the
phenomena of disease, and by observing the un-
aided efforts of nature, to form his indications with
more correctness, and to determine to what object
he ought more particularly to direct his attention.
It has been remarked that a man who is possessed
of an acute and penetrating genius, however
strongly he may be attached to a favourite hypo-
thesis, contrives to adapt it to the information
which he acquires, and this was in some measure
the case with Hippocrates. For, notwithstanding
the grand principle of the all-sufficient and uner-
ring superintendence of nature, we have another
general principle brought into view, which appears
altogether of an opposite tendency, viz. that a dis-
ease is to be cured by inducing a contrary state
of the system, or a contrary action in the morbid
part. Thus, repletion is to be relieved by evacua-
tion, and the effect of excessive evacuation to be
removed by inducing repletion ; the excess or
defect of any of the humours or qualities is to be
relieved by the employment of such means as may
augment or diminish the contrary humour or
quality. Perhaps it may be said that in these
cases the practitioner is in fact only anticipating
the operation of nature, or producing that change
which would naturally ensue were there not some
unusual counteracting cause which prevented or
repressed it. But it is of comparatively little con-
sequence in what way he reconciled this apparent
discordance , we have every reason to feel as-
sured that this mode of treatment is frequently

correct, and Hippocrates evinces the superiority
of his genius by not suffering his judgment to be
warped even by the influence of a favourite hypo-
thesis.

A third principle which very materially affected
the practice of Hippocrates was the doctrine of
critical evacuations, to which we have alluded
before. As diseases were supposed to originate
in the prevalence of some morbid humour, so
when they are suffered to run their course with-
out interruption they are relieved by the discharge
of the humour, and consequently the promotion
of this discharge becomes an important indication
which it is often easy to accomplish, and which
proves very effectual. Hence an important part
of his practice consisted in the employment of
evacuations of various kinds, and especially of pur-
gatives, of which he used a great variety and ad-
ministered them with great freedom. This, in-
deed, was the only part of his practice which can
be considered as decidedly active, but even here
we do not perceive that he transgressed the limits
of prudence, while in the selection of the remedy
and its adaptation to each particular case, he
manifested considerable judgment and sagacity.
With the same intention he prescribed diuretics
and sudorifics ; he drew blood both by the lancet
and the scarificator ; he applied the cupping-
glasses ; he administered injections and inserted
issues. He made very frequent use of external
applications, such as ointments, plaisters, lini-
ments, &c, and was familiarly acquainted with
the effects of external temperature. His materia
medica was tolerably copious, and embraced many
articles which still retain their place in our phar-
macopoeias. They were almost exclusively of
vegetable origin, for the preparations which depend
on chemical processes, such as metallic salts and
oxides, the strong acids, with the spirituous com-
pounds, were then totally unknown.

One important part of medical practice to which
Hippocrates paid particular attention was the regu-
lation of the diet ; in this he displayed much sa-
gacity and discernment, as well as on all points
connected with the management of his patients,
with regard both to the cure and prevention of
disease. He appears to have been the first who
noticed what has been called the epidemic consti-
tution of the seasons, that inexplicable condition
of the atmosphere, or of those influences to which
the body is exposed, which appears to render it
more or less obnoxious to certain morbid causes,
and even to generate these causes at certain pe-
riods, without our being able to refer their produc-
tion to any more general principle.

The tendency of the practice of Hippocrates to
allow the operations of the system to pursue their
course without interruption, united with his natu-
ral sagacity, enabled him to acquire great skill in
prognostics, so that there is no part of his writings
which exhibits more distinctive marks of a sxipe-
rior understanding than those in which he treats
on this topic. Upon a review of the character
and writings of this celebrated individual, we con-
ceive that we are warranted in the conclusion,
that while there are few persons of any age or
nation who attained to greater distinction among
their contemporaries, or whose memory has been
more cherished by posterity, there was perhaps no

188

MEDICINE, (HISTORi' OF)

one whose fame was more merited or established
upon a firmer foundation.*

CHAP. III. — History of Medicine from the time
of Hippocrates until its introduction into
Rome — Establishment of the Dogmatic sect —
Plato — Aristotle — School of Alexandria —
Erasistratus — Hcrophilus — Division of Medi-
cine into different departments — Into the Dog-
matic and Empiric sects— Their general prin-
ciples.

We have not much to add respecting the state
of medicine during the period which immediately
succeeded to the death of Hippocrates. The ad-
vance which he made in the science, and the im-
provement which he introduced into the practice,
were so considerable, that no one appeared for
some centuries who was able to proceed, at least
in any considerable degree, beyond the point of
perfection to which it had been brought by the
great father of medicine. In conformity with the
custom of the times, Hippocrates transmitted his
profession to his sons Thessalus and Draco, and
we are informed that it continued to descend in
the direct hereditary line for several successive
generations. Polybus, his son-in-law, is singled
out as having fully maintained the credit of his
illustrious relative, and it is even said that many
of the writings usually ascribed to Hippocrates
are in reality the production of Polybus. (Clerc,
part i. liv. iv. ch. 1.)

The only other names which we meet with in
the annals of medicine among the Asclepiades,
that are in any considerable degree distinguished,
are, Diodes of Carystus, and Praxagoras of Cos.
The former of these obtained a high reputation
for his learning and practical skill : he appears to
have adopted for the most part the opinions and
practice of Hippocrates. (Clerc, part i. liv. iv.
ch. 5. Schulz, p. ii. cap. 1, § 10-22. Sprengel,
t. i. p. 366-2.) Of the latter, although he is enu-
merated among the successful improvers of the
art, we have only very imperfect and unsatisfac-
tory accounts. We are, indeed, informed that he
paid great attention to anatomy, that he particu-
larly noticed the state of the pulse, and derived
many of his indications from this source ; but we
have little except the general fact of the estima-
tion in which his name was held by his contem-
poraries, which can enable us to form an estimate
of his merit. ( Clerc, part i. liv. iv. ch. 6. Schulz,
p. ii. cap. 1, § 23-8. Sprengel, t. i. p. 372-4.)
The name of Chrysippus may be noticed in this
place as one who appears to have been a kind of
irregular practitioner, as we should style him, who
did not belong to the family of the Asclepiades,
and was principally remarkable for the innova-
tions which he introduced into practice.-j- But
like too many of those whose fame is principally
founded on the novelty of their opinions, we do
not find much to commend in them. We are told

* Clerc, part i. liv. iii. Conring, cap. 2, §11, et alibi.
Schulz, per. I, §3, cap. 1-4. Douglas, Biblioer. Anat. p.
1 et seq. Barchusen, diss. No. 12. llallt.r, Bib. Med. lib.
i. § 17-21. Sprengel, § 3, chap. 3. Enfield, vol. l,p. 412-4.
jlikin's Gen. Biop. in loco. Ooulin, Enc. Meth. " Miide-
cine," in loco. Cabanis, ch. 2, § 3. Ackermann, Inst.
Hist. Med. p. 70-8. Eloy, Diet, in loco. Nouv. Diet. Hist,
in loco. Renauldin, Biog. Univ. '• Hippocrate."

t Pliny remarks of him, " Horum (referring to previous
physician?) placita Chrysippus ingenti garrulitate inu-
la vit." Nat Hist. lib. xxix. cap. 1.

that he did not allow, in any case, of bleeding,
and that he discountenanced the employment of
all active purgatives ; and, in short, that he re-
jected many of the most powerful and effective
agents in the treatment of disease. (Clerc, part ii.
liv. i. ch. 1. Schulz, p. i. sect. 3, ch. 5, 6. Spren-
gel, t. i. p. 365.)

Draco and Thessalus, in conjunction with their
relative Polybus, are generally regarded as the
founders of what has been considered as the first
medical sect or school which was established upon
rational principles. It obtained the name of the
Hippocratean, or more generally the Dogmatic
school or sect, because it professed to set out with
certain theoretical principles which were derived
from the generalization of facts and observations,
and to make these principles the basis of practice.

Although we can have no hesitation in pro-
nouncing this to be the correct and legitimate
method of pursuing the study of medicine, yet it
must be acknowledged at the same time that it is
a method which, if not carefully watched and
strictly guarded by prudence and sagacity, is ex-
posed to the greatest danger of being corrupted by
ignorance and presumption. Hence we may easily
conceive that it would be liable to fall into the
grossest errors, and to lie open to the most serious
imputations, and that a fair plea would always be
found for exclaiming against the introduction of
what is termed theory into the practice of medicine.
This abuse of the principles of the Dogmatists gave
rise to the rival sect of the Empirics, who, per-
ceiving the false reasoning of the former, and the
injudicious practice consequent upon it, professed
to be guided altogether by experience, and to dis-
card all theory. For inany centuries these two
sects divided the medical world, and even at this
day, after all the revolutions of opinion and the
improvements of science, we may observe very
distinct traces of their influence. It was not,
however, until a considerably later period that the
Empirics formed themselves into a distinct sect
and became the declared opposers of the Dogma-
tists. (Sprengel, sect. 4, ch. 1.)

Besides the individuals who belonged to the
family of the Asclepiades, and who made medi-
cine their particular profession or pursuit, most of
the philosophers of Greece bestowed a certain de-
gree of attention upon this science; for it appears
that among the ancients, a knowledge of medicine
was regarded as one of the branches of philosophy
which was included in a course of general educa-
tion. The only two, however, of the Grecian
philosophers whom it will be necessary to men-
tion on the present occasion, are Plato and Aris-
totle, who, although they did not compose any
treatises on medicine strictly so called, make fre-
quent allusions to it in various parts of their
writings. The former of these authors, in his
dialogue styled Timams, and in his treatise de Re-
publica, has entered into various physiological dis-
cussions respecting the functions of the bodv, and
the supposed effect of their derangement in pro-
ducing the morbid conditions of the system, and
has offered various incidental observations on the
practice of his contemporaries. But it does not
appear that either the theory or the practice of
medicine received an y improvement from this
philosopher. He made little or no addition to tho

MEDIC 1JNE, ^ HISTORY OF)

189

actual stock of our knowledge in any branch of
natural science, while his peculiar genius rather
led turn to the formation of hypotheses and specu-
lations derived from fanciful analogies, tinged with
that air of mystery which pervades most of his
writings. (Clerc, part i. liv. iv. ch. 3. Stanley's
Hist, of Phil, part v. ch. 22, p. 79 et alibi. Spren-
gel, t. i. p. 337 et seq.)

Both the original turn of mind and the pur-
suits of Aristotle were much better adapted to im-
prove the science of medicine than those of Plato.
He made very great advances in the knowledge of
nature ; he was peculiarly well situated for the
acquisition of new information on all subjects con-
nected with natural history, and he diligently
availed himself of his advantages. He was the
first writer who published any regular treatises on
comparative anatomy and physiology, and his
works on these subjects may be still read with
much interest, after all the additions which have
been made to them by the labours of the moderns.
(Douglas, Bibliogr. Anat. p. 9-11.) But, not-
withstanding all these favourable circumstances,
it may be questioned whether the influence of
Aristotle has not been ultimately somewhat un-
favourable to the progress of knowledge. With
his valuable facts and observations he mixed up a
large portion of recondite and refined speculation,
so that it is frequently not easy to separate the
one from the other ; and so great was the ascen-
dency which his genius acquired over the minds
of men for many centuries after his death, that
all his opinions, the most unfounded as well as
the most philosophical, were indiscriminately re-
ceived as established truths, which no one ven-
tured to oppose or to controvert, (Clerc, part i.
liv. ii. ch. 4. Schulz, p. ii. cap. 1, § 2 et seq.
Stanley, part vi. passim. Sprengel, sect. 4, cap. 2.)
The next circumstance which we are called
upon to notice in the history of medicine, is the
establishment of the school of Alexandria. This
was effected by the munificence of the Ptolemies,
who, about three hundred years before the Chris-
tian era, laid the foundation of the celebrated
Alexandrian library and of the school of philoso-
phy, which is graced by so many illustrious
names. The science of medicine was cultivated
in this school with peculiar assiduity, and we owe
some very essential improvements to its professors.
Among the most famous of these are Erasistratus
and Herophilus. We have not much accurate
information respecting the personal history of
these two individuals, nor have any of their works
been transmitted to us; but we have a detailed
account of their opinions and practice, given us
by Galen, Ccelius Aurelianus, and others, so as to
enable us to form a tolerably correct estimate of
their merits. They are particularly mentioned as
being the first who dissected the human subject,
for which purpose the bodies of criminals were
allotted to them by the government; and it ap-
pears that they amply profited by the advantage
which was thus given them, so as very consider-
ably to advance our knowledge of the structure
of the body, especially by pointing out those cir-
cumstances in which the human subject differed
from that of the animals who most nearly resem-
bled it, and in correcting the errors on this point
into which their predecessors had fallen. Nearly

every part of the great system of which the body
is composed, profited by their labours ; they ascer-
tained, with much more correctness than it had
been previously done, the structure of the heart
and the great vessels, and of the brain and nerves,
and they even seem to have had some imperfec
knowledge of the absorbents. We are informed
that Erasistratus was the pupil of Chrysippus, and
that he imbibed from him his prejudice against
bleeding, and against the use of active remedies,
trusting more to the operations of diet or the
natural efforts of the system : hence we are to
regard him as having improved the practice of
medicine only indirectly, by the addition which
he made to our knowledge of anatomy. (Clerc,
part ii. liv. i. ch. 2-4. Schulz, p. ii. cap. 3, § 35-66.
Sprengel, t. i. p. 439 et seq. Lauth, p. 140, 1.)
The anatomical fame of Herophilus is so inti-
mately blended with that of Erasistratus, that we
are unable to assign to each his respective share
of merit ; but it would appear that the former was
more correct and more skilful in the practical de-
partment. Of this we have one proof in the fact,
which is stated by Galen, that Herophilus was
one of the first who paid very minute attention to
the varieties of the pulse ; and his name is handed
down to us by the ancients as entitled to the
highest respect, both from his character and his
acquirements.*

An important circumstance in the history of
medicine, and more especially in that department
to which our attention is particularly directed,
occurred soon after the establishment of the Alex-
andrian school, viz. the division into distinct pro-
fessions, which were exercised by different indi-
viduals. Previously to this period, the practice
of what is more especially styled medicine and
of surgery was exercised by the same person ;
the tarpos of the Greeks corresponding nearly to
what we should now term the general practi
tioner. But about this time the separation into
the departments of dietetics, pharmacy, and sur
gery commenced, and was gradually admitted into
all succeeding schools or sects. The terms did
not, however, possess precisely the same signifi-
cation as in modern times. Dietetics compre-
hended not the regulation of the diet alone, but
every circumstance connected with the general
health or management of the patient, and corre-
sponded very nearly to the " medicus," or phy-
sician of modern times. The second included
not merely the department of the apothecary or
the compounder of drugs, but the performance of
many of the operations of surgery ; while to the
third was allotted the treatment of surgical dis-
eases, many of the operations, however, being
committed to the professors of the second branch.
That this separation eventually tended to the im-
provement of the respective branches of the pro-
fession will scarcely be doubted, although it must
at the same time be acknowledged that many of
the distinctions which were introduced were frivo-
lous and invidious, and arc now rapidly yielding
to the superior intelligence of modern times.
(Celsus, lib. i. prsef. Schulz, p. ii. cap. 5. Clerc,

* Clerc, part ii. liv. i. ch. 6. Sr!,ulz. p. ii. cap. 3, sec.
2-34. Sprengel, t. i. p. 43 et seq. Lauih. p. 139, 140.— For

an account of the Alexandrian school generally, see
Sprengel, sect. 4, ch. 3; and Lauth. liv. IV.

190

MEDICINE, (HISTORY OF)

part i. liv. ii. ch. 9. Eloy, " Partage de la Mede-
cine.")

It was about this period, i. e. shortly after the
establishment of the Alexandrian school, that the
great schism to which we have so often alluded
took place. It was occasioned by the formation
of the rival sects of the Dogmatists and the Em-
pirics. Neither of these terms, in the first in-
stance, bore exactly the same meaning which
they convey to a modern ear. The controversy
really consisted in the question, how far are we
to suffer theory to influence our practice. While
the Dogmatists, or, as they were sometimes styled,
the Rationalists, asserted that before attempting
to treat any disease, we ought to make ourselves
fully acquainted with the nature and functions
of the part which is affected, or rather of the body
generally, with the operation of medical agents
upon it, and with the changes which it undergoes
when under the operation of any morbid cause ;
the Empiric, on the contrary, contended that this
knowledge is impossible to be obtained, and, if
possible, is not necessary ; — that the minute and
internal changes of the system and of its different
parts are beyond the reach of our most acute ob-
servation, that it is alone essential to watch the
phenomena of disease, and to discover what reme-
dies are best fitted to relieve the morbid symptoms ;
that our sole guide must be experience ; and that,
if we step beyond this, either as derived from our
own experience or observation, or that of others
on whose testimony we can rely, we are always
liable to fall into dangerous and often fatal errors.
We may remark that this controversy, like so
many others which have occupied the attention
of mankind for a succession of ages, is partly
verbal, and in so far as it is not verbal, that it is
a question of degree. The boldest Dogmatist
professes to build his theory upon facts, and the
strictest Empiric cannot combine his facts without
some aid from theory. The uniform experience
of all the schools and sects from the days of Hip-
pocrates to the present time, demonstrates that the
undue extension of either of these systems is in-
jurious, that they both originate from a partial
view of the subject, and may generally be traced
to some defect either in the acquired information
or natural disposition of the practitioner. The
controversy, however, forms so prominent a fea-
ture in the history of medicine, that it will be
necessary to advert to it very frequently in the
following pages ; and we shall find that in esti-
mating the value of the various opinions or modes
of practice which will successively pass under our
review, it will in most cases be necessary to in-
quire from which of these sects they emanated.*
Respecting the individuals to whom the origin
of these sects should be referred, there is some
degree of obscurity : the Dogmatists generally
claim Hippocrates for their founder, and it is cer-
tain that he investigated with great care the func-
tions of the animal body, the action of morbid
causes upon it, and the operation of remedies, or,
as we should style them, the general principles of
pathology and therapeutics. But while, in this
respect, he acted upon the principles of the Dog-

* For an elegant summary of the arguments employed
in tills controversy, the reader is referred to Pcrcival's
Essaj s, Nos. 1 arid 2.

matists, he was no less remarkable for the accu-
racy with which he observed the phenomena of
disease, and the actual operation of remedies upon
individual cases, or even upon particular symp-
toms ; and it may be affirmed that, in most in-
stances, when his preconceived hypotheses seemed
to be in contradiction to the results of his expe-
rience, he wisely followed the latter. We may,
however, easily imagine that his successors, not
being possessed of his sagacity and industry,
would prefer the easiest method of indiscriminately
adopting all his principles and speculations, to the
more arduous task of correcting or extending them
by their own observation, and that they would in
this way bring all theoretical reasoning into dis-
repute. It is more probable that this feeling
would be gradually induced in the minds of prac-
titioners, than that it would be at once announced
by any single individual ; and as a matter of his-
torical fact, the ancients themselves were divided
in their opinion as to the person to whom they
should ascribe the origin of the Empirical sect.
Pliny attributes it to Acron, a physician of Sicily,
(Lib. xxix. cap. 1,) who was contemporary, if not
prior to Hippocrates ; while Celsus states that
Serapion of Alexandria, who was said to be a
pupil of Herophilus, was the first who distinctly
professed the opinion that theory is to be totally
discarded in medicine, and that direct experience
should be our sole guide. (In praef. sub initio.)
We have little correct information respecting
either the history or the practice of Serapion ;
none of his writings have been transmitted to us,
but from the scattered notices which we meet
with concerning him, dispersed through the works
of the ancients, it may be conjectured that he was
a man of considerable acuteness and sagacity, ami
that he generally adopted the practice of Hippo-
crates and his school, although he discarded their
theory. (Schulz, per. ii. cap. iv. § 8. et seq.)

All the medical men of the period at which we
are now arrived, and for some centuries subsequent
to it, were attached to one or other of these rival
sects, and, it would appear, in nearly an equal
proportion. Unfortunately, however, for the Em-
pirics, it has happened that all their writings have
perished, so that we are obliged to form our opinion
of their merits principally from the representation
of their antagonists. There is, indeed, one happy
exception in the works of Celsus, who, in the
commencement of his treatise, has given an ac-
count of the leading opinions of the two opposing
sects in so candid and judicious a manner, as al-
most to supersede any more elaborate discussion.
It has been thought by many that the view whicn
Celsus gives of the controversy is too favourable
to the Empirics ; and we admit that we can
scarcely read his account without being impressed
with the opinion, that he advocates their side of
the question. Yet the conclusion which he draws
is perfectly candid, and is, indeed, not very remote
from what the most enlightened practitioner would
form at the present day ;— that the perfect rule of
practice is derived from a due combination of
reason and experience; that without experience
all preconceived theory would be vain and useless;
and that by simple experience, without any at-
tempt at generalization, we should frequently fall
into gross errors, and be unable to profit even by

MEDICINE, (HISTORY OF)

the very experience which is so much extolled.
And, indeed, whatever may have been the pro-
fessed plan of the supporters of the two sects, we
shall always find that the practice of the most
eminent of either party actually proceeded upon
a judicious combination of the two systems; and
we are now persuaded that it is upon such a com-
bination that all further improvements of the
science and practice of medicine must essentially
depend.*

CHAPTER IV— On the state of Medicine
among the Romans from its first introduction

into Home until the time of Galen Roman

superstitions — Archagathus — Cato — Asclepi-
ades — Themison— Origin of the Methodic sect
— Thessalus — Saranus — C. Aurelianus —
Doctrines of the Methodics — Pneumatics and
Eclectics — Aretxus —Archigenes — Celsus, his
doctrines and practice — Condition of physi-
cians in Rome — Pliny — Dioscorides.\

For some centuries the school of Alexandria
produced a succession of learned men, not only
in medicine but in the other sciences, and contri-
buted to the advancement of knowledge, or at
least prevented the decay into which it was in
danger of falling after the decline of the Grecian
literature. It was curing this period that the
foundation was laid of the future grandeur of the
Roman empire ; but from the attention of this
people being almost exclusively directed to war-
like affairs, and perhaps also from other causes,
science of all kinds, and medicine among the rest,
was for a long time almost totally neglected.
Rome had extended her empire far beyond the
limits of Italy, and had subdued most of her rivals,
before she condescended even to tolerate the pur-
suit of the arts and sciences. We are expressly
told by Pliny, that for six hundred years she was
without physicians. We cannot conceive it pos-
sible that during this long period no attempts were
made to remove diseases ; we can only understand
by it that there were no individuals eminent for
their knowledge or skill who were engaged in the
profession, or perhaps that it was scarcely regarded
as the object of distinct pursuit, or that individuals
were not especially trained to the exercise of it.
We have, indeed, abundant evidence of two cir-
cumstances ; that in this, as in every other sub-
ject connected with the arts of life, the Romans
servilely copied from the Greeks,* and that, as far
as their medicine was concerned, wherever they
deviated from them it was for the purpose of
adopting various superstitious rites and ceremonies,
indicating the most profound ignorance and the
grossest superstition. Numerous instances of this
kind are incidentally mentioned by Livy ; and
although he wrote in the refined age and splendid
court of Augustus, they are introduced in the

* Galen, de Subfigurat. Empir. et alibi. Celsus in
Praf. Barchusen, Diss. nos. 10 & 13. Clerc, pars ii. liv.
ji. S/iulz, per. ii. cap. iv. Sprcngel, sect. 4, ch. 1, 4.
Jtckermann, p. iii. cap 10-13.

t For a concise, and at the same time a comprehensive
view of this period of the history of medicine, the reader
is referred to the finh section of Blumen bach's introduc-
tion. We may further remark that this work may be
cnnsulted with advantage, in connection with almost ail
the names that pass in succession under our review.

| Suetonius, de Grammar., sub initio: the fact is ad-
mitted by Cicero and by Pliny, and is frequently alluded
lo in various yarts of their writings.

191

thread of his narrative as actual transactions,
without any observation indicative of his disbelief
of their efficacy.§ One of these is the account
which he gives of the introduction of the worship
of iEsculapius into Rome. In consequence of a
fatal epidemic, the senate had recourse to the
usual expedient of consulting the Sibylline books,
where it was found to be enjoined upon them to
transfer the worship of the god from Greece to
their city. A formal deputation was accordingly
despatched for the purpose, by whom the deity,
unwilling to leave his native place, was seized by
a stratagem, and was conveyed under the form of
a serpent into Italy. He was received by the peo-
ple of Rome with unbounded transport ; a temple
was erected to him on an island in the Tiber ;
the usual appendages of priests, with all their
ceremonies, were appointed ; and the plague was
of course suspended. ||

Pliny further informs us that medicine was in-
troduced into Rome at a later period than most of
the other arts and sciences ; that the practice of it
had even been expressly prohibited by the citizens,
and its professors banished. The account which
he gives of so singular an occurrence is, that
about two hundred years before Christ, Archaga-
thus, a Peloponnesian, settled at Rome as a prac-
titioner of medicine, and, as it may be inferred,
was the first person who made it a distinct profes-
sion. He was received in the first instance with
great respect, and was even maintained at the
public expense ; but his practice was observed to
be so severe and unsuccessful, that he soon excited
the dislike of the people at large, and produced a
complete disgust to the profession generally, which
led to the transaction mentioned above.! His
practice seems to have been almost exclusively
surgical, and to have consisted, in a great measure,
in the use of the knife and of powerful caustic
applications. We hear little more of the state of
medicine in Rome for the next century ; but from
certain incidental observations we may infer that
it remained principally in the hands of the priests,
and consisted as before in superstitious rites and
ceremonies. It appears, indeed, that the few in-
dividuals who devoted themselves to the cultiva-
tion of natural science, among other subjects di-
rected their attention to medicine ; and it is par-
ticularly stated that Cato introduced various arti-
cles into the materia medica, and wrote several
treatises on medical topics. We are not able to
form any just conception of their merit from the
account which is given of them ; but it is worthy
of remark that he was a professed opponent to
Grecian literature in general, and we may there-
fore conclude, would not avail himself of the im-
provements that had been made by the Greek
physicians.**

§ The following references may be selected aimiii«
many others of a similar kind .-—Book i. ch 31 Tullus
consults the Sibylline books in order to stop the plague :
—iv .5, tor the same purpose a temple was erected to
Apollo ;-v. 1.), the books were again consulted ;— vii. -J.
a lectistenunm was ordered for the same purpose, and
afterwards the public games ;-vij. 3, the plague was
stopped by the dictator driving a nail.
J| Livitis, lib. x. cap. 47, et epitome ad lib. xi. Val.
Maxxmns, lib. i. cap. 8, § L'. Schuh, p. ii. cap. fi, sect. 4, et
*<;(]■ Montfaucon, Antiq. Supp)., v.i. b. v. ch. 1. Lucianus,
looke s 1'rans. v. i. p. 635, note.

IT Lib. xxix. rap. 1.

** Clerc, pars ii. liv. iii. ch. 1. Scltulz, p. ii.cap.6. Ack-
ermann, p. iv. cap. 15.

192

MEDICINE, (HISTORY OF)

We may presume that the prejudice which was
excited against Archagathua would be gradually
allayed, and that the improvement of the Romans
in intellectual cultivation, although not considera-
ble, would be at least sufficient to make them sen-
sible of the necessity of attempting something
beyond the mere power of charms and incanta-
tions for the removal of disease. Accordingly,
about a century before the Christian sera, we iind
that another individual had acquired a very con-
siderable degree of popularity at Rome which he
maintained through life, and in a certain degree
transmitted to his successors, — Asclepiades of By-
thinia. It is said that he first came to Rome as a
teacher of rhetoric, and that it was in consequence
of his not being successful in this profession, that
he turned his attention to the study of medicine.
From what we learn of his history and of his
practice, it would appear that he may be fairly
characterized as a man of natural talents, ac-
quainted with human nature, or rather with hu-
man weakness, and possessed of considerable
shrewdness and address, but with little science or
professional skill. He began upon the plan which
is so generally found successful by those who are
conscious of their own ignorance, by vilifying the
principles and practice of his predecessors, and by
asserting that he had discovered a more compen-
dious and effective mode of treating diseases than
had been before known to the world. As he was
ignorant of anatomy and pathology, he decried
the labours of those who sought to investigate the
structure of the body, or to watch the phenomena
of disease, and he is said to have directed his at-
tacks more particularly against the writings of
Hippocrates. It appears, however, that he had
the discretion to refrain from the use of very ac-
tive and powerful remedies, and to trust principally
to the efficacy of diet, exercise, bathing, and other
circumstances of this nature. A part of the
great popularity which he enjoyed depended upon
his prescribing the liberal use of wine to his pa-
tients, and upon his attending in all cases, with
great assiduity, not only to every thing which
contributed to their comfort, but that he flattered
their prejudices and indulged their inclinations.
By the due application of these means, and from
the state of the people among whom he practised,
we may, without much difficulty, account for the
great eminence to which he arrived, and we can-
not fail to recognise in Asclepiades the prototype
of more than one popular physician of modern
times.

Justice, however, obliges us to admit that he
seems to have been possessed of a considerable
share of acuteness and discernment, which on
some occasions he employed with advantage. It
is said that to him we are indebted, in the first
instance, for the arrangement of diseases into the
two great classes of acute and chronic, a division
which has a real foundation in nature, and which
still forms an important feature in the most im-
proved modern nosology. In his philosophical
principles Asclepiades is said to have been a fol-
lower of Epicurus, and to have adopted his doc-
trine of atoms and pores, on which he attempted
to build a new theory of disease, by supposing
that all morbid action might be reduced into ob-
struction of the pores and irregular distribution

of the atoms. This theory he accommodated to
his division of diseases, the acute being supposed
to depend essentially upon a constriction of the
pores, or an obstruction of them by a superfluity
of atoms ; the chronic, upon a relaxation of the
pores, or a deficiency of the atoms.*

Asclepiades was succeeded in his professional
reputation by his pupil Themison of Laodicea,
who had the honour of founding a new sect in
medicine, which for some time almost eclipsed
the former rivals ; this was the Methodic sect.
The great object of Themison seems to have been
to adopt a middle course between the Dogmatists
and the Empirics, and to take advantage of the
excellencies of each of them. He was, however,
strongly impressed with the great principle of
Asclepiades, the importance of reducing the sci-
ence to a few general laws, which by their simpli-
city might be universally intelligible and of easy
application. He therefore rejected all the abstruse
and recondite speculations of the Dogmatists, and
substituted in their place a few positions derived
from the tenets of his master, and founded upon
the Epicurean doctrines. He remarks that it is
an essential part of the business of the practitioner
to make himself acquainted with the nature of the
human frame, with its laws while in the state of
health, and with the changes which they experi-
ence from disease. All these he referred to the
respective states of constriction and relaxation,
and to the undue preponderance of one of them
over the other. To these two, however, he added
a third, or mixed state as he styled it, the nature
of which is not very easy to understand ; while by
classing all medical agents under the two great
divisions of astringents and relaxants, we learn
how to apply the appropriate remedy for every
disease.

Themison's doctrine must be regarded as a re-
finement, and certainly an improvement of that
of Asclepiades ; for although we have the states
of constriction and relaxation professedly copied
from his master, it is disencumbered of the more
objectionable speculation of the atoms and pores.
The theory of the Methodics contemplates the
solids as the seat and cause of disease, in which
respect it is directly opposed to that of Hippocrates,
who traced the primary cause of disease to an
affection of the fluids, giving rise to what has been
termed the Humoral Pathology. The humoral
pathology was zealously defended by Galen, and
was universally adopted by his successors until
the seventeenth century, when the opposite doc-
trine of solidism was revived, and has been gain-
ing ground until the present day. It has been
justly objected to Themison's theory, that even
if we admit the correctness of his views respecting
the states of constriction and relaxation of the sys-
tem, there is a palpable absurdity in supposing
that they can be coexistent in what he terms his
middle state, as they are directly opposed to each
other.

There is no work of Themison's extant, but we
have an ample account of his practice in the writ-
ings of Cajlius Aurelianus, who was a zealous

>ar/H n Hv ^ua S^?*' uhi su P ra et alibi - CleTC '
■ in. ch. 4-9. Sprengel, sect.S.eh. ]. Caba-
5. Gouhn, Encyc. Meth., " Medeciw

Chaussier et Melon, in Bioe. Univ.,

nis, ch. -, sect.
Asclepiade."
Asclepiade."

MEDICINE, (HISTORY OF)

103

defender of the tenets of the Methodic sect. They
appear to have been diligent in the observation
of the phenomena of disease, and sagacious in
their employment of remedies ; they seem, indeed,
to have sustained their character of keeping a mid-
dle course between the Dogmatists and Empirics,
avoiding the extremes of either, and combining
the more useful parts of each system in a greater
degree than had been done by their predecessors.
(Celsus, in praf. Clerc, p. ii. liv. iv. sect. 1, ch.
1. Barchusen, Diss. 11. Sprengel, t. ii. p. 20-3.
Acker mann, per. iv. ch. 17.)

For some time after the death of Themison, the
opinions of the Methodics were generally adopted
in Home, and almost superseded those of the pro-
fessed Dogmatists and Empirics, so that we shall
have little to detain us in our progress, except to
notice certain individuals who became remarkable
from their personal history or character, or from
some peculiarity in their opinions or practice.
The first of this description in point of time is
Thessalus, who lived about half a century after
Themison, and who ranks as one of his followers.
He was, however, an individual very different,
both in character and in acquirements, from his
master. He is stated to have been of mean birth
and of defective education, but by cunning and
artifice to have acquired great wealth and a high
reputation. He began his career, in (he usual
mode of ignorance and self-sufficiency, by endea-
vouring to throw contempt on all his predecessors
and contemporaries, by pretending to expose their
errors, and by claiming to himself the discovery
of a new theory of medicine, which should lead to
more correct practice, and should supersede all
farther attempts of the kind ; in fine, he assumed
to himself the pompous title of the conqueror of
physicians (larpovuccf).*

We shall not have occasion to dwell long upon
one who is so unworthy of a place in the records
of science ; it is only necessary to remark con-
cerning him, that he appears to have united the
speculations of Asclepiades with those of Themi-
son, and to have admitted the atoms and pores of
the one, with the constriction and relaxation of
the other. The only addition which Thessalus
made to medical theory which deserves notice, is
the introduction of what he terms metasyncrasis,
or the method of producing an entire change in
the state of the body. This he opposed to the
practice of Hippocrates, who professed to watch
over and regulate the actions of the system, as
well to that of the Empirics, whose aim was to
correct specific morbid actions, or to remove parti-
cular morbid symptoms. The term, as conveying
a conceivable, if not an actual occurrence, was not
without its value, and was generally adopted by
medical writers ; and even in the present day the
principle implied in it serves as the foundation for
some of our most important indications. {Clerc,
p. ii. liv. iv. sect. 1, ch. 2, 3. Sprengel, t. ii. p.
28-31.)

The name of Soranus next occurs among the

* Pltnius, lib. xxvii. cap. 1.— We have an amusing,
and probably a correct account, given us by Lucian, of
the successful knavery practised by an impostor of his
aire, named Alexander ; see Tooke's Trans., vi. p. 630 et
leq. He appears to have been a worthy successor of
Thessalus, so far as respects his arrogance and presump-
tion.

Vol.111 25 b

celebrated Roman practitioners. There is, in-
deed, some reason for supposing that there were
no less than three physicians of this name, but the
one who is most eminent appears to have been a
native of Ephesus, to have studied at Alexandria,
and finally to have settled in Rome. He was a
strict Methodic, and is said to have been highly
respected for his character and talents. His writ-
ings have not been transmitted to us, but probably
the most valuable information which they contain
is handed down to us by C. Aurelianus, whose
work, if not, as some have supposed, a translation
of Soranus's treatise, proceeds upon the same prin-
ciples, and inculcates the same practice. (Clerc,
p. ii. liv. iv. sect. 1, ch. 4. Sprengel, t. ii. p. 33-35.)

There is considerable uncertainty respecting
both the age and the country of C. Aurelianus.
Some writers place him as early as the first cen-
tury of the Christian tera, while others endeavour
to prove that he was at least a century later. This
opinion is principally founded upon the circum-
stance of his not mentioning or being mentioned
by Galen, indicating that they were contempora-
ries or rivals. Numidia has been generally assigned
as his native country, but perhaps without any
direct evidence ; it may, however, be concluded
from the imperfection of his style and the incor-
rectness of some of the terms which he employs,
that he was not a native either of Greece or of
Italy. But whatever doubts may attach to his
personal history, and whatever defects exist in his
writings, they afford us much valuable information
respecting the state of medical science. He was
a professed and zealous Methodic, and it is princi-
pally from his work that we are able to obtain a
correct view of the principles and practice of this
sect. In his descriptions of the phenomena of
disease, he displays considerable accuracy of ob-
servation and diagnostic sagacity; and he describes
some diseases which are not to be met with in any
other ancient author. He gives us a very ample
and minute detail of the practice which was
adopted both by himself and his contemporaries ■
and it must be acknowledged that on these points
his remarks display a competent knowledge of his
subject, united to a clear and comprehensive judg-
ment.

He divides diseases into the two great classes
of acute and chronic, nearly corresponding to dis-
eases of constriction and of relaxation, and upon
these supposed states he founds his primary indi-
cations ; but with respect to the intimate nature
of these states of the system, as well as of all
hidden or recondite causes generally, he thinks it
unnecessary to inquire, provided we can recognise
their existence, and can discover the means of re-
moving them. Hence his writings are less theo-
retical and more decidedly practical than those of
any other author of antiquity; and they conse-
quently contributed more to the advancement of
the knowledge and actual treatment of disease
than any that had preceded them. They contri-
buted in an especial manner to perfect the know-
ledge of therapeutics, by ascertaining with preci-
sion the proper indications of cure with the means
best adapted for fulfilling them. The great defect
of C. Aurelianus, a defect which was inherent in
the sect to which he belonged, was that of placing
too much dependence upon the two-fold division

194

MEDICINE, (HISTORY OF)

of diseases, ami not sufficiently attending to the
minute shades by which they gradually run into
each other ; a defect the more remarkable in one
who shows so much attention to the phenomena of
disease, and who for the most part allows himself
to be so little warped by preconceived hypothesis.
This view of the subject leads him not (infrequently
to reject active and decisive remedies, when he
could not reconcile their operation to his supposed
indications ; so that, although his practice is seldom
what can be styled bad, it is occasionally defective.

There were two points in which C. Aurelianus,
and the Methodics generally, decidedly opposed
the doctrines and practice of the followers of Hip-
pocrates, in trusting the removal of disease to the
restorative powers of nature, and in attributing
diseases to the excess or defect of particular hu-
mours. With respect to the former point, they
conceived that it was as frequently necessary to
oppose as to promote the natural actions of the
system ; and with respect to the latter, they did
not admit the existence of the supposed four
humours ; and, even if their existence could be
proved, they did not conceive that they were in
possession of the means of acting upon them in-
dividually or specifically.

In the treatment of acute diseases, or those of
constriction, the cure was effected by topical bleed-
ing, (for general bleeding was rarely admitted,)
and by narcotic and oleaginous applications, aided
by a pure and sometimes by a moist air. Absti-
nence was strictly enjoined, and indeed often car-
ried to an undue length ; and in the administra-
tion of all remedies the practitioner was frequently
guided by critical periods, generally of three, or
in other cases of seven days. When the ordinary
means of cure were found not to be successful, or
when any circumstance occurred which appeared
to contradict their application, C. Aurelianus had
recourse to a preparatory system. This consisted
principally in certain regulations regarding diet
and exercise, in the use of the bath, frictions, and
other external applications ; when the system was
thus prepared, the ordinary plan of treatment was
had recourse to. Inflammatory diseases were
supposed to depend upon constriction ; abstinence,
rest, and friction were enjoined in the first instance;
bleeding general and local, baths, and certain ve-
getable preparations were then administered, while
purgatives seem to have been seldom if ever em-
ployed. Little regard appears to have been paid
to particular symptoms, and upon the whole we
should be disposed to consider the practice as de-
ficient in promptness and vigour, and not very
unlike that which prevails at this day in many
parts of the continent. We have mentioned
above that C. Aurelianus seldom employed purga-
tives, — an unfortunate prejudice, by which he de-
prived himself of one of the most useful agents in
the cure of disease ; he also generally condemns
the use of what are termed specifics, an error, if
it be one, much more venial : he very sparingly
employs diuretics, condemns narcotics, and rejects
caustics and all similar applications.*

Although the Methodic sect continued to pre-

* Vide Opus, de Morb. Acut. ct Chron. Qlerc, p. ii. Hv.
iv. sect. 1, ch. 5-11 ; we have in this anther a very ample
account of the principles and practice of the Methodics.
Barchusen, Diss. 11, § 5. Haller, Bib. Med. § 72. Sprengel,
l. ii. p. 37 et. seq. Eloy, iu loco. Biog. Univ. in loco.

vail among the Poman physicians during the
greatest part of the two first centuries of the
Christian .-era, some alteration in the original tenets
of Themison were gradually introduced, and it at
length became subdivided into several minor sects
or schools, which, although agreeing in certain
fundamental principles, had each their peculiar
views, which led to their separation from the main
body, and to the adoption of specific appellations.
Two of these were of sufficient notoriety to re-
quire being individually mentioned in this sketch,

the Pneumatics, and the Eclectics or Episyn-

thetics.

The Pneumatics rose into notice about half a
century after the death of Themison. They de-
rive their appellation from the circumstance of
their having introduced into their pathology the
agency of what is termed the spirits (-vtvpa),
which, together with the solids and the fluids,
compose the corporeal frame. It would be some-
what difficult to state, in a few words, to what
supposed substance or power the term was applied;
we may observe in it some traces of the pneumatic
physiology of the modern chemists, while in some
of its agencies it resembles the nervous influence.
This sect has acquired considerable celebrity from
the name of an eminent medical writer, which has
been generally attached to it, that of Areta;us.

There is some uncertainty respecting both the
age and the country of Aretaeus; but it seems
probable that he practised in the reign of Vespa-
sian, and he is generally styled the Cappadocian.
He wrote a general treatise on diseases, which is
still extant, and is certainly one of the most valu-
able reliques of antiquity, displaying great accu-
racy in the detail of symptoms, and in seizing the
diagnostic character of diseases. In his practice
he follows for the most part the method of Hippo-
crates, but he paid less attention to what have been
styled the natural actions of the system ; and,
contrary to the practice of the Father of medicine,
he did not hesitate to attempt to counteract them
when they appeared to him to be injurious. The
account which he gives of his treatment of various
diseases indicates a simple and sagacious system,
and one of more energy than that of the professed
Methodics. Thus he freely administered active
purgatives ; he did not object to narcotics ; he was
much less averse to bleeding ; and upon the whole
his materia medica was both ample and efficient
It may be asserted generally, that there are few of
the ancient physicians, since the time of Hippo-
crates, who appear to have been less biassed by
attachment to any peculiar set of opinions, and
whose account of the phenomena and treatment
of disease has better stood the test of subsequent
experience. We have placed Aretaaus among the
Pneumatics, because he maintained the doctrines
which are peculiar to this sect, and because he is
generally considered as such by most systematic
writers, although perhaps, strictly speaking, he is
better entitled to be placed with the Eclectics.f

Of the sect of the Eclectics we know little ex-
cept through the medium of the writings of their
opponents. The most celebrated of them was

f Clerc p ii. Hv. iv . sectTT^hTa, 3. Barchusen, Diss.
15, p. 2J2 et seq. llaller, Bib. Med. § G4. Eloy, ill loco.
Goultn, Encyc, Method. Medecine, t. hi. p. 385 et seq.
Sprengel l. „. p. 82-7. Chiussier ct Adeh*, Biog. Univ.

MEDICINE, (HISTORY OF)

195

Archigenes of Apamea, who practised at Rome in
the time of Trajan, and enjoyed a very high re-
putation for his professional skill. He is, however,
reprobated as having been fond of introducing new
and obscure terms into the science, and having
attempted to give to medical writings a dialectic
form, which produced rather the appearance than
the reality of accuracy. Archigenes published a
treatise on the pulse, on which Galen has written
a commentary; it appears to have contained a
number of minute and subtile distinctions, many
of which we may venture to affirm have no real
existence, and to have been for the most part the
result rather of a preconceived hypothesis than of
actual observation ; and the same remark may be
applied to an arrangement which he proposed of
fevers. He, however, not only enjoyed a con-
siderable degree of the public confidence during
his life-time, but left behind him a number of dis-
ciples, who for many years maintained a respect-
able rank in their profession. (Clerc, p. ii. liv.
iv. sect. 2, ch. 1. Barchusen, Diss. 15, p. 240 et
seq. Sprengel, t. ii. p. 75-82.)

It may appear singular that we have so many
instances of individuals who have risen to great
eminence, both from their professional skill and
general science, but of whose private history we
possess so little information. This is very re-
markably the case with Celsus. We know little
either of his age, his origin, or even of his actual
profession. There are some incidental expressions
which lead to the conjecture that he lived under
the reigns of Augustus and Tiberius, and particu-
larly the mode in which he refers to Themison
would indicate that they were either contempora-
ries, or that Themison preceded him by a short
period only. With respect to the country of Cel-
sus, we have nothing on which to ground our
opinion, except the purity of his style, which at
most would prove no more than that he had been
educated and passed a considerable part of his life
at Rome.

With regard to his profession, there is some
reason to doubt whether he was a practitioner of
medicine, or whether he only studied it as a
branch of general science, after the manner of
some of the ancient Greek philosophers. This
doubt has arisen principally from the mode in
which he is referred to by Columella (De Re
Rust. lib. vi. cap. 5) and by Quintilian, (Lib. xii.
cap. 11,) and by his not being enumerated by
Pliny among the physicians of Rome in his sketch
of the history of medicine. Yet, on the other
hand, it appears to us that his work bears very
strong evidence that he was an actual practitioner,
that he was familiar with the phenomena of dis-
ease and the operation of remedies, and that he
described and recommended what fell under his
own observation, and was sanctioned by his own
experience ; so that we conceive it, upon the
whole, most probable that he was a physician by
profession, but who devoted part of his time and
attention to the cultivation of literature and gene-
ral science.

The treatise of Celsus " On Medicine" is divided
into eight books. It commences by a judicious
sketch of the history of medicine, terminating by
the comparison of the two rival sects, the Dogma-
tists and the Empirics, which has been referred to

above. The two next books are principally occu-
pied by the consideration of diet, and the general
principles of therapeutics and pathology : the re-
maining books are devoted to the consideration of
particular diseases and their treatment, the third
and fourth to internal diseases, the fifth and sixth
to external diseases and to pharmaceutical prepa-
rations, and the two last to those diseases which
more particularly belong to surgery. In the treat-
ment of disease, he for the most part pursues the
method of Asclepiades ; he is not, however, ser-
vilely attached to him, and never hesitates to
adopt any practice or opinion, however contrary
to his, which he conceived to be sanctioned by
direct experience. He adopted to a certain extent
the Hippocratean method of observing and watch-
ing over the operations of nature, and rather
regulating than opposing them ; a method which,
with respect to acute diseases, may frequently
appear inert. But there are occasions on which
he displays considerable decision and boldness,
and particularly in the use of the lancet, which
he employed with more freedom than any of his
predecessors. His regulations for the employment
of bloodletting and of purgatives are laid down
with minuteness and precision ; and although he
was in some measure led astray by his hypothesis
of the crudity and concoction of the humours, the
rules which he prescribed were not very different
from those which were generally adopted in the
commencement of the present century. His de-
scription of the symptoms of fever, and of the
different varieties which it assumes, either from
the nature of the epidemic, or from the circum-
stances under which it takes place, are correct and
judicious ; his practice was founded upon the
principle so often referred to, of watching the
operations of nature, conceiving that fever consists
essentially in an effort of the constitution to throw
off some morbid cause, and that, if not unduly
interfered with, the process would terminate in a
state of health. We here see the germ of the
doctrine of the vis medicatrix naturse, which has
had so much influence over the practice of the
most enlightened physicians of modern times, and
which, although erroneous, has perhaps led to a
less hazardous practice than the hypotheses which
have been substituted in its room.

But perhaps the most curious and interesting
parts of the work of Celsus are those which treat
of surgery arid surgical operations. It is very
remarkable that he is almost the first writer who
professedly treats on these topics, and yet his de-
scriptions of the diseases and of their treatment
prove that the art had attained to a very consider-
able degree of perfection. Many of what are
termed the capital operations seem to have been
well understood and frequently practised, and we
may safely assert that the state of surgery at the
time when Celsus wrote, was comparatively much
more advanced than that of medicine. The
Pharmacy of Celsus forms another curious and
interesting part of his work, and, like his surgery,
marks a state of considerable improvement in this
branch of the art. Many of his formulae are well
arranged and efficacious, and on the whole thev
may be said to be more correct and even more
scientific than the multifarious compounds which
were afterwards introduced into practice, and

196

MEDICINE, (HISTORY OF)

which were not completely discarded until our
own times.*

There is one circumstance respecting Celsus
which requires to be noticed — that he is the first
native Roman physician whose name has been
transmitted to us. Before his time all those who
arrived at any degree of eminence were either
Greeks or Asiatics, and it would appear that the
native practitioners were either slaves or persons
from the lower ranks of life, who acted in the
subordinate branches of the profession.-)- This
circumstance may be attributed partly to the low
state of science in Rome, even during the period
when literature had advanced to considerable emi-
nence, and still more to the idea of degradation or
servility which seems to have been attached to the
exercise of any art or profession for the sake of
gain. All the trades and manufactures of Rome
were therefore carried on by slaves, and medicine
seems to have been placed in the same class. It
must, however, be observed that many individuals
who were brought to Rome as slaves, either by
their natural talents or by some favourable con-
juncture of circumstances, overcame the disadvan-
tages of their situation, and made considerable
acquirements in different departments of know-
ledge, and among others in that of medicine.
One of the most celebrated of these is Antonius
Musa, who was appointed physician to Augustus,
and obtained great celebrity from his practical
skill : we are told that he was a pupil of Themi-
son, and it appears that he remained attached to
the Methodic sect. (Haller, Bib. Med. t. i. p.
150, 1. Eluy, in loco. Aikin's Gen. Biog. in
loco.)

Before we close this part of our history, it will
be necessary to take some notice of a class of
writers, whose names or works are transmitted to
us, who particularly devoted themselves to the
improvement of pharmacy. The first of these
was Scribonius Largus, who flourished in the
reign of Claudius. He appears to have been, like
Musa, originally a slave, and it may be conjec-
tured from his work " On the Composition of
Medicines," which has been transmitted to us,
that he was never able to supply the deficiency of
his education. It is a mere collection of nostrums
and formula.:, without arrangement or discrimina-
tion, and is solely valuable as indicating the state
of the art at the time of its publication. (Haller,
Bib. Bot. t. i. p. 76, 7, and Bib. Med. lib. i. § 51,
t. i. p. 166, 7. Eloy, in loco. Sprengel, t. ii. p.
55.)

Andromachus, a native of Crete, who lived
under the reign of Nero, is principally known to
posterity as the inventor of certain compounded
pharmaceutical preparations, one of which, the
theriaca, obtained so much celebrity as to have
been retained in our pharmacopoeia until the close
of the last century. It was composed of no less
than sixty-one ingredients, which were combined

*Clerc, par. 2, liv. iv. sect. 2, ch. 4, 5. Barchusen, d\i, a .
15, p. 231, 2. Morgagni, Epistolffi in Celsum. Haller,
^Jib. Med. t. i. § 49. Eloy in loco. Nouv. Diet. Hist, in
oco. Sprengel, t. ii. p. 25-8. Black's Hist, of Medicine,
i. 63-83. Goulin, Encyc. Mctli. " Medecine," in loco.

~ ... r* J.J It: IT.,;.. .i Pnl^n "

Medecine," in loco.
Petit-Radel, Biog. Univ. "Uelse."

t Clerc, par. 3, liv. i. ch. 2. The coudition of the prac-
titioners of medicine i n Rome was the subject of a learned
controversy between Mead and Middleton ; see Life of
Mead, prefixed to his works, v. i. p. 13, Edin. 1765, and
Aikin's Gen. Biog. art. " Middleton."

together with much ceremony and no inconsidera-
ble degree of labour and skill. Its essential ingre-
dient,°from which it derived its name, was t| lc
dried flesh of vipers, against the bites of which
animals it was supposed to be an antidote. But
its supposed medical virtues were equal to the
number of articles of which it consisted, so that
there was scarcely a disease for which the theriaca
of Andromachus has not been proposed as a
remedy. Andromachus is further remarkable as
being the first individual on whom the title of
Archiater, or principal physician, was bestowed
by the emperors, a title which was continued for
several centuries. (Clerc, par. 3, liv. ii. ch. 1.
Eloy, in loco. Haller, Bib. Med. lib. i. § 56, t, i.
p. 178, 9.)

We have next to notice an author of just ce-
lebrity, whose writings form one of the most val-
uable remains of antiquity — Pliny the naturalist.
Although not attached to the medical profession,
and even, as appears from many of his remarks,
by no means favourably disposed to it, in various
parts of his great work he affords us much impor-
tant information, both direct and indirect, respect-
ing the history of medicine in all its branches, and
more especially in all that concerns materia medica
and pharmacy. + We meet with a great number
of curious facts and remarks upon these subjects,
so that we are enabled from them to form a tolera-
bly complete conception of the state of medical
science in the age in which he wrote. We learn
from his works that the ordinary practice was in a
considerable degree what may be termed empirical,
consisting in the application of certain remedies
for certain diseases, without any inquiry into their
mode of operation. The materia medica, which
was extensive, consisted principally of vegetable
products, and these combined together in various
forms, but without any regard to what we should
now regard as scientific principles, either chemical
or pharmaceutical. We find that they possessed
various active remedies, adapted for the greatest
part of the most important indications, so far as
they could be obtained from vegetable or animal
substances, but that in the application of them
they frequently proceeded upon incorrect princi-
ples.

Another writer who lived about the same time
with Pliny, and who, although less distinguished
for general science, holds a conspicuous rank
among the medical authors of this period, is
Dioscorides. The same obscurity hangs over every
thing which regards the personal history of Dio-
scorides as over that of so many individuals to
whom we have had occasion to refer. It was ge-
nerally supposed that he was a native of Asia
Minor, and that he was a physician by profession.
It appears pretty evident that he lived in the se-
cond century of the Christian era, and as he is
not mentioned by Pliny, it has been supposed
that he was a little posterior to him. The exact
age of Dioscorides has, however, been a question

J The late illustrious naturalist Cuvier has formed
what we conceive to be a very just ami candid estimate
of the literary and philosophical character of Pliny,
Bibl. Univ. t. xxxv. in loco; the same inserted into the
translation of Pliny by M. Ai. de Or.m.u™,,,. t i n.

MEDICINE, (HISTORY OF)

197

of much critical discussion, and we have nothing
but conjecture which can lead us to decide upon
it. He has left behind him a treatise on the ma-
teria medica, a work of great labour and research,
and which for many ages was received as a stand-
ard production. The greater correctness of modern
science, and the new discoveries which have been
made, cause it now to be regarded rather as a work
of curiosity than of absolute utility ; but in draw-
ing up a history of the state and progress of me-
dicine, it affords a most valuable document for our
information. His treatment consists of a descrip-
tion of all the articles then used in medicine, with
an account of their supposed virtues. The de-
scriptions are brief, and not unfrequently so little
characterized as not to enable us to ascertain with
any degree of accuracy to what they refer, while
to the practical part of his work the same remark
nearly applies that was made above with respect
to Pliny, that it is in a great measure empirical,
although his general principles, so far as they can
be detected, appear to be those of the Dogmatic
sect. The great importance which was for so
long a period attached to the works of Dioscorides,
has rendered them the subject of almost innume-
rable commentaries and criticisms, and even some
of the most learned of our modern naturalists
have not thought it an unworthy task to attempt
the illustration of his Materia Medica. Upon the
whole we must attribute to him the merit of
great industry and patient research, and it seems
but just to ascribe a large portion of the errors
and inaccuracies into which he has fallen, more
to the imperfect state of science when he wrote,
than to any defect in the character and talents of
the writer.*

CHAPTER "V. — Account of the opinions and
practice of Galen — History and Education of
Galen — Remarks on his character and 'writings
— His physiology, anatomy, pathology, and
practice.

The course of our narrative brings us to one of
those extraordinary characters who are destined
to form an sera in the history of science, both
from the actual improvements which they have in-
troduced into it, and from the ascendency which
their genius enabled them to acquire over the
minds of their contemporaries. Of these, one of
the most remarkable that ever appeared either in
ancient or in modern times, is Galen. Galen en-
joyed both from birth and from education every
natural and acquired advantage; his father was a
man of rank, and his education appears to have
been conducted upon the most liberal and judi-
cious plan. He studied philosophy in the various
schools that were then in the highest estimation,
and without exclusively attaching himself to any
one of them, he is said to have taken from each
what he conceived to be the most important parts
of their systems, with the exception of the Epicu-
rean, the tenets of which he entirely rejected.
His professional studies were conducted upon an
equally extensive plan ; he attended the various

* Clcrc, par. 3, liv. ii. cli. 2. Eloy, in loco, where we
have an account of the various editions, comments,
translations. &r. Sprengcl, t. ii. p. 58-04. Jlckermanu,
p. 4, cap. 1!). Hallcr, Bib. Hot. t. i. p. 79-87. Goulin,
Encyc. Meth. Medecine, " Dioscoride." Du- Petit- Thou-
ars, iiiog. Univ. in loco.

schools and travelled through different countries
for the express purpose of acquiring information,
but it may be presumed that his knowledge of
medicine was principally acquired at Alexandria,
which still retained its character as the great de-
pository of medical science. After passing a few
years at his native city of Pergamus, spending
some time at Rome, and again at Pergamus, he
finally returned to Rome in consequence of the
express request of the Emperor Aurelius, and
made that city his residence for the remainder of
his life.

The works which Galen left behind him are
very numerous, amounting in the whole to about
two hundred distinct treatises ; they are all on
subjects directly or indirectly connected with me-
dicine, and exhibit a great extent of knowledge on
the subjects of which he treats, and a degree of
information, as far as we can judge, greater than
that of any of his contemporaries. He appears
also to have been a man of a superior mind and
of a very decided character ; confident in his own
powers, and paying but little attention to the
opinions of others. Hence he may be accused of
arrogance and of want of candour, and he can
only be defended upon the principle that he was
so far in advance of his contemporaries as to be
fully convinced of the futility of their reasoning
and the deficiency of their information. The re-
sult was that he gained that superiority over his
contemporaries which he assumed, and actually
acquired a sway over public opinion on all points
connected with medicine which has never been
obtained by any individual either before or since
his time. The rank which Galen held in the
medical world has been compared not unaptly to
that which Aristotle possessed in the world of
general science. For centuries after his death his
doctrines and tenets were regarded almost in the
light of oracles, which few persons had the cou-
rage to oppose ; and all the improvements in me-
dicine which were even contemplated, consisted
of little more than illustrations of his doctrines or
commentaries on his writings. In numberless
instances it was deemed a sufficient argument,
not merely against an hypothesis, but even against
an alleged matter of fact, that it was contrary to
the opinion of Galen ; and it may be stated with-
out exaggeration that the authority of Galen alone
was estimated at a much higher rate than that of
all the medical writers combined who flourished
during a period of more than twelve centuries.

Although such a brilliant reputation might in
some measure depend upon accidental circum-
stances and upon the mere personal character of
the individual, we may fairly presume that there
must have been a foundation of a more solid na-
ture ; and upon an actual survey of the writings
of Galen, we shall find ample reason to conclude
that he was a man of great talents and of very
extensive acquirements. In his general principles
he may be considered as belonging to the Dog-
matic sect, for his method was to reduce all his
knowledge, as acquired by the observation of
facts, to general theoretical principles. These
principles he indeed professed to deduce from ex
perience and observation, and we have abundant
proofs of his diligence in collecting experience,
and his accuracy in making observations. But

198

MEDICINE, (HISTORY OF)

still, in a certain sense at least, he regards indi-
vidual facts and the detail of experience as of little
value, unconnected with the principles which he
laid down as the basis of all medical reasoning.
In this fundamental point, therefore, the method
pursued by Galen appears to have been directly
the reverse of that which we now consider as the
correct method of scientific investigation, and yet
such is the force of natural genius, that in most
instances he attained the ultimate object in view,
although by an indirect path. He was an admirer
of Hippocrates, and always speaks of him with
the most profound respect, professing to act upon
his principles, and to do little more than to ex-
pound his doctrines and support them by new facts
and observations. Yet in reality we have few
writers whose works, both as to substance and
manner, are more different from each other than
those of Hippocrates and Galen, the simplicity of
the former being strongly contrasted with the
abstruseness and refinement of the latter. Those
of his works which are the most truly valuable,
and in which he actually rendered the greatest
service to science, are his treatises on physiology.
The knowledge which he possessed on this sub-
ject was much more considerable than that of
any of his contemporaries ; in all that regards the
operations of the animal economy he was much
better acquainted with the facts, and much more
ingenious in the application of them. He appears
to have been well practised in anatomy, and es-
pecially in what may be termed pathological
anatomy he far surpassed any of the ancients.
His knowledge of particular structures was in
many respects correct, and in his mode of classi-
fying them he made no inconsiderable approach
to the philosophical views which have been taken
of them by the anatomists of the present day. It
appears upon the whole probable that he was not
in the habit of dissecting the human subject, and,
indeed, this may be fairly inferred from his own
remarks ; but there is reason to suppose that he
omitted no opportunity of examining the structure
of those animals which the most nearly resemble
it, and that from them he has drawn up his de-
scriptions. Considering this radical defect, it
must be admitted that they possess great merit,
and we may justly express our surprise at the few
points in which they betray the imperfections of
their origin. (Douglas, Bibliog. p. 18-22.)

The pathology of Galen was much more im-
perfect than his physiology, for in this department
he was left to follow the bent of his speculative
genius almost without control. He adopts, as the
foundation of his theory, the doctrine of the four
elements, and, like Hippocrates, he supposes that
the fluids are the primary seat of disease. But
in his application of this doctrine he introduced
so many minute subdivisions and so much refined
speculation, that he may be regarded as the in-
ventor of the theory of the Humoralists, which
was so generally adopted in the schools of medi-
cine, and which for so long a period entirely en-
grossed their attention. The four elements, the
four humours, and the four qualities, connected in
all the variety of combinations, presented a spe-
cious appearance of method and arrangement,
which took such firm possession of the mind as
to preclude all inquiry into the validity of the

foundation, and to present us with one of the
most remarkable examples of the complete pros-
tration of the understanding in a physical science,
where facts were daily obtruding themselves upon
observation, but were either unnoticed or totally
disregarded.

The practice of Galen in its general character
appears to have been similar to his pathology,
and, indeed, to have been strictly deduced from
it. His indications were in exact conformity to
his theory, and the operation of medicines was
reduced to their power of correcting the morbid
states of the fluids, as depending upon their four
primary qualities or the various modifications of
them. Many parts of his writings prove that he
was a diligent observer of the phenomena of dis-
ease, and he possessed an acuteness of mind
which well adapted him for seizing the most
prominent features of a case, and tracing out the
origin of the morbid affection. But his predilec-
tion for theory too frequently warped and biassed
his judgment, so that he appears more anxious to
reconcile his practice to his hypothesis than to his
facts, and bestows much more labour on subtile
and refined reasoning than on the investigation
of morbid actions or the generalization of his
actual experience.

The number of treatises which Galen left be-
hind him is very considerable, amounting to
nearly two hundred separate works, embracing
every department of medical science. His style
is generally elegant but diffuse, and as may be
imagined from the multiplicity of his works, he
frequently repeats and copies from himself. Con-
sidered under the two classes of anatomy and
physiology, and of pathology and practice, the
following may, perhaps, be selected as the most
valuable, both with respect to the absolute addi-
tion which they made to the previous stock of
knowledge, and as to the reasoning employed in
them. Under the first head we may select the
treatise « On the Use of the Parts of the Body,"
in seventeen books, in which he describes the
structure of the different organs, and assigns to
each of them their use. This is a work of great
anatomical research and physiological ingenuity,
which contains many facts that were probably the
result of his own investigation, and exhibits a
very favourable specimen of his reasoning powers,
when not too much under the influence of pre-
conceived hypothesis. The same kind of merit,
although less in degree, may be assigned to the
treatise " On the Motion of the Muscles," and
also to that « On the Formation of the Foetus,"
making due allowance for the greater difficulty
and obscurity of the subject.

Among the works of the second class the trea-
tise "On Temperaments" has been greatly and
justly celebrated, as well as that « On the Seat of
Disease," while that « On the Varieties of the
Pulse" affords a happy illustration of his peculiar
turn of mind, of his acuteness and originality,
and at the same time, of his devoted attachment
to hypothesis. The two works, « On the Differ-
ences and the Causes of Diseases," and "The
Method of Cure," arc more especially interesting,
as containing the most detailed view of his peculiar
doctrines of the humoral pathology, of the indi-
cations of cure which he laid down, and the

MEDICINE, (HISTORY OF)

199

methods which he adopted for their accomplish-
ment. These two latter works exhibit a very
complete view of the practice of Galen and of
that of his contemporaries, and enable us to form
a correct opinion of the state of the science when
he entered upon the study of it, and of the addi-
tions which he made to it. To attempt an ana-
lysis of the works themselves or of the details of
Galen's practice, would carry us far beyond the
limits of this treatise, and, indeed, it would be
principally as a question of literary curiosity that
such an examination could be sustained. Their
general character may be understood from what
has been stated above, and we fully coincide in
the remark of a learned and impartial critic, the
late Dr. Aikin, who, after giving full credit to
Galen for talent and acquirements, thus con-
cludes : — " His own mass and modern improve-
ments have now in great measure consigned his
writings to neglect, but his fame can only perish
with the science itself." The remark which we
formerly made with respect to Hippocrates applies
equally to Galen, that the great superiority which
he acquired over his contemporaries appeared to
repress all attempts at farther improvement.*

CHAPTER, VI. — An account of the successors
of Galen — Decline of medical science — Sextus
Empiricus — Oribusius — Mtius — Alexander
Trallianus — Paulus Eginelus — Account of
the state of medicine among the Arabians —
Conquests of the Arabians — Their patronage
of science — Invention of chemistry — Ahrun —
Serapion — Alkhendi — Rhazes — Ali- Abbas —
Avicenna — Mcsue — Albucasis — Avenzoai —
Averroes — Estimate of the merits of the Arabic
school.

In investigating the state of medicine during
the middle ages, it is apparent than mankind
seemed to be satisfied with the progress which
had been made in the science, or were conscious
of their inability to surpass the limits which had
been assigned to it ; and the result was, that after
the death of Galen we have few illustrious names
to celebrate, and no discoveries to record. Litera-
ture in general was now, indeed, rapidly declining,
and various causes both moral and political were
coming into operation, which suspended the pro-
gress of science and learning for many centuries,
and produced what are justly and emphatically
denominated the dark ages. Into these causes it
is not our business to inquire ; it may be suffi-
cient to remark that they were of so universal a
nature as to operate on the human mind gene-
rally, and therefore to affect every intellectual
pursuit. Medicine, among others, felt their para-
lysing influence, although, from certain incidental
circumstances to be hereafter noticed, it was not
allowed to remain so completely stationary as
most of the other branches of science.

* Covrivrr, Introd. cap. 3, sect. 16; cap. 4, sect. 17, et
alibi. Clcrc, par. iii. liv. iii. ch. 1—8, contains a very
ample account of all that regards the writings and
opinions of Galen. At this period we lose the farther
aid of this candid and judicious historian of medicine.
Barrhuscn. Diss. No. Hi, Nouv. Diet. Hist. "Galien.,"
llallcr. Bib. Med. lib. i. sec. 80, 1. Lauth, liv. v. par. 1.
Sprcntrel, sect. 5, ch. G. Ackermanv, cap. 21, 2. Blumcn-
bach, Introd. sect. 75. Cloulin, Encyc. Metll. Medecine,
"Galien." Renauldin, liiog. Univ. "Galien."

About the period when Galen flourished, the
Roman empire began to exhibit very decided
symptoms of that decline which, proceeding with
more or less rapidity, was never altogether sus-
pended until it terminated in complete destruction.
Even in the most splendid state of Rome, the cul-
tivation of science was very limited, and we have
had occasion to remark that almost all the physi-
cians who acquired any considerable degree of
celebrity were natives of Greece or Asia, and
wrote in the Greek language. This was the case
with Galen himself and with the few individuals
who succeeded him, whose names are of sufficient
importance to be introduced into this sketch. The
medical writers of the third and fourth centuries
have been characterized by Sprengel as "de froids
compilateurs, ou d'aveugles empiriques, ou de foi-
bles imitateurs du medecin de Pergame." (T. ii.
p. 170. Jourdan's Transl.)

The only exception to this remark is Sextus
Empiricus, who appears to have been a contem-
porary of Galen, and probably derived his appel-
lation from the sect to which he attached himself,
as there are some treatises of his still extant in
which he attacks the principles of the Dogmatists
with considerable acutcness. We may conclude
from his works that he was a man of learning
and talents, well versed in the principles of the
philosophers, and familiar with all the branches
of literature and science which were cultivated in
his time. (Enfield, v. ii. p. 136.) He is, however,
the last medical writer to whom the character of
Sprengel does not strictly apply. Oribasius, who
lived in the fourth century, iEtius in the fifth,
Alexander Trallianus in the sixth, and his con-
temporary Paulus, were all zealous Galenists, who
professed to little more than to illustrate or com-
ment on the works of their great master. Their
writings are principally compilations from their
predecessors ; they are, however, occasionally cu-
rious from the incidental facts which they contain,
and by furnishing us with extracts or abstracts of
treatises which are no longer extant ; but this
constitutes almost their sole value. The only ad-
ditions to the practice of medicine which they
afford are an account of certain surgical opera-
tions, which is given us by /Etius, and a treatise
by Paulus on midwifery, which is more complete
than any that had previously appeared, and was
long held in high estimation. But. even these,
which form but a small portion of the whole of
their works, arc connected with so much credulity
and superstition, as to indicate at least the most
degraded state of the science, if not the defective
judgment of the writer. ^Etius expressly recom-
mended the use of medical arts and incantations,
and that, not, as has sometimes been done in a
more enlightened age, from a knowledge of the;
effect they might produce on the imagination of
the patient, but apparently from his own opinion
of their physical operation on the system. ( Con-
ring, cap. 3, sect. 18-20. Sprengel, sect. 6, ch.
1-3.) It must, however, be admitted that both in
Alexander Tallianus and in Paulus we meet with
various descriptions of disease, which indicate that
they possessed the talent of accurate observation ;
and we may conclude that, although in what re-
spects opinions they were the devoted followers of
Galen, yet in the simple detail of facts their av-

200

MEDICINE, (HISTORY OF)

thority may be relied upon with considerable con-
fidence.*

With the death of Paulus, which took place
about the middle of the seventh century, we may
date the termination of the Greek school of medi-
cine, for after his time we have no work written
in this language which is possessed of any degree
of merit. Those which occasionally appeared
were mere servile transcripts of Galen and his dis-
ciples, or compilations formed without judgment
or discernment, devoid of original observation, or
even at any attempt at generalization or arrange-
ment. To this degraded state was the science of
medicine reduced in the former seats of learning,
when a new school arose in a different quarter of
the world, which will require our attention, from
the actual additions which it made to our know-
ledge, as well as from the mode of its origin and
the nature of its connection with the Grecian and
Roman schools.

The city of Alexandria still retained its reputa-
tion as the great school of medicine, partly resting
its fame on the excellence of its former professors,
and in some measure depending on the value of
its extensive library and other institutions favour-
able to the cultivation of science, the forms of
which at least were still preserved. But even
these feeble remains were destroyed by the con-
quest of the Arabians in the seventh century, who
in the genuine spirit of blind bigotry appeared to
be actuated by the barbarous desire of totally
eradicating science from the face of the earth.
The catastrophe which befel the Alexandrian
library is too well known to be repeated in this
place ; a calamity, the full extent of which can
scarcely be appreciated by one who is in the habit
of regarding literature only as it exists in modern
times, when books of all descriptions are multi-
plied to an excessive degree, and when the loss
occasioned by the most splendid collection would
be nearly confined to a single nation or commu-
nity. It appears, however, that notwithstanding
the brutal violence of the Saracen invaders, some
books escaped from the general wreck of literature
and science, and that there were not wanting
some individuals who were capable of estimating
their value. Among these relics were the writings
of Galen, and we are informed that at an early
period of the Saracenic empire they began to be
held in very high estimation ; they were translated
into the Arabic language, were commented upon
and elucidated in various ways, and soon acquired
a degree of celebrity scarcely short of what they
had previously enjoyed among the Greeks them-
selves. The Arabians were also in possession of
the works of Hippocrates, but the simplicity of
this author was less adapted to their taste than were
the metaphysical refinements and elaborate ar-
rangements of Galen, so that, while the latter was
regarded with a respect amounting almost to vene-
lation, the former was little read or estimated.

After the immediate successors of Mahomet
had completed their conquest of a considerable
part of the civilized world, they rested from their
warlike triumphs, and seemed disposed to add to
the splendour of their empire by the cultivation

* Freind, Hist. Med. p. 398 et se(|., and p. 420 el seq.
Opera a VVizan, Load. 17'!3. F.lov, " Paul d'Egine."
Jialler, Bib. Med. t. i. p. 311-13.

of the arts of peace. The patronage of literature
was an express object of many of their rulers, and
even the works of the Greek philosophers were
translated and studied with much assiduity. But
the spirit of Mahomedanism was decidedly averse
to intellectual improvement, and wc accordingly
find that no additions were made to general science,
and that very little was accomplished even in the
collection of facts and observations. To this re-
mark, however, medicine forms an exception ; for
although the Arabian physicians adopted implicitly
all the theories and speculations of Galen, and
seldom ventured in the smallest degree to deviate
from his practice, we are indebted to them for the
description of some diseases, which either made
their first appearance about this time, or had not
been before specifically noticed. - } -

We have to notice, in this place, a curious oc-
currence in the history of science, and one which
indirectly produced a very important effect upon
the subject of this dissertation — the invention of
chemistry. The origin of chemistry, like that of
all other sciences, is obscure and uncertain. Traces
of what may be called chemical operations are
to be found even among the Jews and Egyptians,
but it is generally admitted that they are to be re-
garded as incidental occurrences, depending upon
accidental observations, pursued no further than
the object immediately in view, and not considered,
even by those who practised them, as more than
mere insulated facts, leading to no general princi-
ples nor to any farther investigations. The prac-
tice of chemistry as a distinct pursuit seems to
have originated with the Arabians, and by them
was made subservient to the purposes of medicine,
(Freind, pars 2, sub init. Sprengel, t. 2. p. 246-
266.) It is not our business to inquire into the
mode in which this art took its first rise, or to
trace its subsequent progress, except so far as may
be connected with our present subject; and this
will be the most conveniently accomplished hy
giving in succession a brief account of the most
distinguished writers who belonged to the Arabian
school of medicine.

The earliest Arabian writer on medicine of
whom we have any certain account, would appear
to be Ahrun, who was a priest at Alexandria. He
published a treatise entitled "Pandects;" it has
not come down to us, but it deserves to be noticed
as it is said to have contained the first description
of the small-pox. He was contemporary with
Paulus, and from the account of his works which
has been transmitted to us by Rhazes, we may
conclude that the scienee of medicine was culti-
vated at that time with at least as much success
among the Arabians as among the Greeks. During
the next three centuries, although we meet with
the names of many individuals who acquired a
certain degree of temporary celebrity, we have
none who rendered themselves so far pre-eminent
as to entitle them to particular notice in this brief
sketch. The first author of whom it will be ne-
cessary to give any distinct account is Serapion;
he lived in the ninth century, and is said to have
been a native of Damascus. His treatise entitled,

t For an account of the Arabian school of medicine
generally, the reader is referred to Freind who treats
upon everything connected with it in the most ample
manner. Bee also Karchusen. diss l? «,.r 12 et m-
Sprengel, sect. 6, ch. 5. Cabanis, sec. 0.

MEDICINE, (HISTORY OF)

201

according to the fancy of the translators, " Aggre-
gator," " Breviarium," or " Therapeutica Metho-
dus," was written originally in Syriac ; its pro-
fessed object was to give a complete system of the
Greek medicine, and to incorporate with it the
principles and practice of the Arabians. Like
those of the rest of his countrymen, the greatest
part of Serapion's work is taken from those of
his predecessors, and particularly from Galen; but
it contains some few novelties with respect both
to doctrine and to practice; and in one point, the
preparation and composition of medicines, as well
as in the articles employed, we may notice a de-
cided improvement. (Holler, Bib. Bot. t. 1, p.
183-9.)

At the same time with Serapion lived Alkhendi,
a multifarious writer, who obtained a very high
degree of celebrity among his contemporaries,
perhaps more from the variety of his acquirements
than from the excellence he attained in any par-
ticular department. He is said to have assiduously
cultivated mathematics, and the various branches
of natural philosophy as well as medicine ; and
among other subjects to which he particularly di-
rected his attention, we find astrology expressly
enumerated. In relation to his varied attainments,
he was styled the subtile philosopher, the learned
physician, and the Greek astrologer. As an ex-
ample, both of the spirit of the age and of the
genius of the individual, we may remark that
Alkhendi applied the rules of geometrical propor-
tion and of musical harmony to regulate the doses
of medicine, and to explain the mode of their ope-
ration — a mistaken application of science, which,
however gross it may now appear, we must reflect
was not entirely exploded until long after the re-
vival of letters.*

We now come to one of the most illustrious of
the Arabian school, Rhazes. He was born at Irak
in Persia, in the ninth century ; is described as a
person of varied acquirements, as being well versed
in general science, and, as his writings demon-
strate, of unwearied industry. There is some
reason to doubt whether the principal work which
has been transmitted to us under his name, enti-
tled " Continens," is precisely in the form in which
it was left by its author; but there appears to be
sufficient proof of its general authenticity to enable
us to deduce from it, as well as from his other ac-
knowledged works, an ample and correct view of
the opinions and practice both of Rhazes himself
and of his contemporaries. For the most part,
the writings of Rhazes are deficient in method
and arrangement, and they consist principally of
abstracts and comments on Galen and the Greek
physicians ; but they also contain observations
that appear to be original, and we even meet with
the description of some diseases which were either
new, or at least were not noticed by the ancients.
Rhazes gives us a correct and elaborate descrip-
tion of the small-pox and measles, detailing the
theory which was formed of their nature and ori-
gin by the Arabians, and the treatment which
they employed. The most curious and original
work of Rhazes is his « Aphorisms," in one part
of which he professedly gives the result of his
own observation and experience. But even this

* For an account of the earlier writers of the Arabian
school, see Freind, Hist. Med. pars 2, sub init.
Vol. III. — 26

treatise, which was long regarded as of the high-
est authority in the schools of medicine, contains
little that is really new or valuable ; and when we
compare it with its celebrated prototype, we can-
not but be impressed with the very small advance
which had been made in the science and practice
of medicine during a space of nearly thirteen cen-
turies. The most important additions which Rha-
zes made were, perhaps, rather in surgery and in
pharmacy than in medicine strictly so called ; and
it is worthy of notice, that in the latter depart-
ment we have some of the earliest indications of
the free employment of what were styled the
chemical remedies. (Freind, p. 4S3-91. Bailer,
Bibl. Med. Prac, lib. ii. § 135. Eloy, in loco.
Lauth, p. 280-2. Sprengel, t. ii. p. 285-301.)

A short time after Rhazes lived AH- Abbas, a
writer of considerable celebrity, who obtained the
appellation of the magician. His principal work,
entitled " Opus Regium," professes to contain a
complete view of the state of medicine in all its
branches ; it consists chiefly of abstracts of the
doctrines and opinions of the Greek physicians,
but along with these are contained some original
observations. At the time of its publication it
was very highly estimated, and perhaps may be
considered as possessing more real value than
most of the works that proceeded from the Ara-
bian school. (Freind, p. 481. Haller, Bib. Med.
lib. ii. § 137, t. i. p. 380. Sprengel, t. ii. p. 301-5.)

The fame of Ali-Abbas was, however, almost
entirely eclipsed by that of Avicenna,j" who flour-
ished about a century later, and who rose to the
highest pitch of celebrity, so as to be regarded by
his countrymen as superior to Rhazes, or even to
Galen himself. Avicenna was born at Bochara
in the year 980, and was carefully educated in all
the learning of the times, consisting principally
of the Aristotelian logic and dialectics, with the
imperfect mathematical and physical science, that
was then taught in the schools of Bagdat. He
appears to have been possessed of an ardent de-
sire for acquiring knowledge, and of great indus-
try, but united to a portion of fanaticism, indica-
tive of a defective judgment, and fostered by the
spirit of the age, which induced him to conceive
himself under the influence of supernatural reve-
lation. After a foundation of general science he
entered upon the study of medicine, which he
prosecuted with the same diligence and with the
same spirit of enthusiasm. His reputation became
so high that he was early introduced to the court,
and for some years was without a rival in his pro-
fession. His death, which took place in his fifty-
sixth year, was probably hastened by some politi-
cal intrigues, in which he unfortunately became
entangled.

The works which Avicenna left behind him are
numerous, and embrace both general science and
medicine. The former long maintained a high
character for extent of information and profundity
of learning, and according to the standard of the
age were probably entitled to this commendation.
But his fame, both with his contemporaries and
with posterity, principally rests upon his great

t The actual name of this individual issaid to have been
Al-Hussain-Abou-All-Bep-Abdallah-Ebn-Sina. Sprengel,
t. ii. p. 305. In most cases it appears that the names by
which the Arabians are generally known in Europe
were not their real names.

202

MEDICINE, (HISTORY OF)

medical work, entitled, " Canon Medietas," which

may be regarded as a kind of encyclopedia of all
that was then known of medicine, and of the
sciences connected with it, anatomy, surgery, the-
rapeutics, and botany. Its celebrity was so great
as to have acquired for its author the title of prince
of physicians; for some centuries it was the re-
ceived text-book in most of the medical schools,
both of the Arabians and the Europeans ; until
the revival of letters it superseded, in a great
measure, the works even of Galen, it produced
scarcely less numerous commentaries and epi-
tomes, and had not entirely lost its authority two
centuries ago. Yet the matured judgment of one
of the most learned and candid of the modern
critics has not hesitated to bestow upon this so
much vaunted production the character of an ill-
digested and servile compilation, containing little
that is new either in the way of observation or of
practice. Indeed, the sole aim of Avicenna seems
to have been to collect matter from all quarters,
without paying any regard to its value, or to the
mode in which it was arranged. He was a de-
voted admirer of Aristotle and Galen, and seemed
to imagine that the ultimate object either of the
philosopher or the physician consisted in being in-
timately acquainted with their writings, and in
defending them against all objections. Upon the
whole, after making every allowance for the pe-
riod in which he lived, it seems difficult to account
for the very great credit which he acquired, not
only during his life-time, but which was attached
to his writings after his death ; a credit so much
greater than what they merit, either from the im-
portance of the information which they contain,
or the mode in which it is conveyed.*

There are two Arabian writers of the name of
Mesue, whose celebrity entitles them to a brief
notice in this place, although considerable uncer-
tainty attaches to both their individual history and
to their works. The elder of them is said to have
lived in the eighth, and the younger in the tenth
century ; and they are both represented as being
Christians of the Nestorian sect, but to have ex-
ercised their profession at Bagdat. The elder Me-
sue is principally remarkable as having been
among the first who made correct translations of
the Greek physicians, and especially of Hippo-
crates and Galen, into Arabic; for although he
appears to have composed many original works,
we do not find that they rose into any high repute
even among his contemporaries. To the younger
Mesue is usually ascribed a treatise on materia
medica and pharmacy, which for a long time was
in great estimation, and was republished and com-
mented upon even as late as the sixteenth century;
it probably contained a full view of the state of
the science when he wrote, and is interesting, as
it indicates the introduction of several new reme-
dies into medicine ; but in other respects it is to
be regarded merely as a literary curiosity. (Freind,
p. 481, 2. Haller, Bibl. Med. Prac. lib. ii. § 126.
Eloy, in loco. Enfield, v. ii. p. 213. Sprengel,
t. ii. p. 325.)

The last of the Arabians who acquired any

* Freind, lib. ii. p. 491-2. Haller, Bib. Med. lib. ii. § 139.
Eloy, in loco. Lauth, p. 282-5. Enfield, v. ii. p. 222, 3.
Sprengel, t. ii. p. 305-22. Mutton's Math. Diet., in loco.
Ooulin, Encyc. Mctli. Medecine, " rfvicenne." " Jlvi-
cenne," in Biog. Univ.

considerable distinction as a writer on medical
subjects, is Albucasis. So little is known of his
personal history, that both his birth and the coun-
try in which he lived have been the subject of
controversy, and appear to be entirely conjectural.
His principal works are on surgery ; and the re-
putation which he acquired in this department is
almost as great as that of Avicenna in medicine.
He seems to have been a man of learning and
talents, to have made himself master of the writ-
ings and practices of his predecessors, and to have
improved upon them. The description which he
has left of his operations shows him to have pos-
sessed a degree of boldness and dexterity which
could only exist in one who was well acquainted
with his art, and had been habituated to the prac-
tice of it. His practice was what we should now
consider as unnecessarily severe, making much
more use of the knife and of the actual cautery
than is done in modern times, and in all respects
inflicting both more pain and more permanent in-
jury on his patients. The works of Albucasis
appear, however, to have afforded by far the most
complete view of the practice of surgery which
then existed ; and from this circumstance, as well
as from their real merit, they were, for many ages,
considered as standard performances, and employed
as the text-book in various schools and colleges.
(Freind, p. 506-524, 2. Haller, lib. ii. § 148.
Eloy, in loco. Lauth, p. 285, 6. Sprengel, t.
ii. p. 327-32.)

It remains for us to give an account of two in-
dividuals, who, although natives of Spain, and re-
siding principally in that country, were of Sara-
cenic origin, and wrote in the Arabic language—
Avenzoar and Averroes. Avenzoar was born at
Seville, in the end of the eleventh century, and is
said to have lived to the unusual length of one
hundred and thirty-five years ; but probably some
error may have crept into this statement in con-
sequence of both his father and his son having
been, like himself, engaged in the practice of me-
dicine. His principal work, entitled " Thaissyr,"f
which consists in a general compendium of medi-
cal practice, displays more originality and discri-
mination than the writings of any of the native
Arabians ; so that, although he was professedly a
disciple of Galen, he does not hesitate, on certain
occasions, to shake off his authority when his
opinions or practice were not sanctioned by his
own experience. We may collect, from certain
parts of his works, that he practised both surgery
and pharmacy, as well as medicine properly so
called ; and we have many valuable observations
on each of these departments. Upon the whole,
we may consider Avenzoar as respectable both
from his general character and his professional
skill, and entitled to our regard as one of the im-
provers of his art. (Freind, p. 492-503. Haller,
lib. ii. § 142. Eloy, in loco. Sprengel, t. ii. p.
332-7.)

Besides the reputation which Avenzoar derived
from his own merits, he was perhaps still more
known among his countrymen as being the pre-
ceptor of the celebrated Averroes. Averroes was
a native of Corduba, and flourished in the twelfth

t Frr ind designates the Thaissyr as " liber qui omnia
nerel*" ™ d,clM Precept* in plerisque tnorbis conti-

MEDICINE, (HISTORY OF)

203

century ; he was of illustrious birth, and highly
educated in all the branches both of literature and
of science which were then taught in the Saracenic
colleges of Spain. From certain political causes
he was, in the early part of his life, the subject of
religious persecution ; but he succeeded in repel-
ling the attacks that were made upon his faith,
and was finally reinstated in all his former honours
and in the public estimation. These circumstances,
coinciding probably with the peculiar tempera-
ment of his mind, gave to his character a degree
of ascetic gloom and austerity ; but he appears to
have been a man of distinguished worth and of
superior abilities. Averroes' professional occupa-
tions were principally in a civil capacity ; he is
therefore to be regarded, not as a practitioner, but
as a scholar who pursued the study of medicine as
a branch of physical science. But such was his
ardour in the pursuit of general knowledge, and
the fondness which he manifested for this particu-
lar department, that he made himself intimately
acquainted with it in all its details, and in his
great work entitled " The Universal," he shows
that he was not deficient in any part of the sci-
ence which could be acquired by the mere study
of books. As a philosopher he was a zealous and
obsequious follower of the opinions of Aristotle,
and as a physician, of those of Galen ; he pub-
lished many comments on both of them, which
acquired the highest degree of reputation, and
for many ages were considered as standard per-
formances. Yet there is reason to suppose that
he was ignorant of the Greek language, and, like
his contemporaries, became acquainted with Aris-
totle and Galen only through the medium of
Arabic translations. The great estimation in
which the works of Averroes were held is proved
by the number of editions of them which were
published from time to time, one of which appeared
at Venice so late as the commencement of the
seventeenth century. With respect to his medi-
cal writings, as they do not profess to be the re-
sult of original observation, we cannot be sur-
prised that their reputation is no longer supported.
They are indeed entirely neglected ; and it may be
affirmed that, notwithstanding the celebrity which
they once enjoyed, and which they so long main-
tained, they have not left a single permanent addi-
tion to the science.*

With Averroes terminated the Arabic or Sara-
cenic school of medicine ; after his time we have
no writer whose name is sufficiently distinguished
to deserve particular mention : even the study of
the ancients began to be neglected, while no ori-
ginal observations were made, and no novel opin-
ions or speculations were framed which might
tend to exercise the mind or dissipate the dark-
ness which now covered all parts of the world.

If we inquire into the causes of the great cele-
brity of the Arabian school of medicine, we shall
be led to the conclusion that they were rather in-
cidental and factitious than derived from its abso-
lute merits. It has been justly observed that a
considerable portion of this celebrity must be as-
cribed to the comparative condition of the neigh-
bouring countries. From the eighth to the twelfth

* Frcind, p. 503-6. Bayle's Diet., in loco. Morcri's Diet.,
in loco. JIallcr, lib. ii. stxt. 142. Eloy, in loco. Nouveau
Diet. Hist, in loco. Enfield, t. ii. p. 220-231. Spreugel, t.
ii. p. 337-41.

centuries was, perhaps, the period in which Europe
was in the state of the most complete barbarism
and superstition. The only remains of a taste for
literature and science, or for the fine arts, were
found among the Moors and Arabs; and it was
from this source, by the intervention of the cru-
saders, and the intercourse which was thus effected
between the Asiatics and the Europeans, that the
philosophical and medical writings of the Greeks
were first made known to the inhabitants of Italy
and of France. And even after their introduction
into Europe, it appears that they were for some time
read only in Arabic translations, or in Latin ver-
sions made from these translations ; so that it was
not until a considerably later period that they were
perused in their native language. Indeed so com-
pletely was the study of the Greek tongue sus-
pended during the dark ages, that it may be
doubted whether the writings of the ancient phy-
sicians might not have been entirely lost to pos-
terity had they not been preserved in these trans-
lations.

There are, however, two points in which the
Arabians conferred a real obligation upon their
successors, the introduction of various new arti-
cles into the materia medica, and the original
description of certain diseases. The additions
which the Arabians made to pharmacy consisted
partly in the vegetable products of the eastern or
southern countries of Asia, which were only im-
perfectly known to the Greeks, and with which
they had no intercourse. Among other substances
we may enumerate rhubarb, tamarinds, cassia,
manna, senna, camphor, various gums and resins,
and a number of aromatics, which were brought
from Persia, India, or the oriental isles. But a
still more important addition which they made to
the pharmacopoeia consisted in what were styled
chemical remedies, such as were produced by some
chemical process, in opposition to those substances
that were used nearly in their natural state. With
respect to the origin of pharmaceutical chemistry,
it may be sufficient to observe that a rude species
of chemical manipulation appears to have been
practised in Arabia in the fifth century, that dis-
tillation was performed, and that the metals were
subjected to various processes, by which some of
their oxides and salts were produced. The imme-
diate object of these processes was the transmuta-
tion of the metals ; an operation which, for many
centuries, formed a main subject of attention to
almost all the individuals who were considered
as cultivators of natural philosophy.

With respect to the second subject alluded to
above, the description of new diseases, it is well
known, that from causes which are now altogether
inexplicable, diseases of the most marked and dis-
tinct nature, which are the least liable to be mis-
taken or confounded with other affections, and
which, had they existed, are too violent to have
been overlooked, are not mentioned by the Greek
and Roman physicians, and are described for the
first time by the Arabians. Of these the two most
remarkable are the small-pox and the measles.
There is some reason to suppose that the small-
pox had been known in China and the more re-
mote parts of India at a much earlier period, but
it is generally admitted that it was first recognised
in the western part of Asia, at the siege of Mecca,

204

MEDICINE, (HISTORY OF)

about the middle of the sixth century, when it
raged with great violence in the army of the be-
siegers. We have remarked above, that the disease
was alluded to by Ahrun shortly after its appear-
ance, but it was Rhazcs to whom we are indebted
for the first clear and distinct account of its symp-
toms and treatment. There is no subject in the
whole range of medical science of more difficult
solution than that which respects the origin of
diseases, especially such as, when produced, are
propagated solely by contagion. Into this subject,
however, it would be improper for us to enter in
this place, as our readers will find it fully con-
sidered in the appropriate articles ; it is here only
alluded to as an historical fact, in connection with
the writings of the Arabians.*

We are indebted to them for the transmission
of the works of the ancient Greek physicians, to
which they made certain additions of insulated
facts with respect to the description of diseases,
but with respect to the general principles of thera-
peutics the additions, if any, were few and im-
perfect. In anatomy they made no advances, and
we have reason to suppose that the examination
of bodies, either in a sound or morbid state, was
scarcely practised by them. Medical theory was
much attended to, but their theories consisted more
in subtile refinements, formed upon the Aristotelian
model, than in the study of pathology, or an ac-
curate discrimination of the phenomena of disease.
Some little advance appears to have been made in
surgery by Albucasis, but he is the only individual
who seems to have aimed at improving this branch
of the profession ; and it may be doubted whether
the practice of surgery was not, upon the whole,
in a retrograde state, during the period of which
we are now treating. It is in the department of
pharmacy alone that they made any additions of
real value ; and, although in this case it may be
attributed more to accidental circumstances than
to any enlightened spirit of improvement, yet it is
incumbent upon us to acknowledge the obligation,
which was both extensive and permanent."!"

CHAPTER VII.— State of medicine in Europe
after the extinction of the Arabian school —
Medical schools of Monte- Cassino and Salerno
— Medicina Salcrnitana — Constantinus Af-
ricanus — Actuarius — Rise of the study of
anatomy— Mondini— Gilbert— Effect of the
crusades, of the reformation, and of the inven-
tion of printing, on the literature of Europe

On medical science — Alchemists — Establish-
ment of universities — Linacre — Chemical
physicians — Paracelsus — Appearance of new
diseases.

During the flourishing period of the Saracenic

* On the origin of the smallpox, see Freind, p. .'52-49 ;
Mead's Discourse on Small-Pox and Measles ell i ■
T/inmpson's Enquiry into the Origin of Small-Pox ; Ploii-
quet, Literatura Digesta, "Variola, Antiquitas His-
tona," in loco: ample references may be found in this
learned and laborious compilation on all analogous
topics, but we may regret that the writer appears to have
aimed rather at multiplying his authorities than esti-
mating their value.

f We are indebted to Freind for a candid and judicious
account of the Arabian medical school, p. 529-33. Holler's
second book of his Bibl. Med. Prac. is devoted to the
same subject. See also Robertson's Charles V. vol. i. note
2^. Bcrringlon's Middle Ages, App. No. 2. (ribbon's
History, vol. x. ch. lii. rfekermann, cap. xxvii-xxix.
Oelsncr, Des Effets de la Religion de Mahommed, p. 196.

school of medicine, which may be considered as
extending from the eighth to the twelfth century,
the science remained nearly stationary, or was
even retrograde among the successors of the
Greeks and Romans. We have scarcely a single
name of sufficient importance to arrest our atten-
tion, and we have no improvements to record,
either in theory or in practice. The only attempts
that were made in Greece or in Italy during this
period, which deserve to be noticed, are connected
with the Neapolitan schools of Monte-Cassino and
of Salerno, which acquired some degree of repu-
tation in the eleventh century. It was at this pe-
riod that the physicians attached to the school of
Salerno wrote the verses on dietetic medicine, en-
titled " Medicina Salernitana,' a work which, as
afterwards published with the commentary of Ar-
noldus de Villanova, acquired considerable celeb-
rity, and may be regarded as a valuable document,
by its affording, in a small compass, a correct idea
of the state of Italian medicine at that early period.*

In connection with this subject we may notice
Constantinus Africanus, who is supposed to have
flourished about the end of the eleventh century.
He was, as his name imports, an African ; he
possessed an ardent desire to obtain knowledge,
studied in the schools of Bagdat, and is said to
have travelled even to India. At his return to his
native country he was regarded as a sorcerer, and
was compelled, in order to save his life, to take
refuge in Italy, where he was finally attached to
the university of Monte-Cassino. He principally
employed himself in translating the works of the
Greek and Latin physicians into Arabic, which
was at that time the general language of science.
His translations are, however, said to be incorrect,
and his style barbarous ; while his works, which
are not professed translations, appear to be com-
posed of transcripts from other authors, without
any particular merit, either of selection or of ar-
rangement. (Freind, p. 533, 4. Hatter, Bibl.
Med. lib. iii. sec. 159. Eloy, in loco. Sprengel, t. ii.
p. 355, 6.)

We must mention in this place a writer whose
real name has not been transmitted to us, com-
monly called Actuarius, from the office which he
bore in the court of Constantinople ; (for the ori-
gin of the term, sec Adelung, Gloss. Man., in
loco). He is supposed to have lived in the twelfth
century. The works which he left are numerous,
and, although consisting principally of extracts
from Galen and the Arabian physicians, with
whose writings he appears to have been familiar,
are not without some additions derived from his
own observations and experience. He is consid-
ered as having been the first Greek physician by
whom chemical medicines are mentioned, as well
as various articles of the materia medica, which
were originally introduced by the Arabians. We
may regard Actuarius as a diligent collector of

xalt the merits

.... sec. 3. of what

tes Medicina?," is entitled, " Scriptores

Medici inter Arabes pracipui," p. 180-6. Portal , Hi*

Arabes, t. i. p. 143 Pet seT" b2T h °\ d ™ 0"™*;"'
" Arabes " olumenbach, Introd. sect. 6.

lernhana to SC Jo b hn th c° (V\ tin v " rsfcs of the Medicina S=-
w"k "he\e „* oeen'Uli 1 d''° T^ ? M ° f U,i3
rabiles;" Bib. Med lib ii ^ '/d'tiones fere innume-
n TO' m™ "ii- sec. 140. See also Eloy t. n.

p. 599 , AcUrmann, sec. 422, and Blumenbach, sec. 114

9 : this is perhaps too much disposed to ej
of the Arabian school. Kuhn. Bib. Med i
he styles "Fontes Medicina? " ;= <,„>■•■'

ityle

lici i
Anat. ch.

MEDICINE, (HISTORY OF)

205

facts, acquainted with all the information of his
age, and as more free from prejudice and bigotry
than the generality of his contemporaries. (Freind,
p. 452-462. Eloy, in loco. Sprengel, t. ii. p.
241-4.)

After the extinction of the Saracenic school of
Spain, we have an interval of about three hundred
years, from the twelfth to the fifteenth century,
during which what are termed the dark ages still
remain enveloped in the deepest gloom ; every de-
partment of science was neglected, and among
others that of medicine fell into its lowest state of
degradation. What remained, either of literature
or of science was in possession of the monks,
who were themselves grossly ignorant, and whose
interest it was to preserve mankind in the same
state of ignorance. The exercise of the medical
profession was principally in their hands, and they
still adhered for the most part to the doctrines and
practice of Galen, but with these they mixed up
a large portion of superstition, and had not unfre-
quently recourse to magic and astrology. By these
means they obtained an unbounded influence over
the minds of the people, and operated so power-
fully on the imagination of their patients, as in
many cases to give an apparent sanction to their
confident assumption of supernatural agency. —
(Sprengel, sec. vii. ch. i.) The only branch of
science which was cultivated with any ardour or
success, was chemistry. The chemistry of these
times can indeed only be interesting to us, as
having led indirectly to the discovery of various
substances which have been found of great im-
portance in i: ' 'ine, to which we have already
referred. Its iu. mediate objects were two-fold, the
transmutation of the baser metals into gold, and
the discovery of what was termed a universal
medicine, which should possess the property of
removing all diseases, and preserve the constitution
in a state of health and vigour; objects which it
is unnecessary to observe were completely vain
and illusory. Yet by promoting a spirit of re-
search, and by making the experimentalist ac-
quainted with the various forms and properties of
the substances on which he operated, they gave
him some insight into the physical laws of matter,
and by a gradual although very slow process, laid
the foundation of the splendid improvements of
modern science. Many of the alchemists of the
dark ages, we can have no doubt, were impostors
of the lowest description, who were completely
aware of the folly of their pretensions ; but at the
same time there were others who appear to have
been the dupes of their own credulity, and who
bestowed a large portion of their time and fortune
upon these researches. Between these two ex-
tremes there were some rare cases of individuals
who may be entitled to hold an intermediate rank,
who were sincere and honourable in their views,
and without giving full credit to the professions of
the alchemists, conceived that the objects at which
ned were at least not altogether impossible.
To these we may add another class of individuals,
consisting of that singular and unaccountable
compound of knavery and folly, which is not con-
fined to the subject now under consideration,
where it is extremely difficult to draw the line be-
tween these two qualities, or to decide which of
them forms the predominant characteristic.

The school of Salerno, to which we have re-
ferred above, obtained a degree of celebrity from
its local situation, this city being one of the great
outlets from which the crusaders passed over from
Europe to Asia in their expeditions to Palestine ;
and it was probably from this circumstance that
Robert of Normandy stopped at Salerno, in order
to be cured of a wound which he had received in
the holy wars. It was on this occasion that the
verses mentioned above, and which were addressed
to him, were written. Upon the decline of the
Saracenic universities of Spain, the only medical
knowledge which remained was in Italy, where a
few individuals, who were not of the ecclesiastical
profession, continued to comment on Galen and
Avicenna, and occasionally to deliver lectures ;
but we have a long dreary interval, in which there
is nothing to arrest our attention, or to relieve the
dull monotony of ignorance and superstition.

During this period the school of Salerno still
retained its reputation, and was even favoured
with especial privileges by the emperors ; but its
merits were probably rather comparative than ab-
solute, for we do not find any improvements that
emanated from it, nor any authors whose writings
maintained their celebrity after the age in which
they were produced. It is, however, in one re-
spect deserving of our notice, as it appears to
have been the earliest establishment in which
what may be styled regular medical diplomas
were granted to candidates, after they had passed
through a prescribed course of study, and been
subjected to certain examinations. The regula-
tions are upon the whole judicious, and display a
more enlightened and liberal spirit than might
have been expected in that age, when the human
mind was in so degraded a state. (Freind, p.
535-7. Eloy, art. « Salerne." Lauth, p. 291, 2.
Ackermann, cap. xxxi.) The school of Salerno
maintained its celebrity until the thirteenth cen-
tury, when it was eclipsed by the general diffusion
of medical science through Europe, and more par-
ticularly by the rising reputation of the universi-
ties of Bologna and Paris.

It was about this period that we may date the
commencement of a practice which has eventually
proved of the greatest importance to medical sci-
ence in all its departments — the study of human
anatomy. We have already had occasion to re-
mark that the ancients, even in their most en-
lightened ages, seldom if ever ventured to examine
the human subject, but were content to derive
their knowledge of it from the dissection of ani-
mals which were supposed the most nearly to
resemble it, making up the deficiencies by the
casual examinations which were afforded them by
accidents or diseases, and perhaps more frequently
by supposed analogies, or rather by the efforts of
the imagination. The individual to whom the
credit is ascribed of having so far overcome vulgar
prejudice as to have introduced this most impor-
tant improvement into his art, is Mondini, a pro-
fessor in the university of Bologna, who is said
to have publicly dissected two female subjects
about the year 1315, and who published an ana-
tomical description of the human body, which
appears to have had the rare merit of being drawn
immediately from nature. This work deservedly
obtained a high reputation : for three hundred

206

MEDICINE, (HISTORY OF)

years it was considered as a standard performance,
and was used as a text-book in the most cele-
brated of the Italian universities. Mondini is
also entitled to the gratitude of posterity for
having given a very early, if not the first exam-
ple of anatomical plates ; the figures were cut in
wood, and although, as might be supposed, they
were not executed with much elegance or deli-
cacy, they are said to have been correct and ex-
pressive.*

About the same time with Mondini lived Gil-
bert, surnamed Anglicanus, a writer who must be
considered as peculiarly interesting to us, from his
being the earliest English physician whose name
is sufficiently celebrated to entitle him to a place
in the history of medicine. There has been
much controversy respecting the date of his birth ;
but it appears the most probable that he flourished
in the beginning of the fourteenth century. At
this time medical science, as well as all other
kinds of knowledge in this country, was in a
state of the lowest degradation. There were no
public means of instruction in any of the branches
of natural philosophy. The light of science,
which had dawned in the south of Europe, had
not yet extended to the remote shores of Britain,
and the learning of the age, which was confined
to the monks, consisted entirely of scholastic dis-
quisitions and the disputations of polemical theo-
logy. We are not therefore to expect, in the
writings of Gilbert, much of genuine philosophy
or of real science ; his principal work, which is
entitled " Medicinae Compendium," consists chiefly
of subtile distinctions, disquisitions respecting
trifling and insignificant topics, with minute divi-
sions of his subject, which lead to no useful pur-
pose or general conclusion. His medical theories
are principally taken from Galen, while his mode
of reasoning proceeds upon the technical princi-
ples of the Aristotelian dialectics ; he adopts the
former without discrimination, and employs the
latter without judgment. He frequently refers to
the Arabian physicians, and there is some reason
to suppose that it was through their means, i. c.
through the medium of the Latin translations of
their writings, that he made himself acquainted
with the opinions of Galen. (WurtorCs Hist, of
Eng. Poet. v. i. p. 443.)

But although we are compelled to pass this
general censure upon the works of Gilbert, justice
demands it of us to admit that his defects may be
fairly ascribed to the age and country in which
he lived, and that he deserves great commenda-
tion for the attempt which he made, however im-
perfect it may have been. Nor are his works
entirely without merit or originality ; he has de-
scribed some diseases in such a manner as to
show that, under more favourable circumstances,
he might have excelled in the art of making ob-
servations ; he occasionally gives us some parti-
culars of his practice, which prove that he was
capable of exercising a correct judgment in the
treatment of the cases which were submitted to
him, and we are indebted to him for some addi-
tions to the materia medica, and for some improve-

* freind, p. 546. Haller, Bibl. Anat. sec. 120, t. i. p.
146, 7. Eloy, in loco. Portal, Hist. Anat. t. i. 209-16.
Sprengel, t. ii. p. 432-4. Douglas, Bibliogr. Anat. p.
36-9. Blumenbach, sec. 118.

ments in pharmacy. (Freind, p. 547-50. Eloy,
in loco. Aikin's Biog. Mem. of Med. in Gt. Brit,
p. 8, 9. Sprengel, t. ii. p. 402-6.)

About this period, a grand polilical revolution
was commencing in Europe, which eventually
produced an entire change in the civil condition
of its inhabitants, and indirectly affected, in an
equal degree, its science and its literature. The
feudal system, after being firmly established for
some centuries, began to be shaken, perhaps in
the first instance by the crusades. These expe-
ditions, although undertaken from a spirit of gross
superstition and bigotry, yet by giving a degree
of excitement to the mind, and still more by
making the crusaders in some degree acquainted
with the literature of the Arabians, laid the foun-
dation for subsequent improvements. There has
been much controversy, not only respecting the
absolute merit of the Arabian literature, but re-
specting the influence which it had on that of
Europe. On the first of these points, so far at
least as regards the medical sciences, we have al-
ready offered a few remarks ; and on the latter
we may observe that at the period of the crusades,
whatever may be our estimate of the absolute
merit of the Saracenic schools of learning, they
were undoubtedly superior to those of the Chris-
tians, if indeed these latter can be entitled to the
appellation. The armies of the crusaders were
certainly not the best adapted either for appre-
ciating the learning of the countries which they
invaded, or for transferring any portion of it to
their own ; but still an intercourse of two or three
centuries could not fail of having produced some
effect, and in fact we know, not only that Arabian
books were read and studied in Italy and France,
but that it was almost exclusively by the medium
of these books that the knowledge of the Greek
and Roman authors was kept alive.|

The advantages which were derived to the Eu-
ropeans from their intercourse with Asia, were,
however, of but little moment compared to the
great events to which we alluded above. The
first of these was the capture of Constantinople,
in the middle of the fifteenth century, by Mahomet
the Second. The Greek monasteries of this city
had been for some time the refuge of the learned
men who had been driven from Italy by the per-
petual wars in which that country had been so
long engaged. They had taken with them, what
they considered as their most precious treasures,
the manuscripts of the ancient classical writers,
probably regarding them more as objects of curi-
osity than of real importance. These manuscripts
had now been buried for a long time in their li-
braries, their existence being unknown to the rest
of the world, when the monks were expelled from
their retreats by the Turkish conqueror, ami,
flying into Italy, carried back with them their
classical manuscripts. A spirit of improvement
had already begun to manifest itself in this coun-
try, which was considerably incited by their
guests, who in their turn, by their change of
situation and by the new society into which they

t Gibbon, cli. I.\i. Sprengel, sect. 7, cli. iii. We must
remark that the opinion expressed in the text respect-
inn the influence of the crusades on the literature and
science of Europe differs in some degree from that of
"des v ii p.^s'" '"* ,ntereatin « work on the Cru.

MEDICINE, (HISTORY OF)

207

were introduced, became more aware of the value
of their literary treasures ; while their own ac-
quirements, limited as they were, gave them a de-
gree of respect with their new associates which
tended to inspire them with a desire of further im-
provement. (Achermann, ch.xxxii. Cabanis,§7.)

The other event to which we referred, and
which occurred about thirty years after the de-
struction of the Byzantine empire, was one of in-
finitely more importance both in its immediate
and its ultimate effects. Considered in all its
bearings, both moral and political, it may probably
be regarded as the most important which has ever
occurred in the history of civilized society. Our
readers will not need to be informed that the great
event to which we refer is the Reformation. Into
the causes of this event, the motives of Luther
and his associates, the difficulties with which they
had to struggle, and the means by which they
succeeded in overcoming these difficulties, it is
not our business to inquire. It only remains for
us to notice its effects on science, and more par-
ticularly on medical science. We have remarked
above that a certain degree of mental exertion had
begun to manifest itself in the fourteenth century,
that this was in some measure brought into action
by the excitement produced in consequence of the
crusades, and that the minds of men were thus
prepared to receive the great truths which were so
powerfully impressed upon them by the reformers.
The first effect, however, of the Reformation was
rather unfavourable to the progress of science and
literature. The attention was entirely absorbed
by the violence of theological controversy, and the
civil feuds which succeeded put a stop to the
peaceful labours of the scholar and the philoso-
pher. But if a temporary pause was thus pro-
duced, the subsequent advance was proportionally
rapid. No sooner were the minds of men deli-
vered from the thraldom of theological bigotry,
than they felt a strong impulse to free themselves
from the tyranny of opinions on all other subjects
in philosophy; and although it still required the
lapse of some centuries to shake off the undue
authority of Aristotle and Galen, and to form a
fair estimate of their real merits, they were at
least regarded as fair topics for discussion, while
innovators were every day rising up who ventured
to question their infallibility without the danger
of being stigmatized as schismatics and heretics.
(Enfield, v. ii. book 8, ch. ii.)

The happy invention of the art of printing,
" an art which derides the havoc of time and bar-
barism," and which fortunately occurred about the
same period, most powerfully tended to co-operate
with the labours of the reformers, both in religion
and in science, by affording them the means of
more readily communicating the result of their
inquiries, and of preserving the records of know-
ledge from the danger which they had lately ex-
perienced of being totally lost or destroyed.* One
of the first uses which was made of this impor-
tant invention was not only the multiplication of
the works of the ancient classics, which had been
brought by the Byzantine monks into Europe,

* For remarks on the scarcity and value of books, see
Robertson's Charles V., v. I. ch. v. note 10; Warton's
Hist, of English Poetry, passim; Berrington's Middle
Ages, book vi. p. 507, 3.

but, by making mankind sensible of their value,
other works of a similar kind were eagerly sought
after, and thus, in the course of a few years, man-
uscripts were discovered of almost all the classical
writings of which we are now in possession.
(Gibbon, v. x. ch. Ixvi. Warton, passim. Ber-
ington, book vi. p. 478 et seq. Shepherd's Life
of Poggio, passim. Hallanis Middle Ages, v.
iii. p. 577 et seq.) The munificence, and even
the voluptuous extravagance of Leo X. and the
other Italian potentates, by the direct encourage-
ment which they gave to literature and the fine
arts, powerfully coincided with the current of
public opinion. For although, by inciting the
daring spirit of Luther to take those steps of open
hostility against the papal authority which he
probably little contemplated in the first instance,
they produced effects very different from those
originally intended, yet they must be considered
as among the indirect causes which conspired to
produce the great mental revolution of the fifteenth
century.

The science of medicine in its various depart-
ments was not slow in partaking of the beneficial
effects of the change which we have been de-
scribing. The writings of the Greek physicians,
which had for some centuries been studied through
the medium of Arabic translations, or even of
Arabic commentaries, were now read in their
original language or in correct Latin versions. It
was found that Avicenna, Averroes, and the great
luminaries of the Saracenic schools, had in many
cases either misunderstood or perverted the doc-
trines and tenets of Galen, and his genuine
writings now began to be substituted for the im-
perfect transcripts of them which had so long oc-
cupied their place. The works of Hippocrates
were also printed in their original form ; but it re-
quired a considerably longer period of mental
education to enable the bulk of medical readers
to appreciate his merits, so that, although various
editions of his works were printed, and learned
treatises written to explain them, Galen still re-
tained the pre-eminence in public estimation.

A practice began to prevail about the fifteenth
century which very materially contributed to ad-
vance the science of medicine, and especially the
practical part of it, — the publication of mono-
graphs of particular diseases and of individual
cases, with the reports of hospitals or other public-
institutions. This plan was not, indeed, altogether
new, for we meet with narratives of cases even
in Hippocrates ; but it had been either misunder-
stood, or had been so much perverted from >ts
original design and legitimate object as to have
been rendered of little value. Many of these
early collections, it must be acknowledged, were
formed without judgment, and consisted rather of
marvellous stories than of histories from which
any practical inference could be deduced ; but
they served the purpose of inducing a habit of
observation, and of directing the attention more
to facts than to mere hypotheses. In each suc-
ceeding age we find this plan to have been more
generally adopted, and at the same time to have
been much improved in its method ; so that vvo
may undoubtedly aonsider it as one of the means
by which medical knowledge has advanced so *•>
pidly in modern times.

208

MEDICINE, (HISTORY OF)

Before we close our second period of the history
of medicine, it will be necessary to make a few
observations on the progress of chemistry, and on
the influence which it had on medical science.
We have already made some remarks on the rise
of this science, and on the progress which it made
among the Arabians, and have stated that it origin-
ated in the futile and sordid desire of converting
the baser metals into gold. In its primary object
it of course totally failed ; yet in the numerous
and laboured efforts which the alchemists made to
accomplish their object, it is admitted that they
acquired considerable information about the nature
and properties of the bodies on which they ope-
rated, and thus produced various compounds, prin-
cipally of a metallic nature, which were eminently
useful in the arts of life, and especially in phar-
macy. We farther owe to the Arabian chemists
the discovery of the process of distillation, the art
of preparing extracts; they introduced the use of
sugar into pharmacy instead of honey in the com-
position of syrups and conserves : they seem to
have made some approach to the formation of the
mineral acids, and to have procured several of the
earthy and neutral salts.

The art of alchemy was early transferred into
the different countries of Europe, and was pur-
sued with as much ardour as by the Arabians, and
perhaps with even more superstition and credulity.
Some of the alchemists acquired, during their life-
time, a high degree of popularity, and notwith-
standing the unphilosophical nature of their occu-
pation, are not altogether unworthy of notice in
the history of science. Albertus Magnus, bishop
of Ratisbon ; Raymond Lully, a Spanish ecclesi-
astic ; and Arnoldus of Villanova, a professor in
the university of Barcelona, all flourished in the
thirteenth century, and left behind them writings
which, although they are encumbered with a mass
of folly and mysticism, exhibit, in a certain de-
gree, the spirit of philosophical research, together
with an ample share of industry and patient in-
vestigation.* In the same age Jived Roger Bacon :
he may be classed among the alchemists, inasmuch
as he adopted some of their principles and prac-
tices ; but in the turn of his mind, and in the spirit
with which he entered upon his experimental re-
searches, he exhibited a genius which far out-
stripped the age in which he lived.f The philo-
sophy s stone, which was the object of so much
painful research, besides its property of producing
gold, was supposed also to possess the power of
curing all diseases, and hence obtained the title
of the universal medicine. This vain and fantas-
tical notion was indirectly the cause of some
pharmaceutical discoveries ; for to this we may
consider ourselves indebted for the mercurial pre-
parations, and for the experiments of Basil Valen-

* Freind, p. 543-5. Bayle's Diet. art. " Albert." Eloy,
" Arnauld de Villeneuf," Morcri. art. " Albert." t. i. p.
209 ; and " Arnaud de Villeneuf," t. i. p. 346, 7. Aeker-
mann, § 44G, 7. Berington, book v. p, 370. Sprengel, t.
ii. p. 437-443. Blumenbach, § 120-3. Turner's Modem
History of England, book ii. chap. i. p. 7, 8.

+ Freind, p. 537-543. Campbell, in Biog. Brit., in loco.
Bale, Scrip, lllust. Brit. p. 342-4. Cave, Hist. Lit. t. ii.
p. 324-G. Bayle, in loco. Eloy, in loco. Berington,
book v. p. 373. Hallam's Middle Apes, vol. iii. p. 539,
note. Nouv. Diet. Hist, in loco. Sprengel, t. ii. p. 397. 8.
Wood's History of Oxford, by Gutcli, vol. i. p. 332-344.
Enfield, in Hist. Phil. vol. ii. p. 340-8; anil in Jliliin's
Gun. Biog., in loco. Suard, in Biog. Univ., in loco.

tine on antimony, which led to their introduction
into medicine about the end of the fourteenth
century.

Among the distinguishing features of the period
at which we are now arrived, we must not omit
to mention the various universities which were
established in most of the great cities in the
southern parts of Europe, of which the medical
chairs, in most cases, formed a very distinguished
part. We have already had occasion to mention
the university of Salerno, which was the first of
these establishments after the destruction of the
Roman empire. The next in order of time ap.
pears to have been that of Montpellier, which is
said to have been established not long after that
of Salerno, and which acquired a high degree of
reputation, which it maintained for many cen-
turies. We are informed that Bologna had ac-
quired considerable celebrity as a school of medi-
cine in the thirteenth century ; that about half a
century later, medical lectures were delivered in
the universities of Vienna and Paris; and that
about the same time, medical schools were esta-
blished in Padua, Pavia, Milan, Rome, and Naples,
and most of the other cities of Italy, which each
of them acquired a certain degree of reputation,
necessarily varying with the abilities and charac-
ters of their . professors, but all contributing to ad-
vance medical science, both by the actual acquisi-
tion of knowledge, and by the influence which
they exercised in removing the undue veneration
that was still paid to the writers of antiquity.*
In the north of Europe, the progress of literature
and science was much more tardy. The natural
sciences were scarcely regarded as an object of
attention, and medicine was still strictly confined
to the study of the works of Galen, or even to
those of his Arabic translators. The only excep-
tion of which our country can boast, is Linacre,
a native of Canterbury, who, after studying at
Oxford, travelled into Italy, and spent some time
at the court of Florence, where he acquired a
portion of that love of literature which so emi-
nently distinguished the family of the Medici.
On his return to England, he was appointed phy-
sician to the royal household, and employed his
influence in establishing medical professorships in
the universities of Oxford and Cambridge, and in
forming the foundation of the London College of
Physicians.§

From the various causes which we have men-
tioned, and probably from some others of less mo-
ment, a spirit of general improvement now began
to manifest itself; the arts and sciences gradually
revived ; philosophy, in all its branches, was
studied on a more correct plan and with a more
enlightened object, and medicine was not slow in

t The dates of the establishment of the various univer-
sities may be found in Eloy, t. iii. p. 223. The learned
work of Tiraboschi, " Storia della Literatura Italiana,"
contains the most ample information respecting the uni-
versities of that country. See also Lauth, Hist. U' Ana-
tomic, liv. v. part iv. sec. 1. § 2.

§ Freind, p. 587-501. We here lose the assistance of
this learned and judicious historian. Eloy in loco. Ca-
bants, p. 144.5. Sprengel, t. ii. p. 8. jiikin's Biog. Mem.
of Med. p. 28-4/. In connection with Linacre, we may
mention the name of Key, Kays, or, as it was Latinized,
according to the custom of the times, Cains, whose libe-
X y J n °,„ ? !fn U,U J e , rS " 5 - ° f CamtaMg* deserves honour-
able sermon. Axkm in Biog. Anec. p. 103-136; and in
Gen. Biog., in loco. Eloy, in loco.

MEDICINE (HISTORY OF)

209

partaking of the beneficial influence. One of
the first symptoms of this improvement was an
increasing relish for the writings of Hippocrates,
and the revival of his method of studying and
practising medicine. The taste for complicated
theory and refined speculation gradually declined,
and in the same proportion the value of correct
observation and an accurate detail of facts began
to be duly estimated.

A circumstance which tended in a considerable
degree to shake the authority of Galen, and to
diminish the veneration in which his opinions had
been held for so many ages, was the rise of the
sect of the Chemical Physicians. After chemistry
had been used with advantage for the purpose of
improving the processes of pharmacy, it was ap-
plied to the explanation of the phenomena of
vitality, and of the operation of morbid causes
upon the living system. The theories of these
chemical physicians we now regard as altogether
false and inapplicable ; but they were advanced
with so much confidence that they obtained many
adherents, and for some time the opinions of the
medical world were divided between the rival doc-
trines of the Galenists and the Chemists.

Among the most noted supporters of the che-
mical theory was Paracelsus, an individual whose
claim to our notice depends more upon his con-
summate vanity and presumption than upon his
abilities or acquirements. His professed object
was to undermine the authority of the Galenists ;
and for this purpose he did not hesitate to hold
forth the most absurd claims, and to practise the
basest acts of quackery. He boasted that he had
discovered the elixir vitae, the universal remedy,
of which mankind had been so long in search ;
and he publicly burned the writings of Galen and
Avicenna, because, in consequence of his disco-
very, they were of no further use. It is some-
what difficult to determine in what degree Para-
celsus was actually the dupe of his own folly ; but
whatever may have been his real opinion as to
the efficacy of his elixir, his own death, at the
early age of forty-eight, served to humble the
confidence of his followers, and to reduce his re-
putation to its real standard.

But although the personal character of Para-
celsus received an irreparable shock by this event,
his doctrines continued to attract a number of
zealous advocates. With respect to the nature
of these doctrines, it will be necessary for us to
say but a few words in this place. The leading
principle of the Chemists was, that the living
body is subject to the same chemical laws with
inanimate matter, and that all the phenomena of
vitality may be explained by the operation of these
laws. The proofs which they adduced in favour
of this principle, and the illustrations which they
gave of the nature of these laws, were completely
futile and unsatisfactory ; and it may be asserted
that the strength of their reasoning was much
more apparent in the mode by which they
attempted to controvert the hypothesis of the
Galenists than in the direct arguments which
they brought forward in favour of their own doc-
trine. In truth, the chemical elements of Para-
celsus were at least as hypothetical as the physio-
logical elements of Galen, and were even less
applicable to the explanation of the vital actions

Voi. Ill — 27 6*

of organized beings. The only obligation which
we owe to the chemical physicians, is the intro-
duction into medicine of certain substances, chiefly
metallic preparations, which, in the hands of the
more enlightened practitioners of modern times,
have proved very valuable additions to the materia
medica.*

After the death of Paracelsus, his peculiar
theories fell into disrepute and were little attended
to ; but the sect of the Chemical Physicians con-
tinued to flourish even as late as the seventeenth
century, when we meet with many examples of
men of learning and sagacity, who attempted to
explain the phenomena of the animal economy
by the laws of chemistry. To the visionary
speculations of the Chemists there was united a
large portion of superstition and mysticism ; and
so much did this feeling coincide with the spirit
of the times, that even the men who were the
most illustrious for their learning and science
were either actually infected with these notions,
or did not venture so far to oppose the prevailing
opinions of their contemporaries as to avow their
disbelief of them. Astrology and magic were
generally practised by the members of the medical
profession, while various rites and ceremonies
were observed, which implied the belief of super-
natural agency, but which, by a singular incon-
sistency, was supposed to be a constant and neces-
sary part of the process.

Before we conclude this portion of our subject,
we must notice the remarkable circumstance, that
about this period, during the fourteenth and
fifteenth centuries, some very formidable diseases
made their appearance in Europe, the origin of
which is still very obscure, after all the discussion
and investigation that has taken place respecting
them. Among these, one of the most remarkable
is what was termed the sudor Anglicunus, which
is first mentioned about the end of the fifteenth
century, and which, for about fifty years, raged at
intervals with extreme violence in England and
in some other countries in the west of Europe.
(Sennert, De Feb. lib. iv. cap. 15. Freind, p. 567,
8. Fbmquet, " Febris Sudatoria," t. ii. p. 162. Cul-
len's Synopsis, t. ii. p. 77, 8. Sprengel, t. ii. p.
491-4.) In the fifteenth century we have the
first correct description of the hooping-cough ; and
from the manner in which it is spoken of by the
contemporary writers, it would appear that it was
considered by them as a new disease. The sea-
scurvy, if not entirely unknown to the ancients,
was at least not distinctly recognised until this
period, so that, if it existed previously, we may
conclude that it was less violent in its effects ; a
circumstance which has been ascribed, with great
plausibility, to the spirit of naval enterprise which
sprang up at this period, and which led to the un-
dertaking of long voyages. (Freind, p. 583. Spren-
gel, t. ii. p. 494-6.)

The great number of establishments which
were formed during the dark ages for the cure of
leprosy, was at one time supposed to be a proof

* Clerc, p. 792 et seq. Sarchusev, Diss. 10. Conring,
cap. xi. sec. 16, 17. Haller, Bib. Med. t. ii. p. 2 et seq.
Eloy, in loco. Spi-engel, sect. ix. ch. 2. Qabanis, sect.
ix. Hutchinson's Biog. Med. vol. ii. p. 197-209. Enfield,
vol. ii. p. 451-4. Jlikin's Gen. Biog., in loco. Blume\-
bach, Introd. sect. 169. 'Renauldin, in Biog. Univ.. " Pa-
racelse."

210

MEDICINE, (HISTORY OF)

that it was a new disease in Europe, imported, as
was imagined, from Asia by the crusaders. There
has been much nosological discussion concerning
the exact nature of the disease to which this term
ought to be applied ; whether there were actually
two species of leprosy, one which was indigenous
in the east, and another species in Europe. Some
writers have conceived that a combination of the
two was produced at this period, while others, ,
again, have supposed that the disease had previ- ]
ously existed in Europe, but that, in consequence |
of the greater degree of communication between
the different parts of it which was brought about
by the crusades, the disease was either more ex-
tensively propagated, or at least was brought more
into notice, and that more active means were there-
fore employed for its relief. (Sprengel, t. ii. p.
371-5.)

It was about the same period, when the western
part of the old continent was in its lowest state
of degradation, that we hear of the ravages of
those varieties of fever emphatically styled the
plague, which were described in the thirteenth,
fourteenth, and fifteenth centuries as invading va-
rious parts of Europe and Asia, and sweeping
away a large proportion of the inhabitants. (Plou-
quet, " Febris Maligna," and " Pestis," in loco.
Culleti, t. ii. p. 74-7, 139-41.) The accounts
which we have of these epidemics would indicate
that they were not an absolutely new disease, but
that the symptoms were modified and aggravated
by the peculiar condition of the great bulk of the
people ; a conclusion which is confirmed by the
fact, that, as the physical and moral condition of
nations has been ameliorated, the occurrence of
these diseases has become proportionally rare, so
that we conceive them to be almost incompatible
with the improvements in civilization and in medi-
cal police which exist in the greatest part of Eu-
rope.

But whatever may be our opinion concerning
the origin of the leprosy and the plague, there is
another disease where, from the peculiarity of its
symptoms, its decidedly contagious nature, the or-
dinary method of its propagation, and the univer-
sality of its occurrence, we are enabled to fix the
date of its appearance in Europe with more cer-
tainty. It is now generally agreed that it was
near the close of the fifteenth century that the
symptoms of syphilis were first recognised in Italy,
from which country the disease very rapidly ex-
tended over the whole of Europe. Concerning
its primary origin much controversy has taken
place ; many writers have attempted to prove that
it was brought into Europe from America by Co-
lumbus; but this opinion, which was at one time
pretty generally received, is now abandoned, nor
are we able to offer any plausible conjecture re-
specting its introduction from any other quarter.

The same difficulty indeed exists in this case as
in that of all those diseases which are produced
i.y no cause except by a specific contagion. Al-
most every individual is obnoxious to them upon
the application of this cause, and this liability ap-
pears to be little affected by constitution, age,
habits of life, climate, and other external circum-
stances. The question is, how were they first
produced 1 It is impossible to imagine that the
first created individual was born with all these

diseases upon him, yet we know of no distinct
cause now in operation which could, in the first
instance, have generated them. These remarks
apply to the small-pox and the measles, which, as
was stated above, were first known to the Euro-
peans about the middle of the sixth century, and
it applies perhaps, still more remarkably to the
case of syphilis. This point must be regarded aa
one of those mysteries of which at present we are
unable to offer any solution. It is true that the
manners of the age in which this disease is re-
corded to have first made its appearance were
grossly licentious, and in many respects unfavour-
able to health; but still we see no satisfactory
reason why the specific poison of this disease
should have been generated ; yet it appears impos-
sible to conceive that, if it had previously existed,
it could have remained for any length of time un-
known or undescribed.*

We have now brought down our sketch of the
history of medicine to the period when the light
of improvement was bursting forth from various
quarters, when men were engaged in the investi-
gation of the different departments of science upon
a plan which, although not free from error, was
more correct than that of their predecessors, and
which by a slow but steady process led to the
establishment of those principles which eventually
produced the complete triumph of truth and phi-
losophy over error and superstition.

CHAPTER VIII. — General view of the state
of medicine during the sixteenth century-
Revival of the Hippocratean school — Account
of the Galenists — The Chemists — The Anat-
omists — Vesa litis, Fallopius, Eustachius.

We have already given an account of the man-
ner in which the taste for the classical writers of
antiquity was gradually developed during the fif-
teenth century, and we stated that in medicine, as
well as in the other departments of science, the
Greek writers began to be studied in the original
instead of their being read through the medium
of translations and commentaries. As this taste
was further matured, the works of Hippocrates
continued to rise into estimation in preference to
those of Galen, and a new school of medicine was
formed, which obtained the name of Hippocratean.
the professed object of which was to proceed upon
the inductive principle, of first ascertaining facts,
and by their generalization to form the theory.
That in every instance they adhered to this plan
we cannot affirm ; indeed we have too many in-
stances where they forgot or misapplied their own
principles, but still the importance of accurate ob-
servation was generally admitted, and although
mankind could not at once abandon their former
errors, they became aware of their existence, and
of the method by which they might be corrected.

The contest between the Galenists and the
Chemists, which agitated the whole medical world
during the fifteenth century, was indeed still main-
tained through the sixteenth; but it was con-
ducted upon more rational principles, and by men
of more enlarged and more enlightened "views.

* Freimi, p. 568-583. Astruc. Do Morbis Veneriis.
Hunter on the Ven. Dis. p. 9. in. Sprengel, t. ii. p. 499
etseq. flouqwt, " Syphilis, Historia'&c.fn loco. Black's
Hist, of Medicine, p. 140-135.

MEDICINE, (HISTORY OF)

211

The Galenists were for the most part more scien-
tific and learned than their adversaries ; they con-
sisted of the professors in the universities, and
what may be styled the regular practitioners; and
although they were still strongly attached to the
tenets of their master, they did not omit to collect
facts and to watch the phenomena of disease.
Their practice may be characterized as being at
the same time complicated and inert ; their mate-
ria medica was principally taken from the vegeta-
ble kingdom, while their prescriptions were long
and multifarious, consisting of a prodigious num-
ber of articles, combined together in such a man-
ner as to render it almost impossible to conceive
the probable operation of the compound, their in-
dications at the same time being derived from an
incorrect hypothesis, and being often either unin-
telligible or impracticable.

The Chemists were the bold empirics of the
day, without learning or experience ; but they
endeavoured to supply the deficiency by confidence
and temerity, and by these formidable weapons
they frequently triumphed over their adversaries.
They discarded the long prescriptions of the Ga-
lenists, rejected many of the articles of their phar-
macopoeia, while they introduced the active
metallic preparations, and made free use of the
most powerful remedies of all kinds. The rival
sects mutually upbraided each other with the
injurious effect of their respective plans of treat-
ment, and probably there was but too much
foundation for their accusations ; for if on the one
hand the Chemists, by their rashness, committed
many fatal blunders, the Galenists, by their feeble
remedies, must have frequently failed in subduing
disease or arresting its progress.

It appears that upon the whole the Chemists,
like the analogous characters in the present day,
acquired a greater share of popularity than their
opponents. Their arrogant pretensions, the more
decisive and intelligible nature of their indications,
coupled with the artifices which they practised for
the mere purpose of acquiring popularity, gave
them a decided advantage over their more learned
and more dignified rivals, who were both unable
and unwilling to contend with them in the race
of empiricism. By degrees, however, the chemi-
cal physicians rendered themselves more worthy
of the public estimation, by making themselves
better acquainted with the principles and practice
of their art ; the search after the philosopher's
stone was gradually abandoned ; and although
many of the doctrines which they still professed
were altogether unfounded, they were less palpably
absurd than those of their predecessors.

Another circumstance occurred about the period
of which we are now treating, which contributed
to produce a most important reform in the science
of medicine — we refer to the study of human
anatomy. With a very few exceptions, which
have been noticed above, during a space of more
than a thousand years, since the death of Galen,
very little advance had been made in our acquaint-
ance with the structure of the body. The profes-
sors of the Arabian school, with their successors
in Italy and France, for the most part contented
themselves with copying the descriptions of the
ancients, without ever calling in question their
accuracy, or endeavouring to confirm or refute

them by their own observations. Even after the
examination of the human subject had been prac-
tised for some time, and its necessity generally
acknowledged, it was long before mankind could
so far frea themselves from the tyranny of autho-
rity as to admit that any imperfection could exist
in the works of Galen, or that his descriptions
were not to be preferred even to the evidence of
the senses.

In reviewing the state of medical science during
the sixteenth century, it will assist us in our pro-
gress if we arrange the principal authors under
the three classes of the Physicians strictly so
called, the Chemists, and the Anatomists. Under
the first head we propose to include both the wri-
ters who still adhered implicitly to the tenets of
Galen, and those who, paying less regard to mere
authority, devoted themselves more to observing
the phenomena of disease and the effects of
remedies, and who may be considered as having
laid the foundation of the modern Hippocratean
school. Of these, some of the most distinguished
by their character or writings were Cornarus and
Mercurialis in Italy, Hollerius, Fernel, and Duret
in France, Lommius and Forest in Holland, Sen-
nert, Plater, and Foe's in Germany, and Linacre
in England. (Sprengel, t. ii. passim. Cabanis,
ch. ii. § 10.)

The limits to which we are confined will not
permit us to enter into any detail of the individual
merits of these authors, or into any analysis of
their writings or opinions. For the most part
they were possessed of a competent knowledge of
ancient literature, and well acquainted with the
works of the Greek physicians; many of them
were professors in universities or teachers of medi-
cine, and engaged in extensive practice. They
were generally diligent collectors of facts, and
many of them voluminous writers, either publish-
ing their own observations, or commenting on the
ancients. Their practice was in a great measure
taken from Galen, with the additions that had
been derived from the materia medica of the Ara-
bians, and in a few instances from the Chemists ;
but these latter were regarded as dangerous and
empirical, and it was not until they had been long
sanctioned by popular use that they were received
into the authorized pharmacopoeias. The actual
advance which the practice of medicine received
from these authors was not very considerable ; but
by their learning and diligence and their general
respectability they contributed to raise the charac-
ter of the profession, and to prepare the mind to
receive the improvements in science which were
gradually unfolded in the next century, and to
apply them to the department of medicine.

With respect to the Chemists of this period,
although they composed a numerous and active
body, yet there is none of them whose name is
sufficiently distinguished above his fellows to
require being particularized in this place. As
science and knowledge gradually advanced, the
absurdity of their speculations was more generally
perceived, and their pursuits were either aban-
doned, or were directed by a more philosophical
spirit ; and although the search after the univer-
sal medicine was not entirely discarded, they began
to occupy themselves with inquiring into the
chemical constitution of the body, and investiga

212

ting the changes that were induced in it by dis-
ease. This investigation was indeed attended
with little success ; their experiments were crude
and imperfect, and their modes of analysis alto-
gether inefficient. But still some impprtant ob-
servations were made, and new processes were
invented, and the foundation began to be laid for
the more enlightened views of their successors in
the succeeding century.

But the benefit conferred upon the science of
medicine by the labours of the Chemists was
trifling and uncertain compared to the great and
direct advance which was produced by the re-
searches of the Anatomists. Some attention had
been paid to the structure of the body by the ear-
lier Italians, and they had even ventured, in a few
instances, to dissect the human subject ; yet
scarcely any discovery or any improvement de-
serving of notice had been made for many ages,
when Vesalius, about the middle of the sixteenth
century, entered upon his career of inquiry. He
was the first anatomist who threw off the yoke of
authority which had been imposed by a blind
veneration for the opinion of the ancients, and
who ventured to conceive the possibility of error
in the writings of Galen. Vesalius prosecuted
his researches with unwearied diligence, and dis-
regarding the obloquy which was heaped upon
him, he succeeded in publishing an anatomical
work, which at this day we behold with admira-
tion, and which maintains its character as a faith-
ful transcript of nature. (Eloy, " Vesale." Hol-
ler, Bib. Anat. lib. 4, § 1C3. t. i. p. 180 et seq.
Sprengel, t. iv. p. 5-9 ; Douglas, Bibliogr. Anat.
p. 64-73. Renauldin, in Biog. Univ. " Vesale.")
But the reputation of Galen was too firmly
established to be affected in any considerable
degree by the observations of any single individual,
however highly he might be entitled to the respect
of his contemporaries. Long and acrimonious
discussions occurred between the defenders and
the opposers of Galen, some maintaining that his
descriptions of the parts of the body were abso-
lutely perfect, while others undertook to prove, by
direct and palpable facts, that Galen's knowledge
of the human form was not complete. It was
asserted, on the one hand, that he had seldom
examined the human subject, and that his descrip-
tions were frequently taken from apes and mon-
keys ; an imputation which was firmly denied by
his zealous advocates. Eustachius, Fallopius, and
others of great and deserved reputation for their
anatomical skill, undertook the defence of Galen ;
and it was not until after a long and severe strug-
gle that the truth was established, and that it was
agreed that the anatomy of the ancients was in
many parts imperfect, and that the errors which
had been pointed out by Vesalius actually existed.*
It would be foreign to our purpose to enter into a
minute examination of the labours of the indi-
vidual anatomists, or to mention in detail the suc-
cessive improvements which were effected in^their
department. With respect to the practice of medi-
cine, which is our more immediate object, it does
not appear that they effected any direct improve-

MEDICINE, (HISTORY OF)

ment but they contributed indirectly to its ad-
vancement in no small degree by completely esta-
blishing the important point that the opinions of
the ancients were not to be considered as infalli-
ble but were to be subjected to the ordeal of free
inquiry.

CHAPTER IX. — Stute of medicine during f/ ie
seventeenth century — The chemical and ma-
thematical sects — Progress of anatomy — Fana-
tics — Chemical physicians — Sylvius — WilBt
— Sydenham — Mathematical physicians.

All the changes of opinion which we have de-
scribed as occurring in the sixteenth century con-
tinued to advance with an accelerated progress
during the seventeenth. The preference which
was given to Hippocrates over Galen was daily
gaining ground, and, as the consequence of this,
the habit of correct observation was confirmed,
and the value of the observations was more justly
appreciated. ,

In the mean time, anatomy was making rapid
strides. Being a science which depended more
immediately upon the accumulation of matters of
fact, which required for their attainment little
more than industry and mere observation, errors
were more readily discarded than on those sub-
jects in which much reasoning was necessary,
and in which it was rather an inference from
facts than the facts themselves, which constituted
the object of the investigation. The investiga-
tions of the anatomists extended to every part and
structure of the body ; the forms and textures of
the bones, the muscles, the nerves, the vessels,
and the various viscera, were each in their turn
made the subject of particular and minute exami-
nation by some of the eminent men of the age.
These labours were amply rewarded by the splen-
did discovery of the circulation by the immortal
Harvey, and of the absorbent system by Asselli,
Rudbeck, and Bartholine ; while the structure
and office of the lungs, and the relation which it
bears to the heart, were explained by Malpighi,
Hooke, Mayow, and their associates.j-

With respect to the chemists of this period,
their opinions were gradually disengaged from the
tissue of mystery and credulity in which they had
been so long involved, when about the middle of
the century the science w T as finally placed upon
its correct philosophical basis by the genius of
Boyle. He correctly regarded it as an investiga-
tion into the change of properties which bodies
experience by their action upon each other, and
he pursued the investigation, not by presupposing
the existence of certain occult causes and hypo-
thetical agencies, but by an accurate examination
of the effects which bodies actually produce upon
each other when placed within the sphere of their
mutual action. £

It is, however, not a little remarkable that while
the science of chemistry generally, and more espe-
cially the sect of the Chemical Physicians, was
purifying itself of its grosser errors, we meet with
not unfrequent instances where it continued to be

* Haller, Bib. chir. lib. 5, " Schola Italica ;" and Bib.
Anat. lib. 5. " Schola Italica." Fallopius, § 200, t. i. p.
218 et seq. Eustachius, § 205, t. i. p. 2X\ et seq. Doug/as,
Biblio-r. Anat. in Fallopio, p. 94-06, et in Eustachio, p.

dfr-ioo

.t, Th ?.' bur , tn v °lume of Sprengel is principally occii-
pted with a luminous view of the anatomical discoveries
of tins period.

J Campbell , in Biog. Brit, in loco. Haller, Bib. Med.
lib ix sect. 703 t. i,j. p. 109-13. Nicholson \n Aikinl
til' c g ^' n . ^ C0 - More "' in Brewster's Encyc, in
loco. Suard et Cutter, in Biog. Universale, in loco.

MEDICINE, (HISTORY OF)

213

combined with a singular degree of fanaticism.
There was indeed no period, since the time of
Paracelsus, when there were more remarkable ex-
amples of the prevalence of this spirit, and in no
country were they more notorious than in Eng-
land. The writings of Fludd, who practised in
London in the early part of the seventeenth cen-
tury, afford a curious compound of learning and
folly, of profound erudition, united to an implicit
faith in astrology, and in all the cabalistic opinions
of the Jewish doctors.* Perhaps a still more re-
markable example of this combination is that of
the celebrated Kenelm Digby, a man of rank and
of refined education, who during his travels on
the continent became initiated into this mysterious
chemical philosophy, and on his return gave a
specimen of his opinions by publishing an account
of the virtues of the sympathetic powder.-j- An-
other of these individuals who obtained great
celebrity was Valentine Greatrix, who cured all
diseases by the imposition of the hand, and who
even ventured to oppose his power in this respect
to the royal touch of Charles.^ These circum-
stances are interesting, not merely as forming a
part of the history of medicine, but as displaying
a singular feature in the history of the human
mind ; demonstrating the difficulty which exists
in eradicating from it errors and follies even the
most gross and palpable, when they have once
become deeply rooted. §

While what may be more strictly termed che-
mistry was advancing into the state of a science,
a combination was formed between its principles
and those of physiology, which gave rise to the new
sect of the Chemical Physicians. Their leading
doctrine was, that the operations of the living
body are all guided by chemical actions, of which
one of the most important and the most universal
is fermentation. The states of health and of dis-
ease were supposed to be ultimately referable to
certain fermentations, which took place in the
blood or other fluids, while these fluids themselves
were the result of specific fermentations, by which
they were elaborated from the elements of which
the body is composed. Again, certain humours
were supposed to be naturally acid, and others
naturally alkaline, and according as one or the
other of these predominated, so certain specific
diseases were the result, which were to be removed
by the exhibition of remedies of an opposite nature
to that of the disease in question. According to
the theory of the Chemical Physicians, fever was
supposed to originate in an acid condition of the
humours, and was consequently to be cured by
alkalies; and in conformity with what is so often
found to take place in tracing the history of medi-

* Enfield, v. ii. p. 454, 5. Sprengcl, t. v. p. 6-9. F.loy,
in loco. Haller, Bib. Med. t, ii. p. 409. jtiltin's Biog.
Mom. of Med., p. 271-5. Hutchinson's Biog. Med., v. i.
p. 303-5.

t Sprengcl, t. v. p. 9. Eloy, in loco. Campbell, in Biog.
Brit., in loco. Aikin's Gen. Biog., in loco. Nouv. Diet.
Hist., in loco, jlikin's (Miss) Mem. of Charles I., v. i. p.
410-10. See " A late Discourse," &x. by Sir K. Digby,
translated by R. White : a work which affords one of
those embarrassing cases where it is so difficult to assign
the exact limit between credulity and empiricism.

I Phil. Trans, for 1099, p. 332-4. Lowthorp's Abrid. of
Phil. Trans., v. iii. p. 11, 12. Sprengel, t. v. p. 10. Hutch-
inson's Biog. Med., v i. p. 373-e0.

§ Sprengcl, sect. 13, ch. i.

cine, they discovered that alkalies were actually
the most efficacious remedies for fever.

The individual who may be considered as hav-
ing first given a connected and consistent view of
the theory of the medical chemists, is Sylvius.
He was born at Hanau, in Flanders, in 1614 ; he
graduated in the university of Basil, practised for
some time at Amsterdam, and finally was ap-
pointed to fill the chair of practical medicine at
Leyden, where, by his genius and eloquence, he
acquired a high degree of popularity. From this
circumstance, his peculiar opinions obtained a
very extensive circulation, and the hypothesis of
fermentation, with the acid and alkaline states of
the fluids, after some time became the fashionable
doctrine of the French and German physicians,
and had many zealous defenders in our own
country. ||

One of the most respectable of the advocates of
the chemical doctrines of medicine, was our
learned countryman Willis. He was only a few
years younger than Sylvius, and was early in life
attached to the science of chemistry, which he
afterwards applied with much ingenuity to the
explanation of the functions of the animal eco-
nomy. In the year 1659 he published his cele-
brated treatise on fermentation and on fever, the
object of which is to prove that every organ of the
body has its peculiar and appropriate fermentation,
and that a morbid state of these ferments is the
cause of all diseases. The hypothesis is in itself
totally false, but it is supported by considerable
ingenuity, and his works are of real value, as
containing an accurate account of the phenomena
of disease. Willis was also the author of some
treatises of very considerable merit on the nervous
system, and on various physiological topics, by
which his reputation is amply supported as one of
the most eminent medical philosophers of the age.f

The reputation of Willis has, however, been
somewhat obscured by the still higher reputation
of Sydenham, a man scarcely inferior to any that
has passed under our review. He has been fre-
quently styled the English Hippocrates, and there
are various points of analogy between them, both
as to general character and as to their peculiar
mode of viewing the operations of the animal
frame. The writings of Sydenham, like those of
his great predecessor, abound in theory, but they
also resemble those of Hippocrates, in containing
the most accurate detail of facts, indicative of a
mind of great sagacity, which enabled him to
seize upon the most essential features of a disease,
and to direct his attention to those points alone
which tended to illustrate the nature of the morbid
changes that were produced. But the great merit
of Sydenham, that which has raised his reputation
to so high a pitch of celebrity, and which causes
his works to be still read with admiration, is the
same with that which was ascribed to Hippo-
crates, viz. not allowing his speculative opinion;
respecting the nature or cause of diseases to inter-
fere with the treatment. He carefully observed
the operation of remedies on the symptoms, and

||.E/oy, "Dubois." Haller, Bib. Med., lib. ix. t. ii. p.
027 et seq. Sprengel, sect. 13, ch. v. Biog. Univ., in loco

IT Barchuscn, Diss. 23, sect. 15 et seq. Halkr, Bib.
Med. sect 085. Eloy, in loco. Sprengcl, t. v. p. 7 *
Jiikiu, in loco. Biog. Univ., in loco.

214

MEDICINE, (HISTORY OF)

the action of the various external circumstances
to which tiiC patient is exposed, and from their
effect he deduced his indications. He accommo-
dated his theory to the facts, not, as is too fre-
quently the case, the facts to the theory. He
agreed generally with Willis, in ascribing the
origin of disease to certain morbid fermentations,
and he conceived the primary changes to take
place, not in the solids, but, according to the
opinion almost universally adopted at that period,
in the fluids; this, indeed, may be regarded as a
necessary consequence of the assumed hypothesis.

In one important point he agreed very nearly
with Hippocrates, that diseased action consists
essentially in an effort of nature to remove some
morbid or noxious cause, and that the great object
of the practitioner is to assist in bringing about
the proper crisis, and to regulate the actions of
the system so as to prevent either their excess
or their defect. The practice was necessarily of
a kind which, in the present day, would be styled
somewhat inert, consisting rather in attempts to
palliate certain symptoms than in any attempt to
counteract or remove their cause. But although
we may conceive that the object in view was not
always precisely what it would have been, had he
not been somewhat biassed by his hypothesis, the
mode in which he proceeded to effect his indica-
tions is in most cases very judicious. We may,
perhaps, venture to affirm that there are few prac-
titioners, even in the present day, who were better
acquainted with the juvantia and lsedentia, who
were more successful in attaining a just medium
between excessive caution and undue vigour, and
whose proceedings were more guided by the dic-
tates of a sound understanding, enlightened by an
extensive range of observation and an ample store
of well-digested experience.*

We have spoken of Sydenham in connection
with Willis and the chemical physicians, because
in many parts of his writings he adopts the hypothe-
sis, that fermentation and other chemical changes
in the state of the fluids are the primary causes
of disease. Yet we have been, at the same time,
especially careful to point out that the distinguish-
ing merit of Sydenham consisted in his not mani-
festing an undue attachment to any theory, but in
devoting himself to the study of disease, and the
effect of remedies upon it. This merit was not
unperceived by his contemporaries, and we learn
that he was held by them in great respect. Yet the
general spirit of the age was so entirely devoted to
hypothesis and speculation, that he can scarcely
be said to have made any great impression upon
the general state of medical opinion, or to have
materially diverted the mind from an almost ex-
clusive attention to the theories which were then
so prevalent. Indeed, with every feeling of ad-
miration for the character and acquirements of
Sydenham, it must be admitted that he was not
himself fully aware of the great principle, which
is the foundation of true philosophy as well in
medicine as in every other department of science,
that all theory not derived from the generalization
of facts is objectionable, and almost necessarily
leads to erroneous conclusions. Sydenham's na-

* Haller, Bib. Med. lib. 10, t. iv. p. 188 et seq. Eloy,
in loco. Sprevgel, t. v. p. 5(56-576. Cabanis, sect. 12.
Mihin, in loco. Renauldin, in Biog. Univ.

tural sagacity caused him to feel the value of the
inductive method, but it was more from this cir-
cumstance than from any abstract conception of
its importance, that he was induced to adopt it.
The state of medical science was indeed scarcely
ripe for that reform which had now commenced in
many other departments of philosophy. It is
more a science of observation than of experiment,
and the observations are of peculiarly difficult
execution, depending upon the combined opera-
tion of various causes, and involving much com-
plication in the effects, the respective proportions
of which it is often extremely difficult to ascertain
and to appreciate. Hence it required a more
matured state of medical knowledge before we
could arrive at the great truths which had been
promulgated by Bacon, and which were generally
recognised in the other departments of science.
Although mankind were aware of the importance
of observation and experience, they were not sen-
sible of their full value ; and it required another
century and various successive revolutions of
theory before they could be detached from the
hypotheses that had been transmitted to them from
their predecessors, and had been sanctioned by the
authority of so many illustrious names.f

One of these revolutions was produced by the
rise of a new theory of medicine, perhaps mote
captivating than any which had yet appeared,
from its scientific aspect and its high pretensions;
we allude to the doctrines of the mathematical
physicians ; or, as they have been termed, the
iatro-mathematical School. The rapid advance
which had taken place in mathematical science
during the latter part of the sixteenth century,
and the fortunate application of it to various
branches of natural philosophy, induced some of
the Italians to apply it to the explanation of the
phenomena of the living system. Of these one
of the first, both in order of time and of celebrity,
was Borelli. He was a profound mathematician,
and a man entirely devoted to scientific pursuits,
and in his well-known treatise on muscular mo-
tion he illustrated, in a very happy manner, the
mode in which certain functions of the body may
be elucidated and explained on mechanical prin-
ciples. Some of the data which he assumes are
now admitted to be incorrect, and in some cases
the deductions are not the fair results of the pre-
mises ; but upon the whole it is allowed that he
established many important points, and consider-
ably advanced our knowledge of the animal eco-
nomy. The new path of inquiry, which had been
thus so successfully opened by Borelli, was soon
occupied by many of his contemporaries and pu-
pils, and according to the usual custom on such
occasions, it was carried by them far beyond its
legitimate limits, and was applied to various topics
with which it had little connection. One of the
most active and ardent in this pursuit was Bellini,
who was a professor at Pisa, and who exhibited
such marks of early genius as to become a lec-
turer at the early age of twenty. His acquire-
ments were varied, and his talents were splendid,
but they may be pronounced to be rather showy
than solid, and to be^ more adapted to excite ap-

.J,^% haVe a ? , ampIe »ceounTcTf tlie~~iatro-chemical

™« iJfrTJ' 1 '. § J, 3 - ch ' vi; ; i,s advocates were nui

rous and respectable, but few were of that distinction
which entitle* them to be noticed in this sketT

MEDICINE, (HISTORY OF)

215

plause than to advance true science. The mode
of reasoning which had been employed by Borelli
to explain the action of the muscles, which is
essentially a mechanical function, and where such
reasoning was therefore appropriate, was extended
by Bellini to all the functions and actions of the
body both in health and in disease. He maintained
not only that every part of the body is under the
influence of gravity and mechanical impulse, but
that these are the sole agents, and that we may ex-
plain all the vital functions merely by the application
of the principles of hydrostatics and hydraulics.

The imposing air of the new hypothesis in-
stantly dequired for it a number of converts, em-
bracing many of the most learned men of the age.
The body was regarded simply as a machine com-
posed of a certain system of tubes ; and calcula-
tions were formed of their diameter, of the fric-
tion of the fluids in passing along them, of the
size of the particles and the pores, the amount of
retardation arising from friction and other mecha-
nical causes, while the doctrines of derivation, re-
vulsion, lentor, obstruction, and resolution, with
others of an analogous kind, all founded upon
mechanical principles, were the almost universal
language of both physicians and physiologists to-
wards the close of the seventeenth century. In
proportion as the mathematical sect gained ground,
that of the chemists declined, while between the
two the old Galenists may be considered as nearly
extinguished. In Italy and in England the ma-
thematical doctrines had many learned and zeal-
ous adherents ; it had also some followers in
France, although in this country as well as in
Holland and Germany, the chemical theory still
continued to prevail.*

When we consider the very great influence
which the iatro-mathematical sect exercised over
the theories of their contemporaries, we may per-
haps be surprised that it did not produce any very
ilecided or immediate effect upon their practice.
In fact their reasoning was more applicable to
physiology than to medicine, for while it appeared
to afford a satisfactory explanation of the pheno-
mena of muscular contraction, of the circulation,
and of the other functions in which motion was
concerned, it was obviously less applicable to the
explanation of the obscure and secret agencies by
which diseased action is either produced or re-
moved when present. It was, indeed, frequently
employed by the pathologist to explain the proxi-
mate cause of disease and the operation of reme-
dies, but, except in a few instances, it can scarcely
be considered as having had much effect upon the
actual treatment. For the most part the practice
that was adopted by this sect was founded upon
the principles of the humoral pathology, and may
be said to have been fundamentally that of the
Galenists, although with considerable additions,
derived from the more energetic treatment and the
enlarged materia medica of the chemists. The
great advantage which the science of medicine

* Sprengel, sect. 14. Cabanis, ch. 2, § 9. In Italy we may
■elect, as among the most eminent of the intra-mathe-
matical sect, Uorelli, Bellini, Castelli, and Guglielmini ;
in France! we have the celebrated Sauvages, and in our
own country Pitcairne, Charleton, Keill, Jurin, Mead,
and Freind; we may remark, however, that some of
these, although practitioners of medicine, are principally
indebted for their reputation to their physiological writ-
ings.

derived from the mathematicians was of an indi-
rect nature, depending upon the habit of close
reasoning and strict deduction, which is requisite
in all mathematical inquiries, and which, although
in this instance incorrect in the application, and
sometimes even founded upon a fallacious basis,
were detailed with much labour and ingenuity,
and tended both to improve the intellectual powers
of the individual, and to raise the character of the
medical profession.

During this period, while the minds of men
were engaged in these controversies, and while so
much attention was paid to theoretical reasoning,
the practical part of the science was apt to be re-
garded as of secondary importance. Certain in-
dividuals, indeed, among whom Sydenham may
be mentioned as a most illustrious example, con-
tributed in an eminent degree to improve our
knowledge of the phenomena of disease and of
the effect of remedies upon it ; but it must be con-
fessed that for the most part medical men were
more anxious to establish their favourite doctrines
than to investigate the truth, and we find that, in
the account which they give of the details of their
practice, they appeared to be much more influenced
by the desire of assimilating their experience to
the tenets of their sect, than of inquiring how far
these tenets were themselves sanctioned by their
experience. In some instances there is too much
reason to suspect that the operation of the theo-
retical views of the practitioner was decidedly un-
favourable. The opinion which was entertained
by the chemical physicians of the nature of fe-
ver, that it depended upon an acrid state of the
fluids, led to the indiscriminate use of alkalies in
all cases which were considered as belonging to
this class of diseases. Again, certain hypotheti-
cal opinions which were entertained by the mathe-
matical physicians respecting the mechanical con-
dition of the blood, caused them to employ the
lancet in cases where we should now consider it
as decidedly injurious. But it does not require
the illustration of particular cases to prove the po-
sition, that where the theoretical views which
were entertained of the nature of the disease were
incorrect, and where the practitioner was guided
by these views, the result must have been fre-
quently unfavourable. Happily, however, for
mankind, there were not wanting individuals who
rose superior to the spirit of the age, who disre-
garded the controversies of the contending sects,
and who followed the inductive method of studying
medicine which had now been introduced into
philosophy by the commanding genius of Bacon.
Besides Sydenham, our own country may justly
boast of the names of Morton, Mead, and Fieind.t
who, although not without their bias towards par-
ticular 1 opinions, were men of superior minds, whe
were fully aware of the imperfection of medical
science, and of the value of experience as the
means of remedying this imperfection.
CHAP. X. — Account of the sect of Yitalists—
Van Belmont — Stahl, his system — Hoffman,
his system, pathology, influence of his doctrines
— Solidism — Baglivi— Disciples of Stahl.
While the medical world was thus divided be-

t For the character and writings of these eminent
physicians the reader is referred to the respective arti-
cles in JrJIoy und lluller, Bib. Med.

216

MEDICINE, (HISTORY OF)

tween the rival opinions of the chemi ts and the ; express terms, the great and important principb

tint the living body possesses powers of a specific
nature different from those which belong to inani-
mate matter, yet so much mysticism and error
were mixed with it, that it produced little effect

mathematicians, a new sect was gradually rising
up, which, although in its commencement it was
perhaps equally remote from the principles of true
science, became by successive improvements freed
from many of its exceptionable parts, and finally
triumphed over both the contending parties. It
originated with Van Helmont, who commenced
his philosophical career as a disciple of the chemi-
cal school of Paracelsus. He was a man of a
powerful mind, but with a considerable mixture
of enthusiasm and even of fanaticism, who be-
came disgusted with the Galenic mode of studying
and practising medicine, and embraced the bolder
and more efficacious system of the chemists. But
he made this great and essential addition to their
doctrine, — that the changes which are produced
in the body by its own spontaneous actions, as
well as by the operation of remedies, are under
the influence of a specific agent, which resides in
or is attached to the living system, and to which
he gave the name of archeus*

It would not be easy to give any exact defini-
tion of the term, or to assign the precise meaning
which was attached to it. Sometimes he seems
to consider it as an abstract principle or power
distinct from the material part of the universe ;
sometimes as a species of element, and at other
times as a certain modification of matter which
acquires peculiar qualities or agencies.-j- In con-
sequence of his early training in the chemical
school, he occasionally speaks of the archeus as a
kind of ferment, and it would appear that he re-
solves all the operations of the living system and
all the functions into certain fermentative pro-
cesses effected by the action of the archeus. In
short the archeus was tho convenient and never-

on the opinions of his contemporaries. Nearly
half a century had elapsed after his death, during
which time the physicians and physiologists were
still defending the doctrines of the chemists and
the mathematicians each against their respective
antagonists, when a new impulse was given to
medical theory by the appearance of the cele-
brated Stahl, who was born at Anspacli in the
year 1660. His education was almost exclusively
occupied with the study of medicine. At the
age of twenty-three he became a public lecturer,
and from this time he bore a conspicuous rank in
his profession, both as a teacher and a practitioner,
during the remainder of his life. He was brought
up in the principles of the chemical school, and
hence his attention was early turned to the study
of chemistry, in which science he effected a still
greater revolution of opinion than in that of medi-
cine. He possessed a character and disposition
well adapted to become the founder of a new sect.
He had great activity of mind united to great in-
dustry ; he was zealous and enthusiastic, at the
same time inclined to fanaticism and mystery; he
was bold, confident, and arrogant, fully impressed
with the importance of his own opinions, and dis-
posed to place little reliance on those of others.
His arrogance, however, probably induced him to
enter upon investigations which he might not
have attempted had he contented himself with
following the track of his predecessors, and to his
declared contempt for the learning of his contem-
poraries wc may consider ourselves as in part at

failing aid to which he had recourse for the pur- ; least indebted for his original speculations, and for

pose of explaining all the actions of the system
either in health or in disease ; it was equally the
cause of digestion and of sanguification, of fever
and of inflammation. Van Helmont, both from the
peculiar turn of his mind and from the course of
study to which he had devoted himself, was little
qualified to watch over the phenomena of disease,
or to discriminate between the nice shades which
so frequently serve to characterize the different

the actual additions which he made to our know-
ledge. This contempt and arrogance were carried
to such an extent that he professed to set little or
no value upon any of those studies that are usually
associated with medicine, even that of anatomy;
and he appeared to pay no regard either to the
assertions or the arguments of his contemporaries
when they opposed any of his favourite doctrines.
Besides his ardour in the pursuit of medical

morbid affections. Accordingly it does not appear ; science, he appears to have had a decided turn for

that he introduced any improvement into the prac-
tice of medicine, or indeed into any of the colla-
teral departments ; he is solely entitled to be no-
ticed in this place as having laid the foundation
for a new series of opinions, which were gradually
moulded into one of the most important theories
which had occupied the attention either of the
physician or the physiologist. t

Although, strictly speaking, Van Helmont must
be regarded as the individual who first stated, in

* He probably took the term from Paracelsus, who
speaks of it as a new word which he had introduced into
medicine ; Chirurg. Mag. tract .5, cap. 15.

t See the section of his " Ortns Medicinre," entitled
"Archeus Fabcr ;" also Castelli's Lexicon, "Archeus."

J Eloy, in loco. Haller, Bib. Med. lib. 8, t. ii. p 518 et
»eq. Enfield, v. ij. p. 458-(i0. Goulin, in Enc. Meth.
Medecine, in loco. Sprcngel, sect. 13, ch. 3 : this author
gives us a very minute analysis of the writings and
opinions of Van Helmont. Although his absurdities are
not concealed, we conceive that the account is somewhat
too favourable Hutchinson's Biog. Med. v. i. p. 414-423.
Fournier, in Biog. Univ. in loco.

metaphysical reasoning, and in the formation of
his theories he was probably influenced by the
doctrines of Descartes, which were then embraced
by many of the learned men of Europe.

Stahl saw the errors and deficiencies of both
the prevailing theories ; he therefore laid it down
as a fundamental position, that neither chemical
nor mechanical reasoning is applicable to the phe-
nomena of life, and he consequently bestowed all
his attention on the study of what he termed vital
actions. These actions he refers to the operation
of a principle which he styles anima, and which
in many respects resembles the archeus of Van
Helmont. (Physiol, sect. 1, numb. 3, sect. 13, et
alibi.) The basis of the Stahlian doctrine is simi-
lar to that of the Cartesian system, that matter is
necessarily and essentially passive or inert, and
that all its active properties or powers are derived
from an immaterial animating principle, which is
superinduced upon it or added to it. It is by the
operation of this spiritual principle upon the ma-

MEDICINE, (HISTORY OF)

217

terial organs of the body that all the vital func-
tions are produced, and it is on the absence or
presence of this principle that the difference be-
tween living and dead matter essentially depends.
Stahl observed with considerable acuteness the
action which the mind exercises over the body,
and he proved that these effects could not be re-
ferred either to a mere chemical or mechanical
agent. This point, clear as it now appears to us,
had not been distinctly recognised before his time,
or rather, it may be said that the contrary opinion
formed the basis of both the prevailing theories.
But although he laid down this great truth, and
established it by incontrovertible arguments, there
is considerable obscurity respecting the nature of
this immaterial or superintending agent ; and when
we enter upon the detail of his description, we
become involved in a labyrinth of metaphysical
subtlety. We are told that the anima superin-
tends and directs every part of the animal economy
from its first formation ; that it prevents or repairs
injuries, counteracts the effects of morbid causes,
or tends to remove them when actually present,
yet that we are unconscious of its existence ; and
that, while it manifests every attribute of reason
and design, it is devoid of these qualities, and is
in fact a necessary and unintelligent agent. He
examined with much attention the nature of the
different functions, their relation to the anima, and
their dependence upon it; he endeavoured to ex-
plain the effect of organization, and the mode in
which organization operates in producing these
functions. In these investigations he displays con-
siderable acuteness, and he contributed materially
to advance our knowledge of the laws of vitality ;
but still his ideas are, in many respects, confused
and indistinct, and he is more disposed to enter
into subtile disquisitions respecting the nature of
his supposed principle, than to examine the actual
phenomena of the animal economy, and from
them to deduce his general laws.*

Contrary to what is frequently the case, the
hypothesis of Stahl had a considerable influence
upon his practice. As all the actions of the sys-
tem are under the control of the anima, and as
the office of this principle is to preserve the sys-
tem in its perfect state, the duty of the physician
is reduced to the mere superintendence of its
actions, generally to co-operate with its efforts, or
if they should be irregular or injurious, which we
are to suppose is seldom the case, to endeavour to
restrain or counteract them. These views tended
to repress the energy of the practitioner still more
than the pathological doctrines of Hippocrates,
inasmuch as the anima of Stahl was conceived to
exercise a more direct influence over the operations
of the economy than the ipvcts of Hippocrates,
which was simply a general expression of these
actions, and which, according to circumstances,
miight be either beneficial or injurious to the sys-
tem. As a specimen of the mode in which Stahl
applied his theory to practice, we may select his
doctrine respecting plethora. He supposed that
the body had a general tendency to the plethoric
state, hecause he ohserved that spontaneous cvacu-

* Halter. Bib. Med. lib. xi. t. iii. p 575etseq. Eloy, in
loco. Cullcti, Preface to his "First Lines," p. 12-18.
tiprengel, sect. 15, eh. 1, t. v. p. 105-270. Blumtnbach,
§ 130. Thomson's Cullen, v. i. p. I64-It2. Revauldin,
Bine, t'niv. in loco.

Vol. III. — 28 t

ations of various kinds occasionally took place,
and these he assumed were produced by the provi-
dent care of the anima, in order to remove a
plethora which must have previously existed so as
to render them necessary. An important office
of the superintendent principle is therefore to pro-
duce the necessary evacuations in order to pre-
vent or remove this plethora, and hence it becomes
the duty of the practitioner to watch over the
evacuations, to promote them if too scanty, or to
repress them if too abundant. (Pathol, pars ii.
sect. 1, mem. 2, § 3 et alibi.)

The theory of Stahl, so far as it tended to fix
the attention upon the vital actions of the system,
and to overthrow the mechanical hypotheses which
had so long and so generally prevailed, may be
considered as having performed an essential ser-
vice to the science of medicine. The appearance
of metaphysical acuteness which it presented, in-
dependent of its real merits, acquired for it a de-
gree of popularity in an age when the attention
had been particularly directed to subjects of this
description. It certainly produced a considerable
revolution both in medical language and in medi-
cal opinions; and although Stahl had but few fol-
lowers who received his doctrines in their full ex-
tent, it was partially embraced by many of the
most intelligent and learned men of that period,
and it has ultimately had a great and extensive
influence on the state of the science. Indepen-
dently of the defects inherent in the system itself,
the spirit of inquiry was now so widely diffused,
and the importance .of patiently investigating the
phenomena of the animal economy was so gene-
rally admitted, that the merits of all theories were
more strictly canvassed and subjected to more se-
vere examination. From the same combination
of causes a variety of rival hypotheses were pro-
duced, which tended to prevent the exclusive
adoption of any one of them in preference to the
rest ; and the same state of things was still farther
promoted by the great number of medical schools
which were established in all the great cities of
Europe, each of which was anxious to advance
its claim to the public attention.

We have given to Stahl the great merit of
having clearly perceived and decisively established
the important truth, that the operations of the
animal economy cannot be explained by the laws
either of chemistry or of mechanics, and that wc
must therefore have recourse to something of a
specific nature, peculiar to the living system itself.
Yet, although he succeeded in pointing out the
insufficiency of the existing theories, the one
which he substituted in their place, the action of
the superintending anima, was no less difficult to
comprehend, was equally hypothetical, and equally
liable to objections. His genius was not of a kind
which was adapted to slow and patient investiga-
tion, and we accordingly find that he either de-
fends his system upon general grounds, or rests
satisfied with merely pointing out the errors and
deficiencies of his adversaries. A powerful and
sagacious mind was still wanting, which might
carefully examine into the nature and operations
of the powers that exclusively belong to the living
body, and after ascertaining the facts, might ge-
neralize them, and thus deduce the correct theory.
This was a process of much labour and difficulty,

218

MEDICINE, (HISTORY OF)

one which coulJ only be accomplished by slow
degrees, and which it might be expected would
require the co-operation of various individuals.

Of those whom we should be disposed to re-
gard as having mainly contributed to this gradual
progression, the first in point of time as well as
of celebrity is Hoffmann. He was the contempo-
rary of Stahl, and his colleague in the university
of Halle ; he may be considered likewise as his
rival, for although they both contributed so con-
siderably to advance our knowledge of the animal
economy, and, to a certain extent, by pursuing a
similar mode of reasoning, yet they were persons
of very different habits and dispositions, and at-
tempted to attain the same object by very different
means. Hoffmann was a prolix and discursive
writer, whose collected works occupy many folio
volumes, and the very titles of which, as detailed
by Haller, extend to no less than thirty-eight
quarto pages. (Haller, Bib. Med. t. iii. p. 536-
576.) It must therefore be supposed that they
contain much that is of little value, and exhibit
many marks of the hasty manner in which they
were composed. Yet he appears to have been a
diligent observer and collector of facts, and there-
fore, notwithstanding the repulsive aspect of his
works, they are highly estimated and frequently
referred to. He attended much more to the de-
tails of practice than his colleague, and, indeed,
the basis of his great work, " Systema Medicinse
Rationalis," is essentially practical, in which his
physiological and pathological doctrines are, for
the most part, introduced in an incidental manner,
as supporting or elucidating his practical observa-
tians. Of the nature or details of his practice it
will not be necessary to enter into any minute ex-
amination. It did not differ very materially from
that of his contemporaries, although the circum-
stance of his being less exclusively attached to
any single hypothesis has rendered him more dis-
posed to take a candid and unprejudiced view of
the various points which would necessarily fall
under his observation. In his leading doctrines
he must be classed with the mathematical phy-
sicians, but at the same time he adopts many of
the opinions of the chemists, and indeed not un-
frequently derives his indications from the supposed
chemical condition of the fluids. But the great
and important addition which Hoffmann made to
theory, both medical and physiological, is the dis-
tinct manner in which he refers to the operations
of the nervous system, and its influence on the
phenomena of life. Many of the actions which
Stahl ascribes to the action of his hypothetical
principle, the anima, Hoffmann explained by re-
ferring them to the nervous influence, a physical
power no less real than that of gravity or chemi-
cal affinity, but of a specific nature and operating
by its own laws, the knowledge of which is to be
acquired by observation and experiment. (Thom-
son's Cullen, p. 195, 6.)

But whatever merit Hoffmann may have had
as a practitioner, his reputation with posterity
must principally rest upon his merit as a patholo-
gist. Although, as we have stated above, he con-
sidered the fluids to be occasionally the primary
seat of disease, yet in most cases he conceives it
to originate in an affection of the solids. In
order to explain this affection, he assumed that

what he terms the moving fibre possesses a cer-
tain degree of action or tone, which constitutes
its natural state, and is necessary for the perform-
ance of its functions. Various circumstances, as
well external as internal, were supposed either to
increase or diminish this tone ; if it were increased
beyond its due limit, the state of spasm is the re-
sult ; if it were unduly diminished, the contrary
state of atony was produced. This celebrated
theory, which under various modifications entered
so largely into the speculations of most of the
pathologists of the seventeenth century, cannot
be maintained in all its parts as it was detailed by
Hoffmann ; it must, however, be admitted that it
made a considerable approach to a correct view
of the subject, and that it may be regarded as the
germ from which the more mature doctrines of
his successors immediately emanated. It has been
supposed that he borrowed it from the constricted
and relaxed fibre of the ancients, but even if we
admit that this may have furnished him with the
first hint, it was so far new-modelled and ex-
tended by him as to deserve the merit of origi-
nality.*

This hypothesis of the nature of the moving
fibre, together with the more extensive influence
which the nervous system was imagined to exer-
cise over the various operations of the animal
economy, may be considered as forming the basis
of both the physiology and the pathology of
Hoffmann. Unfortunately for the fame of this
writer, in consequence of the multiplicity of his
works, and the hasty manner in which they were
composed, it is very difficult to obtain a consistent
or connected view of his theory ; but, upon the
whole, we conceive that he is entitled to the
merit of having materially advanced our know-
ledge of the laws of the animal economy, and
still more, of having pointed out the track which
might be successfully pursued by others for the
farther advancement of this knowledge. With
respect to the works of Hoffmann it may be fur-
ther remarked, that as in the course of his expe-
rience he gradually enlarged and corrected his
pathological doctrines, and continued to publish
them from time to time, in detached portions, but
without giving them in a condensed or abstracted
form, we frequently meet with what appear to be
inconsistencies and contradictions, and are obliged
to collect his opinions rather from inferences and
from indirect remarks, than from any clear and
explicit statement of them.j-

In giving an account of the pathology of Hoff-
mann, we have somewhat anticipated an impor-
tant point of medical theory, to which we must
now revert. We have had occasion in various

* Cullen, in the preface to his " First Lines," bears
ample testimony to the value and importance of Hoff-
mann's physiological speculations, ami acknowledges
the use which he had made of them in the formation of
his own hypotheses.

t Haller, Bilil. Med. lib. x. sec. 877 t. iv. p. 536etseq.
Nonv. Diet. Hist, in loco. Eloy, in loco. Cullen. preface
to his "First Lines," p. 18-25. Sprengcl, sect. 15, * I
Blumenbacfi, sect. 419. Ooulin, in Enc. Meth. Medecioe,
ID loco. Tkomsorrs Life of Cullen, v. i. p 182-200. Biog-
Lniv. in loco. Of his works the following may be se-
lected ns the most original and valuable: -Systema
M ? dl Si n 5P Kationalis; Medicina Consultatoria; Opus-
cula Med. Phys. ; Consult, et Respons. Cent. ; Pallmlogia
Generalis; rherapia Generalis; Semeiologia ; Philoso-
phia Corporis hum. vivi.

MEDICINE, (HISTORY OF)

219

parts of this history to notice, that through all the
succession of opinions from the time of Hippo-
crates to the period at which we are now arrived,
with a very few exceptions, the hypotheses were
all founded upon the humoral pathology. This
opinion was maintained equally by the mathema-
ticians, the chemists, and the metaphysicians.
The changes that were produced in the system,
whether mechanical or chemical, were equally
supposed to take their origin from the fluids, while
the metaphysician imagined that it was upon the
fluids that his immaterial superintending principle
exercised its action. We may regard the publi-
cation of Glisson's treatise, « De Ventriculo et
Intestinis," which appeared in 1671, as having
laid the foundation for the change of opinion
which afterwards took place respecting this doc-
trine. It was in this work that the hypothesis of
muscular irritability was originally brought for-
wards, a specific property, which is supposed to
be attached to the living fibre, and from which is
deduced its peculiar power of contraction.* But
the first writer who systematically opposed the
theory of the humoral pathology was Baglivi.
He was born near the conclusion of the seven-
teenth century, and after rising to early eminence
in his profession, and acquiring a high reputation
for his sagacity in the treatment of disease, and
for the assiduity which he displayed in the acqui-
sition of medical knowledge, was prematurely cut
off at the age of thirty-four. (Eloy, in loco.
Haller, Bibl. Med. lib. xii. sec. 954, t. iv. p. 197
ct seq. Goulin, in Encyc. Meth. Medecine, in
loco. Chaussier et Addon, in Biog. Univ., in
loco.) He proceeded upon the Hippocratean plan
of watching attentively and accurately describing
the phenomena of disease ; but he differed from
him as to their primary seat, rejecting the princi-
ples of the humoral pathology, and placing the
causes of them in the altered condition of the
solids. His account of the nature of the solids,
and the actions of what he terms the moving
fibres, is by no means conformable to our modern
notions on the subject, and may be pronounced
to be incorrect; but the opinion that the fluids
are affected secondarily, in consequence of a pre-
vious affection of the solids, was a great and im-
portant point of theory, which has been gradually
gaining ground since the time that it was first
promulgated by Baglivi, and may be regarded,
with certain modifications, as the current hypo-
thesis of the present day. The doctrine of solid-
ism had, indeed, no direct or immediate effect
upon the practice of medicine, but by drawing
the attention more to the state of the muscular
and nervous systems than to that of the fluids, it
tended to correct many of the erroneous opinions
which had previously prevailed respecting the
actual condition of the system when labouring
under disease, and in this way powerfully contri-
buted to improve our knowledge of the relative
state of the different parts of the animal economy,
and of the operation of remedies upon it. The
gradual subversion of the humoral pathology may
also be regarded as a remote cause of the favour-
able reception with which the doctrines of Hoff-

* See especially the fifth chapter of the treatise enti-
tled " De fibris in genere." Eloy, in loco.

mann were received, while the attention which
he paid to the action of the nervous system con-
tributed, in its turn, still farther to favour the
theory of solidism in opposition to that of the
humoral pathology.

The theory of Stahl, notwithstanding its defects
and inconsistencies, was calculated to make a
considerable impression upon the public mind at
the time when it was advanced, and it accordingly
met with numerous supporters. It clearly pointed
out the inadequacy of all the previous hypotheses,
founded merely on mechanical principles, to ex
plain the phenomena of vitality, while it was
powerfully recommended by its simplicity ; and
perhaps even its metaphysical aspect might render
it not the less acceptable to his countrymen, who
were deeply interested in the speculations of
Leibnitz, and the controversy to which they had
given rise. It was not, indeed, generally em-
braced in its full extent ; but with certain modifi-
cations it remained the favourite doctrine with
many of the Germans, until it was gradually
superseded by the more correct views of Hoff-
mann, and still further by the powerful and com-
manding genius of Haller.

Of the followers of Stahl, who adopted his
opinions with the fewest alterations, we may select
the names of Juncker and Alberti, who were both
of them professors in the university of Halle, of
which they contributed for many years to support
the reputation which it had acquired under their
illustrious predecessors. They were both of them
voluminous writers, and they devoted a consider-
able part of their labours to expounding and illus-
trating the principles of the Stahlian system.
But their works being more theoretical than prac-
tical, and being intended rather for the purpose
of defending certain opinions than for the acqui-
sition of knowledge, are now sunk into oblivion,
or are merely referred to as historical records of
an hypothesis which formerly engaged so much
attention.

With these remarks on the theory of the vital-
ists we shall close the review of the state of
medical science during the seventeenth century.
Up to this period we have adopted the chronolo-
gical arrangement, and by pursuing this method
have been enabled without difficulty to trace the
successive stages of the progress of our art. But,
as we approach nearer to our own times, the
number of subjects which claim our notice are so
multiplied, that it will be necessary to continue
the historical sketch upon a different plan. Dis-
regarding therefore, to a certain extent, the mere
order of time, we shall, in succession, give an
account of those individuals who have acquired
the greatest degree of celebrity, endeavouring at
the same time to class them according to the
opinions which they adopted, pointing out their
connection with each other, and with the general
state of medical science.-j-

t It may be necessary to observe that we have already
somewhat deviated from the chronological arrangement
in considering Hoffman and Stahl as belonging to the
seventeenth century, although it was not until near the
close of it, in the years 1693 and 1C94, that they entered
upon their office as professors at Halle. But by admit-
ting of this irregularity, we have made the division tc
correspond more nearly with the changes whlsh toolt
place in the state of medical science.

220

MEDICINE, (HISTORY OF)

CHAPTER. XI.— Introductory remarks — Gen-
eral progress of medical science — Boerhaave,
character of his writings, his pathology — Gau-
bius — Gorier — Haller, his character, patholo-
gical doctrines, his disciples, his opponents —
Whyft — Semi-animists — Sauvages — Cullen,
his pathology and practice, his pupils — Brown,
his system — Darwin, his system.

From the revival of letters to the commence-
ment of the eighteenth century, including a period
of between two and three hundred years, the
great aim and object had been to apply to medi-
cine the same scientific principles which had been

brated Boerhaave was teaching medicine with
equal zeal, and we may venture to say with more
success, at Leyden* Boerhaave was originally
educated for the profession of theology, but owing
to some doctrinal scruples he fortunately relin-
quished his intention, and devoted himself to the
study of medicine in all its branches. There are
few examples, either in ancient or in modern
times, of any individual who arrived at higher
eminence, both in general knowledge and in the
departments more immediately connected with his
profession. His acquaintance with botany and
with chemistry were such as to enable him to
teach both these sciences with the greatest success ;

found successful in the advancement of the other ; wn ile n j s lectures and his writings on medicine,
departments of philosophy. The most distinguished J botn theoretical and practical, were long considered
medical writers of that period had therefore em- '
ployed themselves rather in collecting opinions
and in reasoning upon them, than in examining
into the grounds on which these opinions had been
formed, or inquiring in what degree they were
applicable to the explanation of the phenomena of
the animal economy. For the most part, as we
have had occasion to remark, they failed in their
direct object ; at the same time, however, a con-
siderable body of information was gradually ac-
quired, and the views which now began to be un-
folded in consequence of the pathological specula-
tions of Hoffmann, and the practical observations
of Sydenham and the modern Hippocrateans, led
to the establishment of the same spirit of induc-
tive investigation in medicine which had been for
some time adopted in the other departments of
natural science. We have passed over the age of
mere learning, and we now enter upon that of
observation and experiment. Scholastic disquisi-
tions were completely disregarded, abstract theory
was rapidly falling into disrepute, and hypotheses
were no longer considered as deserving of atten-
tion unless they professed to be derived from the
generalization of facts. The necessary result of
this state of things has been to detach the mind
from the arbitrary influence of theory, to diminish
the authority of great names, and to induce the
inquirers after truth to rest more upon their own
exertions than upon the authority of others. We
have, indeed, still to lament the errors and per-
versions of the human mind, to witness the at-
tempts of ignorance and arrogance to usurp the
place which is due to modest desert and patient
research ; but such attempts for the most part have
obtained only temporary success, and after an
ephemeral celebrity have been consigned to their
merited contempt. In the mean time, notwith-
standing these occasional interruptions, the pro-
gress of knowledge has been rapidly and steadily
advancing. Experiments, well contrived and pa-
tiently conducted, have been performed in every
department of physiological and medical science ;
observations have been made with more minute-
ness, and recorded with more accuracy; our im-
proved knowledge of chemistry has enabled us to
introduce the most important reforms into phar-
macy, while the discovery of various new articles
of the materia medica has given us additional and
powerful means of opposing the progress of dis-
ease.

While Stahl and Hoffmann were promulgating
their doctrines in the university of Halle, the cele-

as standards of excellence. He had a mind and
character peculiarly well adapted for his situation
and the age in which he lived, when a variety of
new facts and new hypotheses were brought into
view, and when it required a consummate degree
of judgment to weigh the opposing evidence, and
decide between the merits of the contending
parties. His moral qualities were no less admi-
rable than his intellectual acquirements; and if
we add to these his elegance as a writer, his elo-
quence as a lecturer, and his entire devotedness to
his profession, we shall be at no loss to account
for the celebrity which he enjoyed during his life-
time, and the reputation which he left behind him.

Boerhaave has been compared to Galen, and it
may be asserted that he will not lose by the com-
parison. If Galen possessed more genius, Boer-
haave possessed more judgment; while in their
scientific acquirements, and in the extent of their
information, it would not be easy to decide between
them. They were both eminently skilled in the
art of availing themselves of the knowledge of
their contemporaries in all the branches of science,
of applying it to the elucidation of their particular
department, and of modelling and combining into
a well-digested system all the scattered materials
which they obtained from so great a variety of
sources. In the stability of their systems, how-
ever, we observe a remarkable difference, for while
Galen's doctrines were implicitly adopted for many
centuries, the system of Boerhaave, notwithstand-
ing its real merits and the applause which it ob-
tained during the life of its inventor, shortly after
his death was assailed from numerous quarters,
and was unable to maintain its ground. The age
in which Boerhaave lived was not one of autho-
rity but of investigation, and the enlightened spirit
which pervades his own works tended in no small
degree to foster that taste for inquiry which led his
contemporaries not to rest satisfied with his theories,
however beautiful might be their aspect, and how-
ever happily they might appear to explain the
phenomena of life, if they were found to be baseJ
upon principles which were themselves conjectural
and gratuitous.

The great object of Boerhaave in the formation
of his system was to collect all that was valuable
from preceding writers, and by means of these
materials to erect a system which should be truly
eclectic. The basis of his doctrines is in a great
measure mechanical, derived from the hypothesis
^Boerhaave was elected to "the ctair of medicine in

MEDICINE, (HISTORY OF)

221

of Bellini and Pitcairnc, but he unites with this
certain parts of the humoral pathology, and adopts
some of the opinions of Hoffmann. To these he
added various original observations, by which he
has given ample proof of his talents as a saga-
cious practitioner. His language is remarkably
perspicuous, and his reasoning, if we admit his
premises, is fair and conclusive. But the grand
error of Boerhaave consisted in his depending
more upon opinions than upon observations, in
his endeavouring to form a system which should
be composed of the united speculations of others,
rather than to ascertain the correctness of the
principles from which these speculations were de-
duced. His system accordingly met with the fate
of all such as are built upon hypothesis ; it could
not stand the test of experiment and observation,
and notwithstanding the efforts of some of Boer-
haave's pupils, who were zealously attached to
their master, it was generally discarded in no long
period after the death of its inventor. But although
the system of Boerhaave may have yielded to the
more perfect and enlarged theories of his succes-
sor, he must be ever regarded as one to whom
the science of medicine is deeply indebted. His
Institutions and his Aphorisms would alone serve
to immortalize his reputation as a correct observer
and a sagacious practitioner, and if we compare
them with any contemporary performance, which
is the fair method of judging of the merits of
works of science, we cannot fail to recognise their
great superiority.*

In forming his system, Boerhaave was not un-
mindful of the doctrines of Hoffmann, and par-
ticularly of the influence which the brain and
nerves exercise over the operations of the animal
economy. But although he introduces it on cer-
tain occasions, and in some instances allows it to
act a prominent part,-)- yet he was by no means
fully aware of the extent of its power. This in-
deed may be considered as the radical defect of his
pathological doctrines; he regards the solids too
much in the light of mere mechanical agents,
without sufficiently taking into account those pro-
perties which specifically distinguish them from
inanimate bodies. This deficiency was to a certain
extent supplied by his nephew Kauw Boerhaave,
(Thonson's Cullen, v. i. p. 219,) and by his
favourite pupil and successor Gaubius, (lb. p. 220,)
who introduced the agency of the nervous system
in many cases where it had been omitted by Boer-
haave himself. They were both of them men of
considerable talents and acquirements, and the
improvements which they made in medical theory-
were of real value. The writings of Gaubius,
especially his Nosology and his Institutions of
Pathology, were long held in high estimation, and
were employed as text books in the medical schools.
(Haller, Bibl. Anat. t. ii. p. 166, 7. Eloy, in
loco. Aikin's Gen. Biog. in loco. Thomson's
Cullen, v. i. p. 220, 1. Desgenettes, in Biog.
Univ. in loco.) In the same connection we may

* Haller. Bih. Me4 lil>- xii. t. iv. p. 14v> pt eeq. Eloy,
in looo. Cullen, Preface to liis "First Lines," p. i!.j-:).3i
Hutchinson's Biog. Mod. v. i. p. f-j et seq. Nouv. Diet.
Hist, in loco. Thomson's Life of Cullen, v. i. p. 200-17.
Blumenbnrh, Intro, I. § 418. Gonlin, in Encyc. Moth. Me-
decine, in loco. Biograpbie Universale in loco.

fSee particularly Ins work entitled " Pra-lectiones de
Morbis Nervorum."

mention the name of Gorter, an eminent professor
and practitioner at Harderwyc, who, while, like
Boerhaave, he adopted the essential parts of the
mechanical theories of his predecessors, made con-
siderable use of the agency of what he termed the
vital force in explaining many of the operations
of the animal economy. (Eloy, in loco Haller,
Bibl. Anat. t. ii. p. 169, 70. Sprengel, t. v. p.
314-16. Thomson's Cullen, v. i. p. 218. Renaul-
din, in Biog. Univ. in loco.) The writings of
Gorter are very numerous, and prove him to have
been an industrious cultivator of medical science,
while his great practical work, entitled " Com-
pendium Medicinae," indicates a talent for correct
observation, and an accurate discrimination of
morbid symptoms.

But the great support and ornament of the
Boerhaavian school was Van Swieten. He was
born at Leyden in the last year of the seventeenth
century, and was one of the most favoured and
meritorious of the pupils of Boerhaave. In con-
sequence of his theological opinions not coin-
ciding with those of the state religion, he was
expelled from the university of his native city, in
which he held a professorship, and accepted an
invitation from Maria Theresa to the court of
Vienna. Here honours and distinctions of all
kinds were heaped upon him ; but these he amply
repaid by the unremitting attention with which
he devoted himself to the medical school of that
metropolis. Of the high reputation which it has
since enjoyed he may be said to have laid the
foundation, while by the publication of his Com-
mentaries on the Aphorisms of Boerhaave, he
demonstrated at the same time the high respect
which he retained for his preceptor, and the extent
of his own information on all subjects connected
with medical science. The Commentaries of Van
Swieten contain a large and valuable collection of
practical observations, partly the result of the
author's own experience, and partly derived from
his extensive knowledge of books. He adopted
the theory of Boerhaave with little alteration, and
in this respect the work must be regarded as funda-
mentally defective ; but the great body of facts
which it contains, detailed as they are in a clear
and perspicuous style, will always insure it a place
in the library of the medical student. {Eloy, in
loco. Naitche, in Biog. Univ. in loco.)

The intimate connection which subsists between
the doctrines of pathology and an acquaintance
with the laws of the animal economy in its
healthy and perfect state, makes it necessary for
us to give some account of an individual who,
although not a practitioner of medicine, contribu-
ted perhaps more to our knowledge of the nature
of disease than any one who has hitherto passed
under our reviow. We refer to the great name
of Haller, who has been not unaptly termed the
father of modern physiology. He was the pupil
of Boerhaave, and imbibed from him his thirst for
knowledge, his correct judgment, his undeviating
candour, his unblemished integrity, and in short
all the intellectual and moral qualities which we
have admired in the professor of Leyden. But
to these qualities Haller added a more extensive
and original genius, which led him never to rest
upon the unexamined opinions of others, and a
clearness of conception which taught him, both in

222

MEDICINE, (HISTORY OF)

his language and his mode of reasoning, to avoid
all ambiguous and undefined terms, and all irrele-
vant arguments. He possessed a mind at the
same time comprehensive and correct, equally
adapted for discovering new paths to knowledge,
and for investigating those which had been pre-
viously entered upon by others. The innate
powers of the components of the body, which had
been imperfectly seen by Glisson and by Hoff-
mann, were examined by Haller with his charac-
teristic acuteness, and the result of his long and
well-directed experimental research was rewarded
by the establishment of his theory of irritability
and sensibility as specific properties attached to
the two great systems of the animal frame, the
muscular and the nervous, to which, either sepa-
rately or conjointly, may be referred all the phe-
nomena of the living body. But perhaps a still
more important service which Haller rendered to
science was the example which he held out of
carefully abstaining from all opinions founded
merely upon speculative grounds, and of deducing
his general principles exclusively from experiment
and observation. He gave an impulse to science
no less by the actual discoveries which he made,
than by the spirit with which he conducted his
researches, so that we may regard the publication
of his Elements of Physiology, as having intro-
duced a new era into medical science.*

It would be incompatible both with the imme-
diate subject of this essay, and with the limits to
which it is necessarily restricted, to give a detailed
account of the controversies and discussions to
which the theory of Haller gave rise. Notwith-
standing its merits, and the evidence by which it
was supported, it was opposed, either in its full
extent or in certain of its parts, by many indi-
viduals of high respectability ; while on the con-
trary various experiments were instituted, by
which his conclusions were confirmed and his
principles extended. Among those who were the
most successful in these researches we may select
the names of Zimmermann, (De Irritabilitate,)
Caldani, (Instit. Physiol.) Fontana, (in Haller,
sur la Nature Sens, ct Irrit. t. iii.) Tissot, (Ibid. t.
i. et iii.) Zinn, (Exper. circa Corp. Cal. etc.) and
Verschuir. The last of these physiologists par-
ticularly distinguished himself by his experiments
on the contractility of the arteries, (De Arter. et
Yen. Vi. Irrit.) a point which had been left unde-
cided by Haller, but which formed a most import-
ant addition to the theory of the action of the
vessels, and which had previously been rather
assumed as what was probable than deduced from
any ascertained facts.

Among the most powerful opponents of the
doctrine of Haller we may select the names of
Whytt and Porterfield. They were natives of
Scotland, and during the earlier part of the last
century were residents in the metropolis of that
kingdom, and bore a conspicuous part in the sci-
entific institutions for which it was so justly cele-
brated. The former of them was professor of
medicine in the university of Edinburgh at the

* Elye, in Mem. Acad. Scien. 1777. Henry's Life of
Haller. Sprengcl, sect. 15, ch. iii. Jlikin's Gen. Biog. in
loco. Thomson's Cullen, v. i. p. 221-240. Cuvier, in Bio-
graphie Universale, in loco. Dewar, in Brewster's En-
cyc. art. " Haller." Blumenbach, Introd. § 468. Goulin,
id Enc. Meth. Medecine, in loco.

time when it was rapidly advancing to that high
reputation which it afterwards more fully attained
under the genius of his illustrious successor Cul-
len. They opposed that part of the theory of
Haller which ascribes all the actions of the living
system to certain powers necessarily connected
with the material parts of the frame, as well as to
the separation of these actions into the two dis-
tinct powers of irritability and sensibility .f The
controversy which Whytt carried on with Haller
was conducted with acuteness and ability, but it
manifests a degree of acrimony which it is impos-
sible not to regret, particularly as occurring in an
individual who was otherwise so much entitled to
our respect. And this is more especially the case
when we consider the nature of the objections
which he urged against the Hallerian hypothesis,
which were rather of a metaphysical nature than
such as were either founded upon experiment or
deduced from observation. His doctrine of the
vital motions of the body, which formed the prin-
cipal subject of the controversy, may be regarded
as intermediate between that of Haller and Stahl,
or rather compounded of the two. He attributes
these vital motions to the operation of the sentient
principle, which is supposed to be something dis-
tinct from the corporeal frame, at the same time
that it is necessarily attached to it, and is under
the influence of physical causes, not like the ani-
ma of Stahl, acting by a species of independent
consciousness and volition. The great error which
pervades the speculations of Whytt and Porter-
field consists in their reasoning more upon meta-
physical than upon physical principles, and in
their assuming certain powers, the proof of which
rests more upon their supposed necessity to ac-
count for the actions of the system than upon any
independent evidence that we have of their exist-
ence. They did not indeed, like the Stahlians,
consider the sentient principle as something inde-
pendent of the body, and only as it were appended
to it, but as a principle or power necessarily be-
longing to the living body, and imparting to it its
vitality, although essentially distinct in its nature
from any of the properties of a mere material
agent. Whytt may be regarded as the foundei
of the sect which obtained the name of the semi-
animists, which, under various modifications, in-
cluded some of the most distinguished physiolo-
gists both in this country and in France. Of the
latter, one of the most eminent was Sauvages;
he was a native of Languedoc, and received his
education at Montpellier, which, during the early
part of the eighteenth century, held a very high
character as a school of medicine. In 1734 he
was appointed one of the professors in the univer-
sity of that city, and during the remainder of his
life contributed materially to maintain its credit
by his talents both as a writer and a teacher. His
reputation with posterity will principally rest upon
his methodical nosology, a work which contains
an arrangement of diseases into classes, orders,
genera, and species, on the same plan which hud
been employed in the arrangement of the subjects
of natural history. The Nosology of Sauvages
is a work of _great and or iginal merit, which,

mluT;Jlu^^7^^^^^ d Involuntary

Fv na^h ,„•„' °"' Cal £f ayS - Porterfield on the
£ye, passim, and papers in Edinburgh Meiliril I
Thomson's Cullen, v. i. p. 241-258.

Essays.

MEDICINE, (HISTORY OF)

223

although now in some degree superseded by the
improvements of later writers, mainly contributed
to the advancement of medical knowledge by pro-
ducing accuracy in the use of terms and in the
discrimination of the characters of disease. (Eloy,
in loco. Haller, Bibl. Anat. " Boissier," t. ii. p.
300-4, § 999/)

The same kind of service which Haller rendered
to the science of physiology was performed for
that of the practice of medicine by his contempo-
rary Cullen. Among those who have made the
study of medicine their professed pursuit, no one,
since the revival of letters, has risen to greater
eminence during his life-time, nor has left behind
him a higher reputation than this celebrated indi-
vidual. During the greatest part of a long life,
he was engaged in the teaching of medicine or
some of the collateral sciences, first in the univer-
sity of Glasgow, and afterwards in that of Edin-
burgh, which latter he contributed, in no small
degree, to raise to the rank, which it long held, of
the first medical school in Europe. His peculiar
excellence as a lecturer afforded him an ample
opportunity of promulgating and enforcing his
doctrines, while their real merit, no less than the
mode in which they were announced, rendered
them in the highest degree popular among his
pupils and contemporaries. He possessed an
acute and ardent mind ; he was well skilled in the
medical literature both of the ancients and the
moderns, but he had no undue respect for the opi-
nions of others on the mere ground of authority.
He detected the defects of former hypotheses with
shrewdness and sagacity, while he proposed his
own views with a degree of candour and modesty
which tended to render them the more acceptable,
and disposed his audience to receive them in the
same spirit with which they were proposed.

With respect to his physiological writings, they
afford, in some respects, a remarkable contrast to
those of Haller ; for while the latter are extended
to a great length, and are filled with the most mi-
nute and elaborate details, the former are no less
remarkable for their compressed brevity, consisting
principally in general views and abstracted deduc-
tions. Contrary, however, to what is so fre-
quently the case with respect to works of this de-
scription, they are not to be regarded as mere
speculative positions, but as the condensed result
of patient research and extensive observation.
Some of the leading doctrines of his pathology
were professedly borrowed from Hoffmann ; but
to these he made many important additions by
taking advantage of the various improvements
that had been made in physiological knowledge,
principally by means of Haller and his pupils.
Still later discoveries in this science, and in that
of chemistry, have indeed proved that certain
parts of his system are not tenable, and that
others require to be considerably altered and modi-
fied ; but it may be asserted that no one produced
a more powerful and lasting effect upon the state
of medicine in all its branches, both theoretical
and practical, than Cullen. But his great and
appropriate merit, and which entitles him to the
admiration and gratitude of posterity, is the saga-
city and diligence which he manifested in the de-
scription and discrimination of the phenomena of
disease. In this talent he may be considered as

rivalling Sydenham or any of his most distin-
guished predecessors, while the recent improve-
ments in physiology and the other branches of
medical science gave him an advantage which he
did not fail duly to improve. In his treatment of
disease he manifested no less judgment and saga-
city than in the formation of his theories. He
was prompt and decisive, without rashness ; he
estimated the powers of remedies by a cautious
and accurate examination of their effects, with
little bias from hypothesis, and with even some-
what of a sceptical disposition of mind, which
prevented him from falling into those errors and
inconsistencies to which the practice of medicine
is so peculiarly obnoxious.

In giving an account of the system of Boer-
haave we remarked that in its formation he pro-
ceeded upon the eclectic plan, founding it upon
the opinions of others, which he endeavoured to
connect together and to mould into a consistent
and uniform theory. Cullen adopted the more
philosophical mode of generalization and induc-
tion. He disclaims all hypotheses and theories
not immediately derived from facts, and made it
his great business to collect, by actual observation,
the materials from which he might deduce his
general principles. In this object he was emi-
nently successful, and it is this which gives his
writings their great value, a value which they
must ever retain amidst all the revolutions of opi-
nion, which attach to medicine more than to any
other branch of science. But, although he was
so sensible of the advantage of the inductive mode
of investigation, he was not a mere empirical prac-
titioner, who disregarded all theoretical reasoning,
and never ventured to go beyond the simple result
of experience. On the contrary, he inquires in
all cases into the remote and primary causes of
disease, and endeavours to deduce from them hi:-;
indications of cure. Many of his individual specu-
lations are indeed remarkable for their subtilty and
refinement, and may be characterized as exhibiting
more ingenuity than judgment. At the same
time it is not a little remarkable that these specu-
lations, however carefully they were elaborated,
had but little influence on his practice ; and it is
gratifying to observe with what caution he applies
his hypotheses to explain or direct his method of
treating disease.

His great work, entitled " First Lines of the
Practice of Physic," is the one on which his re-
putation will principally rest; but the merits of
his Institutions, of his Nosology, and of his Lec-
tures on the Materia Medica, are each of them
sufficient to have entitled him to a distinguished
rank among the improvers of medical science. The
last of these works, in which he takes a more
philosophical view of the operation of remedies
than had been done by any of his predecessors,
is one of peculiar value. It contains a great va-
riety of important pathological observations, toge-
ther with a complete theory of therapeutics, and
being the latest of his publications, we find in it
his more matured and corrected views on many
topics which had been treated in his formei works.
In none of them do we find more of that spirit of
rational scepticism to which we have alluded
above, and which led him to be more confident in
opposing the opinions of others than in maintain-

224

MEDICINE, (HISTORY OF)

ing his own. Like Haller, with whom we have
already taken occasion both to compare and to
contrast him, he contributed to introduce into me-
dical reasoning a philosophical spirit, which has
produced a permanent and highly salutary effect
upon the healing art, and which associates the
name of Cullen with those of the great benefac-
tors of the human race.

It is not easy to give, in a short compass, an
account of the pathological doctrines of Cullen,
because they consisted rather of a number of indi-
vidual parts, as applied to the explanation of particu-
lar phenomena, than of one comprehensive sys-
tem, which constituted a general theory of diseased
action. The foundation of the system is, however,
sufficiently simple ; that the living body consists
of a number of organs, which are all of them pos-
sessed of powers of a specific and appropriate na-
ture, distinct from those which are attached to in-
animate matter. These powers are so ordered,
that they have a tendency to preserve the whole
machine in a perfect state, when its actions and
functions proceed in their ordinary course. When
any irregularity supervenes, either from internal
or external causes, if it be not in an excessive de-
gree, the self-regulating principle is sufficient to
control the operation of the morbid cause, and to
restore the system to its healthy condition. This
regulating principle, or, as it was termed, the vis
medicatrix naturae, differs essentially from the ar-
cheus of Van Helmont or the anima of Stahl,
inasmuch as it is supposed not to be any thing
superadded to the body, but one of the powers or
properties necessary to its constitution as a living
system, and the existence of which is recognised
by its effects. Although the laws of gravity and
of chemical affinity affect the animal body, so far
as it is composed of material organs, yet its ap-
propriate actions are under the immediate influence
of the specific laws of vitality. Hence all expla-
nations, depending upon mere mechanical or che-
mical reasoning, were abandoned, and in their
place was substituted the vital action of the parts,
and more especially that of the extreme branches
of the arterial system, or, as they are styled, the
capillary arteries. Although it may appear that
both Stahl and Hoffmann had to a certain extent
preoccupied the ground which was taken by Cul-
len, as to the foundation of his system, and al-
though the system, as detailed by him, is defective
in some of its subordinate parts, yet we must ad-
mit that the ample and explicit manner in which
it was stated gave it the aspect and much of the
merit of novelty, while the applications which he
made of it were frequently just, and always inge-
nious. His physiology and his chemistry were
not in all cases cowect ; he did not pay sufficient
attention to the distinction between the powers of
the muscles and the nerves, which had been so
well discriminated by Haller, and he even con-
founds their physical structure. But with all
these abatements we still regard the pathology of
Cullen with much respect, and consider him as
one of those who greatly contributed to improve
the science no less than the practice of his art.*

* For a minute detail of the opinions of Cullen and
those of his immediate predecessors and contemporaries,
tbe reader is referred to the learned and ample work of
I)r. Thomson, which may be characterized as contain-

What may be termed the Cullenean school of
medicine, including both his numerous pupils and
the writers who either embraced his peculiar opi-
nions, or adopted his method of investigation,
comprehends a large proportion of the most dis-
tinguished of the British physicians during the
remainder of the eighteenth century. The ra-
tional empiricism, as it has been styled, which he
so firmly established, both by precept and exam-
ple, has, in this country at least, so far superseded
the taste for mere speculation and hypothesis, that
we are perhaps disposed to run into the opposite
extreme, and to undervalue all attempts to inves-
tigate the abstract principles of pathology, and to
employ ourselves solely in the accumulation of
facts, without duly attending to the general con-
clusions that may be deduced from them.-f-

We have, however, to notice one singular ex-
ception to this remark, where an hypothesis was
advanced, of the most bold and lofty pretensions,
disdaining the support of facts and experience,
and professing to explain all the phenomena of
life and of disease by a few simple aphorisms. In
tracing the history of science, although it is pro-
per for the most part to estimate books and opin-
ions solely by their intrinsic merit, without any
regard to the personal character of the author, yet
we find them on some occasions so intimately
connected that it is impossible altogether to sepa-
rate them. This is the case with the celebrated
Brown, whose theory appears to have originated
as much from spleen and disappointment, and a
determination to oppose the doctrines of Cullen,
as from a more legitimate motive.

Neither the education of Brown nor his natural
character were of the kind the best adapted for
the prosecution of medical science. He was ori-
ginally destined for the ecclesiastical profession ;
and when he afterwards entered upon that of
medicine, he never devoted himself to those ele-
mentary studies which are indispensably neces-
sary to a correct knowledge either of theory or of
practice. But what he wanted in knowledge he
endeavoured to supply by the force of his own
genius, and by meditating upon a few general or
abstract principles, he ventured to form a new
system of pathology, which he announced with a

ing a philosophical history of medicine and pathology
during the beginning and middle of the eighteenth cen-
tury. The account which is given of Cullen's pupils
must be perused with much interest, an interest winch,
in the case of the writer of this article, is exalted by the
sacred sentiment of filial piety ; p. 461, 644-6. See also
Sprengel, t. v. p. 359-360. We think that this writer, in
criticising the doctrines of Cullen, is somewhat deficient
in that candour for which he is in most cases so conspi-
cuous; Encyc. Brit, in loco; .likin's Gen. Biog. in loco;
Kerr, in Brewster's Encvc. art. " Cullen.

t In this brief sketch vve can do no more than merely
mention the names of some of our countrymen, who,
either by the publication of single cases or of mono-
graphs on certain diseases, have contribnted to the
advancement of pathological or practical knowledge.
Among others we mav select those of Gregory the able
successor of Cullen, Pringle.M'Bride, Huxham, Fothergill.
Cleghorn Brocklesby, Lind, and Russel. ]n our own tiroes
we have had the no less illustrious names of the Hunters,
of Percival, Withering, Johnstone, Falconer, Heberden,
Ba.lhe Haygarth, Ferriar, Currie, Willan, Baleman,
Marcet and Parry. In mentioning the name of Gregory,
Jn i» ''f'.'-'f |, <7ll<>wcd toexpress the feelings of respect
-ii^?!W ,C v he " as alwa >' s Ml fnr »' s preceptor. The
J,TZZi n U , S ht , erary tast0 - nis clear and con.prel.en-
sive judgment, and more especially the interesting mode

::;.k ';; :„ r:""r"^"" bis *»««"&», an £ nt & »

LSa! ° f U,e m0 * ^""='-'*<i ornament; of

MEDICINE (HISTORY OF)

225

degree of confidence that, while it exhibited the
strong powers of his understanding, proved no
loss the deficiency of his information. Medicine,
which had hitherto been a conjectural art, was
now to be built upon a few certain and fixed
principles, which, by superseding all that had
been previously written upon the subject, and by
being independent both of observation and of ex-
perience, required for its attainment little previous
study or learning. The novelty of the attempt,
the easy access which it promised to a science
which before appeared of difficult approach, and
the plausibility of some of its leading positions,
acquired for the new theory a prodigious degree
of popularity in the university of Edinburgh,
where it was first promulgated. Brown had
been, in the first instance, patronized by Cullen ;
but from some causes, both of a personal and a
professional nature, which it is not difficult to
comprehend, he forfeited the good opinion, and
became the bitter antagonist of the doctrines of
his former friend. The controversy to which this
schism gave rise was carried on for some years
with great vehemence, and was by no means con-
fined to the place where it originated. In this
country the Brunonian system obtained many
adherents when it was first proposed, principally
indeed among the students or younger members
of the profession ; while in some parts of the con-
tinent, more especially in Italy, it was adopted by
men of learning and science, and became the pre-
vailing hypothesis in some of the most respectable
medical schools.

The general principles of the theory are few
and simple. He assumed that the living body
possesses a specific property or power, termed ex-
citability ; that every thing which in any way
aifects the living body acts upon this power as an
excitant or stimulant ; that the effect of this opera-
tion, or excitement, when in its ordinary state, is
to produce the natural and healthy condition of
the functions ; when excessive, it causes exhaustion,
termed direct debility ; when defective, it produces
an accumulation of excitement, or what is termed
indirect debility. All morbid action is conceived
to depend upon one or other of these states of
direct or indirect debility, and diseases are accord-
ingly arranged in two great corresponding classes
of sthenic or asthenic ; while the treatment is
solely directed to the general means for increasing
or diminishing the excitement, without any regard
to specific symptoms, or any consideration, but
that of degree, or any measure but that of quan-
tity. Such general views and sweeping doctrines,
however alluring to the uninformed or the mere
theorist, arc altogether inapplicable to practice;
and it is a subject for our admiration how they
could be for a moment entertained by any one who
had studied the phenomena of disease, or who
was acquainted with the intricate and complicated
relations of the different functions and actions of
the living system. Accordingly in this country,
where, in consequence of the prevalence of the
Cullcnean school, the attention was more directed
to practical than to theoretical details, the pro-
fessed adherents of Brown were neither numerous
nor influential ; and even in Italy, where for some
time it enjoyed considerable popularity, it has
long ceased to be maintained. Yet it must always
Vol. III. — 29

occupy a distinguished place in the history of me-
dical science, as exhibiting a remarkable example
of the force of original and unaided genius in erect-
ing a system plausible and captivating in its as-
pect, but devoid of the essential support of facts
and observations, and therefore fated to share the
lot of all systems built on so untenable a basis.*

In connection with Brown, we must notice a
theorist whose general principles bore a consider-
able resemblance to those of the « Elementa Me-
decina;," but whose character, talents, and ac-
quirements were of a totally opposite kind. The
" Zoonomia" of Darwin exhibits genius and origi-
nality ; but in no other respect does it bear any
resemblance to its prototype. Darwin possessed
a knowledge of medicine and all the collateral
sciences in their full extent ; he was familiar with
practice, and had a taste for minute detail and
experimental research which, while it appeared to
qualify him for a medical theorist, enabled him to
give to his system an imposing aspect of induc-
tion and generalization. His speculations, al-
though highly refined, profess to be founded upon
facts; and his arrangement and classification, al-
though complicated, seems consistent in all its
parts. No theory which had ever been offered to
the public was more highly elaborated, and ap-
peared to be more firmly supported by experience
and observation, while every adventitious aid was
given to it from the cultivated taste and extensive
information of the writer. Yet the Zoonomia
made little impression on public opinion ; its lead-
ing doctrines rested rather upon metaphysical than
upon physical considerations, its fundamental po-
sitions were found to be gratuitous, and many of
the illustrations, although ingenious, were con-
ceived to be inapplicable and inconclusive. It is
now seldom referred to, except as a splendid mo-
nument of fruitless labour and misapplied learn-
ing.*

CHAPTER XII. — Remarks on the state of
practical medicine at the conclusion of the
eighteenth century — State of medicine in
France, Lieutaud — State of medicine in Ger-
many, Be Haen — State of medicine in Italy,
Morgagni, Burserius, Rasori — Epidemics —
Improvements in pharmacy.
While the British physicians were principally
occupied in collecting facts and recording their
observations, and, with the exception of the tem-
porary suspension which was occasioned by the
Brunonian controversy, were more intent in adding
to the stock of knowledge than in forming sys-
tems, the continental physicians were more dis--
posed to pursue the eclectic plan of Boerhaave.
In France this was accomplished with the most
success by Lieutaud. He was a native of Pro-
vence, and was for some years a professor at Aix ;
in 1749 he was appointed physician to the royal

* Beddoes's Observations, prefixed to his edition uf
Brown's Elements; a writer possessed of originality
and genius, hut perhaps not unaptly characterized by
Kothe as "a blind adherent of [he new chemists and of
Brown." MKenzie, in Brewster's Enc., ;irt "Brown.'
Parr's Dirt., art. "Brunonian System." Aikin's Gen.
Biog., in loco. Sprengel, t. vi. p. 155-158, 315-334. Suard.
in Biographie Universale, in loco.

t Brewster's Enc, in loco. Sprengel, vol. vi. p. 2fi!)-7u,
278!). Yvung's Med. Lit., p. 54-5. Brown's Remarks on
the Zoonomia, an acute, but rather severe critique.
Suard, Biographie Universelle, in loco.

226

hospital at Versailles, and finally to the court of
France. He was eminent both as a practitioner
and an anatomist ; his great work, the " Synopsis
universes Praxeos Medicse," published in 1765,
contains much information on all topics connected
with medicine, and is valuable from its real merits
in this respect, while it is interesting as affording
a correct view of the slate of medical science in
France at that period. With respect to his gene-
ral principles, he was an eclectic, uniting certain
parts of the old doctrines of the mathematicians
and the humoralists with those of Hoffman and
the vitalists. (Hutchinson's Biog. Med. vol. ii.
p. 63 et seq.) Upon the whole, however, we
conceive that we shall not be accused of partiality
or want of candour if we give it as our opinion,
that the views of Lieutaud and his countrymen
are less matured than those of his contemporaries
in this island or in Holland. We may remark,
in speaking of France, that for many years the
great seat of medical science in that country was
Montpellier. Its university was established in
the thirteenth century, and was one of the earliest
of those which rose to any considerable eminence ;
a distinction which it maintained until it was ri-
valled by that of Paris, which gradually acquired
its splendid reputation during the course of the
seventeenth century. To the name of Sauvages,
who was mentioned above as distinguished for his
learned work on nosology, we may add those of
Bordeu, Barthez, and Astruc as among the most
eminent members of the school of Montpellier.
(Moreau de la Sarthe, Encyc. Meth. Medecine,
in loco.)

Of the medical schools of Germany, the most
celebrated during the seventeenth and eighteenth
centuries was Vienna. We have already men-
tioned the exertions that were so successfully made
for its advancement by Van Svvieten, who was
appointed one of its professors in the year 1734.
After he had occupied this situation for about
twenty years, he associated with himself his coun-
tryman De Haen, who materially contributed to
support the reputation of the university, particu-
larly by his talents as a practitioner. His great
work, entitled " Ratio Medendi," is a valuable
repository of facts and observations ; upon which
we may make the same' remark that we offered
above respecting Lieutaud's " Synopsis." De
Haen has been characterized as a man of great
learning united with much practical skill, and a
talent for correct observation ; but, on the other
hand, he appears to have been unreasonably pre-
judiced against new opinions, and even improve-
ments, in his art ; for not only was he one of the
most zealous opponents of Haller's theory, but he
was no less decided in his opposition to the prac-
tice of inoculation, and to the use of various new
remedies, which were at that period introduced
into medicine, the value of which is now generally
recognised. The state of medical theory then
prevailing in Vienna was nearly the same with that
which was taught in the universities of Leyden
and Paris ; the doctrines of the humoral pathology
may be considered as forming the basis of their
hypotheses, but upon these was engrafted a certain
portion of the new views respecting the actions
of the nervous system and the contractibility of
the muscular fibre.

MEDICINE, (HISTORY OF)

""""in Italy, which so early acquired a MgJ\ degree
of celebrity for its medical schools, and which still
retains a considerable portion of its former repu-
tation the sciences of anatomy and physiology
were cultivated with success, while they were but
little attended to in the other parts of Europe.
What may be styled anatomical pathology took its
rise in Italy in the seventeenth century. The in
dividual to whom the merit of having opened this
new road to the improvement of medical know-
ledge is principally due is Bonet, (Haller, Bibl.
Med. lib. 10, § 750. t, iii. p. 236 et seq. Eloy, in
loco. Dezeimeris, Arch. Gen. de Med. xx. 158,
9,) who was born at Geneva in 1620, and at an
advanced period of his life published his great
work entitled, " Sepulchretum," which was after-
wards enlarged by his learned and industrious
countryman Manget. (Holler, Bibl. Anat. lib. 7,
§ 749, t. i. p. 103 et seq. Holler, Bibl, Med. lib.
11, § 889, t. iii. p. 603 et seq. Eloy, in loco.)
The Sepulchretum has been styled " the Library
of true Pathology ;" it consists of a great col-
lection of cases, in which we have a history of
the diseases with the appearances found upon dis-
section. The plan which had been commenced
by Bonet and Manget was followed up by Valsalva,
an eminent professor of Bologna, and was still
farther perfected by the illustrious Morgagni.
This eminent anatomist was a pupil of Valsalva's,
and afterwards became professor in the University
of Padua, where for nearly sixty years, until his
death, which took place in 1771, he devoted him-
self without intermission to the study of his fa-
vourite pursuit. The principal works of Morgagni
are his " Adversaria Anatomica," his " Epistols
Anatomical," and more especially his great patho-
logical collection entitled " De Sedibus et Causis
Morborum per Anatomiam indagatis." It pro-
ceeds upon the plan of Bonet's Sepulchretum,
and contains the observations which were made
both by himself and by Valsalva, and has always
been regarded as a repository of facts and obser-
vations on anatomy and pathology unequalled in
extent and in accuracy. (Eloy, in loco. Haller,
Bibl. Anat. lib. 8, § 797, t. ii. p. 34 et seq. Hut-
ler, Bibl. Med. lib. 12, § 1029, t.iv. p.424 etseq.
Renauldin, Biog. Univ. in loco.)

The Institutions of Berserius afford a favoura-
ble view of the state of medical science in Italy
at this period. He was born at Trent in 1724,
studied first at Padua and afterwards at Bologna;
he was for some years a professor in the university
of Pavia, and finally removed to Milan, where he
died in 1785. (Vide Prsef. ad Instit. Med. Prac.
ed. Lips. 1787.) Burserius was rather an eclectic
than an original theorist, but his work is much
valued for the information which it contains, and
much admired for the elegant manner in which
the information is conveyed. Like his contempo-
raries in Holland, France, and Germany, his doc-
trines are essentially founded upon those of trie
humoralists, but to these he unites various parts
of those of the solidists and vitalists, and has
proved himself deserving of the praise, not only
of learning, but of candour and judgment.

We have already had occasion to remark upon
the eflect which was produced in Italy by the
theory of Brown ; it was embraced by many of
the learned men of that country, and for some

MEDICINE, (HISTORY OF)

227

time acquired a considerably greater ascendency
over public opinion than it possessed even in its
native city. It was not only defended in their
publications, but its doctrines were applied to
practice, and it was not until their insufficiency
had been detected by fatal experience that the de-
lusion was removed.* At the conclusion of the
eighteenth century it would seem that the medical
theories of the Italians were considerably similar
to those of the Cullenean school, and that the
Italians, like the English physicians, were little
disposed to form systems of medicine, but devoted
themselves principally to the cultivation of anato-
my and physiology, in addition to the more imme-
diate studies of their profession.

In tracing the additions and improvements
which the science of medicine received during the
eighteenth century, we must not omit to notice
the descriptions of new diseases, either those
which were conceived to have actually originated
during this period, if there were any such, or
those which had not been previously discriminated
with sufficient accuracy from others that in many
respects resembled them. The various epidemics
which, from some unascertained and unexplained
causes, have at •different times passed over large
portions of the surface of the earth ; the endemic
diseases attached to particular situations, origina-
ting in some circumstance connected with the
atmosphere, soil, or climate of certain districts, or
in the occupation or mode of life of its inhabi-
tants; and lastly, the contagious or infectious dis-
eases, which have invaded entire cities or commu-
nities from unknown or at least obscure causes,
and after spreading destruction on all sides, have
disappeared from causes equally unascertained.

The first of these classes, the epidemic diseases,
were made an especial object of attention, in the
latter part of the seventeenth century, by Syden-
ham, whose remarks on them are among the most
interesting of his works ; also by Morton and by
Ramazzini : at a somewhat later period we have
the valuable observations of Huxham, of Lancisi
and Torti in Italy, and of Stoll at Vienna. The
science has been much enriched by various de-
scriptions of the diseases incident to the army and
navy, among which we may particularly notice
those of Pringle, Brocklesby, D. Monro, Hunter,
Lind, Hillary, Blane, Trotter, Larrey, and Desge-
nettcs.j- The formidable disease which has been
emphatically termed the plague, as it appeared in
London, the Low Countries, Marseilles, Moscow,
and other parts of Europe, in the latter part of
the seventeenth and the beginning of the eigh-
teenth century, and as it still exists in Turkey,

* Rasori of Genoa appears to have been the first who
made his countrymen acquainted with the doctrines of
Brown, of which lie was a zealous adherent; subse-
quently, however, he found reason, from the result of
experience, to change his opinions, and very candidly
and honestly expressed his conviction of their erroneous
tendency. An ample account of the pathological doc-
trines which are at present the most generally received
in Italy, under the title of " Nouva Dottrina ltaliana,"
may be found in the various publications of Tommasini,
the learned professor of Bologna.

t For a very complete list of works on these subjects
the reader is referred to the valuable work of Professor
Ballinga.il on Military Surgery, p. 227 ct seq.

Egypt, and the adjoining countries,^ as well as
the less formidable, although more extensive visi-
tations of the influenza, have each had their his-
torians ; and it is truly gratifying to observe that
in most cases the writers have been more anxious
to collect facts and to obtain correct information
than to support any particular theoretical views. §
In reviewing the state of medical science during
the eighteenth century, and tracing its gradual
advancement, we are naturally led to remark upon
the great additions which have been made to
pharmacy, both in regard to the introduction of
new articles into the materia medica, and the im-
provement that has taken place in the preparation
of various substances, and the mode of their ad-
ministration. It has been remarked that in pro-
portion as our knowledge of the virtues and quali-
ties of medicines has been matured, our pharma-
copoeia has been simplified, both as to the number
of articles employed and the mode of compound-
ing them. Accordingly, if we compare the suc-
cessive editions of the British pharmacopoeias and
dispensatories, we shall find that a number of
superfluous and inert substances have been from
time to time rejected, and that the complex formu-
la? of the older physicians have been reduced in
the same proportion. At the same time some
substances of real efficiency have been added,
while the improvement in chemical science has
enabled us to obtain the active principles of these
substances in much more condensed and commo-
dious forms. This remark may be illustrated by
Peruvian bark, a remedy which for a long period
afforded a fertile field for controversy both as to
its power over disease, the nature of its operation,
and the mode of its administration. Practitioners
have long been aware of the futility of most of the
points which were the subject of so much warm
and even acrimonious discussion, and are satisfied
with recognising its value as a powerful curative
agent in certain diseases, without endeavouring to
discover the nature of the occult qualities on
which its operation depends; while the chemist
has lent his aid in pointing out a mode by which
its active proximate principle may be procured,
detached from the inert matter with which it is
naturally combined. The skill of the modern
chemist has likewise been most beneficially exer-
cised on the metallic preparations; giving them
more fixed and definite combinations, pointing out
the modes by which they may be produced with
more ease and certainty, and ascertaining the
chemical relation which they bear to other sub-
stances, so as to indicate how they may be com-
bined with them without decomposition, or even
with an increase of their activity.

t Becker's account of the " Black Death," which ra-
vaged so large a portion of the globe in the fourteenth
century, may be mentioned as a work worthy of our
notice, both as containing many interesting details of
this tremendous pestilence, and as exhibiting a curious
specimen of medical hypothesis.

§ For the names of the authors who have treated on
these topics, we refer to the respective articles of this
work. Copious lists of authors may also be found in
Young's Medica] Literature, a work no less remarkable
for its learning than for the condensed form in which it
is communicated. Much valuable information on this
subject will be found in Sprcngel, sect. to. eh. 3. art. 2

223

MEDICINE, (HISTORY OF)

CHAPTER XIII. — Cursory remarks on the

swte of practical medicine since the com air /la-
ment of the present century — Difficulty of ac-
quiring medical experience — State of medicine
in Great, Britain — Pathologists of France —
Physiologists of Germany — Mt diced journals
— Medical societies — Schools of medicine —
■'■'■stions for the improvement of medical
science.

As the historian of medicine approaches nearer
to his own times, he finds his path encumbered
v.iih almost insurmountable difficulties. The
subject on which he has to treat differs, perhaps,
from every other branch of science in this circum-
stance, that our actual information does not in-
crease, in any degree, in proportion to our experi-
ence. Hence it follows that the accumulation of
materials frequently rather retards than promotes
its progress. In other sciences, although truth is
not to be attained without a certain degree of
laborious research, yet to those who are willing to
bestow on it the requisite attention, it is for the
most part attainable, or, if it still elude our grasp,
we are at least sensible of the deficiency, and can
generally ascertain the precise nature of the ob-
stacles which impede our progress. In other sci-
ences, when we enter upon an inquiry, or propose
to ourselves any definite object for experiment or
observation, we are able to say whether the result
of our inquiry has been satisfactory, and whether
the object in view has or has not been accom-
plished.

But this is unfortunately not the case in medi-
cine. There are certain peculiarities necessarily
connected with the subject, which render it ex-
tremely difficult to appreciate the value of experi-
ment and observation. In our experiments we
are seldom ahle to ascertain with accuracy the
previous state of the body on which we operate,
and in ^*ur observations we are seldom able to
ascertain what is the exact cause of the effect
which we witness. The history of medicine in
all its parts, and especially that of the materia
medica, affords ample testimony to the truth of
these remarks. In modern times, and more re-
markably in Great Britain, no one thinks of pro-
posing a new mode of practice without supporting
it by the results of practical experience. The
disease exists, the remedy is prescribed, and the
disease is removed ; we have no reason to doubt
the veracity or the ability of the narrator; his
favourable report induces his contemporaries to
pursue the same means of cure, the same favour-
able result is obtained, and it appears impossible
for any fact to be supported by more decisive tes-
timony. Yet in the space of a few short years
the boasted remedy has lost its virtue, the disease
no longer yields to its power, while its place is
supplied by some new remedy, which, like its pre-
decessors, runs through the same career of expec-
tation, success, and disappointment.

Let us apply these remarks to the case of fever,
the disease which has been styled the touchstone
of medical theory, and which may be pronounced
to be its opprobrium. At the termination of the
last century, while the doctrine of Cullen was
generally embraced, typhous fever was called a
disease of debility, and was of course to be cured

by tonics and stimulants. No sooner was it
ascertained to exist, than bark and wine were ad-
ministered in as large doses as the patient could
be induced or was found able to take. No doubt
was entertained of their power over the disease;
the only question that caused any doubt in the
mind of the practitioner was, whether the patient
could bear the quantity that would be necessary
for the cure.

To this treatment succeeded that of cold affu-
sion. The high character and literary reputation
of the individual who proposed this remedy, its
simplicity, and easy application, the candid spirit
which was manifested, and the strong testimonials
which were adduced by his contemporaries, bore
down all opposition, and we flattered ourselves
that we had at length subdued the formidable
monster. But we were doomed to experience the
ordinary process of disappointment ; the practice,
as usual, was found inefficient or injurious, and
it was after a short time supplanted by the use of
the lancet. But this practice was even more
short-lived than either of its predecessors; and
thus, in a space of less than forty years, we have
gone through three revolutions of opinion with
respect to our treatment of a disease of very fre-
quent occurrence, and of the most decisive and
urgent symptoms.

Are we, then, to conclude that all medical
treatment is of no avail ? that it is all imaginary
or deceptive ? We should feel most unwilling to
be compelled to form such a conclusion, nor do
we conceive that it necessarily follows from the
premises ; but we think that the facts prove the
importance of extreme caution in forming our
conclusions, and still more that mere experience,
without the due combination of well regulated
theory, is a most fallacious guide. What objec-
tion can the man of mere experience, the rejecter
of all theoretical deductions, urge against the
multiplied testimony that is now presented to us
in favour of the Homoeopathic doctrine] — what
answer can be made to the Report that has been
recently brought forward by the medical commis-
sioners of Paris on the subject of Animal Mag-
netism ] The conclusion that forces itself irre-
sistibly on the mind is, that no medical testimony
is sufficient to establish a fact which is in itself
incredible, and that this previous incredibility can
only be ascertained by an extensive and accurate
knowledge of the functions and properties of the
living body, both mental and corporeal, in all its
modifications and under all circumstances, and by
a correct and careful generalization of the know-
ledge thus obtained. These considerations, as
well as others which will present themselves to
the mind of the reader, may be deemed a sufficient
reason for our attempting no more than to offer a
few general remarks on the state of medical sci-
ence during the period at which we are now ar-
rived. We shall therefore devote this chapter to
some cursory remarks on the practice of medicine
as it now exists in the different countries of Eu-
rope, as well as on the state of some of the col-
lateral or auxiliary departments, and shall conclude
by some suggestions for the best means of pro-
moting its future progress.

The prevailing and predominant feeling of the
most enlightened and the most judicious of the

MEDICINE, (HISTORY OF)

229

British practitioners during the period referred to,
has been to place little value upon theory, and to
devote their minds almost exclusively to the obser-
vation and collection of facts. There can be no
doubt that this is a less injurious extreme than
the opposite ; but if the statement which has been
made above be correct, it will probably be admitted
that this system may be carried too far. And the
same exclusivcness has also induced them to pay
too little attention to some of the collateral de-
partments of science. In pathology and in phar-
maceutical chemistry they have been far out-
stripped by the French, and in physiology by the
Germans. But at the same time that we feel it
necessary to pass this judgment on our country-
men, we must fully admit that the spirit of rational
empiricism, to which we have referred above as
the characteristic feature of the Cullenean school,
has produced a most beneficial influence on the
general state of medical practice. If it has, on
some occasions, produced fluctuation of opinion,
and on others indecision or inertness, it has tended
to sweep away much error, and to purify the sci-
ence from many of the antiquated doctrines and
practices that still maintain their ground among
our continental brethren. This is more especially
the case with our pharmacopoeias, where, if we
compare those of London and Paris, we shall be
struck with the number of what we conceive to
be useless articles that are still retained in the
latter, sanctioned by the authority of the scientific
and enlightened body of men who compose the
medical faculty of the French metropolis. We
are, however, indebted to France for the most im-
portant improvements which have taken place in
pharmaceutical chemistry : by their method of
obtaining the proximate principles of various
vegetable substances, and the greater precision
which they have introduced into the formation of
the metallic preparations, they have conferred a
great and lasting benefit on the art, which, among
all the revolutions of opinions and practices, can
never be contravailed.*

But the glory of French medical science is its
pathology. We are justly proud of our Hunters,
our Monros, and our Baillie ; and there are cer-
tain individuals among our contemporaries who
are emulously treading in their footsteps. But
any feeling of national vanity which we might be
disposed to indulge, must be effectually repressed
when we look at the illustrious band of French
pathologists, when we review the labours of Pinel,
Andral, Breschet, Broussais, Corvisart, Cruveil-
hier, Dupuytren, Laennec, Bayle, Louis, Gendrin,
Foville, Chaussier,-)- and others, who have directed
their attention more exclusively to pathology;
and when we add to these the names of those
who are to be regarded more in the light of phy-

* We have a very learned review of the state of medi-
cine during the earlier part of the present century, from
the pen of the celebrated Sprengel. It is peculiarly va-
luable, from the numerous references which it contains
to the writers of Germany, and from the view that it
presents of the opinions which prevail in that country.
The German physiologists afford a singular admixture
of profound investigation and fanciful mysticism.— Ed.
Med. Journ. v. xii. p. 385 et seq.

t We may refer our readers for an interesting account
of the progress of pathology since the commencement
of the present century, to a series of papers in the Ar-
chives Generates de Medecine, by M. Dezeimeris, t. xxix.
et seq.

siologists, Bichat, Vic-d'Azyr, Cuvier, Richerand,
Magendie, Edwards, Dumas, Legallois, Adelon,
Desmoulins, Serres, Blainville, Flourens, St. Hi-
laire, Dutrochet, and others, we must admit that
France exhibits an unrivalled assemblage of medi-
cal philosophers. From the united labours of
such eminent men it is impossible not to antici-
pate the most important results ; but we believe
that we are justified in asserting that, so far as
the practice of medicine is concerned, the benefit
is still rather in anticipation than in existence.
With certain exceptions, but these no doubt very
important ones, we should characterize the French
practice as decidedly less effective than that of
our country ; dependence is placed on remedies
which we conceive to be inert, and much of the
dietetic regimen which enters so largely into the
treatment can produce no effect in the removal of
disease. In short, their " medecine expectante,"
although it may be a less dangerous weapon in
the hands of ignorance or presumption, is, in the
same proportion, less powerful and beneficial when
under the direction of skill and judgment.

If France is pre-eminent for its pathology,
Germany is no less so for its physiology and its
anatomy. The names of Camper, Blurnenbach,
Ludwig, Summering, Meckel, Wrisberg, Reil,
Tiedemann, Wenzel, Sprengel, Jacobsen, Carus,
Pfaff, Oken, Osiander, Ackermann, Rosenmuller,
Gmelin, Walter, and Treviranus, [J. Miiller,
Wagner, Henle, Gerber, Bischoff, Burdach, Va-
lentin,] may be selected from many others as
among the most celebrated throughout Europe,
and as having made most important additions to
our knowledge on the subjects to which they have
particularly directed their attention. Yet in Ger-
many as in France, the effect of this scientific co-
operation on the practice of medicine is not yet
fully experienced. The treatment of disease is
perhaps not more effective than in France, while
it is still more encumbered with complicated for-
mulas and with antiquated practices, which in
this country have been discarded because they
have been found useless or even injurious.t Italy,
which so long took the lead in all scientific pur-
suits, now offers the prospect of a splendid ruin,
where we occasionally meet with an illustrious
name, such for example as those of Scarpa, Cal-
dani, Mascagni, Rolando, Bellingeri, and Tomma-
sini, but where medical science, if it has not
retrograded, has at least remained stationary.
The practice of medicine has, however, had some
zealous cultivators ; we have already remarked on
the activity with which the Brunonian controversy
was pursued, and the excitement which was then
produced seems to have had a beneficial effect in
rousing the dormant energy of the mind, of which
some traces are still visible.

A circumstance which has materially contri-
buted to the improvement of the knowledge of
practical medicine is the publication of periodical
works, whether in the form of journals or of the
transactions of societies. They have brought be-
fore the public the daily occurrences and passing

J In speaking of the practical writers of Germany, it
would be unjust to omit the name of Frank, and not to
acknowledge the obligation which he has conferred upon
medical science. Among the pathologists, Hartmann of
Vienna and Conradi of Gottingcn are perhaps the best
known in this country.

230

MEDICINE, (HISTORY OF)

events in a commodious and interesting form, and
thus by exciting attention to them have tended
both to diffuse and to increase our knowledge on
these subjects. It is, however, very much to be
regretted that so valuable a mode of communica-
tion should, in too many instances, be used as
the medium of personal animosity, and that what
ought to be employed for the promotion of the
welfare of mankind should become a vehicle of
the basest and the most malignant passions. On
this point, as well as on the one referred to above,
justice compels us to state that the French metro-
polis offers us an example by which we might
profit, in the number, extent, and general charac-
ter of its medical periodicals, and the same senti-
ment leads us to remark that the medical periodi-
cals of London are decidedly excelled by those
of Edinburgh and Dublin. Among the published
transactions of medical societies, the Medico-Chi-
rurgical may fairly be selected for our approbation;
these, in the short space of about twenty-four
years, have amounted to eighteen volumes, and
have acquired a character which is too well estab-
lished to require recommendation or sanction.

In connection with their transactions we may
mention the effect of the societies themselves,
which, when they are confined to subjects of me-
dical science, must be highly beneficial. Perhaps
no single institution has contributed more to the
improvement of our profession than the Edinburgh
Medical Society, which for so long a period has
maintained a reputation that reflects the greatest
credit, not merely on its members, but even on
the university to which it is attached. It is, indeed,
a remarkable and an honourable circumstance that
an association, principally composed of students
and entirely conducted by them, should have pro-
ceeded for above half a century in so uniform a
course of respectability; that during this period
they should have admitted of free discussion with-
out deviating into licentiousness, and that amidst
the fluctuations to which such an association must
necessarily be subject, successors have at all times
been found able to direct its progress and qualified
to support its reputation.

Another circumstance to which we must briefly
advert, which is both the cause and the conse-
quence of the progress of our art, is the improved
state of medical schools of all descriptions, both
those attached to universities or to public hospitals,
and those conducted by private individuals. By
a very singular anomaly it has happened that in
this country the highest medical honours have
been hitherto conferred by those bodies who did
not profess to give the requisite means for their
attainment. This circumstance may, indeed, in
one point of view be regarded as paying the
highest compliment to the English universities ;
but we believe that a very general sentiment now
prevails among their most respectable members
that this anomaly ought no longer to be suffered
to exist, and that medical honours ought to be be-
stowed upon those, and those only, who have
gone through with what may be considered a suf-
ficient course of preparatory studies, and who are
able to give satisfactory proof that they have taken
due advantage of the means of improvement pre-
sented to them. But whatever may have been
wanting in the English universities has been long

supplied by that of Edinburgh, and, at a later
period, by those of Glasgow and Dublin. The
great London hospitals and some of the private
schools, especially those of anatomy, have for a
number of years possessed teachers of the highest
talents and most admirably qualified for their
office ; but our metropolis could not be said to hold
out the means of a complete medical education
previous to the establishment of the London Uni-
versity and the King's College. These rival
schools, rivals as we trust they will always be only
in the talents of their professors and the excellence
of their arrangements, have each of them laid down
an academical course of medical instruction which
appears to be complete in all its parts, and which
must have the most salutary influence on the
character and qualifications of the future members
of the profession.

The perusal of the foregoing pages will, we
trust, enable our readers to form a tolerably accu-
rate conception of the progress of practical medi-
cine, of the obstacles which it has had to encounter,
of the degree in which it has overcome these ob-
stacles, and of its present state of improvement
This we are not disposed to underrate ; but at the
same time we must acknowledge, that when we
reflect upon the immense mass which has been
written on the subject, the result seems scarcely
adequate to the labour that has been bestowed.
We may, therefore, be pardoned if we offer a very
few remarks on the means by which, as it appears
to us, the object in view might be more effectually
attained.

This, we think, should be attempted precisely
upon the same plan as in other departments of
science : — in the first place, by a more careful ex-
position of facts ; and, secondly, by a more careful
generalization of them. In medicine there are
various circumstances which render it less easy to
ascertain the facts than in most other cases. These
depend partly on the nature of the subject, and
partly on the situation and character of the ob-
server. It was the shrewd remark of a learned
professor that in medicine there are more false facts
than false opinions. On all topics, either historical,
scientific, or literary, mankind possess a strong
avidity for the marvellous. From the constitution
of the human mind, the love of novelty is one
great principle by which the attention is excited
and the intellectual powers are called into action.
Hence, in a rude state of society, nearly the whole
art of medicine consists in the dexterous employ-
ment of this agent, and hence it is still found the
most effectual method of attracting the notice of
the multitude, who are incapable of close reasoning
or calm investigation.

Perhaps one of the most easy and at the same
time the most effective means of counteracting this
mischievous influence, would be never to receive
the evidence for any medical facts upon the au-
thority of a single individual. They should, if
possible, emanate from associated bodies, either
from public hospitals, medical schools, or societies,
the officers of which may afford their united testi-
mony to the alleged facts. Another point which
appears to us of vital importance, and which bears
essentially upon every department of medicine, is
that nothing should be received without the name
of the author. The custom of anonymous writing,

MEDICINE, (HISTORY OF)

231

which has of late increased to so great an extent,
has produced the most unhappy effects, both on
the state of medical science and on the character
of its professors ; it has given rise to a degraded
and depraved taste, no less at variance with honour
and honesty than with the spirit of scientific re-
search. We will venture to assert that no man
ought to publish any statement or any opinion to
which he would scruple to attach his name. It
may occasionally happen that an individual of a
timid or a modest disposition may, by this restric-
tion, be deterred from detecting an error or con-
troverting a train of false reasoning, but the loss
which might by this means be incurred would be
amply repaid by the greater authenticity and the
greater correctness of our medical publications.

With respect to the second suggestion, the more
accurate generalization of facts, when the facts
themselves are fully substantiated, — this must be
accomplished by the due exercise of judgment and
sagacity, and can scarcely be directed by any ge-
neral rules. We may remark, however, that one
obvious mode of attaining this end is to arrange
our insulated facts as much as possible in the form
of statistical tables, by which we may readily ob-
serve their connection with or relation to each
other, and may thus be prevented from forming a
hasty or unauthorized conclusion, derived merely
from single cases or individual observations.

Another important means of obtaining the ob-
ject in view is to preserve great precision in the
use of technical and scientific terms. How many
controversies have occupied the mind for ages, and
have filled almost innumerable volumes, which
have essentially turned upon the definition of a
word ? How frequently have remedies been pre-
scribed, not for the symptoms, but for the name of
a disease 1 How frequently has an article of the
materia medica been employed, not from an expe-
rience of its actual effects, but from some nominal
property assigned to it by an imperfect analogy or
imaginary quality ] The means that have been
proposed to check these aberrations, to rectify the
above-mentioned errors, and to reduce medical
science to its appropriate and correct limits, are
indeed few and simple, and not of difficult appli-
cation. But there is one essential requisite, with-
out which they can be of no avail, — a mind dis-
posed to the reception of truth, determined to
follow it wherever it may lead the inquirer, united
to a high sense of moral obligation, which may
induce the medical practitioner to bear in mind
that his profession is a deposit placed in his hands
for the benefit of mankind, and that he incurs an
awful degree of moral responsibility who abuses
this sacred trust, or diverts it to a base or selfish

purpose.

J. Bostock.

[Sketch of the state of American Medi-
cine before the Revolution.*— As may na-
turally be presumed, in a country circumstanced
as the American colonies were for a long period
after their original settlement, the medical profes-
sion continued for a succession of years in a low

* [This article formed the essential part of the annual
address delivered in 1842, before the Medical Society of
the State of New York, of which Dr. Beck was then pre-

fhn *„ « e addr ° SS '£ l'" b ' islle(l "' ">e transactions of
Hie State Society. — R. D.]

and degraded condition. In point of respectability,
it undoubtedly stood lower than either the legal or
theological professions. The persecutions of the
mother country had filled the ranks of the latter
with men of learning, talents and piety — while
the offices of honour and emolument under the
crown, offered allurements sufficiently powerful,
to induce many who were distinguished in the law
to emigrate to this western world. With medicine
it was far otherwise. It is only in populous towns
and cities that our art can flourish ; and the wilds
of America, however fragrant they might be with
the spirit of freedom, offered no attractions to the
medical men of the old world. The advantages
attending an emigration were too distant and pre-
carious to warrant such a step ; and accordingly
for a long time, with some few exceptions, none
but those who had failed to attain respectability or
employment at home, would venture on so dan-
gerous an experiment. Nor were the young na-
tive physicians for a long time calculated to rem-
edy the evil. To become a well-qualified physi-
cian, requires a course of study and a variety of
observation which was not to be obtained in any
of the colonies. There were neither lectures nor
hospitals which could be resorted to, while the
great expense attending a foreign education put it
out of the power of all, except a favoured few, to
avail themselves of the only means of becoming
regularly instructed. Under such circumstances
it was not to have been expected, for a long series
of years after the first settlement of the country,
that our profession would be at all distinguished
for character or knowledge. The progress of civil-
ization, an augmenting population, together with
the increasing facilities of European communica-
tion, tended gradually to meliorate this condition
of things, and for many years preceding the revo-
lution, medicine could boast of not a few names
who shed a lustre upon the profession to which
they belonged.

With those preliminary remarks, I propose to
give a brief sketch of the state of medicine in this
country anterior to the revolution ; and, for the
sake of convenience, shall consider it under the
three divisions of medical practice, medical liter-
ature, and medical institutions.

Medical Practice. — The earliest practitioners
of medicine in this country appear to have been the
clergy — this was at least the case in New-Eng-
land, where, for several years after the first settle-
ment of the colony, the functions of the physician
and divine were performed by the same individual.
This combination has not been uncommon in the
history of the world. In the early dawn of med-
icine, the priests of Egypt and Greece collected
and preserved what was known of the healing art,
and in the infancy of every country the same as-
sociation will probably be found to exist. Nor is
it, by any means, an unnatural one. Physical
and moral evil are so intimately connected that
those who are administering relief to the one, can-
not be regardless of the other. Hence, in the ab-
sence of the regular physician, the priest appears
to be his most proper representative. Besides this,
the character of the first emigrants, and the high
tone of religious feeling which drove them for an
asylum to this western world, continued for a long
time to give a preponderating influence to the

232

MEDICINE, (HISTORY OF)

clergy, in all the secular as well as religious con-
cerns of the colony. In the annals of the first
colonists, accordingly, will be found the names of
several clergy men who practised the healing art.
Besides these, some of the first governors of the
eastern colonies also practised physic. Two of
them, of the name of Winthrop, appear to have
been particularly celebrated. One of them was
Governor of Massachusetts, the other of Connec-
ticut and New Haven. Of the latter, Cotton Ma-
ther says : " he was furnished with noble medi-
cines, which he most charitably and generously
gave away upon all occasions." (Magnalia, p. 31.)
He was a member of the Royal Society of Lon-
don, and some of his communications are to be
found in their transactions. Amid such practice,
however, as this must necessarily have been, it is
easy to conceive that nothing could be done to im-
prove the state of medicine, and that the greatest
facilities must speedily have been offered for suc-
cessful imposition upon the credulity of the public.
This supposition is fully confirmed by the fact
that so early as the year 1649, a law was passed
in Massachusetts, " that no chirurgeons, midwives,
physicians, or others, presume to exercise, or put
forth any act contrary to the known approved
rules of art, in each mystery and occupation, nor
exercise any force, violence or cruelty, upon or
towards the body of any, whether young or old,
(no, not in the most difficult and desperate cases.)
without the advice and consent of such as are
skilful in the same art, (if any such may be had,)
or at least of the wisest and gravest there present,
and consent of the patient or patients, if they be
mentis compotes, much less contrary to such ad-
vice and consent, upon such severe punishment
as the nature of the fact may deserve."* This
appears to have been the very first attempt of the
civil authority, in any of the colonies, to put a
restraint upon those who pretended to the prac-
tice of physic. Salutary as this law may have
been, in some respects, it afforded but a slender
protection against the existing deficiencies in the
profession. It made no provision for the educa-
tion of medical men, and it established no test of
their qualifications.

The State of New York, I believe, is entitled
to the honour of adopting the first effectual mea-
sures for regulating the practice of medicine. This
was not, however, until so late a period as 1760,
when the General Assembly of the Province or-
dained that " no person whatever should practise
as a physician or surgeon, in the city of New
York, before he shall have been examined in
physic or surgery, and approved of and admitted
by one of his majesty's council, the judges of the
supreme court, the king's attorney-general, and
the mayor of the city of New York, for the time
being, or by any three or more of them, taking to
their assistance for such examinations such proper
person or persons as they in their discretion shall
think fit." (Laws of New York, from 1752 to
1762, by Livingston & Smith, vol. ii. p. 198.) If
the person so examined was approved, a certificate
was given, allowing him to practise physic or sur-
gery, or both, throughout the province. In case

* General Laws and Liberties of the Massachusetts
Colony, in New England, revised and reprinted by order
tf the General Council, held at Boston, A] ay lo, 167?.

of non-compliance, the penalty was a fine of five

pounds. •

In 1772, a similar law was adopted in ISew
Jersey. These examples were not imitated in the
other colonies, where the practice continued un-
restrained, and physicians were responsible to no
authority for mill-practice. In Connecticut, an
attempt was indeed made to effect a reformation
in this respect, but so strong was the current of
prejudice against the measure, that it completely
failed. As far as my investigations have ex-
tended, the foregoing is all that was done, or even
attempted by the constituted authorities, in behalf
of our profession, previous to the Revolution ; and
it shows conclusively how little its present re-
spectability is owing either to the colonial govern-
ments, or to the mother country.

During the period embraced in this sketch, the
division of practice into distinct departments, so
generally adopted in Europe, was not recognised
in this country. Both physic and surgery were
practised by the same individuals ; besides this,
it was the general custom of physicians to pre-
pare and compound their own medicines. In the
year 1765, Dr. John Morgan, a distinguished
physician of Philadelphia, endeavoured to intro-
duce a change in the existing mode of practice,
by recommending a separation of it into the three
branches of physic, surgery, and pharmacy, and
appropriating each of these departments to a sepa-
rate class of practitioners. Having spent several
years of his life in the acquisition of professional
knowledge, in countries where he had seen the
practical operation of this system, he became
deeply impressed with the importance of it to im-
prove the character of the profession at home.
On his return, he accordingly not merely recom-
mended it in a discourse which he published, but
adopted it in his own practice. Although in
every respect fully accomplished, he consequently
declined engaging in any surgical operations, and
confined himself entirely to niedicine.-f- What-
ever may be thought of the general utility or pro-
priety of such a plan, it was undoubtedly at that
early period somewhat premature, and probably
did not meet with much encouragement.

Until about the middle of the last century, mid-
wifery was exclusively in the hands of females,
and physicians were called in only in preter-
natural and tedious cases. According to Dr.
Bartlett, of Massachusetts, Dr. James Lloyd was
the first systematic practitioner in midwifery in
that section of the United States. He had en-
joyed the instructions of Warner, Sharpe, Smellie.
and Hunter, of London, in 1753, and in the fol-
lowing year settled in Boston. (Medical Com-
munications and Dissertations of the Mass. Med.
Soc. vol. 2, p. 244.) In 1756, Dr. William
Shippen, Jr., on his return from Europe, com-
menced the same branch of professional business
in Philadelphia ; and although at this period
physicians were scarcely ever employed in natural
labours, it is stated by his biographer, Dr. Wistar,
that he did away completely with this prejudice,

t A discourse upon the institution of medical societies
in America, delivered at a public anniversary commence-
""'';' he'" " the college of Philadelphia, May 30, 1765;
with a preface containing the authors apology for at'
tempting to introduce the regular mode of practwiBg
physic id Philadelphia. I'hiiad jtw

MEDICINE, (HISTORY OF)

233

and in the course of a few years was fully
occupied. (Eulogium on Dr. Wm. Shippen. By
Caspar Wistar, M. D., Philad. 1818, p. 31.)

These are the two first physicians employed as
regular accoucheurs in this country, of whom we
have any notice ; and they deserve especial com-
mendation, as having led the way in overcoming
deep-rooted prejudices, and in transferring to the
profession, from the hands of ignorant and unedu-
cated females, the practice of a difficult and deli-
cate art.

From the connection subsisting between the
mother country and the colonies, as may natu-
rally be presumed, the same doctrines prevailed
in both, and the practice was essentially the
same. At the beginning of the eighteenth cen-
tury, the celebrated Boerhaave commenced his
career. Gifted with every endowment, natural
and acquired — a mind powerful and generalizing
— a fascinating eloquence — learning the most
varied and profound, and a character radiant
with every virtue, this great man was eminently
qualified to take the foremost lead in the medical
world. Not merely the age in which he lived
bowed at once to the supremacy of his genius,
but his doctrines continued to control the opinions
and practice of medical men during the larger
portion of a whole century. The leading feature
in the system of this distinguished theorist, was
the great and undue importance which he gave to
the fluids in the production of disease. These,
according to him, became variously changed, not
merely in their physical properties, but in their
chemical composition. They became morbidly
thick or thin, while they were contaminated by
acid and alkaline acrimonies, and various other
morbific matters. To such conditions of the
fluids, diseases were attributed ; and medicines
were supposed to act by counteracting and chang-
ing them. Such were the doctrines prevalent in
the old world during the last century. Their in-
fluence was no less undisputed in this country,
and the general practice was modified by them.
In the management of diseases, medicines were
accordingly given with the view of thinning or
incrassating the blood, and altering its qualities.
Much confidence was placed in the powers of na-
ture, and the results of critical days watched with
the greatest anxiety. On these, it was supposed
that the materies morbi w r as discharged, and thus
the relief of the patient effected. The matter was
looked for chiefly in the urine, and, according to
Dr. Rush, " glasses to retain it were a neces-
sary part of the furniture of every sick-room."
(Rush's Obs. and Inqs., vol. iv. p. 396.) In
the treatment of fevers, sudorific medicines were
principally resorted to, and to aid their operation,
and to facilitate the elimination of the morbid
matter, the supposed cause of disease, patients
were confined to their beds, and cool air denied
them in the most rigid manner. Bleeding was
not a general remedy in fever. In yellow fever,
so far as we can judge from the opinions of a
single individual, it was considered of doubtful and
even dangerous tendency. Dr. John Mitchell, a
distinguished physician of Virginia, in his account
of the yellow fever which prevailed there in the
years 1737, '41 and '42, in speaking of this sub-
ject, says, " plentiful bleeding is a means com-

Vol. III. — 30 u»

monly found most effectual to obtain this end,
(i. e. to ward off local inflammation,) in the be-
nign inflammatory fevers; but we cannot apply
this most effectual remedy in this disease, because
it evacuates only or chiefly the red globules of the
blood, which, as we see by its state taken notice
of above, are in too small a proportion already ;
and bleeding further breaks the texture of the
blood, which above all things is to be avoided in
this disease ; for after plentiful bleeding, the pulse
sinks, or at least is so low and feeble about the
state of the disease as to prove of dangerous con-
sequence ; which some instances I have known
seem to confirm." (American Medical and Phi-
losophical Register, vol. iv., p. 198.) He did not,
however, discard bleeding altogether. In small
quantities, he found it serviceable to prepare the
system for other evacuations. The remedies
which he principally relied on were sudorifics,
but more especially cathartics. Upon the im-
portance of this latter class of remedies, he dwells
with peculiar urgency, and many of his views are
characterized by great good sense and practical
acumen. It was entirely by the observations and
suggestions of this physician, that Dr. Rush, as
he himself frankly acknowledges, was afterwards
led to the free use of purgatives in the yellow
fever of 1793.

In relation to yellow fever, the prevalent opinion
at this period was, that it was a contagious dis-
ease. Both Drs. Mitchell, of Virginia, and Lining,
of Charleston, express decided opinions on this
subject. Dr. Lining, too, expresses the belief
that, like small-pox and measles, it does not
attack the second time. It is hardly necessary to
state, that the accurate and extended observations
of more recent times have completely disproved
both these positions. Indeed, if there be any one
point in medicine which may now be looked upon
as settled, it is that the yellow fever is not a con-
tagious disease ; and numerous observations in-
contestably show that it may assail the human
constitution a second time.*

According to Dr. Rush in his account of the
state of medicine between the years 1760 and
1766, bloodletting was used plentifully in pleuri-
sies and rheumatism, but sparingly in all other
diseases, (Observations and Inquiries, vol. iv. p.
396,) a practice, it must be admitted, much more
judicious and safe, to say the least, than the in-
discriminate and sanguinary practice which was
afterwards adopted by this distinguished theorist.
At this period, according to the same authority,
some of the most potent and useful articles of the
Materia Medica were but partially exhibited, owing
to the prejudices of the public, and in some mea-
sure to the fears of the physician. Among them
were the Peruvian bark and opium, both of which
it was necessary to disguise by admixture with
other medicines. Blisters were generally used,
but their application was confined to the last
stages of fevers. Dr. Rush says " wine was given
sparingly even in the lowest stages of what were
then called putrid and nervous fevers." (Ibid. vol.
iv. p. 399.) Nevertheless, I find that so early as
1746 the liberal use of wine in typhus fever was
recommended by that distinguished physician,

* [For the conflicting views on these subject*, Bee
Fever, Yellow. — R, D.J

234

MEDICINE, (HISTORY OF)

Dr. Colden, Lieut. Governor of the colony of
New York. In the year just mentioned, a fever
of this description prevailed epidemically at Al-
bany, and in many cases proved fatal. " It had
the appearance of a remittent, with frequent low
pulse, except in the paroxysms, when it was high;
a dejection of spirits, great restlessness, an entire
prostration of appetite, clammy sweats of a rancid,
putrescent smell." By the physicians of the place,
it had been treated as an intermittent, but without
success. By the advice of Dr. Colden, Madeira
wine, to the extent of a wine glass full every four
or five hours, was ordered, and with the happiest
effects. One patient who recovered, drank a gal-
lon in a few days. In all these cases the wine was
given in the last stage of the disease. (Lond.
Med. Obs. and Inq. vol. 1, p. 215.)

Although the physicians in the colonies gene-
Tally followed the prevalent practice of the mother
country, yet they are entitled to the credit of ori-
ginating some modes of practice of great value.
The most important of these is the application of
mercury in the treatment of inflammatory com-
plaints. This practice took its origin as far back
as the year 1736, and the credit of originality is
generally conceded to Dr. Douglass, a physician
of Boston, by whom it was used in the angina
maligna which prevailed extensively over the colo-
nies at that period, and committed the most dread-
ful ravages. (New England Journal of Medicine,
vol. 14, p. 4.) By Dr. James Ogden, a respecta-
ble physician of Long Island, this practice was ex-
tensively applied in the same disease about the
year 1749. (New York Med. Repository, vol. 5,
p. 97.) The preparation of mercury which was
used was calomel. In consequence of the success
which attended the use of this remedy in this dis-
ease, it was shortly after resorted to in other in-
flammatory complaints ; and about the middle of
the last century, it was in common use in this
country in pleurisy, pneumonia, rheumatism, and
others of the phlegmasia?. I am aware that the
credit of this practice is claimed elsewhere - x * but
there can be no doubt that in its origin it is exclu-
sively American, and that to our colonial physi-
cians the world is indebted for one of the greatest
improvements ever made in practical medicine.

Among the events which characterized the his-
tory of our colonial medicine, the most remarkable,
and certainly the most exciting, were those which
attended the introduction of the practice of inocu-
lation for the small-pox. This was first introduced
into this country in the year 1721 j and it is to a
clergyman, Dr. Cotton Mather, that the honour
belongs of having first recommended it. During
this year the small-pox raged in Boston with un-
paralleled fury and fatality. Dr. Mather having
read, in the Transactions of the Royal Society of
London, an account of a new mode of mitigating
the violence of the disease by inoculation, as prac-
tised in Turkey, communicated it to the physi-
cians of the place, and urged their adoption of it.

* Dr. John Armstrong, in his work on Typhus, gives
the sole credit of this practice to Dr. Robert Hamilton
of Lynn Regis. In another place, I have shown the in-
correctness of this statement. (S»e New York Medical
Gazette, No. 1.) From the account of Dr. Hamilton
himself, it appears that his attention was not called to
the practice until the year 1764 ; whereas it had been in
verv general use in this country many years before.

With the exception of one individual, it was

unanimously opposed by the faculty. This indi-
vidual was Dr. Zabdicl Boylston, who, with the
confidence of an honest and enlightened mind,
commenced his operations on his own children
and servants.f The controversies which ensued
were of the most ferocious and disreputable charac-
ter. Such was the tempest of popular indigna-
tion raised against the practice, chiefly by the in-
flammatory conduct of the physicians, at the head
of whom was Dr. Douglass, that both Drs. Mather
and Boylston were in danger of losing their lives.
Passion and prejudice on the one side were, how-
ever, met by decision and success on the other ;
and inoculation, defended by almost all the clergy,
many of whom preached and wrote in its defence,
soon triumphed over opposition, and became pre-
valent in Boston and the neighbouring towns.
From thence it was introduced into the other colo-
nies, and although uniformly resisted at first, the
public mind became gradually reconciled to it. So
early as 1738, it was practised in Charleston,
S. C. during the epidemic small- pox which then
prevailed there. In 1759 it was generally adopted
in Philadelphia, where its dissemination was very
much facilitated by a defence and recommendation
of it by Dr. Redman. The true merit of Dr.
Boylston, in relation to the introduction of inocu-
lation, will not be appreciated unless it is stated
that at this time the practice had only just found
its way into Europe. By a singular coincidence,
the first case of inoculation in Europe took place
in England in April, 1721, only two months be-
fore the first experiment of Dr. Boylston, and en-
tirely without his knowledge. This was the case
of the daughter of Lady Wortley Montague.
This celebrated female, during her residence in
Constantinople, having become acquainted with
the safety of the practice, had her son inoculated,
and on her return to England, her daughter was
subjected to the same operation, and with perfect
safety. (The History of the Inoculation of the
Small-Pox, &c. By William Woodville, M. D.
vol. 1, p. 85.) This led the way to the speedy
diffusion of the practice in England, as the expe-
riments of Boylston did in this country. It is
gratifying to know, that although opposed anil
slandered at home, this eminent physician was ap-
preciated abroad. In 1725 he visited England,
and was received with the highest favour and at-
tention by the most distinguished characters in
the nation, and even by royalty itself. He WW
elected a fellow of the Royal Society, it being the
first instance in which that honour was conferred
upon an American.

Among the practices peculiar to the colonies,
was the administration of mercury as a prepara-
tive to inoculation. By the illustrious Boerhaave,
it had before this been suggested that mercury

t The first experiments by Boylston were made on the
Z,l i June; 1,21, on his own son, thirteen years of age,
and two Macks , n his own family, one of thirty-six and
the other two years of age, and all with success. During
the prevalence of the smallpox in that and the follow-
'» 5 ™; ne '"oculated with his own hand two hundred
V, v >" s " ven . <*, both S e X es, from nine months to
hv nt'hrr n'n yMrS ° f a i e " Thirty-nine were inoculated
Z° I ™» P &' C ' anS ,? fter the tumu| t had somewhat sub-
sided, making , n all two hundred and eiehtv-six. of
nken ,1" V£ \r^ n""" 5 «be same period 5,759'had

s?K:as;^;^ had died ' *

MEDICINE, (HISTORY OF)

235

would prove an antidote to small-pox ; and from
him, no doubt, the hint was taken. In 1724, Dr.
Huxham also recommended calomel, not merely
in the natural small-pox, but also when inocu-
lated. (Woodville's History of Inoculation, vol. 1,
p. 342.) It was only in the colonies, however,
that the practice was tried on a large scale ; and
an interesting account of its effects has been left
us by Dr. Benjamin Gale, of Connecticut, in a
paper published in the Philosophical Transactions
for 1765. The credit of the practice is given by
him to Dr. Thomas of Virginia and Dr. Munson
of Long Island, by whom it was established in
1745. According to the statements of Dr. Gale,
it appears that the deaths from the natural small-
pox, before inoculation was introduced into New
England, averaged 1 in 7 or 8 ; when inoculation
was introduced, the deaths amounted to I in 30.
By improvements and proper precautions, they
were reduced to 1 in 80 to 100 ; and finally, by
preparing the system by the previons use of mer-
cury, the deaths were only 1 in 800 or 1000.*

For the early and prompt investigation, as well
as the sound and original views which, they ad-
vanced in relation to the pathology and treatment
of that acute and now well-known disease, croup,
our colonial physicians are entitled to the highest
applause. Although not unknown or unnoticed
previously, the credit is generally conceded to Dr.
Home of Edinburgh, of having given the first full
description of this disease. This appeared in
1765. In 1771, Dr. Crawford published his
" Disquisitio Inauguralis de Cynanche Stridula ;"
and in 1778 appeared the elaborate work of
Michaelis of Gottingen, entitled " Dissertatio In-
auguralis de Angina Polyposa sive membranacea."
These were all the foreign publications which had
appeared on this interesting subject. Between
the years 1770 and 1781, in this country, Drs.
Rush, S. Bard, Chalmers, Middleton and Bayley,
all published in relation to it, and by them, espe-
cially the two latter, more correct views were en-
forced than had been entertained by Home and
others. Contrary to the opinion of Home, that
the secretion of mucus on the inside of the trachea
was the cause of the disease, Dr. Bayley estab-
lished the fact that the disease was an inflamma-
tion of the mucous membrane of the trachea, and
that the effusion and false membrane were the
consequences of this inflammation. Based upon
the idea that it was an acute and rapid inflamma-
tion, the treatment recommended was of the most
decided character. Bloodletting ad deliquium —
the free use of tartar-emetic, at first to produce
vomiting, and then to keep up nausea, together
with the free use of calomel, were all originally
recommended by them, although the credit of
every one of them has since been claimed by
others.f In determining the true nature of this

* Historical Memoirs, relating to the practice of In-
oculation for the smallpox-, in the British American
Provinces, particularly in New England. Bv Benjamin
Gale. See Philosophical Transactions, abridged, vol. 12,
p. 229. b

t As a sample of the manner in which practices ori-
ginating in this country, are appropriated abroad, not
from design, but icnorance, the following may be adduced.
Dr. Stokes, in his recent and invaluable treatise on
diseases of the chest, in speaking of tartar-emetic in
croup, holds the following language : " For the intro-
duction of this inestimable remedv in the treatment of
the croup, the science is indebted to Dr. Cheyne. In his

disease, as well as the treatment most efficacious,
the merit of Bayley stands pre-eminent, and the
tract which he has left on this subject, is sufficient
of itself to establish his reputation as an original
observer, and an able and accomplished practi-
tioner.^

If we may believe the authority of Dr. Doug-
lass, who wrote about the year 1753, and of
Smith, the historian of New York, the general
character of the profession could not have been
very elevated, and quackery must have flourished
in great perfection. Smith says, " few physicians
amongst us are eminent for their skill. Quacks
abound like locusts in Egypt, and too many have
recommended themselves to a full practice and
profitable subsistence. This is the less to be
wondered at, as the profession is under no kind
of regulation." (History of New York, by Wil-
liam Smith, A. M. p. 326.) That in a state of

Essay on Cynanche Trachealis, published in Edinburgh
in 1801, we find the treatment recommended; and it is
no small evidence in its favour, that in the year 1832,
after an experience greater than falls to the lot of most
men, the opinions of this philosophical investigator of
disease have remained unaltered. How changed would
be the character of medicine, if, in support of many of
our remedies, there could be brought forward such evi-
dence, and such an advocate!" p. 144, Amer. Ed. Dr.
Bayley recommended and used the same remedy, in the
same way, and with the same objects in view, a quarter
of a century before.

J Cases of Angina Trachealis, with the mode of cure :
in a letter to William Hunter, M. D. &c. By Richard
Bayley, Surgeon. Printed, New York, 1781. For the
purpose of showing the views of Bayley in relation to
t lie nature and cure of this disease, I shall quote the fol-
lowing from his paper. " When the Angina Trachealis
is theoretically considered, there will probably be formed
(as is generally the case when facts are not ascertained)
opinions as various as the information and different
faculties of men may suggest. I am induced to adopt
the following: That the larynx, aspera arteria, and
bronchial pipes have one common membrane, which, we
are informed by injection, consists of little more than
an infinity of blood-vessels, and consequently liable to
inflammation, as all vascular parts are. An increased
action of these vessels (as in pleuritic and puerperal fe-
vers) occasions a preternatural secretion of lymph,
which, from the ingress and egress of the air, becomes
condensed, and assumes the appearance of a membrane,
and its compactness will depend on the age and habit
of the patient and the state of the atmosphere.

" The common opinion is, that those who die of this
complaint are suffocated by the membrane's closing the
wind-pipe. Another more respectable opinion is, that a
spasm of the muscles of the larynx closes the scene.
The circumstances which precede death in this disease,
compared with those appearances which have regularly
taken place in the cases which I have seen successfully
treated, sufficiently explain the cause of the patient's
death from the laws of the blood's circulation. To pre-
serve the healthful state of an animal, it is necessary
that the whole mass of blood should circulate through
the lungs in a given time, and the free admission and
expulsion of air contributes to this regular process ; the
change, also, which gradually takes place in the lungs,
seems more directly to account for the swelled face, tu-
mid jugulars and the full staring eyes, which are symp-
toms that accompany the progress of this complaint
and add to this, the larynx, aspera arteria and bronchia
have been found pervious in every subject I have dis-
sected, while the ramifications have been as regularlv
filled with a glairy mucus.

" From what precedes, it is obvious that the angina
trachealis is considered as an inflammatory disease, the
treatment of which must vary in every degree, according
to its violence: and though the common antiphlogistic
treatment will in some cases relieve, if early applied,
yet the most desperate may yield to repeated bleedings ad
deliquium from the jugulars, the free use of tartar-emetic
and other evacuants, with a large blister covering the
larynx and aspera arteria, while the mucus filling up the
ramifications of the bronchia may be emptied by tne
action of vomiting." See New York Medical Repository,
vol. 14, p. 346. Although not published until the yeat
1781, the paper of Bayley contains tin.' result of his ob-
servations and practice for a number of years previ.
ously.

236

society where the means of medical education
were so scanty, and where no laws existed to re-
gulate the profession or restrain admission into its
ranks, quackery should be very rife, is certainly
by no means singular. It would be unjust, how-
ever, to suppose that it is peculiar to such a state
of society, or even that it prevailed to a greater
extent than it does in the present day. Mortifying
as it is, it is, nevertheless, a fact that it is peculiar
to no particular age, or country, or state of society.
It has existed from the earliest periods, and will
continue to exist as long as human beings are
found upon the face of the earth. The rude
savage and the polished citizen are equally its vic-
tims, and civilization and refinement only render
its forms more complicated and insidious. At no
period in the history of this country, it may safely
be asserted, has empiricism flourished to the same
fearful extent as at the present time, notwith-
standing our boasted improvements in other re-
spects. Assuming a thousand different disguises,
it is, in many high places in our country, sapping
the very honour of the profession, and corrupting
it to the core. Notwithstanding the prevalence
of quackery in the colonies, it does not appear
that the well-educated part of the profession lent
it any countenance, and it would be well if the
same could be said in the present day. A recol-
lection of these facts should therefore moderate
somewhat the severity of our judgment in rela-
tion to the state of our colonial medicine, at the
same time that it should excite us to renewed dili-
gence in endeavouring, if possible, to correct ex-
isting abuses.

II. Medical Literature. — I come next to take a
brief notice of the state of medical literature pre-
vious to the revolution. Although not abounding
in materials of very high interest or importance,
the medical literature of this period is by no means
contemptible. In forming a judgment in relation
to it, we should recollect the circumstances in
which the American physician was placed, and
the slender inducements which were held out to
undertake the labours of authorship. The two
great motives which induce men, in any age, to
write — the love of literary distinction, and the
hope of pecuniary gain, then exercised but a fee-
hie and limited influence ; and accordingly, the
colonial physicians only turned authors on some spe-
cial emergency of public duty, or for the purpose of
promulgating and enforcing some new and useful
mode of practice. The capabilities of our early
physicians, therefore, ought to be judged of, not
so much by the quantity, as by the quality, of the
productions which they have left us ; and an im-
partial review of them will show us that they do
not suffer by a comparison with the productions
of their European brethren at the same period.
Some of them were not thought unworthy of
being published in the Transactions of the Royal
Society, while others found a place in the publi-
cations of the learned medical associations of the
day, in the mother country.

A brief review of what appeared in the colonies,
will be, not merely interesting, as a matter of his-
torical record, but will furnish the best evidence
of the general drift and progress of medical mind
during this period.

The earliest medical publications appeared in

MEDICINE, (HISTORY OF)

Massachusetts, and were called forth by the preva-
lence of epidemic diseases; and the first appears to
have been a tract by Thomas Thatcher, a clergy-
man and physician, of Massachusetts. It was
entitled " A Brief Guide in the Small-Pox and
Measles," and was published in the year 1677.
Cotton Mather, in his Magnalia, gives the life of
this person, and represents him as a man of learn-
ing and ingenuity.

In 1721, Benjamin Colman, a minister of Bos-
ton, printed a small pamphlet entitled — " Some
Account of the New Method of Receiving the
Small-Pox, by Ingrafting or Inoculating;" in
which he defends the practice of inoculation,
which had just been introduced by Dr. Boylston.

Five years after this, Dr. Boylston, while on
his visit to England, published there, at the re-
quest of the Royal Society, " An Historical Ac-
count of the Small-Pox, inoculated in New Eng-
land." In the following year it was reprinted in
Boston.

In addition to the above may be mentioned the
names of Thomas Howard and Nathaniel Wil-
liams, both of whom were clergymen as well as
physicians. The former wrote a Treatise on Phar-
macy, in 1732; and the latter a pamphlet »0n
the Method of Practice in the Small-Pox in
1730."

The most voluminous writer; however, who ap-
peared at this period, was Dr. William Douglass.
He was a native of Scotland, and emigrated to
New England about the year 1716. Although a
man of talent and learning, he appears to have
been of an unhappy temper of mind, to which he
gave loose in many of his writings. He was a
most virulent opponent of the practice of inocula-
tion, and did all in his power to excite popular
indignation against it. Besides several publica-
tions on this subject, he has left a tract on the
putrid sore throat distemper which prevailed epi-
demically in the colonies, entitled — " The Practi-
cal History of a New Epidemical Eruptive Mili-
ary Fever, with an Angina Ulcusculosa, which
prevailed in New England in 1735 and '36."
This was published in 1736, and is in every re-
spect a paper of great value. Besides giving
the fullest account that we have of this dreadful
epidemic, it contains the first suggestion in rela-
tion to the use of calomel as a remedy. This essay
has recently been reprinted in the New England
Journal of Medicine and Surgery, vol. xiv. p. I.
The most elaborate work, of this author was
" A Summary, Historical and Political, of the
First Planting, Progressive Improvements, and
Present State of the British Settlements in North
America." This was published in 1760, and
contains some amusing notices of the state of the
profession in the colonies.

These were pretty much all the medical writers
of whom Massachusetts could boast for upwards
of a century and a half.

In the middle and southern colonies, medicine
appears to have been cultivated with much more
success than in the eastern. This may be ac-
counted for by the fact that the former enjoyed
the services of several foreign physicians, who had
early emigrated thither, enriched by the best medi-
cal education which Europe could afford. It ap-
pears also to have been more common with them

MEDICINE, (HISTORY OF)

237

to send their young men to foreign universities to
complete their medical studies. In addition to
all this, a taste for researches in natural history
began to develop itself much sooner in some of
the southern colonies, and doubtless produced a
salutary effect in spreading the influence of liberal
sentiments. To these causes is to be attributed
the early superiority of the southern colonies more
especially.

Of the colonial physicians none were more
aclivc or distinguished than those of South Caro-
lina. In 1734, a native of this state, William
Bull, obtained a degree in medicine, at the Uni-
versity of Leyden, and on that occasion, defended
and published an inaugural dissertation, " De Co-
lica Pictonum." He had studied under Boer-
haave, and seems to have commanded the respect
of his associates. By the celebrated Van Swieten,
he is spoken of in his commentaries as the very
learned W. Bull.* In 1749, John Moultrie re-
ceived the degree of doctor in medicine, at the
University of Edinburgh, and published a thesis,
" De Febre Flava." He was the first native Ca-
rolinian who obtained this honour at that univer-
sity. According to Dr. Ramsay, ten other native
Carolinians obtained the same honour, between
the years 1768 and '78. (Ramsay's Review of
Medicine in the 18th century. New York Medical
Repository, vol. iv. p. 398.) As more particularly
distinguished in this section of the country, the
names of Drs. Lining, Chalmers and Garden, de-
serve to be especially noticed. They were all
natives of Scotland, and emigrated in the earlier
part of the last century. Being men of unques-
tioned abilities, learning and enterprise, they con-
tributed greatly, both by their influence and writ-
ings, to elevate the character of the profession.
To Dr. John Lining, we are indebted for some of
the most valuable statical experiments ever pub-
lished. They were continued throughout the
whole of the year 1740. He ascertained his weight
in the morning and evening ; the weight of the
food which he swallowed, and the weight of the
urine and alvine excretions ejected. The result
of these troublesome experiments was published
in 1743, in the Transactions of the Royal Society
of London. (Vol. xlii. p. 491. Thomson's His-
tory of the Royal Society, p. 129.) In 1753 he
published « A Description of the American Yel-
low Fever," in a letter to the celebrated Dr. Ro-
bert Whytt, professor of medicine in the Univer-
sity of Edinburgh. This was the first account of
this terrible disorder which had emanated from
this continent, and stands to this day unrivalled
for the general accuracy and minuteness of its de-
scription. (Edinb. Essays and Obs. vol. ii. p. 370.)

To Dr. Lionel Chalmers we are also indebted
for several valuable productions. In the year 1754
he communicated to the Medical Observations and
Inquiries of London, a paper on the Opisthotonos
and Tetanus. These appear to have been very
prevalent, at that time, in Charleston, and Dr.
Chalmers seems to have had a large experience

i colica in regiooihus America' nicridionalilius
tam fretiuens est, ut trio pro morbo endemio haberi i>os-
sit; ii t i ali etuditissimo vim Gulielmo Bull, in his oris
nato, et, nunc feliciter ibi medicinam exercente
amlivi, qui et pulchram de hoc morbo scripsit disserta-
tionem inauguraleni, quarn de academia Lugduno Ba-
tava defendit anno 173-1. Van Swieten's Commentaries,
vol. iii. p. 357.

in them. The remedies which he principally re-
commends are, bloodletting in the commencement,
the warm bath, the free use of opium and emol-
lient enemata. (Vol. i. p. 87.) In 1768, he pub-
lished " An Essay on Fevers," in which he enters
into an extensive discussion of the theory of
febrile diseases, and proposes a new method of
treating them. Contrary to the prevalent belief
of the time, Dr. Chalmers endeavours to show
that the cause of fever is not to be sought for in
the fluids, but in the solids, and he considers the
immediate cause to be " a spasmodic constriction
of the arteries and other muscular membranes."
Whatever can give much pain or stimulate the
nerves so as to cause them to excite such constric-
tions, he thinks may bring on fever. As an inevita-
ble consequence of this spasm and constriction, irre-
gular distributions of blood take place, producing
engorgements of the different viscera, and to this
irregular circulation are owing all the phenomena
of fever. Spasm of the extreme arteries and irre-
gular distribution of the blood being the leading
features of fever, he recommends two indications
in the treatment. First, to relax the spasm — se-
cond, to relieve the internal fulness of the system;
and the two agents which he recommends for
accomplishing these purposes are, sweating and
purging. Such is a very brief account of his
theory of fever, which he supports with much
talent and learning. The whole work displays a
compass of observation, and a power of theoretical
discussion, which should have raised its author to
a higher rank than he seems to hold in the lists
of medical fame. To perfect originality, the theory
of Dr. Chalmers can lay no claim. The doc-
trine of spasm had been previously suggested by
the celebrated Hoffmann, from whom both Chal-
mers and Cullen doubtless borrowed it. Whether
Chalmers was at all indebted to Cullen for any
of his views on this subject, it is not easy to say,
although it seems very improbable, the essay of
Dr. Chalmers having appeared several years before
the " First Lines" of Dr. Cullen were presented
to the public. Besides this, Dr. Chalmers was the
author of an extensive and valuable work on the
climate and diseases of South Carolina, in two
volumes/f- He also recorded and published an
important scries of meteorological observations at
Charleston, continued for ten years, i. e., from
1750 to 17604

Dr. Alexander Garden was another distinguished
physician of Charleston at this period. From
all the accounts which we have left of him, he
appears to have been a man not merely thoroughly
versed in his profession, but highly accomplished
in literature and general science. He was much
devoted to natural history ; and the Transactions
of the Royal Society contain several of his papers
on this department. As a proof of the high esti-
mation in which he was held, it may be mentioned,
that Linnaeus, with whom he corresponded in
Latin, gave the name of Gardenia (in honour of
him) to "one of the most beautiful flowering
shrubs in the world." He was a member ol the
Royal Societies of Upsal and of London. The

t An account of the Weather and Diseases of South
Carolina, by Lionel Chalmers, M. IX, of Charleston,
S. C, 2 vols. London. 1770.

1 A general table of the results of these observations
may be seen in his work on Carolina, vol. i. p. 43.

238

MEDICINE, (HISTORY OF)

only medical production which he has left, is an
account of the anthelmintic properties of the Spi-
gelia Marilandica, together with a botanical de-
scription of the plant.*

Virginia could also boast of some distinguished
men in the profession; and among these especially
were Clayton and Mitchell. Dr. John Clayton
was of English origin, and came to Virginia about
the year 1705. (Thatcher's Medical Biography,
p. 224.) He was particularly eminent as a bota-
nist, and devoted a long life to the investi-
gation of the plants of Virginia. As the result
of his labours, he published in 1743 a Flora Vir-
ginica. It was afterwards republished by Grono-
vius at Ley den, in 1762.J- Besides this, he pub-
lished in the Philosophical Transactions several
papers in relation to the culture of the different
varieties of tobacco, together with a full account
of the medicinal plants of Virginia. The cele-
brated author of the Notes on Virginia has left
the following respectful testimony to the character
of this eminent naturalist and physician: "This
accurate observer was a native [incorrect] and
resident of Virginia, passed a long life in explor-
ing and describing its plants, and is supposed to
have enlarged the botanical catalogue as much as
almost any man who has lived." (Notes on Vir-
ginia, by Thomas Jefferson, p. 63.)

Dr. John Mitchell was another Englishman
who emigrated to Virginia about the beginning
of the last century, and no less distinguished for
his attainments in medicine and natural history.
The productions by which his name has been
handed down to posterity are, " An Essay on the
Causes of the Different Colours of People in Dif-
ferent Climates,"and " Letters on the Yellow Fever
of Virginia." The first of these is a production
of no ordinary character. It was published in the
Philosophical Transactions of 1743, and occupies
about fifty pages. The first part of this paper is
occupied with the consideration of the cause of
the colour of the skin generally, and he endea-
vours to establish the following propositions : 1.
That the colour of white people proceeds from the
colour which the epidermis transmits; that is,
from the colour of the parts under the epidermis,
rather than from any colour of its own. 2. That
the skins of negroes are of a thicker substance
and denser texture than those of white people,
and transmit no colour through them. 3. That
the part of the skin which appears black in
negroes is the corpus reticulare cutis, and external
lamella of the epidermis ; and all other parts are
of the same colour in them with those of white
people, except the fibres which pass between these
two parts. 4. That the colour of negroes does
not proceed from any black humours or fluid
parts contained in their skins, for there is none
such in any part of their bodies, more than in
white people. 5. The epidermis, especially its
external lamella, is divided into two parts by its
pores and scales, two hundred times less than the

* Edinb. Essays and Observations, Physical and Lite-
rary, vol. 3, p. 1-15. For an interesting account of Dr.
Garden, see Ramsay's History of South Carolina, vol. ii.

f Flora Virginica exhibens plantae quas nobilissimus
vir D. D. Johannes CI ay tonus Wed. Doct. &c. in Virginia
crescentes observavil, collegit et obtulit £>. Joh. Fred.
fironovio, cujus studio et opera descriptae et in ordinem
eexualem systematicum redacts sistuntur. Lugduni
Patavorum 1702.

particles of bodies, on which their colours depend.
Having established these propositions by a scries
of facts and reasonings, he comes to the conclu-
sion that the proximate cause of the colour of
negroes is three-fold, viz. : the opacity of their
skins, proceeding from the thickness and density
of their texture, which obstructs the transmission
of the rays of light from the white and red parts
below them ; together with their greater refractive
power, which absorbs those rays, and the small-
ness of the particles of their skins, which hinder
them from reflecting any light. The difference
thus depending upon a difference in the texture
of the skin, he next proceeds to show that the
different colours of the human race can readily be
explained by the effect of climate and mode of
life, in modifying the texture of the skin. He
supports the scriptural doctrine of the common
origin of man, and thinks the primitive colour
was a medium between white and black ; " from
which primitive colour the Europeans degenerated
as much on the one hand as the Africans did on
the other : the Asiatics, — unless, perhaps, where
mixed with the whiter Europeans, — with most of
the Americans, retaining the primitive and original
complexion.£ Such is a brief account of this
most ingenious and elaborate paper. Any ana-
lysis of it, however, must do it injustice. To
appreciate the philosophical acumen and learning
which it displays, it ought to be read at full length.

Another paper by Dr. Mitchell is an account
of the yellow fever which prevailed in Virginia in
1741, of which I have already had occasion to
speak in a previous part of this discourse. This
was not published at the time, but the manuscript
fell into the hands of Dr. Franklin, by whom, a
short time before his death, it was, given to Dr.
Rush. It has since been published in Coxe's
Medical Museum, and in the Medical and Philo-
sophical Register of New York. (Two Letters,
vol. iv. pp. 183, 383.)

Another physician of Virginia, and a native,
Dr. John Tennent, deserves to be mentioned, as
having written the first account of that valuable
medicine, the Polygala Senega, By him it was
used freely, after depletion, in pleurisy and peri-
pneumony, and, as he states, with great success.
This appeared in 1736. (See Edinburgh Medical
Essays and Observations, vol. v. p. 376.)

Among the medical men of Pennsylvania, there
are several who are entitled to notice, as having
contributed to the colonial literature of our profes-
sion. In 1740 Dr. Thomas Cadwallader, of Phi-
ladelphia, published "An Essay on the Iliac Pas-
sion," in which he exposes the absurdity of the
practice then in vogue, viz. : that of treating it by
quicksilver and drastic purges. He recommends
in their stead, mild cathartics, with the occasional
use of opiates. (Miller's Retrospect of the Eigh-
teenth Century, vol. i. p. 317.) By Dr. Thomas
Bond, an eminent physician of Philadelphia, two
communications were published in the London
Medical Observations and Inquiries, one an ac-
count of a worm bred in the liver, (Vol. i. p. 68,)
1754 ; another on the use of bark, in scrofulous
cases, 1759. (Vol. ii. p. 265.) The men, how-
ever, who w ere particularly d istinguished, in Phi-

X See the Abridgement of the Philosophical Transac-
tions, by Drs. Hutton, Shaw and Pearson. Vol. 9. p.50.

MEDICINE (HISTORY OF)

239

ladelphia, for their zeal in the cause of medical
science, were Drs. John Morgan and William
Shippen, both natives of that place, and the
founders of the first medical school established in
this country. Dr. Morgan, after studying medi-
cine at home, went to Edinburgh, where he re-
ceived the doctor's degree, on which occasion he
published an elaborate thesis on the formation of
pus — " Tentamen Medicum de Puris Confectione,
Edinburgh, 1763." In this dissertation he main-
tained the doctrine that pus is a secretion, pre-
pared by a peculiar action of the secretory vessels
of the part. The credit of originality, as it re-
gards this doctrine, has generally been awarded to
the celebrated John Hunter. The evidence, how-
ever, appears to be conclusive that he was antici-
pated by Dr. Morgan.* After receiving his degree
at Edinburgh, he travelled for some time on the
continent, industriously engaged in acquiring
knowledge, and everywhere received with the
highest honour. As a proof of the, estimation in
which he was held abroad, it is only necessary to
state, that on his return home, in 1765, he was a
fellow of the Royal Society of London, corre-
sponding member of the Royal Academy of Sur-
gery of Paris, and licentiate of the Royal Colleges
of Physicians of London and Edinburgh. Not-
withstanding his devotion to science, Dr. Morgan
was not a prolific author. Besides his Thesis, all
that we have left is his « Discourse," already
noticed, « On the Institution of Medical Schools
in America," in 1765, and "A Recommendation
of Inoculation, according to Baron Dimsdale's
Method," 1776.

Dr. Shippen was born in 1736, and about the
year 1760 took his degree at Edinburgh, on which
occasion he wrote and published a thesis, " De
Placenta? cum Utero Nexu." Besides this, I do
not know that he published any thing, but he is
greatly and justly celebrated as the first person
who lectured on anatomy in this country.

Last, though not least, the contributions of the
eminent men who adorned our profession in New
York, require to be briefly commemorated. Among
these, the first place is unquestionably due to
Cadwallader Colden. He was a native of Scot-
land, and received his education at the university
of Edinburgh. In 1718, he settled in New York.
He soon, however, relinquished the practice of
physic, and became a public character, holding in
succession the offices of surveyor-general of the
province, member of the council, and finally lieu-
tenant-governor. Although thus withdrawn from
the profession, he did not lose his fondness for
medical and philosophical pursuits. Among his
medical productions is an " Account of the Cli-
mate and Diseases of New York." This was
published when he was surveyor-general of the
province, about the year 1720. It is an execed-

* Sec Cullcn's First Lines, edited by Professor Charles
Caldwell, vol. i. p. 225, note by Prof. Caldwell. Dr.
J: i mes Curry, lecturer at Guy's Hospital, also gives the
credit of priority to Dr. Morgan, and he adds: " I could
not avoid giving that merit to Dr. Morgan, who dis-
cussed the question with great ingenuity, in his Inau-
gural Dissertation, on taking his degree at Edinburgh,
in 1703; whilst I could find no proof that Mr. Hunter
had taught, or even adopted, such an opinion, until a
considerably 'later period." See Loud. Med. and Phys.
Journal for 1817; also New England Journal of Med.
and Surg. vol. vi. n 401.

ingly interesting paper, giving as it does the only
account we have of the climate and diseases of
this city, at so early a period. In relation to con-
sumption, now so fatally prevalent, he makes the
following interesting remarks : " The air of
the country being almost always clear, and its
spring strong, we have few consumptions, or
diseases of the lungs. People inclined to be con-
sumptive in England, are often perfectly cured by
our fine air, but if there be ulcers formed, they die
in a little time." (Medical and Philosophical Re-
gister of New York, vol. i. p. 309.) He also
wrote " Observations on the Fever which prevailed
in the City of New York in 1741-2," in which
he made a number of valuable suggestions in re-
lation to the draining and purification of the city,
with the view of preventing the recurrence of the
disease. (Ibid, vol. i. p. 324.) Besides these he
published a treatise " On the Cure of Cancer,"
another « On the Virtues of the Great Water
Dock," (Ibid. vol. i. p. 300) ; also, a letter on the
" Sore Throat Distemper, which prevailed epidem-
ically in this country," in 1735. (London Med.
Obs. and Inq. vol. i. p. 215.) Dr. Colden also
pursued the study of botany with great assiduity.
He described between three and four hundred
American plants, which were afterwards printed
in the Acta Upsaliensia. In honour of his daugh-
ter, who imbibed the ardour of her parent in this
science, Linnasus named a plant of the tetandrous
class, that was first described by her, Coldenia.

Dr. John Bard was long an eminent practitioner
of New York. ' His professional writings, how-
ever, are few. They are — "A Case of Extra-
Uterine Foetus," published in 1760, in the Lon-
don Obs. and Inq. (vol. ii. p. 369) ; several pa-
pers on the nature and character of the yellow
fever, and " An Essay on the Nature and Cause
of the Malignant Pleurisy," which proved so fatal
to the inhabitants of Huntington and some other
places in Long Island in the winter of 1749.
(Med. and Philos. Register, vol. i. p. 409.)

Of the physicians of New York, none were
more distinguished for their learning and ability,
than Dr. Peter Middlcton. On the formation of
the medical school in New York, he was appointed
professor of the theory of physic. At the open
ing of the school, in 1769, he delivered a discourse
in which he took an extensive survey of the state
of medicine among the different nations of the
globe. This production was afterwards published,
and affords ample proof of the learning and ability
of the author.-)- He also wrote a valuable practi-
cal letter on the " Croup," already alluded to.±

Dr. John Jones was a native of Jamaica, Long
Island, and was born in 1729. Having acquired
the elements of his profession at home, he repaired
to Europe, and enjoyed the advantages of tuition
under the most renowned men of our profession
at London, Leyden, Paris, and Edinburgh. On

t A Medical Discourse or an Historical Inquiry into
the Ancient and Present. State of Medicine ; the substance
of which was delivered at the opening of the medical
school in the city of New York: by Peter Middlcton, M.
D. and Prof, of the theory of physic in King's College.
New York, 17tiU, pp. 72. A copy of this is in possession
of the writer.

J This letter was published in 1780, and addressed In
Dr. Richard Bayley. In it, he sanctions the practice of
Dr. Bayley, as confirmed by his own experience. See
New York Med. Repository, vol. xiv. p. 347.

240

MEDICINE, (HISTORY OF)

his return to his native country, he speedily rose
to the highest eminence. As a surgeon, he un-
doubtedly stood first in this country. In 1768 he
was selected to fill the honourable station of pro-
fessor of surgery in the medical school of New
York, and ranked high as a teacher. The only
work of any consequence which he has left us is
a volume upon wounds and fractures, published
in 1776.* A new edition of this work was
printed in 1795, with memoirs of the author, by
James Mease, M. D., of Philadelphia. Besides
this, there is an interesting paper " On Anthrax,"
by Dr. Jones, in the first part of vol. i. of the
Transactions of the College of Physicians of
Philadelphia.

Before closing this account of our colonial me-
dical literature, it would be unjust not to notice
the Transactions of a Society, which contributed
in no small degree to raise the scientific character
of the country. I mean, the American Philoso-
phical Society. The first volume of their pro-
ceedings was published anterior to the revolution,
and contains some papers on important medical
subjects. It may be stated, too, that four Ameri-
can physicians were elected fellows of the Royal
Society of London, before the revolution. These
were, Drs. Boylston, Mitchell (of Virginia), Gar-
den, and Morgan. Besides these there were ten
other Americans who had been raised to the same
honour, viz : four of the name of Winthrop, Paul
Dudley, President Leverett, Thomas Brattle, Cot-
ton Mather, Benjamin Franklin, and David Rit-
tenhouse. (Ramsay's America, vol. i. p. 271.)

No medical journal of any description appears
to have been published until after the war of our
independence, and the only inaugural dissertation
that was published was from the New York Col-
lege, in 1771, by Samuel Kissam, M. D., on the
Anthelmintic Virtue of the Phaseolus Zuratensis
Siliqua Hirsuta, or Cow-Itch, a copy of which
may be seen in the library of the New York His-
torical Society.

III. Medical Education and Institutions. —
Under this head may be embraced all those acts
and establishments of the colonial governments,
whose object was the preservation of the public
health, as well as those institutions of a public
nature, which originated from the combination of
individual enterprise and liberality.

From the commercial character of the country,
it may readily be supposed, that our first medical
establishments were lazarettos, or hospitals in-
tended for the reception of seamen and others
infected with contagious disorders. Accordingly
we find a hospital of this description established
by Massachusetts, nearly one hundred and fifty
years ago, at Rainsford island, in the harbour of
Boston. Another was at an early period erected
on State island in the Delaware, and appropriated
to similar purposes for the port of Philadelphia.
After the practice of inoculation had become set-
tled, hospitals were gradually established in differ-
ent parts of the country, for the purpose of carry-

* Plain Concise Practical Remarks on the Treatment
of Wounds and Fractures ; to which is added an Appen-
dix on Camp and Military Hospitals. Principally de-
signed for the use of young military and naval' sur-
geo.iS in North America: by John Jones, M. D., profes-
sor of surgerv in King's College, New York: pp. 114—
Philadelphia, 1776.

ing patients through this process. Several of
this description were in existence shortly after the
middle of the last century. These were, how-
ever, entirely the result of private enterprise,
without any legislative aid, and were, therefore,
only of temporary duration. Among the physi-
cians who devoted themselves to this kind of
business, Dr. Barnet of New Jersey seems to have
been the most conspicuous. Useful as the fore-
going institutions undoubtedly were, they could
not have produced any effect of consequence upon
the existing state of medical science. In 1750, a
project of a higher order was set on foot in Phila-
delphia ; this was the establishment of a hospital,
upon the plan and embracing all the advantages
of the European hospitals, and the individual
with whom it originated was Dr. Thomas Bond.
No sooner was the object proposed to the citizens
of Philadelphia, than measures were adopted to
carry it into execution. For that purpose, a peti-
tion was presented to the Assembly of the colony
soliciting the aid of that body, the result of which
was a grant of £2000, on condition that an equal
sum should be raised by subscription. The pro-
posed amount was speedily raised ; and early in
the year 1752, patients were admitted into a
building which had been procured for their tem-
porary accommodation. The erection of the pre-
sent building was not commenced until 1755. In
the year 1769, a similar project was started in
New York, and the credit of first suggesting it is
due to the late Dr. Samuel Bard. In consequence
of a public discourse delivered by him, a general
interest was excited in the measure.-j- The liberal
contributions of the governor of the province,
(Sir Henry Moore,) the corporation of the city,
and the legislature of the province, enabled the
governors to commence the erection of the build-
ing in 1773. After being nearly completed, it
accidentally took fire, and was nearly consumed,
in 1775. The present building was not com-
pleted until 1791, when it was opened for the re-
ception of patients. (An Account of the New
York Hospital, 1811.) These were all the hos-
pitals that were attempted anterior to the revolu-
tion.

Among the most singular features connected
with the history of our colonial medicine, is the
fact that so little attention was paid to professional
education. This is the more remarkable, inas-
much as our colonial ancestors were fully alive to
the importance of general instruction, and the
most honourable efforts were made to establish it

f The agency of Dr. Bard is mentioned in the follow-
ing terms by Dr. Middieton, in his Discourse delivered
1769. " The necessity and usefulness of a public infirm-
ary, has been so warmly and pathetically set forth in a
discourse deli vered by Dr. Samuel Bard, at the commence-
ment m May last, that his excellency Sir Henry Moore
immediately set on foot a subscription for that purpose,
to which himself and most of the gentlemen present
liberally contributed. His excellency also recommended
it, in the most pressing manner, to the Assembly of the
province, as an object worthy of their attention; and
the corporation of the city have given assurance of
granting a very valuable and commodious lot of ground
for erecting the building upon; so that there is now al-
most a certain prospect of this benevolent and humane
foundation soon taking place ; and as it is to be on the
most catholic and unexceptionable plan, it is to be hoped
that it will meet win, u,e countenance and encourage-
ment ot every ate and eO0(J member of so-
ciety whatever party or denomination he may choose to
be distinguished by on other occasions." Note, p. (MX

MEDICINE, (HISTORY OF)

241

on a respectable foundation. So early as the year
1638, Harvard University, in Massachusetts, was
founded. In 1691, William and Mary College,
in Virginia ; in 1700, Yale College, in Connecti-
cut; and in 1746, Princeton College, in New
Jersey, were severally established ; yet in none
of them was any provision made for instruction
in medical science. With the single exception,
too, of New York, already noticed, and that so
late as 1760, the law imposed no qualifications
upon those who entered the profession, nor were
they subjected to any examinations. The educa-
tion of physicians, therefore, at this period, re-
stricted as it was to the personal instruction of
those with whom they studied, must have been
limited indeed. The only mode of supplying this
deficiency, was by resorting to foreign countries ;
and it appears that almost all the distinguished
physicians who flourished anterior to the revolu-
tion, had received their education in Europe. It
is a fact certainly highly honourable and worthy
of record, that Harvard College no sooner began
to send forth her graduates, than some of them
found their way to foreign universities, where
they obtained the degree of Doctor of Medicine.
In 1642, Samuel Bellingham graduated at the
first commencement at Harvard, and shortly after-
wards obtained a doctor's degree at Leyden. In
1650, John Glover and Leonard Hoar left the
college, and were afterwards honoured with the
doctorate abroad, the former at Aberdeen, the lat-
ter at Cambridge in England. Hoar afterwards
became president of Harvard College. In 1674,
Edmund Davie graduated, and subsequently was
made an M. D. at Padua. (See the Catalogue of
the Graduates of Harvard College.)

As may be supposed, this practice became more
and more common, till the period of the revolu-
tion; and this, together with the number of for-
eign physicians of talent and education who emi-
grated to this country, tended, in no inconsiderable
degree, to correct the deficiencies of domestic in-
struction. The first attempt at establishing a
regular system of medical instruction in this
country, was not made until a very few years be-
fore the revolution ; and for this we are indebted
to Drs. William Shippen and John Morgan, both
natives of Pennsylvania, who projected the plan
during the prosecution of their . studies abroad.
In 1762, Dr. Shippen returned to his native
country, and in the year delivered a course of
lectures of anatomy to a class of students amount-
ing to twelve in number. These lectures were
repeated in 1763 and '64. In the following year
Dr. Morgan, who had just returned from Europe,
pronounced " A Discourse upon the Institution
of Medical Schools in America," before the trus-
tees of the college, in which he proposed a plan
for teaching the different branches of medicine,
and portrayed with prophetic ardour the blessings
which would flow from such a measure. Happily
he spoke to a body of men capable of entering
into his expanded views ; and measures were
soon after adopted for forming a medical faculty.
Dr. Morgan was appointed professor of the theory
and practice of medicine, and Dr. Shippen pro-
fessor of anatomy and surgery. The other sta-
tions were not immediately filled. In 1768, Dr.
Adam Kuhn, a pupil of Linnaeus, who had just
Vol.. Ill 31 v

returned to his native country, was chosen pro-
fessor of botany and materia medica ; and in

1769, Dr. Rush, who had just finished his educa-
tion at Edinburgh, was chosen to the chemical
chair. At the same time, Dr. Thomas Bond gave
clinical lectures at the Pennsylvania Hospital.
Being thus provided with professors on the most
important branches of medicine, the school went
into complete operation, and the lectures were
continued to the year 1775, when they were sus-
pended by the war of the revolution. Dr. Shippen
at this time had delivered fourteen courses, and
the annual number of students had increased to
between thirty and forty. (Eulogium on Dr.
William Shippen, by Caspar Wistar, M. D. p. 27,
1818.)

New York soon became emulous of the exam-
ple set her by Philadelphia, and in 1768 adopted
measures for extending similar advantages to
medical students. A full medical faculty was
regularly organized under the superintendence of
the trustees of King's (now Columbia) College,
of which Samuel Clossey, M. D. was professor of
anatomy, John Jones, M. D. professor of surgery,
Peter Middleton, M. D. professor of physiology
and pathology, James Smith, M. D. professor of
chemistry and materia medica, John V. B. Ten-
nent, M. D. professor of midwifery, and Samuel
Bard, M. D. professor of the theory and practice
of physic. At the opening of the school, a learned
discourse, already noticed, was delivered by Dr.
Middleton. A measure so honourable to those
immediately concerned in effecting it, and to the
city itself, promised not merely to elevate the cha-
racter of our profession, but to be productive of
general good to the community. The fair pros-
pects thus anticipated, were all arrested by the war.

The schools thus started in Philadelphia and
New York, were the only ones attempted before
the Revolution. The first medical degrees were
given by the college of New York. In 1769, the
degree of Bachelor in Medicine was conferred
upon Samuel Kissam and Robert Tucker. In

1770, the degree of Doctor in Medicine was con-
ferred upon the last of these gentlemen, and in
May of the following year, upon the former. In
June, 1771, the degree of Doctor in Medicine
was conferred on four students, by the Philadelphia
college, being the first given by that institution.

With regard to the works that were commonly
read and studied, the following is stated by
Bartlett : " Though the works of Hippocrates,
Galen, Stahl, and others, were not unknown,
those of Sydenham, and his followers, were prin-
cipally studied by our oldest practitioners, till the
time of Boerhaave, whose invaluable labours com-
menced in 1701, which, with the commentaries
of Van Swieten; the practical writings of Whytt,
Mead, Brooks, and Huxham ; the physiology of
Haller ; the anatomy of Covvper, Kiel, Douglass,
Cheselden, Monro, and Winslow ; the surgery
of Heister, Sharp, Le Dran, and Pott ; the mid
wifery of Smellie and Hunter ; and the Materia
Medica of Lewis, were in general use at our
political separation from the British empire."*

* A Dissertation on the progress of Medical Pcinnce in
the Commonwealth of Massachusetts. By Josiah Hart-
lett. Communications of t lie Med. Soc'y of Mu^sacku ■
setts, vol. 3, p. 2-10.

242

MEDICINE, (HISTORY OF)

Such is a sketch of the state of medicine during
our colonial existence. The Revolutionary war
succeeded. During that eventful period, our pro-
fession stood firm in their country's cause ; and
the names of Warren * Mercer,! and Rush,*
show that they were not idle spectators of the fray.
Nothing was done, however, for the advancement
of medical science. The newly-formed medical
colleges were broken up, and all the energies of
the country directed to the attainment of a na-
tion's highest hope and ambition. The revolution
accomplished, and an independent government
established, a new career was commenced. In
common with every thing else, medicine felt the
sacred impulse, and during the brief period of our
independence, how has the scene changed ! In-
stead of the feeble beginnings of one or two insti-
tutions, about thirty medical colleges are now to
be found in different parts of our country ; every
city has its hospitals ; a thriving professional
literature has sprung up among us, and we can
now boast of authors whom we are not ashamed
to mention along with those of European birth.
What nation ever accomplished so much in an
equal space of time, and under equal circum-

stances ?

J. B. Beck.]

Dissertation on the State of Medical
Science, from the Termination of the
Eighteenth Century to the Present Time.
CHAPTER I. — Introductory observations — Im-
portance of Comparative Anatomy and Phy-
siology, as extending the foundations of medi-
cal science — Misapprehensions involved in the
general principles of Hoffmann and Cullen —
Improvements recently effected in the physi-
ology of the essential conditions of life in the
higher animals — in the physiology of the Ner-
vous System — in other departments of physi-
ology — Vital changes in the fluids, as well as
in the solids, must be held to be ultimate facts
in physiology and pathology.
In attempting to give a general view of the
most important changes of doctrine and improve-
ments of medical science which have been made
since the close of the last century, as well as of
the leading facts which have engaged the atten-
tion of the profession during that time, we do not
hesitate to acknowledge our strong sense of the
extent and difficulty of the undertaking, but trust
that our remarks will be received with candour
and impartiality.

The First Lines of Dr. Cullen and the Treatise
on the Blood, &c. by Mr. Hunter, may be held to

* Major General Joseph Warren was born at Roxbnry,
near Boston, in 1741. He studied medicine and practised
his profession at Boston. At the first breaking out of the
Revolution, he turned his attention to arms, and was
slain at the battle of Bunker Hill, June 17, 1775. See
Thatcher's Medical Biography.

1 " Hugh Mercer, M. D., a general in the Revolutionary
war, was a distinguished physician, who, like Warren,
fell in the defence of the liberties of his country. He was
a native of Scotland, and educated at Edinburgh. He
early emigrated to Virginia, and settled at Fredericks-
Imrg, where he practised medicine for several years
ivitli great reputation. During the Revolution, he
zealously engaged in defence of the liberties of his
adopted country, and fell in the battle of Princeton
1777 ' Prof. Sewall's Lectures, 1825, p. 60.

\ Oi Rush was a member of the Congress of 177f, i and
cue ol Ue signers of the Declaration of Independence.

be the most important systematic works on medical
subjects which were published, in Britain, during
the latter part of the eighteenth century; and all
the additions to medical knowledge, and improve-
ments in the principles of medicine, which have
been made since they were published, may be in-
cluded in such a review of the recent progress of
the science.

When we compare the general notions as to
medical science which are prevalent at the present
day, with those which are recapitulated by Dr.
Cullen in the Introduction to the last edition of
his First Lines, as holding their place, up to his
time, in the schools of medicine, the most impor-
tant observation that occurs to the mind is the
present general, although not always avowed re-
cognition of this principle : — That the phenomena
of disease, like all other phenomena of living
bodies, belong to a class of facts, and constitute a
subject of investigation, altogether distinct from
those which are presented by any forms or changes
of inanimate matter. Dr. Cullen states that " the
Mechanical Philosophy had been applied (soon
after the discovery of the circulation) towards
explaining the phenomena of the animal economy,
and continued till very lately to be the fashionable
mode of reasoning on the subject;" and he very
properly admits that it must " still in some re-
spects continue to be applied," but adds that "it
would be easy to show that it neither could, nor
ever can be, applied to any great extent in explain-
ing the animal economy." Now an important
step has been already made in the progress of
medical science, when this proposition has received
the general assent of the profession, — and when
the study of Mechanical Philosophy is recom-
mended to the student of medicine, not as one of
the foundations of medical science, (with the ex-
ception of a few simple applications of its princi-
ples in some parts of Physiology,) but simply as
an example of successful scientific investigation.
A nearly similar observation may be extended
to the study of Chemistry; for although it be true
that all vital actions are attended by, and in part
dependent on, a series of continual chemical
changes, and although a certain knowledge of
chemical principles is therefore required of the
physiologist, yet the chemical changes of animated
nature are as distinct from those which we pro-
duce at pleasure in dead matter, as the stimulation
by nerves and the contraction of muscles are dis-
tinct from any of the principles and powers of
mechanics. Excepting in its application to the
Materia Medica, the chemistry of dead matter
avails little in the science of Medicine ; and al-
though little progress has yet been made in the
inquiry, it has become obvious that the chemistry
of living matter is, in fact, one of the departments
of Physiology, the peculiar laws of which must
be studied and ascertained in living bodies them-
selves, and in the products of their vital changes.
The chemical part of the changes that take place
in respiration, and in the digestion and assimila-
tion of food, has been carefully and successfully
investigated of late years ; but the result is, that
merely chemical principles are equally inadequate
for the explanation of those changes, and of their
effects on the system, as merely mechanical prin-
ciples are for the explanation" of the movements

MEDICINE, (HISTORY OF)

243

which, in the economy of the higher animals, are
equally essential parts of these functions.

It is farther obvious, that all those functions of
living bodies which are now properly distinguished
as the animal functions, i. e. all those which ne-
cessarily imply the intervention of some mental
act, can derive no elucidation from anything that
is ever seen in the inanimate world ; and that, in
so far as the science of medicine is dependent on
the knowledge of them, it must be built on obser-
vations made on the living state of animals exclu-
sively.

Although, therefore, some degree of acquaint-
ance with other natural sciences is properly ex-
pected of a physician, yet it is chiefly as an exercise
of the understanding that the study of these sci-
ences must be recommended. The direct appli-
cations of any parts of the knowledge derived from
that study, either in the science or practice of
medicine, are very partial; and the cultivation of
that knowledge is chiefly desirable, " not for the
sake of the fruits, but to be ploughed in as a dressing
to the soil."

It remains, therefore, as the only rational foun-
dation of medical science, that we must trust to
the careful examination of the structure and func-
tions of living bodies themselves, as existing in
health, as altered by injury or disease, and as in-
fluenced by remedies. It is by accurate observation
and careful generalization of facts confined to this
department of nature itself, that the general prin-
ciples or Laws of Vitality (whether in the state
of health or disease) are ultimately to be made out,
which will bear the same relation to the science
of medicine, as the principles of gravitation, of the
inertia of matter, of motion communicated by im-
pulse, &c. bear to mechanical philosophy; or as
the laws of heat, of electricity, and of chemical
affinity bear to chemistry.

But in order that this may be effectually done,
it is now generally admitted that an extension
must be given to the inquiry which has not until
lately been in the contemplation of most medical
inquirers. It is only by tracing the varieties of
organization and of vital phenomena throughout
the different order of animals, and even in vege-
tables, that we can expect to be able to ascertain
the most general laws of vitality, and distinguish
them from the conditions of existence of individual
families or genera : it were easy to show that
limited and erroneous ideas have originated from
the attention of medical inquirers being fixed on
the economy either of the human body or of those
animals only, which approach the nearest to man;
and that the true foundation of medical science
must be laid in an extensive knowledge of anatomy
and physiology, human and comparative. The
clear perception of this truth has been gradually
impressed on the medical inquirers of the present
a^e, chiefly by the influence of the labours of John
Hunter in this country, of Blumenbach in Ger-
many, and of Cuvier in France ; and the great,
though hitherto unfinished work of Tidemann
may be quoted as evidence of the form and extent
which have thus been given to medical science. It
must, however, be admitted, that in the writings
of professed comparative anatomists much talent
and ingenuity have been fruitlessly exerted in
questions us to the analogies of structure to be

traced in the different classes of animals, which
have no bearing on strictly physiological or medical
inquiries.

In the systematic writings of Hoffmann and
Cullen, " the state and affections of the primary
moving powers of the animal economy," as dis-
tinguished from any principles of chemistry or
mechanics, were first regarded as the main objects
of inquiry in the investigation of diseases ; and
the proper path of pathological inquiry may be
said, therefore, to have been opened by these au-
thors. But it will now be pretty generally admitted,
that these moving powers of the animal economy,
so long neglected in the older schools of medicine,
were erroneously conceived by them. Hoffmann,
in a passage which is quoted by Cullen, as giving
the best epitome of his doctrines, asserts, " quod
solus Spasmus, et simplex Atonia, ajquabilem,
libreum, ac proportionatum sanguinis omnisque
generis fluidorum motum, quibus excretionum
successus et integritas functionum animi et cor-
poris proxime sistitur, turbando et prevertendo,
universam vitalem ceconomiam subruant et des-
truant; atque hinc universa Pathologia longe
rectius atque fecilius ex vitio motuum microscos-
micorum in solidis, quam ex variis aflectionibus
vitiosorum humorum, deduci atque explicari possit;
adeoque omnis generis aegritudines internse ad
prxternaturales generis nervosi affectiones sint
referenda?." Now this passage plainly implies
two propositions, which were maintained by Cul-
len as well as by Hoffmann, and formed an essen-
tial part of the system of both, but which subse-
quent inquiries have shown to be not only hypo-
thetical, but most probably erroneous, — viz. first,
that all movements of fluids in the living body
depend on the impulse of moving solids ; and
secondly, that all movements of living solids de-
pend essentially on the nervous system.

In opposition to these ideas of the "moving
powers of the animal economy," two propositions
may be stated as very prevalent opinions, if not
generally admitted principles, at the present day : —

1. That, although the principle of voluntary
motion certainly resides in the Nervous System,
yet the supposition of the principle of all vital
motion, or as some have expressed it, the principle
of life itself, being lodged exclusively in the Ner-
vous System, is an unfounded hypothesis ; and, 2.
That the fluids of living bodies are liable to move-
ments, or variations of movement, peculiar to their
living state, but independent of any impulses
which they receive from the solids.

The first of these propositions is the general re-
sult of the inquiry as to the relation of muscular
motion to the nervous system of animals, which
was begun in the last age by Haller and Whytt,
and continued in the present chiefly by Bichat,
Legallois, and Flourens in France, and by Cruick
shanks, Brodie, and Wilson Philip, in this coun-
try. It has been clearly shown, indeed, that the
involuntary motions of the body, and the property
of Irritability itself, resident in the muscular fibres,
are liable to much alteration from causes acting
in the Nervous System ; buv there is not only
good evidence against the hypothesis of their de~
pendence on an injluence or energy constantly
flowing into the muscles through the nerves, but
no satisfactory evidence that any intervention of

244

MEDICINE, (HISTORY OF)

change in a nerve is necessary, to enable a stimu-
lus to act on a muscle.

The second proposition, stated above, is the
general result of many observations made on dif-
ferent classes of living beings, and particularly on
the movements in the capillary vessels of vcrtc-
brated animals, by Haller and by various physio-
logists and pathologists, chiefly in Germany, since
his time. These observations have, perhaps, hitherto
attracted less attention in this country than they
deserved ; but many facts might be stated to show,
that no powers of contraction which can be either
attributed to the smaller vessels of animals from
what is known of the larger, or detected by micro-
scopical examination of the small vessels them-
selves, will suffice to explain those fundamental
changes, as to the distribution of the blood through
the capillary vessels of the body, which led both
Hoffmann and Cullen to look to a disordered
action of these vessels as the true origin of the
most important diseases.

It is easy to perceive that these alterations in
the views of physiologists as to the " primary
moving powers of the animal economy," must
necessarily involve a most material change in any
speculations which we can entertain as to the fun-
damental nature of diseased actions.

It may be added that another principle, which
held an important place in Pathology even in the
writings of Cullen, and likewise, in a somewhat
different form, in those of Hunter, has since been
very generally and properly abandoned. This is
the principle of the Autocrateia, or Vis Naturae
Mcdicatrix, not indeed regarded by Cullen as it
had been by Stahl, as an attribute of the human
mind, but still held out as a power of the animal
system, to which changes occurring in the course
of disease might be reasonably referred, and by
which they might be explained.

It is perfectly true that the greater number of
diseased actions are essentially temporary in their
nature, and that there are various and wonderful
provisions of nature for avoiding and repairing
injuries, to which the body is liable; but unless
we substitute final for physical causes, — the « id
propter quod" for the " id ex quo," — the know-
ledge of this general fact gives no assistance in
tracing the laws of the animal economy, to which
either these or other changes, occurring in disease,
are to be ascribed. The critical termination or
gradual decline of idiopathic fever, the resolution
of inflammation, the exudation and organization
of lymph on inflamed surfaces, the processes of
suppuration and of sloughing, the function of
healthy absorption, and the increase of absorption
from pressure, are all examples of changes which
frequently, although not uniformly, tend to the
preservation of life; but it is quite certain that
these different processes depend on very different
principles or laws of the animal economy ; and
the knowledge of the fact, that these different laws
are wisely designed for the preservation of life,
gives no assistance in the inquiry as to the nature
of the laws themselves, which is the inquiry that
the pathologist has to pursue.

It must be owned, however, that although, in
these different aspects, we may hope that medi-
cine is cultivated at present on sounder principles
than fifty years ago, yet as there has been no

strictly systematic writer of high repute since the
time of Cullen, so the attention of medical men
has been seldom fixed on these first principles of
the science ; and their efforts have been directed
chiefly to the elucidation of subordinate depart
ments, capable of more direct practical application,
and demanding a more detailed notice.

I. The first of the more special improvements
which may be noticed as having been effected
within the last forty years is, the elucidation of
those fundamental questions in Physiology which
bear most directly on Pathology, viz. those which
illustrate the causes of sudden or violent death ;
and the more precise information which we now
possess on these points may be traced, in a great
measure, to the labours of Bichat, who fixed the
attention of physiologists on the essential distinc-
tion of the Organic and the animal life of all the
more perfect animals, and on the importance of
the function of Respiration, as the closest and
most permanent bond of union between the two.
This intermediate character may likewise be as-
signed to digestion, and to all the functions neces-
sary to the life of animals which are dependent on
movements excited, directly or indirectly, by sen-
sation, as distinguished from those strictly organic
functions in which no mental act is concerned.

The ideas of Bichat of the three modes of sud-
den death, that beginning at the brain, at the
lungs, and at the heart, were in some respects in-
complete. He was not aware that by certain
kinds of injury of the brain or spinal cord, death
may be produced, not through the intervention of
failure of respiration, (as in the case of what is
strictly called death by Coma,) but by a sedative
impression suddenly communicated to the heart,
and therefore strictly in the way of Syncope; he
did not seize the right view of the manner in
which the circulation is brought to a stand when
the access of air to the lungs is in any way ob-
structed, and was so far inaccurate in his notion
of death by Asphyxia ; he had not studied, at the
time of his death, the action of Poisons on the
animal economy, so as to be aware of the illustra-
tions of his own principles which these afford;
and he had made little application of his views as
to violent death to the more complex changes
which constitute disease. But these deficiencies
have been .since supplied. The experiments of
Legallois and of Dr. Wilson Philip, and the clini-
cal observations of Brodie, Travers, and others,
have sufficiently illustrated the direct effect of vio-
lent concussion, or shock, in whatever manner
produced, on the heart and other organs of circu-
lation. The dependence of the death by asphyxia,
not on the loss of power in the heart, but on the
stagnation of blood in the lungs, and failure in the
supply of blood to the left side of the heart, has
been satisfactorily established by the experiments
of Dr. Williams of Liverpool, and Dr. Kay of
Manchester. The different modes in which death
is produced by Poisons (which are the more im-
portant as they are the facts in nature most ana-
logous to the changes which constitute the most
deadly diseases) have been clearly pointed outbv
Sir B. Brodie, and amply illustrated by the re
searches of Orfila and Dr. Christison. What is
more important in a pathological view is the pecu-
liar depressing influence on the vital actions of

MEDICINE, (HISTORY OF)

245

the sanguiferous system, which many poisons, be-
longing to different classes, (e. g. opium and
arsenic,) are shown to exert ; — which in the case
of some of the mineral and vegetable poisons, as
arsenic or tartar-emetic in large doses, tobacco,
digitalis, hydrocyanic acid, is the immediate cause
of death ; — and which is the most striking part
of the effect produced by animal poisons, such as
that of a venomous serpent or the most virulent
contagious effluvia. It may be added that the
different modes in which excessive Cold and ex-
cessive Heat, and Electricity or lightning, produce
death, have been sufficiently elucidated by experi-
ments of Chossat, Brodie, and others, and by cases
recorded by many practical observers; and that
the different effects of violent Hemorrhages have
been carefully investigated by Dr. Marshall Hall,
Dr. Blundell, and others.

From all these obseivations.it is now fully un-
derstood that the ultimate effect of all causes of
sudden death may always be referred to their ar-
resting, in ways which we can distinctly specify,
the flow of arterial blood throughout the body ;
which is, in all cases, the essential condition of
all its vital actions, although in different tribes of
animals, and in different states of the same, the
degree of rapidity of the requisite supply of this
blood is remarkably various.

It is also distinctly understood that, in all cases
of sudden death in the higher animals, most
nearly approaching to man, this essential condition
fails from one or other of two general causes,
either because the vital agency of the powers
moving the blood is directly depressed or sus-
pended, or because the action of the air on the
blood is obstructed, and the blood therefore stag-
nates in the lungs ; — that the vital action of the
sanguiferous system may be suspended in two
ways, either by various agents, chiefly acting
through the nervous system, which impress it in
the manner of a Concussion or Shock, or after
the manner of one of the virulent poisons above-
mentioned, which act nearly as a concussion does ;
or by abstraction, sudden or gradual, of the vital
stimulus : — and lastly, that the action of the air
on the blood may be obstructed also in two ways,
either by such injury of the Nervous System as
produces insensibility or Coma, and ultimately ar-
rests the mechanical actions of respiration, which
depend on sensation ; or by direct impediment to
the admission of air to the Lungs, arresting the
respiration more directly or producing Asphyxia.

Although it is only in a few cases of disease
that life is extinguished in so simple a manner as
in any of these instances of violent death, yet it
is plain that the scientific treatment of all diseases
must be very much guided by a clear perception
of the landmarks which are presented to the care-
ful observer, by the study of these simplest cases
in pathology.

II. The next important addition to the science
of medicine has been furnished by the labours of
those physiologists who have done so much within
the last twenty years to determine the different
purposes which are served by the different parts
of the Nervous system. The general result of
these inquiries may be thus stated : that the very
different offices to which the nervous system has
Vmg been known to minister, in different parts of

the body, are not determined, as was formerly sus-
pected, by the various organization of the parts,
but by the various endowments of different por-
tions of the nervous matter itself, in relation to
those mental acts of which they are the seat and
the instrument.

The dissections, experiments, and clinical ob-
servations of Sir Charles Bell, Mr. Shaw, and
Mr. Mayo, in this country, of Magendie, Serres,
Desmoulins, and Flourens in France, and of Ro-
lando and Bellingeri in Italy, [and of Valentin,
J. Miiller, and others, in Germany,] are the most
important of those by which it has been ascer-
tained, that the conditions which are necessary to
all the sensations, and to the excitement of all
muscular motions by mental acts, are confined to
those nerves, and to those portions of the spinal
cord, and its immediate prolongations within the
cranium, to which we now give, without difficulty,
the names of sensitive and motor respectively.
We can specify those portions of this Cerebro-
spinal Axis, on which each of the sensations pe-
culiarly depends; we can point out the use of
parts within the cranium, in immediate connection
with the Cerebro-Spinal Axis, by which voluntary
or instinctive motion in different directions is de-
termined ; we can form some idea of the parts of
the nervous system, and of the peculiarities of
structure, by which the influence of mental acts
over the involuntary motions and other organic
functions, is maintained ; and we can show that
the brain and cerebellum are not essential to the
performance of the functions of the spinal cord
and nerves ; that they are neither required for
sensation, nor for those instinctive actions which
are most intimately linked with sensations, but are
superimposed on those organs with the intention
of combining sensation and instinctive action with
the higher attributes of mind. These parts of the
nervous system furnish the conditions, not of sense
or motion, but of intellect, of desires, and moral
feelings ; they are required, not in order that sen-
sations may be felt, but that they may be remem-
bered and availed of for that purpose, — not in or-
der that volitions may act as stimuli on muscles,
but that they may be so excited, and so succeed
one another, as to produce regular and useful vol-
untary actions, under the guidance of desires, and
of judgment and experience, as distinguished from
blind instinct.

[The views of Dr. Marshall Hall, in regard to
the true spinal system of nerves, have shed great
light on many circumstances connected with the
nervous system, which were previously regarded
as anomalous. Dr. Hall divides all the nerves
into 1. the cerebral, or the sentient and volun
tary ; 2. the true spinal or excito-motory ; ana
3. the ganglionic, or the nutrient and secretory
He believes, that a peculiar set of nerves consti
tute, with the true spinal marrow, or the gray
matter as their axis, the second division ; the ex
citor nerves pursuing their course principally from
internal surfaces, characterized by peculiar exci-
tabilities, to the true medulla oblongata and me-
dulla spinalis ; and the motor nerves pursuing a
reflex course from the medulla to the muscles,
having peculiar actions concerned in ingestion and
egestion. The views of Dr. Hall on the excito-
motory function have been embraced by J. Mill-

246

MEDiCINE, (HISTORY OF)

lcr, Grainger, Carpenter and most observers, and
have been extensively applied to the elucidation
of spasmodic diseases more especially ; some of
which are induced by causes seated in the spinal
marrow, or at the centre, whilst others are caused
by excentric irritation, or in a reflex manner.]

So far the different endowments of the differ-
ent parts of the nervous system may be held to
have been determined by observation and experi-
ment j and if we decline to enter farther into the
speculations of phrenologists (which have at-
tracted so much attention of late years), as to the
connection of the individual parts of the brain
with the different intellectual powers, or with the
exercise of these powers on particular objects of
thought, it is not because we regard the general
principle of those speculations as unphilosophical,
but simply because they are founded on a kind of
observations which is open to various sources of
fallacy, and derive little or no support either from
experiments on animals or pathological observa-
tions on the human body, and appear, therefore,
to be built on insufficient evidence.

The knowledge of the endowments of the dif-
ferent parts of the nervous system, so far as it has
been hitherto attained, is a great and important
step in physiology ; it is of importance in the
diagnosis of many of the diseases in which the
nervous system is concerned, as fixing the precise
seat of these diseases ; and it enables us to explain
the great diversity of symptoms, which may re-
sult, in different cases, from apparently similar
lesions of the brain and cerebellum, and so to sur-
mount what was formerly a serious difficulty in
pathology ;* but it is susceptible only of occa-
sional and partial application in the practice of
medicine, simply on this account, — that practical
questions as to the treatment of diseases, especi-
ally of different diseases of the same texture,
must always turn much more on their nature than
on their seat.

III. Many other improvements in Physiology
have been effected since the close of the last cen-
tury, on which it were out of place to dwell here,
because they are hitherto susceptible of still more
partial application either in pathology or practice ;
but which must not be omitted in any general ac-
count of the progress of medical science. The
chemical analysis of the Blood has been carried
to a high point of perfection ; and the varieties in
the proportion of its constituents in different cir-
cumstances, the essential differences of venous
and arterial blood, the essential nature of the pro-
cess of coagulation, and the circumstances by
which it may be accelerated, retarded, or pre-
vented ; the alterations effected by inflammation

* It is due to the memory of the late Dr. Gordon of
Edinburgh, to state, that as early as 1813 he had inferred,
from pathological facts already known, that the brain
and cerebellum are not concerned in sensation nor in cer-
tain voluntary actions. He thought that palsy, in any
of its forms, when produced by disease within the cra-
nium, higher than the medulla oblongata, might be re-
ferable, not to loss of the essential conditions of sense
or of voluntary power, but to what he called a " noxious
influence," transmitted in some such cases, and not in
c thers, from the seat of the disease to the nerves of the
parts arTi.cted. Of the share which the medulla oblon-
gata and spinal cord may have in these functions he
spoke doubtfully, as the state of our information at that
time required. The facts which he had collected on this
subject are contained in a paper in the twenty-fourth
volume of the Edinburgh Review.

in the proportion of the fibrine, and in the pro-
perty of coagulation ; the organization of the
fibrine which exudes from inflamed surfaces; and
the proofs resulting from these last facts, of the
existence of strictly vital properties in the blood
as well as in the solids of the body, are all points
that have been elucidated by numerous experi-
mental inquirers, following the path which had
been opened by Hunter and Hewson; and among
these Bostock, Berzelius, Marcet, Hey, Thackrah,
Davy, Prevost and Dumas, Le Canu, Denis,
Gendrin, Schroeder Van der Kolk, Eabington, and
Prater, [Andral and Gavarret, Mandl, Donne.Wag-
ner, Gulliver, and Wharton Jones,] may be par-
ticularly mentioned.

The nature of muscular contraction in general
has been more fully investigated by Prevost and
Dumas than by any previous physiologists ; and
the question, repeatedly agitated, whether there
be any change of volume in the fibres at the time
of their contraction, has been resolved in the ne-
gative by these authors, by Mayo, and others.
[The whole subject of the histology and physiol-
ogy of the muscles, has been ably investigated by
Bowman, Gerber, Skey, Martin Barry, Bishop,
and others.] The vital actions of the heart have
been particularly studied, and the use of its valves,
and of the peculiar convoluted structure of its
muscular fibres, if not fully ascertained, have been
much elucidated by the dissections and experi-
ments of Gerdy, of the late Dr. Duncan, of Wil-
liams of Liverpool, Corrigan, Hope, Carlile, [Pen-
nock and Moore, Cruveilhier, Williams of Lon-
don,] &c, as well as by the clinical observations
of Laennec, and the correction of some of his
conclusions by Professor Turner and others. The
nature of the vital power which can be ascertained
to exist in arteries has been satisfactorily deter-
mined by the experiments of Parry, of Wede-
meyer, and of Poiseuille. The auxiliary forces
which contribute to the flow of blood along the
veins, and particularly the effect produced on its
movement there by acts of inspiration and expi-
ration, have been partially indicated by Carson,
and more clearly pointed out by Magendie and
Sir D. Barry. And the flow of blood in the
capillary vessels, under various circumstances, has
been carefully examined, and subjected to compar-
ison with the movement of fluids in the lower
classes of animals and in vegetables, by numerous
observers, of whom the most deserving of notice
are Thomson, Hastings, Black, and Marshall Hall
in this country ; DuTrochet, [Magendie,] Leuret,
and Gendrin in France ; and Schultze, Dollinger,
[Wagner, J. Muller,] and Kaltenbrunner, in Ger-
many.

On the whole, it may be stated that the inves-
tigation of the powers by which columns of blood
are moved through the larger vessels of the hu-
man body, seems to be nearly complete ; but far-
ther inquiries are still demanded, to determine the
nature and estimate the efficacy of the powers, by
which the movement of the blood is affected and
its distribution regulated, after it has been diffused
throughout the innumerable ramifications of the
capillaries ; and this deficiency is the more impor-
tant, as it is clearly in the alteration of vital ac-
tions of which the capillaries are the seat, that all
the most formidable diseases originate. The prin-

MEDICINE, (HISTORY OF)

247

ciplc of Endosmose and Exosmose, illustrated by
the experiments of Dutrochet and others, cer-
tainly does not develop the sole agent of vital
movement in the capillaries ; but it exhibits move-
ments, even in inanimate fluids, which may be
said to bear the same relation to the chemical ac-
tions of these fluids on one another, as certain of
the movements of living fluids bear to the vital
changes to which they are destined.

In regard to the functions of Nutrition, Secre-
tion, and Excretion, to which the circulation is
subservient, perhaps the most important informa-
tion, lately obtained, is of a negative character.
Notwithstanding the opposite opinion of some
eminent physiologists, it may be stated as the
general belief, and as a fair inference from a re-
view of the different departments of living beings,
as well as from experiments and observations on
the higher animals, that these processes are inde-
pendent of any influence or energy necessarily de-
rived from the nervous system.*

It may also be laid down as a principle es-
tablished, chiefly by the observations of Cuvier,
that the differences among the products formed
from the blood in the living body, great and nu-
merous as they are, cannot be explained by the
differences of organization, or by any peculiarities
of the vascular arrangements, of the parts where
they show themselves.

Several circumstances, in regard to the intimate
structure of organized substances, both animal and
vegetable, have lately attracted much and deserved
attention, as clearly distinguishing them from any
products of the chemical attractions which subsist
among the particles of dead matter. The most
important are, the very general tendency of sub-
stances which are the result of vital action, to
take the form of globules, or rather of cells, in
which a containing cyst and a contained matter
are usually discernible ; the total absence of crys-
talline arrangement in the living and growing parts
of these textures; and the fact, that the par-
ticles of earthy and saline matters which enter
into the composition of organized substances, how-
ever small their proportion to the whole, are never
aggregated together, but are equally diffused
through the whole mass, and retain the original
form and dimensions, even after the whole of the
strictly animal or vegetable matter has been burnt
out. These facts, established by Dr. Prout in this
country, and by Milne Edwards, Tiedemann, Ras-
pail, and others abroad, clearly indicate that the
attractions and repulsions which subsist among
the elements constituting organized bodies, at the
period of their formation by living action, are es-
sentially different from those by which the same
elements are actuated in other circumstances ; and
establish the existence of a distinct set of laws,

* It is perfectly in conformity with this doctrine to
state, that the nutrition of certain parts, as of voluntary
muscles and the organs of sense, and that the secretions
nf other pans, especially of mucous membranes, are ha-
bitually excited hy voluntary motions and by sensations,
and therefore become deficient when certain nerves of
voluntary motion or of sensation, are injured or palsied.
This principle seems to furnish the true key to the facts
observed in numerous recent experiments on animals,
by Brodie, Wilson Philip, Swan, Breschet, Leuret and
Las.-i.iijrne, Magendie, and others, as to perversion of
secretion and nutrition from section, particularly of the
fifth and eighth nerves. And trie same principle may be
applied >o various important phenomena in disease.

regulating their combinations in living structures,
to which the general title of Vital Affinities has
been happily applied. [A comprehensive descrip-
tion of the opinions of many recent histologists
on cells and cell-life is given by Dr. Carpenter in
the Brit, and Foreign Med. Review for Jan.
1843, p. 249.]

As the analysis of the blood has been improved,
so many of the proximate principles which go to
the composition of animal substances have been
detected in it, or procured from it by very simple
means, that the processes by which the solids of
the living body are nourished, or the prepared
fluids furnished, have been gradually more and
more regarded as nearly approaching to simple
transudation, or, as it has been appropriately
termed, Chemical Filtration. And since the pro-
cess of assimilation or sanguification, by which
foreign matters are added to the blood either in the
adult or foetal state, has been minutely traced, so
much contrivance for the gradual formation of the
blood has been developed, that we are the less sur-
prised to find so many proofs of its very hetero-
geneous nature when it comes to the extremities
of the arteries, and is applied to the purposes of
nutrition and secretion ; and of the apparent sim-
plicity of these processes themselves.

One principle, at least, may be held to be nearly
established on this subject, that the materials of
the different Excretions already exist in the com-
pound blood, and are only evolved or separated,
not formed from the blood, at those organs at
which they respectively appear. This is certain
as to the urine, from the result of the experiments
of Prevost and Dumas, and of pathological obser-
vations by Dr. Christison and Dr. Bostock in the
human body, from which it appears that when the
kidneys are extirpated or more gradually ob-
structed, and rendered unfit for their office, the
urea, or peculiar matter of the urine, shows itself
in the blood. As the peculiar matter of bile ap-
pears now to have been detected, even in healthy
blood, and as there are undoubtedly cases of in-
tense jaundice, in which the bile-ducts appear on
dissection pervious and empty, even throughout
the substance of the liver, — where there is there-
fore no reason to suppose that any secretion of
bile had taken place, — we have good grounds for
extending the same conclusion to the liver, as we
have stated in regard to the kidneys. And there is
still less difficulty in extending it to the excretions
by the skin and the lungs. We may consider the
function of excretion, therefore, (which is a con-
comitant of vital action in all living beings without
exception,) as having its origin in all parts of
vital action in all living bodies, or more probably
in the nourishing fluid which penetrates and
vivifies them all ; and as the necessary comple-
ment of the process of assimilation, by which ex-
traneous substances are incorporated with or-
ganized matter.

The important discoveries as to the nature of
the corresponding process of Absorption, which
have been made of late years by Magendie, Se-
galas, Fodere, Meyer, Tiedemann, [Sir D.] Barry,
and many others, (when duly compared with the
comments of other physiologists,) may be thus
expressed, — That although the set of vessels de-
scribed for a century past by the name of absorb-

2i3

MEDICINE, (HISTORY OF)

ents arc really destined to the office of absorption,
and their structure, in various ways, is peculiarly
adapted to it, yet it is not through them, nor
through any one set of vessels exclusively, that
the absorption of extra-vascular substances into
the circulating mass is effected ; that a function
precisely similar is executed in many living beings,
without any set of vessels being appropriated to
it; and that the absorption of extra-vascular mat-
ters in the higher animals must be ascribed, there-
fore, in the last result, to peculiar relations sub-
sisting, in the living state, between those matters
and the circulating blood, rather than to the pe-
culiar nature or forms of the vessels which are
the organs of absorption ; and, accordingly, that
the degree of absorption is very much influenced
by two circumstances in the condition of the cir-
culation at the part where any such extraneous
matters may lie, — viz. by the fulness of the ves-
sels, and by the rapidity of the current at that
part ; being always diminished when the vessels
are much distended, and likewise when the flow
along these vessels is much retarded or suspended,
as by the removal of atmospheric pressure from
any portion of the surface of the body.

Another principle in regard to absorption in the
more perfect animals, of complex structure, which
recent inquiries have illustrated, and which has
been already briefly noticed, as probably of funda-
mental importance, viz. the careful provision which
nature has made for the very gradual intermix-
ture of any foreign matter, thus introduced, with
the nourishing fluid of the body receiving it.

such facts, it is obvious that there must be con-
trivances, in all living beings, for the fulfilment
of those still mysterious laws and conditions, by
which the chemical changes effected by them on
the surrounding elements are regulated and con-
trolled ; and among these contrivances, the arrange-
ments of the different absorbent vessels and of the
excreting organs must evidently be ranked.

The chemical nature of the changes which take
place in the air, and in the blood, or nourishing
fluid of all living structures, in respiration, has
been often and carefully investigated since the
time of Black, Priestley, and Lavoisier, especially
by Ellis, by Allen, and Pepys, and more lately
by Edwards, Dulong, [Gmelin, Tiedemann, Mit-
scherlich, Liebig,] and Collard de Martigny. The
general result is, that the absorption of oxygen and
the evolution of water and carbonic acid are the
essential changes ; but that the products thus
evolved are the result, not of a simply chemical
action at the lungs or corresponding organs them-
selves, but of the vital actions throughout the
system, by which the blood acquires the venous
character before it reaches the lungs. The adapta-
tion of arterial blood to the maintenance of vital
action in general, and of circulation in particular,
seems to be one of the primary laws or conditions
of vitality, for which it is in vain to look for an
explanation, and the mode of operation of which
is illustrated by what has been already said of the
nature of death by asphyxia.

The questions, whether the maintenance of the
heat of living animals is satisfactorily explained

Thus, when extraneous matter is received into the ! by the strictly chemical changes that take place

prima? viae, it is not only acted on by the fluids
there provided for its reception, and part of it re-
jected, but the absorption of what is capable of
assimilation is divided between two sets of vessels ;
what is taken up by the veins is carried to the
liver, and certain combinations of the elements
contained in it are there expelled ; — what is taken
up by the lacteals is mixed with certain elements
of the blood in the absorbent vessels, and particu-
larly in the mesenteric glands ; and both portions
are carried through the capillaries of the lungs, —
where certain matters are evolved from them, and
at least one important element added to them, —
and arc subjected to thorough agitation and inter-
mixture on both sides of the heart, before they
are admitted into the arteries, in a condition fit for
the purpose of nutrition.

That these arrangements, and others which
have a similar effect in the lower animals, are in-
tended to secure the very gradual intermixture
and incorporation of fresh nourishment with the
blood, we shall be prepared to admit when we re-
member, that throughout all the classes of organ-
ized beings, and in all periods of their independent
existence, the assimilation of the crude nourish-
ment, taken in from the external world, is always
effected by means of organized matter already ex-
isting in each living structure itself; and farther,
that in the case of animals at least, the greater
part of the ingesta, which are subservient to nutri-
tion, are themselves organized substances, the pro-
ducts of vital action in some of the lower orders
of living beings, and the assimilation of which
may therefore be said to have commenced in these
'ower orders of the animated creation. From

in the body, and especially at the lungs, and how
far it is dependent on any action of nerves, have
been prosecuted with great zeal, since the time of
Black, Crawford, and Lavoisier, by Sir B. Brodie,
Dr. Davy, Legallois, Hales, Drs. Wilson Philip
and Hastings, Chossat, Edwards, Dulong, and
Despretz, [Liebig,] and others. The general con-
clusion is in favour of the sufficiency of the che-
mical changes to explain it, and of the influence
of that particular change on which the evolution
of carbonic acid depends, in elevating the tempe-
rature of animals ; and there is, perhaps, no case
in physiology to which the maxim, " Frustra fit
per plura quod potest fieri per pauciora," is more
fairly applicable : but two points have been like-
wise ascertained, which were not in the view of
the first speculators on this subject, viz. 1. That
the chemical changes on which the temperature
of the living body depends, cannot be confined to
the lungs, nor to the formation of carbonic acid
in the body ; and, 2. That these changes are re-
markably liable to influence from causes, and
especially from injuries, affecting the nervous
system.

The power which living animals possess ol
maintaining a temperature lower than that of the
surrounding air, has been shown by De la Roche
and Berger, and by Edwards, to depend merely
on the increased evaporation from them, and there-
fore on a simply chemical principle.

In regard to the function of digestion, the most
important additions to our knowledge have been
made by Drs. Marcet, Prout, Wilson Philip, and
Sir B. Brodie, in this country, by Tiedemann and
Gmelin, in Germany, and by Magendie, Londe,

MEDICINE, (HISTORY OF)

249

and Leuret and Lassaigne, in France ; and of
these the following chiefly demand attention : —

1. The division of alimentary matters into the
great families of albuminous, saccharine, and oily;
and the necessity of mixture of at least two of
them for the nourishment of man and of the, most
analogous animals, — (another fact which shows
how much hitherto unexplained contrivances must
be included under the term assimilation of food.)

2. The secretion of an acid solvent liquor, con-
taining the muriatic acid, in the stomach, subse-
quent to the reception of aliment, and regulated
to a certain degree in its quantity and strength by
the nature of the aliment received. 3. The great
diminution of this secretion, usually caused by
section of the par vagum, particularly in the neck,
in circumstances when we know that the sensa-
tions of the stomach and of the lungs are very
much perverted. 4. The appearance of matter
possessing in some degree the characters of albu-
men, in the chyme thus formed, even in the sto-
mach, and the increasing proportion of this matter
in the upper part of the bowels, and in the con-
tents of the lacteals and thoracic duct. 5. The
formation of globules, similar to those of the blood,
in this albuminous matter, likewise commencing
in the stomach. 6. The gradual combination of
the acid and oil of the chyme with the alkali of
the bile, in the course of the small intestines, and
the gradually increasing proportion of the peculiar
animal and excretory matter of the bile, in tracing
the contents of the intestines downwards, as the
acid and the albuminous matters disappear. 7.
The albuminous and slightly acid nature of the
pancreatic juice, its greater abundance in her-
bivorous animals, and the corresponding fact, that
in the human body vegetable food is chiefly acted
on after it has passed the pylorus. 8. The reap-
pearance of acidity at the ccecum, and probably
renewal of a certain degree of the digestive pro-
cess in the great intestines.

[The observations of Dr. Beaumont, of the
United States Army, on an individual having a
fistulous opening into the stomach, have confirmed
many of these positions ; and thrown great light
on the phenomena of digestion. It would seem,
from the experiments of Eberle and Schwann,
that a nitrogenized substance is thrown off from
the stomach, which the former terms pepsin, and
which is an active agent in digestion. The
agency of this pepsin is regarded by Liebig to be
similar to that of diastase, in the germination of
seeds. Both are bodies in a state of transforma-
tion or decomposition ; — the latter effecting the
solution of the starch — that is, its conversion into
sugar ; and the former, the conversion of alimen-
tary matter into chyme. The prevalent belief
amongst physiologists and chemists is, that pep-
sin, by inducing a new arrangement of the ele-
mentary particles or atoms of the alimentary
matter, disposes it to dissolve in the gastric acids.
Liebig does not believe that the digestive process
is a simple solution, but a species of fermentation,
not identical, however, with any of the known
processes of fermentation occurring in organic
matters out of the body.]

Besides the great discovery of the various en-
dowments of different parts of the nervous system,
some farther improvements have been effected in

Vol. III. — 32

that part of physiology which treats of the strictly
animal functions — sensation, thought, and volun-
tary motion. Various facts as to the conditions
requisite for the exercise of the senses, and par-
ticularly of the sense of sight, have been ascer-
tained ; and the general views of physiologists as
to the information which the senses convey, and
the mental processes which they excite, have be-
come, at least in this country, more scientific and
precise.

Perhaps the most important proposition which
| can be stated in this part of the subject, is one
; which has been best illustrated by Dr. Reid and
the other Scotch metaphysicians, — that many of
the mental acts, which are naturally and uniformly
excited by the exercise of the senses, bear no re-
semblance whatever to the sensations from which
they originate ; that not only the general ideas
which arise in the mind in consequence of im-
pressions from without, (such as time, space,
number, power, &c.) are wholly unlike any thing
which was ever presented to our senses, but the
notions which we form of the qualities of the ob-
jects of sense themselves, (such as hardness, soft-
ness, extension, motion„&c.) bear no resemblance
to the sensations which lead us to form them.
Our ideas, therefore, are not, as some philosophers
have supposed, merely " transformed sensations ;"
nor does the external world itself appear to us as
the " express image of our sensations ;" and the
true source of much of our knowledge is, not in
the mere intimations of sense, but in the judg-
ments which by the constitution of our nature we
intuitively form, in consequence of receiving
these intimations. (See Stewart's Philosophical
Essays, « On Mr. Locke's Account of the Origin
of our knowledge.")

When this principle of intuition, which must
necessarily be admitted as one source of the in-
formation acquired through the senses, is duly-
considered, it will appear that we have no me&ns,
a priori, of judging what is the kind and extent
of information, as to the qualities of external
things, which any sense may be capable of com-
municating, to man or to other animals ; and it is
still doubtful, whether or not many reported cases
of alleged transference of the higher or peculiar
senses from one part of the system to another, are
referable only to this general principle.

At all events, it is obvious that as we neces-
sarily include under the term mental acts many
phenomena which are neither included in sense,
nor logically deducible from the intimations of
sense, the study of these mental acts, as we teel
them in ourselves, and as we judge from their re-
sults that they are felt by others, (a study which
on many accounts demands the attention of the
physician,) must be prosecuted quite separately
from that either of the sensations or motions of
any living beings ; and provided that the attention
be fixed on matters of fact, and all useless contro
versies be avoided, this study may be prosecuted
with more advantage in the writings of metaphy-
sicians than of mere physiologists. In this view,
the treatises of Dr. Abercrombie, on the Intel-
lectual and Moral Powers, are peculiarly valuable ,
and perhaps the view there given of our mental
constitution may admit, for the sake of the medi-
cal student, of still further abridgement.

250 MEDICINE, (HISTORY OF)

Lastly, in enumerating the additions whichVstem, the nervous system, & c " h J™ Jff" ™"

nutely traced by Soemmering, Meckel, I ledemann,
Serres, Allen Thomson, and many others. [See
an interesting report on the ovum of man and the
mammifera, before and after fecundation, by T.
Wharton Jones, in Brit, and For. Med. Rev. Oct.
843, p. 513-] The peculiarities of the blood of the

physiology has received since the end of the last
century, we must not omit the numerous observa-
tions which have been made on the necessary con-
ditions of the function of Generation, and on the
mode of life and development of the foetus. These
observations have been made chiefly on different
classes of the lower animals ; and the varieties of
this function in the different classes, and the con-
clusions to be drawn from the study of these, in
fixing the essential conditions of the function,
have been admirably stated by Cuvier.

The ovum of some of the mammalia has been
detected, first by Biier, in the Graafian vesicle of
the ovary; the nature of the changes, at the
ovary, which precede and follow the escape of the
ovum, and the fallacies attending the appearance
of the corpus luteum, have been elucidated (per-
haps not yet completely determined) by Sir Eve-
rard Home, Magendie, and others ; the existence
of animalculas in the prolific male semen has been
confirmed by Magendie, and Prevost and Dumas;
the necessity of the actual contact of the male
semen with the ovum that descends from the
ovary, has been put almost beyond dispute by
the experiments of Drs. Haighton and Blundell ;
while the ascent of the seminal fluid in ordinary
circumstances to the ovaria themselves has been
disproved, both by their experiments and by the
observations of Prevost and Dumas. [Still there
appears to be but little doubt that the ovum is
fecundated in the ovary.]

The changes produced in the uterus by concep-
tion, the nature of the connection between the
ovum and uterus, and the manner in which the
ovum is nourished both before and after the for-
mation of the placenta, have been subjected to new
and careful examination, chiefly by Breschet and
Velpeau in France, and Dr. Lee in this country.
In reference to the general principles of physiolo-
gy, the most important proposition that has been
stated on this subject is that which appears to be
nearly established by this last author, — that there
is not only no vascular connection between the
mother and the foetus, but none, or next to none
between the uterine vessels and the placenta ;
and, therefore, that there is no force, acting in the
way of propulsion, which will explain the appli-
cation of portions of the maternal blood to the
nourishment of the fcetus ; while at the same time
the experiments of Magendie and others have
proved, that any substance which may be circu-
lating in the blood of the mother finds ready ac-
cess to that of the fcetus, but that there is little or
no transference of fluids in the opposite direction.

The numerous and careful observations which
have been made on the development of the fcetus
in its earlier stages, in different classes of animals,
by Pander, Wolff, Rathke, Biier, Prevost and Du-
mas, [Bischoff, Henle, Martin Barry, Krause,
Wagner, Valentin, Purkinje, T. Wharton Jones,]
and other, chiefly German physiologists, have suf-
ficiently established, although in opposition to the
opinion of Haller, the general doctrine of the
Epigenesis, or growth by the formation of parts
out of the fluids of the ovum, as opposed to that
of the Evolution, or growth by the extension of
carts ; and the gradual development of the differ-
ent organs and textures, the bones, the vascular

foetus have also been examined ; and the curious
discoveries of Sir Astley Cooper and Dr. Lee, of
the formation of albuminous matter in the thymus
gland, and in the liver, of the fcetus, have distinctly
shown that here, as well as in the adult, there are
contrivances adapted to the general object of As-
similation, the particular intention of which is still
mysterious.

The knowledge of the essential nature of the
changes, occurring at birth, by which life, previ-
ously maintained by organic functions only, is
placed in dependence on the sensations of the new
being, and so rendered truly animal and independ-
ent of the mother, is necessarily dependent on
that correct exposition of the essential conditions
of life in the adult, to which we have already ad-
verted. The changes in the state of the circulat-
ing system, and of the lungs, consequent on birth,
have been examined and accurately described by
Chaussier and various other authors, particularly
with a view to important questions in medical ju-
risprudence. And those peculiarities of the vitality
of the very young warm-blooded animal, in which
it approaches to that of the cold-blooded, especially
its power of resisting the privation of the natural
stimuli of heat and oxygen, have been particularly
remarked by Edwards.

Various facts, of great importance as illustrating
both the influence of hereditary constitution and
of the habits of parents, and also that of climate,
air, exercise, diet, and mode of life, on the growth,
the healthy functions, and the diseases of the hu-
man body, have been ascertained and recorded by
different practical authors ; the distinctions of the
different races of men now inhabiting the earth
have been carefully observed by Blumenbach,
Lawrence, Prichard, Desmoulins, Mayo, and others;
and the peculiarity of some of these races as to
liability to, or exemption from, different kinds
of disease have been to a certain degree investi-
gated by various authors, since the time of Rush,
in America, and by Drs. Fergusson, Johnson,
Marshall, and others, who have had opportunities,
in the British service, of making such inquiries in
different regions of the globe.

In the present state of Physiology, perhaps the
most important inference that can be drawn from
this hasty survey of the recent additions to the
science is that of the extent which must be given
to the idea of. Vital Action, beyond what can be
included in, or explained by, the Vital Motions of
living solids. It is true, indeed, as stated by Cut
len, that the •« primary moving powers of the ani-
mal economy" (by which he understood the vital
powers of the moving solids) must be more or
less concerned in all the changes which take place
in the healthy body, and in all the deviations from
these which constitute disease ; but they are only
a part, and frequently not the most fundamental
part, of these changes. It is probable that there
may be movements in the nervous system, corre-
sponding to all the changes, mental or bodily.

MEDICINE, (HISTORY OF)

251

which are connected by nature with its living
condition ; but they are movements which elude
our senses ; and we must be content to know the
changes that take place in the nervous system it-
self, only by their effects on the mind on one
hand, or on the body on the other. As to the
changes in the fluids of the body which are es-
sential to the life of the solids, it seems certain
that even the motions of the fluids in the capilla-
ries, and still more that the peculiar chemical ac-
tions to which they are there subservient, cannot
be explained either by the ordinary laws of che-
mistry, or by any modifications of the impulse
communicated to them from the solids ; and, there-
fore, that there must be certain Vital Affinities,
and Vital Attractions and Repulsions, in which
the fluids as well as solids must participate, and
on which all vital phenomena are essentially de-
pendent.

When Mr. Knight stated, as the result of a la-
borious inquiry in vegetable physiology, that the
vital power of generating new wood does not re-
side either in the outer layer of the alburnum or
in the inner layer of the bark, but " in a fluid
which pervades the vessels of both" he stated
a principle which is equally applicable to the
whole economy of animals; and under which
must necessarily be included the most important
of those Laws of Vital Action, which it still re-
mains for physiologists to develop. And as we
must take the fluids, and the changes proper to
the fluids, into account in all attempts at explana-
tion of physiological phenomena, so we must be
prepared to admit a Humoral Pathology as essen-
tial to the explanation of all the more important
phenomena of disease ; but this must be a patho-
logy founded on observed changes, not simply of
the mechanical or chemical condition, but of the
strictly vital properties of the fluids, and especially
of the blood.

CHAPTER II.- —Recent additions to our know-
ledge of the external causes of diseases — Of
those which operate generally, and of those
which are of local and temporary operation
only — Additions to our knowledge of the na-
ture and treatment of acute diseases — Of in-
flammatory diseases — Of their consequences,
and varieties — Of idiopathic fever — Its essen-
tial distinctions from inflammation — Its vari-
eties and complications — Of other epidemic
diseases — Their different modes of fatal ter-
mination, and the adaptation of remedies to
them.

Next to the additions which have been made
since the end of the last century to our knowledge
of physiology, we may place the numerous im-
portant observations by which our information as
to the external causes of disease has been rendered
more extensive and more precise. These obser-
vations, and the inferences from them, demand the
more attention from physicians, that they necessa-
rily involve a kind of evidence essentially differ-
ent from that on which we proceed in other medi-
cal inquiries. And if we durst hope that the pro-
gress of human wisdom and virtue would bear
any proportion to that of human knowledge, we
might expect that the lessons to be drawn from
these inquiries would prove of even greater im-

portance to the future happiness of mankind than
any which we can gather from the history or
treatment of diseases.

These inquiries have in some instances been
prosecuted by individuals in civil life ; but the op-
portunities of making decisive observations on
some of the causes of disease which occur in the
experience of medical officers of fleets and armies,
— who are perfectly informed of the whole circum-
stances of the organized bodies of men under their
observation, and often see these circumstances
suddenly altered, or have even the power of alter-
ing them at pleasure, — are much superior to those
which other practitioners enjoy; and the peculiar
value of such observations has never been so well
understood as during the last war.

In stating the general result of recent observa-
tions on the causes of diseases, it is well to keep
in view, first, the old and well-known distinction
of predisponent and exciting causes, and, secondly,
the division of the latter class of causes into those
which result from the very conditions of our exist-
ence, and therefore operate generally among our
species, and those which are of local and tempo-
rary existence only, and are commonly known by
the name of morbid poisons.

In regard to the predisposition to disease, many
important facts were well known to the patholo-
gists of the last age ; but as to one, and that pro-
bably the most important of all the circumstances
of predisposition, our information has lately been
much extended. This is the great predisposition,
given to acute diseases especially, by the previous
influence of causes of Debility, which may usually
be referred either to deficiency of the natural ex-
citements of the human system, therefore to im-
perfect nourishment, or defective nourishment from
previous diseases, impure air, deficient exercise,
long-continued heat, long-continued cold, or per-
manent mental depression ; or else to excessive
and exhausting excitement, therefore to fatigue,
watching, or intemperance of all kinds.

The great amount of disease and mortality,
which may be traced to the operation of these de-
bilitating causes, applied long previously to the
commencement of any diseased action, has been
illustrated by statistical inquiries into the health
and probability of life of different classes of the
community, and of the inhabitants of towns as
compared with those of country districts; and
among the authors of such inquiries, Drs. Perceval
(of Manchester), Bisset Hawkins, [Sir James]
Clark, and M. Villerme, [Quetelet, and Chadwick,
and W. Farr,] deserve particular notice. The
influence of some of the individual causes now
mentioned has been more specifically demonstrated
by the experience of military and naval medical
officers ; among whom we may particularly men-
tion Sir Gilbert Blane, Sir James Macgrigor, Dr.
Trotter, Dr. Johnson, Dr. Robertson, and Dr. Lt/s-
combe.

Of those exciting causes of disease which are
of pretty uniform operation, the application of
cold is that which it is most important to under-
stand ; and on this subject our knowledge has
been rendered much more satisfactory and precise
by the observations of Dr. Currie, and by the
practitioners who followed his directions as to tho
use of cold in febrile diseases. From those obsei-

252

MEDICINE, (HISTORY OF)

vations it may be stated, as a general result, that
the morbific effects of cold depend, not simply on
the temperature applied, nor on the suddenness of
the application, nor on the previous heat of the
body; but on the intensity and duration of. the
sensation which is produced by its application, and
especially on the circumstance which primarily
determines the duration of that sensation, viz. the
facility with which, from the previous state of the
system, the circulation on the surface of the body
is checked and depressed.

In regard to the Morbid Poisons, which excite
diseases often of the most virulent and appalling
character, but confined to certain seasons or local-
ities, there has been much and often violent dis-
cussion within the last forty years ; during which
time the contagious nature of the fever of this
climate, of yellow fever, of plague, of purulent
ophthalmia, of erysipelas, dysentery, and malig-
nant cholera has been successively and freely
agitated ; the laws of the origin and diffusion of
the malaria producing intermittent and remittent
fevers have been investigated ; and the extraordi-
nary protection against small-pox afforded by vac-
cination has been first established as a general law
by the observations of Jenner, confirmed by others
in all parts of the world, and afterwards ascertained
to be subject to limitations, the exact amount of
which is still doubtful.

Perhaps the most important results of the labours
bestowed on these important subjects are the fol-
lowing : —

1. The contagious nature of the common con-
tinued fever of this country has been firmly estab-
lished ; at the same time the truth of the repre-
sentations of the older authors, as to the variations
to which this disease is liable at different times
and places, in duration, in symptoms, in the effects
of different remedies upon it, and the extent to
which these can be borne, and in the degree of its
contagious property, has been fully and repeatedly
demonstrated.

2. The influence of the most important auxil-
iary causes which favour the extension of this dis-
ease, — the cold weather of this climate, imperfect
nourishment, and mental depression, — has been
fully exemplified and repeatedly observed, particu-
larly in the disastrous history of various military
enterprises, and in the equally melancholic civil
history of one unfortunate portion of the British
dominions:* whether these circumstances of pre-
disposition ever suffice for the generation of the
disease, without the aid of a specific contagion, is
perhaps still doubtful.

3. It has been well ascertained, particularly by
the researches of Dr. Bancroft, that neither the
accumulation of human effluvia from healthy per-
sons, nor the effluvia from putrid animal and vege-
table matters, (however injurious to the strength,
and in various ways to the health, of the human
body,) are a sufficient cause for the production of
contagious fever.

4. Several of the conditions which appear chief-

* It is gratifying to be able to state that the members
«>f the medical profession in Ireland cannot be charged
cither with want of zeal to alleviate the distresses of
their countrymen, or with want of judgment and intel-
ligence, in attempting to draw from these distresses,
themselves, lessons of the highest importance to pos-
terity.

ly to favour the development and propagation of the
malaria, which is the other great cause of fever,
have been sufficiently investigated, perhaps more
successfully by Dr. Ferguson, (Edinb. Philoso-
phical Transactions, vol. ix.) than any other au-
thor. It appears certain that the stagnation, and
subsequent evaporation of water on the earth's
surface are essential to the development of this
poison, and that the higher the temperature at
which this evaporation takes place, the more vio-
lent is the poison generated. It is very doubtful
whether any putrescent matter is necessarily con-
nected with its formation ; but it must be admitted
that there is some condition necessary to that pro-
cess, which is still unknown, and that we must
still be guided in a great measure by experience,
in judging of the situations where it is chiefly to
be apprehended. [From all the writer's observa-
tions, it would not seem to be cither of animal or
vegetable origin, but to be geological, or connected
with locality.]

5. It has been clearly ascertained that the con-
tagious fever of this climate, which usually abates
during the summer, is seldom or never met with
in the tropical climates ; and this fact seems to be
illustrated by the important observations of Dr.
Henry, by which it appears that the contagious
effluvia of the exanthemata, as well as of typhus,
loses all its efficacy at the temperature of 140° or
even 120°. On the other hand, it is certain, that
the fever from malaria is greatly aggravated in
these climates, and takes, occasionally, quite the
form of the most malignant Yellow Fever. [Yet
there would seem to be a marked difference be-
tween yellow fever and those fevers that are com-
monly regarded as malarious — intermittent and
remittent, for example.] It has been ascertained,
also, that the worst epidemics of that kind, which
have so frequently appeared in certain localities in
the hot climates, are generally to be ascribed to
certain local causes, and are confined within cer-
tain limits or boundaries ; so that among those
who keep beyond these limits the disease hardly
ever spreads, whatever the intercourse of persons
already affected with others may be ; as has been
repeatedly exemplified at Gibraltar, New York,
&c. ; but it is still doubtful whether, within these
limits, and at these times, the worst form of the
yellow fever does not spread by contagion.

6. It has been equally demonstrated that the
Plague spreads by contagion chiefly, if not ex-
clusively, although with very various rapidity on
different occasions ; and that precautions to pre-
vent the intercourse of the sick with the healthy
are more certainly efficacious in checking the ra-
vages of that than any other epidemic disease; as
has been repeatedly found in the experience of
the British colonies in the Mediterranean, as well
as of the army in Egypt. [Still, many observers
deny its contagious nature].

7. It has been shown, to the satisfaction of the
greater number of medical men who have seen
the diseases prevailing epidemically, particularly
in civil life, that the purulent ophthalmia is a con-
tagious disorder ; and that erysipelas and dysen-
tery do also occasionally spread by contagion ; but
it has also distinctly appeared that completely iso-
lated cases of the two last diseases, occur so much
more frequently in some seasons and countries

MEDICINE, (HISTORY OF)

253

than in others, that there must be some cause, not
yet understood, corresponding to the idea usually
aifixcd to the term " epidemic or atmospheric in-
fluence," which aids In determining many attacks
of these diseases.

8. The numberless observations which have
been made, in so many different quarters of the
globe, on the diffusion of the malignant cholera,
have still left such an obscurity on that point as
clearly to indicate that the mode of extension of
that " nova pestis" must be very peculiar. The
present writer has no difficulty in expressing his
own conviction that the disease has a contagious
property ; which conviction is founded simply on
the repeated observation of persons who had in-
tercourse with those ill of the disease, becoming
themselves affected in a proportion infinitely greater
than those, similarly circumstanced in other re-
spects, who avoided such intercourse. But, on
the other hand, it is equally certain that in various
instances, where it has prevailed epidemically, this
superior liability of those holding intercourse with
the sick has not been observed ; it has affected so
many, in whom no such intercourse could be as-
certained, or appeared possible, and has left unaf-
fected so many others, whose intercourse with the
sick had been frequent and close, — that we can
hardly suppose contagion the only mode in which
it can diffuse itself.

It may be added, that whatever be the true
origin of the poison which generates the cholera,
it certainly possesses in an extraordinary degree
the properties, which all other morbid poisons
possess in some degree, of lying latent for a length
of time, — in certain localities, or in the constitu-
tions of individuals, or in both, — and afterwards
resuming its activity and rapidly extending itself,
without any assignable cause.

The additions which have been made to our
knowledge of the nature and proper treatment of
diseases during the time under review, may be
traced, for the most part, to the extent and minute-
ness with which the study of morbid anatomy
has been cultivated. The example of Baillic, in
London ; the lectures of the late Dr. Gregory, in
Edinburgh, (who, although not deeply learned in
morbid anatomy, was keenly interested in the
subject, and took every opportunity of inculcating
its importance;) the laborious researches of Aber-
crombie and others, have had much influence in
extending this study among British practitioners;
but we must admit that it is to the zeal of the
profession in France, and to the opportunities af-
forded by the French hospitals, that we are chiefly
indebted for the increased extent and precision of
our knowledge of the changes of structure effected
in the human body by disease.

This study has, indeed, engaged so much atten-
tion of late years, that the term pathology has
very often been used as synonymous with morbid
anatomy ; as if there were no other sources, from
which we could draw our knowledge of the
changes in the living body, constituting disease,
than the changes in the dead body which disease
leaves behind it. This, however, is a manifest
error in science. These alterations in structure
produced by disease are only one of the elements
of our reasoning on the nature of diseased actions
themselves ; and there are many other facts, as to

the external causes of diseases, the nature of their
leading symptoms, their consequences, local and
general, in the living body, and the juvantia and
Ixdentia affecting them, which likewise furnish
the proper elements of inductive reasoning, for
the determination of those law r s of the animal
economy, which it is the object of the science of
pathology to establish.

It is also an important practical error to fix the
attention, particularly of students of the profes-
sion, too much on those characters of disease
which are drawn from changes of structure al-
ready effected, and to trust too exclusively to
these as the diagnostics of different diseases ; be-
cause in many instances these characters are not
clearly perceptible until the latest and least reme-
diable stages of diseases ; the very object of the
most important practice in many cases is to pre-
vent the occurrence of the changes on which
they depend ; and after they are established, the
cases are very often hopeless, or admit only of
palliative treatment. In those diseases in which
most can be done by art, our practice must al-
ways be guided in part by conjecture, because, if
we wait for certainty, we very often wait until the
time for successful practice is past ; and therefore,
although an accurate knowledge of the whole
history of each disease is essential to its proper
treatment, yet in a practical view the most impor-
tant part of its history is the assemblage of symp-
toms, by which its nature at least, if not its pre-
cise seat, may often be known, before any decided
lesion of structure has occurred. Accordingly,
when this department of pathology is too exclu-
sively cultivated, the attention of students is often
found to be fixed on the lesions to be expected
after death, much more than on the power and
application of remedies, either to control the dis-
eased actions, or relieve the symptoms, during
life.

But although in this, as in other instances,
there has been an admixture of error, if not in
our scientific acquisitions themselves, at least in
our estimate of their value, and our judgment of
the uses to which they may be applied, yet it is
evident that the department of morbid anatomy is
that in which the grand improvement of medical
science has lately been effected ; and that it is
from judicious reasoning on the more intimate
knowledge thus acquired of the nature of diseases,
that any material improvement in the precision
of our practical rules has resulted.

These observations apply particularly to the
case of inflammatory diseases, those in which
remedies avail the most, and with the history of
which, therefore, it is most important to be fa-
miliar.

The characteristic effects of inflammation, ad-
hesion, suppuration, ulceration, and gangrene,
have been investigated with great acuteness and
success by Mr. Hunter and his followers, among
whom Dr. Thomson, of Edinburgh, [Professor
Alison himself, Dr. Macartney, of Dublin, and Dr.
0. J. B. Williams,] may be particularly noticed ;
and the provisions of nature for the favourable
terminations of all these processes are now well
understood. The nature of the process of inflam-
mation itself has been carefully scrutinized, in so
far as microscopical observations avail in the re-

254

MEDICINE, (HISTORY OF)

search, by Drs. Wilson Philip, Thomson, Hastings,
and Black ; and more lately by Andral, Gendrin,
Kaltenbrunner, [Magendie, Gulliver, W. Addison.]
and others. It may be confidently asserted that
these observations have proved the inadequacy of
any explanation of the process, which turns
merely on the changes in the contractile power
of the vessels concerned. It was, indeed, clearly
perceived by Mr. Hunter, that changes in the
vital properties of the blood itself must necessarily
be taken into account, in attempting any explana-
tion of inflammation and its consequences : and
the inquiries of the three last-mentioned conti-
nental authors, of Schroeder van der Kolk, Pring,
Rogerson, and others, have opened a prospect of
some more definite information being acquired as
to the nature of the essential changes which these
vital properties undergo during these processes.
[See a Report on the Present State of Knowledge
of the Nature of Inflammation, by Mr. T. Whar-
ton Jones, in Brit, and For. Med. Rev. for April,
1844, p. 567.]

But the most important recent additions to our
knowledge of inflammatory diseases have been
the accurate observations made on the varieties of
inflammation, and consequently increased preci-
sion of our views as to the different modes of
fulal termination to be apprehended in different
inflammatory diseases ; and these may be consi-
dered under several distinct heads,

1. Much has been done in regard to the differ-
ent course and effects of inflammation, as it affects
different textures of the body ; and the fact has
been established, that even in its acute, and still
more in its chronic form, inflammation frequently
spreads extensively, lasts long, and produces de-
cided lesions in one texture, without in the slight-
est degree affecting others in its immediate neigh-
oourhood. Repeated observations on the bodies
of those who have died of pleurisy, of bronchitis,
of peritonitis, and of dysentery, as well as of
more external inflammations, leave no room for
doubt on this point. Formerly the diagnosis of
different inflammatory diseases seldom extended
farther than the organs chiefly affected, and the
functions of which were deranged ; but we now
consider the texture primarily affected to be one
of the most important objects of inquiry, and to
be frequently within the reach of careful scrutiny.
The variety in the course and effects of inflam-
mation to be expected in different textures, — in
the cellular, serous, fibrous, and mucous mem-
branes, in the different parenchymatous viscera,
the muscles, bones, &c. was first pointed out as a
particular object of attention by Bichat in France
and Dr. Carmichael Smyth in England ; its im-
portance was strongly inculcated by Dr. Gregory
in his lectures ; and our knowledge of these va-
rieties in the different parts of the body, and of
the symptoms by which the attacks of inflamma-
tion in the different textures may, in general, be
first distinguished, has been greatly extended and
improved by many other authors, — by Thomson,
Abercrombie, Pemberton, Brodie, Travers, Has-
tings, and others in this country ; and by Pinel,
Corvisart, Bayle, Laennec, Rostan, Lallcmand,
Andral, Louis, &c. in France. The distinction
of the different species of inflammation attacking
the eve, and the accurate anticipation of the dan-

ger of each by all the recent writers on the eye,
furnish a beautiful example of the increased pre-
cision which the attention to variety of textures
has given to pathology.

Farther, not only the effects to be expected from
inflammation in the various textures have been
ascertained by dissections, but characteristic
symptoms resulting during life from these conse-
quences of inflammation in several parts of the
body, not open to ocular inspection, have been
clearly pointed out by recent authors.

This is remarkably the case in regard to inflam-
mations within the chest. The lesions resulting
from these, as well as other organic changes in thai
part of the body, may certainly be very frequently
ascertained by manual examination, and by auscul-
tation and percussion, according to the methods
of Laennec, with a precision formerly unknown.
The usual effects of the inflammation of the
pleura, and of the bronchia?, may almost always
be recognised and distinguished by percussion and
auscultation ; and there are many instances of
these diseases occurring'without any complication,
which might formerly have been confounded under
the general term pneumonia, and which it is not
only satisfactory, but practically important, even
in their later stages, to distinguish, because they
admit of relief from different modes of treatment.
There is, in general, more difficulty in forming a
judgment as to the existence or extent of inflam-
mation in the substance of the lungs; for this
inflammation is very frequently combined with
others within the chest ; and although the " rale
crepitant" and the " peripneumonic »puta" are
occasionally well marked and characteristic symp-
toms, yet they are by no means to be depended on
as constant symptoms. The effects of inflamma-
tion, either of the external or internal surface of
the heart, frequently show themselves unequivo-
cally, on auscultation and percussion, and by the
increased action and obvious enlargement of the
heart resulting from them ; but there are cases,
particularly of the former, where much injury
may be done, without such indications clearly
presenting themselves, even to the most experi-
enced observer.

One important result of the recent observations
on the effects of inflammation within the chest is,
the ascertained rarity of circumscribed collections
of pus in the substance of the lungs, and the fre-
quency of such collections exterior to the pleura ;
the established easy diagnosis of the two kinds of
Empyema, the one with and the other without
pneumothorax, from fistulous communication with
the bronchia? ; and the distinction of the former
class of cases of empyema, according as the com-
munication has been opened from without in-
wards, in consequence of ulceration of the diseased
pleura, or from within outwards, in consequence
of tubercular disease and ulceration of the lungs;
the former of these two cases admitting sometimes
of gradual cure, the latter being only an accident
in the course of incurable phthisis.

Another important addition to our knowledge
of thoracic disease is the discovery of the fre-
quency, and explanation of the nature, of the
change called Emphysema of the Lungs, as a
consequence of long-continued Bronchitis, par-
ticularly when combined with spasmodic Asthma.

MEDICINE, (HISTORY OF)

255

All these improvements, as well as the original
discovery of the application of the sounds heard
in the chest to the diagnosis of its diseases, are to
be ascribed chiefly to the industry and acuteness
of Laenncc.

The occurrence of inflammation of the Larynx
and glottis in adults, tending to a fatal termination,
by mere thickening of the membrane, by effusion
of pus behind it, or by the cedema glottidis,
without the formation of the false membrane of
croup, is an important fact ascertained by the ob-
servations of Baillie, Farre, Lawrence, and many
others ; and the diagnosis of the cases of the
kind in which the bronchi are unaffected, and an
operation promises relief, is another advantage
which the new methods of examining the chest
afford.

The existence of inflammation of the Mucous
Membrane of the great Intestines in all cases of
dysentery, and of inflammation of the same mem-
brane of the small intestines in a certain class of
cases of diarrhoea, the diagnosis of inflammations
of this membrane from those of the peritoneum,
its remarkable tendency to ulceration, its frequent
(though by no means uniform) combination with
inflammation of the liver, particularly in the hot
climates, and with continued fever in this climate,
and the indications of its degree, and of its stage,
to be drawn from examination of the stools, are
important additions to our knowledge of abdomi-
nal inflammations, which we owe to the labours
of Somers, Ballingall, Johnson, Robertson, and
many other military and naval practitioners, — of
Abercrombie, Cheyne, Harty, and others in this
country, and of Petit and Serres, Broussais, An-
dral, Chomel, Billard, &c, in France. The in-
stantaneous change of symptoms, violent pain,
and rapid sinking, which succeed the perforation
of intestine by an ulcer beginning in the mucous
membrane, and effusion of feculent matter on the
peritoneum ; the correspondence of this accident
to the perforation of the pleura in phthisis, and
the evidence, thence resulting, of variety of en-
dowment of the serous and mucous membranes,
are striking-illustrations of the increased precision
of our pathological information.

The varieties of inflammation within the Head,
and of its results, have likewise attracted particu-
lar attention, chiefly since the publication of the
writings of Lallemand and Rostan on the soften-
ing of the brain, certainly one of the effects fre-
quently produced by inflammation there. The
inflammation of the membranes may often be dis-
tinguished, by the acuteness of the symptoms, in
its earlier stages, from that of the substance of the
brain. Much more minute diagnostic marks have
been proposed by the authors just named, by
Bouillaud and others ; but subsequent observa-
tions have shown that on these no great reliance
can be placed ; and in fact, as the only symptoms
which can yet be relied on, as indications either
of inflammatory effusion or disorganization within
the cranium, are affections of sensation or volun-
tary power, and as these result only from changes
at the base of the brain, therefore generally in
parts at some distance from the actual seat of dis-
ease, and the affection of which may be said to be
accidental, it is evident that there may be great
variety in the symptoms, independent of varieties

in the diseased states themselves ; and accordingly,
we cannot with any certainty anticipate either the
nature or the exact seat of the effects of inflam-
mation within the head, from any symptoms or
combinations of symptoms ; — all that we can pre-
tend to distinguish (and that not with absolute
certainty) is the period of the disease when the
symptoms no longer depend on the inflammatory
action itself, but chiefly on effusions or disorgan-
izations consequent upon it, and continuing alter
it has subsided.

2. The distinctions of inflammatory diseases
according either to the organs or textures affected,
and the usual effects produced in these, are not
the only distinctions of practical importance in
that class of diseases which have been elucidated
by modern pathologists. A very important class
of their observations relates to cases which,
although running the usual course, and often with
even more than the usual rapidity, are concealed
or rendered latent by peculiarity of constitution,
and can only be recognised with certainty by such
unequivocal local indications of effusion or disor-
ganization, consequent on inflammation, as those
to which allusion has just been made. The cir-
cumstances in which these latent inflammations
are most to be apprehended (which are in general
those in which the system is much weakened, the
quantity of blood lessened, and the sensibility
blunted, as in the last stage of fever or of some of
the febrile exanthemata,) are very important to be
known, because, in some such cases, if the prac-
titioner is on his guard, he may detect their exist-
ence while it is yet time to apply remedies.

Again, many important observations made by
modern pathologists have given precision and
authority to the statements of older writers, as to
inflammations occurring and producing exactly
their characteristic effects in various parts of the
body, but running their course so slowly, as to
take the form of chronic instead of acute disease ;
as in the case of cold or chronic abscess on the
surface of the body ; chronic pleurisy leading to
extensive empyema, without either acute pain or
inflammatory fever ; partial inflammatory indura-
tion of the brain, or hepatization of the lungs
confined to individual lobules, &c. The know-
ledge of this form of inflammation is obviously
important, as suggesting and justifying a corre-
sponding modification in the use of the usual
antiphlogistic remedies.

The term Sub-Acute Inflammation has also
been properly applied by Dr. Armstrong and others
to a form of truly inflammatory diseases of various
textures, where not only the symptoms, general
and local, are milder, but the local consequences
which show themselves much less extensive than
in the more decided and acute cases, and the
amount of depletion necessary to avert danger is
much less, while at the same time there is no such
extension of the period of the disease as to justify
the use of the term chronic.

3. What makes it peculiarly important to
attend to these varieties in the intensity and dura-
tion of strictly inflammatory disease, even in the
same parts of the body in different individuals, or
at difierent times in the same, is the obvious ap-
plication of this principle to other cases, where
the symptoms are in the first instance those ot

256

MEDICINE, (HISTORY OF)

inflammation, but the ultimate result is the esta-
blishment of other forms of disease, which have
been often regarded as quite distinct from, or even
incompatible with inflammation. Of this the
most striking example is in the case of Dropsy, or
serous effusion in various parts of the body, the
connection of which with inflammation has lately
been the subject of much inquiry.

The lectures of the late Dr. Gregory, and the
writings of Rush, of Cheyne, of Abercrombie,
[of D. Davis,] and others, have satisfied the great
majority of practitioners in this country, that the
acute Hydrocephalus of Cullen is to be regarded
in general as an inflammatory disease, although
in many fatal cases no other effect of the inflam-
matory action can be found than the serous effu-
sion into the ventricles ; and the cases recorded
by Blackall, by Abercrombie, by Crampton, and
many others, have also shown that there are many
cases of general dropsy, beginning, or repeatedly
renewed, by inflammatory attacks, and admitting
of great relief from a certain extent of bloodlet-
ting, generally premised to, or combined with, the
purgative or diuretic medicines. This practice,
which had been repeatedly adopted by various
practitioners, and again fallen into disuse, has
been put on the proper footing by numerous
dissections, which have shown the very frequent
complication of dropsical effusion with repeated
inflammatory attacks, (often of the sub-acute or
chronic character, but known by their usual pro-
ducts,) in the heart, lungs, liver, or kidneys;
while, at the same time, these observations suffi-
ciently demonstrate that any great extent of
dropsical effusion is hardly ever the effect of in-
flammation alone ; that some more permanent
lesion of these parts is usually likewise present ;
and that even when partly or chiefly dependent
on inflammation in its origin, the effusion is very
generally persistent long after this cause has dis-
appeared.

Nor is dropsical effusion the only form of
disease, usually regarded as chronic, to which we
may confidently assert, (trusting to the informa-
tion acquired by recent pathologists,) that inflam-
mation may give rise, or into which it may gradu-
ate. Attentive observation shows that many of
those organic changes of structure which are
commonly called Obstructions in the more impor-
tant viscera, whether combined with dropsical ef-
fusion or not, appear frequently to originate from
the causes of inflammation, to be attended with
some of the first symptoms of inflammation, and
to combine themselves with, or graduate by insen.
sible degrees into, the acknowledged effects of in-
flammation. It is true that in many other cases
their invasion is quite gradual and insidious, and
there is no evidence of more than mere " perver-
sion of nutrition" in their development ; and that
such organic alterations of texture likewise differ
essentially from the simple effects of inflammation,
in being hardly at all liable to absorption, to
which the simply inflammatory effusions are pe-
culiarly prone ; it is clear, therefore, that in every
case there must be some condition, independent
of inflammation, necessary to their production ;
\ et the inference from the former class of facts is
^till a fair one, that an inflammatory action, ge-
nerally of the sub-acute or chronic kind, is, in

many cases, one of the conditions on which their
orowth depends. These points have been keenly
discussed of late years by the French pathologists,
particularly Broussais, Laennec, and Andral ; the
first of these authors certainly attributes too much
to the " phlegmasies chroniques" as the cause of
all chronic diseases ; the second probably too lit-
tle ; and the conclusion now stated seems to agree
very nearly with the opinion of the last, who is
generally thought in this country the best informed
and most judicious of the present French patholo-
gists.

[Of late, however, by many pathologists, as by
Papavoine, Fabre and Constant, Gerhard and Rufz,
Piet, Barthez and Rilliet, and others, the acute
hydrocephalus of authors has been regarded as
tubercular meningitis, the tubercular matter be-
ing deposited in the meshes of the pia mater;
and many of the cases classed under hydrocepha-
lus are, unquestionably, of this character.]

Of those cases of visceral organic disease, often
connected with dropsy, and often originating in
inflammatory action, there is one, the frequency
of which was not suspected, and the indications
of which were not understood, until very lately,—
viz. the granulated or tuberculated state of the
secreting portion of the Kidneys, first ascertained
by Dr. Bright to be the almost inseparable con-
comitant of the albuminous state of the urine,
which had been previously noticed by Dr. Wells,
Dr. Blackall, and others, in many cases of dropsy,
but which exists also, not unfrequently, without
any dropsical symptom.

This discovery is the more important, as the
effect of the diseased condition of the kidneys is
to alter the nature and diminish the quantity of
one of the great excretions from the body; from
which results, as the experiments of Dr. Christi-
son and Dr. Bostock, [Rayer, Martin Solon and
others,] have shown, a palpably diseased condition
of the blood, and an undoubted example, there-
fore, of the kind of morbid changes to be appre-
hended from such a cause. All that has yet been
ascertained on this point is this, that when the
urine is albuminous, and its specific gravity low,
and the serosity of the blood therefore unnaturally
loaded with urea, or extractive matter resembling
urea, the health is always precarious, inflammatory
diseases of different parts are apt to occur, and
organic disease, particularly of the lungs or brain,
frequently supervenes ; and that in the last stage
of such disease, when the secretion is almost
suppressed, slight febrile symptoms rapidly ad-
vancing to coma, as in the true ischuria renalis,
have been repeatedly observed.

Again, the tendency of inflammation, when it
occurs in particular constitutions, to pass into, or
give origin to, organic disease, is thought by many
pathologists to be remarkably exemplified in the
case of scrofulous Tubercles, and to be one of the
principles, regarding the origin of that very fre-
quent and fatal form of organic disease, which it
is most incumbent on the practitioner, with a view
to the prevention of such diseases, to have con-
stantly before his eyes. On this point likewise
there has been lately a difference of opinion both
among French and English pathologists ; and it
is evident that tubercles frequently ori-inatc with-
out either the causes or the indications of inflam

MEDICINE, (HISTORY OF)

257

mation showing themselves ; and that the dis-
tinctions between tubercles and the usual effects
of inflammation (particularly as to the subsequent
liability to absorption) are such as to show, that
they can in no case be ascribed to inflammation
as their sole cause. But when all these admis-
lions are made, it may still be held as a principle
of the highest practical importance, that in cer-
tain constitutions or in certain circumstances, an
inflammatory attack, if not very speedily remedied,
is very likely to act as the immediate cause of a
deposition of tubercles, and consequent chronic
and nearly hopeless disease.

The nature of the peculiarity of constitution,
which disposes to this rather than other conse-
quences of inflamrar.tion, is in all probability to
be sought in the composition and vital properties
of the blood ; and some of the microscopical ob-
servations of Gendrin, (particularly that of the
presence of translucent globules in the fibrinous
effusions of healthy inflammation, and their ab-
sence in incipient tubercles,) seem to afford a
fairer prospect of successful investigation of this
point than any former observations had given.
In the mean time the external causes, which par-
ticularly favour the development of that constitu-
tional peculiarity, and especially the relative effi-
cacy of climate and of impure air, imperfect
nourishment, and deficient exercise, during child-
hood and youth, in producing it, have been illus-
trated by statistical inquiries, of the kind formerly
mentioned, which are necessarily much more valu-
able, in this view, than the records of the experi-
ence of any individual.

Besides the connection of inflammatory action
with various forms of organic disease, of which
we have thus spoken, much stress has been laid
by some recent authors on increased determinations
of blood, approaching and sometimes amounting
to inflammation, as a main cause of many chronic
diseases which arc merely functional, e. g. of neu-
ralgic pains, of different spasms, of dyspepsia and
other effects of deranged secretions in the prima;
vise. This speculation has pretty certainly been
carried too far by some, particularly by Broussais
and his followers in France, and by the late Dr.
Parry in this country. In many such cases it
seems certain that the increased determination of
blood is the consequence, not the cause, of other
derangements of vital action ; yet that it often
occurs and aggravates the evil, and affords a fair
indication for practice, seems well ascertained ;
and the remarks of Dr. Parry on the beneficial
effects of spontaneous haematemesis in some cases
of urgent dyspepsia, and the accurate observations
of Dr. Wilson Philip on the effects of local bleed-
ings in what he calls the second stage of dyspepsia,
may be quoted in proof of this position.

4. Another important set of observations on
inflammatory diseases consists of those which
have been made on the characters, and progress,
and peculiar dangers of Specific Inflammations
resulting in general from particular causes only,
and differing from the usual form of inflammation
in the nature of their local symptoms and effects,
or in the character of the accompanying fever, or
in both these particulars.

The distinction of Phlegmonous and Erysipe-
latous inflammation in external parts, as well as

Vol III. — 33 w*

of the specific cutaneous inflammations of the
exanthemata, had indeed been long known, and
our knowledge of the great variety of inflamma-
tions affecting the skin has been greatly extended
and corrected, particularly by the labours of Wil-
lan and Bateman. But even Dr. Cullen, who re-
ferred the erysipelas, with great propriety, to his
class of Exanthemata rather than Phlegmasia?,
and considered the fever attending it as by no
means symptomatic of the inflammation, but as
resulting from a cause acting in the interior of the
system, and of which the inflammation was like-
wise an effect, had not a correct view of the pe-
culiarity of the inflammation itself. He supposed
that peculiarity to depend merely on the texture
affected ; the true skin being, according to him,
the seat of this inflammation, while the phlegmon
is seated in the cellular membrane. He did not
advert to the circumstance, that the disposition to
spread along the surface, and the deficiency of
organizable lymph in the inflammatory effusion,
were local symptoms equally peculiar and char-
acteristic of this inflammation, as compared with
other inflammations of the same texture, as the
priority of the febrile symptoms, and their fre-
quently typhoid character; and therefore did not
form the notion which French pathologists annex
to the term specificite, as applicable to this form
of inflammation.

Subsequent inquiries have, however, distinctly
shown, that this principle is of real and great im-
portance, as applicable both to this and other in-
flammations. It appears from the researches of
the late Dr. Duncan, of Mr. Travers, Mr. Law-
rence, Dr. Butter, and others, that when this in-
flammation extends from the skin to the cellular
membrane, as so frequently happens in erysipelas,
it preserves the same local characters in the latter
texture as in the former ; that in some cases this
kind of diffuse inflammation affects the cellular
membrane extensively without extending to the
skin ; that it often prevails epidemically, and is
certainly sometimes propagated by contagion or
inoculation ; that it may arise from different pecu-
liar causes, of which the most frequent seems to
be the introduction into the system of some kind
of animal poison, as in the case of poisoned wounds
from dissection : that in this as in other cases,
when such a poison acts on the body, a peculiar
derangement of the nervous system and depression
of the vascular system are very often observed,
giving to the fever attending such inflammation
the character to which we apply the term
Typhoid ; and that there is frequently a danger
from this form of fever, quite independent of that
which the local inflammation could effect ; and
not to be remedied, sometimes even to be aggra-
vated, by the use of means for subduing that local
inflammation.

Farther, it seems well ascertained that on in-
ternal membranes, and sometimes in connection
with this erysipelatous inflammation on the sur-
face, there are examples of a similar diffuse form
of inflammation, tending to serous and sero-puru-
lent effusions chiefly, not to exudations of organ-
izable lymph, and that the fever attending this in
flammation is more or less perfectly typhoid ; and
the danger resulting from it so little in proportion
to the intensity or duration of the inflammation,

259

MEDICINE, (HISTORY OF)

that in the most rapidly fatal cases the inflamma-
tory appearances found on dissection are generally
the least obvious.

Such examples of internal erysipelatous inflam-
mation may in some instances be pretty certainly
distinguished from the more usual form of inflam-
mation in internal parts ; they have been most
decidedly observed in the peritoneum; and the
epidemic and contagious Puerperal Fever, although
not the only case of the kind, is that to which the
foregoing remarks most particularly apply ; but in
this as in other contagious diseases, there appears
to be great variety, in different epidemics, particu-
larly as to the extent to which the inflammation
goes, and to which the remedies for inflammation
may be safely carried.

These statements appear to be fair deductions
from the facts stated on this subject by Armstrong,
Hey, Mackintosh, Campbell, and others, who have
witnessed extensive epidemics of this kind, parti-
cularly when compared with the cases of this form
of peritonitis, (sometimes evidently in connection
with erysipelas,) recorded by Dr. Abercrombie,
and with several that have fallen under the ob-
servation of the present writer.

There is strong reason for thinking that there is
something equally peculiar or specific in the inflam-
mation of Dysentery, when it prevails epidemically,
and when it extends itself (as the writer is satis-
fied he has occasionally observed) by contagion ;
and it seems quite certain that a peculiar spread-
ing inflammation of the mucous membrane of the
fauces, tending to a peculiar aphthous exudation
on its surface, and attended with a dangerous
typhoid fever, sometimes prevails epidemically, as
in the experience of Dr. Bretonneau of Tours,
who gave it the name of Diphtherite.

In all these cases it may be at least reasonably
conjectured that a peculiar animal poison is either
introduced into or generated in the blood, which
circulates through the system, and by its depress-
ing or sedative influence causes the peculiarities,
both in the local and the general symptoms, and
progress of the disease, which distinguish it from
simple or healthy inflammation of the same parts.
It is an important observation, first put in a clear
view by Mr. Travers, that a similar peculiarity is
given to the general symptoms resulting from ex-
ternal injuries, by the influence of a violent con-
cussion or shock, affecting the system at the time
when such local injuries are received ; but it may
be doubted whether the term Irritation, applied by
him to the constitutional affection, either from
such injury, or from specific inflammation, is the
best that could have been chosen. The rapidly

only from the analogy of the contagious exanthe-
mata and their communication by inoculation, but
also from what is observed as to the effects of in-
flammation affecting the lining membrane of veins,
where much of the inflammatory effusions must
necessarily be mixed with the circulating blood.
In this case, even although the vein has inflamed
from a simple injury, without evidence of any
specific cause having been applied, such typhoid
symptoms, according to the observations of Hunter,
of Travers, James, Arnott, and many others, seem
almost invariably to occur. Indeed, as the veins
of the uterus have been found inflamed in several
cases of puerperal fever, it has been suspected by
Dr. Lee that that disease may be generally de-
pendent on this cause.

Another observation which has been made on
cases of inflammation of the veins, by Mr. Arnott
and others, is likewise of great importance. It
has been found that this inflammation is very fre-
quently followed by rapid inflammation, and still
more rapid purulent depositions in distant parts,
particularly in the cavities of joints, or in the in-
ternal cavities ; and it seems probable that it is in
this way that we are to explain the occurrence of
such rapid inflammation and suppuration in inter-
nal parts, particularly the Liver, which has been
often observed after severe injuries of the head or
other parts of the surface.

This observation ought evidently to be taken in
connection with another, made by many recent
authors, by Guthrie, Rose, and others in England,
and by Dance, Velpeau, &c. in France, of the
frequency of internal inflammation, going on with
extreme rapidity to deposition of purulent or tu-
bercular matter in internal parts, immediately after
the amputation of a limb, where such formations
from the blood had been previously established;
and both observations should be taken in connec-
tion with the facts, which seem established by the
researches of Yelpeau, Kaltenbrunner, Gendrin,
and others, — -first, that the veins leading from ex-
tensive collections of matter, especially in chronic
cases, are often found loaded with pus; and,
secondly, that the conversion of globules of blood,
or of fibrine, into pus, takes place not only in
extravasated effusions, but within the vessels of
parts in a certain stage of inflammation.

The inference from all these facts appears to
be, that purulent matter generated in the human
body itself, if by any means it is caused to circu-
late in the blood without finding a ready outlet,
disposes not only to peculiar febrile symptoms,
but also to inflammation of a peculiar character,
which goes very rapidly to extensive suppuration,

spreading Traumatic Gangrene described by Lar- in whatever part may be most prone to such dis

rey and others seems to be an effect produced in
some cases on the local inflammation consequent
on a violent injury, by the concussion which has
such an influence on the constitutional symptoms;
and indeed more or less of gangrene or sloughing
is always to be apprehended from inflammation
excited in a system where the powers of the cir-
culation are remarkably depressed.

That an animal poison, circulating and multi-
plying itself in the blood, is an adequate cause
both for the local peculiarities and for the peculiar
typhoid symptoms, attending the specific inflam-
mations above noticed, appears pretty certain, not

ease ; and this is evidently an important addition
to our knowledge of Specific Inflammations, and
is applicable, as will presently appear, to several
cases of the most important chronic diseases.

The inflammation of Syphilis is another exam-
ple of specific inflammation resulting apparently
from a morbid poison circulating in the blood, and
falling on particular textures ; and in regard to
the several points of great importance seem to
have been ascertained by the observations of Aber-
ncthy, Pearson, Rose, Guthrie, &c. in London,
of Carmichael in Dublin, of Dr. Thomson in
Edinburgh, [ f Ricord of Paris,] and others, pat-

MEDICINE, (HISTORY OF)

259

ticularly the variety of its forms and progress in
different individuals even at the same time, and
the more gradual change of the character of the
disease and malignity of the virus in the progress
of time ; the fallacy of the old opinion that in any
of its forms (as they now present themselves) the
disease is absolutely void of natural tendency to
a favourable termination ; the variety of treat-
ment which its different forms demand ; the fre-
quent combination of syphilitic inflammation,
either with healthy inflammation on the one hand,
or with scrofulous disease on the other ; the ag-
gravation of the disease, in either case, which
may result from the use of mercury ; and the pro-
per restriction of the virtues of this medicine, in
regard to syphilis, to the character of an altera-
tive rather than an antidote.

The inflammation of Gout is another to which
the term Specific is properly applied ; and the im-
portant discovery of Dr. Wollaston, of the exis-
tence of uric acid in the concretions which result
from long-continued gouty inflammation, at once
tends to explain the known connection of gout
with the calculous diathesis, and connects this
with the other specific inflammations dependent
on a morbid matter in the blood.

The inflammation of Rheumatism may also be
held to be strictly specific, although the existence
of any peculiar ingredient in the blood cannot be
ascertained. That there is something peculiar in
the vital constitution of the blood in this disease
appears, however, to be rendered highly probable
by the nature of the peculiarities that most re-
markably distinguish it ; by the tendency to affect
different parts and textures in rapid succession ;
by the total absence of suppuration as an effect
of this inflammation ; by the apparently increased
proportion of the fibrine, and complete separation
of it from the red matter in the blood drawn, and
by the remarkable proportion of fibrine in the ex-
udation produced by this inflammation when it
affects the heart. The frequency and danger of
the affection of the heart and pericardium in this
disease have been completely established by the
observations of Pitcairn, Dundas, Wells, Davis,
Abercrombie, and others, and is one of the impor-
tant additions lately made to Pathology. The
circumstances in which it is most to be appre-
hended are by no means so clearly made out ; but
the writer has no difficulty in stating his convic-
tion, that large and repeated bleedings in the be-
ginning of rheumatism increase the risk of this
metastasis ; and in assenting to the observation
of Dr. Elliotson, that after it has occurred it is
more properly met by local than general bleedings.
The labours of Willan and Bateman have been
more successful than those of any others in dis-
tinguishing the many different forms of inflamma-
tion (particularly chronic) to which the skin is
liable, but the classification of these diseases,
Which they have attempted, is more formal and
precise than the nature of these ever-varying forms
of disease will justify.

5. The great improvements which have been
thus effected in our knowledge of the history and
varieties of inflammatory diseases are of practical
importance in the treatment of such diseases, not
Dy suggesting new remedies, but chiefly by giving
us more precise information than we could other-

wise have had, of the particular danger which is
threatened in each case of such diseases, and of
the particular symptoms indicating such danger;
and thus guiding us as to the proper time and the
proper extent of the application of those, which
we already possess and understand. Many at-
tempts have been made, during the period under
review, to add to the number of the general anti-
phlogistic remedies, or of those adapted to particu-
lar inflammatory diseases; and it is generally
thought that some important auxiliaries to blood-
letting and the other evacuations have been dis-
covered ; but it must be owned that there has been
no such decided success in this inquiry as in those
of which we have already spoken : and although
it is right to avail ourselves of these auxiliaries in
all cases where evident contra-indications to them
do not exist, yet, as a general rule, in the early
stage of inflammatory diseases the less that is
trusted to them, and the more to the ordinary
means of depletion, the better.

This observation may be particularly applied to
the use of Mercury in inflammatory diseases,
which has been so highly recommended as a
remedy for inflammations by Hamilton of Lynn
Regis, Armstrong, Travers, and various other
practical authors within the last half century, that
its virtues might be supposed to have been com-
pletely ascertained ; but those who are aware of
the fallacies attending the observation of the
effects of remedies in acute diseases, particularly
of such as are only employed as auxiliaries to
others of acknowledged efficacy, can easily under-
stand that they may have been much overrated.
It has been often represented that not only the
purgative mercurial medicines, as general evacu-
ants, and as means of acting particularly on the
secretion of the liver, are of peculiar importance,
but the action of mercury on the system at large
is the surest means of controlling those effusions,
and particularly the effusion of coagulable lymph,
on which the danger of several inflammatory dis-
eases essentially depends ; and in some instances
a less defined and more specific virtue in checking
inflammation has been attributed to the constitu-
tional affection from mercury. Thus the remedy
has been successively vaunted in the case of acute
hydrocephalus, of cynanche trachealis, or laryn-
gea, and (generally in the form of calomel and
opium) in that of pneumonia, bronchitis, pleuritis,
pericarditis, peritonitis, hepatitis, and dysentery ;
and reference has been often made to the effects
which may be observed from it in inflammation
of the iris, tending to effusion of lymph there, as
demonstrative evidence of its peculiar efficacy.

But it may be stated with confidence, that in
the opinion of many of the best informed mem-
bers of the profession, there has been much ex-
aggeration in all these statements. That there is
something very peculiar in the effect of mercury
on acute inflammation, particularly of the liver
and of the mucous membrane of the bowels, in
the hot climates, the numerous and concurrent
authorities which might be quoted on the subject
leave no reason to doubt ; but that any such de-
cided effect can be observed from exciting the spe-
cific effects of mercury (marked by its action on
the mouth) during the acute stage of any internal
inflammation in this country, has certainly not

260

MEDICINE, (HISTORY OF)

been established to the satisfaction of most prac-
titioners. That calomel is one of the most con-
venient purgative medicines in such diseases is
certain, and it is equally certain that it is one of
the best corrigoifs that can be used along with
opium, when the soothing effects of the latter
medicine are demanded ; because it both corrects
its constipating effect, and probably aids in deter-
mining its action on the skin, and, when given
with opium, much more generally represses than
excites vomiting. When given so as to act only
in these ways, it may be unquestionably held to
be a useful, though not one of the most powerful
remedies in inflammatory diseases. But when its
action on the mouth has been excited in the course
of acute internal inflammation, (which is the only
fair way of judging of any specific agency of the
mineral on the inflammatory process,) we have
not only been very generally disappointed of
seeing any improvement of the symptoms imme-
diately follow that change, but are constrained to
add that we have more frequently seen an aggra-
vation of them.

In more chronic inflammation, attended with
slighter febrile symptoms, or when strictly a local
disease, and tending obviously to gradual deposi-
tion of coagulable lymph, it is generally allowed
that a certain degree of deobstruent rather than
antiphlogistic efficacy (unfortunately often inade-
quate to the evil to be overcome) is attributable to
the agency of mercury on the constitution. It is
in those cases of syphilis where chronic induration
around the ulcers is the most characteristic ap-
pearance, that the beneficial action of mercury is
in general most distinctly seen ; and not only in
the case of iritis, but in inflammation of the peri-
osteum, of the larynx, of the liver, perhaps of the
peritoneum, when sub-acnte or chronic, a similar
beneficial influence is sometimes distinctly percep-
tible. Two cautions, at least in this climate, are,
however, certainly important -.first, that a dysen-
teric affection of the bowels is often produced by
mercury affecting the system ; and, secondly, that
it very often acts as a cause or aggravation of
scrofulous disease, in those who have that very
common tendency.

Another auxiliary to bloodletting, in inflamma-
tory diseases, particularly in inflammations of the
chest and in rheumatism, which has come into
pretty general use in this country, is the solution
of tartar-emetic, given in frequently repeated and
often large doses, but without exciting vomiting.
The possibility of patients in inflammatory dis-
eases taking very large quantities of this and
many other medicines, particularly if they be not
largely bled, without the usual effects of these
medicines showing themselves, has been abund-
antly demonstrated by the experience of Rasori
and many other Italian physicians, and of Laenncc
and his followers in France; but whether there is
any peculiar advantage in establishing this " tole-
rance" of the medicine, and then trusting to a re-
medy which produces no sensible effects, is a very
different question. Under the impressions that
we have in this country of the efficacy of blood-
letting in acute inflammations, and of the compa-
rative inadequacy of all other means yet proposed,
we do not think ourselves justified in placing our
chief reliance on this treatment, excepting where

the loss of blood is clearly and strongly contra-
indicated. When bloodletting is pretty freely
employed, much smaller quantities of the tartar-
emetic than the continental physicians are in the
habit of prescribing are found with us to excite
and maintain nausea ; and it certainly has not
been shown, to the satisfaction of the practition-
ers in this country, that the medicine, in any way
in which it can be given without sensible effect,
is a more powerful antiphlogistic than when used
so as to maintain nausea for hours together. When
given in this way, (for which purpose one-third
to one-half of a grain every two hours will usually
be found sufficient) it is now generally regarded
as the most powerful auxiliary to bloodletting in
the diseases above-mentioned, and in particular
has In a great measure superseded the use of
Digitalis as a sedative and antiphlogistic ; the
general judgment in regard to the last being, that
in moderate doses it is inefficient in this view,
and in larger doses unmanageable and hazardous.

The colchicum is another medicine introduced
within the last twenty years into practice, with
the character of an antiphlogistic or sedative
rather than an evacuant ; and in the case of a fit
of goat, the effect of a few doses of this medicine
is certainly often more nearly specific than that
of any other medicine which we can mention, in
an inflammatory disease. But experience, as well
as theory, might be quoted in favour of the doc-
trine, which was keenly advocated by the late Dr.
Gregory in his lectures on gout, that the human
body always becomes peculiarly liable to other
more dangerous diseases, when the attacks of
gout are arrested in any other way than by the
regimen which corrects the tendency to the dis-
ease. The antiphlogistic virtues ascribed to col-
chicum in other inflammatory diseases are much
less generally admitted ; but it is generally thought
that, by the continued use of this medicine, at-
tacks of acute rheumatism may in many persons
be somewhat alleviated and shortened.

A change, and, in the opinion of the present
writer, a very material improvement, has taken
place within these few years in the judgment of
many practitioners as to the use of opium in ab-
dominal inflammations, whether affecting the
serous or mucous membrane. It has been clearly
shown by Dr. Armstrong and others, that when
full bleeding has been premised, opium may be
given freely and repeatedly, often with extremely
good effect as to the relief of suffering ; certainly
without any injurious effect on the alvinc evacua-
tions, (which seem frequently to be promoted or
procured more easily by enemata after the use of
opiates ;) and it may be pretty confidently as-
serted, with a considerable diminution of the mor-
tality below what is common when bloodletting
and purgatives are the only remedies employed.
It is very doubtful, however, whether the notion
of Dr. Armstrong, that opiates are here of use by
their diaphoretic agency, is the correct one. In
the cases which the present writer has observed,
the beneficial effect of the opium has been best
marked when the pulse has been earlv much de-
pressed, and has not risen after bloodletting, so
that farther loss of blood has seemed hazardous or
impracticable. When opium in these circum-
stances has quickly relieved pain and vomiting,

MEDICINE, (HISTORY OF)

261

and procured sleep, the pulse has frequently im-
proved beyond expectation ; and a patient who
previously seemed quite exhausted has been re-
stored to a state in which farther bloodletting, if
required, has been perfectly well borne. That
opium, as an auxiliary to bloodletting in these
inflammations, can lessen the quantity of blood
required to be drawn is very doubtful ; but unless
the writer is greatly mistaken, it may be confi-
dently asserted that it will enable patients to bear
a loss of blood under which they would otherwise
have sunk, and thus permit the effectual remedy
to be applied repeatedly, and ultimately with suc-
cess, in cases where it would otherwise have be-
come inapplicable. Of this the writer has been
convinced, not only by finding the mortality from
the disease under his own observation less since
he has given opium freely, (which might have
been accidental,) but especially from observing
that in the cases which proved fatal under this
treatment, the extent of inflammatory appearances
found on dissection has always been great and
unequivocal ; very often indeed these have been
complicated with organic disease ; whereas, before
he adopted this kind of practice, he has repeatedly
had the mortification of seeing patients sink early
in the disease, in whom the inflammatory appear-
ances found on dissection have been remarkably
slight,* — certainly less than must have existed in
other cases, where recovery took place. Death in
cases of abdominal inflammation does not depend,
as in most other internal inflammations, on the
lesion of any organ essentially concerned in main-
taining the fundamental function of circulation ;
it results from a sympathetic affection of the cir-
culation consequent on the inflamed state of the
intestines ; it can be demonstrated that this sym-
pathetic affection is much greater in some persons
than in others, suffering under the same amount
of abdominal inflammation ; and it seems reason-
able to suppose, that whatever blunts the intensity
of the sensations, produced by the disease in the
bowels, and procures ease and sleep to the patient,
will lessen the degree of that sympathetic affection
of the circulating system. It should always be
remembered, (whatever judgment be formed of
this or other individual remedies,) that it is not
by interrupting the functions of the bowels them-
selves that acute enteritis is fatal ; that restoring
the functions of the bowels is therefore only a
secondary object, requiring little aid when the
main object can be accomplished, and certainly
not to be urged as long as there is any risk of the
means used to accomplish it aggravating the in-
flammation. In this respect a useful practical
caution may be fairly deduced from the more ac-
curate knowledge we now possess of the causes
of death in inflammatory diseases.

The advantage of local bloodletting by punc-
tures or incisions, in those cases of diffused in-
flammation of external parts, which threaten to be
dangerous by extensive suppuration and slough-
ing, has been established by the observations of

* It is proper to state that the writer has been oftener
disappointed of the effects of opium in acute dysentery
than in peritonitis, and that in some cases of the latter
disease which he baa seen prevailing epidemically, and
.is he believes spreading by contagion, he has also found
it quite inadequate.

O'Halloran, Copland, Hutchinson, Lawrcnce,Dun-
can, and many others.

The additions recently made to our knowledge
of idiopathic fever may be put in a smaller com-
pass than those which regard inflammation, be-
cause the study of morbid anatomy gives us
much less assistance in this inquiry, and notwith-
standing the amount of labour bestowed on it,
much less real and definite improvement has been
effected.

It has been ascertained, chiefly by the labours
of the French pathologists, but likewise by those
of many authors on fever in London, Dublin, and
Edinburgh, that the lesions most generally found
in fatal cases of what is usually called continued
fever, in Europe, are serous effusion in the ventri-
cles and between the membranes of the brain ; an
increased vascularity, with increased secretion of
mucus, on more or less of the bronchial mem-
brane ; an cedematous, and often a condensed and
softened state of part of the lungs ; and thicken-
ing, patches of vascularity, and partial ulceration
or sloughing, of some part of the mucous mem-
brane of the prima via3, especially of the glandu-
lar structure there, and most frequently at the
lower part of the ileum, often attended with en-
largement of the corresponding mesenteric glands.
The blood found in the body, or drawn from it
during life, very generally, if not uniformly, coa-
gulates less firmly than in health, and sometimes,
especially in cases rapidly fatal, is nearly fluid.
All other morbid appearances are comparatively
rare, and several appearances, particularly conges-
tion of blood in the back part of the lungs and in
the mucous membrane lining the depending por-
tions of the intestines, are fallacious ; depending
on the stagnation of the blood in these parts, both
after death and in the extreme stage of debility
before death, and on the imperfect coagulation of
the blood.

It seems to be also ascertained that the whole
of these appearances are seldom found in any one
case; that those found are often remarkably va-
rious in different individual cases, although a
great portion of the symptoms may have been
very similar ; that although all these appearances
are such as occur in decided inflammations, and
form part of their character, yet the effusions of
coagulable lymph and of pus, which are those
most characteristic of inflammation, are very
rarely found after fevers, and that after some cases
of well-marked continued fever these morbid ap-
pearances are altogether absent.

The question that has been most keenly de-
bated of late years, both in France and this coun-
try, is, whether all the symptoms of continued
fever can be ascribed to the influence of local in-
flammations in some part of the body, and what
is usually called idiopathic fever be thus resolved
into symptomatic; or whether fever is a general
disease of the system, with which certain loca\
inflammations, sometimes in one part and some-
times in another, frequently combine themselves.
The former doctrine has been warmly espoused
by Broussais and his followers in France, and by
Dr. Clutterbuck, Dr. Mills, and others, in this
country ; but the opinion of some of the most
eminent of the Parisian pathologists, and of the
school of Montpellier, and the general opinion of

262

MEDICINE, (HISTORY OF)

the profession in this country, is decidedly in
favour of the latter ; principally for the following
reasons, which, it will be observed, are chiefly
taken from the history of the disease as known
from observation of the living body, and have
been, therefore, too much neglected by those whose
notions of pathology arc limited to observations
on the dead body, and the inferences thence di-
rectly resulting.

1. The cases to which we give the name of
fevers may be distinguished in practice, and in
general without difficulty, if their whole progress
is traced, from the other cases in which inflam-
mations of the same parts are found on dissec-
tion ; by the slighter degree of the local symp-
toms, as compared to the intensity of the general
symptoms; by the greater depression of strength,
and particularly the easier depression of the
strength of the circulation ; by the greater defi-
ciency of secretions, as shown, after some days,
by the dryness of the mouth and tongue ; by the
greater disturbance of the nervous system, and
greater prevalence and peculiar character of deli-
rium, generally blended with a peculiar tendency
to stupor; by the imperfect coagulation of the
blood, or aggregation of the coagulum ; and not
unfrequently by the appearance of a peculiar
cutaneous eruption.

2. The cases of fever, thus characterized, are
found to be generally of local and temporary ex-
istence among mankind, and are for the most part
distinctly referable either to a malaria or a conta-
gion ; and thus, in their origin as well as their
symptoms, bear an analogy to the effects of cer-
tain Poisons on the living body ; whereas cases
of Inflammation, resembling the effects of injuries
or accidents rather than of poisons, occur in pret-
ty uniform frequency in all great communities
similarly situated as to climate and habits of life.

3. When the cases, which are thus character-
ized as fevers, prove fatal, the appearance* on dis-
section are very generally slighter, (particularly in
the circumstance already remarked, of the general
absence of the most characteristic inflammatory
effusions,) than those which we are accustomed to
see in the cases to which we give the name of In-
flammations ; therefore they do not afford so satis-
factory an explanation of the fatal event ; and
occasionally they are altogether absent.

4. The cases thus characterized as fevers, have
a much greater tendency to spontaneous favourable
termination, than is seen in cases of undoubted
inflammation, where the same internal parts are
affected, and the same amount of febrile symp-
toms exists ; as is seen in the regular decline of
the paroxysms of intermittents, and in the frequent
decline of continued fever, with or without critical
evacuation, where no active remedies are used.

5. The decline of the cases characterized as
levers very often takes place under the use of
stimulating remedies, which are known by expe-
rience to be hurtful in similar stages of undoubted
inflammations; so that the experience of the ju-
vantia and Ixdentia clearly indicates a distinction
of these diseased states.

6. When patients recover from the worst stage
of the cases characterized as fevers, with little or
no artificial evacuation, or under the use of stimu-
lants, experience shows that the health is more

perfectly restored, and that there is much less risk
nlc diseases succeeding them, than may al-
ways"be apprehended when recovery takes place
from decided and dangerous internal inflammation,
under a similar treatment.

[7. The researches of MM. Andral and Gava-
reit have clearly shown, that in all cases of inflam-
mation, the ratio of the fibrinous element of the
blood is augmented, whilst in fevers of all kinds,
unless when complicated by manifest local inflam-
mation, it is diminished.]

These considerations would entitle us to regard
fevers as specifically different from inflammations,
even if certain inflammatory appearances on indi-
vidual parts of the body attended the general fe-
brile symptoms as uniformly in them, as in the
contagious exanthemata ; but this conclusion is
much strengthened by the fact already stated, that
the parts of the body in which inflammatory ap-
pearances may be found after death from fevers
are remarkably various ; and by observation, which
may easily be made in such fatal cases, that the
only symptoms which can be certainly connected
with the appearances on dissection, particularly in
the chest or abdomen, aTe often symptoms occur-
ring late in the disease, and sometimes apparently
supervening, from known causes, on the original
affection.

In regard to the essential nature of the morbid
state, which is thus properly distinguished both in
theory and practice, from the effects of inflamma-
tion, we cannot say that more progress has been
made of late years, than in regard to the essential
nature of the progress of inflammation itself. As,
indeed, all explanations are founded on compari-
sons, and as the phenomena in both these cases
hardly admit of comparison with any others in
nature, it is not to be expected that this investiga-
tion can ever be carried far. And as it is gene-
rally allowed that fever (both symptomatic and
idiopathic) originates in the capillary vessels, i. e.
in that part of the living frame which is the seat
of the functions hitherto involved in the greatest
obscurity, pathologists have been naturally and
properly deterred from prosecuting the inquiry,
until this department of physiology be farther elu-
cidated. It may be stated, however, that the ac-
count given by Hoffmann and Cullen, of the
febrile reaction consequent on the diminution of
secretions and excretions in the commencement of
fever, of the increased stimulation of the heart
being consequent on obstructed circulation in the
capillaries, — may still be held to be so far satisfac-
tory;* but that the idea of a Spasm of the extreme
vessels being the immediate cause of that diminu-
tion and obstruction, and thereby of the increased
stimulation of the heart, has neither been confirmed
by any actual observations, nor generally regarded
as a satisfactory account of the phenomena ; and
perhaps the least theoretical expression of what
is known on the subject is merely this, that there
is, in the commencement of fever, a deficiency of
the vital actions in the capillary vessels, naturally

* Perhaps the most striking fact which can be stated
in support of that doctrine, is the rapid abatement of
the symptoms, and shortening of the period of a parox-
ysm ot intermittent fever, observed by Dr. Mackiniosb
?."., °u \ e V° res " lt from bloodletting in the cold stage,
Hp I V. ■! ' ""^"i'y lessen the amount of stimulus
then acting on the heart.

MEDICINE, (HISTORY OF)

263

followed by increased excitement of the heart ;
and that, in the case of idiopathic fever, this is
combined with the peculiar sedative agency of a
ooison, generated in or absorbed into the blood,
the effect of which varies remarkably in intensity
on different occasions, and is often very dangerous ;
although, like that of other poisons introduced in-
to the system, it is essentially transient.

The most important improvement which has
been lately effected in our knowledge of idiopathic
fever, as in the case of inflammation, may be said
to consist in the more accurate discrimination of
its Varieties ; and the most important of these
may be ranked under the following heads ;

1. Certain distinctions, of obvious practical im-
portance, have been pointed out as to the intensity
and succession of the proper febrile symptoms
themselves. The variety described by Dr.. Arm-
strong, Dr. Bateman, and others, under the title
of Congestive, though perhaps improperly named,
may sometimes be distinctly recognised, both in
cases of fever and of the contagious exanthemata ;
and may be said to be that in which the sedative
agency of the remote cause of the disease acts
with extreme force, the usual reaction is suppress-
ed or obscured, and the symptoms of the first or
cold stage assume their maximum of intensity :
the chief appearances being, feebleness of circula-
tion and of muscular strength, coldness of surface,
and stupor or confusion of thought, resembling
the first effect of concussion of the brain, rather
than the usual febrile delirium.

Again, the distinctions drawn by French au-
thors, between the Fievre Adynamique, in which
the weakened state of the circulation, the Fievre
Ataxique, in which the disorder of the nervous
system, — and the Fievre Inflammatoire, in which
the degree of febrile reaction, — is the predominant
character, although not essentially different from
those by which the Low or Putrid Fever, Brain
or Nervous Fever, and Inflammatory Fever, had
been previously characterized in this country, are
yet important, both as familiarizing practitioners
to these varieties, and to the causes which may
sometimes be assigned for them, and as giving
something more of precision to the use of these
terms.

[It has been, too, a question of no little import-
ance to determine, whether adynamic fever differs
materially in different countries, and at different
times in the same country ; being frequently, as in
the French metropolis, and in the United States,
accompanied by inflammation and ulceration of
the glands of Peycr, and other characteristic phe-
nomena, (dothinenteria, typhoid affection ;) whilst
in other countries, as in Great Britain, it exhibits
itself more frequently by a distinct eruption, and
absence of intestinal ulceration {typhus), and in
certain localities, again, may assume an erysipe-
latous character, as in the adynamic fever, {black
tongue), which in the year 1842 was observed
epidemically in different parts of this country.
The writer's opinion is affirmative; yet some pa-
thologists regard them as distinct diseases, ub
origine.]

2. Numerous and accurate observations have
been made, particularly by Drs. Perceval, Cheyne,
Grattan, and other Dublin physicians, Drs. Bate-
man, Tweedic, and others in London, and Andral,

Chomcl, and Louis, in France, confirming and ex-
tending those of Sydenham, on the more compli-
cated forms of fever, in which the symptoms de-
noting or threatening local inflammation in the
head, chest, or abdomen, combine themselves, either
from the first, or at different periods during the
disease, with those of the idiopathic fever ; and it
has been clearly shown that it is by no means ex-
clusively with the inflammatory form of the gene-
ral febrile symptoms — firm pulse, hot skin, &c. —
that this combination may take place ; but that,
on the contrary, the danger in a majority of the
worst cases of fever in this climate depends on a
complication of local affections, with general symp-
toms, which, if standing alone, would as clearly
demand stimulants.

The observation of such varieties in the general
symptoms and in the local concomitants of fever
is especially important when taken in connection
with the varieties in the symptoms which, in the
fatal cases, immediately precede death, the different
modes of fatal termination to which different
cases obviously tend, and the different kinds of
practice which are, therefore, evidently demanded.
When we see, for example, that some cases of
fever are fatal within a few days of their com-
mencement, with the pulse full and the skin hot
almost to the moment of death, and headach and
delirium, followed by stupor, as the most promi-
nent symptoms ; and that others are fatal only
at the end of several weeks, the pulse being feeble,
or very easily depressed, the skin cool or easily
chilled, and the body wasted by inanition, or more
quickly reduced by diarrhoea, for many days before
death, but the head clear almost to the last ; it
becomes obvious that Dr. Cullen's memorable in-
junction, to form the indications on "the means
of obviating the tendency to death in fever," must
be followed by very different means. Perhaps the
most systematic account of the different modes of
fatal termination which are to be expected in fevers,
and by the expectation of which the practice must
be chiefly regulated, is to be found in the work of
Hildebrand on Typhus.

3. The observations, begun by Sydenham and
others of the older authors, on the comparative
frequency and mortality of the different forms of
fever at different ages, in different climates, differ-
ent seasons, or in different epidemic visitations of
the disease, have received many important addi-
tions.

The last-mentioned point is, perhaps, that ou
which it is the most important to have certain in-
formation. In the fevers of the hot climates, for
example, it appears distinctly from numerous
practical observations, that in some seasons the
danger is chiefly from the rapid increase of symp-
toms denoting an inflammatory action at the brain
and at the liver or stomach, headach, delirium,
stupor, pain and tenderness at stomach, urgent
vomiting, &c, and that these symptoms are safely
and effectually met by full evacuations ; but it
seems equally certain that, on other occasions, and
in the more malignant epidemics, the febrile de-
pression is more formidable, the depleting practice
less effectual, the danger of debility from it much
greater, and stimulating remedies sometimes
(though unfortunately seldom) obviously success-
ful.

264

MEDICINE, (HISTORY OF)

The present writer can say with confidence,
from his own observation, that the fevers which
were prevalent in Edinburgh from IS 15 till 1S20
were materially different in character from those
which have prevailed since 1825; that at the
former time the pulse generally preserved a greater
degree of firmness throughout the disease ; that
when death occurred, it could be more distinctly
ascribed to the inflammatory complications ; that
bloodletting was better borne, and seemed much
more decidedly useful ; and that the indications
for the use of wine, and the benefit from it, were
much less frequently seen. When the statements
of Dr. Welsh on the fever of 1817-18 in Edin-
burgh are compared with those of other practical
observers, either of former or later epidemics in
Scotland, it will probably be admitted that the
observation now made is in conformity with the
experience of others. About the former period,
several of the best observers, — Dr. Duncan in
Edinburgh, Dr. Bateman in London, and many
of the military and naval practitioners, — exerted
themselves to show the safety and efficacy of
bloodletting in fevers, even of the typhoid type ;
but in many of the fevers prevalent since that
time, caution has appeared equally necessary in
regard to bloodletting, and wine has seemed
equally useful and important as in the days of
Huxham or of Gilchrist. And it is only by such
observations that we can be duly impressed with
the importance of the practical cautions given by
Sydenham, by Cullen, and others of the older
authors, as to the importance of attention to the
nature of the prevailing epidemic, in regulating
our practice in fevers.

What has been said of the connection of fever
with the local inflammations frequently attending
it, may be applied likewise to the Contagious
Exanthemata, in which there is a similar combi-
nation of general febrile symptoms, consequent on
the introduction of a poison into the blood, with
peculiar local inflammations chiefly of mucous
membranes; but these are of a more definite cha-
racter, both as to seat and duration, than in the
former case. In these, likewise, a remarkable
variety of epidemics, as well as of individual
cases, has been repeatedly observed of late years ;
of which the peculiarly malignant or typhoid
measles, prevalent in Edinburgh in 1807-8 and
in 1815-16, were striking examples. The idea
entertained by Dr. Watt and some others, of an
increased mortality from measles compensating for
the diminution of mortality in early life which had
been effected by vaccination, seems to have been a
hasty inference from the observation of such an
unusually fatal epidemic, and has fortunately re-
ceived no confirmation from subsequent experi-
ence.

The malignant Cholera, which has been the
object of so much attention within these few
years, has all the characters of a disease proceed-
ing from a peculiar or specific poison, whatever
ihe source of that poison may be. Many of its
symptoms approach nearly to those of the conges-
tive form of fever above mentioned ; and the
typhoid symptoms and strong tendency to stupor,
observed very generally in this country in those
who recovered from the stage of collapse, clearly
indicate its analogy to the worst febrile epidemics.

It is obvious from what has been said, that
much has been done in the last half century to
increase the number and the precision of the data,
by which we are habitually guided in the applica-
tion to individual cases of this class of diseases,
of remedies of known and acknowledged power,
e. g. bloodletting, general or local, purgatives, nau-
seating medicines, counter-irritants, stimulants ;
and it were unreasonable to doubt that in this
way the efficacy of medical treatment over these
diseases, in the practice of intelligent and judicious
men, has been gradually and considerably in-
creased. We must ascribe much less to the pecu-
liar efficacy of any new remedies recently intro-
duced. The application of Cold in the early
stage of Fever and of Scarlatina is one of those
from which the most beneficial results have been
anticipated, and the temporary efficacy of this
remedy, and the safety of applying it during the
stage of greatest vascular excitement, in the sim-
pler or less complicated forms of these diseases,
were ascertained by Currie and many others; but
a careful observation of the " modes of fatal ter-
mination " of these diseases is sufficient to show
that the cases to which this remedy can be safely
and freely applied, are not, in general, those in
which danger is chiefly to be apprehended ; and it
is probably to the conviction of this truth that we
ought to attribute the gradual disuse of the most
powerful method of applying cold in such diseases,
the cold affusion.

The free use of saline medicines in fever has
been lately recommended by Dr. Stevens and
others, on the supposition that they have a pecu-
liar or specific power of correcting the morbid
state of the vital properties of the blood, which is
indicated by its imperfect coagulation, and are
therefore qualified to obviate the typhoid tendency
in fevers ; and it is certain that the indication
which it is thus proposed to fulfil is one of real
existence and importance, and that the eflect of
small quantities of saline matter in accelerating
the coagulation of fresh-drawn blood, would seem
to favour the idea of its power to correct that
morbid condition. But it is a mistake to suppose
that the mere reddening of venous blood by sails
is an indication of any such change on the vital
properties of the blood, as would be requisite to
make their use effectual for the purpose in view;
experience of the saline medicines in fever does
not authorise our attributing to them any peculiar
power over the typhoid symptoms ; and although
the saline injections into the veins have frequently
had an extraordinary temporary exciting effect in
the stage of depression or collapse of the malig-
nant cholera, yet the very frequent accession of
coma, after that copious admixture of saline mat-
ter with the blood, will hardly justify the hope of
any improvement as to that most formidable part
of the typhoid symptoms resulting from the saline
treatment.

We must still admit that the only medicines to
which we can confidently ascribe a peculiar or
specific virtue of controlling the morbid actions
which constitute fever are bark and arsenic, when
used in the intervals of intermittents ; and the
improvement in the administration of the former
medicine effected by the introduction of the Sul-
phate of Quinine into general practice by Pelletier

MEDICINE, (HISTORY OF)

265

and other French pharmaceutical chemists, is one
of the most important additions which chemistry
has given to medicine during the period under
review.

CHAPTER III. — Recent additions to our know-
ledge of chronic diseases — 1. Of organic dis-
eases — Their diagnosis — Their arrangement
and classification — Their connections with
each other and with acute diseases — Their
treatment — 2. Of functional disorders — Their
connections with one another — The general
principles of their treatment — General reflec-
tions on the past history and future prospects
of medicine.

It will easily he understood from what has been
already said, that some of the chief recent im-
provements in medical science will be found in
the increased extent and precision of our informa-
tion as to Organic Diseases, i. e. diseases depen-
dent on permanent changes of structure in some
of the organs. This department of medicine has
likewise been studied with great care and minute-
ness by the French pathologists. It must be ad-
mitted that the diseases which are thus character-
ized are for the most part incurable ; and that,
most generally, it is only in so far as they are
complicated, either with inflammation or with
strictly functional disorders, that they admit of the
application of any remedies of more than pallia-
tive operation ; yet the knowledge of their exist-
ence is frequently of practical importance ; and
when the information which we acquire from stu-
dying their symptoms in the living body, and their
appearance in the dead, can be connected with the
investigation of their predisponent and exciting
causes, and the mode of their formation, it may
be usefully applied, even at present, and we may-
trust will hereafter become more extensively appli-
cable, to the prevention of evils for which the past
history of medicine gives us little reason to expect
that any medical treatment will ever supply a
remedy.

The most important additions made to our
knowledge of this class of diseases may be men-
tioned under the following heads : —

1. The diagnosis of them, during life, has been
greatly improved by comparison of symptoms,
observed in many cases, with accurate investiga-
tion of the lesions discoverable on dissection.
This, indeed, appears from what has been already
said of the improved diagnosis of chronic inflam-
mation and its effects, which, in many instances,
are not to be distinguished during life, (otherwise
than by their often abating, spontaneously or
under remedies, more favourably,) from the more
strictly organic diseases.

It is chiefly in the discrimination of chronic
diseases of the thorax and abdomen, that the ad-
vantages of the methods lately brought into use
may be observed. The observation of the func-
tions which appear chiefly disordered is, certainly,
in chronic as in acute cases, our first guide to the
organ which may be judged to be affected ; but
this observation is sometimes deceptive, and often
insufficient for such distinctions as may be confi-
dently and usefully drawn. We now know that
effusions, either into the cavity of the chest or
into the air-passages, that morbid condensation or

Vol. III. — 34 x

morbid rarefaction of the substance of the lungs,
or the formation of cavities within them, all
modify the sound emitted by the chest on percus-
sion, or the resonance of the voice from it, or
alter, or add to, the natural respiratory murmur,
generally or locally ; and so produce peculiar
symptoms, which, when existing alone, may be
recognised by most persons without much diffi-
culty ; and even when combined, as so frequently
happens, with one another, still frequently enable
us to judge of the nature of complex cases with a
degree of precision formerly unattainable.

The existence of enlargement of the heart and
of dilatation of the aorta, and of obstruction to the
transmission of blood through the heart, is in
almost all cases distinctly discoverable by manual
examination, connected with a few facts easily
ascertained, as to the sense of palpitation and the
manner in which it is excited ; in some cases,
more specific information is obtained as to dis-
ease of the pericardium by percussion ; and as to
disease of the valves of the heart by the modifica-
tions of the natural sounds of the heart's action,
perceived by auscultation ; and the existence of
aneurisms within the chest, otherwise impercep-
tible, may sometimes be ascertained in this way.

As an example of the increased precision of our
knowledge of chronic diseases of the chest, we
may instance the judgment which no careful ob-
server will now hesitate to pronounce, on Dr.
Cullen's definition of hydrothorax, comprising a
number of symptoms which it is of great import-
ance for the practitioner to observe, but none of
which, singly or combined, do necessarily indicate
that disease ; and two of the most important of
which, the starting from sleep with palpitation,
and the sound of fluctuation in the chest, actually
never attend the disease, unless it be complicated
with others ; while the symptoms most truly cha-
racteristic of the effusion into the chest, (the dull
sound on percussion, and absence of respiratory
murmur, altering their place on change of posi-
tion,) are not mentioned in this definition at all.

It is true that much obscurity often attends the
diagnosis of the more complex chronic diseases
of the chest, even with all the aids that we now
possess ; and that to clear up this obscurity, in too
many cases, would answer no practical purpose ;
but the statement that has been made of the
improvements of diagnosis, as applicable to the
simpler cases at least, since the time of Cullen,
does not appear to be exaggerated.

It has been found that the existence of organic
disease, giving an unnatural density to parts
within the abdomen, may also be detected in
some instances by aid of the sound emitted on
percussion, (as practised by Piorry and others,)
with more certainty than by the touch alone.
Many organic changes of structure to which the
different parts of the alimentary canal and the
chylopoietic viscera in general s.re liable, have
been carefully observed, and their symptoms (un-
fortunately some of them sympathetic and remark-
ably various) been recorded ; and the discovery
of the connection of organic disease of the kid
neys with urine of low specific gravity and albu-
minous character, has enabled us to speak with
confidence of the chief cause of derangement of
the health in many cases which are otherwise ex-

266

MEDICINE, (HISTORY OF)

tremely obscure. It is well observed by Andral,
that organic diseases of the liver, when, as often
happens, they are neither made known by en-
largement of the organ, nor by jaundice, nor even
by any obvious deficiency of bile in the faces, are
at present more obscure than those of any other
important viscus. The organic diseases of the
testes, the prostate gland, and the urethra in man,
and those of the uterus and ovaria in women,
have been subjected, of late years, to repeated and
careful inquiry ; the symptoms which may excite
suspicion of them are known, and detection of
them by examination is seldom a matter of much
difficulty.

As examples of the increased precision given
to our knowledge of the variety of organic dis-
eases, we may mention the accurate descriptions
of those of the eye by Ware, Travers, Lawrence,
[Mackenzie,] and others in this country, as well
as by many foreign authors ; and, again, the
minute discrimination of the diseases of the joints,
as they originate in different textures, by Sir Ben-
jamin Brodie ; all which distinctions, in cases
which are carefully traced from their commence-
ment, may often be recognised.

2. Not only has much been done to enable us
to pronounce, with more confidence than formerly,
on the existence of organic changes of structure
in various parts of the body, but the whole his-
tory of the changes which come under this de-
scription has been much elucidated by observation,
both in the living and dead body.

Most of these depend on the deposition, and
many ultimately on the ulceration, of adventitious
or morbid matter of one kind or another, either
substituted for or added to the original materials
of the different textures; whether these are ex-
ternal and exposed to view, or internal, and to be
recognised, partly by the functions which seem
chiefly deranged, and partly by the modes of ex-
amination to which we have referred. From the
time of Mr. Abernethy's Classification of Tumours,
many minute descriptions of the great variety of
these deposits have been attempted both in Eng-
land and France, [and America,] to some of
which we shall presently advert ; but it is per-
haps impossible to embrace all these varieties in
any formal arrangement. Probably the most suc-
cessful attempt of the kind is that now in progress
by Dr. Carswell, which affords a good illustration
both of the increased accuracy of our knowledge
of morbid anatomy, and of the advantage which
is taken of the arts of the draughtsman and en-
graver, to diffuse and perpetuate that knowledge.

We have already spoken of the important prac-
tical question frequently presenting itself, how far
an inflammatory action produced by the usual
causes of inflammation may be concerned in de-
termining their formation, and how far they must
be referred to mere " perversion of nutrition" from
unexplained causes. This question frequently
occurs, and may be answered nearly in the same
terms as to every variety of morbid structure, from
the simplest morbid cysts or hydatids up to bony
concretions, and scirrhous or cancerous tumours ;
and the writings of Broussais, Laennec, and
Andral, show the importance attached to it by
modern French pathologists. All that can be
said in regard to it in general terms is this, that

effusions which are simply the effects of chronic
inflammation, may produce, probably in any part
of the body, effects and symptoms almost exactly
similar to those which result from the deposition
of morbid matter, and the growth of adventitious
textures ; and that effusions, in the first instance
produced by inflammation, may probably be gra-
dually converted in different cases into any such
morbid growths ; but it is obvious that some addi-
tional condition of the morbid slate must exist in
every case where such conversion takes place;
and experience instructs us, that when that un-
known condition exists, all sorts of morbid de-
generations of structure may be gradually effected,
without either the application of the usual causes
of inflammation, or the appearance of its usual
symptoms.

There are two general grounds of distinction
among adventitious textures or morbid growths,
which are of obvious and practical importance,
and have therefore fixed the attention of many
pathologists, but which are often not easily recog-
nised in individual cases, and are evidently not in
all cases strictly observed by nature.

The first is the distinction of the diseases pro-
perly termed malignant from those which either
become inert and stationary, or tend, however:
slowly, to a spontaneous favourable termination.
When a decidedly scirrhous tumour has formed
in any part of the body, when a deposition of the
nature of the encephaloid matter or medullary
sarcoma has taken place, or when a sore has
assumed the character of hospital gangrene, no-
thing but continually extending ulceration and
ultimately exhausting constitutional disturbance
can be expected ; whereas the more common
tumours, encysted or sarcomatous, on the surface
of the body, polypi, of the common kind, on rau-
cous membranes, fibro-cartilaginous tumours of
internal parts, e. g. of the uterus, even the most
common morbid depositions on the coats of the
arteries, or valves of the heart, or in the substance
of the liver or kidneys, although they may inter-
fere with important functions, and so prove dan-
gerous, are not necessarily destined in themselves
to such unfavourable progress.

The other distinction is one which points to
the same conclusion, both as to prognosis and
practice, but by no means coincides with the for-
mer, between those organic diseases which are
constitutional, and those which are strictly local-
We apply the former term to those formations
which are known by experience to be found very
generally in different parts of the body at once,
and particularly in internal parts at the same time
as in external ; the matter composing which has
been found also, by Langslaff, Velpeau, and many
others, in the blood within the vessels, chiefly in
the veins leading from parts where extensive de-
positions have been going on, and of which it has
been frequently observed that the removal of a
limb, seriously affected by them, has been quickly
followed by a rapid deposition of the same kind
in internal parts. This character is so far appli-
cable to the scrofulous tubercles, the whole history
of which has been so fully elucidated by Stark, by
Baron, Lloyd, [Gulliver,] and others in this coun-
try, and by Baylc, Laennec, Andral, Denis, Lom-
bard, and others in France : but the latter particu-

MEDICINE, (HISTORY OF)

267

lars above stated have been found to apply more
uniformly to two other kinds of morbid or adven-
titious structure, accurately described and distin-
guished only within the present century, and
which are formed in general more rapidly than
the scrofulous tubercles, viz. the medullary sar-
coma, cncephaloid disease, or fungus h&matodes,
and the melanosis ; the first of which varies con-
siderably in different instances, and has therefore
acquired the above and various other names from
Abernethy, Hey, Wardrop, Burns, Farre, Monro,
Tertius, and others who have described it within
the last thirty years, in this country ; while the
latter is so very peculiar, that since it was de-
scribed by Breschet, Laennec, and Beclard in
France, and by Fawdington, Cullen and Carswell,
and others in this country, there has been no
difficulty in restricting the term to the proper de-
scription of cases.

In regard to these diseases, although we can
point out several circumstances which seem to
predispose to them, yet it seems obvious, from
what has been very frequently observed in regard
to them, that the circumstance which gives the
strongest predisposition to the formation of any
one of them in any part of the body, is the previ-
ous existence of the same morbid texture in ano-
ther part, and that the chief cause of their forma-
tion is a constitutional peculiarity rather than a
local irritation.

Many other kinds of morbid growths (particu-
larly those which differ the least from the sound
textures of the human body) have no such ten-
dency to occur simultaneously or in succession in
different parts of the body, and may therefore be
more safely and advantageously removed in many
instances where they have formed in external
parts. The tendency to reproduction after the
removal of an affected part is less uniform in the
case of the scrofulous tubercles than of the other
diseases now mentioned ; but the great tendency
to repeated deposition in internal parts is what,
in fact, gives the great fatality to scrofulous dis-
ease, for individual tubercles are not uniformly
destined to extension, or even to ulceration, and
the epithet of malignant is, therefore, not strictly
applicable to them. On the other hand, the ten-
dency to reproduction after removal is very strongly
marked in the true scirrhus after it has subsisted
for some time in any part of the body, and parti-
cularly after any of the lymphatic glands have
been affected by it ; so that we must always ex-
pect that malignant form of disease, however
strictly local in the first instance, to become con-
stitutional shortly after it has discovered itself.

The facts stated as characterizing the constitu-
tional organic diseases seem to leave little room
for doubt that they essentially depend on altera-
tions of the constituents and vital properties of the
blood ; and that the peculiar matter of which they
consist is, at least to a certain degree, elaborated
in the interior of the vessels, and forms part of the
circulating fluid, if not from the commencement,
at least in the progress of the disease. This prin-
ciple is evidently illustrated by what has been
already stated as to the evidence of purulent mat-
ter circulating in the blood in cases of inflamed
veins, or of extensive suppuration of other parts.
And the dependence of such local depositions on

a morbid state of the blood is farther illustrated
by the facts observed in regard to the singular dis-
ease lately called Purpura, but long since accu-
rately described by Dr. Duncan, sen., under the
more characteristic term haemorrhoea petechialis ;
some cases of which, indeed, approach very nearly
to those cases of melanosis where the morbid
matter is most generally deposited.

The phenomena of Scurvy, strictly analogous
to those of purpura, afford the only example yet
known of an alteration of the vital properties of
the blood, the essential cause and auxiliary pre-
disponents of which are known, and the means
of correcting which are equally simple and certain.
The peculiar efficacy of the citric acid in particu-
lar, according to the statements of Sir G. Blane,
seems well ascertained. But the absolute ineffi-
cacy of the same treatment in cases of purpura
sufficiently indicates that similar conditions of the
blood may result from various causes. Numerous
recent observations on purpura have shown that
it is often complicated with inflammatory diseases,
and then may admit of relief from antiphlogistic
treatment, — a conclusion quite in accordance with
what has been stated as to other diseases connected
with a morbid condition of the blood.

There is yet another description of organic dis-
ease in which it is pretty certain that the morbid
product is the result of vital changes which take
place among the constituents of the blood in the
interior of the vessels, viz. some of the fungous
growths or vegetations which are occasionally
found attached to the valves of the heart. From
several cases, which he has himself seen, the pre-
sent writer has no hesitation in agreeing to the
doctrine of Laennec, that certain of those sub-
stances are not growths from the lining membrane
of the heart, but coagula of blood, gradually form-
ing and attaching themselves, and acquiring a
peculiar organization.

There are many cases of disease in which or-
ganic lesions of the solids composing the animal
frame are effected without the deposition of new
or adventitious matter, — cases of atrophy, or hyper-
trophy, or alteration of the form and position of
parts, leading in many cases to derangement of
functions, or giving still more unequivocal indica-
tions of their existence, by alteration of the out-
ward appearance of the body. These cases have
likewise attracted the particular attention of pa-
thologists ; and what is most important in this
department of pathology is, the distinct apprehen-
sion of the manner in which (consistently with
known laws of the animal economy) many of
these alterations of structure are effected, in con-
sequence either of inflammations and effusions, or
of other organic diseases, or even functional dis-
orders, previously existing. Thus, atrophy of
parts may often be traced to their disuse, and
hypertrophy to their excessive use, in consequenee
of other disease, and both illustrate the depend-
ence of nutrition on local changes occurring at the
extremities of the arteries. The emphysema of
the lungs already mentioned, and the enlargement
of the bronchi, are naturally consequent on many
cases of bronchitis and effusion into the air-pas-
sages, but constitute, when effected, important
organic diseases in themselves. In like manner
the common case either of dilatation or hypertro-

268

phy of the heart, so fully investigated by Corvi-
sart, Laennec, Bouillaud, Andral, Baillie, Burns,
Farre, Hope, and many others, is very seldom a
diseased state in itself, but is the natural conse-
quence, produced in a healthy part by obstruction
to the exercise of its function, of disease (inflam-
matory or organic) of one part or other of the
membrane lining the inside of the heart and aorta.
So, also, the expansion of the cranium and un-
folding of the convolutions of the brain in the
chronic hydrocephalus is a consequence of the
gradually increasing effusion of serum in its inte-
rior ; the gradual conversion of the kidney into a
cluster of cavities, communicating with each other
and filled with fluid, is the natural effect of ob-
struction of the ureter, causing enlargement of the
calices, and compression and absorption of the
glandular substance ; and the great alterations in
the form and other qualities of bones, both in the
mollities ossium and in the spina ventosa, appear
to be, frequently at least, consequent on morbid
growths from their internal or medullary mem-
brane.

3. Not only the history of most of the organic
diseases has been greatly elucidated, but the more
general consequences which they produce, the
predisposition which they naturally give to other
diseases, and therefore their connection with in-
flammations, with functional disorders, and with
one another, have in many instances been made
out ; and in a practical view, this is one of the
most important inquiries concerning these dis-
eases in which pathologists have lately been en-
gaged.

Thus it is now well understood that the very
common disease of the arteries, which begins by
deposition of lymph on their inner membrane, and
generally goes on to ulceration and irregular bony
depositions there, is naturally the great predispos-
ing cause of many and very different diseases, —
that in the trunk and extremities it often leads to
aneurism, and in the extremities it is often con-
nected with gangrenous inflammation ; that' in
the brain it often leads to rupture of vessels and
apoplexy or palsy ; that in the neighbourhood of
the heart, and especially when the morbid depo-
sits extend to the valves of the heart, it obstructs
the circulation there, and leads to dilatation and
hypertrophy, to palpitations, to fits of syncope,
sometimes to angina pectoris ; that the obstruction
on the left side of the heart gives a great predis-
position both to peripneumony and to rupture of
blood-vessels, producing haemoptysis and apoplexy
of the lungs, and seldom fails, sooner or later, to
induce chronic bronchitis, with which, in certain
constitutions, fits of spasmodic asthma are com-
bined ; — farther, that this as well as other causes
of obstruction to the free flow of blood through
the heart and lungs, producing habitual dyspnoea,
leads naturally to congestion in the great veins,
and thereby to enlargement of the liver; and that
it is chiefly after the disease of the heart and arte-
ries has already become complicated with disease
of the lungs or liver, that dropsy, more or less
general, is so apt to supervene. In like man-
ner we can easily trace the connection, in many
cases, of bronchitis and asthma with emphysema
of the lungs ancl consequent habitual dyspnoea,
and then with enlargement of the liver and

MEDICINE, (HISTORY OF)

that of obstructed liver, first with

dropsy ;' ^. — -

dyspeptic symptoms, and then cither with ascites,
or with diarrhoea, dysentery, melama, or htemate-
mesis.

But in all these cases it is to be observed, that
the pre-existing organic disease acts only as a
great and permanent predisposing cause of the
various derangements, functional or organic, which
thus combine themselves with it. When existing
alone, any one of these organic diseases may
exist, at least in some individuals, for a length of
time without causing any very urgent symptoms ;
and the occurrence of these complications may
very often be ascribed also, in part, to the action
of exciting causes of disease, — cold, intemperance,
exertion, &c, and to inflammatory attacks con-
nected with these. In fact it is chiefly by warning
us of the specific dangers to be expected from
such exciting causes, and of the importance both
of avoiding them, and of watching for any fresh
accessions of inflammatory symptoms, and using
depleting remedies as early as possible to subdue
them when they appear, that the knowledge of
the usual successions of such diseases is useful.

4. The precision which is thus given to our
views of the effects to be expected either from
bloodletting or other evacuations in the varying
circumstances of organic diseases, of the time
when they should be used, the objects to be gained
by them, and the circumstances in which no ad-
vantage can be anticipated from them, is certainly
the principal practical improvement which has re-
sulted from our extended acquaintance with the
pathology of such diseases. In cases of dropsy,
additional evacuant remedies, of the cjass of
diuretics, particularly the digitalis and the pyrola,
have been introduced within the last half century,
and from the former, at least in many cases, very
striking effects have been obtained.

Many hopes have been entertained, at different
times, of the discovery of medicines possessed of
a true and specific deobstruent or alterative power;
but it must be admitted that these have been ge-
nerally disappointed. At the same time it is pro-
bably going too far to say, in the words of Sir B.
Brodie, that when any texture of the body has
been altered from its natural condition by disease,
that natural condition is never restored. We un-
doubtedly meet with cases where unexpected re-
covery from what appear to be the symptoms of
unequivocal, although probably incipient organic
disease of some of the internal viscera, takes
place under the judicious use of mercury, or of
the sulphureous and saline mineral waters, or of
iodine; and we cannot regard the recommenda-
tions of these remedies and the rules for their ad-
ministration, contained in many recent works, as
practically unimportant, nor doubt of the intro-
duction of the last-named medicine, by Dr. Coin-
dct, having been a real addition to the resources
of medicine. But it must be admitted that the
virtues of all these remedies have been much ex-
aggerated by most of thos e who have undertaken

* When disease of the liver has been found connected
withonranic °r habitual disease within the chest, it has
been often supposed, in this coumrv, that the former has
been the primary disease; but the present writer is quite
satisneu t.mt the statement of Andral, as to the pre-ei:
istence of the thoracic disease, in most such cases, and

ner a ny , cor°rcc P L 0,JUCt,0n ° f l ' le llVCr diseasC ' is Very **'

MEDICINE, (HISTORY OF)

269

to recommend them ; that in a great majority of
cases they are obviously quite inadequate to the
object to be accomplished ; that when they have
succeeded, the morbid structures which existed
have probably approached more nearly than is
usual to the effects of simple chronic inflamma-
tion, and been obviated in part by the repeated
although cautious use of the ordinary remedies
for inflammation ; that some of these remedies
have injurious effects on the body which are often
just objects of apprehension, (of which mercury
in scrofulous habits is the most important exam-
ple ;) and that, in the present state of our know-
ledge, the discretion of the medical practitioner is
very often most usefully exercised in withholding
any such remedies, and confining himself to pal-
liative treatment only, in cases which are truly
beyond the reach of any alterative or deobstruent
medicines yet known.

Important practical observations have been made
by Sir Benjamin Brodie and others, on the diag-
noses of those organic diseases of more external
parts, especially of bones and cartilages, in
which counter-irritation has proved most success-
ful ; but these are perhaps rather to be regarded
as cases of chronic inflammation and its conse-
quences than of strictly "perverted nutrition."

This is not the proper place to dwell on the
surgical treatment of those organic alterations of
texture which admit of relief from such means ;
but the great improvements in the treatment of
aneurisms, of strictures of the urethra, of polypi
of the uterus, and the use of various escharotics
to destroy the surface of intractable ulcerations,
as in the case of the arsenical solution applied to
the hospital gangrene, of the nitric acid to phage-
denic venereal sores, of the lunar caustic to the
more common syphilitic ulcers, — even of different
escharotics to incipient ulcerations of the os uteri,
are all examples of the successful application of
expedients of this kind, the proper use of which
was formerly imperfectly understood.

The last class of diseases which may be no-
ticed in this sketch of modern improvement in
medicine is that where the functions of different
organs only are disordered, without either inflam-
mation or fever, or organic alteration of structure;
and although this class is very numerous, and de-
mands much of the care of medical practitioners,
it need occupy only a small share of our attention
at present ; because the disorders which it com-
prehends are less accurately defined, their history
is more various, the effects of remedies upon them
are more uncertain, and the observation of their
effects is liable to more fallacies ; so that the in-
formation which we can acquire in regard to them
cannot have the same character of precision as
that which we possess in regard to those diseases
of which the symptoms and anatomical charac-
ters are better marked and more uniform. In
some instances, however, merely functional dis-
eases have been described and distinguished of
late years with a degree of precision formerly un-
known, and practically important.

The greater number of the functional derange-
ments to which we here allude are included under
the two heads of disorders of the digestive organs,
and disorders of the nervous system; but some
cases of dropsies unconnected with perceptible

organic disease, some cases of derangement of
secretion unconnected with digestion, and many
chronic affections of the bronchi, and of the sur-
face of the body, may be held to belong to this
class, as being derangements of secretion rather
than either inflammatory or organic diseases.

Now it may be remarked of these diseases,
that perhaps the most important general principle
lately ascertained in regard to them, is that of the
sympathetic, connection existing among them, and,
therefore, the possibility of effectually correcting
one disorder of this class by applying remedies,
apparently, to another. Thus the dependence of
many disorders of the nervous system on imper-
fect digestion, and derangements of the bowels,
not as the sole, but in many instances as one of
the conditions of their existence, seems well es-
tablished ; and it is generally believed that the
same principle extends to disorders of distant se-
cretions, (e. g. to that disorder of the secretion of
urine on which the formation of calculi depends,)
and to many chronic cutaneous diseases. The
Treatise on Purgative Medicines, by Dr. Hamil-
ton, senior, and the Essay on the Constitutional
Origin of Local Diseases, by Mr. Abernethy, have
strongly impressed the practitioners of this coun-
try with the importance of careful attention to the
state of the primes via? in many cases, where the
organs chiefly affected appear to be distant from
that source of irritation. It may be doubted
whether the remedies which have appeared so use-
ful in the hands of these practitioners have always
acted merely in the way they supposed ; it may
be doubted, for example, whether the purgatives
used by Dr. Hamilton in chorea, in hysteria, or in
threatening of hydrocephalus, have acted merely
as evacuants of irritating matters from the bowels,
or chiefly as derlvants from the brain and spinal
cord ; it may be doubted whether the small doses
of mercury prescribed by Mr. Abernethy in cu-
taneous ulcerations and other disorders of exter-
nal parts, have acted merely on the stomach and
bowels, or chiefly as alteratives on the whole sys-
tem ; and it is certain that in different states of
the prima? vire, different plans of treatment from
those chiefly insisted on by those authors, will be
found most effectual. Still, the general principle
of correcting the functional disorders of other
parts of the body, by the diet, regimen, and medi-
cines, which most effectually improve and preserve
the state of the digestive organs, is generally ac-
knowledged as highly useful and important.

Another important observation lately inculcated
by several practical authors, is that of the ready
transition of functional disorder, when neglected
or irritated, into inflammation, generally of the
more chronic character, and the importance, there-
fore, of the antiphlogistic treatment in a number
of cases, which, judging at least by their first
symptoms, might be supposed to present no indi-
cations for loss of blood, or even for low diet.
The writings of Dr. Cheyne and other recent au-
thors on hydrocephalus, of Dr. Parry, of Dr. Wil-
son Philip on dyspepsia, and of Broussais and his
followers, afford many illustrations of this obser-
vation ; and as usual, when a principle previously
neglected has been illustrated, this kind of prac-
tice has been carried too far by the last mentioned
authors.

270

MEDICINE, (HISTORY OF)

The attention of the profession has been pro-
perly fixed by several practical authors of late
years, on certain forms of disorder of the nervous
system, which were not formerly distinguished
with sufficient accuracy, and which demand the
more attention as they often closely resemble the
inflammatory diseases of the nervous system, al-
though the most successful treatment of them is
very different from that which true inflammations
require. The Delirium Tremens, so accurately
described by Pearson, Sutton, Armstrong, &c, —
and the power of opium, [and even of large quan-
tities of alcoholic liquors,] under proper manage-
ment, in controlling it, is the most striking exam-
ple. The accurate investigation of cases of spec-
tral illusions and somnambulism or reverie, is like-
wise of modern date. We may mention, also, the
careful diagnosis of neuralgic pains, and the use
of some remedies, of the class commonly called
tonics, such as the carbonate of iron, recommended
by Mr. Hutchinson and others, in their treatment;
the dependence of many such disorders on morbid
action at the roots of the sensitive nerves of the
parts apparently affected, (which seems to be as-
certained by the observations of different authors
on what has been termed Spinal Irritation) ; and
more especially the important observations of Dr.
Marshall Hall, Mr. Travers, and others, on a state
of excitement, resembling inflammatory fever, in
certain constitutions, to which they have given
the name of Reaction after the Loss of Blood ;
and again those of Dr. Abercrombie, Dr. Gooch,
and others, on the symptoms closely resembling
hydrocephalus in children, which are consequent
on long-continued diarrhoea, or other evacuations,
and abate under the use of stimuli.

It were tedious to enumerate the different indi-
vidual medicines which have recently been pro-
posed and approved by many practitioners in
strictly functional diseases ; but it seems import-
ant to remark, that the advantages to be derived
in many chronic disorders unconnected with or-
ganic disease, from change of scene or of climate,
from residence in the country, from the vegetable
alteratives, as they have been called, such as the
sarsaparilla, and from the saline, sulphureous, and
chalybeate mineral waters, have been more fully
appreciated of late years than formerly ; and there
is good reason for thinking that such remedies and
regimen, acting primarily, or at least most obvi-
ously, on the organs of digestion, may often be
effectual, not merely in correcting functional de-
rangements, but in so restoring the natural vital
properties of the blood, as to obviate the predispo-
sition to organic disease, which might otherwise
be gradually formed.

On the whole, in taking a general view of the
different stages of improvement of medical science,
it may be stated that the ancient physicians, enter-
taining the most inaccurate notions as to the func-
tions of the body in the sound state, and as to the
essential nature of diseases, were yet enabled, by
empirical observation, to acquire a surprising ex-
tent of accurate information, as to the external
causes and natural progress of diseases, and as to
the power of remedies over their most formidable
6y mptoms. In more modern times physiologists have
acquired a general knowledge of the nature of all

those functions in which the visible movements of
the body are chiefly concerned, and so far contri-
buted to the elucidation of many diseases ; while
the distinctions of the different diseased states, so
far as they appear during life, have been ably ar-
ranged and classified in the systems of Nosology ;
the application of remedies to them has been re-
duced to a more regular system than formerly;
and the lists of really efficient remedies have been
gradually curtailed, and their properties more accu-
rately determined.

The great improvement of late years has been
chiefly owing to the more diligent cultivation of
morbid anatomy, whereby the localities, the vari-
eties, and the natural effects (whether perceptible
during life or after death,) of almost all the dis-
eased states of the body have been more accurately
ascertained. At the same time, by the improve-
ments in physiology, the immediate causes of the
fatal termination of diseases have been in most
cases explained ; and thus the immediate objects
to be attained by medical practice have been more
clearly defined, and additional precision given to
the administration of remedies, the powers of
which had been already established.

In looking forward to the farther improvement
of the art, we can hardly expect that the most
numerous class of remedies, — those which pro-
duce sensible effects on the body, — can either be
made to exert more power, or be directed with
much more accuracy towards the objects which
they are capable of accomplishing, than they may
be at present, by well-informed and judicious prac-
titioners. Our hopes of the increasing usefulness
and efficacy of our art must depend, partly on the
improvement of medical education, and the more
uniform diffusion, through the members of the
profession, of the knowledge which we already
possess ; but partly, also, on the progress which
may yet be expected in two lines of inquiry, in
which our success has been as yet only partial,—
first, in the discovery of Specifics, which may
counteract the different diseased actions of which
the body is susceptible, as effectually as the cin-
chona counteracts the intermittent fever, citric acid
the scurvy, or vaccination the small-pox ;* and,
secondly, in the investigation of the Causes of
disease, whether external or internal ; i. e. of the
conditions under which, either the vital actions of
the solids, or the vital properties of the fluids of
the body, become liable to deviations from their
natural state.

That the vices, and follies, and necessities of
mankind will, throughout all generations, be a
fruitful source of disease, as well as of other mis-
fortunes, is as certain as that an origin of moral
evil has, for mysterious purposes, been implanted
in every human breast; but there is nothing irra-
tional or Utopian, or inconsistent with the past
progress of human knowledge, in the hope that

„,! Ei'S-* he re " re,te( '. that one so philosophic in his
Srif Professor Alison should encourage the
mnr,» ,u : s P«»fics," which has been the occasion of
n t ,nr flC ?"?{ ln an<1 "' '"' the Profession, than any
other fallacy. Not one of the agents which he has

taSto'wC?^?- 10 ^ e P ithet " W-« all prophy
,,'d VonP nr h CtIOn ,s ex P'*cable on general principles,
fne the vorv "' a , re - ca Pable of neutralizing or reliev-
cv^reemL ! |jln nH ts for tlle prevention of wbfc*
i i uvt' r" 1 , writer is not aware of a single
specinc in the lists of the materia inedica.]

MEDICINE, PRACTICAL, (PRINCIPLES OF)

271

our knowledge of the cause? and intimate nature
of diseases may be gradually so extended, and
our powers of resisting them so increased and de-
fined, that human judgment and foresight may ul-
timately be found adequate either to prevent or
relieve all the sufferings, which we now regard as
necessarily attendant on our physical constitution ;
and therefore, the defect of those moral qualities,
rather than ignorance of the laws of nature, be
justly chargeable for all, as it already is for many,
of those physical evils which it is the office of the
physician to alleviate. w p Alison.

MEDICINE, PRACTICAL, PRINCIPLES
OF. — In the article Disease was necessarily pre-
sented to the reader a long catalogue of evils,
which, however, man has not been left unprovided
with the means of meeting or of combating ; some
of them he has been enabled to mitigate, and
others have quite disappeared before his increasing
knowledge and skill. In the same manner as
beasts of prey and venomous and offensive rep-
tiles lose their ferocity, or recede in all parts of the
earth, and finally disappear, before the advancing
civilization of mankind, so, also, it would seem,
do the diseases which prey upon health and life
become modified by the resources of man's inge-
nuity, or disappear before his discoveries and grow-
ing wisdom ; and when philosophers perplex
themselves concerning the origin of evil, they lit-
tle suspect how many of the physical as well as
moral ills of humanity are destined to disappear
before the sagacity, the research, and the enlarged
virtue of the species. The great kingdoms of na-
ture have each already and amply contributed to
reward human industry by remedies for the mala-
dies of men ; placing within man's power various
substances which taken in certain quantities, or
externally applied, produce beneficial effects on
the frame when it is labouring under disease ; that
is to say, when its functions are disordered, or the
structure of its parts is changed or impaired. Ex-
periencing the effects, also, man has learned how
to avoid many of the causes of disease. His rea-
son to a great extent protects him ; and would do
so more effectually but for the force of habits
formed before his reason acquires strength. By
regulating the impressions made on the body and
mind by some of the actual agents of disease, he
has even converted them into occasional remedies;
and, the practice of medicine becoming more com-
prehensive in its scope, and no longer confined to
the administration of drugs or to the mere cure
of maladies, has so far advanced as to include the
means of preserving health unbroken in a great
variety of circumstances, by which the mind and
body are liable to be temporarily affected in the
course of life.

These agents of disease have already been
spoken of, as being external to the body or in-
herent in it : the air which surrounds it ; the food
which supports it; the exercise which promotes
all its actions ; the sleep which, after labour, re-
freshes it ; the mind which governs and directs
its voluntary actions and ennobles it ; and all the
inherited or congenital peculiarities to which it is
liable, as well as all the accidents to which it is
exposed in its prugiess from the helplessness of
infancy to the second helplessness of old age.

When by the undue impression of any of these
agents their morbid effects are produced, such
effects consist of disorder in some of the corpo-
real actions, of which the secondary results have
been pointed out as very various. If there is,
first, some increase or some decrease of the energy
of the nervous or of the vascular system, ex-
hibited in one function, in more than one, or in
all, there follow changes in the structural condi-
tion of the parts affected ; whilst new formations
seem produced by peculiar modifications of action,
distinct from mere depression or augmentation of
vital power. Certain laws of sympathy, of rela-
tion, and of conversion, have also been detected,
which were comprehended in our general notice
of disease ; and by reasoning from the evident
object of some morbid actions, an attempt was
made (professing, certainly, little novelty) to es-
tablish the probable final cause of all.

If any endeavour to attain to general principles
in medicine be thought worthy of encouragement,
they must be sought, it appears to us, by pursuing
the route thus marked out ; by a review of the
causes of disease, and of the forms which it as-
sumes ; of the results to which it leads, and of
the general objects to which it tends. It is agreea-
ble to believe that medicine is now cultivated by
many labourers in a spirit so philosophical, that
the young student who falls into the vulgar error
of considering such a general view superfluous,
may confidently be told that he will live long
enough to see and to regret his mistake.

Before the forms and products of disease had
been so minutely investigated as to admit of being
detailed with any approach to exactness, the an-
cients were led, by the simple observation of the
causes of disease, to adopt natural measures for
restoring the equilibrium of a function disturbed.
If a man became ill from exposure to a hot sun,
he was cured by a cool regimen ; and if from ex-
posure to cold, a return to health was promoted
by warmth, and sometimes by mere insolation.
If too much food disordered him, he was relieved
by abstinence ; if too much exercise or labour had
exhausted him, he was renovated by rest. Thus
contraria contruriis medenter became one of the
first maxims, or one of the first general principles
in medicine. As knowledge advances, the gene-
ral principles of treatment acquire a wider and a
firmer basis ; but this first principle, to which the
ancients in their regulation both of treatment and
regimen paid especial regard, has in some periods
of medical history been departed from with dis-
advantage, and sometimes, and even recently, been
utterly denied. The wise physicians of Greece
saw nothing unreasonable in the belief that when
the system was disturbed by a burning fever, the
body was struggling to produce coolness; and
when they beheld the frame shaken with a chil-
ling ague, they concluded that an effort was
making for that restoration of bodily warmth
which they found to follow the cold fit : nor, pro-
bably, was their conclusion incorrect. Without
neglecting these observations, the modern physi-
cian has much more to do. He endeavours to as-
certain in what consist the first movements of ner-
vous or vascular disorder, and in any disease pre-
sented to him, what actual change is already pro-
duced, and what further is threatened ; so that his

272

MEDICINE, PRACTICAL, (PRINCIPLES OF)

measures may be properly directed, and with a
promptness proportioned to the occasion ; for he
has not only to remove effects obviously induced
and existing, but to check, suspend, and stop the
less palpable actions out of which the structural
mischief grows.

He knows that there is in many or in all func-
tional disorders, and even in some which have
gone on to the production of structural change,
a tendency to salutary terminations. In the pa-
roxysm of an intermittent, he can admit that the
successive stages seem intended to effect the quies-
cence in which they terminate. Deep-seated ab-
scesses, for instance in so large and important a
viscus as the liver, show in their progress a ten-
dency to seek or form communications by which
the purulent collection may be carried away with
safety. Almost all, perhaps all, the irritations of
phthisis are the concomitants of an effort, always
going on, for the riddance of the lungs from them ;
and the most deplorable changes in the course of
schirrhous affections appear to be but the attempts
of nature to break up or to separate from the body
a portion so peculiarly diseased that its continued
attachment to the system is inconsistent with the
continuance of life. Admitting that these are the
best means of relief which the laws of disease al-
low, and seeing, in too many melancholy exam-
ples, the inefficiency of the laws to the salutary end
proposed, he cannot but draw the conclusion that
art was intended to step in and supply what is
wanting; and that it may often direct the actions
thus originated, and sometimes most beneficially
counteract them by others artificially excited. To
know when to do this is an essential part of the
wisdom of practical medicine, and a knowledge
of the means of doing it is another of equal im-
portance.

As a general rule it may be stated, (and the
highest authorities might, if necessary, be quoted
for it in every age of medicine,*) that wherever
it can be safely done, the natural tendency to
cure, supposing it to be evident, is to be followed.
In very slight disorders no benefit arises from in-
terference. A slight cold, or a slight diarrhoea,
for example, will cure itself by the discharge
which constitutes one of the first of the effects of
the disorder. A slight hemorrhage, or a slight
external inflammation, may also be left to itself;
but for a more violent or continued hemorrhage,
although its object be apparent and salutary, we
must substitute means which are capable of giving
equal relief, and are at the same time more under
our control. A more severe inflammation, also,
or even the slightest, if seated in a part not ex-
posed to sight, can seldom or never be permitted
to proceed uncontrolled ; because inflammation
seldom terminates without some product which
may excite secondary inconvenience, — in other
words, seldom terminates simply in what is called
resolution, but either, when continuing, or when
it attains a certain vehemence, ends, by a neces-
sity arising from the laws of disease, in copious
effusion, or in suppuration, or in the thickening or
other alteration of parts, or the agglutination of
opposite surfaces, or in ulceration, or mortification;

* Medicinac leges nature legibus debent esse coneenta-
neae. Felix medicatio cui adjutrix natura auccurrit,
jrrita vcro qua; repu?nante natura tentatur. Fcmclius,
in prrefat. lib. i. See also Hoffmann, vol. iii. s. 2.

the inconvenience or the danger of which effects,
in the head, the chest, the abdomen, or the articu-
lations and extremities, are such that art must be
vigorously employed to arrest the progress of the
first functional disorder, and prevent the advance
to those new formations or structural changes
which, albeit they are natural methods of cure, are
methods inconvenient and ineligible, or unsafe.

But it often happens that in the functional dis-
order, the disordered action is too violent, and will
not be altogether suppressed : in these cases our
efforts are limited to its moderation, and to con-
ducting it to the least dangerous or least inconve-
nient termination that circumstances will permit.
If effusions or suppuration cannot be prevented,
their extent may be limited, or their escape facili-
tated ; and if structural change cannot be alto-
gether prevented, means may be found of saving
a considerable portion of the suffering organ, so
that its natural function may remain but slightly
impaired.

When medical aid is sought for at a period too
late to secure these advantages, and morbid ac-
tions have passed, unrestrained, into their ordinary
effects on structure, medicine yet has its principles
and resources. Circumstances have changed, and
measures must be adapted to them. If effusion
has taken place, as in various forms of dropsy, its
absorption or its removal may be effected ; if sup-
puration, its discharge, and sometimes its absorp-
tion ; if structural change, its gradual repair or its
removal. The resources are not always effica-
cious, but they always deserve a trial. Even
when promising to be most successful, the frame
is irritated by the presence and persistence of the
disease, the strength of the body is reduced, and
life is endangered. This irritation must, if possi-
ble, be allayed, the debility guarded against or
removed, the danger to life averted. Whilst these
indications are pursued, some new disease may be
excited, or some of the conversions of which we
have spoken (see Disease) may take place. The
supervention of a new disease, — for instance, of
pleuritis or phthisis, — always demands prompt
attention ; the conversion of the original disease
into another is occasionally salutary ; that is to
say, when the new disease is less dangerous than
the old, and entirely takes the place of it, as in
the case of an affection of the skin supervening
on disease of some internal organ. It is a very
common object of art to produce this kind of con-
version. Even a febrile disorder of the constilu-
tion has sometimes been considered capable of
producing curative effects : Celsus enumerates
among the accidental circumstances which cure
the sacer ignis, a day's fever ,- « medicamentura
ejus fortuitum est, uno die febris, quae humorem
noxium absumat;" (lib. v. cap. 28, s. 4,) thus
adding the theory of the cure also. The authority
of Hippocrates may be quoted to support a similar
fact concerning convulsions dispersed by fever;
and even epilepsy removed by the supervention
of an intermittent ; and Bartholinus and Salmuth
are quoted by Hoffmann to the same effect. Hoff-
mann adds that he has often observed the convul-
sions produced by worms put an end to when a
febrile action had destroyed the worms ; consider-
ing the attendant fever as a salutary process set
up to rid the body of the worms, effecting its put

MEDICINE, PRACTICAL (PRINCIPLES OF)

273

pose either by heat or by producing acrid bile.*
Even chronic glandular disorders, which are per-
haps generally exasperated by any febrile disorder,
sometimes have disappeared, and old enlargements
of the glands have seemed to be removed by an
absorption induced by the fever attendant on
measles.-) -

In all these instances, if we admit the facts
without cavil, and in any other instances in which
it may be thought salutary to excite any degree
of fever, it can only be understood that certain
circumstances accompanying the febrile state, cer-
tain conditions of the extreme vessels and nerves,
are the causes of any benefit that is obtained. It
must generally be more desirable to induce the
same condition, if practicable, by other means, —
by medicines which can affect the capillaries or
the ultimate nervous actions without producing a
concomitant fever; and this, we shall see, is ano-
ther principle of practical medicine. By some of
the older physicians, as by Van Helmont and
Campanella, the disposition to regard fever as
always a curative effort led to the mischievous
doctrine that by all means the fever should be
increased by calefacients and tonics. (See Baglivi,
De Praxi Medica. lib. i. cap. xii. sect. 2.) This
is one among many instances in which a correct
principle has been hurtfully perverted ; and the
remains of this prejudice only disappeared in the
memory of practitioners yet living.

If medicine could be so directed as to reach the
first link in the chain of diseased effects, deep-
seated and often hardly discernible, in the nervous
and vascular systems, and to which the term
proximate cause has often been applied, the treat-
ment of mere symptoms would become but a
small part of our duty. It is to this point that
the efforts of enlightened medicine constantly
tend. Whilst we try to relieve pain, we carefully
seek for the diseased action of which it is a symp-
tom ; and, not content to allay the pain by de-
stroying acuteness of sensation, seek to remove
the diseased action, that a permanent cure may be
effected. If we desire to suppress the immode-
rate evacuations of diarrhoea, we carefully consider
what particular state of the intestinal canal occa-
sions the disorder ; and in such a case inconside-
rate and empirical practice, never successful except
by chance, may even be fatal. To attempt to
remove the effusions attendant on chronic pleuritis
or peritonitis, without regarding the continuance
of the inflammatory disease, or to attempt to
counteract the prostration of strength in a fever
by other means than removing the febrile state,
would be so exclusively to attend to mere symp-
toms, as to follow methods of treatment most in-
efficient and unsuccessful.

Yet it arises from the defective state of our
pathology, combined with our anxiety, and even
with our duty, to relieve the afflictions of the sick,
that we are often glad to treat symptoms only ;
and sometimes it would appear, that when promi-
nent symptoms are removed, the disease is at an

* Ipso quoque compluries obeervavi, motus convulsi-
ve ex vermibus, accedente febre vermibusque per eestum

vol liilem acrtm enectis, sponte cessasse. Opera omnia,
vol. lii. sect. 2, cap. 1. De optima nattlra morbis medendi
methodo, sect. x.vv.

t Dr. Forbes has communicated to us a striking fact
of this kind.

Vol. III. — 35

end. As we can generally see and act upon the
symptoms, although we are oftentimes unable to
penetrate to the primary disordered actions, it
happily follows that the limitation of our know-
ledge concerning the causes of disease does not
determine the limits of our practical power, or
always produce uncertainty or inconvenience.
To the philosophical inquirer, however, it will
always be unsatisfactory to be unable to account
for some of the principal achievements of medi-
cine ; as the cure of an intermittent by bark, of
syphilis by mercury, and of scabies by sulphur.
In each of these cases the curative means are
employed with singular confidence, and with
general success ; in each we see the grounds of
hope that there are, even now, undiscovered reme-
dies of equal efficacy in other maladies ; yet, in
each case, to speak candidly, it would be presump-
tion to attempt an explanation of the mode in
which the methods employed produce their marked
and salutary effects.

To meet the complications of disease, the prin-
ciples of treatment must often be equally compli-
cated : two or more simple principles being not
only simultaneously acted upon, but respectively
modified by the existing circumstances of morbid
complication. Chronic inflammation may exist
with effusion, and both with debility ; and al-
though the principal indication or principle to be
followed is in such a case to put an end to the
inflammation, respect must be had to the existing
debility, and relief from the mere effusion must
neither always be postponed until the difficulty
of acting on first indications is overcome, nor at-
tempted without regard to the original cause or to
the actual strength of the patient. There may be
unequal growth, redundancy, or hypertrophy, in
one or more portions of the frame, deficiency in
others. General plethora may be combined with
general debility. In these and numerous other
complications, the principles of cure, being two-
fold or three-fold, demand more from the practi-
tioner than lectures on books can inculcate ; a
discriminating wisdom which must partly depend
on his organization, and partly on his attention
to the instructive examples afforded by daily
practice.

Structural change is always preceded by disor-
dered function, and the principles of treatment
which are the ordinary guides of practice have
reference to the means of restoring functional
regularity. Disordered function consists, we have
said, (Art. Disease,) of, 1, vascular disturbance
or irregularity, producing local or general excess
or defect of sanguineous supply ; 2, nervous dis-
turbance or irregularity, producing local or general
excess or defect of nervous energy ; 3, of combi-
nations of these disturbances, producing various
affections of nutrition, secretion, absorption, evacu-
ation, muscular motion, or the sensorial offices, or
the intelligence and will.

The modes in which we attempt to control
these morbid states, and re-establish natural ac-
tions, would seem, then, very obviously to be such
as tend to equalize the vascular and nervous ac-
tions, simply or conjointly, and in every degree
of their functional combination ; in other words,
to excite or depress, to stimulate or to allay, in
every case, as each case may require. In the

274

MEDICINE, PRACTICAL (PRINCIPLES OF)

practice of surgery, or rather in the medicinal
means employed in external affections, we can
generally recognise these simple principles ; and
when to stimulate and when to lower is acknow-
ledged to be so compendious a surgical principle
as nearly to include every other. In the treat-
ment of such cases as fall under the physician's
care, the principles are, we apprehend, equally
applicable, although their simplicity is in some
degree hidden by the variety of the phenomena,
the frequent obscurity of their origin, and the
number of the constitutional and local means
employed. If this be so, the Brunonian doctrine
erred less in its principle of dividing diseases into
two great classes, than in the application of the
principle to the actual arrangement of diseases,
and in not admitting the simultaneous existence
of states compounded of and exemplifying both
the divisions.

Admitting the great difficulty of determining
in what precise manner medicines produce their
least doubtful effects, we plainly observe how both
vascular and nervous excitements are sometimes
lessened by evacuants, general or partial ; by
general or local bleeding, by purgatives, diuretics,
and diaphoretics ; and how the evacuant plan is
supported by the auxiliary one of diminishing the
supplies introduced into the system. It is equally
clear that we try to rouse both the vascular and
nervous systems by stimulants, including various
agents exerting a more or less durable tonic power
on the contractile forces, or on the digestive func-
tion, or directly on the nervous system, or on the
vascular extremities on the internal or external
surfaces. Several of the agents employed in cer-
tain circumstances as general evacuants are local
stimulants, which in other circumstances are used
simply as such ; those, for instance, which excite
the bowels, the kidneys, the uterus, or the skin.
In some instances even venesection, the most
direct evacuant, has the effect of a stimulus, by
removing some oppression, as in apoplexy ; in
other cases, as of nervous excitement connected
with vascular disturbance, it is a direct sedative ;
and in certain states of fever a brisk purgative,
by its effects on the intestinal surfaces, acts as a
stimulant to the whole system. We are also
possessed of means of allaying inordinate actions
by medicines which do not act as evacuants, by
sedative applications. Opium and other medi-
cines of this class are daily employed as auxilia-
ries to bleeding, and as means of restraining vio-
lent muscular actions, or irregular and profuse
secretions, or sensations too acute, or mental ex-
citement so great as to be incompatible with re-
pose or with reasonable mental acts. The same
substances, in smaller doses, are sometimes used
as stimulants ; and as irritation is often connected
with debility, all stimulants may sometimes be
said to act as sedatives. All that belongs to a
knowledge of the ordinary properties of medicines
of different kinds or in different doses may soon
be known ; but the great art of medicine (ex-
pressed in a well-known and often-quoted saying
of Boerhaave,) is the application of the proper
medicine in the proper dose at the proper time.

Both in cases requiring evacuants or stimulants,
and also in cases of long-continued disorder of
any function or organ, leading to structural

changes and new formations, the employment of
evacuants, of stimulants, or of sedatives, may be
so regulated as to produce gradual alterations of
action, to suspend actions which are morbid, or to
restore, or excite, or regulate actions which are
only disturbed. When thus employed, the medi-
cinal means are called alterative, and they have
already been spoken of under the head of Altbh-

ATITES.

There can be no doubt that the operation of
medicines prescribed with these intentions is con-
temporaneously exerted both on the nervous and
the vascular system, and generally by a primary
influence on the functions of digestion and assi-
milation.

Besides the general effect of medicines as sti-
mulants, evacuants, or sedatives, they commonly
possess, as we have seen, a power of acting locally,
from which, in many instances, even their general
operation is obtained : the various purgatives act
with greater or less energy on particular portions
of the intestinal canal, some on the duodenum,
some on the colon and rectum, and yet all may
be employed as evacuants. But there are a few
medicinal substances which seem to exert a still
more especial influence on particular parts of the
body : it may, perhaps, be said that iodine espe-
cially stimulates the absorbent and glandular sys-
tem ; there can be no doubt that the secale cor-
nutum singularly stimulates the muscles of the
uterus, and that the strychnine exerts the same
power over the whole system of voluntary mus-
cles. We are content therefore to employ these
agents empirically.

In a great variety of cases, and for a great
variety of purposes, external irritants are employ-
ed ; to aid in checking acute diseases, and to sus-
pend those which are chronic ; to relieve local
internal plethora ; to free internal parts from pain-
ful disorder ; to disembarrass, as it were, in some
cases, the constitution from superfluous or morbid
humours, and prevent their specific irritations of
glandular or other tissues. In the familiar in-
stance of cynanche tonsillaris it may often be
noted how the scarlet colour of the fauces, with
the swelling and other appearances of inflamma-
tion, disappear as soon as a blister has been ap-
plied with effect to the throat ; the relief being
plainly attributable here to a simple transference
of action. The cough and some of the other
symptoms of phthisis are generally, although but
temporarily, relieved whenever a pustular eruption
is produced on the chest by the antimonium tar-
tarizatum applied in the form of ointment ; anil
this suspension of symptoms is the result, per-
haps, of a transference of irritation from the
bronchial mucous surface to the skin, rather than
of any suspension of the disease itself; although
it is often sought to suspend the actions of dis-
eases themselves by similar means, or by setons
and issues. When the new actions induced by
counter-irritation produce relief from pain, the
effect may either be ascribed to a transference of
irritation, inducing an altered condition of the
nerves, or to the discharge of humours from the
circulation, which in such cases were productive
of nervous irritation, as in others they seem to be
of all the disordered actions of the scrofulous con-
stitution.

MEDICINE, PRACTICAL (PRINCIPLES OF)

275

As the advantage obtained from alterative medi-
cines appears to be derived through their influence
on the functions of digestion and assimilation, and
by their general operation on the nervous and
vascular system ; so, on the other hand, it may
sometimes be observed that medicines of great
power are singularly modified in their effects by
the state of the body at the period of their adminis-
tration. In the latter case, all the operation of
the medicines seems happily directed to a specific
movement or alteration in the part of the system
particularly affected, and their usual effects on the
system at large are placed in a state of abeyance.
Calomel, and opium, and wine, have been given
to an enormous extent in tetanus, and sometimes
in other affections, without salivation, or mental
elevation, or oppression. In certain states of ner-
vous irritation, very young children have taken,
with advantage, opiates in doses which would
have been destructive to them in a state of health.
The same observation has been made in the case
of adults affected with calculus ; the quantity of
opium given in such cases having sometimes been
governed solely by the relief afforded, and yet
producing no effect on the system in general.
(Parr's London Medical Dictionary, article Cal-
culus.') In hydrocephalus, the power of sustain-
ing immense quantities of calomel has been
ascribed to the peculiarly insensible state of the
nervous system ; but the same power is occasion-
ally seen in cases of croup, although certainly in
the latter affection the debility produced by large
quantities of mercury sometimes becomes a serious
consideration on the decline of the original malady.
To these illustrations may be added that afforded
by the tolerance of large bleedings, of calomel, and
of opium, in inflammatory disorders in general,
and of the tartar-emetic in pneumonia especially.

The best approach to the general principles of
practical medicine, and the most convincing illus-
trations of their authenticity, are to be gained by
reflecting on the intentions of all the usual parts
of practice in the most common examples of dis-
ease.

Taking the example of fever, the most general
morbid affection of the frame, we may perceive
that the intentions acted upon are sometimes to
check the first depression by direct stimulants and
tonics, which is chiefly, if not solely, practicable
in fevers of an intermittent type. When excite-
ment supervenes on the first depression, we seek
to allay it by evacuants, acting either on the mu-
cous and cutaneous surfaces, in the shape of pur-
gatives and diaphoretics, or on the whole system,
by venesection. We lessen the quantity and
stimulating quality of the food. When inflam-
matory actions arise, to these means are added
local depletion, or local evacuation, and sometimes
sedatives, as the application of cold, or the combi-
nation of opium with calomel ; and very frequently
we resort to some of the forms of counter-irrita-
tion ; all these means being varied according to
the seat of the inflammation. After a certain
period the febrile actions decline, the different
organs are left in a state of weakness ; even the
inflammatory affections which still linger behind
seem connected with debility : and now we resort
more freely to tonics and stimulants, medicinal
and regimenal. Throughout the whole course of

a disease, various in its forms, in its symptoms,
and uncertain in its results, there are certain plain
rules for our guidance, few in number, drawn from
the existence of certain states of increased, or dimi-
minished, or irregular actions at the time. The
principles are not obscure, but it is still their wise
and timely application which constitutes a good
practitioner. In following, for instance, that ap-
parently plain indication of giving tonics or stimu-
lants in the stage of debility consequent on fevers
or other maladies, not only is it necessary to com-
mence their administration with exact attention to
the proper time for so doing, but delicately to ap-
portion our attempts to the existing strength ;
according to the ancient and sage maxim, that de-
bilibus debilla, valentibus valentiora conducunt,
a rule which was supported by John Hunter,
when he maintained the principle of not "in-
creasing the action without giving real strength,"
and that we should always have regard to " the
balance which ought to subsist between the power
and action of every part." (Treatise on the
Blood, &c. Introduction.)

In the course of a fever we find the most re-
markable exemplifications of the effect of mental
derangement ; certain states of the mind seeming
to increase or moderate the symptoms of a disease
to which they also increase or lessen the predis-
position.

There is a very important sedative appliance,
the effect of which is never so universally observ-
able in fever ; although it is not to be overlooked
in any affection ; namely, repose of the affected
or disturbed organ. With as much care as the
surgeon takes directly to impede the undue use
of maimed or diseased extremities or parts of the
body, should the physician forbid or obviate the
undue exercise of the whole muscular system in
a fever ; and not only of the muscular system, but
of the system of circulation and the nervous system.
It is, indeed, in some degree with this view that he
inhibits a full or stimulating diet ; but he must also
prevent, as much as possible, the access of all ex-
ternal circumstances which excite the senses, the
mind, the volition, and the locomotive forces.
The benefit of this kind of repose in a fever is
always in proportion to its extent. In slighter
maladies, its use needs no illustration.

In the treatment of inflammations, not origin-
ating in the state of fever, the same principles are
followed ; active evacuations during their active
stage, combined with various sedative means,
sometimes opium, sometimes the tartar-emetic,
which, although an evacuant when employed,
after the old method, in small doses, is a sedative
when given to the extent common in modern
practice, and particularly, as has been mentioned,
in pneumonia. The chronic forms of inflamma-
tion, like those in the latter period of fevers, are
sometimes combated by stimulants, external or in-
ternal, and these may be simultaneously employed
with some local forms of evacuation, and also with
sedative agents ; the emptying of distended and
disordered vessels, the excitement of the vessels
themselves, the strengthening of the body, and
the expulsion of morbid humours, all requiring to
be attended to.

The importance of local applications, both in-
ternal and external, is seen to be very great. Even

276

MEDICINE, PRACTICAL (PRINCIPLES OF)

in acute inflammations they are highly serviceable
auxiliaries, and in chronic affections they are often
alone equal to effecting a cure. Whilst by gene-
ral bloodletting and other evacuants we seek to
lessen the quantity of circulating fluid, and to
lower the energy of the heart, by local means we
still endeavour to alter the state of the capillaries ;
and in cases in which neither general evacuants
nor general stimulants are required, local means
applied to the internal or external surfaces may
perhaps effect all that the case requires. Such is
the result of daily experience; and the fact is con-
sistent with the physiological character of the ca-
pillaries, the powers of which are to a certain ex-
tent independent of the heart; insomuch that
they are even exerted for a time after all commu-
nication between the capillaries and the heart is
cut off. The application of leeches, of blisters,
of friction, and of cold and warmth to the body,
amply illustrate the action and the utility of local
measures in inflammations, in fevers, and in va-
rious local affections : and in other cases, diuretics,
purgatives, expectorants, emmenagogues, are used
with a design of obtaining specific local actions,
which are often excited with equal certainty and
advantage.

External applications include the various forms
of bathing, which may be so ordered as to answer
in different cases the purposes of a stimulant, of a
sedative, or of transferring vascular and nervous
excitement to external from internal parts. (See
Bathing.) The use of fomentations is equally
applied to all these purposes, to stimulate inactive
parts, or to allay pain and inflammation.

When it is the object of our practice to relieve
a patient from the inconveniences or threatened
dangers of plethora, the reduction of the quantity
of circulating fluid is in ordinary cases the plain
indication or principle which we keep in view 7 ;
and this we attempt to pursue by direct evacuants,
bloodletting, and purgatives which stimulate the
capillary extremities in the intestines to the evacu-
ation of fluid ; perhaps, also, by diuretics and
diaphoretics, which act in a similar manner on the
kidneys and skin. These indications may become
combined with that of giving tone to the contain-
ing vessels ; or, more commonly, with that of
guarding some particular organ from the effects
of determination or congestion ; and we fulfil the
latter indication by local depletion, by the sedative
action of cold, by establishing artificial discharges,
and ~uj warning the patient against hurtful exer-
cise or postures. Whilst we try by these means
to diminish the quantity of fluid already existing
in the body, and to avert its evil consequences,
we are careful to cut off the supplies, by a proper
regulation of the quantity and of the quality of
aliment ; and we debar the patient from solid or
fluid stimulants which would counteract our
evacuating plan. In some cases of congestion, as
of the skin, or of the abdominal viscera, the ad-
mission of medicinal or dietetical stimulants, and
of external stimulating applications, may consti-
tute a part of the indications.

In all the approaches to ansemia and to atrophy,
our principles of proceeding are totally different.
To supply proper food, and by cautious attempts
to rouse or stimulate the powers on which the di-
gestion and assimilation of that food depend, not

only demands every resource of medicine, but the
judicious application of the air as a means of
renovation, and the careful avoidance of evacu-
ants which would destroy the feeble remains of
vitality.

In combating the proflavine, we have to coun-
teract the increased discharge by stimulants which
act on the too much relaxed extremities of the
capillaries, or we have to lessen the determination
to them by new modes of evacuation, or we have
to remove their state of congestion by local de-
pletion instead of permitting the evacuating dis-
charge to proceed uncontrolled ; and external
means are sometimes employed to assist one of
these kinds of indication and sometimes another:
the direct removal, also, or allaying of the irrita-
tion of the capillaries, whether directly or sympa-
thetically excited, is often had recourse to, and by
the use of sedatives.

In the case of suppressed secretions, whatever
may be the cause of the suppression, our means
of relieving and removing the disorder are still
either vicarious evacuants, or stimulants, or seda-
tives. Take the periodical uterine discharge as
an example. Its suppression is sometimes cured
by bloodletting or by leeches ; sometimes by pur-
gatives ; sometimes by local, sometimes by speci-
fic, sometimes by general stimulants, as tonics,
exercise, change of air, and diet ; and sometimes
by sedatives, which remove irritations of the af-
fected organ incompatible with functional regu-
larity.

In violent nervous disorders, where at first
sight it might appear that our principles of treat-
ment were more numerous, it is found on exami-
nation that they are only more complicated than
in common cases. In epilepsy, in hysteria, in
mental disorders, whether the cause is in the brain
itself, or in its blood-vessels, or in some other
organ, the means of cure are but the means of
evacuation or of stimulation, or of allaying mor-
bid movements, general or local, immediate or re-
mote, occasional or habitual.

In the case of morbid formations, and in that
of scrofula, we attempt to control evident disor-
dered actions in the nerves and blood-vessels, ac-
tions not easy to be defined, by diminishing or by
increasing the supply of blood or of nervous
energy sent to them, by allaying irritations, and
by setting up new and controllable actions to op-
pose and suspend the old.

Hereafter, in these instances of morbid forma-
tions, as in those of calculi and of poisoning,
very material chemical principles may enlarge our
views of practice, and add to our means. These
are at present extremely limited, and chemical
medicine, of which Paracelsus may be said to
have been the founder, is yet in its infancy ; in-
deed it is yet very doubtful if any instances of
the successful application of chemistry to medi-
cine can be cited ; the chemical medicines, so
called, which are employed in cases of calculus, or
of simple gastric acidity, not appearing to act as
direct chemical agents, but by their influence on
the organs of digestion. Yet the detection of
some fluid ingesta in the blood, and in the urine,
as well as the direct influence of atmospheric air
on the blood, are facts sufficient to defend chemi-
cal therapeutics from the imputation of extrava-

MEDICINE, PRACTICAL (PRINCIPLES OF)

277

gance ; and we cannot but be of opinion that the
improvement of medicine will, during the next
century, proceed much in that direction. More
accurate investigation of the fluids in a state of
health will lead to a fuller acquaintance with the
changes- effected in them by disease, and it is not
forbidden to us to hope that more direct means
may eventually be discovered of checking several
diseases than we have yet ventured to suppose the
existence of. This probability, however, has been
recently disputed ; the chemists, on the one hand,
being accused of expecting too much from their
science, and the physiologists, on the other, re-
proached with a neglect of chemistry. Dr. Tho-
mas Thomson of Glasgow, a chemist of the first
reputation, and a man of great knowledge and
great wisdom, expressed himself on this subject
in the following terms, in a work published a few
years ago : —

" I need not observe to those gentlemen who
have paid attention to the subject, that by far the
most likely means of improving physiology is a
cautious application of chemistry to the investiga-
tion of the different constituents of the human
body. An accurate knowledge of the chemical
composition of every organ, and of the alterations
produced on that organ by disease, would proba-
bly throw new and unexpected light upon the
nature and treatment of many diseases. Physi-
ology hitherto has been handled almost exclusively
by the anatomists. These gentlemen have acted
with a zeal and industry that cannot be too much
admired.* * * * * A new and more subtile species
of anatomy remains still to be applied. Where
the labours of the anatomist terminate, those of
the chemist should begin. This chemical inves-
tigation of the animal body may be just said to be
commencing at present; for it was not till the
atonic theory was brought to considerable simpli-
city and perfection, that such an investigation was
possible. It is easy to see that it must contribute
prodigiously to the advancement of physiological
knowledge."*

More recently, Dr. Prout has expressed him-
self in terms more sanguine : and to the contro-
versy which ensued between this distinguished
pathologist and Dr. Wilson Philip, a physician
who stands peculiarly characterized by the philo-
sophical spirit with which he has cultivated physi-
ology, pathology, and the practice of medicine, the
reader might with less hesitation be referred, if the
discussion had not provoked more discourtesy than
should ever be shown by great improvers of
science, to whom truth alone should be of any
real consequence.-)- All parties and all authorities
will, we believe, at least concede that chemistry
may and will prove a valuable auxiliary to physi-
ology and to pathology ; and that its subsequent
application to the treatment of diseases may not
unreasonably be expected. No one will be found,
we imagine, to contend that chemistry will ever
explain every thing in physiology, or that the prac-

* An Attempt to establish the First Principles of Che-
mistry by Experiment. By Thomas Thomson, M. D. Re-
gius Professor of Chemistry in the University of Glas-
gow, &c. &c. Lond. 1825. Introduction.

f See the Report of Dr. Front's Gulstonian lectures,
and the whole controversy, in the Medical Gazette for
1831; also a paper in the same volume by Dr. Stevens,
on the Treatment of Malignant Diseases.

tice of medicine will ever rest on chemical prin-
ciples alone.

[Of late, increased attention has been paid to
chemistry, owing to the researches in organic che-
mistry of Liebig, Boussingault and Dumas, and
others ; but they do not modify the inferences ex-
pressed above.]

There is much reason to believe that the advan-
tage derived from medicines in some states of dis-
ease arises from the changes they effect in the inti-
mate elaborations carried on within the blood-ves-
sels, and of which the products are the various
healthy and morbid secretions. Such would seem
to be particularly the case in the instance of specific
inflammations ; and the same is very probably true
as respects several or all of the morbid formations.
The disposition of a scrofulous constitution to-
wards the formation of tubercles is probably con-
nected with as definite a change in the character of
the blood as that which more palpably, and by gene-
ral acknowledgment, exists in chlorosis and in scor-
butus, in some fevers, and in the Asiatic cholera.
In many of these cases, as well as in colica picto-
num, and in the tremours produced by exposure to
mercurial fumes, it cannot at present be decided
how far the supposed sanguineous detriment exists,
or if existing, to what extent it is combined with,
or even dependent on, injury of the nervous system.

In several disorders which the pathologist un-
hesitatingly admits to be nervous in their charac-
ter — in tic douloureux for example — the cure by
specific modes of treatment seems to depend on
some change wrought in the condition of the
nerves or nervous system itself different from mere
sanguineous excitement or congestion, and differ-
ent from deficient supply of blood. The whole
subject of nervous pathology is in great obscurity.
It is possible that the minute ramifications of the
several nerves may possess various properties as
distinct from and to as great a degree independent
of those of the larger nervous masses as are some
of the functions of the capillaries from those of
the heart ; and a knowledge of such properties,
if existent, must be preliminary to any near ap-
proach to correct principles of treatment in ner-
vous disorders.

A few medical applications require to be sepa-
rately alluded to, as being employed on mere me-
chanical principles ; — demulcents in irritations of
mucous passages ; some of the anthelmintics, as
the filings of tin ; and various emplastra, when
the intention is to give support to subjacent or
neighbouring parts. None of these require fur-
ther observation.

The principle of treatment sometimes recom-
mended in chronic and obstinate diseases, and
spoken of in the article disease, that, namely, of
producing some strong impression or commotion
of the system, in the hope that the system may,
in such an artificial and general disturbance, rec-
tify or fight itself, might, in different cases, pro-
duce its advantages by acting on the nervous or
on the vascular system, or on both. As views
of treatment become more and more understood,
such treatment, however, will be less and less re-
sorted to ; and if sudden and violent measures
should be thought desirable in lingering states of
disorder, the principles of their application and use
will be better comprehended. It may be observed

2T8

MEDICINE, PRACTICAL (PRINCIPLES OF)

that much of the success of irregular practitioners
seems no less to depend upon this principle than
that part of the benefit often ascribed to the use
of various mineral waters arises from the general
change of diet, regimen, and habits of life, with
which a temporary residence at watering places
is almost in all cases accompanied. The princi-
ple by which these circumstances effect favourable
changes in the health seems especially deserving
of consideration, both in such cases of chronic dis-
order as are connected with morbid conditions of
the nervous system, including those which espe-
cially and in various degrees affect the mind ; and
in all diseases which depend upon, or which have
induced, an altered condition of the blood.

Careful consideration will generally show, even
in chronic, and obstinate, and anomalous maladies,
some clear indications to be followed for the re-
lief of the patient ; and in the cases in which any
expectation of a perfect cure is to be indulged, the
means of effecting it can hardly ever be wanting
to those who can reasonably entertain the ex-
pectation. The very principle on which relief
seems sometimes to be obtained by changing the
habits of the patient in many particulars, may
perhaps be found, if inquired into, to be resolva-
ble into that of removing some unexpected cause
of irritation, which removed, digestion and assi-
milation, and the proper distribution of venous
and sanguineous energy are restored, and the ba-
lance of health is regained. The means of relief
will still be found to have been something which
has imparted power or stimulus to overcome the
morbid obstacle, or something which has directly
allayed some morbid irritation ; or, lastly, some-
thing which has produced a delayed or much re-
quired evacuation of some morbid material, or
something which has improved the state of the
blood. The principle of relieving long-continued
ailments by attention to the digestive organs is
spoken of by Dr. Hebcrden in his Commentaries.*
It has of late years gained much attention in this
country, and still more on the continent, insomuch
that practitioners have not been wanting who
have ascribed every possible disorder to primary
digestive derangement. A direct improvement of
the blood is a very probable consequence of such
a plan, and various ameliorations of nervous and
vascular actions may follow, or may only accom-
pany this change.

The first principles of practical medicine, then,
are few and simple. In a work every article of
which is an illustration of those principles, we
need not dwell longer on the principles them-
selves. It may almost be said, employing the
words of Hoffmann, that there is no other method
of cure, and that there should be no other inten-
tion in the physician, than to reduce to order the
actions and excretions when not in a natural
state ; and that all kinds of medicines do but this,
to allay actions which are excessive, and excite or
promote and equalize those which are depressed
and obstructed.j- But the means of fulfilling

* De Ratione Medendi. See also Baglivi. In chronicis

pauca remedia requiruntur -semper tamen

in mortorum diuturnitate consulendum est digestioni-
bus. Animadv. Pract. Nov.

t N'jque aliara dari medendi viam. vel etiam meden-
tnm debere esse intentionem, arbitramur, quam ut mo-
llis et excretiones, a naturali statu desciscentes, in ordi-
nem reducunt. Omnia cnim remediorum genera id tan-

these indications are very various ; and if the
judgment of the practitioner is exercised in their
application, so their increase and diversified com-
bination afford equal scope for his ingenuity and
invention. Departing from all rational principles,
physiological or pathological, the physicians of
the middle ages vainly sought some universal
medicine which should accomplish every varied
indication at once. Such dreams have long ceased
to be indulged in, although some base pretenders
yet insult the public sense by professing them;
and the only hope of attaining to principles of
universal application depends on the gradual im-
provement of our knowledge of all the actions of
the body in health and disease. The principles
of medicine, not dependent solely on a doctrine
of solidism or of the humours, lead, therefore, to
no extreme and exclusive practice; and the influ-
ence of the moving powers is admitted without
excluding just views of their solid and fluid re-
sults. The mutual dependences of the nervous
and vascular energies, and the properties of and
changes effected in the blood, being all taken into
consideration, we admit nothing but what is
known, and wait for further explanations from
the constant progress of all the sciences connected
with medicine.

From early infancy even to extreme old age,
the few principles now enumerated seem at pre-
sent to be the constant guide of our art in its at-
tempts to rouse, to regulate, or to appease, actions
insufficient, or too disorderly, or too energetic, to
be consistent with comfort, with freedom from uh-
easiness and pain, or with the maintenance of
health and strength of body or of mind. In all
the varieties of their application, the object is to
restore healthy actions as soon, and with as little
waste of strength, and with as little suffering as
possible : or, as a fashionable physician of ancient
Rome was in the habit of professing to do, cito,
tuto, et jucunde: and where a cure is out of the
power of our art, the same principles lead to
means of relief by which life is made comfortable
for a long period, during which the patient if left
to nature would be consigned to misery. The
time may come, when, guided by yet undiscovered
knowledge, and new and more direct principles,
the tendency to tubercular and other morbid forma-
tions may be surely checked ; chronic inflamma-
tions readily cured ; and fever suspended in its
first movements. But the day of these triumphs
is yet distant.

Hoffmann mentions it as the first criterion of a
man skilled in the medical art, to know " cur et
quare hoc vel illiud alimentum ad valetudinem
conservandam morbosque sanandos salutare vel
minus tale sit dicendum ;" and he quotes with de-
served praise the eulogium of Thuanus on Holle-
rius, a famous physician of Paris, who by constant
meditation had so improved his judgment, that he
often cured those ill of such deplorable maladies
as the other physicians of the time, « riding rapidly
through the streets," (per vicos vaga cursitatione
mulos fatigantibus,) knew little or nothing about
We may confidently recommend to the student
the diligent perusal of the works of the admirable

ZTJZ , \ m vel """isauctos motus sedent ae no-
dercntur, vel depressos et impeditos excitent, promove-
ant et rursus a;quci es reddant. Opera omnia, Prefet.

MEDICINE, PRACTICAL (PRINCIPLES OF)

279

physician whom we have here and already more
than once quoted in this article. His learning and
admirable good sense, the liberal spirit in which
he viewed all parts of medicine, his discrimination
as regards the innumerable controversies existing
in his time, his wise direction of the medical prac-
titioner's mind to things concerning which the
senses could give information, things useful and
about which men could speak reasonably, — « quse
in sensus incurrunt, qua; usum habent, et de qui-
bus cvidens ratio constat et dare potest,'' — rather
than to subtile disquisitions relating to things more
obscure ; — these and many other merits have not
only endeared his name to learned physicians, but
to liberal scholars, from the time when his writings
appeared to the present day. Notwithstanding
the subsequent undoubted advancement of medi-
cine, there are few pages of his voluminous works
to which the practical physician may not yet refer
with advantage.

The number of writers in whose publications
any specific notice of the abstract principles of
medicine is to be found, is not very great. We
do not mention writers professedly on the practice
of medicine, whose works are like the separate
articles of this work, illustrations of principles.
Many valuable observations occur in Baglivi,
(Opera Omnia, Lugd. 1733), and many ingenious
ones in Cabanis, (Du Degre de Certitude de la
Medicine) ; the works of M. Broussais, amidst
much false and much doubtful theory, contain
views and principles both original and important.
In Dr. Heberden's Commentaries will be found a
sensible chapter, De Ratione Medendi, and another
in Dr. Gregory's Conspectus Medicinae Theoreti-
cs, with the same title. Dr. Burne made it the
subject of an excellent oration delivered to the
Medical Society of London a few years ago, and
since published. And we may mention, that in
the Outlines of Pathology, just published by Dr.
Alison, the English reader is for the first time pre-
sented with so clear, condensed, and comprehen-
sive a view of the whole subject of disease, as can
hardly fail to lead those who read it with care and
reflection to a knowledge of the principles by
which their practice should be regulated in all
diseases.

At the same time, no reading nor reflection can
make a good practitioner. Like an able orator,
he must add to all the rules of his art daily habit
and practice. His mind must be continually pre-
sented even with numerous examples and illustra-
tions to guide and assist his judgment, and to cor-
rect the errors of reasoning on a practical subject.
The symptoms of disease may be well understood
and remembered, and the general principles of
practice; but the treatment of diseases compre-
hends a multiplicity of details, essential or indis-
pensable to the cure, and yet which easily, or
almost inevitably, escape the memory of him who,
although thoroughly grounded in the principles
of medicine, is not continually exercised in pre-
scribing for the sick.

The great utility of teaching by examples, se-
lected at the bed-side, or by what is called clinical
teaching, so long neglected in this country, and
for the introduction of which we owe so large a
debt of gratitude to Rutherford and Cullen, begins
to be universally acknowledged. The full benefit

of this admirable method will be the inheritance
of another generation. A long existing defect in
this respect has doubtless obscured the principles
of practice, and in many instances quite shut
them out of the practitioner's view during his
whole life.*

But, if so engaged and so prepared, — by the
principles already mentioned, and by others here-
after to be discovered, or by additional means of
fulfilling the indications of medicine, the practi-
tioner of the medical art has the privilege of feeling
assured that he is useful ; and the art itself, thus
guided, and in every stage of its imperfection even
to its final advancement, will continue to be of
most singular service to mankind ; relieving the
sick, to use the expressions of Hippocrates, from
the greatest of evils, from diseases, from pains,
from sadness of mind, and from death.

By no one circumstance, we would add, will
the practitioner find himself more assisted in his
practical efforts, more enriched in practical re-
sources, and better able to command them in all
emergencies, than by the cultivation of a sincere
and anxious desire to relieve his patients from
whatever physical evils oppress them : — in all the
varieties of his practice, no other feeling will so
surely and so happily stimulate his mind.

J. CONOLLY.

MELiENA. — This name (/uAaiva voxtcos, the
black disease,) was adopted by Sauvages from the
writings ascribed to Hippocrates, to designate a
genus of disease which he defines, " Alvifluxus
materia? nigricantis, atro-rubrse, dejectione aut
vomitione frequenti notatus ;" and this is the
sense in which it is generally employed by modern
nosologists and practical writers. We mean,
therefore, by melsena, the occurrence, as a symp-
tom in any disease, of very dark-coloured, gru-
mous, pitchy, often highly-fetid evacuations by
stool, commonly joined with sanguineous vomit-
ing ; or we use the word as the name of a disease
in which such evacuations, with or without vomit-
ing of blood, constitute the characteristic symptom.
In these two senses authors speak of symptomuHc
and idiopathic meloena; but even where the latter
phrase is with most propriety employed, the
hemorrhage may generally be traced to some con-
stitutional disorder or local organic disease as its
primary cause. It has been mentioned in the
article Hjematemesis, that there is so close an
affinity between that disease and meltena, that
often they are not easily to be discriminated.
Hoematemesis is properly an hemorrhage from
the mucous membrane of the stomach, and is
chiefly characterized by vomiting of blood : me-
Icena properly consists in hemorrhage from the
mucous membrane of the small membrane, and is
chiefly characterized by the dark evacuations by
stool which have just been described. But as

*For an account of Dr. CuIIen's clinical teaching in
Edinburgh, the reader is referred to Dr. John Thomson's
recently published life of Cullen. Every pupil of the
great school of Edinburgh must rejoice to see the reputa-
tion of one of -its greatest founders, and one to whom
practical medicine is so immensely indebted, placed in
its true light by a man of learning and science, and res-
cued from the superficial criticism in which it has of late
years been too much the habit of a certain class of wri-
ters and lecturers to indulge when mentioning Dr. Cu
len's practical works.

280

MEL^NA.

these two symptoms very frequently concur in
the same case, — as blood poured out by the sto-
mach is often carried downward into the intes-
tines, and blood elTused in the duodenum may
pass upwards through the pylorus into the sto-
mach ; and as, moreover, these two hemorrhages
are so much akin to each other in their seats,
their causes, pathology, and treatment, a distinc-
tion between them is not always easy, and is
seldom practically important. There exists, how-
ever, sufficient distinctions between them in all
these respects to make it proper to treat of them
separately in a system or a dictionary of medicine.

Si/nonymes. Mi\aiva vovcos 1 (Hippoc. de Mor-
tis, lib. ii.) Morbus niger; Fluxus spleneticus ;
Mekena splenetica (Sauvages); Secessus niger
(Hoffmann).

The description of the fi/Aaiva vovaos by the
author of the treatise "On Diseases" ascribed to
Hippocrates, is rather a matter of literary curiosity
than of any practical importance. It is in the
following words, translated as literally as the
English idiom will permit: —

" The patient vomits black bile (/uAatvav), re-
sembling lees of wine ; at other times a matter
resembling blood. Sometimes the matter vomited
resembles the second wine, (olvov rbv Sevrepov, that
obtained by putting the grapes into the wine-
press :) sometimes it is like the ink of the cuttle-
fish ; sometimes it is acid, like vinegar ; sometimes
it consists of saliva and thin phlegm ; sometimes
of greenish bile. When the black blood-like
matter is vomited, it smells like putrid or sanious
blood ((Wei olov <p6vov S^eivY The fauces and
mouth are scalded by the acrimony of the vomit ;
it sets the teeth on edge, and effervesces with the
earth on which it falls; (this is probably the
meaning of rhv y'iv a'ipu.) When the vomiting is
over, temporary relief ensues ; but the patient
cannot bear. either emptiness or fulness of the
stomach, the first causing flatulence and acid
eructations, the latter a sense of weight at the
preecordia, and a feeling as if the breast and back
were pricked with sharp instruments. There are
aching pains of the sides ; a slight fever ; the
sight grows dim ; and the patient is unable to
stand. His complexion turns dark-coloured, and
he becomes emaciated." Such is the description
of the disease : the treatment it is unnecessary to
give at length, even were it possible to render it
faithfully. As far as we can understand it, it
consisted in purgatives given frequently, (jpdp/iaKov

■xin'iaKtiv Oapia,) emetics, ((papfiaKOTToaias ras avoi,)

and afterwards venesection, if not forbidden by
debility ; a diet of whey, milk in the proper sea-
son, and whatever is cooling and laxative, ex-
cluding sweet, oily, and rancid articles ; emollient
clysters, if required on account of costiveness ; a
great quietude, and regularity of regimen. " If
these things be done," adds our author, " the dis-
ease, as age advances, is removed, even if it re-
mains in the habit till old age. But if the skin
assumes a dark hue, it (quere, the colour or the
disease?) will continue till death."*

* Hippocrat. irepi vovawv, lib. ii. ad finein. Opera, p.
486, edit. Foe'sii, Geneva 1 , fol. 1507. The writer of this
article has had the kind assistance of a friend distin-
guished by his philological attainments in revising the
above translation. The last passage is scarcely intelli-

It is remarkable that the above description con.
tains not a word respecting the black discharges
by stool, which, with Sauvages and the moderns,
characterize melama, though this sympton (l™-
Xu>p^fara piXara, bico'tov aTp.a) is often mentioned
in other parts of the Hippocratic writings.

Hoffmann treats at considerable length of hae-
matemesis and melaena, the latter of which (vomi-
tus cruentus cum secessu nigro) he considers by
far the more dangerous form of the disease, and
identical with the morbus niger of Hippocrates.
(Opera Omnia, torn. ii. p. 214.)

Sauvages introduced the name of melama to
denote this particular disease. He makes it a
distinct genus, and assigns to it several species,
some of which appear to be founded on observa-
tion, if not on correct pathology ; others are hy-
pothetical and fanciful.

Although Cullen has omitted melaena in his
catalogue of diseases, he gives some account of it
in his " First Lines," principally with reference
to its pathology.

Morgagni, Haller, Lieutaud, Tissot, (Epist. ad
Zimmermann. Epistols Medico-Practicae, 12mo.
Lausannae, 1782,) but especially Portal, (Me-
moires sur plusieurs Maladies, torn. ii. pp. 129,
seq.) have, among continental writers, mainly
contributed to advance our knowledge of the his-
tory, pathology, and treatment of this disease,
The series of cases and dissections recorded by
Portal are particularly worthy of diligent perusal.

In the publications of our own country, Dr.
Francis Home, (Clinical Exper. and Hist p.
127,) Dr. Marcard, (Edin. Med. Commentaries,
vol. iv. p. 203,) and more recently Dr. Brooke
(Irish College Transactions, vol. i. p. 124,) and
Dr. Cheyne (Dublin Hosp. Reports, vol. i. p. 259,)
of Dublin, Dr. Ayre, (On Marasmus, pp. 113,
117, first edit. 1818,) and Dr. Belcombe, (Med.
Gazette, vol. iv. p. 109,) have recorded instructive
cases and dissections of this disease. But there
are few subjects in pathology which stand more
in need of fuller and more careful investigation.

General history and symptoms. — Melama, as
well as hematemesis, so generally occurs as a
symptomatic affection, that a description can
hardly be framed which shall embrace all the va-
rious symptoms by which it is accompanied, ac-
cording to the various causes which produce it. A
much better notion of these will be gathered from
a perusal of the cases above referred to, especially
those so admirably detailed by Portal, than from
any general description. The following may, how-
ever, be taken as a comprehensive view of the
usual course of what has been termed idiopathic
melaena.

The patient has for a considerable time shown
symptoms of progressive constitutional disorder;
the functions of the stomach have become debili-
tated ; those of the liver and the bowels are im-
perfectly and sluggishly performed. The counte-
nance has assumed a sallow, dusky, or " leaden"'
hue ; the adnata; of the eyes have become dull or

gible, but seems to indicate that the disease in question
is one of a very chronic nature and slow of removal;
Tavra iroiuv K ai ap.a rfj ^Aua'17 aKoQcvycrat Kai r, voBW.
tt Kai KarayfipaaKti avv r«3 (ni^arr rjv Si ptXavOfi, irvva-
noOvfiaKtt. The two other diseases, called aWr, ' ,xi\aim

V c Z°»rl & l n \ '^^w l>8««) have nothing to do with
our present subject.

MEL^JNA.

281

greenish ; the tongue is furred and clammy, or
more or less dry ; the breath often tainted. The
pulse is habitually frequent, or is periodically ac-
celerated towards evening ; in other cases it is
intermitting and irregular; and there are palpita-
tions of the heart, or a pulsation at the epigas-
trium. The symptoms altogether are those of
aggravated dyspepsia, to which are often super-
added those of visceral congestion. On examina-
tion of the abdomen there is to be felt a circum-
scribed enlargement of general tension and ful-
ness in one or more of the abdominal regions ;
sometimes also tenderness to the touch. Upon
the occurrence of any exciting cause of hemor-
rhage, an attack of melama is induced, which is
most commonly, but not always, accompanied by
hematemesis, and at any rate with the same or
very analogous symptoms. After complaining of
much precordial oppression and anxiety, tensive
pain of the hypochondria, or dull pain at the
scrobiculus cordis, with nausea, general uneasiness
of the abdomen, and more or less tormina, — to-
gether with the common hemorrhagic symptoms
of giddiness, coldness of the extremities, a tenden-
cy to faint, &c. — the patient is suddenly seized
with vomiting of dark-coloured blood, together
with a discharge, by stool, of blood of the same
appearance, or more frequently of a very dark and
often extremely fetid semi-iluid mass, of the con-
sistence and colour of tar. Sometimes this dis-
charge by stool occurs without any vomiting : it
is invariably accompanied by great faintness and
exhaustion. Occasionally the black matter dis-
charged by stool is mixed with blood of more
unequivocal appearance, or with dark-coloured
bile, which may be distinguished from the former
by dilution with water; which brings out a yel-
lowish or greenish tinge. In some comparatively
rare cases, the matter discharged by stool and vo-
miting is of a sooty blackness, (owv tt6\vttov Qohbv,
Hippoc.) has no smell, and assumes neither a bil-
ious nor sanguineous tinge on dilution with water:
this appears to be the true melanosis of the an-
cients. For some time after the cessation of the
hemorrhage the patient remains in a very weak
and precarious state, extremely liable to its recur-
rence, and requires to be carefully watched. Even
after the attack appears to be entirely over, a pre-
disposition to its return remains, and unless this
be overcome by medical treatment, or by the re-
sources of the constitution, it will in most cases
ultimately prove fatal.

Appearances on Dissection. — Although a
considerable number of dissections of patients
whp have died of this disease have been recorded,
the subject is one which stands in need of much
further investigation with a view to a satisfactory
pathology of the several varieties of melsena and
hematemesis. It is sufficiently established, by the
researches of Portal, Andral, and other morbid
anatomists, that no lesion of the mucous mem-
brane of the stomach and intestines, except in
some very rare cases, is to be met with in cases of
gastric and intestin 1 hemorrhage. (See Hema-
temesis.)

In a few cases partial reddening, softening, and
oozing of dark-coloured fluid (similar to that dis-
charged during the disease) is stated by Portal to
have been observed in the villous membrane of

Vol. III. — 36 x'

the bowels. Morgagni records a case where the
whole tract of the intestines was found " horribly
inflamed." But much more frequently no trace
of disease is discovered in the stomach and intes-
tines ; these organs have on the contrary been
found remarkably pale and exanguious, (Mor-
gagni) while marks of congestion appeared in the
turgescence of the mesenteric and gastric veins,
loaded with dark-coloured blood. (Portal.) Chro-
nic enlargement or structural disease of the liver
and spleen has been found in cases where the
symptoms had led to suspect them to exist during
life. It is highly desirable that in future investi-
gations not only the state of these viscera be most
carefully examined, but also the condition of the
circulating system, and especially of the heart and
great vessels, morbid alterations in which have
only of late begun to attract a proper degree of
attention, as causes of venous congestion and of
passive hemorrhage.

Causes. — The predisposing and exciting causes
of gastro-intestinal hemorrhage have been pretty
fully considered in the article Hematemesis, anii
therefore it is not necessary to prolong the present
article, by recurring at any length to this part of
the subject. Organic disease, a cachectic or greatly
debilitated state of the constitution, sedentary em-
ployment, intense anxiety and close application to
business, and a full and stimulating diet, with ne-
glect of air and exercise, are the most usual pre-
disposing causes, to which must be added fretful-
ness and irascibility of temper. These causes are
most apt to induce a predisposition to melsena in
males about the age of forty-five or fifty, in females
about the time of the cessation of the menstrual
periods. The exciting causes are those which oc-
casion hemorrhage in general, as intemperance or
any kind of excess, but especially any violent
mental emotion or struggle, and none so frequently
as a burst of passion. This has often induced not
only a first attack of melsena or hematemesis, but
the same cause has given rise to its recurrence at
several times, when the patient seemed to be going
on favourably, and to the final catastrophe, by
bringing on a last and fatal attack. This is well
illustrated in Portal's first case, (that of the bota-
nist Aublet,) and furnishes a most important cau-
tion as to the moral management of patients who
are predisposed to, and especially who have alrea-
dy suffered from this disease. Irritating and dras-
tic purgatives are well known to occasion bloody
stools, when injudiciously employed, and some-
times when given with every proper precaution:
but they can hardly be supposed to induce a true
attack of melsena, unless where a great predis-
position exists.

Varieties of Melsena* — It is important in
melsena, as in hematemesis, to distinguish with as
much accuracy as possible the varieties which ex-
ist in the disease, or the species into which it may
be distinguished, according to the nature of its
causes, the kind of constitution in which it occurs,
and the series of symptoms which precede or ac-
company it. It is evident that on such discrimi
nation alone, a rational pathology or judicious the-
rapeutical system can be founded. The fullest
and most accurate enumeration of these varieties
which has yet been made, is that of Portal. (Op
citat. p. 211.) His species are the following:- -

282

MELJENA.

1. melcena supervening in acute (continued) fevers;

2. preceding, accompanying, or following intermit-
tent fevers ; 3. supervening on strong mental emo-
tion, cases of which are so common ; 4. following
suppression of hemorrhoids or other habitual eva-
luations, and especially supervening on the cessa-
!ion of the menses ; 5. depending on the effect of
gout upon those organs in whose substance the
vena porta? is ramified ; 6. that arising from scur-
vy, whether from this disease occasioning, as it
often does, congestion of the spleen and liver, or
from an alteration in the quality of the blood; 7.
occurring in dropsy, either from the compression
produced by the fluid effused in the abdomen, or
from the accompanying organic disease of the liver,
spleen, and other viscera. This division is evi-
dently not strictly pathological, but it is much pre-
ferable to that of Sauvages, and may be useful to
those who have leisure and opportunity for a fur-
ther investigation of this very important subject.
Portal illustrates each of his proposed species by
reference to his own cases, and to some instances
furnished by other authors. Pinel's division into
species, of hematemesis, (Diet, des Sciences Me-
dicates, art. Hematemese, torn, xx.) (under which
he comprehends melaena,) may also be consulted
with advantage, but not implicitly adopted. Dr.
Mason Good's division of melaena into two species,
(melaena cholxa and melaena cruenta,') appears
captivating by its simplicity ; but he is evidently
mistaken when he professes to derive it from Hip-
pocrates ; and moreover he starts with a generic
definition totally at variance with the usual accep-
tation of the term melaena, and which seems to
rest wholly on the dark hue of the skin, the only
circumstance common to melaena, (the melaena
cruenta of Good,) and the green jaundice described
by Dr. Baillie, (his melaena cho/sa.)

Pathology* — This branch of the subject has
been in a great measure anticipated in the article
Hematemesis. It may, however, be useful to
take a brief review of the opinions which have
been adopted respecting the nature of melcena by
pathologists. The notion universally entertained
before the time of Hoffmann and Morgagni, was
that melaena depended on a flow of black bile, or
of dark venous blood (for these terms seem to have
been almost convertible, bills atra, melancholicus
humor, fxx sanguinis, &c.) from the spleen,
which was supposed to be its great reservoir, into
the stomach and intestines, through the veins called
vasa brevia. The latest supporter of this opinion
was Van Swieten ; but it is not very easy to un-
derstand what he means by atrabilis.

According to Hoffmann, melaena consists of a
true hemorrhage from some of the viscera of the
abdomen, most commonly from the small intes-
tines; but in conformity to the notions of his time,
he conceived that this could only take place by the
rupture of a vessel. He therefore supposes that
the branches of the meseraic veins ramified on the
inner surface of the ileum are ruptured in conse-
quence of impediments to the return of the blood
through these veins, in hypochondriacal and he-
morrhoidal subjects, in whom this disease, he says,
chiefly occurs; from which impediments follow
» distensions, spasms, and congestion in those ves-
sels, and finally effusion." {Hoffman, op. citat.
p. 214.) Cullen adopts Hoffmann's view of this

disease : he considers it to be a venous hemorrhage,
from obstructed circulation in the vena porta; and
its branches ; he thinks that its causes are of the
same nature with those which give rise to the he-
morrhoidal flux ; but does not deny that in some
cases there may be a true atrabilis, producing the
symptoms of melaena. (First Lines.) Portal chiefly
differs from Hoffmann and Cullen, in referring he-
matemesis and melaena to arterial hemorrhage
from the stomach and intestines, occasioned by
the afflux of blood by the arterial branches being
greater than the corresponding veins can take up;
maintaining that this is mostly owing to the com-
pression of the trunk or branches of the vena
portae, occasioned by obstructions not merely of
the spleen, as was formerly thought, but also of
the liver, pancreas, mesentery, and other viscera of
the abdomen. The opinions of Portal, modified
by the doctrines of Bichat and his school, respect-
ing arterial exhalation from mucous membranes,
constitute the now generally adopted pathology of
melaena and hematemesis. (See Hematemesis.)
The dark colour of the blood, as has been observed
by Portal, (and the observation is as old as Are-
taeus,) does not prove that the blood is derived
from the veins, for the fluid and gaseous contents
of the alimentary canal will act upon it after it is
poured out, and deprive it of its bright colour.
Perhaps this explanation of the intense blackness
and pitchy appearance of the stools in melama, is
not quite satisfactory. Dr. Ayre has ingeniously
contended, that as no trace of lesion is generally
found in the mucous membrane on dissection, the
hemorrhage which constitutes melaena and hema-
temesis does not take place from the capillary ex-
halants of the mucous membrane, but from the
extreme minute ramifications of the vena porta? in
the glandular texture of the liver. He argues that
a certain degree of congestion of that important
viscus will occasion an excessive and vitiated se-
cretion of bile, constituting the common autumnal
cholera, and the various modifications of bilious
disorder ; but that when this congestion occurs in
a still greater degree, the extreme branches of the
vena portae are so distended that they cease to se-
crete bile, and pour out the dark and highly car-
bonized blood which oppresses them, unchanged ;
that this is taken up by the biliary pores and con-
veyed by the gall-ducts to the duodenum, whence
it either regurgitates into the stomach, or is carried
down the course of the intestines. Dr. Ayre con-
ceives, therefore, that melaena and hematemesis
scarcely differ, but in degree, as to the pathological
condition which occasions their symptoms, from
cholera and other bilious disorders ; and he accord-
ingly proposes the same treatment for both. (Ayre
on Marasmus, 1st Edit. 1818.) These views are
certainly ingenious, and, if established, would be
highly important. But the arguments adduced
by Dr. Ayre in his work are not conclusive ; and
his theory must still be considered as an hypothe-
sis which may not impossibly afford the true ex-
planation of some cases of hematemesis and me-
laena, where there is evidence of hepatic conges-
tion existing in a great degree.

The pathology of melaena is still an obscure
and very interesting object of inquiry. It is highly
probable that in certain cases it depends not so
much on mechanical obstruction and congestion

MELJENA.

283

of the blood in the veins of the abdominal organs,
as on a change in the physical and perhaps vital
qualities of the blood itself, (Andral, Pathol. Anat.)
which gives it a tendency to escape every where
from its vessels. Such a state seems manifestly
to exist in certain cases of purpura and of scurvy,
in fevers of the typhoid type, and in some malig-
nant varieties of small-pox, in all of which melaena,
as an occasional symptom, occurs. Fully to de-
velop this as yet mysterious condition of the
blood, its dependence on the state of the nervous
system, its connection with the nature of fevers
and other diseases, is a problem of the greatest
importance and difficulty in pathological science.

Though we have considered melsena as altoge-
ther a hemorrhagic disease, yet it may be proper
to notice two cases in, which the symptoms may
closely resemble those of hemorrhage, yet not be
truly such. The first is a discharge from the in-
testines of very dark and putrescent bile secreted
in abundance from some irritation or congestion
of the liver ; the second, a truly melanotic dis-
charge, proceeding (as supposed by Dr. Marcard
in the case related by him,) from the breaking
down of what he calls an atheromatous encysted
tumour, in fact a mass of melanosis, either con-
nected with the liver or alimentary canal, or else
perhaps from a secretion of matter of the same
kind from the mucous membrane of the stomach
and intestines. The production of melanosis is
not well understood. Does it consist of blood
very little altered ? Is the black matter vomited
in cases of scirrhus pylorus for a considerable
time before death, of the nature of melanosis ?

Melanotic matter is distinguished from the san-
guineous dejections of melaena by the absence of
smell, and by the effect of dilution with water.
The latter circumstance distinguishes it also from
bile.

[A variety of melaena would seem to be pro-
duced by morbid secretion from the mucous folli-
cles, (Copland, Diet, of Pract. Med., art. Me-
l;e?ja ;) and of this nature are, doubtless, the
black discharges, which the writer has repeatedly
seen, where the lining membrane of the intestines
has been long irritated under the use of mercurial
and other cathartics.]

Diagnosis. — Except the two cases just men-
tioned, and that of hematemesis, the discrimina-
tion of which from melsena (as they may jointly
occur, and at any rate require similar treatment),
is not practically important, melasna cannot re-
quire to be distinguished from any other affec-
tions, except hemorrhage arising from ulcerations,
wounds, and injuries of the intestines, (which are
not properly to be referred to melaena,) and the
hemorrhoidal discharge. From the latter, where
any necessity arises for discrimination, a better
diagnosis cannot be laid down than that of Hoff-
mann, who says that melsena is to be distinguished
by the tormina and spasmodic pain by which it is
accompanied, and the imminent danger of death
in which it places the patient , whereas the hemor-
rhoidal discharge is free from spasmodic pain of
the bowels, and brings relief to any uneasiness
which previously existed. Ulceration of the bow-
els is known by peculiar symptoms, which will be
pointed out in treating of that affection.

Prognosis. — Melaena is almost always a

symptom portending considerable danger. The
only exceptions to this are where it occurs as a
truly critical hemorrhage in fevers, or where it is
attendant on hematemesis in young and plethoric
females of unbroken constitution, and with vica-
rious or suppressed menstruation. The profuse
discharge of blood, the debilitated state of the sys-
tem in which it often occurs, and the organic dis-
eases with which it is apt to be complicated, are
the circumstances which constitute the danger by
which its degree is to be estimated. The putres-
cent blood effused into the intestines and stagna-
ting there, acting as a poison upon the nervous
system, or re-absorbed into the circulating mass,
was thought by Hoffmann to be the chief source
of danger in this disease ; and hence the great
stress which he and others of the continental
writers laid on clearing out the bowels by laxative
clysters.

Treatment. — In the treatment of melaena, we
have to deal with an intractable and too often an
incurable disease, and almost always with an
enfeebled and exhausted habit. Organic disease
is always to be suspected in chronic cases, and
where the disease occurs in advanced life, or in
persons much exhausted by sedentary labour and
anxiety, or weakened by intemperate habits, it is
commonly a symptom of what is popularly but
expressively termed " a breaking-up of the consti-
tution." There is, therefore, little scope for ac-
tive, much less for heroic remedies. Both during
the hemorrhage and in the intervals, or after its
cessation, the greatest quiet is to be enjoined ; all
disturbance of mind or body is to be sedulously
avoided. The strength must be supported by the
mildest nourishment, in such regulated quantities
as not to disturb the stomach. The bowels must
be kept open by the gentlest means, as castor-oil
and mucilaginous clysters ; nervous irritation is to
be allayed by camphor and hyoscyamus. Opium
and stimulating anti-spasmodics are to be avoided.
Refreshing and antiseptic beverages, as lemonade,
whey, &c. may be allowed in moderation ; wine
only where the debility is such as to require it,
and where there is no febrile movement in the
pulse ; regard being also had to the constitution
and previous habits of the patient.

Respecting astringents, we may refer to what
has been said in the article on Hematemesis ;
observing only that they must in the case of me-
lsena be employed with still greater caution. This
applies especially to the more powerful remedies
of this class. The mineral acids are useful rather
as refrigerants and gentle tonics than as astrin-
gents. Where more of a styptic effect is required,
the diluted sulphuric acid should be preferred ;
where a tonic or alterative effect is wished, the
nitric. Dr. Mason Good recommends in prefer-
ence the vegetable acids, and particularly the
acetic. The remedy which has acquired the
highest reputation as a styptic in melaena is the
oil of turpentine. It appears to have been first re-
commended by Mr. Adair, in the fourth volume
of "Medical Facts," &c. Dr. Brooke, of Dublin,
and Dr. Cheyne, have since published cases illus
trative of its employment, which have been already
referred to, and Dr. Elliotson, in his published
lectures, has borne testimony to its usefulness
Dr. Brooke gives three cases, in all of which the

284

MELANOSIS.

hemorrhage was effectually and promptly arrested
by the remedy when other treatment had failed.
One of his patients died shortly afterwards, but
the case was one of long standing, and probably
connected with organic disease of the stomach ;
but this could not be ascertained, as inspection of
the body was not allowed. The other two cases
were doing well at the date of the paper, but only
a short period had elapsed. It is evident that the
oleum terebinthinae, however successful in arrest-
ing the hemorrhage, has no influence on the pri-
mary cause of the disease, and therefore can be
esteemed only a valuable palliative remedy. The
formula employed by Dr. Brooke was the follow-
ing:

K Olei terebinthinae, guttas xxv.

Aquae cinnamomi, f.^i.

Syrupi aurantii, f.£i.
M. fiat haustus ter die sumendus.

In Dr. Cheyne's case the result was less favour-
able, but the circumstances of it are not the less
instructive, especially as it illustrates a caution
given by Hoffmann, that astringents given in me-
laena are, in cachectic habits, likely to produce " a
sudden transition to dropsy." A profuse melaena
had continued two days. The patient, (a tailor,
aged twenty-four, and of cachectic habit,) was
growing weaker and weaker, when a " small
dose" of ol. terebinth, was ordered to be taken
every second hour. Dr. Cheyne does not state
how many doses were taken ; but it stopped the
hemorrhage, but at the same time " seemed to
lock up the bowels, so that for nearly three days
he was without a stool, his abdomen all the while
increasing in bulk. On the 16th, (the ol. tere-
binth, had been prescribed on the 11th,) there
was evident fluctuation, and the stools, when at
length obtained, consisted of hardened colourless
faeces. First, crystals of tartar, then blue pill
with squills, were given, which last affected his
mouth in two days, and were discontinued. On
the 28th, having taken a purgative, the hemate-
mesis and melaBiia recurred ; it continued two
days, and the tension of the abdomen diminish-
ing, he grew very weak and faint, and died on
the 30th. The dissection is given at length, but
need not be inserted here. Dr. Cheyne candidly
owns that the treatment in this case was too ener-
getic ; that with more of expectancy the patient
might have lived longer. This is an instructive
point of the case : another important one is, the
alternate morbid excess of action in the serous
and the mucous exhalants — a fact often to be
noticed in practice, and in the present instance
affording a valuable caution against the too free
use of astringents in certain hemorrhages.

When the hemorrhage is arrested without any
such unfavourable concomitant events, we must
endeavour to support the strength of the patient
by moderate restoratives, according to the circum-
stances of the case, and do what we can to obviate
the recurrence of hemorrhage by proper regimen,
and medicinal treatment directed to the primary
disease. This must necessarily vary according to
the nature of the case, and it is unnecessary here
to enter into the details of the various treatment
which may be required in particular cases. The
histories related by Portal may furnish some va-
luable hints if read with due discrimination, and

allowance for national peculiarities of opinion and
practice. His favourite remedies appear to have
been leeches to the anus, and a course of very
gentle alteratives, such as lime-water with infusion
of camomile, of taraxacum, and other cichoracea?,
pills composed of soap and bitter extracts, clysters,
tepid bathing; and in cases where a more tonic
treatment was indicated, he prescribed the waters
of Vichi, (a saline chalybeate highly impregnated
with carbonic acid gas,) cinchona, and the mode-
rate use of sound wine. In old and feeble per-
sons especially, he found the best effects to result
from the employment of the two last mentioned
articles. George Goldie.

MELANCHOLIA. See Insanity.

MELANOSIS, from /u>a?, black, and vdcros, dis-
ease. — Syn. Melanoma; [black cancer, black
tubercle ;] tumeurs melaniques ; degenerescence
noire ; cancer noire ; cancer melane.

The term melanosis is employed to designate a
morbid product, the distinctive character of which
consists in a dark brown or black colour, of va-
rious degrees of intensity.

Although there can be no doubt that many of
the ancient physicians were aware of the existence
of the disease, — at least in some of its forms,
which we are about to describe, — there is no such
description of it in their writings as would lead
us to believe that they regarded it either as a dis-
tinct disease, or in any other point of view than
as one of the many local or general morbid states,
which they supposed to originate in the predomi-
nance of one of the four elements — the atrabilis
— of their humoral pathology.

The first account of this disease (the discovery
of which is claimed by Dupuytren) was given by
Laennec, in the Bulletins de la Faculte de Mede-
cine de Paris, in 1806, and it was then named by
him melanose.

This distinguished pathologist describes mela-
nosis as an accidental product, possessing a degree
of consistence equal to that of the lymphatic
glands, a deep black colour, a homogeneous tissue,
somewhat humid, opaque, and presenting an ap-
pearance similar to that of the tissue of the bron-
chial glands of the adult. He says that it after-
wards becomes soft, when there oozes out from it,
on pressure, a yellowish red, thin fluid, mixed
with small black particles, which are sometimes
firm, at others friable, but still presenting a certain
degree of flaccidity to the touch. At a more ad-
vanced period of this softening process, the parti-
cles, and soon afterwards the remainder of the
mass of which they form a part, becomes quite
friable, and is converted into a kind of liquid pulp-

The same author regards melanosis as occur-
ring under the four following forms : viz., 1, that
of masses enclosed in cysts (Melanoses enkys-
tees) ; 2, that of masses without cysts (mito-
ses non enkystees) ; 3, that of infiltration in the
tissue of organs ; 4, that of deposition on the sur-
face of organs.

A liquid form of melanosis (which is, in fact,
the fourth kind of Laennec) has since been ad-
mitted by pathologists. Laennec not only knew
of the existence of the disease under this form,
but has even described it, although he has not
given it a place among what he conceived '.o be

MELANOSIS.

285

the essential forms of the disease. This circum-
stance, which some may consider as an oversight
on the part of Laennec, is obviously to be referred
to a fundamental error in the pathological doc-
trines which he maintained regarding the mode of
formation, development, and termination of acci-
dental or new products ; for he believed that all
these products possessed at first a greater or less de-
gree of density, to which state he gave the name of
crudity; and that they afterwards undergo at
some period or other of their existence, by means
of some change taking place within themselves,
a process of solution, which he describes as the
period or state of softening. The idea, therefore,
of melanosis existing primarily in a fluid form
was repugnant to such doctrines ; consequently
this form of the disease could not be admitted by
him into the class of accidental tissues, to which
he conceived melanosis to belong.

The division of melanosis, as to its forms, es-
tablished by Laennec, has been adopted, with some
slight modifications, by almost every author of
note who has treated of this subject. The results
of more recent researches, however, on melanosis
and other morbid states and products which pre-
sent the same distinctive physical character as the
former, seem to us to suggest the necessity of a
different arrangement of melanotic formations, and
to warrant us in proposing one, which, we think,
will comprehend all the forms and conditions
under which these formations have been observed
to occur.

Melanotic formations may take place in various
and different parts of the body ; may present con-
siderable variety in the forms which they assume;
and may owe their production to the operation of
very different agents.

These circumstances do not appear to have
been well understood, or their importance suffi-
ciently appreciated, as Laennec has confined his
description of melanosis to one kind only of black
deposit ; whilst Breschet,* Heusinger/f- Noack^
Andral,§ and many others, have included under
the same general denomination various and very
different morbid states and products, because of
their presenting, as their most remarkable charac-
ter, a greater or less degree of blackness. To re-
ject every black discoloration or product which
does not agree in all its characters with those as-
signed to melanosis by Laennec, or to collect them
indiscriminately into one entire group under the
same appellation, as has been done by others,
would obviously render the pathology of melano-
tic formations equally incomplete and inaccurate.
In order to conciliate these differences, and at
the same time to facilitate the study of melanotic
formations, we shall consider the latter as suscep-
tible of being grouped under two head,s, each pre-
senting a certain number of forms, the distinctive
or pathognomonic characters of which are derived
from some peculiarity of seat, origin, or nature.

* Considerations sur une Alteration Organique ap-
pelee d6generescence noire, mclanose, &c, Paris, lfciil ;
Journal de Pliys. Kxper. torn., i. i, No. 4.

| Untersuchungen uber die anomahlie Kohlen ; und
Pigmentbildung. Eisenbacb, MXi ; Archives Gen. de
Medecine, t. v.

J Precis d'Anatomie Pathnlogique, t. i. ; Dictionnaire
de Medecine, t. xviii. art. Mclanose.

§ Comment, de Melan. cum in Homin. turn in equis ob-
venieute, &c. 4to., c. tnb. tao. ajn. Lips. 1826.

In accordance with this plan, we shall compre-
hend all anormal black substances, fluid or solid,
found in the body, under the general title of me-
lanotic formations. When these formations de-
pend (as is the case with several of them) on
some change taking place in the economy, or the
important function of secretion, independently of
at least the direct influence of any external cause ;
or, in other words, when they constitute what is
called an idiopathic disease, we shall consider them
as belonging to the first head, and as deserving
the name of true melanosis.

Other melanotic formations have quite another
origin, being the consequence of the accumulation
of a black material introduced into the body from
without ; the action of chemical agents ; and the
stagnation of the blood. These we propose to
include under the title of spurious melanosis.

We are perfectly aware that these terms are
inaccurate, and that to avoid the ambiguity which
the use of them may create, we might have
arranged all black products or deposits under the
general head of melanotic formations, distinguish-
ing each kind in reference to some peculiarity in
its external form, origin, or mode of production.
By doing so, however, we should not have drawn
a sufficiently marked line of separation between
these anormal products, which, as we have already
said, differ in their nature, and offer only one com-
mon externa] character by means of which they
can be recognised by the practical pathologist.

The following tabular view will show at once
the nature of the arrangement which we have
adopted :

Classification of melanotic formations.

I. TRUE MELANOSIS.

Origin. A modification of secretion.

Locality. 1. Tissues, systems, and organs.

a, in the substance and on the

surface of organs.

b, in the cavities of hollow organs.
2. IVew formations.

Form. 1. Punctiform.

2. Tuberiform.

3. Stratiform.

4. Liquiform.

Seat. 1. Molecular structure of organs.

2. The blood.

II. SPURTOCS MELANOSIS.

Origin. A. Introduction of carbonaceous mat-
ter.

B. Action of chemical agents.

C. Stagnation of the blood.
Locality. Of first kind : the lungs.

Of second kind : the digestive or-
gans ; the surface of serous and
mucous membranes ; the cavities
of hollow organs ; new forma-
tions.

Of third kind : the blood.
Form. Of first kind : uniform.

Of second kind : 1. punctiform ;
2. ramiform; 3. stratiform; 4
liquiform.

Of third kind : punctiform and
ramiform.

286

Seat.

MELANOSIS.

1. The blood, contained in its proper
vessels, or effused.

2. Pulmonary tissue: cellular and

membraneous.

From a very cursory view of the several cir-
cumstances included in the above arrangement, it
will readily be perceived that melanotic formations
must differ very materially from each other both in
their composition and conformation.
I. — True Melanosis.

Locality of tlie Disease. — The cellular and
adipose tissues are much more frequently found to
present the true melanotic deposit than any other
tissue of the body. Here, also, the quantity of
the deposit is infinitely greater than in any other
texture, and is always in proportion either to the
quantity of this tissue, considered as a simple ele-
ment, or as a component part of organs ; or to the
facility with which it admits, from its situation, of
mechanical distension. Hence the reason why
the largest masses of melanotic deposit have been
found in the retro-peritoneal cellular and adipose
tissues.

It is also of importance to know that melanosis
may occur in either of these tissues separately.
Marked examples of it, confined to the cellular
tissue, are common in various parts of the body ;
and the most striking example of its circumscribed
existence in adipose tissue is observed in the ap-
pendicular epiploicse, or the fatty appendices of the
colon, these bodies being sometimes converted into
a homogeneous solid mass of melanotic matter.

Occurring, besides, as a primary affection of
these tissues, the melanotic matter frequently ex-
tends to those situated in the immediate vicinity
of the former, which it penetrates, or in which it
forms excavations of various sizes, on account of
the compression and subsequent absorption to
which they have been subjected during the pro-
gressive development of this morbid product.

It is also by means of the cellular tissue that
melanotic tumours spread to a great extent along
the course of the blood-vessels and nerves, be-
tween the folds of the mesentery, and in the cavity
of the pelvis, and where, on account of the size
which they attain, they sometimes give rise to
very serious consequences, to which we shall more
particularly allude hereafter.

Mucous Membranes. — The melanotic deposit,
notwithstanding what has been said to the con-
trary, has very rarely been observed in mucous
tissue. We ourselves have only met with one
example of it in this tissue, and it was even
doubtful whether the deposit had its origin in the
mucous or submucous tissue, both of them being
simultaneously and contiguously affected.

Skin. — An opposite opinion has been enter-
tained regarding the production of melanosis in
this tissue, viz. that when found in" the skin, it
was to be regarded as the extension of that which
existed at the same time in the subjacent cellular
or adipose tissues. Such is frequently the source
of melanosis of the skin ; but we have found it
to exist as a primary affection of this tissue, par-
ticularly in the horse. In this animal the melan-
otic matter may be seen occupying the very centre
of the cutis vera in the form of black points, or
varying from the size of a hemp-seed to that of a

large pea, whether the subjacent textures contain
any of the black deposit or not.

Muscular, arterial, and venous tissues ,• serous
and synovial membranes,- aponeurosis, tendon,
and cartilage.— These have not, so far as we are
aware, been found to contain any trace of the me-
lanotic deposit as a primary disease. All of them
may present the dark brown or black colour of
melanosis, but this arises from contiguity, the im-
bibition or infiltration of the black matter when
in a state of fluidity, or from other causes of a
very opposite kind, to which we shall particularly
direct the attention of the reader in a subsequent
part of this article.

Bone. — The bones are not often affected with
melanosis; the spongy bones, as the sternum,
more frequently than others.

Liver. — Of all the compound tissues or organs
the liver is by far the most frequently affected with
melanosis : in this respect it is inferior only to the
cellular and adipose tissues. The frequent occur-
rence of the disease, as well as the extent to
which it proceeds in this organ, are no doubt in
great measure to be attributed to the predominance
of the cellulo-vascular element which enters into
its composition. We shall, however, endeavour
to show that the melanotic deposit is not confined
to this element, but that it invades, as a primary
formation, the molecular structure of this organ.
Lungs. — Notwithstanding the supposed fre-
quency of melanosis in the lungs, it is by no
means so often observed in this organ as in the
liver ; nor, perhaps, does it ever acquire the same
extent as in the latter, although we are aware that
cases have been recorded of the whole of both
lungs being filled with it. This form of the dis-
ease will be considered under spurious melanosis,
to which division of our subject we conceive it
ought to be referred.

Brain. — Few cases of true melanosis of this
organ are recorded by pathologists. We have
only met with one case, the particulars of which
will be related when we come to consider the
physical and other characters of melanotic forma-
tions. Dr. Hooper (The Morbid Anatomy of the
Human Brain, pi. xii. figs. 2 and 3) has represented
a case of true melanosis of the brain.

Melanosis of the kidney has been occasionally
met with. It is also found in the testes and ova-
ries ; and Andral says that it occurs in the uterus.
It has also been seen in the breast.

The pancreas and lymphatic glands in several
parts of the body, and the thyroid and parotid
glands, have presented the disease in various
forms.

Melanosis of the eye has been frequently ob-
served by surgeons, either alone, or combined with
other morbid products.

Examples of melanosis occurring in the cavities
of serous and mucous membranes are given by
various authors; and Breschet, Cruveilhier, and
Andral, have described it as existing within the
veins. We have also had occasion to observe it
in these cavities ; but it is the spurious melanosis
which has, in general, been observed in these situ-
ations, and has been described as examples of the
true kind.

Blood.— The presence of true melanotic matter
in the blood is an important fact, and one which,

MELANOSIS.

287

under favourable circumstances, may be easily as-
certained.

It has chiefly been in the minute veins of the
liver that we have observed melanosis as a primary
formation in the blood. The vessels which, in
this organ, contain the melanotic matter, appear
like black lines, stria?, or dots, and sometimes in a
pencillated form, all of which appearances may be
recognised as originating in the ultimate extremi-
ties of the veins of the liver, most probably the
hepatic.

We are not disposed to believe that the black
ramiform appearance so frequently seen in the
lungs is owing to the presence of true melanotic
matter in the extreme branches of the veins. Such
may sometimes be the case, although we have not
been able to satisfy ourselves that it really is so.
The black colour of the contents of these vessels
we rather attribute to the simple stagnation of the
blood, and to the subsequent removal of that, the
production of the red colour. A similar vascular
arrangement of black matter has also been seen in
the vessels of the stomach, and described as me-
lanosis by several pathologists. But in this case
error is conspicuous. The writer of this article
has shown in another publication* that the black
colour of the blood, not unfrequently seen in the
vessels of the stomach, in the cavity of this organ,
and in that of the intestines, is the result of a
chemical process, and is always observed when
the blood in these parts is either directly or indi-
rectly brought in contact with the acid products
which they contain : melanotic formations of this
kind naturally take their place among those of
spurious melanosis.

The existence of the matter of melanosis in the
blood accounts satisfactorily for its being some-
times met with in the cavities of some secreting
organs. It is also said to have been found in the
saliva and bile, and likewise in the sweat and
urine, in which last fluid a dark colouring matter
was found by Dr. Marcet, which has received the
name of melanic acid. The presence of melano-
tic matter in these secretions does not, however,
appear to us to have been proved, except in the
serous and mucous. It has, however, been ob-
served in the medulla of bones, and in the hu-
mours of the eye.

Melanotic fluid may be found in cavities, either
natural or accidental, without its being the product
of their secretion. This happens when melanotic
tumours perforate the walls of these cavities, and
pour their fluid contents into them. This we
have observed in the thorax and abdomen ; and
in one case a melanotic tumour had perforated the
right lateral ventricle of the brain, in which was
found a considerable quantity of black fluid, which
afterwards passed into the third and fourth ventri-
cles, and thence into the theca vertebralis. Such
also is, in general, the source of the melanotic
fluid found in accidental cavities.

The production of melanosis, scirrhus, carcino-
ma, and encephaloid formations in the same organ,
and even in the same diseased mass, is occasion-
ally met with.

* Recherchessurla Dissolution Chimiqueou Digestion
des parois de l'Estomac apres la mort, &x. Journal Heb-
domadaire de Miidecinc, 1830. No. 87, p. 351. No. 91,
p. 517.

The simultaneous existence of melanosis with
these diseases, and the real or supposed analogy
which the former presents in regard to its mode
of development, progress, and termination, when
compared with the latter, have induced some pa-
thologists to consider melanosis as a species of
cancer : how far this opinion is founded in truth,
we shall not at present stop to inquire.

Such is, we believe, a correct, though general
statement of the topography of melanosis. We
shall now endeavour to describe the various
forms which it assumes in the different tissues,
systems, and organs of the body.

Of the Forms of True Melanosis.

1. Punctiform Melanosis. — Of the four forms
under which we have included the true melanotic
deposit, the first is that in which the black colour-
ing matter appears in minute points or dots,
grouped together in a small space, or scattered
irregularly over a considerable extent of surface,
and which we have termed punctiform. These
appearances are most frequently met with in the
liver. The cut surface of this organ appears as
if it had been dusted over with soot or charcoal
powder. When examined by the aid of a lens,
the black points sometimes present a stellated or
pencillated arrangement, which in some cases can
be distinctly seen to originate in the ramiform ex-
pansion of a minute vein filled with black matter.
At other times the melanotic matter appears to be
deposited in the molecular structure of the organ
in a manner similar to that of the organizable part
of the blood. In such cases it consists of the
most minute points disseminated throughout the
acini or little lobules of the liver, and which then
assume a uniform grey aspect. The various shades
of grey and black which the liver presents when
thus affected, depend on the greater or less quantity
of the black punctiform injection ; and we are in-
clined to believe that the melanotic tumour in this
organ has, sometimes, a similar origin. We have
always found the two forms, the punctiform and
tuberiform, combined in the liver, lungs, and also
the kidney. The " infiltration des organes par
la matiere des melanoses" of Laennec is, in many
instances, owing to the punctiform dissemination
of the melanotic matter. In others it is obviously
produced, as Laennec believed, by the simple dif-
fusion of the liquid black matter throughout the
tissues of an organ more or less remote from the
part where it was formed. It is likewise to be
attributed to general venous capillary congestion,
or the effusion of blood, and the subsequent
changes which this fluid undergoes, to be men-
tioned hereafter.

Punctiform melanosis is not observed in the
brain, cellular, adipose, serous, and fibrous tissues
It may take place in mucous membranes ; but its
occurrence must be rare, as we have already said
that we have only seen one case of melanosis of
this tissue, in which the submucous tissue was
affected at the same time.

2. Tuberiform Melanosis. — This is by far the
most common of all the forms of melanosis. The
bulk of the melanotic tumour varies greatly, and,
as we have already said, always acquires its maxi-
mum in loose cellular and adipose tissues : some-
tfmes not larger than a pin's head, at others it
equals in bulk the head of a child, or even that

288

MELANOSIS.

of an adult. It is, however, only in the horse
that it acquires such an extraordinary size ; in
man it is seldom larger than an orange.

The great size of melanotic tumours depends
on the agglomeration of smaller ones, the number
of which varies with the size of the aggregated
mass, or with that of the individual tumours of
which it is composed.

The melanotic tumour, when single, is always
of a spheroidal or ovoid form ; and when aggre-
gated, presents a lobulated appearance. In com-
pound tissues or organs it is more frequently
found single ; in the cellular and adipose tissues,
aggregated.

In both of these forms it has been described as
encysted and non-encysted. It is said to be en-
cysted when contained in a membranous capsule,
and non-encysted when it lies in immediate con-
iact with the tissue of the organ in which it is
seated.

The encysted melanotic tumour does not, so
far as our observation extends, occur, unless in a
very imperfect state, in any of the compound tis-
sues. It is chiefly found in the cellular and adi-
pose tissues, a circumstance which the nature of
the tissues sufficiently explains. The cyst of the
tumour consists of cellular membrane — not of new
formation — stretched out in the form of a thin
transparent covering, from the gradual accumula-
tion of the black melanotic matter contained within
it. Hence melanotic tumours of the latter tissues
are always provided with an external covering,
which, as it not only adheres closely to them, but
generally forms a constituent part of their internal
arrangement, is separated from the loose surround-
ing cellular tissues when these tumours are re-
moved, and which are therefore said to be con-
tained in a cyst.

The tuberiform arrangement of the melanotic
matter contained within a cyst is not confined to
the cellular tissue as a simple element, or to those
organs in which this tissue is more or less abund-
ant. We have found it on the surface of the
pleura and peritoneum in man, (^Transactions of
the Medico-Chirurgical Society of Edin. vol. i.
p. 279, and Edin. Med. and Surg. Journal, vol.
xxvii. p. 151,) and also in the horse. In this
situation the melanotic tumours frequently assume
a pedunculated appearance, being suspended by a
slender neck, like some polypi, and are covered by
a thin transparent serous membrane. Under such
circumstances it is often difficult to determine
whether the serous covering of these tumours is a
new product, or merely an extension of pleura or
peritoneum produced by the gradual accumulation
of the melanotic matter in the cellular tissue be-
neath these membranes ; and' the difficulty of the
case is increased if there exist at the same time,
and in the same organ, tumours of a similar nature
either in the sub-serous cellular tissue or in the
parenchyma which it covers. Instances, how-
ever, have occurred which have afforded us the
means of determining the seat of these extra-pleu-
ral and extra-peritoneal melanotic tumours. Thus
we have seen these tumours co-existing with the
more simple forms of the melanotic deposit, such
as stria; or patches, consisting of a fluid or semi-
concrete black matter lying on the free surface of
the pleura or peritoneum, and enclosed in a fine,

loose, spongy tissue, or serous covering of consi-
dcrable tenacity, although almost equal in tenuity
to a spider's web. The pleura and peritoneum
beneath the melanotic deposit were perfectly en-
tire, and therefore the solid material, whether cel-
lular or serous tissue, in which it was enclosed,
must be regarded as a new formation. The in-
ference which we would draw from this is, that
the melanotic tumour may, in some instances,
have a similar origin, viz. in the deposition of me-
lanotic matter on the surface of the serous mem-
branes, and the subsequent or simultaneous forma-
tion of a tissue, which afterwards acquires the
solidity and characters of a general serous enve-
lope.

Melanotic tumours of the pleura pulmonalis
and costalis are found either solitary or aggregated
in considerable number, and vary in bulk from the
size of a pea or less, to that'of a cherry. When
they are found in the peritoneum, it is generally
where this membrane receives the name of epi-
ploon.

4. Stratiform Melanosis. — This form of the
melanotic deposit occurs only in serous surfaces :
it presents two degrees or stages. In the first the
black matter is so sparing in quantity that the
serous membrane on which it is deposited pre-
sents an appearance as if it had been painted with
ink or stained with a deep brown or black colour.
In the second the black deposit is more copious,
forms a distinct layer on the surface of the serous
membrane, above which it is seen to project. The
consistence of the matter thus deposited resembles,
in general, that of firm jelly, and is enclosed, as
we have already said when speaking of the pre-
ceding form of melanosis, either in a soft spongy
tissue, or fine transparent serous membrane of new
formation ; so that, when pressed, it feels pulpy,
but is not removed by a scalpel being passed over
it, unless some force is employed.

This form of melanosis is described by Andral
and others as occurring frequently on the perito-
neum in chronic peritonitis. Such, however, is
not the case. The " melanoses de'posees sous
forme de couches solides a la surface des mem-
branes," described by this author, is of a diame-
trically opposite nature to that which we are now
discussing under the appellation of the stratiform.
It is the result of the chemical action of certain
fluids and gases, formed in general in the digestive
organs, on the blood contained in the vessels of
the pseudo-membranes of the peritoneum, or effused
into the substance of the one, or on the surface
of the other, as we shall endeavour to demonstrate
when we come to treat of this mode of production
of melanotic formations.

The stratiform melanosis of serous membranes
has not been observed to any extent in man. In
the horse it is sometimes considerable in degree
and extent, and is chiefly found on the peritoneum,
pleura, and pericardium.

4. Liquifurm Melanosis. — The appearance of
melanosis in a liquid form has in general been
confined to natural or accidental cavities into
which it has been supposed to be poured by a pro-
cess somewhat analogous to that of secretion. This
is certainly one of the modes to which its presence
in these situations is to be attributed ; but it is also
owing, as we have already remarked, to the effu-

MELANOSIS,

289

sion of the same substance during the softening
process of melanotic tumours ; and it may also be
observed that some of these tumours, when en-
cysted, are found to be composed entirely of the
black fluid or semi-fluid matter of melanosis. We
shall, however, confine our description of the liquid
form of melanosis as it occurs in natural or acci-
dental cavities.

Among the former, the cavities of the pleura
and peritoneum furnish almost the only examples
in which liquid melanosis has been observed, and
that, too, in very small quantity. We have never
seen it in man, and rarely in the horse.

The mucous cavities, particularly in the sto-
mach and intestines, are mentioned by several pa-
thologists as furnishing, not unfrequently, exam-
ples of the presence of melanosis under this form.
But in this instance, as in those to which we have
already more than once alluded, in which other
forms of melanosis are supposed to have their seat
in the mucous tissue itself, the same mistake has
been committed : the blood, either effused into
these cavities or contained in the vessels of their
proper tissue, and having been submitted to the
influence of an external chemical agent, being in
general the material thus improperly denominated.

As an example of accidental cavities in which
fluid melanosis has been found, we may mention
the serous cysts which form in the ovaries, and
the capsules of the ova which have escaped from
these bodies.

Whatever form the melanotic deposit may as-
sume, it is never, so far as we know, confined to
one tissue or organ only ; on the contrary, it is
found to pervade a greater or less number of these
simultaneously or successively ; being, in some
cases, equally extensive every where ; in others,
small in quantity in one organ, while in another
it is so abundant, that hardly any of the natural
texture is to be perceived. The tuberiform deposit
is the most conspicuous and prevalent of all the
forms which this morbid product assumes.

General Characters of Melanosis*

1. Physical Characters. — These comprehend
chiefly the colour, bulk, and consistence of the
several forms of melanosis which we have de-
scribed.

The colour of melanosis, whether in the solid
or fluid state, although always tending to black,
frequently presents various shades of brown, such
as that of bistre or China ink, having either the
dull aspect of soot, or the glossiness of pitch. The
black colour and glossy aspect is more frequently
met with in inferior animals than in man ; and in
both, these appearances are most marked when
the melanotic deposit exists in the form of a firm
tumour. It is hardly necessary to observe that
the quantity of cellular tissue intermixed with the
melanotic matter, as well as the presence of a cer-
tain quantity of blood, give rise to a greater variety
in the shade and depth of colour than this sub-
stance would otherwise present.

The bulk which the melanotic deposit may ac-
quire is sometimes very considerable even in the
human species. It may form irregular or lobu-
lated masses in the cellular tissue as large or
larger than the fist ; and in parenchymatous organs,
such as the liver, it acquires the bulk of a hen's
egg, or even that of a small orange. In the cel-

Vor.. III. — 37 z

lular tissue, the larger masses are almost always
produced by the union of smaller ones, although
in one instance we found in this situation a single
tumour as large as a hen's egg. In the liver,
single tumours of a large size are more common
than in any other of the compound tissues, or
even the cellular tissue, for the reasons which we
have already stated. In the horse, the aggregated
melanotic tumour has sometimes been found to
weigh from twenty to thirty, and even forty pounds.

The consistence of melanosis, as we have al-
ready seen, presents great variety : there are two
circumstances which seem to determine the degree
of consistence which it is found to present when
examined in situ : these are the texture and the
form of the part in which the deposit takes place.
Thus it is never found solid in large cavities, such
as the abdominal and thoracic, for the plain rea-
son that its diffusion is not limited by dense un-
yielding tissues. Even in tumours attached to the
serous covering of these cavities, it is found for
the same reason either perfectly fluid or not more
dense than animal jelly. In loose cellular tissue,
too, one, two, or a limited number of cells, more
or less distended into the form of small tumours,
are occasionally found to contain the black matter
in a fluid state. In the dense texture of the cutis,
on the contrary, even the smallest tumours may
be nearly as hard as cartilage, and are generally
as firm as the pancreas. In the lymphatic glands,
and in the brain, the melanotic tumour acquires
only a medium degree of consistence, although it
is generally firmer in the former than in the latter,
on account of the capsule of the glands acting as
a compressing cause. In the liver and lungs we
perceive the same relation between the structure
of these organs and the consistence of the mela-
notic tumours formed in them. In both they are
pretty firm ; much about the consistence of a
lymphatic gland ; from the black matter being con-
tained either in the capillaries, molecular structure,
or cellular texture of these organs.

It is an important fact that the conditions of
texture and form, or the composition and con-
formation of the tissue or organ in which the
melanotic deposit takes place, determine almost
exclusively the degree of consistence which this
morbid product, and indeed every other, presents
when examined in situ. That absorption and
imbibition exercise a certain influence in modify-
ing, under certain circumstances, the consistence
of this matter, cannot be doubted, inasmuch as
they are known to give rise to very marked
changes in the consistence of some other morbid
products. We have, however, already shown that
the operation of either of these modifying causes,
as regards the consistence of melanosis, must be
very limited, since there is always a direct rela-
tion between the consistence of this morbid pro-
duct and the conditions of the tissues which we
have named, in which it is received and retained.
It is indeed from a knowledge of this pathological
fact that we are led to believe that the primary
condition of melanosis is that of a fluid, formed or
collected in the capillaries and minute cellular
areola?, or combined with the solid or fluid ele-
ments of the body. If this fact is not admitted to
be demonstrated by the evidence which we have
adduced, we should then be compelled to adopt,

290

MELANOSIS.

at least in part, the opinion of Laennec, namely,
that melanosis is, ab origine, a solid accidental
product : as to its being a tissue, as it was be-
lieved or said to be by the same author, we shall
inquire by-and-by, when speaking of its anatomi-
cal characters. And to show that this mode of
origin is not peculiar to melanosis, we may men-
tion that tubercle, cancer, and every other morbid
product can be traced to this their primary and
fluid state of formation. In this respect, therefore,
there is no difference between morbid and natural
products. The law is the same in both: the
hardest texture, in the latter, namely, bone, being
in its primitive state a mere jelly, as scirrhous and
accidental bony formations are in the former.
Even calculi do not form an exception to this law,
the bile, urine, and other fluids, in a morbid state,
constituting the primary forms of these bodies, be-
fore their respective elements become tangible to
our senses by means of chemical agency ; and as
the last link in this chain of analogy, the blood —
the fons et origo vitas — may be regarded as the
representative of the primary condition of organiza-
tion in general.

Like all colouring matters in a fluid state, that
of melanosis, when placed in contact with a white
surface, communicates to it its peculiar tint, but
the stain thus produced is readily removed by ab-
lution. In its natural state, or when mixed with
water, exposed to the air it becomes dry, brittle,
and pulverizable, and does not emit the odour of
putrefaction until after a long period. When
burnt, it swells, gives out a great deal of smoke,
a marked empyreumatic odour, and is converted
into a carbonaceous substance. It is quite opaque,
and has no marked odour or taste.

2. Anatomical Characters of Melanosis. — Seve-
ral of the anatomical characters of melanosis have
already been enumerated in the description which
we have given in the different forms of this
disease. When speaking of what is called the
encysted melanosis, we explained the reason why
this appellation had been employed, namely, that
the single or aggregated masses of melanotic mat-
ter found in the cellular tissue are enclosed in and
united together by a capsule of the same tissue
stretched out by the gradual accumulation of this
matter. This membranous covering (for it is not
a cyst) is generally so thin and transparent, that
the black colour of the melanotic matter is hardly
if at all obscured by it. If the tumour be simple,
and a quantity of the black deposit has been
washed out of it, a multitude of fine filaments
and lamella? are seen connected with the mem-
branous covering of the tumour, traversing the
substance of the latter in every direction, and pre-
senting an appearance resembling cellular tissue
when distended with serosity. When a number
of tumours are united into one mass, they are in-
cluded in a common capsule, and separated from
one another by their respective coverings and por-
tions of cellular tissue contained in the angular
spaces sometimes left between them.

It is in these filamentous and cellular tissues
alone, which are obviously not of new formation,
that blood-vessels or nerves are to be seen. Mi-
nute arteries and veins can be seen ramifying in
both, although they are rarely numerous, and we
have never seen them pass beyond the limits of

these tissues. Large branches and even trunks
of arteries, veins, and nerves are sometimes found
passing over the surface, or included in the aggre-
gated masses of melanotic tumours.

There is a considerable difference as to the re-
lative quantity of cellular tissue and melanotic
deposit which constitute these tumours, when ex-
amined in man and in inferior animals. We have
never found the melanotic tumour in the horse to
contain much cellular tissue: indeed, it is some-
times impossible to detect its presence until after
the tumour has been macerated and the black
matter squeezed out, when there is found to re-
main a small quantity of extremely fine, soft, cel-
lular tissue. In man, on the contrary, we have
seen it at least equal in quantity to the black
matter in tumours nearly as large as a goose's
egg formed in the subcutaneous cellular tissue.
An example of this kind of melanotic tumour,
which we had an opportunity of examining in
the recent state, is now preserved in the museum
of the Royal College of Surgeons in Edinburgh,
and a drawing of it is in the possession of Dr.
Thomson, the distinguished Professor of Patholo-
gy in the university of that city. The cellular tissue
was remarkably conspicuous, in some points almost
as dense as fibrous tissue, formed bundles which
intersected one another in various directions, and
thus formed irregular cells of various dimensions, in
which the melanotic deposit, of the consistence of
fluid pitch, but without tenacity, was contained.

We have stated that the blood-vessels are con-
fined in their distribution to the cellular tissue,
which enters into the composition of melanotic
tumours, and that they are never seen to penetrate
the black deposit. There is, however, one kind
of tumour, already alluded to, which is almost
entirely formed of blood-vessels and a black or
deep brown fluid. We formerly expressed a doubt
whether this tumour should be regarded as one of
the true melanotic kind, by reason of its anatomi-
cal composition being an exception to that ob.
served in all others. This kind of tumour we
have only met with once, and so far as we know
there is only one other example of a similar kind
on record. The subject of our case was an old
man, between seventy and eighty years of age,
brought to the Hotel Dieu of Paris in a state of
incomplete paralysis, and incapable of giving any
account of himself. He lived several days ; had
little or no fever or excitement of any kind. The
paralysis soon became complete and general, and
he died in a state of collapse and profound stupor.
On examining the body after death, black or deep
brown coloured tumours, two of which were as
large as a hen's egg, occupied both hemispheres
of the brain. One of them had made its way
through the walls of the right lateral ventricle,
poured a quantity of the black fluid with which it
was impregnated into this cavity, which had passed
from thence into the opposite ventricle, the third
and fourth, and along the spinal cord to its infe-
rior extremity. Although these tumours were al-
most entirely surrounded by the medullary sub-
stance, they must have been seated originally on
the external surface of the brain between the con-
volutions ; for they were intimately connected
with the pia mater, the blood-vessels of which
constituted by far the greater part of their bull

MELANOSIS.

291

The blood-vessels were crowded together in par-
allel bundles at their exit from the pia mater, be-
came tortuous in the substance of the tumours,
some of them having nearly a line in diameter ;
were reflected backwards at their extremities in
the form of irregular interlaced groups, towards
which two or three small arteries coming from the
pia mater were seen to distribute themselves.
The black colouring matter of these tumours was
very abundant, nearly as fluid as ink, and was con-
tained not only in the loose cellular tissue which
separated the blood-vessels from one another, but
likewise in the vessels themselves. The veins
(or large tortuous vessels described above) were
completely filled with it, whilst the arteries, mi-
nute as they were, were distinctly seen to carry
red blood. The medullary substance was slightly
reddened and somewhat soft where it was in con-
tact with one of the large tumours only. The
cortical substance of the convolutions contained
three or four melanotic tumours rather larger than
hemp-seed. They were quite unconnected with
the pia mater, were not composed of blood-vessels
like the others, presented the usual consistence of
melanosis, and contained but a minute quantity
of cellular tissue.

Besides these black tumours — vascular and
non-vascular — there was one of another kind,
about the size of a small cherry, situated in the
brown substance of the corpus striatum of the
right hemisphere. Instead of being black, it was
of a reddish grey colour, and was traversed by a
great many minute vessels filled with red blood.
It was nearly of the same consistence as the
others, but, when pressed, discharged a small
quantity of a milky or creamy looking fluid.
After having been submitted for some time to
ablution and gentle pressure, it assumed an ap-
pearance somewhat similar to that observed in the
black vascular tumours : its tissue was of a spongy
reticulated character, of a dull red colour, and
vascular. There was no tumour of a similar
kind in any other organ of the body ; but as it
participated in the characters of erectile and car-
cinomatous formations, we may mention at pre-
sent that there existed a somewhat analogous
disease of the right parotid gland. This body
formed a large oblong tumour, composed of a
substance partly of a scirrhous and partly of a
mammary aspect and consistence, grouped into
irregular masses of various sizes, surrounded by
a considerable degree of ecchymosis. At its
upper extremity and on a level with the ear
there was a melanotic tumour of a firm consist-
ence and homogeneous aspect, as large as a
Spanish nut. This tumour had perforated the
external auditory canal, and projected into its
interior.

Black tumours, similar to those of the brain,
were also found in the abdominal viscera. The
duodenum contained one, the ileum five, and the
epiploon one. In the intestines they appeared to
be seated in the submucous cellular tissue, and
formed the bottoms of black ragged ulcers occu-
pying the mucous membrane. They were of a
round or oval shape, flat, the largest of them
about an inch in diameter. The one found in
the epiploon was nearly as large as a walnut. It
was attached to one of the prolongations of this

covering, between which and the tumour there
existed the same kind of vascular connection as
between the pia mater and some of the tumours
in the brain : it presented likewise the same in-
ternal structure as the latter. Those which were
found in the submucous cellular tissue did not
present any peculiarity of structure.

The above description contains the most of
the anatomical facts of any importance connected
with this interesting case, which occurred under
the care of Dr. Meniere, while interne in the
Hotel Dieu, and to whom we feel much indebted
for the opportunity he afforded us of examining
and delineating the appearances we have de-
scribed. When shown to Baron Dupuytren, he
pronounced the case to be one of melanosis ; or,
in his own language, cancer noire; his opinion
being obviously founded on the colour of the
tumours, without any regard to their structure.

Dr. Meniere, on the contrary, who has had ex-
tensive opportunities of examining diseased struc-
tures, considered it to be a case of fungus hsema-
todes, the vascular organization of the tumours
constituting, according to him, the essential cha-
racter of the disease ; whilst the black colour was
merely an accidental circumstance of very inferior
importance. We ourselves are of opinion that
neither of these notions is borne out by the ana-
tomical facts of the case as above related ; and
had we not already extended this part of our
article beyond the limits usually assigned to de-
scriptive details in a work of a practical nature,
we should have furnished collateral evidence suf-
ficient to show that both opinions are exclusive,
incomplete, and inaccurate. We shall, therefore,
only make a few remarks, with a view to our
being justified in placing for the present this case
in the division of true melanosis. And first, we
have two or three melanotic tumours of the ordi-
nary kind in the cortical substance of the brain ;
one in the parotid, or in a carcinomatous tumour
found in that gland ; to which we may add those
of the intestines ; we have here, therefore, as far
as regards these tumours, a case of true melanosis.
Secondly, there existed a large tumour behind the
ear and in the parotid, presenting the most marked
characters of scirrhus and cancer. Here, then,
we have a case of cancer, but not of fungus hse-
matodes. Thirdly, we have the black vascular
tumours of the brain. The question is — did they
present the anatomical characters of scirrhus,
cancer, or fungus haematodes ? Certainly not.
They were no doubt vascular, but must not on
that account be identified with carcinoma or fun-
gus haematodes, for the essential character of both
of these was wanting, viz. a fluid resembling
milk or cream, or a substance of the colour and
consistence of brain ; and, besides, carcinoma and
fungus haematodes do not necessarily possess a
high degree of vascular organization.

The production of the black vascular tumours
of the brain may be accounted for as follows .
The original state of these tumours we believe to
have been the same as that of the small tumour
situated in the corpus striatum, and which, we
said, was of a compound nature, from its struc-
ture resembling that of erectile tumours, and the
fluid it contained being similar to that which is
found in carcinomatous tissue. The melanotic

292

MELANOSIS.

fluid, which we found deposited in the usual way,
that is to say, in the form of small, dense, homo-
geneous tumours, in several points of the brain
and elsewhere, appears also to have been deposited
in these erecto-carcinomatous tumours, after they
had acquired considerable bulk. Thus the black
fluid which they contained, (which we have no
reason for believing differed in any respect from
that contained in those that were not vascular,)
instead of being deposited in the form of a homo-
geneous mass, assumed the form and arrangement
of the anatomical elements of these tumours, that
is to say, was collected in the veins and cellular
tissue of which they were composed. From these
remarks on the origin and mode of production of
the black vascular tumours of the brain, we do
not hesitate to say that, in the strict sense of the
term, they do not merit the appellation of true
melanotic tumours, but that they ought to be con-
sidered as examples of melanosis taking place in
a tissue of new formation, just as it is found to do
in other tissues, whether healthy or diseased.

The other case of vascular melanosis to which
we alluded is mentioned by Lobstein. (Traite
d'Anatomie Pathologique, tome premier, p. 461.)
The patient was an emaciated old woman, be-
tween eighty-five and ninety years of age. The
inspection of the body was made by M. Alex.
Lauth, and also delineations of the melanotic
tumours. Besides melanosis of the spongy sub-
stance of the inferior third of the femur, there
were several black tumours on the anterior region
of the neck, and a large one in the inferior lobe
of the right lung. The former appeared to be
encysted ; they were of a round form, and tabu-
lated ; the most of them movable under the skin,
and were formed of a plexus of veins coming from
the neighbouring veins, which became dilated as
they approached the tumours. All these vessels,
not only those which penetrated, but also those
which formed the tumours, were filled with a deep
brown substance, having, from the presence of an
irregular filamentous tissue, an appearance of
organization. In some of the veins, the substance
which filled them adhered firmly to their internal
surface, and seemed continuous with their tissue,
although the latter differed from the former, from
its being firmer and of a whitish colour.

The matter contained in the tumour in the
lung was fluid, and as black as ink ; it was infil-
trated into the pulmonary parenchyma, which
was reduced to a filamentous tissue. However,
when minutely examined, this tissue was found
to be composed of arteries and veins, swimming
in the melanotic fluid, and containing a quantity
of it in their interior.

Although the author of this observation does
not speak of any other morbid product having
been found in the body, except a small horny ex-
crescence on the left side of the thorax, we feel
satisfied that the vascular tumours which he has
described were precisely of the same kind as those
of which we have just given a description. The
most important circumstance in both cases was
the presence of the melanotic matter within the
blood-vessels of the tumours. In Lobstein's case,
it appears to have been contained in the arteries
as well as veins, whilst in ours it was observed
only in the latter. In either case, the presence

of melanosis in the blood is clearly demon
strated. Venous absorption might be considered
by some sufficient to explain its presence in the
veins ; but it was also found in the arteries ; and
besides, we have already shown that its existence
in the veins of the hepatic tissue is prior to, and
independent of, its presence in the cellular tissue,
or its combination with the molecular structure
of this organ.

3. Chemical Composition. — The melanotic de-
posit in the fluid and solid state has been sub-
mitted to very minute chemical analysis in this
country and on the continent ; the uniform result
of which shows that melanosis bears a strong
analogy in its composition to that of the blood.
The most complete analyses of melanosis that
have been published, are those of Lassaignc and
Barruel,* in France, and of Dr. Henry, of Man-
chester. (A case of melanosis, &c, by Thos
Fawdington.) We shall not enter into the de-
tails of the analysis of the melanotic deposit fur-
nished by each of these able chemists, but shall
content ourselves by giving the facts thus elicited,
which seem to prove that the composition of this
morbid product is very similar to that of the
blood ; referring the reader for further information
to the works mentioned below.

Mons. Lassaigne found the melanotic tumour
of the horse composed of — 1st. coloured fibrine;
2d. a black colouring matter soluble in weak sul-
phuric acid, and in a solution of the subcarbonate
of soda, each of which becoming at the same time
of a red colour j 3d. a small quantity of albumen;
4th. muriate of soda, subcarbonate of soda, phos-
phate of lime, and oxide of iron. According to
Mons. Barruel, melanosis of the human subject is
essentially composed of the colouring matter of
the blood, united with fibrine, both of them "se
trouvant dans tin etat particalier," and three
distinct kinds of fatty matter. The first of these
is soluble in alcohol at a moderate temperature,
crystallizable ; the second soluble in alcohol at a
boiling heat only, soft, and not crystallizable; the
third fluid at the ordinary temperature of the air,
and of a reddish-brown colour. This chemist
found also a considerable quantity of the phos-
phate of lime and iron.

The following is the result of the analysis ob-
tained by Dr. Henry from a portion of a softened
melanotic tumour taken from Mr. Fawdington's
patient, and after it had been kept some time in
spirit : —

1st. By filtering through paper, much of the
colouring matter remained on the paper, and the
colour of that which passed through was much
less intense.

2d. Boiling does not destroy the colour, nor
even when a little caustic potash has been added.

3d. It is not changed by acids even when heated,
except by nitric acid, which deprives it of its black
colour, and turns it yellow.

4th. A stream of chlorine passed through the
liquid destroys the colour, and throws down light
fawn-coloured flocculi.

5th. A few grains of corrosive sublimate stirred

., f° n sulfations sur une alteration or»anique appelee
degenerescence noire, &c. Par G. Breschet, Chef des
trevaux anatomiques a la Facultede M6decinede Far:*,

MELANOSIS.

293

op with the fluid precipitates the whole of the
colouring matter, and leaves the supernatant liquid
quite clear.

(ith and 7th. Nitrate of mercury and muriate
of tin produce the same effect, but more slowly.
We may also mention that M. Foy (Archives de
M^decine, Juin 1828) found in the melanotic tu-
mour of the horse,

Albumen 15,00

Fibrine 6,25

A highly carbonized principle, pro- } n . .„

bably altered cruor 5 '

Water 18,75

Oxide of iron 1,75

Sub-phosphate of lime 8,75

Muriate of potash 5,00

Ditto soda 3,75

Carbonate of soda 2,50

Ditto lime 3,75

Ditto magnesia 1,75

Tartrate of potash 1,75

From the results of all these analyses it is suffi-
ciently obvious that melanosis is essentially com-
posed of the constituent elements of the blood.
The colouring material of its composition appears,
also, to bear considerable analogy to that of the
blood, and is, according to Foy, a highly carbo-
nized principle. Andral puts it as a query, whether
the fatty substances found by Barruel belonged to
the melanotic tumours analyzed by this chemist,
or to the tissues of the organ in which the tu-
mours were formed ? That these fatty substances
may have become incorporated with the melanotic
matter during its deposition is possible; but it
must also be admitted that they may have been
deposited along with it as constituents of the blood,
inasmuch as it has been shown by Lecanu (An.
de Chim. et Phar. xlviii. 308) and by Dr. B. Ba-
bington, that this fluid always contains in the
healthy state a certain quantity of fatty crystalline
and oily matter.

Seat, Nature, and Origin of Melanosis* —
We must refer the reader to the preceding section
for proofs that the material of which melanosis is
composed is formed in the blood, and afterwards
deposited in the various parts in which it is found.
It is not only because this material is seen in the
blood that we have fixed its seat in this fluid, but
because our anatomical researches show that it is
there formed. The chemical analysis which we
have given of this substance confirms the accuracy
of this opinion, by showing that it is essentially
composed of the colouring matter of the blood.
The separation of this colouring matter, as well
as its disposition, in the form of melanosis, must
be regarded as the result of a process similar to
that of secretion. [M. AI. Cazenave (Did. de
Med. 2de edit. xix. 343, Paris 1839) with MM.
Breschet and Barruel, considers it, indeed, both
from chemical analysis and an examination of
tacts, to be nothing more than modified extrava-
sated blood.] Several pathologists in France and
Germany regard the carbonaceous material of me-
lanosis as having its origin in a modification of
the secretion of the natural pigments of the body,
and more especially of that on which the colour
of the hair and skin depends. This opinion was
first entertained by Gohier, (Memoires et Obser-
vations sur la Chirurgie et la Med. Veterinaire,

z*

Lyon, 1813, torn, i.,) who states that melanosis
probably depends on the increase or diminution of
some of the elements which enter into the com-
position of the body of the white and grey horse
or in some remarkable change in the nature of
the secreted fluids. The carbon, says this author,
which is found in melanosis, is too easily separate;/
by calcination, to permit us to ascribe the colou.
of this disease to any other substance. Breschet
afterwards pointed out the analogy which exists
between the black matter of melanosis and that
which colours the choroid, the uvea, the rete muco-
sum of Malpighi in the negro, and the placenta
of certain carnivorous animals. He regarded,
also, the colouring matter of several morbid secre-
tions as of a similar nature, such as melsena, the
black coating of the tongue in fevers, the fluids
rejected by vomiting in yellow fever, &c. — an
opinion which we consider to be by no means cor-
rect. A similar opinion is, however, entertained
by Heusinger in his researches on the accidental
production of pigments and carbon in the human
body. The following are the deductions which
this author gives as the result of his investiga-
tions: — 1. that all the pigments secreted in the
body in the healthy state are rich in carbon : 2.
that the accidental pigments resemble the natural ;
3. that the anomalous pigments are a modifica-
tion of the colouring matter of the blood ; 4. that
their secretion is intimately connected with that
of the fat ; 5. that they announce the predomi-
nance of the venous system, the want of oxida-
tion, and particularly the decarbonization of the
blood. Some of these deductions, viz. that the
secretion of the colouring matter of melanosis is
intimately connected with that of the fat and the
predominance of the venous system, do not ap-
pear to us to be supported either by the evidence
Drought forward by the author, or by such facts
as have fallen under our own observation ; for
in the many cases of melanosis which we have
seen in man and various kinds of animals, there
did not appear to be any visible connection be-
tween this disease, either with regard to its locality,
degree, and extent, and the secretion of fat, or any
state of the venous system in particular. The
much greater frequency of melanosis in the grey
and white, than in the bay, brown, or black horse,
is a circumstance of some importance, and which
may be regarded as favourable to the theory which
ascribes the origin of melanosis to the accumula-
tion in the blood of the carbon which is naturally
employed to colour different parts of the body,
and more particularly the hair. This theory wo
are disposed to adopt, not only as regards the for-
mation of the disease under these circumstances
of colour, but also when it occurs in animals of a
dark colour, and in man indiscriminately, what-
ever may be the peculiar tint of the skin or colour
of the hair. In the first instance, the colouring
matter formed is not deposited in the regular phy-
siological order ; in the second it is formed in too
great quantity. In both cases its presence and
accumulation in the blood are accounted for. Its
deposition as an anomalous product in various
parts of the body follows, as we have already said,
as a consequence of its separation from that fluid
by a process of secretion.

Causes. — The above remarks antioipate the

294

MELANOSIS.

necessity of any further notice on what is called
the proximate causes of melanosis. With regard
to the remote causes of this disease, particularly
the influence of external agents, it does not appear
to us that our knowledge amounts to any thing
more than conjecture. We know that the devel-
opment of colour in general is favoured by expo-
sure to light, heat, and that combination of physical
agents which constitutes the climate of warm
countries ; and that it is retarded by obscurity,
cold, imperfect sources of nutrition, &c. None
of these facts, however, seem capable of affording
us any explanation respecting the remote origin of
melanosis, still less of its affecting one kind of
animal rather than another. We should have ob-
served before, that melanosis occurs most frequently
towards the decline of life.

Progress of Melanosis. — Under this head,
it is our intention to describe, 1st, The changes
which take place in the melanotic deposit itself;
2d, The changes induced by this deposit in the
tissues and organs in which it is contained, or
with which it is more or less immediately con-
nected.

1st, Changes produced in the melanotic depo-
sit. — Only two changes are observed to take place
in the melanotic matter after its deposition. The
first consists in the inspissation or solidification, the
second in the softening or liquefaction, of the me-
lanotic matter. What we have already said on
the various forms, the physical and anatomical
characters of melanosis, will in a great measure
enable the reader to trace these changes to their
respective causes, and to explain the manner in
which they are produced. We have, we hope,
satisfactorily shown that the material of which
melanosis is composed exists primarily in a fluid
form, and that every increase of consistence which
it afterwards acquires, is owing chiefly either to its
combination with the molecular structure, or the
dense unyielding nature of the tissues or organs
in which it is deposited. In the first instance,
(examples of which were pointed out in the liver,)
its consistence becomes considerable ; in the sec-
ond, it acquires its maximum of density, of which
its development in the cutis vera furnished us with
the most striking examples. When retained in
the vessels in which it is formed, it either remains
in its primitive state of fluidity, (see our case of
melanosis of the brain,) or it acquires a certain
degree of consistence, (Lobstein's case of mela-
nosis of the neck, &c. 1. c.) We also found that
when it is effused on the surface of the serous
membrane, the degree of consistence which it
afterwards acquires depends entirely on the devel-
opment of an accidental serous or cellular tissue
within which it is included. Its various degrees
of consistence in cavities, viz. those formed in the
cellular tissue by its gradual accumulation, are re-
ferable to the same causes; the mechanical resist-
ance offered to its diffusion by the tissues and
organs we have named. These facts regarding
the manner in which the solidification of the me-
lanotic matter is effected, as well as the causes to
which it is to be referred, appear to us so conclu-
sive, that it would serve no good purpose were we
to call in the evidence of analogy furnished us by
the mode of development of other products of a
similar and dissimilar kind, as farther proof of the

accuracy of the opinion which we have just ex-
pressed.

From these facts it follows as a consequence,
that the process of softening cannot take place
until that of solidification has been at least carried
to a certain extent: perhaps it never does take
place until it has been carried to its maximum.
For the softening of the melanotic deposit is ob-
served only when it has acquired the form of a
tumour, or occupies an irregular portion of an
organ. Under these circumstances, the softening
of the hardened melanotic mass is effected in the
two following ways : first, by the destruction of
the tissues included within it and around it ; sec-
ond, by the effusion of serosity caused by its stim-
ulating power as a foreign body. The liver and
lungs furnish the best examples of softening of
melanotic tumours, from the destruction of the
tissues in which they are formed. When a por-
tion of either of these organs is occupied by the
melanotic deposit which has so accumulated as to
compress or obliterate the vessels contained within
it, that pass through it, or ramify in its immediate
vicinity, congestion or death of the parts to which
these vessels are distributed, follows as a necessary
consequence. Besides this cause of effusion, (con-
gestion,) the stimulus of the melanotic tumour is
now more particularly felt, and the serous part
of the blood is poured out in abundance, which,
mixing with the melanotic matter, converts it into
a soft pulp, or a thin dark-brown or black liquid.

It were needless to insist farther on these
changes, or to combat the opinion which Laennec
entertained in regard to the manner in which he
imagined the last process was accomplished : that
melanosis is not a tissue, but an unorganizable
fluid, capable only of a certain degree of solidifi-
cation, must appear obvious to every impartial
pathologist who has had an opportunity of oli-
serving it in the different tissues and organs in
which it is deposited, and under the vaiious forms
which it assumes.

2. Changes induced by the melanotic deposit
in the tissues and organs in which it is contained,
or with which it is more or less immediately con-
nected. — These changes are few in number, viz.
irritation, compression, and ulceration.

We have just alluded to irritation as a conse-
quence of the presence of masses of the melanotic
deposit, and the subsequent afflux of blood to the
surrounding parts. It is seldom carried to the
extent of inflammation and ulceration ; and when
either of these occurs, it is almost always confined
to the tissues in immediate contact with the mela-
notic masses.

Compression, we have also said, may be carried
to such a degree by the gradual accumulation of
the melanotic deposit, that circulation ceases in
the cellular tissue in which this deposit is con-
tained. The same thing also occurs in the cellu-
lar covering of melanotic tumours, and more par-
ticularly in the skin and mucous membrane of the
intestines, when, from the bulk of the tumours,
these tissues become more or less stretched. Hol-
low organs, such as veins, the rectum, and colon,
are occasionally much compressed, nearly or en-
tirely obliterated. These effects, however, are
only observed when the melanotic tumours have
acquired a great bulk, and are, therefore, much

MELANOSIS.

295

more frequently met with in the horse than in
man.

Ulceration is not common as a consequence of
melanosis, and in the cases in which we have ob-
served it, it was obviously to be referred to the
combined operation of the two causes mentioned
above; compression, perhaps, having a greater
share in its production than irritation. Thus we
have only observed it in the skin and mucous
membrane when greatly stretched by melanotic
tumours situated beneath them. We have a very
good example of ulceration of the mucous mem-
brane of the intestines in our case of melanosis
of the brain, &c.; and Breschet gives a case of
ulceration of the skin of the groin produced by a
large melanotic tumour situated immediately be-
neath it. (Loc. cit. p. 10.) Ulceration of the
skin, notwithstanding its great thickness, is more
frequently seen in the horse. The writer of this
article has related a case in which the ulceration
was accompanied with suppuration, and which
may be regarded as an example of ulceration from
irritation rather than from compression and sub-
sequent obliteration of the capillaries. (Transac-
tions of the Medico- Chirurgical Society of Edin-
burgh, vol. i. p. 267.) With regard to the mela-
notic ulcer, its form is sometimes regular, at other
times very irregular ; its edges thin, soft, beveled
from within outwards, pale, or more or less red,
or tinged with black, and a black fluid oozes from
its surface. But if chronic inflammation super-
venes in the tissues surrounding it, these tissues
acquire a considerable degree of thickness from
their being infiltrated with serosity and coagulable
lymph. They thus become hard, and project
around the orifice of the ulcer in the form of a
broad everted border, or form on its internal sur-
face a number of irregular projections or excres-
cences. When cut through, a grating sound is
produced, and the cut surface presents a pale grey
colour, such as is observed in scirrhus.

Ulceration from melanosis of other tissues and
organs of the body has very rarely been met with.
Bayle relates two cases of what he conceives to
be ulceration of the lungs as a consequence of
the softening of melanosis, (Recherches sur la
Phthisic. Pulmonaire, obs. xx. and xxi.) and
which are considered in the same point of view
by Laennec. (Traite d'auscult. mediate, &c. torn,
ii. p. 31.) But we agree with Andral in think-
ing that they were cases of tubercular excavations
or dilatations of the bronchi, the pulmonary tissue
around them being the seat of chronic inflamma-
tion, and infiltrated with what is called black pul-
monary matter.

Symptoms and Diagnosis of Melanosis.
-Among the various modifications of function
to which melanosis gives rise, we do not believe
that the most careful examination will enable the
physician to perceive in any one of them a sign
of the existence of this disease in internal organs.
It is only when melanosis makes its appearance
externally, that he can hazard an opinion that
any derangement of function is owing to its pre-
sence in one or more internal organs ; that op-
pression and difficulty of the respiration are pro-
duced by a similar disease of the lungs, when, by
means of auscultation and percussion, he finds
that certain portions of the lungs are impervious

to the air, without having become so by any other
disease with the characters of which he is ac-
quainted ; and that ascites and oedema of the in-
ferior extremities are in all probability the conse-
quence of compression of the portal system of
the liver, from the presence of melanotic tumour
in that organ. The presence of black sputa in
the first case may, under certain circumstances,
afford him some assistance in establishing his
diagnosis ; as its quantity, and its appearance at
the time that one or more of the supposed tu-
mours in the lung have been observed to soften.

Vomiting and dejections of black matter do
not afford any evidence of the existence of mela-
nosis either in the stomach or intestines, or any
other organ. The same may be said of the state
of the pulse, temperature, and nutrition in gene-
ral. In some cases the pulse and temperature
have assumed a febrile character, and the patients
become lean, pale, or sallow ; changes which may
be attributed to the mere mechanical presence of
a great quantity of the melanotic deposit in im-
portant organs, thus operating on the one hand
as a morbid stimulus, and on the other preventing
the blood from undergoing various important
changes. Melanosis does not appear to give rise
to pain except where nerves have been impacted
within, or compressed by it in some unyielding
cavity. It is for this reason that the eye is gene-
rally the seat of pain in melanosis.

Prognosis. — Under whatever circumstances
this disease may present itself, it ultimately pro-
ceeds to a fatal termination. It is sometimes de-
veloped with considerable rapidity, and when it
occupies important organs, such as the brain or
lungs, the life of the patient is seldom prolonged
beyond a few weeks or months. The fatal effects
of the disease are also retarded or accelerated by
its extent ; being greatly accelerated if it occupies
the greater part or the whole of an organ, or a
great number of organs at the same time, which
is frequently the case, and retarded if limited to
one organ or tissue. But we must again repeat
that, however favourable the circumstances may
be under which it first announces its existence, its
tendency is to increase and ultimately to prove fatal.

Treatment. — From what we have said of this
disease, it is but too obvious that any mode of
treatment that can be adopted must be only pal-
liative in its effects. To have pointed out, so mi-
nutely as we have done, the physical, anatomical,
and chemical characters of melanosis, in order to
show that it originates in a modification of secre-
tion of a carbonaceous pigment analogous to the
colouring matter of the blood, may, therefore, ap-
pear to the reader to be a waste of labour and of
time; but we must remind him that there are a
host of diseases the treatment of which is founded
on no surer grounds, and respecting the history
of which we know much less than we do of that
of melanosis. In this respect, therefore, the scien-
tific practitioner will at least have the advantage
of being able to give a satisfactory reason for the
mode of practice which he may think proper to
adopt in the treatment of this very remarkable
disease.

II. — Spurious Melanosis.

A. From the introduction of carbonaceous

296

MELANOSIS.

matter. — Although certain forms of black disco-
loration of the pulmonary tissue were supposed
by Laennec to originate in the inhalation of the
carbonaceous product of ordinary combustion, an
opinion which was previously entertained by Mr.
Pearson, (Philos. Trans. 1813, part, ii,) there was
no recorded fact that could be regarded as fur-
nishing undeniable evidence of the accuracy of
this opinion till lately, when a case of this kind
occurred in a patient admitted into the infirmary
of Edinburgh. The medical public are indebted
to the late Dr. J. C. Gregory, who had charge of
the patient, for the history of the case, the de-
scription of the post-mortem appearances observed
in the body, and particularly in the lungs, to-
gether with the results of the chemical examina-
tion of the black matter found in this organ.*
The following are the morbid appearances which
were found in the lungs of this patient after
death : " Both lungs presented one uniform black
carbonaceous colour, pervading every part of their
substance. The right lung was much disorgan-
ized, and exhibited in its upper and middle lobes
several large irregular cavities communicating
with one another, and traversed by numerous
bands of pulmonary substance and vessels. These
cavities contained a good deal of fluid, which, as
well as the walls of the cavities, "partook of the
same black colour. A considerable portion of the
pulmonary substance surrounding them was dense,
hepatized, and friable. The rest of the lung was
also somewhat condensed, and very cedematous.
The serum, when expressed, was of the same
black colour as the substance of the lung. The
left lung did not appear to contain any cavities,
but was condensed, and loaded with black serum.
Some minute hard points could be felt in various
parts of both lungs, but they did not differ at all
in colour from the surrounding substance ; and
no distinct tubercular deposition or infiltration
could be detected in those portions of the lungs
which were most hepatized, even with the aid of
the microscope. The texture in these parts ap-
peared quite uniform, and the minute hard points
felt in other parts rather conveyed the impression
of their being merely the ends of small bronchial
branches divided in making the section. The
bronchial glands did not appear enlarged, but par-
took of the same black colour as the substance
of the lungs." No other organ of the body pre-
sented any trace of this black discoloration. As
a minute analysis of the black matter contained
in the serum which was expressed from the sub-
stance of the lungs was made by Dr. Christison,
we shall offer no apology to the reader for giving,
in his own words, the results which he obtained.

" 1. Concentrated nitric acid boiled on it did
not alter the colour.

" 2. Immersion in a strong solution of chlorine
had also no effect.

" 3 A strong solution of caustic potass boiled
on it took up some animal matter, and filtrated
very slowly The first part which passed through
was opaque and black ; but the last portions were
of a pale yellowish-brown colour, and transparent ;

♦Case of peculiar black infiltration of the whole lungs,
resembling melanosis, by J. Q. Gregory, M. D. &c. Edin.
Med. and Surg. Journal, No. 108.

so that none of the black matter was dissolved.
The black matter remained in the filter, and this,
well washed and dried, burned like charcoal pow-
der, without swelling up, and with scarcely any
animal empyreuma, leaving a considerable pale-
grey ash.

« 4. A small portion of black powder, left after
the action of boiling nitric acid, was well washed,
dried, and introduced into a minute glass ball,
with a tube attached, which was subsequently
drawn out, by means of the spirit-lamp flame, to a
fine bore. On the application of a low red heat
to the ball, there was disengaged, at the open end
of the tube, a considerable quantity of gas, which
had the odour of coal gas, and on the approach
of a light, took fire and burned with a dense white
flame. In the tube a dark yellow fluid likewise
condensed, which had very exactly the odour of
impure coal-tar, naphtha, and became a soft mass
on cooling, of the consistence of lard. This,
when compressed between layers of filtering paper,
yielded an oily stain to the paper, and left a white
matter which dissolved in boiling alcohol, and
separated again on cooling, in the form of minute
obscure crystals."

" In the product of this experiment," says Dr.
Christison, " it is scarcely possible not to recog-
nise the ordinary products of the distillation of
coal. A gas of the same quality was procured,
and likewise a napthous fluid, holding in solution
a crystalline principle, analogous to, if not identi-
fied with, napthaline."

The history of this case, the morbid appearances
found in the lungs, and the results of the chemical
analysis of the black matter in particular, do not
permit of a doubt as to the origin and nature of
the black discoloration of the lungs in this inte-
resting case. The profession of the patient, which
exposed him to the habitual inhalation of the coal-
dust always contained in the atmosphere of a
mine, and the black matter found in the lungs
consisting essentially of this substance, are circum-
stances which demonstrate clearly the origin of
the black matter, and its identity with the carbo-
naceous powder inhaled with the air in breathing.
Besides these circumstances, the non-existence of
any kind of black discoloration in any other
organ of the body would furnish a strong reason
for our not regarding this case as one of true me-
lanosis. We have, indeed, never seen, nor do we
know of, a case of melanosis occupying the greater
part of an organ, without other organs being
simultaneously affected to a greater or less extent
with the same disease. Aware of this fact, we
have always entertained doubts regarding the real
nature of a case of black discoloration of the
lungs which we had an opportunity of examining
several years ago, which occurred in a middle-aged
man, who was an out-patient of the Old Town
Dispensary of Edinburgh. He was attended by
Dr. Probart, of Bury St. Edmunds, who was then
in Edinburgh, along with whom the writer of this
article examined the body after death. The mor-
bid appearances observed in the lungs were in
almost every respect the same as those that have
been detailed in the preceding case. The whole
of both lungs was perfectly black ; in many parts
indurated and cedematous— in others softened and
excavated. There were no tubercles, nor was

MELANOSIS.

297

there any similar discoloration in any other part
of the body.

Dr. Allen Thomson has informed us that he has
likewise seen a similar case of black discoloration
of both lungs. No analysis of the black matter
in either of these cases was made ; and besides,
not having been able to ascertain the profession
of either of the patients, our opinion with regard
to the origin and nature of the black discolora-
tion of the lungs in both cases, must be founded
entirely on the anatomical facts to which we have
alluded, viz. the universal black discoloration of
both lungs, and the non-existence of any similar
discoloration of any other organ or tissue of the
body.

[Since then, many other cases have been ob-
served. The affection has received the name of
black lung of coal miners, and by Dr. Stratton
(Edinb. Med. if Surg. Juur., April 1838, p. 490)
it has been termed Anlhracosis.]

It is surprising that no case of universal black
discoloration of the lungs produced by the inha-
lation of carbonaceous matter is to be found on
record previous to that of Dr. Gregory, when we
reflect that so many individuals are daily exposed
in this country to the cause by which it is pro-
duced. We can hardly attribute this silence, on
the existence of such a conspicuous morbid state,
to the paucity of post-mortem examinations. Is
it not more probable that the accumulation of the
carbonaceous matter in the lungs is determined by
a morbid state of these organs 1 — that, although
carried into the lungs with the air, it is removed
by expectoration or absorption, and its accumula-
tion in these viscera thereby prevented 1 We are,
indeed, much disposed to believe that these circum-
stances must tend to favour or prevent the occur-
rence of this diseased state of the lungs. In the
cases referred to, we have not been able to ascer-
tain that there existed any particular morbid state
of the lungs which could have prevented or
favoured the accumulation of the inspired carbo-
naceous matter. We, however, consider it a sub-
ject worthy the attention of the medical practi-
tioner who has the opportunity of studying the
diseases of persons employed in coal-mines,
whether the black discoloration of the lungs is
observed to occur in those only who have suffered
from pulmonary complaints ; although it may be
often difficult to discriminate between cause and
effect, between the original disease and the changes
which must take place in the structure and func-
tions of the lungs from the presence of the in-
spired carbonaceous substance.

Symptoms. — The symptoms presented by Dr.
Gregory's patient as well as our own, were refer-
able to the presence of the inspired carbonaceous
matter, acting, 1st, mechanically, and giving rise
to atrophy of the pulmonary tissue, compression
and obliteration of the air-cells, bronchi, and blood-
vessels ; and, 2d, a3 a foreign body, producing a
greater or less degree of irritation. To these mo-
difications of the pulmonary organs are to be
ascribed the local symptoms, such as the dyspnoea,
cough, the mucous and cavernous rales, and the
increased secretion and expectoration of mucus.
The presence of black matter in the expectorated
Ituids was no doubt to be attributed to the exist-
ence of a direct communication between some of

Vol. III. — 38

the bronchi and the excavations formed in the
substance of the lung. Although there were also
softening and excavation of the lungs in the case
which we examined, it does not appear from the
account which we have received of the history of
the case, that the sputa were discoloured by the
admixture of black matter ; and as it is stated
that the mucous rales heard in this case were
remarkably strong, but not cavernous, it may be
presumed that the absence of the hlack matter
was owing to there being no communication
between the bronchi and the softened or excavated
portions of the lung, or that the solidification of
this organ was so great from the presence of the
carbonaceous matter, that the former did not admit
of being sufficiently compressed to expel any of this
substance with the mucous secretion of the bronchi.

The general symptoms produced by the accu-
mulation of the carbonaceous matter in the lungs,
were chiefly the general cachectic condition of the
body and anasarca, both of them depending on the
state of the pulmonary circulation. The great di-
minution in the quantity of the blood admitted
into the lungs, which must necessarily have fol-
lowed the presence of such a quantity of foreign
matter in this organ, as well as the imperfect
change which must have been effected in that
which was allowed to pass through the pulmonary
vessels, will sufficiently explain the cachectic state
of the patient. The anasarca must also be attri-
buted to the same cause, viz. the presence of the
accumulated carbonaceous matter, and its mecha-
nical effects on the pulmonary veins, thereby giving
rise to general venous congestion and effusion of
serosity into the cellular tissue.

Diagnosis* — Being in possession of such a
limited number of facts in regard to this singular,
if not rare, affection of the lungs, we should not
feel justified were we to assign to it characters by
means of which it may be distinguished from cer-
tain organic affections to which the same organs
are subject. We, indeed, know of no modification
of function, local or general, by means of which
this form of spurious melanosis is to be distin-
guished from true melanosis of the lungs. We
may, however, suggest that, as the former pervades
the whole of both lungs, dyspnoea may be greater
than in the latter, which always leaves a portion,
and often a considerable extent of lung in the
healthy state ; — that respiration will be found to
be natural, or nearly so, in several portions of the
lung affected with true melanosis ; whilst in the
spurious form of the disease, depending on the
universal deposition and accumulation of inhaled
carbonaceous matter, the respiratory sound, or at
least the respiratory murmur, that which takes
place in the air-cells, will either be greatly obscured
or inaudible, and will be replaced by bronchial
respiration, the ronjlement and sonorous rales
which accompany the solidification or condensa-
tion of the pulmonary tissue. We need hardly
mention that the presence of black matter in the
sputa cannot be regarded as a pathognomonic sign,
unless its real nature has been determined by che-
mical analysis.

The only other disease with which this spurious
form of melanosis is likely to be confounded, is
chronic catarrh. We are, however, disposed ta
believe that the presence of anasarca, as well «s

298

MELANOSIS.

the dull sound of the chest on percussion, will be
sufficient to enable us to distinguish the former
disease from the latter, in which the sound of the
chest is not materially affected, and which is not
accompanied with anasarca, unless it be compli-
cated with disease of the heart. The emaciation,
diarrhoea, and hectic, which accompany phthisis,
will prevent the physician from confounding this
disease with spurious melanosis of the lungs, even
when the latter has given rise to softening and ex-
cavation of the pulmonary tissue.

Treatment. — Imperfect as the description may
be which we have given of the changes produced
in the structure and functions of the lungs, origin-
ating in the inhalation of carbonaceous matter,
and in its accumulation in these organs, it is suf-
ficiently obvious that neither the local effects to
which the presence of this foreign substance gives
rise, nor the general disturbance of nutrition and
circulation which follows as a consequence of the
former, can be remedied so long as the offending
cause remains. How far the removal of this can
be accomplished by means of remedies which act
chiefly on the absorbent system, is a point which
remains to be determined by future observation
and experiment.

If the disease has proceeded to such an extent
as to produce general atrophy of the pulmonary
tissue, softening and excavations in various por-
tions of the lungs, its fatal termination must be
inevitable. We cannot, therefore, too strongly
impress on the mind of the physician who has the
opportunity of doing so, the importance of ascer-
taining the early signs of this affection, as well as
the influence which other diseases may have in
favouring its production, as a knowledge of both
circumstances will suggest the means to be em-
ployed either for its cure or the prevention of its
occurrence.

B. From the action of chemical agents. — The
next kind of melanotic formation which we have
to describe, is that which is produced by the action
of certain chemical agents on the blood.

Our attention was for the first time drawn to
this subject nearly three years ago, while making
a »>eries of experiments on the chemical dissolu-
tion or digestion of the walls of the stomach after
death. With regard to the subject of these expe-
riments, it is necessary to observe, that the partial
or complete dissolution of one or all of the coats
of the stomach was found to take place after death,
and to be the invariable consequence of the chem-
ical action of an acid fluid contained in the cavity
of that organ. A peculiar change in the colour
of the blood contained in the veins of the stomach,
was also observed to accompany the chemical dis-
solution of the walls of that organ, and which,
though less frequent in its occurrence than the
latter, was not the less obviously the effect of the
same chemical cause; for, firstly, there was no
discoloration of the blood when there was no soft-
ening or chemical dissolution of the coats of the
stomach : secondly, the discoloration of the blood
was observed only in the vessels distributed, or
near, to those parts of the stomach which were
softened : and thirdly, that both changes were,
r.xteris paribus, nearly in the same ratio as to de-
gree and extent. Although these circumstances
might have been regarded by us as affording suffi-

cient evidence that the discoloration of the blood
was produced by the direct operation of the same
chemical agent by means of which the dissolution
of the walls of the stomach was effected, we made
several experiments on this interesting and impor-
tant subject, the results of which leave no doubt
as to the accuracy of our former conclusion,—
viz. that the discoloration of the blood which ac-
companies the chemical dissolution of the walls of
the stomach, is a direct effect of an acid fluid con-
tained in the cavity of that organ, or, as we shall
afterwards call it, the gastric acid.* If we kill an
animal, a rabbit, for example, or open it while
alive, and during the process of digestion, the
fundus of the stomach is always found to contain
a quantity of this acid, mixed with the food in this
the depending part of the organ. When the sto-
mach is laid open, a sour smell is immediately
perceived to arise from its contents ; and if a por-
tion of litmus paper is placed in contact with the
latter, it acquires, almost instantaneously, a beau-
tiful red colour. If arterial or venous blood is
allowed to flow into the stomach from some of the
neighbouring vessels, so soon as it comes in con-
tact with the digested portion of the food, or that
in which the gastric acid is most abundant, its na-
tural colour is almost immediately changed to deep
brown or black. The rapidity with which this
change takes place in the colour of the blood, as
well as the degree and extent to which it proceeds,
varies with the strength of the gastric acid and
the quantity of the blood on which it is made to
act. When the digested acid food, or the gastric
acid alone, is removed from the stomach in which
it was found, and is put into another stomach, or
other organ, the vessels of which are conspicuous
and filled with blood, this fluid very soon under-
goes the same change of colour which we have
said takes place when it is poured upon the digest-
ed food, and, consequently, when in immediate
contact with the chemical agent by which this
change is effected.

These facts show clearly that healthy blood con-
tained in the cavity of the stomach, or in the ves-
sels of that organ, in a dead animal, is changed to
a dark brown or black fluid. But the influence
of the gastric acid in producing this change in the
blood, is not limited by the conditions to which
we have just alluded. Not only is the blood that
has been poured into the cavity of the stomach or
is contained in the vessels of the mucous and sub-
mucous tissues, changed from red to brown or
black, but likewise that of the sub-peritoneal vessels
of the same organ is similarly altered. We have
also seen the same black discoloration of the blood
in the sub-peritoneal vessels of a neighbouring
organ, such as the liver, spleen, intestine, or dia-
phragm, in contact with that portion of the stomach
which contained half-digested food or gastric acid.
Hence we can readily conceive that if blood is
effused into the cavity of the peritoneum, and in
the vicinity of the stomach, it will undergo the
same change of colour as that which we have said
takes place in this fluid when contained in its
proper vessel s beneath th is membrane. We have

*We employ the term gastric acid, because it indicates
the seat, ami, particularly, t lie property of the chemical
agent by means of which the dissolution of the walls of
the stomach, and the black discoloration of the blond ii
that organ, are produced.

MELANOSIS.

299

produced effusion of blood into the cavity of the
peritoneum around the stomach, in several ani-
mals, and have thus been able to witness its con-
version from red to brown or the deepest black.

The discoloration of the blood in these situa-
tions external to the stomach, and depending on
the influence of the gastric acid, is an interesting
fact, with the nature and origin of which we were
entirely ignorant until we observed the effects of
this chemical agent on the blood contained in the
vessels of the stomach. It is perfectly obvious,
from what we have said, that we have, in both
cases, the same efficient cause. We have taken
a portion of stomach containing gastric juice,
placed it on a coagulum of blood or kept it in close
contact with a portion of intestine on which there
was a greater or less number of vessels filled with
red blood. In both cases the blood assumed a
brown or black colour, no doubt from the acid
having been carried from the interior of the stomach
by imbibition.

There is still another mode in which the black
discoloration of the blood may be produced by the
gastric acid, viz., when this fluid is effused into the
cavity of the peritoneum through an opening which
it has made, generally in the fundus of the stomach.
It occupies the most depending parts, dissolves the
tissues with which it comes in contact, perforates
the diaphragm, and passes into the cavity of the
thorax. Along with these remarkable effects of
the gastric acid, the black discoloration of the blood
is no less conspicuous in all the parts on which
its chemical influence has been exerted.

Such is a very general sketch of the several
modes in which the black discoloration of the blood
is produced, when this fluid is exposed to the me-
diate or immediate influence of the gastric acid.
We have already stated that this condition of the
blood was not produced till after the death of the
animals submitted to our experiments ; that these
animals were in the enjoyment of the most perfect
state of health when killed ; and that the gastric
juice possessed that property — acidity — by which
it is always distinguished during the act of diges-
tion. These facts are the more important when
we consider that they establish the formation of a
series of changes in the blood after death, which
are entirely independent of any morbid condition,
local or general, of the animal in which these
changes are observed. It is necessary, however,
to state that there are two conditions in which the
blood may be placed during life, which render it
susceptible of being acted upon by the gastric
acid : first, when it has ceased, during an uncer-
tain period of time, to circulate ; secondly, when
it is effused into the cavity of an organ. In both
circumstances it is deprived of those properties by
means of which it is enabled to resist, to a certain
degree, the destructive influence of external agents;
and, therefore, undergoes the same changes when
submitted to the action of the gastric acid, as it
does after death.

Locality and Order of frequency of the
Black Discoloration of the Blood, from
the operation of an Acid Chemical Agent.
— As the black discoloration of the blood of which
we are now treating is produced by the operation
of an acid chemical agent, it is consequently met
with only in those organs in which this agent

exists as a healthy or morbid product, or to which
its influence extends in the manner which we
have already stated. Hence, as the stomach is
the only organ of the body in which an acid fluid
is formed, and is at the same time a healthy pro
duct, the black discoloration of the blood is no
where so frequently observed, so conspicuous, and
so extensive as in this organ. The same dis-
coloration of the blood, as to locality and order of
frequency, occurs in the intestines, from the anor-
mal formation of a fluid and gaseous acid product.
It is owing to the proximity of the peritoneum to
these normal and anormal acid products, that
blood situated beneath this membrane on its free
surface or in its cavity undergoes so often the
change of colour in question ; and it is to the
same circumstance of situation that portions of
the liver and spleen are so frequently found to
present the same dark colour. The dark dis-
coloration of the blood in the intestines and in the
other situations just named, depends, perhaps,
more frequently on the presence of sulphuretted
hydrogen gas than an acid fluid in the former,
owing, no doubt, to this gas possessing the pro-
perties of an acid.

Natural and accidental tissues, remote from the
stomach and intestines, are also observed to pre-
sent various kinds of discoloration ; but we allude
to those which chiefly depend on the presence of
various shades of blue, brown, and black. The
blue discoloration, which is sometimes very deep,
approaching to black, is most frequently observed
to occupy the walls of chronic abscesses in various
parts of the body. It is not the consequence of
putrefaction, but is produced by the presence of a
chemical agent, the nature of which we have not
been able to ascertain. The brown and black
discolorations are observed to accompany the death
of parts, preceded or followed by a local accumu-
lation of blood. It is probable that they some-
times originate in the formation of an acid pro-
duct, which afterwards acts upon the blood ;
although they are certainly owing, in general, to
changes which take place in the blood itself of
the dead part, for which reason we shall refer
them to the fourth division of our subject, which
contains the description of the black discoloration
of the blood from stagnation of this fluid, and the
subsequent changes which it undergoes.

Form, Situation, and Extent of the
Black Discoloration of the Blood.

1. In the vessels of the Stomach. — The blood
which undergoes this change of colour derives
the peculiarity of the forms which it assumes
from its being contained in its proper vessels.
The three following forms are the most conspi-
cuous: the punctiform, uniform, and ramiform.
All these forms of black discoloration of the blood
are met with either separately or combined, and
may occupy a portion or the whole surface of the
stomach. They are most frequently observed in
the fundus of the stomach, for the reasons already
assigned; but they may exist in other parts of
this organ, as the pyloric portion, small and great
curvatures, to which external causes, such as
tumours, distension of the colon, enlargement of
the spleen, &c, have given a more depending
position than that of the fundus, consequently
favouring the accumulation of the gastric acid in

300

MELANOSIS.

these parts after death. The situation of these
forms of black discoloration of the blood is also
modified by the quantity and quality of the con-
tents of the stomach. Thus, if the stomach is
nearly empty, the discoloration of the blood is
confined to the surface of the ruga; formed by the
mucous membrane ; and if it is distended by a
quantity of gas, the discoloration is limited to the
depending part of the organ, and terminates in a
defined margin, the course and extent of which
are determined by the superposed gas, which has
prevented the gastric acid from acting beyond the
limits within which it was thus confined. And,
lastly, if the stomach is filled with gastric acid, as
sometimes happens in stricture of the pylorus, the
whole surface of the mucous membrane may pre-
sent a uniform dark brown or black tint.

With regard to these three forms of the black
discoloration of the blood in the vessels of the
stomach, it is only further necessary to observe,
that although the punctiform and uniform are
more frequently produced than the ramiform, on
account of the small veins being more often filled
with blood than the large ones, the ramiform is
most frequently seen ; a circumstance which is
owing to the mucous membrane and the minute
veins within it and beneath it being sooner dis-
solved by the gastric acid than the large veins.
In the punctiform discoloration of the blood, the
mucous membrane presents an appearance as if it
were dusted over with a quantity of fine charcoal
powder ; and when the discoloration is uniform,
it appears as if painted with bistre or china ink,
in the form of patches or streaks of various forms
and dimensions. The ramiform discoloration is
generally the most conspicuous and striking of
the three, because of the black blood being con-
tained in veins of considerable size. They appear
as if they had been injected with chocolate or a
mixture of soot and water. The dark blood pre-
sents a curdled appearance. It does not fill the
veins, but is separated and agglomerated into
small masses, which become gradually less towards
the minute branches, and there appear in the form
of black points, having still a ramiform distribu-
tion, but are no longer contained within the walls
of the veins, the former having been dissolved by
the gastric acid. This is the form of the black
discoloration of the blood which we have said has
been described as melanosis of this fluid, — an
opinion which we hope the preceding details have
shown to be erroneous.

2. Black discoloration of the blood in the ves-
sels of the intestines. — From what we have al-
ready said of this change of the blood in the ves-
sels of the stomach, we have only to add that it is
less frequently observed in those of the intestines,
is seldom so conspicuous, and that it assumes in
general the punctiform arrangement. This char-
acter of the black discoloration in the intestines is
owing to the change of colour taking place in the
blood contained in the vessels of the villosites or
isolated follicles. The black punctiform discolora-
tion is sometimes observed to occupy the mucous
membrane of the greater part of the intestines,
both large and small ; but we believe it is most
frequently seen in the inferior portion of the ileon
and in the duodenum.

A similar discoloration of the blood in the ves-

sels of the villosites and isolated follicles is met
with in various portions of the intestines in par-
ticular, and which is not produced by the action
of an acid on the blood. It is the consequence
of stagnation, and is not to be distinguished from
the former otherwise than by ascertaining the
nature of the contents of the intestines in which
it is observed.

3. Black discoloration of the blood effused into
the cavity of the stomach and intestines. — The
fact of the black discoloration of the blood effused
into the cavity of the stomach and intestines be-
ing produced by the chemical action of an acid
fluid or gas contained in these situations, does not
appear to us to have been even suspected till after
the results of our experiments on this subject were
made known. If we consult the works that have
been published on melaana, (a disease characterized
by the presence of black matter in the fluids
ejected from the stomach and bowels,) we shall
find that the opinions therein expressed, in regard
to the black discoloration of the blood in this
disease, were founded on mere conjecture.

By some pathologists the black discoloration
of the blood was believed to take place in the
venous system ; by others, that it was not effected
till after the blood was effused into the cavity of
the stomach or intestines, and that the red colour
of the blood was then converted into black by the
fluid or gaseous contents of these organs. The
latter opinion was, however, entirely conjectural,
such conversion of the blood never having been
seen to take place. Notwithstanding the impor-
tance of the subject, it was never submitted to the
test of experiment. The matter of black vomit
and dejections was believed to be blood altered in
the stomach and intestines, but whether by a
chemical or vital agent was quite undetermined.
From the results which we have given of our ex-
periments on this particular point at the com-
mencement of this article, it must appear obvious
that blood effused into the cavity of the stomach
is almost immediately converted into a deep brown
or black colour, and, moreover, that this change
of colour is owing to the presence of a chemical
agent ; that this agent is an acid, similar in all its
properties to that by means of which the dissolu-
tion of the food during digestion is accomplished.
We have also stated that, if this acid fluid is not
present, as is frequently the case, no such change
of the blood introduced into the cavity of the
stomach takes place — it preserves its natural
colour : and again, that if the quantity of the
blood be so considerable as not to be acted upon
uniformly by the acid, only a portion of it is black,
whilst the rest is of its natural colour. These
circumstances relative to the presence or absence
of the gastric acid, and the quantity of blood
submitted to its action, appear to us to furnish the
most satisfactory explanation of the essential
phenomena of melrena. They further show that
there is, properly speaking, no difference between
this disease and hacmatemesis. Both of them
originate in the effusion of blood, no matter how
produced, whether by exhalation or a solution of
continuity. In the latter the blood preserves its
natural colour ; in the former it is black, because
of the reasons just stated— the presence of an acid
in the one case, and its absence in the other. On

MELANOSIS.

301

these circumstances alone can the pathologist be
justified in making a distinction between hajmate-
rnesis and mekena.

As this part of our subject is, as we have seen,
intimately connected with the latter disease, we
shall only further add, that the black discoloration
of the blood in the stomach is found to accompany
cancer of this organ much more frequently than
any other disease. Black vomit almost always
accompanies the last stage of this disease, — that
is to say, the stage of softening, because of the
hemorrhage which then takes place. Next in the
order of frequency is follicular ulceration of this
organ. In the intestines follicular ulceration is
by far the most frequent change which is observed
to accompany black dejections. In both organs
the ulceration of the follicles is sometimes so ex-
tremely limited that it is not perceived until after
the mucous membrane has been well washed and
exposed to a strong light, when it is seen to oc-
cupy the central portion or orifices of the follicles
in the form of a red point, with an irregular cir-
cumference, probably the ulcerated border of the
orifices of these follicles. Next in the order of
succession are the numerous diseases of the heart
and its orifices, and several of those of the liver
and vena porta;, which obstruct mechanically the
return of the venous blood, and thus determine its
effusion from the digestive mucous membrane.
And, lastly, we have met with the same discolora-
tion of the blood in individuals the most feeble
and emaciated, in whom this fluid appeared to
have almost entirely lost that plastic property on
which its coagulation depends, and by means of
which its effusion is prevented when accumulated
in the capillary system.

The black discoloration of the blood in the
vessels of the stomach, produced by the gastric
acid after death, is a subject of the greatest im-
portance to the toxicologist, particularly when
considered in connection with the effects which
result from the operations of all poisons possess-
ing acid properties on the blood. Although we
have directed our attention to this subject, and
have been able to ascertain that several of the
changes produced in the blood under these oppo-
site circumstances are so characteristic as to afford
us the means of determining their nature and ori-
gin, we are prevented from making any further
allusion to them, because of the minute descrip-
tive details, into which we should be obliged to
enter, were we to attempt to put the reader in pos-
session of the means whereby he might distin-
guish post-mortem from pathological black disco-
loration of the blood in the digestive organs.
We must therefore refer him for further informa-
tion on this subject to the article Psetjdomohbid

Apr-EAltANCES.

4. Black discoloration of the blood on the sur-
face or in the cavity of the peritoneum. — As we
have already alluded to the manner in which the
black discoloration of the blood takes place in
these situations, we shall only notice a few cir-
cumstances of importance with regard to its seat,
and the lesions which it most frequently accompa-
nies.

We have already said that it is met with in the
vessels which ramify under the peritoneum ; but
it is more frequently seen in those which exist in

2a

the false membranes of chronic peritonitis. When
the blood is effused into the sub-peritoneal tissue,
on the surface of the peritoneum, into its cavity,
or into false membranes, the black discoloration
which it undergoes is remarkably conspicuous,
and frequently occupies a great extent of surface.
It is only when the discoloured blood is contained
within its vessels that it presents, in the situations
just named, a ramiform distribution. There is,
however, a peculiar modification of this form
which requires to be noticed. It occurs in chro-
nic tubercular peritonitis. The tubercles scattered
over a greater or less extent of the peritoneum,
are surrounded by a dark ring, or a multitude of
minute vessels filled with black blood, having a
stellated arrangement. If the tubercles are very
minute, they are obscured by these appearances,
and the peritoneum seems as if spotted with a
deep brown or black pigment, which has been de-
scribed as melanosis of the peritoneum.

The black discoloration of the blood when
effused on the surface of the peritoneum or into
false membranes, has still more frequently been
taken for melanosis, and described as such. It
then assumes the appearance of black patches,
striae, or layers of various extent, occupying either
the visceral or abdominal portions of the perito-
neum, or both at the same time. If the effused
blood has collected in the cavity of the peritoneum,
it undergoes the same change of colour which we
have seen takes place in the blood effused into the
cavity of the stomach and intestines. The ex-
ternal portion of the blood, or that which is in
contact with the peritoneal surface of the intes-
tines, is always deepest in colour, being sometimes
as black as pitch ; whilst that which is more re-
motely situated is either of its natural colour, or
but slightly darkened. From these circumstances,
and from what we have already said on the effects
of the acid fluid and gaseous contents of the sto-
mach and intestines, there can be no doubt that
the black discoloration of the blood contained in
the cavity of the peritoneum is owing to the che-
mical operation of these products. In confirma-
tion of the accuracy of our opinion on this point,
we may mention that we have had several oppor-
tunities of seeing the blood effused into the cavity
of the peritoneum, undergo the change in ques-
tion, in individuals who died from hemorrhage in
consequence of wounds of the abdominal viscera.
Although the description which we have given of
the forms, situation, and extent of the dark dis-
coloration of the blood in the digestive organs, and
in those situated in their immediate vicinity, will
in general enable the practical pathologist to re-
cognise them in his post-mortem examinations,
we would recommend him in all doubtful cases to
test the contents of the former organs. A sour
smell may not be always sufficiently strong to be
perceived ; and besides, his having determined
(by means of litmus paper, for example, some of
which he should always have in his case of instru-
ments,) chemically, the presence of an acid, every
doubt will be removed as to the nature of the
black discoloration of the blood in the parts which
we have named.

C. From the stagnation of the Blood. — Black
discoloration of the blood has been long known to
follow as a consequence of retarded or interrupted

302

MELANOSIS.

circulation. This change in the colour of the
blood is never so conspicuous as when it takes
place in the extreme venous circulation, or in the
capillaries ; and it is only when it occurs in the
latter situations that it has been described as a
form of melanosis. We shall, therefore, confine
our remarks to the black discoloration of the blood,
which follows in consequence of the stagnation of
this fluid in the capillary circulation. It is worthy
of remark, that the black discoloration of the blood
originating in this cause is much more frequently
observed in some organs than in others, and is
never so conspicuous or extensive in young as it
is in old persons. The circulation of the capilla-
ries being influenced by that of the heart and
great blood-vessels, it is also frequently observed to
accompany diseases of the latter organs, which
impede the circulation of the blood in general,
and give rise to a state of venous congestion.
Among the local causes of its production, acute
and chronic inflammation are the most frequent.
This change in the colour of the blood has net,
however, been regarded as a matter of much im-
portance in acute inflammation ; whilst in chronic
inflammation on the contrary, it has received
much attention, as its presence has been considered
as one of the least equivocal characters of this
disease. To these causes of the stagnation of the
blood and its subsequent black discoloration, we
may also add debility, which gives rise to similar
states of the blood in depending parts of the body,
but more particularly the inferior extremities.

Under the influence of these causes, the blood
accumulates in the capillaries, and ultimately
ceases to circulate. After a certain length of time
it coagulates, and the serum is forced out along
with the salts which are absorbed. That which
remains is an almost black substance, of the con-
sistence of firm fibrine, and is probably composed
in great part of the animal principle and hema-
tosine. The black colour thus produced appears
to us to receive a satisfactory explanation from
the circumstance that it follows the stagnation
and coagulation of the blood, and consequently
the separation and removal of the serous and
saline ingredients of this fluid, to the latter of
which, ai> has been clearly demonstrated by Dr.
Stevens, Its red colour is to be attributed.

The degree and extent of the black discolora-
tion of the blood from stagnation of this fluid
will no doubt vary in different individuals, in dif-
ferent organs, and under the influence of different
diseases. Thus it is, generally speaking, most
frequently observed in persons whose circulation
is low ; frequently, as we have already said, in the
old and infirm, and seldom in the young and
healthy ; and in those diseases which mechani-
cally or otherwise impede or interrupt the capillary
circulation. As we have already extended this
article far beyond the limits which we had origi-
nally prescribed to it, we shall confine the few
remarks which we have yet to make on this part
of our subject, to the presence of the black disco-
loration of the blood in particular organs and
diseases, and some of its forms.

There are, strictly speaking, only two organs,
the respiratory and digestive, in which this change
of the blood bears any resemblance to true mela-
nosis.

1. Black discoloration of the blood from stag-
nation in the lungs. — This change of the blood
in the lungs occurs most frequently at an advanced
period of life ; in phthisis pulmonalis ; in chronic
catarrh ; in emphysema ; in dilatation of the
bronchi ; in induration of the pulmonary tissue ;
in disease of the heart ; in one word, in whatever
diseases impede the pulmonary circulation, and
render the function of respiration imperfect. The
black discoloration of the blood in the lungs is
general, if the diseased condition in which it ori-
ginates has exercised its influence on the venous
circulation of these organs in general, as in dis-
ease of the heart ; and it is confined to a limited
extent, although it may occupy a greater or less
number of separate points, when produced by
local causes, such as tubercles. In the former
case, the black discoloration of the blood is seen
most conspicuously in the vessels of the inter and
intra-lobular tissue. In the former tissue it has a
ramiform disposition, in the latter it is capilliform
and punctiform ; appearances which are best seen
on the serous surface of the lung. In the latter
case, the vessels containing the black matter
occupy the circumference of the tubercles, and
have a stellated arrangement. In emphysema,
dilatation of the bronchi, induration of the pul-
monary tissue around tubercular excavations, the
black discoloration is often very extensive, on ac-
count of the great obstacle which these morbid
states oppose to the return of the venous blood,
and the length of time which they have continued
to operate.

Chronic inflammation of the pulmonary tissue
gives rise to the same form of black discoloration
of the blood which we have just said accompanies
induration, because of induration being, in gene-
ral, the consequence of this state of inflammation.
Chronic inflammation of the lungs may, however,
produce the same change in the blood without
being accompanied by induration.

The mucous membrane of the bronchi seldom
presents the grey or slate colour so common in
the mucous membrane of the digestive organs,—
a circumstance that would seem to indicate that
these membranes are not exposed to the influence
of the same agents to which we ascribe the black
discoloration of the blood in question, in the re-
spective organs to which they belong. Be this as
it may, the black discoloration of the blood in the
mucous membrane of the bronchi is seldom con-
siderable, and is rarely observed, unless in old
persons whose lungs are at the same time exten-
sively affected with it. It is also best seen in the
bronchi which communicate with tubercular ex-
cavations, and in the vicinity of ulcers of the mu-
cous membrane itself.

Black discoloration of the bronchial glands,
with regard both to frequency and degree, has
appeared to us to occur under the influence of the
same causes which give rise to the black discolor
ation of the blood in the lungs. It is most fre-
quently seen and most marked in the bronchial
glands of old persons, and it may occur even in
children with tubercular phthisis.

2. Black discoloration of the blood from stag-
nation in the digestive organs. — This change in
the colour of the blood is almost exclusively con-
fined to the mucous membrane of the stomach

MELANOSIS — MENORRHAGIA.

303

and intestines, and follows as a consequence
either of chronic inflammation of that membrane,
or of diseases of the heart or liver which impede
the return of the venous blood. It is limited to
a portion of the mucous membrane when preceded
by irritation, and if it accompanies chronic ulcera-
tion of this membrane or of its follicles, it is often
very conspicuous. When produced by an obsta-
cle to the return of the venous blood, particularly
if the obstacle is situated in the vena ports, it
may occupy the mucous membrane of the stomach
and of the greater part of the intestines. In both
cases the mucous membrane presents a grey,
greyish-brown, or slate colour, which is either
punctiform or uniform ; and which, when exam-
ined with a lens, is seen to depend on the presence
of a similar coloured fluid contained in the capil-
laries. The mucous membrane is at the same
time thicker than natural, and the follicles and
villosities are in some cases hypertrophied.

The appearances produced by the black disco-
loration of the blood from stagnation in the stom-
ach and intestines, are very similar to those which
are the effect of the chemical action of acid fluid
and gaseous products contained in these organs.
In order, therefore, to distinguish the former kind
of discoloration from the latter, it is often neses-
sary to ascertain that no acid chemical agent is
present. From the result of our own observa-
tions we are led to believe that the grey slate co-
lour of the mucous membrane is too exclusively
received as a physical character of chronic inflam-
mation. That it does take place as a consequence
of this pathological state there can be no doubt,
inasmuch as we see it produced, for example, in
the mucous membrane of the vagina and in the
skin from this cause ; but, as we have already ob-
served, it is of comparatively rare occurrence in
the bronchial mucous membrane, which is perhaps
as often the seat of chronic inflammation as the
mucous membrane of the digestive organs. It is
on account of this circumstance, as well as from
actual observation and experiment, that we are
led to believe that this character of chronic in-
flammation of the digestive organs has frequently
been mistaken for the discoloration of the blood
produced by chemical action of the acid contents
of these organs. R Carswell.

MENINGITIS. See Brain, Inflammation

OF.

MENORRHAGIA. This term (derived from
ptjvti, mensis, and fayvvpi, rumpo) implies mor-
bidly profuse menstruation. Some authors have
attempted a distinction between those cases where
the menstrual discharge is simply over-abundant,
and those where, along with the peculiar men-
strual secretion, pure blood is expelled. Dr. Mack-
intosh of Edinburgh, and Mr. Burns of Glasgow,
have restricted the name of menorrhagia to the
latter description of cases, calling the former only
immoderate flow of the menses. Others, again,
have chosen to class those instances where a mix-
ture of pure blood is passed, under the head of
uterine hemorrhage. The great object ought to
be, not to mislead by too nice and critical refine-
ment in nomenclature. The term uterine hemor-
rhage is so constantly limited in practice to cases
unconnected with menstruation, and occasioned by

organic disease, accidental injury, or the con-
sequences of pregnancy or parturition, that it is
much more convenient to include under the title
at the head of this article all those instances of the
discharge of real blood from the uterus which oc-
cur in connection with the menstrual functions.
The cases, indeed, are very rare in which any
strikingly profuse menstruation exists, without
more or less of real blood escaping at the same
time. Dr. Dewees states that, in a very extensive
practice of many years' duration, he has scarcely
ever known a case of genuine menorrhagia with-
out the admixture of pure blood. (System of
Midwifery, p. 147.)

Menorrhagia is a disease occasionally of great
obstinacy, sometimes of alarming severity ; and as
much of the success of the treatment depends
upon a proper discrimination of the different con-
ditions which give rise to it, it becomes necessary
to point out somewhat at length in what this dif-
ference consists. At the same time it must be
acknowledged that it will be impossible to go mi-
nutely into every variety of case which may occur
in practice.

Menorrhagia not only includes the immoderate
quantity of discharge at each monthly period, the
time remaining regular ; but it is also understood
to comprehend the too great frequency of the re-
currence of menstruation, even when the quantity
lost is not unusually abundant : still the definition
of " morbidly profuse menstruation" ought to be
remembered, because to constitute the disease the
quantity lost must be relative. Many women
remain in perfect health who are accustomed to a
very considerable discharge regularly, thus men-
struating every two or three weeks habitually ;
and yet, as long as the health continues unim-
paired, or nothing more than has always been
usual takes place, it would scarcely ever happen
that medical advice would be applied for to abate
the symptoms. In healthy menstruation the dis-
charge takes place every twenty-eight days, lasts
from three to four days, and the quantity lost upon
an average is about five or six ounces. But this
is merely a general rule : the exceptions are nu-
merous ; and it is only when it becomes an ex-
ception to the individual's ordinary habits, that
disease should be considered to exist. The effect
of climate in these cases is very remarkable ; and
what would be considered a very scanty menstrua-
tion in the warmer climates of the east, would be
deemed menorrhagia in Lapland. A curious blun-
der was committed in this respect by Dr. Freind,
who stated that the quantity of menstrual dis-
charge in this country averaged about twenty
ounces — a menorrhagic excess by no means com-
mon ; the mistake arising from his having quoted
Hippocrates without reflecting that the <5iio k6tv\ixi
"Attikoi applied only to the females of Greece.

Menorrhagia may occur in very opposite states
of the system, and has therefore been divided into
active and passive ; the former arising from too
great activity in the vessels of the uterus, the lat-
ter from a want of tone in their secreting orifices.
Either of these states may exist in a plethoric
habit of body, or in one of great debility ; but in
general the local condition is of the same charac-
ter with the constitutional in the same individual.
After a long continuance of the disorder, the

304

MENORRHAGIA.

strongest and most plethoric frames arc brought
down to the state of weakness, and the active
Menorrhagia may thus become passive. In active
menorrhagia, for a short time, sometimes for two
or three days before the expected period, there is
a sensation of unusual fulness about the pelvis,
with throbbing referred to the situation of the
uterus itself, along with sense of heat and weight ;
the external parts of generation are often slightly
swollen, and the mammse become hot, tumid, and
painful. The circulation is quickened, the mouth
hot, the tongue dry with thirst, and there is a
general feeling of oppression, with headach and
giddiness. After these symptoms have lasted for
a certain time, the function of menstruation begins;
but the discharge comes on with violence, in
gushes, and usually accompanied with pure blood,
as proved by the presence of coagula. The pro-
gress is then variable ; sometimes after the first
few hours the patient feels relieved, lighter, and
cooler, and the rest of the period passes over more
quietly and naturally ; but in more aggravated
cases the flow still proceeds in equal or increased
quantity, and lasts for several days, occasionally
subdued, but again breaking forth on the slightest
exertion, till at the end of the period the patient
is left weak and languid, with a feeble pulse and
a Dale countenance. By the time of the recur-
rence of the monthly period the individual is per-
haps restored to the previous state of health ; but
the same train of circumstances is again renewed
with perhaps increased severity ; and the com-
plaint rarely lasts long without the number of
Jays intervening between the periods being rapidly
diminished, till at last scarcely one period is over
before the next approaches. The condition then
quickly becomes one of passive menorrhagia, both
local and general, the symptoms of which are
more formidable, and the treatment more difficult.

The patient in passive menorrhagia is habitually
languid and with feeble powers, or may have be-
come so from previous long-continued loss of blood
in the more active form of the disease. She is
.subject, perhaps, to palpitations of the heart, and
violent headachs with throbbing and beating in
the temples, singing in the ears, and giddiness —
all arising, not from plethora or absolute determi-
nation of blood to the head, but from exhaustion
and relative determination. This is a very im-
portant distinction, and one which has been too
frequently and often fatally overlooked. For a
further investigation of this interesting subject the
reader is referred to the experiments of Dr. Kellie
of Leith, and the practical observations of Dr.
Marshall Hall ; and also to the article Bloodlet-
ting in the present work. For the difference in
the pathology of active and passive menorrhagia,
we may also refer to the able article Hemorrhage,
in which is comprehended much that will apply
to the morbidly profuse menstruation, the circum-
stances being but very slightly modified by the
periodical nature of the discharge, and the fact of
its being merely an excess of a natural one.

In passive menorrhagia there are rarely any pre-
f.ursory symptoms ; if the periods are still regular as
to time, they are irregular and unnatural as to dura-
tion and the quantity lost. In general the return
is also much too frequent, so that at last one pe-
riod is followed nearly immediately by another, or

there will be one continued discharge, varying
from time to time in profuseness, from a mere
oozing of a thin, half serous discharge, to the full
gushes of coagulating blood. When apparently
the discharge is safely over, the least excitement
of body or mind, the slightest exertion or disturb-
ance, will reproduce it, and the difficulties are
again as great as ever. The usual effects of mor-
bid loss of blood gradually or rapidly present
themselves. When the complaint has been of
long standing, but not very suddenly violent, the
complexion becomes sallow and cadaverous ; the
countenance either pinched and emaciated, or
bloated and anasarcous 5 the pulse rapid and
feeble ; the legs and feet, and often the whole of
the cellular membrane distended with fluid ; the
respiration short and difficult ; and, in fact, all the
symptoms of confirmed and extreme cachexia are
observed. But the most dangerous character of
the complaint is manifested in the sometimes sud-
denly profuse menorrhagic discharge, the absolute
danger being much influenced by the previous
resisting power of the individual. In these in-
stances alarming syncope has occasionally been
brought on, and the most active measures become
imperatively necessary, to rescue the patient, and
prevent a fatal termination. Instances of death
would no doubt be much more frequent, did we
not possess very efficient means in general to ar-
rest the discharge. Besides the exhaustion from
the menorrhagia itself, it is nearly always the
case that patients are afflicted in the intervals with
profuse leucorrhcea ; and if they are exposed to
become,, pregnant, abortion will be very apt to fol-
low. We have also frequently remarked that
those who have suffered much from menorrhagia,
are peculiarly liable to uterine hemorrhage after
abortion or parturition at the full time.

There is one species of menorrhagia which is
not uncommonly met with in practice, and yet has
not, we believe, been noticed in books, — where,
instead of the periods being regular to the month,
or much more frequent than ordinary, the interval
is protracted considerably, even to six, seven, or
eight weeks. In these instances, whenever the
menstruation is regular to the usual time, the dis-
charge is not excessive ; but upon any disturbance
to the general health, there is more or less of de-
lay, and the discharge is then morbidly profuse.
This is common both with married and unmarried
women ; but when it takes place with the former,
it is very frequently mistaken for abortion, being
often accompanied by pain and the expulsion of
solid masses of coagulated blood with flakes of
albumen, not very unlike an early ovum. These
women are said in common language to become
obstructed, but it is under very different circum-
stances from amenorrhcea, as the protracted period
is always followed by profuse hemorrhage. The
patients complain for several days, even for two or
three weeks, previous to the appearance of the
discharge, of the symptoms mentioned as usually
preceding active menorrhagia, and particularly of
a more than ordinary sensation of pulse or throb-
bing in the situation of the uterus.

The causes of menorrhagia may be divided into
the constitutional and the accidental ; but it often
seems to require a combination of both to excite
the disease. The active menorrhagia is found to

MENORRHAGIA.

305

occur in plethoric habits, often apparently as a
natural relief to the overloaded system, but aggra-
vated or excited by luxurious living, a sedentary
and indolent life, hot rooms, and also by very vio-
lent exercise or any other fatiguing exertion. The
passive menorrhagia, on the other hand, is caused
by all those circumstances which lower the bodily
powers, and weaken the action of the heart and
arteries. But in both of these cases there are local
causes which peculiarly tend to direct the mischief
to the uterus, and increase the circulation in the
vessels of that organ, leading to the increased dis-
charge, whether that be the immediate effect of
excess of activity, or diminished power of reten-
tion : such are blows and falls, or any other local
violence ; frequent and recent abortions, leucor-
rhcea, over-indulgence in sexual intercourse, irri-
tation in the bladder, diarrhoea, tenesmus, piles,
ascarides or scybala in the rectum, or even habi-
tual or accidental costiveness.

In all severe or protracted cases, resisting the
usual means of relief, it would be right to make
an examination as to the actual state of the uterus
itself, as symptoms closely resembling menorrhagia
may be owing to organic mischief, particularly
ulceration, polypus, and inversion of the womb.
These causes are not immediately connected with
the present article, and therefore can only be allu-
ded to.

There is a frequent cause of menorrhagia not
much attended to, and not mentioned in systematic
works on the subject, but the knowledge of which
is highly necessary. It has often been observed
that the most obstinate forms of chronic menor-
rhagia occur in those persons who have an impe-
ded or disordered circulation through the abdomi-
nal veins, particularly where there is organic or
functional disorder of liver. The same cause will
very frequently produce hemorrhoidal disturbances;
and it is very easy to understand that the uterus
in such cases will be a ready outlet for the over-
distended blood-vessels of the lower part of the
trunk. We have no doubt that this is not at all
an uncommon cause of obstinate menorrhagia,
and we are still more convinced of the truth of
the opinion by the success which has often at-
tended the adoption of a peculiar plan of treat-
ment presently to be noticed, and which is only
adapted to that condition.

Treatment. — In the treatment of menorrhagia
it is especially important that we should inform
ourselves as much, and as accurately as possible,
of the actual state of the disease, and of the pecu-
liar cause or combination of causes to which its
origin may be attributed. It is too often the case
that medical men in such instances, as a matter of
course, order medicines containing infusion of
roses and the mineral acids, and such-like. This
is the every-day routine ; and in more obstinate
cases the astringent gums or metallic salts are
added. But however proper such medicines may
be in many, they are by no means applicable to
all the cases, and much valuable time is lost by
this careless mode of prescription.

In discussing the management of menorrhagia,
we must bear in mind that sometimes we are
called upon to arrest the violence of the discharge
from the uterus at the moment, and which is oc-
casionally so excessive as to hazard the life of the

Vol. Ill 39 2a*

patient, unless readily restrained. We shalh
therefore, in the first instance, treat of this highly
necessary part of the subject, and afterwards of
the mode of restoring the patient's health in the
more chronic forms of the disease, and in the in-
tervals of the discharge. In a patient who has
been till recently in a robust and plethoric condi-
tion of body, and in whom the menorrhagia has
been of recent origin, or has arisen from tempo-
rary and accidental causes, it will be often advisa-
ble during the actual profuseness of the discharge,
to diminish the action of the heart and arteries by
abstraction of blood from the arm, exactly on the
same principle on which we should be led to
similar practice in hemorrhage from the lungs. It
is only in recent cases, however, or in very pletho-
ric subjects, with a strong full pulse, that we may
safely venture upon this plan ; and then the quan-
tity of blood abstracted must entirely depend upon
the circumstances of the case, the powers of the
patient being a much better guide than the seve-
rity of the symptoms. When the discharge is
excessive, that alone will reduce the powers of
life to so low an ebb that much additional loss
of blood would be dangerous. After having ab-
stracted blood from the arm, when the case re-
quires this evacuation, we may proceed to the
other measures, which are proper to all cases of
urgent and immediate danger from menorrhagia.
The free application of cold to the abdomen, pel-
vis, loins, and back, is one of the most powerful
means we possess of restraining menorrhagia :
the cold hip-bath, dashing cold water, or vinegar
and water, on the person, injecting cold water into
the vagina, and applying ice, both externally and
internally, to the os uteri, may be had recourse to
with much and often decisive advantage. It is
necessary that in these cases the application of
cold should not be intrusted to the nurse or atten-
dants without the superintendence of the practi-
tioner, as they are rarely aware of the mode in
which alone the applications can be effectual.
After placing cloths dipped in cold vinegar and
water to the pubes, they often cover up the patient
with the bed-clo.hes, warm and comfortable, soon
converting the wet linen into a hot and reeking
fomentation. Besides which, by the want of
judgment, the application of cold, when properly
applied in the first instance, will often become
prejudicial from being continued too long. Cold
is a most powerful sedative, and when the powers
of life are reduced to an extreme state of exhaus-
tion from loss of blood, it often becomes necessary
for a time to reverse our treatment, and, when the
hemorrhage has ceased, to rouse up the sinking
pulse and failing powers by the cautious applica-
tion of stimuli and artificial warmth. We may-
do this more safely when we have made the state
of the patient more secure, by another very effec-
tual plan for restraining the hemorrhage — plug-
ging the vagina. In the uterine hemorrhage
which occurrs shortly after parturition, this expe-
dient is not safe ; because, when the blood, by the
plug in the vagina, is prevented from flowing ex-
ternally, the uterus itself may again expand to a
very considerable extent, from the blood being
poured into its cavity ; and in this way death may
take place, although there is no external flooding.
This can only happen, however, where the uterus

306

MENORRHAGIA.

is in a condition to undergo the expansion, and in
menorrhagia this is not the case. A dossil of lint,
or a fine cambric handkerchief, may be gradually
introduced into the vagina up to the os uteri, so
as to fill the vagina firmly throughout its whole
extent, and be allowed to remain there. Many
prefer soaking the material previously in some
strong astringent liquid, and this is, perhaps, still
more efficacious. If a plug [or tampon] produce
pain, it must be withdrawn ; and at all events it
should not be allowed to remain more than twen-
ty-four hours, because it is apt to become very
offensive and irritating from the putrefaction of
the discharge. On withdrawing it, unless it be
done very gently and gradually, a fresh discharge
of blood is apt to be occasioned ; but it can easily
be restrained by another plug, or some of the other
remedies.

Strong astringent injections into the vagina,
consisting of solutions of alum or sulphate of
zinc in infusion of galls or decoction of oak-bark,
are often of service. They certainly possess great
power, and act partly by coagulating the blood at
the orifice of the uterus, which acts as a compress
upon the mouths of the bleeding vessels. There
is a remedy which is perhaps the most certain of
any in restraining the discharge ; but as it is not
always safe, it should, in the writer's opinion, only
be employed in cases where other plans less dan-
gerous have failed — it is that of injecting the
uterus itself with an astringent injection. A gum
elastic male catheter is carefully inserted within
the os uteri, and, by means of a syringe, a very
small quantity of a solution of alum or of the
acetate of lead is to be gently introduced into the
cavity of that organ. Two instances have oc-
curred, within the last four or five years, where
violent vomiting was the consequence, followed by
the uterine inflammation and death ; and although
certainly such unfortunate results of the practice
are exceedingly rare, the knowledge of them must
render any one cautious in applying it. Of course,
where it is possible to ascertain the immediate
cause of the hemorrhage, and that cause can be
removed, our remedies will have but a poor chance
if such a precaution be neglected. A loaded state
of the rectum has been often overlooked in cases
of menorrhagia, and even when recognised, many
have been unwilling to produce any action of the
bowels, from fear that the exertion or the disturb-
ance might reproduce or increase the discharge.
Accumulations of hard faeces in the rectum should
always be removed as speedily as possible, and
this may be safely and effectually accomplished by
a lavement of cold water. This remedy alone,
indeed, has often stopped an obstinate case of
menorrhagia.

Of the internal medicines for restraining the
discharge in the violent degree we have mentioned,
opium and the acetate of lead are the most to be
depended upon. Where the patient is much ex-
hausted, opium may be given in large doses. Mr.
Burns advises at least as much as two grains at
once; and where it cannot be given by the mouth,
it is to be introduced into the rectum as an injec-
tion or a suppositary. Many practitioners exhibit
the acetate of lead in insufficient doses, dreading
the deleterious effects which lead is known some-

times to produce in the animal economy.* When
combined with opium, these effects are considered
as less likely to be occasioned, and the usual
practice has been to give one, two, and even three
grains of the acetate of lead, with from half a
grain to a grain of opium, every one, two, three,
or four hours, according to the urgency of the
symptoms. Dr. Mackintosh of Edinburgh has
related a case (Elements of Pathology, vol. ii. p.
363) where the effects of the acetate of lead with
opium were very strikingly displayed, in doses of
five grains every three hours, for several succes-
sive times, without any of the signs of the poison
of lead ever appearing. As opium will not always
agree, and as the harmless effect of lead has been
attributed to the opium being combined with it, it
is very satisfactory that Dr. A. T. Thompson has
lately proved that the addition of acetic acid to
the acetate of lead, so as to make an excess of
acid, entirely prevents the deleterious property.
Other remedies have been given in the acute form
of menorrhagia with success, and though not so
much to be depended upon as those already men-
tioned, must not be lost sight of. Emetics have
now and then been serviceable, but would only
be safe where we wanted rather to depress the ac-
tivity of the circulation. The same precaution is
necessary with respect to digitalis, which has been
much praised by several authors. Large doses of
the nitrate of potash or of the oil of turpentine
have been also highly spoken of. The most com-
mon remedies are the astringent ones, viz. kino
and catechu in large doses, alum, sulphuric acid,
rhatany root. Alum whey may be given as drink,
or a very weak solution of sulphuric acid, made
palatable with sugar.

[Many recent writers have spoken well of ergot
in the dose of from five to eighteen grains, three
times a day ; but farther observations, as to its
efficacy, are needed. The same may be said of
monesia, which has been given by different prac-
titioners in various forms of hemorrhage from the
uterus. (See the author's New Remedies, 4th
edit. p. 421, Philad. 1843.) Recently, Professor
Simpson, of Edinburgh, (Lond. and Edinb. Juurn.
of Med. Science, July 1S43, p. 661,) has highly
extolled gallic acid, given in the interval, as well
as in the flow, in doses of from 10 to 20 grains in
the 24 hours, made into pills. It possesses, ac-
cording to him, the advantage over most other
hsemastatic agents, that it does not confine the
bowels. He was first induced to prescribe it, from
finding a case of very obstinate menorrhagia get
well under the use of Ruspini's styptic, after many
other remedies had entirely failed ; and from its
being alleged, that gallic acid is the active ingredi-
ent in that styptic. It has received high enco-
miums from Dr. Stevenson, in similar cases.
(Edinb. Med. and Surg. Journ. July 1 843, p. 183.)

The infusion of matico has very lately been
given with great advantage where an internal
styptic was needed. (Braithwaite's Retrospect,
Part VI. art. 79 and Part. VIII. art. 7.)]

* D , r - Dewe e9 states, in his "System of Midwifery,"
page 149, that sugar of lead has been declared a danger
OU6 remedy, but " upon what ground we are at
determine, having used it most freely for more than
twenty years, without the slightest inconvenience from
it. He relates a case where lie gave it, as an injection
into the rectum, in scruple doses.

MENORRHAGIA.

307

In all these cases the most perfect quiet and the
horizontal posture are indispensable.

In the more chronic form of the disease the
above plans are more or less applicable, but much
will depend upon the character of the individual
case. When the individual is plethoric, bloodlet-
ting may be required ; and in many cases Dr.
Mackintosh has found advantage from the applica-
tion of a leech or two to the os uteri itself. Cool-
ing saline medicines may be taken, and the bowels
kept open by saline purgatives, avoiding, however,
any irritation of the canal. The infusion of roses
with Epsom salts will be found one of the most
useful forms of purgative, and if it irritates the
bowels, henbane may be added. Cold hip-bathing,
and also cold astringent injections, will be found
useful. This plan, with great quiet, will be found
to moderate the attack, and may be continued in
the intervals ; and it is worthy of remark that the
next return of the menstruation may often be ren-
dered comparatively trifling by the use of a full
purgative about twenty-fours before the period,
where that can be ascertained, avoiding any medi-
cine of a drastic or stimulating quality. In these
instances the diet should be very bland and spare :
wine must be left off, although the common remedy
in families for every sort of menorrhagia is to
drink rather freely of port wine.

In the more feeble constitutions, already, per-
haps, reduced by a long continuance of so debili-
tating a malady, besides the remedies above men-
tioned to abate the immediate violence of the dis-
charge, we must endeavour in the intervals to
strengthen the general frame, and restore tone to
the uterus itself. But in these instances we often
find it extremely difficult to restrain the discharge
itself, however trifling it may be in amount. The
least exertion or excitement will reproduce it, and
in spite of all our remedies it continues day after
day, exhausting the strength. Dr. Mason Good
(Study of Medicine, vol. v. p. 66,) is of opinion
that in these cases there exists a relaxed state of
the solids and an attenuated state of the fluids ;
and certainly the discharge in nearly every such
instance appears very thin, and to contain an
unusual proportion of serum. Small and repeated
doses of the acetate of lead are more serviceable,
perhaps, than any other internal medicine, and it
may be combined with opium or an additional
quantity of acetic acid. The other astringents
mentioned before are preferred by some authors,
given in more moderate but more frequent doses.
The ergot of rye, with the idea of its promoting
contraction of the uterus, has been tried in me-
norrhagia in small and often repeated doses, and
by some, it is said, with success ; but others have
had no reason to speak favourably of it.

In the intervals, every remedy which can give
general and local power must be employed. Cold
bathing, cold hip-bathing, especially, will be found
of great use ; and the efficacy of the water may
be increased by the addition of salt or vinegar.
This should be used from two to five minutes
every night and morning, and a cold astringent
injection should also be thrown up to the uterus.
AH violent exertions should be avoided, and es-
pecially shaking in an uneasy carriage, or horse-
exercise. The free use of the flesh-brush will
give steadiness to the circulation, and answer

nearly all the salutary purposes of exercise, with-
out the risk of mischief from too much fatigue or
exertion. The diet should be nourishing, but
not stimulating : fluids and the watery vegetables
should be taken but sparingly, and only a small
quantity of wine, of which claret or port is per-
haps the best. Of medicines, the vegetable tonics
are scarcely so serviceable as the mineral ; but
they may often be combined with advantage. The
salts of iron require to be carefully administered ;
but in spite of their well-known effects of in-
creasing or producing the menstrual discharge
when deficient, their general tonic and astringent
effect upon the blood-vessels is often exerted with
marked benefit in cases of menorrhagia of the
atonic character. The sulphate of zinc may be
more easily managed than steel medicines, and in
many instances has been more useful ; from one
to two grains being taken in the form of pill three
times a day.

In a case of complication of obstinate skin-
affection with menorrhagia, arsenic was found ser-
viceable to the eruption, and during the exhibition
of this remedy the menorrhagia ceased. This
was quite accidental ; but the writer was after-
wards induced to try its effect in menorrhagia of
the atonic character, where that was the only
complaint ; and the success of it has occasionally
been very considerable. It has been given in doses
of five to ten drops of the liquor arsenicalis,
gradually increased to twenty-five, or thirty, three
times a day, carefully watching the effect of the
medicine, and diminishing the dose, or discontin-
uing it altogether, when the peculiar deleterious
qualities have been evinced.

Perhaps no artificial medicines are so powerful
in their action in chronic cases of menorrhagia aa
the natural medicinal springs, which contain mi-
nute portions of iron in solution ; though some
of the benefit may be fairly attributed to the
change of scene and the purity of atmosphere.

In that congested form of menorrhagia which
has been mentioned, accompanied by protracted
intervals between the menstrual periods, much ad-
vantage is derived by abstracting blood from the
uterus or from the neighbouring parts, whenever
the proper day has passed over without the ap-
pearance of any discharge, and directly the sense
of fulness and throbbing in the pulse is percepti-
ble. The bowels also should be freely purged,
and the feet put into hot water : in short, the
treatment should be partly made up of that ap-
propriate to cases of amenorrhea, modified by cir-
cumstances ; whilst in the intervals horse-exercise
and active exertion will be not at all improper but
highly salutary. At the time of the actual ex-
istence of the profuse discharge, the most perfect
quiet is essential, and those remedies which have
been directed to alleviate the immediate symp-
toms.

In obstinate cases of menorrhagia, where we
have reason to suspect the existence of a conges-
ted state of the liver, or an obstructed or rather a
retarded circulation through the abdominal veins,
before mentioned as a very common though sel-
dom noticed cause of this disease, nearly all tho
usual remedies for menorrhagia will fail, and the
great number of them will do absolute mischief.
Although during the immediate flow of the '.'as ,

308

MENSTRUATION, (PATHOLOGY OF)

charge, if violent, the remedies for checking it
formerly mentioned become necessary, yet in the
intervals we must direct our attention chiefly to
the condition of the abdominal viscera. Small
doses of alterative mercurial medicines, particu-
larly the Plummer's pill, will be found very useful,
and the decoction or extract of dandelion should
be given in full doses. A pill of rhubarb, soap,
and ipecacuanha, is a very advantageous combina-
tion to keep the bowels open, and this may be as-
sisted, if necessary, by domestic enemata; it
being of great consequence especially to prevent
the collection of any hard or lumpy faces in the
large intestines. In addition to all this, the writer
particularly recommends in all such cases the
frequent application of a few leeches to the anus.
Even in very debilitated and exhausted constitu-
tions, this remedy, when carefully watched, may
be safely administered, and relief will often be
very rapidly manifested. q t OCO ck

MENSTRUATION, PATHOLOGY OF.—

It is not intended in the present article to discuss
the various theories of this important function of
the human uterus, which have at various times
prevailed. It will be sufficient to state generally
that we consider the menstrual discharge to be
the consequence of a peculiar periodical condition
of the blood-vessels of the uterus, fitting it for
impregnation, which condition is analogous to
that of " heat" in the inferior animals. In Dr.
Hooper's work " On the Morbid Anatomy of the
Human Uterus," there is an exact representation
of the uterus of a woman who was instantaneously
killed by an accident during menstruation ; and
every one must be struck with the resemblance
which it bears to the description given by Mr.
Cruikshank in the Philosophical Transactions
(1797) of the appearances observed by him in
rabbits killed during the state of genital excite-
ment, usually called the time of heat. The actual
presence of the discharge is the resolution, if we may
so term it, of the previous condition of the vessels
which separate it ; for the uterus is fitted for the
purposes of impregnation before the menses begin
to flow. An instance in proof of this may be
given from the Philosophical Transactions (1817)
of a young woman who bore two children succes-
sively without any previous menstruation ; which
function, in fact, did not show itself externally
till after the third pregnancy, which ended in a
miscarriage.

The function of menstruation lasts, upon the
average, for about thirty years of the life of
woman, beginning at puberty, and ending some-
where between forty and fifty years of age, unless
interrupted by disease, by pregnancy, or by suck-
ling. During this large proportion of female life
there is a great liability to derangements, of one
form or another, in the menstrual process ; and
to which much importance is attributed, though
from some remains of the old doctrine that the
menses were the outlets of " peccant humours,"
more anxiety is generally expressed in cases of
diminished or suspended discharge than in those
where it is unnaturally profuse. Women have
also been always in the habit of considering the
time of the first appearance of the catamenia, and
if their final cessation, as requiring particular

caution and management, and as tending to the
development of a healthy or diseased condition
for a long period of life. The actual flow of the
menstrual discharge itself is also looked upon as
a time of great delicacy, and as demanding pecu-
liar attention ; so that very few diseases can exist,
and very few plans of treatment be recommended,
without the presence of the menses in some way
influencing the nature of the symptoms or the
remedies to be applied. It is in this especially
that the character of the female constitution in
disease is manifested ; for before puberty, and
after the cessation of the menstruation, the female
differs but little from the male in the character of
disease, unless in those points which may be
considered as accidental, such as organic diseases
of the sexual organs.

In the present article we propose to consider
the medical management of the female at the first
appearance of the menstrual discharge, during
the continuance of it, and at the final cessation.

Instances of precocious menstruation are by no
means uncommon ;* but occasional discharges of
blood from the vagina of young children cannot
be considered in this light, unless accompanied
by the usual signs of puberty. Precocity must
always be considered relatively as to climate, for
the difference in hot and cold countries is very
great. Dr. Denman has quoted an opinion cf
Hume (the historian), which is scarcely borne
out by facts ; the difference in the time of life
when the menses appear being assigned as the
reason why women in hot climates are almost
universally treated as slaves, and why their influ-
ence is so powerful and extensive in cold coun
tries, where personal beauty is in less estimation
" In hot climates, women are in the prime of theii
beauty when they are children in understanding;
and when this is matured, they are no longer
objects of love. In temperate climates, their per-
sons and their minds acquire perfection at, or
nearly at the same time, and the united power of
their beauty and faculties is supposed to be irre-
sistible." (Introduction to the Practice of Mid-
wifery, p. 83.) The influence of civilization
seems to have been entirely overlooked in this
theory ; as otherwise the most chivalrous devotion
to the fair sex would be found in the savage in-
habitants of the countries of perpetual snow.
Precocious menstruation can scarcely be con-
sidered as a disease, but it certainly is not de-
sirable, for many obvious reasons; and as artificial
circumstances may hasten it, avoiding such causes
or counteracting them may not only prevent, but
may even supersede it. For example, cases have
been related in which girls have menstruated,
with all the signs of puberty, at nine or ten years
of age, in the East Indies ; and having been re-
moved to Europe, the function has ceased, with-
out disorder of the health, and has not appeared
again till the age of fourteen or fifteen, at which
it usually comes on in this country. Hot and
crowded rooms, luxurious habits, early excited
passions, and improper indulgences, are well
known to promote an early development of
sexual power, and should be carefully counter-

* We refer in particular to a rase by Dr. Wall, of Ox-
ford, in the second volume of Medical and Cliirurgical
Transactions.

MENSTRUATION, (PATHOLOGY OF)

309

acted in those cases which seem to call for inter-
ference. An opposite condition to precocity is
also very commonly met with ; but however late
the period may be at which menstruation first
comes on, it is not a disease in itself, so long as
the symptoms of puberty are not manifested.
The parents of a young woman are often anxious
upon this point, and request medical aid to bring
on the menstruation ; but, unless by attending to
the general health, the practitioner is not justified
in interfering. In some unfortunate instances,
the 6igns of puberty never come on, from some
organic deficiency in the genital organs, particu-
larly the ovaria ; and all attempts to excite a
menstrual discharge would be pernicious.

For a very considerable period before puberty,
often two or three years, symptoms of the ap-
proaching important change in the system may
be detected. It is not at all uncommon to meet
at this age with very obstinate disorders, such as
headachs, epileptic fits, or cutaneous affections;
and upon finding the usual plans of treatment
fail, medical men are in the habit of prophesying
a cure when menstruation is established : this
arises from long experience of the frequent truth
of such a result. As the time draws near, the
system becomes more irritable ; there is a general
uneasiness, and an alteration of the moral charac-
ter ; there is also very commonly much languor,
flushing, sensation of fulness, headach, livid marks
round the eyes, disordered appetite, impaired di-
gestion, and disturbed or unnatural heavy sleep.
These symptoms continue for a longer or shorter
period ; and immediately preceding the first ap-
pearances of the discharge, there is much pain
and weight, with fulness in the head and pelvis,
and throbbings and swelling of the mammae.
Although the actual discharge is rarely quite re-
gular to the month for the first half year or so,
passing over a month or two, yet the usual con-
stitutional symptoms just enumerated as directly
preceding the discharge are found to observe the
lunar intervals and to be aggravated monthly,
even for some time before the flow of the menstrual
evacuation itself. With many, the symptoms
above mentioned are either so slight or so tempo-
rary, that no great attention is paid to them.
Where medical aid is required, the plan of treat-
ment must depend a great deal upon circum-
stances ; as a general rule it is best to temporize,
knowing that a little patience will carry the pa-
tient to the termination of the discomfort. Should
there be any very great disturbance, with a full
pulse and much headach, the abstraction of a
small quantity of blood will be prudent. The
diet should be carefully regulated, and abstinence
from meat or wine strictly enjoined. The bowels
should be kept rather more open than usual, but
not with any of the more irritating and drastic
purgatives, under the idea of exciting the uterus
to action, as is too commonly recommended ; the
object being to lead the patient through the strug-
gle without any force or disturbance. We should
watch excess of action of every description, and
restrain it, but not attempt to stimulate any appa-
rent deficiency, unless actual disorder of health
be manifested. Circumstances may arise, how-
ever, to call for more decisive measures ; and the
menstruation may be so protracted as to constitute

one of the forms of amenorrheca, the nature and
treatment of which have been detailed elsewhere.
(See Ajienoiikhcsa.)

During the menstrual period, when quite regu-
larly and properly performed, no medical treat-
ment is required ; but it should never be lost sight
of, either by the patient herself or by her medical
attendant, in case of any accidental illness, or any
general plan of management of the health. Wo-
men expect this carefulness, from the great im-
portance they habitually attach to the proper per-
formance of the function ; and therefore, in pre-
scribing for females, it is always right to inquire
as to the expected time, as well as the regularity
of the periods, to guide us as to the propriety of
continuing or remitting any part of the remedial
measures. There are many things to be guarded
against on these occasions which might be safely
followed at any other time ; and while much de-
pends on the patient's own prudence, still the
physician is constantly blamed if he lose sight of
the necessary precautions. It is necessary to
avoid any very active purgative medicines during
menstruation, particularly those which irritate the
lower part of the rectum, as they are apt to pro-
duce a morbid increase of the discharge. Medi-
cines containing the preparations of iron, strong
diuretics, emetics, myrrh, or mercury, are usually
ordered to be suspended during the periods, al-
though it is very doubtful whether the milder
mercurial medicines in gentle doses can be pro-
ductive of mischief. Cold bathing ought also to
be discontinued, particularly the hip and foot
baths ; and yet it is a well-known fact that the
dippers attached to the bathing-machines at the
sea-side are in the habit of being for several hours
in and out of the sea during the catamenial flow
without detriment. Wetting the feet or exposure
^to rain under these circumstances has now and
then suddenly suppressed the menstruation, and
brought on illness of an alarming nature. Dr.
Dewees states that in America it is not at all un-
common for young girls, bent upon a party of
pleasure, to put the feet in cold water to stop the
discharge. It need scarcely be stated that all
vaginal injections to restrain leucorrhcea must be
left off at these times. Any very violent exercise
is to be carefully avoided during menstruation :
partly because it is very apt to produce too profuse
a discharge, and partly because, on account of
the increased weight of the uterus and relaxation
of the vagina, a serious degree of prolapsus uteri
has been often occasioned by it. Some aggra-
vated instances of this distressing complaint, even
in unmarried women, have occurred in the writer's
own practice, which have been brought on by
dancing, by horse-exercise, and by over-fatigue in
walking, during the menstrual period.

The Jews, and even more modern nations, be
lieved that there was something deleterious and
contaminating in the menstrual discharge itself;
and hence various directions and regulations as to
seclusion and cleanliness of person. It is not
necessary now to controvert these doctrines , but
it were well, perhaps, if more strict attention
were to be paid to some part of the regulations
even in the present times. Either by accident or
by criminal impatience, sexual intercourse has
sometimes been permitted during the period of

310

MENSTRUATION, (PATHOLOGY OF)

menstruation ; and, although not constantly, yet
such conduct has been frequently followed by the
most serious effects — generally by profuse hemor-
rhage ; at other times by a sudden suppression of
the discharge ; to which have succeeded fever,
delirium, obstinate hysteria, confirmed mania, and
even catalepsy. (See Amenorrhea.)

When the function of menstruation has been
once fairly established, it may become disordered
in several ways, each forming distinct classes of
diseases. Menstruation may be faulty in respect
to the quantity of the discharge, the quality of
the discharge, the regularity of its appearance,
the time of its duration, and the degree of pain
with which the process is accompanied. When
the discharge has been in any way suppressed in
a peculiar condition of health, what has been
called vicarious menstruation has sometimes peri-
odically occurred from other parts of the body,
the stomach, the lungs, the bowels, &c., although
Dr. Dewees evidently doubts the existence of such
anomalies. For a minute account of these seve-
ral forms of disordered menstruation, the reader
is referred to the articles Amenorrhea, Dys-
menorrhea, and Menorrhagia.

During pregnancy and suckling, menstruation
ceases. This is undeniably the general rule.
Under the head of Lactation, the exceptions to
this law of nature, as regards suckling, have been
noticed, and no one perhaps will deny their occa-
sional occurrence. But many practitioners of
extensive experience in midwifery have denied
the possibility of menstruation going on during
pregnancy, and declare the supposed cases to be
either false altogether, or that the discharges
which do sometimes occur during pregnancy are
not menstrual, but are irregular in time, sparing
in quantity, and sanguineous in character. They
rest their arguments upon the fact, that at a very
early period of pregnancy the os uteri is closed
by the thick glutinous secretion which is poured
out by the glands at the cervix ; and also, that
from the interior of the uterus being coated with
the decidua vera, there is no surface from which
the menstrual fluid could be secreted. Many ex-
perienced medical men, and women themselves
in general, believe not only in the possibility, but
in the comparative frequency of menstruation
during the first three or four months of pregnan-
cy ; and Dr. Dewees mentions a case in which
he was firmly convinced that it went on regularly
to the seventh month, lasting three or four days,
exactly as usual, not sanguineous, at least not
containing perceptible coagula, and only differing
from common periods in being less and less abun-
dant as the pregnancy proceeded, after the fourth
period. The first argument, as to the impossi-
bility, is scarcely tenable, when we recollect how
ieadily slight hemorrhages find their way through
the os uteri in spite of its closure, from some ac-
cidental disturbances of the ovum at any period
of pregnancy, without being followed by miscar-
riage; and if such discharges can escape, why
not the menstrual 1 In reply to the second, Dr.
Dewees asserts, that as menstruation occurs from
the cervix uteri in the unimpregnated uterus, as
well as from the body and fundus, there is suffi-
cient space for some menstrual fluid to be secreted
in that part of the cervix which remains unco-

vered by the deciduous membrane, and, as is well
known,' is not taken up into the body of the
uterus till an advanced period of pregnancy. He
states that a very small space will be sufficient
for the purpose, as was proved by discovering in
a post-mortem examination that the uterus of a
young woman who had menstruated quite regu-
larly and properly to the time of her death, re-
tained only a surface healthy enough to perform
the menstrual function, of the size of the finger-
nail, all the rest of the interior being in a state of
disease. In stating the opinions on both sides, it
will be scarcely necessary to advert to our own ;
but, although firmly convinced that a perfectly
regular discharge as to period is not uncommonly
found to continue for the first two, three, or four
months of actual pregnancy, yet we do not there-
fore conclude that such discharge necessarily
comes from the uterus, or is exactly menstrual.
In what the difference consists between the men-
strual fluid and blood is not accurately known ;
that it does not coagulate is not saying much, as
the blood of persons affected with scurvy, or of
those killed by lightning or by some of the power-
ful narcotic poisons, does not coagulate; and
menstruation is rarely very profuse without co-
agula being also expelled, no other secretion ever
containing pure blood mixed with it, unless from
organic lesion.

From habit, there is a tendency of the circula-
tion towards the uterus every month, even during
pregnancy; and few women are found who do not
experience the symptoms occasioned by it, for the
first month or two : hence it is that miscarriages
are so apt to occur at those periods at which men-
struation would have appeared, had not the process
been interrupted by pregnancy ; and hence, also, a
periodical relief resembling menstruation may
occur for the first few months, the blood-vessels at
the cervix uteri, or the upper part of the vagina,
giving way for the purpose. When this occurs,
as it is unnatural, and might lead to abortion,
great care is required ; and when patients have
shown a tendency to it, they should be kept in the
horizontal posture for a few day r s, and a few
ounces of blood be abstracted from the arm, or, by
means of leeches or cupping, from the neighbour-
hood of the uterus. Although it is not pretended
that these cases are common, and they can only
be regarded as exceptions to a general rule, yet it
is important that no one should blindly deny their
possibility, since it might lead to a neglect of those
precautions which pregnancy requires.

The important period of the cessation of the
menses is liable to the same varieties as that occa-
sionally observed on the first appearance, and is
also accompanied with many very striking changes
in the animal economy. It is an age which is al-
ways looked upon by the female sex with a cer-
tain degree of apprehension, as one in which the
foundation is often laid of many a painful and
dangerous malady ; and yet those who previously
are suffering from long-continued general illness
or any obstinate chronic disease, are accustomed
to look forward to the time when the constitution
shall become settled, as it is termed, for a relief to
their sufferings and a restoration to more perfect
health. When the uterus is no longer in a con-
dition to perform the function of menstruation, the

MENSTRUATION, (PATHOLOGY OF)

311

power of conception also ceases ; and it has been
considered by some authors that this was a wise
ordination to prevent women from becoming mo-
thers at so advanced an age that they would be
incapable of properly attending to their offspring
while still too tender to provide for themselves. As
it has been generally acknowledged that the uterus
is most fitted for impregnation directly before or
after each menstrual period ; so it also happens,
that for a short time before that process ceases for
ever, there appears to be an unusual degree of
stimulus in the generative faculty ; and many
women who have ceased to bear children for
years, or who have been hitherto barren through
the whole of their married existence, at this time,
to the surprise of their friends and of themselves,
become pregnant. Still more commonly, how-
ever, does it happen that women mistake their
condition under these circumstances, and so obsti-
nately believe themselves pregnant, that it be-
comes exceedingly difficult to convince them of
their error. It is easy to suppose that at this par-
ticular age such mistakes are likely to arise, for
the symptoms that naturally accompany the ces-
sation of the function much resemble those of
pregnancy. Women are unwilling to be thought
beyond the age of bearing children, and are per-
haps on that account misled by their wishes ; but
they not unreasonably are struck with the first
sign which generally occurs, — namely, the passing
over of the menstrual period ; and their attention
is ready to seize hold of every flattering explana-
tion of the circumstance. Other symptoms are
soon manifested ; the size increases, the breasts
even become swollen and painful, the stomach
disordered, and the appetite capricious, so that a
pregnancy sickness is not uncommon ; flatulence
collects in the intestines, and whilst on this ac-
count the size still increases, the sudden motions
and rolling about of the confined air are mistaken,
even by women who have previously borne many
children, for the plunging of a foetus. It is only
by time, or by an examination per vaginam, that
the mistake is detected, much to the annoyance
of the patient and her friends ; but the symptoms
are easily removed by the free exhibition of car-
minatives and purgatives, the use of active exer-
cise, and bandaging the distended abdomen, which
has probably been allowed more room to expand
than formerly, from a fear of tight lacing in preg-
nancy.

In this country the average age at which women
cease to menstruate, or " the time of life," as it
has been called, is forty-five. Where they have
begun early, it generally ceases early ; and, on the
other hand, where they have begun late in life, it
often lasts much later than common. Some wo-
men have ceased entirely before the age of thirty ;
others have gone on to nearly sixty, or even be-
yond this period. Many of the cases, however,
which have been related of women who have con-
tinued to menstruate till seventy, eighty, or up-
wards, or who have begun again ten or -fifteen
years after having apparently left off for ever, were
not genuine cases of menstruation, but sanguine-
ous discharges, generally irregular, and arising
from some disease of the uterus.

Menstruation ceases sometimes at once, when
the female has arrived at the usual age ; but this

rarely happens, unless accidentally, as it may be
termed. For instance, something or other takes
place to check the expected discharge, which
would have had the same effect at a much earlier
age, such as cold, fright, some acute illness, or
any other fortuitous occurrence. At any earlier
period the menstruation would return on the cessa-
tion of the illness ; but now it seems to take the
opportunity of departing without further trouble,
and never again appears. Much more frequently
the change is gradual, and accompanied with such
irregularities that it has not inaptly been called
« the dodging time of life" The quantity varies
much as well as the regularity of the return ;
sometimes for two or three successive periods it is
extremely scanty, and then suddenly is so profuse
as to partake of the character of uterine hemor-
rhage, and even to create alarm as to the imme-
diate result. The discharge sometimes returns
every two or three weeks, and then ceases for
several weeks, or even months, and afterwards
perhaps for a time recurs as regularly as usual.
In females in whom it has been always previously
the most regular, and when the person has been
uniformly healthy and of temperate habits, the
cessation of the function goes off the most quietly,
and with the least subsequent derangement of the
system. Many, however, who have not been so
fortunate in their state of health, by being carefully
conducted through this critical period, have appa-
rently renewed their existence, have lost their pre-
vious delicacy of constitution, and become more
healthy than ever ; so that it has been remarked
that their lives are likely to be prolonged to a more
advanced age than men of equal standing and at
the time of equal health.

But this is the most favourable termination of
the period ; for with many it is only the beginning
of a train of great suffering and of constant illness,
ending in an early death.

[It would not seem, however, that this critical
age, critical period, or critical time of life, as it
has been termed, is so full of danger as the epi-
thet < critical' might suggest ; for the statistical
researches of De Chateauneuf, and of Lachaise,
Finlaison, (Reports on the Evidence and Ele-
mentary Facts on which the Tables on Life An-
nuities are founded, Lond. 1829,) and others,
have shown, that between the ages of forty and
fifty no more women die than men. . (D. Davis,
Principles, &c. of Obstetric Medicine, i. 290,
Lond. 1836, and Desormeaux and P. Dubois, in
Diet, de Med. 2d edit. xix. 467, Paris, 1839.) M.
Constant Saucerotte has, indeed, attempted to esta-
blish, by statistics on a great scale, that the mor-
tality amongst women is greater between the
ages of thirty and forty than between forty and
sixty ; and Muret, in his statistics of the Pays
du Vaud, did not find between forty and fifty a
more " critical" age than between ten and twenty.
(Churchill, Outlines of the Principal Diseases of
Females, Prof. Huston's edit., Philad. 1842.)]

Whenever there is any tendency to organic dis-
ease, or any weak point in the frame, this is tne
time when the mischief becomes manifest, and
the symptoms are first detected. It is not, as Dr.
Dewees has very properly remarked, that the par-
ticular diseases are caused by cessation of the
menses, but the seeds of such affections already

312 MENSTRUATION, (PATHOLOGY OF) — MILIARIA.

existing are roused into activity by the changes
which take place in the system at that period.
For perhaps thirty years of the woman's life there
may have been an habitual monthly discharge of
from four to six ounces, more or less, of a secre-
tion which is nearly allied to pure blood, from the
uterus ; and it is not surprising that, on this being
stopped, the long habit should produce a tendency
to the same relief every month ; which not taking
place, the excess is thrown back upon the circula-
tion, and local congestions are the consequence.
Even under the most favourable circumstances
there are symptoms of congestion, shown by head-
ach, shortness of breathing, oppression at the prae-
cordia, and a tendency to corpulency. But when-
ever any organ is in a state of disease, however
latent hitherto, the redundancy is thrown especially
to that quarter, and the disease is rapidly called
into activity.

It is not surprising, from the great alteration
which takes place in the organs connected with
the function itself, or those which have been par-
ticularly affected by it, that they should be the
parts most liable to become diseased at this time ;
and certainly most organic diseases of the uterus
and mammae date their perceptible origin from
this period. Besides cancerous tumours, medul-
lary sarcoma, hematoma or fungus haematodes,
attacking the uterus and breast, many serious dis-
eases of other parts often arise. Apoplexy is not
an uncommon occurrence, but is not so often fatal
at this age as at one more advanced. Organic
disease of the liver or of the other abdominal vis-
cera is much more common than of the lungs, the
abdominal circulation being perhaps more closely
influenced by the want of the uterine secretion.
Very obstinate disorders of the skin frequently
make their appearance at this age for the first
time, producing great distress and disorder of the
health. There is sometimes an apparent effort of
nature to substitute some other discharge as a
compensation for the one which has been sus-
pended ; and it is right always to respect these
contingencies, as, however disagreeable they may
be, the removal or cure of them may be danger-
ous. Leucorrhoea is a very common instance of
this natural relief; and discharges of blood from
the hemorrhoidal veins is another, which now and
then becomes periodical. Ulcers sometimes form
and discharge copiously, on the legs or behind the
ears, and should not be carelessly healed, unless
other measures are taken to prevent mischief.

The medical management of the important pe-
riod of cessation of the menses may be easily col-
lected from what has been already remarked.
Recollecting the condition of the system, particu-
larly of the circulation, it will be necessary to
keep it free from disturbance as much as possible,
to relieve any organ or part of the body which
may appear oppressed or in a state of congestion,
and to watch carefully the first threatenings of any
local disease. Should the pulse be full and hard,
and should there be any general plethora, frequent
small bloodlettings will be advisable. Every local
pain, heat, or sensation of fulness, should be re-
lieved by leeches or cupping. The bowels should
be kept carefully and freely open by purgatives
which do not irritate, but which produce watery
motions, such as the neutral salts or castor oil. If

the pulse is habitually quick and hard, small but
repeated doses of mercurial medicines may often
be of service, and remove any obscure inflamma-
tory action which may insidiously be going on.
The diet should be mild, and moderate as to quan-
tity, meat and wine either omitted or but sparingly
allowed. Exercise must be regulated by the cir-
cumstances of the case ; it is very desirable where
no local mischief appears to exist, as it promotes
regularity of action and general health ; but other-
wise great quietude should be observed. The
production of artificial discharges by means of
issues, setons, or perpetual blisters, so much in
vogue formerly, is now no longer fashionable, from
the dislike patients have to such remedies; but
viewing what is often effected naturally, we can-
not doubt but that their more frequent employ-
ment would be highly advantageous.

In some peculiar constitutions most of the dis-
turbance consequent upon cessation of the uterine
functions seems to attack the nervous system, and
hysteria, epilepsy, or mania sometimes takes place.
The management of such cases requires some
modification in the treatment above recommended:
conium has been found of great service by some;
and now and then even mild tonics are required
to steady the irritable condition of the frame.
When such diseases arise for the first time at this
period of life, they generally prove obstinate,
and often incurable. Some have proposed to at-
tempt to reproduce the menstruation, as a means
of relief when any of the formidable disorders
above mentioned come on, by the employment of
violent remedies of the emmenagogue class ; but
this practice might be highly dangerous, and pro-
bably excite uterine diseases of the most fatal

description. ~ T

r C. Locock.

[MENTAGRA. See Sycosis.]
MESENTERIC DISEASE. See Tabes Me-

SENTERICA.

MILIARIA. — This term, derived from milium,
a millet seed, is applied to a minute vesicular
eruption which occasionally appears in the pro-
gress of various acute disorders, the vesicles re-
sembling in size and colour the seeds of the millet
plant.

It has been regarded by some authors as an
idiopathic eruptive fever, to which the name mili-
ary fever has been given. By many of the older
writers it has been confounded with scarlatina and
rubeola ; and from its having been occasionally
observed to co-exist with purpura, the idea proba-
bly first originated that it was only a modification
of this eruption. We have also on record several
accounts of an epidemic miliary fever,* which has
at various times prevailed, though it is evident
that the eruption was only an accidental or symp-
tomatic affection, and as little entitled to charac-
terize an epidemic as petechiae that appear in some
epidemic fevers, and from which the disease has
been termed petechial or spoiled fever.

The miliary eruption appears in the form of
small round vesicles about the size of a millet-

* Pujol, Mem. sur la fievre miliare qui regna en Lan-
guedoc et dans lea provinces linoitroplies, durant le prin-
temps de 1782. Payer, Histoire de l'epidemic de suette
TOis^ 6 1 lil a rtgne, en 1621, dans le department de

MILIARIA.

313

seed, surrounded by slight inflammation. It is
most abundant on the neck, breast, and back, but
is less copious on the face and extremities, and
sometimes comes out in irregular patches, fre-
quently appearing and again disappearing without
evident cause. The vesicles are at first so exceed-
ingly small that they can hardly be distinguished
except by their roughness : when examined
through a lens, the round, vesicular form of the
eruption (each vesicle containing transparent
lymph) is distinctly visible, though, from the red
colour of their undcr-surface being transmitted
through the transparent pellicle, they are of a red
colour; the lymph, however, becomes, in the
course of twenty-four or thirty hours, opaque, and
thus gives a pearly white appearance to the erup-
tion. From this evidently originated the two
varieties mentioned by the older writers ; the red
and the white miliaria, (rothen friesel and weisse
friesel of the Germans,) — a distinction not only
unnecessary but unfounded, as it is apparent that
both these supposed varieties are only different
stages of the same eruption.

Miliaria is sometimes rapid in its progress, and
the eruption copious and generally diffused : in
other instances it is partial and slow, and though
the vesicles are usually distinct, they sometimes
cohere and become confluent, and thus assume the
form of phlyctenae or small bullae.

Its duration is various : it sometimes passes off
in a day or two ; the vesicles either breaking, or
the lymph being absorbed, slight desquamation of
the cuticle terminates the disorder. According to
Bateman, it frequently lasts from seven to ten
days, and sometimes much longer : indeed, under
the treatment formerly pursued, when the sick,
according to the expression of Blackmore, lay
" drowning in sweats," it was not uncommon for
crops of vesicles to be renewed a second, third, or
even a fourth time, and the whole disease to be
protracted to nearly fifty days.

The only disease with which miliaria can pos-
sibly be confounded is eczema. From this it may
be distinguished by its being invariably symptom-
atic of some acute febrile disorder, and by its rapid
progress and short duration. Besides, in eczema
the vesicles are usually confluent, and confined to
a circumscribed or limited space, whilst in miliaria
they are generally distinct, and much more nu-
merous.

With regard to the diseases in the progress of
which miliaria occasionally appears, we may ob-
serve, that since the introduction of the cooling
regimen which now forms an essential part of the
treatment of every variety of febrile disorder, it is
comparatively rarely met with. In common, con-
tinued fever, even in the worst forms of it, when
judiciously managed, its appearance is almost
unknown. We cannot bring to our recollection a
single instance out of the numerous cases which
we have had under our care in the Fever Hospi-
tal, though we have had repeated occasion to ob-
serve it in the crowded, ill-ventilated apartments
of the lower orders, when ventilation has been
unattended to, and a stimulating regimen adopted.

Miliaria is more apt to appear among women
after delivery than in any other circumstances.
So frequent, indeed, was its occurrence half a cen-
tury ago, that it was described bv some writers as

Vol. Ill — 40 2 b

an epidemic among lying-in women. From 'he
accounts given of the management after delivery,
by those who witnessed it at the period referred
to, there can be no question that the eruption was
induced by the injudicious mode of treatment
adopted. In later times, since the adoption of a
more cooling plan of management after delivery,
not only are febrile disorders less frequent and
violent, but the miliary eruption is seldom ob-
served ; and when it does occasionally appear, its
origin may be always traced to an over-heated
atmosphere, over-loading the patient with bed-
clothes, and the stimulating regimen adopted by
the poorer classes, under the mistaken notion that
the parturient female may be thus prevented from
catching cold. Miliaria is also a frequent accom-
paniment of the milk-fever, and of ephemera or
weed, when the perspiration is injudiciously en-
couraged. Dr. Burns thinks that this is by far the
most frequent form under which the miliary rash
appears, but he states that it is sometimes observed
in women who have been much reduced, but who
are free from fever.

With other fevers, Bateman remarks, in which
a similar method of treatment was pursued, though
in a less degree, and the patient was confined to
bed, the miliary eruption, with its attendant lan-
guor and exhaustion, was frequently conjoined,
especially with catarrhal and rheumatic, and also
with typhoid, remittent, and intermittent fevers.
Whence the writers who have described the mili-
ary fever, speak of it as being disguised under, or
counterfeiting the characters of these fevers re-
spectively. In the summer, indeed, when ventila-
tion and coolness are not sufficiently attained or
attended to, a slight miliary eruption is even now
occasionally seen ; a miliaria clinica, in fact, may
be thus induced by any circumstance that confines
a person to bed ; as an accident, or a surgical
operation, an attack of hysteria, a state of asthenia,
&c. From the increase of cutaneous heat, con-
nected with the exanthematous fevers of the noso-
logists, some degree of miliaria is liable to occur
in them all, but more especially in scarlatina ;
and a few larger pearl-coloured vesicles also occa-
sionally appear. (Practical Synopsis of Cutaneous
Diseases, p. 245.)

The miliary eruption does not afford any relief
to the symptoms of the disease on which it super-
venes : it is generally preceded by an increase of
the fever, and a sensation of heat, pricking, or
tingling of the skin. A peculiar acid smell of
the perspiration is also perceptible, though wc ap-
prehend, from this fetor of the perspiration being
frequently noticed in various forms of fever in
which there is no cutaneous efflorescence, its
connection with the eruption is not satisfactorily
established.

Though there be no proof of miliaria being
contagious, several attempts to induce the disease
by inoculation having failed, it is affirmed by
Frank, (De Cur. Horn. Morb. Epit. torn. iii. sect.
322,) and other writers, to be often epidemic, and
in some localities endemic. Rayer has given an
excellent description of an epidemic miliaria, at-
tended with symptoms of a malignant character,
which proved in many instances rapidly fatal.
From the account given by this writer, it seems to
have prevailed epidemically, chiefly in Picardy,

314

MILIARIA — [MILK SICKNESS.]

Languedoc, and Normandy ; but it is so little
known at Paris, that many physicians have ex-
pressed their doubts of the reality of such a dis-
ease. From observations made during epidemic
visitations, it appears that no age is exempt from
it, though the greater proportion of cases occur in
adults, and that females are more frequently the
subjects of it than males.

In the epidemic which prevailed in the autumn
of 1821, in the departments of the Seine and
Oise in France, and which was very fatal, we are
told by Rayer that the eruption was preceded by
feverish indisposition accompanied by copious per-
spiration, which continued throughout the pro-
gress of the disease.

The eruption appeared generally about three or
four days afterwards, first on the neck or around
the ears, and spread to the chest and back, and
thence over the abdomen to the inferior extremi-
ties. The rash was sometimes generally diffused ;
in other cases it was only partial ; the vesicles
being distinct, small, and diaphanous, though
sometimes large and confluent, so that on some
parts of the body large bullae appeared. The
odour of the perspiration was often extremely
fetid, which continued in general during the pro-
gress of the disease.

The disorder was in many instances mild, but
in the more severe cases inflammation of the mu-
cous membrane of the intestines, or of the lungs,
or of the brain or its membranes, supervened, and
rendered the disease more dangerous.

Its duration was various. The more severe
cases often terminated fatally within twenty-four
or forty-eight hours. In the milder cases, it
sometimes disappeared in eight days ; more gene-
rally, however, it was protracted to the end of
the second week, and sometimes lasted three
weeks.

[One of these epidemics occurred in 1837, and
another in 1841 and 1842. In one part of Dor-
dogne, according to a report made to the Acade-
mic Royale de Medecinc, by MM. Rayer and
Bricheteau, of a population of 82,200 persons,
10,400 were attacked by the disease, of whom
800, or one in thirteen, died.]

Treatment. — From what has been stated of
the nature of miliaria, it is evident that it is to be
regarded only as a symptomatic affection. Free
ventilation and a cooling regimen constitute not
only the best means of preventing, but of remov-
ing the rash; therefore when it supervenes on
acute diseases, the cooling antiphlogistic treatment
is to be pursued. For this purpose the chamber
is to be duly ventilated ; the linen of the patient
changed as often as circumstances permit ; the
ihirst abated by cooling subacid drinks ; the bow-
els regulated ; and the diet should be of the mild-
est kind. Tonics have been often found benefi-
cial, and none are better than the mineral acids —
as the diluted sulphuric or oxymuriatic, which
may be taken at intervals. When miliaria occurs
as an epidemic, the same treatment has been suc-
cessfully pursued ; and when complications arise
in the progress of the disorder, the particular local
affection must be treated on the principles already
fully detailed in the article Fever.

[The epidemic of Dordogne, referred to above,
was found to prevail most in marshy situations,

and to be treated most satisfactorily in the same
manner as intermittent fever, by sulphate of qui-
nia, and other tonics ; particular care being taken
not to interfere in any manner with the progress
of the miliary eruption.] A TwEED1R

[MILK FEVER. See Lactation.

[MILK SICKNESS.— Under another head,
(Art. Feveh, Continued, vol. ii.' p. 183,) a dis-
ease was referred to, which was, at one time,
ascribed to a plant called by the natives of Ten-
nessee Indian hachy. The vegetable poison was
presumed to enter the circulation, without neces-
sarily inducing injurious effects on the animal,
but afterwards causing fever and even death in
those who used its milk. Of late, many inquiries
have been made into the nature and causes of
this disease, which has also received the names
of trembles and sick stomach; but we hear no
more of its being occasioned by the vegetable
above mentioned ; whilst it has been ascribed to
other plants — the rhus radicans, or rhus toxicoden-
dron, for example, (J. J. Mcllhenny on Milk Sick-
ness, Springfield, 1843); and even to arsenic in
the soil, (J. S. Seaton on Milk Sickness, Louis-
ville, 1841.)

The discrepancy, amongst observers, as to its
nature is indeed, surprising; some denying that
it is a distinct disease, and regarding it as a form
of gastro-enteritis (N. Crookshank); others con-
sidering it to be nothing more than an autumnal
fever of a congestive type, attended with great
irritability of the stomach. Thus far, the causes
would seem to be wholly unknown ; (J. Travis,
Western Journal of Medicine and Surgery, Aug.
1840 ; G. B. Graff, Amer. Journal of the Med.
Sciences, April, 1841, p. 351 ;) but, according
to Professor Drake, ( Western Journ. of Medicine
and Surgery, Nov. 1841, p. 370,) in the state of
Ohio, transforming the surface of the infected
districts by the hand of art has been found infal-
lible.

In man the disease is generally believed to be
induced by using as diet the flesh or milk of ani-
mals infected with it ; and it is affirmed by Dr.
Graff, that butter and cheese, manufactured from
the milk of a diseased animal, are the most con-
centrated forms of the poison, although they may
possess no appearance, smell or taste, which dis-
tinguishes them from the healthy article.

It is affirmed by Professor Drake, that undue
importance has been attached to the disease. The
mortality from it, he says, is very small, compared
with that from many other maladies, about the
causes of which few inquiries are made. " There
can be no doubt, that more persons annually die
in the west from autumnal fever, than have died
from milk sickness from the commencement of
its settlement. Even in the districts where the
disease is endemic, it does not destroy as many as
pleurisy or cholera morbus."

The most appropriate treatment has been that
adopted in remittent fever, modified according to
the special indications.

RoBLEY DUNGLISON.

MIND, ALIENATION OF. See Ixsa-

IflTY.]

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

315

MIND, SOUNDNESS AND UNSOUND-
NESS OF. (As a treatise on Mental Derange-
ment is incomplete without a consideration of
various medico-legal questions connected with that
subject, it may be thought that the contents of the
present article should have been comprised in the
former one on Insanity. The reader will perceive
that the subjects now entered upon are treated in
a more comprehensive manner than such a con-
nection would allow. Under Unsoundness of
Mind are comprised several defective states which
do not come under the head of Insanity. For
this reason it is more consistent with propriety
and distinctness of arrangement to take up the
consideration of all these subjects in a separate
article, for which no more suitable inscription
could be devised than that here adopted.)

What constitutes soundness and what unsound-
ness of mind 1 In other words, by what distin-
guishing circumstances are we led to pronounce
as to the presence or absence of such a state of the
mental faculties as renders a man incompetent to
the management of his affairs, and absolves him
from moral responsibility 1 Is this state of the
understanding absolute, and, if it exists at all, ex-
tending to all cases and varieties of circumstances,
or does it admit of degrees and modifications'?
Of these and several other subordinate questions
physicians are liable to be called upon for a solu-
tion, and for such a solution as may facilitate the
judgment that is to be formed in particular in-
stances ; in those especially which present circum-
stances of unusual doubt and perplexity. The
conditions on which depends unsoundness in the
mental faculties are various disorders or defects in
the functions or structure of the brain. With
such states of that organ, and with their manifes-
tations, persons who profess the study of medical
science are supposed to be conversant. They are
accordingly expected to supply information as to
the nature of such affections, their extent and du-
ration, their distinguishing characters and ultimate
results. The general facts and references which
are applicable to these subjects constitute a part,
and by no means an uninteresting division, of
medical jurisprudence. This department of legal
medicine may be said to comprise all that may
tend to elucidate the various questions which arise
in connection with mental disorders and defects ;
in the first place as to the relations which persons
labouring under them bear to human society, and
the alteration both in respect to rights and respon-
sibility which arise from the circumstances of their
state ; and, secondly, as to the modes of proceed-
ing which are requisite, in order as far as possible
to secure such individuals and others from the in-
jurious results connected with the peculiar condi-
tion of the former.

It is remarkable that our medical literature is
particularly defective in respect to this branch of
professional inquiry. Except the short treatise of
Dr. Haslam, which is doubtless well known to
our readers, we have scarcely anything in the
English language expressly relating to this sub-
ject ; and Dr. Haslam's work, although it displays
in some striking remarks the strong sense which
distinguishes the author, is much too limited in
its scope and too discursive to furnish all the as-

sistance which is required. By some German
and French writers the subject has been treated
in a more systematic and comprehensive manner.
In the various works of Metzger, Heinroth, Reil,
and Hoffbauer, and in particular treatises and oc-
casional commentaries by MM. Esquirol, Georget,
Marc, and others, almost every topic connected
with the inquiries above defined has been consi-
dered and discussed, under the several relations
of which it is susceptible ; and from the different
points of view selected by these writers, much in-
formation may be obtained. We shall endeavour
to afford our readers, such of them at least as are
not conversant with the original authors, an op-
portunity of estimating the value of these re-
searches by laying before them in a short space a
general survey of their results.*

By the writers above mentioned, the subjects
of lunacy and mental incompetency have not been
considered principally with reference to specific
enactments or the decisions of lawyers in any
particular country. This, indeed, is not the point
of view in which such questions will be most pro-
perly contemplated by physicians. It is the busi-
ness of medical writers to record facts as they pre-
sent themselves to the observer of nature, and to
found on a correct statement of facts such results
as common sense, aided by the habit of reflection
on similar topics, may enable them satisfactorily
to establish. When this shall have been accom-
plished in a manner unexceptionable and com-
manding general assent, legal' regulations must,
and no doubt will, sooner or later, be made to ac-
commodate themselves.

Of all the works on this subject with which we
have any acquaintance, the treatise of Professor
Hoffbauer is the most comprehensive ; displaying
at the same time the results of calm reflection,
and long and extensive observation on the ques-
tions to which it relates. We shall, in the re-
marks which we have to offer, follow the plan of
this writer, and take up the different points which
offer themselves to our consideration nearly in the
order in which he has surveyed them.f

The Roman law and the code of Prussia specify,
incidentally, various defects and disorders of the
mind, and in the latter compilation the terms em-
ployed are in some instances defined. The French
code, in the opinion of Hoffbauer, has adopted a
course which indicates the good sense of the legis-

* It should be mentioned that a large portion of Dr.
Conolly's Inquiry concerning the Indications of Insanity
is devoted to this particular subject.

t Herr Hoffbauer was not a practical physician, but a
doctor of laws and professor in the University of Halle,
who made psychology and diseases of the mind the par-
ticular subject of his studies. He is the author of seve-
ral works on insanity and the inquiries connected with
it. The first, entitled "Untersuchiingen iiber die krank-
heiten der Seele, u. s. w." was published in 1802-1807.
He afterwards published, in conjunction with Reil, the
celebrated author of Researches into the Structure of
the Brain and Nerves, a work entitled "Beytriige zur
Beforderung eigner kurmethode auf psychischen wege."
His most popular work, entitled " Die Psycologie in ihren
hauptanwendunden auf die Rechtspflege nach den allge-
meinen gesichtspunkten, &c." has been translated into
French, with notes by the editor, M. Chambeyron, and
additional comments by MM. Esquirol and Itard. Pro-
fessor Hoffbauer shows, in many instances, a want of
practical knowledge of insanity, but he has discussed
admirably the legal relations of mental deficiencies. A
critical analysis of his works has been given by Profes-
sor Heinroth, in his "Lehrbuch der Storungen dea See-
lenlebens," th. 2.

310

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

lator : it makes occasional references to the va-
rious classes of affected persons, whose states arc
distinguished respectively by the terms of Maii-
ness, Dementia, and Imbecility; but it no-
where determines the precise import of these ex-
pressions. " In fact all legislation ought to be
founded on the knowledge of the objects to which
it is applied ; but this knowledge failing, it is bet-
ter that the law should not define, than that it
should define erroneously, and thus introduce
errors which would only be perpetuated by its au-
thority." The triple division which the French
code recognises corresponds with facts, and with
the actual distinctions of nature. In reference to
mental disorders and defects we distinguish three
very different states, involving mental incapacity.
These are, idiotism or congenital weakness in all
its degrees, depending on an originally imperfect
formation or development of the brain ; secondly,
insanity in several forms ; thirdly, dementia or
intellectual decay. This last state, though con-
siderably varied in particular modifications, is
most frequently a permanent failure of the mental
powers ; it is the result of long-continued insanity,
of old age, when life is protracted beyond its na-
tural period ; sometimes it ensues on apoplexy or
paralysis, or on repeated and severe attacks of
epilepsy : in other instances it appears as the se-
quel of fever attended with delirium ; and in these
last cases alone it often terminates in the recovery
of health and a sound state of the mind.

The distinguishing characters of dementia have
been described in the article Insanity, and we
shall not recapitulate them at present, but merely
remark that this morbid state is very distinct in its
features from idiotism, as it is likewise from in-
sanity. For medical purposes these distinctions
must be carefully observed, but the same division
is not in all respects the most advantageous with
reference to legal questions, in which an account
is to be given merely of the degrees of incapacity.
Such, at least, is the opinion of the author whose
method we follow. At present, we are disposed
to adopt his arrangement in this particular, and in
the first place to divide mental affections into two
departments, which may be distinguished as de-
fects and diseases of the mind. The former class
comprehends the different modifications and de-
grees of natural deficiency as well as those of de-
mentia or decay ; the latter, all the forms of in-
sanity, whether moral or intellectual.
I. Mental Deficiency.
Mental deficiency includes all the degrees of
intellectual weakness, from the slightest appear-
ance of dulness or incapacity to absolute fatuity.
Different modifications of mental weakness are
included under this head, whether arising from
natural imperfection in the organ of intellect, or
the consequences of disease : they are arranged
according to the degrees in which the mind is
found to be defective in its operations.

Before we proceed to this arrangement, we
must distinguish, with Hoffbauer, two marked
differences in the character of mental deficiency.
One modification of this state is termed imbecility
(blbdsinn), and the other stupidity (dummfieit).
The former is said to consist in a defect of inten-
sity, the other in a want of extensity. By inten-
sity M. Hoffbauer describes the energy with which

a sound mind applies itself to judge with accuracy
on the objects of reflection, or on the data already
furnished by the senses and by perception ; exten-
sity is a similar energy directed externally to sen-
sation and apprehension, or to the acquisition of
ideas. The former defect renders the intellect
unable to examine with sufficient exactness the
data on which j dginent is to be exercised, the
latter renders it liable to suffer some of these data
to escape. M. Chambeyron, the French trans-
lator of Hoffbauer, objects to this distinction. He
says that until we can determine in each kind of
mental alienation the precise nature of that cere
bral change of which it is the symptom, it is bet-
ter to follow the method of Pinel ; to observe
what are the phenomena which are generally
grouped together, and of each of these groups to
constitute a distinct species ; a principle of ar-
rangement which may equally be followed in the
distribution of mental as of other disorders. This
observation points out the only sound and philo-
sophical foundation on which nosological distinc-
tions can rest, but to us it does not appear to lead
justly to a rejection of M. Hoffbauer's attempt to
discriminate the different forms of mental weak-
ness. There is in fact, if we are not mistaken, a
marked diversity among men as to the relative
degrees of energy in their internal and external
faculties, meaning by the former the powers of
judgment and reflection, of reason, the faculties
by which the mind decides on truth and falsehood,
right and wrong, and in general of relations ; and
by the latter the ability for external perception
and apprehension. When the whole constitution
of the mind is weak, so as to render the individual
barely competent to the business of life, these dif-
ferences are the more striking and conspicuous.
Many persons whose power of judgment is very
deficient have a tolerable share of quickness in
apprehension ; others, on the contrary, (and these
often appear much more defective than the former
class,) are slow of perception, and let many things
escape them which would be observed by ordinary
men, yet they make occasionally shrewd remarks,
and give tokens in their conduct which indicate a
sagacity much beyond the measure of intellect
which common observers ascribe to them. St
Hoffbauer is correct in distinguishing two classes
among weak and half idiotic persons. One of
these may be described as imbecile or defective iu
judgment, in the powers of reason and discrimi-
nation, while the other or stupid class show their
deficiency chiefly in obtuseness or slowness of per-
ception and apprehension, and in a consequent
ignorance of external things and relations.*

That form of intellectual weakness which is
distinguished by the term imbecility differs in
several respects from stupidity or obtuseness of
the mental faculties.

" In reference to the faculty of judgment, it
may be observed that the stupid or obtuse person
is more liable than the imbecile to form erroneous
decisions; the latter experiences great difficulty
in bringing himself to any conclusion. Secondly,
the stupid person sometimes judges very correctly
on subjects to which his attention has been

*HoiTbaner has explained his ideas on the nature of
" Uudsinu and dummhcW more fully in ins L'ntersuchun-
gen, th. l. s. 9.

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

317

strongly applied ; occasionally he comes even more
directly to a right conclusion than those who are
possessed of superior intelligence. When he errs,
it is through neglect of some of the considerations
which ought to have formed the groundwork of
his judgment, and he will say, in order to excuse
himself, that ' he should never have dreamt of
this or that circumstance.' To the imbecile the
most simple act of judgment is difficult : for in-
stance, a lady who said that she was twenty-five
years of age, and had been married six years,
could not, after many efforts, tell how old she was
at the period of her wedding. Thirdly, the stupid
man may often be induced to correct his mistake,
some particular circumstance being suggested to
him which leads to its detection. The imbecile
man can scarcely rectify his error, being unable
sufficiently to concentrate his attention on any
particular subject. The stupid man has not this
defect, but he views every subject on one side
only, and is embarrassed by every complex idea.

" In relation also to memory, there is a decided
difference between stupid and imbecile persons.
The latter appear to be almost entirely defective
in this faculty : the former recollect after a long
interval of time some insulated circumstances or
transactions. The reason of these peculiarities is
the total want of attention to present objects which
is characteristic of the one state, and the partial
but concentrated attention to them which is ob-
servable in the other.

" Weakness of intellect displays itself in both
these classes of persons, when their defect is in a
high degree, by a propensity which they have to
talk to themselves. This is most observable when
the affected individual is alone or supposes him-
self to be so. In reality, we employ words not
merely for purposes of intercourse, but as an in-
strument of thought, and the weakest intellects
require their aid in the most perceptible manner.
When the mind is morbidly weakened, the silent
and unperceived or the mental employment of
words is insufficient : they must be repeated more
or less audibly. This practice is not uncommon
with imbecile and stupid persons, but when in
society they generally perceive its incongruity and
abstain from it. If, however, such individuals
talk to themselves, knowing themselves to be in
the presence of other persons, it is a proof of
greater deficiency.

" Another distinction between the stupid and
imbecile is that the former imagines himself to be
at least equal to other men in intelligence, whereas
the imbecile is ever conscious of his state, and even
exaggerates his defect.

" This difference between them is easily ex-
plained, as well as the results which it induces in
their conduct. The stupid act rashly and without
reflection; the imbecile can never come to a de-
termination. Hence, also, the imbecile becomes
cautious, timid, and even misanthropic, unless
when assured of their security by finding them-
selves under the protection of persons of whose
kind intentions toward them they are well con-
vinced : to the guidance of such persons they give
themselves up with blind confidence.

"The pusillanimity and misanthropy of the
imbecile lead them to a species of devotion, if

2b*

such it ma} T be termed. Supposing themselves to
be despised and ill-treated by men, they arc led to
apply for support to the common resource of the
unfortunate. The stupid, more confident in them-
selves, fancy that they acquire merit by their de-
votions, or confer a favour on the divinity."

This account of the phenomena of mental
weakness might suffice for ordinary purposes, but
the deficiency exists in different degrees, and one
stage in the approach to idiotism has results, in
respect to social relations, which do not belong to
a different grade in the same scale. M. Hoff-
bauer has for the first time made the attempt to
define the gradations of mental deficiency as a
basis for suggestions on the legal bearings of this
state in particular degrees. It was hardly to be
expected that he should accomplish this under-
taking at once in a manner wholly free from error,
and requiring no correction or improvement. The
outline which he has sketched is drawn with great
ability, and is evidently the result of extensive
observation, assisted by no ordinary talent for
generalizing phenomena and tracing their con-
nections. The subject is so important that we
shall incur the risk of being thought somewhat
prolix, and give an abridged extract of this author's
description of the five stages or degrees into which
he divides the affection of imbecility (blodsinii),
and the three degrees of stupidity or obtuseness
(dummheit).

" The first degree of imbecility manifests itself
in the incapability of forming a judgment re-
specting any new object, even when the necessary
data are furnished, and the question is one which
in itself presents no difficulty: in this degree of
the affection the individual can very well judge
respecting objects to which he is daily accustomed,
and in familiarity with which he may be said to
have grown up ; he often shows, in the pursuit of
his daily concerns, a minute exactness which ap-
pears to him a matter of absolute necessity. His
memory is very limited ; not that he absolutely
loses the remembrance of things, but because he
cannot apply his recollections according to his
wishes. He scrupulously observes whatever he
thinks becoming in his situation, because he fears
to give offence in neglecting it. When he gives
himself up to avarice, there is observed in him
rather an apprehension of losing than a desire of
accumulation. The propensity to talk alone, and
the species of devotion to which we have alluded,
is seldom to be met with in this instance, the for-
mer because the routine of daily occupations,
above which the individual seldom raises himself,
makes but small demands on his intelligence; the
latter because his infirmity is not so remarkable in
ordinary society as to render it a subject of gene-
ral observation, and entail upon him frequent an-
noyance, and thus make him feel the necessity of
seeking support elsewhere. He is very subject to
gusts of passion, which nevertheless are as easily
appeased as they are excited."

The preceding description will be found to co-
incide accurately with many cases of mental de-
fect arising from original or congenital weakness
of the intellectual faculties. We could furnish
instances from our own observation which strik-
ingly exemplify it. The statement given of the
second degree belongs obviously to dementia or

318

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

mental decay, and will be found very accurately
to describe many instances of senile dementia.

" In the second degree of imbecility the patient
still judges and acts consequently with respect to
subjects that are familiar to him, but even on those
subjects it often happens that he is deceived, be-
cause, through a distraction which is a second
nature to him, he forgets places, times, and cir-
cumstances. He observes so little what takes
place or what passes around him, that he often
fancies himself in a different spot from that in
which he really is, mistakes strangers for persons
of his acquaintance, confounds the present with
the past, but more often with the future, and be-
lieves himself at home when he is at the house of
another person.

" The individual affected with imbecility in the
third degree is unfitted for all matters which re-
quire more than a mechanical mode of action, but
he preserves sufficient intelligence to be aware of
his weakness and the superiority of others with
respect to the mental faculties. We may likewise
remark in him that propensity to devotion and to
misanthropy which we have mentioned above.
His mind is not completely inactive, although it
cannot raise itself to any high pitch; hence he
has the propensity to talk to himself. He has
not the power of seizing any idea so clearly as to
impress it on his mind ; hence a very marked de-
fect of memory, and a propensity to pass rapidly
from one topic to another. He is very irritable
and suspicious, fancies a design to insult him
where it is impossible, because his state yet per-
mits him to feel and resent injuries; of which
susceptibility those around him often take advan-
tage to his annoyance.

" The fourth degree of imbecility is marked by
a clouded state of the understanding and the me-
mory, with a great insensibility, which neverthe-
less leaves the patient a confused idea of his
weakness. He eagerly seeks excitement by various
stimuli."

" In the fifth degree of imbecility there is a
nullity of intelligence ; the attention cannot be
directed to any object ; all the faculties whose
activity depends upon the intellect are destroyed or
oppressed. The phenomena which depend upon
attention are wanting, and those which imply its
absence take their place. The imbecile in this
degree is insusceptible of passions, of joy, of
grief, of pleasure, in a word, of every kind of
moral feeling. He is eve.n but little sensible of
pain and other physical inconveniences. He only
takes nourishment because it is given to him, like
an infant ; the natural wants, such as hunger and
thirst, have no effect upon him. He has no me-
mory, he has neither devotion nor the desire of
talking to himself, which is observed in other im-
becile persons, but which implies in them to a cer-
tain degree a consciousness of their state."

The fifth stage of imbecility thus characterized
by Hoffbauer, is precisely the last grade of demen-
tia or the fatuity which is the consequence of
cerebral diseases. It has been more particularly
described in the article Ixsaxitt, under the dis-
tinctive term Amentia, appropriated to the last
stage of the disease.

" Stupidity, generally speaking, is a defect less
severe than imbecility, according to the definition

that we have given of both. The slightest degree,
however, of imbecility indicates an imperfection
of the intellectual powers less severe than the
greatest degree of stupidity.

«We admit in stupidity three principal de-
grees.

« In the first, the individual is incapable cf
judging and of self-determination, only when it
is necessary to weigh opposing motives. Then
he feels his incapacity, and has recourse to the
intelligence of others, unless pride happens to
prevent him, which is often the case. If he acts
absurdly, it is often because he applies to his
actions a rule good in itself, but the application
of which requires other considerations.

" The subject of the second degree of stupidity
forms a judgment accurately and often promptly
upon things by which he is daily surrounded ;
but he commits serious errors whenever it is ne-
cessary to exert a certain vigour of judgment: he
embarrasses himself in any train of reasoning,
however simple it may be. His memory is per-
haps faithful, but it is slow ; he cannot, without
great difficulty, express a complex idea, if it is
the result of his own reflections, and has not been
received from another. When his faculties have
been somewhat developed by education, he is an
obstinate partisan of any thing which is, as we
say, good in theory but useless in practice ; be-
cause he cannot observe the circumstances which
distinguish particular cases, and appreciate them
according to their just value. These two condi-
tions are, however, indispensable, in order to make
with propriety the application of general rules.

"In the highest degree of stupidity the indi-
vidual cannot go beyond one single idea ; and he
must completely lose that one before he can pass
to another. He is hence less capable of judging
than the imbecile, because the comparison of
several ideas is necessary to form a judgment.
Individuals who are afflicted in the third degree
of stupidity often express themselves in half-
uttered words, return incessantly to the same
subject, make known their ideas by sentences,
short, incoherent, and unfinished, like children
who can retain words, but do not know how to
connect them together ; they express often the
subject and the attribute without connecting the
one to the other by the affirmative or negative.
If they wish to say ' the rose is beautiful,' they
will say « rose beautiful,' or only rose, or beautiful,
according as the subject or the attribute strikes
them most. Often they reverse the natural order
of words, and say, for example, 'rose beautiful
is ;' and when they perceive an omission which
they wish to repair, they become still more per-
plexed.

" With respect to legal relations, the first de-
gree of imbecility may be assimilated to the second
degree of stupidity, and the highest degree of the
latter to the third degree of the former."

M. Esquirol has made objections to the minute-
ness and attempted accuracy of these distinctions.
He thinks it difficult, if not impossible, to deter-
mine the exact limits of each stage. The endea-
vour to lay down rules with accuracy scarcely
attainable in practice may sometimes impose un-
necessary difficulties. This is undoubtedly true,
and perhaps it may be admitted that the modifica-

MIND, (SOUNDNESS AND UNSOUNDNESS OF^

319

tions and degrees of which Hoffbauer's arrange- |
ment consists are more numerous than they ought ,
to be. Yet the necessity of adopting some method '■
of this kind is obvious, unless we determine to re-
gard mental deficiency as an absolute state, and I
admitting of no gradations. Experience proves
more and more the error of such a proceeding.
The want of some rule by which the various de-
grees of incapacity may be measured, and the
relations of each determined, has often been felt ;*
and M. Hoffbauer's arrangement will at least be
useful as furnishing a scale to which approxima-
tions may be made in particular instances. M.
Esquirol seems to suppose that Hoffbauer in-
tended only to describe different degrees or va-
rieties of dementia ; but this appears to us to
have been the case only in some instances. The
first or lowest stage both of imbecility and of stu-
pidity are clearly intended for, and strikingly
characteristic of, natural weakness in some of its
varieties.-)-

We proceed now to the practical application
of these distinctions, but in this we must be
satisfied with suggesting a few of the most im-
portant considerations.

" In matters of criminal accusation, all legal
culpability is annulled when it is proved that the
party labours under imbecility amounting to the
third degree, or even nearly approaching it. Im-
becility in the first and second degree may either
annul or weaken culpability, or leave it unaffected
under different circumstances. Ignorance of the
law and of the illicit nature of actions may some-
times be alleged as excuses in criminal accusa-
tions, in the instance of imbecility amounting to
the first degree. But this plea can only be allowed
to be valid under one of the two following condi-
tions : — 1st, when the law which has been vio-
lated by the imbecile neither forms part of general
relations which concern himself as well as other
members of society, nor belongs to his own par-
ticular habits or circumstances : 2dly, when the
action forbidden by the legislator is not contrary
to the law of nature.

" The second degree of imbecility may lessen
or destroy culpability in cases in which the first
degree leaves it entire.

" In the first degree of imbecility, inattention or
absence of mind, want of foresight, &c, are not
considered as excuses when they have regard to
objects universally known, as to fire, or to those
which are familiar in use to the imbecile, as the
tools, &c. of his rofession. In all other instances
his fault loses the degree of culpability which be-

*Dr. Haslam has made this remark, bur. no attempt to
furnish a scale of distinction. See Haslam on Medical
Jurisprudence, as it relates to Insanity, p. 00. Any per-
son who has attended inquests must he aware that the
want of some certain rule or principle, by which both
physicians and those who have to give the verdict may
be assisted in forming their judgment, is often felt.

r Hoffbauer's distribution of the forms and degrees of
mental weakness, which has obtained great celebrity in
Germany, is highly commended by Professor Hcinroth,
(Storungen des Seelenlebens,) who, however, contem-
plates the subject in a different point of view. Hfiinroth
suggests an additional modification, consisting in (wil-
lenssrhwiirhr) weakness of will or irresolution, and e.\-
timidity and fickleness of disposition ; but this
case ran never become a matter of legal consideration.
It is even questionable, as Heinroth observes, whether
(dummheit) stupidity, as above defined, can ever do
away entirely all moral responsibility.

longs to it, according to the expression of jurists,
in abstracto. This is also the case when the act
is the result of sudden anger or fear, to which
weak persons are prone.

«The imbecile in the second degree has less
responsibility than in the first. His incapacity ia
greater, as likewise is his proneness to sudden
emotions.

» Similar considerations affect the responsibility
of persons labouring under stupidity, when it
passes the middle degree above described. In
fact, the latter being incapable of extending their
thoughts to several objects at the same time, must
omit many considerations of which intelligent
persons never lose sight. Such an individual is
so much the less responsible for his actions, as he
is known to be incapable of the reflection which
might lead another to rectify his mistakes.

" The principles established in reference to cri-
minal law, on the ignorance of the parties, are
applicable in civil law to the question — whether
an individual is in a condition to recognise the
illicit nature of an act by which he has trespassed
on the right of another. In imbecility in the first
or second degree, ignorance of the law may be
pleaded as excuse under circumstances analogous
to those before alluded to.

" All the arrangements which the law autho-
rizes or prescribes in regard to imbecile persons,
are founded either on their own interest or on
that of others, and have for their object the per-
sonal security of either party. These arrange-
ments refer, 1st, to the appointment of a tutelu
for the administration of the property of the weak
or idiotic person, and of a curatela for the care
of his person ; 2dly, to seclusion, when it is re-
quired for preventing dangers likely to accrue to
society or to the individual, from his unrestrained
enjoyment of personal freedom. All the measures
judged necessary for his security and for the pro-
tection of society, must be taken with as much
mildness as possible.

" An imbecile person, whose affliction reaches
the third degree, can no longer be judged compe-
tent to the care of his own property : this may be
observed a fortiori, if his disorder passes that de-
gree. But in the appointment of a tutela, regard
must be had to the necessity, greater or less, of
such protection, and especially to the particular
character, habits, inclinations, &c. of the indi-
vidual. It must be considered whether he is
likely to commit actions which, though indifferent
in themselves, may .occasion public offence, or
whether an excessive liberality or ruinous prodi-
gality may not expose him to dissipate the pro-
perty that may be left at his disposal.

" The administration of his property should be
left to the imbecile in the second degree, and a
curator should be appointed for him under par-
ticular circumstances, as, for example, when his
character calls for such an arrangement, and when
some interests are at stake which require practical
intelligence, and especially constant attention.
With such exception, it is unjust to deprive him
of the management of his affairs. The inconve-
niences to which he may contingently be exposed
cannot be compared with the certain annoyances
connected with a tutela, and some reliance may

320

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

be placed in general on the vigilance which self-
interest calls forth even in defective minds.

" Persons imbecile in the second degree are
more subject to act without reflection than those
whose defect belongs to the first or the third stage.
The former are rather irresolute and timid than
precipitate in action, and the latter too negligent
and inactive. Hence, though in the second de-
gree imbecility does not generally authorize the
appointment of a tutela, it often requires that in-
dividuals should be subjected to an especial sur-
veillance.

" The imbecile whose infirmity does not exceed
the first degree cannot justly be subjected to a
tutela, or to any particular surveillance, except
under circumstances in which his inclinations or
habits, his family, relations, or fortune, or the
affairs under his management, require such an
arrangement.

" What has been observed in respect to the de-
grees of imbecility may be applied to stupidity, on
the principle above laid down. Only it must be
remembered that this last infirmity renders indi-
viduals more liable to rash and hasty actions than
does imbecility.

" Imbecile persons in the third degree are evi-
dently incapable of making wills; as their state
renders them competent only to actions, which,
if not unreasonable, are without reflection. The
case is not so in the instance of imbeciles in the
first and second degree, even though under certain
circumstances, before adverted to, they may occa-
sionally be subjected to a surveillance or even to
a curulela. The object of this curatela is to pro-
tect them from injuries which they might bring
upon themselves if left to their own discretion,
and to prevent engagements which they might
contract and be unable to fulfil. These conside-
rations are not, however, reasons for depriving
them of the power of making a will. By a testa-
ment they might deprive those who would inherit
ab intestalo, but they prejudice no formal right.
Besides, a testament does not require the same
intelligence as the administration of property : it
only depends upon a single arrangement, for
which the testator has sufficient time for delibera-
tion."

To this last opinion of M. Hoff bauer, it is ob-
jected by M. Chambeyron, that by the simple ap-
pointment of a tutela the imbecile person is assimi-
lated to a minor, and declared incapable of any
civil act, except under some particular circum-
stances, and when the authentic consent of the
tutor may authorize him to contract. Why then,
it is inquired, should there be any exception for
the right of testating 1 The author has given a
satisfactory reason why this right should be pre-
served inviolate in certain instances, namely, that
individuals may and do retain the requisite degree
of intelligence for entering into the arrangements
in question, though in other respects in a state
which renders the appointment of a guardian, or
some especial surveillance, advisable. The incon-
gruity pointed out by M. Chambeyron has respect
to positive institutions, and the observation of M.
Hoffbauer is founded on general principles.

We shall here terminate the consideration of
mental weakness or defect, and now proceed to the
second division of our subject, namely, Diseases

of the Mind, — a term which wc adopt for tho
sake of convenience, though, on the ground of
strict propriety, objectionable.
II. Diseases of the Mixd coxsidehed is
relation to Jurisprudence.

] . Of Intellectual Derangement or Men-
tal Illusion. — Monomania and Mania. — Pro-
fessor Hoffbauer adopted an ingenious, though
erroneous, idea as to the nature of these diseases.
On this he has founded some practical conclusions,
of which the validity is very doubtful ; they de-
serve, however, for reasons which will appear, a
few moments' consideration. Mental illusion
(wahnsinn) consists, according to him, in a loss
of that due proportion which, in the sound state
of the mind, the powers of sense and perception
bear to the influence of imagination. The influ-
ence of imagination may become excessive in two
ways ; first, by increased intensity or exaltation
of this faculty, the other powers remaining the
same ; or, secondly, by depression of the latter,
while the faculty of imagination remains un-
changed. The former is monomania, in which,
as the author supposes, the mind is not destroyed
or generally affected. The latter is mania, and
in this the powers of the understanding, percep-
tion, apprehension, are greatly impaired.

No practical error is likely to arise from this
opinion, as far as it respects the nature of mania.
Persons who are generally deranged or raving
mad, cannot be supposed by any one to be ac-
countable for their conduct, or capable of mana-
ging their affairs. No dispute exists among jurists
or physicians on this subject. The state of ma-
niacs is, in general, too manifest to admit of any
doubt. The lunatic perceives the objects and per-
sons who surround him, but his imagination trans-
forms them, and they are mistaken by him as to
their nature and identity. « Hence in civil law
the acts of such an individual manifestly lose all
their consequences, and can neither convey any
right to another, nor place the agent himself under
obligation. In criminal law he is discharged from
all responsibility, and consequently from all culpa-
bility ; since what he wills to do in his imaginary
situation is not what he would do in his real situ-
ation, were he only aware of the latter. This
state of disease fully justifies the placing an indi-
vidual under a tutela, and the disposing of his
person in that way which shall appear most con-
ducive to his recovery, or, in hopeless cases, to bis
security and comfort."

It will be apparent to those who entertain a
correct opinion as to the nature of monomania, or
partial derangement of the understanding, that a
great part of this reasoning applies almost equally
to persons affected by that form of disease. But
here we find Professor Hoff bauer's theory leading
him into error, an error which is not peculiar to
As his opinion is common to many, and

him.

the inference to which it has led him is by no
means a matter of indifference, we shall cite some
of his observations, and presently add the com-
ments of a practical physician, the powers of
whose acute and penetrating mind have been
directed to this subject.

Hoffbauer supposes that, in partial insanity
characterized by hallucinations, the representation

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

321

of unreal objects, or the illusory transformations
of existing ones, such illusions can only pervert
the judgment when the affected train of ideas is
brought into play ; and that on matters uncon-
nected with this illusion, the individual is to be
considered as a sane man. " In this relation,
therefore, insanity cannot be recognised by the
law. In civil law all the acts of the party preserve
their validity, and in criminal law their culpabili-
ty." In fact, there is no reason why a man who
thinks he has legs of glass, and in other respects
is in possession of all his faculties, should not be
capable of contracts, and responsible for illegal
acts which have no connection with the subject
of his madness. Such a species of insanity seldom
prevents a man from managing his own affairs,
or undertaking any legal relations for others.
Swedenborg, so celebrated by his visions, who
was confessedly a madman, fulfilled the duties of
his office in so distinguished a manner, that the
king of Sweden ennobled him. The author knew
a doctor in laws who had taken it into his head
that all the freemasons had entered into a league
against him. This person, who in other respects
was perfectly sane, held with high credit a chair
in an university.

In general, in relation to the insane, the ruling
idea or illusive opinion characteristic of their dis-
ease, considered with respect to the imputability
of their actions, ought not to be regarded as an
error, but as a truth ; or, in other words, their ac-
tions ought to be considered as if they had been
committed under the circumstances in which the
patient believed himself to be. At Brieg a soldier
killed a child because he thought he saw the Deity
near him commanding him to do it. Dr. Glan-
witz, in his report, came to the conclusion that
the man should be confined in a lunatic asylum.

" When the question relates to consent to some
particular matter, regard must be had to the pre-
vailing idea, inasmuch as upon its truth or falsity
depends the reality of the consent. If, for exam-
ple, in a civil affair, as a contract, we suppose that
the contractor would not have given his consent
without a previously existing illusion, this idea is
looked upon as an error, not imputable to the per-
son concerned. As to the question, whether the
r esults of the act are cancelled or not, this must
depend upon what the laws have decided with
respect to involuntary errors.

" In practice, it is difficult to decide whether an
affair undertaken by a person labouring under
madness, with a fixed illusion, is valid or not, on
account of the errors likely to result from this
fixed illusion. For as long as this person enjoys
his rights, it is not the business of another to ex-
amine if his act is valid or not. And besides, the
person himself neither could nor would acknow-
leoge his error."

From what has preceded, we apprehend how
important it is to determine, in cases of permanent
illusion, the paramount idea ; to know whether it
brings on a derangement, more or less complete,
of the intellectual faculties ; or only prevents the
perfect use of the judgment in relation to certain
objects ; to discover what influence it has, on one
side, upon the notion which the patient has of
himself and of his relations with his equals, and,
on the other, upon his actions in general. When

Vot.III 41

the prevailing error draws with it a total incohe-
rence of ideas, the case approaches to one of im-
becility.

" When a patient attacked by madness, with
one fixed illusion, has a false notion of himself
and of his relations to others, this circumstance
ought to be taken into consideration. For in
criminal justice actions ought to be regarded as if
the person really was in the state and in the cir-
cumstances in which he believed himself to be.
Thus the crimes committed by madmen fancying
themselves kings and princes, ought not to be
punished according to their nature and heinous-
ness ; the culpability is lessened or destroyed.

" We ought, above all, to have regard to the
illusion under which the patient is carried, by his
paramount idea, to commit actions which he con-
siders as matters of duty. In religious madness,
for example, the acts which a person afflicted with
this form of the disease commits, ought still less
to be punished ; because no kind of human suf-
fering could have any effect upon a lunatic of this
description ; divine punishment, or the hope of
eternal reward, weighs much more strongly upon
his mind than the fear of anything within the
power of man."

Similar opinions have been advanced in a man-
ner less restricted, by a high legal authority in
France. The following observations are under-
stood to convey the sentiments of the advocate-
general, M. de Peyronnet, as they were delivered
in a process on the "Affaire de Papavoine:"*
" The advocate-general," says the report, " pro-
ceeds to examine whether every kind of insanity
ought to absolve from culpability, and after dis-
tinguishing, in the clearest manner, partial from
total derangement, sustains and demonstrates that
the last can alone extricate a criminal from the
penalty of the laws. This reasonable distinction,
thus laid down by the public authority, throws the
strongest light upon the questions of mental alien-
ation, the most intricate question in medical juris-
prudence, which some physiologists have solved
in a manner as unfavourable to accusation as in-
jurious to morality, and alarming to society. M.
de Peyronnet here cites some passages from Lord
Hale. Of these we should prefer to cite the
English text, but as the advocate-general has given
to some of the expressions a more definite turn,
in a manner which displays fully his own way of
thinking, we shall crave permission to deviate from
our usual course, and cite the exact words of M.
de Peyronnet :

" <I1 est une demence partielle et une demence
totale : la premiere est relative a tels ou tels objets.
Quelques personnes qui jouissent de leur raison
pour certaines choses «ont sujettes a des acces
d'une demence speciale, a tels discours ou tels
sujete, ou bien elle est en partielle dans ses de-
grees ; telle est la condition d'une foule d'insenses;
et surtout des personnes melancoliques dont la
folie consiste la plupart du temps a temoigner des
craintes, des chagrins excessifs, et qui cependant
ne sont pas entierement privees de l'usage de la
raison. Cette demence partielle semble ne pas

* Discussion Medico-legale sur la Folie, &x. par le
Docteur Georget. Paris, 1826. See, also, Examen Me-
dical des Proces criminels des nommes Leger, Feldtman,
Lecouffee, Jean-Pierre, et Pavoine, &c, par le Dr. Geor-
get. Paris, 1825.

322

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

excuser les crimes que commettent ceux qui en
sont atteints, mime en ce qui en fait Vobjtt prin-
cipal ; car toute personne qui s'arme contre lui-
meme ou contre d'autres, est jusqu' a un certain
point dans un etat de demence partielle lorsqu'elle

se rend coupable Je suis en outre

force d'admettre qu'il est une importante distinc-
tion entre les cas civils et les cas criminels. Dans
les premiers, des qu'il est prouve que la raison de
rhomme est alteree, la loi annulle ces actes, quoi-
quHs riaient ancune relation avec les circonstan-
ces qui causent sa demence, et. qui auraient pu
injluer sur sa conduite. Mais brsqu'il s'agit de
decharger un homme de la responsibilite de ses
crimes, et surtout de crimes atroces, o?i ne pent
point reclamer I 'application de cette regie, incon-
testable pour une question de propriete.'

"After having laid down principles so precise,
so positive, so satisfactory to the jury," continues
the reporter, « the advocate-general applies them
to the cause." The same writer cites further the
following passage, which leaves no doubt as to the
views of M. de Peyronnet : " The pretended
insanity of the accused is a pretext had recourse
to in despair of the cause : certain it is that this
derangement cannot have been total; it is likewise
proved that it could not be partial, and in this last
supposition, if even allowed, it could not serve for
an admissible excuse."

M. Georget, possessing much more correct
knowledge of the real nature of monomania, or
partial illusion, considered the joint opinion of
these lawyers as highly objectionable. He ex-
pressed his astonishment at the sentiments of Lord
Hale. " This writer," he says, " appears profess-
edly to consider property of higher value than
human life ! There is then no excuse for an un-
fortunate lunatic, who in a paroxysm commits a
reprehensible action, even although it should ap-
pear to be the result of his particular illusion !
And yet the civil acts of this same individual are
to be annulled, although they have no relation to
the insane impressions which might have influ-
enced his conduct ! And even M. de Peyronnet
could cite such maxims as these with approbation ;
we do not at least find he has objected to any part
of them. All monomaniacs, according to this
statement, are liable to become criminals in spite
of the sixty-fourth article of our penal code, and
may undergo the penalties recorded for atrocious
offences."

M. Georget has refuted these opinions on
grounds which must be conceded by the jurists
of all countries, viz. on those of experience and
correct knowledge as to the real state of mono-
maniacs. Such persons, as he has clearly proved,
though they reason correctly on a variety of sub-
jects remote from the particular one on which
their illusion turns, are yet more fully deranged
than they appear to be, and are even liable to dis-
play perversities both in feeling and action. Cases
like those of Swedenborg and the German profes-
sor mentioned by Hoffbauer, very rarely occur.
Even in these instances, had we been enabled to
follow the individuals affected into private life and
to observe their personal deportment, it is almost
certain that something would have been discover-
able in their moral character and habits different
from those of ordinary men. M. Georget's obser-

vations have led him to form nearly the same
opinion as to the nature of monomania or partial
derangement as that which we have expressed in
a former part of this work. (See Insanity.)

The facts of a remarkable case of this descrip-
tion which came out in evidence some years ago
before an English court, confirm in a striking
manner the character here ascribed to this disease.
For a full account of this we must refer to a
" Report of the judgment in Dew vers. Clarke and
Clark, delivered by the Rt. Hon. Sir John Nicholl
in the Prerogative Court of Canterbury. In this it
was proved that the individual " in the ordinary
transactions of life conducted himself and his af-
fairs rationally ; was a sensible, clever man ;
amassed a considerable fortune by his profession ;
took good care of his property ; and that several
of his friends and acquaintance, some of them
medical persons, never even suspected that he was
deranged in mind." It was stated by those who
wished to prove his sanity, that " he was a man
of irritable and violent temper, of great pride and
conceit, very precise in all domestic arrangements,
very impatient of contradiction, entertaining high
notions of parental authority, rigid notions of the
total and absolute depravity of human nature, of
the necessity of sensible conversion, and of the
necessity or expediency of confessing to other
persons the most secret thoughts of the heart." It
was proved that this person, such as he is above
described, having a daughter " amiable in disposi-
tion, of superior talents, patient under affliction,
dutiful and affectionate, modest and virtuous, moral
and religious," was in the habit of " tying this
daughter to a bed-post, flogging her with the most
unmerciful severity, aggravating her sufferings by
the application of brine, flogging her repeatedly
with a horsewhip, pulling her hair out by the
roots, and compelling her to perform the meanest
drudgery." It is scarcely necessary to add that
the able and enlightened judge before whom the
investigation of this case was brought, declared
the individual to be " non compos mentis."

If such is in general the real character of par-
tial insanity, and if in cases which come near to
the idea usually entertained of this disease, are
(when and if they occur) rare exceptions to the
general fact, it will be allowed that criminality
should be attached with extreme caution to any
individual in whose case the existence of insane
illusion has been proved, however limited in its
extent this particular phenomenon of the disease
may appear to be. The same consideration ought
to weigh in an equal degree in questions which
respect the exercise of personal rights.

The only remaining topic connected with illu-
sion which we shall at present consider, is the
subject of lucid intervals.

Hoffbauer has well observed that much depends
upon the duration of lucid intervals. In some in-
stances these intervals are very short ; in others
they are of equal length with the periods of dis-
ease, and sometimes they last much longer than
these periods. In the former case the individual
has consciousness of his actual state with relation
to external circumstances, but not with relation to
his former periods of existence. His life is only,
in his view, in insulated fragments ; his know-
ledge of himself is inaccurate and confused. This

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

323

observation can only be applied in a more limited
manner to cases in which lucid intervals are nearly
of equal duration to the periods of disease. We
cannot follow M. Hoft'bauer into the inferences
which he founds upon this observation.

We must likewise take into consideration the
circumstance that repeated attacks of disease
weaken the understanding, and that, when they
are frequently recurrent, the individual generally
falls into a state bordering on dementia, in which
the remembrance of persons and relations becomes
very defective. In such instances it must become
a subject of inquiry to what form and degree of
mental deficiency, as before distinguished, his
particular case belongs.

In all examinations respecting insane illusions,
it will be necessary to bear in mind the well-
known fact, that many lunatics display great arti-
fice in evading questions relating to their morbid
impressions, even while these impressions are
strongly fixed in their minds. Hoffbauer is in-
correct in attributing this dissimulation to the sup-
posed fact, that the lunatic during a lucid interval
has perceived his hallucination to be absurd. We
know that such dissimulation and evasion have
been practised in cases in which no lucid intervals
have occurred, especially when the lunatic has
been frequently interrogated upon the subject of
his erroneous convictions. A striking fact, exem-
plifying this observation, is mentioned by M.
Chambeyron.

The statement of what the English law has
positively determined with reference to insanity
comes within a comparatively short compass. Lu-
nacy, when proved to exist, absolves from guilt in
cri.ninal cases. " For," as it is observed by Sir
Edward Coke, " the execution of an offender is
for example, < ut poena ad paucos, metus ad omnes
perveniat ;' but so it is not when a madman is
executed ; but should be a miserable spectacle,
both against law and of extreme inhumanity and
cruelty, and can be no example to others. But if
there be any doubt whether the party be compos
or not, this shall be tried by a jury. And if he be
so found, a total idiocy or absolute insanity ex-
cuses from the guilt, and of course from the pun-
ishment of any criminal action committed under
such deprivation of the senses: but if a lunatic
hath lucid intervals of understanding, he shall
answer for what he does in those intervals, as if
he had no deficiency. Yet, in the case of abso-
lute madness, as they are not answerable for their
actions, they should not be permitted the liberty
of acting, unless under proper control ; and in
particular they ought not to be suffered to go loose
to the terror of the king's subjects." (Black-
stone, book iv. c. 2 and 3.) The question is,
what will be considered as lunacy. In the penal
code of France, it seems, from M. Georget's
statement, that partial insanity is a sufficient plea
against responsibility for offences: this we rest
upon the sixty-fourth article. It would appear,
however, from the passages cited above from Lord
Hale, (which, however, the reader ought to com-
pare with the original text of that lawyer,) that
partial insanity is not considered in English law
as entirely cancelling responsibility for actions, or
consequently culpability, or what the Germans
more correctly term (strafbarkeit) punishability.

It is observed by Professor Hoffbauer, that in
cases of partial illusion it is extremely difficult to
ascertain how far the influence of the insane error
extends, and what trains of thought and acts of
the understanding are within or without the limits
of its sphere. If this be borne in mind, and it be
also fully made known to juries that monomania
generally involves a morbid perversion, and some-
times occasions a total change of the moral cha-
racter of the individual affected, the cases of pun-
ishable criminality occurring under circumstances
of mental disease will probably be reduced to a
very small proportion.

The exercise of civil rights is suspended when
a lunatic is proved to be such : he is neither ca-
pable of entering into marriage, nor of any other
contracts. These disqualifications, however, only
subsist during actual derangement : in a lucid in-
terval a lunatic resumes the exercise of personal
rights.

The chancellor, on receiving information as to
the state of a deranged person, issues a writ " de
lunatico inquirendo," and on lunacy being esta-
blished by the verdict of a jury, appoints commit-
tees to take care of the individual as to his person,
and to administer his estate.*

2. Of Moral Insanity, in its relation to
criminal and civil law. — In the essay on in-
sanity contained in a former volume of this Cy-
clopaedia, we described a form of mental derange-
ment, under the title of moral insanity, consisting
in disorder of the moral affections and propensities,
without any symptom of illusion or error im-
pressed on the understanding. The question
whether such an affection really exists or not is
very important in connection with medical juris-
prudence, and we find it to be an indispensable
duty here to enter upon it and consider it under
this relation.

We must first observe that no such disorder has
been recognised in the English courts of judica-
ture, or even in general admitted by medical
writers in England. By them it has been laid
down that insanity consists in, and is co-extensive
with, mental illusion. English writers in general
admit only that form of insanity which the Ger-
mans term wahnsinn ; they know nothing of
moral insanity either as requiring control in the
exercise of civil rights, or as destroying or lessen-
ing culpability in criminal ones. Thus in a re-
port of judgment issued not many years since by
one of the most distinguished lawyers in this
country, it is laid down that « insanity is deluded
imagination, the substitution of fancies for reali-
ties." In the same report we find the following
remarks : —

" As far as my own observation and experience
can direct me, aided by opinions and statements I
have heard expressed in society, guided also by
what has occurred in these and in other courts ot
justice, or has been laid down by medical and
legal writers, the true criterion is— where there i3
delusion of mind there is insanity ; that is, when
persons believe things to exist which exist only,

* For further particulars as to the modes of proceeding
respecting lunatics, see the Appendix to Dr. Cox's work
on Insanity, and Paris and Fonblanque's Medical Juris-
prudence, vol. i. p. 289 & seq. ; also Blackstone, book I.
c. 8, s. 18. Item, c. 15, 4. Book ii. c. 19, 1. Book lii, s.
2<. Book iv. c. 2, 2.

304

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

or at least in that degree exist only in their own
imagination, ami of the non-existence of which
neither argument nor proof can convince them,
they are of unsound mind ; or, as one of the
counsel accurately expressed it, 'it is only the
belief of facts which no rational person would
have believed, that is insane delusion.' This de-
lusion may sometimes exist on one or two parti-
cular subjects, though generally there are other
concomitant circumstances, such as eccentricity,
irritability, violence, suspicion, exaggeration, in-
consistency, and other marks and symptoms which
mav tend to confirm the existence of delusion,
and to establish its insane character."*

The right honourable and learned judge after-
wards cites some authorities, both medical and
legal, in support of his opinion. The former are
principally the sentiments of Dr. Battie and Dr.
F. Willis. Dr. Battie says that " deluded ima-
gination is not only an indispensable, but an es-
sential feature of madness."

Dr. F. Willis, in his treatise on mental de-
rangement, which was the substance of the Gul-
stonian Lecture delivered before the College of
Physicians in 1822, thus points out the difference,
according to his apprehension, between an un-
sound and a sound mind : —

" A sound mind is one wholly free from delu-
sion. Weak minds, again, only differ from strong
ones in the extent and power of their faculties;
but unless they betray symptoms of delusion, their
soundness cannot be questioned." " The man of
insane mind from disease, having been once com-
pos mentis, pertinaciously adheres to some delu-
sive idea, in opposition to the plainest evidence of
its falsity, and endeavours by the most ingenious
arguments, however fallacious they may be, to
support his opinion."

Lord Coke and Lord Hale are referred to for a
similar opinion.

It seems, then, to have been the prevalent judg-
ment both of medical and legal writers in this
country, that delusion constitutes the essential
character of insanity; and hence, unless the ex-
istence of this characteristic phenomenon should
be proved, it would probably be very difficult to
maintain a plea on the ground of insanity in this
country, with a view to the removing culpability
in a criminal accusation.

We have now to call the attention of our read-
ers to facts and to the opinions of practical men,
established upon the ground of experience, which
authorize a very different conclusion.

In the first place, we shall take the liberty of
referring to the article Insanity in this work, in
which a select number of cases has been given in
a brief and condensed statement, and the opinions
of some practical writers have been cited, particu-
larly those of MM. Pinel, Esquirol, and Georget.

The German writers, Hoffbauer, Reil, and
Heinroth, admit more or less distinctly the exist-
ence of moral insanity, or of a mental disease
consisting exclusively in undue and morbid excite-
ment of the passions and feelings. In this they
appear in part to have been influenced by the
opinion of Pinel. Neither Pinel, however, nor

* Report of the judgment in Dew v. Clarke and
Clarke, delivered by the Right Hon. Sir J. Nicholl. Lond.
1826.

the German writers above-named, have assigned
to moral insanity so general a description as the
truth warrants, nor have they referred to it all the
different forms which really belong to it. Reine
tollkeit and reine melancholie, simple madness of
excitement and simple melancholy, are indeed
brought under one category by Heinroth, but with
an imperfect conception of their relations. (Stor-
ungen des Seelenlebens, th. 2. Formenlehre.)

Hoffbauer defines tollkeit to be a state in which
reason has lost her empire over the passions and
the actions by which they are manifested, to such
a degree that the individual can neither repress
the former nor abstain from the latter; it does not
hence result, as he observes, that the person af-
fected may not be in possession of his senses, and
even of his usual degree of intelligence.

Hoffbauer points out many varieties of tollkeit.
One of these consists in general excitement and
want of the power of self-government. "The
individual," he observes, " abandons himself with-
out restraint to the indulgence of all his appetites
and passions in the most shameless and unre-
strained manner, without regard to decency or
propriety."

The writers, then, whom we have cited, admit
the existence of a form of madness consisting in
excessive excitement of passions, though they
have not recognised moral insanity under so gene-
ral a character as we have ascribed to it. A simi-
lar observation applies to MM. Pinel and Esquirol.
The former, indeed, adopts the term of manie
sans delire ; he says that persons labouring under
this form of disease display at no period any lesion
of the understanding, but are governed by a sort
of instinctive madness (instinct de fureur), as if
the affections alone had sustained injury from the
morbid cause — " comme si les facultes affectives
seules avoient ete leasees." (Traite Medico-Philo-
sophique sur 1' alienation mentale, par Ph. Pinel,
sec. edit. Paris, 1809.) These expressions set
forth exactly the idea which we have endeavoured
to convey, but we wish to render the observation
general, and M. Pinel's cases are all instances of
persons who were subject to violent attacks of
anger or fury. We may, however, perceive that
the writers above-named admit as matter of fact
the existence of a variety of mental diseases, con-
sisting in disturbance of the active and moral
powers. We shall now collect from them and
others a few striking examples.

The following instances were published by M.
Marc, and have already been cited by more than
one continental writer. The facts display, as the
author observes, a struggle in the mind of the indi-
vidual between the instinctive desire which con-
stitutes the whole manifestation of disease, and the
judgment of the understanding still unaffected and
struggling against it. (Consultation Medico-legale
pour H. Cornier, femme Berton, accusee d' homi-
cide, par M. Marc, &c. Chez Roux.)
• « In a respectable house in Germany, the mo-
ther of the family returning home one day, met a
servant, against whom she had no cause of com-
plaint, in the greatest agitation ; she begged to
speak with her mistress alone, threw herself upon
her knees, and entreated that she might be sent
out of the house. Her mistress, astonished, in-
quired the reason, and learned that whenever this

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

325

unhappy servant undressed the little child which
she nursed, she was struck with the whiteness of
its skin, and experienced the most irresistible de-
sire to tear it in pieces. She felt afraid that she
could not resist the desire, and preferred to leave
the house." " This circumstance occurred about
twenty years ago in the family of M. le Baron de
Humboldt, and this illustrious person permitted
me to add his testimony."

« A young lady," continues M. Marc, " whom
I examined in one of the asylums of the capital,
experienced a violent inclination to commit homi-
cide, for which she could not assign any motive.
She was rational on every subject, and whenever
she felt the approach of this dreadful propensity,
she entreated to have the strait-waistcoat put
on, and to be carefully guarded until the pa-
roxysm, which sometimes lasted several days, had

lord with a pitchfork for demanding his rent, and
had pursued him with that intent. " In going
into the prison, I saw," says Metzger, " an old
man with white hair, of a respectable appearance,
who received me politely. I inquired first con-
cerning his health. < I am ill through old age,' he
replied, ' and tormented with gout, with the stone,
and with the scurvy, evils for which I can have no
remedy.' He desired to know who had sent me
to see him ; I told him it was the tribunal? < 1
ought to be judged,' he replied, < by a French tri-
bunal ;' and he pretended that I should find proof
of what he said in a writing which he forced me
to take. At last I informed him of the reason of
his arrest. His eyes then became sparkling, and
he said in French, with much volubility, that MM.
and were his mortal enemies ; that

" Mr. R., a distinguished chymist and a poet,
of a disposition naturally mild and sociable, com-
mitted himself a prisoner in one of the asylums
of the Fauxbourg St. Antoine." " Tormented by
the desire of killing, he often prostrated himself at
the foot of the altar, and implored the divine as-
sistance to deliver him from such an atrocious pro-
pensity, and of the origin of which he could never
render an account. When the patient felt that
his will was likely to yield to the violence of this
inclination, he hastened to the head of the estab-
lishment, and requested to have his thumbs tied
together with a ribbon. This slight ligature was
sufficient to calm the unhappy R., who, however,
finished by endeavouring to commit homicide upon
one of his friends, and perished in a violent fit of
maniacal fury."

" A servant-maid, twenty-six or twenty-eight
years of age, whose menstruation was perfectly
natural in every respect, nevertheless experienced
at each period a sort of excitement which did not
apparently affect her judgment, but which rendered
her extremely dangerous, since, without provoca-
tion, she menaced every person with her knife,
and one day having realized her menaces, she was
sent to a lunatic hospital."

Plattner and Etmuller have related several
instances of homicidal melancholy, but observe
that it consists in mental disorder involving no
lesion of the reasoning power or understanding.

The following case, reported by Metzger, has
been already cited by several authors. M. Hoff-
bauer has observed that it is not a case of delu-
sion ; that the individual concerned did not
labour wider any erroneous idea impressed upon
his understanding, but was only not master of his
actions. He was under the influence of excessive
pride and impetuosity of feeling.

A Russian colonel came to Konigsberg to re-
ceive an inheritance, and committed there so many
acts of violence, that he was summoned before the
tribunal of justice. His conduct before the ma-
gistrates was equally unreasonable. He had be-
come so much an object of dread at Konigsberg,
that nobody would execute any commission for
him — the very chimney-sweepers required a guard
if sent to sweep his chimneys. At last, after
several complaints made against him, he was ar-
rested because he had threatened to stab his land-

2c

they had several times tried to ruin him ; that he
had experienced much injustice and oppression on
the part of the tribunal ; and that they had dis-
posed according to their own will of the inherit-
ance of his brother. Being asked what were his
occupations, he replied, ' that he was, as every
honest man ought to be, free and content, even in
prison; that he amused himself with poetry, and
copied verses relating to his real situation.' " The
following are the conclusions of Metzger : " Al-
though Colonel L. appears to judge and act ra-
tionally in every thing beyond the circle of his
false impressions (he should rather have said dis-
ordered feelings), yet it is clear, from his conver-
sation, conduct and actions, that pride, passion
and suspicion have produced a degree of insanity,
which renders him dangerous to society, and makes
his confinement necessary."

Reil has given the details of a case which has
been cited by Professor Heinroth. (Storungen des
Seelenlebens, th. 2. Formenlehre, s. 216.) A
countryman, who was in the habit of throwing
stones at every person whom he could assail, was
at length on this very account taken up and con-
fined in a madhouse. There he behaved with the
utmost propriety, gave no indication of disordered
mind, of delusion, or violence, and became so
active and diligent in his employment, that he was
supposed to be perfectly sane, and was dismissed
from confinement. On the evening after his re-
turn home, as soon as his neighbours, who came
to welcome him, had withdrawn, he shut himself
up in his house with his wife and children, and
murdered them all.

The following instances of propensity to infan-
ticide are given by Dr. Michu. In both cases the
individuals were afflicted by the consciousness of
their state, confessed it, and recovered without any
sinister event.

" A countrywoman, twenty-four years of age,
of a bilious sanguine temperament, of simple and
regular habits, but reserved and sullen manners,
had been ten days confined with her first child,
when suddenly, having her eyes fixed upon it, she
was seized with the desire of strangling it. This
idea made her shudder ; she carried the infant to
its cradle, and went out in order to get rid of so
horrid a thought. The cries of the little being,
who required nourishment, recalled her to the
house ; she experienced still more strongly the
impulse to destroy it. She hastened away again

326

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

haunted by the dread of committing a crime of
which she had such horror; she raised her eyes
to heaven, and went into a church to pray.

" This unhappy mother passed the whole day
in a constant struggle between the desire of taking
away the life of her infant, and the dread of yield-
ing to the impulse. She concealed, until the eve-
ning, her agitations ; then her confessor, a respect-
able old man, was the first who received her con-
fidence, who, having talked to her in a soothing
manner, advised her to have recourse to medical
assistance.

" When we arrived at the patient's house, she
appeared gloomy and low, and felt ashamed of her
situation. Being reminded of the tenderness due
from a mother to her child, she replied, < I know
how much a mother ought to love her child ; but
if I do not love mine, it does not depend upon me.'

" At Bures, the wife of a butcher, forty years
of age, of a nervous constitution, the mother of
several children, of a mild amiable character, en-
dowed with good sense, who had always enjoyed
good health, experienced anxiety of mind in con-
sequence of the derangement of her affairs, of
which her husband was a chief cause.

" One night, she had a dream, and thought she
perceived a cord, which she tried to seize in order
to hang herself. On awaking, she was silent, and
had confused ideas which soon fixed themselves
in a project of strangling her children. She men-
tioned to her husband, shedding tears, this dread-
ful design, and requested that her children and
even the knives belonging to the trade might be
put out of her way."

M. Esquirol has repeatedly declared his convic-
tion that there exists a species of homicidal mad-
ness, in which " no disorder of intellect can be
discovered ,•" the murderer is driven, as it were, by
an irresistible power; he is under an influence
which he cannot overcome, a blind impulse with-
out reason : it is impossible to divine the motive
which induces him, without interest or disorder
of intellect, to commit acts so atrocious and so
contrary to the laws of nature.

The same writer observes that physical or moral
causes which can be assigned, often give rise to
this disordered state.

" In two cases this affection resulted from the
change produced by puberty ; in four the propen-
sity manifested itself after the individual had heard
the history of a woman who had strangled her in-
fant and separated its head from its body. This
principle of imitation is one frequent cause of
madness. ' Some individuals,' said M. Delaplace,
' possess, from their organization or from bad ex-
ample, fatal propensities, which are excited by the
description of a criminal action, when it has be-
come the object of public attention. Under this
idea the publicity of crimes is not without danger.'

" When the affection has continued for some
time, and the individuals possessed with the desire
of committing murder have been observed, we
have seen that this state is, like the delirium of
lunatics, preceded and accompanied by headach,
and pains in the stomach and bowels ; these symp-
toms have preceded the impulse to murder, and
have become more severe when this dreadful pro-
pensity is exasperated." (Esquirol, sur la Mono-
tnanie Homicide.)

In the following case the co-existence of physi-
cal disease could be distinctly traced.

« A peasant, born at Krumbach in SwaHa, and
of parents who had not very robust health, twenty-
seven years old and unmarried, was subject, from
nine years of age, to frequent fits of epilepsy.
Two years ago his disease changed its character
without any apparent cause ; instead of a fit of
epilepsy, this man found himself from that time
attacked with an irresistible desire to commit mur-
der. He felt the approach of this attack some-
times many hours, sometimes a whole day before
it seized him. From the moment in which he felt
this presentiment, he desired, with earnestness,
that he might be tied down, that he might be
loaded with chains, to prevent his committing a
horrid crime. ' When the fit takes me,' he said,
< I am impelled to kill or strangle even an infant.'
His father and mother, to whom he was tenderly
attached, would be the first victims of this mur-
derous propensity. ' My mother,' he cries out,
with a fearful voice, " save yourself, or I shall be
obliged to murder you !' "

The following case was published by Pinel, and
affords the most striking example of this " instinc-
tive fury." It likewise furnishes an instance of
the homicidal propensity evidently connected with
physical disease.

" A man who had previously followed a me-
chanical occupation, but was afterwards confined
at Bicetre, experienced, at regular intervals, fits
of rage, ushered in by the following symptoms.
At first he experienced a sensation of burning
heat in the bowels, with an intense thirst and ok
stinate constipation. This sense of heat spread
by degrees over the breast, neck, and face, with a
bright colour ; sometimes it became still more in-
tense, and produced violent and frequent pulsa-
tions in the arteries of those parts, as if they were
going to burst : at last the nervous affection
reached the brain, and then the patient was seized
with a most irresistible sanguinary propensity;
and if he could lay hold of any sharp instrument,
he was ready to sacrifice the first person that came
in his way. In other respects, he enjoyed the free
exercise of his reason ; even during these fits, he
replied directly to questions put to him, and
showed no kind of incoherence in his ideas, no
sign of delirium ; he even deeply felt all the hor-
ror of his situation, and was often penetrated with
remorse, as if he was responsible for this mad
propensity. Before his confinement at Bicetre, a
fit of madness seized him in his own house : he
immediately warned his wife of it, to whom he
was much attached ; and he had only time to cry
out to her to run away, lest he should put her to
a violent death. At Bicetre, there appeared the
same fits of periodical fury, the same mechanical
propensity to commit atrocious actions, directed
very often against the inspector, whose mildness
and compassion he was continually praising.
This internal combat between a sane reason in
opposition to sanguinary cruelty, reduced him to
the brink of despair, and he has often endeavoured
to terminate by death this insupportable struggle.
One day he contrived to get possession of the cut-
ting-knife of the shoemaker of the hospital, and
inflicted a severe wound upon himself in the right
side of his chest and arm, which was followed by

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

327

a violent hemorrhage. Strict seclusion and a
strait-waistcoat restrained his suicidal purposes."
(I'inel, Traito sur l'Alienation.)

The influence of imitation or sympathy in ex-
citing this strange propensity is illustrated by the
results of Henriette Cornier's trial. This was a
very remarkable case of infanticide, which under-
went much discussion, and became the subject of
very general conversation in France. Many
females of respectable classes, who were strongly
impressed by the relation, and the horror occa-
sioned by it, were seized with a similar propensity.
M. Esquirol has detailed the circumstances at-
tending several of these cases, on which he was
privately consulted. The facts of Henriette
Cornier's history, which is one of the most
striking examples of the kind on record, are so
remarkable that we shall not consider our com-
ments on this subject to be complete without in-
serting a brief abstract of them.

Henriette Cornier, femme Berton, aged twenty-
seven years, domestic servant, was of mild and
lively disposition, always full of gaiety and viva-
city, and remarkably fond of children. In the
month of June, 1825, a singular change was ob-
served in her character : she became silent, me-
lancholy, absorbed in reverie, and was soon dis-
missed from her service. She fell gradually into
a permanent stupor. Her friends were alarmed,
suspected that she was pregnant, but were mista-
ken : they could never obtain from her any ac-
count of the cause of her dejection, though she
was frequently interrogated. In the month of
September she made an attempt to drown herself
in the Seine, but was prevented.

In the following October, the relatives of H.
Cornier procured her another employment at the
house of Dame Fournier. The change of condi-
tion made no abatement in her dejection and pro-
found melancholy.

On the 4th of November, the conduct of Hen-
riette Cornier not having been previously in any
way different from her usual behaviour, she sud-
denly conceived and immediately executed the act
for which she was committed.

About noon, Dame Fournier went from home,
and told H. Cornier to prepare dinner, and to go to
a neighbouring shop, kept by Dame Belon, to buy
some cheese. Henriette had frequently gone to
this shop, and had always caressed a beautiful
little girl, nineteen months old, the child of Belon.
On this day she went to the shop and displayed
the greatest fondness for the little girl, and per-
suaded Dame Belon, who was at first rather un-
willing, to let her take it out for a walk. H. Cor-
nier immediately took the child with her to the
house of Dame Fournier, then empty, mounted
the common staircase with a large knife which
she took from the kitchen, and stretching the child
across her own bed, with one stfoke cut off its
head. The head, which she held in her hand, she
placed by the casement and then put the body on
the floor near to it. All these proceedings occu-
pied about a quarter of an hour; during this time
Henriette Cornier remained perfectly calm ; she
experienced no emotion of any kind. Dame Be-
lon presently came to seek for her child, and called
Henriette from the bottom of the stairs. ' What
do you want ?' said the latter, advancing on the

corridor. ' I come to seek my child,' said Belon,
ascending the stairs. ' Your child is dead !' re-
plied Henriette, with perfect coolness. Belon,
alarmed, became more earnest; and Henriette
again pronounced the words, ' II est mort, votre
enfant !' As Belon forced her way into the room,
Henriette took the child's head from the casement
and threw it, by the open window, into the street.
The mother rushed out of the house, struck with
horror. An alarm was raised ; the father of the
child and officers of justice, with a crowd of per-
sons, entered. Henriette was found sitting on a
chair near the body of the child, gazing at it, with
the bloody knife by her, her hands and clothes
covered with blood. She made no attempt for a
moment to deny the crime ; confessed all the cir-
cumstances, even her premeditated design and the
perfidy of her caresses, which had persuaded the
unhappy mother to entrust to her the child. It
was found impossible to excite in her the slightest
emotion of remorse cr grief; to all that was said
she replied, with indifference, < J'ai voulu le tuer!'
' I intended to kill the child !'

When Henriette Cornier was brought to trial, a
plea of insanity was set up. MM. Adelon, Es-
quirol, and Leveille were appointed to visit her
and report on the ' actual moral state of the ac-
cused.' After several visits, these distinguished
physicians declared that they could discover no
proof of insanity, yet they were not decided as to
the non-existence of such disease. The affair was
put off; Henriette Cornier was taken to the Sal-
petriere. There she was inspected repeatedly by
the physicians, whose last report concludes that,
" from February 25 to June 3, they had observed
in Henriette Cornier merely a dejection of mind,
slowness in the manifestation of thought, and pro-
found grief; 2dly, that these phenomena are ex-
plained by circumstances, and therefore no proofs
of derangement; 3dly, that the opinion as to the
question of her sanity is materially affected by
facts relating to her previous history. If the alle-
gation is proved that, long previously to the com-
mittal, her habits, her whole character, had become
changed ; that she had become at a particular
period dejected, gloomy, taciturn, restless, prone
to reverie, and had occasionally attempted suicide,
it would seem that her present state is not the
result of existing circumstances, since it had lasted
a year before the commission of the act, in which
case the opinion as to her sanity would be mate-
rially influenced."

At the renewal of the trial of Henriette, M.
Esquirol and several other physicians were exa-
amined. The opinions of the physicians leaned
generally towards the real existence of derange-
ment. The advocate-general treated the existence
of monomania as a mere figment invented by
medical persons for the sake of paralyzing the
hands of justice. In the end, the jury brought
in a verdict that Henriette Cornier had committed
homicide voluntarily, but without premeditation,
and she was condemned to perpetual imprison-
ment, with forced labour, and to be branded with
the letters T. P., which sentence she heard without
betraying the slightest emotion. It is observed by
M. Georget that the judges on this trial evinced
reluctance to suffer a clear investigation by physi-
cians of the actual mental state of the accused,

328

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

and in other respects exerted an unusual influence
towards the condemnation. The public sentiment
appears to have been against Chat of the physi-
cians, and M. Georget was treated with ridicule
by the journalists of Paris. Yet it is impossible
for any person of sound judgment to read the
account of this trial, which is given from official
documents, without strongly suspecting that the
unfortunate woman who was the subject of it,
acted under the influence of an impulse which
resulted from disease.*

On the whole it seems to us fully manifest that
there is a form of insanity, existing independently
of any lesion of the intellectual powers, in which,
connected in some instances with evident consti-
tutional disorder, in others with affections of the
nervous system excited according to well-known
law T s of the animal economy, a sudden and often
irresistible impulse is experienced to commit acts
which under a sane condition of mind would be
accounted atrocious crimes. Most of the French
writers by whom this affection has been recog-
nised, particularly Messrs. Esquirol, Georget,
Marc, and Michu, have termed it monomanie
homicide, which is assuredly an erroneous desig-
nation, unless the sense of monomania is to be
changed. That term is always used to express
partial illusion, or intellectual derangement af-
fecting only a certain train of ideas ; whereas, in
connection with the homicidal impulse now under
consideration, there is confessedly no delusive
opinion impressed on the belief, and the intellec-
tual faculties are wholly unaffected.

It must be allowed that instances may and do
occur in which the discrimination would be diffi-
cult between manifestations of insanity and acts
of a criminal nature, and that this difficulty would
be increased by the admission of a form of in-
sanity free from hallucination or illusion. For
the distinguishing characters of this form of in-
sanity we must refer to the article already cited,
and to this we shall add a few particulars, chiefly
the observations of M. Esquirol.

1. Acts of homicide perpetrated or attempted
by insane persons have generally been preceded
by other striking peculiarities of action, noted in
the conduct of the same individuals ; often by a
total change of character.

2. The same individuals have been discovered
in many instances to have attempted suicide, to
have expressed a wish for death ; sometimes they
have begged to be executed as criminals.

3. These acts are without motive ; they are in
opposition to the known influences of all human
motives. A man murders his wife and children,
known to have been tenderly attached to them ;
a mother destroys her infant.

4. The subsequent conduct of the unfortunate
individual is generally characteristic of his state.
He seeks no escape or flight ; delivers himself up
to justice ; acknowledges the crime laid to his
charge ; describes the state of mind which led to

* Discussion Medico-legale sur la Folie par le Docleur
Georget, Taris, 1826. See, also, Ex amen Medical des
proces criminels des nominee Legor, &c. par le Docteur
Georget, Paris, 1823 ; arid Nouvelle Discussion Medico-
legale sur la Folie, par le inenie, 1828. Bee, also, Mate-
riaux pour I'Bastoire Medico-legale del-Alienation Men-
tals par M. Marc. Annates d'Hygiene Publique et de
Medecine Legale. Paris, 1830.

its perpetration : or he remains stupefied and over-
come by the horrible consciousness of having been
the agent in an atrocious deed.

5. The murderer has generally accomplices in
vice and crime ; there are assignable inducements
which led to its commission, motives of self-in-
terest, of revenge, displaying wickedness premedi-
tated. Premeditated are in some instances the
acts of the madman, but his premeditation is
peculiar and characteristic.

After all it cannot be doubted that there must
be instances extremely difficult of discrimination,
but this admission does not alter the matter of
fact, or change our conviction that disease leads
in some cases to homicide, although the faculties
of the understanding are at the same time un-
clouded by any illusion.

We have dwelt more at length on the form of
moral insanity which leads to homicide, because
in criminal justice it is the most important, at the
same time that it is the most striking and charac-
teristic. But there are other instances to which
similar observations may be applied. We could
adduce facts which prove that other criminal acts,
or acts which are criminal when perpetrated by
sane persons, have been attempted or committed
under circumstances which left no doubt of their
resulting from mental disorder, while yet of that
disorder illusion formed no part.

The propensity to suicide is in many particu-
lars analogous to the impulse to homicide. It is
doubted by many whether suicide is, in general,
really an act of insanity, though a verdict of
lunacy is generally found in inquests, owing pro-
bably to the extreme barbarity of the penal law
on suicide. With relation to this subject the
following considerations are, as we think, con-
clusive.

1. The propensity to suicide is very often com-
bined with the impulse to homicide. This has
been observed long ago, but the evidence adduced
by M. Falret puts the fact beyond all doubt. (De
l'Hypochondrie et du Suicide, p. 170, et seq.
Paris, 1S22.) These impulses are so often con-
joined as to prove clearly that the conditions
which give rise to one are in close affinity and
conjunction with those from which the other
originates.

3. Suicide is in a very marked and striking
manner hereditary, and this is a strong ground
for regarding it as constitutional, or depending on
disorder in the state of organic structure. Dr.
Rush, Dr. Esquirol, and others have recorded in-
stances of the hereditary transmission of this
propensity. M. Falret has collected a variety of
observations on the subject, and has concluded
that, of all the forms of insanity, that which dis-
tinguishes itself by this tendency is probably that
which the most frequently becomes hereditary.

3. Like other forms of madness, suicidal insa-
nity prevails most in certain seasons and tempera-
tures. M. Falret says it is most frequent in the
summer and autumn. MM. Fodere and Duglas
observed that at Marseilles suicides were most
frequent when the thermometer of Reaumur wa<
22 degrees above zero.

4. Acts of suicide, like those of homicide, are
generally preceded by a morbid change in the
character and habits of the agent. Individuals

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

329

who had been cheerful, active, animated, taking a
lively interest in the pursuits of life, in the society
of their friends, in their families, became melan-
choly, torpid, morose, and feel an aversion to-
wards their relatives or most intimate associates,
become listless and indifferent. These appear-
ances have often been observed to be the preludes
of some attempt at suicide, and have sometimes
put the relatives of the individual on their guard,
and have led to a prevention of the fatal catas-
trophe.

5. Suicide is connected in many instances with
diseases of structure, or with disorders of the func-
tions of physical life, some of which have been
detected by necroscopy, others by observations
made before death. This general fact is suffi-
ciently established on the observations made on
the subject by Awenbrugger, Leroy, Fodere, and
Esquirol, although we must confess that the same
obscurity yet involves the physical causes of sui-
cidal as of other forms of insanity.

6. Like the impulse to homicide, this propen-
sity to suicide is simply a moral perversion, and
therefore neither falls within the restricted defini-
tion of insanity, which has been the most preva-
lent one. There is generally no particular illusion
impressed on the understanding of the self-de-
stroyer ; on the other hand, there is a perversion
of the strongest instinct of nature, that of self-
preservation. Nature has ordained no other law
more universal in its influence than the desire
which all animated beings display, and which is
indeed the primary principle in the greater part
of their actions, and throughout the whole period
of their existence, to preserve their existence, and
to secure themselves from the influence of cir-
cumstances which bring it into danger. It is the
characteristic of moral insanity to pervert the
natural instincts or propensities, and suicide dis-
plays the most signal of these perversions.

Under the head of moral insanity we have
adverted to a form of disease of which the prin-
cipal or sole manifestation is a propensity to break
and destroy whatever comes within reach of the
individual ; in short, an irresistible impulse to
commit injury or do mischief of all kinds. This
propensity is observed in cases in which it is im-
possible to discover any motive influencing the
mind of the person who is the subject of it. No
illusive belief, for example, can be detected, that
the lunatic is performing a duty in perpetrating
that which manifests his disease. There are, in-
deed, cases of a different description in which
this illusion is the groundwork of the proceeding,
but these belong to another class of mental dis-
orders.

Many lunatics, whose disorder was merely a
destructive propensity, have set fire to houses or
public buildings, and it is not to be doubted that
men have been occasionally executed as criminals
for such actions, who, if they had been kept in
confinement, would have proved to be insane.
Until the existence of moral insanity is distinctly
recognised, there will always be a danger of this
event ensuing on the trials of mischievous luna-
tics. Popular feeling is generally excited in such
instances against the perpetrator of a destructive
act, and this circumstance increases by much the
probability of a criminal condemnation.

Vol. III. — 42 2 c*

There are several modifications of moral in
sanity, and two most decided examples which
require the arrangements suggested by Hoff bauer
in some cases of imbecility : we allude to the
placing of individuals under curatela, or guardian-
ship, for personal security, who do not require
confinement. Extreme parsimony has induced
persons to starve themselves. When an indi\i-
dual would destroy himself through this propen-
sity, which is in some instances the effect of dis-
ease, (see Insanity,) he is sometimes declared a
lunatic and sent to a place of confinement. There
is no other way of proceeding by which his life
can be saved under the existing regulation. But
confinement is unnecessary for such a person,
who is in no way dangerous to society. If the
management of his property — for such individuals
are generally possessed of property — could be so
settled as to ensure his having the usual supports
of life, this would be sufficient. Another case is
that of profuse extravagance, and this is the most
common. Individuals whose moral character is
perverted by disease often become profusely ex-
travagant, and the apprehension of ruin to their
families is the motive which induces the latter to
take measures with a view to prevent such a
calamity. Confinement is more often requisite
with regard to cases of this description than those
of an opposite one, on account of other manifes-
tations of disorder which are combined with the
leading propensity; but there are probably many
individuals who are wholly incompetent, through
a habit of thoughtless extravagance resulting from
disease, to administer their own estates, or manage
their domestic affairs, and in whose condition
there is yet nothing that requires confinement in
a madhouse. Many of these are examples of
extreme difficulty as to the proceedings which
ought to be adopted. It will be advantageous,
however, to the medical persons who may be
consulted in such cases, to be fully in possession
of the circumstances connected with them, and
aware of the difficulties with which they are sur-
rounded, although these difficulties may be almost

insuperable. T „. „

J. C Prichard.

[Of late years, owing, more especially, to the
occurrence of some important criminal cases in
England, in which there was question of insanity,
numerous essays have appeared on the subject by
well-informed observers ; and in this country an
able and comprehensive treatise has been published
expressly on the subject of the forensic applica-
tions of insanity, by Dr. Kay, (A Treatise on the
Medical Jurisprudence of Insanity, 2d edition,
Boston, 1844,) which has been most favourably
received by the medical and legal professions. His
views agree mainly with those contained in the
previous article, by Dr. Prichard. The cases of
Francis, for shooting at Queen Victoria, and of
M'Naughten, {Report of the Trial of Daniet
M 'Naugktm, for the wilful murder of Edward
Drummond, Esq. By R. W. Bousfield and Rich-
ard Merrett, Lond. 1843,) who was tried for the
murder of the secretary of Sir Robert Peel, and
acquitted on the ground of insanity, gave occasion
to numerous essays on the responsibility of the
lunatic — the chief of which are those of Dr. Prich-
ard {On the different forms of Insanity, in rr-

330

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

lation to Jurisprudence, London, 1842) ; Mr.
Forbes Window ( The Plea of Insanity in Crim-
inal Cases, Lond. 1843), and Mr. Rumball
{M'Naughten. — A Letter to the Lord Chancel-
lor upon Insanity, Lond. 1843).

These cases led to a review of the whole sub-
ject of Insanity, in its relation to Medical Juris-
prudence, in the House of Lords, and to answers
from the fifteen Judges to questions submitted to
them by the Lords, which were read to the House
in the name of all the Judges except one (Mr.
Justice Maule) by Lord Chief Justice Tindall, on
the 19th of June, 1843.

These answers must be regarded as the then
legal opinion in England, in regard to the points
submitted to the Judges. The questions and
answers were as follows :

Question 1. What is the law respecting alleged
crimes committed by persons afflicted with insane
delusion, in respect of one or more particular sub-
jects or persons ; — as, for instance, when at the
time of the commission of the alleged crime the
accused knew he was acting contrary to law, but
did the act complained of, with the view, under
the influence of some insane delusion, of redress-
ing or avenging some supposed grievance or in-
jury, or of producing some supposed public ben-
efit] Answer. The opinion of the Judges was,
that notwithstanding the party committed a wrong
act while labouring under the idea that he was
redressing a supposed grievance or injury, or under
the impression of obtaining some public or private
benefit, he was liable to punishment.

Question 2. What are the proper questions to
be submitted to the jury, when a person alleged
to be affected with insane delusion, respecting one
or more particular subjects or persons, is charged
with the commission of a crime, murder for ex-
ample, and insanity is set up as a defence] An-
swer. The jury ought in all cases to be told that
every man should be considered of sane mind
until the contrary were clearly proved in evidence.
That before a plea of insanity should be allowed,
undoubted evidence ought to be adduced that the
accused was of diseased mind, and that at the time
he committed the act he was not conscious of
right and wrong. This opinion related to every
case in which a party was charged with an illegal
act, and a plea of insanity was set up. Every
person was supposed to know what the law was,
and therefore nothing could justify a wrong act,
except it was clearly proved that the party did not
know right from wrong. If that was not satis-
factorily proved, the accused was liable to punish-
ment ; and it was the duty of the judge so to tell
the jury when summing up the evidence, accom-
panied by those remarks and observations which
the nature and peculiarities of each case might
suggest and require.

Question 3. In what terms ought the question
to be left to the jury as to the prisoner's state of
mind at the time when the act was committed 1
No answer.

Question 4. If a person under an insane delu-
sion as to existing facts, commits an offence in
consequence thereof, is he hereby excused 1 An-
swer. If the delusion were only partial, the party
accused was equally liable with a person of sane
mind. If the accused killed another in self-de-

fence, he would be entitled to an acquittid ; but
if the crime were committed for any supposed in-
jury, he would then be liable to the punishment
awarded by the laws to his crime.

Question 5. Can a medical man, conversant
with the disease of insanity, who never saw the
prisoner previous to the trial, but who was present
during the whole trial, and the examination of all
the witnesses, be asked his opinion as to the state
of the prisoner's mind at the time of the commis-
sion of the alleged crime, or his opinion whether
the prisoner was conscious, at the time of doing
the act, that he was acting contrary to law 1 or
whether he was labouring under any, and what
delusion at the time ? Answer. The question
could not be put in the precise form stated above,
for by doing so it would be assumed that the facts
had been proved. When the facts were proved
and admitted, then the question as one of science
would be generally put to a witness under the cir-
cumstances stated in the interrogatory.

Mr. Justice Maule dissented from this last
answer. In his opinion, such questions might
be at once put to medical men without reference
to the facts proved, and he considered that this
had been done, and the legality of the practice
thereby confirmed, on the trial of M'Naughten.

A century ago, the doctrine was, that to excuse
a man from punishment " he must be totally de-
prived of his understanding and memory, and not
know what he was doing, any more than an in-
fant, a brute or a wild beast, — such a one is never
the object of punishment." At the commence-
ment of this century, in the celebrated trial of
Hadfield, for shooting at George the Third of
England, it was maintained that " delusion, when
there is no frenzy or raving madness, is the true
character of insanity ;" and in order to render the
madman irresponsible for crime, it must be shown
" that the act in question was the immediate un-
qualified offspring of the disease." In a few
years after, however, the doctrine of " right and
wrong" sprang up, which has maintained its
ground to the present day ; and the jury were in-
structed to acquit, if the prisoner, at the time of
committing the crime, was incapable of distin-
guishing between right and wrong, and did not
consider his act any crime against the laws of
God and Nature. The doctrine of right and
wrong was forcibly laid down in the case of
M'Naughten, by Chief Justice Tindal.

Different interpretations have, however, been
given of « right and wrong ;' and, as a practical
test, when used in a moral and religious sense, it
is inefficient, and always difficult to be established.
According to the fifteen judges, right and wrong
would seem to mean lawful and unlawful. "Be-
fore a plea of insanity should be allowed," they
say, " undoubted evidence ought to be adduced
that the accused was of diseased mind, and that
at the time he committed the act he was not con-
scious of right and wrong ;" and they add, " Every
person was supposed to know what the law was,
and therefore nothing could justify a wrong act,
except it was clearly proved that the party did not
know right from wrong." Yet numerous cases
are on record in which unquestioned madmen
have been clearly aware of the illegality of acts
they have committed. An intriguing, unruly.

MIND, (SOUNDNESS AND UNSOUNDNESS OF)

331

vicious madman was detected with a piece of
iron, which he had contrived to shape like a dag-
ger : into this iron he firmly fixed a handle.
This weapon was taken away from him. He
immediately became excessively abusive, and was
placed under restraint. After this he was more
violent, and uttered the most revolting impreca-
tions. In a fit of fury he exclaimed to the keeper,
"/'// murder you yet. I am a madman, and
they cannot hang me for it." When Martin set
fire to York Minster, a conversation took place
among the inmates of a neighbouring mad-house
in relation to the occurrence. The question dis-
cussed was, whether Martin would suffer the ex-
treme penalty of the law for the crime. Various
were the opinions expressed. In the midst of the
conversation, one patient, apparently as mad as the
rest, exclaimed : " He (Martin) will not be hanged
— of course he will escape." " For what reason ?"
asked several voices. " They cannot hang him,"
replied the lunatic, " because he is mad, — he is
one of ourselves." (Winslow, Op. cit. p. 16, and
Guy, Principles of Forensic Medicine, Part 2,
p. 255, Lond. 1843.)

A recent writer (British and Foreign Medical
Review, July 1843, p. 108) after objecting to these
tests, that they do not answer the purpose in-
tended, and that " a man may know that the act
of murder or incendiarism, which he is perpetra-
ting, is wrong, that it is an evil, wicked, and illegal
act, and yet be a homicidal monomaniac," sug-
gests that the true and only test of responsibility
is, " whether or not the individual had at the time
any power of control over his actions ? and this
is probably the best single test; still its applica-
tion is environed with the same difficulties as the
others.

The most atrocious crimes are sometimes com-
mitted by persons, the unsoundness of whose in-
tellect had not been previously suspected. A man
of the name of Steinberg killed his wife and four
children, at Pentonville, near London, in 1834;
another, of the name of Staninought, a respectable
tradesman, killed his son in 1835 ; another, Lucas,
destroyed his children in 1842 ; and numerous
cases of the same kind might be cited, where there
were no previous symptoms of insanity, nor any
obliquity of the moral, to justify interference.
They were cases of homicidal impulse, suddenly
arising, and destroying all control on the part of
the unfortunate agent ; and the fact, that, in most
cases, the victims were nearly allied, and previously
perhaps dear to the destroyer, assimilate them to
those of ordinary insanity, which is apt to be di-
rected towards individuals most closely connected
with the insane.

Another difficult case is, where eccentricity or
waywardness has existed in an individual, or
where insane delusion has been manifested on
some unimportant subject, whilst on all others the
mind may have been apparently sound, — whether
such aberration ought to free from responsibility
for criminal acts not connected with such delusion ?
The usual course in courts of law has been to
regard such persons as entirely responsible ; yet
it is obvious that the rule ought not, in justice, to
be held absolute; otherwise cases of homicidal
monomania, like those referred to above, must be
treated as if they had occurred in those of sound J

mind, which, even if considered expedient, would
scarcely be just. Mr. Chitty (.4 Practical Treatise
on Med. Jurisprudence, Amer. edit. Philad. 1835)
refers to the case of a lady, who consulted most
of the eminent physicians in London on the sub-
ject of a piece of wood, which she thought was
constantly burning in her throat, and whose mind
on every other subject was sound ; and we have
daily examples of the strangest hallucinations in
the hypochondriac. The writer, within the last
few years, has attended three persons, who be-
lieved that they had a living snake in the stomach,
and who could not be persuaded to the contrary.
Two of them were engaged in business, and ma-
naged all their affairs with their wonted judgment.
Suppose, then, that a crime had been committed
by any one of these persons, ought he to suffer
the penalty of the law> Humanity and justice
would certainly suggest that the hallucination in-
dicated an unsoundness of mind, which might,
under adequate exciting causes, be exhibited sud-
denly under other forms.

There would be less difficulty in this matter,
when a verdict of insanity is rendered in these
cases, were the community adequately protected
against subsequent outbreaks of a similar charac-
ter. It not unfrequently happens, however, that
medical testimony is adduced in favour of the in-
sanity of a prisoner, when the testimony of the
same witness could be easily, and perhaps pro-
perly, obtained to show, that at the time of trial,
the prisoner was perfectly sane : hence, according
to the laws of most, if not all of the States, it is
a matter of.no great difficulty for one who has
escaped punishment on the ground of insanity at
the time of committing the offence, to procure, soon
after the trial, his discharge from prison under the
certified plea of entire restoration ; and thus to be
left at full liberty to pursue his perilous volition,
should fresh causes revive the homicidal impulse.
" There are some," says a recent writer, (Guy,
op. cit. p. 265,) " who argue, that to confine the
insane for life is an injustice, inasmuch as the dis-
ease under which they labour may be completely
cured. It is an injustice towards the individual,
but the step is demanded by a regard to the pub-
lic safety ; and when all the alternatives arc
weighed, it will be found to be the least injustice
that the case allows of. The practical question is
this : what amount of injustice are we willing to
inflict on the individual in order that society at
large may be protected ? If the public safety re-
quires that the homicidal monomaniac should be
put to death, let the principle be boldly proclaimed
and acted on ; but if, on the other hand, this
seems too great a sacrifice, and too glaring an in-
justice, we must be content to confine him for
life, to prevent the possibility of future mischief.
This degree of injustice to the individual a regard
to the public safety will justify. Nor is there any
good reason to fear that, by exempting the mad-
man from the punishment of death, we shall
weaken the hold which the law has on the man
of sound mind ; for in order that he may escape
death, he must successfully feign insanity — a task
of no ordinary difficulty — and if he succeeds, a
perpetual sacrifice of liberty awaits him. It is not
likely, therefore, that society will suffer any injury
from the adoption of the course here advocated ;

332

MOLL USCUM — MORTIFICATION.

and we may perhaps find, that it gains something
by openly attributing to disease some of the most
revolting crimes which degrade and debase our
ommon nature."

There is great force in these views ; yet the
mind revolts at the idea of a person being exe-
cuted, who under a homicidal impulse has taken
the life of another, as in the cases referred to
above, where the atrocity of the act was the great-
est, and perhaps the sole, evidence of the existence
of the mental unsoundness.

In regard to the nature of the testimony relied
upon in cases of insanity, and the mode of judging
of the same, there is much room for animadver-
sion. Too great weight appears to be given to
medical testimony in such cases. It has always
been the expressed conviction of the writer, that
medical men are no better judges of the existence
of mental alienation, than well-informed and dis-
criminating individuals not of the profession. The
only advantage, at least, which they can be pre-
sumed to have, is from the constant habits of ob-
servation and discrimination which the practical
exercise of their profession requires. Yet for no
other reason than that they belong to the medical
profession, inferior men, whose judgments on other
subjects would be contemned, are often relied upon
to establish the existence or non-existence of a
mental condition which demands the most rigid
and careful scrutiny. A modern able writer,
(Brit, and For. Med. Rev. July, 1843, p. 110,)
thinks it essential for justice " to abolish medical
testimony as it is at present given on trials for
crime, where insanity is the plea." " Questions
of this important nature," he adds, " should be
referred to a board of twelve or more competent
men : the state of mind of a person accused of
crime should not be left to be decided by those
members of the profession whom the prisoner or
his friends may select for their known support of
his case. As to the question of responsibility and
punishment, that should be intrusted to the au-
thorities of the law." The whole subject is, as
before remarked, surrounded with difficulties ; and
hence much room is left for the ingenuity of coun-
sel, to act upon a jury generally composed of men
who are eminently unqualified for forming any
correct judgment on the intricate subject submitted
for their decision. RoBLEY Dunglison.]

MINERAL WATERS. See Waters, Mi-

KEllAL.

[MOLLUSCUM. — This cutaneous disease, first
so called by Bateman, consists of numerous tu-
mours, varying in size from that of a pea to that
of a pigeon's egg, filled with an atheromatous
matter, which are developed in the substance of
the cutis, and are of various shapes — some round
or flattened, and having a large base ; others ad-
herent by means of a pedicle.

When the disease is in its simple form, it ap-
pears to be wholly local ; and after having attained
a certain degree of development it is apt to re-
main stationary through life. Occasionally, as in
a case described by M. Tilesius, and in others by
M. Biett, the whole body is covered with these
tumours, which are at times hard and contain no
atheromatous matter, (Biett, in Diet, de Med. xx,
137. Paris, 1839.) >L Biett has seen another

variety, more especially in young women after
parturition, which consists of small flattened tu-
mours, slightly fissured at the top, of irregular
shape, and of a brownish or fawn colour; indo-
lent, and occurring more particularly on the neck.

A more singular variety is that described under
the name Molluscum Contagloaum, of which
many cases have been published of late years.
(Paterson, Edinb. Med. <Sf Surg. Journ. hi, p.
279 ; Henderson, Ibid, lvi, 213 ; Jacobovics, Du
Molluscum, &c, Paris, 1840 ; and Wilson On
Diseases of the Skin, Amer. edit., Philad. 1843.)
It is considered to consist of a morbid enlargement
and derangement of the sebaceous follicle, rather
than of a tubercular affection of the proper tex-
ture of the cutis vera, (Wilson, op. cit.), and is
characterized by the presence of round, hard tu-
bercles, which are smooth and transparent, and
when pressed pour out, from an orifice on their
summits, a little opaque or milky fluid. The af-
fection is uncommon, — several of the most expe-
rienced dermatologists having seen no case of it.
M. Biett affirms ( Op. cit.) that no case has been
observed in France. It is communicable, and is
accompanied by tumefaction of the glands, and,
occasionally, by so much constitutional irritation
as to gradually destroy the patient.

The causes of Molluscum are unknown, and
the treatment is unsatisfactory. In simple Mol-
luscum, — the first variety, no mode of management
has been of much service ; in the variety described
by M. Biett, a strong solution of sulphate of cop-
per has dispelled the tumours. In the contagious
variety, eutrophics have been prescribed, especially
arsenic, and external agents been applied with the
view of exciting the tumours to inflammation.
The liquor potassse, and the solid nitrate of sil-
ver, have been used with this view.

Dr. R. Paterson is inclined to look upon inter-
nal remedies in general as too tedious, " when
the local ones can be applied with so little pain to
the patient, such surety to the destruction of the
tumour, and in so much shorter a space of time."
Robley Dunglison.]

MORTIFICATION. The term mortification
is generally employed in this country to express
that state which has been induced in a part of the
body by the complete and permanent extinction
of its vital properties. On the continent, how-
ever, the term gangrene is employed to signify
the same state; whilst in England it is more
commonly used to denote the incipient stage of
mortification : a state of a part in which there is
a diminution, but not a total extinction of the vital
properties; in which the blood is still supposed to
circulate in the larger blood-vessels, and the nerves
to retain a part of their sensibility ; the complete
cessation of circulation and an entire want of
sensibility characterize the second or last stage of
mortification, which is called sphacelus, whether
the dead part has or has not become putrid,
whether it has been separated or not from the
living parts. Again, some pathologists confine
the term gangrene to the death of the superficial
texture of parts, and particularly of the soft
parts ; and sphacelus, to the death of the whole
substance of an organ, as of the soft parts and
bones at Vhc same time.

MORTIFICATION.

333

Other denominations have been given to this
pathological state, founded on particular condi-
tions of the affected part, which have been ob-
served to precede or accompany mortification.
Thus, we have what is called hot gangrene, or
that which is preceded or accompanied by inflam-
mation ; and cold gangrene, or gangrene without
inflammation. We have also humid gangrene,
from the affected part containing a greater or less
quantity of decomposed or other fluids ; and dry
gangrene, when these fluids are not present, or
only in very small quantity, and which being fre-
quently the case in gangrene affecting the exter-
nal parts of old people, has, on that account, also
been named gangrsena senilis.

Although some of these distinctions are, no
doubt, of considerable importance, some of them
are extremely vague and improper, and much less
deserving of our attention than the conditions of
the part affected with mortification, and the causes
by which this state is induced.

Before entering upon the general considerations
which present themselves on the several kinds of
mortification which occur, it may be well to re-
mark that we shall employ the terms gangrene
and sphacelus as they are generally employed in
this country ; that of mortification constituting
the generic sign of the disease of which they indi-
cate particular stages. Although, however, the
adoption of these two terms is founded on the
differences which exist between the morbid condi-
tions to which they are applied, and their use is
necessary to distinguish a state of a part yet sus-
ceptible of recovery from one that is not, we shall
find that it is by no means easy to determine —
even when external parts are the seat of mortifi-
cation, and, consequently, when any of the pheno-
mena of this disease are capable of being submitted
to actual observation — whether the vitality of the
affected part be partially or wholly destroyed. It
is, perhaps, on this account, and as expressing
also a favourable doubt, that the term gangrene is
much more frequently employed than that of
mortification or sphacelus.

As the descriptive characters of mortification
were originally drawn from the appearances which
this disease presents when it attacks the external
parts of the body, they have ever since been em-
ployed by the pathologist as the means of enabling
him to detect it in internal organs after death. It
may, however, be fairly questioned whether the
application of the term mortification has not been
too restricted ; and whether parts deprived of
their vitality and separated from the living tissues
should not be designated by the same appellation
as those which, similarly situated, differ from them
only in point of colour, and perhaps smell. Soft-
ening of the cerebral substance, of the mucous
and frequently of the serous membranes, consti-
tutes a state of positive death ; but the softened
substance, in these instances, presenting neither
the peculiar colour nor odour of external parts
when mortified, it has been considered necessary
to distinguish softening from mortification, by a
term expressive of its principal character — that of
softness. We shall, therefore, treat in this article
only of tttbse states which are usually compre-
hended under the term mortification.

Considered in a general point of view, and in

relation to the causes by which it is produced, or
the morbid conditions of the part in which it oc-
curs, we find that mortification takes place in a
variety of ways, and under very different circum-
stances. A knowledge of these facts suggests the
propriety of arranging the several kinds of morti-
fication under the three following heads: —

1. Mortification from cessation of the circula-
tion.

2. Mortification from the violent operation of
mechanical, chemical, and physical agents.

3. Mortification from the deleterious influence
of certain poisons.

Cessation of the circulation in a part of the
body may be produced in the three following
ways : — by inflammation ; by mechanical causes
which obstruct the passage of the blood ; by local
or general debility.

1. MORTIFICATION FROM INFLAMMATION.

There is no tissue or organ of the body which
may not become affected with mortification as the
immediate or mediate effect of inflammation. Mor-
tification is, however, much more frequently ob-
served in those organs in which the vascular sys-
tem predominates, or in which an inordinate accu-
mulation of blood is readily produced, on account
of their great sensibility and their direct exposure
to the influence of those causes which give rise to
inflammation. Hence the reason why gangrene
and sphacelus occur more frequently in the skin
and cellular tissue, mucous membranes and lungs,
than in the other tissues and organs of the body,
as immediate effects of inflammation ; and why
they are so rarely observed in serous and fibrous
tissues, which contain few or no blood-vessels.

Not only is mortification rarely observed in
these latter tissues, but it may also be said never
to occur in them as an immediate effect of inflam-
mation, for they are never found in a state of
gangrene or sphacelus, unless the cellular mem-
brane with which they are in contact, and from
whose vascular system their nutrition is derived,
has previously been diseased. Such also is the
case in caries, (death of bone,) as a consequence
of inflammation of the periosteum and medullary
membrane.

These circumstances enable us to explain why,
in certain cases, mortification takes place in one
tissue and not in another, although the inflamma-
tion by which it is preceded is the same in kind,
degree, and duration. There are, however, many
other circumstances of perhaps still greater im-
portance, the single or conjoint operation of which
favours in a most remarkable manner the termina-
tion of inflammation in gangrene and sphacelus.

1. Certain diseased states of an organ or tissue
— of the solids in general, or of the blood in par-
ticular — are circumstances which, while they pre-
dispose to inflammation, give at the same time to
this pathological state a peculiar tendency to ter-
minate in gangrene or sphacelus of the parts which
it affects. Thus, chronic inflammation of a portion
of an organ, particularly when accompanied by
induration and obstructed circulation of the affected
part, is not unfrequently followed by gangrene and
sphacelus ; and still more frequently is this the
consequence of an acute attack of the same dis-
ease, either in that portion of the organ previously
modified, or in a contiguous portion of it, through

331

MORTIFICATION,

the medium of which the nutrition of the former
was derived.

2. In like manner, when inflammation occurs
in an organ in a state of congestion, depending
on the presence of an obstacle to the return of the
venous blood, the danger of its terminating in
mortification is increased in proportion to the ex-
tent of the obstacle or the degree of congestion to
which that obstacle has given rise.

3. The state of general debility which prevails
at the termination of protracted fevers, or during
the first period of convalescence, is well known not
only to favour the development of inflammation,
but to give to this disease a great tendency to ter-
minate in mortification.

4. The influence which a diseased state of the
blood exercises in the production of mortification
is well exemplified in scorbutus ; local inflamma-
tion in this disease, even when it has only arrived
at the congestive stage, frequently terminating
with great rapidity in gangrene and sphacelus.

The termination of inflammation in either of
these states is likewise regarded by many to depend
much on the nature of the cause by which the in-
flammation has been induced. It would, how-
ever, be more correct to say that the termination
of inflammation in gangrene or sphacelus depends
on the nature of the change which follows the
immediate operation of such a cause on the organ
in which inflammation afterwards take place.

It is true that, independently of any peculiarity
of constitution, a mechanical stimulus will pro-
duce inflammation very different in its external
characters, intensity, extent, duration, and mode
of termination, from that which follows the opera-
tion of a chemical agent or certain poisons. But,
were we to attribute these differences solely to
something peculiar in the nature of the exciting
cause, we should find it impossible to account for
the various phenomena by which they are accom-
panied. For, in one case, the inflammation may
be intense, and the gangrene by which it is fol-
lowed comparatively slight in degree and limited
in extent ; in another, it may be mild or imper-
fectly developed, and yet gangrene and sphacelus
succeed each other to a great extent ; and in a
third, whether severe or mild, its termination in
mortification may take place slowly, or proceed
with frightful rapidity. All these varieties, also,
are observed, without a corresponding change in
the causes by which they are produced ; the same
cause producing at one time only inflammation, at
another gangrene or sphacelus.

Instead, therefore, of seeking in the nature of
the exciting cause itself an explanation of these
remarkable differences, we must have recourse
either to the peculiar change which it has induced
in the part which afterwards becomes the seat of
inflammation, or to some previous modification of
the kind to which we have already alluded ; such
as a morbid state of an organ, of the body in
general, or of the blood in particular.

The above are some of the more remarkable of
the circumstances which favour the development
of gangrene or sphacelus as a consequence of in-
flammation: the following are some of those
which exercise an opposite influence.

1. The first of these in importance is a perfect
state of health, whereby inflammation, instead of

terminating in gangrene or sphacelus, as it would
have done in an individual less favourably cir-
cumstanccd, is limited to one or other of its more
simple forms, — as the adhesive, suppurative, or
ulcerative.

2. The structure and situation of an organ,
whereby the increase in quantity of the fluids of
nutrition and secretion, which takes place during
inflammation, is either entirely prevented, or very
limited in degree and extent. All secreting organs or
surfaces which possess a free exit to their supera-
bundant fluids, natural or morbid, furnish exam-
pies of this kind ; as the serous and mucous mem-
branes, which, compared with the testes or breasts,
in which the circulating and effused fluids are re-
tained, are rarely the seat of gangrene or spha-
celus as the direct consequences of inflammation.

3. The importance of an organ, whereby death
supervenes before mortification can take place as
a consequence of inflammation. Mortification of
the brain and heart seldom or never occurs, unless
when it follows inflammation produced by the di-
rect operation of mechanical causes. When it
occurs as an idiopathic affection in the brain and
heart, the derangement of function by which it is
accompanied becomes so great not only in these
organs themselves but throughout the whole body,
that general death supervenes, before the inflam-
mation has acquired that degree of severity which
gives rise to local death or mortification.

General phenomena of Gangrene and
Sphacelus^ — As the more remarkable changes
which take place in the circulation, innervation,
temperature, colour, and consistence of a part af-
fected with gangrene or sphacelus, as a conse-
quence of inflammation, are seldom observed un-
less on the external surface of the body, we shall
describe them as they occur in the skin and sub-
jacent parts.

When inflammation is about to terminate in
gangrene, the inflammatory redness assumes a
darker tint ; it becomes deep purple, livid, or
almost black ; the temperature of the part dimi-
nishes, but not always its consistence, which, on
the contrary, may be increased, from the presence
of accumulated fluids ; small vesicles appear on
its surface, formed by the effusion of serosity, or
serosity and blood, under the epidermis; the sen-
sibility of the paTt, which, as well as the tempera-
ture, was previously increased, is now much dimi-
nished, and the seat of the pain which accompanies
the inflammation is transferred to the deep-seated
tissues in contact with those which have now
passed into the state of gangrene.

When these modifications of colour, consistence,
temperature, and sensibility, continue to increase.
and terminate in sphacelus, the part thus affected
assumes a still deeper tint ; it becomes of a dirty
brown or black colour, sometimes grey, greyish
yellow, or greenish. The vesicles or phlyctena
become more numerous and larger, or the whole
of the epidermis covering the sphacelated part
may be completely separated and distended with
bloody serum, or ruptured from the same cause,
and lying in wrinkles in the denuded and dis-
coloured cutis. The skin and cellular tissue be-
neath the epidermis are swollen ant! puffy, and
Crepitate when pressed; or they are soft, and
flaccid, and cold, emd may be cut. pinched, or

MORTIFICATION.

335

otherwise stimulated, without pain or feeling of
any kind being induced : and, lastly, the sphace-
lated surface emits a strong cadaverous odour.
When these latter appearances present them-
i, but more particularly when the peculiar
oilour of gangrene is perceived, they may be re-
garded as certain signs not only of complete death
of the affected part to a certain depth, but also that
putrefaction has already taken place. The local
emphysema and fetor of putrefaction produced
during life, constitute, therefore, signs of great
value in mortification. Their absence, however,
furnishes no proof that local death may not
already have taken place; for putrefaction or
chemical decomposition of an organ may not fol-
low as a consequence of the cessation of those
powers by means of which it was enabled to resist
the injurious influence of external agents, until
some time has elapsed, the length of which will
depend on various circumstances, but more par-
ticularly on the quantity of fluids contained in the
affected organ, and the degree of temperature to
which it is exposed.

So long as gangrene continues to spread, the
dark-red colour by which it is characterized is
diffuse, and loses itself insensibly in the surround-
ing skin. But when it is about to terminate
favourably, the dark-red colour becomes more cir-
cumscribed, gradually disappears, and is replaced
by a brighter red, which extends over the affected
surface, accompanied by a diminution of the swell-
ing and pain. By-and-bye the natural tempera-
ture returns, and the healthy characters and func-
tions of the part are restored, without any solution
of continuity having taken place.

A similar change of colour is observed to pre-
cede the cessation of sphacelus. It appears on
the limits of the dead parts in the form of a narrow
circle, and announces that adhesive inflammation,
the means which nature employs to arrest its pro-
gress, has commenced. Ulceration then takes
place along the internal border of the inflamed
skin, and a separation is thus effected between the
living and dead parts, the latter falling off in the
form of what is called a slough. The loss of
substance which is thus occasioned, is either par-
tially or wholly repaired by means of the coagu-
lable lymph which is thrown out on the denuded
surface, and which, becoming organized, assumes
a membraneous or granular form, according to the
nature of the tissue to be repaired, and constitu-
ting ultimately what is called a cicatrix.

Such are the general characters of mortification
produced by inflammation of the skin and subja-
cent textures. We say subjacent textures, because
inflammation of the former, when such as to pro-
duce gangrene and sphacelus, is always compli-
cated with inflammation of the latter.

In other tissues and organs these phenomena
are, as we have already observed, more or less
modified : the differences which they present de-
pending principally on the degree of vascularity
and sensibility of the affected organ. Hence the
variety observed in the quantity of blood, and the
kind and extent of the effusion by which it is fol-
lowed in inflammatory gangrene and sphacelus ;
the change of bulk which organs undergo in
either of these stages of mortification; the extent
to which their temperature and sensibility may be

reduced before they become actually dead ; and
the length of time that elapses from the commence-
ment to this the ultimate effect of the disease. '
Examples of these varieties will be found in the
following details on mortification of particular
tissues and organs.

Mortification of particular tissues from Inflam-
mation.

1. Mortification of the Cellular Tissue.
— The cellular tissue is not only more frequently
the seat of mortification, but is also more exten-
sively and more rapidly destroyed by it, than any
other tissue of the body. It presents, likewise,
considerable variety in these respects, in different
parts of the body ; gangrene and sphacelus occur-
ring more frequently in the subcutaneous than in
the submucous cellular tissue ; in the fingers more
frequently than in the toes ; in the thigh and arm
than in the leg and fore-arm, owing to the one
being more exposed than the other to external in-
jury, or other exciting causes of inflammation.

A greater quantity of cellular tissue in one part
than in another, whereby the diffusion of the
effused fluids is facilitated, and the presence of
fibrous envelopes which afterwards prevent their
escape to the external surface, contribute likewise
to the greater frequency of the disease, and favour
its extension and the rapidity of its progress. The
most remarkable example of the influence which
these circumstances exercise in the production of
gangrene and sphacelus of the cellular tissue, is
met with in erysipelas phlegmonodes.

a. Subcutaneous cellular tissue. — When erysi-
pelas attacks the subcutaneous cellular tissue of
the extremities, and although it may at first be
limited to a very small space of the forearm, for
example, it sometimes spreads with great rapidity
over the whole of that part of the limb, extends
upwards to the shoulder and neck, and descends
along the back, breast, and side. Throughout the
whole of this course the muscles, blood-vessels,
nerves, and tendons are laid bare, and float in the
putrid cellular tissue, and in the serosity, pus, and
blood, that are effused during the violence of the
inflammation.

Such is the state of the cellular tissue not only
in erysipelas phlegmonodes when it occurs as an
idiopathic disease, but also when it succeeds to
slight wounds or punctures of the arm in blood-
letting, and the fingers in dissection. In such
cases the cellular tissue appears to be the primary
seat of the inflammation, which may either extend
in the manner we have described, or be confined
to the cellular sheath of the blood-vessels. In the
latter case we have frequently what is called phle-
bitis ; the venous circulation is interrupted ; the
blood ceases to circulate, coagulates, and nutrition
not being maintained by the formation of a colla-
teral circulation, gangrene of the extremity follows
as an inevitable consequence.

Besides the diffuse form of gangrene and spha-
celus of the subcutaneous cellular tissue, there is
also a circumscribed form which is observed in
forunculus, common carbuncle, or anthrax. The
great accumulation of blood, and the still greater
and rapid effusion of serosity which takes place in
these circumscribed acute inflammatory affections,
produces a state of extreme induration and com-
pression of the cellular tissue, a greater or less

33G

MORTIFICATION.

portion of which being thus as if strangulated, dies
from want of nutrition, becomes separated from
• the living parts, and is expelled, in the form of a
grey or straw-coloured spongy or pulpy mass,
through an opening made in the skin by a similar
process, by ulceration, or a surgical operation.

In cynanche. parotidea, or mumps, the cellular
tissue of the salivary glands is very similarly situ-
ated as in carbuncle or anthrax. It is this tissue
that is the seat of the inflammation, congestion,
and effusion ; and being prevented by the unyield-
ing nature of the glandular tissue of the organ
from accommodating itself to the increased quan-
tity of the fluids thus poured into it, it soon
sloughs, even sometimes before the glandular tis-
sue has undergone any remarkable change of
colour or consistence, and before suppuration has
commenced.

It may be remarked here that mortification
of the adipose tissue always follows that of the
skin and cellular tissue, and in fat persons occa-
sions sometimes the most frightful loss of sub-
stance.

b. Submucous cellular tissue. — When diffuse or
circumscribed inflammation of the cellular tissue,
terminating in gangrene or sphacelus, occurs in
internal organs, it presents the same general cha-
racters as those we have just now described. In
these, however, it never proceeds to the same ex-
tent as when it affects the external parts of the
body, either on account of the progress of the dis-
ease being checked by one or other of the circum-
stances to which we formerly alluded, or from
death taking place at a very early period.

The diffuse form of the disease in internal or-
gans is seldom observed except in the pharynx
and larynx, either as a primary affection or in con-
nection with erysipelas phlegmonodes of the limbs,
face, or neck.

In these situations the sloughing of the submu-
cous cellular tissue is very limited, and always
accompanied by a corresponding state of the mu-
cous membrane which covers it. The effusions
of albuminous and puriform fluids which take
place at the same time, occasion a great increase
of bulk, and produce dysphagia, great difficulty of
breathing, or complete asphyxia. Hence the fre-
quently fatal termination of the disease before it
has passed into gangrene or sphacelus, and which
has sometimes been described under the name of
serous, albuminous, and purulent oedema of these
parts.

Circumscribed inflammation of the submucous
cellular tissue terminating in gangrene and spha-
celus, seldom occurs as a primary affection. It
follows, in general, inflammation of the mucous
membrane, but may afterwards proceed to a con-
siderable extent, and occasion sloughing of all the
other tunics of the organ in which it occurs, but
more particularly those of the intestinal tube :
such is a frequent cause of intestinal perforation,
and the fatal peritonitis by which it is followed.

c. Sub-serous cellular tissue. — Gangrene of this
tissue as a consequence of inflammation is more
frequently observed than sphacelus. Neither of
them occurs to any great extent, even where this cel-
lular tissue is most abundant, and where it might
be called re/ro-serous rather than sub-serous, as
in the mediastinum, iliac and lumbar regions.

Inflammation assumes a gangrenous termina-
tion more frequently in the sub-peritoneal than in
the sub-pleural cellular tissue. In some forms of
peritonitis, for example, this state is very marked,
although not to be detected by ocular inspection.
It is only after the peritoneal covering of the in-
testine has been divided circularly, and the intes-
tine itself is stretched or pulled out, that the dis-
eased state of this tissue becomes visible. When
thus treated, the intestine may as it were be un-
sheathed, that is to say, drawn out of its peritoneal
covering, the muscular coat now constituting its
external surface.

The great facility with which the sub-serous
cellular tissue is thus torn in some cases of acute
peritonitis, its pulpy softness in some points, and
occasionally a certain degree of foetor, disposes us
to believe that these morbid appearances indicate
a near approach to it, if not an actual state of gan-
grene.

In the cavity of the pelvis, and in the iliac and
lumbar regions, these appearances are more marked
and more easily detected. Not only gangrene but
sphacelus of the cellular tissue is occasionally
found in these regions ; the inflammation which
precedes it being sometimes confined to the cellu-
lar tissue, at others extending to the peritoneum.

Gangrene and sphacelus of the sub-peritoneal
cellular tissue occurs more frequently in the cavity
of the pelvis than in any of the other regions
which we have named, on account of the number
and importance of the organs which it contains.

Chronic and acute diseases of the uterus and
rectum, as cancer and phlebitis, extend their
ravages to this tissue, and excite gangrenous in-
flammation.

External violence, also, is not an uncommon
cause of a similar state of disease in this situation;
and we have known more than one case in which
a blow or fall has occasioned, from the superven-
tion of inflammation in the cellular tissue, exten-
sive destruction of the contents of the pelvis, such
as denudation and necrosis of a part of the sacrum,
gangrene and sphacelus of the neck of the uterus,
and perforation of the vagina.

d. Lamellated cellular tissue, or that which
separates the larger subdivisions of organs. Gan-
grenous inflammation of the cellular tissue of
muscular, glandular, and other organs, is less fre-
quently observed than the former as a primary
disease. It is only in certain of these organs,
particularly the muscles of voluntary motion and
the lungs, that we can detect with certainty its
existence as a primary affection. We shall notice
its occurrence in the latter only, on account of
the peculiar character of the lesion to which it
gives rise in this organ. A distinct layer of cellu-
lar tissue separates, one from the other, the
numerous lobules of which the lung is composed.
Either of these— the interlobular cellular tissue,
or the lobules themselves — may become the spe-
cial seat of gangrenous inflammation.

When a portion of lung is examined, in which
the interlobular cellular tissue is alone or princi-
pally affected, it presents a number of lines of
considerable breadth, of a straw-colour, having the
peculiar distribution of the lobules, and formed by
the effusion of pus into the cellular tissue by
which they are separated. In this stage o' the

MORTIFICATION.

337

inflammation, the cellular tissue is cither very
soft or easily ruptured, and when sphacelus takes
place, is converted into a grey pulp, in which one
or several lobules float, attached only by a narrow
peduncle composed of their respective blood-ves-
sels and bronchi obliterated.

2. Mortification of Mucous Membranes.
— Although inflammation of the mucous mem-
branes is not unfrequently observed to terminate in
gangrene and sphacelus, such is by no means so
frequently the case as was imagined by the older
pathologists. Great congestion, some forms of
melanosis, and several other kinds of discoloration
of this tissue, produced not only during life but
after death, were frequently confounded by them
with mortification. The mucous membrane of
the throat and intestines is more frequently the
scat of this disease than that of any other organ.

In the former it is occasionally met with to a
limited extent in cynanche tonsillaris and pha-
ryngca, and constitutes the distinctive anatomical
character of cynanche maligna or angina gangre-
nosa, whether it occurs alone or in connection
with scarlatina.

In the latter it follows as a consequence of
certain forms of acute enteritis, either when the
inflammation affects the mucous tissue itself, or
its follicular structure at the same time.

In either of these situations the mucous and
follicular textures are primarily affected, and may
be converted into sloughs of considerable extent,
without the submucous cellular tissue being
destroyed.

Thus deprived of their vitality, the mucous and
follicular textures are, at first, of an ash-grey or
straw-colour, and may afterwards become brown
or black. They arc, however, frequently of the
colour of the matter with which they are in con-
tact : the fluid part of which is readily imbibed
by the soft, spongy tissue of the slough.

The mucous membrane which surrounds the
slough is generally gorged with blood, indicating
either a state of great congestion, or gangrene.
Its colour, particularly in the throat, is livid or
deep purple. When, however, the gangrenous
inflammation is confined to the follicles, as those
of Peyer (glandula; agminate), and when the
greater part or the whole of the follicle has
sloughed, little congestion or inflammatory red-
ness may remain. And, besides, if these glands
have previously been the seat of disease, as in
tubercular phthisis or chronic enteritis, a slight
attack of acute inflammation may be sufficient to
destroy their vitality, without any remarkable in-
crease of vascularity or redness being found in
them to indicate the nature of the destructive
cause.

In this, as well as in many other cases of the
same disease in other parts of the body, the state
of sphacelus must be determined by the colour,
consistence, and smell of the part, taken in con-
nection with the other collateral negative evidence,
afforded by the absence of any other cause capable
of producing such a state.

On the inside of the cheeks, the surface of the
velum and amygdala and pharynx, the presence
of circumscribed portions of inspissated mucus, or
small patches of coagulated albumen or lymph,
formed on the surface of the mucous membrane

Vol. III. — 43 2n

or epithelium, may likewise be confounded with
sphacelus. Detached portions of the epithelium
may also assume the appearance of sloughs of the
mucous membrane.

Gangrenous inflammation of the mucous mem-
brane of the air-passages is by no means common,
unless it be accompanied by a similar disease of
the pulmonary tissue, in which case it is generally
confined to the smaller bronchi. We have, how-
ever, seen it follow perforation of the trachea from
malignant disease of the oesophagus, and necrosis
of the thyroid cartilage, to which we shall refer
more particularly afterwards.

The mucous membrane of the genital and uri-
nary organs is seldom affected with mortification,
unless it has been previously injured by mechani-
cal causes, as in some cases of stone of the blad-
der and kidneys, in lithotomy, stricture of the
urethra, and difficult labour, by the improper use
of instruments, and also the pressure of the head
of the child, to which we shall afterwards refer
more particularly, as belonging to another division
of our subject.

Of these two systems of organs, the uterus pre-
sents the most marked examples of mortification
as an immediate consequence of acute inflamma-
tion. It attacks the internal surface of this organ
either immediately or shortly after delivery ; is
confined to a small portion of it, particularly to
that which gave attachment to the placenta ; or
occupies its whole extent. The colour of the
part affected is of a dirty yellowish grey, brown,
black, sometimes greenish or bluish ; it feels soft
or spongy, is easily torn, and is generally covered
with putrilaginous fluid substance of a strong gan-
grenous odour. When this substance has been
removed, the surface is generally found to be
rough and irregular, from the presence of the re-
mains of the placenta, and more frequently from
an exudation of fibrinous matter, which we have
sometimes found to cover the whole surface from
the fundus to the os tines.

The substance of the uterus is sometimes af-
fected in this manner to a considerable depth, but
is more frequently only softened, without having
undergone any remarkable change of colour. The
presence of pus in the fibrous structure of the
uterus is seldom observed beyond the gangrened
or sphacelated surface, but is frequently met with
in the veins and lymphatics. The appearances
which we have described as occurring in gan-
grenous inflammation of the internal surface of
the uterus present considerable variety, owing, ap-
parently, to differences in the seat and extent of
the inflammation, and the period at which it
proves fatal. But as the investigation of these
and other circumstances connected with the patho-
logy of this important subject does not come
within the scope of this article, we must refer the
reader for further information to the articles Puer-
peral FEVER-and Uterine Phlebitis.

3. Mortification of Serous Membranes.

The few general remarks which we have made on
gangrene and sphacelus of the sub-serous and
retro-serous cellular tissue, show that the same
morbid states must occur in the serous membrane
itself. For as the bloodvessels of this membrane
are principally, if not entirely, derived from those
of the cellular tissue with which it is in immc-

338

MORTIFICATION.

diate contact, any disease capable of arresting the
circulation in the vessels of the latter, must be
followed by a similar result in those of the former,
the portion of which so circumstanced being soon
deprived of its vitality. This is, in fact, the mode
in which serous membranes become affected with
gangrene or sphacelus. It is not from their being
loaded with blood, under the stimulus of inflam-
mation, that they die and are separated, but from
the supply of their nutritive fluid having been cut
off, on account of the morbid condition of the cir-
culation in the cellular tissue to which we have
just alluded, or from this tissue having been de-
stroyed by suppuration, ulceration, or sphacelus.
Sloughing of the serous membrane occurs from
one or all of these morbid states, the immediate
or subsequent effects of inflammation, and is often
followed by a solution of continuity which esta-
blishes a communication between the serous cavity
and that of the neighbouring organ ; such as be-
tween the cavity of the peritoneum and that of
the stomach, intestines, uterus, kidneys, and gall-
bladder, or between the cavity of the pleura and
bronchi. The contents of these organs are effused
into the serous cavities, and excite a degree of in-
flammation which is seldom equalled either in the
rapidity of its progress or the certainty with which
it destroys life. The inferior portion of the small
intestine is the seat and source of these fatal
changes of structure much more frequently than
any other portion of the digestive tube, or any
other organ of the body. And, besides, sloughing
of the peritoneum perhaps never occurs under the
circumstances we have already mentioned, except
in the situation of the glands of Peyer, or occa-
sionally in those of Brunncr. Inflammation of
these glands is extremely common in various dis-
eases of the digestive organs, and whether acute
or chronic, may give rise to the same fatal result,
viz. perforation of the intestine and peritonitis.
(See Perforation of Ougajjs.)

The colour of the sphacelated serous membrane
is generally of an ash-grey, sometimes ochrey
from the presence of bile or blood. It is soft and
spongy, and frequently does not present any pe-
culiar smell. Before it separates, the sub-serous
cellular tissue around it is frequently seen injected
with fine red capillaries ; occasionally, also, all
the tunics of the intestine are pale, and the acci-
dental opening appears as if it had been made by
excision. But the external border of the opening
is always smooth, although irregular, whilst on
the internal surface of the intestine it is rough or
ragged, or presents other marks of being ulcerated.

A dark brown, dark blue, or black colour of
the peritoneum, extending over a considerable
portion of its surface, has frequently been de-
scribed by older authors as indicating the presence
of mortification of this membrane. These disco-
lorations, however, depend on causes very different
from those which give rise to mortification, and
the nature of which is particularly noticed in the
article Melanosis.

Gangrene and sphacelus of the pleura take
place under circumstances very similar to those
which produce them in the peritoneum. Slough-
ing of the pleura is, however, by no means so fre-
quent as that of the peritoneum, as a consequence
of inflammation of the sub-serous or pulmonary

tissue. This is owing, in the first place, to the
pleura pulmonalis receiving a superior supply of
nutritive material from the highly vascular tissue
of the lungs, as well as from the interlobular cel-
lular tissue with which it is continuous ; and in
the second place, from its not being so exposed as
the peritoneum, when laid bare, to the operation
of highly stimulating fluids.

Gangrenous inflammation of the pulmonary
tissue is, next to the presence of tubercle, the
most frequent cause of perforation of the pleura
pulmonalis from sloughing.

The presence of air and other fluids in pneu-
mothorax and empyema have been known, either
from their stimulating qualities, or the mechanical
distension which they occasion, to produce gan-
grene and sphacelus to a considerable extent, of
both pleura? ; and the violent inflammation which
follows some mechanical injuries is well known to
produce a similar effect.

Sloughing of the serous membranes of the brain
we have never seen as an immediate consequence
of their inflammation ; nor do we believe that it
ever occurs to any extent, unless it is induced by
a mechanical cause, such as wounds and blows on
the external surface of the head, or the presence
of foreign substances in the brain itself. The
same may be said of synovial membranes.

4. Mortification of Fibrous Membranes,
— We have already stated that these membranes
become deprived of their vitality, slough, and are
separated, only when the cellular tissue with
which they are in contact has previously been de-
stroyed. The death of cartilage and bone, as
fibrous tissues, takes place in a similar manner,—
that is to say, from previous disease of the peri-
chondrium or other contiguous tissue, and of the
periosteum. It is, however, worthy of remark,
that the vascular system of the medullary mem-
brane, particularly of long bones, may be the pri-
mary and chief seat of the disease, which after-
wards gives rise to necrosis and sphacelus of the
periosteum. We allude here to phlebitis of the
medullary membrane, which succeeds to amputa-
tion and some external injuries ; and, although
belonging, in this case, to the province of surgery,
it is more immediately connected with medicine,
and the duties of the physician, than might, at
first sight, be believed. For it is of importance,
not only in a surgical point of view, to know that
such is the nature of the inflammation which
often follows amputation and some diseases of
bone, but also as regards the diagnosis and treat-
ment of the diseased states to which it so fre-
quently gives rise in internal organs. Thus, we
have not only purulent infiltration in the lungs,
liver, brain, &c, but, in some cases, also gangrene
and sphacelus, particularly in the two former of
these organs, as consequences of phlebitis of the
medullary membrane of bone.

5. Mortification of Muscular Tissue.—
Inflammation of muscular tissue seldom termi-
nates in mortification, unless produced by an in-
jury which affects at the same time other neigh-
bouring tissues. Gangrene and sphacelus of the
muscular tissue of the organs of deglutition and
digestion, and perhaps of the heart, sometimes
accompanies similar states, or severe inflammation
of the other tissues with which it is in contact,

MORTIFICATION.

339

but particularly of the cellular tissue. The loss I
of substance, thus occasioned, of the muscular
tissue in a hollow organ such as intestine, becomes
afterwards a serious, and, perhaps, irremediable
evil ; for muscular tissue not being reproduced, a
cicatrix, equal in extent to the loss of substance
sustained, is formed, which, possessing a contrac-
tile property, gradually diminishes in bulk, and
ultimately constricts, even to complete obliteration,
the cavity of the tube in which it exists. Such
instances are not rare in the small intestines after
fever, and the writer possesses a delineation of a
case in which there were three strictures of the
small intestine, through which only a small probe
or writing-quill could be passed.

We have not seen a case of gangrene of the
heart, unless some forms of softening, to which
this organ is liable, are to be regarded as of this
nature. (See Softening of Organs.)

Gangrene and sphacelus of arterial and venous
tissues may be noticed here, from the functional
connection which exists between them and the
heart. They are observed more frequently in the
latter than in the former tissue, but do not occur
in either until after the cellular sheath of the ves-
sels has been destroyed.

When gangrene or sphacelus of the spleen is
observed, it is found to follow external injury, fol-
lowed by peritonitis, or, as it is believed by some,
a morbid state of the blood, with which it is in
general greatly distended, as in severe cases of
some intermittent and remittent fevers of marshy
countries. The appearances, however, which this
organ presents in these fevers is, perhaps, in a
great measure owing to putrefaction.

3Ior(iJicat ion of particular Organs from Inflam-
mation.

Having pointed out what appears to be the
most important of the circumstances observed in
mortification of the elementary tissues of the body,
we shall now proceed to describe those which pre-
sent themselves when this disease takes place in
organs. In doing so, we shall confine ourselves
to the consideration of mortification of what is
called the parenchyma of organs, or what in more
precise language may be called the compound tis-
sue of organs, — the result of a peculiar combina-
tion of the simple or elementary tissues.

We have already remarked that the frequency
of mortification, the extent to which it proceeds,
and consequently its severity, are, cscteris paribus,
in proportion to the quantity of the cellular and
vascular elements which enter into the composi-
tion of an organ. In this point of view no organ
of the body is so conspicuous as the lungs, and in
none does mortification occur so frequently, or
proceed to such an extent. Being exposed, too,
to the direct influence of a great number of those
agents which excite inflammation, as well as to
the injurious operation of those causes which pro-
duce, mechanically or otherwise, great derange-
ment of the circulation in general, the frequency
of the occurrence of mortification in this organ is
very considerably increased. For these reasons,
and because of the characters of the disease being
particularly well marked, we shall commence with
the description of mortification of the pulmonary
tissue.

1. Mortification of the pulmonary tissue,

[Gangrene of the Lung, Necropneumonia.~\ —
Although inflammation of the pulmonary tissue is
extremely common, it does not frequently termi-
nate in mortification. It is, however, highly pro-
bable that inflammation of this tissue proceeds
frequently the length of the first stage of mortifi-
cation of gangrene, without our being able to take
cognizance of it during life, or, in a great many
cases, to detect it after death.

[Of 305 cases of pneumonia, analyzed by M
Grisolle (Traite Pratique de la Pneumonie,
Paris, 1841), not one ended in gangrene ; and of
75 cases of pulmonary gangrene, described in
the Medical Journals, not more than 5, at the
most, according to the same observer, could be
fairly pointed out as the sequence of pneumo-
nia.]

At one period of the history of pathological
anatomy, mortification of the lungs was recorded
as a common occurrence. The fallacy of this
statement was pointed out by Laennec, who con-
sidered gangrene (used by him in the sense in
which we have employed mortification) as rather
a rare disease ; but it is by no means so rare as
this distinguished author was disposed to believe.
He states, in his work on " Mediate Auscultation,"
that he had only met with two examples of it in
the course of tWenty-four years, and that he knew
of only five or six cases of it that had occurred
in the Parisian hospitals during the same space
of time : we ourselves have seen twice the num-
ber of cases in the same hospitals, during a period
of not more than three or four years.

[The disease is certainly not so frequent as is
usually imagined. It does not often occur in
private practice, but in eleemosynary institutions,
into which those of broken-down constitutions are
freely admitted, it is often seen. In the Philadel-
phia Hospital, in the nine months prior to August
1838, four cases were admitted, all of which ter-
minated fatally. " It is a disease," says Dr.
Craigie, " the presence of which it is difficult to
distinguish, in the early stages, from that of other
diseases of the lungs ; its determining causes are
totally unknown, and it is not known that in any
genuine instance of it the patient has made a re-
covery."]

When, as a consequence of inflammation, the
pulmonary tissue is affected with gangrene, its
colour becomes of a deep red, approaching almost
to black, whilst its consistence equals that of
hepatized lung or liver. When pressed, it breaks
down between the fingers like a portion of hepa-
tized lung when similarly treated, but instead of
pus, there oozes out from it blood and a dirty
white or greenish fluid of the consistence of milk
or treacle, having a vel^r disagreeable odour.

When decomposition has taken place through-
out the whole of the affected part, or in other
words, when the state of sphacelus is produced,
the pulmonary tissue seen under the pleura appears
sunk beneath the surrounding surface, presents a
dirty white, yellowish grey, brown, or greenish
black colour, and frequently, when extensive, a
mottled aspect, in which all these tints are per-
ceived ; it feels flaccid and pulpy, and, when cut
into, appears as if converted into a putrid sanies,
in which shreds of pulmonary tissue and blood

340

MORTIFICATION.

vessels float or lie detached, and which diffuses
around the most insupportable odour of sphacelus.
Complete death of the pulmonary tissue may
take place in several points of the same lung at
the same time, but in such cases it is limited in
extent, and is much more frequently the result of
a septic agent than of inflammation. It is when
it is confined to one point that it has been found
to extend so as to occupy the fourth, the half, or
even the whole of a lobe.

In both cases the sphacelated substance may be
limited all round by the adhesive inflammation, or
it may be confounded with a gangrenous state of
the neighbouring tissue. In the first case we have
what is called uncir cum scribed [or diffuse] , in
the second circumscribed mortification. The more
extensive, however, the state of sphacelus, the
more rarely do we find adhesive inflammation to
have taken place.

In the circumscribed and multilocular form of
sphacelus, we have sometimes found it confined
to one, two, or a very limited number of lobules,
the line of separation between the healthy and
diseased parts being distinctly marked by the in-
terlobular cellular tissue. In this form of the di-
sease, therefore, we are disposed to believe that
the gangrenous inflammation commences in, and
is confined to, the pulmonary tissue ; whereas in
the uncircumscribed and diffuse form it attacks
both the pulmonary and interlobular at the same
time.

The circumscribed and multilocular form of
sphacelus just described may have its seat deep in
the substance of the lung, or immediately under
the pleura. In the first case one or more of the
bronchial tubes are perforated, and thus afford an
exit to the dead pulmonary tissue, which is gra-
dually discharged by expectoration. In the se-
cond case, besides this salutary mode of evacuation
of the sphacelated part by perforation of the
bronchi, there is another which frequently takes
place, and becomes the immediate cause of death,
viz., perforation of the pleura. We have already
said that sphacelus of the pleura pulmonalis, when
a consequence of inflammation, depends on the
previous destruction of its sub-cellular and pul-
monary tissue, on account of its nutrition being
derived from the vessels of these tissues. Spha-
celus of either, therefore, is followed by sphacelus
of the pleura, which then presents an appearance
similar to a portion of skin destroyed by the
cautery or caustic potass. When the slough thus
formed is separated, or merely ruptured by the
pressure of the fluids or air beneath it, a commu-
nication is established between the cavity of the
pleura and that produced by the destruction of
the pulmonary tissue : one of two consequences
then follow ; viz., acute pleurisy alone, or pleurisy
combined with pneumothorax. In the first case
the gangrenous excavation communicates only
with the cavity of the chest ; in the second, with
this cavity and the bronchi at the same time. It
is this latter condition of parts which enables us
to explain the formation of pneumothorax in this
disease, although in some rare cases a gaseous
product has been found without perforation of the
bronchi, and which appeared to have been the
product of decomposition.

When circumscribed sphacelus is not immedi-

ately followed by a fatal termination, the lung is
found some time after to contain a certain num.
ber of excavations of an ulcerous character, the
nature and origin of which were cither imperfectly
or not at all understood, until investigated by
Laennec*

[In all the cases of gangrene of the lungs that
have fallen under the author's observation, the
subjects were addicted to spirituous liquors. The
only pathognomonic symptom, as has been observed
by Dr. Stokes (on Diseases of the Chest, Amer.
edit., p. 324, Phil. 1844), is the extraordinary and
disgusting odour of the breath and expectoration,
which is generally constant, but in some cases
may not be readily appreciated unless the patient
is made to cough.

The treatment consists in the employment of
the chlorinated preparations internally, or of
chlorine by inhalation, — in allaying irritation by
opium, and supporting the patient by wine-whey
and nourishing diet]

2. Mortification of the Iiiver. — Mortifka-
cation of the substance of the liver is an ex-
tremely rare occurrence as a consequence of in.
flammation ; so rare is it indeed, that we have
not met with a single well-marked case of it in
the course of twelve years, during which period
the writer has been in the almost daily habit of
inspecting the bodies of the dead, and of exam-
ining with care every organ of the body. Nor
does it appear that it is a more frequent occur-
rence even in warm climates, where the liver is
so often the seat of acute inflammation. " Gan-
grene," says Annesley, " has been remarked by
many writers and teachers as one of the termina-
tions of acute inflammation of the liver; but al-
though we have observed this disease, and made
post-mortem examinations of it, the number of
which 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 which have been
taken for gangrene have been merely that black,
congested, and softened state of the organ which
is sometimes observed in the more acute attacks
of 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 as a termination
of the disease. "f

3. mortification of the Kidneys. — Gan-
grene and sphacelus of the substance of these
organs is very rarely met with, unless the exciting
cause has been of a mechanical or chemical nature:
we shall therefore defer what we have to say on mor-

* See Traite de l'Auscultation Mediate, &c. vol. i. P-
445; and the article Ulceration in this work.

t Annesley on the Diseases of India, &c., vol. i., p.
434. The explanation given by the author of the ap-
pearances to which lie refers may be correct, that is to
say, that they may have been produced after death; but
that any disease can " run into gangrene after death,"
is what we cannot admit without confounding together
opposite phenomena, and the limits which language bM
established between them. Gangrene, being the decom-
position of a living tissue, can only take place in a body
that is not dead. Putrefaetion is the term which the
author should have employed, and is used in contradis-
tinction to that of gangrene, to denote the decomposi-
tion winch takes place in dead animal matter.

MORTIFICATION.

341

tification of the kidneys until we come to consider
the influence of these agents in the production of
this disease.

The testes and mammx are occasionally affected
with gangrene and sphacelus as the consequences
of inflammation or mechanical violence, and both
organs are sometimes so extensively destroyed as
to be rendered unfit for the accomplishment of their
important functions : but as the treatment of mor-
tification of these organs requires the skill of the
surgeon, we shall not enter into the description
of its pathological characters as it occurs in them.

There now remains to be described, mortifica-
tion of the lymphatic and salivary glands, and
of the brain and nerves. In neither of these com-
pound tissues, however, is this disease observed
(unless in some very rare instances, and then
limited in extent,) as a" consequence of common
inflammation. The former are not unfrequently
affected with this disease, where they are super-
ficially seated, and where they are exposed to the
influence of certain putrid and septic substances
carried into them by absorption, and to which we
shall refer in another place. The latter have sel-
dom presented any traces of gangrene or sphace-
lus except in cases of external injury, pressure, or
ligature.

To render the enumeration of the tissues sub-
ject to death from inflammation complete, we may
also mention the teeth, hair, and nails. Inflam-
mation of the capsule, bulb, or roots of these bo-
dies, is frequently followed by their decay and
entire separation.

State of the Vascular System in Mortifi-
cation. — Were we to confine our observations to
the changes which take place on the external sur-
face of organs affected with inflammation termin-
ating in mortification, as we have done in the pre-
ceding pages, we should form a very imperfect
idea of the real nature of this disease. In this as
well as in every other morbid state, we must look
into the interior of the affected organ, examine
the several elements of which it is composed ; de-
termine the changes that have taken place in each,
the order of their succession, and, as far as it may
be possible, the influence which they exercise in
the production of the various phenomena of the
disease. The interesting experiments and anato-
mical and microscopical investigations which have
been made by several distinguished pathologists
on this part of our subject, will enable us to give
satisfactory information on several of these import-
ant points.

When the transparent part of an animal, such
as the web of the frog's foot or mesentery of the
rabbit, is placed under the microscope, and sub-
mitted to the stimulating influence of a mechani-
cal or chemical agent, the capillary vessels of the
part, as well as the blood which under these cir-
cumstances flows into them, are seen to undergo
a regular series of changes, referable to the hydrau-
lic and dynamic conditions of both, and which
constitute the pathological state of a part, called
inflammation.

Without entering into the details connected
with this interesting subject, it will be sufficient
for our present purpose to slate that when inflam-
mation has arrived at what Kaltenbrunner calls
its perfect state, that is to say, when the capilla-

2d*

ries are distended with blood which has ceased ra
circulate, that part from a deep red soon changes
to a dark brown or black colour.

Cessation of the circulation, coagulation, and
discoloration of the blood, are the successive
changes which announce that the functions of the
inflamed part are about to cease. The change of
colour which takes place is found to depend
chiefly on a corresponding and similar change in-
duced in the blood contained in the vessel of the
affected part, or that has been effused during the
inflammatory excitement. Soon after the stagna-
tion of the blood, the globules of this fluid are
seen to unite, adhere to the internal surface of the
vessels, and form a solid dark-coloured mass oc-
cupying their whole calibre. The sensibility e*
the part rapidly diminishes after the coagulation
of the blood, although the nerves themselves are
not observed to undergo any perceptible change.
The coagulation of the blood is also followed by
the cessation of absorption, for the most active
poisons introduced into a part, the vessels of which
are thus obliterated, either produce none of the
effects which are peculiar to them, or do so very
tardily and ineffectually, in which latter case they
may have found their way beyond the obliterated
vessels by imbibition. Under these modifications
of function, after a certain length of time nutrition
ceases in the affected part, the temperature of which
sinks to that of external objects. Its consistence
diminishes so soon as decomposition commences,
and the colour which it assumes varies with the
quantity and quality of the fluids it contains, and
the chemical changes which these undergo from
the action of the gaseous products of decomposi-
tion. Death or mortification of a portion of the
body succeeding to inflammation, we therefore
regard as an immediate consequence of cessation
of the circulation, of which we have examples on
a large scale, in ligature and spontaneous oblitera-
tion of the principal artery of a limb, unaccompa-
nied by the establishment of a collateral circula-
tion.

The state of the vessels, and of the blood which
precede the physical signs of mortification, may be
regarded as representing that state of a part which
we call gangrene. The blood has ceased to circu-
late, it is even coagulated ; the application of arti-
ficial stimuli to the neighbouring tissues, furnishes
no evidence of their possessing sensibility or con
tractility. Yet, as under these circumstances we
know that actual death may not have taken place,
that the blood may resume its fluidity and circu-
late anew, and sensibility and contractility again
return, the state to which we have alluded may
properly be regarded as furnishing us with what
may be called the anatomical and physiological
characters of gangrene, — a state in which the
functions of a part are suspended, analogous to
that of the whole body in asphyxia, but not de-
stroyed, whether we regard it as susceptible of re-
covery, or as an intermediate state which separates
inflammation from mortification.

When the recovery of a part from the state of
gangrene is about to commence, circulation be-
comes more active all round the circumference of
the diseased part ; the coagulated blood gradually
disappears by the separation of its globules, and
their transmission into the neighbouring currents;

342

MORTIFICATION.

absorption is manifested by the more or less rapid
removal of the effused fluids, sensation and motion
return, and the part is restored to the healthy
state.

We have already enumerated the changes which
mark the transition from gangrene to mortification.
The separation of the dead part takes place within
limits fixed by the state of the vascular system.
Thus, the line of demarcation between the dead
*nd the living parts does not extend beyond the
obliterated vessels ; for before adhesive inflamma-
tion has taken place, they are found obliterated to
a greater or less distance beyond the mortified
part. Their obliteration is not necessarily the
consequence of the effusion of coagulable lymph.
It depends on the plastic property of the blood
contained within the vessels, which unites with
their living membrane, becomes organized, and
thus secures their permanent obliteration.

Obliteration of the blood-vessels, as the cause
of mortification of the kind of which we are now
treating, is a subject deserving of the most serious
consideration both of the surgeon and physician.
For it is to this state alone of the blood-vessels in
the vicinity of the dead part that immunity from
one of the most dangerous consequences of the
disease, viz. hemorrhage, is to be ascribed. The
presence of coagulable lymph, its organization
and union with the parts into which it has been
effused, constituting what is called adhesive in-
flammation, contributes no doubt to prevent he-
morrhage during the process of separation of the
dead part, or of sloughing. But we are disposed
to believe that it is the prevention of hemorrhage
from the smaller vessels only that is secured by
the adhesive inflammation, while that from the
larger ones is prevented by the previous coagula-
tion of the blood contained within them. That
it is to the coagulation of the blood in the large
vessels of a limb that we must attribute the non-
occurrence of hemorrhage after sloughing, is ren-
dered still more obvious from what occurs in
some cases of extensive and spreading gangrene, of
the inferior extremity for example, and to arrest
which it is found necessary to have recourse to
amputation. The limb is removed, but the large
blood-vessels yield little or no blood ; they are, in
fact, obliterated by firm coagula. There is no
adhesive inflammation present in such cases, and
gangrene and sphacelus succeed to the operation,
because of the vessels not having been divided
above the point at which they were obliterated.

Such is the state of the large blood-vessels
which we have found to accompany sphacelus
without hemorrhage. When, on the contrary,
hemorrhage occurs in this stage of mortification,
these vessels are found pervious, and filled with
fluid or imperfectly coagulated blood ; and the
cellular and other tissues are more or less infil-
trated with serosity, sero-sanguinolent, and puri-
form fluids.

Termination of Mortification. — We have
already enumerated the most important and con-
spicuous local effects of mortification of tissues
and organs, such as changes in colour, consist-
ence, sensation, motion, temperature, and bulk,
to which we might add those of form, in conse-
quence of loss of substance of various extent.

The solution of continuity which follows the

separation of the dead part may, if formed in the
substance of a solid organ, be followed by ulcera-
tion, instead of being repaired by granulation or
the organization of coagulable lymph ; or it may
be followed by perforation, if the solution of con-
tinuity takes place in the walls of a hollow organ,
as the intestine, or on the surface of a solid organ,
as the lungs, — a termination of sphacelus to
which we formerly alluded.

When the dead part is separated, and the af-
fected organ is seated internally, it may either be
retained for an indefinite period, or it may be al-
most immediately expelled through the natural
passages, such as the bronchi, trachea, intestines,
&c. The dead substance is thus sometimes eva-
cuated entire, as in the case of sloughing of a
portion of intus-suscepted intestine, and in some
rare cases of partial gangrene of the lungs. In
parenchymatous organs, however, the dead portion
is much more frequently broken down into shreds
by a species of maceration in the surrounding
fluids before it is ejected, and is then accompanied
by a greater or less quantity of these fluids at the
same time.

Signs and Symptoms of Mortification. — T
determine the existence of mortification of an in-
ternal organ is, in the great majority of cases,
beyond the power of the physician. The evi-
dence which he is enabled to collect from the
modifications which take place in the functions
of the affected organ, from the state of some par-
ticular system or of the economy in general, is
frequently far from being sufficient to warrant
him in giving a decided opinion on the existence
of this disease. Besides, the derangements of
function to which it gives rise are, in some cases,
either so slight as not to be recognised, or of suck
a kind as not to be distinguished from others pro-
duced by very different morbid states. Nor can
we fix any determinate relation between the ex-
tent of the disease and the severity of its effects,
such, at least, as are made manifest to us through
the medium of functional derangement. These
remarks apply equally to both stages of mortifica-
tion, and to the kind and degree of inflammation
by which they are preceded. With regard to the
latter, it is well known that mortification, and that
too of the lungs, may succeed tc- inflammation so
slight as not to have induced a degree of indispo-
sition sufficient to excite the attention of the pa-
tient, far less to induce him to apply for medical
advice. In such cases it is sometimes not until
sphacelus has taken place, when the presence of
a cavity can be detected by means of the stetho-
scope, and the contaminating influence of the
putrid fluids has already commenced, that the ui»
fortunate patient sends for assistance, or finds hi
way to an hospital.

There are certainly no gtnera symptoms which
can be considered as the exclusi.e effects of eithet
state of mortification. The violence and extent
of the inflammation by which mortification may
be preceded, may lead us to fear such a termina-
tion, but cannot enable us to detect it when it has
occurred, even when those symptoms — sudden
prostration and sinking of the powers of life —
and to which so much importance has been at-
tached, are present. Inflammation alone giv"
rise to these fatal symptoms in persons naturally

MORTIFICATION.

343

feeble, and in those in whom innervation and nu-
trition in general are so modified by previous ex-
cess or privation, as to give to diseases, the most
insignificant in themselves, that peculiar assem-
of character generally known under the
appellation of adynamia.

We have already enumerated, at the com-
mencement of this article, the more common and
obvious conditions of organs which, independ-
ently of the general conditions which we have
just named, favour the production of mortifica-
tion, when these organs are attacked with inflam-
mation. We refer the reader to what we have
said on this part of our subject, as furnishing ad-
ditional evidence in favour of the opinion we have
given regarding the difficulty of determining the
existence of mortification by the manifestation of
any particular modification of function of the organ
in which it has taken place.

Although we reject, as a sig?i of mortification,
the sudden occurrence of prostration and sinking
of the powers of life in general, succeeding to in-
flammation, we must nevertheless regard these
phenomena as of great and serious import in such
cases, inasmuch as they indicate that the progress
of the disease is not arrested, and that by means
of absorption the system in general has been
brought under the poisonous influence of the de-
composed and putrid fluids of dead animal matter.
These symptoms, which we attribute to the ab-
sorption of dead animal matter, are of course
common to mortification from inflammation as
well as from other causes.

The state of the pulse in persons affected with
mortification of an. internal organ is very various.
If the previous inflammation has been slight, it
may not have been much increased in strength or
quickness, and may retain this state after the oc-
currence of sphacelus, and till near the period of
dissolution, when it rapidly sinks, and becomes
remarkably slow, feeble, and sometimes intermit-
tent. If the inflammatory excitement accompa-
nies the state of sphacelus, the pulse may continue
quick, but it is feeble and easily compressed, and
always sinks before death. The temperature of
the skin is generally morbidly increased at the
commencement, but becomes less than natural
towards the termination of the disease, when the
surface is often cold and covered with a clammy
sweat. At the same time the tongue and teeth
become covered with sordes, the breath frequently
exhales a fetid odour, and there is occasionally
singultus, low delirium, and picking of the bed-
clothes, or a state of stupor terminating in coma ;
the countenance assumes a cadaverous aspect,
and the whole body as well as the evacuations,
which are sometimes involuntary, give out the
most offensive fumes, impregnated with the stench
of dead and putrid animal matter. In this state
the patient dies unconscious, and generally with-
out a struggle. These, the general effects of the
absorption of the putrid fluids of sphacelated tis-
sues, are not always so conspicuous; nor do they
proceed in all cases to a fatal termination with
the same degree of rapidity. When they assume
the aggravated form just described, life is seldom
prolonged beyond the third, fifth, or seventh day.
But when they are marked chiefly by a state of
prostration, a quick, feverish, and feeble pulse, a

hot skin, and an offensive smell of the secretions,
the course of the disease may be prolonged to the
second or third week, when it terminates as before
described : it is only in this form of the disease
that recovery has been known to take place.

The odour of gangrene, as it is commonly
called, is perhaps the only pathognomonic sign of
the existence of mortification. We have alluded
several times to the presence of this odour in the
breath of the patient and in the secreted and ex-
creted fluids, as an almost constant sign of the
contaminated state of the blood in the last stage
of mortification. But the gangrenous odour to
which we at present allude is that derived imme-
! diately from the affected organ, and which may,
with few exceptions, be regarded as the only sign
of the local existence of sphacelus to which we
can attach a positive value. We need hardly re-"
mind the reader that it is not, however, present in
every case of sphacelus ; — that it is only either in
those cases in which a communication exists
naturally between the external surface of the
body and the sphacelated tissue, or in those in
which a preternatural communication has been
established in consequence of the disease itself,
and through which the putrid effluvia are dis-
charged into natural canals, as in perforation of
the bronchi and intestines from without inwards ;
or on the surface of the body, in perforation of
the walls of the chest and abdomen in the oppo-
site direction.

We have seldom an opportunity of detecting
the putrid odour of sphacelus, unless when this
disease occurs in the lungs, the digestive organs,
the urinary organs in the male and female, and
in the organs of generation in the latter. When
present in the breath, it is necessary to discover
its source, as it may have its origin in the mouth,
pharynx, oesophagus, or stomach, or in the larynx,
trachea, or lungs; this may be easily accomplished
by submitting each of these portions of the diges-
tive and respiratory apparatus to a separate ex-
amination. It may not be unimportant to ob-
serve that extensive sphacelus of the stomach, or
rather of accidental tissues formed in this organ,
may occur, without the eructations with which it
is often accompanied, or even the fluids then
ejected by vomiting having any the slightest de-
gree of putrid odour: a circumstance which we
attribute to the property which the gastric acid
possesses of removing the tainted smell of animal
substances.

Much importance is not to be attached to this
character of sphacelus when perceived in the al-
vine evacuations. We have already stated that
the excreted fluids acquire this particular odour
in consequence of the absorption and the subse-
quent separation from the blood of the putrid
animal matter; consequently the presence of this
odour in the dejections may be entirely owing to
the elimination of these fluids by the mucous
membrane of the intestines from the blood. It
may indeed be laid down as a rule, that unless
this odour in the alvine evacuations be accompa-
nied by the presence of portions of the intestine,
or rather of the mucous membrane of the intes-
tine, it cannot be regarded as a sign of sphacelus
of this organ. It is chiefly in some forms of
chronic dysentery that the odour of putrefaction

344

MORTIFICATION.

and the presence of sphacelated portions of the
thickened mucous membrane are observed at the
same time in the discharges which accompany
that disease. An entire portion of intestine is
never discharged unless in intus-susccption fol-
lowed by sphacelus. We shall have occasion to
notice this morbid condition afterwards, under the
subdivision of the present subject which treats of
mortification in consequence of a mechanical ob-
stacle to the return of the venous blood.

With regard to the putrid odour of sphacelus
in the fluids discharged from the urinary organs
and vagina, it is only necessary to observe that,
in the former it always accompanies a turbid,
bloody, or puriform state of the urine ; and that,
in the latter, there is present at the same time a
sanious discharge, sometimes containing blood,
and sloughs of the mucous and sub-mucous tis-
sues.

The putrid odour is never so conspicuous as in
sphacelus of the pulmonary tissue, and when a
communication exists between the sphacelated
substance and the bronchi. It is conveyed by the
expectorated fluids, composed of those coming
from the seat of the disease, as well as from the
mucous membranes in general. These fluids are
sometimes of a dirty grey, brown, or green colour;
puriform or sanious ; containing sometimes shreds
or small portions of the sphacelated lung; and
are occasionally streaked with blood. If hemor-
rhage has taken place, blood alone may be expec-
torated in greater or less quantity. In sphacelus
of this organ, too, there are various physical signs
which, with those already mentioned, and parti-
cularly the latter, enable us to detect not only the
existence of this state, but also its situation and
extent, the state of the surrounding pulmonary
tissue, and the mode in which the disease has
terminated, — circumstances of greater or less im-
portance as regards the prognosis and treatment.

The most important of these physical signs are
the following ; but we must observe that they are
confined to the second stage of mortification, or
sphacelus, and that those of the first stage, or
gangrene, are in no respect different from those
of pneumonia : — so soon as sphacelus has taken
place, a loud crepitous rattle is produced, which
gradually assumes a gurgling sound, as the quan-
tity of fluids increase, and the sphacelated tissues
become separated from the surrounding pulmo-
nary substance, or broken down. The cavernous
rattle continues for an indefinite time, and is re-
placed by pectoriloquism when the contents of the
excavation are partially or wholly removed. The
resonance of the voice is remarkably distinct and
strong in excavations of this kind, particularly
when large, and may, according to Laennec, be
distinguished from that which accompanies ab-
scess of the lung, from its having nothing of that
floating kind of sound of the latter, and is rarely
accompanied by the veiled puff, so common in the
abscess.

When the sphacelus extends to the pleura, and
the dead portion is separated, thus establishing a
communication between the cavity of the chest
and that formed in the substance of the lung, we
have, besides the signs already enumerated, those
of pleurisy and pneumothorax combined with
liquid effusion. If at the same time a communi-

cation exists between the bronchi and the excava-
tion, there is heard either the- metallic tinkling or
the utricular resonance. The crepitating rattle of
pneumonia, which is sometimes heard previous to
the occurrence of sphacelus, may continue after
the occurrence of it, and may, in some measure,
serve to indicate the progress of the disease to-
wards a fatal termination. We have never but
once had an opportunity of hearing the crepitating
rattle where it indicated the return of the pulmo-
nary tissue to the healthy state. The excavation
occupied two-thirds of the inferior lobe of the left
lung, and the resolution of the disease was indi-
cated, not only by the state of the pulmonary tis-
sue around the excavation, which was crepitant,
and did not contain more blood than usual, but
likewise by the presence of an organized false
membrane, which lined the internal surface of the
excavation, a means which, as noticed first by
Laennec, seems sometimes to be employed by
nature to limit the progress of mortification.

We must again repeat, that with all these signs
our diagnosis can never acquire a positive degree
of certitude, unless they are accompanied by the
putrid odour of sphacelus.

We have already said that the progress of mor-
tification, although in general more or less rapid, is
sometimes slow. Laennec speaks of it as existing
in a chronic form in the lungs. It is then accom-
panied with hectic fever, sometimes considerable,
but generally less intense than in most cases of
phthisis ; the skin feels hot, sometimes even disa-
greeably so, to the hand ; and the expectoration
and breath are fetid. This state is accompanied
by rapid emaciation, and the disease may be rea-
dily mistaken for phthisis ; more commonly, how-
ever, death supervenes before emaciation has made
much progress, the disease appearing to have a
greater tendency to produce cachexia than maras-
mus.

We regard the cure of mortification of the
lungs as an exception to the rule, and we have
certainly not witnessed this fortunate termination
of the disease, except in two or three instances, in
which it was not very extensive. In these cases,
too, the progress of the disease was limited at an
early period, ho doubt by the obliteration of the
blood-vessels, and adhesive inflammation. That
such was the state of the pulmonary tissue around
the excavations which were found to exist in these
cases, we feel convinced, not only from the disease
being stationary from the commencement, but from
the general secondary symptoms of mortification,
viz., those produced by the absorption of the putrid
fluids, not having manifested themselves during
the course of the disease. It is, however, stated
by Laennec, that he has known several patients
recover, who, judging from the extent of the pec-
toriloquism, had gangrenous excavations of great
size. In one of those patients there was slough-
ing of the pleura as well as of the pulmonary tis-
sue, giving rise to a pleurisy, which was not cured
till after a period of fifteen months.

Prognosis of Mortification.— The prognosis of
this disease, in the last stage, is always unfavour-
able, because, on the one hand, of its being ac-
companied by a loss of substance, and on the
other because of the affected organ, or the consti-
tution in general, being frequently in a situation

MORTIFICATION.

345

which the resources of our art can neither remedy j
nor relieve. Our prognosis will, of course, be
greatly modified by the circumstances of each
case ; the extent of the disease, its seat, the state
of the affected organ previous to its occurrence,
the age and constitution of the patient, and the
situation in which he was placed previous to the
attack. In all cases in which we can determine
that the progress of the disease has been arrested,
will our prognosis be the more favourable ; but in
those in which the secondary symptoms which we
have several times brought under the notice of the
reader, are present, the death of the patient may
be regarded as inevitable.

Treatment of Mortification. — The treatment
of mortification from inflammation must be con-
ducted in reference, 1st, to the cause of the dis-
ease; 2d, to the disease itself; and, 3d, to its
effects, mediate or immediate. With regard to
the first head, the efficacy of the means employed
will depend much on the extent and degree of the
inflammation which accompanies the stage of
gangrene or sphacelus, the nature of the affected
organ, and ihe general condition and age of the
patient. The progress of the inflammation may
be arrested, or its violence moderated, by the
prompt and well-regulated use of antiphlogistic
remedies, such as general and local bloodletting,
saline purgatives, rest, quiet, and total abstinence
from food. In those cases in which the inflam-
matory symptoms have been slight, even from the
commencement of the disease, the antiphlogistic
treatment has been found to be injurious rather
than beneficial, both on account of the debility
which is present, and because of its having ap-
peared to retard or prevent the accomplishment of
that salutary process by means of which the pro-
gress of the disease is arrested. There are other
cases in which the use of antiphlogistic remedies
is forbidden, by the nature both of the general and
local symptoms. There is a total absence of pain,
no sign of inflammation in the affected organ, and
a state of general debility or prostration. The
early occurrence of these symptoms, as well as
their presence in the last stage of almost every
case of mortification, have rendered many physi-
cians very cautious in the use of debilitating re-
medies, and have induced them to place more re-
liance on the judicious employment of tonics and
stimuli, and other means calculated to support the
strength of the patient, and assist nature in carry-
ing on the process of elimination and reparation.
It is only by a knowledge of the circumstances of
each case that we can at all judge of the applica-
bility of cither mode of treatment, or when the
one should be employed in preference to the other.
It is on the same principles that we can reasonably
hope to exercise a salutary influence over the dis-
ease itself, that is, as regards the removal of the
dead portion, and preventing the effects to which
it gives rise. The most dangerous of all the
effects of mortification are those which follow the
absorption of the putrid fluids of the sphacelated
tissues, to remove or even mitigate which no
means have yet been devised on which any reli-
ance can be placed. It has been proposed to
employ solutions of the chlorides of lime and
soda, as washes, to destroy the putrid effluvia
which accompany sphacelus. We are not certain

Vol. III. — 44

how far they have been found to accomplish the
end in view. Besides, these solutions can be had
recourse to only in a very limited number of cases
of this disease, and when confined to the organs
of generation and the urinary bladder.

II. MORTIFICATION FHOM A MECHANICAL OB-
STACLE TO THE cmcriATioN or the blood. —
The blood may be prevented from arriving at, or
returning from, a part of the body by mere me-
chanical causes. In both cases mortification is
the consequence of the cessation of the function
of nutrition, either from a deficiency of the arte-
rial or the stagnation of the venous blood. A de-
ficiency of the arterial blood may be occasioned by
ligature of the principal artery of a limb, a colla-
teral circulation sufficient for the nutrition of the
limb not having been formed ; or it may follow in
consequence of coagulated blood, or fibrine, or-
ganized or unorganized, occupying the entire cali-
bre of such an artery or its principal branches,
from ossification of the walls of these vessels, or
their conversion into a solid fibrous or ligament-
ous tissue.

Stagnation of the venous blood may depend on
obliteration of the veins caused by the pressure of
tumours situated in their immediate vicinity ; ac-
cidental products formed in their cellular sheath ;
or the presence of fibrine or other solid substances
derived therefrom, formed within the veins, and
either simply lodged within them, or more or less
intimately connected with their lining membrane ;
and, lastly, diseases of the heart, which greatly
obstruct or prevent the return of the venous blood
to this organ. Mortification may also occur in
consequence of the arteries, veins, and nerves
having all at the same time been submitted to se-
vere pressure, as in the case of ligature and tu-
mours.

Mortification from a mechanical obstacle to the
circulation of the blood is by no means equally
frequent, either as regards the causes we have just
named, or the part of the body in which it occurs.
Mortification in consequence of the stagnation of
the venous blood is much more often seen than
that which follows an obstacle to the arterial cir-
culation, owing obviously to a difference in the
organization and relations of the arterial and ve-
nous systems, whereby the latter is more frequently
and more easily subjected to the influence of me-
chanical agents, capable of modifying, in the man-
ner alluded to, the circulation of the blood. Me-
chanical causes which compress or obliterate the
veins are often incapable of producing the same
effects on the afteries, from the circulation in the
former tending to favour rather than oppose their
operation, and which in the latter has a powerful
influence in resisting every external force which
tends to diminish their capacity. And besides,
stagnation of the blood in the venous system, by
whatever cause produced, may, correctly speaking,
be said to depend on the relation which exists be-
tween it and the arterial system ; that is to say,
the mechanical cause is but an obstacle to the
passage of the venous blood, while the quantity
of this fluid and the extent of the stagnation that
follows are determined by the arterial system.

The situation of parts and the mode in which
their circulation is affected, are circumstances
which modify in a remarkable manner the f r e-

346

MORTIFICATION.

quency of mortification. Mortification from me-
chanical causes which obstruct the circulation of
the blood, occurs in the great majority of cases in
the extremities, and far more frequently ID the
inferior than in the superior, partly from their
being isolated from other organs which might fa-
cilitate the formation of a collateral circulation,
and partly from their situation and position, both
of which are unfavourable to the circulation of
the blood. Mechanical causes, which produce
general death when situated in organs on the in-
tegrity of whose functions life in general more or
less immediately depends, give rise in them only
to local death or mortification. In the former the
operation of these causes is necessarily of short
duration, and is always confined within narrow
limits when it is carried to a degree to produce
sphacelus. Should their influence extend to the
circulation of the whole of an organ, such as the
lungs or liver, the obstacle to the return of the
blood from either being situated in the heart, a
state of general congestion is produced, but
which never amounts to what is properly called
gangrene.

In the latter, on the contrary, mechanical causes
which impede or interrupt the circulation of the
arterial and venous blood, may continue to operate
for a considerable length of time, producing all
the regular stages of mortification, as various de-
grees of congestion, gangrene, and sphacelus.
Mortification, however, does occur in the extremi-
ties without being preceded by these changes, the
reason of which we shall endeavour to assign
presently.

With regard to the relative frequency of morti-
fication of the kind of which we are now treating,
it is also of importance to know that this disease
is more frequently produced by disease of the
heart than of the blood-vessels, and that in this
case it is never observed in any other part of the
body than the inferior extremities. There are,
however, several circumstances, to which we shall
particularly allude hereafter, which hasten the ter-
mination of congestion of these parts from disease
of the heart, in gangrene and sphacelus, and with-
out which such a termination would not unfre-
quently not take place.

From these general remarks on the influence
of mechanical causes, operating through the me-
dium of the circulation, in the production of mor-
tification, and the comparative frequency of this
disease in different parts of the body, it is obvious
that the descriptive characters of this disease so
produced must be founded on the phenomena
which it presents when it affects external organs.
We shall therefore commence with the description
of that form of the disease which occurs most
frequently, and which affects the inferior extremi-
ties in consequence of an obstacle to the return
of the venous blood from these parts, produced by
disease of the heart.

1. Mortification of the inferior extremi-
ties from disease of the heart. — The first
local sign that an obstacle exists to the return of
the venous blood from the inferior extremities is
manifested by the appearance of slight oedema
around the ankles. The serosity gradually accu-
mulates in those parts, spreading thence through-
out the cellular tissue beneath the skin and be-

tween the muscles ; the feet, and afterwards the
legs, thighs, and scrotum in the male, and labia
pudendi in the female, become swollen ; the skin
assumes a smooth and glossy aspect, feels tense,
and sinks into the cellular tissue when pressed,
and does not resume its former shape and situation
till raised by the return of the serosity beneath it.
The colour of the skin, at first natural, becomes
pale and waxy, and may continue in this state
during the greater part of the course of the dis-
ease. When discoloration of the skin is about
to take place, it is seen to depend on the presence
of a few subcutaneous veins, which gradually in-
crease in bulk and number, coalesce in several
points, and communicate a slightly mottled aspect
to the skin, of a dull red or purple colour. On
one or more of these points where the congestion
is greatest, and where the skin is less yielding, as
over the tibia and above the malleoli, phlyctenae
or large bulks are formed by the effusion of sero-
sity, either alone or mixed with blood, under the
cuticle. When these burst, the cutis beneath pre-
sents a dark red or brown colour, and very soon
is converted into a dirty yellow or ash-grey slough.
The separation of the slough is sometimes pre-
ceded by an increase of redness in the surround-
ing cutis, which, from its anatomical characters
and the increased temperature and pain by which
it is accompanied, is obviously of an inflammatory
nature. At other times the redness which pre-
cedes or accompanies the separation of the dead
part is very slight, and is evidently owing to mere
venous congestion, occasioned not only by the
disease of the heart, but also by the serosity ac-
cumulated in the cellular tissue of the limb, which,
from the pressure it occasions, further retards the
return of the venous blood, and aggravates all the
symptoms produced by the primary cause of the
disease.

Although, after the separation of the slough, a
loss of substance of considerable extent in depth
may appear to have been produced, it perhaps
never proceeds beyond the cellular tissue; and it
is because of this tissue being greatly distended
with serosity, that the loss of substance which
follows sloughing appears to have penetrated
deeply into the substance of the limb.

Congestion, gangrene, and sphacelus may take
place on several parts of the leg, but they are in
general limited to the parts we have enumerated,
and rarely occur on the feet or toes.

We have already remarked that the temperature
of the extremities is always below the natural
standard during the first periods of the disease,
and that it does not acquire a morbid increase till
the distension of the cutis is great, and this tissue
becomes discoloured from the congested state of
the capillaries. An increase of the sensibility
takes place at the same time, and is always
greatest where the cutis is most distended, and
sometimes amounts to a degree of pain of a dart-
ing, pungent, or burning character, which greatly
increases the sufferings of the patient. Although
the temperature and sensibility of the limb are
sometimes very great while the cutis is still entire,
but tense, congested, or inflamed, they are never
so considerable as when sloughing has taken
place, accompanied by inflammation of this tissue.
It is also in such cases that the pulse becomes

MORTIFICATION.

347

quick and the skin in general hot ; — in one word,
that febrile symptoms make their appearance.
Under these circumstances life is seldom prolonged
beyond a few days, otherwise the death of the
whole limb would follow as the inevitable conse-
quence of the increased disturbance of the circu-
lation, occasioned by the febrile excitement; — a
termination which the author of this paper has
witnessed in two cases, in one of which the
sphacelus extended even to the walls of the abdo-
men.

The progress of this kind of mortification, al-
though generally slow, is occasionally very rapid.
This difference depends chiefly on the two follow-
ing circumstances, — a naturally unyielding state
of the skin, and the effect produced on the venous
circulation of the limb by the effused serosity. It
is principally to the latter circumstance that we
wish to direct attention, as it may suggest some
means to prevent its occurrence and the evils by
which it is followed. As soon as the blood has
accumulated to a certain extent in the venous
system of the inferior extremities, serosity is ef-
fused in greater or less quantity, and compresses
the veins. A second obstacle is thus created to
the return of the venous blood, and consequently
the progress and termination of the disease are
greatly accelerated. These effects of compression
from the effused serosity are first manifested by
the sudden appearance of congestion of the skin,
which generally occupies the greater part of the
leg. The skin retains its glossy aspect, but be-
comes all over mottled with various shades of
red and purple; is seen traversed in every di-
rection by minute veins and capillaries distended
with blood, and the whole limb acquires a degree
of hardness peculiar to this state of the circulation.
The sloughing which follows may take place
without the supervention of inflammation, — at
least without this state being marked by uniform
redness of the skin, — is more extensive than in
the previous form of mortification, but does not
extend beyond the skin and cellular tissue.

The separation of the sloughs in mortification
from disease of the heart is seldom followed by
hemorrhage ; and when it does occur, it consists
merely in a slight oozing of blood from one or
more points of the denuded surface. This cir-
cumstance, as well as the state of the blood gene-
rally found in the veins after death, is readily
accounted for. The blood in the veins in the
immediate vicinity of the sphacelated part of the
limb, is found coagulated, or these vessels are
filled with fibrine. More remote from this part,
and sometimes in the greater part of the limb, the
blood with which they are distended is also more
or less coagulated, but becomes more fluid as we
examine it further from the seat of the sphacelus.

Prognosis. — In no disease can our prognosis
be more certainly fatal than in mortification in
consequence of disease of the heart. Its very
occurrence is a sure evidence that the disease on
which it depends would soon terminate fatally
without the aggravation of suffering which this,
perhaps the worst of its effects, never fails to pro-
duce. The only favourable circumstance — if such
it can be called — relates to the duration of the
disease. If the mortification is the consequence
of the stagnation of the blood occasioned by the

disease of the heart alone, we may venture to
predict that its progress towards a fatal termina-
tion will be slower than when to this, the primary
cause, is added the obstructing influence of the
effused serosity.

Treatment. — The treatment of mortification
from disease of the heart is not only extremely
restricted but entirely palliative. The general
treatment which has been or is still employed
against the primary disease, and which has been
found ineffectual in arresting its progress, is also
that which, if no such disease existed, would be
adopted for the cure of the mortification. Under
such circumstances experience has shown that
little more can be done for the patient than to
mitigate his sufferings by the frequent administra-
tion of anodynes ; the application of cold lotions,
warm fomentations or poultices to the affected
limb ; using one or other of these as the feelings
of the patient or the stage of the disease may
suggest. Both on account of the patient and the
assistants, a solution of the chlorides should be
used so soon as sloughing has taken place. The
limb should also be kept in an elevated position
by means of pillows ; and as the foot is often cold
while the leg is painfully hot, some relief is ob-
tained by covering the former with warm flannel,
and the latter with compresses that have been
dipped in cold water or the saturnine lotion. It
is probable that the occurrence of mortification
from disease of the heart might in some cases be
prevented by the early confinement of the patient
to the horizontal position, by the occasional use
of friction with a view to facilitate the venous cir-
culation of the extremities, and the application of
a well-adjusted bandage from the toes upwards,
which would not only prevent the occurrence of
great congestion by equalizing the circulation
throughout the limb, but also the oedema which
follows, and so greatly aggravates the disease.

2. Mortification of internal organs from
a mechanical obstacle to the return of the
-venous blood. — We do not believe that there
is a single example of mortification of an entire
internal organ from an obstacle to the return of
the venous blood, and produced by a mechanical
cause. We have already stated the reason of this
exception, namely, the facilities afforded for the
formation of a collateral venous circulation ; and
the duration of the mechanical cause capable of
producing local death being limited by the greater
importance of these organs. Mortification of por-
tions of internal organs is, however, occasionally
met with, and which can easily be traced to ces-
sation of the circulation from compression of the
veins: the lungs, liver, and intestines are the
organs in which this form of mortification is most
conspicuous. It occurs in the lungs when the
cellular structure of these organs has become con-
solidated by the deposition of coagulable lymph,
and produces that state of the pulmonary tissue
termed hepatization. We allude here to the grey
hepatization most frequently observed around tu-
bercular excavations, and which is regarded as
the consequence of chronic pneumonia. The
colour of the indurated pulmonary substance may
be grey, purple, livid, or nearly black, and its
consistence sometimes such as to equal that of
cartilage. In this state it is highly probable that

348

MORTIFICATION.

it never regains its natural structure and con-
sistence. When carefully dissected, not only are
the veins contained within it found compressed or
obliterated, but also the arteries are much dimi-
nished in bulk. In fact, all the elementary tissues
of the indurated portion of lung are atrophiated ;
and if the accidental deposit by which these
changes are produced is not removed by absorp-
tion, the former are soon deprived of their vitality,
and both are converted into a soft substance, the
colour of which will depend on that of the part
previous to this change, as well as the degree of
putrefaction which it may have undergone before
it can be examined.

Sphacelus of the walls of tubercular excavations
is sometimes produced in a similar manner. The
veins and arteries which traverse the septa, or
ramify in the walls of these excavations, become
obliterated by the conversion of the blood which
they contain into masses of firm fibrine. This
change may take place previously or subsequently
to the formation of the excavations. In the former
case the expectoration is copious, sometimes con-
tains pretty large portions of tuberculous matter
and softened cellular substance, the odour of
which is extremely offensive. In the latter case
the only change observed in the expectoration is
a tinge of brown, dirty grey, or green, with per-
haps a more marked odour of sphacelus.

Induration of the pulmonary tissue and com-
pression of the veins may likewise be produced by
the tuberculous matter, when deposited in such
quantity as to occupy a large portion or the whole
of the lobe of the lung. The author of this arti-
cle has represented a striking example of indura-
tion from infiltration, as it is called, of tuberculous
matter terminating in sphacelus, in the first Fas-
ciculus of his work on the " Elementary Forms
of Disease." The whole of the upper lobe of the
right lung was converted into a solid mass as firm
as a piece of boiled cow's-udder, of a pale straw
colour, of a homogeneous aspect, and presenting
here and there only a few faint traces of the inter-
lobular sections. The upper portion of this lobe
contrasted strongly with what we have just de-
scribed. It was converted into a mass of dirty
yellowish grey substance as large as an orange,
some parts of it soft and spongy, others quite
pulpy or consisting of a dirty grey sanies, in
which the blood-vessels, veins, and arteries, were
lying denuded and obliterated by firm coagula.
There was no increase of vascularity, indicative
of previous inflammation, in the infiltrated pul-
monary substance, around this the sphacelated por-
tion ; and therefore we regard this case as strik-
ingly illustrative of the manner in which local
death is not unfrequently produced by the accu-
mulation of accidental products of the parenchyma
of organs.

When speaking of mortification of the lungs
from inflammation, we alluded to the occasional
occurrence of this disease without it, being pre-
ceded by the usual phenomena of pneumonia.
Although we are not prepared to demonstrate that
such cases should be considered as of the same
nature as those we have included under the pre-
sent head, we are satisfied that we have seen one
or two instances of sphacelus of the pulmonary

tissue depending on induration as a consequence
of chronic pneumonia. This opinion is founded
not only on the sudden occurrence of the state of
sphacelus without the signs or symptoms of pre
vious inflammation, but on the presence of grey
indurated pulmonary tissue, which we found form-
ing part of the boundary of that which was spha-
celated : such a degree of induration could not
have been produced by adhesive inflammation,
subsequent to the sphacelus, as death took place
within too short a space of time to allow of such
being accomplished.

Sphacelus of portions of the liver is not very
rare in those cases in which it is nearly filled with
cancerous tumours. These tumours produce, me-
chanically, extensive obliteration of the veins ; and
when a portion of the liver becomes incarcerated
by them, it is converted into a dark brown slough,
generally soaked with blood, and sometimes mixed
with softened and detached portions of the neigh-
bouring tumours.

An obstacle to the venous circulation gives rise
more frequently to sphacelus in the digestive or-
gans than in the liver. It is chiefly in the intes-
tines that cessation of the circulation from a
mechanical cause is seen to terminate in sphacelus:
we shall adduce one example only of sphacelus,
namely, that which occurs in the intestines in the
case of intus-susception.

We shall allude shortly to the mechanism of
this morbid condition of the intestine, in order
that the cause of the sphacelus, in which it some-
times terminates, may be clearly understood. When
the superior portion of intestine passes into the
inferior, or becomes invaginated, it carries along
with it that part of the mesentery to which it is
attached. If it does not suffer much compression,
the invaginating process may go on to a great ex-
tent ; but if it is compressed to such a degree that
the return of the venous blood is obstructed, this
stage of the disease is arrested, on account of the
congestion which follows of all the coats of the
invaginated portion. The congestion is not the
consequence of inflammation ; it is produced by
pressure, and in the following manner : when the
mesentery is put on the stretch by the descent of
the superior into the inferior portion of the intes-
tine, the veins belonging to it are compressed be-
tween the walls of both portions, just at the point
where the invagination terminates superiorly. If
adhesive inflammation takes place at this point,
the peritoneal surfaces of both portions become
united, and the veins obliterated. As the arteries
are much less affected by pressure than the veins,
they continue to pour their blood into the invagi-
nated portion ; this fluid gradually accumulates,
and produces an extreme degree of congestion of
the mucous and submucous coats, givirir to them
a deep red or almost black colour. In this state,
however, the intestine is not deprived of its vita-
lity. It is in a state of gangrene, but not of spha
celus ; for its structure is still entire, and when it
has been separated and evacuated, presents, after
having been macerated for some time, so as to de-
prive it of the blood which it contains, the most
perfect state of integrity of all its tunics. Occa-
sionally, however, a portion or the whole of the
invaginated intestine is found in a state of com.

MORTIFICATION.

349

plete sphacelus, and is passed in the form of irre
gular spongy masses or shreds of a dirty ash-grey
brown, or black colour.

It is not unimportant to know that the invagi- |
nated intestine may be detached in separate por-
tions, and passed at different intervals of time. In
such a case the physician might be led to suppose j
mat there were several distinct portions of intes- 1
ane invaginated, whereas there is only one por-
tion. If the invaginated portion of intestine be
considerable, it is, perhaps, never separated all at
once ; on the contrary, it is detached, as we have
said, in several distinct portions, two, three, five,
or even eight ; differences which depend on the
manner in which the invaginated intestine is dis-
posed of. For if considerable, it does not present
a cylindrical form -, it is drawn up into the form
of abrupt, flattened, or angular coils, determined
by the attachment of the vessels and mesentery,
so that stagnation of the blood takes place suc-
cessively in different points, and from below up-
wards, being always greatest at the inferior extre-
mity of the invaginated portion.

The symptoms of intus-susception derive no
peculiarity from the existence of gangrene or
sphacelus, unless when a part or the whole of the
invaginated portion is passed by stool. We may,
however, observe that this disease may, in the
great majority of cases, be distinguished from
stricture of the intestines occurring after ulcera-
tion, by a careful examination of the previous
history of the patient. Disorder of the functions
of the digestive organs, referable to chronic dis-
ease of the intestinal canal, will be found to have
existed for a greater or less length of time before
the occurrence of those symptoms which indicate
an obstacle to the passage of the food or faeces
from stricture : these symptoms are but slight at
first, repeated at irregular intervals of time, and
become more aggravated at every succeeding
attack ; whereas in intus-susception the presence
of a mechanical obstacle is announced suddenly
without being necessarily preceded by any marked
derangement of the functions of the intestine ; the
symptoms to which it gives rise are rapid in their
course, steady in the increase of their severity, and
are aggravated by all the internal remedies calcu-
lated to relieve or remove the former.

There are no means of distinguishing this dis-
ease from internal strangulation of the intestine
until the sphacelated portion is passed by stool.
The existence of the former disease may, perhaps,
be suspected previous to this period by the oozing
of blood from the congested mucous membrane
of the invaginated intestine.

The natural cure of intus-susception furnishes
us with the most interesting examples of the effi-
cient good which can be accomplished by adhe-
sive inflammation. The serous membranes being
endowed with a property which enables them to
supply a quantity of coagulable lymph sufficient
for the full accomplishment of this process, by the
lowest possible degree of inflammation, the solu-
tion of continuity which follows the separation of
the dead portion of the intestine is often repaired
without any appreciable disturbance of the eco-
nomy. The union of the intestine, let it be re-
marked, is effected, not between a mucous and
serous surface, but between the two serous sur-

2e

faces of the invaginated and invaginating por-
tions of the intestine, and just at the point where
the invagination commences: there the separation
takes place, and there also the union is effected
previous to the separation, which is to maintain
the continuity of the intestine, and secure the life
of the patient. Under these circumstances the
diameter of the intestine may not undergo any
perceptible change, and the passage of the food or
fceces is accomplished with the same facility as be-
fore the occurrence of the disease.

It is consolatory to know that patients may sur-
vive the loss of a considerable extent of intestine
from intus-susception, and that, too, without their
general health having suffered any perceptible
alteration. By far the most remarkable instance
of this kind that has come to the knowledge of
the writer of the present article, occurred in the
practice of his excellent and distinguished friend,
Dr. Forbes, of Chichester, with whom he had the
opportunity of examining several of the portions
of intestine passed by the patient. There was no
less than eight portions of intestine passed by
stool, varying from eleven to thirty-two inches in
length, the length of the whole amounting to
twelve feet of entire intestine ! Each portion
was complete in itself, presenting, in fact, the ap-
pearance of healthy intestine, that has been allowed
to remain for a certain length of time in alcohol.
They consisted of the jejunum and ileum, some
of them having their serous, others their mucous
surface outwards (which is always the case when
the intus-suscepted intestine separates in distinct
portions), on the former of which the blood-
vessels, on the latter the glandular agminate, were
most conspicuously visible. The most interesting
feature of this case was the complete recovery of
the patient, at least from the immediate conse-
quence of this disease. The subject of this re-
markable case was a poor woman of the name of
Ann Newland, resident at Emsworth, in Hamp-
shire, and was a patient of Mr. Lyne, surgeon at
that place. She had been confined to bed by an
anomalous chronic affection for many years pre-
viously to the intus-susception. The first portion
of intestine came away in the year 1826, the last
in 1829. She died in March, 1831, aged thirty-
seven years. The greater part of the intestine
passed, is preserved in the Museum of the Chi-
chester Infirmary.

This case also acquires great additional value
from the circumstance that the form and dimen-
sions of the intestine, at the point where the solu-
tion of continuity had taken place, were found,
after the death of the patient, to have undergone
very little alteration. A slight contraction of the
small intestine, and the presence cf a thin, pearly-
coloured false membrane, little more than half an
inch in breadth, and surrounding it in the form
of a zone, were the only external appearances
which indicated the original seat of the disease.
On the corresponding and internal surfaces of the
intestine there was also seen a narrow, slightly
elevated, smooth ridge, covered by mucous tissue,
and traversing the whole circumference of the in-
testine, the walls of which, opposite, were con-
siderably thickened.

If any doubt could remain that these appear
ances were to be admitted as positive evidence of

350

MORTIFICATION.

the union and cicatrization of the original solution
of continuity of the intestine, that doubt would be
entirely removed by the fact that the solution of
continuity had taken place in the situation of one
of the glands of Peyer, and in such a manner that
this gland was divided into two nearly equal por-
tions, one of them terminating in the cicatrix, and
the other being situated at the extremity of one
of the detached portions of intestine.

With regard to the treatment of mortification
from intus-susception, there are two points which
deserve the chief consideration of the physician ;
the reduction of the invagination, and the separa-
tion of the dead portion of intestine. The re-
duction of the invagination is not to be effected
by the direct operation of any means which we
have in our power to employ. If this is at all to
be accomplished, it must be by preventing the ac-
cumulation, or diminishing as much as possible
the quantity of the fluid contents of the intestine,
— that is to say, by confining the patient to a
state of absolute rest, by depriving him of food
and drink as long as possible, by general blood-
letting, and the use of emetics so employed as
not to act upon the intestine. Purgatives must be
avoided, as having the direct effect of increasing
the disease. If this treatment fails to give relief,
the physician should act as if there were a cer-
tainty that the reduction of the invagination is
rendered impossible by the adhesive inflammation,
and that a cure may be expected to follow the sepa-
ration of the dead part of the intestine. Under
these circumstances he must wait patiently, and
endeavour to remove every cause which can tend
to retard or prevent the accomplishment of this sa-
lutary result. At this period of the disease he can-
not do better than enjoin rest and quiet, and sup-
port the strength of the patient by the frequent
administration of small quantities of nutritious
fluids, or enemata of a similar kind.

Numerous examples of mortification from an
obstacle to the venous circulation are met with in
those adventitious formations known under the
denominations of scirrhus, cancer, medullary sar-
coma, fungus nematodes, fibrous tumours, &c.
We do not, however, think it necessary to do
more than indicate the occurrence of the disease
in such cases, as we have already alluded to it
when speaking of mortification of the lungs and
liver produced by a mechanical obstacle to the re-
turn of the venous blood. Such adventitious pro-
ducts, from their situation, connection, and mode
of development, are often destroyed in part, and
sometimes entirely, solely on account of the veins
in their immediate neighbourhood, or contained
within them, being so compressed as to prevent
the passage of the blood through them. These
substances become gorged with blood, particularly
at their circumference, where sloughing com-
mences, which proceeds towards their interior,
with a rapidity and extent proportioned to the de-
gree of congestion by which it is preceded.

The rapid development of some of these acci-
dental formations often depends on the destruc-
tion of the surrounding tissues by mortification,
whereby they are relieved from the restraint im-
posed on them by external pressure. They now
ehoot forth with surprising rapidity, and undergo
such a change in their conformation and other phy-

sical characters, that, although still the same disease,
they are no longer recognised as such, and receive
new names, which not a little embarrass the stu-
dent of pathology.

3. Mortification from obliteration of the
Arteries. — Although this form of mortification,
confined as it is almost always to the extremities,
be regarded as the exclusive object of surgical
treatment, we shall give a small outline of the pa-
thology as it occurs in two distinct morbid states
of the arteries of these parts, that the physician
may be the better prepared to distinguish it from
that which arises from disease of the heart, and
another form of mortification of the extremities
which still remains for us to describe, — viz. that
occasioned by the use of unsound rye as an article
of food.

The two forms of mortification of the extremi-
ties to which we here allude, originate, the one in
spontaneous rupture of the internal and middle
coats of the trunk of an artery, the other in the
obliteration of a similar vessel or of its principal
branches by the presence of organized fibrine,
fibrous or osseous substances.

Mr. J. W. Turner, professor of surgery in the
University of Edinburgh, was the first who di-
rected the attention of the pathologist to the oc-
currence of spontaneous rupture of the internal
and middle coats of an artery. There is, how-
ever, nothing in the histories of the cases which
he has published which throws any light on the
morbid condition of the arteries which precedes
the rupture of their internal and middle coats.
That such must have been the case is obvious from
the following facts. One of the patients, whose
case is related by Professor Turner, was in the
act of raising himself in bed by resting on the
palms of his hands, when he experienced a sen-
sation as if something had given way at the joint
of the right arm. Five days afterwards, the same
patient, while in the act of moving his right leg,
perceived a sudden sensation of numbness and
weight extending from the ham downwards.
Another patient, while turning his hand behind
his back to put in his coat-pocket, felt a sudden
acute pain in the bend of the elbow joint, and a
sensation of numbness in the hand and fore-arm.
It is, therefore, obvious that in none of these cases
the rupture, which was afterwards found to have
taken place in the internal and middle coats of the
brachial and popliteal arteries, could have been
produced had there not existed a previous state
of disease of these vessels. In one of the cases
only did mortification take place. Half an hour
after the rupture of the popliteal artery, no pulsa-
tion could be felt in any of the arteries of the foot,
or in the ham. The foot was cold : no pain was
excited by pressure on any part of the limb, but
the patient complained of occasional cramp-like
pains in the calf of the leg. The morning after
the attack the foot was pale and cold, and below
the ankle the integuments were entirely void of
sensation when pressed, pinched, or tickled, and
the muscles of the foot seemed to have lost the
power of contraction. The next day several mot-
tled purple patches appeared on the instep and
fore-part of the ankle, which gradually extended
over the whole foot, till the surface, by the fifth
day, became entirely livid. As the discoloration

MORTIFICATION.

351

advanced, the foot swelled slightly, and hecame i
(Edematous, and appeared to acquire an increase
of temperature. Soon after the attack the patient
complained of severe burning pain in the foot,
and a feeling as if it were crushed, which con-
tinued till near his death. About the ninth day
the soft parts above the ankle began to swell and
to be hot and painful on pressure ; the swelling
gradually increased, and extended till it reached
the upper part of the calf of the leg. The in-
teguments above the ankle began to become dis-
coloured at the same time, and the discoloration
increased till the lividity reached the calf of the
leg, and at last rapidly extended nearly to the
knee. The soft parts adjoining the discoloured
skin were swollen and very painful on pressure;
but no redness appeared, nor any inflammatory
line between the dead and living parts. The parts
discoloured were completely sensible, and the cu-
ticle raised into globular vesications, filled with
limpid or reddish scrosity. The constitutional
symptoms in this case were greatly aggravated by
a previous state of disease. Death, however, did
not take place till eighteen days after the pulse
had ceased in the leg. The coats of the artery
were found torn, thickened, and obliterated in
several points by coagulated blood, fibrine, and
lymph.*

The second form of obliteration of the arteries
which gives rise to mortification, consists, as we
have said, in the presence of fibrine, fibrous, or
bony substances formed in these vessels. When
the quantity of these substances is such as to in-
terrupt or prevent entirely the circulation of the
blood through the principal arterial trunk or
branches of one of the inferior extremities, morti-
fication is almost always the consequence, because
of the advanced period of life at which this form
of the disease generally occurs, and the very un-
favourable state of the arteries to the formation of
a collateral circulation.

It is to this form of mortification that we would
confine the term gangrnena senilis; the idio-
pathic and dry gangrene of authors.

We have already stated one of the reasons
which have induced us to give a general outline
of the kind of mortification which we are now
describing, and we might have added a still more
weighty reason for our doing so ; viz., the import-
ant pathological evidence with which it furnishes
us in regard to the production of mortification,
independently of the previous existence of local
inflammation ; a subject on which it would appear
some doubt is still entertained. We should not
have thought it necessary to recur to this circum-
stance, having already shown that mortification,
from a mechanical obstacle to the return of the
venous blood, and produced in a variety of ways,
is not an uncommon occurrence in internal organs,
were it not that the facts then adduced might be
regarded as incomplete, from their being chiefly
founded on the results of post-mortem examina-
tions. In the form of mortification which we are
now about to describe, no such objection can be

*On the sudden spontaneous Obliteration of the Ca-
nals of the larger Arteries of the Iiodv, kc. bv J. W.
Tinner, Professor of Surgery in the Royal College of
Burgeons, Edinburgh. Edinburgh Medico-Chirurg. So-
ciety's Transactions, vol. iii.

raised, as all the facts which the pathology of a
disease can afford as evidence of its scat and
nature, are, in this case, equally conspicuous and
decisive.

The first change which announces the occur-
rence of local death from obliteration of the arte-
ries of one of the inferior extremities, occasioned
by the presence of the accidental products which
we have named, is a dark-red, purple, or almost
black discoloration of the skin of the fleshy or
under portion of one or more of the toes of the
foot. There is, in general, no previous swelling
of the affected toes, no increase of their tempera-
ture or sensibility. The discoloration, alone, is
often the first circumstance which attracts the
attention of the patient to the existence of the
disease; and we have seen two cases in which the
discoloration had gained the upper surface of the
toes, before the patients were aware of the pre-
sence of this insidious and fatal affection. In
some cases, however, a prickling or tingling sen-
sation, or a certain degree of numbness and cold,
are perceived in one or more of the toes, and
which, when examined, are already found to be
discoloured ; not red, hot, swollen, and painful,
but of a purple or livid colour, colder than natural,
not painful when pressed, and shrunk rather than
increased in bulk. An increase of temperature,
sensibility, and bulk of the affected toes, is, how-
ever, occasionally observed at or near the com-
mencement of the disease ; but as they are not
constant, so are they not necessary changes. This,
the first period of the disease, presents, indeed,
none of the local characters of inflammation, if
we except the circumscribed accumulation of blood
on which the discoloration of the skin of the toes
depends, the isolated existence of which is, how-
ever, of no value, inasmuch as its presence can be
accounted for from interruption to the arterial cir-
culation of the limb.

The discoloration extends slowly until it has
pervaded the whole of the skin covering the toes,
then proceeds upwards over the back and sides of
the foot, and sometimes mounts nearly as far as
the knee, although more frequently death takes
place from the constitutional disturbance which
ensues, before it has passed the foot or ankle joint.
During its progress, the discoloration generally
presents the same purple or livid tint which it did
at the commencement ; and although it may be
preceded by some swelling and congestion of the
skin and subcellular tissue, its progress is seldom
marked by the bright red colour of inflammation ;
and when inflammatory redness of the skin takes
place, accompanied with heat, pain, and tumefac-
tion, these phenomena must be regarded as effects
of the disease which more frequently tend to in-
crease than to interrupt or arrest its progress.

The bulk of the affected parts depends chiefly
on the situation and extent of the obstacle to the
circulation. If the obstacle be extensive, the
quantity of blood admitted to the foot is too small
to give rise to congestion ; and this not taking
place, there is little or no effusion of serosity.
Hence there is no increase of bulk in mortifica-
tion from this cause; and if the obstruction has
been effected slowly, the foot and leg may even
be atrophiated previously to their being attacked
, with mortification, the dead parts being shrunk.

352

MORTIFICATION,

dry, and indurated. These physical characters
of the disease are entirely owing to the hydraulic
conditions to which we have just alluded ; for if
the obstruction to the passage of the arterial blood"
be only partial, and particularly if it has occurred
suddenly, a considerable degree of congestion is
induced, and consequently the effusion of a greater
or less quantity of serosity, whereby the bulk of
the foot, and more frequently of the leg, is more
or less increased : even in this case, however, there
is not any marked increase of bulk in the toes,
the primary seat of the disease. It is in its pro-
gress upwards that the congestion and oedema
become manifest ; that the skin becomes tense and
painful ; and that the febrile symptoms, if they
have not yet occurred, appear, increase rapidly in
severity, aggravate the local affection, and hasten
its fatal termination.

From the nature of the obstructing cause, and
the unfavourable conditions under which it occurs,
the progress of the mortification is seldom arrested;
and if it is so, the separation of the dead parts is
rarely accomplished, and perhaps a cure never
effected.

It is stated by some pathologists that this form
of mortification sometimes occurs in young per-
sons, and is much more frequently met with in
males than in females. The former statement we
believe to be an error originating in an imperfect
knowledge of the causes of this disease ; for as
we ourselves have never seen it in young persons,
and as this statement has not been supported by
other than mere negative facts, and these too very
incomplete, we must continue to regard it as a
disease peculiar to persons advanced in life, and
occasioned by morbid states of the arterial system,
which occur only in such persons, at least to such
an extent as to produce local death.

With regard to the greater frequency of the
disease in males than in females, we should say
from our own personal observation, that this state-
ment is correct only in so far as it regards its oc-
currence in the inhabitants of towns and cities ;
but that in those of agricultural districts, where
the occupations and mode of living of both sexes
are much of the same kind, it appears to occur as
often in females as in males.

In every case of gangrena senilis which we
have examined after death, we have found the ar-
teries of the diseased limb obliterated in such a
degree as to interrupt the circulation of the blood.
The obstructing cause consisted, in five or six
cases, of a fibrous tissue formed either in the walls
or cavities of the arteries, whereby these vessels
were converted into nearly solid cords of liga-
mentous consistence. This state we have traced
from the toes more than half way up the leg ; it
was always connected with ossification of the
larger branches and trunks of the thigh and other
parts of the body. In other two cases, the obstruc-
tion depended on extensive ossification of the
principal arteries of the limb ; and in several
others it was produced by solid fibrine formed
around spiculi of bone projecting from the internal
surface of the arteries.

Connecting this state of the arteries with the
external appearances of the mortification with
which it is accompanied, we can have no hesita-

tion in admitting that this form of the disease is In the form of mortification of which we have

the immediate consequence of a deficient supply
of arterial blood, and that therefore, if the facts
already adduced were considered insufficient to
prove that some of the other forms of mortifica-
tion which we have described may aleo take place
without being preceded by inflammation, those
which we have now brought fojward will, we
trust, remove any doubts that may have been
entertained on this highly important part of our
subject.

The description which we have given of these
two forms of mortification from rupture of the
internal and middle coats of the arteries, as well
as from obliteration of these vessels, is, we hope,
sufficiently characteristic, and euch as will enable
the physician to distinguish them from other forms
of this disease which belong especially to his de-
partment of the healing art.

III. MollTIFICATIOX FROM LOCAL A^JD GENE-
RAL debility. — As a state of local debility capa-
ble of inducing mortification is always connected
with, and essentially depends on, a state of general
debility, we shall confine the observations which
we have to make on this form of mortification to
the affection as it occurs under the influence of the
latter condition of the economy.

Whatever may have been the causes of the ge-
neral debility, we regard this state as constituting
the essential condition of the disease ; — a state in
which the physiological and physical properties of
the solids and fluids of the body are so modified,
(we commonly say enfeebled or debilitated,) that
every function of the economy is slowly, ineffec-
tually, or imperfectly performed : innervation and
nutrition in particular are so circumstanced, that
even those agents on which the varied phenomena
of health and life more or less immediately de-
pend, now become the causes of disease and of
death. Illustrations of this important fact meet
the eye of the physician in the every-day occur-
rence of diseases of various kinds, but they seldom
arrest his attention unless they occur under extra-
ordinary circumstances, — such, in fact, as are ob-
served in those cases of decay and death of the
solids to which we shall presently more particu-
larly allude. We have seen that mortification of
various parts of the body may be produced by
mechanical causes whose operation is entirely
limited to the rascular system, in which they im-
pede or arrest the circulation of the blood. This
fluid, as well as the solids in general, may be in
the healthy state up to the moment at which the
local mechanical cause begins to operate and ma-
nifest its effects, and these are characterized by a
diminution of all those properties, the extinction
of which is the death or mortification of the part
thus circumstanced. A similar healthy condition
of the solids and fluids may precede mortification
from inflammation, but the phenomena of the dis-
ease are the opposite of the former. Local death
does not take place until after the morbid stimulus
has increased every property of the part to which
it has been applied, to its maximum. The part
is thus exhausted of its strength, if one may be
allowed the expression, and being deprived also
of the means of renewing it, from the changes
which have taken place in its more essential ele-
ments, it soon sinks into a state of absolute death.

MORTIFICATION

353

now to speak, the fluids of nutrition as well as the
solids are, as we have said, in a previous state of
disease, and this state is the cause of the general
debility which constitutes the essential character
of this form of mortification. Notwithstanding,
we have classed it with the two former, because
of their being all preceded by the same state of
the circulation. In none of these three forms of
mortification does local death take place without
being preceded by cessation of the circulation ; a
circumstance, we believe, of sufficient importance
to authorize our having brought them all under
the same general head.

The most marked examples of mortification
from general debility are met with in individuals
whose strength is greatly reduced by want and
fatigue, by the violence of acute diseases of an
adynamic character, and by chronic diseases ac-
companied with much pain, extensive suppura-
tion, or which compel the patient to remain for a
long time in the same position. Under these cir-
cumstances the local phenomena of mortification
present, no doubt, considerable variety ; but those
which constitute the type of the disease, whether
local or general, are always the same, unless in so
far as they vary in extent and degree. Thus,
mortification from debility may be preceded by a
certain degree of pain, increased sensibility and
temperature of the part affected ; but these changes
are not constant, and therefore not necessary to
the production of the disease. A local accumula-
't>n of blood constitutes, in general, the first per-
ceptible change in the part which is about to be
deprived of its vitality. This may take place from
the part being submitted to pressure from 'ts own
weight or that of the body, from slight friction,
puncture, or similar causes. In some of these
cases the blood accumulates, partly from the in-
fluence of gravitation, and partly from compression
of the veins ; as, for example, in mortification of
the soft parts covering the sacrum, heels, elbows,
&c. of persons who have escaped the dangers of
typhoid fevers, and who are left in that state of
prostration which precludes the possibility of
changing the position of the body. It is, perhaps,
still more conspicuous in some patients similarly
confined with paraplegia from injury of the spinal
cord. Sloughing, or at least sphacelus, may have
proceeded to a considerable extent before its exist-
ence has even been suspected ; the patient seldom
complaining of any uneasiness till inflammation
has been induced by the presence of the dead
tissues.

A state of local congestion is also frequently
the only change which precedes the sphacelus of
the skin to which leeches have been applied, or
which has been scarified or punctured. The skin
around the leech-bites assumes a dirty purple,
livid, or almost black colour ; looks sometimes as
if it had been injected with ink ; presents no pre-
vious redness, heat, or pain, and is not swollen
except where the blood is accumulated ; it drops
oil" in the course sometimes of twenty-four hours,
leaving a number of circular openings, which
unite and spread by similar succeeding conges-
tions and sloughing of the contiguous skin; —
effects which are always to be dreaded when it is
found necessary to apply leeches to weak scrofu-

Vol. III. — 45 2d'

lous children, greatly debilitated by confinement
within the walls of an hospital, or low, damp, ob-
scure, ill-ventilated dwellings.

The occurrence of mortification in scorbutus
affords another striking example of the influence
of general debility in the production of this dis-
ease. Portions of the skin often become gorged
with blood, die, and slough, without our being
able to discover that these parts have received any
previous injury. The prostrate condition of all
the functions of the economy, indicated by an
unwillingness or the incapability to move ; the
feebleness of the pulse, the fluidity of the blood,
and the imperfect state of nutrition in the worst
forms of this disease, convert, as it were, the na-
tural and healthy influence of physical agents into
a means of destruction. Even the mastication of
the food necessary for the support of those affected
with this disease, cannot be performed unless at
the risk of inducing mortification of the gums,
and other soft parts of the mouth. The sloughing
of these parts from this cause is sometimes very
extensive, accompanied by a continual oozing of
blood, and occasionally terminates by the loss of
the greater part of the teeth, and even portions of
the alveolae. For a more detailed description of
the varieties of form, extent, progress, and termi-
nation, as well as the treatment of this form of
sphacelus, we must refer the reader to the article
Scorbutus.

There is one other form of sphacelus from
general debility which requires to be more parti-
cularly noticed in this place. It is that which has
received the names of noma ; cheilocace ,- stoma-
cace gangrenosa sen maligna; necrosis infan-
tilis, [cancram oris, gangr synopsis, gangrenous
stomatitis] ,- pourriture des gencives ,- gangrene
scorbutique aux gencives ; wasserkrebs der kin-
der,- gangrenous aphthae,- water-canker. The
gangrene and sphacelus which have been described
under these various appellations occur generally
in infants, and in children from two to five years
of age, attack the mouth and cheeks, and the ex-
ternal parts of the female organs of generation.
Their occurrence in the mouth may be owing to
the presence of several diseased states of the
mucous follicles, mucous membrane, or walls of
this cavity. Thus gangrene and sphacelus may
follow inflammation of the follicles or mucous
membrane of the mouth, the inflammation being
limited to these parts, as in follicular aphthae, or
combined with pharyngitis, scarlatina, small-pox,
or scorbutus, examples of which will be found
under these several heads. But the form of
mortification to which we wish to direct the at-
tention of the reader occurs in the parts which we
have named without being preceded by any of
these lesions. It commences, however, in the
mouth, in the mucous membrane, and, perhaps
nearly at the same time, also in the cellular tissue,
generally of one, rarely of both cheeks. The
general and local phenomena of the disease have
been well described by Baron, (Mem. sur une
affection gangreneuse de la bouche, Bulletins de
la Faculte, 1816,) Isnard, (Dissertation sur une
affection gangreneuse particuliere aux enfans,
Paris, 1818,) Billard, (Traite des Maladies des
Enfans, &c. ) Richter, (Der Wasserkrebs der Kin-

354

MORTIFICATION.

der, Berlin, 1828. Journal des Progres, &c. tome
iii. 1830,) and others, of which the following are
the most important.

Symptoms.— -In the first stage of the disease,
the mucous membrane of one of the cheeks pre-
sents in some cases a small superficial ulcer with-
out pain or discoloration. Sometimes there may
be two or three ulcers, seldom more. In other
cases, instead of an ulcer, a small whitish or yel-
lowish grey spot appears on the mucous mem-
brane, which sloughs, and gives rise to an ulcer
similar to the former, or presenting the same co-
lour as the slough by which it was preceded. It
is not certain whether the disease commences by
ulceration or sphacelus of the mucous membrane,
but we are inclined to believe that it commences
by the latter process. But, however this may be,
there is observed nearly at the same time a greater
or less degree of tumefaction of the cheek, oppo-
site the ulcer or slough of the mucous membrane,
which increases with great rapidity, and soon ex-
tends to the eyelids and lips. The skin of the
swollen parts is pale and glistening, resembling
wax, hard towards the centre of the swelling, and
more or less elastic. A copious discharge of
fluids takes place from *he mouth, consisting at
first of glairy saliva, ana afterwards of a dirty
sanies, which give a strong offensive odour to the
breath. There is no pain in the cheek, little or
no increase of its temperature ; and so little are
the functions in general disturbed, that children
affected with the disease in this stage are some-
times able to amuse themselves with their compa-
nions, and partake of their ordinary meals without
any apparent inconvenience.

The commencement of the second stage is
marked by the appearance of a dull yellowish
grey discoloration of the skin on the centre of the
swollen cheek, where it is hardest, and opposite
the sphacelated mucous membrane of the mouth.
The portion of skin thus discoloured soon be-
comes black, and sloughs ; the whole substance of
the cheek undergoes the same successive changes,
and in the course of a few days, sometimes less
than a week, the cheek, lips, and eyelids are con-
verted into a soft putrid mass, which, falling off,
destroys sometimes nearly the whole of one side
of the face, lays open the cavity of the mouth,
and exposes the gums in a state of sphacelus, the
inferior and superior maxillary bones denuded or
necrosed, and deprived of their teeth. In milder
forms of the disease the sphacelus may be ar-
rested before it has proceeded far in breadth or
depth, or after it has destroyed only a limited
portion of the cheek and lips, and without having
attacked the bones. The general symptoms which
accompany this the last stage of the disease, are
sometimes so mild, so disproportioned to the local
ravages of the disease, that one cannot help being
struck with astonishment. There is even a craving
for food, which the little victims devour with
greediness and apparent relish, and which they
continue to do even until within a few hours of
their death. The intellectual faculties are seldom
much affected. In other cases there are from the
commencement a low state of fever, a weak quick
pulse, heat of the skin, thirst, and loss of appe-
tite. The fatal termination of the disease is like-
wise sometimes announced by a state of great

prostration and colliquative diarrhoea, excited pro-
bably by the absorption of the putrid fluids, and
their passage into the stomach and intestines
When this form of mortification attacks the labia,
it presents the same local and general phenomena,
commencing with a sloughing or ulcerated state
of the mucous membrane of these parts, accom-
panied with the same kind of tumefaction ami
discoloration, and terminating in sphacelus, which
spreads with great rapidity, and destroys to a
greater or less extent the neighbouring parts.

From the above description of this form of
mortification, little doubt can be entertained as to
its being a disease arising in that state of general
debility which we have already endeavoured to
explain. All the phenomena which it presents
are also so characteristic, that it is not likely to
be confounded with any other disease except
malignant pustule, from which, however, it may-
be distinguished, as has been observed by Rayer
and others, from the latter disease, when it affects
the cheek, always commencing on the external
surface.

Prognosis. — The prognosis of this disease is
extremely unfavourable when it attacks children
in hospitals, for few of them survive its ravages.
We have, however, seen its progress arrested in a
few instances, and in two cases the patient sur-
vived the loss of a large portion of the cheek and
a part even of the inferior jaw. When children
are placed in more favourable circumstances,
where they enjoy fresh air and receive all the care
that their situation requires, the remedial means
are more efficacious, and the mortality of the dis-
ease less considerable.

[Even in hospitals, however, the deaths are not
always in very large proportion. In the year
1838, of twenty-three cases, treated in the chil-
dren's asylum of the Pennsylvania Hospital,
nineteen recovered, and four proved fatal. (See
the writer's Practice of Medicine, 2d edit. i. 34:
Philad. 1844.) It would seem to be frequently
complicated with pneumonia. M. Baudeloeque,
indeed, asserts that the complication is invariably
found to exist; and MM. Barthez and Rilliet
( Trait c Clinique des Maladies des Enfants, i
152 : Paris, 1843,) met with it in every instance
that came under their notice.]

Treatment. — As soon as the disease is per-
ceived, the slough or ulcers of the mucous mem-
brane, whether of the labia or mouth, are to be
touched with a mixture composed of equal parts
of honey and muriatic acid, or with the latter
alone. But when the disease is more advanced,
when the swelling is considerable, and the stage
of sphacelus has arrived, Mons. Baron strongly
recommends that the sphacelated tissues be di-
vided, and the actual cautery, heated to whiteness,
carried deep into their interior. (Loc. cit.) This
treatment is said to be by far the most successful.
Marjolin states that he has employed it with com-
plete success, and also the nitrate of silver, in the
state of powder, introduced into the incised spha-
celated tissues. (Dictionnaire de Medecine, torn,
x.) The muriate [chloride,] of soda is also an
efficacious remedy, as it is found not only to ar-
rest the progress of the disease, but likewise re-
moves the stench by which it is accompanied.
[Liquor Potasss, nitric acid, pyroligneous acid,

MORTIFICATION.

355

chlorine and tincture of chloride of iron, have
likewise been advised, with or without incisions ;
hut the caustics or excitants that have met with
most favour, have been sulphate of copper, and
nitrate of silver in the solid form, so as to produce
an eschar over the whole of the sloughing parts.
Dr. B. H. Coates (North Amer. Med. $ Surg.
Journal, 1826,) recommends the following ap-
plication: Cuprisulpk. 3ij., Cinchon. pulv. §ss.,
Aquae, f.^iv. M. ; or the cinchona may be omitted.
When sloughs have formed on the cheeks, the
yest cataplasm, or poultices containing powdered
bark, or chlorinated lime, or chlorinated soda, or
pyroligneous acid, may be applied to the part
previously washed with any of the lotions already
mentioned.]

Every precaution ought to be employed to pre-
vent the putrid fluids from being swallowed, and
perhaps the best means of doing so is to wash out
the contents of the mouth with a decoction of
bark, or a gargle of muriatic acid and honey ; and
to prevent them accumulating, the patient should
be made to lie on the affected side of the face, so
that they may find a ready exit. The swollen
parts should be covered with cloths dipped in an
aromatic fomentation, and occasionally rubbed
with the liniment of ammonia, or other stimulating
substances. Although this disease originates in a
state of general debility, the local treatment which
we have pointed out is regarded as the only cer-
tain means of arresting its progress. The opera-
tion of general remedies is too slow to have any
control over a disease which proceeds with such
rapidity, and therefore general remedies must be
regarded only as auxiliaries. They should consist
of nutritious fluids and small quantities of wine,
but the administration of the latter in particular
must be regulated by the state of the digestive
organs, which in this disease are often greatly dis-
ordered and highly irritable, and therefore require
to be remedied by means suited to the kind of
derangement which they may present in each in-
dividual case.

[Cinchona, especially, and the salts of its active
principle, quinia, may also be freely administered,
and iodide of iron offers prospect of advantage.
Recently, the internal use of chlorate of potassa
has been highly extolled by Dr. Henry Hunt
(Medico-Chirurgical Transactions, xxvi. 142), in
the dose of from Qj. to ^ij., in 12 hours, accord-
ing to the age of the patient.]

II. MortTIFICATTON from the violent ope-
ration OF MECHANICAL, CHEMICAL, AND PHY-
SICAL AGENTS.

The mechanical agents which occasion mortifi-
cation are violent blows and contusions of various
kinds ; the chemical, powerfully stimulating sub-
stances ; and the physical, extreme heat and cold.
All these agents produce the same ultimate effect
in the part of the body which has been submitted
to their influence ; that is to say, they deprive, to
a greater or less extent, such a part of those pro-
perties on which its existence depends. The ef-
fect of a contusion produced by a heavy weight
falling upon or passing over a part of the body,
may be partial or complete death of such a part ;
and that produced by a bullet, instantaneous death
of the soft parts, to a certain extent beyond the

limits of the solution of continuity which it occa-
sions in its passage through them. Strong stimuli,
intense heat and cold, may operate precisely in a
similar manner. The destructive effects of these
agents are, however, not always the same in de-
gree or extent, nor are they always produced in
precisely the same manner. In one case there
may be no gradation of change, no intermediate
state of disease which separates these destructive
effects from the previous healthy condition of the
tissues in which they are produced : local death
may be the immediate consequence of the violent
operation of such agents. In another, the vitality
of the part which has been exposed to the opera-
tion of these agents is not entirely destroyed. In
this case the part may be regarded as in a state
of gangrene ; and in the former, in a state of
sphacelus. In the present case it may or may not
be susceptible of recovery, the result being de-
pendent on the subsequent changes which may
take place in the affected part itself, or in those
parts with which it is connected. Congestion
and inflammation are the changes which always
take place, to a greater or less extent, in gangrene
of this kind. If they can be prevented from
taking place, moderated or removed when present,
the suspended functions of the part may be re-
stored ; otherwise the gangrene terminates in
sphacelus.

The state of congestion and inflammation to
which we have just alluded originates in opposite
states of the vascular system. The congestion
takes place in the gangrened tissues, because of
the vessels being deprived of those properties by
means of which they were enabled to propel the
blood through them. They have ceased to con-
tract, and consequently the blood, although carried
into them in the usual quantity, accumulates in,
and distends them to a greater or less extent. On
the contrary, the blood-vessels situated beyond the
gangrened tissues having received little or no in-
jury, are stimulated either by the presence of the
disease acting as a foreign body, or have been pre-
viously excited by the cause which produced the
gangrene, to such a degree as to give rise to an
increased influx of blood, to an increase of the
sensibility and temperature, and other phenomena
of inflammation. Under these circumstances the
remaining vitality of the gangrened part is soon
destroyed, and consequently a state of real death
produced.

However important it may be in a practical
point of view to be fully acquainted with all the
changes which take place in the structure and
functions of a part which has been submitted to
the violent operation of mechanical, chemical, and
physical agents, we shall not enter into a more
detailed description of them than may seem ne-
cessary to our present purpose, as this part of our
subject belongs almost exclusively to the depart-
ment of surgical pathology.

We may, however, observe, — 1. that the degree
and extent of these changes of structure and
function are proportioned to the intensity of the
agent by which they have been produced, the de-
gree of energy with which it has acted, and the
duration of its operation ; — 2. that the recoverable
or irrecoverable condition of the structure and
functions of the injured part are essentially deter-

356

MORTIFICATION.

wined l>y similar modifications of the efficient
cause; — 3. that congestion or inflammation are
subsequent changes depending on the primary
lesion or its a^cnt, always effects and complica-
tions hut never causes of the disease, unless se-
condarily and under those circumstances to which
we have alluded, that is, when the part is left in
a recoverable state, or in a state of gangrene ; —
4. that, therefore, mortification from the violent
operation of mechanical, chemical, and physical
agents, differs from that produced by inflammation,
an obstacle to the circulation of the blood, and
local and general debility ; the disease, in the for-
mer case, consisting essentially in a simultaneous
lesion of all the elements ; in the latter, of one
element only of the part in which it is produced.
There are, no doubt, slight exceptions to these
general conclusions ; but considering them in a
general point of view, they appear to us to be
drawn from a series of facts sufficiently broad and
distinct to render it necessary to consider apart
these two forms of mortification, independently
of the advantage of doing so in a practical and
scientific point of view.

For the reason before stated, we shall confine
the few observations which we have still to make
on this form of gangrene, to some of the more re-
markable phenomena which it presents when pro-
duced by the action of intense heat and cold on
the external parts of the body, and strong stimuli
on the digestive mucous membranes.

1. mortification from Intense Heat. —
The effects of intense heat on the surface of the
hody are a greater or less degree of excitement, a
temporary or permanent suspension of the func-
tions of the part to which it has been applied ; or
in other words, there is produced a state of in-
flammation, gangrene, and sphacelus. The states
of inflammation and of gangrene do not require to
be described, as the phenomena which they pre-
sent in the present case do not differ materially
from those which accompany the same changes
when they occur without any obvious cause, if
we except the rapidity of their progress, and also
the more sudden and extensive development of
phlyctenae, bullae, or blisters, particularly when
the heat is applied by means of a fluid. The
state of sphacelus produced by the direct applica-
tion of heat presents several very characteristic
appearances. The skin is of a yellow, grey,
brown, or black colour ; dry and hard ; sunk below
the level of the surrounding surface, and quite in-
sensible. These are, sometimes, the only appear-
ances which are at first perceived to follow the
action of intense heat, and are certain indices of
the complete death of the skin to a greater or less
depth. The deeper-seated tissues may also be de-
prived of their vitality, but to what extent cannot
be determined by any change which the cutis
may have suffered. The inflammatory redness
which succeeds to this state appears almost imme-
diately, and indicates by the rapidity of its course
and the peculiar colour which it assumes, the ex-
tent both of the gangrene and sphacelus, the exist-
ence of which could not be determined by any
previous change of the cutis produced directly by
the heat. We do not wish it to- be understood
♦hat we are speaking of gangrenous inflammation.
The degree of inflammation produced by intense

heat may, certainly, be such as to give rise to
mortification ; but in the present case we wish to
show that both stages of this disease may be, and
often are, the immediate effects of the physical
agent in question, and, consequently, whether
capable of being detected or not by any peculiar
change in the affected part, precede the inflam-
mation to which they are often ascribed.

The extent of the sphacelus may be said to be
always increased by the subsequent inflammation;
and parts that were only in a state of gangrene
are, by means of it, converted into a state of
sphacelus; and hence the necessity of preventing
the extension or modifying the violence of the in-
flammation which succeeds to burns or scalds.

Whether the state of sphacelus may have been
produced by the action of the heat or the subse-
quent inflammation, the limits of the disease are
seldom defined before the end of a week or ten
days. The dead are then separated from the
living parts, and an abundant suppuration takes
place from the denuded surface. The solution of
continuity is often imperfectly repaired in conse-
quence of the exuberant production of granula-
tions, which, instead of acquiring the organization
of the cutaneous texture, assume that of contrac-
tile tissue, which often gives rise to great deformity
of the parts with which it is connected. The
general as well as the local effects of intense heat
in case of burns and scalds, are proportioned to
the extent and violence of the injury produced by
this agent. They are characterized by excessive
pain, great mental agitation, and extreme thirst;
the pulse is rapid and hard, the skin hot, and the
secretions in general are diminished in quantity.

If a remission of these symptoms does not take
place soon, the pulse becomes small and feeble,
and the skin covered with a cold sweat ; the suf-
ferings of the patient are announced by wild deli-
rium ; or he sinks into a state of stupor, accom-
panied with convulsion. In some cases of violent
and extensive burns, these symptoms make their
appearance almost immediately after, and are fol-
lowed by death in the course of a few hours.

The general symptoms are greatly modified by
the situation of the burn or scald, independently
of the age, constitution, and temperament of the
patient. For it has been observed that a burn of
any of the extremities gives rise to much less con-
stitutional disturbance than a burn of the walls
of the chest or abdomen, although it may be of
the same degree and extent in each of these parts.
The greater functional derangement in the latter
case depends, no doubt, on the vicinity of the dis-
ease to the important organs contained in the ab-
dominal and thoracic cavities.

It has been asserted that the mucous mem-
branes, and especially the digestive mucous mem-
brane, are not only inflamed in all cases of burns
of any considerable extent, but that the secondary
fever that follows is chiefly owing to this lesion
of the digestive organs. With regard to the latter
statement, nothing can be more obviously erro-
neous, as the intensity of the pain in all such
cases is in itself sufficient to produce the secondary
fever. However far the former statement may be
correct, we have not had sufficient opportunity to
determine. We have seen the respiratory and
mucous membranes red and vascular in one fatal

MORTIFICATION,

357

case, the patient having died at the end of four I
d:iys. In two other cases this membrane in both
of these organs was pale, and without any appro-
ciablc lesion. These two patients were females,
and had the inferior half of their bodies severely
burnt, from their clothes having caught fire : both
of them lived seven or eight days. It is possible
that the difference in the duration of the disease
in these cases may have had some share in effect-
ing the difference observed in the state of the mu-
cous membrane after death. But it is of greater
importance to observe that the secondary symp-
toms were equally severe in all the three patients.

With regard to the local and general treatment
of burns and scalds, we shall only observe that
in the latter, antiphlogistic measures, carried to
the extent which the individual case demands,
must always be had recourse to, although the se-
condary fever, when it occurs at an early period,
and depends more on the shock which the system
has received and the violence of the pain, is but
little under the control of such measures. More
benefit is derived from the administration of ano-
dynes, and the use of those means which the sur-
geon has found to be most successful in allaying
the local heat and pain of the injured part. Opi-
ates are particularly useful in abating the great
nervous excitement which accompanies this form
of fever, and in procuring a temporary respite
from suffering.

It is of much importance to distinguish between
the febrile excitement which immediately follows
the injury, and the secondary fever which is the
consequence of the subsequent inflammation. As
in the latter case, general bloodletting is always
more or less useful. The same indication is
pointed out when inflammation of an internal
organ has taken place, although leeching and
cupping are oftener to be preferred to the lancet.
In stout young persons of a sanguine tempera-
ment it may be necessary to employ both.

2, Mortification from Cold. — The local and
general effects of intense cold are, in many re-
spects, very similar to those produced by intense
heat. If the degree of cold be not very great, the
circulation and temperature, of the skin for exam-
ple, when submitted to its influence, are increased,
as is shown by this tissue assuming a redder co-
lour, and feeling warmer than before. On the
contrary, if the cold be very intense, it may not
give rise to any appreciable degree of local excite-
ment; the vitality of the skin, and even of the
deeper-seated tissues at the same time, may be
either greatly reduced or entirely destroyed by the
direct operation of this physical agent. There is,
however, this difference between the local effects
of heat and cold, viz. that the former may produce
complete disorganization of the tissues submitted
to its action ; whereas the latter never produces
such a change. In the former the local redness
rapidly increases, in the latter it rapidly dimin-
ishes ; and in the same manner does the sensibi-
lity increase and decrease under the influence of
these agents respectively. (We are now speaking
of the immediate, and not the subsequent effects
of cold.) The general effects, or functional disor-
der produced by the immediate operation of cold,
are very different from those produced by heat.
If the cold has been limited in its operation to the

extremity of a limb, complete death of the part
may ensue without any general functional de-
rangement being induced. But if the whole body
has been exposed to its operation, every function
becomes depressed, and a state of lethargy soon
succeeds, from which the patient is often not to
be roused, either by the entreaties of his friends
or the best directed efforts of the physician.

The symptomatic fever which follows the local
effects of cold does not take place until inflamma-
tion has succeeded to these effects, for it depends
exclusively on the presence of this morbid state ;
and hence the similarity said to exist between the
symptoms of mortification from cold, and those
of mortification from heat. It is, in fact, only
after the occurrence of inflammation that the local
and general symptoms of mortification from these
two causes acquire a striking similarity in kind,
if not in degree.

Although a state of gangrene and sphacelus of
a limb or a portion of a limb may be induced by
the direct operation of intense cold, we may not
be able to determine the existence of either until
inflammation has taken place. It is, however,
said that the toes and fingers have been seen to
fall off, having been deprived of life on account of
the intensity of the cold. But by far the most
frequent occurrence of mortification is when a
frozen limb is exposed to natural or artificial heat,
as before a fire or during thaw. The blood that
was before frozen thus regains its fluidity, and
gangrene and sphacelus, if they were not previ-
ously, are now more or less rapidly induced.
Under these circumstances, the skin assumes a
dark red or livid colour, where it is in a state of
gangrene or sphacelus, and the neighbouring skin
acquires an erythematous blush, accompanied with
a prickling or tingling sensation, and a feeling of
weight or stiffness in the limb. By-and-bye phlyc-
tenae appear on the inflamed part of the limb, and
grey, livid, or black spots on that part of it which
is in a state of sphacelus. Then also putrefaction
commences, and extends till its progress is arrested
by the adhesive inflammation. In this kind of
mortification, as well as in every other, the exten-
sion of the sphacelus depends much on the degree
of the subsequent inflammation, to subdue and
still more to prevent the occurrence of which every
means ought to be promptly and sedulously em-
ployed.

The treatment of a frozen limb, for example,
consists in rubbing it with snow or pounded ice,
in order to re-establish gradually its sensibility
and circulation, and afterwards the use of a circu-
lar roller carried from the toes upwards, the good
effects of which depend on the obstacle which it
opposes to the accumulation of the blood in the
limb, and to the distension and swelling to which
the presence of this fluid and the subsequent effu-
sion of serosity give rise.

3. Mortification from Stimuli. — The
stimuli included under the present head, and
which give rise to mortification, are those which
exercise a chemical influence on the tissues with
which they come in contact. The nitric, muriatic,
and sulphuric acids may be cited as furnishing us
with examples of chemical stimuli which produce
local death when they are applied to the skin or

358

MORTIFICATION.

mucous membrane of the digestive organs. The
local effects of these substances resemble very
much those produced by intense heat. Like the
latter physical agent, they instantly destroy, to a
greater or less depth, when strong, the cutaneous
and mucous tissues. In both cases, the vitality
and texture of these tissues are destroyed, and the
functional derangements of the economy are also
very nearly the same, particularly when the former
have been applied to the digestive mucous mem-
brane. The functional derangement, too, which
follows the action of these chemical stimuli, does
not arise in consequence of absorption, but, as is
the case in intense heat, from the sudden shock
which the nervous system receives at the moment
they are applied, and the state of excitement of
this system from the inflammation to which they
give rise. Instead of a state of complete local
death, or sphacelus, we may have as the result of
their action, when diluted, a state of gangrene, or
simply inflammation, and which may, as in simi-
lar states produced by other causes, terminate in
sphacelus. A state of sphacelus is, however, the
far more frequent effect of their immediate opera-
tion in the undiluted state, to which inflammation
occurs as a subsequent change, and which seldom
proceeds, unless in the mucous membranes, beyond
that degree necessary for the elimination of the
dead part.

The local effects of these chemical stimuli are
not often confined to one portion of the cutaneous
or mucous tissues ; they are generally perceived
on several portions of both, the form and extent
of which are subject to great variety, more partic-
ularly in the stomach ; the states of vacuity and
fulness, or the nature of the contents of this organ,
modifying, in a greater or less degree, both of
these local circumstances.

The changes of colour which indicate that local
death has been produced by these chemical stimuli
are well known ; they are either yellow, yellowish
brown, brown, or black, changes which seem to
depend much on the quantity of blood contained
in the part, and the strength of the acid which
has been applied to it.

Perforation of the stomach, giving rise to a
communication between the cavity of this organ
and that of the peritoneum, is not unfrequently
the consequence of the introduction of these acids
into this organ, and we believe that when it does
take place, it is generally soon after their introduc-
tion, and before the peritoneal inflammation which
ensues has been sufficiently long established to
furnish coagulable lymph, and unite some neigh-
bouring organ with the stomach, opposite that
part of it which has been acted upon by the acid.
Under these circumstances, therefore, the perfora-
tion is not the consequence of the separation of
the sphacelated tunics of the stomach by their
subsequent inflammation, but is the result of their
immediate and complete destruction.

There are several important points connected
with this part of our subject which merit particu-
lar consideration, more particularly the change of
colour and consistence to which chemical stimuli
give rise in the mucous membrane of the stomach,
to the former of which we have already alluded,
Dut into the consideration of which we do not
hink it necessary to enter in this place, as we

have already insisted on similar changes in the
article Melanosis, where we have endeavoured
to show that they may be produced by the action
of the gastric acid after death, and present appear-
ances so similar to those of the former as to lead
the toxicologist and medical jurist to commit the
most serious mistakes. As these chemical stimuli
are classed among the poisons, we refer the reader
to the article Toxicologt for a description of the
symptoms to which they give rise, and the treat-
ment which they require.

III. — Mortification fhom the deleterious

INFLUENCE OF CERTAIN POISONS.

The poisonous substances which we propose to
include under the present head are those which
are derived from the animal and vegetable king-
doms. Some of these substances are natural,
others morbid products. The former consist in a
peculiar healthy secretion of certain animals,
which is capable of producing disease or death in
other healthy animals, and for which we have no
distinctive appellation except the vulgar term of
venom. The latter, derived from the animal king-
dom, are generated by a state of disease of the
animal solids and fluids, are capable of producing
the same morbid state to which they owe their
formation, when communicated, directly or indi-
rectly, from one animal to another, and are termed
virus. We have no specific denomination for.the
deleterious agent generated by the decomposition
of animal matter, and by that diseased state of
rye which gives rise to mortification.

Mortification arising from these different sources
may be considered with advantage under the fol-
lowing heads: — 1. mortification from a deleterious
agent generated in healthy animals ; 2. mortifica-
tion from a deleterious agent generated during the
decomposition of animal substances, and in ani-
mals in a state of disease ; 3. mortification from a
deleterious agent generated in vegetables in a state
of disease.

1. Mortification from a deleterious agent
generated in healthy animals. — We have
already said that a peculiar healthy secretion of
certain animals is capable of giving rise to morti-
fication, when directly applied to the body of
another healthy animal. The most striking ex-
amples of this are met with in the effects which
follow the bite of the cobra di copella, the rattle-
snake, and the viper. When the poison of these
animals is inserted into the cutaneous and cellular
tissues of one of the limbs, the most acute pain is
produced, which rapidly extends in both directions
towards the extremities of the limb ; the cellular
tissue becomes cedematous, much swollen, and
hard. If there be any redness of the skin around
the wound, it is of short duration, and is suc-
ceeded by a livid discoloration, which increases in
extent, followed by the formation of phlyctenae,
and diminution of the temperature of the affected
part. The hard cedematous swelling of the skin
and cellular tissue then becomes soft, crepitates
when pressed, and a sanious discharge, of a fetid
odour, runs out from the wound. During the
short time these local changes are taking place,
the functional derangement produced by the ab-
sorption of the poison proceeds with extreme
rapidity, and it may terminate in death i" the

MORTIFICATION.

359

course of a few hours. Almost immediately after
the insertion of the poison, a sense of great op-
pression is felt in the region of the heart: the
respiration becomes laborious ; there is great pain
in the head, or vertigo, and frequently pain in
other parts of the body, but particularly in the
stomach and intestines, accompanied with vomit-
ing and diarrhoea : vision is also sometimes much
impaired, and the pulse small and intermittent.
As the influence of the poison becomes more ex-
tended, to these symptoms are added extreme
debility, great anxiety, the most unquenchable
thirst, cold sweats, hiccup, and frequent fainting
fits : the skin assumes a sallow, jaundiced aspect,
and the breath becomes extremely offensive. Such
is a general description of the local and general
effects which follow the insertion of the poison of
these animals into the cutaneous and cellular tis-
sues. Although the local treatment is strictly
surgical, we may state here that it consists, as re-
commended by Celsus, and very recently by Sir
David Barry and others, in the application of a
ligature to the limb between the wound and the
heart, so as to arrest the venous circulation and
intercept the poison ; the use of the cupping-glass,
and the actual cautery. Various topical remedies
are recommended, and are said to have been em-
ployed with success. Indeed, the local appears to
be much more successful than any general treat-
ment that has yet been devised, in arresting the pro-
gress or in preventing the baneful effects of the poi-
son of these animals. The liquor ammonias is re-
garded as the best internal remedy that can be em-
ployed. It is also said that stimulating sudorifics
have been found useful ; but it does not appear that
much reliance is to be placed on the use of internal
remedies when the poison has once entered the sys-
tem, and when it possesses such a degree of viru-
lence as to destroy the vitality of the part to which it
is originally applied. It is to such cases alone that
our observations apply, as in milder cases mortifi-
cation seldom occurs in consequence of the direct
application of the poison.

2. Mortification from a deleterious agent
generated during the decomposition of
animal substances, and in animals in a
state of diseaset — The production of mortifi-
cation from a septic agent, generated during the
decomposition of animal substances, or in animals
in a state of disease, being introduced into the
blood or applied to the surface of the body or of
sores, is by no means a rare occurrence. The
most obvious and frequent examples of mortifica-
tion of this kind are met with in the bodies of
those who have died from mortification of some
external part of the body, from whatever cause
arising. Mortification of a portion of a limb,
succeeding to inflammation, to a mechanical in-
jury, to an operation, is often followed by mortifi-
cation of some internal organ. The same may
be said of mortification of one internal organ,
giving rise to mortification of another internal
organ, although it is by no means so frequently
observed as in the former case. We have seen a
considerable number of cases of gangrene and
sphacelus of internal organs originating in the
existence of similar states on the external surface
of the body. That such is frequently the origin
of mortification of internal organs there cannot

be the slightest doubt ; for it occurs when this
disease affects an external part of the body from
inflammation, a surgical operation, or other causes
to which the internal organs, which are after-
wards found to be in a state of mortification,
were in no way whatever subjected. The septic
principle is carried into the blood, and appears to
give rise to a state of gangrene or sphacelus,
without these being preceded by any perceptible
intermediate change. For when we examine the
organ thus affected, we do not perceive any of
those changes which accompany inflammation,
such as red induration or suppuration ; nor are
there any symptoms during the life of the patient
which indicate the presence of a local disease.
The lungs and liver may be extensively affected
without the functions of either undergoing any
modification which indicates the existence of such
a disease. They are, however, modified, as well
as those of every other organ of the body, by the
contaminated state of the blood, to which we have
already ascribed that peculiar assemblage of symp-
toms which make their appearance at the close of
the fatal termination of sphacelus.

The morbid appearances of this kind of morti-
fication of internal organs present several pecu-
liarities. The tissues of the organ do not, as we
have already said, exhibit any of those changes
which constitute the anatomical characters of in-
flammation. They are, on the contrary, found to
present those appearances which we observe on a
part of the external surface of the body to which
a virulent poison has been applied, viz. a circum-
scribed dull deep-red, livid, brown, or black colour,
in which state they feel firmer than natural ; or
they are of a dirty grey colour, of a soft pulpy
consistence, or entirely decomposed and trans-
formed into a grey or reddish-brown fluid of the
consistence of pus, around which the other tissues
may not present any material alteration. These
appearances are most frequently observed in the
lungs and liver. They may exist in several
points of these organs at the same time ; may oc-
cupy an extent of surface varying from the fourth
of an inch to two or three inches ; and are much
more frequently situated towards the external sur-
face, than in the central parts of these organs.
In the lungs they are generally seen under the
pleura, and if the patient survives a certain length
of time the contaminating influence of the poison
to which they owe their origin, the pleura sloughs,
and pneumothorax is produced. We have seen
two examples of this termination of sphacelus of
the pulmonary tissue and pleura, arising in, or
connected with, sphacelus of the ankle-joint in
one patient, and in another with sphacelus of the
larynx.

The production of gangrene and sphacelus
from a septic agent generated in a state of dis-
ease is no less conspicuous in what is called
hospital gangrene. Whatever may be the
causes of hospital gangrene, this local disease may
be communicated by means of the fluids of the
diseased part being brought in contact with the
surface of common sores, a scratch or prick, and,
it is said, with the healthy skin. When the dis-
ease is thus produced, for example in a sore, th6
surface assumes a paler or livid aspect, becomes
swollen and painful, and covered with a viscid

360

MORTIFICATION.

grey matter tinged with specks of blood. The
surrounding integuments soon present the same
appearances, arc converted into dirty-grey spongy
sloughs, the extent of which, as well as the pro-
gress of the disease, is marked by the preceding
discoloration, which is often of an erysipelatous
character, affecting at the same time the skin and
subjacent cellular tissue, and thence the adjoining
lymphatic glands, which are also destroyed in the
manner above stated. But although the state of
sphacelus be often preceded by an erysipelatous
redness, the separation of the dead parts is al-
ways accompanied by more or less hemorrhage,
which shows that the plastic property of the blood
by means of which hemorrhage is prevented, as
well as the vitality of the solids, is destroyed in
this kind of mortification. Dr. Hennen, in his
Principles of Military Surgery, states that in
the last stage of the disease there is a bloody
oozing from the surface of the denuded parts ;
that in lifting up the edge of the flabby slough,
the probe is tinged with dark-coloured grumous
blood, with which its track becomes immediately
filled, and that at this period of the disease re-
peated and copious bleedings take place which
rapidly sink the strength of the patient. The
sloughs, whether falling off spontaneously, or de-
tached by art, are thickly studded with specks of
arter'al blood ; and when hemorrhage takes place
from an artery which it is necessary to tie, and
which is ruptured by the ligature, the application
of the tourniquet or other pressure is employed in
vain, for while it checks the bleeding, it accele-
rates the death of the limb, which becomes fright-
fully swollen and horribly fetid.

The constitutional symptoms of this kind of
mortification sometimes precede the local affection,
at other times do not make their appearance until
it is fairly established. But however this may be,
they are characterized by greater or less derange-
ment of the digestive functions, a feeble and quick
pulse, and great weakness of mind and body.
" Men," says Dr. Hennen, " who had borne am-
putation without a groan, shrunk at the washing
of their sores, and shuddered at the sight of a
dead comrade ; or even, on hearing the report of
his death, predicted their own dissolution, and
sunk into sullen despair." The fatal termination
of this frightful form of mortification is announced
by extreme prostration, vomiting, hiccup, involun-
tary dejections, and coma.

The treatment of the present form of mortifi-
cation will depend much on the state of body and
mind of the patient, and the situation in which he
is placed. When it occurs in a healthy indivi-
dual, his removal from the place in which it was
communicated to him, and the topical application
of those remedies (the concentrated acids or actual
cautery) which are now found to be most effica-
cious in arresting the progress of the disease, will
in general effect a speedy cure. In such means,
also, consists the most essential part of the treat-
ment which the situation of those patients will
allow in whom the disease occurs spontaneously,
that is to say, without any direct cause, and whose
mind and body have suffered from the injurious
influence of disappointment and privations of
various kinds. Cheering prospects, wholesome
food, and change of situation, are well known to

be the most effectual means of preventing and
checking the ravages of this disease in haspitals,
or other situations, in which a greater or less num-
ber of patients are confined, and without which
all our remedies are often entirely useless, or pro-
cure only a temporary or partial benefit.

The next form of mortification produced by a
septic agent generated by disease is that which is
called pustule maligue, or charbon, by the
French, and milzbrand, by the Germans. By
some pathologists this disease is believed to origi-
nate in horned cattle, among which it sometimes
prevails epidemically to a very great extent, and
that when it occurs in man, it is always derived
from such animals. By others it is said to occur
sporadically in persons who have no connection,
either directly or indirectly, with animals so dis-
eased. Be this as it may, the important fact is,
that a septic principle is generated in this disease,
which possesses the property of communicating a
similar disease from one animal to another and
from person to person. Hence it is that herds-
men, butchers, and tanners, and all other persons
who handle the skin, blood, and flesh of these
animals, are those in whom the malignant pustule
or carbuncle is generally observed. Enaux and
Chaussier regarded the occurrence of the disease
in such persons as strong proof that it was com-
municated to them by immediate contact ; and in
further support of this opinion, they adduce the
facts that malignant pustule makes its appearance
exclusively on those parts of the body which are
usually uncovered, such as the face, neck, breast,
and shoulders ; the hands and arras, feet and
legs ; and that in general it is observed in such
persons when it reigns endemically among cattle.
(Enaux et Chaussier, Methode de Trailer les
Morsures des Animaux Enrages, &c. suivie d'un
precis sur la pustule maligne. Dijon et Paris,
1785.)

Numerous examples are recorded of malignant
pustule being communicated in the manner above
alluded to, as well as of its being communicated
to persons employed in dressing those affected
with the disease. The blood appears to be strongly
impregnated with the septic principle generated in
this disease, for parts of the body on which this
fluid has been deposited have soon after been af-
fected with malignant pustule, and similar effects
follow its injection into the veins, as was the case
in the experiments of MM. Leuret and Hamont.
(Journal des Progres des Sciences Medicates,
1827.)

Those who eat the flesh are also often affected
with an eruption of malignant pustules, and other
symptoms similar to those which the animal from
which the flesh was taken presented.

Malignant pustule commences in the form of a
small vesicle, filled with a somewhat bloody sero-
sity, accompanied with a circumscribed oedematous
swelling of the skin and cellular tissue beneath it,
which soon extends in breadth, followed by an ery-
sipelatous redness of the skin. As the swelling in-
creases, the skin acquires a glossy aspect, and pre-
sents here and there small and large phlyctens.
The erysipelatous redness soon assumes a livid
tint ; the central portion becomes brown or black,
hard and insensible, whilst the surrounding parts
are tense and emphysematous. These changes

MORTIFICATION.

361

are produced with greater or less rapidity, and
sometimes extend to a considerable distance, fol-
lowed by extensive sloughing of the skin and cel-
lular tissue. The local and general symptoms of
malignant pustule resemble very much those which
follow the bite of the viper, &c. which we have
already described, and require nearly the same
treatment.

Maurand (Histoire d'une Maladie tres singu-
licre, &c. in Hist, de l'Acad. des Sciences, 1766,
i. 97) relates some cases of malignant pustule
produced by the flesh or blood of over-driven cat-
tle, although their bodies presented no appearance
of disease. It would appear that the flesh of such
animals may be eaten with impunity when cooked,
but that if the blood or raw flesh be applied to
the wounded skin, or even to the unbroken skin,
diffuse cellular inflammation is excited, or malig-
nant pustule produced, which frequently terminate
fatally ; and M. Dupuy states that the malignant
pustule or carbuncle of cattle may be produced by
applying to a wound the blood of an animal that
has died of gangrene of the lungs. (Revue Mti-
dicale, 1827, ii. 488.)

The carbuncle of plague and the malignant
pustule present precisely the same local charac-
ters as those which we have just described, and
seem to owe their origin to a similar cause, viz.
the development of a septic agent, and which in
the former seems to be formed during the pro-
gress of the disease in which it is observed. The
number of the pestilential carbuncles vary consi-
derably, and are generally in proportion to the
gravity of the disease which they accompany and
in which they originate. Pestilential carbuncle,
like malignant pustule, may be communicated by
contact or inoculation ; and it is said by Diemer-
broeck and Desgenettes, may prove fatal without
giving rise to the general symptoms of the plague.
(Diemerbroeck, Tractatus de Peste, 1665. Des-
genettes, Histoire Medicale de l'Armee d'Orient,
1S02.)

There can be no doubt that a septic agent is
developed during the decomposition of animal
substances, apart from the living body, capable of
producing mortification. This state, however, is
always preceded by erysipelatous inflammation,
which spreads with great rapidity and proceeds to
a great extent, and followed during its progress
by extensive sloughing of the skin and cellular
tissue, and is accompanied by the same kind of
general symptoms that characterize the action of
all septic agents on the economy. It is difficult
to say how far wounds received in dissection or
in the inspection of dead bodies, and which are
followed by diffuse erysipelatous and gangrenous
inflammation, depend on the presence of a septic
agent developed during the progress of disease, or
alter death. One thing is certain, that the fre-
quency and severity of the disease which follows
such wounds, have, so far as we can perceive, no
connection with the ordinary changes of the solids
and fluids produced by putrefaction ; for the re-
sults of our own experience are in accordance
with the generally received opinion, that it most
frequently occurs after wounds received in the ex-
amination of recent bodies, and also in the bodies
of those who have died of inflammatory effusions
into the serous cavities. Nevertheless similar con-

Vol. III. — 46 2 f

sequences follow pricks and wounds from putrid
bones, and the contact of putrid animal matter
with the abraded surface of the skin ; and Culle-
rier says that gangrene sometimes attacks the penis
of those persons employed to clean out the cess-
pools in Paris, if they are affected at the time with
gonorrhoea.

It would appear that a septic agent is developed
in various grains in a state of disease, but more
particularly in rye, which, when used as an article
of food, has frequently given rise to one of the
worst forms of mortification. This form of mor-
tification has, perhaps, been exclusively observed
in various parts of the continent of Europe, and
particularly in those districts of France, Germany,
and Switzerland, in which rye forms the chief
article of food of the inhabitants. In these and
various other parts of the continent, the local and
general effects of spurred rye, as it is called, have
been observed and described by several physicians ;
but it was not till the year 1597 that they were
traced to the internal use of that diseased grain.
Since then, repeated epidemics have occurred, and
always during rainy seasons, and which have pre-
vailed most in places naturally moist and of a
poor soil, — circumstances to which, in fact, the
ergot or cockspur owes its origin. We shall not
stop to inquire into the causes of the spur in rye,
and besides shall confine ourselves to a general
description of its effects. The effects produced
by the use of spurred rye as an article of food are
very various. In some individuals the influence
of the poisonous ingredient is chiefly exerted on
the brain and nervous system, the most remarka-
ble symptoms being vertigo, dimness of sight,
pain, loss of sensibility, cramps and convulsions,
yellow discoloration of the skin, thirst and feeble
pulse. These symptoms are greatly modified in
degree in different individuals, and are sometimes
slow and at other times very rapid in their pro-
gress. In the most acute form of the disease
death may take place at the end of one or two
days, preceded by dreadful cramps and convulsions
of the whole body. Even in the milder cases,
the convulsions are more or less severe towards
the fatal termination of the disease ; and hence
this form of the disease is called convulsive
ergotism by French writers, and is vulgarly deno-
minated in Germany Kriebelkrankheit, or creeping
sickness. In other individuals, placed apparently
in similar circumstances, the most remarkable
effect which follows the operation of the same
septic agent is gangrene or sphacelus of certain
parts of the body. Hence this form of the dis-
ease has received the name of gangrenous
ergotism, necrosis ustilaginea, seu epidemica.

The local, like the general effects of spurred
rye, present considerably variety. The following
description of them taken from the works of those
authors who have witnessed the disease in various
parts of the continent, contains the principal
forms under which they have appeared. In one
class of patients seen by Dodart, the disease was
characterized by vertigo, a malignant form of
fever, great drowsiness, and gangrene of the in-
ferior extremities. The gangrene was preceded
by a sensation of numbness in the legs, which
became afterwards painful, slightly swollen, but
not inflamed. The skin was cold and livid, ami

362

M

ORT IF ic ATI ON — NARCOTICS.

the sphacelus commenced in the centre of the
limb, and did not reach the skin till some time
after. (Journal des Savans, 1676.)

In a second class of patients, in which the dis-
ease was observed by Noel, surgeon to the Hotel
Dieu of Orleans, the sphacelated parts were dry,
livid, or black : these appearances commenced in
the toes, and gradually extended sometimes as far
as the thighs. In some the sphacelated parts
separated spontaneously ; in others the progress
of the disease was arrested by scarifications.

Lang, who observed the gangrenous ergotism
in Luzerne, Zurich, and Berne, says that the dis-
ease commenced with lassitude and a sensation as
of insects creeping under the skin, without fever.
.Soon after, the extremities became cold, pale,
wrinkled, and benumbed, and at last quite in-
sensible and incapable of motion ; afterwards acute
pain was felt, referable to the central parts of the
limbs, which was exasperated by heat and miti-
gated by cold applications ; there was then, also,
fever and headach ; the pain extended from the
hands and feet to the shoulders, legs, and thighs ;
and lastly, the affected parts became dry, shrunk,
and black, and dropped off at the joints. Entire
extremities were thus separated from the body
without hemorrhage. Many patients lost both
legs, several the arms, and a few both legs and
arms. (Descriptio morborum ex usu clavorum
secalinorum cum pane, 1707.) In other cases,
the chief symptoms were, at first, spasmodic con-
tractions of the limbs, afterwards great weakness
of mind, voracity and dyspepsia, which generally
terminated in fatuity or sphacelus. (Rust's Ma-
gazine, xxv. to which the reader is referred for a
detailed account of the local and general effect of
spurred rye.) The parts most frequently attacked
with gangrenous ergotism are the inferior ex-
tremities. Men are more subject to the disease
than women, and children and old people than
adults.

From the above description of the local and
general effects of spurred rye, it is by no means
easy to say in what manner this poisonous article
of food operates so as to produce mortification.
One thing, however, appears certain, that it is not
by an inflammatory process of the part which be-
comes the seat of the disease. That cessation of
the circulation and loss of the sensibility and mo-
tion of the limb observed to take place at an early
period of the disease, are not the consequences of
inflammation, is clearly proved by the nature of
the local, if not the general symptoms which we
have detailed. All these local changes appear to
be produced as direct consequences of the spurred
rye, acting through the medium of the blood or
nervous system, or both at the same time. For
we have seen that the dead parts are separated
without hemorrhage, and it is stated that the
blood, when taken from a vein, is dark and so
very thick that it only oozes out from the orifice
of the wound.

In several animals which died after having been
fed for some time on spurred rye, and who pre-
sented several of the symptoms already mentioned,
gangrenous spots are said to have been found in
the stomach, intestines, and liver. But the morbid
anatomy of this disease is extremely imperfect,
and does not enable ua to offer any explanation

either in regard to the nature of the disease itself
or its complications; or to suggest any means
other than those already employed in its treat-
ment, and which may be said to be almost entirely
empirical. Bloodletting, emetics, and purgatives
have been employed by some ; tonics and stimuli
by others ; and lastly, anodynes and narcotics, all
of which methods of treatment appear to have
been more or less successful in one form of the
disease, and of little or no avail in another.
Stimulating lotions, warm fomentations, and fric-
tion appear to mitigate the local symptoms, and
along with the general treatment, sometimes to
arrest the further progress of the disease.

R. Carswell.

MUMPS. See Parotitis.

[MYELITIS. See Spinal Marrow, Dis-
eases or the. It has been proposed by Dr. Mar-
shall Hall, to call inflammation of the membranes
of the brain meningitis ; that of the substance or
neurine of the brain myelitis.']

NARCOTICS, (from vapw, stupor,) syn.
hypnotica. — These are medicines which in small
or moderate doses produce temporary excitement
succeeded by depression, which is generally fol-
lowed by sleep. This definition does not compre-
hend the anodyne power strikingly displayed by
many narcotics ; because, although it is undeni-
able that many of them are capable of alleviating
pain, yet, as this is not a general property of nar-
cotics, it cannot correctly enter into a definition
of the class.

Narcotics are commonly confounded with seda-
tives, but there are sufficient reasons for separating
these two classes. In the first place narcotics
operate as diffusible excitants, and by a proper
regulation of the dose, and its administration at
short intervals, their exciting influence only is
obtained ; in the second place, the depression or
collapse which follows the administration of the
full dose of a narcotic is the result of the previous
excitement ; and although this is not in the direct
ratio of the degree of excitement, yet, if the ex-
citant effect be considerable, and raised to its
acme, the succeeding collapse is proportionate.
On the other hand, sedatives immediately depress
the vital energies by a peculiar action upon the
nervous centres, without causing previous excite-
ment ; and, if the dose be sufficiently large, they
destroy both mobility and sensibility. Such are
the distinctions between the effects of the admin-
istration of narcotics and sedatives, — distinctions
undoubtedly sufficient to authorize the separation
of these classes of medicinal agents.

The first effect of a moderate dose of any nar-
cotic is an augmentation of the action of the heart
and arteries, followed by an elevation of the heat
of the whole body, and a slight sensation of ful-
ness in the head. These symptoms are accompa-
nied with an unusual exhilaration of spirits and
aptitude for exertion ; effects which, however, in
a little time subside, and are followed by languor
and drowsiness, gradually terminating in perfect
sleep. The augmented arterial action is succeeded
by a small, feeble, and irregular state of the pulse;
the temperature of the body is lowered ; and the
respiration, which in the first instance was accele-
rated in the ratio of the augmented vascular action,

NARCOTICS,

363

falls below the natural standard ; an imperfect
decarbonization consequently is effected in the
pulmonary circulation ; so that the blood trans-
mitted to the brain being inadequate for due ex-
citement, the whole system necessarily languishes.
The function of the skin is, however, increased,
and passive diaphoresis occurs, accompanied by
itching and the dilatation of all the erectile tis-
sues; finally, the glandular excretions are dimin-
ished, the mouth feels dry, and both the bile and
the urine are evidently defective. The influence
on the stomach varies according to the state of
the organ ; if the narcotic be taken into an empty
stomach, it diminishes the desire for food ; if
swallowed at the time of taking food, the organ is
enervated, and chymification suspended ; if a short
time after a meal, the process of digestion is ar-
rested ; and if vomiting be excited an hour or two
afterwards, the food is ejected in the state in which
it was swallowed. The same effects follow the
introduction of a narcotic into the rectum : the
intestines, besides, frequently lose their ordinary
contractility, and costiveness ensues. This, how-
ever, is the result of a moderate dose of only some
narcotics ; others rather increase than diminish
the peristaltic motion of the intestinal canal.*
After awaking from the sleep induced by a nar-
cotic, the individual frequently experiences slight
headach, some degree of nausea, languor, and a
more than usual susceptibility of impression, with
tremours of the hands, which continue until some
excitant, such as coffee or a glass of wine and
water, be swallowed. By degrees these symptoms
subside, and the system remains in its accustomed
state, unless the dose of the narcotic have been
more than can be termed moderate, in which case
headach, sometimes vertigo and confusion of ideas
supervene and continue for several hours; whilst
anorexia, constipation, and a scanty urinary dis-
charge are experienced for a considerable time, and
the individual is left weak and uncomfortable.

If the dose of the narcotic substance be so large
as to prove poisonous, headach, vertigo, imper-
fection of vision, and stupor, are experienced,
without any previous apparent excitement ; the
person soon becomes motionless and insensible to
external impressions ; he breathes slowly ; and for
some time the expression of the countenance de-
notes only sound and deep repose. By degrees
the features change, and acquire a ghastly char-
acter ; the breathing, under the influence of some
narcotics, is stertorous, as in apoplexy, under that
of others it is soft and natural ; the pulse becomes
irregular, sinks, and at length is almost impercep-
tible ; the muscles relax, the jaw falls, and death
rapidly closes the scene. Many of the symptoms
following the administration of such large doses
of narcotics resemble, in some respects, those at-
tending apoplexy ,• in others, those of epilepsy ;
and occasionally those of hypertrophy of the

♦These effects of narcotics on the alimentary canal
are greatly modified by disease. In subacute inflamma-
tion, or a highly irritable state of the mucous membrane,
vomiting is not (infrequently induced ; in a relaxed con-
dition of that membrane, the atony is augmented, and
indigestion and constipation confirmed; in cancerous
ulceration of the stomach, instead of allaying pain, nar-
cotics cause pain, and excite vomiting and rigors, and
the brain becomes powerfully ejected. In irritable states
of the intestinal canal, however, especially when spasm
is present, they allay griping, resolve spasm, and pro-
duce an anodyne and salutary effect.

brain ; but in every case the distinction is appa-
rent, when the circumstances preceding and at-
tending the attack are duly investigated. Thus,
in apoplexy there are generally premonitory indi-
cations of the threatened attack ; and when the
sopor has commenced, the patient cannot be roused
to any consciousness, which is not the case in
narcotic poisoning. The same kind of sopor at-
tends epilepsy ; it terminates suddenly, and the
attack of the paroxysm is abrupt. Cerebral hy-
pertrophy is a slowly progressing chronic affec-
tion.

The influence of narcotics is modified by a se-
ries of circumstances; for example, by the nature
of the narcotic, the extent of the dose, the time
of the day at which it is administered, the com-
bination in which it is given, the state of health
of the individual, habits of life, age, sex, and tem-
perament ; climate, and idiosyncrasy. Before en-
tering into the consideration of these, let us exam-
ine, briefly, the questions — do the effects of nar-
cotics result from their direct influence on the ner-
vous system ? or is it secondary to their introduc-
tion into the circulation ? These are points which
have been long and strenuously agitated, and on
which the most opposite opinions are maintained.
There is no doubt that narcotics are in many in-
stances received into the circulation, and that they
are most active ; indeed, so much so as to produce
almost immediate death, when they are directly
conveyed into it ; as, for instance, by injection into
the veins : yet even in this case their influence
may be propagated by nervous communication, as
we are led to conclude from the experiments of
Messrs. Morgan and Addison, (An Essay on the
Operation of Poisonous Agents on the Human
Body : London, 1829,) who discovered that they
produce in the sentient extremities of the nerves
on the inner coats of the blood-vessels a peculiar
impression which is conveyed to the brain along
these nerves. This is also demonstrated by the
rapid effects on every part of the system which
follow their administration by the mouth ; often in
a space of time too short to be the result of absorp-
tion. It is also well known that, when the dose
has been so large as to be suddenly followed by
fatal effects, the whole quantity of the narcotic
administered has been found in the stomach.
Some striking objections, it is true, have been
made to the conclusions drawn from the experi-
ments of Mr. Morgan and Dr. Addison ; but the
explanation of the manner in which the effects of
narcotics are diffused over the body does not rest
on their experiments; the nature of the nervous
system enables us to comprehend readily the man-
ner in which this communication of impression is
effected.

The primary action of narcotics is not confined
to the nerves of the stomach ; for if any narcotic,
opium, or atropia, (the active principle o^bella-
donna,) or daturia, (the active principle of stramo-
monium,) for example, be applied to the surface
of the body, the same results follow, although in a
diminished degree, as display themselves, when
they are taken into the stomach. If the applica-
tion be made to an entire membranous surface,
the energy of the narcotic influence is not in the
ratio of the absorbing power of the surface ; and
if it be injected into the thorax, between the lungs

364

NARCOTICS.

and the ribs, the action is more energetic than
when the narcotic is taken into the stomach.
The absorption, however, of narcotics cannot be
doubted ; and when a narcotic substance is ap-
plied to a wound, it is probable that in this case it
operates chiefly by its absorption into the blood ;*
but although its influence can be impeded by a
ligature on the blood-vessels, yet its operation does
not essentially depend on its introduction into the
circulation. When it is injected into the veins,
the animal, as has been already stated, instantly
expires, and this without convulsions. In this
experiment all the muscles of the body are rapidly
deprived of their contractility ; and, therefore, the
action both of the heart and of the respiratory
muscles ceasing, death must necessarily follow.
If these remarks be correct, it is evident that nar-
cotics operate on the brain and the spinal column
by entering the circulation when they are taken in
moderate doses ; but when they are swallowed in
quantities sufficient to prove rapidly fatal, this
effect is the consequence of their immediate influ-
ence on the nervous system ; and when they are
taken into the circulation, their effects may be
still referred to the direct impression which they
make on the nervous system. The nerves most
particularly affected by narcotics are the respira-
tory ; for when artificial respiration is maintained
for some time in an animal poisoned by a narcotic,
the animal recovers.

A question naturally suggests itself — how do
narcotics produce sleep ? Much difficulty attends
the solution of this question ; but some approach
towards it may be attained by keeping in view
the state of the vital functions during sleep. In
this condition of the body, the pulse beats more
slowly than when the person is awake ; the tem-
perature of the body is diminished, the perspira-
tion is decreased, and nearly all the secretions are
suppressed. Now on whatever principle narco-
tics act, if their primary stimulant influence is fol-
lowed by a diminution of the force and frequency
of the circulation, and at the same time of the re-
spiratory effort, the change of the venous into
arterial blood must be necessarily impeded ; and
this alone, by weakening the energy of the brain,
will cause sleep. Such, at least, is the theory
which the writer of this article is inclined to offer.
It may be objected that this explanation applies
equally to all the stimulants ; and such is really
the case, as all transitory stimulants, according to
the extent of the dose, operate like narcotics, and
produce sleep. But there is still something con-
nected with the. anodyne influence of narcotics
which we cannot readily explain, and which re-
quires a more intimate acquaintance with the ner-
vous system than we at present possess.

Circumstances which, modify the action
of Narcotics.

1. Nature of the Narcotic. — The general effects
which have been described as resulting from the
administration of a narcotic are those which opium
produces. When acetate of morphia is substituted
for opium, and a full dose is administered, another
symptom displays itself: the patient, when in the
horizontal posture, is attacked with shocks, as if
electrified ; the head is thrown backwards as in

* M. Lesieur of Paris applies narcotics to blistered sur-
faces in preference to tlieir internal administration.

opisthotonos ; and a paralytic condition of the
bladder of urine supervenes, although there is no
diminution of the secreting powers of the kidney.
If the muriate of morphia be employed, little or no
excitant effect is perceived, whilst the sedative in-
fluence is most obvious. Belladonna, hyoscya-
mus, and aconitum, are more directly anodyne,
and even in small doses affect the sight more than
any other narcotics ; and when the two former are
overdosed, and delirium succeeds, it more resem-
bles the delirium of intoxication than that of nar-
cotism. Irregularity of arterjal action character-
izes the operation of conium, the pulse being in
some instances sunk, in others increased to ono
hundred or more during the whole time of admin-
istering the medicine. When over-dosed, the
breathing is more oppressed, and the thorax more
constricted than with any other narcotic, while
the countenance assumes the aspect of that of a
man who has been strangled. Digitalis accumu-
lates in the system, and veratria (colchicum au-
tumnale) operates chiefly on the duodenum, pro-
ducing copious bilious stools ; thus lessening
febrile action, and allaying pain.

2. Extent of the dose. — The influence of small
and large doses of narcotics has been stated ; and
in many morbid states of the habit they may be
employed to produce either stimulant or sedative
effects. Unless the dose be large enough to dimi-
nish sensibility, they cannot be administered with
the view of procuring sleep. In cases of inflam-
mation, after the use of the lancet, large doses of
narcotics are generally productive of the most
salutary effects; on the contrary, small doses are
likely not only to counteract the benefit derived
from the bleeding, by their stimulant influence,
but, if their administration be repeated, to augment
the evil. In all painful and spasmodic affections,
the extent of the dose is to be limited only by its
effects: thus in tetanus, one hundred drops of the
tincture of opium have been administered every
hour with the best effect ; and the writer of this
article, in cases of gall-stones and renal calculi,
has given upwards of eight hundred drops of the
officinal tincture of opium in less than twelvs
hours, without any effect but that of relieving pain
and aiding the passage of the concretions : indeed,
narcotics may be persevered in to any extent, as
long as they display no determinate action on the
habit. The dose in such cases requires to be
progressively augmented ; if no relief be afforded
in three or four hours, it should be doubled, and
so on until the benefit anticipated be obtained.

3. Period of the day. — When narcotics are
administered in the morning, especially on an
empty stomach, considerable excitement is in-
duced, and the anodyne and hypnotic effects of
the medicine seldom follow ; on the contrary, if
the same dose be given in the evening, little ex-
citement supervenes, and the desire of sleep is so
great that it is impossible to avert it.

4. Combinations. — Narcotics, when uncom-
bined with other substances, produce the effects
already described ; but in combination with many
different substances, their operation is greatly
modified. Thus, in conjunction with tonics, in-
stead of checking chymification, they promote the
appetite and favour the digestive function ; aro-
matics oppose their sedative influence, and delay

NARCOTICS.

365

their soporific effect ; combined with diaphoretics,
whilst the function of the skin is augmented, their
influence on the brain is diminished. Acids pro-
mote their poweis; while alkalies, by decompos-
ing their active principles, and withdrawing the
acids which render their alkaloids soluble, dimi-
nish them, and in many instances render the nar-
cotic inert. We shall notice these effects of com-
bination in describing the individual narcotics.

5. Habit. — Narcotics lose their influence when
they have been taken daily for a considerable time;
and doses have been swallowed under such cir-
cumstances which would at first have proved
fatal. This effect of habit in modifying the action
of narcotics has not been satisfactorily explained,
although M. Charvct has attempted it in reference
to opium. He assumes that the state of conges-
tion of the brain is admitted as the effect of an
over-dose of opium, and supposes that the frequent
use of the drug renders this less considerable ; or
that the brain, accustomed gradually to the flow
of blood and resulting compression, at length is
enabled to bear it with impunity, in the same
manner as when a serous effusion gradually
occurs, or a tumour is slowly developed in
the brain. (Charvet de 1' Action comparee'de
l'Opium.) There is much ingenuity in this ex-
planation ; but the power of habit in modifying
and resisting the influence of some narcotics is
not extended to all ; and, indeed, there is little
similarity of action among narcotics: each has its
own specific or peculiar action on the nervous
system, a circumstance which enables the phy-
sician to accommodate narcotics to the constitu-
tions of his patient. This is peculiarly striking
with respect to the anodyne and hypnotic pro-
perties of narcotics : after the failure of one, the
administration of another will fulfil the intention
of the subscriber, whether it is intended to allay
pain or procure sleep. It is an equally curious
fact, and one of practical importance, that this
force of custom in reference to one narcotic does
not render the system less susceptible of the im-
pression of moderate doses of another : the opium-
eater, accustomed to take a drachm of his favourite
narcotic daily, may be lulled to rest by a few
grains of henbane or conium.

It is unnecessary to mention many instances in
proof of the extent to which the doses of narcotics
may be carried with impunity by those who have
long accustomed themselves to their use. Russell,
in his History of Aleppo, states that Mustapha
Shatar, an opium-eater at Smyrna, took daily
three drachms of the drug, and felt a necessity for
increasing the dose. Dhere, a French author,
mentions the case of an officer of the same nation
who took a drachm of pure opium daily, and ap-
peared in good health, although an alvine evacua-
tion was procured once only in eight days, some-
times once only in fifteen days. But no work
affords so much curious information on this part
of our subject, and so displays the extent to which
the doses of some narcotics may be carried, as the
Confessions of an English Opium-eater. It is,
nevertheless, true that the habitual use of nar-
cotics wears out the powers of life, and leads on
to premature old age. The symptoms which
follow the use of opium, for example, thus in-
dulged in, closely resemble those brought on by

2f*

excess in venery ; marasmus and decrepitude
supervene; the mind equally suffers; and the
wretched individual sinks into the grave a de-
formed and slavering idiot.

6. Age. — The younger the person, the more
energetic is the action of narcotics on the sys-
tem ; they even prove injurious to the foetus, when
they are prescribed to relieve cramps, or allay in-
quietude in the mother; thence the necessity of cau-
tion in administering them to infants, in whom both
convulsions and epilepsy have followed their use.

7. Sex. — Narcotics exert a more powerful influ-
ence on women than on men, a circumstance
which might, a priori, be expected from the greater
susceptibility of the female constitution. To
pregnant females, also, narcotics must be adminis-
tered with the greatest caution, as in this condition
of the female habit a state of the cerebral function
frequently occurs, which is augmented by the
operation of narcotics, and might be productive of
dangerous consequences.

8. Temperament. — There is but one opinion
respecting the power of temperament in modifying
the operation of narcotics. In the sanguine tem-
perament the nervous system is highly sensitive,
and susceptible of every impression, and the body
predisposed to inflammatory action. There can
be no doubt that narcotics will produce a more
powerful impression on such a temperament than
on the opposite or melancholic. In those persons,
for example, who are easily affected by wine, and
in whom inebriety is quickly produced, a small
dose of opium causes powerful cerebral excite-
ment ; thence the maxim of Tralles, « Illi vero
omnes qui vinum non bene ferunt vix bene ferent
opium." On the same account, a condition of
habit likely to favour cerebral congestion is much
more likely to be powerfully influenced by narco-
tics than a spare habit — a fact which ought never
to be lost sight of in practice.

9. Climate. — The action of narcotics is power-
fully modified by climate. The same dose of a
narcotic which produces only beneficial effects in
Great Britain, has been found to operate too pow-
erfully in Italy ; some attention is, therefore,
necessary, in prescribing narcotics, to accommo-
date the doses to the nature of the climate in
which the physician is practising. On the same
principles, season modifies their action, and smaller
doses are required in summer than in winter.
These observations seem, nevertheless, at variance
with the result of temperature on opium, the brain
being less affected when the patient is kept in a
temperature which excites perspiration than in
one which is cooler. M. Hecquet (Vide Charvet
de 1 'Action de l'Opium, p. 58) explains this influ-
ence of temperature in the case of opium, by say-
ing, that as heat favours the flow of sweat, the
opium is carried out of the habit with it, and is
thus prevented from affecting the brain. Charvet
supposes that, as copious sweating diminishes the
mass of the circulating fluids, and renders the
cerebral compression less powerful, the sweating
may be regarded as a favourable crisis whicn
guards the brain from over-compression. Both
opinions are hypothetical ; and it is more likely to
depend on the greater irritability of the habit in
warm climates than in cold, and the consequent
greater susceptibility of impression.

366

NARCOTICS.

10. Idiosyncrasy is more likely to influence the
action of narcotics than any other classes of medi-
cines. In some individuals opium, for example,
even in moderate doses, produces restlessness, de-
lirium, and convulsions ; in others miliary erup-
tions ; and in some its soporific effects are never
experienced until the day following that on which
it is taken.

With regard to the employment of narcotics,
were it consistent with our plan to enter into the
history of this class of remedial agents, we should
remark on the very early period in which mankind
appear to have been acquainted with their effects.
In every nation, and among every people, from
the southern islander, who chews the kava, and
with his own saliva manufactures the intoxicating
bowl, to the polished European, who indulges in
the fermented juice of the grape, all seek in nar-
cotics, not only oblivion from pain, but. a balm for
the cares and sorrows of life — " ducunt sollicita?
jucunda oblivia vita?."

When narcotics are taken in over-doses, they
produce the effects which have been already de-
scribed : post-mortem examinations of the body
display the brain gorged with blood ; and not un-
frequently water is found in the ventricles. In
cases of supposed poisoning by narcotics, however,
care must be taken not to confound the symptoms
with those arising from diseases ; in particular,
apoplexy and epilepsy, which, as has been already
stated, display symptoms closely resembling some
of those attending poison by narcotics.

With regard to the practical employment of
narcotics, it is obvious that they ought not to be
prescribed in cases in which their primary excite-
ment would prove hurtful, unless the dose be large
enough to induce symptoms of diminished sensi-
bility and lessened action without any previous
excitement ; and experience teaches us that this is
the result when a large dose of a narcotic is ad-
ministered, particularly when it is taken immedi-
ately after a copious abstraction of blood ; but if
the dose be small, the opposite effect follows,
proving that the patient may be either greatly
benefited or materially injured by the extent of the
dose of the narcotic, which it may be thought
proper to prescribe. Thus if, in a case of pleurisy,
the pulse be hard, quick, and forcible, and the
pain of the side so acute as almost to prevent even
a half inspiration, if a free bleeding be resorted to,
two grains of opium, in conjunction with the same
quantity of calomel, and a quarter of a grain of
tartar emetic, may be prescribed with the prospect
of much benefit ; but if half a grain only were
ordered, not only would no advantage accrue from
the narcotic, but the stimulant effect alone being
obtained, the benefit of the bleeding would be
counteracted rather than maintained, and the re-
petition of the dose would only increase the evil.
In this respect the action of narcotics does not
differ from that of direct stimulants. In all cases,
therefore, of increased excitement, when pain or
restlessness demands the administration of a nar-
cotic, the dose should be sufficiently large to obtain
at once its anodyne effect, without the primary
stage of excitement.

[Narcotics, in full doses, are precious sedatives ;
and, as such, may be employed in many phleg-
masia?, even from the very onset of the disease.

They are remedies that have been but little under-
stood, and the idea, that they are, under all' cir-
cumstances, stimulants, has occasioned them to be
discarded in diseases in which they would have
afforded signal relief.]

The stimulant influence of narcotics in small
doses is frequently taken advantage of in the
treatment of fevers of a low or typhoid state. The
tincture of opium, for example, given in doses of
ten minims at short intervals, augments the strength
of the pulse, rouses the vigour of the system, and
sometimes supports the strength.

Narcotics may be arranged under two distinct
heads, namely, direct narcotics and indirect nar-
cotics. Under the former may be placed all those
substances which produce their effects by a direct
impression on the nervous system, without neces-
sarily entering the circulation : under the latter
those which enter the blood before acting upon
the nervous system ; for even when they enter the
circulation their influence is still exerted upon the
nerves. The continental physiologists have made
many experiments to ascertain the manner in
which narcotics operate, and have deduced this
inference, that the narcotic must be transmitted to
the brain through the blood before it acts ; but it
is more probable that in full doses direct narcotics
operate by an immediate impression on the sen-
tient extremities of the nerves.

The number of narcotics is considerable, but
the most valuable are opium, and the salts of
morphia, henbane, conium, belladonna, lactuca-
rium, and camphor. It is incompatible with the
plan of this work to enter upon the natural his-
tory, chemical properties, and pharmaceutical pre-
parations of these substances; it is to their im-
portance and employment as remedial agents that
we have to direct the attention of our readers.

Like all other narcotics, opium exerts a primary
stimulant effect on the living system, whether it
be introduced into the stomach or into the rectum,
or injected into a vein, or applied to wounds or
ulcers, or rubbed on the surface of the body.
When taken into the stomach in a solid form, it
undergoes partial digestion ; this process separat-
ing, in a great degree, the active principles, the
meconate of morphia, the narceine and narcotina:
thence the salts of opium act more rapidly than
the entire opium.* During the continuance of the

* The components of opium are —

1. A volatile oil, on which the odour of the drug de-

pends, but existing in such small quantity
that it can scarcely be procured in a separate
form. Water distilled from opium contains it,
and is productive of slight cephalagia wfteH
snuffed up the nostrils, but it displays no other
narcotic property.

2. Gum, including bassorine.

3. Extractive, partly simple, partly unusually any

dized.

4. Resin, with which the colouring matter is closely

combined; and this in conjunction with Hie
volatile oil may he the source of the stimulant
property of the drug.

5. Caoutchouc.

6. Narceine, a new principle lately discovered by IB-

Pelletier; it is crystallizable, is soluble in
water and alcohol ; insoluble in ether; and
has a bitter styptic taste. Its action on the
animal economy is unknown.

7. Mcconine, another new principle, also discovered

by the same able chi mist ; crystallizable; lit-
tle soluble in culd water, but very soluble in
hot water.

8. Morphia, in combination with meconic acid as a

bimeconate.

NARCOTICS.

367

stimulant effect of opium and its salts, the cuticu-
lar secretion is augmented, but some of the other
secretions arc diminished : the urine, for instance,
is scanty and high-coloured ; and after this state
is over, the pale, clay-coloured aspect of the alvine
discharges indicates a greatly diminished excre-
tion of bile. The stimulant effects of a moderate
dose of opium are soon dissipated ; and the ad-
ministration of a much smaller dose, after a short
interval, produces more intense effects than the
first dose, although the reverse of this follows the
continued use of the drug. If the opium be taken
on an empty stomach, the excitement is greater
than when it is swallowed soon after a meal : in
the first case the pulse remains small, although
hard, and symptoms of cerebral congestion rarely
appear ; on the contrary, symptoms of congestion
appear sooner, and are more obvious, if the same
dose be taken just after a meal. From experiments
made by Dr. Crump (An Inquiry into the Nature
and Properties of Opium, &c. 8vo. 1793) and
others, it is evident that the exciting influence of
opium differs little from that of other stimulants ;
but the sleep which follows the excitement of
wine and ordinary stimulants differs from that
procured by the influence of opium ; nor do these
possess the power of opium in relieving pain : it
is therefore fair to conclude that, in its sedative
influence, opium is distinguished from all other
stimulants.

Although it is probable that the effects of opium
on the living system are attributable to its direct
influence on the nervous energy, yet it must be
admitted that there are facts which tend to shake
this opinion ; and one of the strongest is related
by M. Barbier, from which it appears that an
infant was affected by the milk of its mother, who
had taken a large dose of the wine of opium. But
as alcohol is undoubtedly taken up by the absorb-
ents, it is probable that the absorption of the opium
in this case is to be attributed to the vehicle ; and
it is only by admitting the direct influence of
opium on the sentient extremities of nerves, that
we can explain the relief obtained in instances of
severe pain.

Many circumstances, as has been already stated
with respect to narcotics in general, modify the
operation of opium on the living system. The
first of these is age : opium operates with most
energy on the young, consequently the greatest
caution is requisite in administering it to infants,
in whom it often excites convulsions ; even in the
state of syrup of poppies, too often administered
to infants by lazy nurses. A low irritative febrile
state, depending on the continued cerebral excite-
ment produced by the medicine, gradually brings
on marasmus, and undermines the powers of the
constitution. The influence of sex is less than
that of age ; but still experience has proved that
women are more easily affected by opiates than men.

9. JVarcotina, which lias been supposed to be the sti-

mulant principle of the medicine.

10. Sulphates of lime and of potass.

11. A brown, acid.

12. IJgninc or woody fibre.

[The most recent researches have shown, that it has at
least the follow in:; constituents : morphia, narcotin, co-
deia, narcein, itieconin, thebain or paramorphia, pseudo-
morphia, meconic acid, brown acii! extractive, sulphuric
acid, resin, fat oil, gummy matter, caoutchouc, albumen,
odorous principle and lignin.— Pereira. Mat. Med. Amer.
ed. ii. 7lu,Philad. ld-13,]

The effect of custom in modifying the influence
of opium on the system is so well known as
scarcely to require it to be noticed. The extent
of the dose to which it may be carried by those
in the habit of taking it daily is wonderful, but
still larger doses may be given to allay pain and
spasm. Dr. Chapman mentions that, in a case
of cancer in utero, he has given the tincture to
the extent of three pints in twenty-four hours,
without any other effect than that of relieving
pain.

The combination of other substances with opium
greatly modifies its action on the system. When
combined with antimonials, not only are its dia-
phoretic powers increased, but it is rendered less
likely to impede the other secretions. With acids,
half the usual dose will produce the effects of a
full dose, an effect evidently resulting from the pro-
duction of a more soluble salt, the acetate, the
citrate, the sulphate or the muriate of morphia,
according to the acid employed. When we order
it with the view of procuring sleep, we should not
combine aromatics with opium, as these increase
its stimulant, but lessen its sedative influence.

Morphia, the active principle of opium, exists,
as we have already said, as a bimeconate in opium ;
but when it is separated from the other compo-
nents of the opium, it is generally administered in
combination with acetic, or muriatic, or sulphuric
acid, as an acetate, muriate, or a sulphate.* Any
one of these salts, when administered in doses of
a quarter of a grain repeated at short intervals,
causes a sensation of fulness in the head, some
obscurity of sight, tingling of the ears, cephalalgia,
vertigo, and a tendency to sighing and sleep.
The pupils are sometimes dilated, at other times
contracted, and sometimes are not at all affected ;
the pulse is not much accelerated : occasionally
there is a sensation of itching all over the skin,
frequently nausea, and a difficulty in passing
urine. In large doses the cerebral excitement is
alarming. From some observations made by M.
Bailly, in the Hopital de la Pitie in Paris, it ap-
pears that full doses of acetate of morphia some-
times excited shocks like those of electricity, when
the person was lying in the horizontal position :
the muscles lost much of their contractility, and
the sight was greatly impaired. As, in these
cases, the pulse was diminished both in force and
frequency, Bailly was led to infer that morphia
acts as a sedative on the heart, and as a stimulant
on the nervous system ; it would, perhaps, be
nearer the truth to say that it acts as a stimulant
on the nerves of sensation, and as a sedative on
those of motion. It seldom increases the tempe-
rature, although sometimes its salts greatly aug-

* Acetate of morphia is thus prepared: a specific
quantity of morphia dissolved in alcohol is saturated
accurately, with pure acetic acid ; and the solution eva-
porated with the gentle heat of a vapour-bath to dryness
I he sulphate is prepared in a similar manner, care being
taken to employ the acid in a dilute state. The muriate
may be readily prepared by precipitating an aqueous so-
lution of opium by means of muriate of baryta; a me-
conate of baryta, which is insoluble and falls to the
bottom of the fluid, and a muriate of morphia which is
soluble, are obtained. By evaporation of the fluid, the
muriate crystallizes in tussocks consisting of aggrega-
tions of acicular crystals; by pressing these between
colourless blotting-paper, the narcotina is separated, and
the muriate obtained in an impure crystalline state. It
is purified by repeated solutions and reerystallizations.

|For the different modes of preparing morphia and its
salts, see Pereira, Op. cit.J

368

NARCOTICS.

ment the exhalant function of the skin. In over-
doses, whilst the upper part of the body is bathed
in a viscid sweat, the lower extremities are cold ;
there are violent tremours ; the body acquires a livid
hue ; the face has a pinched and cadaverous as-
pect ; and death ensues without convulsions.

The black drop has all the progenies of acetate
of morphia in combination with aromatics.*

From what has been said, it is evident that in
prescribing opium we must always keep in view
both its stimulant and its sedative influence.

\ Codeia. The experience of different observers,
as to the effect of codeia on the economy, has been
discordant. Magendie (Formulaire pour a pre-
parations, £fc, de plusieurs nouveaux medica-
mens, #c.,) states, that it causes sleep, and, in
large doses, stupor. He considers one grain to be
equivalent to half a grain of morphia. A syrup,
each ounce containing two grains of codeia, has
been given in hooping-cough, and in other diseases
in which opium has been found useful ; and with
Dr. Miranda (Journal de Pharmacie, xxiv. 145,
Paris, 1838,) it has proved serviceable in what he
terms " powerful nervous irritations of the mucous
membrane of the stomach." It would not seem,
however, to possess any virtues not contained in
morphia, whilst its cost is excessive. (For the
mode of preparing it, see the writer's New Reme-
dies, 4th edit. Philad. 1843.)

Narcotin. The views in regard to the precise
properties of narcotin are also contradictory; and
owing to the uncertainty in regard to its action, it
is but little employed. It would seem that the ex-
citing properties of opium do not belong to it ex-
clusively, as has been supposed by some, inasmuch
as there are persons who are as disagreeably af-
fected by morphia alone as they are by opium,
which contains both morphia and narcotin. Re-
cently narcotin has been employed as an antipe-
riodic. See Tosrics.

The other constituents of opium are not of
much, if any, therapeutical interest. Narcein,
meconin, pseudomorphia, and meconic acid, appear
to be inert ; and, according to Magendie ( Op. cit.),
thebain or paramorphia, when injected into the
jugular vein, or placed in the pleura of an animal,
causes tetanus and death in a few minutes.]

Practical employment of Opium. — In inter-
mittent fevers the employment of opium is as old
as the time of Galen. The best time for admin-
istering it is an hour before the expected paroxysm,
as at this time it weakens the force of the attack,
and sometimes prevents its accession ; a result
probably due to its stimulant property, whilst, at
the same time, its sedative quality allays the mor-

* The black drop is prepared by rubbing half a pound
of opium, reduced to powder, with four pounds of ver-
juice, one ounce and a half of nutmegs, half an ounce
of saffron, and three ounces of swjar. These ingredients
are fermented with yeast for six days ; the fluid is then
to be decanted, filtered, and inspissated in the air to the
consistence of syrup. The strength of the black drop
compared with that of tincture of opium is as three to
one. An excellent preparation, which owes its activity
to the citrate of morphia, is ordered to be thus prepared
in the Brunswick PharmacoprjBia. " Dissolve four ounces
of opium in forty-eight ounces of water, acidulated with
six ounces of lemon-juice; filter and evaporate to the
consistence of an extract in a water-bath." The citric
acid, in this case, decomposes the bimeconate of mor-
phia, and affords a more soluble salt, the citrate of mor-
phia, which is conjoined with the gum and extractive
of the opium.

bid irritability connected with ague. The dose
should be large ; for example, from forty to sixty
minims of the tincture. When given during the
hot stage, as Lind recommended, it renders that
stage shorter and milder, lengthens the intermis-
sion, and greatly promotes the influence of bark
or the sulphate of quinia in curing the disease.
In combination with calomel, in doses of a grain
of each, it also enhances the sanative powers of
tonics, in cases which resist them when given
alone. But if opium fail to check the accession,
it should not be given in the succeeding paroxysms,
as the repetition of it in such a case only tends to
induce debility.

In continued fevers the use of opium is more
questionable than in intermittents. It should not
be ordered if the temperature of the surface be
much greater than natural, unless there be a ten-
dency to perspiration, which it accelerates, and
thence proves beneficial. If pain and watchfulness
demand its use, the dose should be large, and it
ought to be united with calomel and tartar-emetic,
a combination which greatly lessens its stimulant
properties. In this combination and with James's
powder, Dr. Currie employed it with great ad-
vantage after the cold affusion. In the advanced
stages of typhus, opium is useful as a general
stimulant, in doses of from six to ten minims of
the tincture, or from three to six minims of the
black drop, in combination with camphor and
other cordials. When, in the early stage of con-
tinued fever, the pulse is full and hard, the heat
of the surface greater than natural, the thirst con-
siderable, and there is much headach, the use of
opium is not admissible. Even in the sinking
stage of this disease, wine is a better and more
permanent stimulus. In typhus, the symptoms
that chiefly indicate the use of opium are low
muttering delirium, watchfulness without in-
creased heat of skin, diarrhoea, and subsultus
tendinum : the dose should be small, frequently
repeated, and cool air freely admitted to the cham-
ber of the patient. If the delirium, however, be
accompanied with flushing of the face, impatience
of light, and throbbing of the temples, it must not
be administered.

If opium be prescribed to counteract watchful-
ness, it should be recollected that this may arise
from very opposite causes. When it is accom-
panied with great heat of surface, restlessness,
tossing about in the bed, and determination of
blood to the brain, it proves deleterious; if none
of these symptoms are obvious, then opium is the
best means for overcoming such a state of watch-
fulness. It should be given in full doses, in a
solid state combined with calomel, at the usual
time of rest ; and during its operation the scalp
should be kept cool by enveloping the head in a
cloth wet with a cold lotion. In low delirium it
may be given at the same time as ammonia ; but
if, as sometimes occurs, it increase the delirium
when it is taken into the stomach, then it may be
applied by aid of friction dissolved in oil.

The best preparations of opium are the tincture
of the pharmacopoeias, the black drop, the liquid
laudanum of Sydenham, the solution of the mu-
riate of morphia, and the acetate of morphia.

With regard to the extent of the dose, it should
be held, as a general rule, that double that which

NARCOTICS.

369

is required to produce sleep in a state of health
should be administered in disease ; if acetate of
morphia be preferred to any of the. other prepara-
tions, when narcotic not hypnotic effects are
desired, the following formula will be found
useful :

R Morphiae, gr. ii.
Acidi acetici, m ii.
Misturoe amygd. amarae, f.^vi.
Syr. tolutani, f.ji.
Tere morphiam cum acido et syrupo, dein adde
mistutam. Sumatur quarta pars sext& quaque
hora.

In the phlegmasia?, notwithstanding the gene-
ral rule that opium should not be administered
during the presence of active inflammation, until
the system have been relieved by bleeding, there
are cases in which it proves highly useful ; as for
instance, when the inflammatory action is of a
passive kind, as in malignant ulcerated sore throat,
and in chronic rheumatism. But even when it
is of the opposite description, as in pleurisy, if
venesection be freely employed, nothing is so
likely to subdue permanently the inflammatory
action as large doses of opium in combination
with calomel and tartar-emetic. When the in-
flammation is in the substance of the lungs, as
soon as dyspnoea is relieved, and the symptoms
are reduced to cough and restlessness, opium may
be given with the hope of the greatest advantage:
indeed, all acute inflammatory affections of the
chest may be benefited by opium thus preceded
by antiphlogistic measures. In peripneumonia
notha, both in that variety which constitutes the
catarrhus suffocativus of old age, and that in
which there is a congestion of blood in the pul-
monary vessels, opium is useful. In the first
place it forms an active and useful ingredient in
stimulant expectorant mixtures, with ammoniacum
and squill ; and in the second, after the congestion
is partially relieved, the liberal administration of
opium in combination with demulcents is pro-
ductive of much benefit. It may be said that this
opinion is at variance with the common idea that
opium retards expectoration ; but in reply to this
objection, let us examine what the state of the
chest is in pneumonia. We find that the pain is
aggravated by a full inspiration, and that, in order
to obtain this, the patient must be nearly in the
erect posture. Now, under this state the neces-
sary change cannot be effected on the blood ; and
in the irritable state of the bronchial membrane
the secretion of its natural mucus is hurried, and
the sputa consequently thin and acrid. In this
condition, opium, acting through the pneumogas-
tric nerves, allays pain, and enabling the patient
to take a fuller and more perfect inspiration, it is
easy to comprehend how a thicker and more
slowly secreted mucus will be coughed up more
easily than a thinner and more irritating matter.
it is on this account that opium, instead of re-
straining, frequently promotes expectoration.

[In many of the phlegmasia?, opium is a most
valuable sedative, even from the first onset of the
disease. In sero-enteritis, it was highly extolled
by Armstrong, (Lectures on the Morbid Anatomy,
Nature and Treatment of Acute and Chronic
Diseases, Amer. edit. Philad. 1837,) especially
wnen given after bleeding had been practised ;

Vol. III. — 47

and he was in the habit of saying, that if he him-
self were labouring under the disease, and were
told that he must rest his hopes of recovery on
the lancet singly, or on opium singly, he should
be disposed to select the latter.

What Armstrong said of the use of opium in
these cases has been extended to similar patholo-
gical conditions in other serous tissues and else-
where ; and many advantages have accrued from its
employment, in some form of preparation, in cases
in which, at one time, its use was unknown, or
considered inappropriate. Dr. Christison, (Edinb.
Monthly Journ. of Med. Science, Feb. 1841, p.
91,) has recently shown, that coryza, catarrh, in-
fluenza, and dysentery may be frequently cut
short by a full dose of it ; and that when con-
joined with ipecacuanha, it has often the same
effect on common sore-throat, catarrh and acute
rheumatism. He also is a great advocate for the
full employment of opium early in inflammations
after a deep impression has been made by blood-
letting.

The common remark, that opium is so well
adapted for cases of pneumonia, bronchitis, &c.
because it " diminishes the secretions," appears,
as the writer has said elsewhere, (General Thera-
peutics and Materia Medica, i. 337 : Philad.
1843,) a faulty method of explaining its action.
The suppression of secretions is not a pathologi-
cal condition ; it is only the symptom of such a
condition — and when it is stated, that the indica-
tion is " to restore the secretions," if the expres-
sion have any meaning at all, it can only convey
the idea, that the pathological condition, which
occasions their suppression, must be removed.
Now, we know, that the first effect of the inflam-
mation of a mucous membrane is a diminution of
its natural secretion ; and that, after the inflam-
mation has continued for a time, an increase of
the secretion takes place ; but it is no longer of
the normal character. It is a secretion effected
by vessels labouring under inflammatory excite-
ment. Two opposite effects, then, on the secre-
tory function are produced by different stages of
inflammation. Yet the indication in the two
cases must obviously be identical. It must be —
to remove the pathological condition of which
these effects are symptomatic. A narcotic, in
appropriate doses, is a sedative ; it is, therefore,*
well adapted for allaying inflammatory excitement.

A knowledge of these properties would suggest
the propriety of its employment in the diseased
state of mucous membrane referred to above ; and
experience ought to show, as it daily does, that in
the early period of inflammation of a mucous
membrane it will, in sedative doses, « restore the
secretions ;" and at a later period, when the mu-
cous secretions have become profuse and morbid,
it will diminish them, by diminishing the inflam-
mation that occasioned them. It is obviously,
therefore, incorrect to lay down the broad law,
that " opium diminishes the secretions," and that
its use is improper whenever the indication is « to
restore the secretions." Such an indication ought
never to be imagined. It is unmeaning, and can
only have been suggested in an ignorance of
true pathology ; and the writer is happy to find,
that his views on this subject have met with the
entire accordance of others who have investigated

370

NARCOTICS.

the subject pathologically and practically. " The
objection to the use of opium in the treatment of
bronchitis, pneumonia, &c. on the ground that it
diminishes the secretions," says a recent thera-
peutical writer, Dr. Spillan, (A Manuul of Gen-
eral Therapeutics, &c. p. 155: Lond. 1841,) has
been happily refuted by Dr. Dunglison."]

Opium is indisputably a most useful medicine
combined with ipecacuanha, or camphor, or am-
monia, as circumstances may require, in malignant
peripneumony. In ophthalmia it is exhibited un-
der the same restrictions as in pneumonia. If
pain and irritation be excessive, it may be given
even before bleeding has been resorted to, in which
case it should be combined with calomel and tartar-
emetic. Externally no application is more useful,
after the active inflammation has been subdued by
topical bloodletting. The old solutio opii vinosa
is preferable to the vinum opii of the modern phar-
macopoeias, as it contains only half the quantity
of opium and an aromatic. It acts partly by its
stimulant, partly by its narcotic properties.

Opium has now almost supplanted the use of
the lancet in acute rheumatism : it should be ad-
ministered in full doses, immediately after active
purging, in combination with colchicum. In the
chronic form of the disease the opium may be
combined with sulphate of quinia, or with infusion
of menyanthes trifoliata acidulated with muriatic
acid, which gives activity to the opium by form-
ing a muriate of morphia.

In gout, even in that variety of the disease
which is named retrocedent, opium is truly our
sheet-anchor, and it must be given in full doses.
In some cases it has been administered in doses
of ten grains twice a day with advantage ; and no
consequent inconvenience is experienced if the
dose be not too hastily lessened. In the acute
form of the disease, opium is most useful when
combined with colchicum. Something in this
combination is due to the specific action of the
colchicum on the gall-ducts. It has been sup-
posed that the opium diminishes or impedes the
biliary secretion, because the evacuations which
follow a dose of opium are frequently pale ; but
this only indicates a diminished excretion. In the
lower animals poisoned by opium the gall-bladder
and ducts are turgid with bile, although very little
had found its way into the duodenum. Now, as
colchicum stimulates the gall-ducts, the combina-
tion of this remedy with opium removes the ob-
jection to its employment in gout, as far as regards
the biliary secretion.

It is almost unnecessary to say that in cases of
biliary calculi impacted in the gall-duct, or in
nephritic inflammation arising from the irritation
of renal calculi, either in the pelvis of the kidney
or in the ureters, the best results are to be anti-
cipated from the use of opium, particularly when
the stomach is so irritable as to reject, by vomiting,
every thing received into it. In this case, on
account of the advantages to be expected from
proximity of action, the opium is most beneficial
when exhibited per anum, dissolved in oil. In
suppression of urine, also, from calculi irritating
the bladder of urine, or from stricture of the
urethra, opium in combination with calomel is
the medicine most to be depended on ; and the
came combination acts as a powerful anodyne in

chordee, and the painful micturition of gonorrhoea.
Neither large doses of opium alone, nor large
doses of calomel, produce the effect of the com-
bination of these medicines. Two grains of each
may be administered in the form of a pill every
second or third hour. The writer of this article,
however, has sometimes found it better to order
eight grains of calomel and two of opium, to be
taken every eighth hour until relief was obtained.

Small-pox is the disease among the exanthe-
mata in which opium is most decidedly indicated ;
and we are indebted for this fact to the sagacity
of Sydenham. In the distinct form of the disease
it is not required unless convulsions occur, or the
eruptive fever be accompanied with much rest-
lessness. Perhaps the practice of Sydenham, of
administering opium every night in confluent
small-pox, has been too indiscriminately followed.
It is not required in the greater number of cases
during the progress of the eruption, although it is
occasionally useful for promoting the maturation
of the pustules ; and after the eruption it is
indicated, under the same circumstances as in
typhous fever, in conjunction with cinchona bark
and wine. It is also useful in the secondary fever,
if diarrhoea supervene ; for notwithstanding the
authority of Sydenham, purging at this time ought
to be restrained to a certain extent. In measles,
the employment of opium is contra-indicated in
the commencement of the attack, but after the in-
flammatory symptoms are subdued, and the cough
remains, then opium in combination with calomel
and ipecacuanha will be found beneficial, and still
more so if the diarrhoea, which to a certain extent
is useful, proceed too far. In that form of the dis-
ease which is of a malignant nature, rubeola ma-
ligna, as the fever is of the typhoid type, opium
is indicated, and may be given throughout the
attack, under the same regulations as in typhous
fever.

Much difterence of opinion exists respecting the
employment of opium in hemorrhages. When
febrile symptoms exist, these should be subdued
before opium is prescribed ; when the hemorrhage
is connected with much debility, laxity of the
solids, and a thin state of the circulating mass,
then opium in combination with astringents and
tonics should be administered to allay the irri-
tability which always accompanies this state. In
haemoptysis, when no inflammatory state of habit
exists, when the bleeding is kept up by cough,
and is accompanied with watchfulness, opium is
likely to prove useful : in the opposite state, if
much irritation exist, it should be combined with
either digitalis, or acetate of lead, or hydrocyanic
acid, and cold both topically and generally ap-
plied.

In phthisis pulmonalis opium is administered
to allay cough, and to moderate diarrhoea when it
is present. If the accession of the hectic paroxysm
be well marked, it should be given at that period.
It is usually administered at bed-time ; but as it is
apt to excite much perspiration, it is preferable to
defer it until early in the morning, when the cough
is most severe. The soluble salts of morphia,
especially the acetate, are preferable to opium, as
they do not excite perspiration in small doses.
The following formula will be found very service-
able :

JN ARCOTICS.

371

R Acidi acetici diluti (aceti dest.) f.^iv.

Acetatis zinci solut. P. E. f.gi.

Tinct. opii m. xii.

Decocti lichenis Islandici f.gxi. M.
Haustus quinta quique hora sumendus.

In no disease has opium been more frequently
employed than in dysentery ; but there is much
difference of opinion as to the propriety of this
practice. If pains and tenesmus continue after
the bowels have been freely evacuated, opium,
combined with ipecacuanha, will be found useful ;
but during its use the bowels should be freely
evacuated once at least in twenty-four hours.
When the tenesmus is very urgent, the opium
should be exhibited, in conjunction with demul-
cents, in the form of enema ; and towards the
close of the attack, when the disease may be re-
garded as having passed into diarrhoea, opium is
the proper remedy. In bilious colic, and some
other affections of the bowels in which pain and
spasm arise from the action of highly irritating
matters on the coats of the intestines, and in
which purgatives do not act freely, experience
has proved the propriety of combining opium
with purgatives. In conjunction with calomel in
large doses, it allays the irritation both of the
stomach and the intestines, removes spasm, and
consequently aids the operation of the purgatives.
Indeed, in almost all spasmodic affections opium
is the remedy to be relied upon, whether the
spasm arise from the action of some irritating
substance on the moving fibre, or from irritation
kept up by debility : the cure consists in removing
the irritating cause, and diminishing the suscepti-
bility of the muscular fibre by restoring its tone.
The term " almost all" is employed, because in
some spasmodic affections opium seems to pro-
duce deleterious effects : thus in hay asthma it
augments fever, headach, and the wheezing and
suffocative tightness across the chest, which cha-
racterizes that singular disease. To answer both
the above intentions opium is admirably adapted,
when it is given in combination with sulphate of
quinia and other tonics.

In idiopathic tetanus, opium is a remedy of
great power; in traumatic tetanus it is of less
value even in the largest doses. In the idiopathic
form of the disease, opium should be early ad-
ministered, as the progress of the attack is rapid,
and the power of deglutition may be soon lost.
The extent to which the remedy may be given is
limited only by its effects ; many ounces of the
tincture have been taken before its effects have
been felt. Its stimulant influence quickly disap-
pears, on which account, even after the spasms
are controlled by it, the use of it should not be
discontinued for some time. A case is recorded
in which fifteen hundred grains of solid opium
were taken in the course of seventeen days ; and
another in which twenty fluidounces of the offici-
nal tincture were swallowed in twenty-four hours :
both cases recovered. In general, the following
rules should regulate the progressive increase of
the dose, and its repetition. If the spasms be
moderate, ten or twelve minims may be given
every hour; but if no relief be afforded in three
or four hours, the dose should then be doubled,
and so on progressively until the expected benefit
be obtained, after which the dose should be dimin-

ished in the same ratio. No intermission should
be permitted whilst the spasms continue. When
deglutition is impeded, the opium should be ad-
ministered per anum, and a solution of it in oil
be rubbed upon the spine. Much advantage is
derived from rubbing this oily solution on the jaw
in trismus — a proof of the direct influence of
opium on the nervous system.

In epilepsy, except in cases which are kept up
by habit, after the removal of the irritation which
first caused the convulsions, opium is not useful.
In such cases a large dose is required to break the
habit, but a purgative should be given at the
same time, as in no disease is costiveness so in-
jurious. The old physicians, even Sydenham,
relied much on the influence of opium in chorea;
and if the attack be complicated with hysteria,
after the bowels have been freely opened, it fre-
quently proves useful. But the plan of treating
chorea with powerful purgatives, and afterwards
with the carbonate of iron or with the nitrate of
silver, is so successful as to leave us little to
regret, should opium fail altogether in relieving
the disease. In another painful affection also, tic
douloureux, opium has so frequently disappointed
our hopes, that more reliance is placed on the in-
fluence of tonics than on narcotics in this dis-
ease.

The watchfulness of maniacal patients early
led to the use of opium in cases of insanity : the
only objection to its employment is its tendency
to cause costiveness ; but this is obviated by com-
bining it with aloctics, which operate on the bow-
els without weakening the soporific power of the
opium conjoined with them. By procuring sleep,
and thereby severing the catenation of morbid
sensations, opium is often highly beneficial in in-
sanity, especially that form of it which is produced
by habitual drunkenness. In these cases there is
generally a pallid countenance, a cold clamminess
of the surface, and other symptoms indicative of
great debility, accompanying the want of sleep;
under which circumstances the question of life or
death is often involved in administering or with-
holding the use of opium, and in no situation can
the judgment and discrimination of the practi-
tioner be more seriously employed.

[The writer's experience has shown, however,
that although opiates are trusted to almost solely
by some in delirium tremens, they are rarely, or
never, indispensable ; the disease generally yield-
ing to a proper eclectic and almost expectant
treatment. For his experience in the matter, see
his Practice of Medicine, vol. ii. 277, 2d edit. Philad.
1844.]

In syphilis, opium has been used as the sole
means of cure ; but although experience has de-
monstrated that opium cannot be relied upon for
this purpose, yet as an adjunct to mercury it is
of great value : it enables the system to bear a
large quantity of mercury with impunity, and
also allays the state of morbid irritability which
frequently remains after the cure of syphilis, and,
consequently, favours the return of health.

In diabetes mellitus, opium has a powerful in-
fluence in restraining the quantity and moderating
the saccharine quality of the urine. The dose
must be carried to a considerable extent to effect
this purpose, to six or eight grains in twenty-joij.-

372

N A R C T IC S

hours ; but too often the evil returns as soon as
the dose is diminished. In one case recorded by
Dr. Warren, (Transactions of the College of Phy-
sicians, vol. iv.,) five grains of solid opium were
taken four times a day with evident advantage.
Its beneficial influence has been referred to its
augmenting the action on the skin, and conse-
quently diminishing that of the kidneys ; but as
other diaphoretics do not cure diabetes, this theory
of its operation is not satisfactory.

Besides the benefit arising from the employment
of opium in the diseases already noticed, advan-
tage is also taken of its administration in many
morbid states of the system, to lessen irritation, to
relieve pain, and to induce sleep ; and undoubtedly,
whether it be taken into the stomach or applied to
the surface of the body, its place for these pur-
poses can be supplied by no other substances.
But, like some of the choicest gifts of Providence,
it is abused and frequently employed as a poison,
and this statement might be closed by tracing the
symptoms produced by an over-dose of opium or
of its salts, and pointing out the remedy ; but for
this information we must refer our readers to the
article Toxicology.*

Digitalis is generally regarded rather as a diu-
retic than a narcotic, but under certain states of
habit it exerts a decided and important narcotic
influence. It operates directly upon the nervous
system, producing first stimulant and afterwards
sedative effects. This influence of foxglove was
first satisfactorily observed by Dr. Hallaran in a
case of insanity, in which the tincture of foxglove
was given by mistake for the tincture of opium,
and from the effects which presented themselves,
he was led to conclude that foxglove cannot be
advantageously exhibited under " the pressure of
high arterial action ;" a fact which, indeed, might
have been inferred from the repeated observations
of its uselessness as a diuretic in dropsy, when an
inflammatory state of the habit exists. Dr. Hal-
laran, taking advantage of his accidental discovery,
employed opium as a narcotic in cases of mania,
attended with diminished excitement, and the
benefi' ,v as suc h as to enable him to remark re-
gard..^ it, " I am encouraged to proceed with as
much confidence in the hope of recovery, as I
would in cases of lues, from the mercurial influ-
ence." " Insane persons," he adds, " have re-
peatedly assured me, on approaching to recovery,
that they within a very few minutes have had a
consciousness of relief, both as to mental and cor-
poreal sensations, from the use of digitalis. One
in particular, who for a time had been intent on
seif-destruction, declared to me that the propensity
was never present so long as its efficacy had re-
mained." (Practical Observations on the Causes
and Cure of Insanity, by W. S. Hallaran, M.D.
p. 107-8.) The mode of administering digitalis
in mania is to commence with ten minims of the
tincture for a dose, three times a day, in a glass

* The best works on the nature and properties of
opium and its falls are those of— Dr. Christen: Opium
histories, chemice, atque pharmacologic^ investigatum,
1820.— M. Charvel: De 1' Action de 1'Opium et de ses
Principes constituans snr l'econorrjie animate, Paris,
1826.— Dr. Crump: On Opium, 8vo. 1788.— Dr. Leigh:
Experimental Inquiry into the Properties of Opium,
J786.— Wilson: Experimental Essays, 1795.— Degnise,
Dupuy, and Levrct: Recherrhes et Experiences sur les
Effets de l'Acetate de Morphine, 8vo. Paris, lau.

of water, and to add two minims to every dose
until sleep be procured, or until nausea or vertigo
be experienced, in which case its use should be
instantly laid aside, and ammonia aud cordials
with opium liberally substituted. In this manner
Dr. Hallaran has carried the dose « to one hun-
dred drops with safety and advantage ;" and the
writer of this article has frequently carried it to
sixty minims three times a day, with no other re-
sult than sleep, quiet, and the restoration of the
patient to sound health and intellect. The best
form of the medicine for producing these desirable
effects is the tincture, made with the recently dried
leaves, collected in June, in dry, warm weather,
and dried without artificial heat.

In phthisis, digitalis acts also as a narcotic, but
it is fitted rather for the advanced than the early
stage of the disease. M. Neuman, of Berlin, has
extolled its influence as a narcotic in chronic
catarrh, when this depends on a state of erethism
of the mucous membrane of the bronchi. He
gives it in the form of infusion, made with jii. of
the dried leaves in f.^vi. of boiling water, one
table-spoonful of which is administered every hour,
until nausea, or a sensation of constriction of the
throat, or irregular pulse, supervene. The use of
the medicine is then suspended for a week, and
again renewed if the disease be not removed.

During the use of digitalis its sedative power
on the circulation is to be carefully attended to,
and its accumulation in the system closely watched,
as by carrying it too far and producing extreme
debility we may endanger the life of the patient.
When the symptoms of poisoning display them-
selves, (see Toxicology,) in addition to the means
already recommended for counteracting them,
much benefit will be obtained from the application
of a blister to the pit of the stomach. From the
difficulty of preserving foxglove leaves so as to re-
tain their active properties, the infusion is a bad
form of preparation, and the powder should not
be employed unless it retain the beautiful green
colour and the peculiar odour of the recently
well-dried plant. In prescribing the tincture also,
it must be borne in recollection that the bichloride
of mercury, corrosive sublimate, and nitrate of
silver, are incompatible with it.

Henbane, hyoscyamus niger, is very generally
employed as a narcotic in all the cases in which
opium has been found beneficial. Its active prin-
ciple is supposed to be an alkaloid, which has
been obtained in a separate state, and named
hyoseyamia ; it is taken up both by water and
alcohol. The forms in which henbane is admin-
istered are tincture and extract. The formula of
the London Pharmacopoeia for the preparation of
the tincture is adequate for every practical pur-
pose; that for the extract might be improved. Mr.
Plumbe has procured an extract by macerating
one part of the dried, plant in four parts of alco-
hol for four days, filtering the tincture, and evapo-
rating to dryness in a water-bath ; it has a beauti-
ful green colour, and retains all the active proper-
ties of the plant.

As a narcotic, henbane is analogous to opium
in its effects. It operates directly on the nervous
system, augmenting the force of the pulse, and
increasing the heat of the skin before it produces
sleep. It neither confines the bowels nor affcrls

NARCOTICS.

373

the brain so much as opium. In large doses,
however, it operates as a virulent poison, and in
some habits excites a pustular eruption.

Although henbane was employed as a narcotic
by the ancients, yet Stoerk first investigated its
value. He employed it in all painful diseases;
and owing to its tendency to relax the bowels, it
has been found very serviceable in ileus and colica
pictonum, in combination with colocynth and
scammony. Mr. Brande recommends it as well
adapted for allaying the pain and irritation caused
in the kidneys by red gravel. Smoking the leaves
in the manner of tobacco, soothes the pain of
toothache and relieves the dyspnoea in spasmodic
asthma. When applied to the surface, in the
form of extract, it dilates the pupil ; and much
comfort to the feelings of the patient is derived
from henbane in the form of a poultice in scrofu-
lous ulcers and open cancer.

The tincture is the best form of administering
henbane ; but it is most frequently employed in
the form of extract. The dose of the tincture is
from m. xv. to f.jiss ; that of the extract, from gr. ii.
to gr. xii. Alkalies destroy its narcotic properties;
they consequently are incompatible in prescrip-
tions with it, and may be employed as antidotes,
when it displays poisonous effects either from an
over-dose or from idiosyncrasy.

The results of Stoerk's employment of conium
in cancer and fistulous sores, recommended it as
a narcotic to the attention of modern practitioners.
It possesses considerable narcotic powers ; but so
much depends on the drying and preservation of
the leaves, either in their entire state or in that of
powder, and on the preparation of the extract, as
well as the state of the patient at the time of its
administration, that few narcotics have perplexed
practitioners so much as conium, and to these
causes we must attribute much of the varying
opinions respecting its influence as a remedial
agent. Keeping these facts in view, conium has
been found useful in acute rheumatism, scrofula,
syphilis, and especially in cancer, the pain and
irritation of which are supposed to be more effec-
tually under the control of conium than of any
other narcotic. In these cases the dose should be
gradually increased until indications of an over-
dose begin to display themselves. These are
nausea, dimness of sight, headach, drowsiness,
vertigo, acceleration of the pulse, sweating, dry-
ness of the mouth, diarrhoea, and, if the system be
not relieved, coldness of the extremities, sinking
of the strength, and a fatal result. Some, not all,
of these symptoms usually present themselves be-
fore any perceptible beneficial change in the dis-
eases which have been named is effected by
conium. In many of the cases in which conium
has proved beneficial, its use has been continued
for some time, and the cure has proceeded in the
direct ratio of these sensible effects. On this ac-
count, the dose of conium requires to be progres-
sively augmented until the symptoms of its influ-
ence be sufficiently obvious. The pulse in some
instances sinks; in others it is maintained full,
and at 100 or more, during the whole time of ex-
hibiting the medicine. Sometimes the function
of the kidneys is augmented ; sometimes that of
the skin ; sometimes no effect is produced on the
sensibility of the habit ; occasionally this is greatly

2s

diminished. In that variety of paralysis which is
complicated with rheumatism, in which deficiency
of motion is attended with acute pain, conium has
been found highly beneficial. In six cases of
this affection treated with conium in the Edin-
burgh Infirmary, by Dr. Home, three were re-
lieved and three were cured, although two of
them were of long standing, and one in an old
person. We have witnessed much benefit de-
rived from it in chronic rheumatism, in keeping
down pain ; and in chronic sciatica, our expe-
rience authorizes us to say that it is more to be
depended on than any other narcotic. In inter-
mittent cephalea, conium has been found to be an
excellent adjunct to tonics. In scrofula, notwith-
standing the testimony of Stoerk in its favour, we
have not been able to perceive that it effects more
than any other narcotic'; and except in soothing
the cough, the same character may be bestowed
upon it as a remedy in phthisis. In over-doses,
besides the symptoms already mentioned, its
effects greatly resemble those of opium.

The extract, which is the only preparation of
conium in the London Pharmacopoeia, is a bad
form of the medicine, owing to the difficulty of
preserving it ; whenever a saline crust appears on
the surface, it is no longer of any value. The
tincture of the Edinburgh and the Dublin Phar-
macopoeias is a better form of preparation. We
have found it particularly useful, when adminis-
tered in combination with hydrocyanic acid in a
light decoction of cetraria Islandica, in long-pro-
tracted hooping-cough, accompanied with much
debility, and when the cough is kept up by habit.
The dose of the extract is from gr. i. to gr. vi. ;
that of the tincture from m. x. to m. xl., in any
bland vehicle.

The atropa belladonna, deadly nightshade, pos-
sesses considerable influence as a narcotic, and
some peculiar properties which require to be no-
ticed. According to the analysis of a distin-
guished German chemist, M. Brande, its active
principle is an alkaline substance, which he has
named atropia, and which, in combination with
other sulphuric or muriatic acids, is procured in
beautiful white prismatic crystals, possessing in a
concentrated degree the powers of the plant. The
preparation most employed is the extract, which,
however, is a very uncertain medicine, unless it
be prepared in vacuo, the atropia being volatile
and exhaled during the evaporation of the infu-
sion. Belladonna, in whatever form administered,
requires to be given in minute doses at first, and
then to be gradually augmented until symptoms
of its influence on the system become apparent.
These are dryness of the throat, vertigo, dilatation
of the pupils, slight dimness of sight, extravagant
delirium, and an eruption on the skin, closely re-
sembling that of scarlatina.

The efficacy of belladonna has been well as-
certained in painful and spasmodic affections :
in hooping-cough it has been found useful ; ji
doses of an eighth of a grain, gradually in-
creased until the sight is affected, and a scarlet
eruption overspreads the skin, accompanied with
some degree of headach. Whilst these symptoms
continue, the cough ceases, but returns as they
disappear; but by renewing this state, and main-
taining it for a sufficient length of time, the disease

374

NARCOTICS.

U always shortened. In neuralgia, both internally
administered and externally applied, belladonna
lias been advantageously employed. The influ-
ence of the extract on the radiated fibres of the
iris, so as to dilate the pupil, was first proposed as
a method of facilitating the extraction of cataract
by Professor Reimarus ; and for the same reason
it is frequently employed for aiding vision during
the progress of cataract. A small quantity of the
extract, softened with water, is applied upon the
eyelid : in a short time the pupil dilates, and the
effect continues for many hours. An ointment
formed with gi of the extract, and ^vii of lard,
affords great relief in the pain of hemorrhoids ;
and in chordee when rubbed upon the perineum :
the powdered leaves, sprinkled upon cancerous
sores, greatly abate the pain of these ulcers. The
narcotic influence of belladonna cannot, indeed,
be justly depreciated. In prescribing it, alkalies
should not be combined with it, as they render the
medicine inert ; and the same result takes place
when the atropia is converted into a tannate, by
administering any of the preparations of bella-
donna with astringent vegetable decoctions or infu-
sions. Dr. Reisinger has proposed to employ
atropia, instead of the extract or the infusion of
belladonna, on the ground that it exerts a direct
sedative influence on the nervous energy, whilst
the extract and the infusion exert a primary, sti-
mulant power, like other narcotics.

Belladonna, when given in over-doses, produces
such an effect on the stomach that the organ
rapidly ceases to be excitable by emetics. Under
such circumstances, the advantages of the stomach-
pump are great; for it is obvious that, notwith-
standing the paralysed state of the organ, we may
produce much mischief by inconsiderately aug-
menting, beyond a certain point, the dose of an
emetic.

Like every other narcotic, the activity of bella-
donna depends greatly on the manner in which it
is prepared : in general, so little care is bestowed
on the preparation of the extract, that it is difficult
to apportion the dose. When the evaporation is
conducted in vacuo, as recommended by Mr. Berry,
the dose must be considerably less than that usu-
ally prescribed.

[Stramonium, James Town Weed, Thorn Ap-
ple, produces effects like those of belladonna,
when taken in large doses. In medicinal doses, it
resembles hyoscyamus ; but it is not often used in-
ternally. In nervous asthma, the smoke is often
inhaled with advantage. The leaves are also ap-
plied, warm, to painful tumours, irritable ulcers,
&c. The extract dilates the pupil, and is em-
ployed in the same cases as the extract of bella-
donna.

Aconite, the leaves of Aconilum Nupellus and
A. Paniculatum, Wolf's Bane, or Monkshood,
is occasionally used as a narcotic, especially in the
form of tincture, — taken internally, and applied
externally to the part, in rheumatism and neural-
gia. As a sedative, too, it has been prescribed
in hypertrophy of the heart. The author has de-
rived great advantage from it, employed in this
way, in some obstinate cases of sciatic neuralgia.

The active principle — Aconitia — is a most viru-
lent poison, which has been used in similar cases.
It is, however, exceedingly expensive, and the

drug possesses no virtues over the tincture of aco-
nite! {New Remedies, 4th edit. p. 40: Philad.,
1813.)

Verafria, the active principle of the seeds of
Veratrum Sabadilla, V. officinale, Helenias offici-
nalis, and Asagrsea officinalis, which are known
in commerce under the name Cebadilla, Ceva-
dilla, or Sabadilla, is, like aconitia, a most viru-
lent acro-narcotic. It has been prescribed, inter-
nally and externally, in the same cases as aconitia;
but its employment demands great caution.]

The genus lactuca yields a white proper juice,
which has much of the properties, at least of the
sensible properties, of opium. When inspissated,
this juice, procured from the lactuca sativa and
lactuca virosa, is the lactucarium of the Edinburgh
Pharmacopoeia. The narcotic properties of lettuce
were very early known : Galen, who in the de-
cline of his life suffered from watchfulness, found
much comfort in eating lettuce in the evening ;
and every one who has indulged the same luxury
must have experienced the soporific effects of this
plant. Dr. Coxe instituted a set of experiments,
to ascertain how far lactucarium resembles opium
in its medicinal effects ; and his results were con-
firmed by the subsequent experiments of Dr.
Duncan. Dr. Coxe's experiments led him to
regard lactucarium as precisely the same as opium
in its medicinal properties ; but although it may
be employed as a substitute for opium, in persons
who from idiosyncrasy cannot take opium without
suffering, yet its properties are not exactly the
same. In our opinion, it is one of those sub-
stances which may be well spared from the Mate-
ria Medica, as the same effects which it produces
can be obtained from modified doses of opium.
[Its virtues have, in the writer's opinion, been
greatly exaggerated.]

Camphor is a narcotic, [1] which, like opium,
possesses both stimulant and sedative properties :
when it is taken into the stomach in moderate
doses, it exhilarates, but in large doses excites
nausea, vomiting, and even inflammation of the
organ. It is so penetrating, that, independent of
absorption, it seems to pervade every part of the
frame. It displays its stimulant and sedative
powers in nearly the same manner as opium, the
stimulant effects always preceding its sedative
operation. Its influence is exerted directly on the
nervous system, producing sleep and relieving
pain ; and this is so very powerful that people
employed to open packages of camphor have occa-
sionally fallen asleep. As a stimulant, camphor
is extremely diffusible, its influence being rapidly
extended over the system, and disappearing sooner
than that of any other narcotic : it is, therefore,
well adapted for procuring a sudden and transitory
excitement, in cases in which this is required, and
in which its continuance would prove hurtful.
When it is intended that it should exert a stimu-
lant influence, like opium, it should be given m
small doses, and repeated at short intervals: when
its sedative effects are required, it should be ad-
ministered in large doses, and at considerable
intervals.

Camphor may be employed in every kind of
fever: in intermittents, during the paroxysm, to
allay irritation and procure sleep ; in continued
fever, to subdue spasmodic twitchings, calm deli-

NARCOTICS.

375

rium, and remove watchfulness ; but in these
respects it is inferior to opium. It is, however, an
agreeable and useful adjunct to opium in fever.
In the phlegmasia?, camphor is frequently pre-
scribed on mistaken principles, under a conviction
that its primary action is sedative. Thus, in oph-
thalmia, it is sometimes prescribed as an external
application in the inflammatory or active stage of I
the disease ; whereas it is only suited for that pas-
sive state which is the result of the scrofulous dia-
thesis, and old chronic inflammation of the, con-
junctiva.

In the exanthematous fevers it is useful for pro-
moting the eruption, and restoring it when it has
receded : in confluent small-pox in particular,
attended with much of the typhoid character and
with petechia^ it aids in maintaining the powers
of the constitution, and the maturation of the
pustules ; abating the tendency to convulsions
which frequently accompanies this form of the
disease. One curious result of the external use
of camphor is stated by Rosenstein : he says, that
if the skin be smeared over with a camphorated
ointment, no pustules will appear. In spasmodic
affections, camphor may be administered so as to
act either as a stimulant or sedative ; but in either
case it is inferior to opium. In mania, the powers
of camphor have been greatly overrated ; it lowers
the pulse of furious maniacs sometimes to fifty,
and an evident sedative effect follows, but without
any diminution of their sufferings. « By its dura-
tion," says Dr. Hallaran, " the countenance eventu-
ally assumes a livid aspect; the extremities also
become cold and insensible, and equally livid with
the face. The arterial blood seems as if concen-
trated in the vessels immediately issuing from the
heart ; the action of the lungs is impeded ; and
congestion, determining to the head, is often the
inevitable consequence. The power of reaction
of the heart, under such difficulties, is in fact
suspended ; and the torpor of the system previ-
ously existing is thus greatly aggravated." (Prac-
tical Observations on Insanity, &c. p. 130.) Dr.
Hallaran thence regards it as a very uncertain
medicine in the treatment of mania. In nympho-
mania, however, camphor has been found highly
beneficial ; and it is also an admirable adjunct to
opium in that variety of insanity which frequently
follows a continued course of intoxication.

The opinion that camphor has the power of
allaying the strangury which occasionally follows
the- use of cantharides was first hazarded by Dr.
Grainger in the beginning of the last century, and
is still credited by many ; but it is erroneous : Dr.
Hcbcrden, indeed, has demonstrated, that when
freely administered camphor causes strangury.
The idea that it diminishes salivation is not belter
founded.

In prescribing camphor, its precipitation from
the alcoholic solution, suspended by mucilage in
any bland vehicle, is a good form of administering
it: or it may be held in solution in water by
means of carbonic acid. It has been also success-
fully used in the form of a vapour bath by some
of the continental physicians. The patient is
placed on a chair with an open cane bottom,
beneath which a chaffer, covered with a plate of
iron, is placed ; the whole apparatus is surrounded
With a blanket, which is pinned round the neck

of the patient. A dessert-spoonful of camphor in
powder is then thrown upon the iron plate; it is
instantly volatilized, and involves the body in an
atmosphere of camphor vapour. The patient per-
spires freely ; and in three-quarters of an hour
afterwards he may be rolled in a blanket and car-
ried to bed. The sweating must be maintained
by tepid fluids. In chronic rheumatism this fumiga-
tion should be repeated three or four times a day,
and continued for some time after the pains have
disappeared. The dose of camphor is generally
too small; its narcotic influence being seldom ob-
tained from less than half a drachm : we have
given it, with advantage, to the extent of four
drachms in the day, in low fever. It operates
with more energy when administered per anum
than when taken into the stomach : the camphor
is quickly felt in the breath ; an indescribable un-
easiness succeeds, then vertigo, with pallidness of
countenance, chilliness, and a low intermitting
pulse. Opium, brandy, and ammonia are the
means of counteracting these effects of camphor.*
[Asckpias Syriaca, Silkweed or Milkweed, and
Lycopus, Bugleweed, are officinal indigenous
Narcotics, but they are not much used.]

We consider it unnecessary to enter more par-
ticularly into the consideration of the narcotic
agents ; the ethers, alcohol, and some vegetable
matters, operate by exerting a direct influence on
the nervous energy through the medium of the
circulation ; but this does not affect their practical
utility. It only remains to close our remarks on
narcotics with a few statements respecting the in-
fluence of what may be termed mental narcotics.
Mental impressions rouse or depress the nervous
energy according to circumstances ; we consider
those impressions narcotic which at first rouse the
system, but by repetition at length exhaust it, in
the same manner as stimulant material narcotics
exhaust, and induce sleep. Sound is one of these
mental impressions ; but it is necessary to explain
that it is not the repetition of sound, but of the
same sound, which produces the narcotic effect.
When sound is varied, the opposite result occurs,
the attention is kept awake; and it is a law of the
system that the variation of the stimulus renews
the excitement in such a manner, that collapse is
prevented for a greater length of time than when
there is a repetition of the same sound. It is the
monotony of sound, therefore, such as the gurgle
of rills, or small water-falls, the voice of a dull
preacher, the moaning of the breeze, &c. that is
followed by soporific effects ; and on the same
principle, slow and plaintive music has been
found practically useful in the treatment of some
peculiar cases of insanity. In this case, the
slower, longer-continued, and less varied the im-
pressions are, the more powerful is the sedative
influence of the music; and something is also
produced by the period of the' day and the situa-
tion in which the listener is placed. The stillness
of evening is highly favourable to the employment
of music as a soporific agent ;

" let the sounds of music

Creep in our ears ; soft stillness, and the night
Become the touches of sweet harmony."

And when sleep is induced, there is much less

*The best work to be consulted on camphor is the
Traits de Camphre, by M. Grauffenaur, Strasbourg, lftg

376

NAUSEANTS.

likelihood of its being disturbed than if it occur
during the day. Gentle friction and titillation
produce also soothing effects, on the same prin-
ciple as the monotony of sound ; in cases of pain
we have seen them prove useful, by transferring
the attention from its scat, to the mild and agree-
able impressions of the friction ; and this acquires
power by joining it with monotony of sound.
Thus we know that patting an infant on the back,
whilst at the same time the nurse hums a mono-
tonous tune, is almost always sure to produce
sleep. Were it requisite, many instances of the
beneficial effects of mental narcotics might be
brought forward ; but enough has been said to
show the importance of not disregarding them
in cases in which they are likely to prove bene-
ficial.

[The passes and other manipulations of the
animal magnetizer induce a like effect, as well as
a series of singular and anomalous phenomena,
the consideration of which would be inappropriate

here< ] A. T. Thomson.

[NAUSEA. See Indigestion.

NAUSEANTS. Although the individual
agents in the class of Nauseants belong to Eme-
tics, there is philosophy, as the writer has done
elsewhere (See his General Therapeutics and
Materia Mtdica, i. 91, Philad. 1843), in separa-
ting the consideiation of those agents when em-
ployed simply with the view of inducing nausea
from that of emetics. It has been before said
(See Emetics) that the state of nausea is one of
reduced action, and hence it can be understood,
that if sedation, thus induced, be kept up for a
sufficient length of time, it may succeed in sub-
duing inflammation, and the morbid exaltation of
organic actions, which constitutes ordinary fever.
These effects can be accomplished by nauseating
remedies properly administered ; and hence but
little difficulty is experienced by the practitioner
in laying down his indications for the use of nau-
seants, or in carrying these indications into effect
by one or other of the numerous nauseants that
are contained in the catalogues of the Materia
Medica.

In regard to' the condition of the functions under
the influence of a nauseant, when carried to the
extent of inducing marked nausea, there can be
no difference of sentiment ; but it has been a
question, whether if these same agents be given so
as to fall short of inducing nausea, or any sensible
evidences of their action — in alterative doses, in
other words — they may not modify the functions
in the same manner as full nauseants, but to a less
degree. Much may be said in favour of the affirm-
ative view of this subject, but it is one not easy of
demonstration. Were we, indeed, to deny the po-
sition altogether, it would be difficult to account
for the operation of antimonials, or of many other
reputed diaphoretics in small doses, which are
emetic in larger. All admit, that when the tartrate
of antimony and potassa is given so as to produce
nausea, it is a decided sedative and diaphoretic, —
diaphoretic because sedative. The state of nausea
being, as already remarked, one of diminished
action, the exalted vital manifestations constituting
fever are reduced by it, and diaphoresis, which had
been checked by the febrile irritation, is restored.

In such case, the antimonial — like every oilier
diaphoretic, perhaps — is an indirect agent only.
But if the tartrate be given in doses somewhat
smaller than are requisite to induce nausea, it may
still be conceived, that an action of sedation may
be exerted, although it must be confessed, that wo
have no sensible evidence of such an effect except
the result ; and it must be equally confessed, that
in our uncertainty we ought scarcely to place the
confidence in those agents which is occasionally
done by practitioners. Fortunately, however, this
very confidence is, at times, followed by negatively
beneficial results. It prevents the partisans of
the perturbating treatment of fever, by violent and
repeated cathartics, from causing as much irrita-
tion as they might otherwise do, and gives the
patient a little of that quietude and absence from
disturbance, which are so important in the manaee-
ment of all febrile cases, and especially of such
as are accompanied by erethism in the mucous
membrane of the intestines.

In respect to the therapeutical treatment by
nauseants, they are clearly proper in all internal
inflammations, as well as in every kind of active
hemorrhage ; whenever, indeed, it is desirable to
diminish the force and velocity of the circulatory
movements. In such cases they are amongst our
most valuable therapeutical means, and if the
system can be kept, for any length of time, suffi-
ciently under their influence, the local hyperemia
will often yield after it has resisted other agencies.

In constipation, a union of nauseants with
cathartics becomes occasionally advisable, and, at
times, effectual, after cathartics alone have been
employed without success. If the constipation be
dependent upon any irritated condition of the
exhalants of the canal, the use of debilitants,
such as these now under consideration, reduces
the erethism, and facilitates the operation of the
cathartic. Whenever, too, it is desired to break
in upon a chain of disordered actions, and espe-
cially in the neuroses, nauseants may be benefici-
ally administered ; but in these cases the revulsion,
induced by a nauseating emetic, is generally pre-
ferred, in consequence of the more powerful im-
pression made by it on the nervous system.

The practitioner has to reflect whether the state
of the organic actions be such as to require the
debilitant agency, which nauseants exert, and it is
not generally difficult to arrive at a correct con-
clusion. Perhaps, in all cases, the tartrate of
antimony and potassa is capable of fulfilling the
desires of the physician, but occasionally other
articles are selected — ipecacuanha, by some;
squills, especially when the affection is seated in
the air-passages, by others ; but there is no suffi-
cient reason for the belief that other nauseants are
preferable to the tartrate, — and, moreover, being
devoid of any stimulating property, it can be ad-
ministered in many cases in which the exciting
emetics would obviously be improper.

With similar objects nauseants are had recourse
to in surgical practice. Whenever it is desirable
to depress the energies of the system, and to in-
duce relaxation of constricted parts, they are ad-
vantageously employed. In strangulated hernia,
tobacco smoke or tobacco infusion is thrown into
the rectum ; but the use of tobacco, even in these
forms, is not devoid of danger, and perhaps there

NEPHRALGIA AND NEPHRITIS.

377

is no relaxant effect caused by it which might
not be equally produced by the nauseants above
mentioned.

When a luxated limb has to be reduced, the
force of contraction of the muscles is diminished
during the existence of nausea ; and if the sur-
geon, at the time, employs his manwuvres dexter-
ously, he may succeed in effecting the reduction.

Lastly. — To the obstetric practitioner, nau-
seants are no less useful. When the tartrate of
antimony and potassa is given so as to impress
the system, it removes rigidity of the os uteri;
and in violent or irritable labour the inordinate
activity of the uterus is allayed by it, whilst the
dilatation of the mouth of the organ is facilitated.
In puerperal convulsions, obstructed and inflamed
mamma, and in puerperal mania, their employ-
ment has been found advantageous ; but it is
needless to point out every affection in which they
may be prescribed with benefit. By bearing in
mind the sedative influence which they are capa-
ble of exerting, the practitioner can meet with lit-
tle difficulty in deciding upon the cases in which
their exhibition may be noxious or salutary.

ROBLEY DUNGLISON.]

NEPHRALGIA AND NEPHRITIS. — In
several of the morbid affections incidental to the
kidneys the symptoms are,as we have endeavoured
to show in a former article, (Kidxeys, Diseases
of,) so nearly alike as to render it very difficult,
if not impossible, to distinguish between them
during the life of the patient. Nor is accuracy of
diagnosis of much importance in some of these
affections, the treatment of which experience has
taught us is to be conducted not only on the
same principle, but in the same manner as regards
its minutest details. But to distinguish clearly
between nephritis — inflammation of the substance
of the kidneys, or of their capsules and surround-
ing cellular membrane — and nephralgia — pain of
the kidneys from calculus — is of great moment,
since the remedies most proper for the one would
be unavailing or injurious in the other. In ne-
phritis, especially in that species where the cap-
sule is the scat of inflammation, bloodletting is
absolutely necessary ; but in many cases of ne-
phralgia, bleeding would do harm. Again, opiates
are not proper in nephritis, at least not till the in-
flammation has been decidedly arrested ; while in
nephralgia they are often eminently serviceable
from the commencement of the attack.

In order to form this correct diagnosis, let us
take the definition of nephritis as we find it laid
down by Dr. Cullen in his Nosology, and let us
observe wherein it is applicable to both the diseases
in question, and wherein it applies to nephritis
only. The definition is as follows : " Pyrexia ;
pain in the region of the kidney, often following
the course of the ureter ; frequent desire to pass
urine, which is either limpid and colourless, or
very red; vomiting, numbness of the leg; retrac-
tion or pain of the testicle of the same side."

Now, what we are most carefully to attend to
in the above definition, is the pyrexia — the fever,
and the description of fever. All the other symp-
toms are common to both nephritis and nephralgia ;
indeed, the pain in the latter affection may be
much more intense than in inflammation of the

Vol. III. — 48 2g*

substance of the kidney, and quite as severe as
when its capsule is inflamed, but the pulse is
little, if at all, affected, and the other signs of in-
flammatory fever are absent. But if, with the
symptoms of the local affection, we find a frequent
hard pulse, a loaded tongue, great heat, and dry-
ness of skin, we may at once pronounce the dis-
ease to be nephritis.

While we are careful not to mistake these two
affections of the kidney for each other, we must
also be upon our guard lest we confound either of
them with certain other diseases which are accom-
panied with symptoms very similar. They have,
for instance, been mistaken for lumbago ; but here
again the definition will assist us. In lumbago
there is seldom much fever ; there is no nausea ;
the urine does not present the appearances which
indicate affection of the kidney ; in lumbago the
pain varies ; it is most felt upon resuming the
erect posture after the body has been bent, whereas
in nephritic affection it remains much the same in
every position.

Nephralgia and nephritis may both be mistaken
for inflammation of the psose muscles ; but in in-
flammation of those muscles there is neither nau-
sea nor retraction of testicle, nor alteration in the
flow or quality of the urine ; the pain is increased
considerably on rotating the thigh, and, if the dis-
ease has long subsisted, there is great emaciation.

Nephralgia may be mistaken for enteritis ; for.
as Dr. Pernberton has remarked, enteritis some-
times commences with such severe pain across the
loins as absorbs all other sense of uneasiness ; and
in nephralgia there is often a sympathetic pain in
the abdomen, midway between the os ilium and
navel, which is extremely acute, and much in-
creased upon the slightest pressure. We have
met with instances where this sympathetic pain
has been even greater than that arising from in-
flammation, and where the lightest possible cover-
ing could not be borne without distress to the
patient. Now, in a case of nephralgia, should
the medical practitioner fall into the error of pro-
nouncing the disease to be enteritis, and proceed
to treat it accordingly, that error, though it would
prove a sufficiently inconvenient one to the sick
person, and would reflect discredit upon himself,
might not prove a fatal one ; but how lamentable,
as well as disgraceful, would be the consequence
of his mistaking enteritis for mere nephralgia !
The practitioner should, in every case, be cau-
tious ; he should put together all the symptoms,
and carefully weigh their aggregate force, before
he ventures to pronounce a decided opinion upon
the disease. In severe nephralgia he will particu-
larly remark, that though the pain and tenderness
upon pressure, in the situation above mentioned,
are requisite, yet neither the pulse, nor the tem-
perature of the skin, nor the expression of coun-
tenance, are those of a person labouring under
inflammation of the peritoneal covering of the
intestines ; neither is there the same obstinate
constipation, the bowels being generally acted
upon by emollient enemata.

Another disease, with which a nephritic attack
is liable to be confounded, is colic. The mistake
is not, perhaps, as Galen observes, of much mo-
ment, since, at the commencement, the mode of
treatment in both is pretty much the same. Still,

378

NEPHRALGIA AND NEPHRITIS.

however, it is proper to distinguish between them.
In colic, the pain is more paroxysmal ; there are
intervals of absolute ease ; there are gripings and
distension of the lower bowels ; and the pain,
instead of being in the loins, and following the
course of the ureter, is chiefly about the navel ;
there is no numbness of the thigh or leg, or re-
traction or soreness of the testicle.

It is further to be remarked that a pain in the
region of the kidney, extending through the ure-
ter, and accompanied by almost all the other
symptoms of a nephritic attack, will sometimes
take place from hysteria, so that, to adopt the lan-
guage of Sydenham, it is extremely difficult to
distinguish whether these symptoms arise from
calculus, or from some hysterical affection, unless
perhaps some misfortune having greatly distressed
the patient a short time before the disease came
-on, or the discharge of green matter by vomiting,
should show that the symptoms are rather to be
ascribed to hysterical than to calculous affection.
It is, indeed, very difficult to arrive at any cer-
tainty here ; we should, however, carefully inves-
tigate all the symptoms; we should inquire
whether the patient has previously been subject to
hysteria; we should endeavour to ascertain
whether the uterus and its appendages are in a
healthy state, whether menstruation be performed
with regularity, and whether the secretion be
natural, and we should particularly observe the
state of the urine.

Nephritis, as has been already observed, is no
otherwise to be distinguished from nephralgia than
by the symptoms of inflammatory fever which
attend it; and these symptoms will be more or
less marked, according as the disease occupies the
capsule of the kidney and its surrounding cellular
membrane, or its substance. In the former case,
there will be pain — burning, pungent, and great
— in the region of the kidney; there will be in-
flammatory fever strongly marked. In the latter
case, the pain will be less urgent, — it will be
more of a dull, heavy pain, and the accompanying
fever will be more moderate ; but still the pulse
will be more frequent and harder than in a fit of
the gravel simply ; the tongue will be furred, the
skin hotter than natural ; the symptoms will be
those of subacute inflammation. The former has
occasionally been observed as an idiopathic dis-
ease ; the latter occurs only in consequence of
calculi retained in the kidneys, or external injury,
or perhaps hydatids. The difference of intensity
in the symptoms, depending upon the seat of the
inflammation, seems, until of late years, to have
been overlooked by authors of the highest reputa-
tion.* The late distinguished Professor Gregory,
when, in his admirable lectures, he spoke of idio-
pathic and symptomatic nephritis, appeared to
regard both as affecting the substance of the kid-
neys ; he did not, as far as we recollect, throw out
any hint of their capsules and surrounding cellu-
lar membrane being the chief or the only seat of
idiopathic nephritis.

We have thus endeavoured to point out how
nephritis and nephralgia may be distinguished

* Boerhaave, for example, says, " Ipsos renes vera in-
llamtnatione occupari scimus ex dolore ardi-nte, pun-
gente, magno, inflammatorio, loci ubi renes sunt; ex
febre acuta, continua concomitante."

with tolerable certainty from each other, as well
as from certain affections of the surrounding parts;
but no small degree of obscurity yet remains: it
is extremely difficult to discriminate between an
affection of the kidney itself, and disease of other
parts of the urinary system ; for one extremity of
that system so readily and so rapidly sympathises
with the other, that the same set of symptoms
will often occur wherever the disease in the uri-
nary organs may be located. Thus, a stone in
the bladder may give rise to all the sensations of
disease in the kidney, and a calculus in the latter
may produce every feeling of disease in the blad-
der. We would, therefore, impress upon the mind
of the young practitioner the importance of ex-
treme caution in pronouncing upon disease of the
urinary system.

We now proceed to offer a few observations
upon some of the symptoms which belong equally
to nephritis and nephralgia ; and first, as to the
pain generally following the course of the ureter.
This pain in the region of the kidney is a very
common but not an essential symptom; it some-
times is entirely wanting, and sometimes is so
obtuse that it is not noticed, until vomiting comes
on and attracts the physician's attention, and in-
duces him to make minute inquiries : in other
instances it is extremely severe, yet, upon exami-
nation after death, the kidney of the suffering side
has been found free from all trace of disease, while
the opposite one has been completely disorganized.
Another symptom which is also usually, but not
invariably present, is dull pain, or numbness of
the thigh and leg. Attention to the distribution
of nerves will enable us to comprehend this affec-
tion of the lower extremity, as also that of the
testicle, which frequently occurs. We have only
to bear in mind that the semi-lunar ganglion of
either side sends off branches which unite together,
and with branches of the par vagum, to form the
solar plexus, from which may be traced nerves
going to various parts, and among the rest to the
kidneys and the testes. The renal and the sper-
matic plexuses are derived from the same source,
i. e., from the great solar plexus formed by the
sympathetic and par vagum ; and if we trace the
sympathetic into the pelvis, we shall find that it is
connected with the nerves which pass to the leg.
To account for the derangement of stomach, the
eructation, nausea, and vomiting which attend
nephritic affection, we have also to recollect what
nerves concur to form the renal plexus, and what
nerve it is that supplies the stomach.

The frequent desire to pass urine may well be
explained upon the principle of irritation. The
secretion is either scanty, very high-coloured, and
mixed with blood, or it is limpid and nearly co-
lourless. The former appearances we may expect
to find when calculus is present, or when the
affection has been induced by violent horse exer-
cise or by external injury; the latter are more
likely to take place in acute idiopathic inflamma-
tion. Sometimes there is total suppression, a
symptom, as we have shown under Uhine, Scp-
pnEssrox of, to be of very formidable character;
it is not, however, necessarily a fatal symptom
where the kidneys are primarily affected: we
have known it to subsist for above a week in a
case of nephritis from calculi, and where the in-

NEPHRALGIA AND NEPHRITIS.

379

flammation terminated in abscess, as was proved
by purulent matter in considerable quantity being
! with the urine. In this case the head was
little affected, and though there was great pain,
with most distressing nausea and retching, the
pulse was hardly more influenced than in an at-
tack of gall-stone.

[A recent pathological writer, M. Rayer,
(Traite des Maladies des Reins, Paris, 1839,)
who considers some form of nephritis an ex-
ceedingly common disease, distinguishes four va-
rieties according to the parts of the kidney that
are involved; — 1. nephritis, where the gland
itself is inflamed ; 2. pyelitis, where the pelvis and
calices are the parts inflamed ; 3. perinephritis,
where the inflammation is in the investing mem-
brane; and 4. pyelonephritis, when both the
pelvis and the granular structure are involved.]

Acute idiopathic inflammation of the kidney
may be produced probably by any of the general
causes of inflammation, but especially by exposure
to cold, or violent exercise on horseback. Cases
of this description are, however, of very rare oc-
currence. It does not appear that Dr. Baillie
ever met with an instance of inflammation of the
capsule of the kidney ; and the late Professor
Gregory used to state in his lectures, that he never
saw a case of pure idiopathic nephritis. Symp-
tomatic nephritis, i. e. inflammation of the sub-
stance of the kidney, or nephralgia with inflam-
matory symptoms, is, however, far from uncom-
mon. Its most usual exciting cause is calculous
matter blocking up the tubuli uriniferi, or calculi
formed in the pelvis of the kidney and obstruct-
ing that cavity, or the canal of the ureter. But
it may also arise from other causes, as from a
blow, or a bruise or strain, from severe exercise,
long confinement in a recumbent posture, plethora,
acrid diuretics, excess in the use of spirituous
liquors, poisons.*

There is a great connection between nephritic
affection and gout. In some individuals the two
diseases make their assault simultaneously ; in
others they alternate : we find some members of
a family affected with gravel, and others with
gout ; and families have been known where all
the men had gout, and all the women gravel. It
is to be observed that the former disease is more
common in men, owing, probably, to their freer
mode of living. The descendants of gouty pa-
rents seem to be hereditarily disposed to both dis-
eases. In a family with whose history the writer
of the present article is intimately acquainted, the
paternal great-grandfather and his wife died mar-
tyrs to gout, the one at the age of forty-three, the
other at forty-five : their elder son had occasional
smart fits of gout till the age of sixty-five, when
they left him to return no more till his death,
which happened in his eighty-eighth year ; his
elder son, a man of very temperate habits, never
had gout, but died at sixty-six of severe disease
of the urinary organs: the two sons of the latter,
who have both reached the middle of life, have
hitherto been entirely exempt from gout, but both
exhibit a disposition to nephritic affection.

Inflammation of the kidney may terminate in

* A peculiar irritation, it is said, has been produced
in the kidneys by arsenic, especially by the fumes of that
mineral.

any of the ways of other inflammations : it may
terminate in resolution ; or a profuse sweat, or a
copious flow of urine, high-coloured, thick and
mixed with mucus, may carry off the disease ; or
the same may be effected by a considerable dis-
charge of blood from the hemorrhoidal veins.
The relief afforded by such a discharge has been
noticed by the great father of medicine ;f and his
commentator Galen observes that the untimely
checking of habitual hemorrhoids has given rise
to nephritic affection.

To the intimate connection which subsists be-
tween nephritic affection and gout, allusion has
been already made. That the sudden suppression
of the latter may occasion ischuria renalis, or
renal inflammation, is well known ; and a decided
attack of gout supervening upon nephritis may
effectually relieve the kidneys. If, however, the
symptoms be protracted beyond the seventh day,
suppuration will in all probability ensue, and will
be declared by its usual symptoms, as frequent
irregular rigors, dull, heavy, throbbing pain, &c.
The entire kidney may be thus consumed, and in
its place may be found a collection of pus : cases
of this kind are not uncommon. Again, the in-
flammation may terminate in an indurated condi-
tion of the kidney : its natural structure may be
partially or totally lost ; it may degenerate into
what, by the most skilful morbid anatomists, has
been considered a truly scirrhous state, and then
permanent lameness may be the consequence.
Lastly, nephritis may run into gangrene, as is
well attested by Boerhaave and other systematic
writers. Such a termination is doubtless ex-
tremely rare at the present day ; but an example
of it has been given by Dr. Turner in the fourth
volume of the Transactions of the College of
Physicians in London.

We now approach the subject of treatment;
and, first, of that of pure idiopathic nephritis,
which may be disposed of in very few words.
The inflammation must of course be met by the
same prompt and energetic measures which we
are accustomed to employ for the purpose of ar-
resting acute inflammation of other parts. Blood-
letting, both general and topical, is a remedy of
the first importance, and it should be employed
early, and with freedom, lest suppuration or gan-
grene ensue. The whole of what is understood
by the term antiphlogistic regimen should be
strictly enforced. The warm bath and fomenta-
tions should not be neglected. Mild diluents may
prove useful ; and perhaps some of the class of
diuretic medicines, as the infusion of digitalis ;
but all diuretics which possess a stimulant pro-
perty should certainly be avoided. It is of im-
portance to unload the bowels, and afterwards to
maintain their action ; but saline purgatives, being
disposed to pass off by the kidneys, are improper
in this disease. The mildest laxatives alone
should, in the first instance, be tried ; such as a
draught with one or two drachms of oil of al-
monds, or castor oil with manna, repeated every
third or fourth hour; should this fail, castor oil
in a larger dose may be exhibited ; or the com-
pound infusion of senna with manna ; or, in the
event of the bowels continuing obstinately cos-

t Tolm ve(ppiTiKol(n dlpdppo'iSei hiyiv6nzvai aya06»
Sect. 6, aph. 11.

3S0

NEPHRALGIA AND NEPHRITIS.

tive, recourse may be had to stronger purgatives,
as jalap with calomel. It is, however, to be recol-
lected that, owing to the nausea which is so con-
stant an attendant of nephritis, it will frequently
be found impossible to administer either oily or
other laxatives by the mouth. Emollient glysters,
or glysters of warm water only, should then be
thrown up, and we should desist from all at-
tempts to administer medicine in another mode
until the stomach become more settled. Emollient
glysters are useful both as fomentations and eva-
cuants : by this employment we may unload the
colon, to unload which is of considerable impor-
tance. Blisters have been recommended by some
authors of credit, but we should protest against
their being resorted to.

If, after the lapse of six or eight hours, the
pain and heat in the region of the kidney be not
relieved, and the hardness and frequency of the
pulse remain, nearly the same quantity of blood
should again be drawn from the arm and from the
loins by cupping or the application of leeches;
and should the inflammatory symptoms still con-
tinue, a repetition of the same means may be ne-
cessary. We must be guided here, as in acute
inflammation of other organs, not by the quantity
of blood drawn, but by the impression produced
upon the system by its abstraction.

Such is an outline of the plan of treatment to
be adopted in pure nephritis. If it terminate in
resolution, or by any critical discharge, little will
be left for the physician to do afterwards ; if, in
spite of the most active measures, it run on to
suppuration, the treatment must be such as will
be hereafter pointed out. If the sudden cessation
of pain, hiccup, clammy perspiration, feeble inter-
mitting pulse, great prostration of strength, ischu-
ria, or dark, flaky, offensive urine, indicate that
gangrene has taken place, the case is indeed all
but desperate ; strong cordials and stimulants must
then be resorted to : recovery may follow, but a
fortunate result is a sort of miracle.

In symptomatic nephritis, inflammation of the
substance of the gland, from calculi or any other
of the causes above enumerated, our treatment
must be conducted upon the same principles as
in the foregoing species, but, as the inflammatory
symptoms are less marked, the same freedom in
the use of the lancet will hardly be required at
the onset, and seldom will there be need to repeat
venesection. Local depletion seems more applica-
ble in this grade of the disease. When, however,
the pain has come on very suddenly, and is ex-
tremely acute, blood should be taken to the amount
of ten or twelve ounces from the arm ; recourse
should be had to the warm bath or hip-bath ; and,
if circumstances seem to demand it, local deple-
tion may be subsequently employed. When the
disease has been induced by a strain, or blow, or
bruise, or by violent exercise, &c, a second bleed-
ing may sometimes be necessary, and a strict ad-
herence to the antiphlogistic regimen will be ex-
pedient ; but when it appears clearly to arise from
calculus, we may generally, after one moderate
bleeding, and opening the bowels by mild laxa-
tives, have recourse to opium, in the dose of a
grain every second or third hour, according to the
urgency of the pain. Opium is in fact the grand
remedy in calculous nephritis ; it moderates the

pain and checks the vomiting, relaxes the spasm,
and promotes the descent of the stone into the
bladder. If the affection be simply nephralgia,
bloodletting will seldom be required ; yet if the
pain be extremely acute and long-continued, it
may be expedient, as a measure of precaution, to
take away blood in moderate quantity by cupping
from the loins, or even from the arm, since, though
none of the essential symptoms of inflammatory
action may be actually present, or at least none
which we can detect, we can never be sure that
inflammation will not supervene, or that it is not
already obscurely existing; and we must con-
stantly bear in mind that a degree of renal inflam-
mation, not to be discovered during life, is suffi-
cient to produce abscess of the kidney or a total
destruction of the gland.

In nephralgia, having first unloaded the bowels
by a brisk cathartic, or, if the stomach be in a
very irritable state, by a purgative glyster, opium,
in a full dose, and repeated at short intervals, is
of great service, and glysters of starch, with lauda-
num, may also be employed. Every mean should
be resorted to to favour the descent of the stone
into the bladder, and to afford the patient a chance
of its being passed by the urethra. To increase
the flow of urine, mild diluent liquids should be
freely taken ; with the view of relaxing the parts,
fomentations should be diligently used ; and, as
soon as possible, the patient should be placed in a
warm bath, and, while in the bath, he should en-
deavour to pass urine ; the attempt will often suc-
ceed under these circumstances, though it has
failed before. The means to be adopted, by way
of obviating a return of nephralgia, are those
which have been found most efficacious where the
lithic diathesis is known to prevail. Alteratives
and aperients should be exhibited so as to promote
the proper actions of the organs concerned in the
digestive process. Five grains of the compound
calomel pill may be given every other night, or
five or six grains of hydrarg. cum creta, with an
equal quantity of rhubarb and a grain of ipe-
cacuan. In robust habits we may prescribe from
two to three grains of calomel, combined with
four grains of James's powder and three grains of
compound extract of colocynth and of extract of
hyoscyamus, to be taken at bed-time twice a week,
and to be followed up the next morning by aSeid-
litz powder, or by three drachms of Epsom salts,
a scruple of carbonate of magnesia, and six of
powdered ginger, in half a pint of tepid water.
A tea-spoonful of magnesia in soda-water, or
twenty minims of the liquor potassas in linseed-
tea or barley-water may be given twice a day, or
more frequently, according to the urgency of the
symptoms. But one of the most valuable medi-
cines we possess is the diosma crenata ; the infu-
sion of its leaves has often given decided relief to
nephritic patients when various other remedies
have totally failed.* We have repeatedly wit-

*The diosma crenata has been long known to Briti^li
botanists as a plant highly esteemed among the Cadres
as a remedy in nephritic complaints. It is noticed, up° n
the authority of Sherard, in Ray's Historia Plantarum,
torn. iii. lib. 30, p. ill, under the title of Spiraa Africana,
or Buchu of the Hottentots, and is there stated to con-
stitute the principal ingredient of a certain powder in
use amongst them— " puiiiariiim ingrediens pulverisCy
prii Hottentottorum." It has within the last few years
been favourably introduced to the notice of the profes-
sion in this country.

NEPHRALGIA AND NEPHRITIS — NEURALGIA.

381

nesscd its soothing effects, and it appears to pos-
sess a tonic property — it seems to give tone to the
stomach. It is a valuable addition to the Materia
Medica, and merits a more extensive trial and
more careful observation as to its effects than it
has hitherto received.

[It is recommended by Dr. Joy (Tweedie's Li-
brary of Medicine, 2d Amer. edit. vol. Hi. Philad.
1842) " in chronic diseases of the prostate, blad-
der and kidneys, gravel, &c," — as if the pathologi-
cal condition to be rectified, were in all these
cases identical ! New Remedies, 4th edit. p. 239,
Philad. 1843.]

In cases where there is great weakness of the
loins, accompanied perhaps by dull heavy pain,
mechanical support will frequently afford great
relief. For this purpose a tight bandage may be
applied, or a plaster, such as the emplastrum cu-
mini, emplast. ammoniaci, or emplast. oxyd. ferri
rubri.*

When an abscess forms in the kidney, it may
open in the loins, or it may burst into the pelvis
of the organ, and be discharged with the urine.
In the former event the aid of the surgeon will be
required. If the abscess be of a scrofulous nature,
the termination of the case will in all probability
be unfortunate. The surgeon will have to deal
with sinuses, which will prove very troublesome,
yet by means of setons they may sometimes be
healed. If the ureters be plugged up with scro-
fulous matter, there is no chance of a cure, but
temporary relief may be afforded ; the sinuses
opening at an inconvenient part may be healed by
seton, and an outlet be made in a more favourable
situation. In the latter case, should the abscess
be the result of common inflammation, the patient
has a good chance of recovery. Balsamics, as the
Chian turpentine, may be employed, and the uva
ursi may be of service. Should it be, as it com-
monly is, of a scrofulous character, the prognosis
must be unfavourable. In such cases generally
the infundibula, pelvis, and ureter partake of the
disease ; more or less symptomatic fever attends,
and the patient is worn out by the irritation and
drain. Such, however, is not always the case;
patients do occasionally recover against hope,
whether by the resources of nature alone, or the
aid of medicine, may admit of great doubt ; but
certainly it is the bounden duty of the medical
attendant to bring into the field those remedies
which have the reputation of being useful in scro-
fulous disease — sarsaparilla, cinchona, liquor po-
tassse, conium, cum multis aliis.

The termination in gangrene is happily of rare
occurrence; and when such is the termination,
nothing is to be expected from medicine.

We would, in conclusion, impress forcibly upon
the minds of persons who have once suffered un-
der an attack of nephritis or nephralgia, the con-
sideration that they are extremely liable to a re-
corrence of the complaint, and the importance
therefore of caution as to diet, exercise, &c.
Their diet should be plain and of easy digestion,
ami repletion should be studiously avoided ; they
should be sparing in the use of strong liquors, and

* 0( these I lie ljc>t perhaps is the emplast. oiydi ferri
rubri, on account of iis stiffness and adhesive quality,
not from any effect which we can suppose the iron to
communicate.

should especially abstain from acescent wines;
they should take regular and moderate exercise ;
they should not acquire the habit of spending
many hours in bed, nor should they make use of a
feather-bed ; they should avoid exposure to cold
and damp, particularly the getting wet in the feet.

H. W. Carter.

NEURALGIA.— The term neuralgia, derived
from vtvpov, a nerve, and a\yos, pain, signifies pain
in a nerve. The pain is in some cases felt in the
cord of a nerve, and follows its track; in other
cases the pain is felt in the ultimate twigs into
which the nerves split, so that a space, or spot, or
organ, and not the track of any particular nerve,
aches or is acutely sensible. When it evidently
takes the course of a nerve, the case is clear,
whatever be the character of the pain ; but when
it affects an organ, a space, or a spot, we pro-
nounce the disease to be neuralgia from the cha-
racter of the pain and the absence of such other
circumstances as would be sufficient to occasion it.

In the most exquisite cases the pain is excruci-
ating, sharp, sudden, stabbing, or plunging, as
patients frequently express themselves ; more vio-
lent at one moment than another, and sometimes
greatly mitigated or absent for a longer or shorter
period ; induced instantly, like an electric shock,
by motion or pressure, even by brushing the point
of the finger along the affected part, or it being
shaken or blown upon by cold air. Firm pressure
is frequently borne, and gives ease. If a secreting
organ is in the neighbourhood, it is excited. For
example, when some nerves of the face are affected,
a paroxysm of pain may be induced by masticat-
ing, swallowing, blowing the nose, or even by
speaking; and a flow of tears, nasal mucus, or
saliva, is frequently observed. If there are small
muscles in the neighbourhood, they experience
twitchings ; and, in the severest cases, large and
distant muscles may be convulsed. From these
circumstances some have called the disease neu-
ralgia spasmodica, but, we think, most improperly,
because they are only incidental, and the severest
neuralgia may occur without them. The pain
may be dreadful and occasion delirium.

Such an affection was formerly called tie dou-
loureux, painful tic ; the latter word signifying a
sudden catching or convulsive motion, such as is
noticed in the face or other parts of some persons,
and is as it were a local chorea, and such as is
noticed in some horses that convulsively bite the
manger. Persons with such catchings experience
no pain. But when twitchings occur in neuralgia,
they are attended by pain, and therefore to their
name — tic — in this disease, the epithet douloureux
was added. As the disease was first noticed and
distinguished in the face, where there is an abun-
dance of small muscles and consequently twitch-
ings usually attend it, the twitchings attracted as
much attention as the pain, and the disease ob-
tained its designation from both symptoms. Some-
times, between the shooting pains, there is con-
stant aching ; and sometimes the part feels pain
fully benumbed. We have known the neighbour
ing parts, which were not in pain, benumbed.

The attacks may last days, weeks, or months ;
and may recur after intervals of days, weeks,
months, or years. They may occur chiefly after

382

NEURALGIA.

exciting causes, or without any obvious reason.
They generally occur without warning, but have
been preceded by peculiar sensations and some
kind of indisposition. The disease may be sus-
pended or may cease, by nature or through art, or
may end in apoplexy, insanity, emaciation, and
death.

It most frequently attacks the ramifications of
the fifth pair, and the first and second branches
of the nerve suffer oftener than the third. We
notice it therefore particularly over the orbit, under
the orbit, in the cheek where the pes anserinus is
spread, in the mouth, and along the lower jaw,
and in the lower teeth. Some doubt that it is
ever felt in the portio dura; others declare they
have known it in that nerve. [It is proper to re-
mark, that after the portio dura has passed through
the parotid gland, it is associated with a twig of
the fifth pair.] An hospital patient of ours com-
plained of it not only in the cheek, but in the
course of the portio dura from the stylo-mastoid
foramen. We do not see why the disease should
be confined to nerves of sensation. Two, or even
all the three, branches, are sometimes affected,
and the pain may extend even to the other side
of the face. We have known it extend down
the neck to the shoulder, and along the inside of
the arm to the ends of all the fingers and the
thumb. Various nerves of the legs, arms, fingers
or toes, are occasionally the seat of the disease ;
and an intercostal, a lumbar, and even the sper-
matic nerve, has been attacked. The pain may
be confined to one nerve, or to it and its branches,
may extend to other nerves in the neighbourhood
or at a distance, or it may affect nerves distant
from each other, simultaneously or successively,
and change its seat backwards and forwards. The
pain does not always shoot in the course of the
nerve, but frequently in the opposite direction. It
may not shoot from a nerve through all the twigs,
but only through some.

Neuralgia of this character was perhaps first dis-
tinctly described in 1756 by Andre, the French sur-
geon of Versailles, in his work upon the diseases of
the urethra. Dr. James Fothergill, in the fifth
volume of the Medical Observations and Inquiries,
published in 1776, described it as occurring in the
face, and without being aware that Andr6 had an-
ticipated him — and no wonder, when we consider
the singular mode in which Andre promulgated
his facts — and he tells us that he never saw more
than fourteen instances of it. We have not seen
so many. He observed it oftener in women ; but
this great frequency is not a general fact. He
never noticed it in persons much under forty years
of age, and this observation, we believe, is con-
firmed. It is rare in children, yet continental
writers record cases of it in subjects but seven and
nine years old.

Pain of exactly this character, and not to be
accounted for by inflammation or organic disease
of the part, now and then attacks organs or spots,
and not the track of any nerve. The breast, for
example, the heart, the testis, may so suffer ; and
once we witnessed it apparently in the kidney.
The character of the pain, and the absence in the
part of the ordinary causes of pain, justify us in
regarding it in these cases as neuralgia.

In other cases it is not the character of the pain,

but the evident situation of it in one or more
nerves, that proves it to be neuralgia. Pain is
frequently not stabbing and sudden, not of the de-
scription above given, but equally deserving to be
called neuralgia, because affecting the course of a
nerve. It may be acute, though not electric nor
excited by the slightest friction ; it may be a con-
stant aching. When a nerve is inflamed, there is
great pain. When a portion of a nerve has been
seen of an uniform dark red colour after death ;
when a portion has been found diseased and en-
veloped in gangrenous cellular tissue; or about
double its natural size, of a violet red colour, and
strewed with ecchymoses of the size of pin's heads ;
or a serous, bloody, or purulent effusion has been
discovered among its fibres ; or nerves have been
found hypertrophied and connected with fungous
ulcers ; when a nerve has been bruised, lacerated,
or half divided ; — pain of greater or less intensity
had been felt in the nerve or the parts upon which
it is distributed. (See Abercrombie's Researches
on the Diseases of the Brain, &c.) Cotugno,
Cirillo, Chaussier, Bichat, &c. have seen similar
appearances after neuralgia. In some cases of
disease of the brain or spinal marrow, even where
paralysis is produced, pain is felt at a distance:
the paralysed parts sometimes ache severely in
hemiplegia. In epilepsy and hysteria, pain is
sometimes felt in the course of nerves. A portion
of the pain in structural disease of all organs may
occasionally occur in the branches and twigs of
the nerves irritated by it. Nerves also frequently
suffer pain from rheumatism. There is decidedly
a rheumatic neuralgia. The exquisite neuralgia,
described as tic douloureux, may arise from thoso
vicissitudes of temperature that occasion rheuma-
tism, and may be rheumatic. But pain, not of
that description, though perhaps very acute, per-
haps dull and aching as is usual in rheumatism, 1
is every day witnessed in the situation of nerves,
in persons who have rheumatism in those situa-
tions, and who have been exposed to cold, or per-
haps cold and wet ; and it yields as readily to the
treatment of rheumatism as the ordinary rheuma-
tism of other parts. The neurilema, which is a
fibrous membrane, is probably still more affected
than the nerve, since rheumatism is chiefly a dis-
ease of the fibrous membranes. In rheumatic
neuralgia we observe all the varieties of suffering
occasioned in other parts by rheumatism : some-
times acute pain, with tenderness, heat, and even
throbbing, and aggravation of the pain by heat ;
sometimes dull aching only ; sometimes pain on
motion, pressure, or other modes of mechanical
irritation ; sometimes remittent, intermittent, or
even periodical, pain. The pain is sometimes ex-
quisite and sudden, assuming the character of tic
douloureux, which, we may remark, not only
when rheumatic, but sometimes when not appa-
rently so, may assume a periodical type. It is the
clear situation of the pain in a nerve, and not the
character of the pain, when it is not like the pain
called tic douloureux, that justifies us in rheuma-
tism to pronounce it neuralgic. The nerves
chiefly attacked by rheumatism are the sciatic and
the branches of the fifth. It is frequently very in-
flammatory, so that the surface is tender, hot,
swollen and even red. Sometimes no marks of
inflammation are discoverable, and warmth »nd

NEURALGIA.

383

other stimuli relieve. In the case of the face espe-
cially, (one side only of which is usually affected,
and perhaps not only the nerves, but some of the
surrounding parts,) there is a great tendency to
periodical intermission, and the paroxysms usually
occur in the evening.

In hysterical females, portions of the surface
occasionally become exquisitely tender, [Der otal-
gia,] so that the least pressure with the extremity
of the finger, such as would not occasion pain
were the peritoneum or viscera inflamed, — even
the sudden falling of the bed-clothes upon it, —
causes anguish. The surface of the front of the
body is most frequently affected, sometimes only
of the abdomen, sometimes only of the chest ;
sometimes portions of the back only suffer, par-
ticularly at the spine ; and sometimes nearly the
whole surface of both the trunk and extremities.
As no pain is felt while the part is not com-
pressed, perhaps this condition ought not to be
called neuralgia. But the absence of heat, swell-
ing, redness, and of all signs of internal no less
than of external inflammation, and of structural
affection and serious disease, the perfect inutility
of all the remedies of inflammation, the power of
the remedies of pure nervous affection and neu-
ralgia, prove it to be a morbid sensibility of the
nerves of touch, and perhaps make it merit the
epithet neuralgic. Cases of this description are
occasionally mistaken for chronic peritonitis and
other inflammatory diseases ; and, when the ten-
derness is felt in the course of the spine, it is too
often set down as a mark of disease of the spine
or its ligaments, or perhaps the whole case is re-
ferred to an affection of this portion of the spinal
cord, while the morbid sensibility of the spot is
merely one of the number of symptoms. We
saw this tenderness in an hysterical and neuralgic
middle-aged man who had been exposed to mal-
aria.

The nature of neuralgic affections may be evi-
dent during life, and immediately, or not till after
a lapse of time ; may become evident after death
only ; or may never be discovered.

Inflammatory conditions of the nerves and
structural changes, as well as mechanical causes
of irritation, may be detected during life if the
seat of these conditions is within the reach of ob-
servation : and symptoms may be induced which
clearly point out inflammation or structural change,
even should these be beyond our observation.
Occasionally, however, the seat and cause of the
irritation is not only beyond observation during
life, though discoverable afterwards, but no symp-
toms are produced which indicate them. After
exquisite neuralgia, or that kind denominated tic
douloureux, the cranial bonds have been found of
unusual thickness, so that it was fancied that pro-
bably they had in some degree compressed the
nerves. There is, however, no proof that the
neuralgia was the effect of the growth of the bone.
The latter might have been only one of several
morbid changes going on in the head, and some
of which caused neuralgia. The state of all the
nerves should have been accurately ascertained.
In insanity and idiotism the bones are sometimes
of enormous thickness through the general ten-
dency to disease in the head, and the insanity is
not ascribable to it, but the whole is the result of

the tendency to disease in the head. Here, too,
there is generally no neuralgia. To show that in
some cases of neuralgia the cause becomes ob-
vious after a time only, we may state that Dr.
Abercrombrie quotes one case of exquisite neural-
gia of the face that ceased on the removal of a
piece of china which had been there fourteen
years, and another of ten years' duration that
ceased on the extraction of a tooth. [M. Andral
( Cours de Pathologie Interne) attended a man
who suffered agonizingly from neuralgia, which
irradiated from the mental foramen. The disease
was induced by syphilitic periostosis, and it disap-
peared as soon as the system was affected by mer-
cury. Such cases M. Andral terms false neural-
gia.] Sir Henry Halford mentions the case of a
lady who laboured under violent tic douloureux
till an apparently sound tooth was extracted, on
account of the attacks being frequently preceded
by uneasiness in it, and that a large exostosis was
found at its root. He relates the case of a noble-
man who was liberated from the disease by the
exfoliation of a portion of bone from the antrum
maxillare. To ascribe neuralgia, however, to these
causes, in most cases is very unpathological. In
ordinary rheumatism, which is not inflammatory,
in that form which is unattended by heat, and in
which there is mere aching relieved by warmth
and all stimulants, and probably greatly influenced
by atmospheric changes, the real condition of the
part is unknown. The same is true, not only of
this rheumatism when affecting nerves, not only
of the corresponding form of rheumatic neuralgia,
but of that exquisite neuralgia, when not rheuma-
tic, and when no inflammation nor structural
change, nor mechanical cause, can be detected
before or after death. Good pathological anato-
mists declare they have frequently been unable to
detect any unhealthy appearance, on careful dis-
section.

[The evidence, afforded by pathological anato-
my, is far from being satisfactory. " It is often,"
to use the language of a modern writer on the
subject, Dr. Jolly, " negative, always equivocal,
and never decisive." The affection is, doubtless,
owing to organic changes in the part affected, as
in the case of the various neuroses, but these
changes are as yet inappreciable. By many, de-
ductions have been drawn from a few facts, and,
therefore, prematurely. Of this character, per-
haps, is the view of Mr. Alnatt, (Tic Douloureux,
&c, London, 1821,) that irritation of the sympa-
thetic nerve is productive of the local mischief, in
nine cases out of ten, in the expanded branches
of the fifth, or rather the ganglionic nerves, which
accompany them.]

Occasionally the pain may be sympathetic, may
depend upon no fault of the nerves or even the
nervous centres, but upon disorder of the digestive
organs. Even such an origin cannot always, in
obscure cases, be presumed ; and we confess that,
allowing some of the blame to be deserved that is
laid upon the digestive organs as causing all kinds
of diseases of all parts — a vulgar assumption
easily made and saving a world of investigation
and accurate reasoning, — we have never seen one
case of neuralgia referable to such an origin.

Since this is true of the nature and causes of
neuralgia, we see how various must be its course

384

NEURALGIA.

and its termination, and how various the prognosis
as well as the mode of treatment required in dif-
ferent cases.

[Small tubercles are occasionally developed in
the course of nerves, which give occasion to ex-
cruciating neuralgic pains. These subcutaneous
tubercles are distinguished, during life, by an ex-
amination of the part affected, when a small body,
of the size of about half a pea, is felt under the
integuments. A case of the kind occurring in
the thumb of a shoemaker, and probably from a
puncture of his awl, which was cured at once,
after years of suffering, by excision, is related by
Dr. Marshall Hall. (Edinb. Med. and Surg.
Journal, xi. 466 ; and Principles of the Theory and
Practice of Medicine, Amer. edit, by Drs. Bigelow
and Holmes.)]

[Treatment.] — When inflammation is ob-
vious or presumable, whether rheumatic or not,
local bleeding, mercury, colchicum, and the whole
antiphlogistic plan, general and local, are appro-
priate. Should these not succeed soon, anodynes
may be added ; and the pain may, from an in-
flammatory commencement, degenerate into pain
without inflammation, and demand at last solely
the treatment of another form of the disease.
When rheumatic and yet not inflammatory, the
remedies of this form of rheumatism in other
parts are required ; — stimulants internal and ex-
ternal, tonics, mercury, and all modes of counter-
irritation. Coldness indicates stimulants. Among
internal stimulants, besides generous diet, the
ammoniated tincture of guaiacum is one of the
best. It should be exhibited in such quantity and
frequency as to keep the patient comfortably warm.
A dose of half a drachm may be sufficient, or six
drachms may be required ; and a frequency of
three times in the twenty-four hours may be suf-
ficient, or the dose may require repetition every
two hours ; and in general both may be dimin-
ished after the remedy has been continued for
pome time, because it stimulates more and more,
and its effect lasts longer. When there is debility,
and especially paleness, iron in full quantities
operates in the most salutary manner, much more
so than quinine.

[The oil of turpentine is highly extolled by
some. (Copland, art. Neuralgic Affections, in
Diet, of Pract. Med. ix. 891.)]

The hot bath, of water or vapour, the douche,
electricity, blisters, moxas, sinapisms, tartarized
antimony, croton oil [the ammoniacal preparations
of Gondret and Granville ; (see art. Coujjter-
tubitation)], and acupuncture, [electricity, gal-
vanism, and electro-puncture,] frequently cure,
if combined with all other appropriate means.
Mercury carried to ptyalism frequently cures, pro-
vided the strength will bear it, and the rest of the
treatment is well conducted. Even the cold
shower-bath or cold douche, if followed by good
friction, will cure. A warm temperature of the
atmosphere around the patient, and warm clothing,
may be indispensable. Anodyne narcotics may
be absolutely necessary ; and the salts of morphia,
stramonium, and belladonna [codeia, and cannabis
sativa], carried to a due extent, are by far the best,
and sometimes alone will cure.

[Aconitia, veratria, and delphinia have been
tubbed on the affected parts (see the writer's

Practice of Medicine, 2d edit. ii. 314, Philad
1844), and occasionally with marked advantage.]

If the disease is seen to depend upon any or
ganic affection, or upon a mechanical cause, the
treatment will be evident. Should no structural
or mechanical cause, and no inflammation be dis-
coverable, and should the disease be of the exqui-
site character, then iron is the best remedy. The
use of the subcarbonate of iron was discovered by
the late Dr. Hutchison of Southwell. The old
dose of half a drachm or a drachm will sometimes
succeed. But while exhibiting this remedy in
various diseases, we soon discovered that it might
be given without any inconvenience in far larger
quantities than was imagined.* Even children
of eight years old will often take half an ounce
or six drachms every four hours. If given in
twice its weight of treacle, it rarely constipates.
But strict attention should be paid to keep the
bowels open during its employment, because,
being an insoluble substance and bulky, if it is not
regularly discharged, its accumulation may be
considerable and produce inconvenience. If doses
of a drachm every six hours fail, it should not be
relinquished till those large quantities also have
failed. Although it is the best medicine at pre-
sent known under these circumstances, it fre-
quently fails altogether, and still more frequently
the disease returns, but perhaps yields again and
again to it. In all cases of neuralgia, whether
exquisite or not, unaccompanied by inflammation
or evident existing cause, iron is the best remedy.
Probably other forms would answer as well as the
subcarbonate. When iron fails, or affords but
imperfect relief, it may be serviceable by improving
the general health. Less frequently curative as is
this medicine than we had hoped from Dr. Hut-
chison's statements to find it, the power it was
proved by this gentleman to possess over the dis-
ease induced us to try it in other nervous affec-
tions ; and in those which are less frequently con-
nected with an inflammatory or structural condi-
tion, its power is very great. The first other
disease in which we employed it was paralysis
agitans, and the first case was cured. In most
other cases we have been disappointed, and pro-
bably from organic change of the nervous sub-
stance frequently existing. The next disease was
chorea, and as that is comparatively seldom de-
pendent upon structural change, we have never
once failed in curing it with iron, except when it
has been partial or of very long standing— cir-
cumstances in which structural change is highly
probable. Even in two cases of tetanus out of
three, we were successful with it ; and in the third,
which was fatal, there was too little time to ex-
hibit it.

[The cyanuret of iron has likewise been given,
as well as the different metallic tonics, the acetate,
sulphate and ammoniuret of copper, the oxide and
the cyanuret of zinc, &c, but they have not been
found equal to the subcarbonate of iron.]

Quinine, arsenic, belladonna, stramonium, col-
chicum, are said sometimes to cure this exquisite
form. The want of attention to the stomach and
bowels, and of the observance of good habits, will
aggravate it. Relief is said to be obtained occa-

* See a Paper by Hie author of this article in Dip I3tn
Volume of the Med. CUir. Transaction"-.

NEURALGIA — NOLI ME TANGERE,

385

sionally by the application of steam to the part,
and sometimes by ice. The application of the
strongest narcotics, and all irritants and escharo-
tics, as well as the actual cautery, have occasion-
ally done good.

[In neuralgia of the face more especially, the
cause of which has been considered by Sir Charles
Bell (Practical Essays, Edinb. 1841, p. 101,) to
De seated primarily in the intestinal canal, and
'emotely in the fifth pair of nerves, cathartics, es-
pecially croton oil, have been recommended ; and
this, as well as some other forms of neuralgia,
would seem to have been removed by it, — doubtless,
through the revulsion it excites on the nerves of
the intestines ; but it need scarcely be said, that it
possesses no specific virtue, as has been imagined
by some. In the only case of genuine tic, in
which it was tried by Dr. Christison (Dispensa-
tory, p. 382, Edinb. 1842), no benefit whatever
was derived from it.

Of late, it has been proposed by M. Allier
(V Experience, No. xvi. Jan. 20, 1838,) to com-
press the main artery proceeding to the affected
part during the paroxysm. (New Remedies, p.
182.)]

When all has failed, the division of the nerve,
or the removal of the part, if possible, may be pro-
posed, provided no cause in another part is obvious,
and provided the pain is invariably limited to one
part. Galen was acquainted with the division of
the nerve as a remedy in the disease ; but a royal
French surgeon-marechal appears to have been
the first who performed the operation. Unfortu-
nately it very rarely cures. One portion of the
divided nerve suffers again, or the disease reap-
pears in some other part. Too often there has
not been even temporary relief. Yet amputation
of the finger or thumb, in which the disease was
seated, has succeeded, when the cause of the
affection was local. (Med. Chir. Trans., vol. iv.
and vol. viii.)

When neuralgia arises from malaria, whether
ague has also been produced or not, quinine or
arsenic, long continued in the largest and most
frequent repeated doses that can be borne without
the least inconvenience, are the best remedies ;
and when it is periodical or intermittent, without
evident connection with malaria, they are excel-
lent. But sometimes a full dose of extract of
stramonium or belladonna, repeated every hour or
two from just before the attack is expected to the
termination of every paroxysm, succeeds better.

John Elliotson.

NIGHTMARE. See Incubus.

[NIPPLES, SORE. See Lactation.]

NOLI ME TANGERE, or LUPUS.— The
name of lupus, which was occasionally used by
the older writers on medicine and surgery to sig-
nify any ulcer having a destructive tendency,
(quasi, voracious as a wolf,) was appropriated to
the particular diseases of which we now treat by
Sauvages, who considered it a species of cancer,
and called it " cancer lupus." The other term by
which it is equally well known, is of a still older
date ; and it is no longer certain in what it
originated. Some authors affirm that, the icho-
rous matter which was formed by the ulcerated
parts being supposed to be contagious, this name

Vol. III. — 49 2 a

was given to include an expressive warning to
beware the contact of a thing which produced
such fearful and unsightly effects. Others state,
with greater appearance of probability, that " touch
me not" refers to the inutility of using topical
remedies in its treatment. However this may be,
the terms lupus and noli me tangere are synony-
mous in British medicine, and have always sig-
nified the same thing since they have been used
in any definite sense. Biett, indeed, uses the
latter term to express malignant ulcers of a can-
cerous origin ; but he will not, we hope, be imi-
tated in this, as this application of it would only
serve to add to the confusion which already exists
as to the proper comprehension of this disease.
We shall revert to this, and to other names which
have been used indifferently with it, as we proceed.
There is scarcely any disease of so formidable
and obvious a nature about which such uncertain
and ill-defined notions prevail. It must have been
known to the earliest antiquity. Celsus clearly
and forcibly distinguished it from cancer under
the name of cacoethes ,• and it is not a little re-
markable that the remedies which he recommends
are the same which at the present da} 7 are most
relied on. While other diseases of the integu-
ments have been investigated and described with
a minuteness of research which some have con-
sidered superfluous, systematic writers have slurred
over this with a scanty and superficial notice quite
inconsistent with its importance. Some writers
pass it over altogether, and others handle it in a
manner which gives us as imperfect a notion of
the malady almost as if they had left it altogether
untouched. This does not surely arise from the
rarity of its occurrence, or from the insignificant
nature of the affection. A slight acquaintance
with the practice of any considerable hospital or
dispensary, affords a melancholy proof both of its
frequency and its ravages. In Dr. Good's " Study
of Medicine" we find the subject despatched in
about a page, in which short space he has con-
trived to insert so much of error, that no person
acquainted with the disease could recognise it
from his description. Bateman, in his valuable
" Synopsis," devotes ten pages to aphthae ; but
lupus he is also content to dispose of in one. For
the comparative neglect of this subject he excuses
himself by stating that he is not aware of any
medicine which has been of essential use in its
cure. We suspect, however, that one chief reason
why the subject has been treated in so insufficient
a manner lies in the essential difficulties connected
with it. And these are in fact very great. Nature
herself does not appear to have assigned in many
cases accurate limits to it ; at least in the study of
these destructive ulcerations, the observers of na-
ture are frequently at a loss to find means for
drawing the line of demarcation between true
lupus and diseases considered to be of a different,
pathological nature. In our description of the
varieties, or rather species of this malady, we shall
observe a somewhat similar plan to that of M.
Biett, whose lectures, detailed in the work of MM.
Cazenave and Schedel, deliver the best digested
history of it to be met with in any language.*

* Abn'tje pratique des maladies de la peau, d'apres lea
anteura les plus estimes, et surtout d'aprus les docuniens
prises dans la clinique de M. le Docteur Biett, par MM.

336

NOLI ME TANGERE,

Lupus commences by the slow development of
a tubercular induration in the tissue of the true
skin or mucous membrane ; sometimes, perhaps,
in the subcutaneous or submucous cellular tissue.
According to its situation this tubercle is cither
single, or else several appear together. While it
makes its slow progress towards the surface, the
skin takes on a violet colour, which spreads be-
fore the advancing tubercle, and seldom yields
except to destructive ulceration. After an uncer-
tain time the tubercle makes its appearance on
the surface, cracking the cuticle, and forming a
coarse laminar scab, from under which exudes a
foul ichorous discharge. The crust, which is the
surface of the tubercle, is very closely adherent ;
it spreads and sometimes falls off, exposing an
ulceration of a malignant aspect underneath. The
latter extends, pari passu, with the tubercular
crust ; but sometimes it spreads beyond the space
which this occupies ; every time that this falls off,
a greater extent of ulceration is visible ; and thus
it proceeds, unless checked by art, till it commits
the most frightful ravages.

This general character of the disease applies to
it more particularly when it has its seat on the
face, which, in genuine lupus, is the case in nine-
teen instances out of twenty. But even in this
situation it has much variety which a general
description cannot include. In describing it more
particularly then, we will separately consider it in
three forms : — -first, lupus in which the ulcerative
process destroys chiefly in depth ; second, that in
which the destruction and cicatrization do not
manifest any open ulceration, and are accom-
panied by an hypertrophied state of the skin ;
third, lupus which spreads mostly superficially.
This division of the subject differs but in the suc-
cession from that of M. Biett. It appears the most
practical, and therefore the best adapted for clos-
ing with the difficulties with which the subject is
attended.

1. Deep or erosive Lupus. — The first species in
our division is that in which the ulcerative process
proceeds from the surface towards the centre. We
have placed it first because it is the real type of
the disease, the undisputed lupus or noli me tan-
gere. The French writers have given to the dis-
ease the name of "dartre rougeante" after M.
Alibert, who has divided the latter into three
species. His dartre rougeante idiopathique agrees
with this species, which is more especially the
lupus of the nose. It very rarely occurs in any
other place ; but having run its destructive course
on that organ, it not unfrequently spreads to the
adjacent parts. On the ate nasi, or at the point,
a small tubercle makes its appearance, having its
seat more or less deep in the true skin. As it ad-
vances, it assumes a livid colour. The skin around
it becomes somewhat swollen and painful, and
also assumes more or less of a livid or violet hue.
After a period, which is various in different cases,

A. Cazenave et H. E. Schedel, &c. &c. We wish to ac-
knowledge our obligations to this book. It is written
in an unpretending style, but is now justly reckoned,
both in this country and Germany, to contain more en-
lightened information on cutaneous diseases than any
oilier recent work. We cannot but express a wish that
Great Britain afforded such an opportunity for the culti-
vation of this branch of medical study as the Hopilal
Si Louis at Paris does.

a crust forms on the surface of the tubercle, of
some thickness, and under this an ulceration ex-
tends. The crust falls and is renewed ; and at
every time that it is detached, it is found that the
ulceration has destroyed a deeper layer of the skin.
This proceeds very slowly for a long time, the
loss of substance taking place nearly insensibly.
Although new portions of the incrustation are
frequently falling off, and always carry away with
them a part of the subjacent tissue, it is not till
this process has been going on for a considerable
period that the destruction which it has caused is
perceived.

In most cases this ulceration is accompanied by
a constant discharge, from the nostril of the side
affected, of a thin fetid matter. This latter phe-
nomenon may originate in two ways. It may
arise from inflammation of the Schneiderian mem-
brane, propagated from the irritation of the tuber-
cle producing the destructive ulceration of the
skin. This is a frequent origin of the discharge;
and where it is caused in this manner, it is neither
so unremitting nor of such a bad quality as in the
other case : it partakes here, in fact, more of the
character of a common mucous coryza. The other
source of the discharge is the actual commence-
ment of the tubercular development in the mucous
membrane of the nose itself. It is an indubitable
fact that the disease very often commences here.
It even sometimes produces much internal destruc-
tion without manifesting any morbid alteration in
the skin. The history of its progress, when the
disease begins in the mucous membrane, is dif-
ferent from that of its cutaneous origin ; and we
are disposed to think that, not considering this, it
has been erroneously stated that it sometimes be-
gins without any tubercular formation. But when
we take into account the different structure of the
two tissues, the process is quite analogous, what-
ever apparent difference the first stage of their
progress may present. Its beginning in the mu-
cous membrane is after the following manner.
After some redness and inflammatory swelling in
one of the nostrils, a thin, dark scab forms on the
lining membrane, which, if it be torn off, is soon
reproduced in the same way as the crust of the
external tubercle. The destruction goes on under
this thin layer until it corrodes the mucuous mem-
brane and the subjacent tissues just in a way
corresponding with that in the tubercles before
described. The difference lies not in the character
of the disease, but in the nature of the tissues. In
the mucous membrane, from its soft, pulpy texture
and moist surface,* it is impossible to have the soliJ
induration, denominated a tubercle, which the
firm structure of the skin, covered by its dry
cuticle, permits, unless by the deposition of a
foreign structure, which does not take place in
lupus ; but there does take place a degree of con-
densation of its tissue ; and in some places where
it is most firm in structure, as the hard palate,

*In other cutaneous diseases a similar relation exist'
between the mucous membrane and the skin when the
former becomes invaded by a disease proper to til
Papular eruptions, as lichen, sometimes extend inside
the mouth; but here they take on the appearance of
aphthous vesicles. In squamous diseases not unfre-
quently the internal membrane becomes affected;. but
instead of scales, which, from the nature of the mucous
membrane, could not form on it, excoriations take place.

JN'OLI ME TANGERE.

387

we have known small tubercles to be formed.
The crusty exfoliation takes place in both situa-
tions ; but it is modified as to its density and
thickness by the nature of the membrane which
secretes it. It is in this form, where the tubercular
deposition commences within, that the discharge
is sanious and fetid, being in this case the actual
secretion from the ulcer ; whereas in the former
case it is mucus produced, as we have explained,
by the irritation propagated to the pituitary mem-
brane.

But whether it be in the cutaneous or mucous
tissue that the disease begins, after a short period
the progress of it becomes identical. The subja-
cent cellular tissue and the muscles yield to the
ulceration and are destroyed ; the cartilages fol-
low in their turn, and very frequently the bones
themselves are not protected from its ravages, but
partaking in the general destruction, are corroded
pari passu with the soft parts on the same level.
This seems to be the distinguishing property of
lupus, and of this particular species more espe-
cially. In most other diseases (where there is no
actual deposition of morbid structure, as in can-
cer, &c.) the morbific action affects one tissue in
particular, and is more or less confined by its spe-
cific irritability to this. But in lupus this does
not by any means hold ; its ravages have no re-
spect to contrariety of organization : having de-
stroyed the seat of its original development, it con-
tinues to eat its way through every tissue which
opposes itself in its progress, until its further
course is limited either by the destruction of the
organ or by artificial means.

To return to the history of its progress. The
destruction is generally complete in one of the
alae, or the point of the nose, before it spreads far-
ther on its surface ; but sooner or later the disease
extends so as to embrace both sides ; and wher-
ever it takes up its ground in advancing, it is by
the same tubercular deposit with which it began.
Sometimes after having destroyed the tip of the
nose or one of the a\x, it forms a puckered cica-
trix, and seems to be nearly healed up ; but it
rarely stops in this manner. More generally, after
a while, new tubercles become developed in the
midst of the cicatrix itself, which ulcerate and de-
stroy with all their original virulence. While the
destruction spreads externally in the manner de-
scribed, in general the internal parts are not ex-
empted from the disease. In the majority of cases
some part of the nasal fossa is simultaneously
affected with it. The inner surface of the alae
corresponding to the external disease is a common
place to find it internally ; but the septum narium
is the part where its ravages are most generally
met with. In such cases the discharge is constant,
and becomes an additional subject of disgust to
the poor patient. The crusts which collect on the
septum and on the turbinated bones nearly block
up the passage of the nostrils. Sometimes, in-
deed, union takes place by adhesive inflammation
between the alae and septum, which has to be di-
vided by the knife and cauterized. Where the
disease is not checked by the appliances of art,
nature seldom interferes to make its ravages but
partial. The soft parts of the nose being destroyed
Dy a gradual external progress, and the internal
disease having broken up the septum, the entire

organ is thus carried away, and in its stead re-
mains but a square aperture partially divided by a
partition, a hideous memorial of its devastating
course. The bones sometimes limit its course
after it has destroyed all the soft parts ; but if it
be not arrested before it has gone so far as this,
these are also involved. It is at least common for
the ossa nasi to be affected ; and cases are met
with where the destruction invades the superior
maxillary bones : usually, however, when the
ossa nasi fall, and the septum has been destroyed,
it pursues its course no further among the bones.

This is the general account of its ravages, and
it seldom stops, unless checked by art, till it fulfils
it. Some variety will of course be met with in its
course and in its terminations. Instances will be
met with where it has disappeared after carrying
away one of the alas nasi ; others where it went
no further than to carry away the point of the
nose. These are singular cases, and will be gene-
rally found to have been brought about by art.
We have lately seen a case, however, where the
ala nasi on one side was taken clean away by the
disease, which then stopped spontaneously. In
other instances it has run a more superficial course
from the beginning, and having eaten through
some of the layers of the skin, becomes checked.
In such a case it sometimes leaves the nose thinned
on the sides, and running into a sharp-pointed tip.
It is in these cases that the orifices are liable to be
closed by the adhesive inflammation of the inter-
nal surfaces.

With respect to the stages of the disease, and
the time which they take to run their course, they
are by no means definite. The tubercles remain
indolent for many months, but when they ulcerate,
the disease generally makes quicker progress. No
corresponding relation exists between the duration
of the malady and the destruction which it pro-
duces. While in some it remains without effect-
ing any important loss of substance for several
years, in others the whole nose is destroyed in a
few weeks.

We must again notice the frequency with which
lupus occupies the pituitary membrane. Biett de-
scribes with exactness the case where it com-
mences internally, and eats its way from within
outwards, its arrival at the skin being preceded by
a livid colour. The same author states that it
sometimes commences in the skin, and having in
its course reached the opening of the nares, it tra-
verses their floor ; it then descends along the soft
palate, and having destroyed it, returns along the
palate bone, eating away the roof of the mouth.
But no author has, we think, dwelt sufficiently on
the disease as running its course entirely within.
It has been long known, indeed, that ulcerations
of a bad kind occur at the back of the pharynx,
destroying it deeply, and carrying away the uvula
and soft palate. These too are often called in sur-
gical works by the improper name of « herpetic
ulcers," which infers that they partake of the na-
ture of lupus, as this was and is still too often
designated by the term " herpes exedens."* But
they often occur in other parts of the nasal

* This name was employed before proper limits were
given to cutaneous nosology. To continue to use the

term herpes or herpetic in the present day in any other
than the vesicular disease so called, only' tends to con-
firm error.

388

NOLI ME TANGERE.

cavity, where they are less obvious ; and the in-
sidious latency with which they commit extensive
ravages is sometimes very extraordinary. A great
part or the whole of the septum narium may be
destroyed without its even being discovered by the
patient or by his friends. The chief complaint
which is observed is a stuffing in the nose and
head, which at length proceeds so far as to alter
the voice. This is generally attributed to cold or
catarrh. It is always accompanied by a foulness
of breath, which might lead to an investigation
of its real source ; but this is attributed to worms
by the patient's friends ; for it is to be observed
that this internal lupus occurs almost always in
children under twelve years of age.

Its insidious character we have seen strongly
illustrated in some cases that occurred in dispen-
sary practice, particularly in two observed by the
author's friend, Mr. Smyly. A child, about three
years of age, was brought to the dispensary by its
mother, who asked for some worm medicine to
give it. She said that the child's general health
was tolerably good, but that she had a habit of
picking her nose, and she was certain that worms
was her ailment from her foul breath. Her nos-
trils were examined, and it was found that the
septum was quite perforated by a lupoid ulcera-
tion, which reached nearly to its anterior extre-
mity, and extended backwards so far that its ter-
mination could not be discerned. Mr. Smyly
applied a strong solution of nitrate of silver to the
edges of the ulceration, and enjoined that the child
should return frequently to have it treated with
the necessary vigilance. She did not return, but
was met accidentally, some time afterwards, by
Mr. Smyly, who examined the ulceration anew,
and found it stationary. She did not go back, she
said, because there was nothing the matter with
her nose. She had been brought to an apothecary,
who gave her medicine for worms, and assured
her that this was the whole origin of her com-
plaint. The details of the other case are so re-
markably similar, that it would be needless to
recount them. Superficial examinations in such
cases will often betray the medical practitioner
into deep error. We were impressed strongly by
the above facts with the necessity for circumspec-
tion. In another case of this internal lupus,
which occurred to the author last summer, in a
girl of fourteen years of age, the voice became
completely changed into a nasal tone, and a curi-
ous convulsive heaving of the respiratory muscles
took place during sleep. A constant coryza, with
some fetid discharge, led the author to suspect
lupus of some part of the nasal fossa, although
nothing could be discerned by inspection. It has
lately made its appearance at the root of the nose,
near the lacrymal sac, on each side, and confirmed
the suspicion entertained of the source of the dis-
ease. We notice it for the purpose of calling
attention to the effect which the disease appeared
to have on the breathing during sleep.*

* This singular effect certainly depended on the dis-
ease of the nostrils, for the lungs wen; ascertained to be
quite sound by a careful stethoscopic examination. The
nrenthing was performed quite naturally during the day,
but the moment sleep came on. the respiratory muscles
were thrown into a kind of clonic convulsion, which in-
creased with the intensity of the sleep. The writer was
called twice to witness it for the purpose of getting fur-
ther light as to the nature of the disease. Two things

2. Lupus with Hi/pcrlropln/. — This form
agrees with the first in many points, but its pro-
gress and its results are different. Like the former,
its seat is frequently the nose, but it docs not affect
in particular the ala> and tip. It often occurs at
its upper part, between the eyes, and on the fore-
head just above it. The angle of the eye and the
cheek beneath it are not unfrequent localities. It
may, however, occur on any part of the face, and,
according to Bictt,even affect the whole face. It
begins likewise with tubercles, but they are not
like the round hard bodies of the former species.
They are rather soft, ill-defined rugosities, having
a purplish hue, which spreads from them to the
surrounding skin until a circumscribed patch of
the latter presents this colour. No open ulcera-
tion takes place in the tubercle, but if any single
one be watched, it will be found gradually to dis-
appear, leaving a slight furrow behind. This
takes place partly by desquamation from the sur-
face, but chiefly by an interstitial absorption going
on in the body of the tubercle. Whilst this pro-
cess is going on in one tubercle, others are grow-
ing beside it, and in their turn they undergo the
same imperceptible destruction and cicatrization.
At the same time the whole unhealthy patch of
skin becomes swollen, and presents a peculiar in-
dolent aspect and doughy feel. When this tumid
state of the skin goes on to a certain extent, the
tubercles are no longer prominent, but the depres-
sions left by the cicatrices are more evident. The
base of these often exhibits a white, creamy streak,
contrasting with the purple colour of the tubercles,
which lie generally on each side of the cicatrices.
When the disease, then, is of some standing, it
presents the appearance of a swollen, circum-
scribed patch of the skin, of a violet colour, and
in this area there are spots of a deeper hue, dene-
ting the surface of the tubercles, and white marks,
the cicatrices of tubercles which have disappeared
under the slow process before mentioned.

This form, although also a very chronic malady,
spreads more quickly than the first ; its manner
of extending its limits is the following. On the
edges of the morbid surface flat tubercles arise,
similar to those by which it at first commenced ;
their destruction is effected by the desquamation
before mentioned, while those inside the area, of
an older date, are removed by the interstitial cica-
trization. By this double process much destruc-
tive change takes place in the tissue of the part

struck us as of peculiar physiological interest in con-
sidering this spasmodic action of the muscles of respira-
tion. First, its occurring only during sleep, and second-
ly, its being confined to one side. The following expla-
nation occurrred to us:— The spasm was remotely caused
by the want of free perspiration. The purely voluntary
muscles withdrew their assistance during sleep; and tlie
instinctive respiratory muscles having then more to do,
they were easily thrown, in a weak, irritable child, into
spasmodic action. The spasm having for its end, appa-
rently, the perfect freedom of action of the muscles of
one side, and this the opposite side to which the obstruc-
tion existed in the nasal fossa, we could not help seeing
an analogy between this and the cases where, an ob-
struction existing in one lung, the patient instinctively
lies on the diseased side, to leave the muscles of the
sound side perfectly unrestrained in the respiratory mo-
tion. If this be a true analogy,— and we were persuaded,
whilst considering the case, that it was,— the obstructed
state of one of the air-passages of the nose produced a
sympathetic effect on the lung and the muscles of respir-
ation of one side.— a striking illustration of the svmpa-
thetic consent which subsists between the various parts
of the respiratory apparatus.

NOLI ME TANGERE

389

affected, for although there is no open ulceration,
and there seems to be an actual hypertrophy of
the skin, the latter has lost all the characters of
healthy skin. It is not painful even to slight
pressure. It evidently extends to the subcutaneous
cellular tissue ; indeed it would appear from feel-
ing it, that most of the deposit which constitutes
the swelling exists in the latter. This enlarge-
ment presents to the touch something of the feel-
ing of elephantiasis ; and Biett relates a case
where the swelling of the face proceeded to such
a degree as to present the appearance of the most
frightful form of this disease, with the additional
circumstance of the livid hue proper to lupus.
Such an excessive tumefaction is, however, a very
rare effect of the disease.

It may continue for years without producing
any serious consequences of a constitutional or
of a local nature, save the existence of the morbid
state of the skin just described. Of itself it has
not the least tendency to healing. If it does not
go on increasing, it remains inert for an indefinite
period. It appears to be much more under the
control of internal medicine than the former
species. When it begins to yield to the action
of any remedy, the livid patch of skin, and parti-
cularly the tubercles, show signs of an unwonted
activity by becoming a little hot and painful, and
the colour changing to a deeper red ; the hyper-
trophy then gradually diminishes, and the skin
slowly recovers somewhat of its own suppleness
and texture, but it never returns entirely to its
original state. Its cure has been brought about
by the accidental occurrence of an erysipelas, at-
tacking the skin beside the lupoid patch. The
encroachment of the inflammation on the morbid
structure roused the torpid state of the latter, upon
which a new and healthy action followed, which
removed the disease.

[M. Andral, (Cours de Pathologie Interne,')
affirms, that the presence of erysipelas is the most
favourable condition for the cure of lupus ; and
he suggests, that it would be advantageous if we
could induce erysipelas artificially in such cases.]
We must here notice a form of the disease in
which this second species is complicated with the
first. It is as frequently met with in practice as
the second form, and is more difficult to deal
with, because we have not the same hopes from
internal remedies, which are sometimes success-
fully employed in the latter ; nor can we use the
local escharotics with the same prospect of advan-
tage as in the first form where the disease is more
circumscribed. When the affection is of this
compound nature, it begins with a tubercle of the
first species, which becomes covered with the
crust, as before described. A very ordinary place
for its commencement is under the lower eyelid,
and here it produces very serious effects by the
destruction which sometimes ensues. Tubercles
of the character of the second species make their
appearance at an indefinite period after those of
the first have been going on, and the livid hyper-
trophy of the skin accompanies it. Here, then,
the two kinds of lupus already mentioned simul-
taneously exist and modify each other. The deep
ulceration of the first kind is sometimes cicatrized
by the hypertrophic action which accompanies
the second species, but still new tubercles from

2h*

which become encrusted and have the ulcerated
character in the adjacent spots. This is the
course of a case at present under the author's
observation. In a woman aged forty-five, a tuber-
cle of the first species appeared at the angle of
the eye; it formed crusts and ulcerated during
eight months, when others of a softer nature and
more livid colour sprang up beside them ; in its
progress it reached the edge of the nose, and here
took on the character of the hypertrophic lupus ;
but there always remained one of the tubercles
with the crusts and the deep ulceration of the
first species; — the disease having spread across
the nose, and in one spot sunk so deeply in it
that the mucous membrane became affected.
About fifteen months after its commencement it
developed itself on the hard palate and spread
towards the velum. A perforating ulcer, which
succeeded to a hard tubercle of the first kind, is
now nearly closed by the cicatrization which is
going on around it. This case affords a good
illustration of the kind of affection which we de-
scribe as a combination of the first and second
species. The double character of ulceration in
depth and hypertrophic cicatrization was evinced
both in its first development under the eyelid and
on the nose, and in its posterior eruption on the
roof of the mouth.

Besides this combined form of the malady, the
first and second form may exist separately at the
same time. Whilst the hypertrophic lupus is
manifested on the forehead or the cheek, the
eroding species may be pursuing its course on the
alse or tip of the nose. It is sufficiently common
also, — and we should have mentioned this before,
as it occurs not infrequently in the first form, —
to find pustules of impetigo in the neighbourhood
of the lupoid patches. A crop of these impeti-
ginous pustules often form scabs across the nose,
while the tip is engaged with the more intractable
lupus; but generally there are observed but a few
scattered pustules in some locality adjoining the
latter, as, for instance, on the nose, lip, or cheek.
This complication of lupus has given occasion to
some writers to make use of the term impetigo
erodens.

3. Superficial Lupus. — The third form of lupus
is that which ulcerates superficially. Biett de-
scribes this species first ; and were we to classify
the species of this disease according to the com-
parative frequency with which they occur, we
should have followed his example. We have,
however, doubts whether this species can in reality
be regarded in the light of a variety of the tru«
lupus. It appears to us to differ very widely from
the first species, the real noli me tangere, which,
as we have before stated, is the true type of the
disease. It has, indeed, considerable affinity to
the second form in external characters, but we
think it generalizing too much to consider it as
congenerous with the lupus of the nose. As the
points of resemblance which it bears to the second
form may induce some to regard the latter as a
kind of link connecting this superficial ulceration
with the first form, we shall give its description
here, and superadd some considerations developing
our views of its nature.

The history of this third form is not so uni-
form as that of the last ; the superficial destruc

390

NOLI ME TANGERE.

tion which is essentially its character arises
variously and proceeds in different ways. The
variety which allies it to the second species ori-
ginates by tubercles, or rather tuberosities, in the
skin, large and soft, and differing little from the
surrounding parts in colour. These remain for a
long period indolent, but as they increase in size,
and grow beyond the skin's level, they assume a
dusky livid colour, which spreads to the adjacent
skin for a considerable space. Ulceration at length
commences on the surface of the tuberosities, and
as their bases have become by this time nearly
joined, as the ulcerative process spreads, it pre-
sents often, for a large extent, but one continued
surface. A thin ichor is secreted by the surface,
which sometimes concretes on the edges into
closely adhering scabs ; but these are not like the
solid crusts which cover the tubercles in the first
species. The ulceration has a great tendency to
extend its ravages, and in doing so it does not
spread by direct absorption of the skin, but by the
renewed production of these tubercular indura-
tions which had originated the disease. A circum-
stance which is remarkable in its history is this —
that often, while ulceration breaks out in the new
tuberosities, it closes up in the old places, and in
this manner it has been known slowly to travel
over a great space. The cicatrices which it leaves
behind are of the most disfiguring kind, but they
are not painful unless pressed upon, or when the
patient indulges in spirituous liquors, in improper
diet, or excessive exercise. If they be situated
where there is a depth of soft parts, they are
puckered, and evidently engage the subcutaneous
cellular tissue. Even under the best directed me-
dical efforts it is a long time before the ulcerative
process entirely leaves these cicatrices. There
remains generally at the inferior extremity of the
cicatrising surface a spot which refuses to heal,
and from this the ulceration is ready to spread
again if the medical efforts be relaxed, or from
very slight causes. And even when they become
perfectly healed, they are often the seat of a new
outbreak of the disease. In such instances they
become deeper and more extended, and resemble
very exactly the scars left by deep and extensive
burns. If they occur near any of the natural
openings, they may produce much impediment by
narrowing these in their puckered growth ; and
besides this inconvenience, if they occur at the
mouth they give rise to a very disfiguring aspect
by contracting the commissure of one of the lips,
and thus destroying their symmetry. These marks
are often observed on the face and neck ; and they
are not less common on the skin of the thorax
and the extremities, where they are often of a very
great extent,

Marks of a similar description are often met
with which have ensued on a very different pro-
cess. We find on the face and on the extremities
cicatrices which have not been preceded by any
tubercle or even by any ulceration. The follow-
ing is their manner of forming. The skin takes
on a reddish hue, and appears a little swollen.
After a short time, on this morbid part a slight
exfoliation commences, and by this process the
skin becomes plainly thinned. When this has
continued for a certain period, the skin becomes
pale again, and even less coloured than the sound

surface adjacent to it. It becomes also smooth
and glossv, and this makes a difference between
the cicatrices which remain after this affection,
and those ensuing upon the tubercles and ulcera-
tion, in that the latter arc more or less puckered.
The cause of this difference is obvious. In the
affection we at present describe, the superficial
layers of the skin are nearly exclusively engaged
in the exfoliation ; while, as we have seen, the
morbid process is much more deeply seated where
the scars ensue upon the tuberosities and ul-
ceration.

There is another affection of the skin, of an
analogous character, which deserves to be placed
in juxta-position with the last variety. In this
the deep layers of the skin and the subjacent
cellular tissue are exclusively the seat of the dis-
ease. It manifests itself by the skin assuming a
livid colour, and becoming hard and stiff. This
may remain for many months without showing
any actual disorganization. At length, probably
by the formation of a small abscess arising from
the irritation of the sloughing cellular tissue, the
destruction which has been going on in the deep
parts of the skin is brought to light. From the
opening made by the abscess, which is generally
enlarged by the practitioner, if he has not origi-
nally made it, a large quantity of sloughing cellu-
lar tissue of a yellow colour and firm consistence
will be discharged. On the dislodging of these
sloughs and the use of appropriate dressings, deep
cicatrices slowly form, similar to those above de-
scribed. The few cases of this affection we have
witnessed occurred on the leg. We notice it
under the head of the superficial form of lupus,
notwithstanding that it affects the deep layers of
the skin and the subjacent tissue, because it bears
an analogy to it in progressing in a horizontal
direction. It appears in fact to differ from the
variety last described only in affecting the deep
layers instead of the superficial.

These are the varieties of the form of lupus
which destroy superficially. Doubtless the chronic
nature of its progress, the purple colour which
generally more or less attends it, and its frequent
origin by what we have denominated tuberosities
(to distinguish them from the tubercles of the first
form), are circumstances which show a seeming
analogy between it and the other species, particu-
larly the second ; but notwithstanding these, we
imagine that those who have given attention to
the subject will think that we are justified in
doubting the propriety of making it congenerous
with the other forms, at least with the lupus of
the nose. It appears to have a different constitu-
tional origin; it is curable by different remedies;
and it terminates differently. In several cases of
this nature which we have observed, it happened
in persons who were at one time the subjects of
venereal disease. In some others we think it
could be traced to that analogous state of the sys-
tem produced by courses of mercury. But much
more frequently it depends on scrofula. In short
it appears to us that it is decidedly a scrofulous
disease. This idea is rather strengthened than
opposed by what we have just remarked as to its
sometimes being found connected with a syphilitic
or mercurial taint in the system, as it is known
that the sequelae of mercury or of syphilis are

NOLI ME TANGERE.

391

easily developed in a scrofulous constitution, at
the same time that the latter modifies the nature
of the resulting affection. The variety of this

under the lid, drag it down, and thus produce its
evcrsion. Epiphora and its consequences follow
here as inevitably as where the lid is destroyed, if
third form, "which spreads by the superficial ulcera- 1 it be not prevented by surgical means, which are
tion of the tuberosities, is evidently the same with more available in this case than the former,
the so-called scrofulous ulcer. Biett does not re- When the nares, the velum, or the palate are
cognise this in terms, but we apprehend that it is the seat of the disease, the voice is always more
easily to be collected from his description of the or less altered. It is only, however, when the
affection. It is without doubt to this species that destruction is very great that the articulation is
Rayer alludes in his list of synonyms, where he entirely lost. Partial deafness is sometimes pro-
enumerates" ulceresscrofuleux,scrophule vulgaire duced when the disease affects the Eustachian
vasculeuse." But it appears of still more im- tube, as occurred lately in a case which happened

portance with respect to the nature of this super
ficial ulceration to establish its identity with the
esthiomenic or corrosive scrofula of M. Lugol, in
which the iodine has proved such a powerful
agent. And with regard to this we know that
some practitioners have been successfully employ-
ing this remedy against it without being aware
that there existed any doubt as to its scrofulous
origin, or that it was included under the name of
lupus in the works of writers of authority.* The
success of iodine in this superficial ulceration,
while it seems an evidence of its scrofulous nature,
may be regarded as one criterion of the difference
of its nature from the two former species, for
against these it is found to possess little or none

to the author, where the disease spread from the
nares and velum. When the disease has its seat
in the superior parts of the nasal fossa, it may
produce destruction of a fatal nature. Lallemand
(Lettres sur 1'Encephale et ses dependances) is
of opinion that in many of the cases recorded by
old authors, where abscess cf the brain broke and
discharged pus by the nostrils, the latter was pro-
duced by caries of some of the bones forming the
roof of the nares. This is a situation in which
lupus occurs more frequently than is at all sup-
posed. The considerations which this writer of-
fers in proof of his positions, are, we think, quite
satisfactory, and apply to lupus ; for we are per-
suaded that caries of the bones of the nose is

of the virtues which have given it such a high \ much more frequently the effect of this disease
place in scrofulous affections. Where we state than of all the other causes to which it might be
our opinion of the relation which subsists between referred. The occlusion of the nares has been
the two first species and scrofula, it will further already referred to. This event may occur even

appear what connection this third form stands in
with the other two.

Having thus described the phenomena and
course of the different species of the disease, we
have here to mention some particular accidents
which its destructive nature sometimes gives rise
to from its occurring in certain localities. One of
these, which has attracted much notice from its
disastrous consequences, is the destruction or ever-
sion of the lower eyelid. This occurs in the first
form, or probably still more frequently in that
combination of the first and second which we
have described. One or two tubercles having
formed just under the eyelid, their ulceration per-
forates the conjunctiva, and goes on to destroy a

in the early stages, where the destruction com-
mences by the falling of the crusts from time to
time, and all throughout its course there is a ten-
dency in the swollen edges to unite by cicatriza-
tion.

Such accidental results of lupus are amongst
its most important consequences. Some of them
are rare, but it appears highly necessary to know
beforehand the tendency to their occurrence, that
we may be watchful when the disease exists in
any locality exposed to them, if by any means we
may be able to devise a treatment calculated to
arrest them ere they proceed to such disastrous
effects.

There is in lupus little or no sympathetic dis-

great part or the whole of the lower lid. Besides order of the system : it is quite unaccompanied by
the shocking disfiguration which this produces, fever. The gastro-pulmonary mucous membrane,
more serious effects follow. The protection which ; which is so frequently either primarily or second-
the palpebral afford the eyes is by this interrupted ; arily affected in other diseases of the cutaneous
the tears escape through the broken surface instead ; tissue, is very rarely affected. The disease may

of by their natural channel ; and inflammation of
an unmanageable kind ensues, which causes loss
of sight on this side by producing opacity of the
cornea;. The puckered cicatrices sometimes form

* Confusion must daily occur as to this malady from
our inattention to precision in names. Raver's synonyms
arc, " Dartre rengeautc, herpes esthiomenos (herpes exe-
dens, Bielt), ignis sacer, formica corrosiva, lupus vorax,
noli me tongere, Scrofule vulgaire vasculeuse, ulcSres
Rcrofulenx, &c. Every day adds to these, for it would
appear that every one relating a case considers that for-
mer appellations may be disregarded, and that he may
change or add according as some peculiarity of the case
or Ins own ingenuity supplies him with new terms.
Thus, in the account of two interesting cases of this su-
perficial ulceration detailed in the Medical Gazette, De-
cember 15, p. 367, they are denominated "strumous pha-
gedenic ulcers." A copious supply of names is a proof
that Ihe subject has not been reduced to clear limits; but
adding to them ad libitum only increases the difficulties,
and in fact virtually does away with the utility of noso-
logical arrangement altogether.

exist for several years, and in this period effect a
great destruction, while the general health retains
a perfect integrity. Biett mentions that in cases
of extreme malignity, where its ravages proceed
unchecked by nature or by art, death has been
known to happen from the supervention of a
chronic gastro-enteritis attended by a slow fever
and colliquative diarrhoea. This termination has,
however, been so rarely observed that it may be
doubted whether the internal affection and fatal
result should not be considered as accidentally oc-
curring during the progress of the lupus rather
than depending on it. However this may be in
certain peculiar instances, it is a well-ascertained
character of the disease that its ravages give rise
to a remarkably trivial amount of general disorder
although it usually happens in individuals of
weakly constitutions.

392

NOLI ME TANG ERE.

Causes* — It is very rare to meet any of the
varieties beyond the age of forty, so that it is to
be considered a disease of youth. Between the
ages of six and sixteen it is more common than
at earlier or later periods. It appears that the fe-
male sex is more subject to it than the male. This
has been satisfactorily established to us from the
observation of a considerable number of cases. It
is also a fact that it is particularly prone to occur
in those weakly lymphatic habits in which the
period of puberty arrives late, and the menstrual
function is feebly performed. Authors assert, and
we believe experience proves it to be true, that it
is much more common in the country than in
town, and in places where vegetables and fruits
form the chief food. In the city of Dublin, where
the poor are inured to poverty and uncleanliness,
it is very commonly met with, although some of
the worst cases which are found in the hospitals
come from the country parts of Ireland.

Pathology. — The predisposing causes are im-
portant elements in considering the pathological
nature of lupus ; and in treating of the latter we
would be understood as particularly referring to
our first two species, for we regard the third, as we
have before stated, to be a true scrofulous malady.
We must consider also that Rayer had in mind
this form of the disease exclusively, when he as-
serted that nearly all the individuals in whom the
tubercles of lupus occur have been known to be
subject to scrofulous affections in their youth, such
as glandular swellings in the neck, groins, or
axilla? ; for such an incontestable proof of its
scrofulous nature can refer only to the superficial
ulceration, and can by no means be truly predicted
of the first two species. But, although this be
the case, we cannot overlook the fact, which is
evident from considering the last paragraph, that
the state of constitution in which scrofulous dis-
eases manifest themselves, and the circumstances
which predispose to their development, are also
particularly favourable to the production of lupus.
On the other hand, it is also certain that the latter
considerations are quite insufficient to establish it
as a scrofulous disease, as it is found in persons
of quite the opposite diathesis, and more particu-
larly because it resists the remedies which arc
found so beneficial in scrofula. It was for a long
time reckoned to be a cancerous disease ; and it
would be wrong in a discussion concerning its
nature to omit mentioning this opinion. The
progress and result of lupus give some colour to
the notion of its affinity with cancer. Such loose
resemblances, however, have never been sufficient
to allow accurate pathologists to recognise their
identity. Many of the oldest physicians already
marked some of the distinctions between them.
Celsus, as we have seen, distinguished them with
particular accuracy. Wiseman, and others of our
early writers, also laid down excellent rules for
making a diagnosis between them. Without enter-
ing here particularly into their differences, we con-
tent ourselves with remarking that the symptoms,
both local and constitutional, are quite different in
the two diseases; and that lupus is as decidedly dis-
tinct in character from cancer as it is from scrofula.

But notwithstanding that it is impossible to
identify it on the one hand with scrofula, as some
writers do, or to reckon it as a form of cancer, it

seems to us that in searching for its true nature,
it may be profitable to recollect the frequency of
its occurrence in scrofulous constitutions, and not
to lose sight of the circumstances in which it re-
sembles cancer. Now, with regard to the latter,
it may be remarked that the hypertrophic state of
the skin in our second species is not unlike the
deposit of a new tissue, and also that in our first,
which we have often laid down as the type of the
true lupus, the ulceration is as unsparing in its
destructive course as cancer. Besides the true
cancer, there are cancerous ulcers which come
still nearer the lupus of the nose in character, and
cancerous tubercles which differ indeed from the
tubercles of lupus in some important particulars,
but still they appear to show an approximation in
the character of the two maladies. Dr. Jacob has
given the history of three cases of an interesting
kind in the fourth volume of the Dublin Hospital
Reports. Notwithstanding his arguments to prove
that they are neither cancer nor lupus, it appears
to us that their description answers perfectly to
the character of the latter carried to a great extent.
At that time the history of lupus was compara-
tively but little known, and scarcely any good ac-
count of it was to be found in books. Ravages
to so great an extent are seldom found in this sit-
uation resulting from lupus or even from cancer,
but the description answers so well to the former
disease that no doubt exists in our minds but that
it was really lupus.

Were we called on to declare our opinion of the
essential character of lupus, we should say that it
is an intermediate pathological state between can-
cer and scrofula, partaking somewhat of the na-
ture of both, but constituting a state in which, by
the blending of these two diseases, many of their
peculiar characteristics are lost. In the lupus of
the nose the double nature appears so proportioned
as for each to neutralize the other more perfectly
than in any other of the forms ; and departing
from this on either side, pathological gradations
can be traced which degenerate to true cancer on
one side, and on the other, passing through the
hypertrophic and superficial lupus, lose them-
selves in scrofula. Besides the considerations
offered above in support of this view of its nature,
we consider that it is much strengthened by other
circumstances, as, for instance, the action of iodine,
carbonate of iron, and arsenic on the respective
varieties. The first of these is found to possess
signal virtues in the third form, which is a scrofu-
lous disease ; it is much less useful, if it have any
effect, in the second form ; and it is quite inert in
the first. Whatever powers the arsenic and car-
bonate of iron possess, are almost exclusively
available in the first form ; and it may be remarked
that, while they have no efficacy in scrofulous dis-
eases, they sometimes are found to palliate affec-
tions of a cancerous nature. Although this view
of the pathology of lupus has not, as far as we
know, been advanced before, we put it forward
with some confidence, as we think it accords with
the facts which are known on the subject. But
the question demands much ulterior discussion,
in accordance with that cautious spirit of laudable
scepticism which the modern cultivators of medical
science have been taught to use in weighing the
worth of pathological doctrines.

NOLI ME TANGERE,

393

The influence which a syphilitic taint in the
constitution has in the production of lupus acts in
two ways. One, the most obvious, is, where it
gives rise to a secondary syphilis, assuming the
character of lupus, but to be distinguished from it,
as we shall immediately point out. Another
effect is to predispose to the true lupus. How
far these may be really differences only in degree
of the syphilitic infection of the constitution, we
will not pretend to say, but in practice the two
states occur. A striking case, which the author
has observed, will illustrate our meaning. A
woman, aged forty-seven, came from the country
with an extensive lupus of the nose and of the
palate ; it was that combination of the first and
second species which we have described above.
She had had primary venereal symptoms seven-
teen years before, but no secondary disease of the
skin, throat, &c. ever followed. She has borne
eight children since, of which the first six died
either before or immediately after birth. This
was the way in which the disease showed itself.
She herself attributed the death of her offspring to
the contagion of syphilis ; and there is no doubt
but that she was right, as two of them came away
in the putrid state, which is not an uncommon
effect of this virus on the fcetus in utero. Her
two last children, however, lived and enjoyed
good health. The lupus has now existed two
years, and has never exhibited any of the external
characters of the venereal affection, which it is
sufficiently easy to distinguish. This, then, is an
instance where the original syphilitic taint predis-
posed to the formation of lupus, without impress-
ing on it the marks which denote it to be a form
of secondary syphilis.

A vague opinion was once entertained that the
scanty pus which the ulcerating tubercles supply
is contagious, and that it propagates the malady
on any part of the body with which it comes acci-
dentally in contact. This notion survived the old
error which was so long a time prevalent in the
schools, that all pus was corrosive ; for even when
it became established that purulent matter was a
bland instead of an irritating fluid, exception was
made in respect of that formed by some kinds of
ulceration, and lupus was amongst the number.
In fact, it is still imagined by many that the pus
which oozes from the ulcerating tubercles is the
means by which the slow destruction is effected.
That it produces any specific effect as a direct
chemical corrosive, is, however, no longer tenable;
nor can it even be admitted that any considerable
action is to be attributed to whatever irritating pro-
perties this discharge possesses. If it drop from
the nose upon the hand or arm, it produces no
perceptible effect. A patient with lupus of the
nasal fossae, in whom we had an opportunity of
confirming this, yet complained of a smarting
from it as it trickled through the nose. While,
then, it is denied that the pus has any specific
agency in the destructive results of this disease, it
must be supposed to maintain more or less irrita-
tion on the ulcerating surface, as is the case with
common ulcers which discharge an ill-conditioned
sanies.*

♦See the sixth number of the Edinburgh Medical and
Surgical Journal for nn account of a curious case related
by Dr. Grenville, under the name of " Herpes exedens

Voi. III. — 50

Diagnosis* — It may be easily imagined that
the diagnosis of a disease of such obvious charac-
ters as lupus will be made with facility. This
will be rendered more certain if a clear knowledge
of its different species and their stages be kept in
mind. But, as it has been often confounded with
other diseases, it will give us much confidence in
our diagnosis to be forewarned of the affections
which might lead us into error. "We shall, there-
fore, point them out briefly with their diagnostic
marks.

The pustules which constitute the elementary
form in acne are succeeded by round indurations,
which have a deeper purple colour than the sur-
rounding skin. When these collect in clusters,
as they sometimes do, near the point, or on the
alae of the nose, they have some resemblance to
the tubercles of lupus in their first stage, and have
been mistaken for them. This error will be
avoided by attending to the different nature of the
tumours in question. In acne they have been-
preceded by pustules, some of which are probably
still to be met with in parts where the affection is
least advanced, and besides this there exists round
the base of the tubercle in acne a dull redness
from which the lupoid tubercle is quite free, as the
latter makes its way slowly over the skin without
any marks of inflammation ; for the violet disco-
loration which precedes it does not deserve that
name. The hypertrophic lupus, when situated
on the nose or forehead, is also not unlike acne,
but the history is very different, and even a slight
attention will discover the cicatrices which lie be-
tween the tuberosities in the former, and thus at
once distinguish it.

It might be sufficient to mention the possibility
of mistaking the crusts which form in certain
kinds of impetigo and porrigo for lupus ; but not-
withstanding their general dissimilarity, the mis-
take has been made. The mind is preoccupied
with the idea of lupus in every incrusted appear-
ance which is met with in the alae nasi or its im-
mediate neighbourhood, and these pustular affec-
tions sometimes occur here in a very chronic form.
In examining the case then, we must search for
the primitive form of the eruption which has fur-
nished the crusts. Small pustules will be more
or less obscurely detected, with inflammation in
the skin diffused between them, if these belong to
porrigo or impetigo. Moreover, the crusts which
might cause the mistake are quite opposed in their
character to those of lupus, being irregular, soft,
and easily detached ; while in the latter, as we
have frequently had occasion to state, they are of
a firm consistence, and confined for the most part
to the surface of the tubercle which forms them,
and to which they generally adhere with great
tenacity.

It is stated by authors that the elephantiasis of
the Greeks is liable to be confounded with the
hypertrophic form of lupus. But the tuberosities
which occur in elephantiasis are round, knobby,
and of a dusky sallow or fawn colour, which
overspreads the whole face. If even they be con-

vermiculatus," in which a very copious discharge which
an ulcer furnished was proved by experiment to possess
the power of generating the same ulcer in a part inocu-
lated by it. On microscopically examining the pus, it
was found to be full of animalcula; of various shap<»
and sizes.

394

NOLI ME TANGERE.

fined to the face, they spread over it here and
there, not affecting (as this form of lupus) the
arrangement of a circumscribed patch. In some
aggravated forms of this disease the tuberosities
ulcerate, and furnish black crusts, which might
impose on an unwary observer for lupoid incrusta-
tions ; but tuberosities will be found, which have
not gone on to ulceration, presenting the marks
of distinction before laid down. This malady,
besides, is rarely confined to the face, and when
it has made some progress, it is attended with
constitutional symptoms which do not belong to
any form of lupus. Finally, its great rarity in
this country prevents us from being often put to
the necessity of making the comparison, while our
knowledge of their points of resemblance will
keep us from being off our guard.

Cancer is an affection which must be carefully
distinguished. Whether the affinity which we
suppose to exist between them be grounded in
fact or not, it is of the utmost practical import-
ance to separate the two diseases when we have
to consider them with regard to treatment. Some
cancerous tubercles commence with a warty tuber-
cle, having a considerable resemblance to incipient
lupus. It will, however, be observed that they
are for the most part solitary, while the lupoid
tubercles are scarcely ever so, at least for any
length of time. Their bases too are deep-seated,
and attached by a root which ramifies in the sur-
rounding tissue, which is not the case in lupus.
The most striking difference is the pain, which, as
we have seen, is nearly totally absent in the be-
ginning, and indeed throughout the whole course
of lupus. Cancer is the seat of deep lancinating
pains almost constantly, which are easily increased
by improper applications, and permanently re-
moved by none. Without multiplying points of
difference, one more, with those already recited,
will be amply sufficient to diagnosticate the two
maladies. The circumstance to which we allude
is the age of the individual. We have seen, with
respect to lupus, that it is a disease of youth ; but
cancer is seldom or never met with below the age
of forty. Biett is desirous of appropriating the
name noli me tangere to cancerous tubercles, but
at the same time insists that it should be carefully
distinguished from lupus. We have not adopted
his suggestion on this head, because we think it
would only serve to confound the affections, which
we are desirous with him to keep separate. There
ht-i always existed much discrepancy between the
French and British ideas of cancer, and it would
undoubtedly only serve to increase it were we to
assign to this disease a term which has been
hitherto uniformly appropriated to lupus.

Syphilis assumes the guise of this malady, as it
Joes that of most other cutaneous diseases. We
shall not here discuss the important theoretical
question, whether we are to consider diseases of
the skin produced by a venereal infection of the
constitution the same actual diseases as when
they occur unconnected with any constitutional
taint, or whether we are to regard them as a class
per se. For the exposition of this problem we
refer to the article Syphilis. It is, however, of
undeniable importance to have the means of dis-
tinguishing ordinary lupus from that of venereal
orgin. The crusts which form in the syphilitic

affection arc much darker coloured than those of
the genuine lupus, and the surrounding skin is of
a dark copper hue. The tumefaction which more
or less attends the real lupus is absent, and the
crusts are dry and permanent, and very seldom
give place to any open ulceration. If the latter
do ensue, it is to be recognised by the well-known
characters of the syphilitic ulcer which infallibly
attend it, viz. — the deep centre, and the raised,
hard, and swollen edges. We have lately seen a
case of syphilitic rupia, situated on the point of
the nose, which at the first view we mistook for
lupus, but on a little closer examination we found
that the only point of agreement was the situation
of the scabby crust. It was dry, hard, and flat,
adhering to the tip of the nose with still greater
tenacity than the crust of lupus. There were
present also symptoms of venereal affection in the
throat, and the patient had had venereal iritis.
These were quite decisive of the question in them-
selves. In investigating doubtful cases, these ad-
ditional constitutional symptoms should always
be sought for, and the history of the disease ob-
tained. But as to the latter, it must be remarked
that negative evidence is not to be held decisive,
nor is it even of much value if the other marks be
present, as it is well known that patients will
often refuse to admit the possibility of their hav-
ing had syphilis, while undeniable proofs of its
existence are manifest. There is a syphilitic
affection which commences in the cartilages and
bones of the nose, and having destroyed them by
caries, attacks the soft parts. The bones having
yielded, the nose becomes flat, and the alae ex-
panded. In this state, the affection might be con-
founded with the hypertrophic lupus, for the root
of the nose becomes somewhat swollen and livid ;
but it will be seen that this description differs from
lupus in its progress, its appearance, and its re-
sults. It will be unnecessary to compare them
more minutely.

Treatment. — The treatment of lupus has,
from the earliest periods of medicine, been an ob-
ject of great importance in practice. It does not
put the life of the patient in jeopardy, but the
hideous ravages which it effects, and the sure
though slow progress with which it marches, ren-
der it a formidable disease. Yet, intractable though
it be, its sanability by the efforts of medical art is
perfectly ascertained. Cases are even to be met
with where a spontaneous cure has taken place by
the cicatrization of the surface. Where this does
occur, it generally belongs to the first form, and
the cicatrix is perfect and permanent. There is
much less security in the cicatrices of the other
species. When the malady is left to itself, such a
termination is very rare, and must be regarded as
the exception ; for the destruction seldom ceases
till the nose is nearly level with the face, and then,
which is a remarkable circumstance, it sometimes
does show a tendency to stay its ravages. In
many cases, however, it continues its progress on
the cheek to a fearful extent. Experience teaches
us, ori the whole, to employ the means in our
power sedulously and with vigour, and encour-
ages us never to lose hope of arresting its pro-
gress ; but it also lays before us the difficulties of
a most obstinate disease, and cautions us against
being too sanguine in our prognosis.

NOLI ME TANGERE.

The treatment resolves itself, in this, as in most
cutaneous affections, into general and local means.
We have seen that the system shows but little
sympathetic action in this disease : we should not,
therefore, a priori, expect that internal remedies
would avail much ; they form a part, however, of
every well-digested plan of treatment. In some
cases their efficacy is more considerable, and many
cases will occur where they will demand our first
and most particular care. On the other hand, the
disease will be found in some patients who are in
such good general health that it would be inexpe-
dient to lose any time in the exhibition of general
remedies. In these the local means will form the
main resource, and whatever others may be em-
ployed will be directed rather to obviate particular
symptoms than to make any impression on the
disease through the constitution.

a. Internal Remedies. — When a cachectic state
of the system accompanies the malady, if its cause
be recognised we must apply all our resources to
remove this. If this ever stands to lupus in the
relation of cause and effect, it is where it happens
in the poor, when indigence exposes them to un-
wholesome and insufficient diet, with cold and
uncleanliness. The low, torpid state of the system
which these induce will be evidently best obviated
by reversing as much as possible the condition of
the patient, substituting a light animal diet, and
all the comforts which hospitals and other public
or private charities afford. If we can detect any
diseased action in the chylopoietic viscera, this will
receive a particular attention ; for whether this be
regarded as a cause or merely as a concomitant
effect, no favourable change in the local malady
should be anticipated as long as it remains. Gen-
tle aperients and tonics will tend much to the gra-
dual improvement of the system. Occasional
doses of the pilula hydrargyri and pilula rhei
composita will be a useful remedy when the liver
is found to perform its functions torpidly. The
old authors, who looked so much to the state of
the blood in pathology, attended much to the use
of such remedies, and their practice in this disease
is not thrown into the shade by any in the present
day.

If the individual be obviously of a scrofulous
habit of body, he should be kept steadily under
the use of appropriate internal remedies for some
time. This should be done whatever be the form
of the malady with which the patient is affected.
But, as we have already stated, the superficial
lupus will be the form usually met with in such
constitutions, and therefore that for which an anti-
scrofulous treatment is particularly calculated.
For the remedies proper to be used, we refer to
the article Scrofula. We may mention here,
however, that our experience of iodine has in-
spired us with great confidence in its efficacy.
We have seen striking amelioration produced by
the use of the solutions which Lugol recommends.
The proto-ioduret of mercury is one of the pre-
parations of iodine which has proved of most
utility. The ulceration has been observed to heal
under its use with a rapidity which is quite foreign
to its indolent character. The fourth part of a
grain was given twice a-day to a girl of fifteen
years of age, who had a large patch of deep ulcer-
ation, with tubercles, on the front of the leg.

After ten days of its use, the mouth became af-
fected, contrary to the intentions of the physician,
and in three weeks' time an ulceration which had
been forming a year and a half was almost cica-
trized. We should add that the iodine was used
externally, also, as a lotion, and in cataplasms. Its
efficacy, however, appears to be confined to the
third form, as whatever trials have been made with
it in the lupus of the nose, or even in the hyper-
trophic form, have quite disappointed expectation.
[Iodine, in combination with mercury, has been
found especially beneficial. Blasius advises it
internally and externally ; and it has been recom-
mended highly by Dr. J. W. Schmidt, Jr. of
New York. Both the iodide and red iodide were
given by him. (Amer. Journ. of the Med. Sci-
ences, Feb. 1840, p. 301.) Recently, the iodide
of mercury and arsenic has been greatly extolled
in the form of the liquor hydriodatis arsenici et
hydrargyri, or what has been called, from the
preparer, " Donovan's solution." (Dublin Journ.
of Med. Science, Nov. 1839, and Nov. 1842.)
It is given internally as well as applied externally,
and the writer has found advantage from its use
not only in lupus, but in many obstinate cuta-
neous affections. (New Remedies, 4th edit. p.
353: Philad. 1843.)]

The muriate of barytes was commended by
Bateman for its efficacy in promoting the resolu-
tion of the tubercles. It does not appear to what
species the latter belonged in which he employed
it, but later authors object to its use, that it is a
dangerous remedy from its energetic action on
the stomach. The muriate of lime has been pro-
posed as a substitute, having the same properties,
and free from these objections. One drachm of
the solutio muriatis calcis is to be mixed in a
pint of water, of which a table-spoonful may be
given once or twice a-day at first. This is to be
progressively increased after a few days, till ten
or twelve spoonsful be taken daily. Preparations
of iron have been at various times extolled. The
muriated tincture and the carbonate are more re-
lied on than any other. The latter, particularly,
has been set forward with a zealous advocacy by
writers who confounded the noli me tangere with
cancer. It is doubtful whether they are entitled
to any confidence in either, but as the cases in
which they have been reported to have effected a
cure were undeniably lupus, they deserve a trial.

Arsenic is a remedy which has been extensively-
employed, and the authority of most writers agrees
in recommending its internal use. It is found to
exert considerable influence in checking the pro-
gress of the tubercles, and even in altering the
character of the ulcerated surface. It is variously-
administered. It forms the active ingredient of
the Asiatic pills, a medicine which enjoys great
reputation on the continent.* Fowler's solution
is the preparation which is most approved of in
these countries. This is to be commenced with
the small dose of three drops, to be taken thrice
a-day : it may be gradually increased to ten drops,
but the greatest vigilance is to be observed during
its exhibition. (See Lepra.) Practitioners of
merit prefer minute doses of corrosive sublimate,

* They contain about one-thirteenth of a grain of
while oxide of arsenic, and somewhat more than halt
a grain of black pepper in each pill.

396

NOLI ME TANGERE.

carried to the extent of touching the gums, to
any other internal means. It would be unprofit-
able to swell our catalogue by recounting other
internal remedies whose effects are more doubtful,
and we believe that those above mentioned com-
prehend all that have gained any merited repu-
tation.

b. External applications.— These form by far
the most important part of the treatment, and
indeed often constitute the whole of it. It is al-
ways in combination with these that the efficacy
of internal remedies has been developed, for no
one would think of relying on the latter without
using some of the local applications which have
been at all times the essential therapeutic re-
source.

The local applications are of two kinds : first,
those which are intended to exalt the vitality of
the part, and thus to promote the resolution of
the disease ; secondly, those which, acting as cau-
teries, destroy the morbid part, and excite a healthy
action in the surface beneath it.

The stimulating applications may be tried where
the disease presents itself in the stage of tubercle.
The attempt to effect the resolution of the malady
"will be more feasible in proportion to the earliness
with which it is made, and also to the activity
which the surrounding skin appears to possess.
If the skin show that the circulation is actively
carried on, it will be often useful to apply a few
leeches to the neighbourhood of the tubercles be-
fore commencing the use of the resolvent appli-
cations. Dr. Mac Farlane has experienced the
good effects of such a plan, and recommends it in
these words : " Sometimes the progress of a lu-
poid tubercle may be arrested and the ulceration
prevented by the application of leeches round its
base, especially when the tumour is painful and
covered by inflamed integuments. This, followed
by evaporating lotions and alterative doses of
calomel, will not unfrequently subdue the inflam-
mation upon which the progress of the disease
depends, and reduce it to that indolent and chronic
state in which friction with an ointment, contain-
ing the ioduret of zinc or mercury, may be bene-
ficially employed to promote its absorption."
These ioduretted ointments are topical applica-
tions of decided efficacy ; [and the same may be
said of creasote ointment, and the tincture of
iodine.] Besides these, Biett is in the habit of
using the ioduret of sulphur, made, as the metallic
iodurets, into an ointment, in the proportion of
fifteen grains to an ounce of simple ointment.
This is to be applied with gentle friction to the
tubercles and the skin surrounding their bases.
It stimulates the skin powerfully, and has a greater
resolvent effect on the nascent tubercles than any
other similar application. Rayer objects to its use
in this manner, tha' it is apt to produce erysipe-
latous inflammation of the surrounding skin ;
but this is an infrequent consequence, and when
it does occur is not to be deemed an injurious
effect ; on the contrary, it has been observed to
be a means of dissipating the disease by commu-
nicating its sthenic action to the torpid tubercles.*

* See an interesting observation quoted in the Archives
Generates de Medecine, t. xxiv. p. 584, where, during
ihe treatment of a lupus of the nose in the state of
tubercles, as erysipelas which was epidemic in the ward,
attacked the patient's face. It had been very fatal

In the hypertrophic lupus the employment of
these resolvent ointments is particularly indicated;
indeed, in this form our hopes of cure must de-
pend chiefly on such applications, aided by an ap-
propriate internal medication.

[The oleum jecoris aselli, codliver oil, may
be used in alternation with any of these oint-
ments.]

When the tubercles are once ulcerated, or when
they are already far advanced towards this point,
those stimulating applications are too feeble to be
further of any efficacy. There is one lotion which
comes under this head, which some experienced
practitioners still confide in ; we mean a solution
of arsenic of such a strength as to produce only
its specific stimulating effects on the sore, in the
hope of changing its action. The solution of
Fowler contains the arsenic in the best proportion
for this application ; with this the surface of the
tubercles should be sopped twice or thrice a day,
when this method is judged expedient. It is ge-
nerally agreed, however, that it is the wisest prac-
tice in such stages to have' recourse at once to
escharotic applications.

Arsenic is the substance which is almost uni-
versally allowed to be the most suitable escharotic
which we have the command of in lupus. This
has been anciently established, as we find it first
on the list of the " medicament a adurenlia,"
which Celsus proposes. Its superiority over the
other caustics appears to consist in this, that it
produces a slough promptly and certainly, which
confines itself to the parts immediately touched
by the arsenical preparation. The methods of
employing this powerful mineral have been varied
by different practitioners. Justamond's applica-
tion was once a very favourite form. This is
made by fusing in a crucible two parts of sulphuret
of antimony and one of white oxide of arsenic.
The resulting compound, being pulverized, is of a
blue colour. Sir A. Cooper is accustomed to use
an ointment consisting of white arsenic and sul-
phur, a drachm of each, mixed with an ounce of
spermaceti ointment. He directs some of this to
be spread on lint, and to be applied to the ulcer
for four-and-twenty hours, at the end of which it
is expected that a black slough will be formed, and
when this falls, the surface is to be dressed with
simple ointment. Other eminent practitioners
employ it mixed with simple ointment alone, re-
jecting the admixture of any other substance to
modify its action. When we desire to apply it to
indolent tubercles, it is sometimes found that these
are covered by a thick cuticle, which impedes its
action, for the arsenic has scarcely any effect on
the cutaneous surface so long as the cuticle re-
mains entire. Some advise that in such a case a
small blister should be raised previous to its appli-
cation ; but this end will be probably better
answered by mixing some cantharides with the
arsenical ointment. Mr. Adams has successfully
employed the following ointment :
R. Unguenti cetacei, §ss.
Oxydi arsenici, ^i. .
Emplastri cantharidis, giii. M. fiat unguentum.

He has also found that the callous edges of an

amongst the individuals whom it had seized, but in tliis
patient it proceeded no further than the face, where i'
ran its course safely, and at its disappearance brought
about the complete resolution of the tubercles.

NOLI ME TANGEEE.

397

old lupoid ulcer, which had resisted other arsen-
ical applications, yielded a slough freely under the
use of this for a few days.

Whichever method may he selected for apply-
ing arsenic externally, a certain degree of caution
will lie requisite. It will be prudent to apply it
at one time to no larger a surface than a shilling
would cover, and having produced in this space
the desired eschar, a new portion may, if neces-
sary, be attacked. This way of proceeding is
found to be very effective in establishing a healthy
action in the new surfaces, as well as to fulfil the
end for which it was adopted, that is, to obviate
any unpleasant consequences which might arise
from spreading the arsenic over a large surface.
While it will be prudent to make use of this
remedy with that vigilance which our acquaintance
with its powerful action on the animal economy
must inspire, it is to be recollected that it is a per-
fectly safe application. All practitioners who
have been accustomed to use it testify that they
have never witnessed any of its dangerous effects
produced on the constitution by its regulated use.
There are indeed two cases mentioned by Dr. Mac
Farlane, where, being spread upon extensive ul-
cerations, it was followed by severe inflammation
of the gastro-enteric mucous membrane, appa-
rently in consequence of its absorption into the
system. These examples are, however, exceptions,
and serve rather to exhibit the rarity of constitu-
tional disorder consequent upon its use ; but they
also show us the necessity of observing the cau-
tions in applying it which we have suggested.

The arsenical paste is the application which
has the most decided caustic powers, and on this
account it is by many preferred to the other less
energetic cscharotics.* In the old cases of exten-
sive destruction the edges acquire a degree of
callousness which it requires the most potent re-
medies to affect ; in these it is found advisable to
produce a prompt and decided slough with rapidity,
as it is found that less energetic means, which act
more slowly, only allow of new productions under
the imperfect slough, which increase the ravages
sometimes to a prodigious extent, of which one
of Dr. Jacob's cases is an example. (Dublin
Hospital Reports, vol. iv.) In these instances and
wherever the strongest cautery is required, the
arsenical paste may be used. Its employment
demands particular caution not to surpass a limited
area in its application, as besides the results al-
luded to in the last paragraph, it almost invaria-
bly causes a severe erysipelatous inflammation of
the face. This may in some cases be of little
consequence, but it must in all be prevented from
running too high by the ordinary means of
leeches and proper remedies. Some habits could
not safely sustain this. We should, therefore,
confine the use of this energetic caustic not only
to the kind of ulceration which requires it, but
also to individuals whose constitution will enable
them to bear the erysipelas which attends its use.

In cases where the effects of the stronger arse-
nical applications might be injurious, M. Dupuy-
tren recommends a powder, whose action is, he

*T)ic arsenical paste is made by mixing the " powlre
lie" cil' Frere I !6me w ith saliva into the coiiMst-
ence of a paste. This powder consists of arsenic, cin-
nabar, and burnt leather. (See Rayer's Fonnulaires.")

2 1

says, specific, not caustic. It is composed of
calomel and arsenic in the proportion of one part
arsenic to two hundred of calomel. The quantity
of arsenic may be doubled if it be required more
active. It is sprinkled directly on the ulceration
by means of a dossil of lint, or made into a paste
with thin mucilage. It is to be left on till it falls
away of its own accord, and renewed several
times till it produce a new action in the ulcerated
surface, and a tendency to cicatrise. This is found
to be a very suitable application in children,
females, and individuals of a delicate habit and
irritable skin. Dupuytren applies it to unhealthy
cicatrices, having in the first place produced a
new surface by cauterising them, and this appears
a very excellent method of employing it. Although
this powder is much milder in its action than the
other arsenical applications, the same cautions are
to be observed in its employment, for whatever is
to be apprehended from the absorption of the
mineral, may as readily occur from this as from
the more concentrated preparations.

The nitrate of silver and the muriate of an-
timony, which are so commonly used in other
ulcerations, seem to be superseded by the arsenical
cauteries ; but the former does not deserve to
be neglected ; we can answer for its efficacy in
changing the unhealthy surface. The concen-
trated nitric acid is a favourite escharotic with
some experienced men. In that variety of the
third form where the deep layers of the skin and
the cellular membrane are the seat of the destruc-
tion, it is amongst the best applications for causing
separation of the sloughs and cicatrisation.

A preparation, called " le nitrate acide de mer-
cure," is in high repute at the Hopital St. Louis,
from the success with which MM. Richerand and
Cloquet employ it in producing healthy cicatrices.
It is made by dissolving a drachm of the proto-
nitrate of mercury in an ounce of nitric acid. The
ulcerated surface is to be touched with it by
means of a dossil of lint, and some scrapings of
lint moistened with the same solution to be also
laid upon the part. Its immediate effect is very
painful, but this does not continue. It is also an
excellent application for the soft flabby edges of
unhealthy, half-formed cicatrices, which, we should
remark, are always to be treated with the same
energy as the open ulcer ; they are certain other-
wise to relapse sooner or later into this condition.

[Occasionally, pure creasote has been applied;
and Dr. Alexander Ure (Lond. Med. Gaz. Dec.
3, 1836 ; see, also, Bost. Med. Journ., Nov. 4,
1840, p. 215, for a case cited from Land. Lancet")
found chloride of zinc speedily check, and perma-
nently cure the disease : he applied it in a paste,
made with one part of the chloride and two or
three parts of the anhydrous sulphate of lime.
One or two applications of the paste were gene-
rally sufficient to produce a proper eschar, and
when this was detached, the sore was treated with
water dressing.]

The actual cautery was formerly much es-
teemed in this malady, but now is but seldom
employed. We believe, nevertheless, that it is
sometimes amongst the best methods for obtaining
a satisfactory eschar that we possess. It should
never be employed, however, in lupus of the nose,
for the cartilages become affected by a bad kind

393

NOLI ME TANGERE — NYCTALOPIA.

of inflammation and swelling from its use, which |
increases the evil. Their defective vitality is not
capable of producing a slough. But where the
disease occupies a different situation, it is still used
with much success.

These methods of destroying the diseased sur-
face are generally preferable to extirpation by the
knife, which has, however, been practised with
the most favourable result. (Nouveau Bibliothe-
que Medicale, t. iv.) Cases may happen where
it can be had recourse to, in which the mineral
escharotics are inapplicable, as, for instance, where
a solitary tubercle is situated very near the eye.
It is of particular importance to arrest its progress
as soon as it can be recognised in this situation ;
but the cauterising substances would be dangerous
applications in the vicinity of the eyeball; so that
here, if other things permit it, excision by the
scalpel will be the preferable practice.

In employing the escharotic applications, it
must be a rule with the practitioner to persevere
in their use till the whole of the morbid structure
is destroyed. In order to effect this, it will in
general be required to repeat them several times,
for when the eschar falls, although the new sur-
face present a healthy aspect, the cicatrix may
form imperfectly, and afterwards break out again
into open ulceration. To diminish the chances
of this event, it will be wise not to trust to the
destruction of the mere face of the ulcer, but
rather to repeat the cautery, to procure a deeper
and healthier surface, which will give us better
confidence in its cicatrisation. During the pro-
gress of the latter, attention must be frequently
given to the opening of the nares, as their edges
have a great tendency to unite during this pro-
cess. It is sufficient here to revert to the fre-
quency of this accident, and in individual cases
the ingenuity of the practitioner will suggest
means to promote or to remedy it.

When the cicatrisation is accomplished, every
means should be put in practice to fortify the con-
stitution against the risk of a relapse. To this
end it has been proposed to insert an issue or
seton in the nape of the neck. This would be,
doubtless, particularly in young persons, a wise
precautionary measure. It may, however, be
stated in general, that if the remedies be steadily
persevered with till the malady be quite removed,
the cicatrices will stand sound. The Tagliacotian
operation has been performed where the nose had
been destroyed by lupus. Fears were entertained
that the skin taken from the forehead for the new
nose would not form a junction with the old
cicatrized edges cut to promote union by the first
intention, and that the dormant malady might be
reproduced by the operation : the union was,
however, completely established, and the cicatrix
maintained its integrity, because the cure had been

om P e James Houghton.

[NUMERICAL METHOD. See Statis-
tics, Medical.]

NURSING. See Lactation.

NYCTALOPIA, ffvitniXMfa, (th. vif, <3<//,)
Night-blindness. — A considerable degree of con-
tusion has prevailed among authors in the use of
the term nyctalopia. Some have employed it to
signify blindness by night, and others blindness

by day ; while it has also been used indiscrimi-
nately to denote either of these conditions. The
most approved acceptation, [1] however, among
the best and by far the most numerous authorities,
would appear to be that of night-blindness, while
the opposite condition of blindness by day is pro-
perly designated by the word hemeralopia. This
is the sense in which the terms are used in the
present article.

History and Causes. — Nyctalopia is little
known in this country ; but in the torrid zone, and
in those parts of the globe where the heat and
light of the sun are powerful, it is frequently met
with. It occurs in Africa, in Asia, and in Ame-
rica, and is said to be more common in China than
in Europe. In the East and West Indies, and in
the Mediterranean, it is no unusual disease among
our soldiers and seamen ; and on the eastern
shores, and in the islands of the Adriatic, it is at
times very prevalent. It has also occasionally
assumed an epidemic form in different parts of
France, Germany, Poland, and Russia; and in
some situations it appears to be endemic.

[The Statistical Report of Surgeon-general
Lawson, (Washington, 1840,) shows, that the
affection is seen amongst the troops both of the
northern and southern posts, but much more fre-
quently in those of the latter. In Florida, it is
by no means uncommon.]

Wherever it occurs, it preserves the same cha-
racters, varying only, in individual cases, in the
severity of its attack, in the length of its duration,
or from constitutional peculiarities of the patient.

In persons affected with this disease, when the
sun sets, vision begins to be indistinct, and be-
coming gradually more imperfect as the light
diminishes, it is at length entirely suspended.
The blindness continues during the darkness of
night : in proportion as the day-light returns, sight
is restored, and it again becomes perfect when the
sun appears above the horizon. Blindness and
vision continue, in this way, to correspond with
the setting and rising of the sun, and the approach
and the remission of the paroxysms are in general
gradual; but in some instances the blindness
comes on suddenly at sunset, and disappears at
sunrise in a similar manner.

The degree of blindness varies. In the early
stages of the disease, it is in general partial, and
the patient can see objects in a clear light ; but as
the complaint advances, the powers of vision
become more impaired. Some patients are inca-
pable of discerning the moon or the stars, or even
the light of a candle, when placed close before
their eyes : and some can perceive these bodies,
but not the objects which are illuminated by them;
while others can barely distinguish light from
darkness. After a lapse of time, varying in dif-
ferent cases, the blindness is often complete, and
the patient cannot perceive any object after sunset,
even in the brightest artificial light.

According to Mr. Bampfield, if the disease is
allowed to continue in this degree of severity, the
sight will, in the course of time, become weak
during day-light, and the eye will not be able to
bear the direct or reflected rays of the sun, without
pain and temporary blindness being induced.
(SeeMedico-Chirurg. Transactions, vol. v. p. 39 ;
also Manardi Epist. lib. xv. Epist. ii. p. 43U

NYCTALOPIA.

399

Such cases, however, are not of common occur-
rence.

But even when this irritable state of the eye
has not been induced, it would appear that, on
some occasions, the patient, when placed in an
obscure situation, (Radii Scriptor. Ophthalm.
Minor, vol. iii. p. 176, 177, 179, 192. Lipsise,
1830,) is incapable of distinguishing objects by
day as well as by night ; but this state does not
seem to have been often remarked, and it would
appear that a condition exactly the reverse of this
has also been sometimes observed. (See Lettres
Edifiantes, torn. xxiv. p. 434.)

In general, there is no uneasy sensation or
visible alteration in the eye, to indicate the pre-
sence of any morbid affection. Some authors,
however, describe the pupil as being immovable
and contracted ; whilst others say that it becomes
immovable and dilated, particularly during the
night. These discordant accounts may, perhaps,
have arisen from examinations of different states
or stages of the disease ; for Mr. Bampfield, whose
opportunities of observation were extensive, says,
that after it has continued long, and in the worst
stages, the pupil is often contracted, and the eyes
and actions of the patient evince marks of painful
irritation, if the eyes are exposed to a vivid light,
or if he look upwards." In another place he ob-
serves, " the pupil of the eye is considerably dila-
ted both by day and night, in the proportion of
about one case in twelve, and at night the pupil is
often dilated, and does not perform its expansions
and contractions when exposed to the moon or
artificial light." (Medico-Chirurg. Trans. Ioc. cit.
p. 42.) These were also generally cases which
had been long protracted.

Although no medical treatment has been em-
ployed, the disease, after continuing for a longer
or shorter period, frequently undergoes a sponta-
neous cure. In temperate climates, its usual du-
ration is from one month to six weeks ; but within
the tropics its continuance is generally much
longer, extending from a few weeks to three, six,
or nine months, and even occasionally to a still
longer period. On some occasions it would appear
to be congenital;* and it is also alleged to be at
times hereditary. (Rees's Cyclopaedia, art. Nycta-
lopia.)

The natives of cold countries who reside within
the tropics are said to be more subject to this com-
plaint than the indigenous inhabitants ; and those
Europeans who have once had an attack are very
liable to a recurrence of it while they remain in a
warm climate.

Within the tropics, the disease may be almost
considered as endemic, and does not appear to be
more prevalent at one season than another. But
in temperate climates it most generally occurs
during or after the protracted heat and dazzling
light of summer and autumn. In Germany it
prevailed as an epidemic in the months of July
and August; (« Calore solis existente maximo—

i *,?r!! Case wt l ere tlle P a,i ent, 20 years of age, had
bad he disease - from the Brat time ho was able to take
noti6e ol things?' PWIosoph. maneact. vol. iii. p. 38.
Also the rase f a patient. 23 years old. who states, " se
a quatuorjam annu raborare .achate noctuma " Hal-
Jcri D.sputat torn i. d.sp. rtii. Beet. 2. Lausanne, 1757.
Also an accoffnt of its or.currinsr in three individuals of
the same family, in Radii Scriptor. Ophthal. Minor. Ioc.

remittente solis aestu desiit haec nyctalopia." Hal-
leri Disput. Ioc. cit. sect. 8.) and in Russia Dr<
Guthrie says it is most frequent in June and
July during the hay-harvest. (Edin. Med. Com-
ment, decad. ii. vol. ix. p. 288.) All the cases
which the writer of this article met with in the
Mediterranean took place in the end of summer
and in autumn. It is, however, by no means
confined to those seasons. Hippocrates names it
among the diseases that occur " circa brumam,"
and adds that the greater number had relapses
" ante aequinoctiam." (De Morb. Vulgar, lib. vi.
sect, vii.)

Even at the season of the year when the heat
has not arrived at its greatest height, but when the
sun is long above the horizon, the disease has ap-
peared as an epidemic among troops exposed to
much watching and fatigue. The most remarka-
ble instance, perhaps, is that recorded by Dr. Gu-
thrie in the Edinburgh Medical Commentaries.
" I was lately desired," he says, " to give an
opinion on a curious phenomenon that happened
last war in Finland, where a Russian detachment,
ordered to attack a Swedish post during a light
night in spring, had like to have mistaken one an-
other for enemies, and occasioned bloodshed, owing
to some hundreds in the column being blind after
sunset. The complaint seized the soldiers in
spring, when the nights, from the short absence
of the sun, and the strong reflection from the
snow, must have been very fatiguing to the eyes,
at a period of much martial vigil and alarm ; sur-
prises on both sides being then very frequent,
more especially nocturnal." (Edin. Med. Comm.
Ioc. cit. p. 285 et seq. See also Ephem. Natur.
Curios, dec. iii. Ann. vii. and viii. append, p. 131.)
Night blindness has been described as endemic
in different countries. We have an interesting
account by Chamsem, (Hist, et Mem. de la So-
ciete Royale de Medecine, ann. 17S6, Paris,
1790) of its annual occurrence in this form in
France, at Roche Guyon and the neighbouring
villages, in some of which it occasionally affects
as many as one in nine or ten of the inhabitants.
It appears every year in spring, about the middle
of March, and continues for three months ; some-
times also returning in the autumn. The soil is
here composed of chalk and marl, upon beds of
burrstone (meuliere) and flint (caillou), and the
disease principally attacks those who are much
exposed by their labours in the fields to the re-
flected heat and light from this dazzling surface.
As the summer advances the ground becomes
covered with verdure, and being no longer capable
of reflecting the brilliant light of the sun, the dis-
ease disappears for the season.

According to Richerand, the inhabitants of the
northern regions, where the ground is covered
with snow during the greater part of the year,
become, at an early age, the victims of this disease.
He also says that among artisans the same morbid
state of the vision is sometimes produced from
long exposure to a great intensity of artificial
light. (Elements of Physiology, p. 284, edit.
1812.) oJ *

Nyctalopia is a disease more common to the
labouring classes of people, and those who are
exposed to much fatigue, watching, and other de
bilitating influences — whose diet is often scanty

400

NYCTALOPIA.

or even unwholesome. [Halhr. Disput. loc. cit.
sec. xx ; Gregor. Horstii Oper. Med. torn. ii. lib. ii.
obs. 34. p. 106; also Chamsem, op. cit. p. 139.)
The epidemics which are referred to above were
confined to persons of this description ; and its
frequent occurrence among our seamen leads us
to the same conclusion. A few instances are re-
corded of its affecting individuals among the better
ranks, but in such cases the habits and mode of
life of the patients have not been described with
precision, so as to justify us in forming a different
opinion.

In many cases nyctalopia appears to be a purely
local or idiopathic disease ; but still more fre-
quently it is the consequence, or at least the con-
comitant, of some other affection. All the in-
stances of it which came under the observation of
the writer, happened to individuals more or less
affected with sea scurvy ; and several medical
authors and surgeons of the navy have remarked
the frequent co-existence of the two diseases.*

It is very often symptomatic of derangement of
the digestive organs, so much so that Scarpa,
(Scarpa, Mallatie degli Occhi,p. 252. Pavia, 1801.)
Schmucker, Richter, and several other authors,
seem to consider the disease as almost entirely
originating in this cause.

Some morbid condition of the brain would
likewise appear to be occasionally present ; for
headach and vertigo, pain and watering of the
eyes, &c, have been enumerated as precursory or
concomitant symptoms.-j-

Hippocrates (Op. cit. Predict, lib. ii. sect. ii. p.
110) and Celsus (De Medic, lib. vi. cap. vi. p.
369. Lugd. Bat. 1730) state that females, whose
catamenia are regular, are not subject to attacks
of this disease ; but later observations sufficiently
prove the general inaccuracy of this opinion. It
is indeed true that the proportion of males affected
is in general greater than that of females ; but
this arises from the circumstance that the latter
are usually exempt from the same degree of hard
labour in the fields, and other debilitating causes.
For similar reasons young children are seldom
affected by it.

Persons of different temperaments are equally
liable to nyctalopia ; and it is not peculiar to those
who have eyes of any particular size or colour.

Nyctalopia has been attributed to various other
causes, such as eating rice, sleeping in the sun,
the use of poisonous vegetables, a fit of anger,
(Lettres Edifiantes, loc. cit. p. 434,) &c. It ap-
pears from Haller (Disput. loc. cit. sect, xxi.) that
the inhabitants of Bavaria ascribe the disease to
the use of bread in which darnel is present ; and
this opinion is one of great antiquity ; for both
Virgil^ and Ovid§ mention that " lolium" was

* Sre observations on Hemcrnlopia, or Night Blind
ncss, by Andrew Simpson, surgeon, p. 31, &c. Glasgow,
1819; Blane on Diseases of Seamen, third edition, p. 485.
t " Quandoque fit propter couimunitatem stomachi et
cerebri." Jlvicenna, Cannon, lib. iii. Fen. iii. Tract, iv.
c. v. p. 561. See also Haller, Disput. loc. cit. sec. vi. and
JLond. Med. Observ. and Enquiries, vol. i. art. xiii. p. 3.
Lond. 1771.

I interque nitentia culta

Infelix lolium, et steriles dominantur avens.

Georgic. lib. i. vers. 153.
9 " Careant loliis oculos vitiantibus agri."

Fast. lib. i. vers. 691.

believed to be hurtful to the sight ; and PlautusJ
expressly says that it produces nyctalopia.

[In very rare cases it would seem to be a con-
genital affection, and capable of being transmitted
from father to child. In such cases there must,
of necessity, be a peculiarity of organization. M.
Cunier (Annales de la Societe de Medecine de Gand,
1840, and Lawrence on Diseases of the Eye,
Amer. edit. p. 541, Philad. 1843,) has published
the history of a family in which it appears to have
been transmitted, by hereditary descent, through
six generations.]

Pathology. — In order to produce distinct
vision, a due proportion of light is necessary to
excite the retina. The quantity required for this
purpose depends much on the impressions which
have been previously made on the organ. When
the eye has been exposed to a strong light, a
fainter illumination will not suffice to enable it to
discriminate objects; while, on the other hand,
vision will be painfully acute, even in a compara-
tively obscure light, to those who have previously
been in a state approaching to entire darkness.
Thus the prisoner becomes gradually enabled to
perceive the objects in his cell ; while the man
who has been exposed to the reflection of the
sun's rays from the snow is rendered for some time
incapable of seeing in the less dazzling though
clear light of day. From the operation of the
same law, the eye, in nyctalopia, after being ex-
posed to a long and brilliant sunshine, is not
excited by the feeble light which continues after
sunset, and vision entirely ceases.

When an organ is often and highly stimulated,
its sensibility, it is well known, becomes impaired.
The long-continued action of light accordingly
produces a state of torpor or insensibility of the
retina, which becomes greater in proportion to the
degree of predisposition and length of time during
which the exciting causes continue to operate. In
the early stages of the disease, before any con-
siderable insensibility of the retina has been in-
duced, vision is observed to be more or less per-
fect in a clear light, and according to the degree
of illumination. But after a lengthened attack,
the increasing torpor of the retina renders it in-
sensible to the stimulus of even a bright artificial
light. While this torpid state of the organ re-
mains, the pupil continues dilated and immovable
on the approach of a light which is not of suffi-
cient intensity to excite the retina in the degree
requisite to produce vision.

Nearly the same explanation applies to that
state of protracted disease in which the eye has
become unable to bear the direct or reflected rays
of the sun. The heat and light which occasion
the insensibility of the retina, at the same time
stimulate the vascular portion of the eye, so as to
produce a degree of inflammation. It is in this
state that the eye becomes irritable, and the pupil
contracted, in order to exclude the excess of light.
For while the retina preserves its natural sensi-
bility, the contractions and expansions of the iris
in most instances go on unimpaired, and the eye
appears as in perfect health.

|" Sceledrus. Mirum est lolio victitare te tarn vili
tritico.
Palastris. Quid jam? Seel. Quai luscrliosus. Miles
Gloriosus, p. 475. Colonise, 1578.

NYCTALOPIA.

401

Perhaps it may be thought that, if the disease
be owing to an insensibility in the eye produced
by the intensity of the sun's light, the patient
ought also to be blind when removed to an obscure
place during the day, seeing that in both cases the
stimulus of light is withdrawn from the eye.
This, however, we find, is not always the case.
In explanation it may, perhaps, be alleged that
the action of the sun's rays, for the whole dura-
tion of a long day, will more effectually contribute
to produce that state of the organ which consti-
tutes the disease than when they act only for a
shorter period. The inference seems to be rea-
sonable, but it would require to be confirmed by
repeated observations.

Diseases of the brain, and such other causes as
induce repletion in that organ, may also produce
nyctalopia by injuring the optic nerves, either at
their origin or in their course, and thereby so im-
peding their functions as to render them incapable
of transmitting the slight impressions which are
made on the retina by a faint light. The last
stage of this form of the disease would constitute
complete amaurosis.

The well-known sympathy which exists between
the stomach and the organs of vision will readily
account for nyctalopia appearing so often as an
attendant on disorders of that viscus.

The varied illusions and other affections of
vision familiar to persons subject to dyspeptic dis-
orders, are analogous in many respects to this
disease.

A very different and almost mechanical cause
has been assigned for this disease by different
authors, namely, a rigid and contracted state of
the pupil, whereby a sufficient quantity of light
is prevented from reaching the retina. It is very
evident that such a state of the pupil might occa-
sion the disease ,• and it seems to be sometimes
observed, as several authors have mentioned its
occurrence.*

Diagnosis. — Nyctalopia can scarcely be con-
founded with any other disease. Yet in a com-
plaint of such frequent occurrence in the navy
and army, and which affords such facilities for
carrying into effect the schemes so often devised
by seamen and soldiers to enable them to evade
their duty, it would be an object of importance, if
any sure diagnostic symptoms could be pointed out.
The present state of our knowledge does not,
however, enable us to do so with any thing like
precision. If contracted or dilated pupil were an
invariable concomitant, this would afford a ready
mode of discrimination ; but these states of the
pupil have been rarely observed, even in cases of
long duration. As there are no direct means by
which the disease can be detected,-)- attention must,
therefore, be paid to the character, habits, and
conduct of the individual, and there are few in-
stances in which investigation and experiment

* Avicenna, Cannon, lib. iii. Fen. 3, Tract, iv. cap. v.
p. 5G1. Dan. Sennert. Opera, torn. iii. lib. i. par. iii.
Beet. ii. Chap. xliv. p. 25G. Lugd. Hi56. Tli. Zuinger,
Piednjatreja, oba. xxv. p. uz Basque, 1721. Fel. Pla-
ten Praxeoa Medic, tuin. i. cap. vi. p. 193. Herm. Boer-
Mam* de Morb. Oculor. p. 15!). Gattinga;, 1750. Gre-
gorii Conspect. Med. Theor. p. 81. ed. tenia.

t " il n'y a point de signes qui fasse connoitre

cette maladie, Mors le rapport du malade." Maitre-Jeao,
Tiaite des Maladies de PUSH, 2de partie, ch. iii. p 246,
a Pans, 1740.

Vol. III. — 51 2i*

will not suffice for its discovery. For some re-
marks on this point, see the section on Blindness,
in the article Feioj> t ed Diseases, vol. ii. p. 136.
Prognosis. — The prognosis in nyctalopia may
generally be considered favourable ; and, when
proper means of treatment are speedily adopted,
the disease is seldom protracted. It even fre-
quently undergoes a spontaneous cure ; and the
instances are rare in which it is followed by any
bad effects. It has also been occasionally removed
by the supervention of diarrhoea, of hemorrhage
from the nose, and of abscesses and eruptions
about the head and face. In two of Dr. Forbes's
cases, (Edin. Med. and Surg. Journ. vol. vii. p.
419,) epiphora succeeded ; and according to Mr.
Bampfield, (Medico-Chirurg. Trans, loc. cit. p.
40,) lippitude and myopism are sometimes conse-
quent upon it. This author also states that total
loss of sight has been known to ensue, and refers
to Bontius in support of this opinion. But from
the passage in Bontius, (De Medic. Indor. lib.
iv. p. 32. Parisiis, 1645,) it is somewhat doubtful
if the disease which is alluded to was nyctalopia.
Some authors, however, have been of opinion, that
the treatment of the disease is not always success-
ful. According to Sennertus, (Opera Omn. torn,
iii. par. iii. § ii. cap. 44, p. 227. Lugduni 1656,)
and Ettmuller, (Opera Omnia Comp. Colleg. Pract.
lib. ii. art. 1, p. 33. Lond. 1701,) it is seldom
cured, and Boerhaave (De Morb. Ocul. § 158.
Gottingse, 1750) says, "nullum remedium scio,
quod hoc malum tollere possit."

Treatment. — Physicians have very generally
endeavoured to adapt their mode of treating a
disease to the theory which they have formed re-
specting its cause. This remark has been fully
verified in the treatment of nyctalopia. The hu-
moral pathologists, who supposed the disease to
depend upon a superabundance, thickening, or
congestion of the humours, had recourse to such
remedies as they considered adapted for diminish-
ing, altering, or evacuating the various humours
of the body in general, and of the eyes in particu-
lar. For these purposes they recommend attenuant
diet and bleeding, both general and local. They
employed also purgatives, particularly those which
they considered as suitable to diseases of the eyes
— " oculis appropriata." Nor were other eva-
cuants omitted — sternutatoria, pituitaria, and the
like. Various local applications were also made
use of, such as collyria, unguents, and powders,
elaborately compounded with all the superfluous
science, and multifarious ingredients resorted to in
ancient pharmacy. Some things were recom-
mended as remedies on principles evidently the
most absurd. Thus, according to Galen and Cel-
sus, hieracion was advised, because " accipitres
aiunt scalpendo earn, succoque oculos tingendo,
obscuritati visus mederi ; ob idque vocant hiera-
cion." (Foresti Opera Omnia, lib. xi. obs. 38.
Francof. 1634.) Euphrasia was thought good
for the sight, from an imaginary resemblance be-
tween the spots on its petals, and the eyes. Many
other equally fanciful examples might be adduced,
but it may suffice to quote the following from an
author of high celebrity : — « Capras negant lip-
pire, quoniam ese quasdam herbas edant : item
dorcadas : et ob id fimum earum cera circumda-
tum nova luna devorare jubent. Et quoniam

402

NYCTALOPIA.

noctu aeque quoque cernant, sanguine hircino sa-
nari lusciosos putant, nyctalopas a Groecis dictos."
(C. Plinii Sccund. Natur. Hist. torn. iv. lib. xxviii.
§ xlvii. p. 61G. Parisiis 1085.) Thus it would
appear that, from the visual faculties possessed by
those animals, of seeing by night as well as by
day, the employment of their livers in the cure of
nyctalopia took its rise. This is a remedy, the
astonishing powers of which have been extolled,
both in ancient and modern times, and in coun-
tries the most widely separated, with a confidence
truly inexplicable. The livers of various animals
were occasionally employed ; but those of he-
goats, bullocks, and of sheep, were preferred.
Sometimes the vapour of the heated liver was ap-
plied to the eyes ; at other times the viscus itself
was given to the patient to eat ; in both cases
frequently after it had undergone the most com-
plicated preparations, particularly with various
stimulating substances. It is difficult to believe
in the production of a cure by such means ; and
yet it would require no small degree of incredulity
to set aside altogether the evidence which has been
adduced in favour of these remedies.

A recent German writer has given a remarka-
ble instance of the apparent power of this hepatic
treatment of nyctalopia. As the account is alto-
gether curious, we give the narrative at length.
The author, Dr. Edward Meissner,* informs us
that in a small town in Podolia, on the banks of
the Bug, having a population of about 2000, some
weeks before Easter, in the year 1810, he met
with more than a hundred cases of nyctalopia.
" I discovered this," he says, " accidentally one
evening, when my surgeon, a Jew, came home
hurt, having been overturned by the man who
drove him, and who had suddenly become blind as
the sun set. Upon inquiring why none of these
people were brought to me, I was told that they
very well knew how to cure themselves, and
would do so as soon as they were at liberty to use
the means. It was then the time of fast, when
those of the Greek church use no animal food,
but live chiefly on bread and grits prepared with
oil. I was assured that at the same period every
year a great many people were seized with nyc-
talopia, but that when Easter came they ate the
liver of a black cock or black swine, and were
cured in a few days. I had ten of these people
brought to me both during the day and in the
twilight, but could perceive nothing particular in
their eyes, except a great immobility of pupil. In
other respects they were all in perfect health, and
would submit to no other kind of treatment, as-
suring me that they knew they would be quite
free from their malady within fourteen days with-
out my medicines. On Easter day they began to
eat liver and other unimal food. Two of those
I had examined, on the third day saw as well as
ever ; and all were completely cured by the fol-
lowing Sunday."

The writer of this article has repeatedly seen a
cure apparently produced by fumigating the eyes
with the vapour of bullock's liver. The disease
occurred in persons who were in some degree

* Bemerkungen aus dem Tasclienbuche eines Arzes
.vahrend einer Reise von Odessa, &x. Jlallc, ]819. See
also Encyclopadisches VVorterbuch. B. V. p. 388. Berlin,
830.

affected with scurvy ; and various measures had
been employed for its removal without benefit.
The patients themselves had recourse to the bul-
lock's liver, and declared that one or two fumiga-
tions entirely cured their complaint.

We are as yet but little acquainted with ner
vous diseases, and are too well aware of their inter
mitting nature to put implicit faith in the efficacy
of such a remedy. The disease in these, as in
many other instances, may have undergone a
spontaneous cure ; or it may have owed its re-
moval to some cause which was unknown or un-
observed. It must be acknowledged that the
minute history of nyctalopia is still very imper-
fect.

[Besides, it is important to bear in mind, that
the disease often gets well spontaneously. Dr.
Wharton, of the United States Army, cured several
cases by simply excluding light. The cure was
effected in from 24 to 60 hours. (Lawrence, Op.
cit. p. 540.)]

Could any remedial exhalations have proceeded
from the broiling liver 1 or did the application of
heat alone suffice to excite the torpid retina into
healthy action 1

In the case of the Podolians above mentioned,
it is obvious that we are entitled to attribute the
case as much, at least, to the general change in
their diet, as to the specific influence of the black
pig's or cock's liver.

Viewing nyctalopia in the light of a more
rational pathology, it is hardly necessary to say
that, to give hopes of successful treatment, regard
must in all cases be had to the nature of the
causes which immediately induce the disease.
If it appear to proceed from fulness of blood in
the head, or any affection of the brain, bleeding
and other means, tending to remove such a con-
dition, are of obvious propriety. If derangement
of the digestive organs give rise to the complaint,
emetics, purgatives, or such other remedies as are
suitable for removing the primary disease, must
be employed ; and when scurvy, or any other
general affection of the system prevails, the appro-
priate means for its removal will be adopted as the
first step in the treatment ; and after the chief pre-
disposing cause has been subdued, attention will
then be paid to the treatment of the local affec-
tion. Nyctalopia, however, is often unaccom-
panied by any specific or formal disease, and ap-
pears to depend upon general and local debility.
In such cases our efforts will be directed to restore
the general strength of the body, and more par-
ticularly of the eyes; and this will be most readily
accomplished by avoiding the exciting causes, and
by employing tonics and stimulants, both general
and local. Dr. Guthrie informs us that, in a week
or fourteen days, the disease " is cured by the use
of a bitter tonic infusion,-j- although the patient
continue his daily hard labour, providing he sleeps
as at other seasons during the night." Although
the complaint may certainly be in this way removed,
yet a cure is induced still more speedily by the
application of blisters to the parts immediately
adjacent to the local affection. They stimulate
the eyes more effectually than general remedies
do ; and as during their application the patient is

fivlade, he believes, from the "Ccntaurea Cyanus"o'
Linmeus. Edin. Med. Comment, loc. cit. p. 28A

NYCTALOPIA — OBESITY.

403

usually allowed to go to rest at night, they consti-
tute an important part of the remedial process in
the case of seamen or others subject to night-
watching. The merit of more particularly recom-
mending blisters, and determining their efficacy in
the cure of this disease, belongs to Mr. Bampfield,
though the remedy is not new, as they are known
to have been employed from a remote period. His
words are, " A succession of blisters to the temples,
of the size of a crown or a half-crown piece, ap-
plied tolerably close to the external canthus of the
eye, has succeeded in every case of idiopathic
hemeralopia which I have seen. Under their ap-
plication, the retina appeared to regain its irrita-
bility, and sensibility to impressions from light, in
the same gradual manner as it was deprived of
it." (Medico-Chirurg. Transactions, loc. cit. p.
47.) In his practice, one or two applications
were often sufficient to remove the complaint ;
but the third, fourth, or fifth generally produced a
complete recovery. The instances are but few in
which there was occasion for a greater number of
blisters ; or by keeping them open, the cure was
generally completed within a fortnight. During
the time in which they are applied, exposure to a
bright light ought to be carefully avoided ; and the
patient should be allowed a sufficient time for
sleep. The eyes may also be frequently bathed
with cold water, or some tonic or astringent lotion.

Besides blisters, other local stimulants have
been employed, particularly the vapour of am-
monia ; frequently, however, with indifferent suc-
cess. The stimulus of electricity has been used
with advantage ; and, reasoning from analogy, it
might be expected to prove highly beneficial, as
also galvanism.

It may be proper just to notice in this place the
analogous but reverse lesion of vision, termed
Hemeralopia by those who give the name of
nyctalopia to the affection of which we have been
treating, in which the patient is blind during the
day, but sees comparatively well at night. This
disease is noticed by Hippocrates, and many other
authors, both ancient and modern ; but as it has
never fallen under our own observation, except as
a mere symptom of ocular inflammation, and as
its occurrence as an idiopathic affection is, we are
convinced, extremely rare, we deem it unnecessary
to give any particular account of it. It may no
doubt arise from such local affection of the retina
of an organic though unknown kind, as to entitle
it to be considered idiopathic ; the relative excess
of light producing here the same effect as its
relative deficiency did in nyctalopia. When, how-
ever, not the immediate consequence of inflamma-
tion of the eye, it has commonly been observed as
the temporary attendant of hysteria, or as a symp-
tom of worms, or other irritation sympathetically
affecting the brain generally, or the optic nerves
in particular. It therefore deserves no separate
consideration in this work as a distinct disease.

James Grant.

OBESITY. — This term, from the Latin obesi-
tas, fatness, corpulency, its synonym polysarcia,
from «r<fXvy, much, and cip^, Jlesh, and many others
of similar import, are used to signify an excessive
development of fat in the body.

Of all aninia! solids, fat may be named as that

which may vary most in quantity without material
infringement on the health. Thus we see persons
in very various degrees of fatness or leanness en-
joying the best health ; and even the same indi-
vidual, under different circumstances of diet and
regimen, may become fat or lean without and
corresponding change in the well-being of his
body. There is, nevertheless, in most individuals,
a certain degree of stoutness which best comports
with that regular balance of functions which
constitutes perfect and permanent health. This
degree in some persons may not rise above lean-
ness ; and in these even a moderate degree of
embonpoint is often a precursor or a sign of dis-
order ; whilst in many, a fulness and rotundity of
person is natural, and not only consistent with,
but indicative of perfect health. This statement
shows the impossibility of defining absolutely what
degree of obesity is to be considered as morbid,
although in its excessive degrees it is unquestion-
ably a disease and a cause of disease. Cullen
describes obesity as morbid " when it renders per-
sons from a difficult respiration uneasy in them-
selves, and from the inability of exercise, unfit for
discharging the duties of life to others." (First
Lines, ed. by Cullen and Gregory, vol. ii. p. 208.)
Fat may be developed in excess at any period
of life, but some ages are much more disposed to
obesity than others ; and these are infancy and
maturity. Infants at the breast sometimes acquire
a prodigious size from the deposition of fat.
Usually this is chiefly confined to the subcutane-
ous tissue, and very little affects either the cavities
or the interstices of the muscles ; but when such
children are affected with somnolency and a short-
ness of breath, which renders sucking difficult and
movement laborious, the accumulation of fat may
be supposed to be more general, and to oppress by
its mass the organs of respiration, circulation, and
motion. This condition is almost uniformly caused
by an excess of nourishment, and is not unusually
attended by a torpidity of the bowels. Fat in-
fants are generally good-tempered ; and it is diffi-
cult to say whether this be a cause or a conse-
quence of their fatness ; but a fretful disposition
is generally consorted with an irritability of the
secretory organs, which is opposed to any super-
fluous growth. The obesity of infancy generally
diminishes after the second year ; and it is not
unusual to see the subjects of it become as thin as
other children before the age of puberty. The
demands of other solids of the body, which the
increasing exercise at this period produces, operate
against the superfluous deposition of fat ; and the
fuller development and greater activity of the
mental faculties perhaps have a similar effect. In
some of the most remarkable cases on Tecord,
however, the inordinate development of fat con-
tinued and increased regularly from infancy up-
wards. A German girl, who was exhibited some
years ago in Paris on account of her prodigious
size, at her birth weighed 13 lbs. ; at six months,
42 lbs. ; and 150 lbs. at four years. She showed
great physical strength as well as size, for when
six years old she was able to carry her mother.
She ate much milky food in her childhood, and
afterwards drank large quantities of tea, but did
not eat more than another person. She men-
struated at the age of nine years, and always

404

OBESITY.

enjoyed very good health, being active and lively
in her disposition. At the age of twenty she
weighed 450 lbs., she then could carry in each
hand a weight of 250 lbs., and could walk for an
hour without requiring rest, but her breathing was
short on going up stairs. Her arms measured
eighteen inches (French) in circumference ; and
the fat formed annular rolls, as in the thighs of
^ery fat infants. (Diet, de Medecine, art. Poly-
sarcie.) Many similar cases are related in Mr.
Wadd's amusing monograph on Corpulency, from
which we extract the following.

Isaac Butterfield, born at Heightley, near Leeds,
Feb. 20, 1781 ; in November 1782 he measured
three feet in height, thirteen inches round the
arm, two feet two inches round the thigh, sixteen
inches across the shoulders, and weighed near one
hundred weight. He died Feb. 1, 1783.

A child named Thomas Hills Everitt was pub-
licly exhibited in London in 1780. He was not
remarkably large when born, but began to increase
rapidly when six weeks old, until his death, which
happened at eighteen months. At eleven months
he measured three feet nine inches in height ; two
feet six inches round the breast ; three feet one
inch round the loins ; one foot ten inches round
the thigh ; fourteen inches round the leg ; eleven
inches and a half round the arm, and nine inches
round the wrist.

Mary Tate, aged twelve years, the daughter of
a publican in Cambridge, and one of twins,
weighed thirteen stone ; the other child died at
two years. When Mary was born, she was not
larger than is usual, but began to increase at five
years; and at six she was publicly exhibited.
Her parents were corpulent. She was attacked
with a fever which prevailed at Cambridge a few
months before her exhibition, and recovered with-
out any apparent diminution of size. Mr. Wadd
has collected a great number of other instances
of obesity, but as they are merely named, with
scarcely any particulars of their history, they are
objects of curiosity rather than of medical interest.
In most of the well-recorded instances of obesity
in early life, there has been an uncommon develop-
ment of muscular strength ; and in this respect
the obesity of childhood differs from that super-
vening in after-life.

[A girl, said to be only ten years old, called the
"Ohio giantess," was lately (1844,) exhibited in
Philadelphia, who was said to weigh 265 pounds ;
anu the case of a girl is detailed, who weighed
256 pounds, when only four years old. (Philoso-
phical Transactions, No. 185.) Dr. Elliotson
(Human Physiology, Lond. 1841, part 1, 301,)
saw a female child, but a year old, who weighed
sixty pounds. In these cases the specific gravity
of the body may be much less than that of water.
It is said that there was a fat lighter-man on the
Thames who had fallen overboard repeatedly,
without any farther inconvenience than that of a
good ducking ; " since, though he knew nothing
whatever of swimming, he always continued to
flounder about like a firkin of butter, till he was
picked up." (Fletcher, Rudiments of Physio-
logy, part i. p. 71, Edinb. 1835 ; and the writer's
Human Physiology, 5th edit. ii. 239 : Philad.
1844.) The Lowell Advertiser, of this very date,
(Sept. 1844,) states that a coloured girl, aged

fourteen years, a native of Nassau, N. Y., had
died in that city, weighingyu'e hundred pounds.]

A remarkable case of obesity in early age was
lately brought before the Royal Institution by Mr.
Pettigrew. It was a boy, twelve years of a<>e
who weighed 198 lbs. The great increase of his
bulk took place after confinement, in consequent
of a fracture of one of his limbs. His health is
now good, and his habits, appetites, and mental
development present nothing uncommon for a
boy of his age. He is not deficient in activity,
but he says that he cannot lift more than five
stone weight.

After the completion of longitudinal growth
the adipose membrane again receives the overflov
of the nourishment of the body ; this is less re
markable in males than in females, in whom the
nutrient function is naturally more active. In
both sexes, however, the irritation of the genera-
tive organs at the early epoch of maturity seems
to have a remarkable effect in diminishing the
plumpness of the body ; and the absence of this
influence in eunuchs produces the sleek smooth
surface so remarkable in their bodies, in which
the inequalities of bone and muscle are buried in
a bed of fat. It is a familiar fact that some of
the lower animals fatten much more readily after
the removal of the testicles or ovaries. It is per-
haps partly in connection with this circumstance,
and partly from the abatement of other excite-
ments of youth, that obesity more frequently and
more decidedly shows itself as maturity advances;
and it is after the fortieth or forty-fifth year that
it attains its greatest degrees. The diminished
mobility of both mind and body which is percep-
tible at this age, and the greater inveteracy of
habits of living, render corpulency then a much
more serious evil than in earlier life ; for these
circumstances, unless steadily and vigorously
counteracted, will infallibly increase it in a degree
that must abridge life by encroaching on the func-
tions of various internal organs, and laying the
foundation of fatal diseases. This we shall see
sufficiently explained in the situations which fatty
accumulations occupy at these ages. Besides the
thick bed of fat in the subcutaneous tissue, and
in the interstices of the muscles, the mediastinum,
the pericardium, the mesentery, and the omentum,
become the seats of prodigious adipose deposi-
tions. Such subjects, besides a largeness and
rotundity of body and limb generally, have a pro-
tuberant abdomen, and the loose texture in the
axillae, under the chin, and about the mammae of
women, becomes in like manner distended with
fat. The effect of these accumulations is mechan-
ically to oppress the adjoining organs; hence,
shortness of breathing and asthma, weak or irre-
gular action of the heart and palpitation, an op-
pression and consequent disorder of the digestive
apparatus, inability of movement, obstructions to
a free circulation of the blood, and dropsical effu-
sions. The cavity of the head is the only one
which escapes the deposition of fat ; and this ex-
emption exposes its contents to a still greater evil.
The various obstructions to the circulation, and
the increased pressure to which the mass of fat
throughout the body subjects it, produce a deter-
mination of blood to the head, and congestion ;
whence arise somnolency, torpor of the mental

OBESITY.

405

and animal functions, and sometimes apoplexy
and sudden death.

We have hitherto considered obesity as a sim-
ple hypertrophy, but there is reason to believe
that in many cases the fatty substance encroaches
on the nutrition of other structures. In very fat
subjects, both in man and in the lower animals,
the fibres of the muscles are often interspersed
with depositions of fat, sometimes to such a de-
gree that the latter constitutes the greater part of
what once was muscle, and the remaining fibres
are commonly softer and paler than is natural.
All the muscles arc liable to this change, and the
heart among the rest; the consequence necessa-
rily is a diminution of their contractile power.
We have seen the heart thus more than half con-
verted into fat ; the adipose tissue of the base and
surface having encroached on the muscular fibres,
so that at the base and along a great part of the
wall of the right ventricle, and at the septum of
the ventricles, these fibres only formed a thin
stratum irregularly terminating in the adipose
tissue. Laennec describes this state of the heart,
and says that " the fatter the heart is, the thinner
in general are its walls ; and on cutting into them
the scalpel seems to reach the cavity without en-
countering almost any muscular substance, the
columnae carnffi appearing merely as if bound
together by the internal lining membrane." (Dr.
Forbes's Trans, p. 637.) He distinguishes it
from fatty degeneration by the marked difference
between the muscular fibre and the fat, the latter
seeming rather to have superseded the fibres than
to have been formed in them. The effects of this
change must be unquestionably to render the
action of the heart weak, and the circulation lan-
guid and inefficient ; and some of the instances
of the sudden death of fat persons may reason-
ably be ascribed to a rupture of the organ in this
weakened state. M. Berlin describes a case of
the rupture of a prodigiously fat heart. But the
mere diminution of power in the heart, and its
oppression by a load of fat, without any rupture,
seem to have caused death in some cases. Dr.
Brian Higgins of Dublin, the first discoverer of
equivalents in chemistry, appears to have died
from this cause ; and there are many similar ex-
amples on record. These forms of obesity must
have a tendency to increase ; for as fat is deposited
in and around the muscles, they will be less dis-
posed to that habit of exercise on which their de-
velopment mainly depends, whilst obesity and its
causes will increase together.

Without dilating this article with cases of ex-
traordinary obesity, we may state generally that
the fat, which is computed to constitute an average
of from l-10th to 1-1 5th of the weight of the body
in persons of ordinary degrees of stoutness, in
extreme cases amounts to 4-5ths ; and the abso-
lute weight, which runs commonly from 10 to
14 stone (14 lbs.), has been known in remarkable
cases of this disease to reach to from 30 to 50
stone. Mr. Lambert, of Leicester, who is always
placed at the head of the list, weighed 52 stone
11 lbs. There is detailed in the twelfth volume
of Corvisart's Journal de Medecine et de Chirur-
gie, an interesting account of a case of obesity by
M Dupuytren, with a full description of the tis-
sues affected, and the proportion of fat in various

parts of the body : an extract from this has already
been given in the article Htpehtropht, and it is
therefore unnecessary to repeat it here.

Obesity is sometimes partial : and it has its seat
in no part more frequently than in the omentum,
which has been known to increase to the weight
of 20 or 30 lbs. This gives the appearance of
what is vulgarly called a pot-belly. The mediasti-
num is likewise occasionally filled with fat with-
out a corresponding obesity of the body ; and the
double chin often occurs as a partial obesity. The
mammse, abdominal parietes, and nates of women
are likewise sometimes the seats of fatty enlarge-
ments ; the latter are so to a ludicrous degree in
the Bosjesman Hottentots.

Pathology. — Fat is an oily matter contained
in minute vesicles which are agglomerated toge-
ther in masses in the cellular tissue of various
parts of the body. Whether there is a peculiar
adipose tissue, or whether the fat is deposited in
the common cellular structure, is a matter of dis-
pute amongst anatomists. Dr. W. Hunter de-
scribed the adipose tissue as distinct, and as con-
sisting of cells which do not communicate with
one another. He grounds his opinion on the fol-
lowing facts. The parts where fat most commonly
accumulates are not those which are most subject
to (Edematous and emphysematous swellings, nor
do the forms of parts increased by fat, and of those
whose cellular tissue is distended by serum, re-
semble each other. Adipose accumulations do
not pit on pressure, or gravitate towards the most
dependent part, as anasarcous effusions do : the
scrotum, so commonly the seat of the latter, is
scarcely ever affected with fatty enlargement. W.
Hunter's opinions have been adopted by Monro,
Mascagni, Bichat, and Beclard. Haller, Wolff,
Hensinger, Magendie, and Meckel deny the exist-
ence of a peculiar adipose tissue, and consider
that fat is merely deposited in globules in the cel-
lular structure. Meckel supposes the fat to be a
solid, manifesting itself in globules, which make
cells for themselves in the mucous tissue, in which
he asserts there is naturally no cellular division
or communication. A minute examination of
human fat does not confirm this latter opinion, for
it traces its globular form to the presence of an in-
vesting membrane, while the contained oil is liquid
or solid, and the animal temperature according as
elilin or the stearin prevails in it, which varies in
different parts of the body. We are, therefore,
disposed to retain Dr. Hunter's view, which is
confirmed by the distinct and characteristic ap-
pearance which the adipose substance presents
when surrounded by serous infiltration of the cel-
lular tissue.

There has been an equal discrepancy of opin-
ion as to the place of the formation of fat. Haller
and Magendie consider it as a simple exhalation
from the blood. Dr. W. Hunter ranks it as a
secretion elaborated by the specific tissue in which
it is found ; whilst Sir E. Home has framed a
curious hypothesis, that it is formed from the
fcecal part of the food in the colon, whence it is
taken up by the blood-vessels, and deposited in
different parts of the body. Almost the only
argument urged in favour of this last notion is a
supposed resemblance between the retention ot
faces in the colon, and certain cases in which de

406

OBESITY.

cayed animal matter is converted into adipocire :
this resemblance is very slender and distant ; and
if Sir E. Home has proved that an oily matter is
sometimes present in the fseces, he has failed to
prove that it is either formed there, or conveyed
thence into the system ; whilst on the other hand
there are on record cases which prove that fat may
be formed and deposited in the body without any
aid from the colon. Thus the subjects of artifi-
cial anus have been known to get fat, although
no faeces passed through the large intestines. (See
Dr. Mackeever on Laceration of the Uterus, p.
48, 1824.)

The question whether fat exists ready formed
in the blood, or is only elaborated at the point in
which it is deposited, is much of the same nature
as that respecting other secretions, such as urea,
bile, mucus, &c. Commonly none of these are
detected in the blood, but under some circum-
stances they may each be found to exist there ;
and the presence of fat giving a milky aspect to
the serum* is not so uncommon as to exclude the
probability that it always exists, but in propor-
tions too small to be readily appreciated unless
circumstances lead to its accumulation. And we
have the positive testimony of Drs. Christison and
Babington, and more recently of M. Lecanu, that
there is always fatty matter in the blood, accord-
ing to the latter chemist, in ordinary cases amount-
ing to from three and a half to six and a half in a
thousand parts. (Journ. de Pharm. Sept. and
Oct. 1831.) These facts, coupled with the well-
known presence of oily matter in the chyle, re-
move much of the difficulty of explaining the rapid
accumulation of fat in the body under some cir-
cumstances, and its still more speedy reduction in
others. These changes, if not the result of simple
exhalation and absorption, are obviously more near-
ly allied to them than they were formerly considered
to be ; and although the secernent power of ves-
sels is undoubtedly concerned in the deposition
of fat, we must not overlook the cohesive quality
of this substance, by virtue of which it agglome-
rates to matter of its own kind, whilst watery
liquids have but little affinity for it. Hence we
can perceive why blood surcharged with fatty
matter from the chyle promptly deposits it, espe-
cially where adipose substance already exists ;
whilst for its removal there must be an augmented
energy of the absorbent function. This view,
which is but an hypothetical one, would assign
the chylopoietic viscera as the probable seat of the
formation of fat, although there may be reason to
believe that it becomes modified and perfected in
its progress through the circulation.

Another conjecture has been proposed by Dr.
Bostock, that fat is formed like other secretions
from the blood ; and its production, by removing
a superfluity of hydrogen, is a means of main-
taining a uniformity in the composition of the cir-
culating mass. The kidneys are the emunctories
of azote, and the lungs of carbon, whilst fat, the
prevailing ingredient of which is hydrogen, may
maintain the balance by carrying oft' the superflu-
ous hydrogen. If this were the mode of its pro-

* We once saw this milky appearance of the serum
very remarkable in the blood of a corpulent patient suf-
fering under an attack of pneumonia ; she had been
largely bled previously.

duction, the excessive development of fat ought to
be accompanied by an unusually copious secretion
of urea by the kidneys, a circumstance not, as far
as we know, attributed to cases of obesity.j- Of
the excretions, that of the liver bears the nearest
analogy to fatty matter ; and this fact suggests a
question whether an obese diathesis may not be
sometimes connected with a comparative torpidity
of this viscus.

Causes. — These may, as usual, be divided into
predisposing and occasional. The predisposing,
as consisting in a peculiar habit or temperament
of body, is frequently hereditary. At the first
glance, we may be led to say that the predisposing
cause is the most powerful, inasmuch as no mode
of diet and regimen will succeed in making some
persons fat, whilst others increase to a great size,
without, in these particulars, exceeding the bounds
of moderation. A more comprehensive survey,
however, of the symptoms in different cases, sug-
gests that the constitutional cause is not always
of the same nature, and that therefore it has a
varying share in the production of morbid obesity.
A full diet, especially abounding in oily, carneous,
saccharine, and farinaceous matter, will seldom
fail to fatten a person naturally disposed to corpu-
lency ; and if to this, rest of body and mind be
added, this effect is almost certain. Some indi-
viduals, having a strong constitution and good
general health, require these to make them fat, and
become so only in proportion as they indulge in
them. These persons, in whom the predisposing
and exciting causes may be said to be nearly
balanced, constitute a large proportion of the
cases of moderate obesity that are commonly met
with. In them the circulation and other functions
are effective and regular, the secretions free, and
the bodily and mental powers little embarrassed.
Their corpulency is merely an overflow of health,
the deposition of fat being the outlet by which the
blood-vessels deliver themselves from impending
plethora, and is accompanied by an increase rather
than a diminution of other solids. This form we
would denominate sthenic obesity. A preponder-
ance of the same predisposing cause, the hyper-
trophic diathesis, gives a more marked form of the
disease, and constitutes the greater number of
those cases of uncommon size and strength which
are frequently shown about the country. When
this form of obesity becomes much pronounced,
by the embarrassment which it causes in the func-
tions, it tends to pass into the second variety of
the disease, which we would term asthenic.

In asthenic obesity, the predisposition is still

t We cannot omit the opportunity to express here our
conviction, that a more frequent and habitual attention
to the state and composition of the excretions would
greatly en large our knowledge of the pathology of dis-
eases. The interesting study of animal chemistry has
established, to a certain degree, that the great excretory
organs, the liver, the lungs, and the kidneys, act as ba-
lancing forces, which keep the blood of a uniform na-
ture ; and it must, therefore, be obvious, that the inor-
dinate or imperfect action of any of these would lead to
a more or less disordered state of this fluid, which must
necessarily react on the functions at large. Without
advocating an absolutely humoral system of pathology,
we cannot but view a disordered state of the fluids as
an important link in the concatenation of diseased ac-
tion, and as a main object of therapeutic efforts. For a
clear insight into this subject, much patient and well-
directed research is required ; and had we a few moi--
such inquirers as Dr. Prout, we might sanguinely 1«*
forward to the attainment of this point.

OBESITY.

407

more strong, and probably consists of a greater
number of constitutional causes. This predispo-
sition is frequently hereditary, and is commonly
allied with a leucophlegmatic temperament, a soft,
languid pulse, defective excretions, and a low irri-
tability of the body. There is in such individuals
a sufficient activity of the first part of the diges-
tive process; but a somnolent disposition, often
present for some hours after meals, indicates the
admixture of chyle in the circulation, and a tar-
diness in its assimilation. The chyle thus sup-
plied probably abounds more in fatty particles than
in albuminous globujes. Until, therefore, the
former are deposited from the circulating mass in
the adipose membrane, the blood does not recover
its natural and most healthy constitution. There
is good reason to believe that naturally this adi-
pose matter is always at the command of the ab-
sorbent functions, and that, in case of the excre-
tions being augmented in a greater ratio than the
supply of nutriment, it is taken into the circula-
ting mass to make up for the waste. In a person
of sanguine temperament, the demand on the adi-
pose membrane equals the supply : such an indi-
vidual makes blood fast, and suffers from plethora
Defore there is any considerable increase of fat in
the body. A person of spare habit, again, is lia-
ble to neither form of hypertrophy ; as either the
incapacity of his digestive organs, or the activity
of his excretions, preclude all superfluous accu-
mulation. In asthenic obesity, on the other hand,
there is a defect in the assimilatory process by
which the oily matter is made available to supply
the excretions of the body ; and this defect may
be either in the absorbent function, or in that ac-
tion by which the matters excreted are formed ;
but it is most probable that the same defect of tone
which manifests itself in the state of the body
generally, extends to both these functions. Hence
asthenic obesity resembles atonic dropsy, in which
it not unfrequently terminates : it occurs towards
the later periods of life, and in persons whose
constitutions have been weakened by various ex-
cesses. It is not unfrequently the accompaniment
of chronic disease of the liver, and more rarely of
the stomach ; and is sometimes a symptom of a
chlorotic state in young women. It is in this
form of obesity that the muscles become paler,
lose their substance, and are displaced by deposi-
tions of fat.

We have already stated that good living and a
life of ease are the most efficient occasional causes
of obesity ; this is universally acknowledged ; and
Dr. Arbuthnot says, " you may see an army of
40,000 soldiers without a' fat man ; and I dare
affirm that by plenty and rest, twenty out of the
forty shall grow fat." The portly appearance of
butchers, landlords of inns, and butlers, is obvi-
ously referable to their good living and moderate
exercise.

With respect to the quality of food which is
most fattening, much variety is seen ; either ani-
mal or vegetable diet being capable of producing
the most marked effect, if taken in sufficient quan-
tities. Thus the negroes of the West Indies, and
the Chinese slaves, sometimes acquire an enor-
mous size during the sugar season by drinking
the cane-juice ; and it was remarked by Galen,
that the keepers of vineyards, who live on nothing

but figs and grapes, become fat. The ladies of
Tunis and Tripoli are fattened, to please the tastes
of their lords, with farinaceous food, and a seed
called drough. " Among the Asiatics there is a
sect of Brahmins who pride themselves on their
extreme corpulency. Their diet consists of fari-
naceous vegetables, milk, sugar, sweetmeats, and
ghee. They look upon corpulency as a proof of
opulence ; and many arrive at a great degree of
obesity without tasting anything that has ever
lived." (Wadd's Remarks, &c. p. 80.)

Malt liquor, consisting of a saccharine and fe-
culent infusion, rendered readily digestible by the
stimulant and stomachic properties of the bitter
and spirit with which it is combined, is highly
nutritious, and some of the most remarkable sub-
jects of obesity have been addicted to excessive
indulgence in ale or porter. The following case
is related by Mr. Wadd.

" A few years ago a man of about forty years
of age hired himself as a labourer in one of the
most considerable ale-breweries in the city. At
this time he was a personable man ; stout, active,
and not fatter than a moderate-sized man in high
health should be. His chief occupation was to
superintend the working of the new beer, and
occasionally to sit up at night to watch the sweet
wort ; an employment not requiring either activity
or labour : of course at these times he had an
opportunity of tasting the liquor, of which it
appears he always availed himself: besides this, he
had constant access to new beer. Thus leading
a quiet inactive life, in a short time he became of
such an unwieldy size as to be unable to move
about, and was too big to pass up the brewhouse
staircase ; if by any accident he fell down, he was
unable to get up again without help. The inte-
guments of his face hung down to the shoulders
and breast : the fat was not confined to any par-
ticular part, but diffused over the whole of his
body, arms, legs, &c. making his appearance such
as to attract the attention of all who saw him. He
left this service to go into the country, being a
burthen to himself, and totally useless to his em-
ployers. About two years afterwards he called
upon his old masters in a very different shape to
that already described, being reduced in size nearly
one half, and weighing little more than ten stone.
The account which he gave of himself was, that
as soon as he had quitted the brewhouse he went
into Bedfordshire, where having soon spent the
money he had earned, and being unable to work,
he was brought into such a state of poverty as to
be scarcely able to obtain the sustenance of life,
often being a whole day without food ; that he
drank very little, and that was generally water.
By this mode of living he began to diminish in
size, so as to be able to walk about with tolerable
ease. He then engaged himself to a farmer, with
whom he staid a considerable time, and in the
latter part of his service he was able to go through
very hard labour, being sometimes in the field
ploughing and following various agricultural con-
cerns for a whole day, with no other food than a
small pittance of bread and cheese. This was
the history he gave of the means by which this
extraordinary change was brought about. He
added, his health had never been so good as it
then was "

408

OBESITY.

In another case, from the same writer, more of
the asthenic kind, the subject, a woman who died
suddenly at the age of forty-four, weighing twenty-
three stone, had subsisted chiefly on vegetables
and pastry, and drank large quantities of milk and
water, consuming above a gallon in the course of
each night. She was totally incapable of rising
from her bed, and required three strong men to
place her in her chair.

While these cases show that the quantity more
than the quality of nutritious aliment supplies
the disposition to obesity where it exists, it is at
the same time certain that fat meats, butter, milk,
the saccharine, the finer farinaceous, and the oily
vegetable substances, with malt liquors for drink,
are the most fattening kinds of food ; and varied
combinations of these are more effectual to this
end, inasmuch as they are more inviting to the
appetite, and more manageable, even in large
quantities, by the digestive organs, than simple
substances, however nutritious.

Besides food, there are other circumstances
which contribute greatly to the production of
obesity. Absolute rest is less powerful than some
kinds of moderate exercise, as it can seldom be
indulged in without such an interruption to health
as would prevent the fattening process. The
obesity which ensues on absolute rest is generally
more of the asthenic kind. There is no mode of
living that seems to dispose more to obesity than
that of a regularly employed coachman. The
gentle exercise and free exposure to the open air
which their occupation entails upon them, gives a
good appetite and easy digestion ; and while they
seldom fail to indulge these, they are rarely called
upon for those exertions of the lower extremities,
or of the whole frame, that reduce the body by a
general increase of the excretions.

Mental repose, both of the powers and passions,
has been considered a great promoter of obesity.
We think, however, that the sluggish minds and
easy tempers of fat people are as often the effect
of the phlegmatic constitution which disposes to
obesity, as a cause of this state. They are fre-
quently accompaniments of asthenic obesity ; and
a somnolent inactivity of the mind, as of the body,
may be the effect of an advanced state of any kind
of corpulency : but the case of David Hume, the
historian, who became very fat during his intel-
lectual labours, and that of Napoleon under the
most powerful excitements of passion and mental
energy, and many others which we could cite,
prove that fat and stupidity are not such inseparable
companions as Lord Chesterfield represented them.

The national differences which are observable
in the disposition to obesity are probably referable
more to the temperament, diet, and habits of the
people, than to any peculiarities in climate. It
has been stated that obesity sometimes commences
after convalescence from a fever, or after a course
of mercury ; and all that can be said in explana-
tion is, that these influences seem to produce in
various respects a change in the constitutional
diathesis, as other morbid tendencies, not pre-ex-
istent, are occasionally developed by the same
causes. We have known a partial accumulation
of fat succeed to repeated attacks of erysipelas in
he part; this bears more analogy to common
nypertrophy.

[In the view of Liebig, (Animal Chemistry,
Webster's edit. p. 85, Cambridge, Mass. 1842,)
the abnormous condition, which causes the undue
deposition of fat in the animal body, depends on
a disproportion between the quantity of carbon in
the food, and that of the oxygen absorbed by the
skin and lungs. In the normal condition, the
quantity of carbon given out is exactly equal to
that which is taken in with the food, and the body
experiences no increase of weight from the accu-
mulation of substances containing much carbon
and no azote ; but if the supply of highly carbon-
ized food be increased, the normal state can only
be preserved by exercise and labour, through
which the waste of the body is increased, and the
supply of oxygen accumulated in the same pro-
portion. The production of fat, Liebig maintains,
is always a consequence of a deficient supply of
oxygen, for oxygen is absolutely indispensable for
the dissipation of the excess of carbon in the food.
" This excess of carbon, deposited in the form of
fat, is never seen in the Bedouin or in the Arab
of the desert, who exhibits to the traveller with
pride his lean, muscular, sinewy limbs, altogether
free from fat ; but in prisons and jails it appears
as a puffiness in the inmates, fed, as they are, on
a poor scanty diet ; it appears in the sedentary
females of oriental countries ; and finally it is
produced under the well-known conditions of the
fattening of domestic animals."

Whether the view of Liebig be admitted or not,
it is certain that the circumstances which favour
obesity are absence of activity and of excitement
of all kinds.]

Treatment. — It is sufficiently obvious from
all that has preceded, that diet and regimen con-
stitute the most effectual means of cure in this
disease ; and Dr. Radcliffe's pithy motto, " to keep
the eyes open and the mouth shut," promises
more benefit than any medicinal prescription.
The following cases, which are only specimens
out of a very long list, will illustrate the efficacy
and safety of this plan, as well as its modes of
application, better than mere general rules.

Mr. Wood (the miller of Billericay, whose case
is related by Sir George Baker in the Medical
Transactions of the College of Physicians,) at his
forty-fourth year had attained such a size that he
was a burthen to himself, and incapable of per-
forming common acts of exertion. At the sug-
gestion of the rector of his parish, he resolved to
follow the example of Cornaro in a life of abste-
miousness. He had been accustomed to indulge
in large quantities of ale and animal food, with
an unsparing proportion of fat. These he left off
gradually, and substituted puddings of flour and
milk ; and at last, one made of sea-biscuit, eaten
twice only in the day, was his only food. He
first substituted water for beer, but afterwards
brought himself to do without any liquid. By
this plan he reduced himself ten or eleven stone,
and was " metamorphosed from a monster to a
person of moderate size; from the condition of an
unhealthy decrepid old man to perfect health and
the vigour and activity of youth."

A country tradesman, aged about thirty, of a
short stature, and naturally of a fresh sanguine
complexion and very fat, applied to Dr. Fothergill
for assistance. He complained of perpetual drow

OBESITY.

409

siness and inactivity ; his countenance was almost
livid, and such a degree of somnolency attended
him that he could scarcely keep awake whilst he
described his situation. Dr. Fothergill advised
him immediately to quit all animal food, to live
solely on vegetables and every thing prepared from
them, allowed him a glass of wine and a little
beer occasionally, but chiefly confined him to
water. He pursued this plan very scrupulously,
lost his redundant fat, and grew as active as usual
in about six months. Dr. Fothergill recommended
a perseverance for a few months longer, then to
allow himself light animal food once or twice a
week, and gradually to fall into his usual way of
living. He grew well, and continued so.

A young unmarried woman, about twenty-three
years of age, of low stature and very' fat, con-
sulted the same physician, on account of great
difficulty of breathing, somnolency, and incapacity
for any exercise. It was a hardship to her to be
obliged to go up stairs, and at last to cross the
floor of her apartment. It seemed to Dr. Fother-
gill that mere obesity was her principal malady ;
indeed she had no other complaint but such as
might be accounted for from this supposition.
She was ordered to pursue a vegetable diet, and
in the summer to drink the waters at Scarborough.
She conformed to these directions, became more
agile, less sleepy, less averse to exercise : she
walked up stairs at Scarborough from the Spa, a
task of no little difficulty to people much less en-
cumbered. A continuance of the same diet was
urged : she was dissuaded from it by her friends,
and died of fat in the twenty -seventh year of her
age. (Med. Obs. and Inq.)

A gentleman of great respectability in the mer-
cantile world, who weighed thirty-two stone nine
pounds, put himself upon a strict diet of four
ounces of animal food, six ounces of bread, and
two pounds of liquid, in twenty-four hours. In
one week he lost thirty pounds weight, and in six
months he was diminished the astonishing quan-
tity of one hundred and thirty-four pounds. His
health and spirits were much improved ; and con-
sidering his remaining size of twenty-three stone,
he was very active. (Wadd, p. 82.)

Mr. W., of Whitehaven, at about thirty years
of age weighed twenty-three stone, ate and drank
with great freedom, and in great abundance. He
became at length so lethargic that he frequently
fell asleep in the act of eating, even, in company.
By the advice of Dr. Gregory of Edinburgh, he
took a great deal of exercise, lived sparingly, and
slept little. The prescribed diet was brown bread
and tea ; but the patient, finding it necessary to
fill his stomach, ate a great quantity of apples:
and to enable him to take the necessary exercise,
he found a pint of port or sherry per diem indis-
pensable. He retired to rest at eleven, and rose
between four and five o'clock. His only medicine
was three brisk purges a week. By this system
he reduced himself to fifteen stone, with great im-
provement to his health. (Wadd, p. 85.)

A baker, living in Pye-corner, attained the
weight of thirty-four stone, and could not move
out of his chair for many years. He would fre-
quently eat a small shoulder of mutton five pounds
weight, and proportionally of other things, and
drink a gallon of good beer. He was moreover

Vol. III. — 52 2 k

of a costive habit, and required four times the
strength of an ordinary purgative to operate on
him. He with great resolution persisted for one
year in living on water-gruel and brown bread,
and lost nearly two hundred pounds of his bulk.
(Wadd, p. 102.)

These cases sufficiently prove the efficacy of a
plan of abstinence ; but there are cases in which
its application will require some caution and mo-
dification. It is especially in relation to the treat-
ment that we wish to preserve the distinction
between the sthenic and asthenic varieties of
obesity. The former will bear measures that
would be insufficient or unsafe in the latter.
Thus a sudden and total prohibition of animal
food and fermented liquors would lower the cir-
culation, already too languid in the asthenic
form ; and by retarding the absorptive process,
and weakening the locomotive powers too much
for exercise, change the disease from obesity to a
cachectic dropsy. Experience has shown, on the
other hand, that persons of robust constitution,
when affected with obesity, may with impunity
even abruptly reduce the quantity and quality of
their aliment, and with the most beneficial results.
The inexpediency of laying down any absolute
plan for the treatment of obesity will, therefore, be
obvious ; and the necessary distinctions may very
well be comprehended in the two kinds into which
we divide them.

Treatment of sthenic obesity. — The circulation
is here supposed to be vigorous, the digestion
good, and the absolute strength not impaired ;
although the activity be greatly diminished by the
inroads of the disease. The indications here are,
therefore, 1. to remove the accumulated fat ; 2. to
exclude from the system all material of nourish-
ment beyond what is necessary to supply the de-
mands of the excretions ; 3. to ensure that the
nourishment that is taken in be applied only in
this way. All these indications may be fulfilled
by diet and exercise.

The food should be very moderate in quantity ;
this is the most important point, and the next is
that it be not too nutritious in quality. The
breakfast may consist of tea and brown bread (not
more than four or five ounces) without butter. If
there should be a feeling of great exhaustion in
consequence of the scantiness of this allowance, a
dried herring or a hard-boiled egg may be added.
The brown bread which is made by several bakers
in London, containing the finer particles of bran
and a proportion of rye-flour, is to be preferred, as
it is less nutritious, and acts on the bowels more
than any kind of bread or biscuit. As long as
active exercise can be persisted in, we do not think
it advisable to exclude entirely the use of animal
food. A few (three or four) ounces of lean meat,
white fish, poultry, or game, with a proportion ably
sparing quantity of the less nourishing vegetables,
such as greens, turnips, pulse, sorrel, chiccory,
&c. with two or three glasses of white wine if
required, may constitute the dinner. If the ab-
sence of the habitual quantity produce a painful
sensation in the stomach, the only supplement
that may be added is a cucumber or salad without
oil or egg in the dressing; or, if preferred, an
orange or two, an apple, or a few gooseberries,
strawberries, or currants, with little or no sugaz

410

OBESITY.

may be taken to allay the cravings of a dissatis-
fied appetite. Although it is desirable not to
tempt by variety, nor to allow more than three
articles for the principal meal, yet the varying of
these from day to day keeps the stomach in tone,
and reconciles the patient somewhat to the diffi-
cult task of great moderation. Very little liquid
should be taken during dinner, and the liquid
meal after it should be restricted to a single cup
of tea or coffee with little or no sugar or milk ;
for we are convinced that copious libations of any
kind at this time hurry the chyle into the circula-
tion in an imperfectly assimilated state, and, there-
fore, more abounding in oily particles. There
should be no solid food taken after dinner ; or if
the appetite be very craving, an orange, a roasted
:&pple, or a cup of thin gruel with a little lemon-
juice in it, taken half-an-hour before bed-time,
should suffice ; these contain but little nourish-
ment, and tend to keep the bowels in a soluble
state.

The habit of active exercise is quite as neces-
sary as abstinence, and it requires as much reso-
lution to observe it. In advanced stages of obesity,
horse-exercise is almost the only kind that can be
pursued, the legs being unequal to support their
burthen for a length of time sufficient to be useful ;
but the patient must submit to the roughest
paces of his sturdiest horse. When walking can
be accomplished, the legs must not be spared : this
is the best exercise to reduce bulk, both because
it can be more readily resorted to and longer per-
severed in, and because, being most general, it
excites the excretions more than other kinds. It
may, however, with advantage be varied with dig-
ging, rowing, dumb-bell exercise, and various
other gymnastic pursuits. At least two hours out
of the twenty-four should be imperatively devoted
to the energetic practice of some of these modes
of exercise ; and the more beyond this, the speedier
will be the reduction of bulk. Corpulent persons
ought to limit their period of sleep as much as
possible, by rising early to take a walk or some
exercise before breakfast, and the disposition which
they frequently have to sleep during the day and
after meals should never be indulged in.

A very salutary kind of exercise, and one that
may conveniently be allotted for the fasting task,
is vigorous friction of the limbs and body by the
hands or with a flesh-brush; and this may be ad-
vantageously preceded by the shower-bath, or co-
pious cold ablution. These means promote the
action of the absorbents, and improve the tone of
the cutaneous circulation.

There is little need of medicines in the slighter
degrees of sthenic obesity ; for the functions are
generally pretty well performed. If the bowels
require aid, and the dietetic means before recom-
mended fail, a black draught or a colocynth pill
occasionally will suffice. But in more advanced
states purgatives may be indicated as depletories,
especially if there be also determination to or con-
gestion of blood in the head ; in this case calomel
and jalap, alternated with salts and senna, or the
compound gamboge pill, will be required twice or
three times a week. It has been thought useful
in some cases to diminish the appetite for food by
*>quill, ipecacuanha, and other nauseating medi-
t'lnes we do not recommend this generally, as

nausea is a weakening influence, and renders ex-
ercise a painful effort ; but there may be cases in
which the natural appetite cannot be stinted with-
out real suffering : in these, small doses of ipeca-
cuanha, or, what is better, dissolving in the mouth
a camphor lozenge or smoking a cigar, may occa-
sionally be resorted to, to relieve this craving sen-
sation. As to vinegar and other acids, which for-
merly were reputed remedies in obesity, we can-
not but follow Cullen in condemning their use,
since their effect is only in proportion as they
counteract the digestive process, and the risk
which they entail, of exciting chronic diseases of
the stomach and bowels, far outweighs their thin-
ning powers, which often fail when unsupported
by diet and exercise. Soap and alkalies were
highly recommended by Dr. Flemyng, (Discourse
on Corpulency, London, 1780 ;) and as they
have a certain chemical affinity for fat, and in-
crease the secretion of urine, they seem to promise
advantage : but the illustration of their efficacy in
the case described by Dr. Flemyng falls greatly
before the numerous examples of cure by absti-
nence and exercise. As adjuncts to these means,
alkalies may prove beneficial, and especially in the
common complication of gout with obesity, ten to
twenty grains of soap in the form of pills, m.xv
to xxx of the liquor potassae, or four to eight
grains of the subcarbonated alkalies in ^i of cam-
phor mixture, may be given twice or thrice in the
day.

Treatment of asthenic obesity. — The indica-
tions here are to increase the activity of the func-
tions of circulation and absorption, and to im-
prove the tone of the digestive and locomotive
organs.

Abstinence is an important agent in this as
well as in the other kind of obesity, and the out-
line of the diet before sketched may be followed
here ; but the reduction of the quantity of the
food must be made more gradually, and the qua-
lity with greater care adapted to the powers of the
digestive organs. Thus, if there be a disposition
to gastric irritation, the milder and more farina-
ceous articles are to be chosen, their quantity be-
ing still limited ; but if a nervous dyspepsia ac-
company the obesity, which is the commoner
case, such kinds of animal food which have been
already recommended, together with a little spiced
rice and a small quantity of white wine, once a
day, are more eligible ; no salads or supplements
of any kind being allowed, and the breakfast being
restricted to biscuit or dry toast, with tea or coffee.
The quantity of these articles must be gradually
but steadily diminished as far as the strength and
general health of the patient will permit.

The defect in muscular power which commonly
attends asthenic obesity considerably limits the
means of exercise. Horse exercise is still gene-
rally practicable; and the oftener it is resorted to,
the better. An important substitute may be ob-
tained in friction of the body and limbs ; this is a
powerful mean of promoting the absorption of
superfluous matter, and of giving vigour to the
sanguineous circulation of the surface. Where
there is a relaxed state of the body and an easily
perspirable skin, friction should be preceded by
the salt-water plunge or shower-hath ; but where
the skin is harsh, with a deficient reactive power

O B E S I T Y — CE D E M A ,

411

of the superficial vessels, it may with the greatest
advantage be combined with the vapour-bath in
the manner of Indian shampooing, which is very
effective in giving laxity and freedom to the
cutaneous circulation. In proportion as the mus-
cular strength is restored, it must be engaged in
other kinds of exercise to the utmost of its power;
and in the ratio of its increase will be almost in-
fallibly the diminution of the torpid bulk of the
body and its accompanying disorder.

As there is often considerable derangement of
the organic functions, the aid of medicines is fre-
quently required in asthenic obesity. Those most
needed are those which increase the excretions,
and improve the tone of the animal fibre ; and by
a judicious administration of such evacuants and
tonics much good may be effected. If there be a
deficiency in their action, the bowels must be
moved ; but strong cathartics are not eligible, as
they disorder the digestive function, already weak,
and weaken the whole frame. In common con-
stipation, or torpidity of the whole canal, aloes in
the dose of three to five grains, with a grain of
sulphate of iron, twice a day, is exceedingly well
adapted to fat phlegmatic subjects with languid
circulation. If the colour of the evacuations indi-
cate a defective secretion of bile, a very common
symptom in this form of obesity, calomel or blue
pill must be occasionally combined with these
medicines ; and if there be such a torpidity of the
absorbent function as to cause oedema, pitting, on
pressure, in the fat of the legs and feet, two or
three grains of gamboge may properly be added.
Great advantage may in some cases of the same
kind be derived from a course of a saline chalybe-
ate water, as that of Cheltenham.

Of tonics, the alkaline preparations of iron are
the most eligible, as they seem to facilitate the
conversion of chyle into blood, and promote the
secretion of urine, without increasing the appetite
for food. The mistura ferri composita, and the
tinctura ferri ammoniata are the most convenient
preparations ; and an attenuant and diuretic effect
may also sometimes be usefully obtained by join-
ing with them a little carbonated alkali and nitre.
In no cases is this treatment more beneficial than
in the obesity which occasionally accompanies de-
fective menstruation in females ; and whether this
disorder be a cause or only a concomitant, it is
highly important that the periodic evacuation be
restored to its normal proportion.

Analogy suggests that considerable benefit might
be obtained from the use of iodine, in its known
sorbefacient capacity, in the asthenic forms of obe-
sity ; but we are not authorized by direct experi-
ence to recommend it. Where other complaints,
such as dyspepsia, dropsy, &c, are complicated
with obesity, they must be treated in the usual
way. Obesity may, however, furnish a reason for
modifying our practice when the subjects of it are
attacked with other diseases. Fat persons do not
generally bear bleeding well ; purging suits them
better : but they are often more readily lowered
by any evacuation than their appearance would
lead us to expect.

The period during which it is necessary to pur-
sue the treatment recommended above can only be
determined by the effect produced. It may be
useful and satisfactory to the patient to put to the

test of the balance the beneficial operation of his
plan ; but a restored activity, and the removal of
the discomforts of obesity, give a surer criterion
of his improvement ; if these are accomplished,
although he should still retain some largeness of
bulk, there is no longer reason to consider it a
disease. The return to a more generous method
of living, should, however, be made very gradu-
ally, and with circumspection ; and nothing should
deter the individual from pursuing those habits of
active exercise that have mainly contributed to
free him from his burthen.

C. J. B. Williams.

[OBSERVING, METHOD OF. See Sta-
tistics, Medical.]

03DEMA, (otSyia, from oi&ta, to swell.) — This
term properly signifies a swelling of any kind, but
is now confined to a swelling of a dropsical nature,
situated in the cellular tissue. When the oedema
is developed under the skin, it appears in the form
of a tumour, which retains the impression of a
finger, or any other body that has been applied
with a slight degree of force to the surface. It
has usually been regarded as a species of anasarca ;
and unquestionably it has much analogy with this
affection. In the present article, however, we
shall confine ourselves to the consideration of
those cedematous affections which are not con-
nected with a general dropsical diathesis, and
which may exist for an indefinite length of time
without extending beyond the original site.

ffidema appears under very different circum-
stances ; and we are inclined to believe that, at
different times, the nature of the effusion into the
cellular membrane is different ; the external ap-
pearance certainly is so. We are not, however,
able to prove that such a difference does exist ;
and we shall therefore content ourselves with sta-
ting the different circumstances under which a
swelling, having the character we have assigned
to oedema, may happen, and the variation of treat-
ment which such differences demand.

G3dema exists in the commencement of phleg-
monous inflammation through the whole extent
of the affected part ; and throughout the progress
of inflammation, it occupies the extreme bounda-
ries of the diseased part in a greater or less degree.
In some instances, in consequence of the nature
of the affected parts, the inflammation does not
pass beyond the cedematous stage before it proves
fatal. Such appears to be the case in the disease
to which the term oedema glottidis has been as-
signed, the cellular membrane of the glottis being
the seat of a serous infiltration, which gradually
closes the rima glottidis, and destroys the patient
by suffocation. [See Laryngitis.] In pneumo-
nia, also, portions of the lungs are found in the
cedematous stage, the similarity of which to anasar-
cous effusion has been remarked by Laennec.
More commonly, however, the inflammation pro-
ceeds to induration and suppuration, at least of
the centre, and the oedema is found only in the
circumference. M. Gendrin has given an account
of the pathological state of the cellular tissue hi
this, which he terms an active cedema. He has
derived his information from observing the pro-
cesses set up in the cellular tissue in the neigh-
bourhood of a wound.

412

(EDEMA.

The cellular membrane close to the wound is
hard to the touch ; its areolae are infiltrated with
a reddish, opaque, and gelatinous matter, and
pressure gives issue to a reddish, opaque, and
mucus-like serum. Beyond the inflammatory red-
ness, there exists during life a serous infiltration
which is rather elastic ; and this infiltration is
greater in proportion to the natural relaxation of
the cellular tissue, and the inferior situation of the
part. After death the oedema increases, but the
elasticity diminishes. The oedema extends into
the intermuscular cellular tissue, and the vessels
of the part are evidently enlarged.

Of the treatment of this kind of oedema we
need say no more than that it is that which is ap-
propriate to inflammation, of which indeed it is
only a stage. (See Inflammation.)

The affection which has been termed " skin-
bound," and which occurs in infants, is also a
variety of oedema ; but as Dr. Carswell has given
an excellent account of it under the head Indu-
ration, we shall refer the reader to that article
for information respecting it.

(Edema is a common consequence of rheuma-
tism, particularly of that form which is called
arthritis rheumatica. It may either be the re-
mains of the active inflammation of the joints, or
it may from the first appear as simple oedema. It
may occur in the knees and ankles, but the most
common situation is the back of the hands. It
forms a cold, thick, puffy swelling, and generally
white, and it is sometimes, but not always, rather
tender. It is frequently the seat of dull aching
pain, and the patient can make very little use of
the limb. The fingers are stiff, and the hand
cannot be closed. When the affection is recent,
fomentations frequently repeated, and continued
for half an hour at a time, will sometimes remove
it very quickly, and the patient is cured as it were
by a charm. More commonly fomentations are
useless, as also are local warm and vapour baths ;
they do not even afford a temporary relief. Stimu-
lating mercurial liniments are more useful, and
generally succeed in removing the oedema in the
course of a month. Dr. Elliotson appears to have
employed the hydriodate of potash, but we have
ourselves had no experience of it in these cases.
When, however, the mercurial liniment fails, as
sometimes it will, the preparation in question may
make a good substitute. Its properly of increas-
ing absorption certainly points it out as a probable
remedy. Occasionally a certain degree of oedema
will remain during life, the patient having at the
same time a tolerably free use of the limb.

While the treatment is thus directed to the
local affection, the state of the general health
must not be neglected. Few diseases, perhaps,
are more manifestly attended with disorder of the
digestive functions than rheumatism, and this dis-
order is not unfrequently aggravated by the reme-
dies which are employed in the acute stage. Un-
less, however, when this stage is past, immediate
attention be paid to the state of the digestive
organs, the disease, even in its acute form, is very
liable to return. The treatment of rheumatism
becomes, therefore, the treatment of dyspepsia,
and only by success in relieving this latter affec-
tion can we hope permanently to relieve the for-
mer. (See Rheumatism.)

GSdema is one of the most common attendants
upon amenorrhoea. Amenorrhcea itself depends
upon two opposite states of the system, a state
of plethora, and a state of debility and exhaustion.
In both of these oedema may exist. In the for-
mer, or the plethoric state, together with the com-
mon symptoms of plethora, there is usually much
pain in the lower extremities, particularly in the
lower part of the leg and round the ankles; and
this pain is worse towards night, at which time
also the oedema is much more considerable than
in the morning. Upon examining the legs, the
parts corresponding to the pain are usually cold
to the touch, hard, and of a purplish colour; and
this colour varies from a very light tint to an
actual livid hue. It sometimes resembles purpura
so far as the colour is concerned, but there is evi-
dently no extravasation. At other times real
purpura exists, and many petechial spots are pre-
sent. The oedema is usually in these cases very
firm, not readily yielding to the finger, and the
impression is very quickly effaced. Frequently
there is considerable tenderness in the course of
the femoral vein, and the most common site of
this tenderness is just before the vein pierces the
tendon of the triceps to pass into the ham. This
variety occurs in girls of a florid appearance and
plethoric habit, and the usual period of its occur-
rence is between eighteen and twenty-five years
of age. The tenderness of the vein, which pro-
bably depends upon some inflammation of the
vessel, is not, however, peculiar to this diathesis,
nor to this period of life. It frequently occurs in
that condition which is neither very evidently
plethoric nor feeble, and which equally resists an
extreme mode of treatment, whether depleting or
tonic. The countenance of these individuals is
sallow and unhealthy, but does not exhibit that
fair and pellucid appearance which distinguishes
those who are the subjects of oedema in conse-
quence of exhaustion.

The individuals last mentioned exhibit the
common symptoms of amenorrhoea from debility,
the quick, rolling, and easily compressible pulse,
the palpitation of the heart, excessive nervousness,
&c. ; and the oedema of the lower extremities is
both more considerable than in the former varie-
ties, and much softer. It yields readily to the
fingers, and retains their impression for some
time. In some persons the oedema is so great
that the swollen part overhangs the shoe exces-
sively towards evening ; and though it disappears
during the night, when the patient is in bed, it
returns in two or three hours after rising, gradu-
ally increasing till evening, when, from the weight
and stiffness of the limbs, the patient is compelled
to place them in the horizontal position, the only
position in which she can obtain ease.

03dema occurs also in women at that period
which is known as the change of life, and is in
this case, so far as our experience extends, always
dependent upon a plethoric state of the system.
It varies from the oedema which we have described
as occurring in young persons of a florid com-
plexion, by the absence of the livid colour, and by
the swellings being much less firm and resisting.

The description above given of the different
circumstances under which oedema occurs, suffi-
ciently points out the proper mode of treatment.

(EDEMA — OPHTHALMIA.

413

In the first, or plethoric variety, not only must the
general remedies be employed, as bleeding and
purging, but if there be any tenderness in the
course of the femoral vein, leeches should be ap-
plied to the tender part, and they should be re-
peated again and again, so long as any tenderness
remains.

The second or middle variety requires a mixed
treatment, as we have already indicated ; leeches,
if any tenderness is present in the course of the
femoral vein, and alternate tonic and depleting
remedies as the symptoms vary.

The oedema in the third variety, in which the
system is suffering from exhaustion, is most bene-
fited by the exhibition of steel; but for a more
complete direction for treating these cases we refer
to the article Amenorkhoea, of which disease
oedema is usually one symptom.

When oedema occurs at the change of life,
there are so many symptoms which intimate a
plethoric state, that there can be no hesitation in
recurring to depletory measures, both bleeding and
purging ; and as the oedema is very liable to re-
turn, till the catamenia are entirely suspended, the
repetition of these remedies will be required as
often as this happens.

Old persons are frequently subject to oedema of
the lower extremities, and which as their debility
increases, extends higher and higher towards the
trunk, yet seldom assumes the general phenomena
of dropsy, there being neither a decrease in the
flow of urine, nor any other inconvenience expe-
rienced excepting what is the consequence of the
weight and stiffness of the limbs. Sometimes it
seems to become at length connected with a drop-
sical diathesis, and after many years have elapsed,
during which this oedema has remained stationary,
ascites and general anasarca ensue.

So long as the disease remains merely in the
state of oedema, nothing more is required than to
support the integuments by means of a laced
stocking or bandages; when, however, dropsy
supervenes, it must be treated upon the principles
which have been laid down in the article Dkopst.

Excessive fatigue is also a cause of oedema.
Soldiers, after long marches, are subject to swell-
ings of the ankles, and the oedematous state of
the legs of horses after over-work is well known
to horse-keepers, who are also aware that it is
merely a state of debility ; hence they bandage
the legs of such horses in the stables, that the
cellular tissue may have an opportunity of re-
covering its tone.

OZdema will also be caused by any thing which
obstructs the circulation of the blood through the
venous system ; hence it is common in the latter
months of pregnancy, from the pressure of the
uterus upon the iliac veins. Ligatures also have
a similar effect. The presence of oedema in the
arm in cancer of the breast is probably to be ac-
counted for on the same principle. It seldom hap-
pens till the disease has made considerable pro-
gress, and in the cases which have fallen under
our notice, the axillary glands have been much
affected. In our experience this oedema is much
more common after the removal of the breast, and
upon the recurrence of the disease, than in those
cases in which no operation has been performed.
These appear to be the principal forms under

2 K*

which oedema may appear. How far this is an
affection really different from anasarca may cer-
tainly be questioned ; there is, however, in all the
cases we have referred to, this peculiarity, that the
affection is entirely local ; that it by no means
necessarily leads to dropsy ; and that life may ter-
minate without any apparent progress being made
in converting it from a local to a general affection
of the system. j QHN Darwall.

OPHTHALMIA. Under this head it is pro-
posed to consider inflammation of the conjunctiva
only, although, strictly speaking, the term is more
applicable to inflammation of the eye itself.* The
universal use' of the term to designate inflamma-
tion of this membrane has probably arisen from
this being the most frequent and obvious inflam-
matory affection of the organ. In approaching
the consideration of this subject the student should
first pause to ascertain whether his knowledge of
the structure and functions of the conjunctiva
enables him to announce the changes reasonably
to be expected from inflammation of its texture,
and afterwards should determine whether observa-
tion justifies his anticipations. The conjunctiva
being a modification of the common tegumentary
membrane, intermediate between the skin and mu-
cous membrane, the changes produced by inflam-
mation are of the same character as those induced
by the same cause in these two structures. These
changes are, increased vascularity, tumefaction,
pain and altered secretion. The increased vascu-
larity is characteristic : when the inflammation is
slight, the enlarged vessels present the appearance
of a distinct red net-work spread over the white
sclerotic when more intense, the appearance of
distinct vessels is lost, and the surface assumes a
uniform deep red colour. The tumefaction is in-
considerable unless the inflammation be very se-
vere, in which case the vessels become enormously
distended with blood, and the subjacent and sur-
rounding cellular membrane loaded with serum,
constituting the appearance technically denomi-
nated chemosis on the globe of the eye, or produ-
cing a most distressing prominence of the lids.
The pain is uniformly at first such as is produced
by the presence of a grain of sand beneath the
eyelid, but it subsequently is accompanied by a
sensation of heat, producing the same description
of distress as arises from a scald. The intense
aching pain experienced in violent inflammation
arises from the globe of the eye becoming involved
in the disease. The conjunctiva being lubricated
by a fluid derived from a source different from its
own surface — the lachrymal gland — the first al-
teration in the nature or quantity of the secretion
from the surface cannot be ascertained. The al-
teration, however, becomes speedily obvious, and
is as characteristic of the disease as the other
changes enumerated, purulent matter in considera-
ble quantity being poured out. It must not, how-
ever, be assumed that the secretion of purulent
matter is a necessary consequence of conjunctival
inflammation ; instances of the contrary will pre-
sently be adduced.

Inflammation of the conjunctiva presents the
distinct characters above enumerated, because it is

*[At the termination of this article, inflammation ot
ether parts of the eye has been added.]

414

OPHTHALMIA.

inflammation of a structure of equally distinct
anatomical character, but it is so completely modi-
fied by circumstances, that few other inflammatory
diseases appear in so many different specific forms.
The inflammation of this membrane is either cir-
cumscribed in the form of pustule, or diffused, as
in the different varieties of purulent ophthalmia.
Either or both of these are again modified by the
presence of other diseases, and hence gonorrhceal,
variolous, and 'other distinct species.

Inflammations of the conjunctiva may, there-
fore, be divided into pustular and diffused ; the
pustular into common pustular and variolous,
and the diffused into catarrhal, severe purulent,
gonorrhoea!, and the purulent of infants. The
grounds upon which these specific distinctions are
established will be stated as each is submitted to
inquiry.

While considering the nature of conjunctival
inflammation in general, it is expedient to consider
also the principles which are to guide us in the
treatment of that inflammation. The resources
available for the removal of inflammation in other
structures are equally available in this. The ac-
tivity of the circulation is to be diminished by
general and local bloodletting — the contents of the
stomach and bowels removed by emetics and pur-
gatives — the condition of the system which nau-
seating medicines produce is to be induced — in-
flammation in the vicinity, or counter-irritation as
it is called, is to be excited by blistering — the tem-
perature of the inflamed part is to be lowered by
cold applications — or the condition, whatever it
may be, which warm moisture causes, should be
encouraged by warm fomentations. In conjunc-
tival, more than in any other form of inflamma-
tion, the practitioner has had recourse to the
immediate application to the part of those remedies
to which astringent, sedative, or irritating proper-
ties are attributed, and in considering their appli-
cation to each form of disease, their comparative
value will be submitted to inquiry. Particular
circumstances may demand additional remedies or
peculiar management — the inconvenience arising
from accumulation of purulent discharge is to be
avoided — the gumming together of the lips obvi-
ated — the vessels of the surface may require to be
opened by scarification, or the serum of chemosis
discharged by puncture. It may be necessary to
produce the peculiar constitutional effects of mer-
cury — to encourage the secretions of the skin, in-
testines, or liver — to restore the flow of milk from
the breasts — to regulate the functions of the
uterus — or to reproduce suppressed discharge of
blood from piles. The consideration of conjunc-
tival inflammation in detail will prove the im-
portance of paying the most careful attention to
the differences of constitution presented by differ-
ent individuals, in order to substitute tonic medi-
cines, and invigorating diet and regimen, for a
system of depletion and abstinence. It is obvious
that each specific form of this disease will require
a corresponding variation in the application of
these principles, and that the treatment must be
modified with every modification of the symptoms
induced by circumstances.

In studying the progress and treatment of con-
junctival inflammation, the practitioner should
lever lose sight of the marked and important dis-

tinction to be drawn between the inflammation
and its consequences. Hitherto this distinction
has been so far made as to form a division of the
disease into the acute and chronic stages, but it is
worth considering whether the condition which is
called the chronic stage should be considered an-
alogous to that which exists during the inflamma-
tory or acute stage. The alteration in the treat-
ment to be adopted when the disease assumes the
chronic form, and which is carefully inculcated by
every practical writer, proves that those symptoms
which are to be subdued by depletion and other
similar means have disappeared. It is true that
the increased vascularity, augmented and altered
secretion, and even painful sensation still exist,
but in a very different degree, and of very different
character. The tense, tumid, glazed chemosis sub-
sides, and is succeeded by a soft, pulpy, villous
vascularity ; the secretion from the surface is pro-
fuse, and its purulent nature more remarkable,
and the painful sensation is mitigated and unac-
companied by the scalding which characterizes the
distress of the inflammatory period. The eye is
not injured or destroyed by conjunctival inflam-
mation unless the inflammation extend to the
other textures, producing sloughing of the cornea,
or suppuration of the eyeball ; or unless it pro-
duce the altered or disorganized state of the mem-
brane which leads to vascularity or opacity of the
conjunctiva covering the cornea, or granular con-
dition of the lining of the lids.

1. Mild Inflammation of the Conjunc-
tiva. — That there is a form of conjunctival in-
flammation entitled to the above appellation, which
presents a specific character perfectly distinct from
every other, there can be no doubt. It is rather
vaguely defined by authors under the title of
catarrhal ophthalmia, but does not appear to be
considered so completely different from the severer
purulent ophthalmia as its history, at least accord-
ing to the writer's experience of the disease, in
Ireland, warrants. It is distinguished, as the title
implies, by the comparative mildness of its symp-
toms, the vascularity never passing into true che-
mosis, or inducing sloughing of the cornea; the
pain not being so severe, and the purulent dis-
charge being much less copious. It occurs in
spring and autumn, is epidemic or endemic, and,
whether contagious or not, attacks several indivi-
duals in the same family. It affects young per-
sons more frequently than adults, and sometimes
seizes a great number of children in schools or
other institutions where they are collected. The
following is the history of the disease: The
patient experiences a sensation of itching, with
slight uneasiness, as if a mote or cye-lash had
passed beneath the lid, which is greatly aggravated
by the efforts made to remove it by rubbing or
handling the eye. If the organ be now examined,
nothing more can be discovered than an increase
of vascularity, with a copious flow of tears. Next
day all the characteristic symptoms may be recog-
nised. The conjunctiva lining the lids, especially
the lower, has acquired a uniform deep red ap-
pearance, and that covering the sclerotic, presents
an equal vascular network, permitting the white
structure of the former membrane to appear in
the meshes or areolae ; the vessels not crowding
together so as to produce the deep general redness

OPHTHALMIA.

415

of the chemosis of severe ophthalmia. This vas-
cularity is well represented in Mr. Wardrop's
work on the Morbid Anatomy of the Eye, which
contains more well-drawn and faithful representa-
tions of diseases of this organ than any other ac-
cessible to the student. There can be no difficulty
in distinguishing this characteristic vascularity
from the equally characteristic vascularity of the
sclerotic in internal inflammation of the eye.
The high degree of vascularity, with prominence
of the membrane from effusion of serum beneath
it, constituting the appearance denominated che-
mosis, never perhaps exists in mild purulent con-
junctival inflammation, and therefore, when it
does occur, must be considered evidence of the
presence of the severer form of the disease. The
secretion of purulent matter from the surface is
most obvious after the night's rest ; the eye-lashes
are gummed together by it ; clots produced by the
evaporation of the more fluid parts of the discharge
are formed at the angles ; and when the lower lid
is depressed, flakes and films of it may be observed
in considerable quantity. The existence of puru-
lent discharge is not so obvious in the course of
the day, especially if the patient has been in the
open air, the irritation of the surface causing such
a flow of tears as removes it as fast as it is secreted.
In this case, inquiry should be made as to the
state of the eye upon awaking in the morning,
and the patient should be allowed to remain for a
quarter of an hour with the eyes closed, when,
upon depressing the lower lid, flakes of yellow
matter may be seen floating in the tears. The
sufferer experiences repeated attacks of scalding
pain, with copious flow of tears, so much resem-
bling the effects of a mote or grain of sand beneath
the lid, that he can scarcely be persuaded that
such does not actually exist. Vision is not very
materially impaired during the prevalence of these
symptoms, but there is generally a slight degree
of haziness experienced, especially when looking
at the flame of a candle, and occasionally alarm
is excited by tenacious films of purulent matter
adhering to the cornea.

The symptoms here enumerated continue for
two or three days; the period depending much
upon the circumstances under which the patient
is placed : they then begin to yield and alter, the
painful sensation of a foreign body beneath the
lids, with scalding and flow of tears, becomes less
frequent, the vascularity loses its intensity and
shining appearance, and the purulent discharge is
more freely secreted. Subsequently, these symp-
toms gradually diminish and finally disappear,
leaving the parts somewhat more vascular and
irritable than before this attack ; but in a few weeks
this condition disappears, and the recovery is com-
plete. That this is the true history of the symp-
toms, progress, and termination of mild conjunc-
tival inflammation in a healthy subject can scarcely
be denied ; but it is not the history of the disease
as it is observed in daily practice. This simple
form of inflammation must obviously disappear
after passing through its different stages, unless
the natural processes tending to recovery be in-
terrupted. This interruption, however, generally
takes place. The disease is frequently exaspe-
rated, and the efforts of nature to restore the
healthy functions of the part suspended by inju-

dicious, unnecessary, or injurious interference; or
it is so modified by scrofulous constitution, or by
neglect, filth, and deficient food and clothing, that
its character is totally altered.

The treatment of mild conjunctival inflamma-
tion is as obvious as the disease is simple. The
bowels should be emptied, and the secretion from
the mucous membrane of the intestinal canal ex-
cited by purgatives in moderate and repeated
doses. The infusion of senna and tamarinds, with
the addition of sulphate of magnesia and oi tar-
trate of antimony in the proportion of a grain to
eight ounces, may perhaps be preferred for this
purpose. The abstraction of blood by the lancet
is seldom required ; but it is frequently necessary
to apply eight or ten leeches to the hollow oi the
temple behind the external angular process of the
frontal bone, or over the cheek-bone. The bites
of leeches in the thin and flaccid skin of the eye-
lids generally produce so much irritation and in-
flammation, that their application there is often
injurious. Locally, cold or warm applications
may be resorted to, according to the relief the
patient experiences from one or the other. If
there be much heat and scalding pain, a light fold
of old linen, wrung out of cold water, may be laid
over the closed lids, and changed as it becomes
warm ; or a soft sponge or scrap of flannel, wrun<>
out of hot water, and held in the hollow of the
hands beneath the eyes, may be used to induce
the soothing effects of warm moisture. At bed-
time the edges of the lids should be smeared with
cream, unsalted butter, or any other oily applica-
tion not rancid or burned. Rest of the lids should
be enjoined, as the constant friction of the surface
greatly increases the irritation ; the eyes should
be kept closed as much as possible ; but the
patient should not be immured in a dark room, or
have his eyes covered with a shade, as is frequently
practised. The propriety of applying astringent
washes to the inflamed surface during the first
stage of the disease may be justly questioned. It
is not to be denied that such applications may
have the effect of arresting the progress of the
disease at once ; but if they have not that effect,
they are liable to produce an increase or irritation. '
In Dublin, where no adequate relief is afforded to
the destitute poor in their own homes, it is often
expedient to endeavour to cut short the disease
by the direct application of a strong astringent
solution, to prevent the establishment of that
chronic vascularity and opacity of the cornea
which filth, starvation, and rags would otherwise
produce. For this purpose, a saturated solution
of acetate of lead or alum may be resorted to with
perfect safety and decided effects, and a few drops
introduced between the lids every night and morn-
ing. To remove the vascularity and that condi-
tion which accompanies the secretion of purulent
matter, weaker astringent solutions may be used
more freely. Five grains of alum or of the acetate
of lead to an ounce of water, make a wash as effi-
cient and safe as any other of the various salts
resorted to for this purpose : the comparative
value of these will, however, be presently con-
sidered.

In addition to the above observations, an ab
stract of Mr. Lawrence's valuable account of
catarrhal ophthalmia, delivered in his lectures.

416

OPHTHALMIA.

may not be inappropriate He observes that it
originates from atmospheric causes or peculiarities,
is caused by exposure to cold, and corresponds to
catarrhal affections of other mucous membranes.
In individuals predisposed to this affection, being
out in an east wind for a quarter-of-an-hour, or
half-an-hour, will sometimes infallibly bring on
an attack. He enumerates the following symp-
toms: — stiffness, smarting, uneasiness from ex-
posure to light, watering and external redness,
followed by mucous discharge, without consider-
able pain or intolerance of light. The conjunctiva
becomes of a scarlet colour in mottled patches at
first, but subsequently of uniform appearance, the
redness commencing at the circumference, and
extending to the cornea. Sometimes spots of
ecchymosis occur in the vascular network from
the activity of the inflammation, and occasionally
pustules round the margin of the cornea ; but true
chemosis never exists. The characteristic symp-
tom of a sensation of a foreign body beneath the
lid he attributes to the irregularity of surface pro-
duced by vascular distension. The secretion from
the surface is at first thin, but subsequently be-
comes of a thicker consistence and whiter colour,
resembling pus, at first confined to the inner angle
of the eye, or to the fold of reflection of the con-
junctiva, but afterward is poured out in sufficient
quantity to agglutinate the lids at night. These
symptoms are accompanied by those of inflamma-
tion of other mucous membranes, and are found
to remit by day and to become exasperated at
night. The affection, he says, passes through a
certain course and then subsides, yields readily to
treatment, and is, generally speaking, free from
danger unless improperly treated. It is dis-
tinguished from the severe purulent ophthalmia
by its milder character ; and although the appear-
ances of the two approximate, yet the difference
is rather in degree than in kind. The disease, he
observes, demands mild antiphlogistic treatment :
cupping and leeching in ordinary cases, and oc-
casional venesection in full habits ; an active
aperient, sometimes an emetic, followed by saline
and sudorific medicines and diluent drinks. Lo-
cally, he recommends warm in preference to cold
applications ; but observes that the latter are
sometimes comfortable to the patient, and not in-
jurious; and after the inflammation subsides,
suggests the application of blisters, exposure of
the organ to the air, and he objects to shading the
eye unless there be intolerance of light.

2. Severe Inflammation of the Conjunc-
tiva, COMMONLY CALLED PURULENT OPHTHAL-
MIA. — The severer form of conjunctival inflamma-
tion presents itself in three different shapes, the
Egyptian, or, as it is called for distinction, the
purulent ophthalmia, gonorrhccal ophthalmia,
and purulent ophthalmia of infants. These three
forms, if not specifically distinct, and characterized
ey peculiar symptoms, are at least distinguished
from each other by origin, history, progress, and
consequences. The common severe purulent
ophthalmia is to be now considered. This disease
probably always existed in the form in which we
at present occasionally observe it ; but the atten-
tion of the profession was particularly called to it
upon the return of the troops from Egypt, among
whom it spread with such uncontrollable violence

and destructive consequences, that it acquired the
title of Egyptian ophthalmia. The following
history of the disease, as it occurred at that period,
is extracted from Dr. Vetch's Treatise on Diseases
of the Eye. " The British army which formed
the first expedition to Egypt left that country in
three divisions. Great part of the whole touched
at Malta, and a considerable portion also at
Gibraltar, at which places ophthalmia not only
continued to present itself in the regiments which
had brought it with them, but was communicated
at the former place to several women with whom
the soldiers associated ; and at Gibraltar it became
from that time by no means an unfrequent com-
plaint among the troops who had never been in
Egypt. On the whole, however, the climate of
Gibraltar has proved rather favourable than other-
wise to the amelioration of the complaint. From
Malta and Gibraltar the greatest part of the army
proceeded to Great Britain and Ireland. In two
regiments of fencibles disembarked at Portsmouth,
the disease continued to present itself from the
time of their landing until they were disembodied
a short time afterwards. The regiments disem-
barked in Ireland having been placed in the same
barracks and garrisons with the Irish militia
regiments, the infection appears, from such evi-
dence as I have been able to obtain, to have been
communicated to them. If the disease existed at
all in England, it seems to have been entirely
overlooked till the summer of 1804, when it ap-
peared with alarming violence in the second bat-
talion of the fifty-second regiment, at that time
stationed with the light infantry division in bar-
racks, near Hythe in Kent. Not a man of this
battalion had been in Egypt, and it was entirely
composed of a body of volunteers received in one
draft from the Irish militia, and very shortly after
their arrival at Hythe the disease made its ap-
pearance. It continued to disseminate itself more
extensively in this regiment during the remaining
part of 1 805 ; and in the following summer of
1806 it also began to prevail in the first and
second battalions of the forty-third regiment, and
the first, second, and third battalions of the 95th,
all stationed at the same place and under the
same command. Whether the disease was spread
from the battalion in which it first commenced, or
was derived from the same source, that is, the
Irish militia, of which the others were equally
composed, it would be now difficult to determine.
The battalion in which this renewal of the infec-
tion first showed itself in this country was the
second of the fifty-second, and a very considerable
number of cases had occurred in the first battalion
when it embarked for Sicily in 1806. From the
time of their landing in Sicily the disease con-
tinued to cripple this otherwise fine battalion.
Part of the army of Sicily was dispatched to
Egypt, and on its return to Sicily a fresh stock
of the infection of ophthalmia was brought with
it ; but the disease, or an infectious ophthalmia
of the same character, was in the first instance
carried to Sicily from this country by the first bat-
talion of the fifty-second regiment. From this
station alone, I believe more than one hundred
and thirty cases were sent home totally blind.
When the disease had existed for some time in
the light infantry brigade, composed, as I have

OPHTHALMIA.

417

already stated, of the fifty-second, forty-third, and
ninety-fifth regiments, stationed in Kent, it broke
out in other regiments which had no communica-
tion with the former, but had formerly suffered
much from the disease in Egypt, though till this
period it had remained either altogether dormant,
or prevailed in an extent so limited as to escape
attention. Three hospital stations were established
for the exclusive reception of those affected with
the disease, towards the latter end of 1807, to the
superintendence of which I was appointed. The
numbers were chiefly composed of men from the
regiments already mentioned ; but in the summer
of 1806 it contained no less than nine hundred
cases, consisting of detachments from more than
forty different corps. Previously to the sailing
of the expedition to Walcheren in 1809, the num-
ber of acute and highly purulent cases was also
very great, but as they were received in an early
stage of the disease, there was little or no eventual
loss, and from that period the disease continued to
decline."

Dr. Vetch proceeds to account for the disap-
pearance, temporary suspension, and recurrence
of the disease, by attributing such recurrence to
relapses with return of purulent discharge occur-
ring in crowded barracks. He ascribes the com-
parative exemption from the disease enjoyed by
the French army, to the circumstance of their not
being confined to barracks or subjected to fasti-
dious discipline, but bivouacking in the field, or
being quartered on the inhabitants of the towns
they occupied ; and in proof of it, instances the
exemption enjoyed also by the English troops in
the peninsular war. In Ireland, at the period
alluded to by Dr. Vetch, the disease raged with
perhaps still greater violence, and in consequence
of want of sufficient accommodation for the nu-
merous cases in the military hospitals, wards were
opened for their reception in Stevens's hospital
under the diroction of Mr. Colles, where the
writer had an opportunity of observing its exten-
sive ravages, and the comparative value of the
different means adopted for its removal. That
the disease here spoken of is the same as that
now observed, and commonly denominated puru-
lent ophthalmia, can scarcely be doubted ; and
although its appearance among the troops in
Egypt, and its subsequent history, has conferred
upon it a certain distinction of character, yet it
can scarcely be denied that it existed previously,
and perhaps more particularly in Ireland.

The condition or symptoms which characterize
the severer forms of conjunctival inflammation or
purulent ophthalmia, whether Egyptian, gonor-
rhceal, or infantile, are the chemosis or turgid
vascularity with effusion of serum into the sub-
jacent cellular membrane ; sloughing, abscess, or
ulceration of the cornea ; and alteration in the
structure of the conjunctiva leading to granular
lids and vascular and opaque cornea. The symp-
toms as they actually occurred in the form of the
disease just alluded to are so well described by
Dr. Vetch, who enjoyed ample opportunities of
observing the disease, that his account is here in-
troduced. " The first appearance of inflammation
after the application of the virus is observable in
the lining of the lower eyelid. It assumes first a
mottled appearance and then a fleshy redness. A
Vol. III. — 53

little mucus is generally present at the doubling
of the conjunctiva at its lower part. The disease
I know from observation may remain in this state
for twelve hours before it invades the conjunctiva
covering the eye ; sometimes it may be longer ;
and in some cases where the contact of the virus
has been slight, or removed by immediate wash-
ing, the disease never went farther than producing
the redness of the lining of the palpebra. In
sclerotic inflammation the lining of the eyelids
preserves in some degree its natural whiteness,
especially just under the tarsi, for days and weeks.
The progress of the inflammation, when it extends
from the conjunctiva of the eyelid to that covering
the globe of the eye, is often so rapid as to elude
any distinct observation ; but frequently it ad-
vances more gradually, preserving a defined line,
till it extends over the whole membrane as far as
the cornea. No part can be said to be more vas-
cular than another, as the whole seems equally
injected, and no space unoccupied. The disease
is often thus far advanced before the attention of
the patient is so much excited as to make him
complain ; a certain degree of stiffness being
sometimes the only sensation which accompanies
it. The first and chief uneasiness in this stage
of the disease is described as arising from the feel-
ing of sand or dirt rolling in the eye. This sen-
sation is not constant, as it comes on suddenly
and as suddenly departs, confirming to the patient
the idea of something extraneous being lodged in
the eye. I have always observed that its attacks
are in the evening, about the time of going to
bed, or very early in the morning. Their dura-
tion varies; sometimes an attack abates in an
hour, and sometimes continues the whole night ;
those coming on in the evening being always the
most severe. This symptom requires particular
attention, as its accession is a certain index of the
disease being on the increase. From the observa-
tions I have already made, its exacerbations and
remissions are easily explained. When a vessel
on the globe of the eye is first injected and ren-
dered turgid, it excites an uneasy sensation in the
conjunctiva of the palpebra, the same as if it
moved over a particle of sand or extraneous mat-
ter. As the tone of the vessel diminishes, and
the lining of the eyelids becomes accustomed to
the new feeling, the painful impression ceases.
A farther increase of the turgidity of the vessels
already distended, or the distension of others,
serves to excite afresh this feeling of uneasiness.
The time at which I have said that this symptom
generally comes on is when the patient is pre-
paring for sleep, because he is then confined to a
closer atmosphere ; and not only is the eye de-
prived of the beneficial effects of the open air, but
the temperature is farther increased by the closing
of the eyelids in the attempts to sleep. The first
stage of the disease may be, therefore, character-
ized by its great and uniform redness, without
that pain, tension, or intolerance of light which
accompanies most other forms of ocular inflam-
mation ; — exactly the reverse of which takes
place when inflammation affects the sclerotic coat.
From the beginning of the operation of the virus,
there is a disposition to puffiness in the cellular
texture between the conjunctiva and globe of the
eye. The puffiness often suddenly swells out into

418

OPHTHALMIA.

a state of complete chcmosis ; and at other times
it makes a more gradual approach to the cornea,
advancing equally on all sides ; the close attach-
ment of the membrane at this part causes the
swelling as it were to double over the margin of
the cornea. While effusion is thus taking place
upon the eye, oedema is likewise going on beneath
the integuments of the palpebrae. This effusion
ought to be considered as perfectly continuous
with the chemosis arising from the internal sur-
face of the conjunctiva, and following its reflec-
tion on the eyelids. To the oedema of the palpe-
brae, there is no other resistance than what the
integuments afford ; and, therefore, in a short
time, it forms a tumour of astonishing magnitude,
and the external swelling may by its pressure pre-
vent the chemosis from acquiring the magnitude
which would otherwise occur. This enormous
tumefaction of the palpebrae is generally consen-
taneous with the complete formation of the che-
mosis, which is when it has reached the cornea
and surrounds it. In proportion as the integu-
ments of the palpebrae, by yielding to the oedema,
swell out, they drag the tarsus to which they are
attached inwards, producing inversion of the eye-
lid; and the integuments of the upper and lower
eyelids meet, forming a deep sulcus between
them. To examine the eye, it is therefore neces-
sary, first to introduce the finger to the bottom of
the sulcus, and then, by separating the swollen
eyelids, to bring out the inverted cilia. Unless
our treatment have an immediate effect in re-
ducing the external oedema, few cases admit of
any very minute examination of the eye itself.
With the accession of the external swelling, the
discharge, which was before moderate and con-
sisted of pus floating in the watery discharge,
now flows in a continued stream of yellow matter,
which, diluted with the lachrymal secretion, greatly
exceeds in quantity that derived from the most
violent attack of gonorrhoea. The clothes, and
anything within the reach of contact, soon become
embued with the matter, the smallest particle of
which is capable of producing infection. Al-
though the tumefaction may be at first farther ad-
vanced in one eye than the other, it generally
reaches its maximum of height in both about the
same time.

The patient, reduced to a state of great uneasi-
ness by the irritation of the swelling, and by its
confining the discharge, begins now to suffer at-
tacks of excruciating pain in the eye itself. This
is chiefly what indicates the mischief going on,
and from which the patient must be immediately
rescued, in order to save the organ. Here it is
enough to observe, that the medical adviser must
be careful how he allows himself to be lulled into
security by any remission or palliation of this
symptom. An occasional sensation, as if needles
were thrust into the eye, accompanied with fulness
and throbbing of the temples, often precedes the
deeper-seated pain. This last is often of an inter-
mitting nature, and a period of excruciating tor-
ture is succeeded by an interval of perfect ease.
Under the latter form, I have met with it in the
greatest number of cases, and the exacerbation
and remission have often occurred with great
iegularity. Sometimes the pain shifts instantane-
ously from one eye to the other, and is seldom or

never equally severe in both at the same time; and
sometimes, instead of the eye, it occurs in a cir-
cumscribed spot of the head, which the patient
describes by saying, he can cover the part with
his finger. Sooner or later, one of these attacks
of pain is terminated by a sensation of rupture of
the cornea, with a gush of scalding water, suc-
ceeded by immediate relief to the eye in which this
event has happened, but generally soon followed
by an increased violence of the symptoms in the
other. This first sensation of rupture is, when
the disease is left to improper treatment, often fol-
lowed by a second and a third ; till, exhausted by
its own violence, the attacks become shorter and
less severe ; not, however, till after the lapse of
many weeks, and even months, do they altogether
cease. During this stage of the disease, there is
seldom the slightest alteration of the pulse unless
the lancet has been freely employed. The pa-
tient's general health is little impaired, his appe-
tite continues natural, but sleep almost totally
forsakes him. As the pain abates, the external
tumefaction subsides also, and a gaping appear-
ance of the eyelids succeeds. This may be termed
the third stage of the disease. The cilia, which
before had been pushed inwards, are now separa-
ted, and stand outwards. The previous inversion
of the cilia may be explained by comparing the
palpebra to a sail bent to a rope ; the more the
sail is distended, the cord is drawn upwards and
inwards. The swelling of the second stage having
abated, the eyelids are prevented assuming their
natural state, in consequence of the granulated
state of the conjunctiva which lines them; and
now eversion, more or less, takes place. This in
general proceeds, however, no farther; but between
this state and a complete eversion there is every
degree of a diseased or granulated state of the
inner surface of the palpebra. In some cases it
disappears rapidly and of itself; in others it forms
an inveterate disease, and, combined with some
degree of sclerotic inflammation, becomes the
cause of opaque cornea. The pain of the second
stage of the disease arises, in part, from the de-
structive changes which have commenced in the
cornea, aggravated by distension of the eye, con-
sequent upon an augmented quantity of an aque-
ous humour. The formation of that fluid, I have
already hinted, may take place through the me-
dium of the ciliary processes, and the appearance
of the cornea gives no reason to suppose that its
internal surface partakes of the inflammation, or
that the aqueous humour is increased by any mor-
bid effusion. The distension seems entirely owing
to an augmented activity in the secreting vessels;
and these certainly are situated in the posterior
chamber. Neither does there appear any reason
to warrant the idea that the ulceration ever pro-
ceeds from within outwards. But the distension
of the anterior chamber probably favours the
escape of the aqueous humour sooner than it
would otherwise happen. The swelling and the
purulency prevent us from making any very accu-
rate examination to ascertain the progress of the
ulcer. The account I have given of it in a former
chapter is an analysis of what takes place in oph-
thalmia. When any large portion of the cornea
sloughs, an adventitious and vascular membrane
is often produced, which finally forms a staphylo-

OPHTHALMIA.

419

ma. In some few cases, I have seen the lens and
its capsule exposed without any external covering
whatever, and for a short time the patient sees
every thing with wonderful accuracy ; but as soon
as the capsule gives way, the lens and more or
less of the vitreous humour escape, the eye
shrinks, and the cornea contracts into a small,
horn-coloured speck. This total destruction of
the globe of the eye generally insures the safety
of the other, and renders it less liable to be affected
by future attacks of inflammation. When one
eye is lost by styphyloma, and the other remains
useful, it is well to do what nature has left undone,
and, instead of attempting to reduce the sac by
puncturing it, at once to lay it open and extract
the lens."

The account here given by Dr. Vetch is calcu-
lated, in an eminent degree, to impress on the
mind of the student the importance of this disease;
he is not, however, to expect to meet with it in
this form in daily practice. He will not always
have an opportunity of observing the first symp-
toms of the attack, as the patient seldom presents
himself until the complaint is fully established,
and he will not often find the symptoms so rapid
in progress or violent in degree. The practitioner,
in studying an individual case, has before him the
vascularity, tumefaction, scalding pain, and puru-
lent discharge in the severest form. His first con-
sideration should be to recall to his memory the
dangerous consequences which he is called on to
avert, and which constitute the prominent symp-
toms of the disease. In the first or inflammatory
period, he is to recollect that the eye may be lost
by sloughing or abscess of the cornea, or by sup-
puration of the whole eye-ball; in the second
stage, he has to apprehend the injury or destruc-
tion of the cornea from ulceration, or that change
of organization of the conjunctiva which proceeds
to permanent increased vascularity, and that pecu-
liar condition denominated granular lids. The
nature of the pain experienced by the patient
should receive particular attention : if it be the
characteristic scalding sensation of sand beneath
the lids, it is indicative of severe conjunctival in-
flammation only, but if this be accompanied by
intense aching, extending to the temples and sides
of the head, it is evidence of the extension of the
inflammation to the eye-ball itself; the cornea and
fibrous sclerotic refusing to yield to the distension
of inflammatory action, like muscular fascia? and
the coverings of joints under similar circumstances.

As sloughing or abscess of the cornea is the
consequence most to be apprehended during the
inflammatory period, the practitioner watches with
anxiety for any appearance indicative of this evil.
It is not perhaps possible to detect the first change
which the cornea undergoes in this process, but
when this transparent structure assumes a dirty
white opaque appearance, either wholly or par-
tially, the mischief is easily recognised ; and when
subsequently the sphacelated portion comes to be
cast off by the usual process of ulceration, and
exhibits a line of separation between the dead and
living parts, no doubt of the nature of the injury
nn be entertained. Abscesses in the structure of
the cornea are also liable to occur during the in-
flammatory period, and have probably been often
confounded with the sloughing here described, the

distinction being difficult, and the two destruc-
tive consequences sometimes being combined, and
constituting a condition analogous to common an-
thrax. Abscess of the cornea is peculiar in this
respect, that it does not appear to consist of a dis-
tinct sac of purulent matter, but merely a deposit
in the cellular or laminated structure of the cor-
nea ; it consequently does not open at one point
and discharge its contents, but breaks into an open
ulcer, not easily distinguished from the broken
surface ot a slough. The colour of the opacity
of the cornea constitutes the best criterion ; if the
spot be of the usual straw-coloured tint of puru-
lent matter, and not the dull, dirty white of dead
macerated cornea, abscess, not slough, is the pro-
cess in progress. Abscess, also, probably occurs
more frequently in circumscribed spots, and sel-
dom extends to the entire circumference of the
cornea. The secretion of purulent matter in the
chamber of the aqueous humour is easily distin-
guished from abscess of the cornea at its com-
mencement, by the purulent matter falling down
in the aqueous humour between the iris and cor-
nea, and by its surface assuming a horizontal level,
repeatedly described under the title of hypopion,
onyx, or unguis ; but when the whole chamber
is filled with pus, and the cornea consequently
presents a uniform yellow appearance, the real
nature of the appearance is not so obvious.

Causes* — In every day practice, where the
cases are comparatively few, the inquiry into the
cause of the complaint is not so important as when
numbers of persons collected together are violently
attacked; because the occurrence of a few in-
stances of the disease would not justify the adop-
tion of preventive measures by a large commu-
nity, which are imperatively called for where it
rages among smaller numbers more crowded toge-
ther, as in barracks, schools, and ships. That any
cause producing irritation of the conjunctiva, — as
strong light, currents of cold air, or the contact
of dust blown through the atmosphere, — or any
cause usually producing inflammation of mucous
membranes, — as sudden transitions from heat to
cold, or peculiar conditions of the atmosphere, —
is likely to produce purulent ophthalmia, can
scarcely be denied ; but the extent to which these
causes operate, or the circumstances under which
they become influential, have not been ascertained.
The occurrence of the disease in particular coun-
tries, and in barracks, schools, and ships, is noto-
rious ; but the real causes of such occurrence
have not been satisfactorily determined.

The rapid extension of the disease among the
individuals of crowded communities has naturally
led to the belief that it is contagious, and not only
communicated by actual application of the dis-
charge of a diseased eye to a sound one, but even
through the medium, whatever it may be, by
which diseases notoriously contagious are trans-
mitted. The discussion respecting the contagious
nature of the affection is involved in the same dif-
ficulties and contradictions which embarrass the
inquiry into the nature of contagion in general :
sufficient facts, however, have been adduced to
justify the separation and removal of communi-
ties among whom the disease breaks out, and to
induce the prudent practitioner to enjoin the
greatest attention to the prevention of contamina

420

OPHTHALMIA.

tion by actual contact of the matter of the disease
withthe eyes of those not affected by it.

Prognosis* — The prognosis in severe purulent
conjunctival inflammation must obviously be most
cautious. The patient should be made fully ac-
quainted with the immediate danger of destruction
of the organ to be apprehended from sloughing or
suppuration, as well as the prospect of slow and
doubtful recovery in consequence of the great al-
teration or disorganization of the conjunctiva pro-
duced by the intense inflammatory action. In
forming his prognosis, the practitioner must of
course be guided by the degree of violence of the
attack, the habit and constitution of the patient,
and the experience he has had as to the modifica-
tion of the disease by climate or other circum-
stances.

Treatment. — In severe conjunctival inflam-
mation the principles inculcated in the commence-
ment of this article should not be overlooked. The
resources available for arresting the inflammatory
action are, as has been observed, bleeding general
and local, emetic and nauseating medicines, pur-
gatives, diaphoretics, and, according to some, mer-
cury. Locally, astringent, sedative, stimulant,
cold or warm applications, and occasionally blis-
ters, scarifications, and other remedies directed to
peculiar conditions, must be resorted to. Before
the practitioner makes up his mind respecting the
value of bleeding in this disease, he should pause
to consider the effect of this depletion in arresting
inflammation of mucous membranes generally ;
and having done so, he will probably be prepared
to admit that in many cases the lancet is not so
valuable a resource as might be expected, or as it
is found to be in inflammation of serous mem-
branes or other structures. The advantage of
bleeding in croup cannot be denied, but it is to be
recollected that this disease is more liable to ter-
minate in effusion of coagulable lymph than in
secretion of purulent matter. Catarrhal inflam-
mation of the lining membrane of the nostrils or
the trachea and bronchial tubes, and dysentery in
the acute form, are treated by bloodletting more
with the view of diminishing the febrile symptoms
than with the hope of cutting short the local in-
flammatory action. Bleeding will not cure con-
junctival inflammation, but it is a most valuable
auxiliary means of relief, by reducing the part to
a condition in which other remedies become more
effectual. The writer has seen the abstraction of
blood carried to the greatest extent possible, con-
sistent with the safety of the patient ; he has seen
repeated bleedings of forty, fifty, and even sixty
ounces, and streams flowing from the arm and
temporal artery at the same time, without generally
beneficial results. More moderate bleedings, suited
to the intensity of the symptoms, habits, and con-
stitution of the patient, should, however, form
part of the treatment. It is scarcely necessary to
say that persons emaciated by want, enervated by
drunkenness and debauchery, or debilitated by
respiration of impure air, are not fit subjects for a
system of depletion ; on the contrary, such treat-
ment is most destructive to them, and the very
reverse of it is demanded.

The means by which blood should be removed,
or the sources from which it should be drawn, de-
serve consideration. Many prefer opening the

temporal artery, from a theoretical notion that by
emptying one branch of an artery, those ramifying
from the same source have the force of their cur-
rents diminished ; but it never has been proved
that this is actually the case, and it may even be
doubted that any advantage is derived from the
preference, while much inconvenience, irritation,
and heat is produced by the bandage required to
secure the wounded vessel. If advantage be de-
rived from a local diminution of the circulating
fluid, it may more reasonably be expected from
opening the jugular vein ; because in this case
this vessel cannot, like the temporal artery, be in-
stantly refilled by the heart's action : therefore,
when the size of the vein, the formation of the
patient, and other circumstances are favourable,
this vessel should be selected. Bleeding in the
arm, however, from its greater convenience, and
the ease with which it may be performed, is
generally preferred, and perhaps in the majority
of cases without disadvantage to the patient.

The local abstraction of blood by leeches or
cupping is the next resource, after the effect of the
general depletion has been ascertained ; it may be
resorted to in the evening if the general bleeding
took place in the morning, or, according to the
urgency of the symptoms, may be postponed till
the following day. Twelve, eighteen, or twenty-
four leeches should be applied to the temple or
over the cheek-bone, so as to leave an opportunity
of stopping the bleeding by pressure should it
become necessary. The irritation, inflammation,
and tumefaction produced by the application of
leeches to the swollen eyelids more than counter-
balances the good, if any, derived from emptying
the vessels of the inflamed part. The advantage
from the bleeding by leeches appears to depend
upon the continued trickling of blood, which is
perhaps best encouraged by the application of
compresses of old linen wrung out of warm water
and removed and replaced every ten minutes, or as
often as they become soaked with blood. The
application of a few leeches to the conjunctiva of
the lower lids has latterly been recommended anil
practised, and may perhaps be resorted to with
safety and even advantage in the after stages of
the disease ; but in a case of violent purulent oph-
thalmia threatening destruction of the eye, the
effect is too inconsiderable to risk any aggravation
of the inflammation by the leech-bites.

Local abstraction of blood from the inflamed
conjunctiva by scarification has been practised from
the most remote periods; the same objection ma) 1 be
made to it as is offered to the application of leeches,
that is, the small quantity of blood drawn, and the
great extent of injury inflicted. When the che-
mosis or vascular tumefaction of the conjunctiva
is very great, and the membrane projecting between
the lids or overlapping the cornea, the writer, in
place of merely scarifying or scoring the surface,
runs an extracting knife from one end to the other
of the tumour, by which the effused serum is
allowed to escape, tension is relieved, and generally
a considerable quantity of blood discharged. From
this practice advantage is frequently derived with-
out any injurious consequence either temporary
or permanent.

' As it is of the utmost importance that the
practitioner should be informed as to the value of

OPHTHALMIA,

421

bleeding in this disease, the opinions of Dr. "Vetch,
Mr. Lawrence, and Mr. Guthrie, are here sub-
joined. Dr. Vetch observes, " A perfect command
over the disease depends less on lowering the sys-
tem than on the temporary cessation of arterial
action by the syncope, which it becomes the object
of the operation to produce. This practice, be-
sides its efficacy, will accomplish the cure with a
much less expenditure of blood than is occasioned
by the repeated bleedings generally had recourse
to, where this method of rendering one equal to
the cure of the complaint has been neglected.
Sometimes, before the approach of faintness, the
redness of the conjunctiva for the most part dis-
appears ; but this is no security against the return
of the disease, if the flow of blood be stopped
without deliquium animi succeeding." And again,
(page 217, Treatise' on Diseases of the Eye,) " Of
three thousand cases admitted into the ophthalmia
depot, I am not aware of any one in which the
practice of depletion, assisted by the remedies
mentioned, did not prove effectual when the pa-
tient was received under the first attack of the
disease." He then states that twenty-five men
only were lost to the service of all those admitted
into the ophthalmic depot ; " but an unfortunate
feature of this very dreadful complaint is its great
tendency to recur, even after the eye has recovered
its healthy and natural appearance ; and although
it be in our power to conquer its present violence,
no treatment can prevent relapses from taking
place. As long as the lining of the palpebral con-
tinues villous, this accident is liable to recur, with
all the severity of the original attack." From this
last observation it is to be suspected that numbers
of these men were discharged as cured when
labouring under pulpy and villous conjunctiva,
subsequently proceeding to granular lids and
opaque cornea ; especially when it is known that
thousands were lost to the service notwithstanding
the prevalence of the bleeding practice.

Mr. Lawrence (Lectures, reported in the Lan-
cet,) says, " The first measure is to take blood from
the arm, and this in large quantity, so as to pro-
duce syncope : you may expect to derive much
more benefit from one bleeding of this kind than
from the repetition of smaller ones. It may be
necessary to repeat the venesection ; and if the
symptoms should remain urgent, you must not
hesitate to do it : you may subsequently take
blood by cupping from the temple, and apply nu-
merous leeches about the eye." In his account
of gonorrhceal ophthalmia, bleeding is still more
strongly recommended.

Mr. Guthrie (Lectures, reported in the Medical
and Surgical Journal,) states, " It was deemed
necessary to abstract blood in large quantities ;
indeed sixty, eighty, and even one hundred ounces
have been drawn. It was often thought necessary
to re-leech the eye and blanch the countenance to
effect a cure, and I have no doubt that it has been
done with success; and the extreme vessels of
the conjunctiva have been so drained as to be ren-
dered incapable of going on with the secretion.
Those who find fault with this practice in all
probability never saw the disease ; for it is the
most efficient mode of proceeding, and the best
when there are no local means employed."

After the requisite depletion by the lancet, the

2l

practitioner avails himself of the other resources
within his reach. If there be reason to believe
that there are crudities in the stomach, with foul
tongue and headach, an emetic may be adminis-
tered with advantage ; and when the nausea sub-
sides, the bowels should be freely opened, and the
discharge kept up by the administration of suitable
medicine at proper intervals. A few grains of
calomel at night, followed by repeated doses of
the common mixture of infusion of senna and
sulphate of magnesia in the course of the follow- :
ing day, may probably answer every purpose.
From the advantage derived from nauseating me-
dicines in other forms of inflammation, similar
advantage has naturally been expected from its
administration in purulent ophthalmia ; but in
consequence of their not answering the exagge-
rated expectations of the practitioner, they have
not, perhaps, been resorted to to that extent they
deserve. The effect may be advantageously se-
cured by the addition of tartar-emetic to the pur-
gative mixture, or the same medicine alone in
solution may be given after the bowels have been
freely opened, in doses sufficient to produce slight
nausea, and secretion from the skin encouraged at
the same time by confining the patient to bed.
Tobacco has been resorted to for the purpose of
exciting nausea; but experience has not yet
proved that it possesses any superior advantage,
while we are less familiar with its effects than with
the preparations of antimony. Mercury has been
recommended and resorted to for the removal of
conjunctival inflammation, but with little success.
The opinions of Mr. Lawrence, Beer, Delpech,
and others, are unfavourable to the practice.
Without accomplishing any valuable object, it
reduces the patient to the condition which is most
calculated to perpetuate the destructive change in
organization of the conjunctiva.

Whatever importance is to be attached to the
opinions of English writers on the present sub-
ject — respecting the paramount value of bleeding
and low living in the treatment of the disease, the
Irish practitioner must undoubtedly be circumspect,
in this respect, in his treatment of the poor. It
may be very well to bleed and otherwise reduce
those who have been well fed and have enjoyed
all the comforts of life ; but the practice is utterly
inadmissible in a country where the poor are
abandoned to a state of destitution, and, if not
absolutely starved, are so ill fed, and clothed, and
lodged, that frequently no healthy action can be
roused until the constitution be invigorated. In
Dublin it is often absolutely necessary to place a
patient, a few days after the first attack of puru-
lent ophthalmia, on full diet, consisting of animal
food with ale or porter, accompanied by the ad-
ministration of bark or other tonics.

In the treatment of purulent ophthalmia the
management of the patient, with respect to the
temperature, ventilation, and lighting of his apart-
ment, should not be overlooked. The practice of
immuring a patient in a close room, with windows
shut and curtains drawn, and with the addition of
an enclosure of curtains round his bed, involving
him in a contaminated atmosphere loaded with the
excrementitious effluvia of his body, is most per-
nicious. The close, stinking, crowded, and dark-
ened ward to be found in some hospitals, called

422

OPHTHALMIA.

the eye-ward, is equally destructive. The author
of this article has almost daily opportunities of
witnessing the refreshing and salutary effects of
what may justly he called a meal of fresh air, on
persons subjected to such treatment; and he in-
variably finds that patients obliged to go out of
doors are more easily managed, and escape with
less injury, than those confined in the way just
mentioned.

With respect to this part of the treatment, Dr.
Vetch makes the following observations : — " Ien-
tertain so favourable an opinion of the effects of
the free exposure to the atmosphere, that although
no person can better appreciate the importance of
decisive measures in the early stage of the dis-
ease, I would in favourable weather risk the delay
of a journey on foot or horseback, or in a car-
riage, or a voyage by sea, provided the eye be
freely exposed to the air. Even when the second
stage has commenced, by the appearance of a
cheir.osis and purulent secretion, I have never seen
any other than the best effects to attend a change
of place. Soldiers who have commenced a march
with the disease completely formed, though ex-
posed to heat, dust, and fatigue, and not abstaining
even from intoxication, are invariably better at the
end of the journey than when they set out. The
instances of this fact which I could adduce from
my own observation are innumerable ; and I am
informed by Mr. Murray, surgeon to the forces,
that so strongly did he observe the beneficial ef-
fects of exposure to the air, when a great number
of men affected with the disease was sent, under
his care, to the interior of Sicily, that he was in-
duced to march them from one place to another,
with a view solely to the good effects he saw re-
sulting from it."

In considering the local treatment of severe
purulent ophthalmia, the first and most important
point to be determined is the value of powerfully
stimulant or astringent applications made directly
to the inflamed conjunctiva in the first or inflam-
matory stage of the disease. The great advantage
of strong astringent solutions in arresting the pro-
gress of that disorganizing change which follows
violent conjunctival inflammation is undeniable ;
but it requires much circumspection to avoid con-
founding the advantages derived from astringents
in the chronic stage with those derived from simi-
lar applications in the acute. The question to be
determined is, whether a powerful stimulant or
astringent, as ten or twenty grains of nitrate of
silver in an ounce of water, or ten grains in a
drachm of lard, can be with safety and advantage
applied to the surface of the inflamed conjunctiva
in the first attack of violent purulent ophthalmia.
When a patient presents himself in the first stage
of purulent ophthalmia, with severe scalding pain,
and with the conjunctiva in a state of chemosis,
overlapping the cornea and projecting between the
eyelids, few practitioners will feel inclined to soak
the eye in a ten grain solution of nitrate of silver,
or thrust a portion of the ointment (ten grains to
the drachm) between the lids and the swollen and
turgid conjunctiva. The most strenuous advo-
cates for the stimulating practice inculcate the
necessity of allaying inflammatory action before
or during its adoption. Whether incipient puru-
lent ophthalmia of the character now under con-

sideration can be at once cut short or not by the
application in question, has not yet been esta-
blished to the full satisfaction of practitioners.
The circumstances under which the experiment
may be made to enable the observer to arrive at a
just conclusion seldom occur, because he rarely
meets a case in its very onset which he can pro-
nounce to be violent purulent ophthalmia, the
severe characteristic symptoms not being yet deve-
loped. If purulent ophthalmia rages in a regi-
ment, a school, or a ship, and the surgeon, watch-
ing narrowly the symptoms of the accession of the
disease, applies this stimulating astringent to the
surface with decided effect ; or if a patient in the
hands of a practitioner for the treatment of gonor-
rhoea presents the symptoms of conjunctival in-
flammation, and is similarly treated with similar
good effects, the question must be determined in
the affirmative. Several military surgeons, who
have enjoyed the best opportunities of observing
and treating the disease, are decidedly favourable
to the practice.

Mr. Lawrence, however, in his book on Vene-
real Diseases of the Eye, speaks of it with caution
and reserve. After quoting the authority of Mr.
Melin, Mr. Bacot, Dr. Ridgeway, and Dr. O'Hal-
loran, on this subject, he observes, " I have not
seen purulent ophthalmia, whether ordinary or
gonorrhceal, treated on this plan ; nor am I aware
that any case of the latter kind is recorded. De-
structive or injurious consequences have so fre-
quently resulted under the usual management of
this disease, that I should certainly employ the
local astringent if I met with a case favourable
for the trial ; that is, where the affection had not
extended beyond the conjunctiva. Bloodletting
might be resorted to at the same time. In most
cases, however, our aid is not sought until the
cornea has become affected ; and it is, therefore,
too late for the astringent plan." In a note he
adds, " Since the statement in the text was writ-
ten, I have employed the caustic solution in two
cases of conjunctival inflammation with the best
result. One of these was mild gonorrhceal inflam-
mation. The other was catarrhal inflammation
of the membrane, affecting both eyes of a gentle-
man who had been convalescent from gonorrhoea
for a few weeks. As he was a person of robust
make and full habit, and the eyes were very red
and stiff, I took three pounds of blood from the
arm, and purged him freely, with relief of the
local symptoms, which were completely removed
by a subsequent application of the caustic solu-
tion."

The practice here alluded to is advocated so
strenuously by Mr. Guthrie, that it is desirable to
have his opinions conveyed in his own words.
The following extract is, therefore, made from his
lectures reported in the Medical and Surgical
Journal. " In the more formidable affection which
runs its course in three or four days, neither the
nitrate of silver in solution nor the vinum opii a' e
effective ; it requires a more powerful local appli-
cation. The disease begins externally, and is a
local disease of a peculiar character. If we can
set up a new action, or alter that which is going
on, we check the original affection, according to
the principle of John Hunter, that no two dis-
eases or actions go on at one and the same linK-

OPHTHALMIA.

423

Acting on this principle, I took the nitrate of sil-
ver in substance, and made it into an ointment.
I did not arrive at its exact composition at once,
but gradually acquired it by degrees ; it was made
at various times, of five, six, ten, and twenty
grains to the drachm ; and after trying all these
different preparations, I came to the conclusion
that the ten grain ointment was the best. Take
half a drachm of the salt, and powder it in a glass
mortar, then sift it through a bit of muslin, so
that it is reduced to an impalpable powder, for if
there are any grains left, they will stick in the
cornea, or in the folds of the conjunctiva, and pro-
duce a slough. Ten grains of this impalpable
powder should then be thoroughly incorporated
with a drachm of hog's lard, on a glass slab with
an ivory paper-cutter ; and in order to ensure pro-
per attention in the preparation of this ointment,
I sought for something to mix with it, which
would require some time for its incorporation,
and selected the liquor plumbi acetatis for this
purpose. Fifteen drops are to be duly mixed with
the ointment ; and as it generally requires some
minutes to do this, there is reason to believe that
the trituration is complete. There has been, as
usual, some dispute concerning this ointment; the
first thing said was that it was violent and useless :
well, that has been got over. The second stage
was to attribute the introduction of it to some
other person. The third to alter the composition,
and instead of the liquor plumbi acetatis to mix
opium, &c. with it. I have no objection to this,
if the gentlemen will only leave me the principle,
which is all I contend for. I care not if they
change all the component parts, or whether they
apply it by a brush of the little finger, or the
probe. It has been said that it is soon valueless
and inert. All I can say is, let those who think
so have it applied to their eyes, and they will soon
change their opinion, even if it be a year old.
Before the ointment is applied in this purulent in-
flammation, the discharge must be well cleansed
out by a solution of alum; then the ointment
having been inserted, the lids must be moved
freely up and down so that the whole conjunctiva
gets its due proportion of ointment, and this is
shown by its turning white. If it does not turn
white, it has not been sufficiently applied, and will
not answer the purpose ; if we wish to be quite
sure, we turn out the eyelids, and rub the oint-
ment on them ; this application gives pain, which
lasts for half an hour to an hour, or more ; it is
not quite so acute as the vinum opii. I had rather
that the pain should last an hour or more, as the
action going on is more likely to be changed.
When I apply this ointment, I generally direct
the patient to lose blood, not to the amount of
sixty ounces, but to about twenty, and I had
rather that he should faint: and I do this hecause
the application will only alter the action in the
extreme vessels, and not that which is behind them
in the ball itself, and it is therefore necessary to
diminish action in them by bleeding. If, how-
ever, the inflammation is moderate, I do not bleed
at the time, leaving directions that if the patient is
not better in the evening, or the next morning, blood
should then be taken. Warm narcotic fomenta-
tions may be employed to relieve uneasiness, and
opium should be given to allay pain and obtain

sleep, while a solution of alum, half a drachm to
half a pound, should be injected from time to time in
the eye to clear it ; but should the patient sleep, he
must not be disturbed. A mild ointment may be ap-
plied to the lids at night, to prevent their adhering
together. The next morning the discharge is again
to be removed, and the ointment re-applied, for on
no account should the action we are desirous of
exciting be suffered to cease ; the other remedies
are likewise to be continued. In addition to these
I would give calomel and opium, so as to affect
the mouth, and the other more common remedies ;
and rest and diet should be attended to. When I
hear of twenty or thirty persons losing their eyes
from this disease, I say that it must always be so,
unless they are treated on this principle, bearing
in mind that some diseases in certain persons are
incurable from the first, and that no one means of
cure is applicable to every case. I am certain, how-
ever, from experience, that the plan I have recom-
mended is the most generally efficient and certain
of any that has hitherto been advised, whilst it is
also less injurious to the constitution."

There is much difference of opinion as to the
comparative value of cold or warm applications in
the acute stage of purulent ophthalmia. Either
in ophthalmic or any other local inflammation, the
advantage to be expected from cold applications is
the reduction of the temperature of the part, and
consequent diminution of vascular action ; but
this object is very rarely obtained, and the real
effect of cold in abating inflammation has as yet
scarcely been ascertained. The attempt is made
in conjunctival inflammation by repeated applica-
tions of cloths wrung out of cold water, but these
cloths become so speedily of the same tempera-
ture as the part, that nothing more is effected than
a temporary cooling, followed by perhaps greater
heat and vascular reaction. To obtain the advan-
tages to be expected from cold applications, these
cloths should be changed by a nurse, sitting at the
bedside of the patient, twice in a minute, or a fold
of old linen may be laid across the eyes with the
ends hanging into cups on each side, and cold
water squeezed on with a sponge, or allowed to
drop from a vessel contrived for the purpose. In
this way the application of cold as a remedy in
ophthalmic inflammation, and especially from
wounds or other injuries, is undoubtedly of value,
although many patients prefer the effects derived
from warm moisture. The following objections
made by Mr. Travers to cold applications, in his
Synopsis of Diseases of the Eye, are perhaps
more applicable to their maladministration. " Al-
though the sensation of cold is most agreeable to
an organ under acute inflammation at the moment
of its application, it is generally followed by in-
crease of heat and pain ; and in familiar instances
the pulsatile action of the vessels leading to an
inflamed part is so increased as to evince its stimu-
lating effect, and the reaction thereby induced.
When, however, the acuteness of the inflamma-
tion has subsided, and the sensibility of the part
is in proportion diminished, the effect of cold is
only tonic, and has a salutary tendency to restore
the balance of the circulation. I therefore de-
cidedly prefer a tepid application in the painfully
acute stage of inflammation." With the reserva
tion that cold properly applied is not to be de.<j

424

OPHTHALMIA.

pised, this advice is good for the purposes of
general practice.

Warm applications may be made by stupes,
poultices, or light compresses, all of which are
generally mismanaged, and frequently do more
mischief than good, unless particularly attended to
by the practitioner himself. The stuping is gene-
rally attempted by wringing a flannel cloth out
of a hot decoction of chamomile or poppyheads,
and laying it across the patient's eyes, in which
case the steam is dissipated, and little of it comes
in contact with the eyes. It is best accomplished
by the patient himself, who, sitting up in bed,
should receive a small piece of flannel, wrung out
of the hot water, from the nurse, and hold it in
the hollow of his hands under the eyes, changing
it as it ceases to give out steam. Many little con-
trivances may be made for the purpose with sponge
or other materials, but holding the eyes over ves-
sels of hot water, or exposing them to steam ex-
tracted from a boiling apparatus contrived for this
purpose, is not found advantageous, as the heat
applied is generally too great. Whether any
benefit be derived from the addition of sedative or
other medicinal ingredients to the stupe, remains
to be proved : it is not, however, attended with
disadvantage, and a medical man of any sagacity
will see the necessity of yielding to prejudices for
the attainment of objects directed to the relief of
his patient. If the practitioner determine to add
opium to the stupe, he should give the patient the
advantage, whatever it may be, of its efficient ap-
plication, which is, perhaps, obtained in a neater
and more perfect manner by the addition of a
drachm of the tincture, or a few grains of the
watery extract to a pint of hot water.

Whatever difference of opinion may exist with
respect to the extent to which stimulating or as-
tringent applications should be employed in the
inflammatory stage of conjunctival inflammation,
there is little doubt entertained of the value of as-
tringents in the chronic stage, or that condition of
the conjunctiva which may be considered the ne-
cessary consequence of the violent inflammation
above described. The salts most commonly used
for this purpose are acetate of lead, alum, sulphate
of copper, sulphate of zinc, corrosive sublimate,
and nitrate of silver. Notwithstanding the length
of time these salts have been in use, it does not
appear that any conclusive experiments have been
made to ascertain their comparative value, or the
best proportions in which they should be used.
The practitioner has little more to guide him in
the selection than the vague and uncertain evi-
dence of expressions of confidence in some one
or other by different practical writers. The most
generally valuable, safe, and efficient, are the ace-
tate of lead, alum, and nitrate of silver, the sul-
phates of copper and zinc being more stimulating
and irritating, with less astringent properties.
Weak solutions, however, of sulphate of zinc or
copper are unquestionably of value in the slighter
vascularity of the conjunctiva following catarrhal
ophthalmia, or arising without preceding inflam-
matory action. Saturated solutions of acetate of
load or alum may be used with the greatest safety,
and without producing any such effect as follows
the introduction of other salts. Saturated solu-
tions of sulphate of zinc may also be applied to

the conjunctiva without any other destructive con-
sequence than a temporary increase of vascularity,
pain, and weeping ; but a saturated solution of
sulphate of copper produces violent inflammation,
probably acting chemically, and producing super-
ficial destruction of the surface. Nitrate of silver,
in the proportion of ten or fifteen grains to the
ounce, appears also to act chemically, causing
whiteness of the vascular conjunctiva, but with-
out the irritating and stimulating effects of sul-
phate of copper. Nitrate of silver, even in the
proportion of three or four grains to the ounce, if
used for a month or six weeks, will produce an
olive-coloured indelible stain of the conjunctiva,
and lamentable deformity ; or both it and acetate
of lead, applied while ulcers of the cornea exist,
produce the worst form of opacity by being de-
composed by the tears and deposited on the floc-
culent surface, and there detained until perma-
nently fastened by cicatrization, as has been de-
scribed by the author of this article in the Dublin
Hospital Reports. None of these disadvantages
attend the application of the alum solution, and
its powerfully astringent qualities are undeniable.
The condition of the conjunctiva to which the
reader's attention is called with reference to these
applications, is that which exists from a fortnight
to six weeks after the first attack, when the acute
inflammatory symptoms have subsided, and before
the membrane has acquired the extreme condition
of disorganization denominated granular conjunc-
tiva. In this state a solution of from five to ten
grains of nitrate of silver in an ounce of water,
or the ointment recommended by Mr. Guthrie, will
prove of great advantage; but the practitioner
should not allow the praises exclusively bestowed
upon it to induce him to discard the saturated so-
lutions of alum or acetate of lead, as he may be
assured that they will often be found preferable in
practice, although the particular condition in
which they are so may not have been ascertained.
The effects of the saturated solution of acetate of
lead, when such cases, modified by scrofula, are
accompanied by vascularity of the conjunctiva
covering the cornea, are frequently most remarka-
ble. Dr. Vetch expresses the following opinion
respecting the solution of acetate of lead. '• The
liquor plumbi acetatis in its undiluted state is the
application which I can recommend as the most
efficacious, and at the same time incapable of
doing harm in this, and in every stage of puru-
lent ophthalmia. The sensation it occasions is
that of some dust or sand having got into the
eye, which lasts from ten to twenty minutes; there
is generally a copious lachrymation, and the eye
afterwards feels cool, and the sight is clear."

Whichever of these solutions is preferred should
be fairly dropped into the eye, after it has been
cleansed with sponge and warm water, on awaking
in the morning, and the patient should remain
quiet with the lids closed for half an hour. This
may be repeated In the evening, if not found to
produce increase of pain or irritation, and the pa-
tient should be allowed a weaker solution to wash
the eyes with more frequently in the course of the
day. At night the edges of the lids may be
smeared with cream, fresh butter, or some mild
ointment. On the continent a compound salt,
called the lapis divinus, is much used ; it is made

OPHTHALMIA.

425

by heating eight ounces of nitre, alum, and sul-
phate of copper in a crucible, and, when fluid,
adding half an ounce of camphor, and closing the
vessel until cold. It is used in the proportion of
three or four grains to the ounce and appears to
have the same effect as the sulphate of copper.

The application of the vinous tincture of opium
was first recommended by Mr. Ware, in his
"Remarks on the Ophthalmy." He gives the
following account of the method of applying it,
and its effects : " I would particularly recommend
the thebaic tincture of the old London Dispensa-
tory ; a medicine composed of opium and warm
aromatics, dissolved in mountain wine." " When
first applied, it causes a sharp pain, accompanied
with a copious flow of tears, which continues a
few minutes, and gradually abates, after which a
greater and remarkable degree of ease generally
succeeds. The inflammation is often visibly
abated by only one application of this tincture ;
and many bad cases have been completely cured
by it in less than a fortnight, after every other
kind of remedy had been used for weeks, and
sometimes months, without any success. But
this speedy good effect is not to be expected in all
cases indiscriminately. In some, the amendment
is more slow and gradual, requiring the tincture
to be made use of for a much longer time ; and a
few instances have occurred, in which no relief
was at all obtained from its first application. In
cases of the latter kind, in which the complaint is
generally recent, the eyes appear shining and
glossy, and feel exquisite pain from the rays of
light. However, notwithstanding these symp-
toms, the application is sometimes found to suc-
ceed ; and whether it will or not, can only be de-
termined by making the trial, which is attended
with no other inconvenience than the momentary
pain it gives. When it is found to produce no
good effect, the use of it must be suspended, until
evacuations and other proper means have dimi-
nished the excessive irritation ; after which it
may again be applied, and bids equally fair for
success, as in those instances in which it never
disagreed. If two or three drops of the thebaic
tincture are dropped at once on the globe of the
eye, the pain they occasion will be considerably
greater than if they are placed in the inner angles
of the eyelids, and made to glide gradually on the
c y e > by gently drawing down the lower lid. At
the same time that this latter mode of applying
the tincture is much less painful than the former,
I have found, in a great variety of cases, that it is
equally beneficial." Experience has fully esta-
blished the character here given by Mr. Ware of
the vinum opii ; it is, however, most applicable in
those cases where there is much scalding pain,
lachrymation, and intolerance of light.

If the pulpy villous vascularity produced by the
inflammation above described be neglected, or be
not removed by the applications alluded to, it de-
generates, in about six weeks or two months, into
a still more destructive condition ; the conjunctiva
lining the lids acquiring a rough irregular vascular
appearance, which, from its resemblance to the
granulating surface of a sore, has been named
the granular conjunctiva. This condition, if not
altered or removed, is followed by red vascularity
and opacity of the conjunctiva covering the cor-
Vol. III. — 54 2l*

nea, and almost total loss of vision. To remove
this state of the membrane, the resources of oph-
thalmic surgery have been nearly exhausted, and
frequently without effect. It even unfortunately
happens that the destruction or removal of these
warty prominences or granulations is not followed
by recovery. In fact, the organization of the con-
junctiva is destroyed by the severe inflammation,
and, if ever restored, requires a great length of
time to return to its original condition. These
granulations may be removed either by the knife
or escharotics, and the question respecting the
preference to be given to either method has been
the subject of much controversy. They certainly
may be shaved off by the dexterous use of a small
scimeter-bladed knife, and their removal in this
way is accompanied by the advantage of local
bleeding, and consequently less subsequent pain,
irritation, and inflammation, than attends the use
of escharotics. The partial use of escharotics,
however, is often necessary to complete the re-
moval, as it is impossible to reach all the granu-
lated surface with* the knife. The escharotics
commonly emploved are the nitrate of silver, or
sulphate of copper, in substance. The former is
preferable, its effect is more decisive, and the in-
flammation and irritation, from its application, are
less : the latter is, however, preferred by some.

The operation of applying the escharotic must
not be carelessly performed. Much mischief has
been frequently done by allowing an inexperienced
pupil to rub the inside of the lids with a piece of
sulphate of copper in a slovenly manner. The
upper lid should be everted, and the surface dried
with a cambric handkerchief; the whole of the
granulations should then be repeatedly touched
with a pencil of nitrate of silver until the surface
becomes of a deep ash colour ; it should then be
carefully washed with a plentiful stream of water
from a syringe, lest any particle of nitrate of silver
should adhere undecomposed, and be turned in on
the cornea. If the sulphate of copper be used, it
will require a more continued application to pro-
duce the escharotic effect, and the washing must
be performed with equal care. The application
of the escharotic must be repeated as often as the
granulations are observed to remain after the sur-
face becomes clear from casting off the coat pro-
duced by the nitrate of silver.

[In chronic granular ophthalmia, Dr. Hays
(see his edition of Lawrence on Diseases of the
Eye, p. 267, Philad. 1843,) has found a saturated
solution of the chloride of sodium contribute more
to the cure than any other application. When
the eye is irritable, with injection of the conjunc-
tiva of the ball and lachrymation, he knows of no
remedy that effects such prompt and marked
relief.]

Ointments are frequently resorted to for the
removal of the vascularity and tenderness of the
lids, produced by purulent ophthalmia, especially
where the skin at its meeting with the conjunctiva
becomes red and destitute of cuticle, constituting
lippitudo, a condition which, it is to be recollected,
arises often without preceding acute inflammation.
Where the object is merely to obviate the incon-
venience arising from the dryness produced by
exposure to the air, or the scalding from contact
of the tears, it may be accomplished by the appli-

426

OPHTHALMIA.

cation of a little cream, fresh unsalted butter, or
the spermaceti ointment. It is often, however,
necessary to combine astringent or stimulating
ingredients with the ointment. The ointment of
nitrate of mercury, diluted with five or six times
its weight of oil or lard, is very commonly used,
and frequently with good effect, if continued for a
few days only. The stimulating effect appears to
be salutary as a first and temporary impression,
but when persevered in for a length of time, seems
to have a contrary result. The ointment of oxyd
of zinc is a very safe and efficient astringent ap-
plication, as is also the mixture known as the
ophthalmic ointment of Janin, composed of four
drachms of lard, two of tutty or impure oxyd of
zinc, two of Armenian bole, and one of calomel.
These ointments should, however, be made with
such a proportion of oil as will give them so soft
a consistence that they can be applied with ease
to the lids with the point of the finger or a camel-
hair pencil ; they should also be properly and
(Carefully ground on a flag with a muller, not
merely mixed on a tile with a palate-knife, and
.great care taken that the oily ingredient be not
jancid or burned. Ointment of acetate of lead, or
a mixture of oil or lard, with liquor subacetatis
plumbi, is another application frequently em-
ployed with advantage. As oily applications are
sometimes found not to agree with the surface, the
practitioner may find it necessary to combine
astringents with some tenacious ingredient of a
different description ; for this purpose, clarified
honey may be used, with the addition of alum or
Armenian bole, finely levigated. Honey alone
will often afford relief in the slighter degrees of
vascularity following conjunctival inflammation.

In the treatment of purulent ophthalmia the
advantages to be derived from blisters should not
be overlooked. The extent to which they may
prove beneficial in any particular case can perhaps
scarcely be ascertained; but as their value gene-
rally in contributing to the removal of local in-
flammation is admitted, it is not reasonable to
disregard such a resource. These may be applied
at any period of the disease, but they probably are
more efficacious after the more acute symptoms
have subsided, or before they have set in, and ap-
pear most indicated where there is much irritabil-
ity, intolerance of light, and scalding lachryma-
tion. They should not be applied too near the
eye, as in such case the cutaneous inflammation
sometimes spreads to the lids and increases the
mischief. A patch of the scalp from the temple
to the top of the ear should be shaved, and a blis-
ter of size sufficient to secure a decided counter-
irritating effect, applied and allowed to remain on
until the skin is fully inflamed. A scrap of
blister behind the ear does not produce sufficient
impression to compensate for the annoyance it
occasions to the patient.

GONORRHEAL INFLAMMATION OF THE CON-
JUNCTIVA. — Mr. Lawrence, from whose valuable
work on venereal diseases of the eye it will be
necessary to make copious extracts in treating this
subject, considers that there are two varieties of
gonorrhceal inflammation of the conjunctiva, the
acute and mild. The acute gonorrhoea! ophthal-
mia is perhaps to be considered specifically dis-
tinct from the common severe purulent ophthalmia,

on account of its origin and consequences, rather
than from any decided difference in the character
and symptoms of the disease. There is the same
scalding pain, intense vascular chemosis, profuse
purulent discharge, sloughing, abscess, and ulcer
of the cornea, and permanent disorganization or
granulation of the conjunctiva, observed in the
Egyptian and other severe forms of purulent
ophthalmia. Mr. Lawrence says, » the local
symptoms are not sufficient to establish a dis-
tinction between this affection and common puru-
lent inflammation of the most violent kind, and
its peculiar nature is indicated by the concomitant
circumstances, that is, by the preceding or existing
gonorrhoea." He considers, however, that it ge-
nerally attacks only one eye, while common puru-
lent ophthalmia affects both ; that it commences
in the conjunctiva of the eyeball oftener than in
that of the lids, that the symptoms are more vio-
lent, and that its progress is more rapid.

Notwithstanding the similarity of symptoms
between the severe purulent and the gonorrhoeal
ophthalmia, a repetition of the account of those
symptoms as they occur in the latter in the words
of Mr. Lawrence may not be unacceptable.
" There is the greatest degree of vascular conges-
tion, the most intense and general external red-
ness ; excessive tumefaction of the conjunctiva ;
great chemosis, with corresponding swelling of
the palpebrse ; and profuse yellow discharge. In
the first stage of the disease, which is short, the
inflammation is confined to the conjunctiva, and is
attended with soreness and stiffness, with the sen-
sation of sand or dirt in the eye, and with more
or less uneasiness on exposure to light or using
the organ. The affection soon extends to the
cornea, with severe and agonizing pain in the
globe, orbit, and head, augmented to intolerable
suffering on exposure to light, and with febrile
disturbance of the system of inflammatory char-
acter. The danger to the organ is now most se-
rious and imminent ; and indeed, when the dis-
ease has thus advanced from the raucous mem-
brane to the globe itself, we can hardly expect by
any kind of treatment to avert entirely its de-
structive consequences. The violent inflamma-
tion, which causes the yellow puriform discharge
from the mucous surface of the conjunctiva, pro-
duces effusion into the cellular texture connecting
it to the surrounding parts. Hence the general
swelling of the membrane, and that more consid-
erable tumefaction on the front of the sclerotic,
round the cornea, which is called chemosis. The
latter is often so considerable that the swelled
conjunctiva overlaps the cornea all round, so as
nearly to hide it. Similar effusion takes place
into the cellular texture of the eyelids, enlarging
them considerably, more particularly the upper,
which hangs over and completely covers the lower.
The palpebral swelling is sometimes cedematous,
with the integuments but little redder than natural;
in other instances it is firmer, with the skin, par-
ticularly of the upper eyelid, bright red. The
latter state denotes more active inflammation, and
greater danger to the organ. The chemosis and
the swelling of the lids make it often difficult, and
sometimes impossible, to get a clear view of the
cornea. Although it is desirable to do this, in
reference to prognosis, when we first see the case,

OPHTHALMIA.

427

we should not persist in our efforts at the risk of
augmenting the inflammation or the patient's suf-
ferings. The oedema of the eyelids declines in
the progress of the affection, and then one or both
of them may become everted, the convex edge of
the tarsal cartilage being pushed forwards by the
swollen conjunctiva. The inflamed membrane
exhales at first a thin whitish mucus in small
quantity ; as the inflammation proceeds to its full
development, the discharge becomes thicker, yel-
low, and abundant; the yellow tint and the
quantity of the exhalation being in proportion to
the violence of the inflammation. When the lat-
ter is at its height, the discharge closely resembles
in its appearance, and in the stain communicated
to linen, that which proceeds from the urethra in
venereal gonorrhoea. Although the pain is gene-
rally most severe both in the eye and in the head,
as in other instances where the dense and unyield-
ing texture of the cornea is the seat of inflamma-
tion, and although patients often complain of
burning pain, of tension, as if the eye would
burst, of deep-seated and intense agony, with ex-
tension of these distressing and almost intolerable
sensations to the brow, forehead, and head gene-
rally, there are some instances in which little or
no pain is experienced. The symptoms of acute
gonorrhceal ophthalmia are not equally violent
through the whole course of the affection : it
begins with swelling and increased redness of the
conjunctiva, and some pain in the organ : then
the puriform discharge takes place, with increased
uneasiness : and, lastly, the inflammation extends
to the cornea, with great aggravation of suffering.
Thus the course of the affection may be divided
into three stages, of which the limits cannot be
marked very accurately. In the first there is vas-
cular distension and swelling of the membrane,
with swelling of the lids; the commencement of
the second is marked by the occurrence of the
puriform discharge, and that of the third by ex-
tension of the inflammation to the cornea. The
duration of each of these varies in different in-
stances according to the constitution and state of
health of the individual, and perhaps still more
according to the nature of the treatment adopted.
This variety, however, is observed less in the first
and second than in the third stage ; the two former,
and more particularly the first, usually passing
off very rapidly."

In gonorrhoeal ophthalmia, the immediate de-
structive effects of the inflammation, sloughing,
abscess, and ulceration of the cornea, are more to
be apprehended than in common purulent oph-
thalmia as it now occurs. The appearance of the
cornea when about to slough or suppurate has
been already described ; the process, as it occurs
in the present form of inflammation, is described
as follows by Mr. Lawrence. " The cornea be-
comes dull and hazy before it sloughs, or indeed
before undergoing any of the changes above enu-
merated. Its transparency and polish are com-
pletely destroyed where it has sloughed ; and it is
converted into a dirty yellowish or brownish opaque
surface, which is immediately recognised as de-
prived of life. At first it looks like a portion of
wetted leather ; it is soon separated from the living
parts, when it has a loose, soft, and ragged ap-
pearance. As the lens and capsule which are

exposed by this separation are transparent, the pa-
tient sometimes recovers for a short period toler-
ably good vision. After the slough is detached,
the chambers of the aqueous humour may be ex-
posed by ulceration ; the humour will then escape,
the empty coats will collapse, and the globe remains
permanently shrunk in the socket. More com-
monly, although the whole cornea seems to slough,
the entire thickness does not separate, and the an-
terior chamber is not exposed." The slough of
the cornea, when it does cast off, leaves an ulcer-
ated surface proportioned to the size of the slough,
with or without an opening into the anterior
chamber. If the slough or ulcer does not extend
through the thickness of the cornea, the conse-
quence is simple opacity or staphyloma ; if it does
not penetrate into the chamber of aqueous humour,
the iris passes through the opening, and the pa-
tient suffers from closed, contracted, or irregular
pupil in addition to the opacity. But it is not by
slough alone that these evils are produced :
suppuration or abscess is liable to occur. It is
thus described by Mr. Lawrence : " Suppuration
of the cornea may be general or partial : it is
usually the former. The cornea first becomes
white, and then assumes a yellow colour. The
effused substance is not a fluid, nor is it collected
into a cavity : it is a thick viscid matter deposited
in the texture of the cornea. Ulceration takes
place, and exposes an opaque yellow substance,
which looks like ordinary matter, but it cannot be
wiped off." The abscess of the cornea thus opened
by progressive suppuration goes on to ulceration,
and may extend to the anterior chamber as in the
sloughing process, and with similar consequences.
The successive changes in the ulcer are thus de-
scribed. " If the ulcer should be spreading, the
inflammation remaining unchecked, its surface is
whitish and ragged or flocculent, or of a dirty
yellowish cast with surrounding haziness. When
the inflammation subsides, it becomes transparent.
The commencement of the restorative process is
marked by the surface of the excavation assuming
a light greyish tint with a jelly-like appearance.
A soft semi-opaque substance fills up the breach,
when the surface becomes smooth, and the regular
figure of the cornea is restored."

The prognosis in gonorrhoeal ophthalmia must
obviously be most cautious, and the patient should
at once be informed respecting the nature of his
disease, and the dangers to be apprehended. The
first and most destructive consequence to be feared
is the sloughing of the cornea ; a change of ap-
pearance in the eye indicative of such disorganiza-
tion is therefore to be watched for with great
attention. This change is a haziness, or loss of
the natural transparency of the cornea, proceeding
rapidly to complete dirty white opacity, subse-
quently becoming total or partial slough, with
edges defined by the suppurative process, which
separates dead from living parts. The appearance
of abscess is later than that of slough, but, when
observed even in the slightest degree, should be
viewed with nearly equal apprehension, as it is
impossible to determine the extent to which it
may enlarge either in depth or breadth, while in
the state of abscess or that of ulcer. After the
more acute period has passed over without either
slough or abscess, the appearance of even a small

428

OPHTHALMIA.

speck of ulceration is also calculated to excite
alarm, as it is often most difficult to arrest the
progress of this process before it produces irre-
parable injury of the organ. After the patient is
relieved from apprehension respecting these de-
structive consequences, he should still be taught
to understand that his recovery is to be slow and
even doubtful ; the change of organization in the
conjunctiva, and its conversion into the peculiar
granulated condition, with permanent red vas-
cularity of the conjunctiva of the eye-ball and
opaque cornea, may still prevent recovery ; or even
without such disorganization, the cure may be
greatly retarded by the influence of scrofulous con-
stitution or the local disease. Mr. Lawrence says,
« of the fourteen cases which I have related, loss
of vision took place in nine from sloughing, sup-
puration, or opacity of the cornea. In two of
these one eye was lost, and the other recovered.
Sight was restored in the other five, with partial
opacity of the cornea, and anterior adhesion of the
iris in three of the number. So short a period
intervenes between the commencement and the
full development of the complaint, that in many
instances irreparable mischief is done to the eye
before our assistance is required. If we see the
complaint in the first or second stage, we may
expect to arrest its progress by active treatment ;
but success does not invariably attend our efforts.
Our prognosis will principally turn on the state of
the cornea ; if that should possess its natural clear-
ness, the eye may be saved. If it should become
hazy and dull, and more particularly if it should
have assumed a white nebulous appearance, con-
sequences more or less serious will inevitably
ensue. Great swelling of the conjunctiva, more
particularly great chemosis, profuse discharge of
a yellow colour, and bright redness of the swollen
upper eye-lid, are unfavourable circumstances, as
indicating a high degree of inflammation. When
both eyes are attacked in succession, the disease
is less severe in the second, which, therefore, is
usually saved. Sometimes, however, the inflam-
mation is equally violent in both."

In investigating the Causes of gonorrhceal
ophthalmia, inquiries highly interesting, even in
a general point of view, are suggested. It has
been supposed that the specific form of gonor-
rhceal inflammation existing in the urethra is
transferred to the conjunctiva by that obscure and
inexplicable transition which is denominated me-
tastasis, respecting which we know little more
than the fact of its occurrence. This metastasis
never has, and perhaps never can be proved to
occur, because there can be little doubt that the
contact of gonorrhoeal matter with the conjunctiva
produces the disease of the eye, and it is impossi-
ble to prove positively that such contact does not
take place in all cases of gonorrhajal ophthalmia.
Every individual affected with gonorrhoea must
have the fingers contaminated by the discharge,
notwithstanding the most scrupulous cleanliness
and care; and the application of the fingers to
the eyes for the removal of any irritation there is
so habitual, that it becomes an involuntary act,
which nothing but continued watchfulness could
prevent, and which may occur even during sleep
when the patient is unconscious of it. It is true
dial a person may be so attentive to the preven-

tion of this occurrence, by the utmost precaution
and cleanliness, as to render it highly improbable
that a particle of matter has been applied to the
eye ; but the attendant can only say in such case,
this is most probably metastasis of gonorrhoea to
the eye, but cannot safely assert positively that it
is so. While it appears thus impossible to say
with certainty that metastasis has occurred, it is
equally impossible to prove that it has not; and
many facts and arguments may be adduced in
favour of the conclusion that this is the mode in
which the disease originates.

The disease of gonorrhoea affords other appa-
rent examples of metastasis. The violent inflam-
mation of the testicle produced by suppression of
the discharge from the urethra is surely rather of
this character than an extension of the mucous
inflammation along the lengthened and tortuous
tube of the vas deferens. Irritable bladder, pro-
duced by the same cause, is also most probably
independent of a continuous extension of the
specific inflammation along the whole length of
the urethra to the lining membrane of that organ ;
and even sympathetic buboe generally presents
characters so different from that which arises from
the extension of irritation along the absorbents to
the lymphatic glands from simple injury, that it
is not unreasonable to attribute it to metastasis.
These metastases are of comparatively rare occur-
rence ; so is gonorrhceal ophthalmia, notwith-
standing the probability of the frequent applica-
tion of the matter to the conjunctiva or its vicinity.
The occurrence of the disease in one eye without
extending to the other, notwithstanding the pro-
fuse discharge so likely to come in contact with
the unaffected organ, makes it highly probable
that the disease depends on a cause different from
mere contact of infectious matter. Whatever
doubt may be entertained respecting the occur-
rence of metastasis, evidence sufficient to prove
that the disease can be produced by the contact
of gonorrhceal matter, both in the individual
labouring under the disease of the urethra as well
as others, is on record. Mr. Lawrence, Mr.
Wardrop, M. Delpech, Mr. Bacot, and others,
state instances in which there could be no doubt
of the fact. The writer of this has had this as-
signed as the cause of the disease by a young
man, who without any leading question or know-
ledge of the usual production of inflammation of
the eye by such a cause, stated circumstantially
the fact of gonorrhceal matter having been pro-
jected into his eye while retracting the prepuce,
which confined a quantity of the discharge. Dr.
Vetch details a solitary case in which the experi-
ment was made to determine this matter by an
hospital assistant ; and where gonorrhceal matter
was applied to the conjunctiva with impunity.
It does not, however, appear that Dr. Vetch him-
self conducted the experiment; and it is obvious
that much confidence could not be reposed in the
accuracy of an individual so imprudent and
thoughtless as to incur such a risk. While it
may be admitted that the contact of gonorrhceal
matter to the eye produces conjunctival inflam-
mation, it is by no means proved that it uniformly
has this effect. Some individuals may possess
this dangerous susceptibility, and others not ; and
even the same individual may at one time suffe'

OPHTHALMIA.

429

from the contamination, and at another time not.
Should it be established by observation that this
is the fact, it would be an important illustration
of the general question of contagion, proving
that a morbid poison directly applied to a circum-
scribed spot produces effects at one time and on
one person, which are not observed on other per-
sons or on different occasions. Upon a candid
consideration of this subject, it must be admitted
that it is the duty of the practitioner to warn
patients labouring under gonorrhoea, of the danger
they incur by negligence or inattention, with re-
spect to the precaution necessary to prevent the
communication of the disease to the eye.

With respect to the Treatment of gonorrhosal
inflammation, it is scarcely necessary to observe
that the plans suggested for the relief of common
severe purulent ophthalmia should be carried into
effect with the utmost vigour. Mr. Lawrence ob-
serves, in alluding to the advantage of depletion :
« The only chance of arresting this violent disor-
der, and preserving the eye from its destructive
effects, is afforded by the boldest antiphlogistic
treatment, particularly by the freest abstraction of
blood, locally and generally. We must bleed
largely from the arm, and take blood by cupping
on the temples, or by numerous leeches applied
round the part ; and these measures must be re-
peated at short intervals, until the vascular conges-
tion is relieved and the attendant pain removed.
The other parts of the antiphlogistic treatment
must be combined with the free abstraction of
blood ; but our great reliance must be placed on
the latter. I think that as much blood should be
taken from the arm as will flow from the vein ;
and that the evacuation should be repeated as soon
as the state of the circulation will allow us to get
more." Mr. Bacot and Mr. Wardrop concur in the
opinion respecting the value of depletion. Mr.
Guthrie, on the contrary, places little confidence
in its effects, and relies upon the application of the
ointment of nitrate of silver, as administered in
severe purulent ophthalmia. He even attributes
the loss of the organ in this disease to inordinate
bleeding : he says — " The history of all cases of
this disease, hitherto recorded, is but a melancholy
story of lost eyes, The reason of this loss is, that
they all pursued a similar plan of treatment ; viz.,
they invariably bled the patient to a very large
quantity; one hurJred, one hundred and fifty, and
even two hundred ounces, are stated as having
been drawn, until the patients were blanched as
white as a sheet, or a piece of white wax. This
was accompanied by a due proportion of purga-
tives, emetics, and emollient fomentations, with
mild, astringent lotions and leeches, until in time
the eye or eyes were lost, and the case was brought
to a conclusion. As long as I followed this course
I fared no better than those around me, but suc-
cessive failures led me at last, almost in despair, to
adopt a very opposite method, which has proved,
at least in my hands, much more effective, and
will, I trust, in those of others, remove the oppro-
brium which has been attached to this part of
surgery." He then proceeds to describe the mode
of application of the ointment of nitrate of silver
formerly alluded to, and observes, "I do not mean
to say that one application will alter the action,
and restore the parts to a healthy state ; it must be

re-applied ; neither is the ointment to do every
thing; it may, and must, of course, occasionally
fail." These conflicting opinions may perhaps be
reconciled. Bleeding is undoubtedly a resource
of the utmost value and importance in the general
treatment of gonorrhoeal ophthalmia, and the oint-
ment recommended by Mr. Guthrie is an applica-
tion also of value. The practitioner will therefore
avail himself of both, as circumstances require.
Even Mr. Guthrie, relying as he does on the sti-
mulating astringent, recommends moderate bleed-
ing in conjunction with it; and in the application
of the nitrate of silver ointment in common,
severe purulent ophthalmia, enjoins venesection
as an accompaniment. It is certain that a coarse,
brawny, plethoric, carnivorous man must be freely
bled to save his eyes from destruction in this com-
plaint; while a similar practice adopted towards a
pallid, languid, feeble individual, would prove at
least inefficient, if not injurious. The experienced
practitioner will, therefore, proportion his efforts to
the resistance, and adjust his treatment to each
case according to its symptoms.

It is unnecessary to repeat the observations re-
specting the treatment of severe purulent ophthal-
mia, except to remind the reader that they are
equally applicable to the form of disease under
consideration. It is obvious, however, from the
specific character of the gonorrhoeal inflammation,
that mercury, from its influence on disease at least
allied to this, deserves more consideration as a re-
medy in this than the common form. It is, how-
ever, notorious, that whatever necessity the prac-
titioner may see for the administration of mercury
to correct the mischief to be apprehended from the
specific disease, he cannot rely upon it to cut short
the inflammation. Mr. Lawrence says — " I have
seen both the ordinary purulent and gonorrhoeal
opthalmia proceeding apparently unchecked under
the full mercurial action." Some practitioners,
however, place reliance on this remedy, and some,
assuming as a matter of course that it ought to
cure the disease, administer it in every instance.
The writer of this, considering that mercury is a
poison which should not be introduced into the
system without absolute necessity, and positive
evidence of its beneficial effect in correcting mor-
bid action, feels no inclination to recommend its
administration in gonorrhoeal ophthalmia.

On the supposition that this disease depends on
metastasis, and relying on the unproved assump-
tion that it is accompanied by a suppression of
the discharge from the urethra, it has been pro-
posed to reproduce that discharge by irritating or
stimulating that passage. This resource has been
recommended by the German writers in particular,
who have perhaps weakened the confidence re-
posed in their opinions by practical men in this
country, by their proneness to mould practice on
preconceived theories and unauthenticated facts,
as well as by their reliance on antiquated doc-
trines, authorities, and nostrums. There is no
evidence before the profession to prove, either that
the discharge from the urethra ceases with the ap-
pearance of the ophthalmia, or that, if it does, its
restoration removes the affection of the eye. Mr.
Lawrence observes, after quoting the authority of
Richter, Scarpa, and Beer, as to the expediency
of reproducing the urethral discharge, " In spito

430

OPHTHALMIA.

of the confidence which one is inclined to repose
in the practical knowledge and judgment of those
whose advice has just been quoted, I cannot help
thinking that the measures in question have been
recommended rather on theoretical grounds than
from experience. At least these writers do not
mention any results of their own practice; nor
have I met with any cases in which the employ-
ment of such means is mentioned. In none of
the instances which ha-ve come under my own
observation has the gonorrhoea! discharge been
suppressed, so that the reason for this kind of
practice has not existed. Again, when the vio-
lence and rapidity of the disease are considered,
in contrast with the slowness and uncertain ope-
ration of this treatment, we cannot doubt that ir-
reparable injury would be done to the organ
during the time lost in such attempts.

Purulent Ophthalmia of Infants. — This is
a most formidable disease ; indeed it is probable
that the loss of vision from this cause is four
times greater than that from all the cases of com-
mon purulent and gonorrhceal ophthalmia put
together. It is particularly necessary that the
young practitioner, especially the accoucheur,
should be aware of this, because some writers de-
scribe the complaint as trivial, and its treatment
as attended with little difficulty. This opinion
has probably arisen from the circumstance of the
frequent occurrence of a very mild form of con-
junctival inflammation in new-born infants, un-
attended by any destructive consequences, and
generally disappearing without medical aid. The
disease now under consideration presents all the
characters of the severest purulent ophthalmia.
The vascularity is enormous, but in consequence
of the organization of the parts, and the yield-
ing of the texture of the lids at this early period
of life, there is less of chemosis than general
tumefaction of the coverings of the eye. The
pain, if a judgment may be formed from the ex-
tent of the inflammation and the sufferings of the
infant, is very great. The purulent discharge is
as profuse as in the worst forms of common severe
purulent or gonorrhoeal ophthalmia. The conse-
quences are equally formidable ; and destruction
or injury of the organ by slough, abscess, and
ulcer of the cornea, prolapse of the iris, staphyloma,
or escape of the contents of the eye-ball, equally
to be dreaded. There is one consequence, how-
ever, most destructive in purulent ophthalmia in
adults, not encountered here; this is the perma-
nent alteration in the structure of the conjunctiva,
proceeding to red vascularity of the transparent
part of the membrane, and granular lids. The
escape from this description of disorganization, of
such frequent occurrence at more advanced periods
of life, arises probably from the high degree of
vital energy and active operation of the functions
of growth and nutrition existing at this period.

The disease generally commences within the
first three days after birth. The eye first appears
moister than natural ; redness of the lids ensues ;
a small quantity of purulent matter collects in the
inner canthus ; the white of the eye is slightly
bloodshot ; and the child shuns the light and be-
comes restless and peevish. All these symptoms
are speedily aggravated ; the vascularity becomes
intense, causing tumefaction of the lids externally,

and a pulpy villous condition of them internally;
but the redness of the conjunctiva over the ball
seldom extends to chemosis. The purulent dis-
charge becomes profuse, completely glueing up
the lids during sleep, and often accumulating be-
neath them in such quantity as materially to
increase the distress ; and when the eyes are drawn
asunder, it so completely fills the space between
the lids as to prevent the observer from obtaining
a view of the cornea : it accumulates with such
rapidity, that if completely washed away with a
syringe, it is replaced by a fresh secretion in ten
minutes or a quarter of an hour. The discharge
is usually of the colour of common purulent mat-
ter, but is sometimes tinged with blood ; or if the
child be jaundiced, has a greenish tint. When
the infant cries, the tumefaction of the lids in-
creases enormously, and sometimes they become
everted, exposing the red vascular surface to the
air. This is the period at which the sloughing
process takes place ; it is well described by Mr.
Saunders in his Treatise on Diseases of the Eye,
published after his death by Dr. Farre. His
words are quoted here because they are obviously
those of an accurate observer enjoying ample
opportunity of acquiring correct information ; and
because they are the observations of the man who
first applied the sound principles of Hunterian or
English surgery to the investigation of ophthalmic
diseases. He says, " As the disease advances, the
cornea becomes more or less cloudy, and by the
extent of this cloudiness the degree of approach-
ing slough is marked : for the whole of the cornea,
if the whole become cloudy, will ultimately slough,
and the form of the eye be totally destroyed. I
do not mean to say that in every instance in which
opacity of the cornea is apparent, the cornea is
about to pass into a sloughy state ; on the con-
trary, opacity is often the mark of a healthy
action, commencing around the breach of the cor-
nea, for the purpose of restoring the part, and
ought to be hailed as a happy omen. I am now
speaking of a peculiar duskiness of the cornea,
which begins during the progressive state of the
inflammation, which is antecedent to any loss of
substance, but is indeed a sure sign that such loss
is about to take place. When this duskiness
comes on, supposing only a portion of the cornea
about to slough, the extent of it in the space of
twenty-four hours becomes definite; in the same
space of time it becomes elevated and apparently
lessened in extent ; a groove or fissure forms be-
tween it and the rest of the cornea, portions of it
are carried off by the discharge and tears, or some-
times it separates altogether in one mass. I have
several times washed out with a syringe these lit-
tle sloughs entire. But although I am as certain
of the fact as the most frequent observation can
make me, I am equally sure that most commonly
when this disease destroys vision, the destruction
is accomplished in a more gradual manner, not by
a slough of very considerable extent and through
the whole depth of the cornea at once, but by a
succession of sloughs. In other words, the ulcer
left by the casting off of the dead piece of cornea
becomes in turn sloughy, and extends itself by a
succession of sloughy surfaces, until the last
lamina of the cornea sloughs, or being protruded
by the pressure from within, ulcerates, and the

OPHTHALMIA.

431

aqueous humour escaping, the iris passes through
the breach of the cornea. Already the whole
surface of the eye has been in an ill-conditioned
inflammation ; the ulcer, or rather the surface of
the cornea, around the protruding iris is indisposed
to heal, so that more and more of the iris pro-
trudes ; this in turn ulcerates, and the crystalline
and vitreous humours all issue at the orifice.
That the inflammation itself immediately destroys
the parts by sloughing or ulceration is a truth of
which I am perfectly convinced."

Mr. Mackenzie, in his treatise on Diseases of
the Eye, observes with respect to these opinions
of Mr. Saunders, " It is scarcely necessary to
spend time in refuting Mr. Saunders's notion of
its being an erysipelatous inflammation. His opi-
nion regarding the mode in which the cornea is
destroyed in this disease appears of more import-
ance and equally incorrect. He maintains that it
is by sloughing, not by suppuration and ulceration,
that the destruction of the cornea is effected. The
opportunities which I have had of watching the
progress of the affection of the cornea have con-
vinced me of the contrary. Onyx or infiltration
of pus between the lamellae of the cornea is the
uniform harbinger of destruction ; the lamellffi ex-
terior to the pus give way by ulceration ; the ul-
cer spreads and deepens till the cornea is pene-
trated, and often almost altogether destroyed. Any
thing like mortification or sloughing I have never
seen. The coming away of the purulent infiltra-
tion exposed by ulceration must have given rise
to Mr. Saunders's notion of successive slough."

Whether the inflammation be erysipelatous or
not may be ascertained when pathologists have
determined what the term erysipelatous so applied
means. If the cornea ever sloughs in severe in-
flammation of the conjunctiva, it may be admitted
that it does so in this, especially if men of expe-
rience agree that such is the case. Mr. Mackenzie
is undoubtedly right in stating that the eye is lost
in this disease frequently by abscess ; and the fact
perhaps is, that the two processes are often com-
bined ; the dirty ragged ulcer consisting of open
abscess with sloughy surface, and being very
much of the character of anthrax. Whatever
opinion may be entertained respecting the precise
nature of the destructive process, the practitioner
should never lose sight of the danger to be appre-
hended from it. It commences during the active
period of the inflammation, but continues after it
is mitigated, and, if not arrested, terminates in
destruction of the organ.

The investigation of the causes of purulent
ophthalmia in infants is not attended with much
difficulty. It may readily be admitted that the
exposure of the infant to cold, immediately after
its expulsion from the uterus, will probably pro-
duce inflammation of this description ; and to
this cause may reasonably be attributed the fre-
quency of a milder form of conjunctival inflam-
mation at this time of life, which does not assume
the violent character of the other. The resem-
blance between this severe form and Egyptian or
gonorrha'al ophthalmia justifies the suspicion that
it is of equally distinct specific character, and to
be traced to a cause equally peculiar. This cause
may be the application of the matter of leucorrhcea
or gonorrhoea to the eyes during labour. The extent

to which this cause operates, however, has not
been fully ascertained, and the proof of its influence
exists more upon conjecture and reasonable infer-
ence than actual practical evidence. The practi-
tioner knows, from daily observation, that women
labouring under leucorrhcea and even gonorrhoea
produce children unaffected by this disease ; but
he should be equally aware that in the majority
of cases of purulent ophthalmia the mother la-
bours under one of them. The accoucheur should,
therefore, make himself acquainted with the truth
as to this matter, and direct that a sponge and
basin of warm water be ready to cleanse the face
and eyes of the infant immediately after birth,
and if possible before the lids are opened. If it be
known that the mother labours under gonorrhoea,
the practitioner should watch the approach of in-
flammatory action in the first three or four days
after birth, and immediately resort to those vigor-
ous measures already enumerated to arrest its pro-
gress. These precautions may possibly be super-
fluous, and disregarded or neglected in the common
routine of extensive practice ; but if one child be
preserved from blindness by them in the course
of a practitioner's life, it is sufficient return for
the trouble.

The Prognosis in this purulent ophthalmia is
a matter of considerable importance to the profes-
sional welfare of the practitioner. In consequence
of the frequent occurrence of the mild form of the
disease, those who have not experienced the de-
structive effects of the other are liable to overlook
its approach, and allow the process of slough or
abscess to proceed without interruption. As soon
as the disease has appeared in the virulent form
above described, the parents should at once be in-
formed that it is liable to terminate in serious in-
jury or destruction of the organ. Persons of the
lower order, unprovided with medical assistance at
their confinement, generally allow the disease to
proceed without interruption during the period at
which any hope could be entertained of averting
the destructive consequences. They seldom seek
relief until a week or fortnight after the first attack,
and then in consequence of not finding the puru-
lent discharge and tumefaction subsiding, as they
were led to expect. When an infant, at this pe-
riod of the complaint, is presented to the practi-
tioner, he should at once satisfy himself whether
the cornea be safe from slough, abscess, or ulcera-
tion, or, as this is attended with some trouble, if
leisure does not permit him to do so, he should
inform the parent in plain and intelligible lan-
guage, that there is danger to be apprehended, and
that the child may have its vision impaired or de-
stroyed by opacities of the cornea, which cannot
at the moment be perfectly distinguished. If he
dismisses the patient without this precaution, or
if he makes any application to the eye without
explicitly announcing the extent of the injury,
the reproach of having blinded the child will be
fastened on him by those who, from culpable neg-
ligence, ignorant confidence in their own opinions,
or sordid love of money, had caused so lamentable
a misfortune. If, upon examination in this after
period of the disease, the cornea be found perfectly
clear and free from ulcer of any kind, the practi-
tioner may entertain sanguine hopes of perfect
recovery, but he should not even then give ex

432

OPHTHALMIA.

pression to these hopes, as relapse may occur, or
some accidental circumstance interfere with the
cure. If slough, abscess, or ulcer have not taken
place in the first week or ten days, there is every
reason, from experience, to expect that no further
bad consequence is to be apprehended than the
troublesome and distressing vascularity with pro-
fuse purulent discharge, which often, especially if
not checked by astringents, continues for six weeks
or more. It has already been observed that the
high degree of vascularity which accompanies this
disease does not degenerate into permanent disor-
ganization of the conjunctiva with opaque cornea
and granular eyelids ; at least this is the result of
the experience of the writer of this article : fur-
ther observation may, however, enable others to
correct or modify this assertion.

To the Treatment of purulent ophthalmia in
infants, the principles laid down respecting the
other severe forms of conjunctival inflammation
are applicable. As soon as the existence of the
disease is fully ascertained, a leech should be ap-
plied over the cheek-bone at the edge of the orbit,
and blood allowed to flow until the effect of the
bleeding becomes obvious by the paleness or sick-
ness of the infant. One or two leeches, at most, on
each side, are sufficient for this purpose ; and as
all the effects of general bleeding are produced by
the application of leeches at the earlier periods of
life, and as the flow of blood does not usually
cease spontaneously in infants, on account of the
great vascularity of the skin, the medical attendant
should not lose sight of his patient until he has
secured such arrangements as will prevent the
possibility of the child's life being endangered by
hemorrhage. It is on this account that the leeches
should be applied on the cheek-bone at the edge
of the orbit, where, from the resistance of the
bone beneath, circumscribed pressure may be made
without delay. The bowels should be emptied
completely ; and for this purpose a grain of calo-
mel, with castor oil or any other purgative to
which the practitioner may be partial, may deserve
a preference. If it be admitted that the adminis-
tration of calomel influences the biliary secretion,
its use is particularly indicated at this period of
life, when the liver performs an office in the ani-
mal economy of still greater importance than it
does at more advanced periods. If the child con-
tinue to suck voraciously, it may be desirable to
rid the stomach occasionally of the accumulated
milk by the administration of a small quantity of
ipecacuanha or other emetic medicine. As soon
as the purulent discharge becomes profuse, care
must be taken to prevent it from accumulating
with the tears beneath the lids, and producing by
mechanical distension an increase of the irritation
and distress. This accumulation is frequently pro-
duced by the eyes becoming sealed up by the eva-
poration of the fluid part of the discharge which
has collected on the outside of the lids. To prevent
it, the eyes should be perpetually sponged gently
with lukewarm water, and by laying a scrap of
old linen squeezed out of warm water over the
ryes as the infant lies on its back in bed. The
edges of the lids may be touched with a little
cream wnen the child settles for a longer sleep,
drid when it awakes the lids should be gently
drawn open, and the accumulated matter forced

out by light pressure and motion of them. Re-
peated syringing of the eye is unnecessary, and
is often injurious by adding to the irritation : the
purulent discharge causes no mischief but by its
bulk producing distension in the way above stated,
and is probably the best, being the most natural,
protection of the surface against the contact of the
tears. When the practitioner makes his visit, it
is, however, necessary to wash away the discharge
completely, in order to obtain a perfect view of
the cornea ; this may be done with a syringe, for
which purpose a neat silver one with a fine orifice
should be used ; but as this may not be at hand,
and as many may not wish to run the risk of
spattering the discharge into their own eyes, a
more simple and equally efficacious method may
be adopted : the infant's head being laid on the
knees of the operator while the body is supported
by the nurse, the eyes should be well sponged ex-
ternally, and the lids drawn open and closed re-
peatedly, so as to extricate the discharge, which
should again be removed with the sponge. After
the child ceases to cry, a few drops of warm wa-
ter should be allowed to flow into the eye between
the lids out of a large camel-hair pencil, and the
lids opened and pressed as before, after which the
child should be, if possible, set asleep, and then
the eyes being suddenly drawn open, a full view
of the cornea may be obtained.

Local applications may be resorted to with two
objects — the alteration of the nature of the inflam-
matory action altogether, or the diminution and
removal of the purulent discharge. For the for-
mer object, the nitrate of silver is recommended,
and it cannot be denied that it may effect it ; but
it must at the same time be confessed that the
practice has not yet been fully submitted to the
test of experience. The question for considera-
tion is, whether a practitioner, as soon as he has
ascertained beyond doubt the existence of this
severe form of inflammation, can with safety, and
a fair prospect of advantage, introduce a solution
of nitrate of silver of ten grains to the ounce, or
an ointment of ten grains to the drachm, between
the lids. That this and other astringents may be
used with success to put a stop to the purulent
discharge, after the first symptoms of inflamma-
tory action have been subdued, cannot be doubted.
With this view, a five-grain solution of nitrate of
silver, or saturated solutions of acetate of lead or
alum, may be resorted to : the acetate of lead
cannot, however, be employed if slough or ulcer
be present. A large drop of saturated solution of
alum may be put into the eye once or twice in the
twenty-four hours, and the nurse may be allowed a
weaker solution of four or five grains to the ounce
to use occasionally. Mr. Mackenzie recommends
a solution of one grain of corrosive sublimate, in
an ounce of water, as a wash to be freely used.

If slough or abscess has taken place, it does not
appear that any other than the plan of treatment
above stated can be adopted, or that any local ap-
plication can be made likely to suspend the pro-
gress of either one or the other. Mr. Saunders,
reasoning on the fact that bark and other tonics
are employed with advantage in gangrene, and
that the slough of the cornea is of this character,
directed the administration of extract of cinchona
[ in such cases. It does not, however, appear that

OPHTHALMIA.

433

Ihe cases are analogous, or that the remedy does
actually prove of advantage. The slough, or ab-
scess, is, in the present case, a consequence of in-
tense inflammatory action, not followed by any
diminution of vital action, locally or generally,
consequently not requiring remedies intended to
invigorate the constitution, or accelerate the func-
tions of circulation and nutrition. The suggestion
of Mr. Saunders does not appear to have been
much acted upon in general practice. After the
slough of the cornea has been cast off, or the ab-
scess completely converted into healthy ulcer, or
if the iris be prolapsed and has assumed a red,
granulating appearance, the greatest service the
practitioner can afford his patient is, to prevent
any injudicious interference with the natural pro-
cesses of reparation which are in progress.

SciioiuLOUs Ophthalmia. — The consideration
of what is called scrofulous ophthalmia need not
detain the reader long, if it be admitted that there
is no inflammatory affection of the eye which dis-
plays at its onset such characters as entitle it to
be considered specifically distinct. In fact, there
does not appear to be any such disease, strictly
speaking, and what is commonly called scrofulous
ophthalmia is nothing more than the modification
of any of the preceding forms of conjunctival in-
flammation by that condition of constitution which
we denominate scrofulous. There can be no
doubt that every one of the preceding forms of in-
flammation, and indeed every form of inflamma-
tion of the eye, is liable to assume the scrofulous
character, except the purulent ophthalmia of chil-
dren, which is not so modified in consequence of
the organization of the system at that time of life.
The symptoms considered characteristic of scro-
fulous ophthalmia do not present themselves for
some time after the first attack, and when the in-
flammatory period has subsided, and the chronic
stage fairly set in : then it is that the progress
to recovery is interrupted; the conjunctiva does
not return to its natural condition ; light becomes
painful ; the tears flow copiously ; the purulent
discharge is diminished ; and the continued vas-
cularity causes opacity of, and extension of red
vessels to, the conjunctiva of the cornea ; [and,
according to Dr. Taylor, (Tweedie's Library of
Medicine, 2d Amer. edit., ii. 145, Philad. 1842,)
towards evening, especially after sunset, consider-
able remission of the symptoms takes place, which
had been aggravated through the day : a pheno-
menon which, according to him, is not observed in
any of the other forms of ophthalmia.] To cor-
rect this destructive condition, the obvious resource
is in those means universally admitted to exercise
a salutary influence on the functions of circula-
tion, secretion and nutrition. They may be sum-
med up in a few words : respiration of a pure at-
mosphere, warm clothing, generous diet, bark and
other tonics, warm, salt-water baths, and bathing
in the open sea. It is in this condition of the eye
that the chronic vascularity may be most effectu-
ally removed by the daily application of a satura-
ted solution of acetate of lead, or the aqua lythar-
gyri acetati dropped between the lids night and
morning. It is also in this modification of the
chronic vascularity, with great intolerance of light
and profuse scalding lachrymation, that the vinous
tincture of opium affords most relief. Blisterings,
Vol. III. — 55 2 m

which may be resorted to in any of the preceding
forms of inflammation, appear particularly ser-
viceable here, and should be repeated as often as
they heal, either on the temples, at some distance
from the eye, or behind the ears. Free exposure
of the eyes and face to the air and light is an im-
portant part of the treatment, although a part ge-
nerally neglected or actually interdicted. There
can be little doubt that the miserable condition in
which neglected or mismanaged children are fre-
quently found, with the face scalded with tears,
the head averted, and crying or sneezing on expo-
sure to light, is produced by confinement to a
dark, close room, and covering the eye with a
green shade. Arthur Jacob.

[It has been recommended recently by Dr.
Hocker, and by Mr. Wormald, (Lond. Lancet,
Nov. 19, 1842, p. 285,) to apply the solid nitrate
of silver to the eyelids. A clean stick of the
nitrate, having from one to two inches exposed,
is selected; the patient's eyelids are closed, and
put slightly on the stretch, by applying the
thumb of the left hand to the eyebrow, and gently
raising the skin ; the nitrate, moistened, is then to
be passed over the whole surface of the skin of
the upper, and, subsequently, of the lower eyelid,
two or three times, smoothly, and without much
pressure, bringing not the point but the sides of
the stick in contact with the skin. The object is
only to blacken, not to occasion any severer effects.
In this manner, it is affirmed, the sensibility of
the fifth pair of nerves is diminished, and the
lachrymation and photophobia are relieved. Si-
milarly good effects are stated by Dr. Furnival,
(London Lancet, Dec. 10, 1842, p. 405,) to re-
sult from painting the palpebra? of the affected
eye with the tincture of iodine, pure or diluted.

Variolous Inflammation of the Conjunc-
tiva. — Variolous pustules may form on the con-
junctiva, as upon any portion of the cutaneous
surface. In the opinion of some, however, the
eye suffers in small-pox from common inflamma-
tion merely, although of a very severe form. The
pustule appears, at first, as a small white point,
which gradually becomes elevated and yellow ;
and in spite of every care, if the pustule be over
the cornea, vision may either be wholly lost, or
impaired by opacity or ulceration. Where sup-
puration or sloughing of the cornea occurs, it
may be followed by the various lesions of the
eye-ball, more than once referred to. At times,
secondary variolous ophthalmia occurs at the
time when the pustules are disappearing from
other parts of the body. It is milder than the
variolous conjunctivitis just described, but may be
attended with mischief. It seldom, however, ter-
minates in destruction of the cornea. Opacities
are much more likely to be left. The period of
the attack varies from two to six weeks, after the
apparent termination of the primary complaint.

The Treatment is the same as in all severe
cases of ophthalmitis. General bleeding may be
required, or, if not, it may be advisable to take
blood locally. When pustules form, they should
be opened early, and be cauterized with the solid
nitrate of silver. The same application is advisa-
ble when they burst.

The secondary form of variolous inflammation

434

OPH r J HALMIA.

may require topical bleeding and cathartics, in

the first instance ; but afterwards an opposite
course is generally advisable, and the sulphate of
quinia alone, or associated with other tonics, may
De indicated Vinum opii and a solution of
nitrate of silver, or the solid nitrate of silver, are
amongst the best topical application.".

Inflammation may also attack other parts of
the eye.

Inflammation of the Sclerotica. — Inflam-
mation of the sclerotic coat of the eye does not
often exist alone; being either accompanied, from
the first, or speedily followed, by conjunctivitis.
The iris and cornea suffer to a certain extent,
although, unless from neglect or mismanagement,
serious alteration of structure in either is not
common.

Diagnosis. — Th-bre is a general bright redness
of the globe of the eye, especially around the
cornea, towards the margin of which the radiated
vessels of the sclerotica are seen advancing, and,
along with those derived from the conjunctiva,
passing over the cornea to the extent of about
half a line, forming a fine vascular wreath, which
encircles the cornea wholly or in part, and in
which all the vessels are observed to terminate
with sharp points, and at an equal height : none
pass beyond it, the rest of the cornea remaining
free. This arrangement and mode of termination
of the vessels has been considered, by Jiingken,
characteristic of rheumatic sclerotitis.

In the progress of the inflammation, the iris
becomes implicated, as indicated by contraction
of the pupil, easily seen by comparing the sound
with the affected eye : the iris, also, is less active
than usual. The capsule of the aqueous humour
is affected, giving occasion to haziness of the
cornea. The pain of the eye-ball is severe, and
of a stinging or darting character, extending to
the orbit, forehead, cheek, and occasionally along
the branches of the fifth pair of nerves to the
face. The pain is usually increased by warmth,
and is especially severe from sunset to sunrise.

There is always, along with those symptoms, a
considerable secretion from the eye ; but, instead
of its being mucous, as < in inflammation of the
conjunctiva, it consists of the secretion from the
lachrymal gland. Photophobia or intolerance of
light is always present, but it varies in degree in
different cases. The same may be said of the
constitutional irritation : fever almost always ex-
ists, but, at times, to a much greater degree than
at others.

The inflammation is often restricted to one eye,
and frequently alternates with rheumatic affec-
tions in other parts of the body. It also leaves a
strong predisposition to recurrence on the applica-
tion of slight causes.

The disease is not often seen in children and
old persons.

Treatment. — The treatment of sclerotitis
should be active, especially if the patient be
plethoric, and there be much constitutional irrita-
tion. Blood may have to be taken from the gene-
ral system, and the operation may be repeated
again and again, unless the symptoms are relieved.
Cupping and leeehes and blisters may also be
used, as in the forms of ophthalmia already con-
sidered. Cathartics may be prescribed as revel-

lents, and calomel and opium be administered, so
as to touch the mouth gently.

In regard to local applications, they should
generally be used warm. They may consist
simply of warm water, or warm milk and water ;
or warm decoction of poppy-heads. Warm opiate
frictions have been advised to the temple and
forehead, with the view of averting, or relieving,
the nocturnal paroxysm of pain. Warm lauda-
num, or warm wine of opium, may be used for
this purpose, or a liniment of soap with opium.
It has been advised, that these opiate frictions
should be used especially about an hour previous
to the expected attack.

Applications to the eye, in the form of collyria,
have not been found of much service, and those
that are excitant are injurious during the early
stages. When, however, the acute symptoms
have passed away, and a fortiori when they be-
come chronic, vinum opii — pure, or diluted —
dropped between the eyelids, is often beneficial.
In such cases, too, especially when they are asso-
ciated with evidences of a strumous diathesis,
tonics, as sulphate of quinia, or arsenic, may be
successfully administered.

Throughout the whole course of the disease,
the iris should be kept under the influence of
belladonna.

At times, the catarrhal and the rheumatic varie-
ties of ophthalmia are combined, constituting
catarrho-rheumatic ophthalmia ,• the presence of
which may be diagnosticated, from a knowledge
of the functional phenomena exhibited by the two
varieties respectively. The cornea is very liable
to suffer in this form of ophthalmia from ulcera-
tion, abscess, or interstitial deposition ; or the in-
flammation may extend to the iris, so as to termi-
nate in the effusion of lymph, and in obliteration
of the pupil.

More activity of treatment is required than in
sclerotitis ; and in addition to the remedies ad-
vised under the latter affection, the employment
of the local agents recommended in the catarrhal
variety is demanded.

Inflammation of the Coiinea. — Inflamma-
tion of the cornea is apt to form a part, by exten-
sion, of the different forms of inflammation of
the eye, that have already received attention.
Ceratitis proper, however, commences in the cor-
nea, whence it may spread so as to attain other
tissues. In many cases, it is simple, as where it
has been caused by any extraneous substance, as
a particle of metal imbedded in the substance of
the cornea ; or, what is considered by some to be
more common, it originates frequently in tHe scro-
fulous diathesis, and has been thought to merit
the distinctive appellation of strumous corneitis.

Diagnosis. — The disease generally com-
mences slowly, and insidiously, and the cornea
loses its natural brilliancy, and becomes dull and
hazy, — the surface appearing as if covered with
fine dust, or resembling glass that has been
breathed upon ; and, at a later period of the dis-
ease, it seems studded with minute depressions.
The fine vessels of the conjunctiva and sclerotica
become injected ; — those of the sclerotica, which
is the principal seat of increased vascularity,
being arranged in radii around the cornea, and
presenting a carmine hue : occasionally, too, tho

OPHTHALMIA.

435

vessels are so numerous over the corneal epider-
mis, as to form a vascular network, which covers
the entire surface, and has been termed pannus.
The pain attending inflammation of the cornea,
may be acute in the early stage, and be accompa-
nied by photophobia and by lachrymation. As
in other cases, too, it may come on in paroxysms.
In the chronic stage, it is not violent ; often, in-
deed, it is slight.

The terminations may be like those of other
forms of ophthalmia, — for example, interstitial
deposition ; ulceration ; protrusion of the iris ;
obliteration of the pupil; immobility of the iris;
adhesion of the iris to the cornea, &c. &c.

In all cases, the prognosis ought to be guarded ;
yet, division of the membrane by the knife gene-
rally heals without any inconvenience, as in the
operation for cataract by extraction ; and in cases
of penetrating and other wounds of the cornea,
we often see surprising recoveries.

Treatment. — In this there is nothing pecu-
liar. The general management, advised under
simple and strumous inflammation of the con-
junctiva, is equally appropriate here. Full anti-
phlogistic measures may be required in the acute
stage ; but it must be borne in mind, that the in-
flammation is apt to pass into the chronic form ;
when revellents — as blisters behind the ears, occa-
sional cupping on the nape of the neck, and mer-
cury administered so as to produce a revellent
impression on the mouth, with or without tonics,
as the case may seem to require, will be most ser-
viceable. The internal use of the oleum terebin-
thinae, (gtt. xx. — xxx. ter die,) has been found
serviceable in the strumous form.

Where the ceratitis is of some standing, it is
commonly accompanied by increased secretion of
the aqueous humour, 60 that the cornea becomes
more convex than natural. In such case, it has
been proposed to evacuate the humour by punc-
turing the cornea, with the view of relieving the
painful sense of distension ; and it is said to have
been practised with advantage by several practi-
tioners.

Sulphate of quinia, in conjunction with collyria
of nitrate of silver or sulphate of zinc, according
to Dr. Littell, (.4 Manual of the Diseases of the
Eye, p. 123, Philad. 1837,) evinces frequently a
remarkable control over vascular albugo, or that
form of the disease which is characterized by
lymphatic deposition.

Ixflammatiox of the Iris. — The iris may be
inflamed in consequence of the extension of in-
flammation from other parts of the eye, but it may
be inflamed also idiopathically ; and again, the
inflammation may be modified according to sy-
philitic, arthritic, or other complications. Hence,
various divisions of iritis have been made ; but
these are scarcely necessary, inasmuch as they
are indicated only by a knowledge of the history
of the case, or a careful examination of the pa-
tient.

Diagnosis. — Inflammation of the iris, what-
ever may be its cause or complication, presents
certain phenomena, some of which belong to
itself; others are common to it and to other forms
of ophthalmia.

Those that belong to the iris are loss of its
usual brilliancy, and change of colour. This

change is the result of a combination of the
natural colour of the iris with red blood, red blood
and yellow lymph mixed, or yellow lymph alone.

If the inflammation be seated in the serous
covering of the iris — Iritis serosa — the colour is
not changed, but is modified by the appearance of
a pale grayish coat, which gives a dull aspect to
the membrane. In serous iritis, consequently, a
blue iris may remain blue ; but the colour is ren-
dered dull. The structure of the iris also ex-
hibits change; its fibrous texture is no longer
observable, and tubercles or abscesses may form
in its substance. It also loses its contractility, so
that the pupil remains unchanged in size when
exposed to different degrees of light, and is gene-
rally contracted.

Along with these pathognomonic symptoms are
many which belong both to it and to other inflam-
mations of the eye. Thus, there is zonular red-
ness of the sclerotica, produced by numerous ves-
sels surrounding the cornea, and running towards
its edge : adhesions may also form between the
iris at its pupillary margin, and the capsule of the
crystalline ; and, in rare cases, it adheres to the
posterior surface of the cornea, and more or less
plastic lymph is effused into the anterior or poste-
rior chamber of the eye, or into both, giving rise
to imperfection of vision, and, at times, to total
blindness. Photophobia, lachrymation, and deep-
seated circumorbital pain, generally aggravated at
night, are present to a greater or less degree, ac-
cording to the severity of the inflammation. The
constitutional disturbance is often very considera-
ble, and the symptoms proceed at times so rapidly,
that vision is destroyed in a few days.

Such are the main phenomena of iritis, what-
ever may be the cause or complication.

Causes. — Along with mechanical injuries, and
other agencies concerned in the production of
ophthalmia in general, may be reckoned, — a con-
stitutional predisposition given by syphilis and
scrofula, and, perhaps also by gout and rheu-
matism ; hence we have, in many works, — acute
idiopathic iritis, syphilitic iritis, rheumatic iritis,
arthritic iritis and strumous iritis, as so many
subdivisions.

Treatment. — The first object in a case of
iritis is to subdue the inflammatory action, and
prevent the effusion of lymph. General blood-
letting should be prescribed immediately, and be
repeated according to circumstances ; blood may,
at the same time, be taken from the nape of the
neck by cupping ; and, along with this, cathartics,
nauseating doses of tartrate of antimony and
potassa, and the whole antiphlogistic treatment
and regimen advised under the most acute forms
of ophthalmia already considered, must be di-
rected. Where the disease is less severe, and the
constitution of the individual such as to render it
advisable to be cautious in the abstraction of
blood from the general system, cupping may be
trusted to, along with the general management
and regimen already inculcated.

The most approved method of treatment — after
bloodletting has been practised — is to administer
mercury so as to induce a revellent influence obi
the system, under which effusions of plastic
lymph are prevented, — or removed, if they already
exist.

436

OPHTHALMIA.

R- — Hydrarg. chlorid. mit. gr. xij.
Opii. pulv. gr. iij.
Glycyrrhiz. pulv. ^ss.
Confect. rosae. q. s. ut fiant pil. xij.
Dose, one, every four hours.

The effect upon the system is sufficiently evi-
denced by its touching the mouth. In some
cases, in which full salivation supervened, it ap-
pears, according to Dr. Taylor, (Tweedie's Li-
brary of Medicine, 2d Amer. edit. ii. 162, Philad.
1842,) to have acted like a charm. Still, so many
inconveniences are induced hy ptyalism from mer-
cury, that the remedy should not be pushed to
this extent, if the disease will yield without it ;
and especial care should be taken on this head, if
the iritis be accompanied by a strumous constitu-
tion. In such case, mercury may still be de-
manded, but it should be administered if possible
so as only to affect the constitution gently, and its
agency be kept up for a length of time. Should
salivation supervene in any form of iritis, no far-
ther good can, of course, result from the mercury,
until its effects have subsided.

To relieve the circumorbital pain, frictions with
any of the liniments recommended in the other
forms of ophthalmia may be had recourse to. An
ointment, combining a mercurial with an opiate,
has been strongly recommended.

Collyria are of little or no benefit; and the
various counter-irritants, employed in ophthalmia,
are of service only after bloodletting has been
actively premised. Oil of turpentine has been
extolled as an internal revellent, where mercury
is inadmissible.

To prevent contraction of the pupil, extract of
belladonna may be smeared over the eyebrow once
in twenty-four hours, or a filtered aqueous solution
may be dropped on the conjunctiva. When cau-
tiously employed, it gradually elongates the fila-
ments of lymph that have formed between the iris
and the capsule of the lens ; and, with this view,
its use may have to be continued for months.

In the iritis, which occurs in a constitution con-
taminated by the syphilitic poison, as well as in
the other forms referred to, — the same general
principles of treatment apply, and but slight
modification is necessary. In the rheumatic,
arthritic, strumous, and more chronic forms of
idiopathic iritis, sulphate of quinia is often bene-
ficial, but it should not interfere with the other
appropriate remedies, and especially with calomel
and opium.

Inflammation of the Choroid. — As an ac-
companiment of inflammation of other parts of
the eye, choroiditis has been admitted by all
writers on the subject ; but it has not been de-
scribed by all as an independent disease.

Diagnosis. — The following have been depicted
as the functional phenomena of inflammation of
the choroid. One of the earliest symptoms is the
formation of a blue zone around the cornea : this
is produced by thinning of the sclerotica, which
is succeeded by the protrusion of small tumours
of a dark bluish colour, varying in size, number
and position ; a watery effusion forms gradually
between the choroid and the retina, which pro-
duces absorption of the vitreous humour, and
compresses the retina into a cord-like substance,
simulating the appearance of deep-seated cataract

or malignant tumour of the optic nerve. Tho
pupil is often altered in shape, the iris immovable,
and the cornea opaque ; these symptoms arising
from the simultaneous inflammation of those va-
rious parts. Enlargement of the globe of the eye '
likewise results at times, and morbid changes,
which may render the extirpation of the organ
necessary. There is always more or less pain
and intolerance of light ; but the constitutional
symptoms are generally inconsiderable.

Causes. — Of these we know little. It is a
disease of the adult age, and is said to be more
frequent in females than in males, and especially
in those of a strumous habit.

Treatment. — This does not vary from that
recommended in iritis. Mercury does not, how-
ever, seem to be decidedly beneficial. After active
depletion, tonics, as sulphate of quinia, have been
found of great benefit, and as the disease fre-
quently occurs in strumous habits, their use is
generally indicated. The arsenite of potassa
\Liq. potass, arsenit. gtt. v. — viij. ter die) has
been advised by Mackenzie : (Practical Treatise
on Diseases of the Eye, 3d edit., 1840.) The
morbid appearances in the advanced stage, it is af-
firmed, have disappeared under its use, and health
and vision have been restored simultaneously.

When the eye-ball is tense and painful, and
there is a tendency to choroid staphyloma, punc-
turing the sclerotica and choroid, so as to evacuate
the contained fluid, has afforded relief.

Inflammation of the Retina. — This is an
uncommon affection, except as an accompaniment
of other forms of ophthalmia.

Diagnosis. — As the retina cannot be seen, the
existence of retinitis has to be inferred from dis-
turbance of function. The intolerance of light is
great ; shining spectra, of various kinds, are seen,
and there is a gradual impairment of vision; the
iris is motionless, and the pupil greatly contracted,
whilst the whole globe is highly sensible to the
slightest touch or movement. These symptoms
are usually accompanied by deep-seated pain in
the globe of the eye, which extends to the eye-
brow, and is often very severe, and accompanied
by symptoms of cephalitis. When the disease is
acute, the febrile excitement is often very great.

Extensive disorganization of the internal struc-
tures of the eye-ball is a common result ; and pu-
rulent effusion sometimes takes place, which may
augment to such a degree that the cornea gives
way, the pus is discharged, and the eye-ball col-
lapses.

Acute inflammation of the retina is less seen
than the chronic form, which is characterized by
intolerance of light, of different degrees ; impaired
vision, with ocular spectra, and, ultimately, by
immobility of the iris. It has been considered one
of the most common causes of amaurosis, and re-
quires the revellent treatment recommended under

that disease.

ROBLEY DUNGLISON-]

OSSIFICATION. See Tissues, Advesti-

TIOUS.

OTALGIA and OTITIS, (from ols, aurii,
gen. ures, and i\ylu>, doleoA Ear-ach; pain in
the ear. The ear-ach, which on all occasions re-
sults from a morbid congestion of some part of the
organ of hearing, cannot be intelligibly explained

OTALGIA AND OTITIS.

437

without first considering the affections of which
it is a symptom ; and as the diseases of the ear
have not yet been spoken of in this work, it is
proposed to give a concise account of them in the
present article.

Until the publication in 1821 of the admirable
Treatise on the Ear, by M. hard, of Paris, phy-
sician to the Royal Institution for the Deaf and
Dumb, the profession was in a deplorable state of
ignorance respecting the pathology of this organ ;
an ignorance which has been lamented by every
author who has taken up or happened to allude
to the subject. The situation of the organ deep
in the skull, the intricacy of its general structure,
the minuteness of its various parts, added to the
difficulty of tracing them in their bony case, and
the supposed obscurity and unmanageable nature
of its diseases, have all contributed to deter pro-
fessional men from bestowing their attention, as
well upon the anatomy as upon the pathology
of the ear ; and the consequence is a deplorable
want of knowledge on these subjects. This is
the less excusable, since the work of Itard affords
a very complete and masterly account, not only of
the diseases, but of the anatomy and physiology
of the organ. Itard, indeed, whose treatise cannot
be too highly praised, has done for the organ of
hearing what the illustrious Laennec has done for
the organs of respiration : and yet so little known
in this country are the labours of this author, that
in a small volume just now published on "The
Organ of Hearing," we do not find the name of
Itard quoted. The writer's attention was particu-
larly called to the ear many years since by the
occurrence of cases of chronic disease of the tym-
panum producing a purulent discharge from the
external meatus, penetrating the skull, and de-
stroying the individuals by disorganization of the
brain. Subsequent experience has only tended to
confirm the interesting and important nature of
the subject ; and it is with some degree of confi-
dence, therefore, that we invite the members of
the profession to study this department of patho-
logy. We can assure them that the path which
may appear intricate and impracticable, is so only
because it is untrodden and unfrequented.

The diseases of the ear may be conveniently
arranged, according to the anatomical division of
the organ, into those which are seated respectively
in the external, the middle, and the internal parts
of the ear.

The diseases of the middle ear are the ordinary
cause of otalgia, strictly so called ; on which ac-
count, as well as because they are the most fre-
quent and formidable, we shall enter upon the
consideration of them in the first place.

1. The middle ear comprehends the cavity of
the tympanum, with its contained chain of ossi-
cula, its proper membrana tympani and its de-
pendencies, the mastoid cells and Eustachian
tube ; all which parts, lined with a mucous mem-
brane, present an extensive continuous surface,
apt to be involved in the affections of the tympa-
num. Of the five openings leading to and from
the tympanum, three are closed, the fenestra ovalis
and fenestra rotunda by their proper membranes,
the large opening to the external meatus by the
membrana tympani ; while the other two are open,
the one leading to the Eustachian tube, the other

2m*

to the mastoid cells, — which cells, forming as they
do a cul-de-sac, leave the Eustachian tube the
only open channel of communication with the
tympanum from without. Hence it happens that
in inflammation of this cavity, it and the mastoid
cells become filled with the usual product of in-
flammation of a mucous membrane, a muco-puru-
lent effusion, which has no means of exit, because
the Eustachian tube, the only channel by which
it could escape, is involved in the inflammation
and closed by it. In this manner the delicate
fabric of the ear is exposed to the pressure and
other bad effects resulting from matter confined in
a close cavity ; and hence arise ulcerative perfora-
tion of the membrana tympani, puriform discharge
from the meatus externus, destruction of the organ
by caries, and eventually cerebral abscess and
death.

The inflammation of the cavity of the tympa-
num, like the inflammations of the other parts of
the body, may be intense, or it may be subacute.

a. The subacute internal otitis is an affair of
common occurrence, and constitutes the patholo-
gical condition of nearly all of those cases which
pass under the denomination of ear-ach. The
patient complains of pain in the ear, perhaps of
the head in some degree, accompanied with sing-
ing noises and dulness of hearing. There may be
a slight impairment of the appetite, which appears
to arise rather from the pain than from any febrile
movement, the sanguiferous system and the or-
ganic functions scarcely sympathizing in this
affection. In the corresponding side of the head
there is a susceptibility to the impression of a cold
atmosphere, which induces the patient to wrap up
the head ; with this precaution he is content to
bear the pain for several days, when it usually
subsides, leaving the sense of hearing less acute
for a short period ; after which the organ soon
recovers itself, and the affair is ended.

b. Very opposite to this are the symptoms, pro-
gress, and termination of the acute internal otitis,
or intense inflammation of the tympanum. This
inflammation is characterized by an intense, acute,
unremitting pain, deep-seated in the ear, attended
with loud, clanging, metallic noises, the pain affect-
ing the whole head, but in an especial manner the
side corresponding with the seat of the inflammation.
As the inflammation attains its height, so does the
pain in the ear become distracting, and excites noc-
turnal delirium ; and with this dreadful pain is a
sense of violent distension, as if the part were on the
point of bursting. The pain of the head is propor-
tionably aggravated, and attended with heaviness
and weight. The face manifests great anxiety
and distress; the constitution sympathizes deeply,
but the character of this sympathy is less marked
by the high febrile movement which usually ac-
companies inflammation, than by great general
exhaustion, the effect of continued pain. The
pulse is frequent, but not remarkable for fulness
or strength, nor is there much increase of heat ;
nevertheless all the organic functions are troubled,
and the tongue is furred, the taste vitiated, and
the appetite lost.

This state of things having persisted for twenty-
four or thirty-six hours, the inflammation begins
to decline, the pain to diminish in intensity, and
the metallic noises change to a violent hissing ;

438

OTALGIA AND OTITIS.

the sense of distention and of bursting continues
though in a less degree, but the delirum passes
away, and the pain and uneasy sensations of the
head gradually subside. The taste and appetite
return quickly, and the patient is soon convales-
cent; though the hissing in the ear and the sense
of distension and bursting are troublesome for two
or three weeks, and various noises are perceived
occasionally for some months. The organ, how-
ever, recovers its proper function, but slowly ; the
patient experiencing an indistinctness of hearing,
often of sight, for a considerable period.

Such is the happiest termination of an acute
inflammation of the middle ear.

Instead of this termination in resolution, if the
violent symptoms, present at the height of the in-
flammation, do not abate, the sense of distension
increases to a most painful degree, the general
headach continues urgent, and the delirium mani-
fests itself at times by day as well as at night, and
in the course of two or three days matter is ob-
served to discharge from the ear. In this case the
cavity of the tympanum has become filled by a
puriform fluid, the product of the inflammation,
which has effected a passage by ulceration through
the membrana tympani, and is discharging itself
by this channel.

Should the perforation of the tympanum be
large, and the discharge free and copious, then
the fever and other urgent symptoms quickly sub-
side, and a chronic puriform discharge, the otor-
rhea purulenta, is established. Should the per-
foration be small and the discharge trifling, it
proves insufficient to relieve the sufferings of the
patient ; the distressing signs of matter confined
in the middle ear continue ; and now it becomes
the duty of the practitioner to recommend an
operation to enlarge the opening in the mem-
brana tympani. If a free outlet is thus accom-
plished, complete relief is afforded; the puriform
discharge becomes abundant ; and, as in the for-
mer case, an otorrhoea is established.

The establishment of the purulent otorrhcea is
not always preceded by a form of irrflammation
so acute as that described ; it is often brought
about gradually by a subacute otitis of a chronic
kind, in which case the symptoms are less severe,
are more confined to the ear itself, and the perfo-
ration of the membrana tympani is slowly effected.
This consecutive affection deserves further notice.

[It may happen, that the abscess, when it
breaks, is discharged through the Eustachian tube
into the throat. According to one observer, M.
Itard (il/e'/n. de V Academ. Royal de Med., torn. v.
fasc. iv. Paris, 1836,) this occurs in about one
case in ten. The patient feels the pus passing
down the tube, and ejects it at times in considera-
ble quantity.

The lining membrane of the cavity of the tym-
panum is fibro-mucous, — or at once a mucous
membrane, and a periosteum ; and it has been ob-
served, that the membrane has been the seat of a
blennorrhrjeal inflammation in its outer layer, and
of a more violent inflammation, like the one de-
scribed above, in its inner layer. In the former
case, the mucus may be secreted in such quan-
tity as to impede the entrance of air through the
Eustachian tube into the middle ear, and thus
cause deafness. Where the mucus exists in any

quantity in the middle ear, it may be detected by
catheterism of the Eustachian tube, which has,
accordingly, been employed not only in the way
of diagnosis, but of therapeutics. Air douches are
used for this purpose by means of an apparatus,
which the writer has described elsewhere; dill'er-
ent sounds being rendered according to the pre-
cise condition of the cavity. (Deleau, Sur le Cathe-
terisme de la Trompe d'Eustache, Paris, 1828 :
Itard, Op. cit.: Kramer, On D incases of the Ear,
Amer. Med. Lib. edit. Philad. 1838; or the writ-
er's New Remedies, 4th edit. p. 366, Philad. 1843.]

Otorbhoea Puiiulexta, a purulent discharge
from the external meatus, may arise from some
disease of the meatus itself as a porriginous affec-
tion of the lining membrane of the tube ; in this
case the affection is of little importance. The
otorrhoea about to be described proceeds from the
middle ear, is the result of a suppurative inflam-
mation of the tympanum with perforation of the
membrana tympani, and is a very serious com-
plaint. Inflammations of the tympanum having
terminated in suppuration, and the matter having
worked itself an outlet, it may be reasonably sup-
posed that all diseased action would subside and
cease ; and such, no doubt, would be the favour-
able issue, were it not that, from the peculiar con-
formation of the organ, part of the matter is re-
tained in the cavity of the tympanum and mastoid
cells, and thus becomes a cause of extensive mis-
chief.

The opening of the Eustachian tube being
situated at the anterior and internal angle of the
floor of the tympanum, may appear to offer a
natural and depending outlet to the retained mat-
ter ; but this channel is either closed altogether or
much obstructed by its lining membrane having
been involved in the inflammation ; and although
a free outlet may have been formed by the perfo-
ration of the membrana tympani, yet some matter
is still retained in the cavity and in the mastoid
cells. It is retained in the latter because they
form a blind irregular cavity ; and in the tympa-
num because of the peculiar form of the meatus
externus, which being arched, and having the
crown of the arch on a level with the middle of
the tympanum, resists rather than favours the
spontaneous emptying of the cavity. Under these
circumstances the matter lodges in the tympanum
as in a well, and gives rise to a train of formida-
ble symptoms which constitute the second stage
of the disease.

The perforation of the membrana tympani giv-
ing access to the air, the retained matter under-
goes decomposition, becomes highly irritating, and
induces ulceration of the lining membrane of the
tympanum and mastoid cells ; the osseous struc-
ture is now exposed to the influence of this irri-
tating matter, and a carious disorganization com-
mences. The insidious advance of the caries is
indicated by a dull pain seated principally in the
region of the middle ear, but diffusing itself over
the corresponding side of the head, by the sense
of hearing being blunted, and by a dull and rather
vacant expression of the countenance.

The disorganization proceeds more rapidly in
the mastoid cells than in the tympanum, because
of their less compact structure, and is made ap-
parent by the mastoid process becoming tender on

OTALGIA AND OTITIS.

439

pressure, and the integuments puffy and vascular ;
by-and-bye the perforation of the bone is com-
pleted, and an abscess manifests itself behind the
ear. The point where the carious perforation
happens is usually at the anterior part of the
groove which gives origin to the digastric muscle.
The abscess docs not burst readily, but extends
itself upwards behind the ear, the soft parts offer-
ing less resistance in this direction ; examples,
however, occur, in which the abscess directs itself
downwards under the sterno-mastoideus when it
points low in the neck ; it never extends back-
wards, because of the resistance of the digastric
and trachelo-mastoid muscles and of the deep
cervical fascia.

The caries of the mastoid cells is not limited to
this outward direction, but extends on every side,
and next affects the posterior wall of the cells,
and perforates the petrous portion of the temporal
bone which forms the fossa of the lateral sinus :
the bone is here naturally thin, and, when carious,
presents a worm-eaten appearance. Through these
carious perforations the matter penetrates, and by
irritating and detaching the dura mater, gives
rise to decided cerebral symptoms. The same
process sometimes goes on in the roof of the
mastoid cells formed by the superior surface of
the petrous portion ; but the bone being here
thicker is less easily perforated. Should the pa-
tient still live, the caries will destroy the chain of
ossicula in the tympanum, and they will be dis-
charged through the external meatus ; eventually
the caries will ravage the whole internal ear, de-
stroying the membranes which close the fenestra
ovalis and the fenestra rotunda, and disorganizing
the vestibule, semicircular canals, and scalse of the
cochlea. In this way all the sinuosities and cavi-
ties and bony fabric of the ear are broken down
and confounded together, and the interior of the
petrous portion and of the mastoid process of the
temporal bone presents one large carious ex-
cavation.

To such an extent did the disorganization pro-
ceed in the case of a child two years and a half
old, that the entire labyrinth, consisting of the
semicircular canals and cochlea, was discharged
by the meatus externus. In this instance the
course of the disease was marked by the various
stages of inflammation of the internal ear, suc-
ceeded by the chronic puriform discharge, by the
dislodgemcnt and evacuation of the ossicula of the
tympanum, and, lastly, by the coming away of
the labyrinth itself through the meatus externus,
occupying in the whole a period of several months.
(This case is detailed more at length in Mr. Tod's
work on the " Organ of Hearing," p. 134.)

In the course of the devastation above described,
the portio dura becomes also involved, and the
disorganization of this nerve gives rise to neuralgic
pains, convulsive twitchings, and paralysis of the
muscles of the corresponding side of the face.

At the period when, in the progressive caries
of the temporal bone, the dura mater becomes ex-
posed to the irritation of the corrupt secretion from
the ear, the membrane inflames and suppurates,
and becomes detached by the matter burrowing
between it and the skull ; the patient is then
sometimes carried off at once by meningitis, or
the destructive process may proceed and induce

ulceration of the dura mater and other membranes,
and, finally, of the brain itself. The ulceration
of the brain may be superficial, or may penetrate
deep into its substance and form a suppurating
cavity, having the aspect of an abscess, which
will in some cases occupy the whole of the middle
lobe of the corresponding hemisphere, or the cor-
responding lobe of the cerebellum.

While the disease is confined to the ear, the
sympathetic pain in the head radiating from this
organ is the most marked symptom ; but as soon
as the membranes of the brain become involved,
the cerebral signs predominate and obscure the
original disease. The patient, who probably
hitherto has been in the hands of the aurist, is
now transferred to the care of the physician, who,
finding the signs of cerebral disease marked and
decided, will often fail to trace them back to the
ear as their origin, and therefore regards the case
as an idiopathic cerebral affection. Nor is the
error always cleared up by dissection, because the
morbid appearances in the brain present a satis-
factory cause for the violent symptoms and fatal
termination, and the caries of the temporal bone$
which is less conspicuous on the cerebral surface,
either escapes notice, or is concluded to be the
effect of the cerebral disease. This, we are per-
suaded, is no uncommon case, having ourselves
seen it happen to persons much accustomed to
morbid dissection.

The slow carious disorganization of the ear
may be a work of many years before it reaches
the brain, during which period the puriform dis-
charge from the external meatus varies much in
quantity, particularly if the Eustachian tube is
not altogether closed, the discharge being at one
time profuse by the meatus externus, at another
taking place by the tube into the throat. This
latter effect is manifested by an offensive dark
matter being mixed with the sputa, and which,
collecting in the pharynx during sleep, is hawked
up in the morning in considerable quantity. At
times the discharge is suppressed, as when the
patient takes cold in the ear ; then otalgia super-
venes, with headach and more or less of sym-
pathetic fever, all which signs are relieved by a
return of the discharge. Attacks of this nature
are frequent.

The gradual disorganization is seldom attended
with dangerous symptoms, so long as it is con-
fined to the ear ; but the moment it has reached
the membranes of the brain, pain in the head be-
comes the prevailing symptom, and it is no longer
referred to the ear as its cause. If now, from any
accidental cause, the otorrhoea is suppressed, the
patient experiences an inflammation of the mem-
branes of the brain more or less severe ; [ Cerebral
Otorrhoea.'] The more extensive the disorganiza-
tion, the more severe is the attack, and the more
dangerous. Some patients survive many such
attacks, and die exhausted by long suffering, while
others are cut off* by the attack which supervenes
on the disease first penetrating to the dura mater.
In this case, dissection will discover traces of in-
flammation of the detached membrane, with a lit-
tle pus effused between it and the skull. A sym-
pathetic but fatal inflammation of the membranes
of the brain may occur at the period of the forma-
tion of the external abscess at the root of the

440

OTALGIA AND OTITIS.

mastoid process, of which we have seen an
example.

It is at one of these periods of the supervention
of a meningitis that the physician is called in, and
his first impression of the complaint, as we have
already stated, is apt to favour the idea of an idio-
pathic inflammation of the brain, the patient and
friends directing his attention to the cerebral signs
without alluding to the affection of the ear, they
themselves not being aware of their connection.

"The Diagnosis in such cases is very import-
ant, inasmuch as the bloodletting required to save
the patient in the one instance would destroy him
in the other.

In the sympathetic inflammation of the mem-
brane of the brain, in cases of otorrhcea, there are
prominent local signs as regards the head ; there
is a deep-seated, severe throbbing pain in the mid-
dle of one side of the head, with great tenderness
of the scalp on the same side, which prevents the
patient lying upon it ; there is no marked suffu-
sion of the face and conjunctiva ; the expression
of the eye is rather dull; the delirium is little ac-
tive, and is complicated with heaviness of the
head, and some stupor ; the fever is not severe in
proportion to the local signs, nor is the force of
the circulation great, the pulse being rather tight
than full, and rather sharp than strong ; the fever
is moderate in the day, with a marked exacerba-
tion at night.

In the idiopathic inflammation of the mem-
branes of the brain, on the other hand, instead of
local pain, there is a sense of constriction over the
whole head, without tenderness of the scalp ; the
suffusion of the face and conjunctiva is very
marked ; the eye vivid, the delirium violent, without
heaviness of the head or stupor ; the fever runs
high, and though it may have exacerbations, it is
continually urgent, and the force of the circula-
tion is decided, the pulse being full and strong.

These distinctions cannot fail to strike the phy-
sician, if he is cautious and circumspect in form-
ing an opinion.

The Cause of the otorrhcea is invariably an
inflammation of the tympanum, which may be
excited by a current of air playing upon the side
of the head, or may arise, as it more frequently
does, from the spreading of inflammation by the
sympathy of continuity from the throat along the
Eustachian tube. Hence the origin of the disease
is often referred to the period when the patient
had the small-pox or scarlet fever. The deafness,
which is a common consequence of the scarlet
fever, is produced in this manner.

Treatment, — In speaking of the treatment of
the affections of the ear, described in this article,
viz., of the otalgia, the otitis interna, the otorrhcea,
and of the occasional attacks of inflammation
which supervene on the otorrhcea, all which affec-
tions are stages of the same disease, we cannot do
better than retain the order already adopted, it
being the one in which these stages naturally suc-
ceed each other.

It is scarcely necessary in this place to advert
to the means of relieving the otalgia, or ear-ach,
which has been shown to depend on inflammation
of the tympanum, more or less acute; we shall
therefore pass on at once to the treatment of the
otitis interna, reserving what few remarks we

have to offer on the cure of otalgia for the conclu-
sion *€ this article.

Treatment of the Acute Internal Otitis.— This
intense inflammation of the tympanum can be
controlled only by very decided antiphlogistic
measures, adopted without hesitation or delay, the
object being to arrest the inflammation, and, by
procuring its resolution, to prevent all those disas-
trous consequences which accrue from its termina-
tion in suppuration.

In detailing the symptoms of this otitis, we
stated that the local signs of pain and so on were
intense, while the general febrile movement,
though fully developed, was not urgent in an
equal degree ; and as we hold it to be a principle
in the treatment of all diseases, that the more the
local signs exceed the general, the greater will be
the relief from local depletion, we shall be guided
by this principle in our recommendation of the
treatment to be pursued. In place, therefore, of
relying chiefly on the abstraction of blood from a
vein, we urge the free and repeated application of
leeches to the ear affected ; premising, however,
that one bloodletting should be practised to an
extent consistent with the age, sex, constitu-
tion, and spare or plethoric habit of the patient.
Let blood, then, be first drawn from the arm, or
from the external jugular vein, which is preferable,
to the amount of ten, fifteen, or twenty ounces,
according to the circumstances above-mentioned,
and, guided by the same circumstances, let it be
followed up by leeches applied over the mastoid
process of the ear affected, to the number of from
six to eighteen. Repeat the application of leeches
once in six hours at least ; and that time may not
be lost, let a blister be placed on the nape of the
neck, which will leave the region of the ear free
for the use of more leeches, if required. Fomen-
tations can seldom be borne early in this inflam-
mation i they accumulate heat, and aggravate the
sufferings of the patient ; nor is any medicament
to be introduced into the external meatus for the
same reason. In addition to the abstraction of
blood, and to the counter-irritation, an active ape-
rient, consisting of calomel and jalap, in the pro-
portion of four grains and ten, or of a dose of
calomel, quickly followed by a purging draught of
ten drachms of infusion of senna and two drachms
of tartrate of potash, should be administered;
and in the course of four hours give one or two
grains of calomel, with a quarter of a grain of
tartarized antimony, every two hours through the
first day, and every three or four hours through
the second, when it will generally be necessary to
omit the antimony, on account of the exhausted
powers of the patient ; the calomel to be con-
tinued in such quantity and as frequently as the
then existing symptoms demand, remembering
that, next to the abstraction of blood, our main
reliance is to be placed on the mercury to procure
the resolution of the inflammation. Opium is not
admissible in any form or quantity ; it distracts the
patient.

If by this treatment the urgent signs should
gradually abate and the inflammation pass away,
the patient's appetite will quickly return, and a
speedy convalescence be established. If, however,
the symptoms do not yield to the vigorous treat-
ment adopted, it is to be feared that suppuration

OTALGIA AND OTITIS,

441

of the tympanum will ensue, which will be further
indicated liy the increase of the sense of bursting
of the part, by the throbbing character of pain,
the delirium, and general headach. Fomentations
and poultices may now be had recourse to ; the
anti-inflammatory measures should be relinquished;
and as soon as the ulcerative perforation of the
membrana tympani has been effected, and the
matter begins to discharge itself by the external
meatus, the powers of the patient should be sup-
ported by ammonia, and sleep procured by opium.

If, with the discharge from the meatus, the
throbbing pain, sense of distension, &c. do not
manifestly and speedily subside, it is to be con-
cluded that the perforation of the membrana tym-
pani is too small to admit of the free exit of the
matter, and an operation to enlarge the perforation
is at once to be contemplated ; and being effected,
the sufferings arising from the matter hitherto
confined in the cavity of the tympanum will be
alleviated, a copious discharge ensured, and an
otorrhcea established.

[In cases of blennorrhceal otitis of the middle
car, it has been advised that the air douche should
be employed ; and if a slight mucous rait be heard,
on applying the car to that of the patient, whilst
the air is streaming in, followed by a material im-
provement in the hearing, which may be ascertained
by the distance at which he hears the ticking of a
watch, it has been advised, that it should be em-
ployed daily. Should no improvement, however,
in the sense of hearing take place after the fourth
sitting, it has been considered that the attempt
should not be persisted in.

The careful introduction of the catheter into
the Eustachian tube may be necessary in this va-
riety.]

Treatment of the Otorrhcea. — In the foregoing
part of this article, we have remarked the untract-
able nature of the chronic puriform discharge from
the ear, and that its dangerous tendency depends
on the decomposition and retention of the matter
in the cavity of the tympanum, that cavity, owing
to its peculiar construction, holding the matter as
in a well. The indication, therefore, in the treat-
ment is to prevent this lodgment of the irritating
matter, and the manifest and only means of ac-
complishing this end is by cleansing the cavity of
the tympanum by the aid of injections. As to
the composition of the injections, it matters little ;
warm water or milk-and-water will answer the
purpose as well as any thing more medicated.
Care must be taken in the first use of the injec-
tion, which should be administered without much
force until the parts are become habituated to it,
otherwise a shock from the syringe might be very
distressing to the patient. Should the discharge
persist and become chronic, then astringent injec-
tions would be very proper. Itard recommends
the caustic potass dissolved in rose-water. The
sulphate of zinc offers a good remedy, so does the
nitrate of silver ; the proportions to be weak in
the first instance, and increased in strength as cir-
cumstances indicate.

Although the injections may not be effectual in
restraining or curing the otorrhcea, they have the
power to counteract its destructive and dangerous
tendency to disorganization, an apposite illustra-
tion of which we are able to furnish in the case

Vol. III. — 56

of an old lady, now near seventy years of age,
who has been affected with otorrhcea from both
ears, and deafness, since she had the scarlet fever
in childhood, and who, by the daily injection of
warm water, has preserved the organs from further
disorganization, and has escaped the disastrous
effects and premature death which a progressive
caries inevitably leads to.

[It is proper to remark, that it is extremely-
common to find persons pass through a long life,
who have been subject, from infancy perhaps, to
discharges from the middle ear, and who make
use of no injections whatever. It is important, in-
deed, to be cautious in the use of astringent injec-
tions especially, where the otorrhcea has persisted
long, inasmuch as a sudden suppression of the
accustomed secretion — although morbid — may
give occasion to the transference of the irritation
elsewhere, and, it may happen, to parts of greater
importance. In all cases, it is essential to attend
to the constitutional condition, and if there be
evidences of a strumous complication, as there
often is, the tone of the system must be improved
by remedies that are adapted for scrofulosis, and
especially by the use of iodine — as the iodide
of iron — singly or combined with appropriate diet„
change of air, &c.

Where it is not considered advisable to inter-
fere actively with the discharge, the disagreeable
fcetor, as elsewhere remarked, may be very much
diminished by appropriate injections of a disinfect-
ant nature — as of weak solutions of chlorinated
lime or chlorinated soda. {Practice of Medicine,
2d edit., ii. 361, Philad. 1844.)]

Treatment of the attacks of inflammation
which occasionally supervene on the chronic otor-
rhea. — The violence and danger of these attacks
will be proportionate to the extent of the caries of
the ear and the disorganization of the membranes of
the brain at the period of their occurrence. While
they affect the ear only, they need not excite
alarm, because they subside in a few days by the
application of leeches to the mastoid process, and
by mild antiphlogistic measures. But when the
disorganization has extended to the dura mater
and brain, the inflammation affects these parts in
common with the ear, and the symptoms assume
a very formidable aspect. Yet it must be remem-
bered that the cause of these attacks is the check
given to the discharge either by cold or accidental
obstruction, and that, therefore, the symptoms of
the cerebral affection are more or less sympathetic,
and partake of those of irritation. There is a
train of actions set up in the brain depending on
a local cause, which cause being done away, the
undue actions subside. For this reason every
means must be sedulously adopted to encourage a
return of the discharge, as fomentations and poul-
tices to the side of the head, and bloodletting must
be employed only so far as to restrain the inflam-
mation within limits consistent with life ; for if
blood is drawn ever so freely, it cannot put an
end to the attack, as in an idiopathic meningitis,
and it will sink the patient as soon as the discharge
returns. In these cases mercury is not 'tviuhed ;
it is worse than useless if carried to any extent. In
every attack of this nature the practitioner should
not neglect to examine the affected side of the
I head attentively, as such an attack is apt to super-

442

OVARIA, (DISEASES OF THE)

vene at the period of the formation of an abscess
behind the ear from the carious perforation of the
mastoid process. Should an abscess be discovered
in this situation, a very free perpendicular incision
is to be made, not only down to the process, but
through the carious walls of the process itself into
the cells, and relief will be immediately afforded
to the cerebral symptoms. The writer was once
called to a case of this description, which had been
viewed and treated as an idiopathic phrenitis,
when he discovered a large abscess presenting
behind the ear ; it was opened, and discharged a
quantity of most offensive pus. The patient was
relieved, but she sunk from the copious bloodlet-
tings practised under the erroneous diagnosis of
cerebral inflammation.

In one case in which a free opening was made
into the mastoid cells by incision, as we have ad-
vised, a spontaneous cure of the otorrhoea followed.

The administration of injections in the chronic
otorrhoea must not be adopted without some pre-
caution ; not without first estimating the extent
of the carious disorganization ; for should this
have penetrated the skull, and a fluid be forced
into contact with the dura mater, or this being
ulcerated, into contact with the brain, a fatal in-
flammation would be the result. The extent of
the disorganization may be determined correctly
by the character of the symptoms. While the
disease has not extended beyond the ear, the suf-
ferings are referred to this organ by the patient,
the pain being deep seated in the ear, and radiating
from it over the side of the head ; but as soon as
the dura mater and brain are involved, the signs
of cerebral affection predominate, the complaints
now being all referred to the brain. This diagnosis
will be a safe guide, and should be borne in mind.
The disease being limited to the ear, will be bene-
fited by the use of injections, and further mis-
chief may by them be probably guarded against ;
but when it has reached the brain, injections are
not justifiable.

The treatment of the otalgia does not call for
any particular measures further than such as are
appropriate to the relief of the inflammation, be
it subacute or acute, of which the otalgia is a sign.
The remarks it is of consequence here to make
are, that the otalgia, or ear-ach, is indicative of an
inflammatory congestion of the tympanum, which
should not be neglected however trivial it may ap-
pear. Though the patient may not estimate the
importance of an ear-ach, the practitioner should
do so, and not be content until he has removed it
by the application of leeches to the mastoid pro-
cess, by aperients and so forth; not trusting to
popular remedies placed in the meatus, but reject-
ing them ; and taking a proper pathological view
of the nature of the affection, of the dependence
of otalgia on inflammation of the tympanum, he
should combat it by appropriate remedies accord-
ingly, and so preserve the patient from impair-
ment of the sense of hearing, or from that disor-
ganization of the ear of which even a very sub-
acute otitis may be the unsuspected forerunner.
John Burne.

OVARIA, DISEASES OF THE.

I Of the Structure and Functions of

the Ovahia. — In the human subject, after the
age of puberty, the ovaria form two oblong flat-
tened bodies, about an inch and a half in length,
which are situated on the sides of the uterus in
the posterior duplicatures of the broad ligaments.
They are placed a little below the fallopian tubes,
near the superior angles of the uterus, to which
they are fixed by a short ligament. Their surface,
except at the inferior margin where the blood-
vessels enter, is smooth and convex. In the foetus
at the full period, the ovaria form long, slender
bodies of a prismatic form, and are placed above
the brim of the pelvis. In advanced life, they
become hard and shrivelled, with deep irregular
fissures in their surface.

Each ovarium consists of a peritoneal coat, and
a dense fibrous or parenchymatous structure. In
this latter texture are imbedded from twelve to
twenty vesicular bodies of various sizes, which are
named, from their supposed discoverer, the Graafian
Vesicles, or Ovula Graafiana. They are composed
of a fine membrane, which is separable into two
layers, and contain within their cavity a clear
coagulable fluid.

Branches of the spermatic arteries and veins
are distributed to the ovaria, and they are also
abundantly supplied by nerves and absorbents.

The remarkable changes produced in the intel-
lectual and physical constitution of women, at the
age of puberty, by the development of the ovaria,
have been accurately described by Harvey in the
following passage : " nee minus notum est, quanta
virgini alteratio contingat, increscente primum et
tepefacto utero ; pubescet nempe, coloratior evadit,
mamma? protuberant, pulchrior vultus renidet,
splendent oculi, vox canora, incessus, gestus, ser-
mo, omnia decora fiunt."

There are certain facts which seem to prove
that it is not to the influence of the uterus, but
of the ovaria that we are to attribute all the changes
which take place in the female pelvis, in the mam-
mae and uterine system, at the period of puberty ;
and it seems not improbable from the following
facts, that it is also to certain changes in the
Graafian vesicles at the time of menstruation, that
all the phenomena of that singular process are to
be referred.

The case of a young woman who died at the
age of twenty-nine, in whom the ovaria were
wanting, was published by Mr. Charles Pears, in
the second part of the Transactions of the Royal
Society of London for 1805, and the following
appearances have been recorded. " Having ceased
to grow at ten years of age, she was in stature
not more than four feet six inches high. The
breadth across the shoulders was as much as
fourteen inches, but her pelvis measured only nine
inches from the ossa ilia to the sacrum. Her
breasts and nipples never enlarged more than in
the male subject. She never menstruated ; there
was no appearance of hair on the pubis, nor were
there any indications of puberty in mind or body
at twenty-nine years of age."

In the young woman, whose ovaria were extir-
pated by Mr. Pott in an operation for inguinal
hernia, menstruation ceased, the voice became
hoarse, the mamma? shrunk, and hair appeared on

OVARIA, (DISEASES OF THE)

443

the chin and upper lip. Before this period this
female was stout, large breasted, and menstruated
regularly. (Pott's Works, vol. ii. p. 210.)

Mr. Yarrel has shown that where there is a
shrinking and shrivelling of the ovaria from dis-
ease in young birds, the hen bird assumes in many
instances the plumage of the male. " Thus, in
several mules (hen birds with male plumage) the
ovarium has been found variously diseased ; some-
times the oviducts appear to have been inflamed,
and adhesions to have taken place between their
opposite sides, so that they become obliterated ; at
other times the ovaria are shrivelled and of a black
colour, and appear as if they had never been in
progress to maturity. This black colour also per-
vades the oviduct, which is smaller than natural,
and often impervious in some parts. In old birds
it might fairly have been alleged that the destruc-
tion of the ovarium and the change of plumage
followed only the goneral obliteration induced by
age, and that the one was not dependent on the
other ; but the fact that destruction by disease of
the ovarium in the young bird induces a similar
change, and the destruction of the oviduct by art
being followed by an alteration incomplete indeed,
but in many respects resembling the one men-
tioned, sets the question at rest." (Dr. Seymour's
Illustrations of Diseases of the Ovaria, 8vo. 1830,
p. 36.)

Dr. Elliotson related to the writer of this arti-
cle the history of the following interesting case,
which came under his notice upwards of ten years
ago. " A young woman," he says, " consulted
me for amenorrhcea ; she had never menstruated,
and yet had violent pains every month. I strongly
suspected there was some organic disease, and
wished to obtain permission to examine, but to
this she would not consent, and did not return to
me for a considerable period. She informed me
when she again consulted me, that she had been
married for a year, but had never menstruated. I
then thought I must have been wrong, and that
there was no organic cause. I asked if she was
happy with her husband, and from her answer
concluded that sexual intercourse went on. The
husband afterwards came to me and stated that he
had not encountered any impediment to connection,
but that he gave her violent pain at the time. I
afterwards was permitted to examine, and then
found there was no vagina; the part on opening
the labia being as flat as the palm of my hand.
She had most excruciating pains in the pelvis
every month ; there was every symptom of men-
struation except the discharge. At my desire she
was examined by Mr. Henry Cline, who plunged
a lancet between the labia, but found nothing.
She went on with these monthly pains, which she
had experienced ever since puberty, and her life
was rendered utterly wretched. I begged Mr.
Cline to make another attempt, and he put in a
bistoury as far as he dared go, but found nothing.
Every sort of examination was afterwards made,
and no uterus could be discovered. She remained
several years in this situation, when her husband
died and she has married again. Though there
was no uterus, it was evident from the appearance
of the mamma? and other circumstances, that the
ovaria had been fully developed."

Through the kindness of Mr. Girdwood, of

Paddington, we had an opportunity in 1831 of
seeing a case in many respects similar to the pre-
ceding, in which there appeared to be a deficiency
of the uterus, and an effort at menstruation every
monthly period. The patient was twenty-five
years of age, and had been married two years,
though she had never menstruated. Every month
there was great pain in the region of the pelvis,
which lasted for several days and then went off,
without any menstrual discharge taking place.
The mammae and external sexual organs were
fully developed. On examination at the posterior
part of the vagina, the finger readily passed into
a short cul-de-sac about an inch and a half in
length. From ocular inspection, it was evident
that this cul-de-sac did not reach the meatus
urinarius, but between them was a narrow opening
which admitted the catheter, and which could be
passed up four or five inches. This canal was.
gradually dilated so as to admit the finger the
whole length, but not the slightest trace of a body
like the uterus existed at its upper extremity.

Mr. Ca:sar Hawkins has related to us the case
of a woman who had the vagina and uterus com-
pletely obstructed after parturition, and in whom
there was a monthly effort at menstruation, though
no menstrual fluid was secreted. No swelling of
the abdomen took place ; and though incisions
were made through the vagina into the uterus, no
fluid escaped.

In Beck's Medical Jurisprudence, somewhat
similar cases are referred to.

On the 11th of March, 1831, we examined the
body of a young woman who died during men-
struation from inflammation of the median basilic
vein. The left ovarium was larger than the right,
and at one point a small circular opening with
thin irregular edges was observed in the peritoneal
coat, which led to a cavity of no great depth in
the ovarium. Around the opening, to an extent
of three or four lines, the surface of the ovarium
was of a bright red colour, and considerably ele-
vated above the surrounding part of the peritoneal
coat. On cutting into the ovarium, its substance
around the opening and depression was vascular,
and several Graafian vesicles of different sizes
were observed. The right ovarium was in the
ordinary state. Both fallopian tubes were intensely
red and swollen, and their cavities were filled with
menstrual fluid. The lining membrane of the
uterus was coated with the same fluid, and the
parietrs were soft and vascular. The size of the
uterus was not increased.

In the autumn of the same year a woman,
under twenty years of age, died suddenly from
acute inflammation of the lungs while menstru-
ating. The body was examined by Mr. John
Prout, and the uterine organs were brought to us
for inspection. A red, soft, elevated portion of
the right ovarium was also here observed, and at
one part the peritoneal coat to a small extent had
been removed. The edges of the opening were
extremely thin and irregular, and in the substance
of the ovarium under the opening was an enlarged
Graafian vesicle, filled with transparent fluid.
Numerous small blood-vessels were seen running
along the peritoneal coat of the ovary to the open-
ing. When the substance of the ovarium was
laid open, several vesicles of various sizes, and a

444

OVARIA, (DISEASES OF THE)

different depths, were found imbedded in it. The
left ovarium presented a natural appearance. The
free extremities of the fallopian tubes were gorged
with blood. Their cavities were filled with a red
coloured fluid. The uterus was not enlarged, but
the parietes were gorged with blood, and the
lining membrane of the fundus was coated with
menstrual fluid. A small coagulum of blood like-
wise adhered to the upper part of the uterus.

On the 2d of July, 1832, Sir Astley Cooper, to
whom the writer had mentioned these cases, sent
him the ovarium of a woman who died from
cholera while menstruating. The ovarium was
much larger than natural, and at one point there
was a small irregular aperture in its peritoneal
coat, through which a portion of a slender coagu-
lum of blood was suspended. On cutting into
the substance of the ovarium, it was found to be
occupied by three small cavities or cysts, one of
which was filled with a clear ropy fluid, another
with semi-fluid blood, and the third, which com-
municated with the opening in the peritoneal coat
of the ovarium, with a firm coagulum.

On the 18th of November, 1832, the uterine
organs were removed by Messrs. Girdwood and
Webster, from the body of a young woman who
had died suddenly the preceding day when the
catamenia were flowing. Both ovaria were re-
markably large, and both fallopian tubes weie red
and turgid. The peritoneal coat of the left ova-
rium was perforated at that extremity which was
nearest to the uterus by a circular opening, around
which aperture for several lines the surface of the
ovarium was elevated and of a bright scarlet co-
lour, like extravasated injection. The margin of
this opening was thin and smooth, and did not
appear to have been produced by laceration. Its
centre was slightly depressed below the level of
the edges, but there was scarcely the appearance
of a cavity beneath. The right ovarium was
much larger than the left ; and when cut into, a
cavity or cyst was found which was filled with
half coagulated blood. The peritoneal coat of
this ovarium was entire.

The uterus was large, and when cut into, the
parietes appeared to contain an unusual quantity
of blood. The inner membrane was of a bright
red colour, and coated with a thin layer of cata-
menial fluid. Both fallopian tubes were red and
turgid, and the interior of the left was filled with
menstrual fluid, but nothing in the form of a
Graafian vesicle could be detected in the tube.
The appearances now described have been accu-
rately represented in a drawing made from the
parts within two hours after they came into the
author's possession.

In a paper by Mr. Cruikshanks, published in
1797, there is an account of similar appearances
having been observed by him in a young woman
who had died at the monthly period. " I have
also," he says, " in my possession the uterus and
ovaria of a young woman who died with the
menses upon her. The external membranes of
the ovary were burst at one place, from whence I
suspect an ovum escaped, descended through the
tube to the uterus, and was washed off by the
menstrual blood."

Dr. Power has likewise conjectured that an
ovum escaping from the ovarium at every monthly

period is the cause of menstruation, which he has
defined to be " an imperfect or disappointed action
of the uterus in the formation of the membrane
(drcidua,) which is requisite for its connection
with the impregnated ovum." (An Essay on the
Periodical Discharge of the Human Female, by
J. Power, M. D. 1832.) This hypothesis docs
not appear to have been formed from actual ob-
servations on the ovaria during menstruation, as
Dr. Power has made no allusion to these in his
work, and docs not state that he has ever exam-
ined the body of any individual who died with
the menses upon her. That an ovum, by which
is usually meant an embryo enveloped in mem-
branes, does not pass from the ovarium during
menstruation, is evident from the fact that an
ovum is never formed but as a consequence of
impregnation, and that conception does not take
place at the menstrual period. The facts which
have now been related render it, however, ex-
tremely probable that all the phenomena of men-
struation depend upon or arc connected with
some peculiar changes in the Graafian vesicles, in
consequence of which an opening is formed in
their peritoneal and proper coats. Whether an
entire vesicle, or only the fluid it contains, escapes
through this opening at the period of menstrua-
tion, further observations may hereafter determine.
There is no proof whatever that an ovum passes
along the fallopian tube into the uterus during
menstruation, and it is not clearly established
that this takes place even subsequent to concep-
tion.

[The opinion that menstruation is connected
with periodical changes in the ovary is now em-
braced by most obstetrical physiologists, and espe-
cially by Negrier, Gendrin, and Raciborski. (See
the author's Human Physiology, 5th edit. ii. 348:
Philad. 1844.)]

Menstruation probably does not take place
during infancy, because the ovaria are not then
developed, and it is absent during pregnancy and
lactation, because at these periods they are in a
quiescent state. After the age of forty-six the
catamenia cease, because the parenchymatous
structure of the ovaria has partially disappeared,
and the Graafian vesicles have degenerated into
thick opaque cysts.

In many cases of disordered menstruation, chlo-
rosis, and hysteria, which we have observed, the
symptoms have been clearly referable to certain
morbid states of the uterine appendages, and de-
cided benefit has resulted from the application of
those local remedies which were employed with
the view of subduing the irritation, congestion, or
inflammation, which appeared to be present in
these parts of the uterine system.

II. Diseases of the Ovaria.

1. Inflammation and its consequences^—

In the unimpregnated state, the ovaria are not
very subject to those severe attacks of inflamma-
tion which produce an alteration in their struc-
ture. In most cases of puerperal fever, the peri-
toneal and parenchymatous textures of the ovaria
become inflamed, and not unfrcquently their struc-
ture becomes completely disorganized. In the
article Puerperal Fever in this work, a full
account has been given of these morbid changes,

OVARIA, (DISEASES OF THE)

445

and of the varied symptoms to which they give
rise during life. The adhesions between the
ovaria and fallopian tubes which are so frequently
met with in examining the bodies of women of
different ages and conditions of life, prove that
slight attacks of inflammation of the peritoneal
coat of the ovaria are not of rare occurrence, and
that their presence is seldom discovered during
life. Abscess of the ovarium from chronic inflam-
mation of the parenchymatous structure, though
a rare disease, does sometimes occur, as the fol-
lowing cases will show :

A woman, a;t. 17, of the lowest and most un-
fortunate class of females, was a patient of Guy's
Hospital, under the care of Dr. Bright, in the
autumn of 1823. She was greatly emaciated,
had a very quick and feeble pulse, a shining red
tongue, and constant watchfulness. She suffered
from constant and irresistible diarrhoea, and for
many successive days vomited both food and
medicine : the catamenia were absent. After
having been in the hospital about two months,
she suddenly complained of most acute pain over
the abdomen, and in a few hours expired. On
opening the abdomen, death appeared to have
been produced by the effusion of a large quantity
of pus into the peritoneal cavity, which escaped
from an abscess in the right ovarium, which ab-
scess appeared to arise from suppuration in the
substance of the viscus, similar in every respect to
phlegmonous abscess in any part of the body, and
not connected with any cyst, or change or addi-
tion of structure, the product of morbid growth.
(Dr. Seymour's Illustrations, p. 41.) A woman,
whose case has been recorded by Dr. Taylor, of
Philadelphia, had an abdominal tumour, which
was considered to be an encysted dropsy of the
ovary. On inspecting the body after death, the
tumour, which occupied the whole abdominal
cavity, and weighed seventeen pounds, was found
to be formed by one of the ovaries, but in no re-
spect did it resemble ovarian dropsy, being a large
cyst, containing twenty pints of pus. (North
American Med. and Surg. Journ., 1826.)

[When acute inflammation of the ovary is ac-
companied by metritis or peritonitis, it may be
difficult, if not impracticable, to detect the ovarian
phlegmasia. When the ovary is affected alone,
burning pain will be experienced deep in the side
of the pelvis in which it is situate, accompanied
by the ordinary general symptoms that belong
to acute inflammation of the internal viscera.
Usually, however, the constitutional affection is
not severe. Not much information can be ob-
tained by examination per vaginarn. A re#ent
writer, however, (Leroy d'Etiolles,) speaks of hav-
ing detected the ovarian tumour — owing to its
sinking down — by the finger in the vagina. The
. [Kissed into the rectum, according to M.
Li'.wcnhardt, can reach the situation of the ovary,
and may discover any tumefaction of the organ,
or unusual tenderness on pressure. Pain is like-
wise experienced by the pressure of the distended
rectum during defecation.

In the chronic form of ovaritis, the local phe-
nomena arc of the same character as in the acute,
but less in degree, and it must be diagnosticated
by the same mode of exploration. The disease
is. however, necessarily more obscure.

23T

Inflammation of the ovary, both acute and
chronic, may terminate by resolution, by tumefac-
tion and induration or softening, by suppuration,
the formation of serous cysts, fibrous tumours, &c,
and when both ovaries are affected, the menstrual
function is interfered with, — generally, indeed,
suspended. Sterility is a common consequence of
the ovarian changes.

Ovaritis would seem to have been most fre-
quently induced by sudden suppression of the
catamenia, or by irregular exposure during the
menstrual period. Most frequently, however, it
follows labour, and has often been observed
amongst the morbid appearances in puerperal
fever. It has been affirmed, that females affected
with gonorrhoea are liable to it, in the same
manner as males, affected with the same disease,
are liable to orchitis. Dr. Simpson, however,
(Tweedie's Library of Medicine, 2d Amer. edit.,
iii. 342, Philad. 1842,) states, that he has watched
diligently for its occurrence in some hundreds of
cases of gonorrhoea, which have been under his care
in the Lock Hospital of Edinburgh, but that he
has only met with one, and that a doubtful in-
stance. In two cases, recorded by M. Leroy
d'Etiolles, the disease supervened on the use of
uterine injections. The injections were sent with
moderate force into the uterus by the aid of a gum-
elastic tube. In one, the quantity of marsh mallows
was ten drachms ; and in both cases, the liquid
had scarcely reached the cavity of the uterus, be-
fore the patients complained of acute pain in the
side.

The treatment differs in no respect from that
which is adapted for inflammation of the uterus.]

2. Cysts and Tumours of the Ovaria. —
There are perhaps no organs in the human body
in which cysts containing a fluid are so frequently
found developed as in the appendages of the
uterus, and particularly in the ovaria. These
sacs or cysts, which have not unfrequently been
confounded with hydatids, constitute the disease
termed encysted or ovarian dropsy ; and it scarcely
admits of a doubt, from the progressive enlarge-
ment observed in the Graafian vesicles, that these
cysts often originate in a morbid distension of
these bodies. In other cases, ovarian dropsy
arises from the development of a solitary serous
cyst in the neighbourhood of the uterus, in the
folds of the broad ligaments, or connected with
the ovaria, if not imbedded in their substance.
The whole substance of the ovarium is converted
into a large bag containing a fluid, or into a con-
geries of cysts of different sizes, which have no
communication with each other. These cysts,
which differ considerably in the density of their
coats, contain fluids which vary in colour and
consistence. In some it is serous, mixed with a
slimy, ropy fluid, like jelly; in others it is a puru-
lent fluid, or dark-coloured like coffee-grounds,
and in two instances observed by us, the matter
contained in these cysts resembled custard or soft
cheese. A small ovarian cyst contained a thick
dark-brown fluid like treacle, which did not be-
come decomposed by pressure.

Dr. Hodgkin has recently investigated the struc-
ture and mode of formation of some of the more
complicated varieties of ovarian cysts and tumours.
He has given the following description of tho

446

OVARIA, (DISEASES OF THE)

compound serous cyst, which is often complicated
with malignant disease of the ovaria :

" In this form we observe on the interior sur-
face of the principal cyst, elevations, more or less
rounded and of various sizes, projecting into the
interior of the cavity, and covered by a membrane
which is continuous with the lining of the prin-
cipal sac.

" On making an incision into these tumours,
we find they also consist of cysts of a secondary
order, filled by a secretion, often serous, but
almost as frequently mucous. It is not, how-
ever, merely by this secretion that these cysts are
filled. On looking more minutely into them, we
shall generally find that from one or more points
on the interior of these cysts there grows a cluster
of other or lectiary cysts, upon which is reflected
the lining membrane of the cyst in which they
are contained. Cysts of the secondary order not
unfrequently afford as complete specimens of a
reflected serous membrane as either the pericar-
dium or tunica vaginalis, the lining membrane of
the containing cyst corresponding to the reflected
portion, as that covering the contained bunch of
cysts does to the close portion.

" The proportion which the contained cysts
bear to the cavity of the membrane reflected over
them is extremely various. Sometimes the fluid,
especially when it is of a serous character, nearly
fills the containing cyst, whilst the bunch of cysts
is of very considerable size. At other times the
superior cyst is almost entirely filled by those of
the inferior order, in which case we may generally
find that the nodulose or tuberose elevations,
which we may have observed on the exterior of
the containing cyst, are occasioned by the unequal
development of the contained cysts; for those
which have grown most rapidly and have attained
the largest size, forcibly dilating that part of the
cyst which is reflected over them, produce a kind
of hernia at that part. It sometimes happens that
the distension occasioned by the growth of the
contained cysts is sufficient not only to disturb
the even surface of the containing cyst, but actu-
ally to produce a rupture, which admits both of
the escape of its fluid contents and of the unre-
pressed growth of the secondary or lectiary cysts,
which took their origin from its internal surface."
(Med. Chir. Trans, vol. xv. p. 282.)

Dr. Hodgkin endeavours to explain the forma-
tion of the different heterologe deposits or acci-
dental structures on the same principles. Ovarian
cysts are not unfrequently combined with a great
enlargement of the organ, by which it becomes
converted into a whitish, hard, cartilaginous mass,
like the fibrous tumour of the uterus. These dis-
eases are indeed not unfrequently present in the
same individual, and they commence and run their
course in the same manner. Portions of these
fibrous tumours of the ovaria are sometimes con-
verted into calcareous concretions like those of
the uterus, or a process of softening commences
in different parts, in consequence of which the
fibrous structure is completely destroyed, and
large irregular cavities are formed, containing a
dark-coloured gelatinous fluid. Dr. Seymour in
his valuable work has described ovarian tumours
of the above description under the term scirrhus
of the ovaria, though they are not of a malignant

nature, and have no tendency to degenerate into
cancer. " In the museum of the College of Phy-
sicians there is a preparation," Dr. Seymour ob-
serves, p. 59, " which has received the sanction
of Dr. Baillie as a specimen of this rare disease.
It is a section of a scirrhous ovarium, (resembling
more a section of scirrhous testicle than the ordi-
nary appearance of the ovarium under this dis-
ease,) which was in various parts beginning to
soften, the substance breaking down into thick
brown fetid fluid. This preparation was taken
from a patient who died of cancer of the stomach,
and Dr. Baillie says in his Catalogue is the same
disease. It does not appear whether any dis-
tinguishing symptoms either of the locality of the
disease or its peculiar nature existed during life."

The following example of this disease of the
ovarium, which Dr. Seymour considers to be ex-
tremely rare, and the history of which he has
recorded in his work, came under our notice
several years ago.

At Blandford Mews on the 9th of August,
1828, we opened the body of a woman upwards
of seventy years of age, who had died after long
suffering from a tumour in the hypogastrium with
ascites. An induration had been first perceived
in the abdomen, between the navel and right
ilium, nine years before, after she had suffered
considerably for some months from sense of weight
and dull pain in this situation. The size of the
tumour gradually increased, and some years be-
fore death, (the belly being greatly distended with
fluid,) the operation of paracentesis abdominis was
performed by Mr. Blagden, and several pints of
water were drawn off. In the course of the
succeeding years the operation was frequently
repeated ; but the quantity . of fluid evacuated
gradually diminished, whilst the large indurated
moveable mass came to occupy the whole of the
lower part of the abdomen. She sank gradually
from the interruption to the circulation caused by
the tumour. On opening the abdomen, there was
found attached to the fundus uteri, on the right
side, an ovarian tumour weighing seven pounds,
of a dense and fibrous structure. Several large
cysts, containing a fluid varying in colour and
consistence, adhered to the upper surface of the
tumour. The peritoneum, in contact with its
anterior surface, was converted into a cartilaginous
substance, about a quarter of an inch in thickness.
In the proper tissue of the uterus, at its fundus,
was observed a fibro-cartilaginous tumour about
the size of a large orange. In other respects the
uterus was healthy.

The affections of the ovaria which have now
been described do not partake of the nature of
cancer, and have no disposition to degenerate into
a malignant form. The injurious effects upon the
system which they produce result entirely from
the pressure and irritation which they excite in
the abdominal and pelvic viscera, and some of the
remote organs of the body. The cysts may
descend between the bladder and rectum, and be-
coming firmly fixed by adhesions in this situation,
interrupt the evacuation of the urine and faeces.
In a case which lately came under our observation
in the Saint Marylcbone Infirmary, an ovarian
cyst having become firmly impacted between the
bladder and rectum, produced all the symptoms

OVARIA, (DISEASES OF THE)

447

of stricture of the rectum. In a lady now under
our care, the presence of an ovarian or uterine
tumour in the pelvis, which presses upon the neck
of the bladder, renders it impossible for the blad-
der to be emptied without the introduction of the
catheter. The effects of these tumours in im-
peding the progress of the child through the
pelvis during labour have been fully described by
Dr. Park and Dr. Merriman in the third and
tenth volumes of the Mcdico-Chirurgical Trans-
actions.

When the ovarian cysts remain at the brim of
the pelvis, in the progress of their enlargement
they gradually produce all the usual consequences
of interrupted circulation in the pelvic viscera and
lower extremities. Attacks of inflammation occa-
sionally take place in their capsules, by which they
contract adhesions with the surrounding organs, and
pus is poured out into their cavities. After a time
effusions of dropsical fluid take place into the
peritoneal sac, and sooner or later the patient dies
exhausted from the long-continued pressure and
irritation of the abdominal and other viscera.

Encysted dropsy of the ovarium can generally
be distinguished from ascites by the following
symptoms. The tumour commences on one side
of the abdomen, its surface is unequal, and its
fluctuation, if fejt at all, is very obscure. The
health is at first but little impaired, and the thirst,
scanty urine, and other symptoms which charac-
terize general dropsy, are wanting. The catame-
nia are usually extremely irregular or altogether
wanting. When both ovaria are diseased, Dr.
Seymour states that the menses are always ab-
sent. Great difference is observed with respect
to the progress of the disease in different indivi-
duals ; in some it would appear to become sta-
tionary, or altogether cease to extend ; while in
others it goes on much more quickly to a fatal ter-
mination. In some cases, if we are to credit the
histories which have been given by authors, reco-
very has taken place from a fright, blows, or from
sudden exertion. Dr. Mead relates a case where
eighteen pints of water escaped by a rupture of
the sac through the umbilicus ; Dr. Blundell re-
lates that a lady afflicted with ovarian dropsy,
falling from a carriage, struck her belly against a
stone, and that a considerable discharge of urine
occurred: she recovered, married, and dying sub-
sequently of retroversion of the uterus, the cyst
of her former complaint was found to have burst,
and its contents effused into the abdominal cavity
to have been absorbed.

Cysts containing a fatty matter intermixed with
hair and teeth have frequently been met with
either in the substance of one of the ovaria, or ad-
hering to them by a narrow neck. They have
been found before the age of puberty, and conse-
quently do not arise from impregnation. In
Kuysch's Museum was a tumour of teeth and
hair which he found in a man's stomach. A little
under the right kidney of a dead gelding, Mr.
Colman met with a cyst containing fatty matter,
hair, and teeth : and Mr. Brodie found a jaw, with
full-grown teeth, in the bladder. Dr. Gordon met
with a tumour in the thorax of a woman, which
was considered during life to be aneurismal, but
on examination after death appeared to be com-
posed chiefly of the debris of a foetus, which was

situated in the anterior mediastinum, and adhered
strongly to the sternum. It contained a sebaceous
matter mixed with hairs, and a portion of a bone
which appeared to be the superior maxillary bone.
We are inclined to consider all these singular
productions as wholly unconnected with concep-
tion in the bodies of the individuals in whom they
have been found, and to view them as examples
of that species of monstrosity which has been so
fully described by Ollivier and Breschet, under the
term Diplogeneses par penetration.

Dr. Baillie states that the hairs are most of them
loose in the fatty substance, but many of them
also adhere to the inside of the capsule. Andral
describes these hairs as sometimes intimately
mixed up with the fatty matter, at other times as
isolated from one another, or re-united into inex
tricable tufts. Their two extremities are usually
alike, and in all the cases which he has examined
there has been no bulb. (Precis d' Anatomic Pa-
thologique, torn. iii. p. 710.)

Meckel, however, observed their bulbs in one
of the cases which he examined, where the hair*
were short and isolated, and were almost im-
planted into the walls of the sac which formed the
envelopment of the tumour. He relates also from
Tuniati, a case where the hairs had a white oval
extremity covered by a fine skin, which was con-
fined to the bulb, and was separated from it by
an oleaginous fluid. (Memoire sur les poils et les
dents, &c. par F. Meckel dans le Journal Com-
plementaire cahier, 15 & 65.)

These hairs differ greatly in length and colour,
some are only a few lines in length, some several
inches ; others have been seen which measured
two feet three inches. Andral states that these
hairs have not always a colour analogous to that
of the hair of the individual in whom they are
found. A negress had a cyst with cartilaginous
walls in the mesentery. This contained a seba-
ceous matter, in the midst of which were nume-
rous hairs, of a colour entirely different from the
woolly black locks of the African woman. They
were smooth, soft to the touch, white or red, and
some of a silvery hue, like those of an infant of
the European race.

In almost all the cases where tfeth have been
found, they have been implanted into the frag-
ments of bony or cartilaginous matter, and haw.
resembled the rudiments of maxillary bones and
alveolse. Meckel thinks that these accidental
teeth are produced like ordinary teeth in capsules
filled with a gelatinous fluid.

The presence of these tumours in the ovaria has
sometimes given rise to serious obstacles to the
delivery of the child in parturition, and to fatal
inflammation after labour. The following exam-
ple of this termination of the disease has been
recorded by Dr. Seymour at page 8 : " A woman
about thirty years of age, some weeks after deli-
very, having been admitted into St. George's Hos
pital under the late Dr. Young with symptoms "of
enteritis, which speedily proved fatal, the inferior
portion of the small intestines was found inflamed,
which inflammation appeared to have been ex-
cited by the presence of a tumour of the size of a
large cricket-ball, which had become attached by
a narrow neck to the left ovarium. Its proper
coat was of a fibrous texture and of a purple cv

448

OVARIA, (DISEASES OF THE)

lour, and inclosed a mass of sebaceous matter,
penetrated throughout with long fine hair; after
removing which, a full-grown incisor tooth was
found attached to the fibrous coat."

Treatment of Ovarian Cysts and Tumours. —
Bloodletting, mercury, iodine, diuretics, emetics,
long-continued friction or percussion, and a va-
riety of other remedies have all been employed in
encysted dropsy of the ovaria, and in most cases
without the slightest benefit. Though the pro-
gress of the disease cannot be arrested by these
means, yet the uneasy sensations produced by it
admit of considerable alleviation. Inflammation
of the cyst, and irritation of the bowels from its
pressure, which often arise, may both be mitigated
by the occasional application of leeches to the
abdomen, by fomentations, and the use of cathar-
tics and anodynes. When the distension be-
comes great, recourse must be had to the trocar,
and by a repetition of the operation of tapping,
the life of the patient may be prolonged, and con-
siderable ease and comfort may be thus obtained,
under a complaint which sooner or later must
terminate unfavourably. On the practice of ex-
tirpating the ovaria when diseased, it is not neces-
sary to offer any observations, as it has been aban-
doned by all who have made themselves acquainted
with the pathology of these organs. Several
years ago, an eminent accoucheur of this metro-
polis made an incision through the abdominal
parietes of a young woman who had a movable
tumour in the belly, which he considered to be
ovarian, and which he thought it possible to ex-
tirpate, as Mr. Lizars had done in similar cases
with success. On laying open the abdomen, a
large fibro-cartilaginous tumour presented itself,
which was attached to the fundus uteri by a thick
peduncle. A ligature was applied round this,
and the tumour cut off; but death soon followed
in consequence of gangrene taking place in that
portion of the bowel which had come in contact
with the cut surface. The impossibility of dis-
tinguishing ovarian from uterine tumours, where
the operation is wholly unjustifiable, was strik-
ingly illustrated by this case.

[Subsequent experience has shown the justice
of these remarks. Of late, many operations have
been performed by Dr. Clay, Mr. Walne, Mr.
Southam, Mr. J. Atlee, and others, and some of
them successfully. They are confirmative of
views long ably urged by Dr. Blundell, (Re-
searches, Physiological and Pathological, Lond.
1828,) and strengthened by additional arguments
which he lately furnished to the writer, {Phila-
delphia Medical Examiner, Jan. 27, 1844,) that
incisions into the peritoneal sac are not necessa-
rily so serious as has been generally imagined.
Still, the difficulty in knowing the exact state of
ihe parts is a formidable objection to the operation.
(See Art. Ovaires, (Pathol.) in Diet, de Med.
xxii. 590; Paris, 1840; by Velpeau. Edinb.
Med. and Surg. Journal, April, 1S44, p. 467.
Brit, and For. Med. Review, Oct. 1843, and
Jan. 1844. Amer. Journal of the Med. Sciences,
April, 1844, p. 456; and Medical Examiner,
Aug. 24, 1844.)]

3. Malignant Diseases of the Ovaria. —
Sometimes the ovarium is affected with encepha-
loid disease, or it is converted into a large irregu-

lar-shaped mass of cysts and tumours, the section
of which presents all the characters of hematoid
fungus. This fatal affection usually runs its
course with great rapidity, and soon after its com-
mencement the constitution of the patient is much
more affected than in the organic diseases of the
ovaria which have already been described.

M. Andral has accurately described the changes
of structure produced in the ovaria by these ma-
lignant diseases. " Sometimes," he observes,
" these masses are formed of fibrous, cartilagi-
nous, or osseous tissue ; in other cases they are
almost entirely composed of encephaloid matter.
The walls of the cysts are thick, and their cavities
gradually enlarge until a tumour is formed, which
fills not only the epigastrium, but the whole ab-
dominal cavity. The outer surface of the tumour
is unequal ; in some points a fluctuation can be
felt, while in others it has a hardness and density
equal to bone." (Andral, Precis d'Anatomie Pa-
thologique, torn. iii. p. 708.)

Dr. Seymour has also described this affection
of the ovaria, and has pointed out the connection
which often exists between it and cancerous and
fungoid diseases in other parts of the body, as
the pylorus, lymphatic glands, and even bony and
muscular parts. This malignant disease, he re-
marks, may be recognised during life by the want
of nutrition and broken health of the patient)
the unevenness and rapid growth of the tumour,
the simultaneous enlargement of glands in other
parts of the body, and the occasional occurrence
of lancinating pains ^n the part. The latter
symptom is not constant. The pulse is quick
and feeble, and as the disease proceeds there is
hectic fever, and often aphtha in the mouth, with
an inexpressible sense of debility. (Diseases of
the Ovaria, p. 61.)

This disease occurs even at an early period of
life, and it appears to be excited in some instances
by pregnancy, or to be called into activity by the
process of impregnation. In the body of a young
woman under twenty years of age, Dr. Carswell
found on dissection an ovarian tumour of a ma-
lignant nature, as large as the gravid uterus at
the full period. About five years ago we exam-
ined with Dr. Merriman and Mr. Prout the body
of a woman about thirty years of age who bad
died from malignant disease of the right ovarium
a few days after parturition. In the fourth month
of pregnancy she began to suffer from a constant
sense of uneasiness in the hypogastrium, irritabi-
lity of stomach ; the countenance became sallow,
and the constitutional powers greatly reduced.
The abdomen, not long after, began rapidly to
enlarge, and before the end of the seventh month
it had attained the size it usually acquires at the
full period of pregnancy. An enormous cyst,
which contained a dark-coloured gelatinous fluid,
was found on dissection adhering to the right
ovarium, and within this cyst were observed a
number of tumours of different sizes and shades
of colour, which when opened presented the true
encephaloid or hematoid fungous character.

An interesting case of a similar description, in
which the tumour at first offered an impediment
to labour, and the performance of the Cesarean
operation was contemplated, has recently been
recorded by Mr. Hewlett of Harrow, in the seven-

PALPITATION.

449

tecnth volume of the Medical and Chirurgical

Transactions.

Scrofulous and tubercular disease of the ovaria

is very rarely met with. It is the least common

of all the morbid alterations of structure to which

the human ovaria are liable. r, T

Robert Lee.

PALPITATION.— Palpitation may be defined
to be an increase in either the force or the fre-
quency of the heart's contractions, or of both,
whereby they become not only sensible, but some-
times very troublesome to the patient. They may
vary in force, from a scarcely perceptible degree
to a violence which amounts to convulsion. Not
unfrequently the sound of the beats is audible to
the patient, especially when lying on his side ;
and in this position, the second as well as the first
sound may occasionally be distinguished.

As palpitation is, under all circumstances, de-
pendent on over-excitement of the nerves of the
heart, the phenomenon is always essentially the
same. The varieties which it presents arise
merely from differences in the causes, and from
the different routes which these causes pursue in
order to arrive at, and convey their stimulus to the
heart. Thus the blood conveys the stimulus di-
rectly ; and this it does in three ways : first, by
arriving in excess, as from violent exercise, ple-
thora, &c. ; secondly, by gorging the heart, in
consequence of its transmission being impeded by
a disease of the organ, or an obstacle in some
other part of the circulation ; thirdly, by being of
too stimulant a nature, in consequence of the diet
being exciting. The nerves, on the contrary,
convey the stimulus to the cardiac plexus indi-
rectly, as is the case in emotions of the mind, in
dyspepsia, in hysteria, &c. The nerves and the
blood may also convey the stimulus conjointly, as
happens in fever, and in all other cases in which
morbid nervous irritability co-exists with an or-
ganic affection, or a state of the blood leading to
palpitation.

We have now to take a more particular view
of palpitation in connection with its several causes;
and we shall first glance at the causes of a physi-
cal or organic nature, and those dependent on
states of the blood ; and subsequently dwell at
more length on nervous palpitation.

I. Palpitation, connected with Physical
Causes. — Of these causes, some are inherent in
the heart itself, and others arc exterior to it. The
causes inherent in the heart fall under the follow-
ing heads : —

1. Hypertrophy, and hypertrophy with dilata-
tion. In ther«c affections, palpitation consists in
an increase both of the force and the frequency of
the heart's action, the physical characters of the
impulse and sounds being merely an exaggeration
of those which the heart presents during a state
of calm. (See Heart, Hypertrophy of, and
Heart, Hypertrophy with Dilatation of.)

2. Dilatation with attenuation. Palpitation in
this case consists in an increase of the frequency,
but often not of the strength of the beats, though
the patient may experience the sensation of an
increased impulse. Palpitation of this kind is
more obstinate than any other. Lacnnec cites an
instance in which it lasted eight days; the pulse
constantly beating 1G0 to 180 in the minute.

Vol. III. — 57 2s*

3. Disease of the valves. Palpitation from
this cause varies in its characters according to the
nature, situation, and extent of the valvular affec-
tion, and according to the presence or absence of
hypertrophy, dilatation, or both. (See Heart,
Diseases of the Valtes of the.) Obstructions
in the arterial system fall under this head.

4. Pericarditis, carditis, and inflammation of the
internal membrane. In these, palpitation is either
strong and bounding, or feeble, irregular, and un-
equal ; differences which depend on circumstances
explained in the articles on the above subjects.

5. Adhesion of the pericardium. Palpitation
from this cause is violent, and of an abrupt, jog-
ging, or tumbling character.

The physical causes of palpitation exterior to
the heart are as follows : —

1. Acceleration of the circulation by muscular
efforts. This is the most simple cause of palpita-
tion, and it is strictly physiological. There is an
increase both of the force and the frequency of the
beats. Closely allied to this is the next : viz. —

2. Plethora. It gives rise to palpitation by
preternaturally distending and stimulating the
heart. The palpitation which sometimes exists
during the first three or four months of pregnancy,
is partly attributable to plethora, resulting from
the suppressed catamenia, and partly to the ner-
vous disturbance which attends so important a
change in the system as that of utero-gestation.

3. Ansemia, whether from loss of blood, or from
an insufficient quantity being made by the patient.
In this case, the blood is always attenuated and
impoverished, containing more serum and less
fibrine than natural. Hence it moves with greater
facility in the vessels, and probably, therefore, ar-
rives at the heart either in redundant quantity or
with morbid velocity, thus constituting a physical
cause of palpitation. A highly irritable state of
the nervous system generally accompanies anse-
mia, and is partly the cause of the palpitation.
Hence we shall revert to this subject in treating
of nervous palpitation.

4. Convulsive, epileptic, and hysteric fits.
These cause palpitation, partly by occasioning too
rapid a flow of blood to the heart, and partly by a
participation of the organ itself in the spasmodic
action.

5. Obesity. This causes palpitation in a three-
fold way : a, by the plethora with which it is usu-
ally accompanied ; b, by the weight and inelasti-
city of the thoracic and abdominal parietes, whence
the free expansion of the ribs and descent of the
diaphragm are prevented ; c, by the unusual re-
sistance offered to the heart's propulsive action in
consequence of the extended sphere of the circu-
lation, and the pressure of the adipose tissue on
the capillaries.

6. Obstructions in the lungs; namely, hydro-
thorax, empyema, pneumothorax, hepatization,
extensive bronchitis, affecting the minute tubes,
&c. These cause palpitation (so far as it is inde-
pendent of a concomitant febrile movement) by
obstructing the passage of blood through the
lungs ; whence the heart becomes gorged and pre-
ternaturally stimulated. Obstructions developed
slowly, as tubercles, encephaloid tumours, aneur-
isms of the aorta, &c, commonly occasion little
and sometimes no palpitation. For this there are

450

PALPITATION.

two reasons: 1st, that the mass of blood is dimi-
nished by the concomitant emaciation ; 2dly, that
supplementary respiration is established in the
previous portions of lung, which not unfrequently
become hypertrophous.

7. Asthmatic bronchial constriction. This
causes palpitation by preventing the expansion of
the lungs, and consequently impeding the circu-
lation through them.

8. Acute laryngitis. According to our obser-
vation in a considerable number of cases, this
affection causes palpitation in an eminent degree.
We ascribe it to the same cause as in the prece-
ding case, 7. In the last stage the palpitation
ceases ; for the engorgement of the heart becomes
so excessive that the organ struggles and flutters
rather than palpitates, and the patient, if not im-
mediately relieved, speedily dies of asphyxia.

9. Abdominal infarction : namely, from en-
larged liver or spleen, morbid growths, ascites,
ovarian dropsy, advanced utero-gestation, &c.
These occasion palpitation, principally by pre-
venting the free descent of the diaphragm, and
thus obstructing the circulation through the lungs,
but partly also by compressing the aorta, and op-
posing the passage of the blood through it.

Amongst the causes of abdominal infarction is
to be ranged tight-lacing. We were consulted by
a military officer, who had brought on constant
palpitation and slight hypertrophy by the habitual
use of the dumb-bells while tightly girthed round
the waist.

II. Palpitation from Causes operating

PURELY THROUGH THE NERVOUS StSTEM

There are few affections which excite more alarm
and anxiety in the mind of the patient than this.
He fancies himself doomed to become a martyr to
organic disease of the heart, of the horrors of
which he has an exaggerated idea ; and it is the
more difficult to divest him of this impression,
because the nervous state which gives rise to his
complaint, imparts a fanciful, gloomy, and de-
sponding tone to his imagination. Members of
the medical profession are more apt than others
to give way to these feelings ; partly from their
apprehensions being more keen, and partly from
an impression too widely prevalent, that there is
difficulty in distinguishing nervous from organic
palpitation, and, consequently, that the patient
must remain in a state of anxious uncertainty.
It may be said for the consolation of such, that
the diagnosis presents no difficulty, if to general
signs is added a knowledge of those afforded by
ausculation and percussion.

Nervous palpitation is dependent on dyspepsia,
hypochondriasis, hysteria, chlorosis, gout, mental
excitement, or a naturally irritable nervous tem-
perament; and it presents different degrees, as-
pects, and habitudes, according as it depends on
one or other of these causes. We shall describe
its most common forms, and briefly advert to the
connection between them and their causes.

1. The first and slightest degree is character-
ized by a tumbling or rolling motion of the heart,
with a momentary feeling of fulness, tightness,
and oppression. It is referable to an intermission
of the heart's action, producing congestion ; for
the removal of which the succeeding beat is inor-
dinately violent. This form occurs principally in

dyspepsia, and it may result from so slight a de.
gree of it, that the patient is not conscious of
being an invalid. Slight acidity or flatulence, for
instance, is sufficient for its production.

Dyspeptics do not in general experience a mora
aggravated form of palpitation, unless they are of
a nervous temperament.

2. In the next degree there is a series of quick,
weak, fluttering, irregular beats, with slight anx-
iety, acceleration of the respiration, and a quiver-
ing sensation in the epigastrium : this may last
from a few minutes to half an hour or an hour,
and occur only at distant and irregular intervals,
or several times a day, especially when the patient
is startled. It is apt to supervene at bad-time,
keeping the patient wakeful and restless during a
considerable part of the night.

This form presents itself in nervous and hypo-
chondriacal dyspepsia, in hysteria, and in indi-
viduals who, either from disease or mental excite-
ment, have fallen into a state of high nervous irri-
tability. Amongst the latter class are to be ranked
literary and scientific men, and hard students iu
general. This form occasionally, though rarely,
occurs without any other apparent origin than a
very slight degree of indigestion, the patient being
otherwise strong and healthy.

Individuals, especially females, with naturally
small or thin hearts, — a class characterized by a
delicate frame and a languid, feeble circulation,
are predisposed to the variety of palpitation under
consideration.

3. The next degree amounts to perfect palpita-
tion, consisting in increased impulse, sound and
frequency of the beats, sometimes accompanied
with irregularity of action, and generally with
more or less anxiety, dyspnoea, and even ortho-
pneea. The attack may be only occasional, or may
occur several times a day, or may even last with
little intermission for several days together. This
form is rare in pure dyspepsia, but is of common
occurrence in dyspepsia complicated with hypo-
chondriasis, or engrafted on a nervous tempera-
ment. It manifests itself principally, however, in
hysterical subjects, and those remarkable for great
nervous mobility and irritability. In a lady of
the latter class we have seen it exist in an exqui-
site degree, being excited by the slightest causes.
A word, a look, an idea, a movement, the most
frugal meal, the most gentle stimulant, even a glass
of water, sufficed to induce a violent fit, attended
with heat and flushing ; and she frequently passed
a great part of the night in a state of the most
distressing orthopnoea. The heart and lungs
were sound, and she was restored to health by
bitters, tonics, cold bathing, sea air, and a nutri-
tious but unstimulating diet.

There are many individuals without any defi-
nite ailment, yet calling themselves delicate or not
strong, who, after a full meal, after any unusual
fatigue, or any extraordinary mental excitement,
become languid, listless, restless, sometimes drowsy,
with heat, acceleration of the pulse and respiration,
and a more or less extensive arterial throbbing.
This is generally connected with slight palpitation ;
so slight, indeed, that the patient is seldom con-
scious of it. The symptoms usually subside after
a little repose, especially a tranquil sleep.

Sometimes a slight degree of palpitation subsists

PALPITATION.

451

without intermission for years, especially in young
persons of a constitution at once plethoric and
nervous, and more particularly in females about
the period of puberty.

We above adverted to palpitation from anaimia,
whether occasioned by loss of blood or by defec-
tive sanguification. In this the blood is always
in a thin and impoverished condition, from a defi-
ciency of fibrine and an excess of serum, and the
nervous system is generally in a highly irritable
state. The variety is highly important, as it com-
prises a great number of cases, and requires a pe-
culiar mode of treatment.

When the palpitation results from loss of blood,
the phenomenon is denominated reaction. If
the hemorrhage has been restricted to a brief
period, as a few hours or days, the patient soon
recovers ; but if it has been protracted, as is often
the case from piles, chronic dysentery, menorrha-
gia, polypus, or cancer of the uterus, &c. the case
is much more obstinate and intractable ; for not
only is the state of ana:mia fully established, in
consequence of the system being reduced to a
condition which renders it incapable of reproducing
good blood ; but, by the impoverished state of the
fluids, a train of nervous symptoms is engendered,
which greatly exasperates the malady. Under
these circumstances we have repeatedly seen pal-
pitation last almost without intermission for many
weeks and even months, but gradually yield to
tonic medicines, diet, and regimen.

Anaemia arising simply from defective sanguifi-
cation, as in chlorosis, of the male as well as the
female, places the patient in circumstances very
similar to those last described ; and the palpita-
tion is of the nature above noticed as the third
degree. Here, also, we have seen it last, with
little intermission, for several weeks and even
months. In a medical gentleman, the heart
bounded violently 120 to 150 times per minute for
upwards of four months. Bleeding exasperated the
alFection, and the blood drawn was very serous, and
so deficient in fibrine as scarcely to form a coagulum.
This state of the blood, in connection with pal-
pitation and arterial throbbing, constitutes, in our
opinion, an important feature in the pathology of
purpura hemorrhagica ; for in several well charac-
terized cases which we have seen, and in others
which have been communicated to us, the condi-
tions alluded to existed in an eminent degree.

Nervous palpitation may give rise to hypertro-
phy, (see Hypertrophy, exciting causes;) but
it is surprising how long the heart will in most
cases resist this affection ; and when the palpita-
tion is subdued, how soon it will recover itself
after undergoing slight enlargement. According
to our observation it rarely requires less than a
year, and sometimes several, of very constant pal-
pitation, to produce confirmed hypertrophy.

Every variety of nervous palpitation may be
attended with arterial throbbing ; and the throb-
bing may be either universal, or limited to a par-
ticular put, even to individual arteries, especially
the aorta and carotids. Hence, nervous palpita-
tion is, in general, more audible to the patient than
organic, the sound appearing to rush through his
ears, especially when he reposes on his side in
bod, since each arterial throb causes a rustling
movement of his pillow.

The contraction of the heart in nervous palpi-
tation is less remarkable for force than for an ab-
rupt, bounding, and jerking character, and on this
the arterial throbbing is mainly dependent ; since
the vessels receive the jerk communicated to the
blood by the impulse of the heart. (Treatise on
Diseases of the Heart, by Dr. Hope, page 74 to

Diagnosis of Nervous Palpitation. 1. Ge-
neral Signs. — Nervous palpitation may be discri-
minated from organic by the presence of some or
all of the following signs, viz. by its not being
excited, but, on the contrary, relieved by corporeal
exercise of such a nature as would certainly dis-
turb the action of a diseased heart; by its dispo-
sition to supervene while the patient is at rest,
especially at the commencement of the night when
he lies wakeful in bed ; by a fluttering in the epi-
gastrium ; by the general prevalence of nervous
symptoms ; by the affection being aggravated
when the nervous symptoms undergo an exacer-
bation ; by the pulse and the action of the heart
being natural during the intervals between the
attacks ; and by the intervals being long when the
general health is good. Nervous palpitation, in
short, is intermittent, its causes being only occa-
sional ; whereas organic palpitation deserves the
epithet of continued, its causes being constant.

To the above category of diagnostic signs, some
add, as characteristic of nervous palpitation, an
increase of it after meals, or when the stomach is
loaded or deranged, and an amelioration produced
by dyspeptic remedies; but as the stomach pro-
duces the same effects when there is disease of the
heart, these signs are not pathognomonic of ner-
vous palpitation. To this point we would particu-
larly direct the attention of practitioners ; because
many, in forming their diagnosis of the affections
in question, regard the dyspeptic signs as para-
mount in value to all others.

Though nervous palpitation is often attended
with various familiar nervous affections of the
head, as pain, or sensations of heat or cold con-
fined to particular parts and coming and going
suddenly, temporary vertigo, tinnitus, and confu-
sion of the sight, not increased by lying down or
stooping ; it is not, when purely nervous, accom-
panied with genuine signs of cerebral determina-
tion or congestion : there is no universal throb-
bing headach, with weight and tension, increased
by stooping or the recumbent position ; no stun-
ning sounds and pains in the head on suddenly
lying down or rising up ; no permanent somno-
lency, apoplectic stupor, or regular apoplectic fits,
as in hypertrophy, &c.

2. Physical Signs. — « In nervous palpitation,"
says Laenn.ec, " the first impression which the ap-
plication of the stethoscope to the region of the
heart produces on the ear, shows at once that this
organ has not great dimensions. The sound, al-
though clear, is not loud over a great extent ; and
the shock, even when it at fust appears strong, has
little real impulsive force, for it does not sensibly
elevate the head of the observer. This last sign
appears to me the most important and the most
certain of all, when we add to it the frequency of
the pulsations, which is always greater than in
the natural state. Most commonly it is from
eighty -four to ninety-six per minute." This is a

452

PALPITATION

very accurate description of nervous action of the
heart. The impulse is analogous to that which
occurs in reaction from loss of blood, and which
we have elsewhere denominated jerking. It may
be added that, in nervous palpitation, though the
sounds are increased, they are not materially al-
tered in quality, the first sound being, as in the
healthy state, longer and more suppressed than
the second.

The physical signs of nervous palpitation will
be rendered more apparent by being contrasted
with those of organic. We shall, therefore, sum-
marily recapitulate the latter.

In dilatation, dullness on percussion over an
increased extent indicates that the organ is en-
larged ; further evidence of which is derived from
the dullness, and the impulse being situated lower
down than natural. The first sound is short,
smart, and clear, resembling, and in dilatation with
attenuation becoming identical with, the second.
Both sounds are louder than in a greater degree
of nervous palpitation.

In hypertrophy with dilatation, the dulness on
percussion is increased over a still greater extent,
and the dulness and impulse are also lower down
than natural. Both sounds are very loud, and
the first is shortened, though less so than in pure
dilatation. The impulse is a smart, violent blow,
possessing much more force than in nervous pal-
pitation, and very frequently raising the head of
the auscultator.

In simple hypertrophy, the impulse is a slow,
gradual, and powerful heaving, very sensibly ele-
vating the head. Both sounds are diminished,
and in extreme cases almost suppressed. These
characters are so different from those of nervous
palpitation, that it is only by inattention that the
two affections can be confounded.

In disease of the valves there is a permanent
bellows, sawing, or rasping murmur; whereas
murmur in nervous palpitation is only occasional,
and of a soft character. If the valvular contrac-
tion be great, the action of the heart is irregular.
Irregularity also occurs in nervous palpitation, but
it is not accompanied by those symptoms of an
embarrassed circulation which invariably attend
valvular disease, and in too palpable a form to be
mistaken. Should hypertrophy, dilatation, or both,
coexist with valvular disease, their signs, as above
described, will likewise be present.

The pulse in nervous palpitation is materially
different from that in organic disease. In the for-
mer it is jerking, but has little fulness, strength,
and incompressibility. In dilatation it is full and
soft; in hypertrophy with dilatation, it is full,
strong, and sustained ; and in simple hypertrophy,
though less full, it is strong, sustained, and even
hard. In valvular disease it presents different
characters according to the situation and degree
of the lesion, (see Valves, Diseases of, general
signs,") but the presence of other signs of the val-
vular affection will enable the practitioner to dis-
tinguish the pulse from that of nervous palpitation.
To the physical signs of nervous palpitation,
may, in many instances, be added an intermittent
bellows and sawing murmur of the heart and
sometimes of the arteries, which we have else-
where attributed to the morbid velocity with which
the blood is propelled by the sudden and as it

were spasmodic contraction of the heart. (Treatise
on the Diseases of the Heart, by Dr. Hope, p. 76,)
The murmur occurs whenever the action of the
organ is excited ; and in some instances the
slightest causes suffice to produce the effect, as a
momentary mental emotion, a change of posture,
(from the recumbent to the erect for instance,) a
constrained position, a meal, flatus in the stomach,
&c. We have often found the phenomenon to
subsist for a few seconds or minutes only, that is,
so long as the exciting cause continued in opera-
tion. The patient, if asked whether he is con-
scious of palpitation, replies in the affirmative ;
yet the pulse may not be strong — it may even be
small and weak ; but it will be sharp or jerking.
It is the velocity, therefore, and not the power of
the heart's contraction which causes the murmur.

III. Palpitation from Physical and Ner-
vous Causes. — Nothing is more common than a
conjunction of nervous with organic affections of
the heart ; and these are the cases which present
the greatest difficulty in diagnosis, as the one
masks the other, and it is not easy for the inex-
perienced practitioner to assign to each the share
which it holds in the production of the symptoms.
He will best qualify himself for this task by ac-
quiring a sound knowledge of the two classes of
affections separately. Hence it is unnecessary to
enlarge on this subject. We have elsewhere given
cases illustrating the combination. (Treatise, &c.
p. 493.)

Treatment of Palpitation. — Palpitation be-
ing only a symptom, the treatment must be mainly
directed to the primary affections. To advert to
it here in all its details would be a superfluous
repetition, as it is discussed at large in the several
articles devoted to the primary affections. Palpi-
tation from organic disease of the heart is so inti-
mately connected with the disease itself, that ab-
stract observations on treatment would convey no
definite information ; and we therefore refer the
reader wholly to the various articles on that sub-
ject — to which he will find a guide in the general
article, Heart, Diseases of tfie. The treat-
ment for nervous pulsation of the aorta is noticed
at the conclusion of the article Aorta, Aneurism
of the. In the articles Htsteria, Chlorosis, and
especially Indigestion, he will find ample inform-
ation on the subjects to which they respectively
refer. Here, therefore, we shall merely direct our at-
tention to a few points, which, though embraced in
a general plan of treatment for the primary affection,
are not discussed with so specific a reference to
palpitation as the practitioner might probably wish.

1. Palpitation from Plethora. — This is to be
treated in the first instance by a free use of the
lancet, and by two or three calomel and colocynth
purges at bed-time, worked off by a draught con-
sisting of equal parts of infus. gentian, and infus.
senna? c. with tinct. senna; gi. and potassaj tartrat.
gi. ad ii. or any other purgative neutral salt. This
draught should be repeated every morning for a
week or ten days, until the force of the palpitation
has in a great measure subsided. The subsequent
part of the treatment is principally of a prophylac-
tic nature, the indication being to prevent the re-
generation of too much and too rich blood. The
patient should abstain from animal food on alter-
nate days, and should always take it in limited

PALPITATION.

453

quantity. His diet should consist principally of
farinaceous articles and vegetables, and his beve-
rage should be toast and water. As few things
are more conducive to plethora than an excessive
indulgence in sleep, he would do well to restrict
himself, for a time at least, to six or seven hours
in the twenty-four, or even less. While the pal-
pitation exists, it is dangerous to take violent cor-
poreal exercise, as hypertrophy might be induced ;
out when the symptom seems to be provoked by
exertion, an active life is eminently serviceable.
We have thought it necessary to insist on the
present subject, as we have found plethora to be
a frequent cause of hypertrophy, especially in
those who, while plethoric and subject to palpita-
tion, are compelled by their position in society to
lead a laborious life. Such is the case with a large
class of female servants in the country. The
luxurious and indolent, when plethoric, suffer in
a scarcely less degree.

2. Pulpit at ion during early utero-gestation.
— Should this be evidently connected with ple-
thora, it will readily yield to a moderate abstrac-
tion of blood, a few gentle saline aperients, a
spare, unstimulating diet, and a cool air with good
ventilation.

3. Dyspeptic palpitation. — As the palpitation
generally supervenes at the moment when there is
a morbid stimulus in the stomach, whether this
result from ill-digested food, as is usually the case
in atonic dyspepsia, or from the irritation of almost
any ingesta in the inflammatory species, it is evi-
dent that a judicious regulation of the diet will
constitute one of the most important features in
the treatment. To the article Indigestion the
reader has already been referred. He will there
find an able account of the medical treatment
adapted to all the- circumstances of the complaint.
So long as palpitation exists in connection with
symptoms obviously demanding the exhibition of
medicines, as, for instance, inflammatory irrita-
tion of the mucous membrane, complete torpor
of all the alimentary functions, and with various
others, it is vain to expect a cessation of the pal-
pitation until these symptoms have been relieved.
But palpitation not unfrequently remains after all
urgent symptoms have been removed, and the pa-
tient scarcely looks upon himself in the light of an
invalid. Often have we seen it form the most
delicate test of the slightest dietetic indiscretion.
Here, then, it is that diet and regimen are of the
first importance : they must complete what medi-
cine began.

They are to be adapted to the nature of each
case, and to vary with the variations of its circum-
stances. In atonic gastric dyspepsia the patient
should follow the rules judiciously laid down in
Indigestion, ii. p. 619 et seq.

At p. 620 is also an excellent account of the
means to be employed in order to restore the har-
monious action of the bowels with the stomach,
of restoring or increasing the activity of the excre-
tory organs, and of restoring the tone or improv-
ing the innervation of the stomach. Under tho
latter head the subjects of mineral waters, bathing,
friction, clothing, are fully discussed.

In inflammatory gastric dyspepsia, not only
the medical, but the dietetic and regiminal treat-
ment is very different. Both will be found in the

Vol. III.— 2e*

same article, p. 627, so ably laid down as to super-
sede the necessity for further remark.

4. Palpitation from anaemia. — When this re-
sults from a sudden loss of blood in a healthy in-
dividual, little more is requisite for its cure than
patience, as the symptom subsides in proportion
as blood of the natural consistence is regenerated,
which takes place in the course of ten days or a
fortnight, and sometimes considerably earlier.

When the anaemia results from protracted or
repeated hemorrhage, or from inadequate sangui-
fication, as in chlorotic females, persevering medi-
cal treatment is in general necessary. The pal-
pitation, and its usual concomitants, headach and
arterial throbbing, are invariably exasperated by-
further detraction of blood, to which some resort
from a mistaken view of the nature and cause of
the headach. More and richer blood must be
made, and the remedies best calculated to effect
this object are the preparations of iron, with aloes ;
the latter being useful not only as a bitter tonic,
but by its aperient operation to counteract the too
stimulant effect of the chalybeate. We have sel-
dom been disappointed by the pills of Dr. Aber-
crombie, consisting of two grains of sulphate of
iron, two of aloes, and five of the compound cin-
namon powder in two pills, taken at dinner, and,
if necessary, at bed-time also, the quantity of aloes
being diminished if it should act more than once,
or gently twice a day. Should these pills create
nausea, as sometimes happens, an excellent sub-
stitute is to be found in the decoct, aloes comp.
f.^ss ad f.^i (just sufficient to move the bowels
gently once a day) at bed-time, with a drachm of
the vinum ferri thrice a day.

The carbonate of iron in doses of from one to
three drachms thrice a day, and two grains of the
pil. aloes cum myrr. and pil. galbani comp. re-
spectively at bed-time, is Ukewise an efficacious
plan of treatment. Under the use of all these
remedies we have seen patients speedily recover
from the most unpromising circumstances. The
remedies are to be assisted by a nutritious animal
diet, much fresh air and gentle exercise, and by
the use of the flesh-brush, salt-water sponging,
and even shower-bath.

Before the medicines begin to take effect, the
patient is often importunate for some palliative to
relieve the urgency of the palpitation. We have
found this object best effected by the hydrocyanic
acid (to i. ad vi.) ; the acetate of morphia (gr.
1-3) ; or by the following draught : tinct. hyoscy-
ami ^ss, sp. cetheris nitrici gss, mist, camph. gx.
syrupi aurant. gi. Fiat haustus. Each remedy
may be administered once, twice, or thrice a day,
according to the necessity.

5. Nervous palpitation. — Individuals in whom
palpitation is referable to a highly irritable nervous
temperament, cannot, in general, bear the stimulus
of chalybeates in the first instance, though they
eventually prove of the greatest advantage. With
such, it is best to commence with the lightest bit-
ters, and pass progressively to bark and mineral
acids, and thence to metallic tonics. Of these
sulphate of zinc is one of the least stimulant, and
a grain, with extract of gentian, in a pill twice or
thrice a day, will often agree as well even as bit
ters. In the cases in question, however, medicines
are of far less importance, in the first instance,

454

PALSY — PANCREAS, (DISEASES OF THE)

than regiminal tonics : viz. a bracing air by the
sea-side, sea-bathing, the shower-bath, or salt-
water friction, a regular, nutritious, but unstimu-
lating diet, and a tranquil cheerful mind. After
preliminary measures of this kind for a few weeks,
chalybeates, especially in the form of mineral
waters, will in general prove singularly beneficial.

J. Hope.

[Not unfrequently, cases of irregularity of the
heart's action, especially of the rhythm, are met
with, which appear to be greatly dependent upon
a want of nervous power generally, and of the
nerves distributed to the heart in particular.
These cases are often the source of great anxiety
to the patient. Auscultation may exhibit no evi-
dence of valvular derangement or of altered nu-
trition of the organ ; but a loss of beat is observed
occasionally at the wrist, whilst, at the same time,
the impulse of the heart may be exaggerated.
This pathological condition is often accompanied
by languor, and by irregularity of calorification, —
the hands and feet being kept warm with difficulty ;
and, occasionally, immediately after the irregular-
ity of the heart's action is felt in the epigastrium,
the patient breaks out into a profuse perspiration.
Along with these phenomena he is affected with
flatulence of the stomach and bowels, and, in
many cases, the anomalous symptoms are present,
which have been referred to as belonging to Torpor
of the Colon (q. v.). The subjects of these cases
are often gouty.

The treatment ought to consist of agents that
are calculated to obviate debility and impressibility.
The preparations of iron — as the citrate — iu full
doses are of great service ; and a glass or two of
wine at dinner, or of ale or porter, with animal
food in due quantity, has afforded marked relief.

ROBLEY DUNGLISON.]

[PALSY. See Paralysis.

PALSY, BELL'S. See Paralysis.

PALSY, SHAKING. See Paralysis.]

PANCREAS, DISEASES OF THE. — By
the ancient writers on medicine, the use and the
importance of the pancreas were, it is to be pre-
sumed, little thought of ; for the venerable father
of our art has not even named an organ concern-
ing whose office such a variety of opinions were
advanced in after ages. Of these opinions a
short yet lucid account has been given by De
Graaf. (Tractatus Anatomico-Medicus de Succi
Pancreatici Natura et Usu, cap. 2.) Up to the
period when the pancreatic duct was discovered
by Wirsangus, the notion most generally adopted
seems to have been this, — that the office of the
pancreas was to afford support to the vessels, and
to serve as a cushion or bolster to the stomach, to
protect the latter, when in a state of repletion,
from being pressed and injured by the vertebrae.*
In latter times, however, it has been clearly ascer-
tained to be an important gland. Its office, we
now know, is to secrete a fluid analogous to the
saliva, (hence it has, by Haller and other eminent
physiologists, been called a salivary gland,) and to
transmit by its excretory duct that fluid to the
duodenum. The pancreatic juice, mixing with

* Such was the notion of the celebrated Vesalius.

the bile, probably renders it more bland ; and by
the agency of the pancreatico-bilious fluid, com-
bined with the lymph of the intestines, the food,
already converted into chyme in the Stomach, is
further changed and becomes chyle, the pabulum
of the blood, which has emphatically been termed
the life.

It is worthy of remark that many eminent per-
sons who were ignorant of the true physiology of
the pancreas, who were unacquainted with the
existence of its peculiar secretion, yet considered
it to be the secret source of a variety of important
maladies. Thus Schenkius says that the pancreas
and mesentery are the seats of innumerable and
wonderful diseases; (Exercit. Anatom. lib. i. sect.
2, cap. xxi.) and Fernelius (Lib. vi. pathol. c. 7,)
treating of the morbid affections of the same parts,
affirms that in them he has generally observed the
causes of diarrhoea, dysentery, cachexia, atrophy,
languor, slow fevers, &c. Riolanus again sup-
poses the pancreas to be the obscure seat of inter-
mittents, of hypochondriasis, and of other chronic
disorders.

Important, however, as the office of this gland
is known to be at the present day, we cannot
ascribe to it an influence so extensive and so pow-
erful as these old and most respectable writers
were disposed to assign to it, at a period when its
functions were very imperfectly or not at all un-
derstood. The morbid conditions to which the
pancreas is subject are in fact not numerous. Dr.
Baillie remarks that it is upon the whole less
liable to disease than any other important gland
in the body. (See his posthumous volume, p. 207.)
The symptoms of its disease are moreover obscure,
being for the most part such as belong equally to
morbid affections of other parts contained within
the abdominal cavity. It is, indeed, very seldom
that we are able to discover pancreatic disease in
the living subject, and rarely do we find, upon
examination after death, that this gland has been
the only or even the principal seat of disease.

[There is reason to believe that a close relation
and intimate sympathy exist between the salivary
glands proper, and the abdominal salivary gland
or pancreas; and it would seem that there is a
sympathy between the testes and pancreas (See
art. Parotitis ; and Dr. F. Battersby, in Dublin
Journal of Med. Science, May, 1844, p. 238).
It is, on the average, about six or seven inches
long, and weighs from two and a half to three or
four ounces. Of six observed cases, the mean
weight, according to Professor Gross (Elements
of Pathological Anatomy, ii. 357, Boston, 1839,)
was two and a half ounces, and the mean length
seven inches.]

The deviations of the pancreas from the healthy
state have been regarded by several authors of
high reputation as either of very small moment,ot
as far too obscure to be recognised with any tole-
rable degree of precision. Of all those whose
Genera Morborum are comprised iu Cullen's Sy-
nopsis, Vogel alone says one word about the pari'
creas, and he barely notices its inflammation-
adding the words, < notae deficiunt.' In the com-
prehensive and valuable work of Dr. Mason
Good, we meet with nothing respecting the dis-
eases of the gland in question. Yet though the
opinion of Dr. Baillie above referred to may h e

PANCREAS, (DISEASES OF THE)

455

perfectly correct, and though reading and expe-
rience may have forced upon us the conviction
that the diseases to which the pancreas is liable
can hardly he ascertained during life, or, at all
events, cannot be ascertained until they have pro-
ceeded too far to receive any substantial benefit
from medicine, still, in a work like the present,
the morbid affections of so important a part must
not be passed over in silence. Wc proceed, there-
fore, to offer such an account of those morbid af-
fections as the perusal of some of the best authors,
conjoined with our own (it must be confessed
very limited) observations, enables us to supply.

Inflammation of the pancreas is a disease
of rare occurrence, at least it has seldom been
described by morbid anatomists. A recent in-
stance, however, of what would appear to have
been true inflammation of the gland, has been
given in the Medico-Chirurgical Transactions,
(vol. xvi. part 2,) upon the high authority of Mr.
Lawrence. In the case to which we refer, the
pancreas was throughout of a dull red colour,
which contrasted very remarkably with the blood-
less condition of other parts. It was externally
firm to the touch, and upon being cut into felt
very firm and crisp ; but after having been left
for eight-and-forty hours it became soft. Mr.
Lawrence does not seem to regard this hardness
as a morbid condition of the gland, and for the
following reasons : — 1st, because persons in whom
such a state of the pancreas has been observed
have died of other diseases, without a symptom
of morbid affection of this particular part having
developed itself during life : 2dly, because in these
cases the structure of the gland has been in every
respect perfectly healthy ; and 3dly, because the
hardness soon disappears after death. With all
respect, however, for the opinion of so experienced
a morbid anatomist and so acute an observer as
Mr. Lawrence, we cannot altogether coincide with
him in his reasoning upon this point — we do not
feel satisfied that the induration in question is not
a morbid state. The pancreas is by no means the
only important organ which may be seriously dis-
eased, and yet during the life of the patient betray
no symptom of such disease, and the individual
die at last of some other malady. Induration of
other organs may be discovered upon dissection —
such induration as has been always deemed to be
unequivocally morbid — yet it shall disappear not
many hours after death. Such we have known
to be the case as regards the liver. We have met
with at least one example of enormously hyper-
trophied and indurated liver, where the induration
was lost a few hours after its removal from the
body. Mr. Lawrence's strongest argument is the
otherwise healthy condition of the pancreas ; but
Mr. Baillic, while he remarks that hardness of
this gland is accompanied with little appearance
to the eye of its structure being altered, proceeds
to observe that he believes this hardness to be the
beginning of a process by which the pancreas
becomes truly scirrhous. " It very seldom," he
says, " in this state shows, in any part, the real
scirrhous structure, but I have seen this to be the
case, which renders it very probable that the one
is the beginning of a change into the other." (See
Morbid Anatomy.)

More frequently than with inflammation of the

pancreas do we meet with what are usually re-
garded as its consequences. Examples of abscess
and ulceration are to be met with in various
authors. In the writings of Tulpius, and Bartho-
linus,* and Guido Patin, as cited by Dr. Aber-
crombie, (Pathological and Practical Researches,
&c. Pathology of the Pancreas,) an immense
abscess was found occupying the whole of the
gland. Portal relates several instances of this
disease, and one especially deserves notice, in
which the pancreas was found in a complete state
of suppuration, in a man who died suddenly after
two or three attacks of vomiting followed by syn-
cope : he had previously been suffering under a
paroxysm of gout from which he was supposed to
be recovering. (Portal, vol. v. p. 551 et seq.)
Another case has been recorded by Dr. Percival.
Dr. Baillie never saw but one case of pancreatic
abscess, and that case did not occur in his own
practice, but was under the care of the present
Dr. Heberden.

Gangrene of the pancreas has been men-
tioned by Bonetus, Portal, and others.

Remarkable instances of scirrhns of the
pancreas are also on record. Riolanus found
the gland in such a state, and equalling the liver
in size, in the person of Augustine Thuanus.
Morgagni (Epist. xxx. 10) relates a case where
the pancreas was of unusual magnitude, and uni-
versally unequal with round tubercles of con-
siderable size, and itself of almost cartilaginous
hardness. Similar examples may be found briefly
related by Dr. Abercombie. (See his work above
cited.) Several cases have also occurred to the
writer of the present article in which the pancreas
seemed to be preternaturally hard ; but he has
met with but one instance where the gland was
decidedly and greatly indurated, almost as hard
as cartilage. The subject was a young married
lady, who, after having for many years suffered
from intense pain of head, died with immense
effusion in the ventricles of the brain. The ab-
domen was examined in consequence of her hav-
ing, a short time previous to her death, complained
of excessive pain in the epigastric region. No
morbid appearance was discovered, excepting the
extraordinary induration of pancreas above men-
tioned.

Cancer of the pancreas has sometimes been
noticed. De Graaf (Tractatus, &c. cap. vii. See
also Bonetus, de vomitu observ. 55) has a striking
case from the Miscellanea Curiosa, Med.-Phys.
Germanorum. It occurred in the person of a sur-
geon. The pancreas, which had perforated the
diaphragm, was two spans long, and two hands in
breadth ; it was decayed and putrid — an ulcerated
mass, resembling cancer. In this case not only
was the diaphragm perforated, but the spine was
eroded, and the vena cava had given way. The
cancerous mass had spread further, and had con-
taminated both kidneys, rendering them putrid
and excessively black.

We are not aware of the existence of a symp-
tom or set of symptoms by which inflammation of
the pancreas can be ascertained in the living sub-

* See also F.ibricins (Win.) cent. 4. obs. 71. .Antest Pro-
gram, to the treatise of Fernelius, " de abditis rerum.
causis"— De Graaf ' de Succo Puncreatico,' cap. vii. case
cited from Hiahiuore.

456

PANCREAS, (DISEASES OF THE)

jcct, nor are those which attend ulceration or scir- i
rhua of that gland by any means well deBned.
The pancreas, says Dr. Pemberton, (Diseases of
Abdominal Viscera,) is endowed with so small a
degree of sensibility that ulceration is found after
death, when no pain or other symptom had pre-
viously existed which could lead to a suspicion
that inflammation was going on. If, however,
there be a sense of weight or deep-seated pain in
the region of the stomach, or referred to the back,
with vomiting* of ingesta and of watery fluid ;
if there be gnawing pain at the boundaries of the
thorax and abdomen, urgent thirst, and emacia-
tion,"!" an( ^ }' ct no P ercc ptible tumour in the hypo-
chondria, nor other symptom, in addition to those
just mentioned, to mark an original disease of the
stomach, or concave surface of the liver, or of the
gall-bladder or ducts, or of the small intestines, or,
we may add, of the kidneys, we may safely con-
clude that the seat of disease is the pancreas.

When disease has so far advanced that the
emaciation is extreme, the indurated gland may
be distinctly felt : by placing one hand upon the
back and the other upon the stomach, and employ-
ing considerable pressure, an expression of pain
deep-seated under the hand will in all probability
he elicited from the patient.

But, besides the diseases already mentioned, the
pancreas is subject to certain other morbid affec-
tions. Thus, while tubercle of the gland is men-
tioned by Morgagni, (Epist. xxxiii. art. 28,) a
case of tuberculated sarcoma is related in the Me-
dico-Chirurgical Transactions, (vol. ix. part ii. p.
342 ;) Dr. Abercrombie has given several in-
stances of a mixed state of disease — of hypertro-
phy, with partial induration and partial softening,
resembling medullary sarcoma. (Pathological and
Practical Researches.) "Many cases," says the
latter author, " are on record, of chronic disease
of the pancreas, exhibiting the same diversity of
symptoms which occurred in the examples now
described, and nearly in the following proportion.
Of twenty-seven cases, which I find mentioned by
various writers, six were fatal with gradual wast-
ing and obscure dyspeptic symptoms, without any
urgent symptoms ; in eight there was frequent
vomiting, with more or less pain in the epigastric
region ; and thirteen were fatal with long-con-
tinued pain, without vomiting. In some of these
the pain extended to the back, and in others it
was much increased by taking food. In several
there were dropsical symptoms, and in three or
four there was jaundice from the tumour com-
pressing the biliary ducts. In the morbid appear-
ances, also, there was great variety."

Calculous concretions have been found in the
pancreas. Instances of this have been given by
De Graaf, Portal, Baillie, &c. The calculi in Dr.

* The diseased pancreas may in various ways occasion
vomiting; l»y irritating the contiguous stomach by its
hardness or roughness, or by pressing upon it by its pre-
ternatural size; or it may compress the duodenum. Or
the vomiting may be caused by the secretion of the gland
being vitiated by its being deficient, or altogether sup-
pressed. It is said that dogs, whose pancreas has been
removed, have died of bilious vomiting.

t There is an observation of Prosper Alpinus which
we must not pass over in silence. Speaking of inflam-
mation of the omentum, mesentery, and pancreas, he
Bays " Necessario predictarum partium insensibilium
p'li'leirmone oppressi in expirando angustiam sentiunt."—
DeSlcdicina Methodicd, lib. vii.

Baillie'a case were found to consist of carbonate
of lime. (See Baillie'a Morbid Anatomy ; Pern..
baton on Disease of Abdominal Viscera; Aber-
crombie.)

The pancreas, it is said, has been entirely want-
ing; but we doubt the fact : we believe that in
the cases adduced some portion of the gland ex.
isted. The entire pancreas, as Haller observes,
cannot be removed without the duodenum.}:

After what has been said respecting diseases of
the pancreas, of the great obscurity of their symp-
toms, &c, it cannot be expected that any thing
very satisfactory can be proposed as to their treat-
ment. To use the words of Dr. Pemberton, « the
remedies for a diseased pancreas are as imperfect
as the symptoms which mark its derangement."
Could we even be assured that the pancreas is the
primary or the principal seat of disease, we should
still perhaps be at a loss how to meet the mischief
by strictly appropriate remedies, and as, in the
present state of our knowledge, we never can de-
cidedly pronounce that the gland in question is the
chief seat of disease, our practice must necessarily
be vague ; it must necessarily be directed to
symptoms which belong equally to morbid affec-
tions of other organs as well as to those of the
pancreas. Pain we must attempt to relieve hy
leeches, or cupping, or blisters. We must endea-
vour to restrain the efforts to vomit, and we must
secure at least one regular evacuation daily. Of
the remedies calculated to allay the irritable con-
dition of the stomach which accompanies disease
of the pancreas, a great variety might be men-
tioned : we select the following, simple indeed,
but often very useful : — first, a drachm of tincture
of senna with five minims of laudanum, to be
taken a quarter of an hour before each meal;§
secondly, pulv. calumb. et pulv. rhei ai gr. v„
sodae subcarb. gr. v., pulv. capsici gr. ss., in any con-
venient vehicle just before dinner; or gr. v. of the
compound rhubarb pill may enable the stomach to
retain a portion, at least, of the food, which would
otherwise be rejected altogether. Of the other
numerous remedies which are commonly employed
in derangement of stomach, we need say nothing
in this place. They may each prove occasionally
useful, but they more generally fail even to palli-
ate the symptoms when the pancreas is in fault.
The bowels may be regulated by mild laxatives,
The plan of certain old practitioners is not to be
despised. When they met with cases in which
pain of stomach or of some neighbouring viscus
was chiefly complained of, yet no good evidence
existed of actual disease of any particular part,
they gave an opiate draught at bed-time, and a
common laxative in the morning. This practice
was, we believe, at least as useful as any of the
more scientific plans which have been adopted in
later times. The patients probably lived as long
and their days were as comfortable as they have
been under modern treatment.

In one word, respecting diseases of the pan-

X Utilitatem magnate (pancreatia scilicet) perpetuitas
suadet, qua pancreas in plerisque animalibus reperitur;
neque rcfutant pauca experimenta, in robusto animali fac-
ta, quod particula pancreatis extirpates vitale tuperjicit,
totum enim pancreas aufcrri veqn.it, nisi cum duodena.—
Haller Prime Lineie Physiologies.

§ In the distressing nausea and vomiting attendant
upon the early stage of pregnancy, the above is a very
excellent remedy.

PARALYSIS,

45"

creas, wo think that, in their earlier stages, when
they cannot he exactly ascertained, our practice
must he in a great degree empirical ; when they
have reached that point that they can be pretty
accurately ascertained, little or nothing can be
effected, nothing probably in the way of cure,
little by way of arresting the progress of the dis-
ease. Still, however, it is our duty to recommend
an alterative course of medicine ; at any rate we
may palliate the more distressing symptoms; we
may, as in various other hopeless maladies, render
the closing days of our patients comparatively
comfortable.

[Various diseases have been ascribed to an in-
creased secretion, or hypercrinia of the fluid of
the pancreas, — cases of enterorrhcea, for exam-
ple; and it was suggested by M. Dupuytren,
whether the pancreas may not furnish the matter
evacuated by persons labouring under cholera.
It has, moreover, been presumed by M. Mondicre,
(Recherches sur VHistoire Pathologique du Pan-
creas, in Archiv. General, Mai et Juillct, 1836,)
that the fluid of pyrosis may proceed from the
pancreas ; and, as remarked elsewhere, {Practice
of Medicine, 2d edit. i. 581, Philad. 1844,) we
cannot say that these speculations are altogether
devoid of foundation, or that they are irrational ;
but it may be averred with safety, that the. ob-
served phenomena and arguments in their favour
are by no means convincing. (See on the Dis-
eases of the Pancreas, Art. Pancreas, (Path.) in
Diet, de Medecine, xxiii. 68, Paris, 1841.)]

H. W. Carter.

PARALYSIS, from TrapdXvas, debilitas, rcso-
lutio nervorum of Celsus.

At an early period of the history of medicine
it was a surmise of Galen that two different states
or degrees of nervous influence were requisite to
supply sensibility and the motive power to any
part of the body ; but it was reserved to the pre-
sent century to enlarge upon this idea, and by
careful induction from facts disclosed by minute
anatomical investigation, from the results of direct
experiment and from the effects of certain patho-
logical conditions, to infer that parts endowed
with sensation and voluntary motion are provided
with two classes of nerves, the one sentient, the
other motive nerves.

If a part be deprived of the influence of one or
both of these classes of nerves, from whatever
cause, and to a greater or less degree and extent,
that part is reduced to the condition indicated by
the term paralysis, which we accordingly define
as the total loss or diminution of sensation or mo-
tion, or of both.

Aretams was the first of the ancients to employ
the word paralysis to any extent, but he limits its
signification to denote merely a loss of the power
of motion, (Ktvijotos jxovvov htpytins ri ra'pto-ij.) The
term occurs only once in the writings of Hippo-
crates, and then in a letter to Perdiccas — de struc-
ture hominis. By him, and by many writers
after him, apoplexy and paralysis were confounded
together, and even by Hebenlcn they have been
considered as only different degrees of the same
disease.

It is with much justice that Rostan has repro-
bated the custom of considering the condition of

Vol. III. — 58 2 o

paralysis as a disease in itself, when it undoubt-
edly should be regarded as a phenomenon belong-
ing to and dependent on a number of different
affections ; and it is much to be questioned whether
such a species as that given by Rachoux, (Diet,
de Medecine, Art. Paralysie,) viz. idiopathic pa-
ralysis, is at all admissible.

From the definition above given, it is obvious
that those parts which are naturally endowed with
sensation and the power of motion can alone be
deemed susceptible of the paralytic state. We
cannot, therefore, apply the term to that condition
of a secreting organ when it is incapable of per-
forming its function, as some writers have done
when they speak of paralysis of the kidney, liver,
or pancreas, &c.

From the definition we may further infer a pri-
mary division of paralysis into that of sensation,
or anaesthesia (avaioOficvn'), and that of motion
(axivnaia), each of which may vary in degree, and
may be therefore complete or incomplete.

[Paralysis of Sensation.] — Although the
term anxsthesia seems to have originally been
applied by Areta?us to denote absence or defect
of the sense of touch, there is no reason, from
the etymology of the word, why it should not be
more extensively applied to signify absence or
defect of sensation in general. Adopting this
broader signification, then, we place under this
head those affections of the senses which are de-
nominated amaurosis, anosmia, cophosis or dy-
sxcia, ageustia, as the sight, smell, hearing, or
taste, may be severally deficient, and finally para-
lysis of the sense of touch, which is specially de-
nominated by some anxsthesia.

For full details respecting Amaurosis we
refer to the article under that head. (See Amau-
rosis.)

Anosmia (loss of smell), rarely exists as a
solitary complaint, except it be occasioned, as we
believe it generally is, by an abuse of sternuta-
tories. It is sometimes a congenital defect, an
instance of which is mentioned by Dr. Good, in
the person of a young lady. Another instance is
known to the writer, in the case of a gentleman,
now past the age of fifty.

Tumours compressing the olfactory nerves, or-
ganic alterations of their roots, acute affections, or
long-continued irritation of the Schneidcrian mem-
brane, polypi, disease of the spongy or other bones
of the nose, external injuries, may be enumerated
as the principal causes of anosmia. Serres alludes
to several cases of disease of the roots of the olfac-
tory nerves affecting the sense of smell, and seems
to think that alteration of the external root exerts
a more powerful influence than that of either of
the others.

The cure of this affection is accomplished by
the removal of the above-mentioned causes, and
is attainable only so far as that object can be
effected.

Cophosis (deafness) is not an uncommon
symptom in fevers, or in acute diseases in which
there is disposition to head affection. Disease or
compression of the auditory nerve — disease of the
petrous bone — obliteration of some of the canals
or passages connected with the auditory apparatus
— otitis — are among its most usual causes. There
are likewise cases of nervous deafness, as Mi

458

PARALYSIS,

Saunders designates it, dependent on constitu-
tional causes, producing temporary derangement
of the functions of the auditory nerve.

If the deafness depend on obstruction, it is of
course submitted to surgical treatment ; but if it
be merely a functional derangement, topical coun-
ter-irritation and a general tonic treatment have
been generally found successful in the early stage.

Ageustia (loss of taste) sometimes accom-
panies local palsy of the tongue or of the face, and
sometimes is produced mechanically by the deposit
which covers the sentient surface of the tongue in
fevers, exanthemata, &c, preventing the applica-
tion of the sapid substances to the nervous ex-
tremities. It is likewise occasioned, as Dr. Good
observes, by the long-continued use of tobacco,
whether by smoking or chewing, or of other acrid
narcotics. In the Boston Medical and Surgical
Journal for May, 1832, Dr. Robbins relates the
case of a lady in whom the sense of taste on one
side of the tongue was impaired by want of exer-
cise. Owing to the presence of a very painful
but not unsound tooth on the left side, the whole
force of mastication was thrown upon the teeth
of the right side. Liquids were from habit suc-
cessfully passed through the mouth without
coming in contact with the left side. After two
years' continuance in this state, the painful tooth
was extracted, and when the immediate effects of
the operation of extraction had subsided, the lady
observed that her sense of taste on the left side
was considerably impaired in acuteness, and that
she failed to perceive the true flavour of whatever
was presented to its action. (Vide Lond. Med.
Gazette, vol. x. p. 175.)

This affection, like the preceding, is to be cured
by the removal of its exciting cause.

Anaesthesia (diminution or absence of the
sense of touch or of feeling) affords much matter
of interest to the pathological inquirer. We meet
with it most commonly as a precursor of paralysis
of motion, either in a minor degree, a condition
of numbness, or in that of total insensibility ; fre-
quently it accompanies paralysis of motion, and
rarely follows it.* It more frequently precedes
paralysis of motion of the lower than of the upper
limbs. Sometimes it is coexistent with paralysis
of motion of the opposite side, as in a case by
Cullen, of a gentleman who had loss of motion
without loss of sense of one arm, and loss of sense
with perfect motion of the other. (See, also,
Ephem. Natur. Curios., cent. ii. obs. 196.)

Several cases of complete loss of feeling are now
on record. In these cases the patients are insen-
sible to injuries of the severest kind, — wounds
with sharp instruments, burns, &c, and are con-
stantly liable to accidents of this description, the
skin having lost its protecting sensibility. Dr.
Good quotes a case in which the anaesthesia had
its seat in the right arm ; in this case, the occur-
rence of a phlegmon on the affected arm excited
no uneasiness, and some time after, when the
patient accidentally fractured his arm, he received
intimation of the accident merely from the crash
which it produced. Dr. Yellowley gives the in-
stance of a man who put his feet into boiling

*ln a case reported hy Dr. Colles, of Dublin, in the
Appendix to Sir C. Bell's work, loss of feeling followed
the cure of a partial paralysis of motion of the face.

water, and was not aware of the height of the
temperature till he perceived a vesication forming
on one of his legs: in a similar case by Mr.
Earle, the high temperature of some hot grains,
into which the patient put his legs, was first
evinced by the formation of large sloughs. We
may add that in Dr. Yellowlcy's case above
alluded to, a knife was introduced deep beneath
the nail of the thumb without occasioning pain
or uneasiness.

When anaesthesia occupies the external integu-
ment, in the immediate neighbourhood of any of
the orifices at which that membrane becomes con-
tinuous with the mucous membranes, the latter are
generally similarly affected to a greater or less ex-
tent. Thus in the cases of partial loss of feeling
of the face, the conjunctiva of the eye, so acutely
sensitive in its healthy condition, can bear pres-
sure or friction, or even pricking with the point
of a sharp instrument. The eyeball having thus
lost its proper sensibility, the cornea is apt to be-
come inflamed, opaque, ulcerated, and finally de-
struction of the eye ensues. Hence some phy-
siologists have, with but little show of reason,
argued that the nerve supplying sensibility to the
conjunctiva is likewise the nerve of sight. The
mucous membranes of the nose and mouth like-
wise, participate in the insensibility in these cases.
In the nose, the membrane is unaffected by pun-
gent substances, as ammonia, &c, although the
sense of smell is perfect : the introduction of a
feather into the nostril does not produce any of
the usual effects. In the mouth there is equal
insensibility of the mucous membrane of the
gums, lips, and tongue; the individual will bear
even mustard in the mouth without being incom-
moded : he is insensible of the presence of food
in that part of his mouth which is the seat of the
disease ; so much so that, in a patient in this
condition, a portion of food has been known to
remain in the mouth till it became putrid. In
these cases the sense of taste is generally affected.
Mr. Broughton (Med. and Phys. Journ. 1827)
has related an interesting case, in which the
anaesthesia succeeded to the recovery of paralysis
of motion of the lower extremities ; it occupied
the skin of the nates, part of the loins, perineum,
penis, and upper part of the thighs. In this case
the insensibility extended to a great portion of the
genito-urinary mucous membrane; the patient was
unconscious of the presence of a catheter in the
urethra ; erections of the penis and emission of the
semen took place likewise without the patient
being sensible of them. But the most remarkable
and interesting phenomenon connected with the
case, was the kind of incontinence of urine which
was present : " when the bladder was full, th e
urine overflowed on the slightest irregular move-
ment, and ran out of the penis unconsciously to
the patient." A similar case is detailed by Olh-
vier, in which incontinence of urine was co-
existent with anaesthesia of the inner and anterior
part of the thighs, and of the penis and scrotum.
In these instances we presume that the insensi-
bility of the inner membrane of the bladder is suf-
ficient to account for the incontinence of urine,
for how can those muscular fibres, which to a
certain extent perform the office of a sphincter to
the neck of the bladder, be stimulated to contrac-

PARALYSIS.

459

tion, unless the mucous membrane of that viscus
be sensible of the presence of the urine 1

Anaesthesia is most frequently partial in its ex-
tent ; we sometimes meet with persons who pos-
sess from birth a numbness of one or more fingers.
Often the affection begins locally, but increases its
extent gradually. Cases are recorded in which
the anaesthesia was universal ; in others it has
been reported to occupy the whole surface, with
the exception of a small portion, as in a case by
OHivier, where a patch on the right hip was the
only sensible spot on the whole cutaneous surface;
and in another quoted by Andral, in which the
insensibility extended over the whole body, ex-
cepting a small round spot on one of the cheeks.

In partial anaesthesia existing on one side of
the body, we generally find the insensibility limited
with the utmost precision by the median line.
These cases vary in extent from half the body to
an extremity, part of an extremity, part of the
face, &c. It has also been known to occur in nu-
merous round spots, eight or ten in number, the
surrounding skin being perfectly natural. ( Andral's
Lecture, Lancet, No. 497.) In the anaesthesia of
the face we may here mention an invariable con-
sequence ; the patient complains that when he
puts a glass or cup to his lips, it conveys to him
the sensation of its margin being broken ; and this
circumstance is often the first to direct his attention
to the complaint. When there is cutaneous anaes-
thesia of the extremities, we generally find that
the power over the voluntary muscles is impaired ;
and this we might, a priori, expect to follow loss
of sensation. A case by Dr. Yellowley confirms
this supposition. The patient used to drop glasses,
plates, &c. if her attention were directed from
them ; but so long as she kept her eyes on them,
she held them in perfect safety. A precisely simi-
lar instance is adduced by Foville, (Diet, de Med.
et Chirurg. art. Encephale\ in proof of the above
assertion, as related to him by Sir A. Cooper. A
third case we may mention from Dr. Ley. (Ap-
pendix to Bell on the Nerves, No. Ixxxv.) There
was defective sensibility on one side of the body ;
the patient could hold her child in the arm of that
side so long as her attention was directed to it ;
but if surrounding objects withdrew her from the
notice of the state of her arm, the flexors gradu-
ally relaxed, and the child was in hazard of falling.
The fact is further illustrated by an incident of
daily occurrence. When a person, from sitting
in an awkward position, produces numbness in
his lower extremity by the prolonged pressure on
the sciatic nerve, he will find it almost impossible
to stand on the benumbed leg alone, and that from
the absence of the consciousness that the foot is
applied to the ground.

Anaesthesia varies in its modes of access. In
some cases the patient's attention is first attracted
by the sensation of fine sand intervening between
the skin and the object touched : in others there
is a feeling compared to the creeping of insects
over the skin, and thence named formication :
both these after a little merge into total insensi-
bility. Often the anaesthesia appears suddenly
and without any premonitory symptom.

We cannot always assign a satisfactory cause
foi the condition which we have been describing.
In general, however, it is referable to some change

influencing the nerves which supply sensibility to
the affected part or parts ; in the trunk and extre-
mities, the sensific filaments of the spinal nerves ;
in the face, the ganglionic portion of the fifth
pair. This alteration may exist either in the ner-
vous trunks themselves, or in the nervous centres,
where the nerves are connected with them. Thus
pressure, wound, or disease of a nerve, is constantly
known to affect the sensibility of the parts supplied
by it. Several instances are to be found in authors
where anaesthesia followed concussion of the spi-
nal marrow ; injury or disease of the posterior
bundles of the same could produce a like result.
Loss of sensibility is often connected, too, with
cerebral disease. Local injuries of various kinds
will produce anaesthesia ; it sometimes has com-
menced from a cicatrix, or succeeded the applica-
tion of a blister. The sudden or continued expo-
sure to cold is not an unfrequent cause : most of
the cases related by Mr. Broughton were plainly
attributable to this cause. Mr. Swan gives a case
in which anaesthesia of the hand was produced
by a violent pressure applied to the wrist ; and
Roche mentions one, in which the insensibility
occupied the integument over the trajet of a ball
which entered the body on the right side and ran
round beneath the skin till it struck against one
of the lumbar vertebrae.

Anaesthesia is likewise often connected with
hysteria and hypochondriasis ; sometimes it fol-
lows parturition, as in the case above quoted from
Dr. Ley : it is also sometimes coexistent with
mental derangement. We may add, that the
condition of the circulation in a limb exerts a
marked influence on its sensibility ; suspended
or retarded circulation removing or diminishing
the sense of feeling, as is matter of daily obser-
vation.

The duration of anaesthesia is uncertain and
variable : sometimes the sensibility will return
when least expected ; at other times it will resist
all treatment. When it is the result of spinal
concussion, it may be removed by the treatment
generally adopted for that accident ; and when
produced by cold, the prognosis may also be fa-
vourable.

The treatment of this condition is founded
more on experiment than on a correct pathology.
It chiefly consists in local applications to the af-
fected parts. Friction with various stimulants ;
baths of different descriptions, warm or cold ;
douches, blisters, or epispastics of other forms ;
electricity ; may be enumerated as the chief cura-
tive agents. If an organic cause exist, either in
one of the nervous centres, or in a trunk of a
nerve, it is hardly necessary to observe that pri-
mary attention should be directed to ascertain
how far that is removable.

We may here briefly allude to the remarkable
epidemic which appeared in Paris in the summer
and autumn of 1828. The most singular and
constant symptom was a numbness, passing into
a total insensibility of the skin and subcutaneous
tissues on the hands and feet, and sometimes on
other parts, of more or less extent. This was in
general preceded by some symptoms of gastric or
intestinal irritation, which continued often for
many days or weeks. The insensibility, which
was in general preceded by formication or prick

460

PARALYSIS.

ing pains, was uniformly accompanied with an
(Edematous state of the affected limb; vesications,
likewise, formed on it in different places: the
skin was sometimes red, sometimes of a dark
colour, and the epidermis detached in some places.
The insensibility was so great in many cases, that
no pain was experienced when pins were passed
into the skin. In some cases there was subsultus
tendinum ; in others the muscles were paralysed ;
yet according to the report of M. Genest, (Ar-
chives Gen. de Med. Oct. 1828,) from whom we
have taken the above statement, the latter condi-
tion was not very frequent ; but from the state-
ment of Chomel to the Academy (sitting of 26th
of August), it appears that considerable weakness
of the feet and hands, with impossibility to move
them, was a symptom very constant.

No organic lesion of the nervous system could
be detected sufficient to account for this remark-
able epidemic. From the examinations detailed
by Genest, the intestinal mucous membrane seems
to have been the seat of several ulcerations. To
us there appears much analogy between this epi-
demic and that which is met with in tropical
climates, the beriberi, or the more chronic bar-
biers.

Paralysis of Motion. — The second form of
paralysis is that of motion, to which, from its
being of so frequent occurrence and so serious in
its effects, the term paralysis is more especially
applied.

Like that oi sensation, paralysis of motion is
either complete or incomplete. It presents some
variety in its mode of invasion : it may come on
instantaneously, and without any premonitory
symptom ; the affected parts becoming suddenly
flaccid and powerless, and thrown into a state of
complete resolution : at other times the paralysis
is preceded by inordinate muscular action, viz. by
spasms attended with a considerable degree of
pain, the muscles sometimes remaining in a state
of rigidity after the invasion of the paralysis.
Lastly, we find paralysis coming on slowly and
gradually ; the part being at first affected as to
its sensibility, then becoming slightly torpid, and
at length paralysed ; the palsy then spreads on
step by step, till it occupies a considerable extent.
This is the form to which the term creeping palsy
has been applied.

There are certain phenomena which constantly
succeed to the attack of palsy. Wasting of a
limb is an almost invariable consequence of para-
lysis. This would appear to arise more especially
from the atrophy of the muscles, the result of
prolonged inactivity ; and, in part, from the de-
ranged nutrition, in consequence of the removal
of due nervous power. The muscles of a limb,
when in a state of complete resolution for any
long period, lose their colour, and are diminished
in firmness as well as in dimensions ; the colour-
ing matter in some cases is completely absorbed,
and a yellowish tissue, which however still retains
the fibrous and fasciculated character, replaces
the original muscle ; a change which by some
has been described as the conversion of muscle
into fat.

The circulation in palsied limbs is said to be
more languid than in healthy ones, and the pulsa-
1 f»ns of the arteries have been stated to be dimin-

ished in force and even in frequency. These
statements, however, do not appear to have been
founded on facts universally or even extensively
observed, to say nothing of the sources of fallacy
which lie in the way of a conclusive comparison
of the relative force of arterial pulsations.

The nerves of palsied limbs do not in general
present any obvious change. They have, how-
ever, been found increased in size, and of a yel-
lowish colour ; but it should be noticed that the
enlargement might have arisen from the thicken-
ing of the neurilemma, or from the infiltration of
a fluid, and not from any increase of the medul-
lary substance. We may, moreover, state as the
result of the experience of Andral, that he has
never found the nerves of paralytic limbs either
atrophied or hypcrtrophied. (Andral's Pathol.
Anat. by Townsend, vol. ii. p. 797.) Sir C. Bell,
however, is of opinion, as Dr. Cooke says, that
the nerves of palsied limbs do lose some of their
substance. When the nerves of a paralysed limb
are diseased, it has been remarked that the wast-
ing is more rapid and more manifest than in the
ordinary cases, (see article Athophi;) and judg-
ing from our own observation, we would infer
that the atrophy is likewise more rapid when the
paralysis is the result of spinal than when caused
by cerebral disease. Thus how much more fre-
quently do we observe wasting of the limbs of
paraplegics than of those in whom the paralysis
is in the form of hemiplegia ! Yet we have seen
limbs in the state of palsy, and that of some dura-
tion, in which there could not be detected any
difference from sound limbs. We not unfre-
quently meet with palsied limbs in an cedematous
state, more especially in old persons; we may
also remark that the state of paralysis favours the
formation of vesifications on the affected parts,—
an occurrence more commonly noticed in para-
plegia.

Much has been written respecting the tempera-
ture of paralytic limbs. Does it differ from that
of healthy ones 1 or are they, from the want of
nervous power or any other cause, less able to re-
sist the influence of cold 1 Mr. Earle, by actual
thermometric examination of a considerable num-
ber of paralysed limbs, found that their tempera-
ture was some degrees lower than that of the
sound ones, and observes that, wherever nervous
energy is impaired, the part loses the power of
maintaining a healthy standard temperature, be-
cause the integrity of the nervous power is essen-
tial to the complete performance of the calorific
function. (Med. Chir. Trans, vol. vii.) Obser-
vation, however, has frequently shown that par-
alytic limbs may be of a higher temperature than
others. Dr. Abercrombie's views on this head
place the question in so clear a point of view, that
we shall transcribe his remarks: "In regard to
the temperature of paralytic limbs, I think it is
generally supposed that they arc colder than the
healthy limbs ; but this does not appear to be the
case. The truth seems to be that they have lost
in some degree that remarkable power possessed
by the living body, in a healthy state, of preserving
a medium temperature, and that, according to the
temperature to which they have been exposed,
paralytic parts become hotter or colder than sound
parts which have been exposed to the samp tern-

PARALYSIS,

461

perature. A case has been related to me by a
friend in which a medical man, paying a visit to
a paralytic patient, found the paralytic arm so in-
tensely hot that it was painful to touch it. This,
upon inquiry, was found to he owing to the appli-
cation of very hot bran, which the patient had
made to the arm by the advice of a neighbour,
though he was himself insensible to the change
of temperature." (Abcrcrombic on the Brain,
&c. p. 238.)

The sensibility of paralysed limbs is generally
more or less impaired ; most frequently there is
paralysis of sensation incomplete or complete, the
latter, however, being very rare. Dr. Cooke states
that he " never saw a case of palsy in which sen-
sation was entirely lost ; and an eminent physician
of great experience asserts that a total loss of
feeling in this disease is very rare." Sometimes
the sensibility is exalted, and the patient can
hardly endure the slightest touch upon the affected
limb. Dr. Abercrombie refers to a case in which
the sensibility of the arm was so increased, that
the least breath of cold air excited convulsion.
The sensibility may likewise be so altered that the
patient will draw erroneous inferences from his
sense of touch ; thus, cold bodies will feel hot to
him, and as in the case related by Dr. Falconer,
(Mem. Med. Soc. Lond. vol. vii.) the feeling of
heat will subside as the body in contact gradually
acquires the temperature of the limb.

In general there is but little pain in palsied
limbs ; Drs. Cooke and Abercrombie, however,
speak of patients who suffered extreme pain. We
have observed pain accompanying incomplete
palsy, and we should say that it is in such cases
that pain is to be expected, there being in general
a more or less spasmodic condition of the muscles.
The vital and natural functions, says Cooke,
are generally but little affected in palsy ; some-
times those of respiration and circulation are
somewhat impeded, but this is generally towards
the close of the patient's life. The bowels are
usually more torpid, and less easily brought under
the influence of purgative medicines, but the ex-
cretions are not diminished. When the paralysis
extends to the sphincter, and to the muscular coat
of the bladder, the involuntary discharges are apt
to lead one to imagine that the excretions are in-
creased in quantity-
Paralytics are in general irritable and peevish,
and, if the palsy be of long duration, sometimes
become quite imbecile. Dr. Cooke relates a case,
however, in which the attack of paralysis pro-
duced a remarkable change in the temper of the
patient ; — « from being of an irascible and irrita-
ble disposition, he became perfectly placid, and
remained so until his death about two years
after." The powers of the mind too are not un-
frequcntly afTected, as well antecedently as sub-
sequently to the attack of paralysis. The memory
is most frequently affected in these cases : the
power of recollecting names, whether of persons
or things, as well as the memory of languages, is
often lost ; the habit of substituting one name for
another, and a predilection for particular names,
which the patient will apply to all persons and on
all occasions, are also among the deranged mental
phenomena attendant on these cases. In some

2o*

instances, paralytics even invent names which are
unintelligible to all except those who are in daily
attendance on them. The writer remembers the
case of an old domestic, rather famous for loqua-
ciousness when in health, in whom some curious
defects of verbal memory preceded for a consider-
able period the paralytic attack which ended her
days. She entirely forgot the names of persons,
and first lost the recollection of the names of those
with whom she was most familiar ; yet for some
she invented names, which seemed to please her
better than the real names of the individuals, as
she almost invariably rejected the real names
when they were mentioned to her. She had
nearly the same defect as to names of things ; she
often pronounced the first syllable of the name of
any thing she wished to ask for, but could get no
farther; nor would she be put right. She at
length grew irritable and suspicious of even those
who ministered to her wants ; she husbanded her
few articles of property with the greatest care and
closest watchfulness ; and ultimately she became
amaurotic, and the subject of extensive palsy.
Such instances are, we believe, by no means
rare. Dr. Bright relates one in some respects
similar.

Causes of Paralysis. — It is to the effect of some
alteration in the centres or ultimate ramifications
of the cerebro-spinal system that observation has
taught us to look for the true cause of most of the
paralytic affections met with in practice. There
are forms of palsy where no appreciable alteration
can be detected in any part of the nervous system.
Such are those in which the palsy arises from the
impregnation with metallic particles — lead, mer-
cury, and others, for which no satisfactory cause
is assignable. Yet even in these cases we are
scarcely warranted in denying the existence of
organic lesions merely because they are not ob-
vious to our senses. We would here observe
that close and unbiassed observation is more
called for to promote the elucidation of the class
of affections we are now considering than of any
other, and we may add that an accurate symp-
tomatology is as essential to this important end as
an exact and minute detection of the several mor-
bid appearances of the cerebro-spinal system. It
is mainly by a series of pathological facts, well
arranged, that we can hope to unravel with cer-
tainty the many intricacies connected with that
system in its healthy as well as its morbid state.
To accumulated experimental and pathological
investigations we owe in a great measure the ad-
vances made within latter years, and to such we
look forward, and not without sanguine hope, for
a still farther insight into a class of diseases at
once dreadful to the afflicted and perplexing to
the practitioner.

Paralysis is said to occur more frequently in
men than in women, and generally in persons
past the meridian of life ; it is a common disorder
of old age. Those of a sanguine and what has
been called nervous diathesis arc most liable to it.

Its exciting causes are such as dispose the brain,
spinal marrow, or nerves to diseased action acute
or chronic ; accidents, and a variety of other
causes, both moral and physical. (See Apoplexy
and Inflammation of the Brain.) Exposure

462

PARALYSIS.

to the action of particles of mercury, lead, and
arsenic, produces a peculiar form of paralysis, the
paralysis venenata of Cullen.

Paralysis is often co-existent with various ner-
vous diseases — hysteria, epilepsy, mania, hypo-
chondriasis. It also sometimes appears after
parturition, and occasionally with phlegmasia
dolens.

The duration of paralysis depends so much on
its cause, the constitution of the patient, and
various other circumstances, that no general state-
ment can be made regarding it.

With respect to the extent of parts affected, we
find that paralysis has, to use the words of Heber-
den, innumerable degrees, from the torpor and
debility of a single joint of a finger to a complete
apoplexy, in which sense and motion vanish from
the body. It may, therefore, be divided into, 1.
general paralysis, 2. partial paralysis.

I. General Paralysis. — When both sides
of the body are paralysed, and when, in fact, the
whole muscular system is deprived of the power
of motion, so that the patient cannot move in any
way by an effort of his own, the condition is that
of general paralysis. If the four extremities be
paralysed, the affection would likewise come un-
der this head. It sometimes happens, that one or
more of the senses are impaired in addition to the
motive power ; and not unfrequently the general
sensibility of the body is diminished or destroyed.

It is remarkable to what an extent paralysis of
motion as well as sensation will affect the body
without destroying life. Some interesting cases
are recorded in which the palsy was so general as
completely to deprive the patient of all means of
communication with the surrounding world. One
of the most remarkable of these is that related by
M. Defermon, in the Bulletin des Sciences Medi-
cares for January 1828. It is defective, however,
inasmuch as the examination of the body was not
permitted. M. C. I., of a nervous habit, and hav-
ing lived a dissipated life, was suddenly seized
with amaurosis; which being suspected to have
had a syphilitic origin, was treated accordingly,
without success. Immediately afterwards there
came on a remarkable exaltation of all the other
senses, but especially of that of touch. His in-
tellect being perfect, he was enabled to continue
in the duties of his office in an important financial
department. Some years afterwards his hearing
became dull, and gradually advanced to total deaf-
ness ; at length general paralysis of sense and
motion, except in the tongue and muscles of
deglutition and respiration, supervened; the whole
body became insensible, and the limbs were suc-
cessively paralysed, without the least trace of
external lesion.

The patient was thus shut out from all means
of communication with others ; yet his speech
and intellects were unimpaired. It was accidentally
discovered that a small patch on the right cheek
retained its sensibility ; and by tracing letters on
this sensible spot, his wife and children were
enabled to maintain an intercourse of ideas with
him ! After some time, however, his strength
began to fail, the paralysis extended to the sphinc-
ters, and he sank.

Another somewhat similar but more complete
rase is recorded in the Edinburgh Medical and Sur-

gical Journal, for 1828, by Mr. Davies Gilbert, the
late distinguished President of the Royal Society.
The young girl, the subject of it, had been born
a little before her full time, and at birth was in a
state of great weakness. She did not manifest in
any way the instinct which usually directs other
infants to seek their natural nourishment ; she
was consequently reared with much difficulty.
One of her eyes was much smaller than the other,
which seemed to be of the natural size. Some
weeks after birth she was seized with violent con-
vulsions, which lasted some time. She continued,
however, to grow like other children, but a defi-
ciency of sensation and motion became daily more
obvious. She was destitute of the sense of sight
and hearing, and a cataract was observed upon the
eye which was of natural dimensions. The sense
of taste appeared to be tolerably perfect, as she
afforded some feeble sign of satisfaction when
sweetmeats were given to her. As to voluntary
motions they were totally defective, and she ar-
rived at her seventeenth year without having ever
raised her head, carried her hand to her mouth, or
put a foot to the ground. She was quite dumb,
and only occasionally uttered a feeble cry, which
her attendants regarded as indicating a desire for
food. Some time before death, her feebleness
seemed to increase, and on the day in which she
completed her seventeenth year she expired, so
tranquilly that she was supposed to have fallen
asleep. It is positively stated that this girl had
shown some appearances of menstruation, as well
as other signs of puberty.

On dissection, the brain appeared perfectly
healthy, but on raising it from the cranium it was
found that the dura mater lining the basis cranii
was deficient, and its place occupied by a thin and
semi-transparent membrane, very loose and singu-
larly arranged ; the tentorium cerebelli was like-
wise deficient, so that the posterior lobe of the
brain rested immediately upon the upper surface
of the cerebellum. All the nerves were perfectly
regular.

General paralysis is most commonly the result
of apoplexy, and is then accompanied with ster-
tor, coma, and the other symptoms usually attend-
ant on that disease. The continuance of circula-
tion and respiration are the only remaining signs
of life, the power of swallowing is impaired or
lost, and the excretions pass involuntarily. This
condition either gradually increases, — the paraly-
sis extending to the muscles of respiration, and
the vital powers becoming slowly exhausted, — or
the coma subsides, consciousness is restored, and
the patient is found paralysed in sensation and
motion, to a greater or less extent ; or the paraly-
sis may totally disappear with returning con-
sciousness.

Paralysis from apoplexy is easily detected, by
the suddenness of its invasion and other concomi-
tant circumstances. (See Apoplexy.) In sur-
gical practice, this condition of general palsy is
met with not unfrequently as a consequence of a
severe concussion or compression of the brain.

We observe other cases of general paralysis,
characterized by a development more or less slow.
The tardy progress of these cases distinguishes
them sufficiently from those which are the result
of apoplexy. Most of them partake of the nature

PARALYSIS.

403

of that described above as creeping palsy ; there
is some variety as to the part first affected : some-
times the eyelids fall, or a hand, or foot, or even a
finger or toe become paralysed ; sometimes, also,
the tongue : at other times an impaired condition
or complete loss of sensibility precedes the paraly-
tic attack ; sometimes loss of sight or hearing is
the first indication ; or a series of cerebral symp-
toms, for which it is difficult to assign an adequate
cause : and this is often succeeded by impaired
memory, and deranged mental powers, such as we
have already alluded to. These cases generally
result from disease, acute or chronic, affecting the
brain, or its membranes, or from disease of the
spinal cord. (See Brain, Inflammation of.)

Injuries of the spinal marrow in man and ani-
mals fully authorize the conclusion, that the higher
in the spine the seat of injury is, the greater the
extent of the consequent paralysis. Hence, then,
we may reasonably expect that, in order to produce
general paralysis, the spinal disease must be either
of considerable extent, or situated at the upper
part of the spinal marrow. This statement is
confirmed by the cases (several of which are now
on record) of rapid death following the separation
of the atlas and axis, when a sudden compression
is exerted upon the contained portion of the spinal
marrow by the odontoid process.

The morbid conditions of the contents of the
spinal canal which have been found coexistent with
general paralysis, are pretty much the same as those
of the brain and its membranes. They may be
thus enumerated: — 1. Inflammation of a considera-
ble portion of the cord towards its upper part,
the existence of which is generally indicated by
ramollissement, suppuration, or abscess. 2. Ex-
tensive hardening of the substance of the cord, in
which the membranes are more or less implicated.
3. Tubercles, or circumscribed tumours, developed
in the spinal marrow. 4. Extensive serous effu-
sion, probably an increase of the natural spinal
fluid, as described by Magendie. 5. Thickening,
or fungoid disease of the dura mater, and ossific
growths, either in that membrane, or from the
bony parietes of the vertebral canal.

In the present state of our knowledge of spinal
diseases, it is not easy to assign any general
symptoms which would point unequivocally to the
6pinal cord as the source of evil in certain cases
of general paralysis. From all that has been col-
lected on the subject, however, we think we are
justified in asserting that there are certain pheno-
mena which more frequently, or in a more marked
manner, accompany paralysis resulting from spi-
nal, than that which depends on cerebral disease.
There is in these cases, generally, a more excited
state of muscular action, evinced by spasms,
twitchings, or even convulsions, and sometimes a
permanent contraction. The sensibility of the
surface, too, is often more deranged : thus, formi-
cation, tingling, or numbness, are very frequently
found as the precursors of the form of palsy we
are alluding to. We may further remark, that it
is in cases of spinal disease that we sometimes
see the line drawn with the greatest precision be-
tween the motive and sensorial powers ; the latter
being totally unimpaired, while the former is com-
pletely destroyed ; a fact which seems clearly to
direct us to the two distinct sources whence expe-

rimental physiology would derive these powers.
Ollivier seems to think that diminution of tem-
perature is more obvious in palsied limbs from
spinal disease ; and it would appear from the re-
ports of cases by him and others, that they are
more liable to oedema, vesication, sloughing, &c.
In fine, the mode of access of paralysis dependent
on spinal disease, is, for the most part, such as
has been described as characteristic of the creeping
palsy of authors.

We occasionally meet with cases of general
palsy, well calculated to perplex the pathologist,
presenting many indications of spinal disease ; and
yet, when we come to examine them after death,
no lesion whatever is discernible, or at least a very
slight one, obviously insufficient to account for the
phenomena. We quote such a case from Dr.
Abercrombie as a specimen, and it is further
worthy of notice, as another instance of palsy al-
most universal. " A woman, cet. 20, a servant,
sprained her back in lifting some heavy article of
furniture. Some time after, she began to experi-
ence weakness of the legs, which gradually in-
creased to perfect paraplegia. After some time
the affection extended to the arms, and she then
had not a vestige of motion of any of the parts be-
low the head, except a very slight motion of some
of the fingers ; but the internal functions were all
entire, and her speech was distinct, except that in
speaking she was sometimes seized with spasmo-
dic twitches of the lips and lower jaw. She lived
in that state without any change in the symptoms,
her general health continuing good, for about
twenty years. In the morning she was taken out
of bed and placed in a chair so contrived as to
support her in a sitting posture. Her arms were
supported on a cross board placed before her ; and
if by any accident one of them slipped from its
support, she had no resort but to call the assist-
ance of some other person to replace it. On one
occasion the arm was allowed to hang for two
hours, she having been left alone, and it became
extensively eedematous. In the same manner, if
her head fell forward upon the thorax, it remained
in that position until raised by an attendant. Her
mind was entire. She died of four days' illness
with symptoms of typhous fever. I examined the
body," adds Dr. A., "with the utmost care, along
with Dr. Pitcairn, and we could not discover any
disease either in the brain or spinal cord." (Aber-
crombie, p. 417.)

Cases nearly similar as to the extent of palsy
are recorded by Bretonneau and Ollivier, but in
which a very slight morbid alteration was disco-
vered. In one, the palsy commenced by loss of
motion of the little finger, and rapidly spread to
the extremities, the tongue, and partly to the mus-
cles of deglutition. The patient, however, strange
to say, retained the power of moving the thumb
and two fingers of the right hand. In this case
the only obvious morbid change in the nervous
centres was, a rust-coloured spot three lines in
extent upon the tuber annulare. (Kcvue Medi-
calc, May 1826.) In Ollivier's case, a strong
sense of pricking in the points of the fingers ot
the left hand, and toes of the left foot, was the
first symptom. This was followed in half an
hour by a similar sensation in the same parts on
the right side. On the following day there was

464

PARALYSIS.

general paralysis, but the sensibility was not im- 1
paired. Respiration and deglutition were consi-
derably affected : the difficulty of respiration in-
creased, and she died the third day. There was |
only a slight appearance of infiltration of blood in
the cellular tissue on the outside of the dura
mater of the cord, especially about the lower part.

Now and then cases of general paralysis, appa-
rently dependent on the state of the spinal mar-
row, are observed to recover. Ollivier has re-
corded several examples of this kind. The palsy
spreads from limb to trunk, commencing in the
fingers and toes, and often preceded by tingling
or formication, and more or less numbness of the
cutaneous surface. The paralysis, although gene-
ral in extent, is, however, rarely complete ; the
functions of the rectum and bladder are not at all
or but slightly affected, and the intellectual pow-
ers are entire. In some cases the palsy is pre-
ceded by pains in the dorsal region of the spine, or a
sense of fatigue, and lassitude and weakness of the
spine. It has been observed to follow the stoppage of
an habitual evacuation, abuse of sexual intercourse,
and the suppression of the lochia in women after
parturition. Such cases are supposed by Ollivier,
and with much reason, to be occasioned by a tem-
porary congestion of the vascular system of the
spine, especially the venous system, so remarka-
ble for its numerous and intricate anastomoses.*
He conceives that, although the anastomoses are
large and numerous, yet the circulation is often
deranged and retarded ; for, first, these veins are
destitute of valves ; secondly, he has found in old
persons fibrinous clots filling all the venous rami-
fications of the spinal marrow, as well as those
which accompany its nerves ; and, lastly, he con-
siders that respiration exerts a direct influence on
this portion of the circulating system, and causes
obstacles in it during efforts of various kinds, or
strong emotions, or those affections which in a
greater or less degree excite the respiratory act.
(Ollivier, De la Moelle Epiniere, vol. ii.) As a
venous congestion, such as we have been alluding
to, is not likely to be a permanent morbid appear-
ance, that is to say, might be dissipated under the
influence of various causes, either immediately
prior or subsequent to dissolution, it is not unrea-
sonable to suppose that some of those cases in
which no morbid change was discoverable, may
have been attributable to a similar cause.

The general paralysis of lunatics, as described
by Esquirol and Calmeil, has been already fully
noticed in the articles Bbain, Inflammation of
the, and Insanity. We may here observe,
however, that one of its earliest symptoms, viz.
defective articulation, would alone serve to distin-
guish it from palsy dependent on spinal disease.

It is hardly necessary to advert to the propriety
of observing great caution in forming a prognosis
of any or all of the forms of general palsy now
described. The difficulty of arriving at a certain
diagnosis of the proximate cause must necessa-
rily involve the practitioner in considerable doubt.

11. Partial Pakaltsis. — Under this head are
included those varieties of paralysis in which only

* If the reader can have access to the beautiful and
accurate plates of Breschet, "Du Systeme Veineux," he
may from them form an adequate conception of the ex-
tent and intricacy of the veins of the spine.

a part of the body is engaged ; it admits of a
threefold division — 1. local paralysis; 2. hemi-
plegia ; 3. paraplegia.

1. Local Paralysis. — This division comprises
all those palsies which have their seat in parts of
small extent. Local palsies are most frequently
met with as precursors of a more extended condi-
tion ; yet we sometimes find them localized as
well in cause as in extent. In the former case
they should be regarded with great suspicion, and
should excite a vigilance on the part of the prac-
titioner to counteract, as far as possible, the
threatened danger ; hence the importance of dis-
tinguishing accurately between local palsies under
these different circumstances.

We shall notice local paralysis under the fol-
lowing heads: 1. paralysis of the eyelids ; 2. para-
lysis of the face ; 3. paralysis of a limb or part of
a limb ; 4. paralysis of particular sets of muscles,
or of single muscles.

Paralysis of the Eyelids. — Two forms of
palsy are found to affect the eyelids, which, as
engaging antagonist muscles, are totally opposite
in their effects. In the one, the eye remains
totally or partially closed (ptosis, blepharoptosis) ;
in the other, the eyelids are permanently open, the
patient having lost in a greater or less degree the
power of closing them (Lagophthalmia).

Ptosis has been so named from its chief and
most conspicuous phenomenon, viz. the drooping
or fall of the upper eyelid ; it occasionally comes
under the care of the surgeon as arising from a
relaxation and extension of the common integu-
ments of the lid and consequent folds of the skin,
by which the energy of the levator palpebral
superioris muscle is somewhat but not very con-
siderably diminished. (Weller's Manual of Dis-
eases of the Eye, by Monteath, vol. ii. p. 97.)
But that form which we are about to notice, is
dependent essentially on palsy of the muscle
above-named, owing to some affection of the nerve
which supplies it. It has been named blepharo-
plegia by the Germans, the patient being unable
by any voluntary effort to raise the upper lid,
although the power of closing the lids remains
entire. It is therefore the object of the practitioner
to ascertain in the first place whether this condi-
tion of the eyelid be merely produced by the me-
chanical cause above alluded to, and, secondly, if
it be connected with a deranged state of any of
the muscles of the eyelid. To decide the first
question, we would adopt the proposal of Scarpa.
" If," he observes, " the atony or complete para-
lysis of the elevator muscle of the eyelid have had
any share in producing the relaxation of it, it may
be known by making a transverse fold of the in-
teguments with the fingers or forceps near the
superior arch of the orbit. For if this muscle
has not lost its power of contraction, when it is
relieved, as it were, from the superincumbent
weight of the integuments, the patient is able to
raise the eyelid and open his eye sufficiently ; if
otherwise, the eye remains half closed." (Scarpa,
by Briggs, p. 127.) Such a proceeding, it is ob-
vious, must at once determine the state of the
levator palpebrx muscle ; but it should be remem-
bered that a spasmodic state of the orbicularis
palpebrarum muscle may likewise produce the
appearance of fallen lid. The want of perma-

PARALYSIS.

465

nence of this affection, the occasional power of
raising the lid, and the degree of resistance which
is always made by the spasmodic state of the orbi-
cular muscle to any attempt to open the lids, will
in general be found sufficient to indicate the pre-
cise nature of the affection.

Secondly, the practitioner should direct his
attention to the motions of the eye-ball. It rarely
happens that the fallen lid is a solitary affection ;
in general, and when it does not depend on either
of the causes above named, we find a paralysis of
most of the muscles of the eye complicated with
it. The patient, it will be observed, has no con-
trol over the voluntary motions of the eye-ball ;
when told to look to the ground, he is unable so
to do, and the same inability is manifested when
directed to look upwards or inwards. If the eye-
lids be forcibly opened and held apart, and the
patient be desired to endeavour to close them, the
eye-ball is seen to turn upwards when he makes
the effort. Sometimes the power of looking out-
wards is retained, and in some instances a stra-
bismus in that direction is present.

A moment's reflection will show that symptoms
such as we have now detailed can only be pro-
duced by a palsied state of the third nerve. The
muscles supplied by the nerve are paralysed, and
the eye-ball exhibits motion in only two direc-
tions. One of these is abduction, performed by
the external rectus which is supplied by the sixth
nerve ; the other is to be regarded as an involun-
tary action, instinctively coexistent with the effort
to close the eyelids : it is that by which the eye is
turned upwards, and, according to Sir C. Bell, is
caused by the combined action of the obliqui,
(See Appendix to Bell on the Nerves, p. xxxix.
et seq.) although in such a case as we are now
considering, it is difficult to conceive the inferior
oblique muscle can be exempt from that paralysis
into which all the other muscles supplied by the
third nerve had fallen.

Ptosis, attended with such an imperfection of
the motions of the eye-ball, is to be regarded in
general as a formidable affection ; it is very fre-
quently indicative of cerebral disease, and there-
fore is often witnessed as a precursor or accompa-
niment to hemiplegia. Sometimes it is merely
the result of local compression of the nerve by a
tumour within the orbit. There are occasionally
present symptoms indicating more extensive dis-
ease, the sensibility of the eye being destroyed, as
well as of the integuments supplied by the oph-
thalmic portion of the fifth nerves, or even of the
whole side of the face. Such a case was that
related by Mr. Shaw in the twelfth volume of the
Medico-Chirurgical Transactions.

If the affection which we have thus briefly no-
ticed be dependent on cerebral disease, the treat-
ment must be directed accordingly ; it is obvious
that when it is caused by a tumour in the orbit, it
is almost completely beyond the control of medi-
cine. Cases may occur in which the propriety
of a surgical operation may become a question :
we shall only remark on the necessity of observing
due caution, lest by converting a closed state of
the eyelids into a permanently open one, we
thereby endanger the safety of the eye-ball, from
its unavoidable exposure to irritating particles.

The second form of palsy of the eyelid is that

Vor.III. — 59

in which the patient is unable to wink or close
the lids. It has been denominated lagophthalnda,
vue de lievre, oculus leporinus, from the vulgar
notion that the hare sleeps with its eyes open.
In these cases the eye remains permanently open,
even during sleep, the orbicularis palpebrarum
muscle being paralysed. The eye-ball projects to
an unusual degree from the socket, owing to the
absence of the accustomed resistance from the
lids, and if the patient be directed to attempt to
close the lids, the eye-ball is instinctively turned
up with the effort so as nearly to conceal the cor-
nea ; nor is he conscious of that action. As
winking can only be performed by drawing down
the lid with the hand, free access is allowed for
particles of dust, &c. to the surface of the eye,
which, being likewise constantly exposed to the
air, is necessarily subjected to much irritation and
consequent inflammation.

This form of local palsy is chiefly worthy of
attention from the contrast afforded by it to that
last described ; it is unquestionably dependent on
disease of the portio dura nerve, and therefore is
for the most part only a symptom of a paralytic
affection which comes under our next head.

Paralysis of the Face. — The muscles of the
face receive their nervous supply from the fifth,
as well as from the portio dura of the seventh,
pair of nerves. Of these, as is now pretty gene-
rally admitted, in conformity with Sir C. Bell's
views, the former is a compound nerve, conveying
sensibility as well as the power of voluntary
motion; the latter directs the actions of the mus-
cles in relation to the respiratory act. We have
already alluded to the loss of sensibility of the
face ; it remains to notice these two distinct forms
of partial palsy of the face, according as the mo-
tive portion of the fifth or the portio dura is the
nerve affected.

Reasoning a priori, it is quite obvious that
palsy of the fifth must produce a set of pheno-
mena very distinct from those resulting from palsy
of the portio dura. All voluntary power not only
over the features, but also over the motions of the
jaw, must be lost on the side affected ; whilst, if
the latter nerve be in a state of integrity, those
motions of the facial muscles which are in accord-
ance with the act of respiration are unimpaired.
Mastication is impeded not only by the imperfec-
tion of the grinding motions of the jaw, but also
from the loss of power in those muscles which
place the morsel under the operation of the teeth ;
" in chewing, the action is only on the sound side
of the head ; the masseter and temporal muscles
of the affected side do not rise or bulge out as in
their natural actions, while there remains a per-
fect command over the features through the ope-
ration of the portio dura." (Bell on the Nerves,
p. 106, 4to edition.) The distortion of the coun-
tenance is not very great; the jaw hangs on the
affected side, and the angle of the mouth is de-
pressed, that of the other side appearing to bo
slightly raised ; the distortion is moreover cither
removed or greatly diminished when the patient
laughs or smiles, an effect which all excited states
of the act of respiration tend to produce. The
condition of the face now described is that most
commonly seen in hemiplegia ; it is rarely met
with unconnected with a more extensive palsy,

466

PARALYSIS.

and when it does occur, the sensibility of the face
and eye-ball, nostrils and tongue, is very generally
impaired or destroyed. The disease of the fifth
nerve may be seated either within the cranium
immediately in connection with its ganglion, or
there may be cerebral disease.

In those cases where the portio dura is the seat
of disease, [Bell's palsy,] there is no evidence of
the existence of palsy till those actions are called
for, to the performance of which the palsied mus-
cles ought to contribute. So long as the patient
remains quiet, without speaking or smiling, nothing
remarkable is observable in the countenance ; but
when any of the actions of excited respiration,
laughing, sneezing, coughing, crying, &c. are
produced by the sound muscles, the marked de-
formity of the countenance becomes apparent.
The mouth is drawn to the sound side ; and it
may be observed in general that the disorder of
the features is directly as the intensity of the re-
spiratory act: thus laughing produces greater de-
formity than smiling. The affected cheek re-
mains motionless, while, to use the expressive
words of Mr. Shaw, the face on the other side
" seems convulsed with laughter." The patient
cannot snuff up with the nostril of the paralysed
side ; blowing or whistling is imperfectly per-
formed, or failed in altogether. On further exam-
ination it will be found that voluntary motion
still exists in the muscles of the face and jaw,
varying, however, in degree in each, according as
the voluntary action of the muscle is more or less
connected with respiration. Thus mastication is
perfect ; here the buccinator performs its office
fully as a muscle of mastication, and in one
striking case related by Mr. Shaw the child even
preferred chewing her food with the affected side.
The voluntary action of the muscles influencing
the motions of the mouth are not so distinct as
those of the muscles of the jaws. Although,
when an attempt is made to whistle, it proves
completely ineffectual, yet the patient can " purse
up" the mouth so as to hold a whistle or a pencil
by the action of the orbicularis oris muscle. A
slight power remains of elevating the angle of the
mouth, and an analogous power can be exerted
over the muscles of the forehead.

It is in the cases to which we are now alluding
that we meet with that condition of the eyelids
termed lagoph'halmia, and it generally forms one
of the most painful and distressing features of the
case, in consequence of the constant irritation to
which the eye is exposed. Articulation is some-
times affected in this form of local palsy ; the pa-
tient learns from experience that by supporting the
paralysed cheek with his hand the defect can be
in some degree remedied. It is clearly important
to distinguish between defective articulation arising
from this cause, and that from palsy of the mus-
cles, of the tongue, or larynx. The wasting of
the paralysed muscles is equally conspicuous in
this as in other forms of palsy, and in cases of old
standing gives such a peculiar appearance to the
countenance, as could hardly fail to direct an ex-
perienced observer to the true nature of the com-
plaint. Mr. Shaw, in relating the particulars of a
case, writes thus : " There is a remarkable wasting
of all those muscles of the face which are subser-
vient to respiration and expression. His cheek is

so thin that when he speaks it flaps about as if it
were only skin, and the corrugator supcreilii and
occipito-frontalis, which are principally muscles
of expression, are so wasted that we might at
first sight suppose they had been removed by ope-
ration, and that now the bones were only covered
by skin." (Med.-Chir. Trans, vol. xii.)

Several opportunities have now occurred of as-
certaining the cause of the palsied state of the
portio dura. In many instances it has been sud-
denly produced by the influence of cold ; the affec-
tion, as resulting from that cause, was long known
under the name of Might. An inflamed state of
the parotid gland, a tumour in the neighbourhood
of the stylo-mastoid foramen, or an ulcer over the
course of the nerve, have been found severally to
cut off the nervous supply. Wounds of the portio
dura, whether from accident or the surgeon's knife;
disease of the petrous bone, engaging the aque-
duct of Fallopius ; inflammation of the internal
ear ; or a tumour compressing the nerve at its en-
trance into the internal auditory foramen, may
likewise be reckoned among the causes. In fine,
this form of palsy may have its origin in disease
of the brain.

The symptoms above detailed are such as arise
from a palsied state of either the fifth or seventh
nerve, the other being perfectly free from any dis-
ease. Symptoms, however, so exclusively de-
noting an affection of a particular nerve of the
face, are not frequently to be met with, and then
only at a short period after the invasion of the
palsy ; for if the disease be of any continuance,
the palsy is apt to spread, as it were, to the unaf-
fected nerves. This is more especially the case
when the portio dura is primarily affected, the
slight degree of voluntary power over the muscles
of expression gradually disappearing, but not from
those of mastication. When the fifth nerve is
the primary seat of disease, the branches of the
portio dura retain their integrity for a much long-
er period, and in some instances do not exhibit
any mark of disease ; but in many cases, where
the palsy has been of long duration, the extent of
the disorder of the countenance can hardly be ac-
counted for, except on the supposition that the
disease has extended to the filaments of the portio
dura. We think that a careful observation of the
countenances of individuals who have been hemi-
plegic for some time, will sufficiently confirm this
statement.

It is rare to meet with palsy of both nerves at
the same time.* When such is the cast, there
must obviously be a modification in the symptoms
dependent on the complete resolution of the mus-
cles of mastication as well as of expression. The
characteristics of the countenance of the hemi-
plegic will be conjoined with the strangely-disor-
dered expression resulting from the diseased portio
dura.

In the treatment of local palsies of the face,
especial attention should be directed to ascertain
the state of the brain. If there be reason to sus-
pect that the origin of the complaint is there, of
course the treatment will be directed to thai quar-

*See a case by Dr. Abercrombie, in which the fifth
nerve was paralysed on one si.le of the (ace, and tin
portio dura on the other, occasioned by a tubercle in tl*
brain. Oa the 15rain, p. 17d.

PARALYSIS.

467

ter. If otitis, or the pressure of a tumour exter-
nally, be the cause, then the proper remedies to
subdue the inflammation in the one case, and to
promote the absorption of the tumour in the other,
must be had recourse to. External stimulants,
blistering, directing the steam of boiling water to
the face, local bleeding, will be found useful, but
especially in the cases which have been caused by
cold. The application of strychnine to a blistered
surface has proved successful in some cases ; the
eighth, fourth, or half a grain may be applied on
the dressings. We may here observe that the
acetous preparation of cantharides, rubbed on to
the part with a camel-hair pencil, will be found a
very convenient and cleanly mode of producing
vesication on the face in these cases. Electro-
puncture has been practised with great success by
Pichonniere in several cases of this kind ; the
needles having been sunk in the vicinity of the
branches of the diseased nerve. (Pichonniere sur
la Paralysie partielle de la Face: Paris, 1830.)

Paralysis of a limb or part of a limb. —
In children, palsy of a single limb (generally an
upper limb) is not uncommon ; sometimes de-
pendent on a deranged and loaded state of the
bowels, sometimes on disease of the brain, and
occasionally from congenital deficiencies in that
organ : in such cases, if the child grow up, we
see, to use the expressions of Sir C. Bell, the limb
of a child as it were unnaturally joined to the
body of an adult.*

A peculiar form of palsy of the upper extremity
is described by Dr. Healy, in the third volume of
the Dublin Hospital Reports. " The affection
alluded to attacks persons of all ages, males and
females being equally liable to it. Prior to the
attack, the patient generally enjoyed good health ;
consequently he is not a little surprised, on awak-
ing from a long and sound sleep, to discover total
loss of power of one hand ; and, what is remark-
able, he generally describes the loss of power as
extending to the middle of the fore-arm : in some
few cases it extends to the elbow, and is accom-
panied with a great sense of numbness. The
fingers are so completely paralysed that the pa-
tient is deprived of their use : great dejection of
spirits attends the complaint." No cause could
in general be assigned for these symptoms, unless
the pressure upon the nerves occasioned by lying
with the head resting on the arm; an opinion
confirmed by the fact that in many the palsy suc-
ceeded to sleeping in a chair in that position. Dr.
Healy further remarks, that " this affection has
invariably yielded to electricity."

Dr. Darwall has described a species of paralysis
ailtcting the upper extremity, most of the indivi-
duals attacked having been in the habit of lifting
heavy weights. In some of the cases the palsy
at first occupied the muscles connecting the
humerus to the scapula, especially the deltoid,
which was wasted ; there was, therefore, inability
to raise the arm, but the power of flexing the fore-
arm remained. After some little time, total para-
lysis of the upper extremities gradually supervened.
In one case of this kind, the patient continued for

♦See a case by Rostan, "Sur le Ramollissement du
Oerveaii," obs 1. p. 256. Also roses by Cazauvieilh in
his memoir " sur r Agenesia cerebrate, " Archives Gen. de
Medeciue, 1827.

eight years without any use whatever of his upper
extremities. In some of the cases the paralysis
did not descend below the muscles of the shoulder.
Considerable pain in the deltoid muscle generally-
preceded the paralysis, and one or two of the cases
yielded readily to treatment in that stage. Dr.
Darwall considers this affection as " one primarily
engaging the nerves supplying the elevating mus-
cles ; and that they may have been injured by the
straining necessary in raising or carrying heavy
weights." (Lond. Med. Gazette, vol. vii. p. 201.)

A case in some degree analogous to those last
alluded to is recorded by Dr. Abererombie ; it is
that of a young lad aged 14, who had nearly lost
the muscular power of the upper part of both his
arms, accompanied by a most remarkable diminu-
tion of substance of the principal muscles. The
deltoid and biceps were reduced to the appearance
of mere membranes, and the muscles of the sca-
pula were found nearly in the same state ; the
affection came on gradually, without any sign of
spinal or cerebral disorder.

Local palsy seated in either extremity, or part
of an extremity, is mostly, as all other forms of
local palsy, found as the first step or stage to a
more extended affection. In such cases there is
frequently some indication to direct the practi-
tioner to the true source of the complaint. It is
not uncommon to meet with instances where palsy
affects only a few of the muscles of an extremity.
The muscles affected are, as Sir C. Bellf observes,
generally those which are naturally combined in
action ; although those muscles be in different
parts of the extremity, and are supplied by dif-
ferent nerves as they are by different arteries ; of
which an obvious example may be taken from the
case of paralysis of the short muscles of the ball
of the thumb, in which the palsy also extends to
those muscles of the thumb which lie on the fore-
arm. Sometimes all the extensor muscles will
lose their power, while the flexors preserve it.
This seems to be the case in a patient alluded to
by Dr. Bright. She had no power of extending
her hands ; they were precisely in the condition
of the " drop hand" from the paralysis caused by
lead. She could carry her child between her fore-
arms and arms. Sir C. Bell has found the action
necessary for writing gone, or the motions so irre-
gular as to make the letters be written zigzag,
whilst the power of strongly moving the arm or
fencing remained.

It may be asked, what is the condition of the
nerves in these cases of local palsy ? Some in-
stances have presented symptoms in the com-
mencement indicating an inflammatory state of
the nerve or its neurilemma, which has been
further confirmed by the success which has fol-
lowed local depletion and other antiphlogistic
remedies in such cases. It is not rare to see a
palsied and atrophied state of the lower extremity
succeed to inflammation of the sciatic nerve. In
a case by Shaw, palsy of the extensors of the
fingers and thumb succeeded to tight bandaging
after a dislocation of the shoulder, and was evi-
dently caused by inflammation of the musculo-

tOn the Nervous System; Appendix, p- clx. Tim
reader will find in the appendix to this work a valuably
and highly-interesting collection of tacts connected with
all the varieties of local palsy.

463

PARALYSIS,

spiral nerve. (Mwl.-Chir. Trans, vol. xii. p. 132.)
Dr. Bright has given a case in which complete
paralysis of the fore-arm resulted from the pressure
on the nerves produced by a badly united frac-
ture. Paralysis from pressure on a nerve in
various ways is common. Dr. Abercrombie men-
tions a case of paralysis of the fore-arms and hands
of both sides, induced by pressure in consequence
of leaning for a long time upon a bar of wood,
while the person was stooping forward in his
anxiety to witness some public exhibition.

There are cases of local palsy affecting the ex-
tremities, or parts of them, in which the state of
the circulation in the limb seems a more probable
cause of the attack than any primary disorder of
the nerves : such are those cases detailed by Dr.
Storer, Dr. Abercrombie, and others. The sud-
den accession of considerable pain in the part is
the first symptom ; this is succeeded, after a vari-
able interval, by paralysis. The cessation of pul-
sation in the principal arteries of the limb, with
the coldness and numbness which attend the palsy,
seem strongly to point to the arterial system as
primarily diseased. In Dr. Abercrombie's case,
post-mortem examination proved that the arterial
system was extensively ossified ; and in many
places the arteries were obstructed by firm coagula.
Drs. Graves and Stokes have also given a case of
paralysis of one of the lower extremities from
marked disease of the common iliac, femoral, and
profunda arteries of the same side, those vessels
being completely plugged up by a dark clot, which
likewise extended into many of their ramifications.
(Dublin Hospital Reports, vol. v. p. 1.) There
are paralytic states of the extremities connected
with rheumatism and gout, for an account of
which we refer to the articles on those diseases.

Paralysis of sets of muscles or single
muscles. — The muscles concerned in the act of
deglutition are sometimes affected with paralysis,
but in general towards the close of an old paraly-
tic . affection of great extent. Some few cases,
however, are recorded in which these muscles
were alone paralysed. A well-known case of this
kind is that described by Mr. Hunter. (Trans-
actions of a Society for the Improvement of Medi-
cal and Chirurgical Knowledge, vol. i.) The
patient had laboured under a train of nervous
symptoms for some time ; one morning he awoke
with a sense of choking, a numbness of the right
side, together with a paralysis of the muscles of
deglutition, which deprived him of the power of
swallowing. The palsy did not extend ; and this
patient owed his cure to the judicious employment
of an elastic tube introduced into the oesophagus,
by which food and medicines were administered,
thus obviating the effects of the palsy. Hysterical
palsy sometimes assumes this form, giving rise to
dysphagia. The muscles of the larynx may be
likewise palsied, giving rise to a species of,
aphonia : this likewise frequently takes place in
hysterical cases. Palsy of the tongue, as a soli-
tary affection, is of very rare occurrence. Some-
times one-half of it is paralysed in consequence
of pressure on the ninth nerve upon that side ; as
in a case related by Dupuytren in his Lecons
Oracles, in which a hydatid compressed this nerve,
producing paralysis and atrophy of the same side
of the tongue.

Single muscles are frequently the scat of para-
lysis, in general occasioned by pressure upon the
nerve which supplies the muscle. The palsy of
the deltoid from pressure on the circumflex nerve
by the dislocated head of the humerus, is a case
familiar to every surgeon. Palsy of the sterno-
mastoid muscle may give rise to all the characters
of wry neck. Paralysis of the serratus magnus
anticus muscle from pressure on or injury of (he
posterior thoracic nerve (external respiratory of
Bell) gives rise to a remarkable set of phenomena,
with which, as liable to lead him to mistake the
complaint for something more serious, the practi-
tioner ought to be acquainted. Two cases of this
affection are on record ; one by Gendrin, the other
by Velpeau. In Gendrin's case, there was a
marked deformity produced by a tumour seated at
the superior dorsal region of one side, and which
was evidently formed by the posterior edge of (he
scapula pushed firmly backwards ; it appeared
without any assignable cause in the course of a
few days. The power of drawing the scapula
forwards, and elevating the prominence of the
shoulder, was lost ; and %vhen both rhomboid
muscles were made to act fully, and to approximate
the scapula? posteriorly, the tumour disappeared
completely. This case had been mistaken by two
medical men for distorted spine. The patient re-
covered after a few weeks, under the successive
application of blisters. (See Gendrin's French
translation of Dr. Abercrombie's work on the
Brain, p. 646.) In Velpeau's case the palsy was
caused by violence inflicted on the nerve in its
passage along the inner wall of the axilla. [Yd-
peau, Anat. Chirurg. vol. i. p. 303.)

Many forms of strabismus are occasioned by a
palsy of one or more of the muscles of the eve-
ball ; the sound muscles thus obtaining a pre-
dominance of action.

The internal muscles, those of organic life, are
sometimes palsied. The circular coat of the in-
testines is no doubt frequently the seat of paraly-
sis ; an opinion which would seem to be confirmed
by the frequent occurrence of paralysis of the
sphincter ani.

Paralysis of the bladder, from prolonged over-
distension, frequently comes under the surgeon's
care. In such cases, as well as in that connected
with paraplegia, there is retention of urine. In-
continence of urine is in some cases, in old per-
sons especially, to be regarded as dependent on a
paralysed condition of the fibres which act as a
sphincter to the neck of the bladder. (Bvytr,
Maladies Chirurgicales, vol. ix. p. 274.)

Treatment. — The treatment of the last two
classes of local palsy should be conducted on simi-
lar principles to those laid down in speaking of
paralysis of the face. Of course the palsied states
of the bladder will require a distinct plan of treat-
ment, chiefly surgical. Paralytic limbs maybe
benefited by local treatment, to which we shall
refer more at large in another part of this article.

2. Hemiplegia, (i}/i«<n>, t/im/rfj'wm, andff>3«*i
percutio,) semisiderutio. The term is applied to
denote paralysis existing only on one side of the
body, and affecting not less than the upper and
lower extremities. Some have employed it in al-
luding to paralysis occupying the upper and lower
extremities of opposite sides; but that form of

PARALYSIS.

409

palsy may, with less risk of confusion, be deno-
minated crossed or transverse paralysis (paralyse
croisee).

Hemiplegia is by far the most frequent species
of palsy met with in practice; and it has been
stated, upon the authority of Sir Gilbert Blane's
comparative observations, that it occurs more fre-
quently on the left than on the right side ; the
proportion being as three to two. (See also
Diet, des 8c. Med. art. Purulysie.) In general
the paralysis affects the side of the face as well as
the extremities; the angle of the mouth is drawn
to the sound side, and more or less upwards; the
tongue is frequently half paralysed, as is rendered
evident on its protrusion, when it presents a curve,
the convexity of which is towards the affected
side : sometimes it is only sluggish as it were, the
patient not having the full power of protrusion.
The muscles of deglutition are frequently more or
less engaged. The mode of progression of a pa-
tient labouring under hemiplegia is remarkable.
He is said to "drag the leg," the paralysed lower
extremity being moved along, or perhaps pro-
pelled, by the inclination of the trunk to the sound
side; the foot is generally pointed outwards, and
when the limb is raised it falls as it were by its
proper gravity, presenting that remarkable point-
ing of the foot which cannot fail to have attracted
the attention of any who may have observed a
hemiplegic patient walking. The arm of the
affected side generally is adducted to the trunk,
and the fore-arm appears slightly flexed upon the
arm, the wrist and fingers being likewise in a
slight state of flexion.

Considerable variation is observable in the man-
ner in which hemiplegia appears. The symp-
toms which precede or accompany its invasion
claim much attention from the practitioner, as be-
ing his chief guides in the formation of a correct
prognosis, as well as in the application of suitable
treatment.

1. Hemiplegia is the most common form which
paralysis assumes from effusion of blood within
the cranium. When the coma of the apoplectic
seizure is removed, and consciousness is restored,
the patient is generally observed to be hemiplegic.

2. Hemiplegia sometimes appears suddenly
without previous indication, and with or without
stupor : in such case it is most frequently a pre-
cursor of apoplexy. (Abercrombie, p. 14.)

3. A third variety is that in which symptoms
more or less painful in their character precede the
paralytic attack : pain in the head, with fever of
variable duration and intensity ; more or less dis-
order of the intellectual powers ; spasmodic twitch-
ings of the muscles ; muscular stiffness ; convul-
sions, ending in hemiplegia, with considerable
pain in the paralysed limbs.

4. Another form occurs chiefly in persons past
the meridian of life. The patient is observed to
be morose, heavy, and drowsy ; his digestion is
disordered ; memory and intellect are impaired ;
there is a loss of one or more senses, usually sight
or hearing ; then sudden loss of speech, difficulty
of protruding the tongue, followed by paralysis of
half of it; distortion of the face; complete hemi-
plegia.

5. A train of symptoms of an anomalous, and
to the physician, a perplexing character, some-

2p

times precede the hemiplegia : viz. headach, ner-
vous excitability, deranged functions, with a num-
ber of uneasy sensations referable to various
causes. The patient continues to complain ; nor
is the obscurity of his condition removed till pa-
ralysis begins to develop itself either by suddenly
attacking one half of the body, or by creeping on
from some remote part. It is with such cases as
these that we occasionally observe symptoms re-
sembling chorea, or fits of an epileptic character.
The writer has lately seen a child in whom there
is an incomplete hemiplegia, the lower extremity
being completely paralysed, the upper partially so:
there is also a convulsive action of the flexor mus-
cles in the fore-arm, and a convulsive protrusion
of the tongue, taking place almost every two min-
utes ; there is slight ptosis of the eyelid, but the
features are regular. The case of the celebrated
M. de Saussura is one somewhat in point. (See
Med.-Chir. Trans, vol. vii.)

6. Hemiplegia is occasionally met with at some
period after the receipt of an injury of the head.
We remember such a case in the person of a gen-
tleman about forty years of age, who about two
years previously had been severely wounded in
the head by highwaymen. The hemiplegia,
which came on gradually, and was on the side
opposite to that on which the injury had been in-
flicted, was complete, and resisted every kind of
treatment. The case proved fatal, but the body
was not examined after death.

The morbid state of the brain, with which he-
miplegia in the above-mentioned varieties is con-
nected, have already been sufficiently dwelt upon
in the article Brain, Inflammation of the. In
fact, there is no diseased condition of either the
brain or its membranes with which this form of
palsy has not been found coexistent. With a
few exceptions, not altogether to be relied upon,*
the disease has been found on that side of the
brain opposite to the scat of the paralysis. That
this should be the case, anatomy would lead us to
expect ; the interlacement or decussation of the
fibres of the anterior columns of the spinal marrow
(corpora pyramidalia) at their summits being
now generally admitted, and easily demonstrated.
According to the views of Foville and others, we
should likewise expect to find the optic thalami
and corpora striata, or some of the fibrous radia-
tions which pass through these bodies, the seat of
disease in hemiplegia. And in point of fact we
must admit, that in the generality of cases of this
description, those bodies, or some portion of the
cerebral hemisphere, present a morbid alteration
of structure variable in extent as well as in degree.
Cases, however, it must likewise be admitted, do
occur, in which only one of the bodies above-men-
tioned is the seat of disease, or in which no ap-
preciable alteration can be detected in the hemi-
sphere. Such occurrences can hardly be deemed
as decidedly to militate against the theory of Fo-
ville, &c. inasmuch as our ignorance of the me-
chanism of cerebral action, whether healthy or

* See the cases of Bavle, Revue Medicate, 1825; one
by Bright, (Reports on Diseases of the Bruin,) winch the
author himself admits to be a "doubtful exception ;" and
Morgagni, lib. I. epist. ii. § 10. The most complete ex
ceptiOD with which we art- acquainted is one mentioned
liv Cazauvieilh, Archives G0u.de Modecine, May 1827, j'.
lo-lti.

470

PARALYSIS.

morbid, is alone sufficient to render them anoma- I
lous to us. They should, however, increase our
caution in receiving speculations upon the uses
ascribed to the different portions of the brain, and
should excite us to increased accuracy of detail
and minuteness of inquiry upon these points of
pathological anatomy.

Hemiplegia may be induced by diseases of the
upper part of the spinal marrow, the morbid altera-
tion being on the same side with the paralysis.
Such cases are rare, however ; for it is seldom that
disease would be exactly limited to a lateral half
of the marrow. In general, when they do occur,
the hemiplegia is only a precursor of the general
paralysis above described. Dr. Bright, (Op. Cit.)
Ollivier, and Velpeau (Archives Gen. dc Med.
June 1825,) give cases of this description; and
in the Edinburgh Medical and Surgical Journal
for April 1825, a case is related where hemiplegia
resulted from concussion of the spine, accompanied
with complete anaesthesia of the other side of the
body. The paralysis of motion did not extend.
(See also a case by Portal, Anat. Med. torn. iv. p.
116.)

Cazauvieilh has published two interesting me-
moirs on congenital paralysis, by which he would
signify that which appears at birth, or a short time
after it. To the cerebral alteration on which the
paralysis depends he has given the name " agene-
sie cercbrale," denoting a defect of development
or of growth in the brain or any of its parts. In
the majority of the cases detailed in these memoirs,
the paralysis was in the form of hemiplegia, the
limbs were greatly wasted, stunted in growth, and
with many in a state of permanent flexion. The
upper extremities were generally more altered than
the lower ; in many cases they were bent and con-
tracted, the elbow, wrist, and fingers being flexed.
Among the muscles of the lower limbs, those of
the calf of the leg chiefly presented the phenome-
non of contraction, and thereby kept the foot per-
manently extended. The paralysis was complete
in only a small number of cases. The organic
defects were as follows : a depression on one side
of the cranium indicated a corresponding want of
development of the subjacent cerebral hemisphere,
— a deficiency further proved by the flattened,
non-developed appearance of its convolutions, the
difference of size from the hemisphere of the other
side, the less capacity of the ventricle, as well as
a slight diminution in the dimensions of the corpus
striatum and optic thalamus. The cases observed
by Cazauvieilh were mostly in persons who had
arrived at an advanced age. (See Archives Gen.
de Med. for May and July 1827.)

Intermittent Hemiplegia. — A form of hemiple-
gia, which may be denominated intermittent, has
been alluded to by Sauvages, Morgagni, and Cul-
len. Sauvages, by whom the species has been
particularly noticed, describes it as coming on
every day, and after some hours receding, with an
accession of quotidian fever; and he gives a mi-
nute account of a case of this kind. The case
described by Morgagni was that of a woman aged
forty, who, after severe and long-continued head-
ach, became completely hemiplegic; when thus
affected, she was likewise seized with the same
kind of palsy on the healthy side every day
towards the evening, which went entirely off as

the morning came on. After this disorder had
attacked her seven or eight times at nearly the
same hour ; she died of pneumonia. There was
no examination of the body. (See Cooke on
Palsy, p. 20.)

A case of this description is recorded by Dr.
Elliotson. (London Medical Gazette, vol. vii. p.
486.) The patient, forty-eight years of age, had
been in the East and West Indies, and had had
fever at Bombay and at Batavia, and had suffered
from dysentery and diarrhoea. For two years and
a half previous to his admission into St Thomas's
Hospital he had been subject to paroxysms, which
threw him into the condition of a perfect hemi-
plegic ; totally losing the power of his arm, and
"dragged his leg in a semicircular way, as patients
usually do when labouring under hemiplegia."
The paroxysm began at ten o'clock on every third
or fourth morning, and lasted in its full force from
three to four hours ; " but although it lasted only
that time, he was not perfectly clear from it the
whole day." The man had a sickly aguish
look, and very much the appearance of one who
had suffered from a hot climate. Under the sup-
position that the patient's complaint arose from
malaria, he was treated with large doses of sul-
phate of quinine, five grains every sixth hour,
afterwards increased to ten grains. The effect of
the medicine was a decided improvement in the
general health, and a considerable increase in the
intervals between the paroxysms. It does not
appear that a perfect cure was effected.

Prognosis. — We believe it is quite consonant
with the results of general experience to state, that
hemiplegia, connected with an apoplectic condition
of the enccphalon, is that which is most likely to
recover. That the effused blood may be absorbed
and leave nothing to indicate the situation it oc-
cupied, but a small cavity, is now abundantly
proved. But in cases where there is no effused
blood, it is obvious that less difficulty exists to
restore the brain to its healthy condition, and in
these cases accordingly we frequently find the
paralysis yield readily and even quickly to treat-
ment. When the effusion has taken place, we
sometimes see the disappearance of the palsy and
the absorption of the coagulum to proceed pari
passu,- but such an event does not occur so fre-
quently as we might, a priori, be led to expect.
It sometimes even happens that the coagulum has
been completely absorbed, and yet the paralysis
continues in no degree diminished. The writer
has in his possession a portion of brain of a girl
twenty-two years of age, who had been hemi-
plegic after apoplexy, and continued so, without
any recurrence of apoplexy, till her death, one-
half of the body being completely paralysed. The
brain was healthy, with the exception of a small
cavity not exceeding four or five lines in diameter,
situated about the centre of the left hemisphere,
lined with a brownish-coloured membrane, and
containing a serous fluid of a similar colour. In
fact, it would seem as if, after a certain period, the
cerebral lesion and the palsy lost their relation to
each other as cause and effect, and the latter con-
tinues, as it were, independent of the condition
which originally gave rise to it.

[In rare cases of cerebral hemorrhage, there M
! no paralysis. Cases of this kind occurring w

PARALYSIS.

471

others and one occurring to the writer, are referred
to elsewhere. (Practice of Medicine, 2d edit. ii.
187, Philad. 1844.)]

Treatment of Hemiplegia. — The treatment of
hemiplegia varies according to the time which
has elapsed since its accession. If the patient he
seen immediately after the appearance of para-
lysis, the practitioner must look accurately to the
condition of the nervous system, directing his
remedies to that which appears to be the seat of
the disease. These remedies, though few, are,
when appropriately applied, powerful, and in the
diversity of lesions which give rise to the affection
under consideration, require the exercise of much
judgment and discrimination, in order to their
successful employment.

The principal treatment, then, in this early
stage of hemiplegia, will depend on the precise
nature of its cause, on the general condition of
the patient, his age, and previous state. Bleed-
ing, purging, and other antiphlogistic remedies
may be adopted where there is decided evidence
of plethora, inflammatory or apoplectic. How
far these measures may be carried with safety or
advantage, the circumstances of each particular
case can alone decide ; in general, however, it
will be found necessary to employ them to some
extent, so as to produce a decided effect upon the
system of the patient. When all inflammatory
symptoms have been reduced, a mild mercurial
treatment has often proved extremely useful.
Does it in apoplexy promote the absorption of
the coaguluml Dr. Prichard observes, respecting
the use of mercury in hemiplegia, " that those
patients, in whom a slight degree of ptyalism has
been produced, have almost uniformly appeared
to him to derive material benefit from it, and their
recovery has been more complete than that of
others in whose cases the same remedy has either
not been used or has not been administered to the
same extent."

Due attention must of course be paid to regi-
men. Abstinence from all stimulating elements,
solid or fluid, must be rigidly observed in the great
majority of cases. In a more advanced stage of
hemiplegia, where the urgency of the brain symp-
toms appears to be either diminished or removed,
and where the palsy is the object chiefly worthy
of attention, the physician has in view a twofold
object, — to prevent a recurrence of head symp-
toms, and, secondly, to alleviate the condition of
the limbs. The former end is to be attained
more by avoiding what has a known injurious
tendency than by adopting any particular plan of
treatment ; this, however, is not to be neglected,
as a proper regimen does much towards maintain-
ing a uniform state of the general system : we may
add that in this stage especial benefit will be de-
rived from allowing the patient to enjoy air and
exercise as much as he is able to bear. Change
of air and scene are unequivocally of decided ad-
vantage, and a visit to some watering-place is
often made in this stage of the complaint with
marked benefit. Mental serenity and a freedom
from the cares of business are indispensable.

To alleviate the condition of the paralysed
limbs, the treatment may be applied to the seat
of the original disease as well as to the limbs
themselves. Thus, with a view to act upon the

seat of the primary disease, we have recourse to
counter-irritation in the vicinity, or, as some prefer
it, more remotely. For this end, we employ se-
tons, issues, blisters, tartar-emetic ointment, or
tartar-emetic in powder, sprinkled on the dress-
ings applied to a blistered surface ; frictions with
liniments containing various irritating substances,
among which we may mention the croton oil, as
being an extremely severe irritant. Dr. Prichard
highly extols the practice of inserting a large
issue in the scalp in cases of this kind ; he ad-
vises an incision to be made completely through
the scalp for four or five inches over the sagittal
suture, and the edges of the wound to be sepa-
rated by a row of peas. (Lond. Med. Gazette,
vol. vii. p. 427.)

The treatment of the paralytic limbs consists
in the use of stimulating applications, with the
idea that a stimulus applied to the sentient ex
tremities of the cutaneous nerves may have the
effect of rousing from their state of torpor the
more deeply-seated trunks. Of these external
stimulants we may enumerate the following ; dry
friction with the hand or by the flesh-brush, a
remedy much approved by Dr. Cooke ; warm
baths ; stimulating liniments, prepared of the con-
centrated acids or the caustic alkalies combined
with oil or lard ; brine, or a strong solution of sea-
salt ; terebinthinate applications ; sinapisms ; blis-
ters. Dr. Cullen has found the use of liquid
styrax, in the proportion of one part to two of the
old black basilicon, remarkably serviceable in para-
lytic cases. The application of cold has been re-
commended, and we have known it beneficial
when applied daily in the form of a shower-bath.
Some more simple stimulants than those now enu-
merated have been employed, such as, tickling the
parts with a feather, which, according to the state-
ment of Mr. Wardrop, proved beneficial in a case
of eighteen months' standing, which recovered in
two months. Stinging with nettles was employed
by Celsus, and Graefe is said to use the dolichos
pruriens as an external stimulant applied to the
surface, and maintained in apposition with it by
means of a bandage. It produces some degree of
cutaneous inflammation, but requires frequent re-
newal.

Among the external stimuli we may mention
electricity ; the efficacy of this agent in many
paralytic cases does not want proof. Lightning
has been known to cure paralysis : we extract an
anecdote exhibiting this effect of the electric fluid
from one of the numbers of the Medico-Chirurgi-
cal Review : a vessel on the Atlantic was struck
several times with lightning, insomuch that many
of the crew were strongly electrified. Among the
passengers was a man who had been paralysed in
both his inferior limbs for three years. At the
time of the electric discharge he lay on his bed, but
soon after perceived the return of power to his
limbs, and was enabled to rise with perfect use of
them. The cure in this case was permanent. A
case is related in the Haerlem Transactions, in
which a hcmiplegic patient recovered the use of
his side after a hundred strokes from the gymno-
tus electricus, or electric eel.

Though it must be admitted that electricity is
occasionally a successful remedy in palsy, still it
has by no means equalled the anticipations at n>si

472

PARALYSIS

entertained respecting it. Its failure may be very
well ascribed to a cause which is equally calcula-
ted to impair the power of all stimulants over pal-
sied nerves. "Applied in a certain manner," says
Dr. Cooke, « electricity is a most powerful stimu-
lant to the nervous system ; but as it is also a
stimulus to the sanguiferous system, it has often
been hurtful in those palsies which depend upon a
compression of the brain, and especially when it
has been so employed as to act upon the vessels
of the head." Great circumspection must be ob-
served, lest in the use of electricity we excite the
circulation to such a point as to increase the evil
we seek to remedy. Applied as a topical remedy,
it will be less apt to produce mischief, and for this
purpose the method of electro-puncture, already
alluded to under the head of Local Palsy, may
be resorted to with advantage. The facility af-
forded of gradually increasing the force of the
shock by the employment of the galvanic appara-
tus, renders galvanism a more safe and suitable
agent than electricity ; and according to the con-
clusions of Dr. Bardsley from comparative ob-
servations, its efficacy is superior to that of elec-
tricity.

But there is a class of internal stimulants
which, having a tendency to excite the nervous
system so as often to produce convulsive action,
have been employed in paralytic cases. Among
these we may mention rhus toxicodendron, strych-
nine, brucine.

The rhus toxicodendron (poison sumach^ was
first introduced by Dr. Alderson, of Hull. A
powder from the leaves is given in doses of half a
grain three times a day, and its quantity increased
to two, three, or four grains, carefully watching its
effects. Its most common effect is a twitching or
convulsive motion, or a sense of tingling or prick-
ing in the paralytic part. The medicine, like all
of this class, does not seem much to be relied upon.

Strychnine and brucine, — the former the active
principle of the nux vomica, the latter extracted
from the bark of the false angustura, (brucia anti-
dysenterica ,) — are both remedies of the same
class, powerful excitants of the nervous system.
Strychnine, however, is much more potent than
brucine. Andral ascertained by comparative trials
that six grains of brucine were equal in their
effects to one grain of impure, or a quarter of a
grain of the pure, strychnine : he therefore con-
siders the former a safer medicine than the latter.
Both, however, are dangerous and uncertain: dan-
gerous, from the risk of increasing cerebral irrita-
tion, — an effect which we have frequently seen ;
and uncertain, inasmuch as some persons appear
more susceptible of their effects than others.
Thus, in one individual one-twelfth of a grain of
strychnine, produced severe symptoms; and in
another the dose was raised to a grain without in-
convenience. Andral comes to the conclusion,
that in cases where, as if from habit, the paralysis
continues after the effusion has been absoibed, the
limbs will be improved under the use of strych-
nine or brucine ; that when the brain is still in a
disordered state, these medicines have the effect
of exciting inflammatory action ; but that, in those
forms of palsy not dependent on disease of the
nervous centres, they are advantageous, as, for in-
stance, in the lead palsy, or that from rheuma-

tism. (Journal do Physiologic, 1823.) Strych-
nine may be administered in doses of one-twelfth
or one-eighth of a grain, gradually and cautiously
increased. Brucine may be given in half-grain
doses.

The following observations, from Dr. Alier-
crombie, respecting the administration of stimu-
lants, are well worthy of attention : — " All the re-
medies of this class must be used with a conside-
rable degree of caution ; and perhaps the use
of them may be more safe, and may be carried on
with a greater degree of activity, if the general
system, at the same time, be kept in a very low
state by spare living and occasional evacuations.
This, I imagine, is always to be considered as
an essential part of the treatment, a"nd I cannot
agree with some respectable writers, who hold
that the diet in paralytic cases ought to be nou-
rishing and restorative. With this precaution,
I think it probable that there are many cases
of paralysis in which stimulants may be employed
with much benefit."

Iodine, in various forms, has been of late years
employed in the treatment of palsy. The result
of Dr. Manson's (Researches on Iodine, &c.)
trials of this medicine are not very encouraging.
In scrofulous constitutions, where the paralysis
seems immediately dependent on some local de-
velopment of scrofula, it may be tried with more
hope of success than in any other form.

A sudden excitement of the nervous system has
been known to carry off the palsy. Thus, a vio-
lent fit of mental emotion, anger, fright, have had
this effect. The sudden supervention of a fever
has likewise removed it : hence Dr. Good recom-
mends as a remedy, in some instances of paraly-
sis, a journey into the hundreds of Essex, or some
other marshy district !

Several cases are on record of the spontaneous
cure of hemiplegia, as it were by the mere reme-
dial energy of nature. (See Abercrombie, p. 306,
et seq.)

3. Paraplegia. — It is of importance, for rea-
sons which will presently appear, to decide what
is the established acceptation of this term among
medical writers. The principal modern writers,
as Sauvages, Cullen, Swediaur, Good, (sec their
Nosological Systems,) Baillie, Cooke, and Rostan,
employ the term paraplegia to denote that species
of palsy in which the lower half of the body on
both sides is paralysed. Much confusion existed
among the older writers as to the sense in which
they used this term : Hippocrates signifying by it
any palsy which was the consequence of apoplexy;
Aretseus denoted by it a partial palsy in any situ-
ation ; Boerhaave and Van' Swieten a palsy of all
the parts below the neck. Mr. Earle has in-
fringed upon the unanimity of modern writers by
endeavouring to revive the definition of Boerhaave
and his commentator ; for what reason we are at
a loss to understand, inasmuch as the etymology
(Tlapa, vitiose, and xMoaw, percutio ) of the word
affords us but little guidance.

We have preferred adhering to the definition
of Cullen and others,* as that which is almost
universally adopted, and, moreover, because that

* " But there is another form of paralysis, called para-
plegia, in which the lower half of the body is more or
less impaired in its nervous power."— Baillie.

PARALYSIS.

473

degree of palsy which Mr. Earle employs the
term paraplegia to denote, appears to us to come
more appropriately under our division of general
paralysis. When paraplegia is perfect, there is
complete loss of the power of motion in the lower
limbs, with paralysis of the bladder, rectum, and
sphincters ; there is also in general a considerable
degree of impaired sensation, more, as we have
already had occasion to remark, than in any of
the other forms of paralysis of motion. Very
frequently we find paraplegics more or less af-
fected with spasmodic action in some particular
muscles of the lower limbs ; sometimes this is
confined to the flexor muscles, and we occasion-
ally see a permanent state of flexion of the thighs
on the trunk, and the legs on the thighs ; some-
times, on the other hand, the extensors are thus
spasmodically affected, as in the case of a young
man which occurred to the writer, in which there
was no power of flexing the lower limbs ; but if
at the request of the patient they were placed in
the state of flexion, (for when in that condition
they were more free from uneasiness,) after the
lapse of a short interval they were, by short and
successive twitchings of the extensor muscles,
gradually brought back to the state of extension.
In general there is, along with the palsy of the
limbs, paralysis of the bladder and of the sphinc-
ters ; the former shows itself sometimes by in-
continence of urine, but more frequently by re-
tention. All ages are liable to paraplegia, but it
occurs more frequently in adults and old persons,
and, according to Dr. Baillie, in males than in
females.

In the mode of access of paraplegia there is
less variety than in that of hemiplegia. The first
symptom is generally a derangement of sensation,
a sense of numbness in the lower limbs, with im-
paired power of motion. The weakness of the
limbs is further indicated by the patient evincing
a tendency to trip when walking, being tired after
but a little exertion in that way ; complaining of
a sense of weight and some degree of pain in the
feet and extending up the legs. " The want of
power of motion in the limbs, and the inability to
preserve the due balance of the body, very much
increase, and the person cannot walk without the
assistance of one or two sticks, or the aid of
some other person, who more or less supports
him." (Baillie, Trans. Coll. Phys. vol. vi.)
The paralysis of the bladder and sphincter next
appears, and now the patient is obliged to confine
himself to his bed ; there is a great tendency to
sloughing of the nates, or of any part on which
there is prolonged pressure ; in some cases a com-
munication has been produced between the rectum
and bladder, thus affording the patient a relief
from retention by converting it into incontinence
of urine. The secretion of the kidneys seems a
good deal affected in this complaint; the urine
seems prone to calculous deposit, a remark which
we believe originated with Dupuytren, who ob-
served that catheters left in the bladders of para-
plegica became more quickly encrusted with cal-
culous matter. Sometimes there is a remarkable
degree of flatulency of the abdomen, amounting
even to tympanitis. The uterus is likewise found
to be incapable of its contractions in cases of
paraplegia. This fact was observed by M. Bra-
Vol. III. — 60 2p*

chet of Lyons, who had a patient who became
pregnant during the existence of the paraplegia :
it was necessary to effect delivery by the forceps.
It may be stated that the same physician found,
by experiments on animals, that injury to the
lumbar portion of the spinal marrow destroyed
the contractile power of the uterus.

This form of palsy may depend on disease of
the brain or of its membranes, or of the spinal
cord or its membranes, or disease of the vertebra
or the uniting ligaments. It was not very long
ago supposed that paraplegia resulted only from
spinal disease, and Dr. Baillie was the first to call
the attention of the profession to its dependence
on diseased brain, the spinal cord being perfectly
healthy. If diseased brain can produce a palsy
of one lower limb, as in hemiplegia, why should
not a more extensive or differently situated disease
produce palsy of both lower limbs 1 Were the
views of Foville regarding the influence of the
corpora striata over the lower extremities estab-
lished, it is obvious that the effect of simultaneous-
disease in both would be the production of para-
plegia. It must be confessed, however, that the
general symptoms of paraplegic palsy chiefly re-
semble those resulting from spinal disease : the
tendency to spasm, the frequent impairment of
cutaneous sensibility, the absence, in many in-
stances, of any of those symptoms which so often
precede or accompany cerebral disease, are so many
circumstances connected with paraplegic which
favour the above opinion. Admitting, however,
the possibility of the production of paraplegia by
cerebral disease alone, we cannot but consider
that, as a practical question, it is still sub judice,
and that chiefly from the too frequent neglect of
examining the spinal marrow. Thus we read re-
ports of cases of this affection where post-mortem
inspection discloses marked disease of the brain ;
but from no examination of the spinal marrow
having taken place, we can arrive at no satisfac-
tory conclusion. A case of this kind is reported
in Dr. Abercrombie's work. The patient was a
boy, seven years of age, and before death was
blind, epileptic, and paraplegic. Examination
after death discovered a firm white tumour, the
size of a large bean, lying over the junction of
the optic nerves. There was extensive effusion
to the amount of twelve ounces in the ventricles,
and both hemispheres of the cerebellum were dis-
eased ; the left being much indurated, the right
reduced to a mass of unhealthy scrofulous sup-
puration. The spine was not examined.* Who
could venture, in the true spirit of philosophy, to
state to what cause the paraplegia was attributa-
ble in this case 1j-

Perhaps the greatest difficulty which the prac-
titioner has to encounter in the consideration of a
case of paraplegia, is to determine the precise seat
of the lesion which gives rise to it. In some
cases there are unequivocal signs of spinal dis-

* Mercrombic, p. 18'J. In a case by Mr. Earle, trie
lower part of the spinal marrow was not examined, yet
it is headed " Paraplegia from Disease of Brain." Med
Uhir. Trans, v. xiii. p. 530.

t See an interesting paper on paraplegia in the Med.
and Phys. Journal for June 18'JT, by Ut. Bnrder, who
considers that those cases of paraplegia which are coin
cident with cerebral lesion, are caused by the increased
sjnnal effusion consequent on that lesion.

474

PARALYSIS.

ease, such as great tenderness on percussion over
a particular portion of the spine ; alteration of
the form of the spine ; projection of one or more
vertebra. Mr. Copeland has adopted a very sim-
ple and obviously useful expedient in obscure
cases to ascertain the locality of spinal irritation ;
he takes a sponge dipped in water as hot as can
be borne, and passes it down the whole length of
the spine ; and if there be any irritation confined
to a particular spot, the patient will evince it by
expressing pain, and wincing as the sponge
passes over that region.

The habit of the patient, his previous mode of
life, as well as the symptoms immediately prece-
ding the attack of paralysis, will assist the prac-
titioner to discover whether any cerebral affection
is complicated with the spinal disease ; thus in
some instances, as Mr. Earle remarks, there is an
impaired state of some of the external senses,
accompanied with vertigo, a sense of weight on
the head, and a general disturbance of the cere-
bral functions 5 in some there is likewise derange-
ment of one or more of the mental faculties. In
such cases there can be little doubt of at least the
complication of cerebral disorder. " But," as Mr.
Earle adds, " it is in slighter and more chronic
cases that it is often difficult to form a correct
opinion ; yet to establish a correct diagnosis in
such cases is of the utmost importance both with
respect to the probable termination of the case
and with reference to the proper treatment to be
adopted, that we may not subject the individuals
to useless suffering from the application of caustic
issues and setons to the spine, and the disappoint-
ment which would follow." To obviate this dif-
ficulty, Mr. Earle has proposed an expedient
which we shall give in his own words : " It is
well known that when a nerve is stimulated or
injured in any part of its course, the painful sen-
sation is referred by the percipient mind to the
sentient extremity of such nerve; the familiar in-
stance of the pain referred to the extremity of an
amputated limb may be adduced in proof of this.
The exact reverse of this takes place when there
is a partial paralysis arising from morbid affection
of the cerebral organs. Here the centre of the
sensorial functions being impaired, it appears to
be incapable of transmitting its influence to the
extreme parts of the body ; in such cases, if the
nerves supplying the limbs be irritated, they ivill
convey the impression of such injury only part
of the distance down the limb, about as far as
the commencement of the paralytic affection. I
have repeatedly examined cases of paraplegia
from affection of the spine, and in no one in-
stance have met with the same phenomenon,
which I have therefore been induced to consider
as diagnostic of the paralytic affection being de-
pendent on disease of the brain or its membranes ;
which opinion has in several instances been con-
firmed by examinations after death, in which both
brain and spinal marrow have been carefully in-
vestigated." It is hardly necessary to mention
that paraplegia is a frequent result of concussion
and other spinal injuries.

Treatment of Paraplegia. — As topical reme-
dies are chiefly applicable in this form of palsy,
it must be obvious of what importance it is to
ascertain to what region they may be most advan-

tageously applied. Cupping and leeching are, in
the generality of cases, primarily indicated. Coun-
ter-irritation by blisters, issues, setons, moxas, &c.
may then be had recourse to. Purgatives are to
be administered as they may appear necessary ;
and Dr. Baillie's mode of treatment is well calcu-
lated to be serviceable; he directed a grain of
calomel, or five grains of the pilula hydrargyri,
with one grain of dried squills, to be taken every
night for many weeks; these were followed by
purgatives.

The same treatment of the palsied limbs may
be adopted here as that alluded to under the head
of hemiplegia. The palsy of the bladder will
require the introduction of the catheter, and we
would merely allude to the necessity of using
pressure above the pelvis to ensure the complete
expulsion of the urine.

Certain mineral poisons, viz. mercury, lead, and
arsenic, give rise, when received to a great extent
into the system, to a form of palsy which Cullcn
has denominated venenata. The palsy resulting
from mercury and lead has already been so fully
treated of that we think it needless to allude fur-
ther to it here. (See Artisans, Diseases or,
and Colica Pictoxvm.)

Palsy has, in some cases, followed the use of
arsenic, chiefly where it had been taken or ad-
ministered as a poison. In some of the cases
related by Orfila, the palsy was not extensive,
and appeared a short time before death. In a
young man whose case is related in the Medical
and Physical Journal, there was paralysis of the
four extremities, which continued for some time,
and ultimately proved fatal.

Paralysis A git an s. — [Shaking Palsy.]— The
peculiar affection thus denominated by Mr. Park-
inson is the scelotyrbe festinans of Sauvages, and
from the peculiarity of the patient's gait has been
called by Dr. Good synclonus ballismus (/JaXXi^,
tripudio.)

Mr. Parkinson's description of the disease is
the best we possess ; we therefore subjoin it. " So
imperceptible is the approach of this malady, that
the precise period of its commencement is seldom
recollected by the patient. A slight sense of
weakness with a proneness to trembling, some-
times in the head, but most commonly in the
hands or arms, are the first symptoms noticed.
These affections gradually increase, and at the
period perhaps of twelve months from their first
being observed, the patient, particularly while
walking, bends himself forward. Soon after this
his legs suffer similar agitations and loss of power
with the hands and arms. As the disease ad-
vances, the limbs become less and less capable of
executing the dictates of the will, while the un-
happy sufferer seldom experiences even a few
minutes' suspension of the tremulous agitation;
and should it be stopped in one limb by a sudden
change of posture, it soon makes its appearance
in another. Walking, as it diverts his attention
from unpleasant reflections, is a mode of exercise
to which the patient is in general very partial.
Of this temporary mitigation of suffering, how
ever, he is now deprived. When he attempts to
advance, he is thrown on the toes and forepart
of his feet, and impelled unwillingly to adopt a
running pace, being in danger of falling on hi'

PARALYSIS — PAROTITIS.

475

face at every step. In the more advanced stage
of the disease, the tremulous motions of the limbs
occur during sleep, and augment in violence till
they awake the patient in much agitation and
alarm. The power of conveying the food to the
mouth is impeded, so that he must be fed by
others. The torpid bowels require stimulating
medicines to excite them into action. Mechanical
aid is often necessary to remove the faeces from
the rectum. The trunk is permanently bowed ;
muscular power diminished ; mastication and de-
glutition are difficult, and the saliva constantly
dribbles from the mouth. The agitation now
becomes more vehement and constant ; and when
exhausted nature seizes a small portion of sleep,
its violence is such as to shake the whole room.
The chin is almost immovably bent down upon
the sternum; the power of articulation is lost;
the urine and faeces are discharged involuntarily,
and coma with slight delirium closes the scene."
(Parkinson's Essay on the Shaking Palsy. Lon-
don, 1817.)

But few cases of this disease are recorded : it
possesses many points of similarity to chorea, or
to the palsy from mercury, which has been better
termed tremblement mercuriel. It is therefore to
be distinguished from these diseases as well as
from the trembling which succeeds the abuse of
spirituous liquors ; that which proceeds from the
immoderate use of tea or coffee ; or that which
appears to be dependent on old age. In these
cases the agitation ceases if the trembling limb be
supported, and none of its muscles called into
action ; whereas, in the real shaking palsy, the
reverse takes place ; the agitation continues in
full force whilst the limb is at rest and unem-
ployed, and even is sometimes diminished by call-
ing the muscles into employment. To this we
may add the peculiarity of gait evinced here ;
<' the patient, when he attempts to walk, being
impelled unwillingly to adopt a running pace,"
— a symptom which we would be disposed to con-
sider as pathognomonic.

All is conjecture respecting the anatomical
condition of the nervous centres in this disease :
the symptoms, however, seem strongly to favour
the opinion of Mr. Parkinson, that there is spinal
disease, and in the cervical portion of the spinal
marrow.

The treatment consists in the adoption of the
same measures which are applicable in all forms
of palsy dependent on spinal diseases.

R. B. Todd.

PARAPLEGIA. See Paralysis.

PAROTITIS, (from ira/xuriy, the parotid gland,)
inflammation of the parotid gland, mumps. In-
flammation of the parotid gland is an occurrence
which may be the effect of the common causes of
inflammation generally, in healthy persons, as of
exposure to cold or local injury ; or it may be se-
condary, and consequent to a cachectic state of
the body or already existing disease, as in stru-
mous subjects, and as it takes place occasionally
in a subacute form at the termination of fevers, to
which it has sometimes appeared to be critical.
Parotitis is now and then observed to follow the
inflammatory eruptive diseases, as measles, small-

pox, and scarlatina ; and occasionally to come on
as if from the absorption of acrid matter from
diseases of the surrounding parts, as eruptions or
excoriations. Lastly, parotitis presents itself as a
peculiar and probably a specific disease, character-
ised by the duration of its inflammatory stage,
and originating from no manifest exciting cause,
except contagion. As it occurs under all but the
last-mentioned circumstances, the affection cor-
responds to the parotis of some of the ancient
writers, and to the phlegmone parotidsea of Ma-
son Good : the exception constitutes the empresma
parotitis of the same nosologist, and the cynanche
parotidaea of Cullen, its more general nosological
appellation at the present period.

Parotitis, from whatever cause it may arise, is
characterized by tumefaction of the parotid gland,
recognisable by the eye and hand of the examiner,
together with local pain increased by and render-
ing difficult the natural movements of the lower
jaw, and giving rise to febrile symptoms more or
less severe. The modifications of it which seem
to arise from various causes, and not from conta-
gion, we shall refer to under the term simple
parotitis ; that which has the more peculiar char-
acter, commonly known by the name of cynanche
parotidsea, we propose to treat of afterwards, under
that name, as a distinct disease.

1. Simple Parotitis presents, in most of its
circumstances, phenomena similar to those of in-
flammation in other parts which have the same
relative approximation to the surface of the body,
namely, local pain, tumefaction, and increased
heat, and, as it advances, redness of the superja-
cent integuments ; added to these, there is occa-
sionally a sense of throbbing about the parts, with
headach and other cerebral disturbance, and occa-
sionally even difficulty of respiration and deglu-
tition. The degree of fever which accompanies
it is proportionate to the extent of the local af-
fection and the irritability of the subject. At an
uncertain period, simple parotitis terminates in
resolution, with subsidence of the febrile symp-
toms, or goes on to suppuration or abscess and
ulceration, and may even end, although it very
rarely does so, in gangrene and death.

Parotitis is often so transient and little distress-
ing to the patient as to yield to the mere promo-
tion of warmth to the part by covering it with
flannel or any other additional wrapper ; and it
may be well to remark here that warm applica-
tions to the angle of the jaw, in all inflammatory
swellings of the parotid gland, contribute much
more to the mitigation of pain and other conse-
quent symptoms than the cold epithems usually
found to give relief in inflammation of other
parts. When parotitis is more severe, detraction
of blood from the region of the inflamed gland
will be further necessary ; to be followed up by
constitutional treatment of the antiphlogistic kind,
proportioned to the general effects of the local
disease. If, nevertheless, suppuration should not
be prevented, an early outlet should be made for
the contents of the abscess, and the treatment of
this and every other stage of the disea.n pursued
on the principles laid down in the article Inflam-
mation.

The subacute inflammation of the parotid
gland, which is occasionally found in complies-

476

PAROTITIS.

tion with scrofula and other diseases, is, in fact, a
manifestation of them, and pertains to their dis-
cussion in other parts of this work. When con-
sequent to acute or eruptive fevers, the primary
inflammatory stage is rarely if ever to be recog-
nised, and an abscess of the gland proclaims that
it has existed. An early evacuation of the con-
tained pus will be the direct medium of relief, and
the treatment of debility consequent to such dis-
eases, of which it is generally an indication, the
method to be pursued for the further restoration
of health.

When parotitis is a consequence of any partic-
ular state or disease of the adjacent parts, the re-
moval of its cause must be the first object of at-
tention. Leeches, however, applied to the region
of the enlarged gland will give relief, and their
repeated use may be necessary to counteract the
continued operation of an irritant, the removal of
which perhaps cannot be immediately effected.

2. Cynanche parotidsea is that species of paro-
titis commonly known in this country by the name
of mumps ; in Scotland called branks ; and in
France oreillons and ourles. It is almost uni-
versally admitted to be contagious; it is often
endemic, and sometimes epidemic. It commences
with the local symptoms already mentioned as
common to parotitis in general, but the tumefac-
tion, which is at first distinct, soon extends to the
maxillary glands, (if the latter be not synchro-
nously affected,) over a considerable part of the
throat ; the disease is frequently developed in the
glands of both sides, but sometimes only of one ;
febrile symptoms, varying in degree, but usually
slight, are also present, and increase as the swell-
ing advances, until about the fourth day, when
both the local and constitutional disorder begin to
subside ; and within as many, or sometimes a few
more, they entirely disappear. As the tumefac-
tion diminishes, it not unfrequcntly happens that
the testicles in the male sex, and the mammary
glands in females, begin to increase in size, be-
come hard and somewhat painful, but in this
country soon again recover their former state.
Experience has proved that this local determina-
tion is a favourable omen, for its non-occurrence
as well as its expulsion have been frequently suc-
ceeded by inflammation of some other organ, ge-
nerally the brain or its membranes, and even death
has been the unfortunate issue.

In cynanche parotidaoa the inflammation of the
gland rarely if ever terminates in suppuration, but
almost always manifests a tendency to resolution,
on or about the fourth day of its progress.

When the inflammation has been confined to
the glands on one side, the translation above no-
ticed has generally also been evinced in the cor-
responding testis or breast.

A large majority of persons have passed through
life without ever having suffered from this disease,
and it is not common to find that it has been ex-
perienced a second time. We are not aware that
its prevalence is peculiar to either sex, but chil-
dren are generally the subjects of it, and more
frequently those of a strumous diathesis : in such
subjects, an occasional and apparently consequen-
tial occurrence is a more decided development of
struma in the glands which have been the seat of
vascular excitement. At sea, it has occasion-

ally happened that cynanche parotida?a has at-
tacked a number of sailors in the same vessel,
when the cause of its first appearance has not
been very evident; for, although besides contagion,
exposure to cold and humidity have been com-
monly considered its exciting causes, it has occa-
sionally arisen without any evident reason to sus-
pect that it has been the effect of either.

Treatment. — Common observation has taught
that cynanche parotidsea might in most instances
be safely allowed to proceed without other care
than that of guarding against exposure to cold of
the general surface of the body, but particularly
of the local swelling ; by the abstinence from
food and drink of a stimulating quality, with the
occasional exhibition of gentle laxatives, purga-
tives having sometimes appeared to occasion a
metastasis of the inflammation to another organ.
To promote local warmth, the usual application
of flannel round the neck and jaws is congenial
alike to the feelings of the patient, and calculated
to counteract the proneness to metastasis of the
inflammatory action. When one or both of the
mammary glands or testes are only slightly af-
fected, a continuation of the same plan of treat-
ment will generally be found adequate in aid of
the natural actions of the body ; but if the inflam-
mation should be excessive, either in the original
or consecutive stage of the disease, the antiphlo-
gistic line of treatment must be more rigidly ad-
hered to ; topical detraction of blood by leeches,
or, when the testis is the organ requiring relief,
by several small punctures, with a lancet, of the
superficial vessels of the scrotum, must be adopted,
and even general bloodletting in further relief of
the system. The depleting plan should be ex-
tended to the more active saline aperients, and to
diaphoretic and diuretic medicines of the same
class with antimonials, to be selected and varied
on the general principles of therapeutics, accord-
ing to the particular exigencies of the individual
subject of the disease.

The well-established fact in pathology, of the
tendency to metastasis of inflammation from it?
original seat to some other organ in cynanche
parotide, renders it an important axiom that cold
applications, whether to the parotid, maxillary, or
mammary glands, or to the testes, should be care-
fully avoided, at least whilst the progressive steps
evince the peculiar character of this disease,
The secondary as well as original inflammation,
when confined to these glands, will be soonest
relieved by hot fomentations and the continued
application of flannel : when leeches have been
applied, as before advised, the same object will be
further promoted by enveloping the part in a
bread-and-water poultice, which should be re-
newed at intervals of six hours. Observance of
the horizontal posture, the warmth of bed, and a
suspending bandage, when the testis is enlarged
and painful, will also be important auxiliaries.
If, unfortunately, a metastasis should occur, and
the brain or its membranes (which under such
circumstances is most common), or any other
structure become the seat of the vicarious inflam-
mation, the new form of disease must be the im-
mediate object of attention, requiring precisely
the same treatment as if it were wholly uncon-
nected with its precursor, whilst at the same time

PAROTITIS — PARTURIENTS.

477

an attempt should be made to divert the inflam-
matory action to the organ from which it has re-
ceded, by the immediate application to the latter
of hot fomentations, and subsequently by local
irritants: blisters have been usually recommended
for this purpose, but as the probabilities of suc-
cess (at all events very slight), it is reasonable to
suppose, would diminish in proportion to the
length of time from which the inflammation had
left the particular organ, a sinapism, we conceive,
on account of its quicker action, would be pre-
ferable. [It may admit, moreover, of doubt,
whether the irritation produced by a blister or
sinapism, may not also be transferred to the seat
of the metastasis, and add to the irritation there.]
In advanced life, Dr. Mason Good observes,
cynanchc parotidcea is apt to run into a chronic
form, accompanied with symptoms formidable in
their nature. This is more especially apt to take
place, he adds, in females when menstruation is
on the point of ceasing, and the general action
of the system labours under some disturbance.
The tumour should, if possible, be carried off by
leeches and cooling repellents, as he further ad-
vises, urging as a reason that if it proceed to sup-
puration, which it tends to, though very slowly,
the ulcer rarely heals, usually degenerating into a
foul offensive sore that sinks deeper and spreads
wider, resisting all medical treatment, and at
length destroying the patient. Vomits, frequently
repeated, he continues, have in this case been
found highly serviceable, and those of the anti-
monial preparations rather than ipecacuanha, from
their maintaining a longer action, and determining
more effectually to the surface, or rather to the
elements generally. WlLLIAM Kerr.

[PARTURIENTS; from parturio, 'I bring
forth.' ' Substances that promote the parturient
energy' are thus designated by the writer. The
term has been objected to, (Brit. $ For. Med.
Rev. Jan. 1844, p. 244,) and is objectionable; but
it is not so easy to propose one more appropriate.
Abortives, Amblotics, Phthorics, Apophthorics, and
Ectrotics, used at times, are certainly not less ob-
jectionable. Fifty years ago, no one, in this coun-
try, would have ventured to affirm, that the lists
of the materia medica comprised any agents pos-
sessed of the virtues ascribed to parturients. In
Germany, indeed, ergot has long been regarded
in this light, as its old German names, mutterkorn,
(' womb-grain,') and gebarpulver, (' parturient
powder') sufficiently testify. Within the period
specified, ergot has been brought to the notice of
the profession here, and elsewhere, and has re-
ceived so many testimonials in its favour as to
cause its admission into every work on materia
medica. In no country has it been more employed
than in the United States, and in none has it so
many supporters. Yet there are many who, from
their experience, are not satisfied, that it exerts the
power over the gravid uterus, that has been as-
cribed to it. It must be admitted, as the writer
has elsewhere remarked, (General Therapeutics
and Materia Medica, i. 422, Philad. 1843,) that
no cases could present themselves, in which it is
more difficult to trace accurately the relation be-
tween cause and effect. Every one who has prac-
tised extensively in obstetrics must have observed,

that the parturient efforts occasionally flag, and,
indeed, are wholly suspended ; yet they recur, and
the labour proceeds rapidly to a favourable termi-
nation ; and if in any such case a remedy, pre-
sumed to be parturient, were administered during
the period of the cessation of pain, the recurrence
of the pain in this sudden manner could hardly
fail to be ascribed to the administration of the
presumed parturient. Let the obstetrical prac-
titioner, who has never had recourse to any such
agent, call to mind how few the cases are in
which delivery has had to be aided, in consequence
of the total cessation of the pains, and how com-
mon it is to meet with a partial or temporary ces-
sation ; and he will see, that the absolute necessity
for the use of a parturient is not a common occur-
rence.

But if hesitation be indulged in allowing the
ergot any special powers over the uterus, there
can be none in denying such powers to other re-
puted parturients. They are all indirect agents,
and act only upon the ovum through the mother,
endangering her life, as well as that of the new
being. The drugs and agencies employed with
the view of inducing abortion are of the most
powerful kind, — emetics, drastic cathartics, acro-
narcotic poisons, &c, &c. Many of the German
writers, indeed, (Schroff, Taschenbuch der Arznei-
mittellchre, u. s. w. s. 108,) ascribe to borax a
specific influence over the uterus by which it is
supposed to favour the catamenial secretion, the
pains of parturition, and the lochial discharge,
when their failure is dependent upon inactivity
of the organ. Dr. Copland (Dictionary of Prac-
tical Medicine, art. Abortion) recommends it
combined with ergot, in cases of abortion, when
the embryo only is expelled — the appendages be-
ing retained, and the hemorrhage great.

ROBLEY DUNGLISON.]

PELLAGRA, or PELAGRA. This is the
name of a disease in which a morbid condition
of the skin is a prominent symptom, very preva-
lent amongst, if not exclusively peculiar to, the
peasantry of the northern states of Italy: the
word pellagra is obviously a compound from the
Latin pellis, the skin, and agria, " scabies fera,"
signifying an inveterate eruption.

The earliest account given of pellagra is from
the pen of Francis Frapoli, a physician of Milan,
and was published in the year 1771 ; since which
period it has been the subject of a great deal of
discussion and controversy amongst the Italian
practitioners and medical writers. Of our own
countrymen, Dr. Holland (so far as we have been
able to ascertain) is the first whose description of
the disease was founded on personal observation ;
and excepting a recent sketch of its prominent
features by Dr. James Johnson, his paper is the
only one in our literature to which the desirable
distinction of originality can be attached : it has
not, however, escaped the attention of Parr and
Hooper, (Medical Dictionaries,) and has been
noticed by Good under the title of Elephantiasis
Italica, and by Alibert under that of Ichthyosis
Pellagra. Dr. Holland has expressed himself
decidedly of opinion that it should be classed
among the impctigines, but has remarked its re-
semblance to an inveterate degree of Psoriasis or

478

PELLAGRA.

.epra vulgaris, admitting also that it has some
affinity to ichthyosis. [See, also, L. V. Lagneau,
art. Pellagiie, in Did. de Med. xxiii. 373, Paris
1841 ; and art. Pellagra, in Encyclopudisches
Worlerb. der Medic'udsch. Wissenschaft. xxvi.
444, Berlin, 1841.]

General observation has determined that there
is considerable variability in the symptoms of pel-
lagra, and that they are often complicated with
other forms of disease ; a fact which, with the cir-
cumstances of the protracted period of its entire de-
velopment as well as of its intermitting appearance
and remissions, may in a great measure account
for the conflicting opinions concerning its nature
and history. The poor are almost exclusively its
victims ; and of these chiefly the peasantry and
such as are occupied in agriculture. In the ordi-
nary form of its occurrence, according to Dr.
Holland,* it first appears as a local disease of the
skin, preceded, however, occasionally by languor,
debility, and other indications of a general cachec-
tic state of the body. The local symptoms very
generally show themselves, in the first instance,
early in the spring, at the period when the mid-
day heat is rapidly increasing, and when the pea-
sants are most actively engaged in their labours in
the fields. The patient perceives on the back of
his hands, on his feet, and sometimes, but more
rarely, on other parts of the body exposed to the
sun, certain red spots or blotches, which gradu-
ally extend themselves, with a slight elevation of
the cuticle, and a shining surface, not unlike that
of lepra in its early stage. The colour of this
eruption is a somewhat more obscure and dusky
red than that of erysipelas : it is attended with no
other uneasy sensation than a slight pricking or
itching, and some tension -in the part. After a
short continuance in this state, small tubercles are
frequently observed to arise on the inflamed sur-
face; the skin almost always becomes dry and
scaly, forming rough patches, which are excoriated
and divided by furrows and rhagades. Desqua-
mation gradually takes place, which, though it
leaves behind a shining unhealthy surface in the
parts affected, yet in the first year of the disease
is rarely followed by a repetition of the appear-
ances just described. Towards the close of sum-
mer, or occasionally still earlier, the skin has re-
sumed its natural appearance ; and but that the
further progress of the disease is familiar to every
inhabitant of the country, the patient might be
led to flatter himself that the evil was gone by,
and that there was no particular reason to dread
its recurrence.

With this local affection are connected, even
in the first period of the disease, certain general
symptoms, important inasmuch as they indicate
the constitutional nature of the malady ; namely,
debility of the whole body ; vague and irregular
pains of the trunk and limbs, but especially fol-
lowing the track of the spine and dorsal muscles;
headach with occasional vertigo; irregular appe-
tite, and general depression of spirits. The bow-
els are for the most part lax, and usually continue
so in the further course of the disease. There
are no febrile symptoms, and in females tho raen-

* See his valuable paper on the subject, published in
vhe eighth volume of the London Medico-Chirurgical

Transactions.

struation is generally continued without irregu-
larity.

The remission which the patient obtains during
the autumn and winter of the first year is almost
universally followed by a recurrence of his symp-
toms, in the ensuing spring, under a more severe
form, and with much greater disorder of the con-
stitution. The cutaneous disorder returns and
spreads itself more extensively, but, as before,
affecting chiefly the hands, neck, feet, and other
exposed parts of the body. The skin becomes
callous and deeply furrowed ; and large rhagades
show themselves, especially among the articula-
tions of the fingers. The debility is greatly in-
creased, frequently depriving the patient of all
power of pursuing his active labours, and render-
ing him peculiarly susceptible of all changes of
temperature. Partial sweats break out without
any obvious cause. All the nervous symptoms
of the first year are renewed in a more severe
degree ; there is a general tendency to cramp and
spasmodic affections ; the mind begins to suffer
under the disorder, and the feeling of anxiety and
despondence is very strongly marked. The libido
inexplebilis, mentioned by some writers as one of
the characteristic symptoms of pellagra, did not
come under Dr. Holland's notice, and he is dis-
posed to believe that it has been so considered
from the credulity common upon this topic, pr to
a desire of associating the disease more closely
with the leprosy as described by ancient writers.
The other symptoms already noticed make pro-
gress as the heat of summer advances, and with
greatest rapidity in those patients who are much
exposed to the sun. As in the preceding year,
they begin to decline towards the middle or end
of autumn, but the remission, as well of the local
affection as of the general disorder is much less
complete than before, and the patient continues
to suffer during the winter from the debility and
other effects consequent upon the disease.

In the third year, every symptom is renewed at
an earlier period, and in an aggravated degree.
The constitutional malady shows itself under a
variety of forms, some of the symptoms having a
considerable analogy to those of scorbutus; all of
them indicating a general cachexy, and more par-
ticularly a lesion of all the voluntary functions.
The debility now becomes extreme : the patient is
scarcely able to support himself; and the limbs,
besides their feebleness, are affected with pains,
which still further impede the power of motion.
The diarrhoea continues, and tends, of course, to
augment the patient's weakness. Frequently a
dysenteric state comes on in the latter stages. The
breath is generally fetid, and the odour of the
perspiration often extremely offensive. The appe-
tite and digestion are irregular, yet, on the whole,
perhaps less affected than most of the other func-
tions. Dropsical effusions are now apt to super-
vene, — occasionally ascites, but more commonly
anasarca. Vertigo, tinnitus uurium, and double
vision are almost universally concomitants of this
stage of the disorder, and all the senses become
exceedingly impaired. Some spasmodic affections
are very general, and these not unfrequently of an
epileptic character.

Connected with these latter symptoms is the
effect which the pellagra produces upon the minds

PELLAGRA.

479

of the sufferers, which effect forms one of the
most striking circumstances in the history of the
disoaie. The anxiety, watchfulness, and moral
depression of the patient arc rapidly augmented.
The unhappy objects seem under the influence of
an invincible despondency : they seek to be alone ;
scarcely answer the questions put to them, and
often shed tears without any obvious cause.
Their intellectual faculties and senses become
alike impaired, and the progress of the disease,
where it does not carry them off from debility and
exhaustion of the vital powers, generally leaves
them incurable idiots, or produces maniacal affec-
tions, which terminate eventually' in the same
state. " In demonstration of this tendency of the
disease, I may mention the fact," says Dr. Hol-
land, " that at the time I visited the Lunatic Hos-
pital, at Milan, there were nearly five hundred
patients, of both sexes, confined there, of which
number more than one-third were pellagrosi, peo-
ple brought thither by the termination of their
disorder either in idiocy or mania. Even this
statement gives little adequate idea of the nature
of its ravages. The public hospitals of the coun-
try are far from sufficient to receive the vast num-
ber of persons affected with the pellagra ; and the
greater proportion perish in their own habitations,
or linger, wretched spectacles of fatuity and decay.
Where debility, as generally happens, is the cause
of death, it manifests itself in the latter stage with
the usual concomitants of colliquative diarrhoea,
spasmodic affections, and coma, and produces a
degree of emaciation scarcely to be surpassed in
any other disease."

" Though, for the sake of brevity," continues
Dr. Holland, " I have described this train of symp-
toms as going on from the third year, I may re-
mark that the pellagra is generally of longer dura-
tion, and that other intermissions usually occur in
its progress, giving the patient a certain relief in
"the degree of his sufferings, though little hope as
to the issue of the disease. In some instances, the
cutaneous affection forms the principal indication
of the complaint for several successive years, being
renewed every spring, and disappearing again
every autumn. In other cases, where it has been
found possible to remove the patient to a new
situation and mode of life, the disease is still fur-
ther arrested in its progress. It rarely happens,
however, that these means can be practically
adopted, and the constitutional malady is gene-
rally so far established in the third or fourth year,
that little hope remains of benefiting the patient
either by medicine or change in the mode of
life."

[At times, according to a recent writer, (L. V.
Lagneau, op. cit. xxiii. 373,) the insanity assumes
the religious form, with tendency to suicide, dege-
nerating occasionally into homicidal monomania,
which is directed by preference to children. Nu-
merous examinations of the dead, made in the
Hospital Saint Ambrosia, at Milan, by MM. Pan-
ceri, — father and son, — assisted by M. Briere de
Boismont, {Ibid, or De la Pellagre et de la Folie
Pe/lagreuse, Paris, 1834,) established most incon-
testably that these mental aberrations were owing
to chronic meningitis, often extending into the
vertebral canal. M. Briere de Boismont likewise
found the digestive organs of all manifestly dis-

eased, and presenting evident traces of inflamma-
tion.]

To enumerate all the symptoms which the Ita-
lian writers have attached to pellagra would, in
fact, involve a description of several diseases with
which it is complicated : it appears, however, that
such complications are characteristic of this pecu-
liar malady, and equally so their occurrence under
several varieties of form. At different periods, in
the same individuals, the morbid condition of the
skin has exhibited the appearance of erysipelas,
lepra, psoriasis, elephantiasis, and ichthyosis, and
of such as are usually termed constitutional disor-
ders, in which it appears to merge : scorbutus,
tetanus in its varied forms, chorea, epilepsy, con-
vulsions, dropsies, melancholia, mania, and maras-
mus, form a condensed list. " It is on this ac-
count," Dr. Johnson has observed, " that we see
written over the beds in the Milan Hospital the
various diseases to which pellagra forms the adjec-
tive, as atrophia pellagrina, phthisis pellagrina,
hydrops pellagrinus, paralysis pellagrina, mania
pellagrina, &c." (Change of Air, or the Pursuit
of Health, by James Johnson, M.D. p. 75.) Jan-
sen, one of the most esteemed authors on this
subject, states that the cutaneous affection some-
times disappears, but without any mitigation in
the other symptoms, and that a person accustomed
to see this disease would at once recognise it by
the peculiar odour of the perspiration the patienis
are often bedewed with, compared by him to the
smell of mouldy bread. In the advanced stage,
the victim of pellagra (the mal de misere, as it
has been emphatically called by Vaccari,) experi-
ences, in an extreme degree, the effects of irrita-
tion in all the mucous surfaces, whilst at the same
time the sensibility of the nervous system seems
to be infinitely increased. The whole mouth
becomes painful, tense, and phlogosed ; the palate
cleft; the gums swelled, fungous, and bloody;
the tongue dry and blackish, and covered with a
muddy coating : the teeth blacken and fall out ;
aphthous ulcerations are not uncommon, and the
saliva, which is extremely salt, is frequently secre-
ted in such a quantity, particularly in the morn-
ing, as to constitute complete ptyalism : the voice
is sometimes so changed as not to be recognisable,
and, as may readily be imagined, the thirst is ex-
cessive ; the latter, however, is the only constant
and invariable one of this group of symptoms.
As the disease proceeds, diarrhoea becomes uncon-
trollable, and prior to the fatal issue the emacia-
tion is excessive ; but sometimes the patient is
said to have the appearance of a mummy. Ner-
vous sensations of a very distressing and peculiar
kind also accompany the latter stage; they have
been described as a sense of burning heat of the
head and spine, radiating to the other parts of the
body, and extending particularly to the palms of
the hands and to the soles of the feet; occasion-
ally as if an electric spark or flash of fire issued
from the brain, and darted through the eyes, ears,
and nostrils; all kinds of imagined noises distract
the unhappy sufferer ; saws, grindstones, mills,
hammers, bells, the chirping of birds, and buzz of
insects, at one time or another, appear to assail
his ears ; and thus deprived of sleep or rest, in the.
summit of despair, it not unfrequently happens
that suicide is resorted to ; an ae! which (as if

480

PELLAGRA.

the meins were indicated by some physical asso-
ciation) is often accomplished by drowning, so
often as to have induced Strambi to distinguish
this particular hallucination by the title of hydro-
mania. (Diet, des Sciences Med. art. Pellagra.)

The consideration of pellagra has been encum-
bered with a variety of discordant and trivial dis-
tinctions. Frapolli, for instance, has divided it
into the incipient, the confirmed, and the incura-
ble; Gherrardini into slight, severe, and desperate;
Soler into the dry and moist, from some supposed
difference in the disorder, according as it appears
in dry and elevated situations, or on the flat and
moist surface of the plains ; and Titius into the
latent and manifest, in conformity with the pre-
sence or absence of the eruption, the latter being
a peculiarity in the manifestation of the disease,
but attested by Italian authorities of respectability,
amongst whom are Cevri and Zanetti.

It appears that the knowledge of the nature of
pellagra has been as yet but little extended by
pathological investigation. « In some patients,"
says Dr. Holland, " the liver, in others the spleen,
has been found enlarged and indurated ; marks
of disease are also occasionally seen in the intes-
tines and mesenteric glands, but these appear-
ances are by no means constant, and may more
reasonably be considered as effects than causes
of the disease."

Dr. Johnson, in his notice of some cases of
mania pellagrina, collected from the great hospital
at Milan by M. Briere de Boismont, who visited
Italy in 1830, has included the following remarks
on the pathology of the disease by that writer :
" there is a collection of yellowish serum between
the membranes and in the cavities of the brain ;
congestion of the vessels of the pia mater, plexus
choroides, and of the cerebral substance ; suppu-
ration and hardening of the brain itself; inflam-
mation of the spinal chord and of its membranes,
accumulation of serum in the pleural cavities ;
inflammation and abscesses of the lungs ; ulcers
of the trachea ; dropsy of the pericardium and of
the abdomen ; chronic peritonitis ; ulceration of
the stomach and intestines ; hypertrophied tuber-
cles, and scirrhus of the liver, &c." (Medico-
Chirurgical Review, Jan. 1833.)

The period at which pellagra first made its ap-
pearance, is a point that has been much disputed
by the Italian and German physicians, without
any satisfactory conclusion. According to Mos-
cati, a Milanese of great repute in science, and
some other writers, it has not been known in
TiOmbardy more than between sixty and seventy
years. Allioni, who has attempted to estimate
the various opinions on the subject, dates its rise
in the year 1715, though the attention of the
Milanese physicians was not drawn to it until
1740. Strambi, who was appointed by Joseph
II. the director of an hospital established at Lag-
nano, near Milan, for the reception of pellagrosi,
had the best opportunities of gaining information
on the subject. In his treatises on the pellagra,
published in three successive years, from 1784 to
1787, he mentions the fact of his having seen
many pellagrosi in the hospital, who gave him
distinct assurances of their fathers and grand-
fathers having had the disorder, and from some
varticular instances he thinks himself entitled to

believe that the pellagra must have been known
in Lombardy sixty or seventy years before the
time when he wrote. Frapolli contends also for
its antiquity, but it may be questioned whether
his opinion does not rest on the mere analogy of
a name, it having been formed from the circum-
stance of a minute in the journal of the Milan
Hospital, dated the 6th of March, 1578, which
provides for the reception of patients attacked
with the disease known at that time under the
name of pellarella.

The pellagra, as an endemic disease, prevails
chiefly in the provinces of Lombardy, lying be-
tween the Alps and the Po. This country may
be briefly described as a vast surface of alluvial
plain, little elevated above the sea ; but rising on
its northern side into chains of hills, which inter-
mediately connect it with the Swiss and Tyrolese
Alps. From the long, narrow, and profound
lakes among those hills the numerous rivers issue,
which, flowing southwards to the Po, and giving
their waters into a number of artificial channels
for the purpose of irrigation, maintain that ex-
traordinary fertility of soil for which the plains
of Lombardy have long been celebrated. The
principal objects of cultivation on these plains,
besides the vineyards extensively spread over their
surface, are maize, rice, and millet. In some dis-
tricts, and particularly between the rivers Adda
and Tercino, the pastures are extensive, and yield
a considerable produce of milk, from which the
Parmesan cheeses are made. The hilly country,
just noticed, on the northern side of Lombardy,
is less productive, and cultivated on a more limited
scale. The valleys, however, intervening among
these hills are of great fertility, yield a considera-
ble quantity of grain, and much wine from the
numerous vineyards to which they give shelter.

The district which appears to have suffered
most from the ravages of the pellagra, is that
which formerly constituted the duchy of Milan, and
particularly the Alta Milanese, or Jhat portion of
country lying up towards the hills between the
Lago Maggiore and the Lago di Como. It was
in this part of Lombardy that the disease first
became an object of medical attention ; and some
time elapsed before it was described as appearing
in the Venetian provinces, and near the shores of
the Adriatic sea. (Medico-Chirurg. Transactions,
vol. viii. p. 320.)

The propagation of pellagra has by some been
referred to contagion ; facts and authority, how-
ever, preponderate greatly against this opinion.
Its hereditary tendency is proved by its frequent
appearance at the earliest period of life, as attested
by Dr. Sacco, of Milan, who, in the capacity of
Director of the Vaccine Establishment, has had
the best opportunities of observation. It has,
moreover, been generally remarked that the dis-
ease is continued in succession through families.
Conflicting accounts are given of the sex in which
it most prevails, but there is ample reason to con-
clude that the discrepancy has arisen from the oc-
cupations of the men and women in different dis-
tricts being reversed, and not from any physical
peculiarities in the conformation of either.

In reference to the remote causes, the most im-
portant facts in evidence undoubtedly are, the
limited period during which the disease appears

I

PELLAGRA.

481

to have existed in the country, its being confined
almost exclusively to the lower classes, and its
rare appearance in the towns or cities of Lom-
bardy. The climate is obviously not the cause
concerned ; since this, as far as it is known, has
been unchanged for a much longer period than
that which includes the history of pellagra ; or
had it been changed, it would have affected alike
both the higher and lower classes of the popula-
tion. The same objection may be made to the
opinion that any circumstances of mere locality
are concerned in producing the disease. It may
possibly be true that the plains of Lombardy are
more frequently and irregularly flooded than for-
merly, and that the general surface is more marshy
and unwholesome ; but this does little to explain
the causes of a disorder which is chiefly prevalent
in the higher lands, where such changes have not
equally taken place.

The point, then, to which we are almost neces-
sarily conducted, is the mode of life and subsist-
ence among the peasantry : this, it appears, is as
wretched as the soil is productive ; an evil which
has been progressively increasing for more than
the last half century, and is probably the result
of devastation from repeated wars, political changes,
and the consequent heavy taxes and imposts,
combined with a decaying commerce and bad
arrangement between the landlords and cultivators
of the soil.

The ordinary diet of these people consists chiefly
of maize prepared in different ways, of rice, millet,
beans, and some other articles of vegetable food.
Their bread, which is principally made from maize,
is for the most part of bad quality, ill fermented,
and not unfrequently deficient in salt. Animal
food rarely forms a part of their diet ; and though
living on a soil which produces wine, their poverty
almost precludes the use of it, even when sickness
and debility render it most needful. The same
condition of poverty is evident in their clothing,
in their habitations, and in the want of all the
minor necessaries and comforts of life. By several
of the Italian physicians, the common use of
maize has been considered a specific cause of this
peculiar disorder. Dr. Holland controverts this
opinion by the results of his personal observation
with regard to the peasantry in the northern parts
of Greece, who, though subsisting chiefly on the
snme kind of grain, are wholly free from the dis-
ease, as is also observed in the south-western parts
of Europe, where the same diet is as generally in
use among the lower classes ; and, with the ex-
ception of a disease occurring in the Asturias,
(the elephantiasis Asturiensis of Mason Good),
Dr. Holland further states that he does not know
of its existence in Spain or Portugal, where the
maize is very extensively used. Rice has also
been supposed to be specifically productive of the
disease, but it must be acknowledged that facts by
no means warrant the supposition. One circum-
stance which seems to deserve a prominent place
in the consideration of this part of the subject is,
the first appearance of the symptoms in the spring
of the year, their partial disappearance in the
autumn, their renewal in the ensuing spring, and
the continuance of this alteration for successive
years, whenever the disease is protracted thus long
without reaching its latter stages. This chain of

Vol. III. — Gl 2 <k

phenomena has led Albera, Frapolli, and other
Italian writers, to refer the origin of the disease to
the frequent exposure of various parts of the
body to the action of the sun's heat, which, it
seems probable, is an exciting cause of the cuta-
neous and some other of the symptoms ; but that
it is not the fons et origo mali is proved by the
circumstance of the peasantry of other parts of
Italy and of tropical countries being subjected to
more intense exposure of the same kind without
corresponding results. That such insolation,
moreover, is not the only exciting cause, has been
proved by the fact adduced by Strambi, that the
cutaneous eruption may be prevented by avoiding
exposure to the sun, whilst the other symptoms
proceed in their usual course. There is also reason
to expect that the incipient stage of the disease
would, if induced by this cause, be common when
the sun's heat was most intense, a circumstance
contrary to common observation ; and it may be
presumed, as suggested by Dr. Holland, that the
increased labours of the peasantry in the early
part of the spring, being speedily followed by the
development of the symptoms, must have some
influence on their production at this particular
period. Perhaps, also, adds the same observer, the
periodical returns of the pellagra, during its early
stages, depend in part on the natural periodical
changes of the body itself, independently of the
external causes just alluded to.

It must be acknowledged that the chain of
connection between the causes of pellagra and its
specific symptoms has not hitherto been distinctly
traced ; but we know from universal experience
that identity of disease has a common origin in a
prevailing insufficiency of food, or in the use of
such as is depraved or innutritious in its quality :
we know, moreover, that the combined evils, al-
ready detailed, in the moral and physical condition
of the people who become subjects of pellagra,
have at all times been observed in connection
with the prevalence of analogous disorders, which
have been variously described under the compre-
hensive name of leprosy. It is further evident
that the end of the several processes subservient
to alimentation demands a sufficient and suitable
supply of aliment; and in defect of either, the
immediate wants of the system, as well as the
imperfect actions of the various organs, become
evident by the train of phenomena constituting
the symptoms of disease. Added to and aggra-
vating these in pellagra, we have the direct action
of an irritant (the sun's heat), which, besides the
local effect, and its direct consequences upon the
nervous system, must, by impeding the important
function of the cutaneous secernents, reflect their
uneliminated material through the medium of the
circulation over the whole body, and thereby help
to generate its universal disorder. When we
further consider the diversity of modifying in-
fluences, the mutability of their nature, and their
relative operation, we cannot be surprised at the
diversified appearances, nor at the endless discus-
sions on the identity of diseases of this nature,
arising no doubt from the unwarrantable habit of
endeavouring always to limit to the arbitrary sig-
nification of a name circumstances confessedly
Piotean in their nature, and which have a very
distant analogy to the distinct and circumscribed

482

PELLAGRA — PEMPHIGUS,

characters proper to objects of natural science, the
classifications of which have been the models of
nosological imitation.

The treatment of pellagra, like that of other
endemic diseases which have their origin in the
privation of the necessaries and comforts of life,
has been infinitely diversified, and, according to
general acknowledgment, unsuccessful. The pa-
tients on their admission into the hospital (we
quote Dr. Holland) are immediately allowed a
nutritious diet, and, unless contra-indicated by
some local affection, wine and tonic medicines are
given with the same view. A decoction of the
lichen Islandicus is in common use in the hos-
pital of Milan, as a part of this plan of diet.
The warm bath is very generally employed at the
same time ; a favourite remedy r among the pea-
santry, probably in consequence of its compara-
tive cheapness, but esteemed also by most of the
medical practitioners who are concerned in treat-
ing the disease. Diaphoretics, and especially
antimonials, are in considerable use, under the
idea of correcting the state of the skin, and get-
ting rid of the morbid humours through this
channel. Depletion by bloodletting is very rarely
employed except where some local inflammation
happens to occur, or in the mania which some-
times supervenes upon the disease. Attention is
of course paid to the bowels in correcting the
diarrhoea, and bringing them as far as possible to
a natural state.

Besides these means, a long list of medicines,
commonly termed antiscorbutics, are in popular
use ; but having mentioned the various prepara-
tions of cinchona, sarsaparilla, guaiacum, sassa-
fras, cantharides, terebinthina, and mercurials, it
would be superfluous to enumerate the thousand
remedies for this hitherto untractable and fatal
disease.

From the preceding detail it is evident that the
labour of physicians in the treatment of pellagra
must continue in its results to resemble that of
Sisyphus, until a decided amelioration can be
effected in the moral and physical condition of
that unfortunate class of persons in whom it is
found to occur ; and all former experience of dis-
eases analogous in their nature justifies us in
asserting that when, and not till when, it ceases
to be the opprobrium patrice, will it eease also to
appear to be the opprobrium medicorum.

[The following are the conclusions drawn by
M. Br<<?re de Boismont, from a careful study of
the disease in the districts where it reigned epi-
demically:

First, pellagra is, at times, a primary irritation
of the digestive organs, complicated with irritation
of the nervous and cutaneous systems ; at others,
it is a disease of innervation, with secondary
lesion of the digestive functions. In many cases,
the nervous system alone is attacked. The affec-
tion of the skin, which is sometimes wanting,
and not always in a ratio, as regards intensity,
with the other symptoms, and which may even
disappear without the disease being cured, is evi-
dently consecutive in all cases without exception.
Secondly, the symptoms, causes and lesions, leave
not the slightest doubt as to the inflammatory
nature of the disease, and its true seat. Thirdly,
the exciting causes of pellagra belong to the class

of irritants and debilitants. Fourthly, the patho-
logical alterations found in the digestive, cerebro-
spinal, and external tegumentary systems, arc the
products of inflammation. Fifthly, the three
stages are not always as distinctly defined as has
been pretended ; the second, which is almost
constantly mortal, if the circumstances are not
changed, may remain stationary for many years.
The third is incurable. Sixthly, removal from
the locality, and change of life, exert a happy in-
fluence on the disease, which is not contagious,
but is hereditary, and has a constant tendency to
extend. Seventhly, the antiphlogistic treatment
appears to be most successful ; but to arrest the
progress of the scourge, it is indispensable to have
recourse to proper hygienic and administrative

measures -] William Kerr.

PEMPHIGUS, from ™><K> a bleb, or blister.
This disease belongs to the order Bulks of cuta-
neous diseases. Under the present heading we
shall include both pemphigus and pompholyx, as
we consider the latter as merely a variety of the
former.

Previously to the time of Willan, nosologists
made a distinction between these diseases, de-
scribing pemphigus as an idiopathic eruptive fever
(febris pemphigodes), running through a certain
fixed course like measles or scarlatina, and pom-
pholyx as differing from it, in not being accompa-
nied by fever ; and this view is still supported by
some writers on skin diseases. An additional
line of demarcation was supposed to be found in
the local characters of the eruptions ; pemphigus
being supposed to present bulla? with inflamed
edges, and pompholyx to consist of bulla? without
inflammation or redness around them. These
distinctions will not bear examination. The fever
which sometimes precedes or accompanies the
bulla? of pemphigus, makes no approach to the
regularity of the fevers of measles or scarlatina,
but is, on the contrary, very irregular in its nature
and duration. It may be a short inflammatory
fever, or of a low typhoid type, or it may assume
the characters of an intermittent. The period of
the fever at which the eruption of bulla? appears,
is equally uncertain. The bulla? may appear al-
most simultaneously with the accession of febrile
symptoms, or on the second day of fever, as in
the case related by Seliger, and referred to by Dr.
Willan ; or on the second accession of an attack
of intermittent fever, as in the case related by Dr.
Winterbottom ; or on the fourth day of low ty-
phoid fever, as in the case related by Dr. Dickson
in the first volume of the Transactions of the
Royal Irish Academy. The bulla? may be still
more irregular in their eruption, coming out in
successive crops at uncertain periods of a conti-
nued fever, and, lastly, may appear either as sym-
pathetic with or as a crisis of internal visceral
disease. These irregularities of the type of the
fever, and of the coming out of the eruption, are
sufficient to convince us that pemphigus has no
claim to the title of an idiopathic eruptive fever.
The further supposed distinction between it and
pompholyx, of the bulla? of pemphigus having a
red inflamed edge, and those of pompholyx not
possessing this character, will prove equally in-
valid ; for this character is merely accidental.

PEMPHIGUS.

483

The bullae will possess or will be deficient in this
character, according to the time at which they are
examined. In almost every instance a distinct
circular erythematous patch upon the skin pre-
cedes the formation of each bulla. If the bulla}
be examined before having attained a sufficient
size to occupy the entire of the erythematous
patch, there will then be seen around the circum-
ference a red inflamed edge formed by the outer
margin of the erythematous patch not yet occu-
pied by the bulla? ; but if not examined until a
later period, or if even examined at a very early
period, when (as in pemphigus solitarius) the
growth of the bulla is very rapid, then the entire
of the procursive erythematous patch will be co-
vered by the bulla, and there will be no surround-
ing blush or tumefaction ; or, in other words, the
disease will be the pompholyx of some authors.
These are our reasons for considering pompholyx
as merely a variety of pemphigus.

Pemphigus may be defined " an affection of
the skin, consisting of the eruption of one or
more bulls containing serous fluid, and termina-
ting either in thin scales, in superficial excoria-
tions, or in ulceration."

The immediate pathology of pemphigus is an
effusion of serous fluid from the surface of the
rcte mucosum, which first detaches portions of
the cuticle, and then distends them into bullae.
In most instances there are erythematous patches
upon the skin preceding the appearance of the
bulls. Between these the skin preserves its natu-
ral appearance, or seems very slightly swollen.
If the finger be passed over the surface, each ery-
thematous patch gives a sensation, arising from
the local congestion, of being a little firmer and
more elevated than the surrounding surface ; but
there is no marked increase of thickness or hard-
ness of cutaneous or cellular tissue, such as is
found in the commencement of pustular diseases.
The bullae first appear on the centres of the ery-
thematous patches; and around each bulla there
may or may not be a red margin according as the
bulla occupies only the central portion, or has
spread over the whole of the inflamed base from
which it has arisen. The skin between the bulla?
continues to preserve its natural appearance and
colour. The bullae always commence as such,
and never as papulae or pustuloe ; in the com-
mencement they are translucid, either colourless
or of a pale fawn or slightly bluish cast ; and as
they continue to grow, they assume a hemispheri-
cal shape, and present different sizes from that of
a split pea to a size sufficient to contain a tea-
cupful of fluid. The fluid contained in the bullae
consists principally of albumen ; it readily coagu-
lates by heat into an almost solid mass, and
sometimes, although rarely, the albumen of a bulla
is in such quantity as to coagulate spontaneously
and form a layer lining the distended cuticle.
The fluid of the bullae is usually bland and devoid
of smell, but, in some varieties of the disease to
be afterwards noted, gives out a most disagreea-
ble fetor, and seems to acquire acrid properties.
When the bullae are fully formed they become
opaque, and sometimes, from a trifling admixture
of purulent matter, present a yellowish, or greenish
yellow shade. Arrived at this stage, they may
terminate in various ways. In mild cases the

smaller sized bullae, after having reached their
greatest degree of development and tension, begin
to wither; the cuticle wrinkles; and the albu-
minous portion of the effused fluid, together with
the detached cuticle, dries into a thin brownish
scab, which, falling off, exposes a red patch formed
of the inflamed true skin, with its thin new cuti-
cle. The larger sized bullae burst either sponta-
neously or through accident ; and the broken
cuticle, lying flat upon the inflamed surface, now
dries away into a scale, which separating, exposes,
as before, the red base on which the bulla arose.
For a short time after the larger bulla; are opened,
the inflamed excoriated surface continues to secrete
a fluid similar to that originally effused. In weak-
ly constitutions, after the bullae have burst, the
inflamed surface of the true skin, instead of fur-
nishing a new cuticle, takes on the action of
secreting pus ; and if the pus or scab formed of it
be removed, then presents the appearance of an
indolent ulcer. In more severe forms of the dis-
ease, the fluid of the bullae is thin and ichorous,
forms no crust, and when discharged by the
bursting of the cuticle, exposes an unhealthy-
looking flabby ulcer ; the tissue around softens,
and the ulcer continues to spread as a gangrenous
ulcer, engaging in its destructive progress all the
surrounding tissues without distinction.

No portion of the cutaneous surface is exempt
from the invasion of pemphigus. It may confine
itself to a part, or may spread itself over the entire
surface ; but the parts on which the eruption most
frequently appears are the limbs, particularly the
lower limbs, and the skin of the abdomen. The
bullae also make their appearance on the mucous
membrane of the mouth and of the vagina. On6
variety of the disease (pemphigus gangrenosus)
has a tendency to attack in preference the skin
behind the ears and the folds of the thighs.

Pemphigus may make its appearance as an
idiopathic disease, or as sympathetic of some
internal visceral irritation ; or its bullae may occur
during the course of other diseases, more especially
those of the skin, principally erysipelas, herpes,
prurigo, scabies, and varicella. It is asserted by
some writers that the bullae of pemphigus are
occasionally found on the mucous membrane of
the stomach and intestines. Payer admits the
occasional existence of bulla? on the mucous mem-
brane of the mouth, but denies their existence in
the stomach and intestines. Of their occasional
existence in the mouth there cannot be a doubt.
In the case related by Dr. Dickson, and already
referred to, the patient, a delicate woman, twenty-
three years old, felt on the third day of low fever
a tingling pain and smarting in the tongue and
inside of the mouth. On the next, the fourth
day, a pellucid bulla appeared on the tongue one
inch long, and half an inch broad, turgid, with
faintly yellowish serous fluid, and a smaller one
on the inside of the left cheek. The sensation
felt was as if these bullae were full of scalding
water. On the fifth day, bull-E appeared over
the body ; and on the ninth day the bullae ol 'he
mouth left behind them an excoriated and acutely
sensible surface.

In the abdominal viscera the changes observed
most frequently in fatal cases of pemphigus are
redness, softening, and ulcerations, the ordinary'

484

PEMPHIGUS.

effects of gastro-enteritis. Biett slates that the
internal derangement which he has observed most
constant in pemphigus is the fat liver.

Diagnosis. — Vesicles, or bullae, arc sometimes
found in erysipelas which bear a close resem-
blance to pemphigus; but they are at once dis-
tinguished by the whole surface of the skin on
which the vesications appear in erysipelas being
tense, shining and red. The vesicles of herpes
somewhat resemble the bulla? of pemphigus ; but
exclusively of being much smaller and irregular
in form, they are always clustered upon a red in-
flamed surface ; while the bulls of pemphigus
are scattered, the skin between them preserving its
natural appearance. The extremely small size
and immense numbers of the vesicles of miliary
eruption furnish us with a well-marked line of
distinction between it and pemphigus. Varicella,
or chicken-pox, when fully developed, presents
vesicles, which, however, are easily distinguished
from the bullae of pemphigus by being pretty
equally diffused over the entire body, and by all
being of nearly one size, and much smaller than
the bullae of pemphigus.

Rupia has some characters in common with
pemphigus, and belongs to the same order ; but in
rupia the bulla? are generally fewer in number,
smaller, less tense, and more flattened than in
pemphigus, and the contained fluid quickly be-
comes sanious or purulent. The cutaneous tissue
around the bulla? of rupia is more deeply inflamed ;
and the bulla?, after having reached their full
growth, instead of forming thin crusts or excoria-
tions as in pemphigus, are followed by thick pro-
minent scales, which, when removed, expose
deeply-eaten ulcerations.

These are the only diseases which can be con-
founded with pemphigus. The characters distin-
guishing pemphigus from all other affections of
the skin are so marked, that it is quite unnecessary
to point them out.

Prognosis. — It may be laid down as a general
rule that the more acutely pemphigus sets in, the
less dangerous it is ; and as it shows a tendency
to become chronic or occur in weakly constitu-
tions, or is accompanied by a fever of a low
typhoid type, the more unfavourable is its prog-
nosis.

Causes. — Whatever acts directly as a stimulant
to the skin, or indirectly injures its function through
the medium of the constitution, or of the mucous
tissue of the digestive organs, may be an exciting
cause of this disease, viz. exposure to the direct
and burning rays of the sun, or the application of
any irritating substances. Among mowers in
Ireland, a local form of pemphigus attacks the
skin over the ancles, and is a very troublesome
complaint. It is by the men themselves attributed
to the seeds of the cow parsnip (heraclcum sphon-
dilium). The bites of some serpents, the pro-
longed impression of cold or damp upon the sur-
face previously over-heated, excess in the use of
spirituous liquors or heating spices, depression of
mind, marsh residence, debility however induced,
are also in the list of exciting or of predisposing
causes. The disease has supervened on the sup-
pression of the lochia, of the menstrual discharge,
of hemorrhoids, and of diarrhoea.

The bulla? of pemphigus occasionally accom-

pany epidemic diseases, such as scarlatina; and
from this complication has arisen the description
of pemphigus Helvettcas as an epidemic given by
Laughans. There is, however, no authentic de-
scription of simple pemphigus prevailing as an
epidemic.

Pemphigus is a disease of all climates and sea-
sons ; but one variety, pemphigus gangrenosus, is
generally confined to certain districts as an epi-
demic disease : we shall have occasion to speak
more at large on this form of it. Cullen, in his
" Synopsis," characterizes pemphigus as a conta-
gious disease ; but at the same time observes that
he has only followed Sauvages, and that he has no
knowledge of the disease from personal observa-
tion. Experiment is unfavourable to the suppo-
sition of the disease being contagious. Husson
inoculated five children with fluid taken from the
bulla? of pemphigus, and the disease was not in
any instance transmitted. (RecherchesHistoriques
et Medicales sur la Vaccine.) Martin confirmed
these by similar experiments. (Journal dc Mode-
cine, Chirurgie, et Pharmacie, vol. ii. p. 225.)

The varieties of pemphigus may be considered
with most practical advantage under the heads of
acute pemphigus, chronic pemphigus, and gan-
grenous pemphigus.

1. Acute Pemphigus. — This variety is prece-
ded by febrile symptoms of very uncertain charac-
ters. There is generally a premonitory shivering
fit very well marked, and in some cases there are
two or more shivering fits so distinct, that the
attack at first sight appears to be intermittent fever.
In other cases, after a fit of shivering, there are
the symptoms of continued fever — thirst, loss of
appetite, coated tongue, and dry hot skin ; and
after these have continued usually from one to four
days, the surface about to become the seat of the
eruption, generally the skin of the abdomen and
lower extremities, in a few cases of the whole
body, is affected by a sensation of tingling heat,
and circular red patches of various sizes come out,
irregularly scattered over the surface ; their colour
will not disappear under pressure, and within
twenty-four hours of their appearance bulla? arise
on these patches and rapidly increase, until each
bulla occupies the entire or nearly the entire of
the inflamed plane on which it has arisen. Some
of the bulla?, although rarely, become confluent.
The bulla? having arrived at their full size, usually
within the period of two or three days from their
first appearance, become turgid, burst, and dis-
charge their contents, leaving the surface of the
true skin now exposed, red, excoriated, and pain-
ful. The pain is like the sensation produced by a
burn or scald, and is not felt until the true skin is
exposed by the bursting of the bulla?. The el-
posed cutis is, however, soon covered by a thin
crust formed by the old cuticle, the remnant of the
contained fluid, and a secretion of similar fluid,
which continues for a short time from the inflamed
surface. The thin scab thus formed, after a few
days drops off, and exhibits the true skin covered
with a new cuticle, and of a dark red colour.
This colour remains for an uncertain time. The
febrile symptoms which ushered in the disease
usually abate on the appearance of the eruption,
and continue in a mild degree until the healing of
the broken bulla?. In a very great majority of

PEMPHIGUS.

435

cases the termination of the attack is a marked
crisis, either by diarrhoea or a copious deposition
from the urine.

The duration of acute pemphigus is very uncer-
tain. It never runs its course in less than a week,
and is seldom prolonged beyond a month. When
gastro-intestinal irritation is superadded, the symp-
toms are aggravated, and in such cases the mucous
membrane of the mouth may present bullae resem-
bling those upon the surface, but, from being con-
stantly bathed in moisture, not forming scales.
There is a form of acute pemphigus, in which,
after heat, itching, and redness of a part, a single
bulla arises, (pompholyx solitarius of Bateman,)
and after becoming enlarged to a size sufficient to
hold a tea-cupful of fluid, bursts, and is, perhaps,
succeeded by another following the same course.
In this variety, if a bulla burst before it has
attained its full size, it may heal in the centre,
and the circumference of the bulla continuing to
increase, will produce the appearance of the whole
cuticle of the part peeling off.

Treatment. — The treatment of acute pem-
phigus, when it exists as an idiopathic affection,
is very simple ; the febrile symptoms not gene-
rally running so high as to demand very active
treatment. Mild purgative and diuretic medicine
and cool drinks are generally all that are required.
If the disease be complicated by gastro-intestinal
irritation or inflammation, or be sympathetic with
the disease of any important internal organ, the
cutaneous affection becomes of secondary import-
ance ; the internal disease demands all our care.
Warm baths, or any heating application to the
skin, are improper in acute pemphigus. It is re-
commended in some works to open the bullae as
soon as they are formed. This is not judicious
practice. The distress of the patient is compara-
tively little before the bulla? have burst ; but after
this there is, as we have already noticed, a most
painful sensation of burning, produced by the ex-
posure of the raw surface of the true skin. The
febrile excitement is thus increased, and we shall
both hurry and prolong the pain and fever if we
unnecessarily puncture the bullae. We can apply
to the excoriated surface no dressing so mild as its
own albuminous secretion, and can protect the
excoriated skin from the irritation of exposure by
no covering so effectually as by its own cuticle.
When the bulla; have burst, either spontaneously
or by accident, and the excoriated surface is scald-
ing and painful, the denuded part should be
covered with the mildest dressing, with slips of
gold-beater's leaf, or the delicate membrane which
lines the interior of an egg-shell. When the
bulla? are withering, and cicatrization is taking
place, and after the fever has subsided, it becomes
necessary to support the strength of the system,
and aid it in its curative efforts by the exhibition
of tonics, of which the best is cinchona or sulphate
of quinine. Sometimes the fever which ushers in
acute pemphigus presents almost from its very
onset a low typhoid type ; and while intestinal
irritation is allayed by the mildest purgatives, the
patient's strength requires to be supported by
light broths, and, according to the symptoms, by
wine and bark.

2. Chronic Pemphigus. — This variety of the
disease is generally met with in old persons or in

2a*

debilitated constitutions, is sometimes idiopathic,
but more often sympathetic, with internal visceral
disease ; in the latter, of course, the more serious.
It is the pompholyx diutinus of Bateman, dartre
phlydenoide conjluente of Alibert. This is a
very obstinate and distressing form of skin dis-
ease, and there is scarcely any limit to its dura-
tion. After premonitory symptoms of lassitude,
headach, &c, bullae appear on different parts of
the body. These heal, and are succeeded by
others, which, as the patient's strength becomes
weaker, show a disposition to ulcerate. There is
intolerable pain and burning, from the exposure
of the denuded cutis, and irritative fever sets in.
A crisis may now take place, either by diarrhoea
or by a copious deposition from the urine ; the
bullae dry up and heal, the symptoms of irritative
fever disappear, and the patient believes there is
a perfect cure ; but after a short interval the dis-
ease again shows itself. There is less disposition
in the bulla? of each successive eruption to heal ;
the constitutional irritation produced by the nume-
rous excoriated surfaces prevents rest, destroys
appetite, and finally wears out the patient by ex-
haustion ; or the constant irritation aggravates to
such a degree some internal lesion, otherwise of
little consequence, that a new train of symptoms
sets in, the pemphigus disappears before some
more formidable affection, and the patient dies of
internal visceral disease. The bullae of chronic
are always larger than those of acute pemphigus,
and, as already observed, are more generally sym-
pathetic with some internal disease of function or
of structure than an idiopathic affection of the
skin. Persons advanced in life are more subject
to chronic pemphigus, and whatever debilitates the
constitution, as mental depression, or bad or insuf-
ficient food, or injures the functions of the skin,
as a residence in cold damp situations, may tend
to bring forth the disease ; and in cases where the
previous debility has been very great, the bullae
not only ulcerate, but the surface on which they
have arisen sloughs around the bullae to a con-
siderable extent.

Treatment. — As this disease is so frequently
a symptomatic affection, the treatment is in ge-
neral complex, and must in such circumstances be
directed as much to internal visceral disease as to
the external skin affection. For the treatment of
the rheumatic, gouty, or visceral derangements
which may be combined with chronic pemphigus,
we of course refer our reader to the various heads
under which those derangements are considered.
Internal irritation (if any) being allayed by ap-
propriate means, the patient who is the subject of
chronic pemphigus is then to be put upon a full
and nourishing but not stimulating diet, and tonics
combined with diuretics, as sulphate of quinine
with compound infusion of juniper, or bitters with
alkalies, are to be administered. Locality has often
much # influence over this disease, and hence, if the
ordinary measures above recommended are not
successful, change of air should be enjoined, and
the change should always be to a dry air and a
high situation. The bulla? should not be opened
by art, for the same reasons as given for not open-
ing the bulla? of acute pemphigus. If the bullae
burst and leave indolent ulcerations, these are to
be stimulated with powdered bark or burnt alum,

486

PEMPHIGUS.

or touched, if necessary with solid nitrate of silver.
Warm baths generally aggravate this disease when
present, but are very useful as preventives by
preserving the skin in the exercise of its healthy
functions.

Before we proceed to the third variety, gangren-
ous pemphigus, it is necessary to mention a form
of pemphigus which does not perhaps strictly
come under any of the heads we have named.
For practical utility we have described two forms
of pemphigus, as acute and chronic ; but here, as
in most diseases, this line of distinction is more
arbitrary than real, the two forms running into
one another by imperceptible gradations : perhaps
the term subacute, borrowed from the French,
would be the best name for the variety of pem-
phigus to which we now allude, and which forms
the connecting link between the acute and chronic
forms, This variety of pemphigus corresponds
with acute pemphigus in being accompanied with
fever, but agrees with chronic pemphigus in pre-
senting, not simultaneous, but successive eruptions
of bulls. It is called by French writers " pem-
phigus aigu successif." The accessions of febrile
symptoms are irregular, and with each accession
a new crop of bullae appears on the skin, the whole
attack usually running its course within a few
weeks. The treatment is merely a modification
of that recommended for acute pemphigus, with
this addition, that as the fever which precedes the
eruption takes on an intermittent form, the early
exhibition of bark is called for.

3. Gangrenous (or infuntile) Pemphigus. —
(Pemphigus infantilis of Willan, rupia escharotica
of Bateman and Biett.) Bateman and Biett
place this disease under the head rupia, but im-
properly, for the fluid of the bullae in this disease
is a thin sanious ichor, neither forming thick
crusts, nor turning purulent, which are the distin-
guishing characters of rupia. This form of pem-
phigus is exclusively confined to children, and
very rarely attacks them after the age of five years.
In many parts of Ireland this singular disease pre-
vails to a great extent, principally among the chil-
dren of the poor, and appears to be in some situa-
tions an endemic disease, but from time to time
breaking out as an epidemic, attended with great
mortality. This latter circumstance has probably
originated the belief in the contagious nature of
the disease, very generally entertained by the peo-
ple of the districts where the disease is prevalent.
There are, however, no satisfactory proofs in sup-
port of this opinion. Dr. Macbride, in his " Me-
thodical Introduction to the Theory and Practice
of Medicine," notices an outbreak of this disease.
" In the county of Wicklow, about twenty miles
from Dublin, a disease of this kind (as the author
has been informed) appeared in the year 1766,
but attacked only children, many of whom were
carried ofT, until the cortex was thought of as a
remedy, and found equally efficacious as iji the
malignant sore throat." It is singular that in the
same county the disease is still prevalent. It is
known in different parts of Ireland under the va-
rious popular names of « white blisters," " burnt
holes," "eating hive," &c. No systematic work
on diseases of the skin contains either full or ac-
curate information on this singular form of pem-
phigus. To Dr. Whitley Stokes we are indebted

for our knowledge of its symptoms and treatment,
and we cannot give that information in better
words than his own.

« The approach of this disorder is sometimes,
though rarely, denoted by a livid suffusion like
that of erysipelas slightly elevated. This was
both observed by Dr. M'Donnel of Belfast, and by
Dr. Spear, in the county of Monaghan, at a time
when the disease prevails there epidemically. It
more frequently happens, however, that the com-
plaint comes on in perfect health. One or more
vesicles appear, mostly larger than the best distinct
small-pox ; these increase for two or three days,
burst and discharge a thin fluid having a disagree-
able smell, limpid in most cases, sometimes whitish,
and sometimes yellowish, the latter less dangerous;
usually the weaker the child's constitution is, the
thinner is the matter. Before or after breaking,
the vesicles run together, the sores become pain-
ful, with loss of substance and a thin fetid ichor-
ous discharge ; the edges of the ulcer are under-
mined, and it spreads quickly. The more usual
seats of the disease are behind the ears, sometimes
on the hands or feet, on the private parts, (seldom
on the arm-pit), the breasts, folds of the thighs,
lower belly, on the inside of the mouth or lips.
The disease, however, it is said, seldom passes
from the inside to the outside of the mouth. In
the progress of the disorder, the ulcers enlarge
rapidly, with remarkable fetor, very great dis-
charge, and livid edges. If the sores are behind
the ears, they destroy the connection of the pos-
terior cartilage with the cranium ; they spread to
the meatus auditorius ; to the eyes, the sight of
which seemed in a few cases to have been de-
stroyed one or two days before death ; and they
sometimes extend to the vertex. The constitu-
tional disturbance that accompanies this disease
seems principally the effect of irritation. When
the vesicles burst, the child begins to grow peevish
and fretful, pale, loses its appetite, and the flesh
becomes remarkably flabby. The periods of this
disorder are not very regular ; but it often happens
about the eighth day that the pulse sinks, the li-
vid ity spreads over the whole sore, the fetor and
discharge increase greatly. The smell is so strong
as often to be perceivable at a distance from the
bed. The discharge in one case where the ulcers
affected the arm-pits and breasts, was such that
the linen was completely loaded several times a
day. Death takes place about the tenth or twelfth
day, often preceded by convulsions, sometimes by
extreme debility. Patients are apt to relapse soon
after the sores are skinned over. The causes of
this malady are rather obscure. It seems exclu-
sively confined to children. Dr. M'Donnel saw
twenty cases before the year 1795 ; all the pa-
tients were under four years old. Dr. Spear ob-
served that it was confined to children from the
age of three months to that of five years; but it
has been observed near Dublin in children of nine
years old. It attacks the finest children in prefer-
ence ; the children of the poor more frequently
than those of the affluent ; and those who live in
damp situations seem more peculiarly subject to it
than others. The disease is more prevalent in
summer than in winter. It appears to be infec-
tious, though obscurely so in general ; but in the
year 1800, Dr. Spear observed it to spread epi

PEMPHIGUS.

487

demically. It has been said that the disease
oftener affects the younger from the older than the
reverse. It would be interesting to determine
whether it attacks the same person twice ; it cer-
tainly is apt to return after apparent recovery.
Children, as is well known, are subject to excoria-
tions behind the cars which sometimes produce
formidable sores ; these may, possibly, in a few
cases, resemble the disease we speak of, in its ad-
vanced stages; but in a great majority of these
cases these excoriations are far less rapid and dan-
gerous than the complaint in question. On the
other hand, the swine-pock (varicella) resembles
this disease in its first stage ; but the fever rarely
precedes the eruption in white blisters, and pus-
tules of varicella dry readily.

" This is a disorder of great danger, but of vari-
ous progress in different individuals. It often
happens that a fatal change takes place about
the eleventh day. The unfavourable signs are,
the rapidity with which the sores spread ; the
blackness, first at the edges, after some time spread-
ing over the whole ; the quantity and fetor of the
discharge; its colour, the paler being the most
dangerous.

« It has been alleged by empirical practitioners
in this disease, that after the blackness had co-
vered the whole sore, death was certain ; but I
have observed the blackness to go off, although it
had spread over the whole surface of the sores.
When this appearance abates, livid streaks gene-
rally remain for a day or two. When a favour-
able change is effected in bad cases, the diminu-
tion of the fetor and discharge were the first signs
of the abatement of the malady ; appetite was
afterwards restored."*

Dr. M'Adam, in a paper on this disease in the
same journal, (vol. i. p. 307,) states that the dis-
charge from the vesicles is acrid, and that he has
seen erosions produced on the breast by fluid
which fell accidentally from the vesicles. This
disease was very fatal and very unmanageable in
all its stages. Dr. Willan says, speaking of pem-
phigus infantilis, that treatment was attended with
little success. All ordinary modes of treating the
disease having failed, Dr. Stokes was led to search
after a traditionary empirical cure, of which he
had heard a favourable report. He carefully
watched over some cases treated by a person who
professed to possess the secret of curing the dis-
ease, and having satisfied himself that the treat-
ment was successful, he made himself acquainted
with its details. The principal application was a
compound green ointment composed of a great
number of herbs, some active and some inert.
From one plant " scrofularia nodosa" (great fig-
wort) occurring in several receipts which Dr.
Stokes procured, he was led to fix upon a simpler
ointment made from this plant alone ; the follow-
ing are his directions for treatment. " When the
parts adjoining the sores are swelled, and strongly
suffused with a dusky redness, or if the sores have
been previously dressed by any dry powder, I
apply a poultice of porter and oatmeal. The car-
rot poultice in fermentation, if it can be procured

* Dublin Medical and Physical Essays, vol. i. p. 14C,
l" 11 ". On an Eruptive Disease of Children, by Whitley
Stokes, M. U. S. F. T. C. D., Professor of the Practice of
Medicine.

without any delay, would perhaps be useful. Aftei
about eight hours the poultice should be removed,
and the parts affected very gently wiped with a
roll of lint or soft rag ; then the scrophularia oint-
ment should be applied. It should be as highly
saturated with green vegetable matter as possible.
For this purpose the plant should be taken fresh,
the smaller leaves .selected, and stewed a conside-
rable time with as small a quantity of unsalted
butter as will be sufficient to prevent the leaves
from being scorched. If well prepared, it is of a
full grass-green colour ; but after keeping it be-
comes the colour of box leaves, especially at the
surface ; yet I apprehend it preserves its efficacy,
in a great degree, for many months. When ap-
plied, it should be melted and suffered to cool to
the consistence of honey ; it should be applied by
a soft feather, with the utmost gentleness, to the
whole surface of the sore. Through the whole
of the treatment, the greatest gentleness should be
used. If the ear is strongly drawn open, the
parts affected are made to bleed, which produces
many inconveniences, and retards the progress of
the cure. After smearing the ulcer with the oint-
ment, it should be dressed with the same oint-
ment, with the addition of one-eighth part of wax.
The last ointment should be spread on lint folded
to the dry side, and cut so as to fit behind the
ear ; the whole should be secured by a broad band-
age, drawn under the chin, and fastened over the
top of the head. This dressing, in very severe
cases, should be repeated every fourth or sixth
hour ; but as the fetor abates, larger intervals may
be allowed. I do not pretend that this treatment
will always succeed ; but perhaps, of four such
cases as may occur to any practitioner, not ex-
cluding the most hopeless, it will succeed in three
on an average : and if we could accurately ascer-
tain the mortality which takes place when other
methods are used, we should consider this pro-
portion of success as very satisfactory." This oint-
ment is now introduced into the Dublin Pharma-
copoeia, and is found a most useful application,
not alone in the disease here noticed, but in many
other affections of the skin and scalp. Dr. M'Adam,
in the paper already alluded to, speaks favourably
of the internal exhibition of cinchona in this dis-
ease, and of the external application of strong ung.

hydrargyri nitratis. „ T ™

J bJ D. J. UORRIGAN.

PERCUSSION- See Auscultation, and
Chest, Exploration of the.

PERFORATION OF THE HOLLOW VIS-
CERA. — This term is generally employed to
designate a solution of continuity, in consequence
of disease of the walls of a hollow organ. The
term spontaneous perforation has likewise been
applied to those perforations which occur without
having been preceded by any perceptible modifica-
tion of function, local or general.

Perforation is far from being a rare occurrence
in several organs of the body, and has been ob-
served to take place under various circumstances
in most of them. The relative order of its fre-
quency may be stated as follows : the organs of
respiration ; digestive organs ; organs of genera-
tion in the female ; vascular system ; urinary
organs ; hollow bones ; the eye and the car.

488

PERFORATION OF THE HOLLOW VISCERA.

Perforation of the parietes of the three great
cavities is occasionally observed, and perhaps
more freqvjently in those of the abdomen and head
than in those of the chest.

When perforation takes place in any of these
parts, a preternatural communication is established
between two or more natural cavities ; between
these and an accidental cavity formed in conse-
quence of ulceration, mortification, or the accumu-
lation of pus, blood, or other fluids in the solid
viscera ; and between one or both of these and
the external surface of the body. Hence it fol-
lows that perforation may give rise to the effusions
of a natural or accidental fluid into a serous or
mucous cavity, or on the external surface of the
body, and which, consequently, may be either re-
tained or rejected.

Perforation may, however, occur without a
communication being established between the per-
forated organ and a natural or accidental cavity.
This is accomplished in two ways; 1st, by the
union of a neighbouring organ with that which
is perforated previous to the occurrence of this
lesion ; 2dly, by the formation of a false mem-
brane between which and the surface of the per-
forated organ an organic union had previously
been established.

Examples of these two modes in which a pre-
ternatural communication from perforation is pre-
vented from taking place between two or more
hollow organs, or between these and accidental
cavities, are often met with in the abdominal and
thoracic viscera. One, two, or more portions of
the small intestine are found more or less firmly
united over ulcerations of greater or less extent
which occupy in depth the whole of the coats of
these portions of intestine. A portion of the
epiploon has been found adhering to the surface
of the intestine or gall-bladder, and coveiing per-
forations of these organs ; and the liver, spleen,
pancreas, mesentery, transverse arch of the colon,
and diaphragm, furnish striking examples of the
means which nature employs to supply the loss
of substance occasioned by several diseases, of all
the coats of the stomach, and to prevent a com-
munication from taking place between the cavity
of this organ and that of the abdomen and thorax.
Similar examples are met with in the lungs when
these organs are the seat of tubercular excava-
tions. The walls of these excavations, particu-
larly when they occupy the upper lobes of the
lungs, are often found to be formed in great part
by those of the chest, the pleura pulmonalis and
costalis over the excavation being intimately
united by immediate contact, or by means of
dense cellular or cellulo-fibrous tissue.

The second mode of prevention of a preterna-
tural communication from perforation, viz. the
formation of a cellular or serous membrane, is
much less common than the former. The pre-
sence of this accidental serous or cellular mem-
brane may be confined to that portion only of the
walls of the organ in which the perforation exists,
or it may extend over the greater part or even the
whole of the serous surface of the affected organ.
It is almost always of a limited extent on the
peritoneum when it forms a barrier to the escape
of the contents of the intestines into the cavity
of the abdomen, and more or less extensive on

the pleura when it accomplishes a similar pur-
pose, namely, when it prevents air, pus, or oilier
fluids contained in the lungs, from passing into
the cavity of the chest.

Perforation has been found to occur in conse-
quence of ulceration, mortification, inflammatory
softening, and chemical dissolution. Among these
organic lesions, those which give rise most fre-
quently to perforation are ulceration and mortifi-
cation, because of these diseases occurring in
almost every organ of the body. Inflammatory
softening and chemical dissolution being, on the
contrary, met with only in certain organs, are
much less frequently the causes of perforation.

We shall now take a general view of perfora-
tion as it occurs in the different organs of the
body in consequence of one or more of the lesions
we have named, and shall confine ourselves to
the description of its anatomical characters, and
such other circumstances as may appear necessary
to illustrate this part of its pathology, as the symp-
toms and treatment will be given in the history
of those diseases by which perforation is preceded
or followed, and to which we shall occasionally
refer.

1. Perforation of the Digestive Orgaxs
— This lesion most frequently occurs in that por-
tion of the digestive tube situated beneath the
diaphragm, and more frequently in the intestines
than in the stomach. In both it may occur either
during life or after death. In the former case it
is the consequence of ulceration or mortification ;
in the latter it depends on the presence of an acid,
formed most frequently in the stomach during the
process of digestion. It occurs besides in the
stomach in consequence of the introduction of
irritant and acid poisons.

We are not disposed to believe, and we think
that facts are wanting to prove, that perforation
of the stomach or intestines takes place in conse-
quence of inflammatory softening of the walls of
these organs ; but as the facts on which we found
this opinion will be given in detail in the article
Softening-, we shall not enter at present upon
the investigation of the numerous and important
questions which this subject involves.

1. Perforation of the superior portion of the
digestive tube is occasionally observed to take
place in consequence of several of the diseases to
which it is subject, as well as from some others
which occur in some of the neighbouring organs.
In the oesophagus it is occasioned perhaps most
frequently by cancer, formed either in the walls
of this tube or in the cellular tissue external to it-
Id this case the walls of this muscular tube may
be destroyed within a limited extent without any
communication being formed between it and any
neighbouring cavity ; or, if the disease extends to
the trachea or pleura forming the mediastinum, a
communication may be formed between the cavi-
ties of both, and that of the oesophagus, through
which a portion of the food and drink of the
patient may pass, and give rise to the most dis-
tressing symptoms. It is indeed owing to this
circumstance alone that we are enabled to detect
the existence of such a communication, at least
between the trachea and oesophagus.

The upper part of the oesophagus behind th»
larynx is sometimes the seat of ulcers, which, ei

PERFORATION OF THE HOLLOW VISCERA.

489

tending to the cellular tissue situated between it
and the latter, form collections of pus which im-
pede mechanically, to a certain degree, respiration
and deglutition. The inferior portion of the oeso-
phagus has several times been found perforated,
particularly in children, in consequence, we be-
lieve, of the chemical action of the gastric acid
after death.

Aneurisms of the aorta occasionally produce
perforation of the oesophagus, into which the
blood is effused in greater or less quantity, so
that the patient may live only a few hours, or
several days, after the occurrence of the accident.
In some cases there is no difficulty of swallowing
from compression of the oesophagus, so that the
progress of the aneurism in that direction is not
suspected till the perforation takes place. In
others, this termination of the disease may be
predicted from the obstacle opposed to the passage
of the food or drink.

Perforation of the velum and palate is generally
observed to take place in consequence of ulcera-
tion or necrosis, and in those persons who have
taken large quantities of mercury for the cure of
venereal diseases.

Perforation of the stomach occurs in conse-
quence of ulceration and mortification of a limited
portion of its walls. The ulcer which is found to
have produced the perforation generally bears the
characters of having been produced by chronic
inflammation, that is to say, its edges are hard
and thickened, although sometimes neither of
these states, particularly the latter, is present.
The extent of the perforation compared with that
of the ulcer is always small, and its border, which
is formed by the peritoneum, is generally smooth.
Perforation arising from this cause is met with in
general at the small curvature or pyloric portion
of the stomach, rarely at the great curvature, and
perhaps never at the fundus.

Perforation of the stomach from cancer may be
mentioned at present, as this disease gives rise to
perforation not only from the softening of the
tissue of which it is composed, but also from the
ulcerative process which accompanies its latter
stage. Perforation of the stomach from cancer
occurs, however, most frequently on account of
the softening or sloughing of the cancerous tissue
when it occupies all the coats of the stomach, and
on this account the solution of continuity pro-
duced by these changes is larger than that occa-
sioned by any other cause during life, except
when it follows the operation of corrosive poisons.

Perforation from cancer may occur in any por-
tion of the stomach, but is most frequently met
with at the pyloric portion and at the small cur-
vature.

It is rare that perforation from this cause is
followed by a communication between the cavity
of the stomach and that of the abdomen, on ac-
count, as we have before stated, of some of the
neighbouring organs becoming united to the sto-
mach before the perforation is completed. This
very circumstance however, which prevents the
establishment of a preternatural communication
between the stomach and the cavity of the abdo-
men, gives rise, at some future period, to those
complicated cases of perforation in which a direct
communication is formed between tw> or more of

Vol. III. — 62

the abdominal organs, or between these and the
contained viscera of a neighbouring cavity, or the
external surface of the body. Examples of these
three modes of communication are met with as
the consequence of perforation of the stomach.
Thus, it is not rare to find the walls of the trans-
verse arch of the colon perforated where they had
before occluded a perforation of the stomach, and
a communication established between the respec-
tive cavities of these organs.

In the same manner is occlusion of a perfora-
tion of the stomach by the diaphragm followed by
perforation of the latter, from which the ulcerative
or sloughing process by which this lesion had
been produced, extends to the inferior lobe of the
lung, which had become united to the diaphragm.
In this manner a portion of the lung is destroyed,
several of the bronchi are laid open, and a com-
munication formed between these tubes and the
cavity of the stomach, and consequently between
the latter and the external surface of the body.
Lastly, it sometimes happens that the cavity of
the stomach communicates with the external sur-
face of the body, from the successive perforation
of the walls of this organ and of those of the ab-
domen.

In all the examples of perforation of the sto-
mach to which we have alluded, this lesion is re-
presented as having taken place from within out-
wards. It may, however, occur in the opposite
direction, or, as is said, from without inwards.
Examples of this kind of perforation are rarely
met with, except in cases of cancerous tumours
situated in the left lobe of the liver, the mesentery,
or mesenteric and lymphatic glands, and in scrofu-
lous enlargement of the latter glands.

Mortification, so far as we are aware, has not
been known to give rise to perforation of the sto-
mach, unless when it has been produced by the
presence of an accidental tissue, such as that of
cancer, as in the cases to which we have alluded,
or when it follows the violent operation of power-
fully irritant or corrosive poisons, directly applied
to the walls of this organ. In this latter case the
vitality, and, to a certain extent, the organization
of that portion of the stomach to which the poison
has been applied, are destroyed. The portion
thus circumstanced sloughs, and the cavity of the
stomach, if adhesion has not taken place between
this organ and a neighbouring one, is laid open,
and its contents pass into that of the abdomen*
The solution of continuity thus produced, may
vary from the fourth of an inch to two or three
inches in diameter, and has mostly a round form.
Its edges are seldom irregular, and should they
happen to be so, they are not thicker than the
walls of the stomach, unless blood or serosity has
been effused into the cellular tunic ; the density
of the tissues of which they are formed is seldom
or only partially increased, and never so dimi-
nished that they assume a gelatinous consistence.
The colour which they present is either that pro-
duced by an accumulation of blood in the capil-
laries, or by the effusion of this fluid into the
cellular tissues which enters into their composi-
tion, or by the chemical action of the poison,
either on the blood or on the tissues which form
the boundaries of the perforation. In the former
case the edges arc more or less red, or vascula ■■,

490

PERFORATION OF THE HOLLOW VISCERA.

or both ; in the latter they possess cither a yel-
lowish or orange tinge, or various shades of
brown, amounting to black, as if they were
painted with bistre, or dusted over with charcoal- mortem appearances which accompany perforation
powder or soot. Irritating poisons may produce of the stomach from the gastric acid and acid

with perforation from this natural chemical
agent.

From these, the most remarkable of the post-

the former appearances, but not the latter, which
we believe are the effects of those poisons only
which possess acid properties, as the nitric, mu-
riatic, sulphuric, and oxalic.

The post-mortem appearances of perforation of
the stomach from the introduction of acid poisons,
in particular, into this organ, still require to be
investigated with greater care than hitherto has

poisons, it appears to us that such evidence may
be obtained as will enable us to distinguish per-
foration produced by the former from that produced
by the latter.

The pulpy, thin, transparent, pale, fringed
edges of the perforation from the gastric acid ; its
situation in the fundus of the stomach; the pre-
sence of softening of the coats of this organ be-

been done, and particularly by means of a series ! yond the perforation, accompanied with discolora-

of experiments on living animals, before we can
affix to them that diagnostic importance of which
they seem susceptible, or refer to them with confi-
dence as medico-legal evidence in cases of poison-
ing. Perhaps even in the present state of our
knowledge on this subject, may the toxicologist
derive more assistance from the study of the post-
mortem appearances of perforation of the stomach
from acid poisons than is generally believed.
But in order to do so, he must be intimately ac-
quainted with those of all the other forms of per-
foration, particularly that produced by the gastric
acid after death. We shall give a general sketch
of the physical and chemical effects of this acid
on the stomach, and endeavour to point out the
means by which they may be distinguished from
those produced during life by the acid or irritant
poisons which have given rise to perforation.

Perforation of the stomach, in consequence of
the chemical action of the gastric acid, takes place
almost always in the most depending part of this
organ, viz. the fundus. In those cases in which
it has been met with in other parts of the stomach,
accidental circumstances have concurred which
afforded a satisfactory explanation of this differ-
ence as to its seat. The size of the perforation is
generally large, often occupies the whole of the
fundus, and sometimes a part of the body of the
stomach. Its form is almost always irregular ;
its edges are thin, ragged, more frequently fringed
or filamentous. The tissues of which it is com-
posed are soft, pulpy, gelatinous, and more or less

tion of the blood only where this softening exists,
and the entire absence of redness under any form
in the same situation, are characters which we do
not believe belong to any other form of perfora-
tion. Were it necessary to seek for still stronger
evidence in favour of this opinion, we would refer
to the histories of the cases of the individuals in
whom these appearances have been found after
death, to the results of our own experience on this
subject in animals, and in particular to that stiong
collateral evidence by which it is supported, viz.
the entire absence of all the anatomical characters
of peritonitis, such as redness, increased vascular-
ity, coagulable lymph, or adhesions in the neigh-
bourhood of the perforation, and in general of
effusion of the contents of the stomach,— conse.
quences which may be said to follow invariably
and to a greater or less extent, perforation of the
stomach from the acid poisons, or indeed any
other pathological agent.

If we are correct in our estimate of the dis-
tinctive characters of this kind of perforation, it
follows that this lesion cannot be confounded with
any other, however similar to it, but produced by
a different agent. The analogy which exists be-
tween the former kind of perforation and that
produced by acid poisons depends, as we have
already said, on the acid property of these poisons,
and because, therefore, of the same kind of dis-
coloration being present in both cases. The diffi-
culty thus created is, however, not such as it has
been represented ; nay, we believe that the em

transparent ; either perfectly pale, of a milky hue, barrassment of the toxicologist has arisen from his
or streaked with lines or stripes of a pale yellow, j not being acquainted with those post-mortem ap-
orange, brown, or black colour. These colours : pearances which we have endeavoured to show
are always most marked in, or limited to, the mu- ! are so peculiarly characteristic of the chemical

cous and submucous tissues, the muscular and
serous coats which form the fringed edges of the
perforation being quite pale. It is of the greatest
importance to observe that these colours are
always accompanied with softening of the mucous
and submucous coats to a greater or less extent
beyond the perforation ; or, if these coats have
been destroyed, the muscular is found similarly
altered. If the blood-vessels, whether the capil-
laries or larger branches, were filled with blood
at death, this fluid, wherever the coats of the sto-
mach are softened, presents either the brown or
olack colour of chocolate or soot, and assumes of
course the form and distribution of the vessels in
which it is contained. Such is always the che-
mical effect of the gastric acid on the blood after
death, and therefore we arrive at the important
conclusion that redness, whether arising from the
effusion of blood or vascularity, is incompatible

action of the gastric acid. We may observe be-
sides, that the local characters of perforation from
acid poisons are in several respects very different
from those of perforation from the gastric acid, as
will be seen by comparing the description which
we have given of them with those which accom-
pany perforation from the gastric acid, particularly
as regards the situation of the former, the charac-
ter of its edges, and the redness of the tissues
surrounding it, to which we may add effusion of
the contents of the stomach, and peritonitis.

Perforation from cancer or chronic ulceration
never can be confounded with that from the gastnc
acid.

Perforation in consequence of an ulcer of the
stomach from common inflammation, neither acute
nor chronic, cannot, perhaps, be distinguished
from perforation produced by irritant and eyen
acid poisons. But as facts appear to be wanung

PERFORATION OF THE HOLLOW VISCERA.

491

on this part of the subject, we must leave it in its
present state of uncertainty without any further
comment.

2. Perforation of the intestines takes place
most frequently in consequence of ulceration ; and
in the great majority of cases in the inferior por-
tion of the ileum, in the situation of the glandulx
agminatx, or glands of Peyer. It may occur
also in the points of the small and large intestines
occupied by the glandulx solitarix, as well as in
those of both intestines in which no follicles exist.
The ulceration which preceded the perforation
may have been either acute or chronic, but is far
more frequently of the latter kind, and may have
given no signs whatever during life of its exist-
ence. The ulcerated portion of the intestine is
found either pale or presenting various degrees of
redness and vascularity, and is accompanied with
similar states of the surrounding mucous mem-
branes. The changes in the thickness and con-
sistence of this portion of the intestines present
considerable variety, and vary with the degree and
duration of the inflammation by which they have
been occasioned. The perforation is sometimes
not larger than to admit a common-sized probe ;
at other times so large as to admit the point of the
fore-finger, or even of the thumb. Its edges are
generally smooth, and more frequently circular
than of an irregular shape, and are formed by the
peritoneal coat, except in some rare cases, in which
the ulceration has destroyed to the same extent
the other coats of the intestine. Perforation of
the small intestines may occur in one, two, or
three of the glands of Peyer in the same indi-
vidual, and in either case it almost always gives
rise to a communication between the cavity of the
intestine and that of the abdomen, followed by an
effusion of the contents of the intestine, and peri-
tonitis.

Perforation from ulceration may take place in
the rectum, caput coecum coli, duodenum, and in-
deed throughout the whole of the large and small
intestines, where the mesentery separates to be
reflected over them, without giving rise to much
effusion or a communication with the cavity of the
peritoneum. But this variety of perforation is
chiefly met with in the rectum and caput ccecum,
and is no doubt sometimes the cause of the ab-
scesses which not unfrequently form in the cellu-
lar tissue in the situation of these portions of the
intestinal tube.

In the intestines, as in all organs covered by a
serous membrane, perforation from ulceration is
always preceded by sloughing of this membrane.
When the ulcerative process has destroyed the
sub-serous cellular tissue, and consequently the
vessels which supplied it with the materials of its
nutrition, it soon dies, and is separated in the form
of a pale or grey-coloured slough, or tinged with
the colouring matter of the bile or foeces, and
without the odour of gangrene.

Perforation from mortification of all the coats
of the intestines, is, perhaps, never met with,
unless in some cases of intus-susception and
strangulated hernia. In the former case, the fsocal
matter passes into the cavity of the peritoneum ;
in the latter, a similar consequence may follow,
but much more frequently adhesion takes place
between the intestine, before it perforates, and the

walls of the abdomen, when the perforation of
both takes place, and a communication is esta-
blished between the cavity of the intestine and the
external surface of the body, or what is called an
artificial anus is formed.

We are not aware that there is a single exam-
ple of recovery from peritonitis produced by per-
foration of the intestines. The patient may sur-
vive the accident only a few hours, and seldom
survives more than two or three days, the length
of time depending chiefly on the previous state
of the patient, and the quantity of the faecal mat-
ter effused, although some cases have occurred in
which the quantity of this matter was so small
that it could hardly be detected either by its pre-
sence or odour, while the symptoms were violent,
and the disease proved rapidly fatal. See Fever,
and Peritonitis from perforation of the serous
membrane.

Perforation of the intestine from poisons has
not, so far as we know, been observed. There
are, however, several examples of its having been
produced by the gastric acid after death, but
which have been regarded by some pathologists as
the consequence of disease ; an opinion, the accu-
racy of which will be particularly examined in the
article Softening.

Perforation of the intestines from without in-
wards is occasioned by the same diseases as those
mentioned as giving rise to this variety of perfora-
tion of the stomach. Tubercles and abscesses
are, however, the most frequent causes of it in the
intestines. We have seen the former perforate
the intestine in a number of points, without any
traces of inflammation of the mucous membrane
around the perforation, and without a communica-
tion being formed between the cavity of the intes-
tine and that of the peritoneum. The abscesses
which perforate the intestines are retro-peritoneal,
and most frequently those situated in the loose
cellular tissue situated in the ilio-caecal region.
The coats of the intestines, generally the coecum
or commencement of the colon, are gradually de-
stroyed by ulceration, and a quantity of pus in
proportion to the size of the abscess is evacuated
by the anus.

The preternatural communications which are
found to take place between the intestines and
neighbouring organs, in consequence of perfora-
tion of the former, we have already alluded to
generally, and they are by no means so frequent
as when they are occasioned by perforation of the
latter. Sometimes portions of the small intestines
are found united together, and communicating
with each other by means of several perforations,
through which the liquid freces pass in greater or
less quantity, and examples have been met with
in which the passage thus formed was lined with
an accidental mucous tissue. In the cases of pre-
ternatural communications of this kind which we
have seen, the perforated intestines were included
in a common accidental serous envelope, the evi-
dence of peritonitis having existed at some remote,
period ; and the coats of the intestine more or
less destroyed by tubercular ulceration, com-
mencing in the glands of Peyer. We do not
believe that the peritonitis, in such cases, was the
consequence of the effusion of fa:cal matter from
perforation of the intestine. We believe, on the

492

PERFORATION OF THE HOLLOW VISCERA.

contrary, that it is produced before the perforation
of the serous membrane is accomplished, so that
the coagulable lymph which is thrown out becomes
organized and united with a neighbouring portion
of intestine. Afterwards the ulceration proceeds,
and the preternatural communications we have
described are effected.

Another variety of preternatural communication
of the small intestines, and which takes place in a
manner similar to the former, is that in which
there exists cellular adhesions between the perfo-
rated portion of intestine and the walls of the ab-
domen. The effused ffecal matter is prevented by
the presence of this tissue from passing into the
cavity of the peritoneum. In this tissue it collects
in greater or less quantity, and as the abdominal
parietes with which it is in contact are more sus-
ceptible to its stimulating effects than the former,
they become inflamed, ulcerate, and are perforated,
and a communication is established between the
intestine and the surface of the body, through
which the faecal matter escapes. Andral mentions
a case of this kind. Besides the faecal matter
there escaped an ascaris lombricoides, and several
of these worms were found, after the death of the
patient, contained in the cavity formed in the ac-
cidental cellular tissue which united the perforated
intestine with the perforated walls of the abdomen.

Although it is said that worms perforate the
intestines, we have never seen a case of perfora-
tion which could in any way dispose us to attri-
bute it to such a cause. Were such a case to
happen, it could only be in consequence of inflam-
mation and ulceration excited by these animals ;
and yet we have found them very numerous, — in
one instance amounting to thousands, — without
the slightest trace of inflammation of the mucous
membrane.

There are a few examples of the walls of the
abdomen being perforated in consequence of large
collections of purulent fluid in its cavity ; and we
may mention here tnat perforation of the dia-
phragm may take place in cases in which similar
collections are formed in the cavity of the pleura.

3. Perforation of the walls of the liver, which
form the boundaries of an abscess situated in this
organ, and of the gall-bladder, may with propriety
be noticed in this place. Perforation of the for-
mer, with effusion of the contents of the abscess
into the cavity of the abdomen, is by no means
common, because of adhesion taking place, pre-
vious to the occurrence of this accident, between
the peritoneum covering the abscess, and that of
the stomach, colon, walls of the abdomen, or dia-
phragm. Under these circumstances, however,
the perforation may afterwards extend to the hol-
low organs we have named, and establish a com-
munication between them and the cavity of the
abscess, by means of which its contents are eva-
cuated by vomiting or by stool. A communication
between the abscess and the external surface of the
abdominal parietes where they cover the abscess,
is more common than the former. When the dia-
phragm adheres to the abscess, and is perforated,
three consequences may follow : — the contents of
the abscess may pass into the cavity of the chest ;
into the bronchi, from a portion of the lung which
had adhered to the diaphragm having been de-
stroyed by ulceration or sloughing ; or into the

cavity of the chest and bronchi at the same time.
We have seen only one case of the last variety of
perforation of abscess of the liver, or, more cor-
rectly speaking, of a purulent cyst containing a
great number of hydatids. Although these vesi-
cular animals have sometimes been expectorated
in cases of this kind, such did not happen in the
case to which we allude. The communication
between the bronchi and cyst took place first, fol-
lowed by a yellow-coloured expectoration, which,
because of the existence of the cyst in the liver
having previously been detected, was supposed to
be owing to the passage of the bile into the bron-
chi from perforation. Soon afterward, symptoms
of pleurisy manifested themselves, accompanied
with those of effusion and pneumothorax, the real
nature of which was not understood till after death.
Only one opening was found in the diaphragm,
where it covered a cyst from six to seven inches
in diameter, containing a yellow, puriform fluid
and hydatids. This opening, sufficiently large to
admit the fore-finger, communicated with an ex-
cavation formed in the inferior lobe of the lung,
which adhered but slightly to the diaphragm. In
the bottom of this excavation there were several
openings, some of them, which were small, com-
municating with the bronchi, others larger, lead-
ing into the cavity of the pleura. This cavity
contained a quantity of air, yellow sero-purulent
fluid, and a great number of large and small hy-
datids. The lung was considerably compressed,
and the pleura covered with recent coagulable
lymph.

Perforation of the gall-bladder occurs rarely ex-
cept when biliary concretions, of considerable size,
are lodged within it. In such cases the preterna-
tural communication generally takes place between
this organ and the ascending or transverse portion
of the colon, through which these concretions pass
into this intestine, and are voided by stool. A
similar mode of transmission is afforded them
when they are enclosed in the ductus communis
choledochus. Their transit from either of these
situations into the intestine may be accompanied
with violent paroxysms of pain, or no pain at all;
a difference which is not easily explained. In one
case, in which the pain was extremely severe, and
which terminated fatally, we found the duodenum
perforated in four or five points near the pylorus,
and communicating with the gall-bladder, which
contained two large concretions. In two other
cases, on the contrary, from the history of which
we could not learn that the patients had ever suf-
fered from any of those symptoms attributed to the
passage of gall-stones, and who died of diseases
unconnected with any derangement of the hepatic
organs, we found in one of them a communication
existing between the gall-bladder and the colon,
in which a concretion was lodged and projecting
into the latter, the mucous membrane and other
coats of this intestine being quite healthy. In the
other case there existed a similar communication,
presenting the character of a fistulous passage
(for it was lined with a mucous membrane), about
half an inch in length, into which a small probe
only could be passed. The gall-bladder was
empty and greatly atrophiated in both cases, the
natural consequence of the cessation of its func-
tion. Perforation of the gall-bladder from ulcer3-

PERFORATION OF THE HOLLOW VISCERA,

493

tion is not common. The only case worth notic-
ing which has come under our observation, was
one in which double perforation took place from
ulceration of the walls of this organ. One of the
perforations was situated towards the free surface
of the gall-bladder, and was prevented from com-
municating with the cavity of the abdomen by the
adhesion of a portion of the epiploon : the other
was formed where this organ is in contact with
the liver, so that the bile was effused between them,
and had formed for itself a cavity of considerable
size, covered superiorly only by the peritoneum,
which rose above the surface of the liver. On
this account it could be felt through the parietes
of the abdomen, accompanied with the sensation
of fluctuation, circumstances which led the physi-
cian to diagnosticate the existence of an abscess
of the liver. Caustic potash was applied prepara-
tory to laying it open, but the patient died two
days after, before this plan of treatment could be
carried into effect.

II. Perforation of the Respiratort Or-
gans. — As perforation of the bronchi and pleura
will be described in the articles Pleurist and
Pneumothorax, and as a description of it pro-
duced by mortification has already been given
under that head, we shall only mention a few
facts, with regard chiefly to the comparative fre-
quency of its occurrence in the tuberculat diseases
to which the lungs and some of the neighbouring
organs are subject.

The presence of tuberculous matter in the
lungs is by far the most frequent cause of perfo-
ration of the pleura or bronchi, both of which it
destroys within a limited extent, by means of the
ulceration or mortification which its presence oc-
casions. It is only when situated beneath the
pleura that the tuberculous matter gives rise to a
communication between the cavity of this mem-
brane and the bronchi, or when a tubercular ex-
cavation occupies the same situation. The escape
of the air into the cavity of the pleura is not al-
ways the consequence of perforation of this mem-
brane and of the bronchi. We have already
stated that the opening in the former is sometimes
closed by adhesion of the pleura, and by acciden-
tal serous or cellular tissues, which consequently
prevents the air or other fluids from passing into
the cavity of the chest. It is in this way that
perforation of the thorax takes place, and that a
communication is established between the surface
of the body and the bronchi, through which the
air enters and escapes. But should the perfora-
tion take place in the mediastinum and bronchi,
the inspired air is effused into the cellular tissue
included within the former, whence it passes to
that of the neck, face, and chest, and may pro-
duce extensive and distressing subcutaneous em-
physema.

Perforation of the bronchi without perforation
of the pleura is a much more frequent occurrence
than the former, in whatever part of the lung the
tuberculous matter may have been deposited. In
this case the bronchi may be simply perforated, or
perforated and communicating with a tubercular
excavation. Perforation of the bronchi is not an
unfrequent consequence of the accumulation of
tuberculous matter in the bronchial glands, or the
presence of cretaceous matter in these bodies.

2a

The former occurs in young persons, and espe-
cially in children : the Tatter sometimes in middle-
aged persons, but most frequently in those ad-
vanced in life.

This kind of perforation may sometimes be
detected during life, from the presence of consi-
derable masses of tuberculous matter or concre-
tions in the sputa. Perforation of the bronchi
from the latter cause undergoes sometimes a cure,
from obliteration or cicatrization.

The most fatal kind of perforation of the bron-
chi is that which is accompanied by perforation
of a large branch of the pulmonary artery. This
complication takes place in two ways : — first, a
large bronchus, most frequently the first or second
branch of the trachea, and a corresponding branch
of the pulmonary artery, are perforated by a tuber-
culated bronchial gland situated between them.
In this case a direct communication is formed
between the blood-vessel and bronchus, and the
hemorrhage which ensues is so great and rapid,
that the blood is thrown forth as if vomited, some-
times by the nose as well as the mouth, and may
terminate fatally in from ten to twenty minutes ;
secondly, a tubercular excavation with which
several bronchi communicate, extends in the di-
rection of the pulmonary artery or one of its
principal branches to which it adheres. The cor-
responding portions of the walls of the artery and
those of the excavation ulcerate or slough, and
hemorrhage takes place, first into the excavation,
and afterwards into the bronchi. It is on account
of this indirect communication between the per-
forated vessels and bronchi that hemorrhage in
cases of this kind is generally 7 small at first, di-
minishes and increases at irregular intervals, and
sometimes continues for several days.

Perforation of the pleura from abscess, and the
effusion of blood under the pleura in pulmonary
apoplexy, are not common. In the cases which
we have seen of the latter kind, the pleura ap-
peared to have sloughed because of its having
been separated from the cellular tissue by the ef-
fused blood.

Chronic pleurisy with effusion sometimes ter-
minates in perforation of the walls of the chest
or diaphragm ; and there are examples of fluid
making its way into the bronchi, whence it was
expectorated, and the disease terminating favour-
ably.

For perforation of the bronchi and trachea from
aneurism, see Aneurism: or the AonTA.

III. Perforation of the Organs of Gene-
ration. — Perforation of these organs in the fe-
male, after the middle period of life, is very com-
mon, and, in the great majority of cases, in
consequence of cancer. Cancer of the uterus
and vagina may give rise to perforation of the
walls of both, and a communication be established
between them and the following organs : between
them and the bladder, or rectum separately, or
between them and both of these organs at the
same time. Hence the urine, faecal matter, or
both, may be passed in greater or less quantity
by the vagina, and sometimes the latter makes its
way also into the bladder.

Perforation of the posterior walls of the neck
of the uterus or upper portion of the vagina, is
not unfrequently followed by perforation of the

494

PERFORATION OF THE HOLLOW VISCERA.

peritoneum, and as the progress of the disease
upwards is generally accompanied with sloughing
of the cellular tissue behind this membrane and
the neck of the uterus, a putrid sanies is poured
into the cavity of the former, which gives rise to
peritonitis, rarely less violent than that which is
occasioned by the presence of faecal matter. Per-
foration of the peritoneum is sometimes arrested
by the adhesion of a portion of small intestine,
which may either remain entire, or afterwards be-
come perforated. The latter is the more frequent
occurrence.

Caries and necrosis of the bones of the sacrum
may give rise to perforation of the upper part of
the vagina, from the ulceration and sloughing of
the cellular tissue situated between them extend-
ing to the latter organ. Such a case may readily
be confounded with perforation from cancer.

Perforation of the ovaries and Fallopian tubes
seldom occurs. We have met with it in one of
the latter, between which and the rectum there
existed a communication, through which a puru-
lent fluid, the contents of the tube, escaped, and
was passed by the anus. In another case, in
which the left ovary was transformed into a puru-
lent cyst, similar consequences followed. Both
patients died of other and complicated disease of
the uterus. In another case, a communication
existed between the left Fallopian tube and ovary.
The ovary formed a cyst as large as the two fists ;
the Fallopian tube was from an inch to two inches
in diameter, and both were filled with a sero-puru-
lent fluid, none of which, however, appeared to
have passed into the cavity of the uterus. For
further information on this subject, see Diseases

OF THE UTEHUS AND OVARIES.

IV. Perforation of the Urinary Organs.
— 1. Perforation of the bladder occurs most fre-
quently in the female, and from the extension of
cancer of the uterus, to which we have already al-
luded. It is also occasioned by ulceration or slough-
ing in consequence of pressure during pregnancy
or delivery ; chiefly in deformity of the bones of
the pelvis, or from the improper use of instruments
when employed to extract the foetus.

In the male it is more often occasioned by the
catheter left in the bladder in cases of paralysis
of this organ, and in stricture of the urethra in old
men, than by any other cause. The perforation
is generally the consequence of sloughing of the
walls of the bladder which were in contact with
the point of the catheter.

2. Perforation of the walls of the kidneys sel-
dom occurs. When it happens, the loose cellular
tissue with which these organs are so abundantly
surrounded, becomes the seat of abscess. In one
case of this kind which wc examined, a small ab-
scess was situated between the kidney and de-
scending colon, and communicated with the ca-
vity of this intestine. In another, an abscess con-
taining several pints of pus, and situated between
the kidney, descending colon, and lateral walls of
the abdomen, likewise communicated with this in-
testine. The quantity of pus passed by stool in
the latter case was considerable. The substance
of the kidney was almost entirely occupied with
tuberculous matter, as well as the infundibula and
pelvis. In the former, th<* pelvis of the kidney
contained a large calculus, and its substance was

converted into a firm uniformly grey tissue. Both
cases terminated fatally. The patient, a female,
in whom the former case occurred, was about
twenty years of age ; the other was a man above fifty,

V. Perforation of the Organs of Cincr-
latiox. — Perforation of these organs may be con-
sidered as it occurs in the heart, arteries, and veins.
The occurrence of this lesion in the arteries is
infinitely more frequent than in the heart or veins,
owing obviously to their being subject to diseases
which rarely affect the latter, as well as to the
impulse of the blood, and the distension occa-
sioned by this fluid propelled into them by the
heart : thus perforation of the arteries, in the great
majority of cases, takes place in consequence of
the deposition of a substance resembling bone,
chalk, or putty, which often destroys their walls,
or deprives them of their elasticity. In the fust
case, the internal and middle coats may be perfo-
rated without their having undergone any previous
change of capacity, so that the cellular coat, being
brought in contact with the blood, is pushed out-
wards by this fluid, and forms what is termed cir-
cumscribed false aneurism. In the second case,
the internal and middle coats being deprived of
their elasticity by the presence of one or other of
these substances we have named while yet in a
fluid state, yield to the continued impulse of the
blood, and ultimately form a sac or pouch of vari-
ous dimensions, occupying either a portion or the
whole of the circumference of the artery, and
which, under these circumstances, constitutes
what are commonly called circumscribed and dif-
fuse true aneurism. Perforation of the dilated
coats of the artery takes place at a subsequent pe-
riod, first in the internal and middle, and after-
wards in the cellular. In whichever of these ways
the aneurism is produced, perforation of the cellu-
lar or outer coat of the sac may take place under
the two following circumstances ; — first, when the
surface of the aneurism is free from adhesion with
a neighbouring organ, as sometimes happens
when it is lodged in the thorax or abdomen, when
the blood is poured into the serous cavity of either
of these parts of the body ; secondly, after the
aneurism has become united with a neighbouring
hollow organ, or the walls of the cavity in which
it is contained, when, after the perforation of either
of these, the blood is efiused either directly on the
surface of the body, or escapes by one of the
natural passages, for example, the oesophagus or
trachea.

Perforation of the arteries (we speak of the
larger branches or trunks) is not unfrequently the
consequence of ulceration proceeding from without
inwards. When this happens, the ulceration
may take place originally in the walls of the
artery which becomes perforated ; or in a portion
of an organ in the immediate vicinity of an artery,
to which it afterwards extends, producing a solu-
tion of continuity of its walls. We have already
given examples of perforation of the former kind
in the case of tuberculated bronchial glands ; and
examples of the latter arc met with in several
organs, and particularly in the stomach in some
cases of chronic ulcers, in which one of the coro-
nary arteries of a large branch happens to traverse
the bottom of such an ulcer, and becomes perlu*
rated by the ulcerative process.

PERFORATION OF THE HOLLOW VISCERA.

495

When cancer produces perforation of an artery, it
is in general, owing more to the walls of the vessel
having been destroyed by the extension of this
disease to them than by ulceration. The same is
the case in perforation of veins from a similar
cause. These vessels are not so often perforated
by ulceration as the arteries, and the hemorrhage
is seldom great unless they are considerably
dilated, as in hemorrhoids ; or their walls much
thickened and united with indurated cellular tis-
sue, which prevents them from collapsing, as
sometimes happens in the case of chronic ulcers
of the inferior extremities, accompanied with vari-
cose dilatation of the veins. In a case of this
kind which we had occasion to examine, the he-
morrhage which followed the perforation of the
vein was so great that the patient, a man about
forty years of age, expired in little more than ten
minutes.

There are a considerable number of examples
of perforation, more commonly termed rupture, of
the heart. The portion of this organ the most
subject to this lesion is the inferior and middle
portion of the left ventricle. Sometimes softening
or ulceration, at other times atrophy of the mus-
cular substance in the situation of the perforation,
are the lesions which are found to precede the
occurrence of this accident ; at the same time, the
walls of the ventricle are, in general, more or less
hypertrophiated.

There may be one, two, or three perforations
which traverse the walls of the ventricle either
perpendicularly or obliquely. In the latter case
the hemorrhage which ensues does not, it is said,
prove so suddenly fatal as in the former case. It
does not appear that the quantity of blood effused
bears a necessary relation to the length of time
that supervenes before death takes place.

We have no certain evidence to show that per-
foration of the heart is curable, although Rostan
relates a case in which he conceived he saw the
cicatrix of a perforation of the left ventricle in a
patient, who was supposed to have presented the
symptoms of this lesion some time before her
death, which was occasioned by a second per-
foration.

Perforation of the valves of the heart is seldom
observed except in those of the aorta, and in the
cases which we have seen, it appeared to be the
consequence of the presence of osseous or creta-
ceous matter deposited in their substance or
between their lamina;.

VI. PERFORATION OF HOLLOW BoNES OCCUrS

in cancerous affections of their walls, and when
pus or hydatids are contained within them. The
latter generally produce perforation by exciting in-
flammation and caries of the bone ; the former,
by the gradual transformation of a portion or the
whole circumference of the bone into a lardaceous
or cerebriform substance. In this case, fracture
more frequently takes place than perforation of
the bone.

VII. Perforation of the Ete. — The cor-
nea is that part of the eye which is most frequently
perforated. It may be in consequence of ulcera-
tion or sloughing, accompanied or not by similar
diseased states of the other tunics of the eye ; by
an accumulation of pus, or the presence of ma-

lignant tumours proceeding from within outwards.
(See Ophthalmia.)

VIII. Perforation of the Ear. — Perfora-
tion of the membrane of the tympanum is not
very rare in severe cases of inflammation of the
internal ear terminating in suppuration. The
solution of continuity of the membrane, which
follows the accumulation of the pus in the cavity
of the tympanum, may be the consequence of
ulceration or sloughing, favoured by the mechani-
cal distension to which it is at the same time sub-
jected. So soon as the perforation is completed,
a sudden and copious discharge of puriform fluid
makes its appearance, and which, if there has
been no discharge before from the external orifice
of the ear, may be regarded as a certain sign of
its coming from the cavity of the tympanum in
consequence of perforation of its membrane.

The effects of perforation of the tympanum on
the function of hearing depend on the size and
situation of the artificial opening, and the degree
of integrity of the ossicula with which this mem-
brane is connected. Suppurative inflammation of
the bony structures of the internal ear may pro-
duce in a similar manner perforation of the mem-
brana tympani, as well as accidental products
developed in the same situation.

R. Carswell.

PERICARDITIS. — I. Of Pericarditis.—
The anatomical characters of acute inflammation
of the pericardium are, 1, preternatural red-
ness of the membrane ; 2, coagulable lymph,
adhering to its surface ; and 3, fluid effused with-
in its cavity. These characters we shall treat
of in succession, and at some length ; for as the
anatomical characters are the key to the symp-
toms, the latter cannot be understood, and, conr
sequently, so rapid and fatal a malady cannot be
treated with the promptitude and decision essential
to the safety of the patient, unless the nature of
the former and their intimate connection with the
symptoms are thoroughly known to the prac-
titioner.

1. Preternatural redness of the pericardium. —
The redness very seldom pervades the whole of
the inflamed portion. It presents itself sometimes
in numerous small scarlet specks, with a natural
colour of the intervening membrane, sometimes in
spots of greater or less magnitude formed by the
agglomeration of the specks, and sometimes in
patches of considerable extent. Even these, how-
ever, have, almost without exception, a dotted or
mottled character. In some cases, according to
Laennec, though the inflammation, judging of it
by the thickness of the false membranes, had been
very severe, scarcely any redness exists. Vascular
injection of an arborescent and sometimes stellated
appearance, accompanies redness, and is generally
proportionate to it in degree. Occasionally, how-
ever, the redness is uniform, like a stain.

The pericardium is very rarely, if ever thickened ;
that which is often regarded as thickening being
nothing more than superimposed and intimately
adherent false membrane.

When acute pericarditis degenerates into chro-
nic, the redness loses its brilliancy, sometimes
becoming very deep and of a brownish colour,

496

PERICARDITIS,

and sometimes acquiring a cinnamon hue. Be-
neath a layer of lymph of this colour, we have
seen the surface of the heart of a bluish-white
appearance, like the spots so frequently found on
this organ.

Redness alone does not afford conclusive evi-
dence of pericarditis, as all serous as well as
mucous membranes are liable to vascular injection
from various causes independent of inflammation.
To afford such evidence, therefore, the redness
must be conjoined with an effusion of lymph or
sero-purulent fluid.

2. Coagulable lymph adhering to the surface
of the Pericardium. — The inflamed pericardium
secretes serum and lymph conjointly, and in a
fluid state, from the same vessels. Soon after the
secretion has taken place, the lymph concretes,
while the serum remains fluid. The former, when
recent, is of a pale straw-colour, and of a soft
tender consistence, becoming firmer and more
tenacious as it grows older. Though occasionally
deposited in detached lumps and specks, it gene-
rally forms continuous layers, sometimes covering
a portion only, but more commonly the whole, or
nearly the whole, of the pericardium. The thick-
ness of the deposition may vary from a line to
an inch ; but from a line and a half to three lines
is its ordinary mean. Its adherent surface is
smooth ; the opposite or free is rough and singu-
larly figured. It is sometimes pitted with small
depressions at tolerably regular intervals, present-
ing the aspect of a fine reticulation, or of the
section of a sponge. This occurs principally
where the layer is thin : where it is thick, the
surface is distributed into more spacious cells,
often as large as a pea, and separated by coarser
partitions. The partitions are sometimes irregular,
being higher and thicker in one part than another,
in which case the effect is exactly that produced
by separating two flat plates between the surfaces
of which a layer of soft butter has been spread.
At other times the partitions are very regular; in
which case the appearance, as Corvisart observes,
is analogous to that of the second stomach of a
calf. Occasionally they are very thick and round-
ed, and then they have an appearance somewhat
similar to that of a congeries of small earth-
worms. Not unfrequently they are shaggy and
flocculent, hanging in shreds like tow. Some-
times no cells are apparent, but the lymph is ar-
ranged in transverse, and, as it were, plaited
wrinkles, like undulations of sand on the sea-
shore. When lymph becomes old, and not ad-
herent, it acquires a deeper hue, varying from
cinnamon to an intense brown-red or mahogany
colour. When of the latter colour, it usually
secretes bloody fluid.

Now, what is the object which nature proposed
to herself in the effusion of lymph? Unques-
tionably to effect reparation — the object for which
the effusion is designed in whatever part of the
system it takes place. But how, it may be in-
quired, can it effect reparation in the pericardium ?
By causing adhesion. Supposing that the inflam-
matory process does not terminate by resolution —
by the complete absorption of both lymph and
serum, the most desirable termination which re-
mains is adhesion ; for should this not take place,
ne lymph becomes a secreting surface, which

effuses more and more lymph and serum, until in
a short time the cavity is completely distended,
and the action of the heart so embarrassed that a
fatal termination speedily ensues. But, should
adhesion of the opposite surfaces take place, by
which further effusion is prevented, life may be
prolonged for a considerable period, even for
years; though, as will presently be explained,
the adhesion, so far from being a perfect repara-
tion, gives rise to another form of organic dis-
ease, which eventually proves destructive to the
patient.

Adhesion takes place in some cases and not in
others, — a circumstance which has been attri-
buted to a difference in the quality of the lymph,
dependent on the greater or less energy cf the
inflammation, in consequence of which it pos-
sesses different degrees of aptitude for adhesion.
This explanation, though perhaps not unsound,
is scarcely applicable to the pericardium ; for here
the union or non-union depends mainly on the
absence or presence of fluid in the cavity : the
best lymph, equally with the worst, being incapa-
ble of uniting when interposed fluid prevents the
apposition of the opposite surface. Hence it is
that the upper part of the pericardium, where it
is reflected from the great vessels, often adheres
when the lower part does not: and for the same
reason it is that, when the whole of the perito-
neum is covered with lymph, the intestines ad-
here to each other, but their adhesion with the
walls of the abdomen is prevented by the interpo-
sition of fluid.

Hence the immense importance in pericarditis,
of prompt and energetic treatment in the first in-
stance, in order, if resolution cannot be effected,
to cause absorption of the fluid, and thus afford
the opportunity for adhesion. Temporising inde-
cision is inadmissible ; for unless one or other of
these terminations be induced, the patient inevita-
bly dies.

Such is the object of adhesion : we have now
to describe the process. When the fluid has been
sufficiently absorbed, the depositions of lymph on
the opposite surfaces of the pericardium come in
contact, thicken, blend, and gradually become or-
ganized by vessels presenting themselves under
the successive appearances of blood-stains, strag-
gling lines, and, lastly, of uniform pinkish vascu-
larity, susceptible of injection from the pericardium.
The depositions are thus converted into perfect
cellular tissue, by which the contiguous parts are
more or less firmly, closely, and extensively agglu-
tinated. When adhesion is of recent standing,
the lymph is generally thick, and separable by
mere tearing into two layers, one adhering to
each fold of the pericardium. In proportion as
the disease is older, the false membrane is thinner
and firmer, consisting, in cases that date several
years back, of the finest layer of dense cellular
tissue. In some, even this is not perceptible, the
folds of the pericardium having become amalga-
mated — apparently without the intervention of
any membrane, — so as with difficulty to be sepa-
rable, even by the scalpel. It is in such cases
that pathologists have sometimes erroneously sup-
posed the heart to be destitute of a pericardium.

In some rather protracted cases, generally of at
least two or three months' duration, where, though

PERICARDITIS.

497

adhesion has been established, inflammation has
either recurred or never been completely subdued,
an additional interstitial deposition of lymph takes
place, which has been known to thicken the ad-
ventitious mass to the extent of an inch and up-
wards. In this case it sometimes possesses a
laminated texture, the layers of which are pro-
gressively redder in proportion as they are nearer
the heart ; and sometimes it exhibits different de-
grees of consistence in different parts, one being
almost liquid and purulent, while another has the
density of tubercular induration. (Latham, Lond.
Med. Gaz. vol. iii. p. 5.) Such cases are ordina-
rily fatal at no very remote period.

But adhesions are not always universal ; in
rases of partial pericarditis they are restricted to
the portions inflamed ; and when these portions
are limited, the adhesions are not close or inti-
mate ; for as the gliding motion of the heart within
the pericardium is not prevented, it stretches the
adherent lymph, and converts it into long loose
bands of cellular tissue. But when the portions
inflamed are extensive, partial adhesions are some-
times close and firm, and the intervening parts of
the pericardium may be healthy and in contact.
Instances occasionally occur of adhesions being
partial though the inflammation had been uni-
versal ; and the parts not united are overspread
with lymph and separated by purulent fluid, thus
constituting a series of small, detached abscesses
around the heart.

Cases of partial pericarditis (exclusive of white
spots, of which we shall presently speak) are very
rare in proportion to those of general, scarcely
amounting, according to Laennec, to one in ten.
(De l'Auscult. Med. torn. iii. p. 655.) They
almost always terminate in recovery, and the ad-
hesions, if loose and long, seldom lead to enlarge-
ment of the heart.

Partial pericarditis sometimes leaves no other
vestiges than opaque white or milky spots, which
are a well-known appearance on the surface of the
heart. They vary in extent from a few lines to
two or three inches in diameter; their thickness is
about that of the nail : they consist of condensed
cellular tissue, and with a little care they may
generally be detached without injury to the peri-
cardium beneath. This membrane is commonly
somewhat injected, though not thickened.

Sometimes lymph is converted into small,
roundish, soft granulations, like concrete albumen,
with which the pericardium is more or less exten-
sively studded.

3. Fluid effused within the cavity of the Peri-
cardium. — It has been stated that serum is effused
conjointly with lymph, from the vessels of the
inflamed pericardium. This fluid is sometimes
transparent, and either of a faint yellow, more or
less tinged with green, like that of the interior of
i lemon, or of a pale fawn colour ; at other times
it is less transparent, but very seldom milky or
opaque from containing particles, filaments, or
flakes of imperfectly concrete albumen. Its quan-
tity, though variable, is in general considerable at
the commencement, that is, within the first two,
three, or four days of the disease, — not unfre-
quently amounting to more than a pint. Corvi-
sart once found four. It is speedily diminished,

Vol. III.— 63 2r*

however, by absorption, when the first violence
of the inflammation begins to subside ; and after
the lapse of a few days it is, in the majority of
cases, not more abundant than the concomitant
exudation of lymph. Sometimes, indeed, even in
very acute inflammation, the absorption is so com-
plete that no serum whatever is found, while a
copious exudation of thick concrete lymph fills
and agglutinates the whole cavity.

Should complete absorption of both the fluid and
lymph not take place, nor yet adhesion of the peri-
cardium be established, the fluid presently assumes
a very different character. For it is no longer
secreted by the pericardium, but by the lymph
itself, which, when organized, becomes a secreting
surface ; and its secretion, though at first consist-
ing of clear serum, gradually becomes more and
more turbid, milky, and opaque, until it eventually
assumes the character of pus. Rarely, however,
is perfect pus found in the pericardium ; probably
because the patient dies from irritation before the
suppurative process is fully established. Not un-
frequently the fluid is bloody, and the lymph of a
red colour. This is attributable to the tenderness
of all newly organized structures, in consequence
of which they are apt to become congested, and
to effuse blood when subjected to any unusual
irritation or excitement. The excitement in the
present instance most probably consists in inflam-
mation of the adventitious membrane, either re-
newed, or never wholly suspended.

Compression, exercised by fluid, and even by
great accumulations of lymph, sometimes reduces
the volume of the heart, and renders it atrophous.

Such are the anatomical characters of acute pe-
ricarditis, both in its early and its advanced stages.
It remains to make a few remarks on that form
of pericarditis which appears, from the mildness
of the inflammatory symptoms, to have been
chronic from the first. Its anatomical characters
do not differ very materially from those exhibited
by the advanced stages of the acute form. The
inflammation always pervades the whole of the
cavity ; the redness is deeper and duller than in
the acute affection ; the albuminous false mem-
branes are, in many cases, totally deficient, and
when present, they are thin, soft, and fragile, as
if wasted by suppuration : finally, there is always
a more or less abundant effusion of turbid, milky,
and sometimes completely puriform fluid. Inti-
mate adhesions of the pericardium to the heart
may follow the absorption of this fluid ; but M.
Laennec does not appear to be borne out either
by facts or by analogy, when he supposes that
chronic pericarditis alone is the cause of intimate
adhesion, and that the acute affection only gives
rise to loose adhesion by more or less elongated
bands. According to our experience, the latter
is the more frequent cause of intimate adhesion.

The muscular substance of the heart is, in
general, not affected by pericarditis; but sometimes
it is rendered redder or paler, browner or yellower,
harder, softer, or more lacerable, than natural.
These changes result from inflammation propaga-
ted from the pericardium to- the muscular sub
stance. They will be more fully considered in
the article Carditis.

In scrofulous and phthisical individuals, tuber

498

PERICARDITIS.

cles are sometimes developed in the false mem-
branes of pericarditis, and, according to Laennec,
they may cause the acute to pass into the chronic
state, as frequently happens in the case of pleuri-
tic and peritoneal false membranes.

Signs and Diagnosis of Pericarditis.
General signs. — There is no inflammatory
affection of which the diagnosis has been consi-
dered more difficult than pericarditis. Laennec
states that he has often, on dissection, discovered
the disease, in a severe form, when nothing had
afforded a suspicion of its existence ; and, on the
other hand, that he has frequently witnessed all its
signs without finding a vestige of the malady. Dr.
Latham mentions two cases of what appeared to
be, and was treated as, marked inflammation of
the brain ; yet this organ was found perfectly
sound, and the heart affected with intense pericar-
ditis. (Lond. Med. Gaz. vol. iii. p. 209.) Andral
relates a similar case. (Clinique Medicale, vol.
iii. p. 444.) It is proper to keep these difficulties
prominently in view, in order that practitioners
may be better prepared to contend with them.
But it must be added that such cases as those of
Latham and Andral are extremely rare ; and that,
with the improvements in diagnosis introduced by
modern research, the disease may, we feel assured
from numerous post-mortem examinations, be
nearly always detected. We shall first enumerate
the symptoms, and then endeavour to point out
the causes of their obscurity, the means of render-
ing them available, and the diagnosis from other
inflammatory affections.

The symptoms are as follows ; acute inflamma-
tory fever; a pungent, burning, lancinating pain
in the region of the heart, shooting to the left sca-
pula, shoulder, and upper arm, but rarely descend-
ing below the elbow, or even quite to it. The
pain is increased by full inspiration, by stretching
the left side, and especially by pressure between
the precordial ribs, and by forcing the epigastrium
upwards underneath the left hypochondrium.
When the inflammation is only subacute, the pain
is more or less dull, and does not lancinate. The
next symptoms are, inability of lying on the left
side, and sometimes in any position but one, which
is most commonly on the back ; [the writer has
often observed the incapacity of lying on the left
side to be wanting ;] dry cough ; hurried respira-
tion ; palpitation of the heart, the impulse of
which is sometimes violent, bounding and regular,
though its beats may at the same time be unequal
in strength ; at other times it is feeble, fluttering,
and irregular ; pulse always frequent, and gene-
rally, at the onset, full, hard, jerking, and often
with a thrill. Sometimes it maintains these cha-
racters throughout, but more commonly it be-
comes, after a few days, weaker than accords with
the strength of the heart's action, and, in the
worst cases, small, feeble, intermittent, irregular,
and unequal. Occasionally it possesses the latter
characters from the commencement ; whenever
they exist, they are accompanied by dyspnoea ; a
constrained position, deviation from which induces
a feefing of suffocation ; extreme anxiety ; a pecu-
liar drawn or contracted appearance of the features,
occasionally with the sardonic grin ; faintness,
constant jactitation, insupportable distress and
alarm, cold perspiration, and, finally, from obstruc-

tion of the circulation, by intumescence and livid-
ity of the face and extremities.*

One cause of the obscurity of the above symp-
toms would, at first sight, appear to consist in
their diversified, incongruous, and variable nature.
The pulse, for instance, displays, at one time or
other, almost every kind of character; the disease,
though the inflammation be equally intense, is
sometimes very supportable — at others, agonizing;
in one case it terminates fatally in two or three
days, in another it lasts as many weeks.

Now, in reality, these diversities, while they do
not render the symptoms less pathognomonic of
the disease in general, as will presently be shown,
are invaluable indications in another point of
view — they denote the nature and progress of the
anatomical changes of structure, and, in corre-
spondence, the progress and exact state of the
, malady. For it is ascertained by experience that
a difference in the quality and quantity of the effu-
sion imparts a totally different aspect to the symp-
toms. Thus, when, either from the effusion con-
sisting principally of concrete lymph, or from the
J simultaneously secreted scrum being absorbed, uni-
versal adhesion of the pericardium promptly takes
place, preventing all further fluid effusion, the ac-
tion of the heart maintains throughout much the
same vigour and regularity as it manifested at the
onset of the malady, and the pulse exhibits cor-
responding characters of strength, hardness, and
regularity. Under these circumstances, also, the
position is less constrained, and less pain is pro-
duced by an unfavourable one; in consequence,
perhaps, of the heart being curbed by the adhesion,
and thus prevented from impinging with the same
degree of violence against the thoracic walls.
Finally, as the force and rhythm of the heart's
action, and consequently the circulation, are ade-
quately maintained, the life of the patient will be
prolonged probably for weeks, even though the
inflammation remain unsubdued, and he will sink,
at last, apparently from mere exhaustion by the
effects of protracted irritation.

But should there be a copious serous effusion,
the heart's action is mechanically embarrassed by
the compression that the fluid occasions,— a com-
pression which is the more considerable because
the pericardium, deprived of its distensibility by
inflammation, is incapable of yielding as the fluid
accumulates. Hence the organ, unable to trans-
mit its contents, becomes congested : it flutters,
intermits, beats feebly, irregularly and unequally.
The pulse has corresponding characters, and is
sometimes scarcely perceptible. Hence supervene
faintness, dyspnoea, anxiety, coldness, lividity, a
sense of suffocation on the slightest deviation from
a certain position, with all the other symptoms in-
dicative of an obstructed circulation. If this state
be not expeditiously relieved by remedies, the pa-
tient dies in the space of a few days, or even hours.
Should the fluid be copious from the first, this
series of symptoms will make its appearance
equally early ; but in general, two or three days
elapse before the accumulation becomes consid-
erable ; in which case the former series will exist
during this period, and will then be suddenly re-
placed by the latter. In a few instances we have

* We liavc seen extensive cedonia of the feet supervene
during the lust twelve hours of life.

PERICARDITIS.

499

found the latter exist when the quantity of fluid
was inconsiderable, but that of lymph enormous.
We conceive, therefore, that an enormous accu-
mulation of lymph has the same effect as fluid in
embarrassing the action of the heart. We have
also found the worst class of symptoms occasioned
by a less quantity of fluid in some cases than in
others, — a difference which probably depends in
some instances on diversities in the nervous irri-
tability ; but in others we suspect that it is con-
nected with the coexistence of carditis ; for, when
the affection has been thus complicated, we have
known the feeble, fluttering action of the heart
and all its concomitant train of unfavourable
symptoms, occur, though the effusion within the
pericardium was inconsiderable. The peculiar
expression of the features is occasioned by the
sympathy subsisting between the respiratory nerves
of the face and those of the heart.

Such are the causes of the symptoms. It will
now be apparent that their variability is calculated
to enlighten rather than to perplex the practitioner ;
and that, whatever aspect they assume, they would
still be abundantly sufficient, did no other diffi-
culties interfere, to render the disease one of easy
diagnosis. But unfortunately there are other dif-
ficulties. Some of these consist in the absence
or mildness of certain of the most important
symptoms.

When pain in the immediate situation of the
heart, increased by pressure in the interspaces be-
tween the ribs, or upwards under the left hypo-
chondrium, is accompanied by increased action of
the organ and by fever, there can scarcely be a
doubt of the existence of pericarditis. But some-
times, though rarely, pain is totally absent; in
which case the practitioner must carefully employ
pressure, as above directed ; and if, notwithstand-
ing, no pain be felt by the patient, he must care-
fully turn his attention to the remaining symp-
toms. Should the pulse be feeble, faltering, inter-
mittent, unequal, &c, without any apparent ade-
quate cause, (and it is well known to practical
men that such a pulse rarely if ever exists in or-
dinary cases without a discoverable cause,) this
sign,* especially if attended with the usually con-
comitant signs of an obstructed circulation, affords
evidence of the strongest description.

But there may be neither pain nor an unsteady
pulse. In this case, should the action of the heart
be violent, and of a remarkably bounding or jerk-
ing nature, without any manifest cause, — especi-
ally organic disease of the organ ; and should it
be accompanied by a greater degree of fever and
anxiety than can be accounted for by any other
existing complaint ; finally, should it be attended
with the stethoscopic signs presently to be de-
scribed, the physician will seldom be wrong in
diagnosticating pericarditis. The presumption is
still stronger if, when the symptoms supervene, the
patient is affected with acute or subacute rheuma-
tism, — an affection which, whether severe or mild,
whether in its early or its later stages, is beyond
comparison the most frequent cause of pericarditis.

It was an opinion of Corvisart that the most
acute cases were the most obscure, because, says

•On it alone we have seen M. Chomel found a suc-
cessful diagnosis in tlie last stage of a typhus fever,
when the symptoms were extremely Comdex.

he, "the attack is abrupt, the progress rapid and
the termination always sudden." This obscurity
was felt by that acute observer because he was not
acquainted with any signs of the disease on which
he could depend but the feeble, unsteady pulse
the anxiety, dyspnoea, lividity, and other symptoms
dependent on obstruction of the circulation, —
symptoms which did not always show themselves
early enough to afford him data for the diagnosis
before the case was hopeless. At present, how-
ever, when we are in possession of so many signs,
the same obscurity does not exist. We have sel-
dom experienced, nor have we seen other physi-
cians experience, much difficulty in recognising
the acute pericarditis to which Corvisart refers.
The most obscure cases are those mentioned by
Latham and Andral, in which an inflammation of
the brain or any other organ diverts the attention
from the heart, and the delirium of the patient
renders it impossible to obtain information from
himself. Still, when apprised that such cases
exist, we should think it perhaps not impossible to
provide against them. If, for instance, it were the
general practice, (one which we invariably pursue,)
to place the hand on the precordial region as well
as on the pulse in every severe inflammatory or
febrile affection, in the same way that we daily
feel the abdomen in cases of fever, even though
the patient make no complaint of it, we should
seldom fail to find an inordinately increased im-
pulse or some other anomaly in the action of the
heart, which would lead us to make a regular and
probably successful investigation for pericarditis.
For there can be little doubt that the symptoms in
the cases alluded to, are in reality not absent but
merely masked by others of predominant severity.
Such an investigation is especially necessary in
young children, who cannot explain their sensa-
tions, and seldom give indications of the existence
even of acute pain.

The only remaining cause of obscurity is, in-
flammation of some of the thoracic viscera, parti-
cularly the pleura, the pain of which may be seated
over the heart. Pleurisy may be detected by aego-
phony, extensive dulness on percussion, and di-
minished or absent respiratory murmur. Peri-
pneumony may, in addition to its ordinary symp-
toms, be recognised by the crepitous rhonchus,
deficient respitatory murmur, and dulness on per-
cussion ; finally, bronchitis may be known by the
mucous, sibilous, and sonorous rhonchi. Should
none of these signs be present, the negative evi-
dence thus obtained fixes the disease on the heart;
but should they be present, the diagnosis of the
pericarditis must be made by a general comparison
and cautious consideration of all the symptoms.
In this case, should the affection of the heart be
overlooked, the error is not one of the most serious
kind, as the treatment for pleuritis or peripneu-
mony is well adapted for pericarditis.

In a disease the treatment of which requires so
much decision and promptitude in the practitioner
as pericarditis, it is necessary for him to be thor-
oughly conversant, not only with the symptoms
of deterioration, but also with those of ameliora-
tion. To these, therefore, we shall advert before
proceeding to the physical signs.

If the worst symptoms decline, namely, the
feeble, fluttering, unsteady pulse, the feeling of

500

PERICARDITIS.

faintness and suffocation, and the constrained posi-
tion to which that feeling confines the patient, we
may be tolerably sure that the fluid, on which
these symptoms commonly depend, is decreasing
by absorption. But, notwithstanding, should pain,
violent impulse, fever, and anxiety continue, the
inflammation is in progress, and is adding to the
accumulation of lymph, if not also of fluid. Should,
however, the pain, instead of being fixed and
pungent, become a diffuse uneasiness ; should the
anxiety decrease, and the peculiar vehemence of
the heart's action gradually degenerate into the
beat of a merely accelerated circulation, the in-
flammation may be presumed to be on the decline ;
but it is not until all these symptoms have com-
pletely ceased that it can safely be said to have
terminated.

Still, lymph and adhesion of the pericardium
may remain, rendering the reparation imperfect ;
and such we may consider to be the case so long
as, with every advantage of perfect tranquillity and
abstinence, the motions and sounds of the heart
do not completely regain their natural standard.
Even though this be regained, nothing is more
common than a recurrence of palpitation and other
symptoms of diseased heart when the patient re-
sumes his accustomed avocations. It is not, there-
fore, until, very gradually returning to corporeal
exercise, he finds himself, after an adequate trial,
perfectly capable of his wonted exertions, that the
cure can be pronounced complete.*

Physical Signs. — The impulse of the heart is
greatly increased, — not only heaving the thoracic
walls vigorously, but being remarkable for its ab-
rupt or jerking character ; whence it often shakes
the whole anterior chest. Some beats are gene-
rally stronger than others, even when the action
is regular. The pulse or rather throb of the arte-
ries, often perceptible over the whole body, is of a
corresponding nature, each undulation of the blood
shooting with instantaneous velocity under the
finger, as if through a lax or imperfectly filled
tube, and constituting what is called a bounding,
or, more expressively, a jerking pulse, — the pulse
that we feel during reaction after uterine or other
excessive hemorrhage. Very frequently it is ac-
companied with a distinct thrill. Sometimes it is
stronger and more voluminous, at others smaller
and weaker ; yet in the latter case it still retains
the same jerking character.

When the action of the heart becomes feeble
and faltering, the impulse of the organ of course
sustains a corresponding change ; but, notwith-
standing, the jerk accompanies any isolated con-
traction that happens to be strong.

An impulse and pulse of the jerking description
denote an inordinately abrupt, and as it were spas-
modic contraction of the heart, probably attributa-
ble to an increase of irritability resulting from the
inflammation. It is this peculiarity in the beat
which distinguishes it from the beat of a merely
accelerated circulation, a distinction perfectly fami-
liar to practical men. The peculiarity subsists not
only during the continuance of inflammation, but
so long as the action of the heart remains quick

* See an excellent paper by Dr. Latham, Lond. Med.
Gaz. vol. iii. p. 213, to whom the profession in general,
and ourselves in particular, are greatly indebted for his
researches on this subject.

after the inflammation has apparently subsided,—
a period which generally occupies several weeks,
and, if adhesion of the pericardium has taken
place, frequently as many months. We have
known it exceed half a year. In very protracted
cases it is probable that the irritability of the heart
is kept up either by an occasional recurrence of
inflammatory action, or by the unnatural circum-
stances in which the organ is placed by adhesion
or, finally, by a softened state of the muscular
substance, the result of carditis.

The Sounds. — The sound of the ventricular
systole is not unusually sonorous, but is accompa-
nied with a bellows-murmur. This sign was first
noticed by Dr. Latham, who pointed it out to us
at St. Bartholomew's Hospital in 1826. Since
that time we have never found it absent when the
heart presented the increased jerking impulse
above described. Dr. Latham restricts his obser-
vation to rheumatic pericarditis: to ourselves the
phenomenon has appeared to exist equally in
every form of the disease. When the action of
the heart has been feeble and faltering, we have
found the murmur absent ; but when, in the same
case, the action has, either previously or subse-
quently, been strong and jerking, the murmur has
existed. The reason of this will be obvious from
the explanation which will presently be offered.
The murmur sometimes continues after the heart
appears to have resumed its natural action and the
patient to be well ; but so long as it remains, as
remarked by Dr. Latham, (Lond. Med. Gaz. vol.
iii. p. 214) « his return to the habits and exertions
of health will bring back palpitation and other
symptoms, which bespeak the certainty of mis-
chief still abiding in the heart.

Not the ventricular systole only, but occasion-
ally, though by no means always, its diastole like-
wise is attended with the bellows-murmur ; and
we have found this supersede and as it were anni-
hilate the natural second sound more completely
in pericarditis, than, we think, in any other affec-
tion of the heart. Sometimes, in short, it is a
pure whizzing, as prolonged as, and almost con-
tinued into, the first sound. Three cases at pre-
sent under our care present this character.

What is the proximate cause, and what the
mechanism of these preternatural murmurs 1 That
of the ventricular systole we are inclined to attri-
bute, mainly at least, to the increased velocity
with which the blood is propelled in consequent
of the morbidly abrupt contraction of the heart,—
an explanation which appears to us to be ren-
dered probable by the following considerations:
1. by repeated abstractions of blood, in animals,
at intervals of a day or two, we have produced at
pleasure, the rapid, throbbing, jerking, and thrill-
ing action of the heart and arteries, and, in strict
concomitance with it, the bellows-murmur; 2.
the murmur takes place in nervous palpitation
when the action of the heart and arteries is of the
nature described ; 3. the loudness of the murmur
observes a very accurate ratio to the violence of
the throbbing, and it subsides when the throbbing
ceases, unless there remain an organic lesion, pre-
sently to be described, which generates it on a
different principle.

But though we attribute the murmur of the
ventricular systole mainly to the cause described,

PERICARDITIS.

501

we believe that it may, in some instances, origi-
nate partly in another cause ; namely, constriction
of the arterial orifices consequent on inflammation
of the lining membrane. For, as this membrane
is more liable to inflammation where it constitutes
the valves than elsewhere, it is consistent with
analogy to suppose that, by its intumescence and
loss of elasticity, the orifices will undergo the con-
striction alluded to.

The murmur accompanying the second sound
we are inclined to attribute perhaps entirely to
the same constriction, affecting the auriculo-ven-
tricular orifices. This we infer, because we have
not found it produced in any appreciable degree
by abrupt, jerking action of the heart in reaction
from loss of blood, and in nervous palpitation ;
and because, when we have noticed it in pericar-
ditis, we have invariably found it connected with
a more or less thickened and opaque state of the
valves — a state which, though perhaps scarcely
amounting in every instance to an obstruction
when it was examined in the dead subject, gives
sufficient reason to believe that it might have con-
stituted one during the period of acute inflamma-
tion. Should this be found true, the bellows
murmur of the second sound renders the prognosis
more gloomy, as it bespeaks a more extensive in-
flammation, and the probability of subsequent
valvular disease.

[It may admit of question, whether the bellows
sound accompanying the contraction or dilatation
or both is ever present in simple pericarditis. It
probably, in all cases, indicates the co-existence
of inflammation of the endocardium, — endoperi-
carditis.

The first effect of inflammation of a serous mem-
brane is to diminish, or totally arrest the secretion
that takes place from it in health, — hence the
sound of rubbing of two dry surfaces upon each
other is an evidence of the early stage of pericar-
ditis. A similar sound may, however, be pro-
duced by the friction of plastic lymph, which is
often copiously exuded after the inflammation has
continued for a time. This friction sound is
equally heard during the contraction and dilatation
of the ventricles, and has been termed the to-and-
fro sound. This sound has been compared to the
rustling of taffetas, bank-note paper, or parchment.
When the effusion is considerable, — in addition
to extensive dulness on percussion, the sounds of
the heart seem to be distant, and, consequently,
obscure. This secretion takes place at an early
period of the disease, and is occasionally very
considerable ; the quantity of serum effused in the
first three or four days amounting, at times, to
ten or fifteen ounces. When the disease termi-
nates in health, this is gradually absorbed. Occa-
sionally, there is an evident tremour over the car-
diac region.

Air, it is said, has been found along with the
albuminous secretion, but thismust be a rare oc-
currence. Where it exists alone — pneumo-pcri-
carditis — it is said to be indicated by remarkable
resonance on percussing the region of the heart,
— a resonance, which is much greater than when
a portion of emphysematous lung is between the
chest and the heart. When air is associated with
effused fluid, it may be detected by the sound of

splashing or of fluctuation heard when the chest
is shaken.]

Percussion. — When the pericardium contains
much fluid, the resonance of the precordial region
becomes dull over a greater extent than natural.
The impulse, also, it may be added, is undulatory,
and not exactly coincident with the first sound,
in consequence of the heart having to displace the
fluid interposed between it and the thoracic walls,
before it can impinge against the latter. (See
HrDiiopERicAnnitTM.) M. Louis states that he
has found a temporary effusion of fluid cause a
prominence of the cardiac region. We do not
happen to have noticed this, but we think it very
probable, especially in young subjects, in whom
the cartilages are soft.

Signs and Diagnosis of Chronic Pericar-
ditis.

General signs. — The signs of chronic pericar-
ditis are much the same as those of acute, but in
a very inferior degree. The fever is more that of
hectic or rnarcor, with occasional exacerbation,
when perhaps the inflammation becomes subacute.
The anxiety and restlessness, though sometimes
great, are comparatively supportable. The posi-
tion is less constrained, and we have observed
that the patient often prefers the sitting posture
with the body inclined forwards. The circulation
is less embarrassed, and the action of the heart,
though often abrupt and jerking, is usually some-
what feeble, except during any temporary exacer-
bation of inflammatory action. The pulse, also,
is sometimes not very unsteady though the peri-
cardium be full of fluid ; which we attribute to the
; elasticity of the membrane not being so far de-
i stroyed by the inflammation as to prevent it from
j gradually undergoing extension, and accommo-
dating itself to its contents, whence compression
of the heart by the fluid is in some degree obvi-
ated. The patient, we have thought, more fre-
quently complains of a load and fulness, " some-
thing which he cannot get down," in the scrobi-
culus cordis, in chronic than in acute pericarditis.

Chronic pericarditis, especially if such from its
commencement, is more obscure than acute. We
have, in former years, seen it overlooked more than
once. But these cases, when we now revert to
them, appear to us to have presented sufficiently
characteristic symptoms. The history affords the
greatest light. If the patient, previously exempt
from disease of the heart, has suddenly become
affected with its symptoms, attended by rnarcor
and some degree of fever, within a period seldom
extending beyond a few months, and which he
often dates from a blow or fall on the breast, a
rheumatic fever, or an inflammation with pain in
the precordial region, chronic pericarditis may
be strongly presumed; and if these symptoms
coincide with the physical signs of fluid in the
pericardium, the existence of the malady may be
regarded as almost certain.

Physical signs. — The impulse and pulse have
much the same general characters as in acute peri-
carditis, except that, as the heart's action is less
vigorous, they are not so strong.* The signs of

* Thfl sounds will vary according to circumstances.
When the action of the heart is jerking, and not wholly
devoid of force, the first sound will be attended with a
murmur, u hicb, however, is generally very slight. Whca

502

PERICARDITIS,

fluid tn the pericardium are the same ; namely, the
extensive dulness on percussion and the undula-
tory impulse.

Causes, Prognosis, and Treatment of Pericar-
ditis.

Causes of Pericarditis. — The most frequent
causes are blows or excessive pressure on the
precordial region, inflammation propagated from
the lungs or pleura, and, far above all, rheuma-
tism. From this cause, children and young per-
sons suffer much oftener than others. The re-
maining causes are those of inflammation in
general, viz. cold, febrile excitement, &c.

[The disease may affect the fcetus in utero. In
children that have died in less than forty-eight
hours after birth, adhesions have been found be-
tween the pericardium and heart so strong as to
lead to the belief that the disease had existed for
some time prior to birth.]

Prognosis. — This disease, supposed by Cor-
visart to be necessarily fatal, has, by subsequent
experience, been proved curable, — and completely
curable ; but as the possibility of effecting a com-
plete cure is limited to a very brief period, and as,
unless it be complete, the patient almost inevitably
dies sooner or later from the consequences, the
disease must be regarded as one of the most for-
midable incident to the human race. Some of
these consequences we shall describe in the next
section under the head of adhesion of the peri-
cardium.

Treatment of acute Pericarditis. — The
antiphlogistic treatment, in as energetic a form as
circumstances will allow, should be employed with
the utmost promptitude. The loss of a few hours
at first may be irretrievable ; and hence hesitation
and indecision may seal the fate of the patient.
If the attack be recent, and the patient's strength
will admit, blood should in the first place be drawn
freely and by a large incision from the arm, so as
to bring him to the verge of syncope. From
five-and-twenty to forty leeches, according to the
strength, should then be applied to the praecordial
region, so soon as the faintness from the venesec-
tion disappears, and reaction commences, which
generally happens in the course of from ten min-
utes to an hour or two. Unless the pain be com-
pletely subdued by these measures, the leeching
may be repeated two, three, or more times, accord-
ing to the strength, at intervals of from eight to
twelve hours ; or, what is a better rule, so soon
as the pulse and action of the heart denote a re-
commencement of reaction.

It is not, however, in every case that so active
a treatment is required : we have seen a single
prompt and abundant application of leeches, or a
cupping, at once subdue every formidable symp-
tom. When the patient, either from age, a feeble
constitution, or the advanced state of the malady,
cannot bear extensive depletion, local bleeding is,
according to our observation, decidedly preferable
to general ; but it should be practised effectually,
by cupping to twenty ounces or more, or by the

there is inflammatory constriction of the orifices, a mur-
mur will attend both sounds. Should the heart be di-
lated, as is frequently the case, the sounds will be in-
creased; and should hypertrophy be conjoined with the
dilatation, the impulse will sustain a corresponding aug-
mentation of force

application of from twenty-five to thirty or forty
leeches. When, from depletion having already
been carried to a great extent, or from the ad-
vanced stage of the disease, it is not safe to draw
much more blood, yet it appears expedient from
the persistence of pain, &c. to draw some, we have
generally found that a smaller quantity drawn by
cupping, produced more effect than a larger by
leeching. The cause of this probably is, that by
cupping it is drawn more expeditiously.

[Of late years it has been strenuously advised
to bleed largely and repeatedly ; and M. Bouillaud
(Nouvelles Recherches sur le Rheumatisme arti-
culaire aigtt en general, &c. &c, 2d edit. Paris,
1830,) asserts, that he has, by this plan, rarely
failed to cut short the disease, when he has been
called early. He generally bleeds three or four
times from the arm, to the amount of sixteen
ounces each time, within the first three or four
days, and employs leeching and cupping very
freely. It is certainly good treatment to endea-
vour " to strangle" the inflammation at the onset
by bloodletting ; but if it should not succeed, when
aided by the agents mentioned below, no time
should be lost in having recourse to mercurial and
other revellents. The safest course — even should
the pulse be irregular and feeble, and the signs of
general debility considerable — is to bleed, if the
disease has been of short duration ; but, on the
other hand, as the writer has remarked elsewhere,
(Practice of Medicine, 2d edit. i. 466,) the
cupped and buffy appearance of the blood must
not induce the practitioner to push the lancet too
freely ; for this, especially where the disease has
a rheumatic origin, will commonly continue in
spite of the bloodletting ; and, it is affirmed, will
even augment under its use.]

While the bleeding is in progress, other means
should not be neglected. The intestinal canal, if
at all confined, should immediately be evacuated
by a purgative enema. Three drachms of senna
leaves, and an ounce of sulphate of soda infused
in a pint of boiling water and strained, answers
the purpose. At the same time, five grains of
calomel with five or ten of comp. extr. of colo-
cynth, and two or three of extr. of hyoscyamus,
should be given, and in two hours be followed by
a senna draught.

The strength of the remedies employed must
in each case be apportioned to the vigour of the
patient's constitution ; but the object is the same
in all — expeditiously to prostrate the action of
the heart, and for a time to keep it prostrate by
preventing the re-establishment of reaction. If
this object can be accomplished for the first twenty,
thirty, or forty hours, the disease frequently does
not rally, but remains perfectly under the control
of remedies. We feel satisfied that a degree of
activity in the first instance, which to some may
appear excessive, is an ultimate source of economy
to the strength of the patient ; for the disease is
subdued at once, and the protracted continuance
of depletory measures, the most exhausting to the
constitution, is rendered unnecessary.

In addition to the above measures, diluent
cooling drinks, as four scruples of supcrtartrate,
or two of nitrate of potass in a quart of water.
and flavoured at pleasure, should be allowed m
unlimited quantity, in order, by diluting the blood

PERICARDITIS.

503

to render it less stimulant to the heart. Nausea-
ting doses of tartrate of antimony, as one-sixth
to one-eighth of a grain, every two hours, may be
employed with advantage. [Or it may be given
in contra-stimulant doses from 12 to 24 grains in
the day, in divided doses, where the necessary
tolerance exists. Colchicum often proves useful,
and it has often been thought especially so when
the disease is of rheumatic origin.] The diet
should consist wholly of the weakest slops, as
barley-water, gruel, weak tea, arrow-root, &c.

But the antiphlogistic treatment alone is not to
be relied upon : rarely, if ever, does it, in a severe
case, effect a complete cure. The practitioner
sees all his resources gradually exhausted, while
the disease proceeds with an even, uncontrolled
tenor to its fatal termination. Sometimes, indeed,
all the other symptoms disappear, but the action
of the heart remains stronger than natural ; at
other times the heart even regains its healthy
action, and the cure appears complete : yet in
both these cases the palpitation, accompanied with
symptoms of organic disease of the heart, recurs
when the patient resumes his accustomed occupa-
tions. The reason of this is very intelligible.
Unless the effused lymph, as well as the serum,
be absorbed, it causes an adhesion of the pericar-
dium, and thus establishes destructive disease.
Now antiphlogistic measures can neither prevent
the effusion of lymph, nor with any degree of
certainty cause its absorption. Mercury can do
this, as is visibly displayed in iritis ; mercury,
therefore, is the sheet-anchor of the practitioner.
Dr. Latham is of opinion that its success is re-
stricted to the condition of its producing salivation
rapidly. From many observations we are satisfied
of the general truth of this remark, and would
therefore give the remedy on this principle ; but
we have seen cases in which cures, not falsified
after many months, were effected, though saliva-
tion was not produced. The mineral, however,
was freely administered, and probably produced
its specific effect, though not in an apparent man-
ner. From five to eight grains of calomel, or
from ten to fifteen of blue pill, prevented from
purging by a grain or a grain and a half of opium,
three times a day, commencing after the first
bleeding and a purgative, generally produce the
effect with sufficient expedition. Inunction may
be superadded or partially substituted, if mercury,
taken internally, disagree. A manifest abatement
of the symptoms generally takes place immedi-
ately on the effect of the remedy becoming appa-
rent in the mouth, especially if a free salivation
is established within the first thirty or forty hours.
It should be maintained for a week or ten days, or
even longer, unless the symptoms completely
yield before the expiration of this period.

Should pain continue in the advanced stages
of the malady, and after the period for applying
leeches has passed, blisters may be resorted to,
and repeated in quick succession, with great ad-
vantage. I have occasionally found a third or a
fourth necessary before the pain has been com-
pletely removed. In the repetition of blisters, as
well as ot leeches, cupping, and venesection ; and
in the selection of one of these remedies in pre-
ference to another, much must necessarily be left
to the judgment of the practitioner. It is only

experience which can teach the exact adaptation
of remedies to the circumstances. It must also
be left to his discretion whether to give sedatives
or not. When the restlessness and nervous irri-
tability were great, we have seen much benefit
derived from tinct. hyoscyami, mxv. ad xx. with
the same quantity of tinct. digitalis, in a draught
three or four times a day. Sedative remedies,
however, should not be given until the first seve-
rity of the inflammation has subsided ; nor should
they ever be allowed, by producing their poisonous
effects, to confuse the symptoms, already suffi-
ciently complex, in the latter stages.

During convalescence it is sufficient to say that
a very spare unstimulating diet and extreme tran-
quillity must be imperatively enjoined, until the
action of the heart has become perfectly and per-
manently natural.

An individual who has recently been affected
with pericarditis is peculiarly liable to a recurrence
of it, especially if it has resulted from rheumatism,
and if the reparation has been incomplete. In
this case, should rheumatism return, it rarely fails
to be accompanied with a renovation of the peri-
carditic symptoms.

This cannot be a subject of surprise ; for it is
consistent with general analogy that a part re-
cently injured by inflammation is more susceptible
than a healthy tissue of inflammatory action ; the
reason of which probably is, that the vessels of
newly organized adventitious structures are more
tender and irritable than others. Secondary in-
flammation, however, has not the same energy
and intensity as that of a healthy structure ; it
yields more promptly to curative measures, and is
more completely within the powers of medicine.
Hence a first attack of pericarditis is more dan-
gerous than any subsequent one. It is compara-
tively rare for a patient to die from the direct
effect of a recurrent attack ; and, what is still
more remarkable, he may sustain several without
being left in a materially worse condition than
after the first.

Much discretion, however, is requisite on the
part of the practitioner to bring such recurrent
attacks to a favourable termination ; and the dan-
ger of doing too much is, perhaps, greater than
that of doing too little. He must, in particular,
be cautious of bleeding too extensively, with the
object of reducing the excessive energy of the
heart's action ; for this energy, he must recollect,
is a consequence not of the inflammation only,
but partly also of an organic affection of the organ
left by the primary attack. Nor is there the same
motive for a vigorous employment of mercury ;
for the heart being already irreparably disorganized,
it would be chimerical to entertain the expectation
of effecting a perfect cure. The object, therefore,
should be simply to prevent deterioration by com-
bating the inflammation as it presents itself.

For the accomplishment of this object, a mode-
rate use of bloodletting and mercury suffices; and
leeching or cupping on the precordial region is
more efficacious and less exhausting than vene-
section. Blisters are, in these cases, peculiarly
beneficial ; and they may be repeated in quick
succession as often as they are required and can
be borne. When there still remains a little lin-
gering pain, which scarcely authorises vigorous

504

PERICARDITIS.

measures, but cannot prudently be left, tbe most
valuable and convenient remedy has appeared to
us to be, a plaster composed of a scruple of tartrate
of antimony, five scruples of the emplast. picis
comp. and one scruple of wax to diminish the
tenacity of the adhesion.

In these cases, also, where the sufferings of the
patient, though perhaps not severe, are very pro-
tracted, and accompanied with much loss of rest,
great advantage is derived from a pill of from
three to six grains of extr. of hyoscyamus at bed-
time, and moderate doses of tincture of digitalis
during the day, the specific poisonous effect of
the latter remedy being obviated by omitting it for
a couple of days after every three or four.

Treatment of Chronic Pericarditis. —
When pericarditis is essentially chronic, and the
cavity appears to contain fluid, counter-irritant
remedies are the most suitable. After what has
already been said, it will be sufficient merely to
mention blisters, either in succession or kept open
with savine cerate, the tartrate of antimony and
pitch plaster, and likewise issues and setons.
The last remedy, however, generally creates so
much irritation as to do more injury by deterio-
rating the general health, than good by its local
effect. Mercury to a moderate extent may, if
discreetly employed, be advantageous by promot-
ing absorption ; but in general the patient is too
much reduced by constitutional irritation to admit
of more than the mildest action of this remedy.

The diet may in chronic cases be more nutri-
tious, comprising light animal food and broths.

II. Cahditis. — Inflammation of the muscular
substance of the heart may be, 1. universal, 2.
partial.

1. Of universal carditis, with effusion of pus
generally throughout the muscular tissue, there is
not to our knowledge more than a single instance
on record, and that occurred to Dr. Latham.
" The whole heait," says he, "was deeply tinged
with dark-coloured blood, and its substance soft-
ened ; and here and there upon the section of both
ventricles, innumerable small points of pus oozed
from among the muscular fibres. This was the
result of a most rapid and acute inflammation, in
which death took place after an illness of only
two days." (Lond. Med. Gaz., vol. iii. p. 118.)
Laennec, never having met with or heard of a
case of this kind, and considering an effusion of
pus the only unquestionable sign of carditis, says,
" there does not perhaps exist a single incontes-
table and well-described example of general in-
flammation of the heart, either acute or chronic."
(De 1'Auscult. t. ii. p. 554.) Independent of the
above instance, however, there are probably many
others, which, though not attended with effusion
of pus, will come under the denomination of uni-
versal carditis ; for few will concur with this dis-
tinguished writer in excluding from the proofs of
carditis softening and induration, with increased
or diminished colour of the organ. These are
results of inflammation in other muscles, and
analogy points out that they have the same origin
in the heart. Further evidence is derived from
the fact that, in cases of pericarditis, the charac-
ters in question sometimes occupy only a certain
depth of the exterior surface of the organ, whence
the presumption is almost positive that they ori-

ginate in an extension of the inflammation from
the pericardium. The cases of this description
that are on record, are too numerous to be quoted.
Several have fallen under our own observation.
In this point of view, then, general carditis is not
very rare.

As softening and induration are of sufficient
importance to demand separate articles, we refer
the reader to them for all that remains to be said
on general carditis.

We have already stated, when treating of peri,
carditis, that this affection is greatly aggravated
by the coexistence of carditis. As the treatment
of the two is the same, it is unnecessary here to
enlarge on it.

2. Partial carditis, characterized by the exist-
ence of an abscess or ulceration in the walls of
the heart, is not very uncommon. Bonetus, in
his Sepulchretum, has described a considerable
number of cases. Abscesses are more rare than
ulcers. The latter occur both on the external and
the internal surface of the heart, and are conse-
quent sometimes on inflammation of the mem-
branes of those surfaces, and sometimes on steato-
matous deposition in the cellular tissue beneath
the lining membrane. The external ulcer is
uncommon, but Olilus Borrichus, Peyer, and
Graetz have left perfect descriptions of it. The
first says, " Cordis exterior caro, profunde exesa,
in lacinias et villos cameos putrescentes abierat."
The internal ulcer is more common. Bonetus,
Morgagni and Senac present many cases. We
have met with two or three.

An ulcer, whether external or internal, may
perforate the heart.

The signs of abscesses and ulcers vary in dif-
ferent subjects, and are not distinguishable from
those of other affections. "I know not," says
Laennec, "if auscultation will afford any more
sure signs, and I avow that I think not" (De
1'Auscult. t. ii. p. 664.)

Ulceration is the most frequent cause of rup-
ture of the heart, — fortunately a very rare occur-
rence.

The existence of gangrene of the heart has
never been distinctly proved, and the following
reasons lead to the belief that its occurrence is
perhaps impossible : first, the muscular tissue is
one of those least susceptible of it ; and, secondly,
inflammation of the heart sufficiently intense to
occasion it, is fatal to the patient before gangrene
can take place. The cases on record of reputed
gangrene, appear to have been nothing more than
softening, which incipient putrefaction had ren-
dered more analogous to gangrene.

Adhesion of the Pericardium* — Pericar-
ditis, both acute and chronic, and especially that
originating in rheumatism, frequently terminates
in adhesion of the pericardium. Lancisi, Vieus-
sens, Meckel, Senac, and Corvisart, are of opinion
that, with a complete and intimate adhesion, the
patient cannot live in a state of health. We
know not how it is that Laennec and Bertin have
formed an opposite opinion. The former states
that he had opened a great number of subjects so
affected, who had never complained of any de-
rangement in the circulation or respiration;
whence he infers that adhesion often does not in
any respect interfere with the exercise of those

PERICARDITIS — PERITONITIS.

505

functions. Our experience is entirely opposed to
this doctrine. The complaints of the patient are,
perhaps, not a just criterion, for we have often
found the*working classes disclaim dyspnoea when
labouring under enormous hypertrophy and dila-
tation, and when that symptom obviously existed
in a great degree. Many others, also, especially
children, are naturally inattentive to their own
sensations, and close interrogation is the only
mode of ascertaining that after the attack of peri-
carditis they became incapable of some exercises,
habits, or efforts, which they previously accom-
plished with facility.

We have never examined a case of complete
adhesion of the pericardium without finding en-
largement of the heart, — generally hypertrophy
with dilatation. We have observed that cases of
adhesion terminating in enlargement often hurry
to their fatal conclusion with more rapidity than
almost any other organic affection of the heart ;
and we have, on the other hand, repeatedly seen
patients die from the consequences of an adhe-
sion, the history of which we could trace back,
eight, ten, or more years ; yet such individuals
would not unfrequently represent their health to
have been perfect during the greater part of that
period, and would not admit, until closely interro-
gated, that they had been more or less " short-
winded." Hence we infer that, though adhesion
may not for a time create much inconvenience, its
effects are ultimately fatal. This refers, of course,
to intimate, not to loose adhesion. It appears to
us that a tranquil, abstemious life, by which in
other forms of organic diseases of the heart ex-
istence may sometimes be prolonged to its natural
period, cannot be equally availing here; for as the
action of the organ itself is a constant struggle,
repose is impossible.

How adhesion occasions hypertrophy is easily
understood ; for the organ must increase its con-
tractile energy, in order to contend against the
obstacle which the adhesion, by shackling its
movements, presents to the due discharge of its
function, and, as explained in the article Htpeh-
tropht, increased action leads to increase of
nutrition. The cause of the coexistent dilatation
is not less manifest ; as the shackled organ trans-
mits its contents with difficulty, in a state of
greater congestion than natural, and, as is more
fully explained in the article on dilatation, perma-
nent distension is the most effective cause of this
affection. When the muscular substance is soft-
ened, as frequently happens, dilatation takes place
much more readily, in consequence of the defi-
cient elasticity or tone of the heart's parietes.

When adhesion of the pericardium has pro-
duced hypertrophy with dilatation, its history
identifies itself with that of the latter maladies,
of which it renders the symptoms more severe
and the progress more rapid. To avoid repetition,
therefore, we refer the reader to the article Hi-
pibtbopht, and shall, here, only describe the
signs which are pathognomonic of adhesion.

These signs have generally been considered
very obscure. Dr. Sanders believed that he had
discovered one of a positive nature in a dimple or
retraction taking place, as he states, during the
ventricular systole, in the epigastrium immediately
below the left false ribs. We have searched for

Vol. III. — 64 2 s

this attentively in several cases of adhesion, hut
have not been able to detect it in any degree
which could constitute a sign. Laennec, who
was equally unsuccessful, thinks that it could not
take place unless the stomach, by adhering both
to the diaphragm and the abdominal parietes,
formed the medium of retraction.

In five or six cases we have remarked one sign,
which has not, to our knowledge, been hitherto
noticed ; namely, the heart, though enlarged, beats
as high in the chest as natural, and sometimes
occasions a prominence of the cartilages of the
left precordial ribs. We should, indeed, natu-
rally expect that the adhesion would brace up the
organ, and that, when enlarged and not able to
descend, it must, being bounded behind by the
spine, force the walls of the precordial region
forward.

Another sign, and perhaps the most character-
istic of all, is an abrupt, jogging, or tumbling
motion of the heart, very perceptible in the pre-
cordial region with the cylinder. It is more dis-
tinct when the heart is hypertrophous and dilated ;
and under these circumstances we have found the
jogs correspond with the ventricular systole and
diastole respectively, that of the diastole being
sometimes nearly as strong as the other, and
having the character of a receding motion. This
jogging motion is distinguished from the undu-
latory movement of fluid in the pericardium, both
by its nature, by the synchronism of the jogs
with the sounds, and by the feeling that the heart
at each systole comes in immediate contact with
the thoracic walls.

A third sign consists in a bellows-murmur
with the first sound, which we have always found
present when the heart is enlarged and acting
vigorously. Nor is it, in every case, confined to
the heart: we have often heard it in the aorta,
and formerly experienced difficulty in discrimi-
nating it from the murmur of dilatation of this
vessel. (Vide Treatise, by Dr. Hope, p. 63.)
Although, when the heart is dilated, the murmur
in question may be occasioned partly by the rela-
tive smallness of the orifices, and the greater
angles at which the currents meet in them in
consequence of the unusually rounded form of
the ventricles, as elsewhere explained, it is also,
we believe, occasioned in a great measure by the
sudden velocity with which the fluid is propelled,
as it would not otherwise exist in the aorta.

J. Hope.

PERICARDIUM, DROPSY OF. See Hr

DROPEBICAHDIUM.

PERITONITIS, from ntpirCvuov, peritonaeum
— This is the term now universally used to ex
press an inflammatory state of the serous mem-
brane which lines the interior of the abdominal
cavity, and invests all the viscera contained
therein.

Pain, tumefaction, and tenderness of the abdo-
men on pressure, are the most prominent symp-
toms which characterize this affection during life;
and increased vascularity, thickening, effusions of
coagulable lymph, of serum, of pus, or blood, are
the principal local effects produced by it. These
elementary features, accompanied in general with
more or less of pyrexia, will exist in different de»

506

PERITONITIS.

grees and combinations, in every variety of age,
sex, or constitution, modified, however, by circum-
stances derived partly from the nature of the
cause, and partly from the condition of the patient
at the time of the attack.

Peritonitis may assume either the acute or chro-
nic form. It may exist as a sporadic disease, or
prevail as an epidemic. It may either present
itself openly, with a numerous group of well-
marked symptoms, or creep on in a latent state,
with scarcely one of its characteristic features. It
may be limited in its extent to a small portion of
membrane, or spread over a large surface. It may
run its course uncombined with any other affec-
tion, or be complicated with various diseases.
There is no period of life exempt from its attacks.
It may affect the infant, the adult, and the puer-
peral female : pursuing the same course, and ex-
hibiting similar effects in all, it yet presents a vast
variety of symptoms in individual cases, princi-
pally according to the organ whose peritoneal
covering is the chief seat of the inflammation.

Pure peritonitis is exclusively confined to the
peritoneum, without involving the muscular or
mucous tissues of the intestines, and can in most
cases be distinguished by peculiar symptoms from
inflammatory affections of those tissues. Not
uncommonly, however, inflammation commencing
in one tissue extends to those contiguous ; but
this is by no means uniformly the case; frequently
the very opposite effect is induced in this disease,
and the intestinal mucous membrane becomes re-
markably pale, while the peritoneum is acutely
inflamed.

We shall proceed, in the first place, to notice
the disease as it exists in the acute form in the
different periods of life.

I. Acute Peritonitis in the Infant. —
This disease may attack the infant during its in-
tra-uterine life. Its exciting causes during this
period of existence are obscure : they may possi-
bly be transmitted from the mother to the infant,
or originate from an internal strangulation of the
intestines, of which M. Legoues and M. Ducis
have seen examples. However difficult it may be
to assign a satisfactory cause for its origin, its ex-
istence has been unequivocally demonstrated by
the post-mortem appearances which infants who
have died a few hours after birth have exhibited.
In some cases of this kind, the usual effects of
peritoneal inflammations, adhesions between the
intestines, false membranes, and sero-purulent
effusions into the abdomen, have been detected —
effects which must have been produced during the
abode of the infant in utero. Five cases of in-
fants who died a few hours after birth have been
detailed by M. Billard, in which the above appear-
ances were found. In one instance the child was
emaciated and pale ; and old, solid adhesions
were discovered in the abdomen, apparently indi-
cating that the disease had existed for some time
previous to birth, and had probably become chro-
nic before it terminated fatally. In the other four
cases, the infants presented nothing unusual in
their external appearance.

The causes which may excite peritonitis during
the period of lactation are not very evident. They
probably are essentially the same as may operate
during adult years. Infants are exposed, to a cer-

tain extent, to similar injurious impressions from
external agents, and their organs are at least
equally susceptible of morbid actions.

Symptoms* — The abdomen of the child pre-
sents a tumefied and tense appearance, and is ele-
vated in a point towards the umbilicus. This dis-
tension is caused in the early period of the dis-
ease by flatus in the intestines: it is accompanied
by some dyspnoea, which does not, however,
always indicate a pulmonic affection, but is pro-
duced by the obstruction which the diaphragm
suffers in its descent from the distended abdomen
and the pain which its movements occasion by the
friction of the inflamed peritoneal surfaces against
each other. There is constant abdominal pain,
which is much aggravated by pressure. The
countenance exhibits an expression of suffering:
the features are contracted, and the little patient
cries almost without intermission. Vomiting
usually is present, and the bowels are in most
cases constipated. There is restlessness, with
general debility; hot, dry skin, and frequent, weak
pulse ; and, if prolonged into the chronic state,
the child becomes emaciated, and dies exhausted.

It is difficult to distinguish this disease from in-
fantile enteritis, with which it is occasionally com-
plicated. In its simple form it is usually attended
with more abdominal tenderness on pressure.
Constipation generally exists in peritonitis, while
diarrhoea is frequently an attendant on inflamma-
tion of the mucous membrane. The appearance
of the tongue may assist in the diagnosis, being,
in the latter affection, generally furred with red
tip and edges, and red papilla;, while in simple
peritonitis this redness is not generally present.
Peritonitis is a much less frequent disease during
infancy, not being so likely to be induced by irre-
gularities of diet and the other injurious agents to
which children are particularly exposed, and
which are common exciting causes of enteritis.
M. Billard observes that it may be distinguished
from pleuritis by the sonorousness of the chest,
and from flatulent colic by the pains being remit-
ted in the latter affection, and ceasing on the ex-
pulsion of gas. (Maladies des Enfans, Paris,
1828, p. 449.) The prognosis in this disease is
generally unfavourable. The post-mortem ap-
pearances do not differ from those which the dis-
ease presents in adults, and which will be hereaf-
ter described.

Children of a scrofulous habit are subject to a
form of chronic peritonitis, which deserves distinct
notice : it is characterized during life by great
tenderness of the abdomen on pressure, with oc-
casional paroxysms of acute pain, at first coming
on only once or twice a day, but afterwards be-
coming more frequent, after which the child ap-
pears quite lively, and free from indisposition. At
first the pain is limited, but afterwards extends over
the whole abdomen, which in the early stages be-
comes swollen and tense, but afterwards subsides:
the pulse is generally about 100, with some strength
and fulness, the tongue clean, appetite irregular,
but generally good, and frequently voracious;
some thirst, the bowels free, the evacuations unu-
sually large in quantity, and peculiar in appear-
ance, consisting generally of a whitish-brown
matter, of the consistence of a thin pudding. This
state of the bowels may continue for six weeks or

PERITONITIS.

507

two months with progressive emaciation, until di-
arrhoea, attended with petechias, puts a period to
the child's life. The head seldom suffers, but
cough and dyspnoea occasionally attend. The
usual duration of the disease is four or five
months, but often the child is not confined to his
bed till the last month. Dissection exhibits the
mesentery, bowels, and peritoneum lining the pa-
rietes, united together into one mass ; the perito-
neum thickened, and containing large masses of
scrofulous matter; the intestinal mucous mem-
brane perforated by ulcerations, which form nu-
merous communications between the different coils
of intestine ; and the intestines and abdominal
cavity containing matter resembling that which
was passed during life by stone. The causes of
this disease are unknown, and it in general ter-
minates fatally. Dr. Gregory recommends leeches
and fomentations during the early stages, after-
wards purgatives, mercurial alteratives, tonics,
chalybeates, and absorbents. Laudanum affords
the only relief from the pain. This disease ap-
pears to be a frequent cause of infantile maras-
mus. (Medico-Chirurg. Trans, vol. xi. p. 262.
Dr. Gregory on Scrofulous Inflammation of the
Peritoneum.)

II. Acute Peritonitis in the Adult. — The causes
which predispose to peritonitis in mature years
are involved in some obscurity. They probably
do not differ essentially from those which predis-
pose to other inflammations. It is observed to be
more common during adult years than at other
periods of life ; in women than in men ; and in
sanguine and plethoric individuals than in the op-
posite constitutions. A disposition to local deter-
minations of blood, proved by previous inflamma-
tory attacks and repeated discharges of fluids, is,
according to Broussais, a common predisposing
cause, and to this may be added cold seasons of
the year, residence in damp situations, the abuse
of intoxicating liquors, and over-excitement of
the passions.

The exciting causes may be arranged in three
classes-the mechanical, the chemical, and the vital.

The mechanical causes include all injuries in-
flicted on the abdomen by blows, falls, or compres-
sion, pressure of the gravid uterus, extra-uterine
conceptions, enlarged ovaries, or other morbid
growths within the abdomen. Under this class
may also be included all wounds of the peritoneum,
whether the result of accident, surgical operations,
or strangulation arising from hernial protrusions,
or invagination of a portion of intestine. M.
Broussais considers violent and long-continued
corporeal exertions, violent and repeated contrac-
tions of the abdominal muscles in vomiting, stric-
tures of the colon or rectum producing unnatural
contortion, and friction of the intestines on one
another, as causes of peritoneal inflammation.

The chemical causes include all extravasations
into the peritoneal cavity not quickly absorbed,
whether of blood, urine, bile, chyle, or faeces, and
perhaps the morbid serous secretions of the mem-
brane itself.

The vital causes comprehend all aberrations of
healthy actions, transmission of morbid action
from a part previously affected to the. peritoneum,
or extension of inflammation from a contiguous
organ or tissue to this membrane.

An aberration of action takes place when cer.
tain functions of the system are interrupted, as
when the perspiration, the catamenia, or the lochia
are suppressed, and peritonitis is induced as a
consequence. The remote cause in these cases
arises from the operation, of cold, moisture, or both
combined, applied to the surface, or the drinking
of cold liquids when the body is over-heated.
Transmission of morbid action or metastasis may
be ranked among the exciting causes. We see
examples of this when the retrocession of rheu-
matic, arthritic, erysipelatous, or other inflamma
tions, is quickly followed by an inflammation of
this membrane. According to M. Broussais, the
chill of an intermittent, when the abdominal vis-
cera, and especially the spleen, are suddenly
swelled by the centripetal motions of the fluids,
may prove an exciting cause of peritonitis, exam-
ples of which he has frequently seen during the
course of these diseases.

Extension of inflammation from a contiguous
texture or organ to the peritoneum, is a very fre-
quent cause of this affection. Thus, when the
gastro-intestinal mucous membrane is inflamed,
the inflammation may extend itself to the serous
envelope of the intestines ; or when the uterus or
any other of the abdominal viscera are similarly
affected, the inflammatory action may be propa-
gated to their peritoneal coverings, and the two dis-
eases may either coexist, or a revulsion of the phlo-
gosis takes place, the primary affection subsides,
and simple peritonitis is established. This subject,
however, will be more fully considered when we
come to treat of the complications of this disease.
Symptoms of Acute Peritonitis. — This af-
fection frequently commences by a shivering more
or less prolonged, accompanied by a feeling of ge-
neral indisposition and weariness in the limb,5: at
an uncertain period, reaction takes place, and heat
of skin more or less pungent, with headach, con-
striction at the epigastric region, and frequent, hard,
concentrated pulse, succeed, attended with a sen-
sation of heat and pain in the abdomen, and ten-
derness on pressure. This pain soon becomes the
principal symptom of the disease, and is not un-
frequently the first which appears, not being pre-
ceded by any general febrile symptoms : it is usu-
ally of an acute, tensive, pungent character, and
has been compared by some patients to the sensa-
tion which a cutting instrument or a screw intro-
duced into the affected parts would produce. It
varies much in its permanency, seat, and degree:
in some cases the pain comes on in paroxysms,
which continue for a short time, and then pass off",
leaving in the intervals only an acute tenderness.
" These accessions," says Abercrombie, " seem to be
excited chiefly by flatus moving through the bowels
and distending the inflamed part, and the action
of a purgative is often followed by a violent aggra-
vation of all the symptoms." (Abercrombie on
Diseases of the Stomach, &c. p. 151.) In other
instances the pain is permanent, and is confined to
a single spot of small extent, in which it continues
to preserve its intensity during the whole course
of the disease: in other cases, again, the pain
shifts from one part of the abdomen to another,
and sometimes extends nearly over the whole
membrane. The pain differs much in its degree,
and may even sometimes be altogether absent, or

508

PERITONITIS.

only felt on pressure : in other instances it is very
severe, and much increased by the erect posture,
or any motion of the body ; hence the patient lies
constantly on the back, and cannot, without an
increase of suffering, lean to either side, finding
most relief from remaining motionless, with the
knees in a slight degree elevated. This position,
while it throws the weight of the intestines on the
spine, and therefore removes pressure from the in-
flamed membrane, at the same time relaxes the
abdominal muscles, and prevents any stricture on
the anterior surface of the inflamed parts. The
respiration is frequent, small, and interrupted, and
chiefly performed by the thoracic muscles, the de-
pression of the diaphragm producing on the affected
parts the same effect that pressure does on the ab-
domen ; consequently, full inspiration, coughing,
sneezing, vomiting, or the evacuation of the urine
or faeces, aggravate the pain.

The increased sensibility of the abdomen is
sometimes not perceived unless when pressure is
made ; but in other cases the soreness is so ex-
quisite, that the slightest weight on the abdominal
parietes aggravates it to an intolerable degree.
The pressure of the bed coverings becomes in-
supportable, so that it is found necessary to keep
them from being in contact with the abdomen by
artificial means. This sensibility to pressure is
the grand criterion by which we are to judge of
the existence and degree of the disease ; " and
this," it has been observed, " we are not to esti-
mate solely by the complaint, but by the counte-
nance also of the patient. Even gentle pressure
causes a sudden retraction of the lips and expres-
sion of pain, as if he were pierced by a sharp in-
strument. On the other hand, we are not to
overrate the tenderness (though it is the surest
diagnostic) by the wincing of the patient, espe-
cially if very irritable or young, or afraid of being
hurt, or if the bowels happen to be uneasy and
distended with flatus at the time."*

In addition to pain and tenderness on pressure,
tension and tumefaction of the abdomen are con-
stant and characteristic symptoms of peritonitis :
those in the early stages arise from a tympanitic
distension of the intestines, though at a later
period of the affection they may be caused by
effusion of fluid into the peritoneal cavity. This
swelling, which is equal and regular in general
peritonitis, exists in different degrees in different
individuals, depending partly on the intensity of
the inflammation, and partly on the degree of
resistance which is offered by the abdominal pa-
rietes. It is considerable with those whose belly

* Dr. Dickson: see Loud. Med. Chirurg. Rev. Sept.
1820. In order to form an accurate idea of the sensibi-
lity of the abdomen, the hand should be laid flat on its
centre, and then passed successively on every part of it,
the physician observing at the same time the patient's
countenance, which will at once indicate pain if the
abdomen be sensible. Care should be taken not to make
pressure with the ends of the fingers; for then, by being
applied to one point, it becomes considerable, and will
excite pain where there may be no disease. (Martinet's
Pathology, translated by duain, third edit. p. 68.)

In some subjects the thickness of the muscles and pa-
rietes of the abdomen renders the pain on pressure
scarce perceptible. In such cases M. Broussais directs
us to make lateral pressure towards the centre of the
abdomen. " Elle (douleur) etait plus difficile a supporter
quand on la faisait (pression) lateralcment en la diri-
geant vers le centre. Ce signe est un des meilleurs pour
faire decouvrir les peritonites obscures." (Histoire des
Phlegmasies, vol. ii. p. 492.)

is naturally flabby, or when the abdomen has been
recently distended, as in females after parturition,
and in both sexes after the operation of paracen-
tesis. In individuals, on the contrary, with strong
abdominal muscles, and particularly in thin robust
men, the abdomen is scarcely at all swelled; some-
times it is evidently retracted, especially in the
first days of the attack ; in such cases it is very
hard, and in general the hardness and tumefaction
are in the inverse ratio of each other. (Chomel,
Diet, de Medecine.)

Along with these symptoms there are frequently
present, singultus, nausea, and vomiting, the mat-
ter ejected being at first the contents of the sto-
mach at the time of the attack, afterwards mucus
or bile. The bowels are in general obstinately
costive, though occasionally relaxed. The pulse,
as the disease advances, is in general very fre-
quent, ranging from 120 to 130 in the minute; it
is also very small, as if not only the heart but the
artery at the wrist had contracted upon itself; yet
if it be accurately examined, it will be found,
during the stage of excitement, firmer than natu-
ral, almost feeling like a small whip-cord or harp-
string. The tongue is covered with a whitish fur,
the urine is scanty and high-coloured, and there
is excessive thirst, which the patient fears to gra-
tify, in consequence of the vomiting which the
introduction of fluids into the stomach often in-
duces. (Armstrong, Morbid Anatomy of the
Bowels, p. 92.)

The course of acute peritonitis is in general
rapid, and marked by a progressive increase of all
the above symptoms: the abdominal pain, tender-
ness, and tumefaction become aggravated, the face
more pale, the features contracted, and often co-
vered with a cold sweat,-(- the pulse more frequent,
and anxiety augmented. The malady may re-
main stationary for some days with nocturnal
paroxysms, either marked by a febrile exacerbation
or an aggravation of the local symptoms, and may
not terminate fatally till after thirty or forty days;
but in most instances it runs a much more rapid
course, and in some cases the patient sinks in
sixteen to twenty-four hours from the commence-
ment of the attack.

The approach of death is marked by cessation
of the pain, by the pulse becoming quicker,
smaller, and very weak, feeling like a soft undu-
lating line; by coldness of the extremities, and
ultimately of the entire surface of the body. The
abdomen becomes more tumid and tense, but in
some instances soft and relaxed ; the face is sunk,
and especially hollow round the orbits; the vomit-
ing is succeeded by regurgitation of the liquid
contents of the stomach without any apparent
effort ; and although the intellectual faculties are
often preserved unimpaired to the last moment,
sometimes delirium, a comatose state, or in other
instances convulsive movements of the head or
limbs, precede the fatal termination.

t The French pathologists have given a peculiar term
to the expression of the countenance in this disease,
" face grippee." Slight contractions of the muscles of
the face, and principally of the forehead, are caused by
the force of the abdominal pains, by which the features
are discomposed and appear drawn up towards the fore-
head, which is wrinkled and the nose pointed. (See M-
Oasc. Diet, des Sciences Medicates, article Peritonite.
Roche et Sanson, Etemens de Pathologic, torn. i. p. 585-)

PERITONITIS.

509

Such is the assemblage of symptoms which
acute peritonitis, in its simple and open form,
presents: they are not, of course, all present in
every individual case, but the greater number of
them will be generally found to coexist in well-
marked instances of the disease. Cases, however,
occasionally occur, in which nearly all the above
symptoms are absent. This variety of the affec-
tion will be considered under a distinct head.

Acute peritonitis may terminate by resolution ;
by effusion ; by gangrene ; or it may assume the
chronic form.

Resolution may take place between the fifth
and twentieth day. It is indicated by a cessation
of pain, fever, and other inflammatory symptoms,
a re-establishment of the functions of the neigh-
bouring organs, the capability of turning on the
side, and of bearing pressure on the abdomen,
disappearance of the nausea and vomiting, and
sometimes by the appearance of a critical evacua-
tion, such as diarrhoea, abundant urine, and co-
pious perspiration ; by the pulse becoming slow
and soft, and by the return of quiet and refresh-
ing sleep.

Effusion is a frequent termination in fatal cases.
The fluid effused may be serum, pus, or in some
rare instances blood. These fluids may either
exist singly or in combination with each other, or
with coagulable lymph. The symptoms which
denote effusion are diminution of the abdominal
pain, with sense of weight and oppression in the
affected part, irregular chills, softness of the pulse,
paleness of the countenance, and coldness of the
extremities. (M. Gasc, Diet, des Sciences Medi-
cates.) Effusion may be ascertained to exist in
many instances by percussion, which, when made
on the abdomen in the early stages of peritonitis,
generally elicits a sonorous sound derived from
the tympanitic state of the intestines ; but, as the
effusion increases, this sound becomes progres-
sively more limited and obscure. Fluctuation
can also occasionally be felt,* but in general only
after the disease has existed some time ; for, as
Andral observes, during the early periods of the
disease, the abdominal effusion, small in quantity,
is rather to be discovered by the tension, resist-
ance, and modification of form of the belly, than
by the great increase of its volume or the exist-
ence of fluctuation. (Clinique Medicale, Mala-
dies de l'Abdomcn, p. 539.) Fluctuation may
also be absent, if the effused fluid is contained in
a number of distinct abscesses, separated from
each other by partitions of false membrane, of
which the same pathologist relates an instance.
(Ibid. p. 598.)

It is doubtful, when pus and lymph are effused
in any great quantity, if they are ever absorbed,
and such cases generally terminate fatally, or pass
into the chronic form of the disease. However,
M. Gasc asserts that he has known patients reco-
ver in whom the purulent matter escaped by the
umbilicus, (Diet, des Sciences Medicales, p. 508);
and we have seen cases of ascites consequent on
peritonitis cured by the aid of medicine.

[Auscultation may afford evidences of perito-
nitis before and after effusion has taken place.
As in the inflammations of serous membranes,

* Fur the mode of examining the abdomen, see article
Abdomen, Exploration or.

2s*

the first effect is to arrest the secretions, so that
the membranes are dry ; and careful auscultation
has detected a sound of frottement or friction.
(Barth et Roger, Traite d' Auscultation, Paris,
1841.) The effusion of coagulable lymph may
be detected by like signs, as well as by the hand
applied over the abdomen. In a case of perito-
nitis supervening on ovarian dropsy, described by
Dr. Beatty, when the hand was applied over the
umbilicus and its neighbourhood, the sensation
communicated to it, when a full inspiration was
taken, was that of a grating or rubbing together
of two uneven and rather dry surfaces. By the
aid of the stethoscope, a loud and distinct friction
sound was audible over a space about five inches
in diameter, with the umbilicus for a centre.
Another pathologist, Dr. Bright, states that he
has observed, on several occasions, that when the
circumstances of the disease had rendered it pro-
bable that adhesion had taken place between the
viscera and the peritoneum of the abdomen, a
very peculiar sensation was communicated to
the touch, varying between the crepitation pro-
duced by emphysema, and the sensation derived
from bending new leather in the hand. It has
been presumed by Dr. Corrigan that for the pro-
duction of this sign, the effused lymph must be
in an unorganized condition ; and also by Dr.
Beatty, that it is observed only in cases where
one at least of the opposed surfaces is adherent
to a solid resisting body ; and it would appear
from Dr. Stokes, that in twelve collected cases,
nine presented an organic tumour.]

Gangrene is a much rarer termination ; but M.
Gasc observes that, of all serous inflammations,
peritonitis, when intense, is most disposed to pass
into a state of gangrene. The symptoms indica-
tive of this termination are, sudden cessation of
the abdominal pain, smallness of the pulse, which
becomes concentrated and intermitting, extreme
prostration of strength, Hippocratic countenance,
and speedy death. Dr. Abercrombie considers
this termination rare, and that it is not often
found in post-mortem examination as a prominent
appearance, but when met with is slight and par-
tial, and always accompanied with extensive de-
position of false membrane. It more frequently
occurs when enteritis coexists with inflammation
of the peritoneum.

When acute peritonitis does not prove fatal in
the course of fifteen or twenty days, it generally
subsides into the chronic form. It sometimes,
however, continues acute for a much longer period,
and has even been protracted, as already men-
tioned, to thirty or forty days, and proved fatal at
the end of that period. The symptoms which in-
dicate this form of the disease will be considered
in a separate section.

Diagnosis. — This is frequently attended with
considerable difficulty, as the inflammatory affec-
tions of the viscera and other parts which the
peritoneum covers frequently present nearly simi
lar symptoms as inflammation of this membrane
Neuralgia and rheumatic pains of the adjacent
muscles and nerves may also occasionally be mis-
taken for peritonitis ; and colic, the passage of
calculi along the biliary ducts or ureters, have
been considered by some writers as liable to be
confounded with inflammation of the peritoneum.

510

PERITONITIS.

In gastritis the pain and tenderness on pressure
are confined to the region of the stomach ; the
vomiting in general is more urgent, and is more
easily excited by food or drink, and the thirst,
with desire of cold liquids, is more intense. The
state of the tongue varies in gastritis ; but when
it does present the thick coat on the centre, and
intense redness of tip and edges, it will assist us
in the diagnosis, as this appearance is not observed
in simple peritonitis. When the peritoneal coat
of the stomach is inflamed, the diagnosis will be
more difficult, and can only be established by an
attentive consideration of the general history and
characters of the two diseases which have been
already detailed. — See Gasthitis.

We have frequent occasion to discriminate be-
tween enteritis and peritonitis in practice, and the
symptoms are often so very similar that some
physicians have thought a diagnosis between them
impracticable. Dr. Cullen, after having given
peritonitis a distinct place in his nosology, tells
us, in his First Lines, that it is difficult to say by
what symptoms it may be known, and that when
known it does not require any remedies beside
those of inflammation in general, and' gives this
as a reason for passing it over without further
description. Dr. Philip Wilson, in his work on
Febrile Diseases, asserts, " that peritonitis seldom
exists without the inflammation spreading in a
greater or less degree to the stomach and intes-
tines, nor does inflammation of the latter fre-
quently exist without extending to the peritoneum.
There is hardly room, therefore, for regarding
peritonitis as a distinct complaint." Nevertheless,
the two diseases are essentially different, as well
in the texture affected as in several of their symp-
toms, and in the post-mortem appearances which
they present ; and they can in many, perhaps in
most, instances be discriminated. The treatment
of peritonitis ought also, in some degree, to vary
from that of enteritis.

John Hunter was fully aware of the distinct
nature of these two affections, for he observes,
" If the peritoneum which lines the cavity of the
abdomen inflames, its inflammation does not affect
the parietes of the abdomen ; or if the peritoneum
covering any of the viscera is inflamed, it does not
affect the viscera. Thus the peritoneum shall be
universally inflamed, as in the puerperal fever,
yet the parietes of the abdomen and the proper
coats of the intestines shall not be affected ; on
the other hand, if the parietes of the abdomen or
the proper coats of the intestines are inflamed, the
peritoneum shall not be affected." (On the Blood
&c. p. 244.)

The most important diagnostic symptom be-
tween peritonitis and enteritis is the sensibility of
the abdomen to pressure ; in the former, pain is
excited by a very slight degree of pressure, which
would produce little or no inconvenience in the
latter. The action of the diaphragm in full in-
spiration or coughing does not produce so much
suffering in enteritis, nor is it so much aggravated
by motion of the body or abdominal muscles. The
pain appears much more superficial in peritonitis,
and in many instances is not accompanied with
sickness or any other disturbance of the intestinal
canal. The pain in peritonitis in general is of a
more acute character, and is more frequently

accompanied with constipation. Enteritis pre-
sents some peculiarities according as it affects dif-
ferent portions of intestine, and the presence or
absence of which will assist our diagnosis ; these
have been already fully considered. (See Ente-
kitis.) When the duodenum is inflamed, pain
in the situation of that viscus, and occasionally
jaundice, are present. In inflammation of the
large intestines, there are generally diarrhoea or
symptoms of dysentery, neither of which affections
are common in simple peritonitis; but when the
jejunum or ileum is inflamed, it is more difficult
to discriminate ; the pain in such cases is in gene-
ral not so severe as in peritonitis, and is principally
in the regions which those intestines occupy.

Rheumatism sometimes, though rarely, affects
the abdominal muscles, and may be mistaken for
peritonitis, as it presents the same pain on pres-
sure or motion ; but the pain in such cases is
principally felt at the origin or insertion of the
muscles, shooting to the false ribs and the spine
of the ileum. (See Parr's Medical Dictionary,
vol. ii. p. 21.) In such cases the skin may be
greatly distended, and if the muscles are swelled,
the figure of each is often preserved. The existence
of these peculiar symptoms, conjoined with the
absence of uniform tumefaction, vomiting, or con-
stipation, will probably in most cases enable us to
form a correct diagnosis. Neuralgic pains of the
abdominal viscera or parietes may simulate peri-
tonitis. Andral observes (Clinique M6dicale, torn,
iv. p. 539,) that rheumatic patients are sometimes
attacked with severe acute pains in the abdomen,
which vanish more or less suddenly without leav-
ing any trace of a severe affection ; and M. Cho-
mel states that in several cases acute pains sud-
denly occur in the abdomen, often without any
appreciable cause, and last for ten or twelve hours,
with frequent pulse, nausea, and vomiting, and
yield to the use of opium. (Diet, de Medecine,
torn. xvi. p. 330.) There is some reason to suspect
that these pains may in certain cases originate
from irritation of some portion of the spinal cord,
or of the ganglionic nerves that are distributed to
the different viscera.* Their fugitive characters,
the absence of pyrexia or tumefaction, and the
general history of the case, may enable us to
ascertain their real nature. In doubtful cases we
should examine attentively the spinal column, and
if any tenderness or pain is evident in a particular
spot, it will give an additional probability to out
suspicions.

Hysteria frequently simulates peritonitis, and
nothing but a careful consideration of the history
of the case and watching closely its progress, can
enable us to discriminate between them. In hys-
teric cases, as Dr. Bright well observes, in general
some great incongruity of symptoms will be de-
tected : a tenderness of the abdomen, indicating
inflammatory action beyond any thing which the
pulse or the condition of the tongue would autho-
rize us to infer; a hurry and even labour of
respiration, more marked than in the embarrassed
breathing of peritoneal inflammation ; a sudden
subsidence of the symptoms, and their sudden

*See Whatton, On Spina! Irritation, North of England
Med. and Surg. Journal, Dr. Corripan, Lancet, and Lond.
Med. CJiir. Review, July 183J, p. 182. Tealc, on Neural-
gic Diseases.

PERITONITIS.

511

return; a shifting and changing of the tender or
painful part, and sometimes the decided interven-
tion o( hysteric symptoms, and the very frequent
accompaniment of some evidence of mental causes,
or of irritation and deranged function in the uterus
itself. — all these, together with the general aspect
of the individual, will frequently be guides and
indications to assist us. (Bright's Reports of
Medical Cases, p. 453.)

Colic may be distinguished from peritonitis by
the absence of fever, the pain being relieved by
pressure, the state of the pulse, and the sudden-
ness of the attack. (See Colic.) There are
several other affections which occasionally may
present some of the symptoms of peritonitis which
would lead us into too long a detail to consider.
We have endeavoured to select those only which
either occur most frequently or present the greatest
difficulty in diagnosis. Inflammation of any of
the abdominal viscera, or the passage of calculi
through the biliary ducts or ureters, may occa-
sionally resemble peritonitis, though they in gene-
ral possess sufficiently distinctive characters. (See
the different articles that treat of these affections.)
Prognosis. — Peritonitis is always attended
with considerable danger, but if subjected to active
treatment at an early period there is a fair chance
of effecting a cure, especially if the patient is not
advanced in years, is of a good unimpaired consti-
tution, and capable of bearing depletion to a con-
siderable degree ; or if the inflammation be limited
in its extent and uncomplicated in its form, and
the symptoms much mitigated by the evacuations
employed. A favourable termination is indicated
by the gradual diminution of abdominal pain,
tension, and tenderness, the pulse becoming fuller,
softer, and less frequent; the skin less parched,
soft, and moist ; the respiration less laborious, and
the countenance more open and expressive of
case. An unfavourable result is to be expected
when the patient is of advanced age, and of a
debilitated or broken down constitution ; when
the disease originates from perforation of the sto-
mach or intestines, or rupture of any of the abdo-
minal viscera, or when it succeeds to a wound, a
surgical operation, or to parturition ; or extends
over a large portion of peritoneal surface, or is
complicated with an affection of any important
organ. The danger is also greater when the in-
flammation has existed some time before the em-
ployment of remedies, and when the symptoms
exhibit considerable intensity, and do not yield to
the depletions employed.

Complications* — The fever which accompa-
nies peritonitis may present either an inflamma-
tory, typhoid, or gastric character. The former
is met with most frequently in robust and vigor-
ous patients ; typhoid symptoms for the most part
prevail in old persons of debilitated constitutions ;
and gastric fever will coexist when the gastro-
intestinal mucous membrane is in a state of in-
flammatory excitement. The symptomatic fever
may be so modified by the state of the patient at
the time of the attack, by the coexistence of other
morbid actions, and the prevailing epidemics of
the season, as to present a variety of intermediate
grades. In some instances peritonitis has been
complicated with an intermittent fever, disappear-
ing during the intervals, and re-appearing on the

accession of each paroxysm. (Andral, Clinique
Medicale, torn. iv. p. 571.) In some instances it
has assumed a tertian or quartan type ; (Roche et
Sanson, Elemens de Pathologie, torn. i. p. 591) ;
but such cases are rare. Andral relates an in-
stance of peritonitis supervening on the disap-
pearance of rheumatism ; but it is most frequently
complicated with affections of the abdominal vis-
cera, especially of the stomach or intestines ; the
inflammation spreading from the peritoneum to
the other contiguous tissues which form their
parietes, or pursuing an opposite course, attacking
primarily their mucous membrane, and afterwards
penetrating to and affecting the peritoneum. It
appears sometimes to coexist with an hepatic
affection, and Chomel mentions a form of perito-
nitis called bilious, in which the peculiar symp-
toms of peritonitis were accompanied with a
yellow coating of the tongue, discharges of bile
from the stomach and intestines, with a yellowish
tinge and pungent heat of skin. (Diet, de Mede-
cine, loc. cit.) M. Broussais observes that the
excess of pain is capable of disorganizing the
brain by a too impetuous afflux of blood into its
capillaries, and that after much suffering, the de-
lirium, convulsions, and coma are frequently the
effect of the disease of the brain itself. (History
of Chronic Phlegmasia?, translated by Hays and
Griffith, vol. ii. p. 359.)

The lungs and pleura may also be affected
simultaneously with the peritoneum, in which
case thoracic pain, cough, dyspnoea, and other
pectoral symptoms will be present. This compli-
cation is not very uncommon. M. Duges found
traces of inflammation of the pleura in forty cases
out of two hundred and sixty subjects who died
of puerperal peritonitis, and whose bodies he ex-
amined after death. (Journal Complementaire,
torn, xxx vi. p. 218.) The parenchyma of the
lungs, or the pericardium may be also affected, but
such cases are rare. Other complications may
exist which would lead us into too long a detail
to include : we trust sufficient has been said to
impress on the mind of the medical practitioner
the importance of directing his attention to the
state of other organs and textures in cases of in-
flammation of the peritoneum.

[M. Chomel (Diclionnaire de Mcdecine, 2d
edit, xxiii. 560, Paris, 1841,) is of opinion, from
long observation, that spontaneous and primary
peritonitis is a rare disease. In the space of fif-
teen years, he does not recollect a single case of
fatal peritonitis, in which the assertion was nega-
tived. In this respect, peritonitis is an exception
amongst the serous membranes — the pleura, peri-
cardium, meninges of the brain, being often the
seat of primary phlegmasia?.]

III. Puerperal Peritonitis. — The perito-
neum is very liable to become inflamed in the
puerperal state, those portions especially connected
with the uterine organs. The uterus or its ap-
pendages are generally the first parts that become
affected, and the morbid action spreads by con-
tiguity or continuity to the general surface of the
peritoneum ; it consequently usually exists com-
plicated with an inflammatory affection of one or
more of the textures or organs belonging to the
uterine system. This subject has been already
fully considered in the article Puerperal Fetek,

512

PERITONITIS

to which we refer for details ; but puerperal fe-
males may be afl'ected with peritonitis in its sim-
ple form, when it presents some peculiarities de-
serving attention. Its predisposing causes are the
high degree of irritability of the system which
exists subsequent to parturition, and more espe-
cially in the peritoneum, from the sudden abstrac-
tion of distension which it undergoes by the
contraction of the uterus after the expulsion of
the fetus. M. Chomel observes that the repeated
friction to which the peritoneum is subjected
during labour may account for the primitive de-
velopment of peritonitis in those cases where it
appears without inflammation of the uterus.
(Diet, de Medecine, art. Peritonite.) Dr. Burns
remarks that those who have suffered from uterine
nemorrhage after delivery are most liable to this
disease. (Midwifery, p. 526.) The affection
may also be excited by violence during parturition,
by the application of cold, or the injudicious use
of stimuli. When it occurs during the prevalence
of puerperal fever, it appears evidently to owe its
origin to an epidemic cause, and in some instances
to be communicated by contagion. It may there-
fore be considered as occurring under two forms,
1. as a sporadic disease, and, 2. as an epidemic.
(See Feveii, Puehpehal.)

1. Sporadic puerperal peritonitis sometimes
becomes developed a few days after parturition,
but occasionally two or three weeks intervene, and
in some cases the pulse continues frequent from
the time of delivery till the accession of the in-
flammation. The first symptom that manifests
itself is generally pain in the abdomen, which is
usually preceded or accompanied by rigors ; and
Dr. Denman (Denman's Midwifery, p. 433, 6th
edition,) observes that from the violence and du-
ration of the shivering, we may generally estimate
the danger of the succeeding disease.

The abdomen becomes exquisitely painful on
pressure, and this symptom is usually accompa-
nied by vomiting, thirst, sharp, small, frequent
pulse, and white dry tongue. The symptoms are
in fact, generally speaking, the same as those
which ordinary peritonitis presents, with some
modifications, however, derived from the peculiar
state of the affected parts induced by parturition.
The pain more especially occupies the hypogas-
tric region, and when it extends to other parts of
the abdomen, it still continues most intensely in
this situation, indicating that the peritoneal cover-
ing of the uterus is principally affected. The
abdomen becomes distended more rapidly and to
a greater extent than in the other forms of the
disease, owing to its not offering so much resist-
ance in consequence of its relaxed state subse-
quent to delivery ; but it does not present quite so
much hardness and tension as in ordinary cases.
The lochia are diminished or suppressed. The
lacteal secretion is either not established or is ar-
rested, and the breasts consequently either do not
swell, or collapse after having been swollen. The
disease generally runs a short course, and rarely
terminates in the chronic state. When it termi-
nates favourably, the abdominal tumefaction sub-
sides as rapidly as it had before augmented ; the
lochial and lacteal secretions are re-established ;
the pain abates, and the vomiting ceases ; the
pulse becomes fuller and slower, and the other

signs indicative of termination by resolution,
which have been already described, are exhibited.

The fatal termination is characterized by the
increase of abdominal tumefaction, pain, and ten-
derness, quick irregular pulse, Hippocratic coun-
tenance, cold extremities, and sometimes by the
sudden cessation of pain, while the other unfa-
vourable symptoms continue. Dr. Gordon has
related some cases which terminated by suppura-
tion ; in two instances the matter escaped exter-
nally by the umbilicus, and in a third by the
urethra.

2. Epidemic puerperal peritonitis may be
considered as a variety of puerperal fever, which
has by some been thought to depend in every in-
stance on inflammation of the peritoneum ; but it
has been already demonstrated that various forms
of uterine inflammation may occur in this fever,
and give rise to a variety of symptoms, and that
these local inflammations may exist independently
of each other, though they are frequently com-
bined. (See Fever, Pcerpehal.)

When this fever excites peritoneal inflamma-
tion, it is not, according to Dr. Gooch, « one uni-
form disease, but may occur under different forms;
it is sometimes so mild as to be curable by the
gentlest aperients, and at other times is very ob-
stinate and fatal. In this latter form it sometimes
consists of acute inflammation of the peritoneum
with inflammatory fever, which bears and is cura-
ble only by early and active depletion; sometimes
of inflammation and fever of a low type, in which
depletion is useless and even pernicious." (On
Diseases of Females, p. 14, 15.) He observes
" that in the leading circumstances of the disease
there is certainly a great uniformity: it almost
always commences a few days after delivery, is
marked by pain and tenderness of the belly, and a
rapid pulse ; and if not cured, terminates fatally
within a week, and after death commonly leaves
the depositions and effusion of inflammation:
thus far it is very uniform, but no further." (P.
33.) He describes the leading symptoms of the
epidemic of 1812 — which he witnessed — to be
'• diffused pain and tenderness, with some swell-
ing of the abdomen, a quick pulse, which was
generally at first full and vibrating. Sometimes
it was small, but still it was hard and incompres-
sible ; the skin was hot, though not so hot as in
other fevers; the tongue was white and moist;
the milk was suppressed. As the disease ad-
vanced, the belly became less painful, but more
swelled, and the breathing short; towards the end,
the pulse was very frequent and tremulous, and
the skin covered with a clammy sweat : even in
this state the tongue continued moist and the
mind clear, and death took place generally about
the fifth day. On opening the abdomen, which
was often as large as before delivery, the intestines
were found distended with air; the peritoneum
was red in various parts, its surface was covered
with a coat of lymph ; the intestines adhered to
one another, and the omentum to the intestines;
coagulable lymph was deposited on various sur-
faces, especially in the depressions between the
convolutions of the bowels and on the omentum,
on both which parts it often lay in large masses;
the cavity of the peritoneum contained several
pints of a turbid fluid, apparently serum mixed

PERITONITIS.

513

with lymph. In the uterus, the morbid appear-
ances wire generally confined to its peritoneal
covering, which was coated with lymph, on re-
moving which the membrane itself was found un-
naturally red ; but in some cases the disease had
penetrated deeper into the uterus, the substance
of which was sometimes infiltrated with pus, and
sometimes contained small abscesses about the
size of a nut ; the inner surface of the uterus,
especially at the fundus, often appeared black and
ragged, as if gangrenous. The enlargement of
the abdomen depended entirely on air in the in-
testines ; when there was no air there was no en-
largement, even though the peritoneum contained
several pints of fluid." (P. 39, 40.) He de-
scribes several gradations of this affection, which
have been already considered in the article Puer-
peral Fever.

We have been induced to make this long quo-
tation, in order to demonstrate that puerperal peri-
tonitis, when epidemic, is nearly identical in its
symptoms and post-mortem appearance with the
common form of the disease. The peculiarities
which it presents it possesses in common with the
sporadic form, occurring after parturition, from
which it only differs in its epidemic and occasion-
ally contagious origin, in its frequent complication
with uterine affections, and in being attended, in
some instances, with a fever of a typhoid charac-
ter. It appears to us that the epidemic form is
primarily a fever that excites peritoneal inflamma-
tion which is to be considered as symptomatic of
a constitutional affection ; and that the sporadic
form is an idiopathic inflammation, modified by
the peculiarities of the puerperal state.

This view accords with Dr. Armstrong's ideas
on the nature of this disease. He states that pu-
erperal fever " is a common or specific fever, occur-
ring in the puerperal state, and modified, like
almost every other affection, by the condition of
the patient at the time of the attack. In general,"
he further observes, " it is a common fever com-
bined with inflammation of the abdominal and
pelvic viscera, but it is sometimes genuine typhous
fever, occurring in the same state, and then super-
added to the symptoms of peritonitis, are deve-
loped, rapidly for the most part, those symptoms
by which a fully formed typhus can be recog-
nized." (Armstrong's Morbid Anatomy, p. 96.)
Dr. S. Cusack, of Dublin, in his paper on puer-
peral fever, (Edin. Med. and Surg. Journ. Janu-
ary, 1829,) observes that the low form of puerpe-
ral fever which exhibits a typhoid character was
sometimes epidemic, and that the seasons which
appeared to favour its occurrence are such as give
rise to typhous fever, erysipelas, and diseases of a
low type." It appears, therefore, to originate from
the same causes as epidemic fevers, to exhibit the
same constitutional symptoms, with only this pe-
culiarity, that the uterine organs or peritoneum
are in every case inflamed, an effect which we
might, a priori, expect in the event of fever at-
tacking a puerperal female.

IV. Varieties of Peritonitis. — This disease
presents several modifications in addition to those
above described, which being attended with some
peculiarities with respect to their causes, symp-
toms, and progress, are deserving of separate con-
sideration. The ptiucipal of these are: 1. hemor-

Vol.IIL — 65

rhagic peritonitis ; 2 erysipelatous peritonitis; 3.
peritonitis from intestinal strangulation ; 4. latent
peritonitis; 5. partial peritonitis; 6. peritonitis
from perforation of the intestines ; 7. peritonitis
from paracentesis of the abdomen.

1. Hemorrhagic Peritonitis, [Hemapc'ritonir-
rhagie of Piorry.] — This form of the disease is
very rare : its predisposing causes appear to be a
sanguine temperament, and a constitution liable
to hemorrhagies and inflammatory affections. If
in such persons any irritation acts peculiarly on
the abdominal serous membrane, an hemorrhagic
action may be determined to its vessels, and a
sanguineous effusion thus takes place into the pe-
ritoneal cavity without any rupture of vessels.
The symptoms of this variety are similar to those
of acute peritonitis. The pain, however, appears
to be much more violent, and to be characterized
by marked intermissions : the anxiety is greater ;
it is accompanied with pyrexia, a pulse at first
strong and inflammatory, which afterwards be-
comes expanded and soft, and finally, at the ap-
proach of death, quick and small. The disease
runs a very rapid course, and convulsions, with
coldness of the extremities, precede the fatal ter-
mination. (Broussais' History of Chronic Phleg-
masia^ by Hays and Griffith, vol. ii. p. 182.)

2. Erysipelatous peritonitis. — This variety
appears to owe its cause to the transference of
erysipelatous inflammation from the skin or mu-
cous lining of the throat and fauces to the perito-
neum : its symptoms, as described by Dr. Aber-
crombie, are " sometimes slight and insidious, but
sometimes very severe, and they are chiefly dis-
tinguished by the rapidity with which they run
their course, and by a remarkable sinking of the
vital powers, which occurs from an early period,
and often prevents the adoption of any active
treatment : a remarkable circumstance in the his-
tory of the affection is its connection with erysi-
pelas and other diseases of an erysipelatous cha-
racter." (On the Abdominal Viscera, p. 182.)

In one case which he relates, the day after the
disappearance of erysipelas from one of the lower
extremities, acute pain attacked the region of the
stomach, which, in a short time, moved to the
lower part of the abdomen, and around the umbi-
licus, with little tenderness on pressure, but ac-
companied with great anxiety and restlessness :
the patient sunk rapidly, and died twenty-four
hours after the attack. Dissection discovered a
considerable quantity of bloody sanies in the ab-
domen, part of the small intestines of a dark red
and part of a dull leaden colour, and the whole
were considerably distended.

The form in which the throat is primarily af-
fected seems occasionally to owe its origin to an
epidemic cause. Dr. Abercrombie relates that in
the spring of 1824 it prevailed as an epidemic in
the Merchants' Hospital in Edinburgh. Its lead-
ing features were a slight erysipelatous affection
of the throat, beginning with vomiting and slight
fever : in some cases the internal fauces were co-
vered with aphthous crusts or swelling of the
uvula, and in some cases there were angry ulcer
ations about the lips, with sponginess of the gums ,
the larynx was unaffected in every case, and, ex-
cepting in two instances, which proved fatal by
the supervention of abdominal inflammation, the

514

PERITONITIS.

symptoms were mild, and little treatment was
necessary. In the two cases referred to, the pa-
tients were attacked with the above symptoms,
and, when recovering, pain and tenderness in the
abdomen and serious constitutional disturbance
supervened, and proved rapidly fatal. The two
fatal cases render it probable that the erysipelatous
action may invade the peritoneum as well as the
membrane of the mouth, and that its symptoms
and history sufficiently distinguish it from com-
mon peritoneal inflammation. The post-mortem
appearances were peculiar, consisting of a bloody
serum or pus mixed with shreds of a flaky matter,
but without much or any of that inflammatory or
adhesive exudation which forms so prominent a
character of peritonitis in its common forms.

3. Peritonitis from intestinal strangulation. —
This form may arise from internal or external
strangulation of a portion of intestine. It presents
for some time obscure symptoms, the inflamma-
tion being at first limited to a small space, and it
extends itself gradually from that portion of peri-
toneum which is strangulated to the rest of the
membrane. When the whole peritoneum be-
comes affected, this variety presents the same
general appearance as ordinary peritonitis : it dif-
fers, however, not only in the exciting cause, but
also in the succession of the phenomena which it
presents ; in exhibiting some symptoms which
accompany it in its whole course ; by its termina-
tion, and by the mode of treatment which it re-
quires.

In this variety constipation and vomiting are
frequently the first symptoms which appear, to
which pain succeeds ; febrile paroxysms do not,
however, develope themselves till after the last
symptom, or even later. In the whole course
of the malady, the constipation and vomiting, the
irregular form of the belly, the parietes of which
are elevated in several points above the obstacle,
give a peculiar aspect to this variety of peritonitis.
It is much more dangerous than ordinary perito-
nitis, and in treating it we ought to have more in
view the removal of the exciting cause which still
continues to operate than the management of the
inflammation itself." (Chomel, Diet, de Mede-
cine, torn. xvi. p. 326.)

4. Latent peritonitis. — Nearly all the charac-
teristic symptoms of peritonitis may be absent,
and yet the disease exist and be productive of
serious effects, and even terminate fatally. This
will be most apt to occur in patients of feeble
powers and advanced age, in maniacal persons,
or in those affected with some severe malady,
which may either absorb the attention of the
physician, or mask, by its greater intensity, the
peculiar symptoms of peritonitis. In such cases,
it may steal on without pain or any accompany-
ing pyrexia, and the only criteria by which we
can judge of its existence, are perhaps the ex-
pression of the countenance, and, on a close ex-
amination, some degree of tumefaction and ten-
sion of the abdomen, and, occasionally, an obscure
sensation of pain excited by pressure.

5. Partial peritonitis. — This affection may be
confined to a small portion of the peritoneum
during its whole course. This variety may be
taused by a contusion or wound penetrating into
•he abdomen, or it may succeed to a surgical ope-

ration, in which the abdominal parietes or viscers
arc concerned ; while in some instances it may
arise without any apparent cause. It often com-
mences without rigors, by a pain in a limited
point of the abdomen, augmented by pressure,
often accompanied with some tumefaction or hard-
ness in the affected part, and occasionally with
febrile symptoms of some intensity ; but in gene*
ral the vomiting and alteration of the countenance,
which so frequently attend general peritonitis, are
absent. It may, however, become general, and
then it will present the same phenomena as (he
common form of the disease. When it remains
circumscribed, it commonly terminates favourably
in a short time, the effusion, then small in quan-
tity, being absorbed. In some instances, (he in-
flamed portion becomes the seat of a collection of
pus circumscribed by adhesions, which may escape
into the stomach or intestines by erosion of their
parietes where they have formed an adhesion to
those of the abscess. M. Chomcl supposes that
in most of those cases where, after signs of local
peritoneal inflammation, pus is discharged from
the stomach or intestines, it owed its origin to
this source. Several forms of local peritonitis
have been described by authors. Dr. Cullen
mentions two, neither of which, however, he ven-
tures to discriminate by any characteristic symp-
toms.

The peritonitis omentalis he tells us affects the
omentum, and the peritonitis mesenterica the me-
sentery. (Synopsis Nosologic Methodical torn.
ii. p. 109.) Dr. Mason Good informs us that the
omental peritonitis is characterized by a more
sensible swelling in the region of the omentum.
(Study of Medecine, 1st edition, vol. ii. p. 371.)
The same author describes mesenteric peritonitis as
being attended with a pain deeper-seated, and
more immediately in the mesenteric region, the
external tenderness being less than in the other
forms. Frank states that it is accompanied with
deep pain in the back and in the umbilical region,
that it often terminates in abscess, which may ob-
struct the bowels by mechanical pressure, or open
into the cavity of the abdomen, or into the intes-
tines. {Frank, De Curandis Hominum Motto,
lib. ii. ord. iv. gen. 1.) Frank also mentions a
variety of local peritonitis confined to the lining
of the abdominal muscles, which, when limited to
the covering of the rectus, sometimes causes the
shape of that muscle to be developed, and effusion
of lymph or blood into its sheath, with tension, dis-
tension, and occasionally speedy gangrene. When,
also, the general peritoneal lining of the abdominal
muscles is inflamed, the sensibility to pressure will
be very great, and if it terminates in suppuration,
an immense collection of purulent matter may
form between the peritoneum and muscles, stimu-
lating ascites. The same author also states, that
when the peritoneum covering the bodies of the
vertebra? is inflamed, it will give rise to pain in
the back, in the situation of the lumbar vertebra,
much increased by the erect position of the body,
and resembling in some respects disease of the
kidney. When the peritoneal covering of the
psoas and iliacus internus is inflamed, pain is felt
in the region of those muscles, extending through
the groin to the thigh, which cannot be extended
without an increase of suffering, but is unattended

PERITONITIS.

515

by any difficulty in passing the urine or faeces.
Dr. Abercrombie describes several symptoms of
peritonitis, which seem to arise from the inflam-
mation having its seat more peculiarly in the se-
rous envelope of certain organs. When the cov-
ering of the liver is affected, the case can scarcely
be distinguished from acute hepatitis. When it
occurs in the neighbourhood of the kidney, Dr.
Abercrombie thinks it may give rise to true ischu-
ria renalis, proving fatal by coma and effusion in
the brain.

These varieties of peritonitis are interesting in
one point of view, as they enable us to explain
the predominance of certain symptoms in indivi-
dual cases, and an attention to them may, in some
instances at least, prevent our mistaking affections
of the peritoneum for diseases of the organs which
it covers, and may also be a useful guide as to the
local treatment.

6. Peritonitis from Perforation. — For an ac-
count of this variety, we refer to Peritonitis from
perforation of the serous membrane.

7. Peritonitis from Paracentesis. — In this va-
riety the pain is generally first perceived in the
point where the puncture was made. The flac-
cidity of the abdominal parietes, and the rapid
tumefaction of the belly which occurs when peri-
tonitis arises from this cause, bear some resem-
blance to the phenomena which puerperal peri-
tonitis exhibits. This form has almost invariably
a fatal termination ; in most cases that we have
seen, it ran its course in a few days, and was at-
tended with greater prostration of strength, and
less of febrile excitement than the common form
of the disease.

V. Chronic Peritonitis. — When acute in-
flammation of the peritoneum continues beyond
the fifteenth or twentieth day, it generally becomes
chronic : this species of the disease may, how-
ever, arise primarily from the exciting causes we
have before enumerated, operating on a patient of
advanced age or debilitated constitution. Parti-
cular occupations which cause pressure on the
abdomen, may predispose to or excite this disease,
to which may be added cold and moisture, pro-
longed residence in hospitals, fatigue, unwhole-
some food, protracted intermittents, and any kind
of slow effusion into the cavity of the abdomen.

We shall consider chronic peritonitis under two
heads: 1st, primitive, without being preceded by
symptoms of acute inflammation ; 2d, consecutive,
following as a consequence of acute peritonitis.

1. The primitive form may commence in a slow
find almost insensible manner, without presenting
any very obvious symptom. There may not be
any abdominal pain at its commencement or
during its course, and it may only exhibit the ap-
pearance of simple ascites : in many cases we can-
not ascertain with any certainty its presence dur-
ing life, but when it is more open in its characters,
they are identical with the consecutive form, the
symptoms of which vary considerably in the early
stages. It is in general attended with some ab-
dominal pain, which is mostly deep, not very acute,
and rarely permanent ; in many cases the patient
only complains of pain when his abdomen is
pressed either by the hand or the action of the
surrounding muscles, or on a sudden shock of the
body. There is occasional vomiting and more or

less distension of the abdomen, which sometimes
becomes tympanitic; and in some cases indurated
spots can be felt, which are tender to the touch.
Emaciation, irregular bowels, either constipation
or diarrhoea, or the one alternating with the other;
increasing distension of the abdomen, and inability
to bear even the pressure of the ordinary dress if
at all tight; various dyspeptic symptoms, and
general debility, mark the progress of the disease.
The alvine evacuations are sometimes of a pale
colour and peculiar fcetor, in other instances of a
dark appearance, and sometimes nearly natural.
(Abercrombie, p. 192.)

Dr. Pemberton observes that there is no tension
of the skin of the abdomen, as in the acute species;
on the contrary, that the skin and abdominal
muscles sit loosely upon the peritoneum, which
gives a sensation to the touch, as of a tight band-
age underneath, over which the skin and muscles
may be said, as it were, to slide. (On Diseases
of the Abdominal Viscera.)

In some patients the appetite is often preserved,
and the digestion is but little deranged, in which
cases we may conclude that the peritoneum re-
flected over the stomach is not very deeply in-
volved in the disease. Broussais mentions the
sensation of a ball rolling about in the abdomen,
and sometimes approaching the throat, which he
attributes to the agglutination of the intestines,
these forming, with the gorged mesenteric glands,
a round and mobile mass in the belly, often with-
out any effused fluid. (Lond. Med. Chir. Review,
Sept. 1820, p. 170.)

The general phenomena are very obscure : the
pulse is often natural, except towards evening,
when it becomes quick, with increased heat of
skin, and slight flush on the cheeks, and occasion-
ally some dyspncea and cough. Dr, Pemberton,
however, observes that though the pulse is some-
what accelerated, and the tongue, particularly in
the morning, slightly covered with a white fur,
with considerable thirst, he never observed any
exacerbation of fever in the evening, or any hectic
flushes on the cheeks : on the contrary, the coun-
tenance is full of languor, and the face is pale and
doughy.

In some forms of the disease, the abdomen be-
comes augmented in volume, yields a dull sound
on percussion on a part or the whole of its sur-
face, and occasionally presents the sense of fluc-
tuation more or less obscure, with an cedematous
swelling limited to the inferior extremities or
parietes of the abdomen. (Chomel, Diet, de
Medecine.) In other forms, the abdomen rather
diminishes than augments in volume, and offers
an unnatural resistance on pressure, with, occa-
sionally, some degree of projection near the
umbilicus, occasioned by the intestines matted
together in a mass before the bodies of the ver-
tebra?.

W T ith more or less of these symptoms, the disease
advances slowly, and sometimes remains stationary
for several months, and even may in some cases
present some temporary amendment ; but it gene-
rally terminates fatally, either by tiie supervention
of acute peritonitis or enteritis; or the patient
sinks from exhaustion, the result of long-con-
tinued irritation or diarrhoea. In some instances,
ascites precedes the fatal termination, or purulent

516

PERITONITIS.

effusion into the abdominal cavity takes place,
which may escape outwardly by the umbilicus or
inguinal ring : or the tubercles which have been
developed on the peritoneal surface may ulcerate,
and form a communication between the intestines
and cavity of the peritoneum, with escape of the
contents of the former into the sac of the perito-
neum, inducing acute peritonitis, which proves
rapidly fatal ; or disease of the mesenteric glands
may be induced, and the patient dies in a state of
marasmus with hectic symptoms.

The diagnosis in this disease is extremely
obscure, and is rather to be deduced from a close
consideration of the history of each case, the pre-
disposing and exciting causes, and the assem-
blage of local symptoms, than from any definite
rules.

Its prognosis in general is unfavourable. M.
Broussais, in an early edition of his work, con-
sidered it as incurable ; afterwards, however, he
met with several cases which terminated favour-
ably. Dr. Abercrombie succeeded in curing some
cases in individuals whose families had formerly
suffered from this affection. Dr. Pemberton states
that the symptoms which indicate recovery are an
abatement of the pricking pains in the abdomen,
and a diminution of the frequency of the pulse to
eighty in a minute; but that under these favour-
able appearances a relapse is always to be dreaded.

Morbid Anatomy of Peritonitis. — The
alterations which the peritoneum presents after
death from this disease, are essentially the same
as are found in cases of inflammation of other
serous membranes. The morbid effects are greater
or less, according to the intensity and duration of
the disease. They are sometimes confined exclu-
sively to the peritoneum, evidencing that this
membrane may be partially or generally inflamed,
without the subjacent tissues being affected : how-
ever, in some of the complicated forms of this dis-
ease, morbid lesions of the other intestinal tunics
will be occasionally discovered to coexist with
those characteristic of peritonitis.

The following are the effects of inflammation
of the peritoneum, as far as they are revealed by
dissection :■— - 1. increased vascularity and thick-
ening of the peritoneum; 2. effusion of coagulable
lymph, either in the form of flocculi, membranes,
bands, or masses ; 3. effusion, into the peritoneal
cavity, of various fluids, serum, pus, or blood,
mixed or separate ; 4. gangrene ; 5. tuberculous
formations ; 6. granulations on the peritoneal sur-
face ; 7. ulceration.

1. Morbid appearances in acute peritonitis. —
The first effects of a low degree of inflammatory
action upon serous membranes appear to be simply
an increased deposition of the serous fluid ; and
in this manner it is probable that a certain state
of these membranes, which, if not actually inflam-
matory, closely borders upon it, is sometimes
relieved ; the increased quantity of fluid being
afterwards absorbed, and the parts recovering their
healthy relations. (Abercombie, p. 3.)

When inflammation is fully established, its
earliest effect is increased vascularity, which pro-
duces at first a slight degree of opacity of the
membrane, and red points begin to appear on its
surface, which may either occupy a small portion,
or cover nearly the whole extent of the perito-

neum ; the surface of which at this time appears
dry and shining, but on touching it an unctuous
coating will be detected. Sometimes, instead of
the red points, blood-vessels are developed, form-
ing red stria; more or less numerous. As the in-
flammation advances, the small points become
multiplied, coalesce, and form patches of variable
extent, and the blood-vessels become more evident
and numerous. In a more advanced stage, the
redness is rendered more intense, and occupies a
larger portion of the membrane; sometimes form-
ing broad surfaces of inflammation, which run like
bands along the course of the intestines, and are
bounded by the adhesions which different portions
of the bowels contract with each other. This
redness is frequently arborescent, sometimes inter-
mixed like network. The vascular injection has
been supposed by some to exist in the arterial
capillaries; but Dr. Armstrong observes, that
whatever may be the case during life, it is after
death chiefly seated in the venous capillaries ; for
on a minute inspection, the small ramifications of
the arteries may be seen empty, traversing the
intermediate portion of intestine, like so many
transparent lines. The degree of redness is ulti-
mately influenced by the quantity of secretion
being greater in those cases where there is least
serum and lymph.*

Along with this redness we observe more or
less thickening and opacity of the peritoneum;
an effect produced not only by the hyperemia of
the inflamed part, but also by the effusion of
serum, lymph, or both, into the subserous cellular
tissue, which causes some degree of pulpiness,
and a facility in separating the serous coat from
the subjacent parts. The serous membrane itself
is also thickened by the effused fluid penetrating
between its lamina;, and separating them more or
less from each other, and in some instances a
slight degree of emphysema exists, from the dis-
engagement of air in the connecting cellular tissue;
but when the inflammation is slight, this thicken-
ing is not apparent.

The intestines are much thicker and more
massy, as well as the mesentery and the mesoco-
lon ; and the omentum sometimes is rendered as
thick as a person's hand ; effects which arise from
the extravasation of coagulable lymph into the
cellular substance between the lamina; of perito-
neum which forms them. (Baillie's Morbid Ana-
tomy.

Redness and thickening may be considered as

* Iff. Pcoutettcn asserts that this redness, when intense,
is not owing to the distension of the blood-vessels, but JJ
a sanguine exudation whirl) is formed on the surface of
tlir peritoneum, and which adheres strongly to it; and
that the surface is uniformly red, and appears villous.
Both causes probably concur to produce tin- effect.

Bicbat, M. Gasc, and others, have asserted that the
absence of redness on the peritoneal surface after death
may occur in cases where the membrane was inflamed
during life. M. Scoutelten, (Archives Generates, t"'"-
iii. p. 501,) however, from some experiments he
formed on living animals, has come to a contrary con-
clusion : he asserts that the disappearance of redness
from an inflamed external surface after death is owing
to the pressure of the atmosphere, which has hut a very
modified influence on an internal tissue; and that, con-
sequently, the characters of inflammation are very nearly
the same in those tissues during life and alter death: bis
experiments ace highly ingenious, and would seem to
justify the conclusion he lias deduced from them, vil
that an inflammation of an internal membrane will •*
every case leave increased redness after death.

PERITONITIS.

517

the Crst effect of peritoneal inflammation ; but it
is accompanied or quickly followed by effusion of
serum and lymph, which have been supposed to
be separated simultaneously. Dr. Armstrong,
however, seems to think that the lymph is first
effused ; but it would appear that the degree of
intensity of the inflammation determines the na-
ture of the effusion. When the inflammation is
not very violent, scrum seems to be the earliest
product of the vessels of the affected part ; but if
the inflammatory action is very acute, lymph is
often thrown out in the first instance. This effu-
sion of lymph may take place a very short time
after the commencement of inflammation ; it is' at
first soft and gelatinous, afterwards becomes more
consistent, and finally assumes the texture of a
membrane of considerable tenacity. It generally
soon becomes organized : Andral (Clinique Me-
dicale,) observes that in some cases, twenty hours
after the commencement of peritonitis, vessels can
be traced and injected in this fibrous concretion,
which has become a living texture ; in other cases,
after several months, no trace of organization can
be found in these membranous layers. This
coagulable lymph may assume various forms ; it
may either be deposited in a lamina of variable
thickness, lining the peritoneal surfaces, aggluti-
nating the intestines to each other, to the abdo-
minal parictes, or to the omentum ; or narrow
bands of membrane, of variable length, may con-
nect two or more coils of intestine together ; or a
mass of lymph of a prismatic form may lie between
the intestinal convolutions, filling up their inter-
stices, the anterior flat surface of which mass cor-
responds to the parietes of the abdomen, and the
two other surfaces, slightly concave, are applied on
the two contiguous intestines, and terminate in
their interval by a rounded angle. The lymph
may also be in the form of flocculi, or small shreds
of membrane, floating in a serous fluid, or depo-
sited on the free surface of the peritoneum when
little or no fluid is found.

These false membranes are either of a white
colour, grey, or sometimes a little reddish ; they
vary in their thickness from a quarter to two or
three lines. When the inflammation has lasted
twenty or thirty days, these adhesions acquire a
considerable degree of firmness ; they are often
productive of no inconvenience, but if very nume-.
rous, and uniting the coils of intestine very closely
together, they may give rise to a modification of
the form of the belly, an habitual tension in the
abdomen, and more or less disturbance in the di-
gestive functions. Dr. Abercrombie relates some
cases where fatal ileus seemed to be induced by
the operation of such causes, which appeared to
act by deranging the muscular power of the intes-
tinal canal, or by inducing a strangulation of a
portion of intestine.

Serous effusion, as we have before observed,
may take place very early in this disease ;* but
in general it is not considerable in quantity until
the affection has existed for some time. This,
however, is not always the case .- in some in-
stances, after thirty-six or forty hours, there is a
large quantity of fluid effused ; it is generally

* In some cases of peritoneal inflammation the secre-
tion of this membrane is suspended, and it appears dry.

2t

accumulated in the inferior parts, unless retained
in distinct cavities by adhesions. Its colour varies
very much ; it is sometimes limpid ; and that is
principally the case when the peritonitis has been
partial : -\ at other times it is whitish, greyish,
milky, or yellowish, and occasionally has all the
sensible properties of pus. Dr. Abercrombie ob-
serves, that the opaque milky deposition is com-
monly connected with alteration of the structure
of the membrane, which in such instances pre-
sents a soft thickened appearance, resembling a
part that had been boiled. The more common
appearance of the peritoneum consists of a depo-
sition of false membrane, coexisting either with
the milky flocculent fluid, or with pus, or a fluid
entirely limpid. In the latter case the deposition
on the surface of the membrane will prevent the
re-absorption of the fluid ; so that the accumula-
tion which might otherwise have disappeared will
thus become a permanent cause of ascites, pro-
vided the disease does not prove speedily fatal.
(Abercrombie, p. 3.)

This effusion is sometimes reddish, evidently
from a mixture of the colouring matter of the
blood ; and in the hemorrhagic variety of perito-
nitis, large quantities of blood in a coagulated
state have been found by M. Broussais in the
peritoneal cavity, without any rupture of vessels
being detected, accompanied with extensive ecchy-
moses of the cellular tissue which unites the peri-
toneum to the contiguous parts.

The quantity of fluid effused in peritonitis
varies from a few ounces to several pounds ; its
consistence is sometimes that of water, without
containing any albuminous clots ; at other times
it equals that of milk or the pus of the cellular
tissue, and often contains the flocculi before men-
tioned.

The peritoneum is seldom found in a state of
gangrene in its whole extent ; but eschars of
varrable size, and of a greyish slate-colour or
bluish, are formed, which are easily lacerated,
and exhale a fetid odour. The surface of these
eschars is often covered with a greyish soft mat-
ter, little adherent, which appears to be the com-
mencement of decomposition : these eschars some-
times pervade the entire thickness of the intestinal
tunics, or the great epiploon, or extend deeply into
the abdominal parietes.

There are certain brownish, black, or violet
degenerations of the peritoneum which have been
mistaken for gangrene, but are only the results
of chronic irritation ; they are easily distinguished
by not being readily torn, by being destitute of
the gangrenous odour, and by the great extent to
which the peritoneum is discoloured, the entire
membrane being sometimes affected. These ap-
pearances are a common consequence of chronic
peritonitis.

Ulceration very rarely occurs as a consequence
of peritonitis; though not unfrequently the perito-
neum is perforated in cases where the ulcerative

t nichat observes that, when serous effusion? are the.
consequence of an affection of a viscus, the serosity is
limpid, transparent, and probably of the same nature
with that which is exhaled in its natural state; but
that on the contrary, when the effusion depends on in-
flammation of serous membranes, the fluid is almost
always altered. (Roche et Sanson, Elemens de Patho-
logic, torn. i. p. 552.)

518

PERITONITIS,

process, commencing in the mucous membrane,
erodes the other coats of the intestines ; this natu-
rally leads us to consider peritoneal ulcers as of
two kinds: — 1. primitive ulcers, or those which
occur primarily in the peritoneum as a direct con-
sequence of inflammation ; 2. consecutive ulcers,
or those which originate in the intestinal mucous
membrane.

There are not many cases on record of primi-
tive ulceration of this membrane. M. Scoutetten
observes, that if the patient is not exhausted, and
continues to live for some time, erosions of the
peritoneum, at first slight, become by degrees more
and more deep, and are converted into true ulcers,
which may extend and destroy all the membrane,
and even the subjacent tissues. (Archive Gene-
rales, torn. iv. p. 392.) In a patient who had
suffered from a venereal affection, and had expe-
rienced pains in the lumbar region, most severe at
night, M. Portal found, on examination of the
abdomen after death, several ulcers covered with
pus in the peritoneum situated on the anterior of
the lumbar vertebra and of the kidneys. The
same author cites Bouet and Paw as having seen
subjects in whom the peritoneum appeared eroded
to a great extent. (Anatomie Pathologique, torn,
v. p. 126.) M. Scoutetten observed the dia-
phragmatic portion of the peritoneum ulcerated in
one case to the extent of two inches ; and there is
a case also mentioned by the same author, in
which, after symptoms of peritonitis, the abdomi-
nal parietes were perforated at the umbilicus, and
a whitish fluid of the consistence of pus escaped
from the abdomen. We have before mentioned,
in treating of partial peritonitis, that purulent
effusions in this form of the disease occasionally
escape by an opening into the stomach or intes-
tines ; from this we would infer that ulceration
of this membrane may occur more frequently than
is generally supposed, but there are not many
cases of this description on record.

Consecutive ulceration is much more frequent,
and will be fully considered in the article Perito-
nitis from perforation of the serous membrane.

2. Morbid appearances in chronic peritonitis.
— The organic changes which are the consequence
of chronic peritonitis are very nearly the same as
those which result from the acute form. There
are some peculiarities, however, belonging to the
chronic species which deserve attention. In chro-
nic peritonitis, the redness, the result of increased
■vascularity, is of a darker hue, and the larger
branches of veins are more considerably dilated.
(Armstrong, p. 76.) The peritoneum has ac-
quired a greater thickness, and the inflammation
appears to have penetrated to the subjacent mem-
branes and organs. The false membranes are very
numerous and firm, and unite many coils of in-
testine ; sometimes they form a kind of envelope
which surrounds the great epiploon and the intes-
tines, and sometimes partial pouches are formed
by false membranes which contain a quantity of
fluid : when these membranes are detached, we
find the subjacent peritoneum less red than in acute
peritonitis. In some subjects scarcely any liquid
is found : in these cases the false membranes are
less abundant and less thick ; and the intestines
are united to each other by the adhesions which

the inflammation has caused them to contract, and
not by intermediate albuminous layers. (Scoutet-
ten, Arch. Gen. torn. iv. p. 387.)

In some subjects, on the other hand, a con-
siderable quantity of effusion is found without any
false membrane on the peritoneum, which is
thickened, reddish, and exhibits a multitude of di-
lated blood-vessels. The epiploon is red, thick
and fleshy, and sometimes contains between its
laminse transparent vesicles like hydatids, and sub-
stances resembling granulations are occasionally
seen on its surface.

When the peritonitis has been of several
months' duration, it sometimes occurs that the
abdominal parietes are not distended by effusion
but are pressed close to the intestines. The epi-
ploon is covered with a crowd of whitish tuber-
cles of variable size, surrounded with blood-vessels
more or less developed. These tubercles may also
exist on any part of the peritoneal surface: Dr.
Armstrong has found them under three modifica-
tions, 1. as small miliary points semi-transparent
and firm ; 2. as uniformly opaque bodies of a lar-
ger size and nearly of the colour and consistence
of the kernel of the ripe horse-chestnut ; and,
lastly, as soft white substances, not unlike cut por-
tions of the medullary matter of the brain. The
first and second modifications are seated in the
subserous cellular tissue, and likewise between the
mucous and muscular intestinal coats; but the
soft medullary variety appears to be formed in ge-
neral on the free surface of the serous membrane
itself. (Morbid Anatomy, &c.) Tubercles at first
are extremely minute, but they gradually increase
in size and number, and sometimes coalesce : they
occasionally exceed the size of a large pea. When
small, they are of considerable consistence, and
adhere with such tenacity to the peritoneum, that
they can only be separated by tearing this mem-
brane ; but as they increase in magnitude, they
become softer, and approach in their appearance
to pus, when they can be easily detached. After
being softened, they may again become indurated,
and are sometimes converted into a calcareous
matter. Occasionally, when they have existed
for a considerable time, the peritoneum in the in-
tervals between the tubercles becomes of an ob-
scure red colour, or bluish or black, and presents
a strong contrast with the white appearance of the
tubercles. These bodies may ulcerate and give
rise to perforation of the intestines ; when tuber-
cles exist, there is generally only a small quantity
of fluid in the abdomen, which may be of differ-
ent shades of colour from a grey to a black. In
most instances, where they have been found on
the peritoneum, they existed simultaneously in
other organs, especially the lungs. If the symp-
toms which characterize a tuberculous diathesis
coexist with signs of chronic inflammation or ir-
ritation of the peritoneum, we may have some
reason to suspect a tuberculous state of this mem-
brane.

M. Bayle has described certain bodies which he
calls granulations, presenting a pisiform white
appearance, and being of a hard consistence, not
unlike miliary eruptions of the skin ; but M-
Broussais supposes they are nothing more than a
transformation of the exuded matter which passe)

PERITONITIS.

519

from a liquid to an organized state. (History of
the Chronic Phlegmasia) of Broussais, by Hays
and Griffith, vol. ii. p. 294.)

Chronic irritation may produce several other
morbid changes on the peritoneum or the subse-
rous tissue, the detail of which would include
nearly the whole of the morbid anatomy of this
membrane. It may become cartilaginous, bony,
or scirrhous. The mesenteric glands may be-
come diseased and tuberculous. Broussais has
found vesicles resembling hydatids, and extensive
lardaceous depositions, in the subserous cellular
tissue. This fatty matter was not only deposited
under the peritoneum, but also between the lami-
nse of the mesentery and omentum ; it was of a
white or yellow appearance like tallow, and mixed
with a gelatino-albuminous fluid of thinner con-
sistence and darker colour, which gave the whole
mass a mottled appearance. He supposes this
the result of chronic inflammation of the subse-
rous tissue, but whether those productions are al-
ways to be considered the effects of inflammatory
action is doubtful. They at all events are not the
usual results of this state ; and it appears neces-
sary that a peculiar disposition to such formations
must pre-exist in the constitution, which may be
called into action, and determined to any particu-
lar structure or organ by the existence of chronic
inflammation or irritation there.

M. Scoutetten* has described a morbid appear-
ance, which he considers as peculiar to primitive
chronic peritonitis. It consists of a number of
greyish spots formed by little points, the number
and close propinquity of which determine the in-
tensity of the colour of the spots, which are some-
times brown or even of a black hue. These
spots vary in number, and are sometimes only a
line, and in other instances, an inch in extent.
They are occasionally accompanied with an in-
creased development of vessels. [M. Andral
(Cours. de Pathologie Interne) regards the black
patches as melanic] Minute yellowish vesicles
are also sometimes seen, and an abundant serous
effusion almost constantly coexists, in general
transparent, because the inflammation has not been
sufficiently active to change entirely the mode of
secretion.

Treatment. — The general principles of treat-
ment which are applicable to other internal in-
flammations are equally so to this ; with some
modifications, however, arising from the nature of
the texture affected, and from its relations to the
organs which it covers. We shall first consider
the treatment of this disease in the infant, and
afterwards in the adult, and lastly speak of the
management of chronic peritonitis.

1. Treatment of infantile peritonitis. — Our
principal remedy in infantile peritonitis is the ab-
straction of blood, either general or local. In an
infant under six months, though general bloodlet-
ting may often be required, yet a sufficient quan-
tity can usually be obtained by the application of
three or four leeches to the hand or foot, where
we can easily control the hemorrhage, which can-
not be done so effectively if the leeches be applied

* Archives Generates, torn. iv. p. 398. We have been
much indebted to this author for information on the
morbid anatomy of the peritoneum. This essav con-
tain! more information on this point than any author
we have consulted.

to the abdomen. Applied to the extremities they
are nearly as efficacious in removing local inflam-
mation in infants, as when applied to the vicinity
of the part affected. They seem to produce the
same result as a general bloodletting, as the face
and lips become pale, the pulse falters, and syn-
cope followed by vomiting occasionally takes place.
These effects are apt to be produced when general
bloodletting is carried to a considerable extent;
and sometimes a state of nervous agitation and
general commotion is induced, which, if not
speedily removed, may terminate in death. The
best remedies in a case of this kind are the hori-
zontal position, cool air, and a drop or two of the
tincture of opium. (Dr. Cuming, Transactions
of the King's and Queen's College of Physicians
in Ireland, vol. v. p. 49.)

Where general bloodletting is practised, from
two to three ounces may be abstracted from an
infant between six and twenty months old ; at
two years from three to four ounces ; and when
the age is above four, about five, six, or eight
ounces may be drawn according to circumstances.
After the inflammatory action is lowered by the
abstraction of blood, advantage will be derived
by establishing and keeping up an open state of
the bowels, but we should avoid effecting this by
irritating medicine. Small doses of calomel alone,
or combined with a little of the pulv. corn. ust.
cum opio, if the stomach is irritable, followed at
intervals by castor oil or emollient enemata, will
in general be found to answer sufficiently well.
Fomentations to the abdomen will tend much to
relieve the pain, and should be often repeated, and
continued for some time ; or we may put our little
patient for a few minutes in the warm bath. If
it is judged necessary to apply counter-irritation
to the abdominal surface, warm flannel sprinkled
with turpentine appears to us much preferable to
blistering, as it produces a sufficient rubefacient
effect, without the injurious consequences which
blisters often produce on infants. The recom-
mendation of M. Billard to remove the child from
the breast, appears to us questionable. The sud-
den alteration in diet would be very apt to produce
derangement of the stomach or bowels, a compli-
cation which would add to the danger of the
patient. If the acute symptoms subside, and it
seems probable from the continuance of abdominal
tumefaction, slight dyspnoea, quick weak pulse,
dry tongue, and hot skin, that the affection has
passed into the chronic state, we should suspend
or be sparing of evacuations : a leech or two to
the abdomen may occasionally be necessary. The
strength is to be supported by animal broths, ar-
row-root, &c. ; the bowels regulated by calomel in
the combinations above recommended, according
to circumstances. The warm bath may be occa-
sionally useful; also counter-irritation to the ab-
dominal surface, and in some cases mercurial in-
unction.

Treatment of peritonitis in the adult. — Acute
peritonitis, though generally attended with consi-
derable danger, yet in the greater number of cases
admits of a cure by active and early treatment.
The following are the indications which we should
have in view : 1. to reduce the action of the heart
and vascular system ; 2. to diminish the hyperse-
I mio. of the affected part ; 3. to allay local and go-

520

PERITONITIS.

neral nervous irritation ; 4. to restore the secre-
tions to a natural state, and to excite the peristaltic
action of the bowels ; 5. to relieve urgent symp-
toms. Copious and early bloodletting are the
most efficient means we can employ for the reduc-
tion of vascular action. This is indeed the prin-
cipal therapeutic agent in this disease, in which it
can be employed to a greater extent than in in-
flammation of mucous surfaces. Its efficacy is
greater according as it is used early, and carried
to such an extent as to make a decided impression
on the system. The quantity abstracted is to be
regulated by our estimate of the capability of the
patient's constitution to bear depletion, and not
by any arbitrary rule of quantity. We have seen
five or six ounces produce as decided an effect on
a delicate female as thirty ounces on a robust pa-
tient. We should take the blood from a large
orifice, and allow the stream to flow either until
the pain is relieved, or weakness of the pulse,
paleness, and tendency to syncope is induced; the
apparent debility which the patient exhibits in the
onset of the disease is not to deter us from active
depletion. The pulse commonly rises after vene-
section, and becomes fuller and softer, and the
patient feels relieved and lightened, rather than
exhausted by its employment. The advice which
Dr. Abercrombie gives on the employment of
bloodletting in this disease we have experienced
the value of in many cases : viz. " to follow up
the first bleeding by small bleedings at short inter-
vals, when the effect of the first begins to subside:
in this manner we prolong, as it were, the impres-
sion which is made by the first bleeding, and a
twofold advantage arises from the practice —
namely, that the disease is checked at an early
period, and that the quantity of blood lost is, in
the end, much smaller than probably would be
required under other circumstances : if we allow
the patient to lie after the first bleeding ten or
twelve hours, or even a shorter period, the effect
of it is entirely lost, and a repetition of it, to the
extent of twenty ounces, may be required for pro-
ducing that effect upon the disease, which by a
former method might be produced by five. And,
besides, the disease has been in the interval gain-
ing ground, its duration is protracted, and the
result consequently rendered more uncertain. The
inflammation of a vital organ should not be lost
sight of for above an hour or two at a time, until
the force of it be decidedly broken ; and unless
this takes place within twenty-four hours, the ter-
mination must be considered as doubtful."

[In these cases, the combination of free blood-
letting with opium, as advised under another head,
(see Narcotics,) is often of the most marked
advantage.]

The efficacy of bloodletting will depend in a
great measure on its early employment, but we
are not to abstain from it altogether at even an
advanced period of the disease. If we have not
been so fortunate as to see our patient in the com-
mencement of the attack, still if the state of col-
lapse has not been formed, if (here is still some
pulse and heat of surface, with abdominal pain
and tenderness, we may abstract a moderate quan-
tity of blood from the system with a chance of
pioducing a good effect; or in debilitated patients
apply leeches : but when the symptoms indicative

of sinking arc present, it would be obviously im-
proper to take blood either generally or locally, as
it would only hasten the fatal termination, ami
bring undeserved reproach on a valuable remedy.

Having reduced the general vascular action by
the lancet, our next object should be to diminish
the quantity of blood in the affected part by local
bleeding, which will also assist in keeping up the
constitutional effect produced by venesection.
Gooch, (Diseases of Females, p. 45,) has well
observed, " that as long as the pulse is quick, full,
and hard, it is in vain to take blood from the
affected part ; if we could completely empty its
gorged capillary vessels, they would be instantly
gorged again, whilst the heart and large arteries
are injecting them with so much violence. On
the other hand, after having reduced the force of
the general circulation, the capillary vessels of the
part often remain preternaturally injected. This
I conclude from the fact that the patient is often
not relieved till local bloodletting has been used,
and then is relieved immediately."

Having allowed the patient to recover from the
faintness produced by the general bleeding, the
abdomen should be slightly fomented with warm
water, wiped frequently dry, and leeches should
be applied in numbers proportioned to the urgency
of the symptoms and strength of the patient.
They should be especially concentrated over the
parts where most pain and tenderness on pressure
exist ; and after they have fallen off, fomentations
with cloths dipped in warm water should be assi-
duously applied and repeated for some time,
which will both encourage the bleeding and soothe
the irritation of the inflamed parts. The applica-
tion of leeches may be repeated several times, as
long as any considerable soreness remains.

Either before or during the application of the
leeches, and as soon as possible after the vascular
action has been reduced by venesection, from five
to ten grains of calomel combined with one or
two of opium should be administered, which may
be repeated in diminished doses every three or
four hours. By this combination, the constitu-
tional and local irritation consequent on the in-
flammation, and which has a tendency to aggra-
vate it, will be allayed by the narcotic ; and the
secretions, which have been more or less suspended
or deranged, will be restored by the mercury,
which modifies its action, and determines it to the
skin, and is also supposed to equalize the circula-
tion. After the second or third dose of this medi-
cine, the bowels may be opened by mild aperients,
aided by enemata : castor oil, in doses of from
half an ounce to an ounce in some aromatic
water, may be given if the stomach is not irrita-
ble. If vomiting is urgent, the Rochelle salts
with the subcarbonate of soda, in a state of effer-
vescence with lemon-juice, may be used in re-
peated doses, so as to produce a moderately laxa-
tive effect. Strong purgatives are highly injurious,
and even a small dose of castor oil may exaspe-
rate the disease, if used previously to depletion.
Having evacuated the bowels, the use of the
calomel and opium should be resumed, and con-
tinued till the mercury has affected the system.
As soon as salivation is established, we have
generally found the symptoms become much miti-
gated, and our experience accords with that of

PERITONITIS

521

Dr. Gooch, who remarks that whenever the gums
were ■fleeted in this disease, the patients invaria-
bly recovered. The establishment of mercurial
action not only assists in subduing the inflamma-
tion, but may prevent or remove those effusions
of lymph which afterwards form adhesions that
are often the source of future mischief.

In addition to these means, the warm bath may
occasionally be useful, or repeated fomentations
to the abdomen will tend much to relieve the pain
and soreness. Counter-irritation, by means of
blisters, after local and general bleeding, is gene-
rally recommended ; but we have not been much
in the habit of employing them. While much
inflammatory excitement prevails, they would
prove injurious, and at any period of the disease
their application would deprive us of the most
important means we possess of ascertaining the
degree of tenderness by pressure. The applica-
tion of warm flannel dipped in turpentine we con-
ceive a good substitute, and it will generally pro-
duce a rubefacient effect.

Oil of turpentine, which was first recommended
by Dr. Brennan of Dublin, in puerperal peritonitis,
may be useful internally in certain forms of the
disease, but we conceive it requires to be used
with caution ; it acts as a powerful cathartic, and
at the same time excites the general system ;
hence it would obviously prove injurious, while
much heat of skin, frequent pulse, and indications
of active local inflammation were present ; but in
a debilitated patient, after the acute symptoms
have been subdued, or in cases of puerperal peri-
tonitis accompanied with typhoid symptoms, or
where general and local bleeding cannot, from
the delicacy of the patient's constitution, be car-
ried to the requisite extent, it may be employed
with advantage.

During the whole course of our treatment, the
strictest antiphlogistic regimen should be observed.
Light farinaceous diet, in small quantities, and
rice or barley-water for drink, are most suitable
for the patient ; but if symptoms indicative of a
sinking of the vital powers should appear, wine
and other tonics may be necessary. Dr. Aber-
crombie used injections of beef-tea and cinchona
with advantage.

When we have carried venesection to a consi-
derable extent, and have reduced the vascular
action to such a degree as renders the abstraction
of more blood inadmissible, if we still find pain
and tenderness present, the exhibition of a full
opiate, followed by fomentations or a warm poul-
tice to the abdomen, will sometimes remove the
symptoms. If vomiting is urgent, it may some-
times be checked by saline draughts with tincture
of opium, or by leeching and blistering the epi-
gastrium. When the pulse continues very fre-
quent after the inflammation appears to be sub-
dued, Dr. Abercrombie recommends the use of
digitalis.

A tympanitic state of the abdomen at an ad-
vanced period of the disease may occur from mere
loss of tone, after the inflammation has been sub-
dued. Small quantities of wine or brandy may
be given at short intervals. Frictions of the ab-
domen, and injections of beef-tea, bark, or sulphate
of quinine, turpentine, or tincture of assafcetida,
with a moderate quantity of laudanum, may be
Vol. III. — 66 2t*

repeated every two or three hours. The bowels
may be moved with mild laxatives, such as aloetic
wine, or aloes and hyoscyatnus, but laxatives re-
quire to be given with the utmost caution. The
authorities for the tobacco injection in inflamma-
tion of the bowels are numerous : among others,
De Haen, Fowler, Abercrombie, and Howship,
have recommended this remedy ; the latter author
relates three cases in which, having tried bleeding,
the warm bath, and stimulating injections without
effect, the fume of tobacco cautiously injected
caused a general commotion and rumbling noise
in the bowels, which was soon followed by copious
evacuations of faecal matter. The patients were
all saved. (Practical Observations, p. 19.)

During convalescence the greatest care is neces-
sary in order to prevent a relapse. The patient
should observe the strictest temperance in his
diet, and return with great caution to the use of
animal food or wine. The bowels should be kept
regular, the feet warm, and flannel worn next the
skin for a long time after every symptom has dis-
appeared.

Treatment of Chronic Peritonitis. —
Chronic inflammation of the peritoneum, when
far advanced, is in most cases incurable, especially
when the false membranes and other morbid pro-
ductions are considerable in quantity, or when it
coexists with a tuberculated state of the perito-
neum or subjacent cellular texture, such substances
being for the most part incapable of absorption ;
but where the effusion consists of serum, with
but little or no solid productions, our chance of
success is greater. Much will depend on arrest-
ing the disease at an early stage, at which time a
degree of subacute inflammation often exists,
which will require, with some modifications, the
same treatment as the acute form. At every
period in this disease, when the abdominal pain
and tenderness are present, and the constitution
of the patient is not very much debilitated, blood
may be abstracted from the system to the extent
of six or eight ounces at a time, which may be
repeated twice a week until those symptoms have
disappeared. The application of leeches also may
be frequently adopted ; this will be found the
most effectual mode of relieving the abdominal
soreness. All faecal accumulations should be pre-
vented, and the bowels kept regular by the gentlest
aperients or enemata, but active purgatives should
be avoided, as they may be productive of serious
evil. The warm bath or fomentations to the ab-
domen may be frequently employed, and will
assist much in allaying irritation and pain, and in
determining to the surface. Blisters may also
occasionally be applied to the abdomen, or the ex-
ternal application of turpentine, as recommended
in the acute form, will be found useful in relieving
the abdominal tenderness.

The antiphlogistic regimen is to be observed to
a certain extent, and light nutritious diet, com-
posed principally of the farinacese and milk, in
limited quantities at a time, appears the most
suitable. Muscular exertion, or pressure on the
abdomen, will be found to aggravate the symp-
toms, and are of course to be avoided ; but in
some cases gentle exercise in a carriage will pro-
mote the general health. A sea voyage has been
recommended, and may be useful.

522

PERITONITIS.

During the whole course of the disease we are
to guard against the supervention of acute inflam-
mation, which may be induced by a very slight
exciting cause, and is especially to be dreaded, as
the patient, from his debilitated state, could not
bear the evacuation which would be .necessary
for its removal. When the pain and soreness are
mitigated, if serous effusion exists, its absorption
will be promoted by diuretics. Digitalis, either
in the form of infusion or tincture, may be given
conjoined with the alkalis arid the spirit of nitric
ether ; but care should be taken to excite as little
irritation of the stomach or intestines as possible.
We have found the ioduretted ointment of Lugol,
mixed with equal parts of mercurial ointment, ap-
plied by friction to the abdomen, a powerful means
of exciting absorption in cases of ascites conse-
quent on peritonitis. In some instances it sur-
passes our expectation in producing the complete
removal of considerable ascites in a few weeks.
We have also in some cases exhibited at the same
time internally the aqua mineralis iodinse of the
same author, and found it a valuable auxiliary.
Broussais strongly recommends the introduction
of diuretic medicines, such as the tincture of can-
tharides or squill, by means of friction on the skin,
and it may be proper to try this mode of exciting
diuresis, when, from irritability of the stomach,
we cannot give diuretics internally. Anodynes
may occasionally be necessary, and we should
select those which do not produce constipation,
such as hyoscyamus or conium. Rigid abstinence
has been recommended as a means of producing
absorption, (Med. Chirurg. Rev. Sept. 1820. p.
187,) and in some cases perhaps it may be tried,
but it will be improper where the patient is much
debilitated by a protracted disease. Where all
inflammatory symptoms have subsided, and a state
of exhaustion remains while the effusion con-
tinues, tonics combined with diuretics may be
cautiously tried. We have in such cases derived
considerable advantage from the exhibition of the
ferrum tartarizatum in solution, combined with
the spiritus junip. comp. : it appeared to improve
the patient's general health, and excite the action
of the kidneys at this period of the disease. The
antiphlogistic regimen will require to be relaxed
a little, and more nutritious diet in small quantities
may be allowed. D H Mac Adam

VI. Peritonitis from Perforation of the
Serous Membrane. — This most severe and ge-
nerally fatal form of peritonitis is the result of a
solution of continuity of the peritoneum, which
may arise from various causes, and occur in vari-
ous portions of the sac. In most cases the result
of this accident is the introduction into the sac of
the peritoneum of some solid or fluid substance
which produces a sudden, and generally universal,
inflammation, so that the principal characters of
this form of disease are, the suddenness of the
attack, the terrible rapidity and violence with
which the disease runs to its fatal termination,
and its resistance to ordinary medical treatment.
It will be found that in some of the cases, the
particulars of which will be detailed, all these
peculiarities were not observed, but we shall find,
notwithstanding, that the above characteristics
will apply to the disease in general. The follow-

ing are the most common causes of the accident :
— 1st, external injuries, either of the solid or
hollow viscera of the abdomen, or of the parietal
peritoneum merely ; 2dly, rupture of the bladder
from distension, and of the uterus during parturi-
tion ; 3dly, rupture of some portion of the digestive
tube, from the gelatinous softening of its coats ;
4thly, ulcerative perforation of the serous mem-
brane, arising either from disease in any part of
the subdiaphragmatic portion of the digestive tube,
from suppurations of the solid viscera opening into
the peritoneum ; from ulceration of the bladder or
ovaries ; or from perforation of the diaphragm by
purulent collections on its thoracic surface.

If we examine these different causes with respect
to their frequency, it is plain that from the first
order arise most cases of the disease. In this
order, — which includes surgical operations on the
peritoneum, — the introduction of irritating sub-
stances into the peritoneal cavity is by no means
a necessary occurrence, although, in the case of
rupture from external violence, we see the worst
examples of this formidable occurrence; for, as
will appear presently, the opening in such case
is generally much more extensive, whereby the
quantity of matter introduced comes to be greater,
and the closure of the orifice much more difficult.
In the present article we shall principally con-
sider that form of peritonitis which results from
perforation of the tunics of some portion of the
digestive tube, — an occurrence in the great majo-
rity of cases, the result of circumscribed ulceration
of the mucous membrane and glands. The study
of this form of the disease tends to elucidate those
cases which arise from other causes.

It is necessary to remark, in the first place, that
ulcerative perforation of the intestinal tunics does
not necessarily imply a consequent effusion of
the contents of the tube into the peritoneal
cavity ; for it may happen in many chronic and
even in some acute cases, that in consequence
of adhesions being formed between the two sur-
faces of the peritoneum, at a point corresponding
to the situation of the ulcer, the contents of the
tube are prevented from escaping into the general
cavity. Thus, the serous membrane covering the
opposite fold of intestine, or some of the solid
viscera, may come to form the base of an ulcer
which originally was wholly unconnected with it.
Again, it may happen that this new base to the
ulcer may in it£ turn give way, and an unnatural
communication be thus formed between two essen-
tially different portions of the tube, and the fajcal
contents pass across the serous membrane, but not
enter hs cavity. A remarkable case of this de-
scription is described by Dr. Abercrombie. The
patient, who was fifty-six years of age,
laboured for two or three weeks under imp
appetite, languor, and occasional pain in the abdo-
men, when he was suddenly seized, while walking,
with vomiting of fiscal matter, but felt no other
inconvenience until about a week after, when a
similar attack recurred ; he was then seen by Dr.
Combe, who found him looking unwell, but with
a natural pulse and good appetite. The bowels
were easily regulated, and no signs of organic
disease could be detected. After this time the
vomiting returned at various intervals, sometimes
three or four times a day, and sometimes he was

PERITONITIS.

523

free from it a week at a time. The matter ejected
always consisted of pure feces, sometimes so con-
sistent that it was brought up with difficulty until
he diluted it by swallowing hot water. During
the course of this affection, the body continued
regular or easily regulated, and the matter vomited
completely resembled that which was passed from
the bowels. No tumour could be detected by ex-
amination; his appetite continued good, and he
was never observed to vomit food or other matters
taken into the stomach. In this state he lived for
three months, and died gradually exhausted, with-
out any particular change in the symptoms, except
that a week before his death he vomited a con-
siderable quantity of blood. On dissection, the
stomach was found contracted and adhering to
the parietes of the abdomen on the left side, and
to the arch of the colon. At the place of the ad-
hesion a soft tubercular mass was formed, which
Seemed in general to be about two inches in thick-
ness. The stomach appeared externally healthy ;
internally it showed a mass of ulceration which
occupied the whole of the great curvature, and
covered about one-half of its inner surface. The
pylorus and whole pyloric extremity were healthy.
In the centre of the ulcerated part there was a
ragged irregular opening fully two inches in
diameter, which made a free communication with
the arch of the colon ; and around the opening
there was also some ulceration of the mucous
membrane of the colon. The intestines in all
other respects were healthy. The small intestines
were empty ; the caput coli was distended with
feculent matter, and the colon throughout con-
tained healthy well-formed feces. (On Diseases
of the Stomach, &c.) Chomel has described a
case in which the duodenum communicated with
the colon through the medium of the gall-bladder.
(Andral, Precis d'Anatomie Pathologique.) In
another case on record, a communication existed
between two loops of intestine formed by a little
canal about two lines in length and eight in width,
which was lined by a mucous membrane continu-
ous with that of the intestinal tube.

Many cases are recorded of perforating ulcers
of the digestive tube communicating with the
solid viscera. Thus the base of an ulcer of the
colon has been found constituted by the tissue of
the kidney ; ulcers of the stomach have been
found resting on the spleen ; Rayer has described
an ulceration of the duodenum, the basis of which
was a portion of the liver. The effusion of the
contents of the stomach from ulceration is com-
monly prevented by the pancreas, the substance
or the peritoneal coat of which forms the base of
the ulcer. In this way a perfect cicatrix may be
formed, and the health of the individual be pre-

In most of these cases of perforation without
effusion, a partial and very circumscribed peri-
tonitis ensues, which, by its adhesions, prevents
the escape of the contents of the intestine. It is
further to be remarked that this occurrence is
commonly the result of a chronic disease, so that
time is afforded for the exudation and organization
of lymph. But we are not to conclude that this
adhesion always takes place in chronic ulcerations ;
the contrary is the fact, as will be shown present-
ly. In recent ulcerative perforations, effusion of

the intestinal contents is, as might be expected,
the almost constant result ; but we have seen a
case where not only one but several perforations,
the result of recent ulcerations, occurred, and yet
where no effusion of fecal matter took place.
The following are the particulars of this remark-
able case.

A young woman was admitted into the Meath
Hospital in the beginning of the year 1829. She
had enjoyed good health until thirteen days pre-
vious to her admission, when she was attacked
with cough, followed on the next day by symp-
toms of fever. She complained of cough and
dyspncea ; there was great prostration of strength,
the skin was hot, and the tongue covered with a
white paste. She took saline purgatives and
effervescing draughts without relief. Headach
and deafness supervened.

Two days before admission she complained of
pain in the epigastric region, which was removed
by leeching. On the 24th of January, the day
of her admission, she had intense bronchitis.
Respirations 40, and pulse 130 in the minute.
There was great restlessness, and the belly was
tympanitic. For the next nine days all her suf-
ferings seemed referable to the chest ; but on the
2d of February she had a certain degree of ten-
derness in the epigastric region. This was again
removed by the use of leeches, and for eleven
days there was no prominent abdominal symptom ;
but the distress of respiration and the signs of
bronchitis continued without alleviation. The
exhibition of tartar-emetic was now resorted to ;
and though it produced vomiting, yet the thoracic
symptoms improved so much, and without any
sign of abdominal disorder, that great hopes were
entertained of her recovery. The skin became
cool, the pulse fell to 100, and the deafness
gradually disappeared. On the 12th of February,
however, there was a severe relapse. The thora-
cic symptoms became again violent, with some
epigastric tenderness. She sank on the following
day.

On dissection, the lungs were found filled with
miliary and granular tubercles; in some places
hepatized, and presenting signs of intense inflam-
mation in the bronchial mucous membrane. A
small quantity of sero-purulent matter was found
in the cavity of the pelvis. The small intestines
were glued together by flakes of unorganized
lymph ; and on separating their folds, we disco-
vered four perforations, each sufficiently large to
admit a quill. These corresponded to recent
ulcers in the muciparous glands, which had per-
forated all the coats of the intestine, and, in fact,
rested on the serous membrane of the opposite
fold. No fecal matter whatever was discovered
in the cavity of the peritoneum.

We here see a case where, from recent disease,
no less than four large perforations occurred with-
out any fecal effusion ; a circumstance explicable
by the formation of lymph around each of the ori-
fices, which we must suppose to have taken place
prior to the giving way of the serous membrane
at the base of the ulcers. Accordingly, the usual
symptoms of peritonitis from effusions of the con-
tents of the intestine did not occur. The glueing
together of the small intestines, and the fluid in
the pelvic cavity, must be then considered as r*

524

PERITONITIS.

suiting from the extension of the different (at first '
local) inflammations of the serous membrane ; a
circumstance not to be wondered at when we |
consider that the disease was acute, the fever high,
and the points of irritation of the serous mem-
brane numerous. How far the latency of the ab-
dominal inflammation is to be explained by the
coexistence of intense thoracic disease, we shall
not now inquire.

Peritonitis from perforation of the intestinal
tube, and effusion of its contents, is, as might be
expected, almost always a violent and fatal dis-
ease. It is violent, because it arises from the in-
troduction of a highly irritating fluid into the sac,
and dangerous in the highest degree from the seat
of the inflammation ; it is, moreover, kept up by
the continued ingress of faecal matter through the
perforation, and derives further malignancy from
having supervened in a subject already attacked
by another disease. In fact, although in a few
cases the patients have shown some power of re-
sistance to the disease, and have lived for several
days from the occurrence of the accident, yet these
cases may well be considered as exceptions.

But are vie to believe that the effusion of the
intestinal contents is inevitably followed by a vio-
lent and acute peritonitis ? A case recorded by
Andral is in opposition to this opinion. It was
that of a young person labouring under phthisis,
through whose umbilicus a round worm (ascaris
lumbricoid.es) was discharged. He lived for seve-
ral weeks after this occurrence, and during each
day a small quantity of faecal matter escaped
through the umbilical fistula. On dissection a
chronic peritonitis was discovered, and the serous
cavity contained a fetid fluid quite similar to that
which had passed through the umbilicus, and in
which were several lumbrici.

It is obvious that such a case as this, though of
great rarity, is not without its analogies in other
systems. We know that the occurrence of a pul-
monary fistula is not necessarily followed by vio-
lent symptoms ; that the pleuritis may be so latent
as that the period when the fistula was formed
shall be quite uncertain. As a general proposi-
tion, then, it may be stated that in both the peri-
toneum and pleura a fistula, through which for-
eign substances pass into the sac, may form with-
out violent symptoms or acute inflammation.
These cases, however, are exceptions to the gene-
ral rule ; and the cause of the absence of acute in-
flammation in such instances is still to be sought
for. Perhaps the anaemic state of the body, as in
phthisis, may have some influence.

When we examine the different diseases in
which, at some period, a sudden change in the
physical relations of parts takes place, we ob-
serve, in most cases, that this sudden change is
accompanied by striking symptoms, the sudden-
ness of which leads to the diagnosis. For exam-
ple, the paralysis, which is the result of an apo-
plectic effusion, comes on suddenly ; and by this
is distinguished from that from softening of the
brain, which comes on gradually. Again, a pa-
tient has a recognised aneurism of the aorta : if he
drops down dead, the great probability is that an
internal rupture of the tumour has occurred. If
the signs of an abscess of the liver suddenly dis-
tppear, with copious expectoration, or with a

diarrhoea, a vomiting, or a peritonitis, we diagnoi-
ticate a solution of continuity, an opening into
the lungs, the digestive tube, or the peritoneum.
When a tuberculous or other abscess opens into
the pleura, the empyema and pneumothorax are
ushered in by new and violent symptoms. The
same observations apply to the diagnosis of rup-
ture of the uterus and bladder.

Now, although cases of exception may be met
with in every one of these diseases, yet they are
so rare that the general applicability of the diag-
nosis — as drawn from the suddenness of new
symptoms — is not much infringed on. Apoplexy
may occur with gradual symptoms. We have
already stated that a tuberculous abscess may per-
forate the pleura without violent symptoms, and
so on. On the other hand, suddenness of inva-
sion of new symptoms may be observed without
any solution of continuity. Yet both the want
of suddenness and violence of symptoms in cases
of rupture, and their occurrence where no solution
of continuity exists, are to be looked on as excep-
tions to a general rule.

We shall now detail some examples of perito-
nitis from perforation of different portions of the
digestive tube. " A young woman, aged eighteen,
had been affected for about six months with varia-
ble appetite and occasional pain in the stomach,
which made her frequently sit with her body bent
forward, and her hand pressed upon the epigastric
region. Little notice was taken of the attacks, as
she was going about, and otherwise in good
health ; and for some weeks previous to the attack
now to be described, her appetite had greatly im-
proved. On the 26th of November, 1824, while
in a room by herself, she was heard to scream
violently ; and when a person went into the room,
she was found unable to express her feelings, ex-
cept by violently pressing her hand against the pit
of the stomach. When she was soon after seen
by Mr. M'Culloch, she was moaning as if in ex-
treme agony, but was unable to speak. The pulse
was 86, and very weak. She could scarcely
swallow ; but soon after vomited the contents of
the stomach, which seemed to be merely food
which she had recently taken. Various remedies
were employed without relief. She continued
with every appearance of extreme suffering till
seven o'clock in the morning of the 27th, when
she said the pain was considerably easier, but was
still very severe in the pit of the stomach, and
was extending downwards over the abdomen.
The abdomen was now becoming distended ; and
when we saw her, about three o'clock in the after-
noon, it was distended to the greatest degree, and
very tense. The pulse was extremely feeble ; she
was scarcely able to speak, but her countenance
was expressive of extreme suffering. Nothing
afforded the smallest relief, and she died about
two in the morning — twenty-nine hours from the
attack. Inspection. — The cavity of the perito-
neum was distended with air, and likewise con-
tained upwards of eight pounds of fluid of a whit-
ish colour and fetid smell. There was slight but
extensive inflammatory depositions on the surface
of the intestines, producing adhesions to each
other and to the parietes of the abdomen. On the
upper part of the small curvature of the stomach
near the cardia, there was a small perforation of

PERITONITIS.

525

a size which admitted the point of the little linger.
Internally, this opening communicated with an
ulcerated space on the mucous membrane about
the size of a shilling, with slightly thickened and
hardened edges, and a considerable perpendicular
loss of substance. The stomach in all other re-
spects was entirely healthy." (Abercrombie,
Researches on the Diseases of the Stomach, &c.
p. 35.)

We have given this case at full length, as it
may be considered as an example of the mode of
inflammation of the serous membrane in these
cases, both as to invasion and termination. In
this case, and in some to which we shall just now
allude, the perforation was the result of a chronic
but circumscribed irritation. In another case de-
scribed by Dr. Abercrombie, the peritonitis sud-
denly supervened in a subject apparently affected
with chronic dyspepsia, in which the prominent
symptoms were severe pyrosis and occasional
vomiting. In consequence of a careful regulation
of regimen, the stomach had recovered its healthy
functions, and the patient's general health had be-
come excellent; but he was obliged to observe
great caution in regimen, from the occasional re-
currence of slight attacks of his former symptoms.
During one of these slight attacks, he was sud-
denly seized with excruciating pain in the pit of
the stomach, some vomiting, coldness of the body,
and a small frequent pulse. No relief was afforded
by treatment, and death took place in thirty hours
from the attack. On dissection, extensive recent
peritonitis was shown, and a perforating ulcer of
the stomach near to the pyloric portion. The
stomach, with the exception of the perforating
ulcer, and another, the base of which was formed
by the surface of the liver, was perfectly healthy.
(Op. cit. p. 37.)

In this case there can be little doubt of the con-
nection between the primary symptoms and the
ulcer, the base of which was formed by the sur-
face of the liver ; and in all probability there
would have been a permanent cure, had not the
second ulceration occurred.

In almost all the cases of this form of perito-
nitis, resulting from a perforation of the stomach,
symptoms of a chronic disease of this organ had
preceded the accident for a greater or less space
of time. Of these, local pain and vomiting were
the most frequent, but the degree of severity of
these symptoms, and their effect on the general
health, were exceedingly various. In some of
these cases a cancerous ulceration existed ; in
o'hers, the affection of the stomach was a simple
ciiuimscribed ulcer ; while in a third class, the
disease was the gelatinous softening (ramollisse-
■ment gelatiniformc) of the French authors.*

The immediate cause of the accident in by far
the greater number of these cases, was the pro-
gress of the destructive process ; but in two, the
ellbrt of vomiting seemed to be the cause of the
solution of continuity. Andral describes a case
of an individual who laboured under the symp-
toms of a cancerous disease of the stomach, and

*See Oerard, Dea Perforation's Spontanea <ie l'Es-
tuniac — Travers, Medico-Chirurgical Transactions.—
Oomptou, Ibid:— Journal Gen. de Medecine, 1^1.— Dr.
J. Crampion. Transactions of the Association of the

Kings and Queen's College of Physicians, vol. i.

who was suddenly seized with peritonitis during
the act of vomiting, which had been brought on by
an emetic. On dissection, a perforation of the
stomach was found in the centre of an old ulcera-
tion of the stomach. (Precis d'Anatomie Patho-
logique, torn, ii.)

In another case on Tecord, an old ulcer had ex-
isted, and had formed adhesions with the pancreas.
The perforation took place during the efforts at
stool, and was found to have occurred at one of
the extremities of the above-mentioned ulceration.
(Bouillaud, Archives de Medecine, torn, i.)

It is admitted that in some cases a perforation
of the stomach takes place in individuals who
were in the enjoyment of the best health ; and
that on dissection no evidence of a previously ex-
isting ulceration of the organ could be found.
Here the absence of gastric symptoms, previous
to the fatal attack of peritonitis, is not extraordi-
nary. But even a fatal ulceration of the stomach
may occur with singular latency, as in a case re-
corded by Dr. Abercrombie, where, in a strong
and healthy-looking girl, sudden and rapidly-fatal
peritonitis supervened. On dissection, a perforat-
ing ulcer was found in the smaller curvature, all
around which the coats of the stomach were found
greatly and extensively thickened. This girl had
been residing in the house in which she died for
four months, during which she was never known
to complain of her stomach, or to shou> the smallest
deviation from the most robust health. (Op. cit.
p. 41.) It appeared, however, that she had had
fever some months before this ; and in all proba-
bility this fever was symptomatic of, or connected
with, a gastritis.

We shall now proceed to examine what appears
to be the most common case of this disease, name-
ly, that in which it supervenes on a perforating
ulcer of the lower portion of the ileum. In the
great majority of these cases, the ulcerations were
recent and the disease acute. In many of them,
symptoms of a previous excitement of the muci-
parous glands were observed.

As Louis is the author who has drawn the at-
tention of pathologists more especially to this dis-
ease, we cannot do better than quote from his
memoir (Recherches Anatomico-Pathologiques.
Paris, 1826) the results of his observation of the
first eight cases which he describes. " The pa-
tients who have been the victims of this disease
were young and vigorous, with the exception of
the first, who was weak and of a lymphatic tem-
perament ; they had a good constitution, were
rarely ill, not addicted to excess, and presenting a
sanguine, a bilious, or a lymphatigo-sanguine
temperament. Almost all had been but a short
time in Paris. The causes of their disease were
unknown. If we except a single case, it com-
menced as a slight, continued fever, and presented
no severe symptom before the period of the perfo-
ration ; in but one patient was there a severe diar-
rhoea, which was, however, of short continuance;
in another, it had been moderate ; still less in the
subjects of the second and sixth cases, and not oc-
curring in the remainder. Those with whom the
diarrhoea was for a short time severe, had slight
pains in the epigastrium and more severe pain in
other portions of the abdomen, while in the re-
mainder they were very slight, or not at all pre

526

PERITONITIS.

eent before the period of perforation. Three of
them believed themselves convalescent, and were
considered so for some days, when the symptoms
of this lesion occurred. A fourth seemed to have
been cured rapidly of a slight enteritis ; so that
not only in these four subjects nothing occurred
which could lead to the anticipation of the disease
under which they sank, but it would have been
absurd, from the mildness of their symptoms, to
have apprehended any serious consequences. And
at this moment we have before us the history of
many patients who have died from an acute per-
foration of the intestine, and who, with this ex-
ception, presented no symptom which could dis-
tinguish them from analogous cases where there
was a rapid return to health.

" If the period of the formation of these ulcera-
tions cannot be accurately determined, we shall
scarcely be far from the truth in supposing that it
coincides with the first symptoms of the disease,
from which it would result that the progress of
these ulcerations has been very rapid, and that
they have arrived at their last period in from
twelve to twenty-five days, rarely later.

" At a certain period of the disease, on account
of which the patients had entered the hospital,
they experienced suddenly an exquisite and tear-
ing pain of the abdomen, rapidly followed by
alteration of the features, nausea and vomitings,
&c. &c. These symptoms continued with greater
or less violence from twenty to fifty-four hours,
presenting remissions which were more or less
well marked, and indicating a most intense perito-
nitis, produced by a violent cause acting in a sud-
den manner, just as occurs when an irritating sub-
stance is applied to the surface of the peritoneum.
It is by the reunion of these signs that the lesion
that now occupies us has been recognised by MM.
Lerminier, Chomel, and Martin Solon, under
whose care the patients were. From these cir-
cumstances it appears that we may regard the fol-
lowing as characteristic signs of perforation of the
intestine : if in an acute disease and in an unex-
pected manner a violent pain of the abdomen
suddenly supervenes, if this pain is exasperated
by pressure, accompanied by rapid alteration of
the features, and more or less promptly followed
by nausea and vomiting, ice may believe and
announce that there is a perforation of the intes-
tine."

This autho further remarks, that the most in-
tense pain of the belly suddenly supervening, and
accompanied by alteration of the countenance,
nausea and vomiting, will be insufficient to allow
us to make this diagnosis with certainty, unless
the pain is exasperated by pressure. It is not only
necessary that this character should exist, but also
that the pain shall extend rapidly to the whole
abdomen, so that, if it remains confined to the
point where it has first occurred, we cannot, not-
withstanding the coincidence of other symptoms,
declare that the intestine is perforated, or that any
other viscus has opened into the cavity of the ab-
domen. In illustration of this he states the case
of a man who had laboured under symptoms of
chronic gastritis, when he was suddenly attacked
with violent pain in the epigastrium, soon followed
by nausea, vomiting, and alteration of the counte-
nance. This pain, which was exasperated by

pressure, was confined to a very small space,
where it first occurred. It continued, along with
the other symptoms, for four days, when the patient
died, and on dissection was found to proceed from
an aneurism of the cceliac artery, which had rup-
tured, and caused an effusion of blood behind the
peritoneum.

It is not always that the pain, though occurring
under the above circumstances, continues until
death. In one of the cases of this lesion, which
occurred at the Meath Hospital, there was com-
plete cessation of pain and even of tenderness for
many hours before death. The patient declared
himself much better, yet the other symptoms of
peritonitis continued, such as the coldness of the
extremities, the rapidity of the pulse, the swelling
of the belly, and the Hippocratic expression. In
three of Louis's cases the same circumstance was
observed ; the countenance continued altered, the
nausea and vomiting persisted, the surface was
pale and of a violent hue, and the patients were
perpetually shivering and covering themselves
carefully up in the bed-clothes. They resembled
persons who, having taken a cold bath, cannot
again regain warmth.

We may be further assisted in the diagnosis of
perforation of the small intestine by the seat of
the pain as it first occurs. This is generally in
the ileo-ccecal region ; but it may no doubt be felt
in other situations, according to the place of the
perforation and the disposition of the intestine.

We have now witnessed a considerable number
of these cases, which occurred under our observa-
tion in the wards of the Meath Hospital. In nine
of these cases the diagnosis of perforation of the
intestine was made, and proved to be accurate by
dissection. It is scarcely necessary to remark
that the general features of these cases were the
same, namely, the sudden supervention of the
symptoms of peritonitis, and the rapid sinking
of the vital powers.

In three cases, the serous inflammation super-
vened during the existence of gastro-enteric fever
more or less well marked.

In one case, the symptoms came on on the
seventh day of a catarrhal fever.

In two cases, the disease occurred after symp-
toms of acute enteritis, which in one of the cases
followed a severe debauch.

In one case (which we have before mentioned),
the perforations, though numerous, yet did not
produce any well-marked symptoms, the patient
dying apparently of acute phthisis.

In one case, the symptoms occurred after an
hypercatharsis induced by an over-dose of salts.
The same cause appeared to produce the disease
in another patient, who recovered under the use
of large doses of opium, and to which we shall
hereafter allude.

In several of these cases there had been pre-
vious diarrhoea, which was suddenly checked at
the time when the perforation appeared to take
place ; but in one of them in which this had oc-
curred, a copious purging of natural coloured
faxes came on twelve hours before death. This
patient had used calomel freely the day before.

Another remarkable symptom was the irrita' on
of the bladder, showing itself by sudden inability
to pass urine, and constant efforts at micturition

PERITONITIS.

527

This irritation of the urinary organs occurred in
several cases, and in two was the very first symp-
tom observed. The bladder was found inflamed
in one case ; while in another it was merely con-
tracted and empty, with its mucous membrane
pale. This was remarkably the case in a patient
who was admitted in December 1830. This man
had enjoyed uninterrupted good health until three
days previous to admission, when, on getting up
in the morning to gratify the extreme desire to
pass water, he found himself unable to do so, the
attempt putting him to intolerable torture ; he had
pain in the region of the bladder, not so severe
when he was not attempting to pass urine. The
pain continued during that day, but towards night
became more easy, and he passed about ten ounces
of urine ; still all the attempts at micturition were
attended with considerable suffering. On admis-
sion he presented the general appearance of a per-
son affected with peritonitis : he had acute pain
in the right lumbar region, and great tenderness
in the umbilical, right iliac, and hypogastric re-
gions. What he complained of principally was
retention of urine ; yet the catheter showed that
the bladder contained but a few drops of turbid
high-coloured urine, and that the urethra was un-
obstructed. Towards evening, after the use of an
injection and venesection, he passed a small quan-
tity of urine, the countenance was Hippocratic,
and the patient died at three o'clock on the follow-
ing morning. On dissection, the usual appear-
ances of peritonitis from perforation were seen.
The perforating ulcer existed about eighteen
inches from the ileo-ccecal valve. Three other
ulcers existed lower down, which had not made
their way into the serous cavity. The peritoneal
surface of the bladder was highly inflamed.

In another case, where the symptoms succeeded
a bilious diarrhoea, the sudden supervention of the
pain was also accompanied by inability to pass
urine. On dissection, the perforation was found
large and corresponding to the fundus of the
bladder. And in a third case, in which the dis-
ease appeared on the seventh day of a catarrhal
fever, the first symptom of the perforation was
sudden inability to pass urine. In this case a
turpentine enema opened the bowels, and enabled
the patient to empty his bladder. Here the
opening existed about three inches above the ileo-
ccecal valve, and the mucous membrane of the
bladder was found highly inflamed.

In all our cases, evidences of a previously dis-
eased condition of the mucous glands of the in-
testine existed to a greater or less degree ; in some
instances accompanied by functional disturbance,
in others occurring in a perfectly latent manner.
Of this last remarkable fact many other instances
have been observed by authors.

The peritonitis thus supervening, as might be
expected, almost always runs its course in a very
short time. In the first nine cases recorded by
Louis, death took place in from twenty to fifty-
four hours, while in one case the patient lived
seven days from the first appearance of the symp-
toms of peritonitis. In this instance the symp-
toms, which had been violent at first, became
moderated at the commencement of the fourth
day, and during the remaining three days the pain
of the belly was very slight, and if the first

symptoms had not been so well marked, doubts
would have been entertained of the truth of the
diagnosis. " In confirming," says Louis, " those
diagnostic symptoms which we have established,
this observation is of great importance as con-
nected with prognosis, since it shows that when
once the signs of perforation have occurred, we
must not depart from our diagnosis and admit of
hope even after an arrest of symptoms, and an
apparent amelioration even of some days stand-
ing. This reserve is furthermore necessary from
the fact that the lesion that brought about the
perforation is not so soon arrested, and that the
first perforation may be followed by a second, and
even by a third. (Obs. vi. and vii.) This pro-
longation of life after so severe an accident is in
accordance with the variations which we so con-
stantly observe in the march of diseases, and
points out the analogy between perforations of the
intestines and those of the lung."

In our cases the length of time the patients
lived after the occurrence of the perforation, varied
from twelve to one hundred and twenty hours.
We find, on examining the results of nineteen
cases observed by ourselves, or recorded in the
works of different authors, in which the period of
the perforation could be accurately ascertained,
that the average length of time that the patients
lived after this accident was about twenty-nine
hours. In one of our cases, however, which we
have brought into this calculation, the patient
lived about one hundred and twenty hours ; and
in a case recorded by Louis, the perforation took
place on the 18th of May, and the patient lived
until the 25th of the same month. The shortest
period in which the fatal termination took place
seems to be in six hours. We may observe, that
in some of the cases which have entered into the
above calculation, the perforation occurred in the
stomach, and in one in the duodenum.

We have hitherto been principally occupied
with those cases of peritonitis from perforation in
which the symptoms were well marked, and in
which the intestinal contents passed into the cavity
of the peritoneum. It is a fact, however, that in
a very few cases this accident may supervene
without the ordinary sudden and violent symp-
toms : thus, in the ninth observation of Louis,
we read of a patient who was labouring under
fever with diarrhoea, in whom the symptoms which
appeared to correspond with the perforation were
delirium and shivering, which occurred in the
morning and continued till the evening of the
next day, when the patient sank ; there was also
increased meteorism, and the patient winced only
after a strong pressure of the belly. In this case
the perforation was not suspected, yet Louis in-
quires whether we might not, under similar cir-
cumstances, suspect a perforation of the intestine,
particularly when it is considered that peritonitis
without perforation is rare as occurring in the
course of acute diseases. He thinks that if, in
the course of a continued fever with diarrhoea, the
patient is seized with delirium, shiverings, and ;t
slight tenderness of the belly, which until tnen
had not been painful, we might be authorised to
suspect a perforation of the small intestine.

In the case of the young phthisical patient
recorded by Andral, through whose umbilicu-: a

523

PERITONITIS.

round worm (ascaris lumbricoides) was discharged,
the individual lived for some weeks after this oc-
currence.

It must be always borne in mind that the diag- I
nosis of peritonitis from perforation of the intestine
in ordinary cases, is founded on the greater proba-
bility that the peritonitis thus suddenly superven-
ing proceeds more from the introduction of irritat-
ing matters from the intestine than from any other
cause. It is plain also, that so far as the perito-
nitis is concerned, we shall observe the same gene-
ral symptoms in cases of the rupture of abscesses
into the peritoneal cavity, or the effusion of urine
from rupture of the bladder; but still a few cases
may occur where a sudden and fatal peritonitis
may supervene without solution of continuity of
the serous membrane of the peritoneum. We
need scarcely allude to strangulated hernia further
than to observe that, where the strangulated por-
tion is exceedingly small, so as not to be capable
of detection by external examination, the case may
closely resemble one from sudden perforation of
the intestine. Of this we witnessed a very re-
markable case, where a portion of the intestine
not larger than a small hazel-nut had become
strangulated. The symptoms supervened with
sudden pain, constipation, swelling, tenderness of
the belly, and the other signs of peritonitis.

In the article Hepatitis we have described a
case of peritonitis from the opening of an hepatic
abscess into the serous membrane ; in this case
the patient lived for eight days after the occurrence
of the perforation ; and on dissection we found
the false membrane of the peritoneum in progress
of organization, as shown by the existence of
large blood-vessels of a deep blue colour passing
through its substance, which had assumed a la-
minar structure.

It is scarcely necessary to remark, that the
prognosis in peritonitis from the introduction of
irritating substances into the cavity, must be un-
favourable in the highest possible degree, for two
reasons; — first, from the nature of the exciting
cause, which produces a rapid and universal in-
flammation ; and, secondly, from the previous
existence of some other disease which was the
cause of the perforation. Yet we believe that
even under these almost desperate circumstances,
we are not justified in abandoning the patient to
his fate without an attempt to save life by medical
treatment. We know that the peritoneum may
recover from inflammation after solutions of con-
tinuity in various portions of its extent, and hence
this circumstance merely, though dangerous in a
great degree, is not necessarily to lead us to
despair. It would seem that it is from the intro-
duction of irritating matters into the cavity that
the greatest danger is to be apprehended, and
hence to prevent or diminish the extent of such
an accident should be the principal object of the
physician. In cases of this description the prin-
ciples of treatment are, then, essentially different
from those of ordinary cases of peritoneal inflam-
mation.

In the second number of the Dublin Journal
of Medical and Chemical Science, the writer of
this article has shown the inapplicability of the
ordinary mode of treatment of peritonitis in those
cases. In most of them the powers of life sink so

rapidly that bleeding, either general or local, can-
not be attempted ; neither can we use mercury in-
ternally, from the danger of exciting the peristaltic
action of the intestine, which of course tends to
keep open the communication, and causes a fresh
ingress of fsecal matter into the sac ; nor can we
hope much from the external application of mer-
cury, from its slow action, and the improbability
of its affecting the system under these circum-
stances.

Yet, in a few cases, we find that the patients
may live for several days, and that a process of
organization of the effused false membrane may
be found to have commenced; and hence the two
great indications are, to support the strength of
the patient so as to gain time, and to diminish, as
far as possible, the peristaltic action of the intes-
tine. In the paper above alluded to, we have pro-
posed the use of opium in large doses for the treat-
ment of this form of the disease, to which we were
led from having witnessed the admirable effects of
that remedy in low cases of peritonitis in the
hands of Dr. Graves, who, eleven years ago,
treated successfully two cases of peritonitis after
paracentesis, and occurring in patients of a bad
habit, by means of opium in free doses, and with-
out abstracting a drop of blood. The same phy-
sician employed a similar treatment in a case of
abscess of the liver opening into the peritoneal
sac, and with success, as far as the cure of the
peritonitis was concerned. (See Dublin. Hos.
Reports, vol. 5. Dublin Journal of Medical and
Chemical Science, vol. 2.)

In the paper above alluded to, we have detailed
two cases, in which decided evidence of the utility
of this mode of treatment was obtained. In the
first, in which the symptoms of perforation had
existed for two days, and the patient was in almost
complete collapse, the use of sixty drops of the
black drop in the twenty-four hours, was followed
by most singular improvement : the pulse had be-
come full and soft, the extremities warm, and the
countenance had lost the Hippocratic expression.
The patient could bear pressure on the abdomen,
which the day before was exquisitely painful.
The same treatment being continued for twenty-
four hours longer, every symptom of abdominal
inflammation had subsided : the belly was natu-
ral and the pulse good. At this period the mildest
possible saline laxative was exhibited, which pro-
duced four evacuations, followed by an immediate
return of the symptoms of peritonitis, under which
the patient rapidly sank. On dissection, we found
universal peritonitis, but the intestines were every
where agglutinated together, except in the left
iliac fossa. The perforation existed in the csecum,
and was small ; and the mucous membrane of the
ileum and colon was but little affected.

The interest of this case consists, first, in the
decided advantage derived from the use of the
opium ; secondly, in the danger it shows to result
from any thing that excites the peristaltic action
of the intestine ; and thirdly, in the verification
of the diagnosis of perforation, and the evidence
of a process of cure having commenced.

In the next case the disease was of three days
standing, and it supervened suddenly from a hy-
percatharsis, produced by an over-dose of Glau-
ber's salts. The patient was apparently in the

PHLEGMASIA DOLENS.

529

last stage when the opium treatment was com-
menced. He was ordered a grain of opium every
hour. Next day the symptoms were decidedly
improved, and though he had taken twenty-
four grains, he had not experienced the slightest
coma, headach, or delirium. The same plan of
treatment was persevered in, the daily doses of
opium being gradually diminished until the tenth
day, when the convalescence being completely
established, the remedy was omitted. During
this time, diarrhoea set in for three or four days
severely ; this was treated by the application of a
few leeches to the anus, and the use of anodyne
cnemata. The patient took in all one hundred
and five grains of opium, exclusive of that in the
injections, without experiencing any of the usual
effects of this remedy in large doses.

When we connect these facts, and recollect
that, in bad forms of peritonitis, such as that oc-
curring after paracentesis in debilitated subjects, it
has been found successful, and also that its effi-
cacy has been proved in a case where the perito-
nitis supervened on the introduction of the matter
of an hepatic abscess into the peritoneum, it seems
justifiable to recommend the exhibition of opium
in free doses in cases of peritonitis from the in-
troduction of irritating matters into its cavity.
Of these cases, that from ulcerative perforation of
the intestine seems to be the one most likely to be
benefited by such a treatment, as in these cases
the solution of continuity is but of small extent,
the disease from which it has originated much
more often acute than chronic, and generally con-
fined to a small extent.

It is necessary to remark that in the treatment
of these cases, the strength of the patients must
be supported, and the greatest caution observed,
even for some time after the symptoms of perito-
nitis have subsided, in the use of any thing that
can excite the peristaltic action of the intestine.

William Stokes.

PERTUSSIS. See Hooping-Cough.
PHARYNGITIS. See Throat, Diseases
of the.
PHLEBITIS. See Veins, Inflammation

OF.

PHLEGMASIA DOLENS. Some of the
hypothetical names which have, up to the present
time, been employed by authors to designate the
disease which forms the subject of this article, are
— (Edema Lacteum, (Edime des Nouvelles Ac-
zouchees, Depots Laiteux, les Infiltrations Lai-
teuses des Extremites Inferieures, Hysteralgia
Lactea, Metastasis Lactis. As it has been de-
monstrated by the researches of recent patholo-
gists that the swelling of the affected limbs, and
nil the other local and constitutional symptoms of
this affection, invariably depend on inflammation
of the iliac and femoral veins, we propose to sub-
stitute the term crural phlebitis for phlegmasia
dolens, and the other names which have now been
mentioned and were in general use before the true
nature of the disease was ascertained.

We shall consider crural phlebitis as it is ob-
served, 1. in puerperal or lying-in women; 2. in
women who have not been pregnant; 3. in the
male sex.

Vol. III. —.67 2 u

1. Crural Phlebitis in Puerperal Wo-
men. — In the works of Hippocrates, Rodericus a
Castro, and Wiseman, we find obscure notices of
this disease. Moriceau was, however, the first
author who distinctly pointed out its characteris-
tic symptoms, and he referred the swelling of the
lower extremities to a reflux upon the parts of
certain humours which ought to be evacuated by
the lochia, of which he says, " le gros nerf de la
cuisse s'abrouve quelquefois tellement, qu'il en
peut rester a la femme une claudication dans la
suite." (Traite des Maladies des femmes grosses,
torn. i. 1688, p. 446.) It is not improbable, from
the manner in which Moriceau has expressed him-
self in this passage, that he had actually felt with
the finger the indurated and inflamed femoral vein
in the upper part of the thigh, which he mistook,
however, for a nerve, as some other observers
seem to have since done, for an inflamed absorb-
ent. When the disease was accompanied with
great fever, difficulty of respiration, pain, and ten-
sion of the abdomen, he considered the affection
to be dangerous in proportion to the severity of
these symptoms.

A more full account of crural phlebitis was
published not long after Mauriceau, by Puzos and
Levret, both of whom considered the swelling of
the limbs to depend on a deposit of milk in the
part.

Puzos states that it is a painful and protracted,
and sometimes a fatal disease, and that it occurs
most frequently about the twelfth day after deli-
very, though sometimes as late as the sixth week.
He also observed that one limb only is at first
affected, and that the pain and swelling com-
menced in the groin and superior parti of the
thigh, and descend along the course of the crural
vessels to the ham, and thence along the calf of
the leg to the foot. He observed, likewise, that
the disease attacked the other limb, and that it
presented the same appearances as the first affect-
ed. The extent of the mischief, he remarks, is
readily recognised by a painful cord formed by the
infiltration of the cellular tissue which accompa-
nies the crural vessels. " C'est dans l'aine et
dans la partie superieure de la cuisse, que le depot
commence a donner des signes de sa presence
par la douleur que l'accouchee y ressent ; et la
douleur suit ordinairement le trajet des gros vais-
seaux qui descendent le long de la cuisse ; elle
est meme plus vive dans tout ce trajet. On re-
connoit l'etendue du mal par une espece de corde
douloureuse que forme l'infiltration du tissu cellu-
laire qui accompagne ces vaisseaux, et l'enflure se
joint presque toujeurs a la douleur." (Traite des
Accouchemens, 4to. p. 350. Paris, 1759.) Tuzos
recommended repeated venesection, cathartics, and
sudorifics, and various local applications, as warm
fomentations, and embrocations of oil of almonds
with ammonia.

Levret's description of crural phlebitis strikingly
coincides with that of Puzos, and he refers the
disease to the crural vessels in so direct a manner
that it is singular he did not discover its precise
nature. When the disease attacks one side, a
tumour more or less considerable, he observes, is
found on examination in the iliac fossa. The
cord of crural vessels is also painful through a
great part of its course. "On distingue memo

530

PHLEGMASIA DOLENS

souvent, dans toute son etcndue, de pctites tu-
raeurs olivaires qui l'entourent 5a et 14." (L'Art
des Accouchemens, p. 932, 2d ed. Paris, 1761.)

In a manuscript copy of Dr. William Hunter's
Lectures, taken in 1775, no account is given of
this disease ; but from the following note, written
by Mr. Cruikshanks to Mr. Trye, at the time he
was engaged in the publication of his work on the
subject, it is evident that Dr. Hunter had seen
cases of crural phlebitis, and was convinced that
the opinions of Puzos and Levret respecting the
nature of the disease had no solid foundation.
« They have imputed the swelled leg, which hap-
pens after lying-in, to a depot de lait, but it is
not : to something wrong in the constitution ; the
patient is first seized with pain in the groin, the
pulse becomes smart, and the part becomes tender,
the pain and tenderness get gradually lower down,
and the muscles are stiffened into hard bumps, and
an oedema frequently succeeds the inflammatory
swelling. It is generally called a cold, but it is
not. In some it is over in a short time, in others
it will last some months ; it generally does well."
In the year 1784, Mr. White of Manchester
published an " Inquiry into the nature and cause
of that swelling in one or both of the lower ex-
tremities which sometimes happens to lying-in
women," and he suggested or adopted the opinion
that the disease depends on obstruction, detention,
and accumulation of lymph in the limb, or on
some other morbid condition of the lymphatic
vessels and glands of the affected parts. He con-
sidered it to arise from some local accident during
labour, and to be a purely local disease. Mr.
White saw fourteen cases, either during or subse-
quent to the attack ; but as none of them proved
fatal, an opportunity was not afforded him to de-
termine the truth of his hypothesis by an exami-
nation of the actual condition of the different
textures of the affected extremities.

An essay on the swelling of the lower extremi-
ties incident to lying-in women was published in
17S2, by Mr. Trye, of Gloucester, in which he
referred the symptoms to rupture of the lympha-
tics as they cross the brim of the pelvis under
Poupart's ligament. Six cases came under the
observation of Mr. Trye, and in all recovery like-
wise took place. He clearly perceived, although
he was not able to explain the fact, that an inti-
mate relation subsists between puerperal fever
and the swelled leg of lying-in women. Dr.
Ferriar soon after maintained, without the slight-
est evidence, that there is a general inflammatory
state of the absorbents in this disease.

Dr. Hull published an essay on phlegmasia
dolens in 1800, in which he satisfactorily showed
that it was impossible to account for the phe-
nomenon of the disease on the supposition that
the lymphatics were affected independently of a
considerable primary affection of the sanguiferous
system of the limb. He considered the proximate
cause to consist in an inflammatory affection pro-
ducing suddenly a considerable effusion of serum
and coagulating lymph from the exhalants into
the cellular membrane of the limb. All the tex-
tures, muscles, cellular membrane, lymphatics,
nerves, glands, and blood-vessels, he supposed to
become affected. (An Essay on Phlegmasia Do-
lens, by John Hull, M. D. Manchester, 1800.)

It is a remarkable circumstance in the history
of crural phlebitis, that nearly a century and a
half should have elapsed from the time when it
was first clearly pointed out by Mauriccau, before
an opportunity was presented of ascertaining by
dissection the precise nature of the disease. There
had indeed been opportunities to determine the
accuracy of the different hypotheses which had
been advanced, but these were neglected, and
the seat of the disease and its commencement in
the uterus were imperfectly understood until the
writer of this article ascertained by dissection the
true nature and origin of the complaint. (Patho-
logical Researches on inflammation of the Veins
of the Uterus, Med. Chirurg. Trans, vol. xv. 1829.)
In January, 1823, M. Bouillaud related several
cases and dissections in which the crural veins
were obliterated in women who had suffered from
a swelling of the lower extremities after deli-
very ; and M. Bouillaud distinctly stated that he
considered obstruction of the crural veins to be
the cause, not only of the oedema of the lower
extremities in lying-in women, but of many par-
tial dropsies.

« Elizabeth Perfu, set. 38, was received," he
says, " into the Hospital Cochin two months and
a half after her delivery. She had tuberculous
phthisis, and the left lower extremity was infil-
trated with serum. She died in three months, and
on opening the body the veins of the affected ex-
tremity were found plugged up with a very old,
red-coloured, easily broken-down fibrinous coagu-
lum, which extended into the common iliac vein.
The vena cava and the other veins were healthy,
and contained more or less liquid blood."

Marguerite Colliere, aet. 30, was delivered by
the forceps in the Maternite, about the end of
January, 1822. She entered the Hospital Cochin
on the 20th March following, having the left
lower extremity greatly swollen and infdtrated with
serum. She died on the seventh day after. An
enormous abscess was found in the pelvis, which
appeared to have commenced on the left side of
the cavity before and within the psoas muscle.
All the surrounding parts were extensively disor-
ganized. The coats of the left iliac veins were
thickened, and their interior layers were altered
in structure, and converted into a lardaceous sub-
stance. The whole of the veins of the inferior
extremity were plugged up with a solid friable
clot.

M. Bouillaud observes that Chaussier and
Meckel had both before related cases of swellings
of the lower extremities in puerperal women,
where the crural veins had been found inflamed
and obstructed. (Archives de Medecine, torn. U>
Janvier, 1823.)

In May, 1823, the valuable essay of Dr. Davis
on Phlegmasia dolens was read before the Medi-
cal and Chirurgical Society, subsequently pub-
lished in the twelfth volume of the Transactions.
Although the cases of M. Bouillaud were pub-
lished four months before Dr. Davis's paper was
read, it does not admit of dispute that Dr. Davis
was the first who proved by dissection that phleg-
masia dolens depended on inflammation of tt> e
iliac and femoral veins. So early as 1817 a fata'
case occurred to him, which was examined bj
Mr. Lawrence, in which the iliac and

PHLEGMASIA DOLENS,

531

reins were found inflamed and obstructed. Two
other cases were recorded by Dr. Davis, and an-
other by Mr. Oldknow, in all of which there were
proofs of the previous existence of inflammation
of the crural veins. (Med. and Chirurg. Trans,
vol. xii. 1823.)

For six years after the publication of the cases
of M. Bouillaud and Dr. Davis, pathologists re-
mained in doubt whether these cases should be
considered as examples of genuine phlegmasia
dolens, or be viewed as essentially different dis-
eases, and analogous in their nature to those for-
midable attacks of phlebitis which sometimes suc-
ceed to venesection and wounds. In opposition
to the views of Dr. Davis, it was forcibly urged
that if phlegmasia dolens depended on inflamma-
tion of veins, three out of four patients would die;
whereas death does not take place in one case in
an hundred where that disease is distinctly marked.
Even that distinguished pathologist, Mr. Law-
rence, who had examined the first fatal case which
occurred to Dr. Davis, declared in the Medical
and Chirurgical Society, as late as 1828, that he
was fully convinced from what had subsequently
fallen under his observation, that Dr. Davis's views
were incorrect, and that phlegmasia dolens did
not arise from inflammation of the iliac and femo-
ral veins. Dr. Davis has communicated no addi-
tional information on the subject since 1823, and
he is still of opinion that the inflammation com-
mences in the common iliac, and not in the veins
of the uterus, and that the disease is produced by
the pressure of the gravid uterus during preg-
nancy.

In none of the cases of Dr. Davis does it appear
that any attempt was made to trace the hypogas-
tric veins to the uterus, though it is now certain,
from what is known respecting the progressive
changes witnessed in cases of phlebitis, that the
alteration of structure which he has described
must have originated in the veins of the uterus.

Thus, then, none of the writers who have been
hitherto quoted have made any allusion to phleg-
masia dolens commencing in the uterine veins;
and even Mr. Velpeau, the latest continental
author on the subject, has given it as his opinion
that the affection of the veins is not the primitive
disease, but is the consequence of the inflamma-
tion and suppuration of the articulations of the
pelvis, with which he observed it to be frequently
combined. The puriform fluid found within the
veins he supposes to have been introduced into
their cavity by absorption, and not to have been
the effect of inflammation, nor the cause of those
affections of the articulations, which is now known
to be the case. How far this opinion was incor-
rect, we need not now point out.

It is due to Mr. Guthrie to mention, that in a
paper on inflammation of veins after amputation,
published in the Medical and Physical Journal
for 1826, he suggested the importance of tracing
the veins from the common iliac of the affected
side down to the uterus, and expressed a suspicion
that the disease would be found to originate in
that organ.

All the authors who have treated of phlegmasia
dolens describe it as commencing, in the great
majority of cases, subsequent to the tenth day
after parturition, with symptoms of uterine irrita-

tion and constitutional disturbance of a low ty-
phoid character, and with pain and swelling in
one extremity only. They have assigned various
reasons for these remarkable peculiarities, in the
period and mode of development of the disease,
as pressure of the gravid uterus on the iliac veins
during gestation, the change in the distribution of
the blood from the sudden removal of this pres-
sure, exposure of the extremity to cold, suppres-
sion of the lochia, deposits of milk in the limb ;
all of which, taken singly or combined, are insuf-
ficient to account for the phenomena ; and the
occurrence of the disease after menstruation, abor-
tion, and the malignant affections of the uterus,
proves that these causes are neither necessary nor
sufficient for its production.

The numerous cases and dissections of which
the writer of this article has published detailed
histories in the Medical and Chirurgical Transac-
tions, and in a recent work on the " Pathology
and Treatment of some of the most important Dis-
eases of Women," offer a more satisfactory, and, he
trusts, a conclusive explanation of the phenomena.
They demonstrate, that if inflammation be excited
in the uterine branches of the hypogastric veins,
it may continue to spread along these until it
reaches the common external iliac and femoral
veins, and by the morbid changes induced in them
give rise to all the subsequent symptoms.

The two following cases are here introduced,
not merely because they were the first in which
crural phlebitis was distinctly traced into the ute-
rine veins, but as they afford good examples of
this affection in its most mild and most severe
forms, and illustrate, better than any general de-
scription could do, the phenomena of the disease,
and the alterations of structure produced by in-
flammation in the hypogastric and crural veins.

A patient of the British Lying-in Hospital, who
had been suffering for some weeks before delivery
(May 8, 1829) from the usual symptoms of tuber-
cular phthisis, experienced, on the 4th June, a
sense of soreness in the left groin, which gradu-
ally extended along the inner surface of the thigh
to the ham, and from thence along the posterior
surface of the leg to the foot. She stated that for
two days before the occurrence of pain in the
groin, she had felt great uneasiness in the region
of the uterus, that this suddenly quitted the hypo-
gastrium and passed into the groin, and that from
thence it extended downward along the inner sur-
face of the thigh to the leg. The limb became
swollen twenty-four hours after the invasion of
the disease.

The whole left inferior extremity is now affected
with a hot, painful, colourless swelling, no where
pitting on pressure, except over the foot. The
thigh is fully double the size of the other, and any
attempt to move the limb produces excruciating
pain along the inner surface of the thigh ; and the
pain excited by pressure along the tract of the
femoral vein is so acute, that the condition of the
vessel cannot be ascertained. Several branches of
the saphena major, above the knee, are distended
and hard ; pulse 120 ; respiration quick and labo-
rious; tongue peculiarly red and glossy ; diarrhoea
continues. 10th. Pulmonary affection aggravated.
The limb continues extremely painful, and is still
more swollen. The groin is so tender that she

532

PHLEGMASIA DOLENS.

cannot bear the slightest pressure over it. The
same is the case with the inner surface of the
thigh. The branches of the saphena are still
hard and painful. 11th. The femoral vein under
Poupart's ligament can now be felt indurated and
enlarged, and it is exquisitely painful when
pressed ; as is the inner surface of the thigh, the
ham, and the calf of the leg. There is compara-
tively little tenderness along the outer surface of
the limb. 17th. Diarrhoea, emaciation, colliqua-
tive sweats, and difficulty of respiration increasing.
The left inferior extremity is still much swollen ;
but there is less pain in the groin and in the
course of the femoral vessels. Died on the 24th.

Dissection. — Thorax. Adhesions between the
pleura on both sides. Scarcely a portion of lung
could be observed which did not contain tubercles
in various stages of their growth. The right and
left superior lobes contained several large tubercu-
lous excavations. The vena cava and right com-
mon and external iliac veins were in a sound state.
The left common external and internal iliac veins
were all impervious, and had undergone various
alterations of structure. The common iliac, at its
termination, was reduced to a slender tube, about
a line in diameter, which was lined with a bluish
slate-coloured adventitious membrane. The re-
mainder of the common and the external iliac
veins were coated also with a dark-coloured mem-
brane, and their centre filled with a brownish
ochery-coloured tenacious substance, rather more
consistent than the crassamentum of the blood.

The left hypogastric or internal iliac vein was
in the same condition, but in some places reduced
to a cord-like substance, and its cavity throughout
completely obliterated. The branches of this vein,
taking their origin in the uterus, and usually
termed the uterine plexus, were found completely
plugged up with firm, red coagula. From the
commencement of the branches of this plexus of
the hypogastric vein to the termination of this
vein in the iliac, the whole had become thickened,
contracted, and plugged up with coagula and ad-
ventitious membrane of a dark blue colour.

The same changes had taken place in the ute-
rine plexus, and trunk of the right hypogastric
vein, from the uterus to its unusual termination
in the left common iliac vein. The coats of the
left femoral vein were thickened, and closely ad-
herent to the artery and surrounding cellular sub-
stance; its whole interior lined with an adventi-
tious membrane, and distended with a reddish-
coloured coagulum. The same morbid changes
presented themselves in the deep and superficial
branches as far as they were examined down the
thigh.

A woman, aged forty, who had been delivered
of twins a month before, and had nearly perished
from flooding, and subsequently from an attack
of uterine inflammation, was seized on the 27th
August 1829, with a violent fit of cold shivering,
followed by pyrexia and pain in the right iliac
region and groin. In the course of the two fol-
lowing days, the pain increased in severity, and
extended down the inner surface of the thigh to-
wards the ham, and the whole leg and thigh be-
came much swollen. 29th. The whole right
inferior extremity affected with a general intume-
scence, and completely deprived of all power of

motion. The temperature of the limb, particu-
larly along the inner surface, much higher than
that of the other ; but the integuments retain
their natural colour, and do not pit on pressure.
The femoral vein for several inches under Pou-
part's ligament, is very distinctly felt enlarged,
and is very painful when pressed. Out of the
course of the crural vessels little uneasiness is
produced by pressure. In the right side of the
hypogastrium there is also great tenderness ; pulse
120 ; tongue furred. She appears pale and de-
pressed, and complains of deep-seated acute pain
in the lower part of the back when she attempts
to move. From this period until the 22d Sep-
tember, when she died, she suffered from repeated
fits of shivering, which occasionally assumed a
regular intermittent form ; there was diarrhoea,
with brown tongue ; the glands in the right groin
became much enlarged, and the left inferior ex-
tremity became affected in a manner similar to
the right.

Dissection. — The veins presented nearly similar
appearances to those observed in the preceding
case. The divisions of the vena cava were in
this instance both affected. On the left side the
cavities of the iliac and femoral veins were filled
with a dark purple coagulum, their coats being
not much thicker than natural ; whilst on the
right side the coats of these veins were dense and
ligamentous, and the cavities blocked up by ad-
ventitious membranes, or lymph of a dull yellow
colour. The lower part of the vena cava, for the
space of two inches, as well as the right common
iliac, was obstructed by a tough membrane of
lymph surrounding a soft semi-fluid yellowish
matter. The right common, external, and inter
nal iliac veins were imbedded in a mass of suppu-
rating glands, the purulent fluid of which had
escaped into the adjacent cellular membrane, and
forced its way downwards in the course of the
psoas muscle as low as Poupart's ligament. The
right hypogastric vein was reduced to a small
impervious cord, and its branches were distended
with coagula of lymph of a bright red colour.
The right femoral and its branches were in like
manner impervious, their coats being greatly
thickened, and their interior occupied by coagula.
The cavities of the left common external iliac and
hypogastric veins contained soft coagula, disposed
in layers which adhered to the inner tunic of the
vessel.

The trunk of the left hypogastric vein was
contracted, its coats somewhat thickened, and its
branches filled with worm-like coagula. The
spermatic veins were healthy. The cellular mem-
brane of both lower extremities was infiltrated
with serum.

The causes of uterine and crural phlebitis have
already been pointed out in the article FeVM,
PuEnpEHAL. Inflammation of veins, it was there
observed, rarely takes place in any part of the
body where it cannot be referred to a wound or to
some specific cause externally applied to the coats
of the vessels. In uterine phlebitis the inflam-
mation cannot, it is true, be traced in all cases to
the semi-lunar shaped orifices in the lining mem-
brane of the uterus which communicate with the
sinuses where the placenta had adhered ; yet it
scarcely admits of a doubt that the frequent oc-

PHLEGMASIA DOLENS.

533

currcnce of the disease arises from the orifices of
these veins in the lining membrane of the uterus
being left open after the separation of the placenta,
by which a direct communication is established
between the cavities of these veins and the at-
mospheric air, in a, manner somewhat analogous
to what takes place in amputation and other ex-
tensive wounds.

The veins which return the blood from the
uterus and its appendages may be either wholly
or in part inflamed ; generally, however, the in-
flammation attacks the spermatic veins alone, and
for the most part the one only on that side of the
uterus to which the placenta has been attached :
and it may confine itself to a small portion of the
vessel, or extend throughout its whole course
from the uterus to the vena cava. The same is
the case with regard to the hypogastric veins, one
only being generally affected. These veins are,
however, rarely inflamed in comparison with the
spermatic; and this would seem to depend on the
latter veins being invariably connected with the
placenta, to whatever part of the uterus it may
happen to be attached.

In eight of the twenty-three cases of puerperal
crural phlebitis which have come under the
writer's immediate observation, the disease has
commenced between the fourth and twelfth days
after delivery, and in the remaining fifteen it ap-
peared subsequent to the end of the second week
after parturition. In most of the patients there
was either an attack of uterine inflammation in
the interval between delivery and the commence-
ment of the swelling in the lower extremity, or
there were certain symptoms present which are
to be regarded as characteristic of venous in-
flammation, viz. rigors, headach, prostration of
strength, a small rapid pulse, occasional paroxysms
like those of ague, nausea, loaded tongue, and
thirst.

The sense of pain at first experienced in the
uterine region, has afterwards been chiefly felt
along the brim of the pelvis, in the direction of
the iliac veins, and has been succeeded by tension
and swelling of the part. After an interval of
one or more days, the painful tumefaction of the
iliac and inguinal regions has extended along the
course of the crural vessels, under Poupart's liga-
ment, to the upper part of the thigh, and has de-
scended from thence in the direction of the great
blood-vessels to the ham. Pressure along the
course of the iliac and femoral vessels has never
failed to aggravate the pain, and in no other part
of the limb has pressure produced much uneasi-
ness. There has generally been a sensible fulness
perceptible above Poupart's ligament, before any
tenderness has been experienced along the course
of the femoral vessels ; and in every case at the
commencement of the attack, we have been able
to trace the femoral vein proceeding down the
thigh like a hard cord, which rolled under the
fingers.

A considerable swelling of the limb, commenc-
ing in the thigh and gradually descending to the
ham, has generally taken place in the course of
two or three days, and in some cases immediately
after the pain has been experienced in the groin.
In other cases the swelling has been first observed
in the ham or calf of the leg, and has spread from

2u*

these parts upward and downward until the whole
extremity has become greatly enlarged. The in-
teguments have then become tense, elastic, hot,
and shining, and in most cases where the swelling
has taken place rapidly there has been no pitting
upon pressure or discolouration of the skin. In
several well-marked cases, however, of crural phle-
bitis, at the invasion of the disease, the impression
of the finger has remained in different parts of the
limb, more particularly along the tibia ; but as the
intumescence has increased, the pitting upon pres-
sure has disappeared, until the acute stage of the
complaint has passed away. At the onset of the
disease we have also observed, in several cases, a
diffuse erythematous redness of the integuments
along the inner part of the thigh and leg. In
one individnal only has suppuration of the glands
taken place in the vicinity of the femoral vein
but in several, by an extension of the inflamma
tion, the inguinal glands have become indurated
and enlarged. In some women the inflammation
of the femoral vein has appeared to be suddenly
arrested at the part where the trunk of the saphena
enters it, and the inflammation has extended along
the superficial veins to the leg and foot. The
swelling and pain in these instances have been
greatest along the inner surface of the thigh, in
the course of the saphena veins. In most cases
of crural phlebitis, not only the whole lower ex-
tremity, but the nates and vulva have been affected
with a glossy, hot, colourless, and painful swelling,
which has not retained the impression of the
finger.

The power of moving or extending the leg has
been completely lost after the disease has been
fully formed, and the greatest degree of freedom
from pain has been experienced by the patients in
the horizontal posture, with the limb slightly flexed
at the knee and hip joints. The severity of the
pain and febrile symptoms has usually diminished
in a few days after the occurrence of the swelling ;
but this has not invariably happened, and we have
seen some individuals suffer from excruciating
pain for many weeks, or through the whole period
of the acute stage of the disease.

The duration of the acute local symptoms has
been very various in different cases. In the greatei
number they have subsided in two or three weeks,
and sometimes earlier, and the limb has been then
left in a powerless and cedematous state. The
swelling of the thigh has first disappeared, and
the leg and foot have more slowly resumed their
natural form. In one case, after the swelling had
subsided several months, large clusters of dilated
superficial veins were seen proceeding from the
foot along the leg and thigh, to the trunk; and
numerous veins as large as a finger were observed
over the lower part of the abdominal parietes. In
some women the extremity does not return to its
natural state for many months or years, or even
during life. In the summer of 1831, a lady was
placed under our care for an affection of the left
lower extremity, who, forty years before, had suf-
fered from an attack of crural phlebitis in the
same side. The left leg and thigh had remained
larger and weaker than the other during the whole
of this long period, and was liable to suffer severely
from fatigue and slight changes in the atmosphere.
This lady was attended in her confinement by a

534

PHLEGMASIA LOLENS.

celebrated London accoucheur, who was so strong-
ly impressed with a belief of the truth of the doc-
trine of Puzos respecting milky deposits in crural
phlebitis, that he ordered the infant to be kept
night and day at the breasts, lest the milk should
make its way into the thigh.

In four cases of this affection, after the acute
symptoms had begun to subside, the same appear-
ances were observed in the iliac and femoral veins
of the opposite extremity, and the other thigh, the
leg, and the foot became similarly affected. In two
individuals only has the disease attacked the same
extremity twice. In one woman an interval of
twelve years elapsed between the first and second
attack.

Dr. Hull has given the following description of
the disease. (On Phlegmasia Dolens, p. 133,
Manchester, 1800.) "It has in many instances
attacked women who were recovering from puer-
peral fever, and in some cases has supervened, or
succeeded to thoracic inflammation. It not un-
commonly begins with coldness and rigors. These
are succeeded by heat, thirst, and other symptoms
of pyrexia ; and then pain, stiffness, and other
symptoms of topical inflammation supervene.
Sometimes the local affection is from the first ac-
companied with, but is not preceded by febrile
symptoms. Upon other occasions the topical affec-
tion is neither preceded by puerperal fever nor
rigors, &c. ; but soon after it has taken place, the
pulse becomes more frequent, the heat of the body
is increased, and the patient is affected with thirst,
headach, &c. The pyrexia is very various in de-
gree in different patients, and sometimes assumes
an irregular remittent or intermittent type.

" The complaint generally takes place on one
side only at first, and the part where it commences
is various ; but it most commonly begins in the
lumbar, hypogastric, or inguinal region, on one
side, or in the hip or top of the thigh, and corres-
ponding labium pudendi. In this case the patient
first perceives a sense of pain, weight, and stiff-
ness in some of the above-mentioned parts, which
are increased by every attempt to move the pelvis
or lower limb. If the part be carefully examined,
it generally is found rather fuller or hotter than
natural, and tender to the touch, but not dis-
coloured. The pain increases, always becomes
very severe, and in some cases is of trie most ex-
cruciating kind. It extends along the thigh, and
when it has subsisted for some time, longer or
shorter in different patients, the top of the thigh
and the labium pudendi become greatly swelled,
and the pain is then sometimes alleviated and
accompanied with a greater sense of distension.
The pain next extends down to the knee, and is
generally the most severe on the inside and back
of the thigh, in the direction of the internal cuta-
neous and crural nerves ; when it has continued
for some time, the whole of the thigh becomes
swelled, and the pain is somewhat relieved ; the
pain then extends down the leg to the foot, and is
commonly most severe in the direction of the
posterior tibial nerve ; after some time the parts
last attacked begin to swell, and the pain abates
in violence, but is still very considerable, especUdly
on any attempt to move the limb. The extremity,
being now swelled throughout its whole extent,

appears perfectly or nearly uniform, and it is not
perceptibly lessened by an horizontal position, like
an cedematous limb. It is of the natural colour,
or even whiter ; is hotter than nntural ;
sively tense and exquisitely tender when touched;
when pressed by the finger indifferent parts, it is
found to be elastic, little if any impression re-
maining, and that only for a very short time."

After describing the manner in which the con-
stitutional and local symptoms subside, Dr. Hull
further observes, that " hitherto the disease has
been described as affecting only one of the inferior
extremities, and as terminating by resolution or
the effusion of a fluid that is removed by the ab-
sorbents ; but unfortunately it sometimes happens
that after it abates in one limb, the other is at-
tacked in a similar way. It also happens in some
cases that the swelling is not terminated by reso-
lution. For sometimes a suppuration takes place
in one or both legs, and ulcers are formed which
are difficult to heal. In a few cases a gangrene
has supervened. In some instances the patient
has been destroyed by the violence of the disease
before either suppuration or gangrene has hap-
pened."

2. Crural Phlebitis in Women who ahe

NOT IN THE PUERPERAL STATE. The Cases

which have been related in the work already re-
ferred to, prove that inflammation of the iliac and
femoral veins is a disease not peculiar to women
who have recently been delivered, but that it may
also arise from suppressed menstruation, malig-
nant ulceration of the os and cervix uteri, and
other organic diseases of the uterine organs.

In a lady aged thirty-one, whose case has been
recorded by Tommasini, the catamenia were sud-
denly suppressed from immersion of the body in
cold water. Headach, fever, and swelling of one
of the limbs took place, and in three months she
was attacked with great anxiety, prostration of
strength and spirits, and other signs of a severe
disease. The pulse was frequent and irregular,
and there was great anxiety in respiration ; the
blood drawn was buffy. Phlebitis of the inferior
extremity manifested itself. The pulse became
intermittent, the veins of the limb painful and
turgid, and the skin covered with spots of a dark
colour. The sense of oppression increased, and
death took place about four months after the com-
mencement of her illness. On dissection, the
lungs were found inflamed. In the limb affected,
the coats of the saphena, sural, popliteal, crural,
and iliac veins were thickened, injected, and filled
with coagula of blood which in some parts of the
crural veins appeared to be changed into a fleshy
substance. The coats of the iliac above the
crural arch, to the bifurcation of the vena cava,
were much thicker than the other veins, and more
injected, without any manifest collection of puru-
lent matter. The arterial system was healthy;
the condition of the internal iliac and uterine
veins has not been described, although there can
be little doubt the effusion originated in the
uterus. (Tommasini, Saggio di Pratiche Con-
siderazioni fatte nella Clinica Medica di Bologna,
p. 317.)

In four cases which have come under our ob-
servation, inflammation of the iliac and femoral

PHLEGMASIA DOLENS.

535

veins, giving rise to all the phenomena of phleg-
masia dolens, has followed the sudden suppression
of the catamenia from exposure to cold.

In the first there was great tenderness of the
hypogastrium and left thigh, a rapid feeble pulse,
delirium, brown tongue, vomiting, exquisite pain
in several of the joints both of the upper and
lower extremities, and abscesses formed in differ-
ent parts of the body.

In the second case, which occurred in a young
lady, the whole left inferior extremity was swol-
len, hot, and painful, but not discoloured. The
femoral vein was felt under Poupart's ligament
like a large hard cord, and pressure over it and
along the course of the iliac veins of the same
side produced great suffering. The affection pre-
sented the same characters as in puerperal crural
phlebitis-, and could be distinctly referred to the
sudden suppression of the catamenia.

In another case, referable to exposure to cold,
the disease occurred in both lower extremities.

In the article OUdema it is observed that in
women suffering from amenorrhoea, cedema is one
of the most common attendants. In these cases
there is considerable tenderness in the course of
the femoral veins, the most common site of this
tenderness being just before the vein pierces the
tendon of the triceps to pass into the ham, and
probably depends on some inflammation of the
vessel. (See (Edema.)

From cases which we have likewise related, it
appears that uterine phlebitis sometimes follows
abortion, and that it has taken place and proved
fatal after the removal of a polypus of the uterus
by ligature. Tenderness in the course of the
venous trunks of the lower extremities, and cedema
of the limbs, have also in several cases been traced
to some external injury inflicted on the uterus.

The first case of crural phlebitis from malignant
ulceration of the os uteri, came under our notice
nearly four years ago, and for several weeks before
death the patient experienced great tenderness in
the course of the left femoral vein, with a tense
swollen state of the limb. On opening the abdo-
men, the peritoneum covering the intestines and
liver was found to be inflamed, with an effusion
of purulent fluid into the abdominal cavity. The
os cervix, and a great part of the body of the
uterus, had been destroyed by phagedenic ulcera-
tion, and extensive openings had formed in the
bladder and rectum. On the left side, between
the remaining portion of the uterus and the pelvis,
to the brim of which it firmly adhered, was a
spongy cancerous mass, enclosing within it the
branches and trunk of the hypogastric vein and
artery, and a considerable portion of the common
and external iliac veins. When cut into, it pre-
sented a spongy texture, and a thick whitish puru-
lent fluid escaped, as if from numerous cells, but
which were subsequently ascertained to be cavities
of veins. A portion of the common and external
iliac veins was lost in removing the parts from the
body. What remained of the common iliac was
reduced to a slender tube, which was partially
coated on the inner surface with an adventitious
membrane of a black colour.

The commencement of the external iliac was
also contracted so as to be impervious, and lined
with a dark-coloured false membrane. The com-

mon superficial and deep femoral veins were all
plugged up with firm red coagula, the coats thick-
ened, and the inner surface lined with adherent
false membranes.

The cellular texture of the limb was loaded with
serum ; but in other respects it was healthy, as
were the other tissues.

From these and similar cases which have since
occurred to the writer, to Mr. Lawrence, (Med.
Chir. Transact, vol. xvi. p. 59. 1830,) and to Dr.
Blundell, it appears not only that inflammation of
the veins of the uterus may be produced by malig-
nant ulceration of the os and cervix uteri, but that
this inflammation may extend along the internal
to the common external iliac, and femoral veins,
and thus give rise to all the phenomena of crural
phlebitis, as observed in puerperal women.

[The view that phlegmasia dolens is a crural
phlebitis, is now admitted by the generality of pa-
thologists. (Churchill, The Diseases of Females,
including those of Pregnancy and Child-bed, p
545, Amer. edit., by Dr. Huston, Philad. 1843 ;
Raige Delorme, in Diet, de Med., xxiv. 250,
Paris, 1841 ; and Hiiter, in Encyclopiid. Wor-
terb. der Medicinisch. Wissenschaft. xxvii. 168,
Berlin, 1842.)]

3. Phlegmasia Dolens in Men. — It has re-
cently been ascertained that this disease, in the
male sex, may commence either in the hemor-
rhoidal, vesical, or in some of the other branches
of the internal iliac veins, in consequence of in-
flammation or organic changes of structure in one
or more of the pelvic viscera. Crural phlebitis in
men arises much more frequently, however, from
inflammation being excited in the superficial veins
of the leg, extending upward and involving the
great venous trunks of the thigh and pelvis. Ex-
ternal injuries, exposure to cold and moisture, and
ulcers, are the most frequent causes of inflamma-
tion of the saphena veins. Amputation may also
excite crural phlebitis, both in the veins of the
same side and in those of the opposite extremity.
Tumours, by pressing upon the vena cava and
iliac veins, may also give rise to the disease.

The following observations will illustrate, though
in a less perfect manner than might be desirable,
this interesting part of the pathology of veins.

Mr. Lawrence examined the body of a man
who died at St. Bartholomew's Hospital of cancer
of the rectum, and he found the iliac veins in-
flamed and obstructed. The affection not having
extended into the veins below Poupart's ligament,
none of the usual symptoms of crural phlebitis
manifested themselves.

In two cases of crural phlebitis, related by Mr.
Holberton, the patients died of phthisis, with
diarrhoea and ulcerations of the bowels. In the
first case, the examination was imperfect, but in
the second the writer traced the left hemorrhoidal
veins close to the spots of ulceration in the mu-
cous membrane of the rectum, and the coats of
these vessels were unusually thickened, and ex-
hibited other marks of previous inflammation.
(Med. Chir. Transact, vol. xvi. part i. p. 70.)

The patient whose case has been recorded by
Dr. Forbes, likewise died of phthisis, and suffered
from diarrhoea. The internal iliac vein was not
traced to the rectum, but Dr. Forbes has recently
stated to us his belief that the mucous membrane

536

PHLEGMASIA DOLENS.

of the lower intestines was ulcerated. (Ibid. vol.
viii. p. 293.)

Dr. Cheyne observes in his Report of the Whit-
worth Hospital, which contains an account of
dysentery, that " it is worthy of remark that a
swelling occurred in several of the patients, both
males and females, resembling the phlegmasia do-
lens in all respects but in its connection with par-
turition."

Dr. Tweedie has related cases of fever which
were followed by painful swellings of the lower
extremities, which also in all essential circum-
stances resembled phlegmasia dolens ; but as these
patients recovered, the condition of the veins or
the intestines was not ascertained. (Edin. Med.
and Surg. Journal, vol. xxx.)

Drs. Graves and Stokes have subsequently re-
lated cases of painful swellings of the lower ex-
tremities after fever, which presented all the usual
symptoms of phlegmasia dolens, and were consi-
dered by them to be identically the same diseases.
In both, they remark, oedema occurred unattended
by redness, but accompanied by increase of heat
with great tenderness and pain, and followed for
a considerable time by impaired motion of the
limb. In both diseases the swelling and the other
symptoms are frequently not confined to any one
portion of the extremity, but extend uniformly
over the leg and thigh. In both diseases, how-
ever, we have also often observed that the pain,
heat, and swelling occupied particular parts of the
limb, while the rest was comparatively free from
disease. Thus, in some cases a portion of the
thigh was extensively engaged while the leg and
foot remained in the natural state, and after some
days the diseased action seemed to change its
place, and successively attacked the other portions
of the limb, without, however, any precise order
in the mode of succession. (Dublin Hospital Re-
ports, vol. v. p. 29.)

In the spring of 1833 a case of chronic dysen-
tery came under the observation of Dr. Macann,
in which phlegmasia dolens took place a short
time before death. On dissection, the common,
external iliac, and femoral veins of the left side
were found to be completely obstructed, and their
coats extensively disorganized by inflammation.
The writer is indebted to his friend Dr. Forbes for
this valuable specimen of inflamed veins, which
was presented to Dr. Forbes by Dr. Macann,
previous to his departure for the West Indies.
In the short notice of the case it is stated that
both lower extremities were swollen. It has not
been ascertained whether the condition of the
lining membrane of the rectum was examined by
Dr. Macann, or if he attempted to trace the hemor-
rhoidal veins to their commencement.

In Dr. Cheyne's cases of dysentery it is highly
probable the disease commenced in the hemor-
rhoidal veins, and from the frequent occurrence
of inflammation and ulceration of the intestines
in continued fever, we are disposed to think the
affection had the same origin in the cases of Drs.
Tweedie, Graves, Stokes, and Macann.

A man, whose case is recorded by Cruveilhier
had a sound introduced into the bladder for reten-
tion of urine, occasioned by a swelling of the
prostate. Pain was experienced soon after in
tne of the lower extremities, and the veins be-

came painful and distended like hard cords. The
patient died, and all the different degrees of phle-
bitis were observed in the veins of the limb.
There can be little doubt, M. Cruveilhier observes,
that inflammation of the prostatic or vesical veins
had been induced by the introduction of the in-
strument in this case, but the examination not
having been conducted with a view to ascertain
this point, it was not positively determined.

More frequently, both in the male and female
sex, the inflammation does not commence within
the pelvis, but originates in the superficial veins
of the limb, and gradually extends upwards to the
large deep venous trunks.

Mr. C. Hutchison has related the history of an
interesting case of phlegmasia dolens in a gentle-
man who received a blow on his right shin, im-
mediately over a branch of the saphena vein, by
a small piece of timber accidentally falling upon
it. The accident was followed by considerable
swelling and inflammation all over the limb; pain
was felt in the direction of the upper third of the
saphena before it actually dips to unite with the
femoral vein. The whole leg and thigh soon be-
came enlarged and inflamed, and many months
after the acute symptoms had subsided, when we
examined the limb with Mr. Hutchison, Sir Gil-
bert Blane, and Dr. Gairdiner, there could be no
doubt that the saphena and femoral veins had be-
come completely impervious from inflammation.
(Med. and Chir. Transactions, vol. xv. 1829.)

Sir A. Cooper performed an operation for varix
of the saphena vein, which was followed by in-
flammation of the coats of the vessel and all the
symptoms of phlegmasia dolens.

The following fatal case of crural phlebitis, in-
duced by exposure of the limbs to cold and mois-
ture, has been recorded by Drs. Graves and
Stokes. A young man, of a strong habit, was
employed for two successive days in working in a
ditch, and was consequently obliged to stand in
water above his knees during that time. On the
following day he became affected with lassitude,
vertigo, and general weakness, and complained of
severe pain in the right thigh. These symptoms
continued for seven days, when he was admitted
into the Meath Hospital. His countenance was
anxious and depressed, the tongue furred; thirst,
headach, urine scanty, turbid, and high-coloured ;
pulse ninety-six, skin mottled with petechia?. In
addition to these general symptoms, the respira-
tion was laboured and unequal, with some cough;
face very livid. But his chief complaint was a
severe pain in the upper and anterior part of the
right thigh, which was greatly aggravated by
motion or pressure. He had also severe pain in
the left hypochondrium.

At this time no swelling of the limb whatever
could be detected ; but in the course of two days
the upper portion of the thigh became evidently
swollen, the part being extremely tender, but not
at all red. The pain of the side continued, and
extensive bronchial and pneumonic inflammation
was detected. General bleeding and very free
leeching to the limb were employed. The blood
was not inflammatory, and no relief was expe-
rienced by the patient. The swelling of the thigh
increased ; calomel and opium were freely exhi-
bited, but without any effect. The typhoid symp-

PHLEGMASIA DOLENS.

537

toms increased, and the patient died on the fourth
day after his admission.

On dissection, the right lower extremity was
found to be tense and swollen in its superior por-
tion, while the leg and foot were slightly anasar-
cous. The sac of the pericardium contained some
scro-purulent fluid ; and that portion covering the
auricles and great vessels was vascular, and in
many cases covered with coagulable lymph. Both
lungs were in a state of extreme sanguineous con-
gestion with commencing solidity in their posterior
inferior portion, and general inflammation of the
pleura. The bronchial mucous membrane was
universally red, and the tubes filled with frothy
mucus.

The vena cava contained a few portions of a
substance of a granular appearance, friable, and
of a yellowish colour. This did not adhere to the
vessel, which otherwise appeared healthy. In the
external iliac vein, however, just above Poupart's
ligament, there was a large concretion of a similar
nature nearly plugging up the vessel, and extend-
ing into some of the minute collateral branches.
The lining membrane was red, and in one point
adheied to the coagulum. No puriform matter
could be detected. The femoral and popliteal
arteries were healthy. The cellular tissue of
the limb was cedematous. The condition of the
6aphena vein where it enters the femoral is not
described, although the inflammation most pro-
oably originated in the superficial vessel.

On the 2d of February 1832, the body of an
aged man was brought into the dissecting-room
of Webb-street school. The whole left inferior
extremity was much swollen, and a chronic ulcer
was observed over the tibia. The coats of the
saphena vein along the leg and thigh were found,
on examination, to be much thickened, and
plugged up with coagula of blood and lymph.
The left common and external iliac and femoral
vein to the ham were all completely obstructed
with coagula of blood and lymph, and lined with
adventitious membrane. The lower part of the
vena cava, to the extent of three inches, was filled
with a soft yellowish coagulum of lymph, which
adhered to the inner coat of the vein. The coats
of the principal arteries of the left lower extremity
were ossified.

In April 1832 Sir Henry Halford read an ac-
count to the College of Physicians of crural phle-
bitis as observed in the late Earl of Liverpool.
The attack commenced many years before ; and
it is highly probable, from a circumstance stated
to us by Sir A. Cooper, that it was induced by
exposure to a current of cold air, which passed
through an open window and fell upon the lower
extremities when but thinly clothed, his lordship
being at a crowded levee. The left groin, thigh,
and leg were affected ; and in the acute stage of
the complaint, leeches and the usual antiphlogistic
remedies had been employed by Dr. Pemberton
and Sir A. Cooper. Lord Liverpool subsequently
died from an affection of the brain ; and on exa-
mining the body, the left iliac, femoral, and
saphena veins were found to have undergone
changes of structure similar to those which have
previously been described as occurring in puerpe-
ral crural phlebitis. Sir Henry Halford related
two other cases of crural phlebitis in men. They

Vor.. III. — 68

were similar to the case of the Earl of Liverpool,
and were succeeded by marked tendency to head
affection. In none of the cases of crural phlebitis
which have fallen under our observation, has any
remarkable slowness of pulse or tendency to dis-
ease of the brain been observed. Even where the
vena cava and both iliac and femoral veins have
become completely impervious, the blood has been
returned to the heart without difficulty, and no
affection of the brain has taken place.

In a patient of the British Lying-in Hospital,
who had suffered much from varicose veins in the
latter months of gestation, inflammation of the
saphena veins of both lower extremities came on
two days after delivery with most severe constitu-
tional symptoms. From the left knee to the ankle
on its inner surface, the integuments were hot,
and swollen, and tense, and in several places large
patches of a dark red colour were observed over
the superficial veins, which being laid open in
two places, a considerable quantity of purulent
fluid was discharged. Where the swelling and
tension were least, the superficial veins could be
felt distended like hard cords; as could also the
saphena through its whole course upward from
the ham to its junction with the femoral vein. In
the course of this vein there was considerable
swelling ; and the integuments in this situation,
as far as the middle of the thigh, were hot and of
a dark red colour.

The symptoms which characterize venous in-
flammation in its most severe forms took place,
and she sank on the fourteenth day after delivery.
Dr. Sims assisted us in inspecting the body, when
the following morbid appearances were observed.
The left lower extremity was very much enlarged.
The cellular and adipose membranes from Pou-
part's ligament, along the inner surface of the
thigh and leg to the ankle, were indurated, vas-
cular, and infiltrated with a red-coloured serous
fluid. Several abscesses were observed in the cel-
lular membrane immediately beneath the skin in
the calf of the leg, and an extensive collection of
pus had formed in the interstices of the gastrocne-
mii muscles. The branches of the saphena in
this situation were converted into solid impervious
cords ; and the coats of this vein, from the knee
to its junction with the femoral, were thickened
and contracted, and in the lower part the cavity
was nearly obliterated. The saphena vein was
lined with an adventitious membrane of consider-
able thickness, which was easily separated from
the inner coat. Its opening into the femoral vein,
though reduced in size, was pervious ; and the
coats of the deep femoral vein, from this point to
the ham, were thickened and contracted. The
inner membrane was rugous, and of a deep red
colour ; but no deposit of lymph was observable,
and its canal was pervious. The femoral vein
above the termination of the saphena, and the
whole of the external iliac, were thickened and
slightly contracted in their dimensions, and lined
with a thin coating of lymph. These vessels were
pervious, and the common and internal iliac ex-
hibited no sign of disease. The intestines were
inflamed ; and on the ascending colon there was
a small part in the state of sphacelus. (Medical
and Chirurgical Transactions, vol. xv.)

We have related other cases of inflammation of

538

PHLEGMASIA D OLE NS — PIT YRI A SIS.

the saphena veins, of less severity, occurring in
puerperal women, where the swelling, heat, and
tension were confined to the course of these ves-
sels; and it is now clearly ascertained that the
whole limb does not become affected when the
iliac and femoral veins have remained pervious.
The preceding and other cases likewise prove that
the inflammation in crural phlebitis, when violent,
is not limited to the coats of the veins, but may
extend to the cellular membrane, glands, muscles,
and other contiguous tissues.

In July, 1830, the author was indebted to the
kindness of Dr. Ashburner for the opportunity of
observing the progress of an interesting case of
crural phlebitis in a female about the middle period
of life, who had not been pregnant for several
years. A small ulcer above the left internal mal-
leolus gave rise to inflammation of the saphena
and femoral, and probably of the iliac veins, and
the whole limb became affected with a hot, shining
intumescence.

Sir Charles Bell has informed us that he has
observed upwards of twenty cases of painful
swellings of the superior extremities in women
afflicted with cancer of the mamma. He has
been accustomed to refer these swellings to ob-
struction of the lymphatics, or to compression of
the veins by the induration and enlargement of
the glands of the axilla. No opportunity has yet
occurred to determine by dissection whether or
not the painful swelling of the arms is to be at-
tributed in such cases to inflammation and obstruc-
tion of the veins ; but this has been rendered pro-
bable by the facts already related respecting the
effects produced on the iliac veins by malignant
ulcerations of the uterus. It is rendered still
more probable by the following observation of
Laennec: "that it is not uncommon to find
the veins in the neighbourhood of a cancerous
breast filled with pus, either pure or mixed with
blood; sometimes fluid, at other times more or
less inspissated, and occasionally of the degree of
consistence of an atheromatous tumour." (Trans-
lation, 2d edit. p. 652.)

Treatment. — Puzos recommended repeated
and copious venesection for the treatment of phleg-
masia dolens ; but in all the cases which we have
witnessed, there has been so much feebleness of
pulse and prostration of strength that we have not
ventured to draw blood from the arm. There are
cases, however, occasionally met with where the
symptoms are immediately relieved by a general
bleeding. An example of severe crural phlebitis
after delivery recently occurred in the practice of
Dr. Duffin, where the abstraction of twenty
ounces of blood seemed at once to break the force
of the attack. In a great proportion of cases ve-
nesection is not required, and we are to trust for
the relief of the inflammation to the repeated ap-
plication of leeches above and below Poupart's
ligament, in the course of the crural veins. From
two to three dozen of leeches should be applied
immediately after the commencement of the dis-
ease, and the bleeding should be encouraged by
warm fomentations, or by a bread and water poul-
tice to the part. Should the relief of the local
pain not be complete, it is requisite soon to re-
apply the leeches in numbers proportioned to the
severity of the attack, and to repeat them a third

or even fourth time, at no very distant intervals,
should the disease not yield.

Some patients experience greatest relief from
the use of warm cataplasms to the limb ; others
derive most advantage from the application of
cold, or of a tepid, evaporating lotion.

The bowels are often much disordered in this
disease ; but the employment of strong acrid ca-
thartics is always injurious. Repeated small doses
of calomel and antimonial powder should be given
with some mild purgative, not only with the view
of correcting the disordered state of the bowels
but to subdue the local inflammation, and the
great constitutional disturbance usually present.
It is of importance, also, to administer saline and
diaphoretic medicines, and to procure rest and
relief from pain by anodynes, until the acute
symptoms pass away: the diet should be the same
as that usually allowed to patients who are labour-
ing under inflammatory and febrile diseases. We
have seen no advantage derived from the use of
digitalis in any stage either of uterine or crural
phlebitis. Dr. Sims has informed us that the
painful swelling and tension of the limb, in a case
of phlegmasia dolens, were strikingly relieved by
puncturing the skin in different parts with a fine
needle.

When the acute inflammatory symptoms have
passed away, the limb remains in a weak, oedema-
tous state, and great uneasiness is often experi-
enced from congestion of blood in the veins.
Until the collateral branches, which are to carry
back the blood to the heart, become enlarged, it is
impossible by any means we possess to afford
complete relief. Much benefit may, however, be
derived in this stage of the complaint from the
occasional application of a few leeches to different
parts of the limb, and by preserving it in the ho-
rizontal position. We have seen mischief pro-
duced by having recourse too early to remedies
intended to promote the absorption of the fluid
effused into the cellular membrane. Blisters, fric-
tions, stimulant embrocations, and bandages to the
limb, are only useful when the inflammation of
the veins has wholly subsided, and other vessels
have become so much enlarged as to carry on the
circulation of the blood in the extremity without
interruption.

We have not perceived any sensible benefit
accrue from the use of mercurial ointment and io-
dine in crural phlebitis, and we consider the local
abstraction of blood at the commencement of the
attack to constitute by far the most important part

of the treatment.

Robert Lee.

PHRENITIS. See Brain, Inflammation

OF THE.

PHTHISIS PULMONALIS. See Tuber-
cular. Phthisis.

PITYRIASIS, from mrvpov, bran, denotes a
cutaneous affection in which irregular patches of
the cuticle, varying much in size, appear covered
with thin branny or minute powdery scales, which
fall off and are soon succeeded by others. This
disease is not contagious, and is seldom productive
of inconvenience to the patient ; it never termi-
nates in crusts or excoriations, but, if neglected,
it may alter its character and degenerate into
porrigo. During health, the cuticle over the

PITYRIASIS.

whole body is constantly undergoing changes,
peeling off in minute fragments, while a new and
sound surface is formed below. Of this we have
sufficient proof in the scales which are daily de-
tached from the scalp by the hair-brush, and those
which are always seen on drawing a black silk
stocking off the leg. Now when this process of
exfoliation is greatly increased on particular spots
and patches of the skin, it constitutes the most
simple form of pityriasis. There are several va-
rieties of this affection.

1. Pityriasis capitis. (Dandriff of the head.
Dartre furfuracee volante, Alibert.} This erup-
tion is seen on the scalp and eyebrows of infants
and sometimes of old men ; on the temples and
forehead it has a white mealy appearance ; but on
the occiput it consists of distinct flat scales, semi-
transparent and of a light brownish colour. In
children it is occasionally connected with imper-
fect nutrition, but most frequently originates from
a mere want of cleanliness. In adults and the
aged, dandriff of the head accompanies the fall-
ing off of the hair, which so often takes place
during convalescence and under chronic disease.
This form of eruption sometimes occurs also on
the chin and other parts of the face, when they
exhibit patches of a rough and mealy appearance ;
't is occasionally the result of indigestion, but
more frequently of some local irritation, as acrid
soap or a rough-edged razor.

Treatment. — This eruption, when on the
scalp, in general yields readily to removal of the
nair, washing of the affected parts with soap and
water morning and evening, and anointing them
afterwards with some mild cerate. All causes of
local irritation must be removed, the general
nealth attended to, and a plentiful supply of
wholesome nourishment afforded, should that ap-
pear to have been deficient.

The other forms of pityriasis are more remark-
able for the discoloration of the skin which
attends them than for the mealy or branny de-
squamation of the cuticle; and hence, although
Willan, Bateman, and other English writers, have
considered them as species of pityriasis, Alibert,
(Maladies de la Peau,) Rayer, (Maladies de la
Peau,) and Biet, (Abrege Pratique des Maladies
de la Peau,) arrange them among the ephelides,
or tan-spots. We prefer adhering to the arrange-
ment of our countrymen, because we have always
observed some exfoliation of the cuticle in these
forms of pityriasis, at least during the height of
their course ; and because they differ from true
ephelis in appearing especially on those parts of
the body which are not exposed to the sun's rays.
Three varieties have been distinguished by the
names of versicolor, rubra, and nigra.

2. Pityriasis versicolor. (Chequered dandriff.
Ephelides hepatiques ; chloasma pseudo-porrigo ;
macula; hepaticce ; leberflechte.) This is charac-
terized by yellowish or light brown spots, and
sometimes large patches of the most irregular out-
line, branching into the healthy coloured surface,
or enclosing portions of it ; not in the least ele-
vated, and usually covered thinly by fine powdery
scales. The colour varies in intensity according
to the greater or less vascular turgescence of the
skin, and when this is much excited, verges into
the reddish tint of the succeeding variety. The

most frequent seats of this eruption are the front
of the chest and upper part of the belly ; it ap-
pears also on the neck and back, and sometimes
on the shoulders and arms. It is seldom pro-
ductive of any discomfort, except under particular
circumstances of excitement, when it is accompa-
nied by itchiness of the skin on the patient be-
coming warm in bed ; and should the stomach be
disordered, this occasionally proves very trouble-
some. But the great source of uneasiness is
more commonly in the mind, from the fears of the
patient, who sees in this affection what he ima-
gines to be the copper-coloured blotches of a con-
firmed venereal infection. Many times have we
been consulted by persons affected with the light
brown and red varieties of pityriasis under this
impression, and not a few of them had been sub-
jected to prolonged courses of mercury and sar-
saparilla, — we need not add without benefit. The
difference between pityriasis and syphilitic erup-
tions is abundantly well marked, the latter being
of a darker and more coppery hue, distinctly ele-
vated above the surface, and leading ultimately to
the formation of crusts and ulcerations — appear-
ances which are not observed in any form of
pityriasis.

A diversity of opinion exists respecting the
anatomical seat of pityriasis versicolor ; Dr. Wil-
lan (On Cutaneous Diseases, vol. i. p. 194,) states
that the rete mucosum or cutis is always affected
in this disease, the brown stain being still percep-
tible after the cuticle has been removed ; while
Dr. Bateman, (Synopsis, p. 47,) on the other
hand, asserts that in some cases he has seen the
discoloured cuticle peel off at intervals in a thick-
ened state, leaving a new cuticle underneath of a
red hue. But to this latter statement it may be
fairly replied, that when the cuticle becomes
thickened and thus peels off, the disease has lost
the genuine character of pityriasis versiclor. With
a view to decide the question, we applied a blister
to a portion of skin affected with this disease.
After the cuticle was wholly removed, the mot-
tling still remained ; but the patches, instead of
being tawny, were now changed to a deeper red
than the rest of the excoriated surface; thus
proving to our satisfaction that the anatomical
seat of pityriasis versicolor lies beneath the cu-
ticle.

It is rarely in our power to trace the occurrence
of this cutaneous affection to any satisfactory
cause , we have sometimes seen it connected with
a feeble digestion and indifferent health ; but on
other occasions nothing of this kind could be ob-
served. An opinion held by some, that it is de-
pendent on disease of the liver, probably originat-
ing in the name maculx hepaticx, is certainly
quite groundless. Bateman has observed this
eruption in a severe form to follow the free use
of spirits while fasting, and exposed in an open
boat ; and Dr. Willan speaks of various sources
of irritation of the stomach and skin as possible
causes of this disease, such as acid fruits, mush-
rooms, sudden alterations of temperature, violent
exercise with flannel next the skin ; but the whole
of these are more likely to give rise to urticaria
than to pityriasis.

Treatment. — It must be acknowledged that
we have not much power over this disease by in-

540

PITYRIASIS.

ternal remedies; and after the patient has been
Satisfied as to its innocence and the absence of
of all syphilitic taint, he often ceases to think of
it, and allows time, if it will, to work a cure.
Should the disease seem to have originated from
any irritation either of the cutaneous surface or of
the alimentary cavities, its cause must, if possible,
be removed without delay : when the digestion is
impaired, light tonics are to be used, as infusion
of calumba with sulphuric acid, or small doses of
sulphate of quinia ; the bowels are to be regulated,
and a milk and nourishing diet enjoined, with
abstinence from spirituous liquors, and a very
guarded use of wine and ale, if any be allowed.
When itching exists, a spirit lotion with borax or
alum, or acetate of lead or zinc, will be found use-
ful ; or, what rarely fails to give relief, a lotion
with hydrocyanic acid. The vapour bath at a
moderate temperature will serve to equalize the
cutaneous circulation, and soften the branny
spots. In our hands nothing has proved so effec-
tual in restoring the natural colour and functions
of the parts as a lotion of chloride of lime or
soda, varying in strength according to circum-
stances. The success which has attended this
application has exceeded our expectations ; but
whether its effects are to be regarded as the result
merely of a stimulus, or of its bleaching property,
admits of question.

[Iodide of sulphur makes an excellent ointment
in this as in various other chronic diseases.]

3. Pityriasis rubra (red dandriff.) This dif-
fers from the preceding species chiefly in the
redness of its colour, and the greater excitement
of the surface which attends it. It is more uni-
formly accompanied by heat, itching, and general
languor and restlessness, and may be considered
as remotely allied to psoriasis diffusa, although
altogether free from elevation above the surface,
and vastly more mild in all its symptoms. On its
decline, it leaves sallow faded stains marking the
parts which were affected. The anatomical seat
of pityriasis rubra is certainly deeper than the
cuticle ; its red colour evidently depending on the
injected state of the vascular tissue lying beneath.

Treatment. — We have never in any case of
red dandriff found the irritation such as to require
the abstraction of blood ; but in every instance the
bowels should be opened by mild purgatives, and
those which correct acidity. A soothing or slightly
astringent lotion, such as those already described,
ought to be applied to the affected parts, and any
cause of cutaneous irritation immediately removed.

Dr. Bateman has recommended a diaphoretic
plan of treatment, — antimonials, with decoction
of the woods, and the warm sea-water bath ; and
he adds that he has found benefit from small doses
of the tinct. veratri.

4. Pityriasis nigra (black dandriff; ephelide
scorbutique). This is an exceedingly rare disease ;
so much so that Dr. Willan had not seen it at
the time of his publication, and Dr. Bateman does
not appear to have ever met with it. Alibert has
described it under the name quoted above, and
figured it as it affects the hands (plate 27 bis.)
The cases seen by Dr. Willan occurred in chil-
dren born in India, and brought to this country.
The disease commenced in a partially papulated
state of skin, and terminated in a black discolora-

tion, with slight furfuraceous exfoliations : it some-
times affected half a limb, sometimes the fingers
and toes. (Bateman, Synopsis, p. 49.) In allu-
sion to the foreign origin of this species of pityria-
sis, we may mention a curious dusky mottling
of the skin, which is seen in the children of mu-
latto women by European fathers, when they ap-
proach, as they sometimes do, to the fair com-
plexion of the European. It seems as if patches
of the dark hue of the mother shone through the
pure skin of the father ; and it is chiefly percep-
tible when they are heated with exercise, or the
skin otherwise increased in vascularity.

Some years ago, we had the good fortune to
see a case of pityriasis nigra. The patient was
an unmarried female, aged forty-five, a native of
Scotland, her parents Scotch ; and she had never
travelled to any distance beyond the precincts of her
native city. The skin of her arms, legs, bosom, and
neck, but especially the last, was of a dark tint like
that of a mulatto, but varying in different parts in
depth of hue ; and scattered over the dusky sur-
face were many white spots, from which crusts
appeared to have separated ; and on other parts
some crusts appeared still adhering. Both the
white spots and the mulatto-coloured surface were
slightly scaly. With this disease was combined
an eruption of scabies affecting severely the hands,
from the itching of which she suffered great an-
noyance. The disease had existed for some
months ; and at the time when it commenced she
was reduced to a state of great misery and desti-
tution. By the employment of sulphur frictions,
the warm bath, and a plentiful supply of nourish-
ing food, the natural colour of the skin was nearly
restored after the lapse of some weeks ; but we are
ignorant whether a complete cure was in the end
effected. This case confirms the remark of Dr.
Bateman, that the disease is the result of misery
and filth, but not his opinion that both the disease
and its cause are wholly unknown in this coun-
try. (Synopsis, p. 49, note.)

Treatment. — Our first object in pityriasis ni-
gra is to clear out the bowels by mild purgatives,
and thoroughly purify the surface of the body
with soap and water. A course of tonic aperients,
with the regular use of the warm water or vapour
bath, should then be prescribed, while the patient
is put upon a moderate allowance of nourishing
food. As his appetite and strength improve, the
quantity of food is to be increased, and the warm
bath exchanged for sulphur fumigations; or if the
disease prove obstinate, recourse ought to be had
to the cautious employment of the arsenical liquor,
and the external use of the chloride of lime or
soda, as in pityriasis versicolor.

W. Cumin.

PLAGUE, from *\vyh, Gr. plaga, Lat. a blow
or wound; th. TrytjaatD, to strike. — This is the
name of a well-known and extremely fatal disease,
which is endemic in Egypt and certain other
countries bordering on the Levant, and has made
frequent and destructive irruptions into Europe.
The malady thus designated is called pestis and
pestilcntia by the Latin writers, Xoi^oj by the
Greeks, la peste by the French, pcstilcnza by the
Italians, and pest by the Germans, which las'
name is not unfrequcntly bestowed upon it hv

PLAGUE.

541

ourselves. It is a curious fact that these words
have each in their respective languages a signifi-
cation distinct from the primary one, and expres-
sive of various kinds of moral and physical evil,
the malignancy of the disease in all situations
being thus evinced by its suggesting the same
analogy to people differing widely in physical con-
stitution and mental habitudes.

The words plague, pest, and pestilential, and
their corresponding terms in different tongues,
have frequently, even when applied to diseases, a
sense considerably vague. The disease we are
about to treat of has always been comprised in
these terms, but other maladies have been similarly
designated, with which, probably, it had no quality
in common excepting that of being extremely dif-
fusible and fatal ; and hence by morbi pestilen-
tiales wc are not always to understand a form of
plague in a strict sense of the word. This want
of precision of language is very conspicuous in
Hippocrates and his commentator Galen, (Galcni
Commentar. in lib. i. Epidemic, in lib. iii. cap. xx.;
et in Aphor. lib. iv. &c.) whose idea of a pesti-
lential disease appears to have corresponded very
nearly with that which we express by the term
epidemic ; and a similar want of accuracy is per-
ceptible in the writings of the Arabians, from
whom we might for obvious reasons have expected
the greatest precision.

The subject was so much obscured by the vague
application of terms, that even at so late a period
as 1775 the Faculty of Medicine of Paris pro-
posed the following queries as the subject of a prize
essay : " If plague be a distinct disease, what is
lVs character 1 and what are the means of treating
amTjirevcntUig it?" — queries which were thought
to have "been successfully solved by M. Paris of
Aries. We need scarcely observe, what is now
universally admitted, that the characters of plague
are as distinctive as those of small-pox, measles,
scarlatina, or any other disorder.

This disease is endemic in Egypt, and very often
exists in adjacent territories ; but the former
country is unquestionably the great source whence
it extends its ravages into surrounding districts ;
and a very learned and ingenious writer is of
opinion that there only is it ever engendered, and
that in other regions it is always an alien. (Fo-
dere, Dictionnaire des Sciences Medicales, v. 41.
p. 87.) In Egypt it is said to arise every autumn,
and to prevail till the beginning of June of the
succeeding year : its ravages then cease, and its
contagion is extinguished or remains in abeyance
during summer, to be again called into existence
or activity in the autumn. The vernal equinox
is the period of the greatest fatality of the disease.
About this time, we learn, southerly winds blow
with great violence. They last ordinarily three
or four hours, and are frequently renewed daily
for fifty successive days. They are very warm,
passing over the burning deserts which border
Egypt on the south, and they are, moreover, loaded
with putrid emanations exhaled from the animal
and vegetable substances which arc decomposed in
the lakes formed by the retiring of the waters of
the Aile. or in the cemeteries which its inundation
has reached. At this sickly season, diseases of
all kinds assume a malignant character: it was at
this season, that after the great inundation of

2v

1801, the plague committed the greatest ravages
among the inhabitants of Cairo, and Upper Egypt.
In June the wind blows from the north, and being
cooled in traversing the Mediterranean, renders
that season the most refreshing and salubrious of
the year, during which no sickness manifests it-
self. (Baron Larrey, Description d'Egypte, ou
Recueil d'Observations et de Recherches, &c. pub-
lie par ordre du Gouvernement, Paris, 1821.)

It was to be expected that a disease eminently
contagious should be occasionally diffused through
countries having incessant intercourse with the
land of its origin ; and we find it repeatedly vis-
iting the people, paying allegiance more or less
direct to the Ottoman Porte, and not unfrequently
ravaging Constantinople. Formerly it penetrated
into more northern climes. Previously to the
year 1665 it usually invaded England, as Syden-
ham informs us, at intervals of from thirty to forty
years ; but since the cessation of the celebrated
epidemic of that year, which destroyed eight thou-
sand inhabitants of London in the course of one
week, though two-thirds of the population had
previously fled from the city, it has not been seen
in Britain. In other European countries it has
much more recently manifested itself. Marseilles,
which had previously suffered twenty severe visita-
tions in the course of seventeen centuries, was
ravaged by it in 1720 ; Moscow suffered a severe
infliction in 1771 and 1772; and within the pre-
sent century it prevailed at Noja in the Neapolitan
dominions, in 1815 and 1816; it appeared in the
Lazaretto of Venice in 1818, and at Gressembero-
in Silesia in 1819. But with these exceptions it
has been for a century generally confined to Af-
rica, the land of its origin, and to those portions
of Asia and Europe which own the Ottoman
sway.

[A concise history of the disease is given by
Vetter, in Art. Pestis, in Encyclop. WcJrterb. der
Medicinisch. Wissensch. xxvi. p. 625: Berlin,
1841.]

Symptoms. — The following definition will
suffice to convey a general idea of plague, al-
though, as is usually the case with nosological
definitions, it does not comprise certain cases
sometimes observed, which form exceptions to the
ordinary character of plague : — an exanthematous
disease, the eruption consisting of buboes, car-
buncles, and pustules, white, livid, or black, dis-
tributed in various parts of the body, and gene-
rally attended with malignant and very fatal fever.
Various divisions have been proposed by sys-
tematic writers ; but there is every reason to think
that there is no difference existing between cases
of the disease which can be regarded as specific,
all the varieties being found intermingled in the
same epidemic. Plague possesses two prominent
characteristics — fever and eruption, both of which
are found in fully formed cases ; but examples of
the existence of one of these symptoms without
the other are not of unfrequent occurrence. The
cases in which the eruption is wanting constitute
the most rapidly fatal type of the disease ; whilst,
on the other hand, bubo occurring without con-
stitutional disturbance is the slightest form in
which this disorder, usually so fatal, can exist.
Between these extremes there are various shades
of intensity discernible, which, as well as the most

542

PLAGUE

severe and the mildest type, we shall endeavour
to depict.

The following sketch of the most rapid and
intense form will remind the reader of malignant
typhus, and of cases of the ordinary exanthemata,
in which the system is so entirely overwhelmed
that the eruption fails to appear, or displays itself
hut faintly. The patients are sometimes attacked
suddenly with a loss of strength, a sense of con-
fusion or weight in the head, occasional giddi-
ness, oppression about the praecordia, and extreme
dejection of spirits. They are inclined to be
silent, and show great anxiety in their aspect, but
make little or no complaint, and, either having no
febrile symptoms or such as are very obscure, are
considered by the persons about them as indis-
posed in a slight degree. Death takes place in
such cases sometimes within twenty-four hours,
or occasionally on the second or third day. —
Neither buboes nor carbuncles appear, and it is
rare to find suspicious marks of infection on the
dead bodies. (Russell, History of the Plague at
Aleppo in 1760, 1761, and 1762, p. 96.)

Others, who are at first attacked in the same
manner as the foregoing, become in a few hours
more manifestly disordered. Their eyes become
muddy, the surface of the body cold ; they grow
drowsy and lethargic, and complain of pain at the
heart. As the distemper advances, they often
lose the power of speech ; the skin seldom reco-
vers its warmth, or, if it does, there is a mere
irregular flushing, which soon gives place to cold
and clammy sweats. The pulse sometimes re-
mains nearly in its natural state, but is generally
low and quick. Patients are by turns delirious,
confused, and sensible, hut the comatose disposi-
tion is the most prevalent. Towards the close
there is incessant inquietude. Buboes rarely ap-
pear, and in those only who survive the third day ;
petechia;, vibices, or broad, livid, roundish spots
occur sometimes, but are not common, and the
two latter are seldom visible till after death. All
the cases of this description which fell under Dr.
Russell's observation were fatal, the patients gene-
rally dying on the second or third day, a very few
living till the fifth. (Ibid. p. 97.)

This intense form of the disease is most fre-
quently observed at the commencement of an
epidemic of plague, when it generally possesses
the greatest malignancy. At a later period the
following more mild but still dangerous variety is
that which is most commonly met with.

The disease commences with coldness some-
times amounting to shivering, which is speedily
followed by fever, accompanied occasionally with
vomiting, and uniformly with giddiness and pain
of the head ; but rarely at first with delirium, and
scarcely ever with a comatose disposition. The
fever increases during the latter part of the day
and the following night, but there is a perceptible
remission, though by no means a cessation, of
fever the following morning. In this form of dis-
ease, buboes and carbuncles generally make their
appearance the first day, and it is not unusual to
see successive eruptions of them appear through-
out the disorder.

As the second day advances, there is again an
exacerbation of fever ; some of the sick are harass-
ed by vomiting ; there is distressing headach ; the

tumours are painful ; there is confusion of thought,
occasionally a slight disposition to coma ; and the
muddy eye, so characteristic of the disease, — in
which Dr. Russell says muddiness and lustre are
so strangely blended together — manifest* itself,
The skin is hot, the pulse frequent, the tongue
dry ; the patient is anxious, restless, and complains
of pain or oppression about the heart. As night
approaches, the feverish symptoms are aggravated;
the heat is more intense ; the pulse less full, but
very quick ; the jactitation is great, the eye very
muddy, and the patient is disposed to incoherent
raving or to stupor. Sweat breaking out early in
the morning of the third day always brings a
mitigation of the symptoms, and sometimes proves
completely critical, but more commonly produces
only a remission so favourable as to encourage
the expectation of a more perfect crisis on the
fifth. Bnt where the patient neither sweats nor
experiences a sensible remission on the third day,
as is sometimes found to occur without perspira-
tion, danger is always to be apprehended. During
these remissions, it should be observed, the pulse
becomes slower, softer, and more full, especially
after perspiration ; and though the eyes still re-
main muddy, the anxiety and disquietude abate,
the intellectual faculties are clearer, and the pa-
tient finds himself in every way better.

There are again exacerbations on the third and
on the fourth day. A remission takes place on
the morning of the latter of these days, preceded
by perspirations, but rarely so profuse as that
which takes place on the third. The exacerba-
tion of the fourth day is more severe, especially
towards night, than that of the second and third,
and continues intense till perspiration appearing
on the morning of the fifth, and increasing to a
profuse sweat of various duration, leaves the pa-
tient faint and languid, but in every other respect
manifestly relieved. After this day the subsequent
exacerbations become slighter and slighter, and
the buboes generally advancing favourably to
suppuration, little or no fever remains after the
beginning of the second week, excepting symp-
tomatic heats occasioned by the eruptions. But
where the sweat on the fifth day proves imper-
fectly critical, milder exacerbations, which usually
decline with gentle perspirations, continue to recur
till the seventh day, when a second profuse sweat
places the patient beyond all danger.

The formidable symptoms which generally
occur on the second day in this form of the dis-
ease, sometimes do not take place till the third or
fourth, and hence it sometimes happens that those
who for some days seem to be slightly affected
suffer a tedious illness or die contrary to expecta-
tion, while more alarming attacks terminate fa-
vourably. In the latter case the event remains
doubtful till the fifth day ; in the former till the
end of the week. At these periods a conjecture
as to the result may be made with tolerable suc-
cess; though cases sometimes occur in which
matters remain in suspense some days longer.

A much more severe and fatal form of plague,
constituting the second class of Dr. Russell, be-
gins generally with slight shivering or sense of
cold, which is soon succeeded by fever, accompa-
nied with giddiness, headach, vomiting, and some-
times purging. The fever increasing towards

PLAGUE.

543

night, the face becomes flushed, the eyes glisten,
and the patient either becomes delirious, or drowsy
and comatose. The pulse in this stage usually
continues full and strong, and though the tongue
is not dry, the thirst is excessive ; but the stomach
retains little of the liquid taken, and the patient,
harassed by the vomiting and other symptoms,
passes a very unquiet night. There is an abate-
ment of the symptoms on the succeeding morning ;
but the pulse is frequent and more or less full, the
skin is hot and dry, and the patient dejected. As
the day advances, there is an exacerbation, the
accession of which is accelerated by vomiting and
especially by diarrhcea, which frequently super-
venes at this time. The symptoms during this
exacerbation are muddy eyes and a peculiar con-
fused expression of countenance, quick pulse,
sometimes low and fluttering, but rarely intermit-
ting ; a whitish, but rarely a parched tongue ; the
external heat moderately feverish, or occasionally
intense in irregular flushings ; pain at the heart
or oppression about the preecordia ; burning pain
at the pit of the stomach and incessant inquietude.
The more or less rapid progress of these symp-
toms denotes more or less danger ; but when to
these are joined a faltering in the tongue or loss
of speech, while the surface of the body, losing
its natural or feverish heat, becomes cold and
damp with clammy sweats, death is inevitable,
though perhaps the fatal moment may still be at
some distance. In certain cases, especially where
vomiting has been severe, and where diarrhcea or
hemorrhage adds to the debility, the third day
proves fatal ; but the disease is more commonly
protracted two or three days longer, advancing so
far regularly to its termination, that each subse-
quent night proves worse than the preceding, and
in the day the remissions are so transient and ob-
scure as to leave no room for hope.

Few of the sick recover from this form of
plague, whether the disease be left to itself or
treated methodically ; neither does the result ap-
pear to be materially influenced by the course of
the buboes. They generally appear on the second
day, sometimes on the third, and occasionally
later. Suppuration does not take place, and the
tumours, advancing or not towards this state, have
no visible effect in hastening ' or retarding the ter-
mination of the disease. Carbuncles, as well as
petechia? and vibices, are occasionally met with.
(Russell, p. 101.)

In the cases of which the eruption constitutes
the principal feature, either buboes or carbuncles
form, and frequently both occur in the same sub-
jects. The patients are so little indisposed as to
be able to walk about the streets or labour at their
accustomed avocations, unless prevented by the
inflammation of inguinal buboes. Even in more
intense forms of the disease, the prostration of
strength is in some cases slight ; for in the expe-
dition into Syria of the French army of Egypt,
several soldiers affected with plague were able to
march during a considerable length of time,
(Fodere, Dictionnaire des Sciences Medicales, vol.
xli. p. 77,) and Diemerbroeck relates many exam-
ples of which he was an eye-witness, of infected
persons walking within a few hours of their
death. (De Peste, obs. xxxvi. et liv.)

The pestilential bubo is a swelling of the glands

of the groins, the axilla?, the neck, or of the paro-
tid itself; though tumours in this last situation
are sometimes named distinctively parotids. Bu-
boes are at first small and deeply seated ; they are
more or less painful, but never entirely indolent,
and they advance towards the surface, and in some
cases to suppuration, with various degrees of
rapidity. They terminate either in resolution,
suppuration, or gangrene; but this last termination
is rare, though examples of it are recorded by
authors, (Diemerbroeck, part i. p. 431) ; and it is
remarked that it rarely takes place in the cellular
tissue, but merely in the gland itself, and hence
that it can be ascertained only by dissectior
(Russell, p. 115.) It is considered in all cases a
fatal termination. There is a general opinion
that the suppuration of buboes, if not essential to
the safety of the patient, is in the highest degree
conducive to his recovery ; but it having been
repeatedly observed that buboes never begin to
inflame externally, or to show signs of approach-
ing suppuration till the fever is manifestly on the
decline, and restoration to health having taken
place in innumerable instances though buboes did
not undergo this process, there is every reason to
think that too much importance has been attached
to it, and that it is at most rather a sign than a
cause of recovery. Buboes are rarely solitary,
two, three, or four existing in the same subject ;
and this circumstance, their complication with
carbuncle and other forms of eruption, and the
antecedent and concomitant symptoms which
generally exist, will secure us from confounding
them with syphilitic swellings. It should be re-
marked, moreover, that pestilential bubo in the
groin generally affects the glands in the vicinity
of the crural vessels, though it sometimes appears
in the situation of the ordinary venereal tumour.

Besides buboes situated in glandular parts, tu-
mours to which the same name has been given
are found in various situations, as on the head, the
nape of the neck, the shoulders, the thorax, the
vicinity of the umbilicus ; in short, they may ap-
pear in almost any part of the body or limbs.*
During six or eight days they are small hard
bodies which do not involve the superjacent skin ;
but subsequently to this period they become pro-
tuberant, and the integument is inflamed. They
sometimes disperse, but more frequently suppu-
rate, though more slowly than the glandular bubo.
They are numerous, from five to nine generally
existing in one subject. Dr. Russell calls them
spurious buboes.

Carbuncles may form in any part of the body,
and they are not unfrequently observed in the in-
teguments covering buboes. Various forms of
them are described, but it is probable that varieties
have been multiplied by observers depicting the
same species in different stages of its progress.
They commence generally in a pustular form, but
occasionally like a vesication of the size of a
horse-bean, filled with a dusky-yellow or blackish
fluid. In the more advanced stage they are hard
and very painful, speedily becoming gangrenous,
and forming eschars, which tend to spread and

* Russell, p. 118. Zacatus Lusitanus, apud Dieiner
broeck, p. GG. Goodwin's Historical Account, p. 49, and
Baron Larrcy, in the Dictionnaire des Sciences Medi-
cales, torn. xli. p. 77.

544

PLAGUE,

rapidly destroy the skin, and sometimes muscular I the changes during life leave no determinate trace

and tendinous parts. They occasionally exist in
considerable numbers on the same patient. When
recovery is approaching, suppuration takes place
round the edges of the eschar, which, separating,
leaves aYi ulcer of greater or less depth, discharg-
ing abundantly for some time and then gradually
healing; but in fatal cases the eschar remains
dry, with little appearance of being cast off.

There are other cutaneous affections observed
in plague : of this kind are petechia, at first of a
pale or purplish red, and subsequently livid; a
certain marbled appearance of the skin, evanes-
cent till towards the close of the disease, the
variegating colours being of a pale faint blue or
darkish red, and an erysipelatous efflorescence
remaining visible for a short time. Narrow streaks
of a reddish purple or livid colour are sometimes
observed ; and when they affect the face, they
give a frightful appearance to the countenance,
producing such an alteration of features, and so
disguising the patient, that he can scarcely be
recognised by his acquaintances. Vibices, or
weals, and large blue or purple spots, the macula?
nigrae of authors, occur in the more depending
parts of the body sometimes shortly before death,
but they are more frequently not discoverable till
after this event, and in both cases probably result
from the infiltration into the subcutaneous cellu-
lar membrane of the blood attenuated by the
disease.

Morbid Anatomy. — In a disease considered
highly contagious, a deficiency of information on
this head is to be expected, and we find that
writers on plague are more copious on any branch
of the subject than this. Some authors have,
however, endeavoured to illustrate the nature of
the disease by dissection, but it must be acknow-
ledged without much success. Deidier made
many dissections of persons dead of plague at
Marseilles in 1720 ; but the only material result
of his labours was the discovery that the gall-
bladder was extremely loaded with black or green-
ish bile. (Dissertation sur la Contagion de la
Peste, Montpellier, 1725.) Another observer of
the same epidemic informs us that in some bodies
every thing was found in a natural state, and in
others that nothing was discovered but slight
traces of inflammation of the intestines, which,
the writer remarks, were certainly produced in the
last moments of the disease. (Relation Histo-
rique de la Peste de Marseille, p. 447, 448.)
Savaresi, in his Topography of Damietta, relates
that in three cases the only morbid appearances
were the lining of the intestinal canal and the
stomach being covered with a yellowish mucus,
and a general hardness of the conglobate glands.
(Histoire Medicale de l'Arme d'Orient, p. 89.)
Certain individuals have expected to derive infor-
mation regarding the nature of the disease from
the condition of the blood ; but the humoral pa-
thology does not appear to have furnished results
more satisfactory and uniform than the inspection
of the solids ; the blood having been found in
various states, namely, of a natural consistence
and appearance, unduly liquid, and inflammatory
or sizy. (Relation Historique, p. 447.) In con-
clusion, we are compelled to acknowledge that
plague is one of the numerous diseases in which

after death to explain their nature or the cause of
their fatal issue.

[Of late years, extensive opportunities have ex-
isted for noting the morbid appearances in plague.
As the disease generally occurs in Mahomedan
countries, and as a strong objection exists in them
to post-mortem examinations, difficulties were at
one time thrown in the way of the pathologist :
and besides, as already remarked, the ideas in re-
gard to the contagious nature of the disease, have
prevented physicians from availing themselves as
extensively as they might have done, of the nu-
merous cases that presented themselves to their
notice. In recent periods, the abhorrence enter-
tained for dissections has diminished ; and the
notions of the contagious nature of plague have
not been credited by many physicians ; hence,
necroscopic examinations have been by no means
unfrequent ; so that we have now numerous re-
cords of personal observation, not only of Eu-
ropean physicians, but by a Mahomedan, and
native of Egypt, —Clot Bey. (Bulard, De la Peste
Orientale, &c. Paris, 1839. Clot-Bey, De la
Peste Observe en Egypte, Paris, 1840 ; and E.
Littre, Art. Peste, in Diet, de Med. xxiv. 44:
Paris, 1841.]

Nature of Plague. — This dreadful disease,
like others of the febrile class to which it belongs,
evidently results from the introduction into the
system of a morbific poison ; but much obscurity
prevails with respect to the part of the frame
which it first affects, and many of the pathologi-
cal changes which it ultimately produces. The
external inflammations and the fever are the only
parts of the disease of which we have distinct
knowledge. It has already been stated that ex-
amples occasionally occur of the absence of one
or the other of these phenomena, the imperfection
of medical definitions being exemplified by plague
as by many other diseases. This imperfection,
resulting from the variable phenomena with which
the physician is conversant, so markedly contrasted
with the uniformity presented by nature to the
philosopher, or which in his experiments he can
form for himself, does not invalidate the substan-
tial accuracy of the definition, which compre-
hends an immense majority of cases, and excludes
only what may be justly considered as the excep-
tions to the rule. Many persons have been dis-
posed to look beyond the manifest symptoms of
the disease to the interior changes of which these
are only the signs or the effects ; but it is to be
feared that there has been more of speculation
than of cautious induction from facts in the opi-
nions these individuals have published to the
world ; or at least they have made a portion only,
and this the smaller portion of cases of plague,
the representatives of the whole class. M. Brous-
sais informs us that the causes, the symptoms, and
the changes observed in the bodies of those who
die of plague, show that the digestive canal is the
seat of the inflammation which constitutes the
disease. If petechia;, carbuncles, and inflamma-
tions improperly called buboes, appear, these symp-
toms are only according to him, as in typhus, the
effects of the sympathetic irritation of the skia
and cellular membrane, of which irritation the
heat of the climate favours the development

PLAGUE.

545

(Expos. <le la Doctrine de M. Broussais dans le
Journal Complement, du Dictionnaire, torn. ii. p.
148, 149, et seq.) According to this view, the
eruption hitherto deemed characteristic of plague
is a mere contingency, and the inflammation of
the digestive canal is exalted from an occasional
occurrence into the constituent of the disease.
It has apparently escaped the writer's observation
that the eruption which he attributes to the influ-
ence of heat has accompanied the disease in every
climate in which it has manifested itself, — in our
own in winter, for example, (Sydenhami Opera,
p. 108. De Foe, History of the Plague, p. 2G6);
and that the affection of the intestines is indicated
only in a small proportion of cases, either by
symptoms during life, or by the pathological con-
dition of parts after death. The analogy between
the petechia;, which only occasionally appear in
typhus, and the characteristic eruption of plague,
is too remote to identify these diseases, though
we would willingly admit that they are in some
degree related, as all febrde disorders are to each
other. Professor J. P. Frank places plague in
the same genus with continued nervous fever,
which is, he says, a fever occasioned by causes
acting especially on the nervous system, and
which escape the observation of the senses ; and
this fever, he informs us, may be complicated
with gastric and other inflammations, (J. P. Frank,
De Curandis Hominum Morbis, Epitome, t. i. p.
30, et seq.); an opinion in which we fully concur
with him ; though we do not agree in thinking
plague a mere variety of continued nervous fever
or typhus, but, on the contrary, we deem it an
independent disease which preserves its character
in all climates and situations in which it may
exist.

The strongest analogy with plague which we
have any where found occurs in the following
example of disease, induced, as it would appear,
by exposure to the effluvia of common putrefying
animal matter.

An American merchant-ship was lying at anchor
in Whampoa Koads, 16 miles from Canton. One
of her crew died of dysentery. He was taken on
shore to be buried. No disease of any kind had
occurred in the ship from her departure from Ame-
rica till her arrival in the river Tigris. Four men
accompanied the corpse, and two of them began
to dig a grave. Unfortunately they began in a
spot where a human body had been buried about
two or three months previously. The instant the
spade went through the lid of the coffin, a most
dreadful effluvium issued forth, and the two men
fell down nearly lifeless. It was with the greatest
difficulty their companions could approach near
enough to drag them from the spot and fill up the
place with earth. The two men then recovered
a little, and with assistance reached the boat and
returned on board. On the succeeding morning,
they presented the following symptoms : very
acute headach, with a sense of giddiness and dim-
ness of sight, (which had existed more or less
from the moment of opening the grave;) eyes of
a peculiar muddy appearance ; oppression about
the pracordia ; dull heavy pain in the regions of
the heart and liver, with slight palpitation at
limes, and fluttering pulse ; sense of extreme de-
bility, with occasional convulsive or spasmodic
Vol. III.— 69 2v«

twitchings of the muscles of the lower extremi-
ties ; nausea ; slight diarrhoea ; rigors, succeeded
by flushings of the face, neck, breast, and upper
extremities ; tongue white and much loaded ;
pulse from 110 to 120, weak and irregular; urine
scanty and high-coloured, and skin sometimes
dry, sometimes covered with a clammy sweat.
On the fourth day from the commencement of
the attack, numerous petechias appeared over the
breast and arms, and in one of the patients a
large bubo formed in the right groin, and another
in the axilla of the same side, which speedily ran
to suppuration. To one, the disease proved fatal
on the evening of the fourth day ; to the other,
on the morning of the fifth.

On examination after death, in both cases the
vessels of the brain were found loaded, and an
effusion of lymph existed between the tunica
arachnoidea and pia mater; there was an unusual
quantity of fluid in the ventricles, and upwards of
three ounces of dark-coloured liquid at the base
of the brain. The optic nerve of the right side,
in one of the patients, was surrounded, where it
emerges from the thalamus, by a portion of gela-
tinous matter, and appeared thickened and dis-
coloured ; and the surface of the brain was very
vascular. The heart in both cases was much en-
larged, and distended with blood. In one case,
five ounces of a dark-coloured fluid flowed from
the pericardium when slit open, and the vessels
on its interna] surface were gorged with blood,
and this was indeed the case throughout the
whole portal circle. The stomach, near its pyloric
orifice, was thickly beset, in one case, with small
purple-coloured spots. The intestines in several
places assumed a brownish appearance, as likewise
the omentum. There were numerous petechia?
on the surfaces of both bodies. In one of the
cases, the medulla spinalis, in the dorsal region, to
the extent of three or four inches, was of a light
brown colour ; and in the other case it exhibited
evident marks of congestion throughout. Most
of the inguinal and axillary glands were enlarged
and hardened, and several of them, when cut into,
contained a light straw-coloured matter. No other
morbid alteration of structure existed.

One of the two men not immediately engaged
in digging the grave was attacked on the eighth
day from his being on shore. The symptoms re-
sembled those in the preceding cases. For three
days previously to the avowed attack of illness,
there had been pain and enlargement of one of the
inguinal glands, which, at the period he was
visited, had acquired the size of a hen's egg ; and
early in the disease the breast and arms were co-
vered with petechia?. By active treatment this
person recovered, as likewise did the fourth man,
who had slight indisposition of no decided cha-
racter. (Medico-Chirurgical Review, N. IS. vol.
ii. p. 202, et seq.)

Systematic writers have generally been more
struck with the analogy between plague and
eruptive diseases, than with its relation to typhus
or any form of idiopathic fever, and hence it is
universally found in nosologies placed among tho
exanthemata. But this analogy is not so com-
plete as to cause it to be ranked among diseases
which attack persons but once in the course of
their lives. Popular opinion in the Levant,

546

PLAGUE.

where plague may be considered almost endemic,

imposes this limitation on the disease, an error

not destitute of advantage, as it prevents the sick
from being deprived of the requisite attendance ;
and the kind of confidence it is calculated to in-
spire is to a certain extent justifiable, as second
attacks are unquestionably rare. Dr. Russell in-
forms us, for instance, that he met with only twenty-
eight examples of well-ascertained re-infection in
four thousand four hundred pestilential cases.
This accurate observer cautions us, however,
against regarding this as the precise proportion in
which second attacks occur, there having been no
plague at Aleppo for eighteen years previous to
the appearance of the epidemic he describes; and
he found great difficulty in obtaining accurate in-
formation, after so long a lapse of time, as to the
sickness of his patients, or their exemption from
disease, during the former visitation ; and the num-
ber stated must be understood to comprise the
double attacks which took place from 1760 to
1762 only.

This opinion of the liability of sufferers from
plague to second attacks, is not universal among
writers on the subject. The Chevalier Butel, for
instance, is of opinion, from personal observation,
that an attack of plague in Egypt furnishes com-
plete exemption from all future accidents of the
same nature, though, with some inconsistency, he
subsequently quotes the case of an English phy-
sician, (perhaps he alludes to Dr. Whyte,) who
died of the natural disease six months after an
attack he had inflicted upon himself by inocula-
tion. (Journal Universel, Jan. 1826.)

Authors on plague, however, who at all revert
to this question, are almost unanimous in regard-
ing second attacks as, at least, occasional, if not
frequent occurrences. Diemerbroeck mentions
several, and, among others, that of a Chevalier
Schabhals, a bold and rash man, who was attacked
with the prevailing disease, indicated by violent
fever, a bubo in the groin, and three carbuncles,
from which he had the good fortune to recover.
He consequently became so presumptuous as to
neglect all precaution, and was again attacked,
five weeks after his complete convalescence, with
the malady, of which he died before the sixth day.
(De Peste, lib. iv. hist. 37. 45.) There is reason
to think that some writers have exaggerated the
proportion of second attacks from not having duly
discriminated such attacks from relapses ; thus it
has been urged in evidence of the frequency of
second invasions, that convalescents employed as
nurses about the sick, both at Marseilles and
with the French army in Egypt, were frequently
attacked and perished ; but a sufficient number
have been noticed by judicious observers to war-
rant our concluding that plague does not impart
that kind of security from second invasions which
is afforded by small-pox and certain other exan-
themata.

Diagnosis. — Difficulty will never be experi-
enced in discriminating a well-marked example of
plague from any other disease, provided the prac-
titioner have an opportunity of observing it
throughout its course : for the buboes, carbuncles,
and other external affections attending it, consti-
tute, with the intense fever, a group of phenome-
na which belongs only to this malady. But, on

the first appearance of an epidemic, a difficulty,
arising from various circumstances, has not unfre-
quently been experienced in pronouncing on the
character of the disease. In the first place it often
happens that the early cases belong to the intense
type, in which death occurs before the character-
istic eruption has time to display itself; and, again,
even in cases which ultimately assume the normal
form of the disease, a certain period elapses before
buboes, carbuncles, or other external marks appear.
The symptoms on which — the eruption excepted
— most reliance is placed for discriminating plague,
are the peculiar inflamed appearance of the eyes,
which was previously mentioned, swelling of the
tongue, difficulty of articulation, and tottering
gait. Of these phenomena, the Chevalier Butel
declares that the two first are never absent in any
case of plague ; but it seems more than question-
able whether fhey belong so exclusively to this
disease, that we could pronounce from them alone
on the nature of any case we might witness, espe-
cially at the commencement of an epidemic, unless
our diagnosis were aided by extrinsic circum-
stances ; such as our being aware of the arrival
of persons or goods from infected districts, of the
sufferers having had intercourse with such per-
sons, or having been exposed to effluvia from the
goods, &c. Should such circumstances be shown
to have occurred to the subject of a suddenly fatal
disease, it would certainly be advisable to act on
the assumption of its being pestilential, and to
take the precautions which the safety of the com-
munity requires. Prudence would dictate, also,
that suspicious cases, which do not terminate so
rapidly, should be kept secluded for a period suffi-
ciently long to allow their real character to mani-
fest itself, more especially if the disease occurred
in a country or district of which the geogra-
phical or commercial relation with territories in
which plague was prevailing was such as to ren-
der its importation a probable event.

Mortality and Prognosis. — Plague is one
of the most fatal diseases which afflict human na-
ture ; and the general prognosis in the event of its
introduction into any place must be in the highest
degree unfavourable, unless the early cases admit
of being so totally secluded that any general con-
tamination of the inhabitants may be prevented.
Very accurate statistical details, from which we
may estimate the amount of ravage it generally
commits in proportion to the number affected, or
to the population of the place or district in which
it prevails, are scarcely to be procured, since
plague has not proved in modern times a disease
of the more civilized nations of the world ; and it
is only among a civilized people, and at a very
recent period, that any thing like very precise re-
cords of the fatality of disease is to be found.
But such information as we possess leads to the
conclusion that of those attacked with plague,
fully fifty per cent, perish. At Marseilles, tor ex-
ample, in 1720 and 1721, it is calculated that of a
population of 90,000, 40,000 fell victims to the
disease, though more than 10,000 are supposed to
have escaped infection, (Traite de la Peste, p.
464 ;) whilst the following returns from the hos-
pitals, and, as it would seem, from certain corpo-
rate bodies, show a rate of mortality higher than
this general average:

PLAGUE.

547

L'Hopital de la Charite, from 1 Received. Died.

the 3d of October to the > 1013 585

end of February J

L'Hopital de Jeu de Mail,!

from October to the 3d of I 1512 820

July J

Of 100 manufacturing hatters, there died 53;
and of 134 house-carpenters, 84. The tailors,
who were in number 138, lost 78. Of the shoe-
makers, who were 200, there died 110; the cob-
blers were reduced from 400 to 50 ; and of 500
and odd masons, there perished 350. Of persons
in a still lower station of society, such as porters
and chairmen, the mortality was very great indeed ;
scarcely a sixth part remaining at the close of the
epidemic. (Relation Historique de la Peste de
Marseille, p. 437, 438.)

In the capital of our own country, the ravages
of plague have occasionally been very great.
Thus, of the last five epidemics, those which pre-
vailed between the close of the sixteenth and the
latter part of the seventeenth century, there per-
ished, in that of 1593, between March and Decem-
ber, 1 1,166 ; in that of 1603, the mortality amount-
ed, between the same periods, to 29,992; in that
of 1625, to 34,754 ; in that of 1636, commonly
called — not from the amount or rapidity of its fa-
tality, but from its having lasted twelve years —
"the great plague," 11,000 died between April
and December of the first year ; and in that of
1665 the mortality, for the same period, amounted
to 69,602.* But the estimates transmitted to us
furnish neither the proportion of deaths to the
number treated, nor to the amount of population
amid which plague prevailed ; for it was so cus-
tomary for individuals to fly from London on its
first appearance, that population returns, however
accurate, fail to supply the requisite information on
the second point. Defoe (but we do not regard him
as very precise authority) estimates at two-thirds,
the proportion of the population of London which
fled in 1665. Thus much seems certain, that
these returns record a difference in the amount of
mortality in the same place but in different epi-
demics, which no supposable variation, either in
the amount of stationary population, in the num-
ber of fugitives, or in both conjointly, can possibly
explain.

It thus appears that we are deficient in statisti-
cal details whence to draw a general prognosis,
and that, even if we possessed them of the utmost
accuracy, (epidemic visitations of the disease vary-
ing so much in intensity even in the same dis-
trict,) they would not furnish secure grounds for
estimating the probable danger to a population
from an attack of plague. Observers, however,
are almost unanimous in marking in every epi-
demic three periods at which the fatality, and con-
sequently our predictions, must vary. At the be-
ginning of a pestilence, the disease, though less
diffused than it subsequently becomes, appears in
its most fatal form ; during the increase and height
of an epidemic, though many more persons are
attacked, the comparative mortality is diminished ;

* Graunt's Natural and Political Observations, &c.
London, 2d edit. 1664 A Collection of very valuable
and scarce Pieces relating to the Plague, p. 81, London,
1721. London's Deliverance predicted by John Gadsbu-
ry, London, 1005. Kussell on the Plague, p. 274, 273.

and during its decline there is a decrease at once
in the numbers attacked and the proportion of
deaths. A curious anomaly is, however, pointed
out by Dr. Russell, in the last-mentioned law of
the disease, namely, that persons in constant com-
munication with the sick, who have resisted infec-
tion in the most contagious stages of the pestilence,
are sometimes attacked in its decline. (On the
Plague at Aleppo, p. 262.)

The circumstances which, independently of the
period of an epidemic, should influence our prog-
nosis, must be found in the age and general con-
stitution of patients and the symptoms of the dis-
ease. On the former head it is important to re-
mark that young, robust, and vigorous adults are
more prone to plague, and are more frequently its
victims when attacked, than feeble and valetudi-
nary males, and women and children. (Histoire
Medicale de l'Armee d'Egypte, p. 78. Jackson
on the Plague of Morocco.) Women often ap-
pear to owe their recovery to the supervention of
menstruation ; but it may be questioned whether
this occurrence is not rather an indication of re-
turning health than the cause of it. Of the differ-
ent forms of the disease which we have endea-
voured to describe, that in which the febrile com-
motion is slight, the system appearing to be over-
whelming from the commencement, and not pos-
sessing sufficient vigour to throw out the eruption,
is the most hopeless ; whilst in the mildest degree
of the disease, indicated only by the existence of
bubo, a favourable result may be always calculated
on, unless some gross error of regimen be com-
mitted to aggravate a slight into a serious disor-
der. In an affection of an intermediate degree of
intensity, the result can rarely be predicted in an
early stage. When there is an amelioration of
symptoms with subsidence of delirium on the fifth
day, we shall generally find a critical and favour-
able termination on the seventh ; and it is com-
monly remarked that the fact of the patient's sur-
viving till the eighth furnishes grounds for a fa-
vourable prognosis. Intense fever with unabating
delirium, attended by the three forms of eruption,
— buboes, carbuncles, and petechias, — indicates a
very dangerous disease, from which recoveries are
rare, death frequently occurring from the third to
the fifth day. Inferences as to the result may be
sometimes drawn from individual symptoms. A
copious eruption of buboes is not deemed unfa-
vourable ; but buboes and carbuncles conjointly in
great numbers betoken a dangerous disease, and
one which the constitution frequently proves un-
able to contend with ; and the prognosis is still
more unfavourable if petechias are superadded. A
firm and resisting bubo is a good omen, even
though it should have a carbuncle in the centre ;
whilst one of a soft and yielding consistence is
thought to be less favourable. Hiccough, con-
vulsions, cardialgia, diarrhoea, and colliquative
sweats, are grounds for an unfavourable augury.

Causes. — So much were early observers of this
disease impressed with the evidence of its infec-
tious nature, that in the writings of many of them,
the words plague and contagion are used syno-
nymously ;| and from this kind of metonymy c on-

t — — patet et pestem esse omnium morborum -mi
contagione serpunt, ctiam ad distans.contagiosissiinam,
unde a nostris contagionis solo nomine subauditur
Quill. Bcaumontensis, de Pestc, lib. i. 1689.

548

PLAGUE

sidcrable confusion pervades the works of certain
able authors, and among others those of Dr. Read.
But how conclusive soever this evidence may be
to the majority, there have existed persons, both
in ancient and modern times, disposed to deny its
validity ; and on this account we think it advisa-
ble not to confine ourselves to the bare assertion
of the fact that plague possesses a contagious pro-
perty, but to adduce examples of it which may
prove of sufficient force to convince those who
might be influenced by the doctrines of certain
very well-intentioned but dangerous speculators.

We have already quoted the opinion of M.
Fodere, that plague may be generated by the
abundant endemial causes existing in Egypt,
which this writer in common with many others
regards as the father-land of the disease. Having
had no opportunity from observation of verifying
or refuting this opinion, we shall leave it a matter
undecided, whether all the visitations of plague
arise from a permanent stock of human contagion,
occasionally receiving increments from the subjects
of the disease, when the atmospheric influence is
favourable to its diffusion, and occasionally lurk-
ing in fomites to burst forth at a suitable season ;
or, whether the malady is engendered from time
to time by the endemial causes we have men-
tioned, and there is consequently a reproduction
of the contagious principle in Egypt. But though
disposed to leave this question undecided in the
case of Egypt or other eastern realms in which
plague seems to be naturalized, we must express
an opinion that its appearance in Western Europe
has been owing to imported contagion — an opin-
ion which is supported by a host of the greatest
authorities that are to be found on this or any
other question of pathology. Sydenham, though
by no means inclined to exaggerate in any case
the influence of contagion, and considering the
co-operation of a peculiar atmospheric disposition
or constitution essential to the diffusion of plague,
yet thinks this pestilential constitution inadequate
to its production without importation by fomites
or the arrival of a diseased person from an in-
fected district.* To the authority of Sydenham
might be added that of Mead and others of the
greatest reputation in medicine ; but in a question
of this nature we prefer to the weight of great
names, facts illustrative of its importation, and of
its possessing contagious qualities not exceeded
by those of any disease whatsoever, and sufficient
to account for its diffusion through countries not
guarded against it by rigorous quarantine.

The proofs we shall adduce of contagion will
oe derived principally from the history of the
plague at Marseilles in 1720, this being one of
the most accurately reported of European epi-

La peste, uno dei piu terribili mali che possano affli-
gere il genere umano, benche non sia propriamente lo
stesso che il contagio, pure suole avere fra noi il nome
di contagio perche toccare i corpi, o 1'aria degli appes-
tati ; o le inerci, o robe, loro, se ne infettano i sani, con
piu ibrza e strage che non accade in altri morbi, epide-
'.nici et altacaticci— il perche contagio suo l'anche appel-
larsi la peste. Jl/urntorj.della Peste, edit. 4. 1743.

* Interea aeris dispositionem quantnmvis Xoi/j<i5^
pesti suscitandee per se imparem esse vehementer sus-
picor ; quin pestilential morbum alicubi semper stipersti-
tem aut per fomitem, aut per pesti feri alicujus appulsum,
c locis int'ectis in alios deferri ; ihidemque, non nisi ac-
cedente simul idonea aeris diathesi popularem fieri. —
Sydtnhami Opera, sect. ii. cap. ii.

demies. Its importation into the city appears to
have taken place by means of a vessel commanded
by Captain Chataud, which left Seyde with a
rich cargo on board on the 31st of January, her
bill of health being clean, by which is meant that
both the place and the ship were free from the
disease at the time of sailing; but it was after-
wards learnt that it existed avowedly in the town
a few days after. The vessel then touched at Tri-
poli, which is near Seyde, and had constant com-
munication with it, in order to undergo some
repairs. Here additional goods were taken on
board, and some Turks embarked to be conveyed
to Cyprus. One of these Turks fell sick and
died in a few days. Two sailors who touched
the dead body sickened and died after a short ill-
ness, and in a few days after other two persons,
one of whom was the surgeon of the vessel, took
the disease and likewise died. The captain, be-
coming alarmed, secluded himself from his crew,
and three more men falling sick, and there being
now no surgeon on board, the vessel was put into
Leghorn. The disease of the three men last at-
tacked was fatal at Leghorn, and Captain Cha-
taud received from the medical men of the place a
certificate that they died of pestilential fever. The
ship reached her ultimate destination, Marseilles,
on the 25th of May, and was put under quaran-
tine of merchandise for forty days. On the 27th
another of the crew died. At this time three
other vessels from the same suspected places
arrived, those of Captains Aillaud and Fouque,
and the barque of a second Captain Aillaud. On
the 12th of June the vessel of a Captain Gabriel
likewise reached Marseilles from the same ports.
These ships had all foul bills of health, declaring
that at the time of their departure there was a
suspicion of plague. The goods of all these ves-
sels, as well as those from Captain Chataud's
ship, were landed in the infirmaries for purifica-
tion.

The disease and mortality continued on board
of the first vessel. On the 12th of June the indi-
vidual placed on board as a guard during the
quarantine died, and on the 23d a cabin-boy sick-
ened, and at the same time two porters employed
in the purification of the goods, and subsequently
a third similarly occupied with those of Captain
Aillaud. The disease in all these persons was
the same, and all died in two or three days. On
the 5th of July two porters, shut up with the
merchandise of Captain Chataud, were attacked,
and had buboes in the axilla? ; and some days
after the priest who administered the sacrament to
these men died. The passengers from all these
vessels, even those from Captain Chataud's ship,
were admitted into the town on the 14th of June
with their baggage and private merchandise, after
their persons and goods had undergone fumi-
gation.f

The first case in the town occurred on the 20th
of June, and on the 28th of the same month a
tailor was attacked and perished, with his whole

f The expression in the original is " parfums." The
nature of these perfumes is not mentioned, but the au-
thor of the Relation Ilistorique censures the quarantine
department for their excessive confidence in them, and
the neglect of ventilation. (Relation Historique de U
Peste de Marseille, p. 35.)

PLAGUE

549

family, after a few clays' illness. On the 1st of
July a woman named Ligaziere, living at the foot
of the Rue de l'Escale, was attacked with the
disease, and had a carbuncle on her nose ; and
immediately after, a woman named Tanouse, in
the neighbourhood, took the disease, and had bu-
boes, and from her the whole street appeared to
have become contaminated, the contagion invading
first the houses adjoining that of Tanouse. (Re-
lation Historique de la Peste de Marseille, p. 26
—38.)

It was from this street (Rue de l'Escale) that
the disease was introduced into the Hotel Dieu,
through which its progress is one of the strongest
evidences of contagion that is to be found any
where recorded. This hospital was closed against
pestilential cases and all that had communication
with them, it being intended to reserve it for the
patients who occupied it at the time of the break-
ing out of the disease, those who might be attack-
ed with other disorders besides plague, and between
three and four hundred children (enfans trouves)
who were its permanent inmates. A woman, who
had escaped from the street we have mentioned,
applied for admission, and either the characteristic
marks of plague not having appeared, or having
escaped the observation of the examiners, she was
supposed to labour under ordinary fever, and was
received into the house. She was conveyed by
two girls into the women's apartment, and the
principal nurse changed her linen. On the fol-
lowing day the two girls sickened, and died after
an illness of six or eight hours ; on the day after
this, the nurse became ill and died almost as sud-
denly. From these four patients the disease
spread rapidly through the house, and all its in-
mates, directors, confessors, physicians, surgeons,
apothecaries, and all the other officers, servants,
and nurses perished, excepting thirty of the chil-
dren, who were the sole survivors from a number
of persons amounting to between five and six
hundred. (Relation Historique, p. 94, 95.)

The effect of seclusion was exemplified in the
case of the convents of nuns, all of which cut off
communication with the towiuand remained ex-
empt from the disease throughout the whole of
the pestilence. The Poor-House (La Charite)
adopted the same precaution, and enjoyed the
same exemption till the end of September. It
was then converted into a pest-hospital, its original
inmates being removed with the exception of a
few who were retained as nurses ; of these almost
all perished. (Deidier, Traite de la Peste, p. 353.)
The exemption imparted to religious communities
by seclusion was strikingly contrasted with the
ravages of the disease amid the orders of eccle-
siastics who were employed in offices about the
sick. Of the order of capuchins, who furnished a
great number of confessors to the town and hospi-
tals, forty-three perished, out of the whole body
of fifty-five. (Relation Historique, p. 177.)

The contagious nature of plague is strongly
exemplified, in the early stage of epidemics, by
the gradual manner of its diffusion, the paucity
of the attacks at the commencement, and their
slowly increasing in frequency, till, foci of con-
tagion being multiplied, vast numbers are invaded
at the height of the disease. The rarity of the
early invasions at Marseilles, and the havoc it

ultimately committed, have been described. A
similar mode of progression is observable in all
epidemics of plague. In that of London of 1603,
the number of deaths were progressively as follows:
in March 11, April 26, May 83, June 362, and
July 2999; in that of 1625, in March 23, April
85, May 224, June 954, July 5887 ; in that of
1636, April 37, May 162, June 440, July 456,
August 1239, September 3856; in that of 1665,
April 2, May 43, June 1060, July 5667.

We need not, as it appears to us, enlarge further
on the evidence of contagion in plague, enough
having, we trust, been adduced to convince the
most sceptical. It appears transmissible from in-
dividual to individual in all the ascertained modes
in which diseases are thus communicated ; by
contact, inoculation (from the matter of buboes),
through the atmosphere, and by fomites. Ob-
servers have endeavoured to illustrate certain
obscure points in these different modes of trans-
mission. Thus, with regard to the matter of
buboes or of sinuous ulcers consequent on them,
it has been conjectured that its contagious pro-
perty ceases before the healing of the sore ; but
no precise conclusion having been attained regard-
ing the period when this cessation takes place,
Dr. Russell advises that all pestilential ulcers
should be held infectious till after the expiration
of two months from the first attack, and the pa-
tient secluded accordingly. The contagious dis-
tance from the person of the patient has been
matter of discussion, some persons imagining that
a degree of proximity almost equivalent to contact
is necessary for the communication of plague ; but
there is reason to think that this circumscription
is much narrower than facts justify us in drawing
it ; though it is probable that the effluvia when
once transmitted into pure air are soon blended
with the common mass, and suffer such alteration
as renders them innocuous at no great, though not
an ascertained, distance from the patient. At
what period of the disease the communicable pro-
perty commences, and how soon after convales-
cence it ceases, are points which may be considered
quite undecided. The most accurate observers
are of opinion that consciousness of receiving in-
fection, a feeling occasionally discerned in ordinary
contagious fever, does not occur in plague. (Rus-
sell, p. 302.) When received, it does not hang
ambiguously about a person in any case for more
than two or three days, but its operation once an-
nounced by visible signs of disorder, the progress
of the disease is rapid, there being a difference in
this from the course frequently observed in typhus,
in which the effect of contagion on the system is
frequently manifested by slight indisposition, some-
times lasting for weeks, previously to the complete
formation of the disease. (See Contagion.)

It would be desirable to ascertain the duration
of the latent period of pestilential contagion from
its reference to the safety of intercourse between
infected and healthy districts ; but the information
to be obtained on this important question is of a
very unsatisfactory nature. Only at the beginning
of a pestilence, when foci of contagion are rare,
can any attempt be made to illustrate it, and hence
the data are too scanty to furnish a conclusion
which can be implicitly relied on. Dr. Rus^lII
has known the disease sometimes manifest itself a

b30

PLAGUE.

few hoars, and in some cases two or three days
after intercourse, and is disposed to consider that
infection rarely remains latent beyond ten days ;
but he acknowledges that wider experience is re-
quired to determine positively the latter point.
The period during which contagion may adhere
to unventilated goods appears as unascertained as
the latent period in the case of persons ; but many
circumstances lead to the belief that it is of con-
siderable length.

The question has been raised whether dead
bodies have an infecting power, and M. Desge-
nettes answers it positively in the negative ; but
there is much reason to think that this decision is
too general, however warranted by the experience
of its author. During the pestilence at Mar-
seilles, burying the dead was found so dangerous
an operation, that free persons could not be pro-
cured to perform it, even for an enormous recom-
pense, and consequently the galley-slaves were
employed, on a promise of liberty when the duty
should be completed. They were sent out in de-
tachments. The first, consisting of twenty-six,
were all attacked with the disease in two days,
and successive numbers were sent on the duty,
till, from the 20th to the 28th of August, one hun-
dred and thirty-three had been employed, when
the officers of the galleys refused to send any
more, almost the entire number furnished being
either sick or dead. It was likewise observed in
the plague of London of 1665, that officiating at
funerals was an office fraught with extreme peril.

Certain conditions of the atmosphere influence
the diffusion of the contagion of plague, or the
susceptibility of bodies to be affected by it. Of
these, the most manifest is temperature, extremes
in this respect checking, and warmth within a cer-
tain degree appearing to favour, the propagation
of the disease. It hence occurs that the abate-
ment of pestilence in the east takes place during
the heats of summer, and in Europe in winter.
Popular superstition among the Christians resi-
dent in Europe, fixes on St. John's day as the
exact period of the cessation of pestilence : we
scarcely need remark that this opinion is much
more precise than is justified by facts. The fol-
lowing, according to the most accurate observers,
is the ordinary course of the diminution and ulti-
mate disappearance of plague in the Levant.
There is a manifest abatement of the disease at
the commencement of the summer heats, and in
proportion as these continue and increase, cases
become more and more rare, and finally cease ;
while contaminated goods lose at the same time,
as we are informed, their infecting property. The
uniformity in this course is so great that Chris-
tians who shut themselves up during pestilence,
almost always come abroad in June, the instances
being very rare in which they remain confined
to July. Epidemics in Europe have generally
commenced in spring, or in the beginning of
summer. Autumn has frequently been the period
of their greatest prevalence and fatality, and they
have either been totally extinguished in winter, or
have then received a very considerable check, and
have finally ceased in the early part of the ensu-
ing spring. The great plague which prevailed in
London from 1636 to 1648, presents an exception
»o this rule; but during this extensive period

there was invariably a diminution of cases in
winter, though at no time a cessation of the dis-
ease.

Independently of manifest atmospheric condi-
tions, that inscrutable state of the air to which the
term epidemic constitution has been applied, so
much influences the propagation of plague, that
certain very experienced writers have denied its
possessing a communicable property, unaided by
this atmospheric peculiarity. In illustration of
this view, Dr. Russell informs us that experience
in Turkey, where generally no precautions are
taken in times of pestilence, clearly evinces that
in a certain state of the air a communication with
infected places may subsist without any material
consequences. The return of plague at Aleppo
happens at irregular periods ; the intervals are of
considerable but unequal length ; and in these,
the commerce with Egypt, Constantinople, and
Smyrna, remains uninterrupted. In the intervals
between 1744 and 1760, and from 1762 to 1780,
the plague raged several times in the places now
mentioned, without affecting Aleppo; and even in
two or three years subsequent to 1762, though it
was at Marash, as well as other places not far dis-
tant, with which Aleppo has continual intercourse,
no instances were discovered of communicated in-
fection, and this exemption continued, notwith-
standing that infected families from some of these
places took refuge in the town. It would appear,
moreover, that this constitution, favourable to the
progress of plague, varies considerably in degree.
Thus we learn from the able author last quoted,
that the progress of plague at Aleppo was exceed-
ingly restrained in 1760; it was much more
vigorous in 1761 ; it raged with great fatality in
1762, and in this year was finally extinguished,
though there was no appreciable difference in the
state of the seasons in the respective years to ex-
plain the varying diffusion of the disease, or its
ultimate extinction. To the cessation of this
atmospheric condition, which is known only by
its influence on the propagation of disease,* is to
be ascribed the occasionally sudden and otherwise
inexplicable disappearance of plague in oriental
countries, where no disinfecting process is em-
ployed. Much, too, that ought rather to be attri-
buted to a change in this latent state of the atmo-
sphere, is frequently ascribed in other countries to
disinfecting processes, which are in truth rarely so
general or efficient as to account for the cessation
of pestilence.

[So many contradictory statements of "facts"
have been brought forward, that it is difficult to
form any exact opinion either as to the origin or
the extension of plague. It is certainly an en-
demico-epidemic, and this inference is confirmed
by the influence of season, which, in plague coun-
tries, is a common topic of observation. We have
said, that the decrease of plague in the East to-
wards the middle of June is so remarkable, that at
Cairo, St. John's Day, which is the 24th of June,
is ever understood amongst the superstitious inha-
bitants to put a period to the disease. The unifor-
mity of its decrease as the summer advances is so

* At vero qus qualisque sit ilia aeris dispositio, a qua
morbificus lnc apparatus promunat, nos pariter accom-
plura alia, circa quae vecors ac arroeans plulusophantium
tubra nugatur, plant ignoramus.— Sydenhami Oper.seci-
ii. cap. ii. p. 107.

PLAGUE.

551

marked, that persons, who have previously con-
fined themselves, come forth invariably on that
day, mix with other people, transact their ordinary
affairs, and restrain themselves, in no respect, from
any apprehension that they may take the disease.
But although plague is evidently dependent upon
locality and season, it has been supposed that a
principle may be given off from a plague patient,
which, if concentrated, — as in very malignant
forms of the disease, and in pent-up situations,
where proper ventilation is impracticable, — might
cause it in a healthy individual. Such — as the
writer has said elsewhere, (Practice of Medicine,
2d edit. ii. 509,) — may be the case ; but by many,
who have had ample opportunities for observing
the plague, it has been denied, — and the negative
view is strengthened by facts communicated to
the English Admiralty by Sir William Burnett.

In a recent work, Dr. John Davy, (Notes and
Observations on the Ionian Islands, Sec, London,
1842,)'gives many examples to show that, taking
it for granted that the disease is contagious, it is
but very slightly so ; and hence there is a neces-
sity for a revision of the quarantine laws, " with
a fair prospect" — to use his own words — "of
their being greatly mitigated, and at the same time
rendered efficient, to the great comfort of the tra-
veller, the incalculable advantage of commerce,
and the universal benefit of mankind."]

Treatment. — There are few points in medi-
cine on which greater discrepancy of opinion pre-
vails than the mode of treatment to be adopted for
conducting patients safely through this dangerous
disease. Remedies which are the favourites of
one class of observers, in the hands of others
prove to be fraught with danger. Bloodletting,
emetics, and other heroic measures, are alternately
lauded as cures and censured as poisons. We
believe that had any of the remedies, the reputa-
tion of which has been so fluctuating, been an-
nounced as cures for any of our ordinary epi-
demics, such as small-pox, scarlatina, or continued
fever, without reference to the period or type of
the disease in which they were to be employed,
the testimony for and against them would have
proved equally conflicting. The general treat-
ment of any epidemic, independent of that re-
quired to combat local lesions, may be comprised,
if we mistake not, in few words : — We must de-
plete the excited, and stimulate and support the
sunken and collapsed ; and in an immense majo-
rity of instances, the condition requiring the for-
mer means, if it exist at all, will be found in an
early stage of the disease ; that demanding the
latter, will occur in an advanced period.

The best authorities inform us that bloodletting
is to be employed at the very commencement of
the disease, if the pulse possess sufficient force to
render such a proceeding prudent ; and some are
of opinion that a second bleeding may be occa-
sionally admissible; but that very judicious ob-
server, Dr. P. Russell, cautions us against per-
forming any bleeding after the third day. He
mentions, however, one case (On the Plague at
Aleppo, case ciii.) in which bleeding was success-
fully performed on the third day from both arms
at once, though the patient, a female, had been
bled the preceding day. The presence of buboes,
which Svdenham and others have regarded as a

valid objection to bloodletting, from a dread that
the operation might occasion their recession, ought
not, we are assured by more recent authorities, to
prevent its employment, as neither the eruption
nor progress of these tumours is injuriously in-
fluenced by it. Dr. P. Russell, indeed, remarked,
that where the pain ot buboes was excessive,
bleeding was necessary to moderate that anil other
inflammatory symptoms, for till the fever declined,
these tumours never advanced kindly to suppura-
tion.

Many cases, however, occur, in which the col-
lapse of the system is so well marked from the
commencement that the employment of bleeding
is manifestly inadmissible, and emetics are then
thought the most suitable remedies. Should the
first emetic dose fail to act, it is advisable to repeat
it after the interval of an hour or an hour and a
half. Full vomiting, we are assured, especially
if bilious matter or worms were discharged, was
found so efficacious during the prevalence of
plague at the city of Aix in Provence, that almost
all from whom such matters were ejected recover-
ed, whilst those on whom the emetic failed to
operate perished. (Sauvages, Classes Morborum,
vol. ii. p. 368.) It is probable that the failure of
emetics was not so properly the cause as the token
of death, as it indicated an extremely collapsed
state of the system, of which the sensibility was
almost annulled by the vehemence of the disease.

Purgatives are generally regarded as suspicious
remedies, from the tendency to diarrhoea being so
general in the disease, and its very fatal effects ;
and practitioners concur in declaring costiveness
to be less prejudicial in plague than other febrile
disorders. The irritability of the bowels is so
great, and hypercatharsis is consequently so liable
to be produced by the more active purgatives, that
we are advised to empty the bowels at the com-
mencement of the disease by means of the most
lenient of the class, such as cassia pulp, manna,
or rhubarb, with cream of tartar. Sir Brooke
Faulkner, however, employed calomel and jalap,
without intimating that inconvenience resulted
from the practice. (Treatise on the Plague, p.
238.)

Among the older physicians, the object of
whose practice was to eliminate from the blood
the noxious principle on which they conceived the
phenomena of the disease depended, the more
heating diaphoretics, such as contrayerva and ser-
pentaria, were favourite remedies, whilst their ope-
ration was aided by excluding the air, heating the
apartment, and heaping the patient with bed-
clothes. This method of treatment, so injudicious
in any febrile disorder, is now universally aban-
doned by European practitioners. Some of the
more cooling sudorifics, as liquor ammonite aceta-
tis, and saline draughts, are customarily given by
many physicians, and by some are thought to be
beneficial. Dr. P. Russell says that saline draughts
given in an effervescing state are much more effi-
cacious in checking the retching which is som«
times a distressing accompaniment of plague than
that of ordinary malignant fevers.

It has been stated that diarrhoea is a very com-
mon and very dangerous symptom. The judicious
observer we have so frequently quoted, Dr. P
Russell, informs us that he was at first unwilling

552

PLAGUE.

to administer opium for its relief, from an appre-
hension of aggravating the stupor or comatose
disposition ; but finding that this effect did not
follow its employment, he used it in 1762 much
more freely than he had done in former years,
and in general remarked that where he succeeded
in stopping the looseness early in the disease, the
patient became more alert and sensibly better. In
the more advanced stage, however, we learn from
the same writer, astringents and opiates rarely
checked or suppressed the diarrhoea. Inflamma-
tion of the intestines being one of the. few patho-
logical appearances generally recorded by authors,
there can be little doubt that the diarrhoea which
accompanies plague indicates some inflammatory
affection of the bowels, and that local bleeding,
from the integuments of the abdomen or anus, and
perhaps subsequent blistering, would be found
important auxiliaries in its treatment.

Coma and other affections of the brain it is
customary to combat by means of blisters between
the shoulders, to the nape of the neck, temples,
and occiput. (Sir B. Faulkner, loc. cit. p. 241.)
It is extremely probable that the dread of drawing
blood, which is so general among those who treat
this disease, is the reason why local bleeding is
not conjoined with the counter-irritants to subdue
the cerebral affection. From the symptoms we
have detailed of the intellectual disorder in plague,
there can be little doubt of its depending upon
the same causes as that which accompanies other
malignant fevers, and that the same method of
treatment would be found applicable to both.

Certain remedies of the general febrile state,
besides those already mentioned, have been tried
by European practitioners in this disease. Cold
affusion is thought by Sir B. Faulkner to present
a considerable prospect of benefit if applied at the
very commencement: this writer, however, it
should be remarked, speaks from a very limited
experience of its effects. Several writers speak
favourably of mercury ; some on merely specula-
tive grounds ; others from the analogy, real or
presumed, between plague and other disorders in
which they have observed that this mineral is use-
ful ; — Mr. Stafford from considerable experience.
This gentleman declares that, when his regiment
was infected, thirty or forty cases of axillary tu-
mour recovered under its use, and he relates at
length five severe cases of plague, of which three
recovered under mercurial treatment. The mode
of administering it was internally, in the form of
calomel, and by inunction. The statements of
this writer seem to show that the mineral may be
serviceable in the treatment of the disease. (Cases
by Mr. Stafford, quoted by Sir B. Faulkner, p.
245-253.)

Should the vital powers appear to be failing at any
period of the disease, wine and cordials are adminis-
tered, and many writers advise that they should
be accompanied by tonic medicines, of which ca-
lumba, bark, and serpentaria are those most usu-
sually resorted to.

Friction with oil has been praised as a means
of curing the disease, by inducing diaphoresis, and
likewise as a preservative from infection. The
property of inducing diaphoresis it certainly pos-
sesses; but its power of curing the disease is
questioned by numerous authorities. A writer

whom we have often quoted, — Sir B. Faulkner, —
is equally sceptical as to its prophylactic pow-
ers. On this point he remarks : " There are
so many instances of persons living in the closest
intercourse with the infected who escaped without
the use of oil, and so few well-attested cases of
persons having come into actual contact with pes-
tiferous matter who were protected by oil alone
that I cannot hesitate to conclude that the opinion
of its possessing any independent or certain pro-
phylactic efficacy is destitute of foundation." (Op.
cit. p. 232.) Vaccination has been recommended
as a means of prophylaxis. The last-quoted wri-
ter furnishes us with the following forcible argu-
ment against its claim to such a property. »I
took pains," says he, " to ascertain whether those
who had recently been vaccinated were rendered
less susceptible ; and I found that the instances of
its inefficacy were every where numerous, of which
I may mention rather a striking one, which was
communicated to me by a Maltese surgeon, who
was much employed in the plague, namely, that
of a numerous family who had been recently vac-
cinated, the whole fell sacrifices to the prevailing
contagion, with the exception of the parents, who
had never undergone the operation." (Op. cit. p.
233.) For the prophylactic means to be adopted,
we beg to refer to the articles Contagion and
Disinfection.

The general plan of diet is the same as in other
febrile disorders. Of preparations of animal food
nothing stronger than chicken broth should be
allowed ; the rest ought to consist of preparations
of farinaceous or leguminous vegetables, ripe
fruits, and simple diluents, such as lemonade,
toast-water, or tea.

[It is to be deplored, that all remedial agencies
are too often ineffectual, owing to the malignity
of the disease ; and, accordingly, we are not so
much surprised at the information given by Dr.
Shaptcr, (Tweedie's Library of Medicine, 2d
Amer. edit., i. 230, Philad. 1842,) that a recent
observer, after five months' experimenting with all
kinds of treatment, and all modifications of the
disease, in about 1000 cases, arrived at the melan-
choly conclusion, that, although the medicines pro-
duced their wonted effects upon the organism, the
malady neither ceased nor changed.]

The local treatment of buboes should be limited
to the application of warm emollient poultices.
By the older writers, who erroneously conceived
that the suppuration of buboes was the cause,
rather than the effect, of the abatement of the
fever, various irritating measures were resorted to
for accelerating the process, but sounder patholo-
gical views have occasioned them to be abandon-
ed. When suppuration has taken place, the mat-
ter may be left to discharge itself spontaneously,
or the lancet may be employed to give exit to it.
Should the original aperture be too small, it should
be dilated, as its narrowness is apt to give rise to
sinuses. If the carbuncles require topical treat-
ment at all, it should be of the same simple nature
as that of the buboes. Prior to the forming of
the eschar, a mild poultice only is required: sub-
sequently a slightly stimulating dressing, such as
unguentum resinas, or the same with oleum tere-
binthinae, may be interposed between the tumour
and the poultice. Joseph Brown.

PLETHORA.

553

PLETHORA, irXriQupa, fulness; [Polijasmia
of Andral.] — Before entering on the discussion to
which tliis article is appropriated, the writer wishes
to guard himself against a misconception that has
at times been inconsiderately formed respecting
the doctrines maintained in it. Though connected
with the foundations of all pathology, they are by
no means intended to represent the whole of it.
Pathology regards living actions, which depend on
organized structure, and this both derives its nu-
trient elements from the blood, and returns to it
the effete matter which the nutrient deposits dis-
place. This connection — subsisting without in-
termission so long as life endures — is so intimate,
that whatever affects the condition of the blood
must immediately concern the well-being of the
whole frame ; whence every approach to a correct
pathology of the circulation must contribute to the
establishment of sound principles, and improve
medical science. But pathology embraces more
than the mere lesions of the blood or of its circu-
latory apparatus ; there is a nervous system as
well as a vascular, which cannot be overlooked.
We wish it, therefore, to be understood, that in
the following doctrines of plethora we have not
the slightest intention of establishing an exclusive
pathology, or of claiming for the facts and reason-
ings adduced a higher importance than they in-
trinsically merit.

The term plethora but ill expresses the state of
constitution which it is used to designate, yet it
would be difficult to substitute one more correct
and appropriate. Indeed, no concise term could
convey the compound idea which requires to be
represented, and which involves the conception
not so much of the quantity of the circulating
fluid, as of the relative proportions of its consti-
tuent parts. The term hyperemia, as being of
similar import, would not be preferable even if it
were not otherwise appropriated. It is applied to
denote local accumulations of blood arising from
congestion or determination, in which the pheno-
menon results solely from the increased quantity
of blood, without reference to its quality, and is
consequently expressed with correctness by a term
representing such excess.

Plethora, though inducing a morbid condition
of the body, has not in general been designated a
disease, nor treated of by practical writers, save in
connection with some special malady attendant on
or derived from it. Linnseus has given it a place
in his nosology in the class Deformes and order
Bccolores, and thus defines it : " Rubcdo corporis
a distensis vasis sanguineis, cum dyspneea." Sa-
gar also admits it in the class cachexise, and order
Intumescentise, giving not only a definition but a
description also : " Intumescentia universalis, pro-
portionata et oequabilis ex abundantia sanguinis."
"Amystidis et ventris cultus, pulsus plenus aut
suppressus, venarum amplitudo conspicua, sestus
et gravitas totius corporis, respirandi difficultas,
lassitudo spontanea, stupor artuum, somni turbati,
partes epidelio tectae ruberrimaj, temperamentum
sublaxum, sanguineum." The former of these
would seem to denote rather special disease of the
lungs, and the latter to characterize obesity. Nei-
ther is calculated to convey a clear or correct no-
tion of the morbid condition which excess of blood
occasions. As this condition is present in many

Vol. III.— 70 2w

diseases, and actually gives rise to several ; and
as, even in cases where it does not exist, it is of
importance to be assured of the negative, it can-
not but be deemed an important part of pathologi-
cal science to trace the circumstances which ge-
nerate a state of plethora, and the phenomena
which indicate it, so as to be prepared both to re-
cognise it when present, and to apply means suit-
able and adequate for its correction.

Disease is considered to exist when there is any
observable deviation from health in any of the
functions or structures of the body. When the
whole constitution is disturbed or depraved, with-
out any part being prominently affected, the dis-
ease is said to be general or constitutional, and ac-
cording to its character is called either febrile or
cachectic. If any function or organ be particularly
disturbed, a name is thence affixed ; and if an
organ or function suffer without apparent dis-
turbance of the general health, the disease is pro-
nounced local. On such views have classifications
of diseases been formed, yet are they wholly
wanting in that precision which the productions
of a nosological arrangement should indisputably
possess.

When morbid symptoms of any kind arise, it
is necessary to consider not only the morbid lesions
which immediately produce them, but also the
deviations from health in which these morbid
lesions themselves originate, tracing these back to
the point where deviation from health first occurs.
By such investigation only can the history of dis-
ease be rendered complete, or its true pathology
be established.

It is easy to understand why the investigation
of disease has for the most part commenced with
that period when a nosological malady is consi-
dered as formed. Until this period arrives medical
aid is rarely sought for, the patient's consciousness
of indisposition being aroused only when the
functions of health become so impeded as to fail
sensibly in their accustomed exercise. The ac-
cession is then referred in general to some exciting
cause, real or imaginary, and is considered as
having commenced at the time when the imputed
cause was supposed to operate, a state of previous
good health being assumed. Thus suddenness of
accession has been regarded as a character of most
acute diseases, and the period when the accession
has been first observed has been regarded as iden-
tical with the commencement of disease. Yet it
may be doubted whether any disease, excepting
such as results from a morbific poison, ever takes
place suddenly or without previous derangement
of general health, cognizable by its appropriate
manifestations, and capable of being corrected so
as to obviate the morbid accession to which it
leads. If this can be demonstrated, it is clear that
this introductory stage of disease is of the highest
importance, as being that to which prophylactic
treatment can be most beneficially directed, and
also as forming a part of the ensuing disease es-
sential to its complete history, and without a
knowledge of which its intimate nature or the
series of morbid changes never can be thoroughly
understood.

In tracing the progress of plethora, and the de-
rangements of function which it occasions, it is
necessary to commence at that point where the

D?4

PLETHORA.

equable and temperate exercise of all the functions
of life constitutes the state which we denominate
health. By this means physiology becomes con-
nected with pathology ; the actual transition of
health into disease is elucidated ; and & light is
thus shed on morbid processes which no other
source of investigation can supply. When dis-
ease has made a certain advance, and continued a
certain time, so complex are the derangements re-
sulting, that without some clue for unravelling
their intricacies, an exposition of them is in vain
attempted, and, as the history of physic abun-
dantly shows, conclusions the most opposite may
be arrived at in inquiries directed to the same end.
This could not be the case if the several morbid
changes, as occurring in the respective functions,
were marked in their regular progression, so as to
determine, when any one presented, what were its
antecedents, what would be its consequents. Were
this knowledge clearly possessed, each symptom
of disease would be discriminated as belonging to
a determinate train of morbid actions ; and how-
ever obscured it might be by contingent or deriva-
tive disturbances, it would point out uhequi vocally
the appropriate means of its own correction. With
such accurate knowledge we should not see such
ambiguity prevailing as that in certain maladies
some practitioners enjoin bloodletting where others
give opium and ammonia.

Almost all systematic and theoretical writers
have left their inquiries incomplete ; with each
an important stage of the disease of which they
respectively treat remains unexplained. This stage
embraces the interval between the first deviation
from a state of health, and the occurrence of the
special lesion of which each has taken cognizance ;
and it is chiefly to this stage that we propose to
direct attention in the following pages.

The constant unremitting exercise of the func-
tions, the aggregate of which constitutes all that
we know or can conceive of life, is attended with
a physical expenditure which daily nutrition re-
places. The nutritive matter taken into the
stomach, and which forms the chief support of
animal life, undergoes several successive changes
in its passage through the body ; it is digested,
assimilated to the animal juices, deposited in the
several structures for their appropriate nutrition,
and finally, when no longer fit for supporting their
healthy actions, is taken up by the absorbents and
carried out of the system by appropriate excre-
tories. It is obvious that there is a natural pro-
portion between the ordinary waste of the body
and the supply of fresh nutritive matter, and that
if the latter be either too sparing or excessive, the
functions of life must undergo some deviation
from their healthy exercise.

Considerable variations are liable to occur in
the quantity and quality of food which any indi-
vidual consumes, in the assimilating processes by
which what is taken into the stomach is animalized
and fitted for repairing the waste of the system,
and in the several secretions in which the blood
is expended. If more food be assimilated than the
ordinary waste of the body requires, a state of
repletion must be the natural and inevitable result.
But repletion may also take place under a mo-
derate and even abstemious use of food, when,
from sedentary habits, inactive life, or other cause,

appropriation of blood by the nutrient and other
secretions is languid and inefficient. As repletion,
then, may take place under very different circum-
stances, so is its presence marked by different
phenomena. Whenever it arises, one of two con-
sequences is sure to result ; either it excites the
several functions, if sufficiently healthy and vigor-
ous, to increased actions leading to its speedy ap-
propriation and removal ; or, if these be weakly
and unable at the moment to institute and support
those increased actions by which the redundant
matter is to be appropriated and expelled, then,
oppressed by a labour to which they are unequal,
they manifest a decline of even their ordinary
power, and all the outward phenomena of debility
are displayed. To discriminate this state from
one of real debility arising from exhaustion of
animal power, or from defective nutrition, is a
matter of practical importance not inferior to any
which medical science may be engaged in illus-
trating.

When redundancy of nutriment takes place in
a healthy constitution, its earliest effects manifest
what may be termed rather exuberance of health
than a state of disease. The several functions of
the body are more vigorously performed, the nu-
trition of its several structures is more abundant,
and it acquires increase of bulk, especially if the
habits of life are not of an activity capable of in-
creasing excretion to a degree proportionate to the
nutriment inordinately supplied. And if the ex-
cess be casual or inconsiderable, the self-adjusting
powers of the body are amply sufficient to dispose
of it so as to prevent the transition of healthy ac-
tions into diseased. If from extent or continuance
the excess be such as to urge these powers beyond
a certain point, then their conservative energies
fail and irregular actions of various kinds take
place, laying the foundation of a large proportion
of the specific diseases to which the human body
is liable. The general character of diseases so in-
duced is inflammatory. They are marked by a
quickened circulation, increased heat, and a more
or less depraved state of the several functions.
According to the predisposition of the system,
hereditary or acquired, to the accidental weakness
of particular parts, or to the casual excitement to
which the body may be exposed, is the specific
form of the ensuing disease determined. For this
diseased condition the means of essential relief are,
depletion and abstinence ; the one to remove or
abate the original cause of distemper, — the other
to prevent its recurrence. There can be little
doubt that the process of nature here referred to,
though generative of what we term disease, is yet
intrinsically sanative ; its object being to dispose
by increased energies of that which the ordinary
powers are unable to appropriate and the con-
tinuance of which is inconsistent with their health-
ful exercise.

When repletion occurs in a habit of less natural
vigour, the self-adjusting powers are not so suc-
cessful in effecting early restoration, and inflam-
matory actions are more tardy in their accession.
The interval which precedes the occurrence ol
morbidly increased actions is one of peculiar in-
terest, because its phenomena are of an equivocal
character, resembling in many respects those
which belong to a very different state of the sys-

PLETHORA.

555

tem, anil hence liable to be misunderstood ; and more
especially because they have hitherto been very
imperfectly investigated.

The two kinds of plethora here described may
be conveniently distinguished by the terms abso-
lute and relative; the former implying that the
redundancy exceeds what the healthy state of the
individual constitution would require or bear ; the
latter that, without being absolutely excessive, it
is relatively so in reference to the deficient powers
of the constitution for appropriating or otherwise
disposing of it. Absolute plethora would thus
correspond with the plethora ad molem, ad vasa,
ad venas of systematic writers ; and relative
plethora to the plethora ad vires. With respect
to the plethora ad spatium, or that referred to
reduced capacity of vessels, the actual quantity
remaining the same, — or the plethora ad volumen,
arising from increase of bulk without actual in-
crease of quantity, it would serve but little pur-
pose to notice them in a practical treatise ; the
former being resolvable into relative plethora, and
the latter, if it ever take place, being only a
transitory effect of a temporarily operating cause,
such as increased temperature, by which the
volume of the blood was supposed to be expanded.
The distension of vessels, however, from which
this expansion was inferred, was much more pro-
bably occasioned by the excitement of the arterial
system caused by the stimulus of heat. It is
questionable whether a real plethora ad volumen
ever occurs except in the instance of persons
ascending great heights, at which the diminished
pressure of the atmosphere seems to give rise to
some such effect.

The subject of plethora might be comprised
under the heads of absolute and relative ; but its
discussion would not then be complete, for so
continually is nutritive plethora combined with
another source of vitiation of the blood, that it is
impossible to do justice to the one subject without
at the same time illustrating the other. This
vitiation takes place when under moderate nutri-
tion there is defective excretion ; in which state
the system is oppressed, not so much by the quan-
tity of nutriment, or the labour of disposing of it,
as by the load of excrementitious matter with
which the blood is overcharged. The phenomena
and treatment of this condition of the body are
also of high interest, and deserving attentive and
mature consideration ; for unless its nature be
clearly understood, the treatment must be purely
empirical, and its success precarious and incom-
plete. Each of these morbid conditions will now
be considered ; and the discussion will, we trust,
assist in reconciling some of the apparent ano-
malies and inconsistencies with which medical
practice is so frequently charged.

I. To the first of these conditions, or that of
absolute plethora, belong all the cases of pure in-
flammation which we daily witness. It is usual,
when these occur, to refer them almost exclusively
to the exciting cause which may have immediately
produced them. Yet the fallacy of the conclu-
sion must be obvious when we reflect that, of
several individuals exposed to the same exciting
cause, scarcely two will be affected alike. From
exposure to cold, for instance, one will be attacked
with catarrh, another with rheumatism, a third

with inflammation of the bowels, a fourth with
sore throat; while by far the greater number will
escape altogether. Were the exciting cause solely
chargeable with these several effects, they would
unquestionably be marked with greater uniformity.
The truth is, that the exciting cause produces its
effect because the body exposed to it is prone to
be morbidly affected in consequence of its own
previous derangement ; and the specific form of
the disease is determined, partly by the operation
of the exciting cause, but chiefly by the predispo-
sition of the parts affected to undergo those mor-
bid actions to which the general indisposition of
the system and their own partial weakness render
them liable.

To distinguish by its appropriate phenomena
that condition of an apparently healthy body,
which subjects it to be affected by slight exciting
causes, must be an important part of medical
knowledge. This state and these phenomena the
writer of this article endeavoured to explain and
illustrate at some length several years ago. He
then made known the course of inquiry by which
he was led to investigate these phenomena, and
to trace them backwards to the point where health
first passes into disease. His earlier observations
were conducted on what occurred in his own per-
son, at a time of life when he was prone to severe
attacks of inflammation, and when regard for his
safety compelled him to watch vigilantly the pre-
monitory indications so as to anticipate the ap-
proach of inflammation, and by timely interference
avert its more severe accessions. By close atten-
tion he was enabled to detect those indications in
certain derangements of functions sufficiently clear
and undeniable when noticed, but which might,
on superficial examination, be overlooked or re-
garded as trivial and insignificant. The success
of his early endeavours to arrest advancing dis-
ease encouraged him to observe still more closely,
and detect at still earlier periods, the morbid actions
introductory to inflammation ; in which way he
progressively ascended to the higher links in the
chain of causation, availing himself always of the
knowledge thus acquired so as to apply means of
relief at the earliest period when a necessity could
be perceived ; and with such effect that he suc-
ceeded thoroughly in subduing a liability to in-
flammation, from which he had suffered repeat-
edly and severely for several years. Engaged in
hospital duties of some extent, he had ample
opportunity of making corresponding observations
in a tolerably wide field of practice; and the
result was a full confirmation of all that the ex-
perience of his own case had taught him. From
the principles thus deduced, the writer has derived
much valuable guidance in the investigation and
treatment of disease for more than twenty years ;
an experience which may be considered as justify-
ing some confidence in now again submitting
them to the profession through the medium of a
work devoted to practical medicine. To detail
here the analytical processes of inquiry from which
this experience was derived would extend the
present article beyond its allotted limits. Pre-
mising, therefore, that it was from research so
conducted the following information was obtained,
we shall proceed to state synthetically what we
believe to -be the course of morbid actions con-

556

PLETHORA.

sequent to and resulting from redundancy of
nutritive matter in the blood, both absolute and
relative.

We have stated that absolute plethora is the
parent of pure inflammation. If there be no ple-
thora, inflammation will not be excited by slight
causes ; or if it be aroused through the operation
of an exciting cause, it will be mild and easily
subdued. The severity of inflammation, too, will,
cseteris paribus, be proportionate to the degree of
plethora pre-existing. Previously to the occur-
rence of febrile or inflammatory action, there is
always a sensible interval of disease marked by
evidences of diminished power in the arterial sys-
tem, the oppressed and irregular actions of which
evince its inadequacy to carry on the circulation
with its wonted vigour. The pulse, if examined,
will be found low, oppressed, irregular ; which
state passes progressively into one of permanently
increased action or fever. Multiplied observations
have satisfied us both that the stage of disease here
mentioned precedes that of febrile action, and that
the morbid actions indicated by the pulse succeed
each other in the order here announced ; the first
being that of feebleness or overloaded power, the
second of irregularity, and the third of perma-
nently quickened circulation. It has been already
stated how incipient plethora, when the redund-
ancy is no longer disposed of by the healthy action
of the several organs of appropriation, and when
these can no longer perform steadily the increased
labour, gives rise to the state of feebleness now
under discussion. To comprehend the nature of
these several changes is not difficult, it being rea-
dily explicable by reference to well-known laws
of vital action.

When redundancy of nutritive matter first oc-
curs, its immediate effect is to promote more vigor-
ous circulation, and to excite to increased actions
the several capillaries, especially those engaged
in nutrient secretion. The peculiar stimulus of
the nutritive matter excites these actions ; their
end is to dispose of the redundancy by natural ap-
propriation, and the effect on the frame in the first
instance is only that of increased volume and ex-
uberant health. But to all vital actions, and the
degree to which they can be continuously sus-
tained, there is a limit ; and when increased be-
yond this, they after a time become relaxed, sink-
ing even below the natural standard. By inci-
pient plethora increased actions are excited which
at first differ from perfectly healthy actions only
in degree. In time, however, and especially if
the plethoric state be kept up by excessive nutri-
ment, they become enfeebled and abate ; then it is
that the pulse, which antecedently was fuller and
stronger than natural, first becomes low and op-
pressed. The disposal of redundancy by increased
action of healthful processes proving inadequate,
from inability of the vital powers to continue it,
other efforts are now needed ; and as these, though
in their tendency corrective of what is amiss, no
longer resemble the healthy actions, they must be
considered as morbid ; disease being the result of
their institution. While we thus regard them,
however, we should never lose sight of the cor-
rective tendency which originally belongs to them,
nor fail to profit by the curative indications which
the efforts of nature point out. The minute

changes so induced we pretend not wholly to ex-
plain, though many of them are readily intelli-
gible ; but the cognizable phenomena are suffi-
ciently obvious to mark their connection and de-
pendency, and thus to establish a rational theory
of the course which nature pursues.

Relief by increased nutrient secretion not suf-
ficing, a more general excitement seems now re-
quired, the object of which may be to call into
more vigorous exercise the several excretories ; and
a state of generally increased or febrile action en-
sues. The state of irregularity is obviously the
transition from the state of feebleness to that of
permanently increased action or fever ; and the
end of the latter is to get rid of the original cause
of disturbance. It is in proof of the correctness
of these views that if in the stage of feebleness
depletion and abstinence be resorted to, the feeble-
ness disappears, natural vigour is renewed, and
health is restored, without any febrile action being
instituted ; while if this state be treated with stimu-
lants and nutritive diet, febrile or inflammatory
action is sure to result. We wish here to observe
that in these remarks we use the term fever to
denote, not any of the specific diseases known by
that name, but simple pyrexia, characterized by a
quick pulse, hot skin, and furred tongue, being
the constitutional state attendant on the ordinary
phlegmasia?, and so generally, through a radical
misconception, denominated symptomatic fever.
As the stage of feebleness is relievable by evacua-
tions and abstinence, so are those of irregular
action and of febrile excitement to be remedied by
the same means ; and if these be duly employed,
any or all of these morbid conditions may be
promptly corrected without specific disease or local
lesion of any kind ensuing. But if they be not
employed, and more especially if, through miscon-
ception, stimulants be used and nutritive diet con-
tinued, then febrile action becomes more deter-
minately aroused, and some specific disease of an
inflammatory character is engendered ; or else, if
the constitution be, from natural inertness or the
extent of labour to be performed, unequal to the
effort necessary for generating a state of fever in
inflammation, the general health progressively de-
clines, the powers of life become enfeebled, anil the
constitution finally sinks under some of the com-
plicated forms of chronic disease. When, under
the former of these results, active fever or inflam-
mation occurs, it is in general speedily subjected
to medical treatment ; and as opinions vary but
little respecting the measures to be pursued under
such circumstances, while the urgency of disease
requires them to be employed with proportionate
vigour, it seldom happens that this stage of dis-
ease is improperly treated, at least so far as re-
gards the use of evacuants. At this time the pro-
priety and necessity of active treatment and of
depletory practice are admitted on all sides; yet
previously to the acute attack a deviation from a
healthy state existed, which admitted of detection,
and which as clearly indicated the propriety of
some depletion, though it might not demand it so
imperatively, nor require it to the same extent, as
when the acute attack had supervened. Were
this introductory stage relieved by adequate de-
pletion and other suitable means, there can be lit-
tle doubt that the accession of acute disease might

PLETHORA,

557

in every instance be averted, or at least so greatly
mitigated as to be free from all danger.

It appears from all that has been stated, that
incipient plethora in a healthy constitution excites
at first only increased energies of healthy func-
tions, manifested in the increased bulk and more
florid aspect which such persons usually present,
and in the evidences of more vigorous circulation
which the pulse affords ; that this state of increased
healthy action, if urged too far, declines into one
of diminished power, still evinced by the pulse,
which then becomes low, oppressed, and irregular ;
and that, if these progressive changes be over-
looked or unrelieved, a state of permanent excite-
ment succeeds, such as constitutes fever or inflam-
mation. It is obvious, then, that the increase of
bulk and more florid aspect in which so many
exult as evincing sound health, and which they
endeavour by all the aids of good living to pro-
mote, is not a source of unmixed congratulation ;
but that, on the contrary, it deserves to be re-
garded with no slight suspicion, as actually
verging on consequences by which both health
and life may be forfeited. Up to this period, how-
ever, disease cannot be said to have commenced,
however it may be approached ; and reduction of
diet, with free bowels and increase of active ex-
ercise, would suffice for getting back to sounder
health without any need of medical interference.
When abatement of healthful energies becomes
evinced by a low and oppressed pulse, diseased
actions may be said to commence, and when the
stage of irregular action ensues, sensible progress
may be considered as made towards the establish-
ment of febrile action and inflammatory disease.
When these latter result, medical aid and active
discipline are indispensable ; but up to this period
much may be done by mere reduction of diet and
a free state of bowels to avert the pending mis-
chief. This condition of the body will be further
illustrated, when the practical treatment required
for its relief comes under discussion, the course
of inquiry rendering it necessary to proceed now
to the consideration of the second division of the
subject, or that of relative plethora.

[An examination of the relative proportion of
the constituents of the blood in plethora has
shown to M. Andral, {Hematologic Pathologlque,
p. 41, Paris, 1843 ; or Amer. edit, by Drs. J. F.
Meigs and A. Stille, Philad. 1844,) that it differs
from ordinary blood in the greater quantity of
globules, and the much smaller proportion of
water. In 31 specimens of blood, taken from
plethoric patients, he found the mean quantity of
globules to be 141 ; the minimum 131 ; and the
maximum 154. His researches have led him to
the conclusion, that the grand condition of the
blood, which favours the production of hemor-
rhage, is a diminution of the fibrin as com-
pared with the red globules. In plethora, the
proportion of globules is greater than in the
healthy state, whilst that of the fibrin may be
normal, or below the . physiological condition.
When hemorrhage occurs under such circum-
stances, the quantity of globules diminishes, but
not that of the fibrin ; hence, an equilibrium is
induced, and the hemorrhage may not recur, or
iot until an excess of globules is again produced.
In scorbutic cachexia, as shown elsewhere, the

2w*

quantity of fibrin is diminished, whilst that of the
globules may have remained stationary. In the
31 cases, above referred to, the mean of the fibrin
was 2.7; — less than the average of health; thus
showing a marked difference between the condi-
tion of the blood in plethora and in inflamma-
tion.]

II. In relative plethora the earlier deviations
from a healthy state take place so gradually, and
the constitutional efforts are so feebly exerted, that
for a long time they are nearly unnoticed. Health
is observed to be less perfect ; there is occasional
languor and disinclination to the customary ex-
ertions, with irregular distribution of blood as
marked by coldness of feet and variable counte-
nance; the bowels are irregular, the appetite is
capricious or fails, and both flesh and strength
decline.

At the earlier periods of this state the pulse
will be found weak, often irregular. Sooner or
later a febrile or inflammatory state ensues, marked
by a quickened circulation, some increase of tem-
perature, and a white or furred tongue. This
state may continue for an indefinite period, and be
subject to frequent fluctuations ; most frequently
in course of time some part more particularly
suffers, a local ailment arises which excites atten-
tion, and to which, when discovered, the consti-
tutional indisposition is most commonly ascribed.
In order to judge correctly of this condition of
plethora, it is necessary to mark particularly the
accordance of its phenomena with those which
absolute plethora presents, especially in the
changes which the pulse undergoes. This, here
also, is at first feeble and oppressed, then irregular,
and finally it becomes permanently quickened.

As the incipient lowness of the pulse is the
symptom which so generally misleads, conveying
the impression of debility, and suggesting the
employment of tonic and stimulant remedies, it is
highly necessary to distinguish it from a pulse of
pure debility. Happily there are other circum-
stances besides the pulse to direct the judgment
in this respect ; other obvious derangements co-
exist, displaying a harmony of symptoms, which,
taken collectively, establish beyond a doubt the
existing condition of the vascular system. But
the language which they speak is not always un-
derstood ; their warning voice is unheeded ; and
the deceptive lowness of pulse is suffered to coun-
teract the evidences which the other coexisting
symptoms display. On this account it is that we
dwell so much on an accurate discrimination of
the indications which the pulse affords; not so
much for the positive evidences which it furnishes
— for there are others much less equivocal, and far
more worthy of being relied on — as that, when
this peculiar lowness exists, it shall not be suffered
to bias the judgment or to divert the practitioner
from those measures by which alone the morbid
condition referred to can be corrected. A little
accuracy in the mode of examination, with atten-
tion to the impressions made on the finger, will
readily detect the peculiarities which we have
stated ; and when familiarised to the touch by
habitual perception, there can be little difficulty in
distinguishing them. In the condition of which
we are treating, if firm pressure be made on the
artery, it will be found to resist beyond what iU

533

PLETHORA.

apparent feebleness would indicate, and, on gradu-
ally withdrawing the finger, to rebound with a
force much greater than would at first be imagined.
If the pressure and relaxation be a few times al-
ternated, the sensation will be rendered more dis-
tinct. This inherent firmness is sufficiently indi-
cative of the condition existing, and affords the
best assurance of depletion being well borne. As
we before stated however, and as will be hereafter
more distinctly pointed out, there are other evi-
dences to confirm what the pulse proclaims.

The state of irregularity of the pulse also re-
quires precision in determining both its character
and extent. It may be perceived as affecting both
the force and frequency of the pulsations ; and
the irregularity of force, or that in which the
artery makes a few strong pulsations, as if by a
transient effort, and again relapses into a state of
oppressed and diminished action, indicates, so far
as we have been able to discover, a nearer ap-
proach to febrile or inflammatory excitement than
the irregularity of frequency only ; repeated obser-
vation of which fact has led us to infer that this
stage of irregularity is the connecting link be-
tween the stages of feebleness and of permanently
increased action, and that it consists of the early
but yet imperfect efforts of the vascular system to
form this latter stage ; for when the febrile or in-
flammatory action is fully formed, the irregularity
is no longer perceived.

The decline of power incident to a plethoric
state of circulation has not been overlooked by
theoretic or practical writers, however they may
have failed to mark the order of succession which
the phenomena present in the initiatory stage of
disease, or to have deduced from these conclusions
capable of affording practical guidance. Dr. Gre-
gory, who has faithfully represented the state of
physiological and pathological science as they
existed when he wrote, notices distinctly both the
weakness of the circulating organs and the inor-
dinate burden imposed on them by a state of
plethora. " Multa mala a nimia plenitudine ori-
untur. Homo nonnunquam fere opprimitur,
hebes, languidus, debilis fit, neque ipsa quse san-
guinem movent organa ad tantum onus impellen-
dum valent. Pulsus languet, et aliquando synco-
pe, et vertigo, et palpitatio observantur. Saepius
vero vasa nimis distenta, ad motus praeter solitum
vehementes et abnormes proclivia fiunt." Here
the facts are explicitly stated, but the connection
of the state of debility with that of increased
action is not traced, while symptoms, which be-
long to more advanced periods of disease, and
arise from ulterior derangements, are intermixed,
creating confusion. And, further, the stage of
permanent excitement is regarded rather as the
result of over-distension of vessels, than of the
stimulus of redundant nutritive matter over-ex-
citing the vital powers.

As the succession of these several stages may
be observed taking place naturally, so may the
changes be accelerated and displayed by means
of medical treatment; for if the constitution be
long oppressed, and have long endured the stages
of feebleness and irregularity, moderate depletion
has the effect of relieving the vital powers, so as
to bring on the period of increased action much
sooner than it would otherwise occur. This effect

is strikingly exemplified by Dr. Watt in his valu-
able treatise on diabetes; in which he has shown
that the pulse may be raised from the extreme of
depression to vigorous action by free bloodletting,
and that under this process the blood itself be-
comes changed from a dark grumous mass, scarce-
ly coagulating, to the blood of active inflammation,
with firm coagulum and thick buff. Changes
similar to those recorded by Dr. Watt we have
had repeated occasion to witness both in diabetes
and in cases where no urinary affection existed ;
and for many years we have been accustomed to
refer them to the pathological state of the vascular
system which we are now endeavouring to ex-
plain. This state also will require further illus-
tration when its practical treatment comes to be
considered ; but ere we pursue the subject of
nutritive plethora further, it is necessary to notice
the vitiation to which the blood is liable from its
becoming overcharged with the excrementitious
matter carried back to it by the absorbents, which
in the ordinary course of health ought to be regu-
larly expelled, but which, under impaired energies
or interrupted functions of the excretory organs,
accumulates in the blood, oftentimes to a conside-
rable extent, vitiating its quality, unfitting it for
healthful nutrition, and oppressing and debilita-
ting all the powers of life. The necessity for
noticing this state arises from its being continually
combined in various proportions with the condition
of relative plethora, the progress of which it sensi-
bly impedes, and the phenomena of which it com-
plicates and obscures.

III. In the morbid condition which we are now
to notice, the deviation from health takes place
still more gradually than in relative plethora.
Indeed, so insidious is its advance, that, not pro-
ducing any immediate or special disease, and
marked only by change of aspect and some abate-
ment of wonted powers, it is for the most part
overlooked, or at least undergoes no adequate in-
vestigation. Combined as it is, too, with relative
plethora in every proportion, and by its debilita-
ting effects even ministering to this latter, it be-
comes confounded with derangements of a charac-
ter essentially different, and the influence which
it exerts both in generating and modifying disease,
fails to be recognised. It arises from defective
excretion ; and as exercise is the natural stimulant
for exciting the various excretions to an adequate
performance of their functions, this condition
more peculiarly occurs in the sedentary and the
indolent. It is characterized by great sallowness
of aspect and duskiness of skin ; the pulse is low
and compressible ; the surface of the body is in
general harsh, dry, and deficient in natural trans-
piration ; the tongue is for the most part moist
and clean ; the appetite capricious, often vora-
cious ; the alvine evacuations are inveterately
foul, exhibiting no traces of healthy secretion;
the urine is high-coloured, depositing a dark sedi-
ment, and often very fetid ; even the perspiration
has frequently an offensive odour, and gives a
dusky tinge to the linen which absorbs it. The
state here described has not escaped observation,
having been noticed by medical writers, and even
ascribed by them to the causes here assigned.
Ramazzini more than a century ago represented
distinctly this condition of body, as induced in

PLETHORA.

559

certain artificers by sedentary habits and inactive
life, explicitly referring the sallowness of aspect
and depraved health, together with certain defoe-
dations of the skin, to the excrementitious matter
of the body being imperfectly discharged. In his
work, " De Morbis Artificum," ch. xxx. he re-
marks, " Scabiosi quoque decolores, ac mali habi-
tus esse solent sedentarii artifices, sarcinatores
potissimum, ac mulieres qua? suis in laribus die
ac nocte, ut victum sibi quceritcnt, acu operantur,
ha) enim mala inexercitatos comitantur : nam
vitium capit sanguis ni moveatur corpus, unde
illius cxcrementa in cute restitant, et universus
corporis habitus vitiatur." Again he states,
>< Mala igatur intemperie et multa vitiosorum suc-
corum redundantia laborare solent hujus modi
artifices, ob vitam sellulariam quam degunt, ac
praesertim sutores. Non sic tamen multi alii arti-
fices qui sedendo operantur, uti figuli, textores,
qui brachia et pedes, totumque corpus exercent ac
propterea saniores sunt, ut quibus sanguinis im-
purilules facilius per hujusmodi motum discu-
tiantur." Here are represented as distinctly as
words can convey, both the accumulation of ex-
crementitious matter resulting from inactivity and
defective excretion, and the depravation of habit
to which such redundancy gives rise.

The manifestations now noticed as belonging
to excrementitious redundancy are intermixed in
every proportion with those of relative plethora,
the two conditions mutually reacting on each
other. Arising, however, as they do from totally
different sources, it is highly necessary to discri-
minate them so as to impute to each what belongs
to it, and thus render the practical treatment more
definite and precise. No symptom marks the ex-
istence of excrementitious excess in the blood
more signally than the obstinate foulness of bowels
so often encountered in various maladies, and
which no employment of purgatives seems to cor-
rect. If by their use such relief be given to the
system as empowers it to make a febrile or inflam-
matory effort for impelling blood into the capilla-
ries, renewing more active processes of secretion,
and thus ministering to its own relief; if the
pulse become quicker and firmer, the tongue white
and loaded, with such evidences of increased acti-
vity of circulation as to warrant the use of small
bleedings, these, if employed with sound discre-
tion, and adapted to the powers of the constitution,
will, in conjunction with the excited powers with
which they are used to co-operate, do more to cor-
rect the morbid condition of the bowels, and thus
restore healthy evacuations, than any use of pur-
gatives however judiciously managed or persever-
ingly employed. This fact we have so often wit-
nessed, that when this state of bowels is found to
resist purgative treatment, we have for many years
been accustomed to resort to the moderate use of
the lancet, as the most effectual auxiliary of pur-
gatives that can be employed. Bloodletting, how-
ever, in this morbid condition of the system, re-
quires much caution and a clear conception of the
principles on which its employment is founded, to
guide its use ; for if resorted to at too early a
period, while the powers of life are still torpid and
inert, or if pushed even a little beyond what those
powers can bear, much mischief and formidable
exhaustion may result. Some tendency to re-

newed excitement ought perhaps to be manifested
ere the lancet be used ; but when this presents,
then small bleedings will contribute to rally the
dormant powers far more effectually than the most
potent tonics.

In the transition here noticed of the sluggish-
ness of system belonging to a state of excrementi-
tious redundancy, into the excited power mani-
fested by febrile action, it cannot fail to be observed
how closely the latter corresponds with what has
already been described as occurring in relative
plethora. In fact, so far as the state of excite-
ment is concerned, the conditions are identical,
displaying the same pathological phenomena, and
ministering to the same end, the only difference
being the modification which any great degree of
excrementitious accumulation produces in the ac-
tions and symptoms ; which after all is a difference
more in degree than in kind ; for when relative
plethora has existed for any time, excrementitious
accumulation is sure to become combined, it being
the direct product of the debility and imperfect
excretion incident to this morbid condition.

The consideration of excrementitious redun-
dancy might with propriety have been included
in that of relative plethora, were it not that the
separate notice of it renders its nature and pheno-
mena more clear and explicit. For practical pur-
poses, however, the two states cannot in our con-
ceptions of them be disunited, for relative plethora
gives rise to excrementitious redundancy ; and
when any high degree of the latter primarily oc-
curs, it is most probably incapable of correction
without the intervention of those sanative efforts
which the constitution itself makes when aroused
into febrile excitement. To promote these efforts,
not merely by exciting enfeebled powers with sti-
mulants, as is too much practised, but by dimin-
ishing their labour, and thus rendering them more
adequate to its performance, through the cautious
abstraction of blood, and the establishment of
more efficient excretions, is the process by which
the objects of the medical practitioner will, in
numberless instances, be best attained. To pur-
sue this course, however, requires unbending in-
tegrity on the part of the practitioner, and firm
confidence on that of the patient. It is opposed
by many prejudices; it works not like a charm,
and extravagant expectations of instantaneous
results would not be realized. Time is required
for its success; it is nature that effects the cure,
and her operations are not to be hurried. They,
however, who are willing to abide by her slow but
sure exertions, and who value the re-establishment
of perfect health more than the temporary allevia-
tion of some partial ill, will be amply repaid in
the fulfilment of their more rational desire, so far
as it is attainable by human means ; and we can
confidently say, from the experience of a life
which has for above thirty years been devoted to
medical science and practice, that the satisfaction
which we have derived from witnessing the reno-
vation of health and strength thus effected, has
surpassed even that which the signal relief of
acute disease by active treatment, and the conse-
quent saving of life, has ever afforded.

Treatment* — We proceed now to consider
the practical treatment of the three several condi
tions to which we have directed attention, naiuclv,

560

PLETHORA.

absolute plethora, relative plethora, and excremen-
titious redundancy.

1. Absolute plethora. — In this condition, in-
cluding the diseases to which it gives rise, we
may trace three progressive stages. The first
embraces the period which precedes febrile or in-
flammatory excitement ; in the second, febrile ex-
citement exists unaccompanied by any prominent
local affection; and in the third is superadded
some local inflammation, or other partial derange-
ment, constituting what is usually deemed a spe-
cific disease. When the latter arises, it no doubt
reacts on the constitution, aggravating the several
disturbances in proportion to the importance and
the degree of derangement of the organ or func-
tion specially affected. But if the series of mor-
bid actions here represented be that which nature
follows, it is clear that they are much in error
who ascribe what is miscalled sympathetic fever
to the local disease coexisting, which, instead of
exciting the attendant fever, is only its direct pro-
duct.

The phenomena which mark the incipient stage
have been already noticed and explained ; and it
was stated generally that the proper treatment for
correcting this morbid condition consisted essen-
tially of depletion to remove the plethora, and
abstinence to prevent its recurrence. And this
treatment, if timely employed, would always suf-
fice. Indeed, in the very early periods, abstinence
alone would, by cutting off the supply of inordi-
nate nutriment, give effectual though slower relief.
But were this otherwise, inasmuch as they who
become so affected are still considered as enjoying
perfect health, it would be useless to lay down
rules of treatment to which none would be likely
to resort or conform. Indeed, we should be reluc-
tant to lay stress on this initiatory stage, if doing
so were to induce any suspicion of a wish to bring
under medical discipline those who probably exult
in their not requiring its unenviable interference.
Even if it were in our power, therefore, to arouse
every such individual to a full sense of his ap-
proximation to disease, and of the dangers to
which this exposes him, we should hesitate to
give rise to such incalculable misery as a perpe-
tual watchfulness over the feelings of health could
not fail to occasion ; for though many might, by
timely precaution, avert diseases that would other-
wise ensue, the constant anxiety to which num-
bers would be unnecessarily consigned by the
prevalence of such impressions, however correct,
would greatly counterbalance any good that could
result. It is of consequence, however, that medi-
cal men should have a just conception of this
state when subjected to their observation, so as
not to be misled by delusive appearances ; and it
is of the highest importance, when, as continually
happens, acute and dangerous maladies have a
tendency to return, to be aware of the premonitory
signs that mark an approaching accession, so as
to employ in time the means necessary for avert-
ing its recurrence. To precautions of this kind,
as formerly mentioned, the writer was indebted
many years ago for his own preservation and re-
establishment of health ; since which period he
has had ample opportunity of proving, by exten-
sive application of the principles now inculcated,
the value and efficacy of such timely prevention.

When the stage of disease now under conside-
ration is subjected to medical treatment, the means
of relieving it are simple in the extreme, consist-
ing only of moderate bloodletting, occasional
purging, and reduced diet, with a speedy return
to such exercise as may be required for keeping
the several secretory and excretory organs in the
adequate and healthful discharge of their func-
tions. By these means, pursued without any
sensible impression on the general strength, and
scarcely an interruption of ordinary avocations,
may this condition be effectually relieved, and the
dangers to which it leads successfully averted.
It may conduce to accuracy of conception to ex-
plain here what is meant by moderate bloodlet-
ting. The object is to remove a certain portion
of the circulating fluid in order to diminish the
proportion which the nutrient matter bears to the
watery solvent. This latter is so readily absorbed
and carried into the circulation, that the actual
volume of the blood becomes speedily restored.
For the relief of incipient plethora it will in gene-
ral suffice to abstract twelve or sixteen ounces of
blood at a time, the evacuation being repeated as
circumstances may require, both the amount and
the repetitions being dependent on the individual
constitution. In the case of the writer, when
suffering under this stage of plethora, much
larger depletion was required ; above thirty ounces
being often taken from the arm without the eva-
cuation being otherwise felt than in the relief
which it afforded. If the necessary relief hap-
pened to be postponed, so as to approach the
period of active fever, the bloodletting required to
be of still larger amount. At such time there
was generally some uneasy sensation, caused by
certain local determinations of blood to which the
writer was subject ; and when this existed, blood
was usually suffered to flow without regard to
quantity, until the uneasiness subsided. If the
evacuation stopped short of this effect, the relief
was incomplete, and a speedy repetition of vene-
section was sure to be required, and to a greater
amount. From this free use of the lancet, guided
as it was by a definite purpose, and bounded by
certain limits, though these were not measured
by quantity, the writer .never in any instance suf-
fered injury such as is so often ascribed to large
bleedings, and he is quite satisfied that by ob-
serving the rule which has been stated, more
effectual relief was obtained, and that morbid
actions were restrained with less ultimate loss of
blood, and less prostration of general powers, than
if blood had in the first instance been sparingly
taken.

The principle of carrying bloodletting to the
extent of making some impression on the consti-
tution, and thus arresting the progress of morbid
action, we shall have to consider more fully when
we come to treat of its employment in active in-
flammation. We may here, however, cursorily
remark, that when morbid actions of an inflam-
matory kind prevail to such extent as to demand
direct depletion by bloodletting, effectual relief is
not afforded unless the sufficiency of the deple-
tion is manifested by some impression on the vital
powers ; for under high and active inflammation,
twenty, thirty, forty, ounces or more, may be ab-
stracted without making any impression, when the

PLETHORA.

561

loss of a few ounces more will, by inducing a dis-
position to syncope, at length arrest completely
the inflammatory action, and repress the violence
of disease. In such case, if the depletion be re-
gulated by regard to the quantity of the blood
taken rather than the effects resulting ; and if
from vague apprehension of injury it stop short
of that relief which ought alone to set limits to it,
the morbid action is left unsubdued, and much
greater loss of blood is required eventually to
allay it ; and this with considerable risk of its
then failing to accomplish its end ; for indepen-
dently of the hazard of allowing inflammation to
continue in any organ essential to life, it should
ever be borne in mind that in proportion to the
time during which morbid action of this kind is
suffered to continue unrestrained, will be the dif-
ficulty of finally subduing it; and consequently,
that whenever active inflammation arises, it can
never be too soon nor too effectually arrested.

From ample experience of the correctness of
these views, we have long been convinced that
when active inflammation occurs in a robust and
vigorous frame, copious depletion in the earlier
stages is the surest means of saving animal power
and of accelerating perfect recovery. In the
initiatory stage of plethora, however, such active
measures are not needed. The object here is to
reduce the quantity of blood as the most direct
means of altering its quality ; there is no inordi-
nate action to subdue; and however moderate the
depletion, it must give relief proportionate to its
extent, the ground gained being afterwards main-
tained by other evacuations and abstinence. But
when, from continued or increasing plethora, the
second stage, or that of febrile action ensues, then
the principle which we have noticed becomes di-
rectly applicable. When the oppressed pulse
passes into a state of irregularity, and thence into
one of permanently excited action, as manifested
by a quickened circulation, hot skin, and white
tongue, active depletion becomes necessary, and it
requires to be regulated on the principle now
stated. At this time, too, other auxiliary remedies
are needed. Of these purging is the most direct
and most powerful, and saline purges, which pro-
duce copious watery discharges from the bowels,
are among the most effectual. Several neutral
salts and antimonial preparations are also valua-
ble, as co-operating in the general purpose by the
increased secretions to which they incite the kid-
neys and skin; and by the judicious administra-
tion of these several remedies in conjunction with
low diet, may this second stage in general be
promptly and effectually relieved. The mode of
exhibiting these remedies is so familiarly known
and so continually practised in the treatment of
the several phlegmasia;, which so much prevail,
that it would be superfluous here to enter into
further details.

When local inflammation becomes superadded
to the febrile excitement, we have then to con-
sider not only the general plethora and febrile
condition of the system, but also the state of the
organ or part locally affected. If it be an organ
essential to life, then the utmost activity of prac-
tice is required to guard against the danger
arising from its functions being suspended or im-

Vol. m.— 7i

peded, and from the disorganization of structure
which continued inflammation is sure to induce.

It would exceed our province to notice here
every local inflammation with which a predisposed
body is liable to be assailed. For the purpose of
illustration, therefore, we shall confine our remarks
to two of the more urgent, and, by particularizing
the treatment which they require, exhibit the
principles of practice so clearly as to render them
easily applicable to every corresponding case that
can occur. With this intent we shall select two
organs of primary importance, the brain and the
lungs. When active inflammation of either organ
is manifested by its appropriate symptoms, the
necessary treatment must be promptly and vigor-
ously applied, for the danger arising from sus-
pended or impeded function is considerable, and
both the obstinacy and danger are enhanced in
proportion to the delay of the necessary depletion,
and the insufficiency of its early employment.
If bloodletting be not early and vigorously em-
ployed, such derangement of structure may quickly
ensue as to destroy life, or permanently unfit the
organ for the discharge of its ordinary functions.
The effect of bloodletting in this case is twofold ;
by the quantity of blood abstracted it diminishes
plethora, and by its influence on the moving pow-
ers it moderates or subdues the arterial actions by
which inflammation is upheld. As inflammatory
action in such cases cannot be too soon arrested,
and as suddenness of depletion greatly promotes
its speedy effect on the moving powers, the blood
should be taken from a large orifice, in a full
stream, and with the body erect. To be effectual,
the depletion should be carried to the extent of
making sensible impressions on the local symp-
toms of either head or chest, and this will be
found to coincide almost uniformly with abated
action of the artery as felt at the wrist. When
under the flow of blood the pulse falters, the lips
become pale, and the face bedewed with perspira-
tion, bloodletting may be confidently relied on for
yielding all the relief which this truly potent
remedy is capable of affording. The quantity
necessary to produce this effect varies greatly.
The writer has himself lost from forty to fifty
ounces at one bleeding, and has nevertheless re-
quired a repetition to smaller amount within a few
hours. We have known much larger bleedings
employed in urgent disease with only salutary
effect and without a single bad consequence re-
sulting. As cases of extreme violence are those
in which inadequate depletion would prove most
fatal, it is necessary to notice the amount to which
bloodletting may under urgent necessity be safely
carried. Happily such cases are not the most
frequent, and in the more moderate instances
which most prevail, evacuations much more
moderate will suffice. When by one or two
bleedings, so conducted as to make impression on
the moving powers, the more urgent symptoms
are alleviated, the repetitions may then be regu-
lated so as to keep within the bounds of all pos-
sible risk of excess.

If the plethora be considerable and the fever
continue high, it may still, even though the local
symptoms have yielded, be requisite to take more
blood, so as to bring back the circulation to e

562

PLETHORA.

healthy standard, and subdue remaining excite-
ment, or relapse of inflammation may occur. By
such means, combined with the auxiliary remedies
already noticed, and assisted by the topical treat-
ment suited to each local disease, a state of the
most imminent danger may be speedily changed
to one of perfect safety, provided organic lesion
has not yet taken place.

The practice here inculcated may possibly ap-
pear to some bold and hazardous, but we can con-
fidently appeal to the experience of those whose
opportunities of treating active inflammation have
been greatest, for the soundness of the principles
which we advance, and for the perfect safety of
the measures enjoined. We willingly admit that
the ordinary course of medical practice may be
carried on by less active treatment, for a large pro-
portion of ordinary cases requires no more ; but
when urgent disease occurs, the attempt to dis-
pense with proportionate activity of treatment can
lead only to fatal results or tediously protracted
disease. We have purposely dwelt on the severe
rather than on the milder instances, in order to
show more clearly and forcibly what the principles
are on which the treatment should be conducted.
As the symptoms of each case, and the constitu-
tion to be acted on, denote the activity required,
and thus guide the practitioner in the use of his
remedies, there can be little hazard of the repre-
sentations here made misleading any one into a
rash or excessive use of bloodletting.

It may not be amiss here to take notice of two
consequences, either of which may attend a very
full bloodletting, namely, syncope and convulsion.
They are prone to occur when much blood is
taken, and especially when the patient is bled in
an erect posture. There seems little room to
doubt that both arise from the vessels of the brain
being too much emptied, the enfeebled action of
the heart being insufficient to refill them ; and,
as is familiarly known, recumbency of the body,
which allows the blood to return to the brain with
less of the heart's impulse, is the direct, and, we
may add, uniformly effectual remedy. It has
happened that patients bled to syncope have not
revived ; but this has been of rare occurrence, and
when it has taken place, we should strongly sus-
pect that blood must have been drawn beyond all
prudent bounds, or that the propriety of taking
any blood was questionable. We have witnessed
many instances both of syncope and of convulsion,
and can truly affirm that we never saw a single
case in which injury of any kind resulted. We
are no advocates, however, for bleeding syncope,
and never direct it, although, if urgent disease
were to be arrested, we would go to the vergje of
it, for the reasons already assigned. Convulsion
is an effect more formidable in appearance than
syncope ; and yet, though we have frequently
seen it so induced, we have never known harm
attend it. In its effect of lowering arterial action,
we regard it as perfectly analogous to syncope,
and for all that we have seen, equally innocuous.
Yet, as it is always alarming to the bystanders,
and as neither it nor syncope is necessary to
ensure the full effect of bloodletting in subduing
inflammation, we would willingly avoid both.
There is a caution which we here wish to suggest
to those who may have occasion to draw blood

largely, namely, never to leave a patient so de-
pleted until placed in a recumbent posture. The
following case, of recent occurrence, will illustrate
what we mean. We were requested to visit a
man who had been seized with apoplexy some
hours before. We found that he had been
promptly bled, and to a large amount. The
quantity of blood which we saw could not be
under seventy ounces ; it was thickly buffed in
the earlier drawn portions, and we saw no reason
to doubt the propriety of its abstraction. Having
bled the patient, the medical attendant, pressed by
other engagements, went away directing him to
be placed in bed as soon as possible. Circum-
stances prevented this being done, and when we
arrived he was still sitting in the chair in which
he was bled, held there by four stout men, whose
united efforts were required to restrain the hor-
rible convulsions which recurred every quarter of
an hour or twenty minutes : he had been in that
state for nearly two hours ! His countenance was
ghastly, the eyes glassy, lips livid, and breathing
irregularly laborious. We had him instantly laid
on the ground, and as speedily as possible trans-
ferred to bed ; nothing more was required, for
circulation soon returned, the pulse again became
distinct, the countenance calm, with returning
colour to the lips, and the breathing tranquil.
This was an extreme case, being by far the worst
we had ever witnessed. The bloodletting was
unusually large, and severe convulsions continued
at intervals for nearly two hours, owing to the
imprudent continuance of the erect posture. Yet
so little injury did this man suffer, that in less
than ten days he walked to his physician's house,
free from complaint, to thank him for having
visited him.

It should be recollected that in the practical re-
marks hitherto offered, we have had in view in-
flammatory complaints only as they occur in abso-
lute plethora, consequently in their most active
and violent degree. In this state they require
large depletion, and there is always ample power
to sustain it, the danger being that of falling short
of the quantity necessary rather than of exceeding
it. Diseases of the same species, however, occur
in every condition of the system, and according
as they take place in feebler constitutions, and are
marked by less violence of symptoms, may mea-
sures of less energy be trusted to for their relief.
It is from not noticing the difference of constitu-
tion or the degree of general plethora present under
attacks of local inflammation, that so much diver-
sity of opinion has prevailed among medical prac-
titioners respecting the extent of depletion re-
quired. From peculiarities of local districts, some
practitioners never encounter diseases of this vio-
lence. They accordingly find that copious deple-
tion may be dispensed with ; that if employed, it
sinks the powers of life, and lessens the chances
of recovery, and thence they somewhat hastily
conclude that the active treatment pursued by
others is rash and unnecessary. Diseases of this
languid character may be supposed to prevail most
in large and crowded cities, where the habits of
life are sedentary and luxurious, and where in-
flammatory complaints are connected more with
relative plethora than with absolute. Perhaps
London may be taken as the best exemplification

PLETHORA.

563

of this remark ; and it is very generally believed
that there the corresponding diseases do not bear
the activity of treatment which the provincial
practitioners find indispensable. We have it as-
serted, however, from high authority, that this is a
misconception, and that no such difference exists,
at least to the degree represented ; for that London
citizens both require bleeding as freely and bear it
as well as the residents of any other district. The
subject, however, will come more appropriately
into the next section.

2. Relative plethora. — This variety being of
more frequent occurrence than absolute plethora,
and having connected with it a greater number of
diseases, the consideration of it is still more im-
portant, and entitled to closer attention. In it,
too, the progress of morbid action is more gradual,
and the constitutional efforts to rectify existing
derangements are more varied and more general.
Hence the character of the disease produced by or
incidental to this condition is complicated, and
their elucidation proportionally difficult.

The earlier phenomena being less conspicuous,
attract less attention, and the equivocal character
which they frequently present being liable to mis-
conception, it becomes important to illustrate
clearly the real nature of this condition, to exhibit
distinctly the phenomena which characterize it,
and to point out accurately the practical treatment
suited to its relief, in order to prevent the highly
injurious practical errors, to which misconception
in this respect so continually gives rise.

In relative plethora, as in absolute, the earliest
deviation from health is marked by evidences of
diminished power in the general circulation. The
pulse becomes low and oppressed, and the general
powers enfeebled. When, from natural feebleness
of constitution, or the absence of excitement, this
incipient stage is prolonged for any considerable
time, the impaired energies and deficient exercise
of the several excretory functions give rise to more
or less of excrementitious accumulation, and a
combination of these opposite conditions results.
More frequently, however, this stage passes into
that of increased action, and some congestion, in-
flammation, or other local malady becomes mani-
fested. A hard and frequent pulse, increased heat
of skin, and whiteness of tongue, mark the forma-
tion of the second stage ; and if in moderate de-
gree, and unexasperated by stimulants, this may,
in constitutions not predisposed to any particular
malady or local lesion, continue for months or even
years without any specific disease ensuing, and
with only progressive deterioration of general
health. We have so often met with this state
clearly characterized, that we have been in the
habit of distinguishing it by the term constitu-
tional inflammation, meaning thereby to desig-
nate general inflammatory action in the system,
unattended by local inflammation.

All the phenomena which belong to this stage
are of an inflammatory character. Blood drawn
frequently exhibits a thick, burly coat, with cupped
and with contracted edges, and the treatment of
inflammation is that which alone affords effectual
relief. If taken at an early period, moderate de-
pletion and antiphlogistic regimen will speedily

correct it ; but if neglected or improperly treated
by tonics and stimulants for any length of time, it
becomes more difficult to remove, acquiring obsti-
nacy from its continuance, and through the con-
gestions and local determinations which are prone
to occur during its progress, laying the foundation
of various specific diseases of the worst kind. The
treatment of the several stages requires to be dis-
cussed at some length, and copiously illustrated.

Absolute plethora in its simplest form and ear-
liest stage may be relieved by artificial means,
without any excitement of the system being ne-
cessary to co-operate in the restoration of health.
This the writer has unequivocally experienced in
his own person, and he has thus been enabled to
satisfy himself of a fact which is not often sub-
jected to medical observation. In relative plethora
it is questionable whether the capillary conges-
tions, and other derangements of minute structure
and function attendant on this condition, be re-
movable without some sensible effort of the con-
stitution, and whether febrile excitement, in some
degree, be not a necessary agent in effecting a re-
covery. That it is often contributory to this end,
we entertain no doubt. These observations have
direct relation to the practice suited to the several
stages. Should the earlier of these, in conse-
quence of the decline of health to which its long
continuance gives rise, come under medical cogni-
zance, sparing depletion to lessen the redundancy,
with moderate excitement to arouse the energies
of the system, will be the most judicious and suit-
able treatment. Under extreme feebleness of
pulse and great muscular debility, it may be pru-
dent to commence with gentle excitement, watch-
ing carefully the time when increased action in
the pulse manifests that renewed energy which
will both justify and bear direct repletion. We
are certain, from much observation, that when the
pulse becomes irregular, blood may be taken, not
only with safety but advantage, and that the relief
afforded will be speedily manifested by the in-
creased fulness and tone which the pulse acquires.
For this purpose the earlier bleedings should be
small ; from four to six ounces may suffice to
commence with. The repetitions will of course
depend on the effects, and it is a subject of inte-
rest inferior to none which pathology presents, to
mark in the extreme cases of such condition how
progressively, under repeated venesection, the
pulse rises, and the buffy coat is displayed on the
blood. Some striking instances of this we have
recorded in another place. In an enfeebled and
emaciated boy, labouring under diabetes, 209
ounces of blood were drawn in twelve successive
bleedings, the blood becoming changed from a
dark grumous coagulum of loose texture to the
thickest and firmest buff; and the strength of the
body increased from feebleness hardly admitting
of an erect posture, to a degree of vigour which
enabled him to hold the plough for several hours
a day. It may afford a clearer conception of this
condition, and show the ability which the body
acquires through bloodletting of bearing copious
depletion, to present here a tabular view of the
successive venesections practised in this case, with
their amount, intervals, and the character of the
blood drawn :

564

PLETHORA.

Total amt.

No. Date. Amount, duality of at

blood. each period.

1, Nov. 6, 12 oz. 12 oz.

2, « 7, 14 " 26 «

3, « 9, 17 « 43 «

4, « 11, 14 « 57 "

5, « 15, 17 » buffy, 74 "

6, « 18, 20 » 94 «

7, « 20, 20 « 114 «

8, « 25, 18 " 132 «

9, " 27, 18 « 150 »

10, Dec. 13, 20 « 170 «

11, " 20, 17 « 187 «

12, « 29, 22 « buffy, 209 «

In another case, of a weakly and delicate female,
without any special disease or local ailment, save
pains irregularly alternating in the head and chest,
106 ounces were taken at seven bleedings, with
similar changes of blood, and as well-marked im-
provement of general strength. Such instances
may be deemed conclusive of the fact that the
state of constitution which we are endeavouring
to illustrate has a real existence. In these cases,
the early symptoms were those of seeming de-
bility ; yet if this had been such as is generally
imagined, life must have been inevitably destroyed
by the means employed. If, then, there are states
of disease marked by considerable debility, in
which the constitution not only bears depletion
without sinking, but acquires very considerable
accession of strength under copious evacuations,
it surely must be of the first importance to medical
science to scrutinize such conditions of the system,
and acquire juster notions of its real nature than
are generally entertained.

When, by the judicious combination of small
bleedings and moderate excitement, assisted by
other evacuations, the system is aroused to greater
energy, and a state of febrile excitement ensues,
the treatment of this must be conducted on prin-
ciples with which all are familiar. When a hot
skin, quick pulse, and furred tongue present, no
practitioner is deceived, or fails to resort to proper
remedies. Our great object is to direct attention
to the earlier and more obscure stages, to show
their connection with the febrile state, and to de-
monstrate the correspondence which prevails in
the treatment which they respectively require.
The earlier the advance of such disease can be
detected, the less will the interposition of art be
needed, and the more effectual will it prove, both
in correcting the febrile state, and averting the
local injuries which continued febrile action will
always sooner or later induce. There are occa-
sions when this vigilance in detecting the incipient
deviations from health is of the very first import-
ance ; a signal instance of which we shall briefly
notice, as illustrating what it is wished to impress,
and as proving the soundness of the principles by
the efficacy of the treatment which they dictated,
perfect recovery having taken place under circum-
stances which seemed to augur a very different
result. A young woman applied to the writer
above three years ago, with ovarian tumour, ac-
companied with great inflammatory action, both
local and constitutional. Active treatment was
employed, and the progress of the disease arrested.
Continued attention, however, was required to

keep down inflammation, and both bleeding from
the arm and cupping were in constant requisition.
Auxiliary means were freely employed, but blood-
letting was the remedy which gave most decisive
relief. So sensible was she of the advantage, and
so intelligent in noting the premonitory indica-
tions which marked the necessity of depletion, that
she was accustomed to ask for the lancet or cup-
ping-glass, specifying her reasons for thinking
they were needed ; and on these occasions she
was invariably right. To detail minutely a case
which was subject to medical discipline for so
long a time, would be tedious and unsuited to
our present purpose. It may suffice to say that
the constitutional state tended throughout to in-
flammatory action, and that by the fluctuations of
this the local disease was influenced. The tumour
advanced so as to form a considerable prominence
in the right hypogastrium. Cupping, leeching,
blistering, were all employed, and eventually a
caustic issue was established over it. So much
relief was obtained, that she was occasionally dis-
charged from the hospital, in order to recruit her
general health. After a short absence, however,
she was sure to return with renewed disease, both
local and general. It being sufficiently manifest
that the local excitement was always preceded by
febrile action, the propriety of looking closely aftei
the latter was apparent. If fever was not speedily
arrested, the tumour became active and increased;
when, by early bloodletting, febrile action was re-
duced, the tumour remained quiescent. Early
bleeding was therefore the remedy most worthy
of reliance, and it was resorted to accord-
ingly, with due caution, but determined perseve-
rance. And here we were happily assisted by
one well-marked evidence of renewed plethora and
approaching fever that never deceived us. Ere
pain was felt in the seat of disease, or any of the
ordinary indications of fever presented, a dadc
narrow dry stripe appeared on the centre of the
tongue. If this were unheeded, it soon expanded
at the tip, and spread slowly towards the edges.
By a moderate bleeding, this was promptly re-
moved, and its sure attendants, general fever and
local pain, were averted. By steady perseverance
in the treatment here noticed, all disease was
eventually removed ; and within these few days
we have seen this person in perfect health, and
without a vestige of tumour remaining. Wc
have no hesitation in attributing the fortunate re-
sult to bloodletting, and also to this being regu-
lated on the principles which it is the object of
this essay to inculcate. We may add that it
never required to be carried to the extent of
making even a temporary injurious impression on
the general powers of the constitution.

We have stated that the state of febrile excite-
ment is preceded by certain changes in the pulse
indicative of its approach, and also that we are
not under the necessity of judging solely from
this evidence, for that other derangements coexist,
which evince a harmony of symptoms, and that
the whole collectively furnish indisputable proof
of the actual condition of the vascular system.
On the peculiarities of pulse we are not anxious
to dwell, further than to give a seasonable warning
that they be not suffered to bias the judgment
through fears of an unreal debility. In judging

PLETHORA.

565

of the approach of febrile excitement, we are ac-
customed to rely more on the state of the tongue
than on that of the pulse. When the constitution
is assuming a disposition to febrile excitement, ere
this is announced by the pulse, still feeble and
compressible, the tongue presents a peculiar white-
ness strongly characteristic and expressive, being
distinct from any apparent secretion, and obviously
resulting from some defect of capillary circulation
in the tongue itself. This whiteness we have
often seen disappear under bloodletting ere the
arm was tied up. To describe it more particularly
would be useless ; to be known it must be seen,
and they who are accustomed to inspect inflam-
matory tongues will at once recognise the condi-
tion to which we allude. We know not a stronger
or surer evidence of incipient febrile excitement
than this appearance of the tongue presents, and
when it exists we should consider some abstraction
of blood both justifiable and necessary. It ap-
pears, then, that bloodletting is suited to each stage
of relative plethora. In the stage of feebleness
when long protracted, small evacuations of blood
relieve the oppressed constitution, thus enabling it
to form the stage of febrile excitement which
seems so necessary an agent in correcting the se-
veral derangements of the system. When used
for this purpose, the early depletions should never
be large, from four to six ounces being oftentimes
as much as can with propriety be taken. Accord-
ing as febrile excitement advances, more copious
depletion will not only be borne but required. The
object of the incipient bleedings is not to make
that impression on the moving powers which is
necessary for the abatement of inflammatory action,
but merely to abstract a portion of the circulating
fluid, and thus lessen the plethora by which the
system is oppressed. The blood may therefore
be taken from a small orifice and in a recumbent
posture. According as the period of excitement
approaches, the effect of depletion in hastening its
advancement becomes more manifest ; and indeed
it is a matter of familia- observation to surgeons,
that even while the blood yet flows from the vein,
the arterial powers so sensibly increase that the
tardy and sluggish stream, which at first only
trickled down the arm, becomes converted into a
full and vigorous jet, the blood being oftentimes
propelled to a distance of several feet. When this
degree of increased action is displayed, blood may
be more freely taken, and antiphlogistic treatment
more rigorously pursued.

During the advanced stage, the object of vene-
section is both to abstract blood and to moderate
inflammatory action by the direct impression which
this remedy makes on the arterial system. Wholly
or suddenly to subdue this action is not here in-
tended, unless there be also local inflammation of
a hazardous kind. The abstraction of eight or
ten ounces will often suffice ; that of twelve, six-
teen, or even twenty will very frequently be well
borne.

When local inflammation is superadded, then
the extent and frequency of bloodletting must
depend on the urgency of symptoms present, the
importance of the organ principally affected, and
the clanger of this sustaining injury such as would
be either immediately fatal to life, or ultimately
subversive of health and vigour. Though in this

2 x

state of constitution bloodletting is the remedy
most essential, and which most effectually arouses
the sanative energies of the system, yet other
means are required for co-operating in the general
purpose, and for re-establishing the several func-
tions of life in their healthful and efficient exer-
cise.

Next in power to bloodletting as an evacuant
is purging, and this requires to be employed with
much discrimination, if the full benefits of it are
to be obtained. The objects of it here are both to
deplete the system, and to restore to healthful effi-
ciency the excretory processes connected with the
alimentary canal, which, in the early stages of
relative plethora, are always inadequately per-
formed. Simple as the process seems to be by
which the bowels are evacuated, we scarcely know
a term in medicine more vaguely employed than
that of purging. It is continually used to express
processes essentially different, and which require
to be accurately distinguished from each other.
•By observing closely the effects of different pur-
gatives and the nature of the discharges produced
by them, we may perceive some well-marked dif-
ferences in their modes of operation. Those of
one class simply evacuate the feculent contents of
the bowels ; those of another excite the various
exhalant arteries, producing watery stools ; and
those of a third stimulate the mucous follicles
which so abundantly line the intestines, causing
them to throw off the mucus which they so copi-
ously secrete. When the bowels are merely in-
active, their secretions healthy, and no constitu-
tional disease present, the simple aperients of the
first class suffice to obviate costiveness and prevent
feculent accumulations. Medicines of the second
class are indicated, when, besides unloading the
intestines, it is expedient to abate arterial action,
or allay fever by abstracting fluids from the sys-
tem. Those of the third are required when mu-
cus, inordinately secreted, accumulates so as to
clog and obstruct the secretory vessels themselves,
and also when this accumulated mucus, acting as
a foreign body, becomes instrumental in exciting
or aggravating disease. The particular medicines
belonging to each class will readily present them-
selves to every practitioner, and need not here bo
specified ; neither is it important to distinguish
them by any very accurate arrangement. This
same medicines will act differently on different
habits and under different circumstances, and it is
the effect, not the medicine producing it, that is
the chief object of consideration. On the simple
aperients we have little to remark ; they form a
most useful class of remedies, and may be com-
bined with the second and third classes, so as to
assist in producing every species of alvine dis-
charge. The several aperient neutral salts are
well known as the principal purgatives for pro-
ducing watery stools. When increased discharges
of mucous secretions are required, our chief reli-
ance is on certain preparations of mercury and of
antimony. The stomach, forming part of the ali-
mentary canal, requires itself to be occasionally
unloaded, which is effected by emetics. And heic
too we should distinguish between those emetics
which simply discharge the floating contents of
the stomach, and those which cause it to throw
off increased mucous secretions. Even though

566

Pi.iDTHORA

vomiting be not resorted to, the mucous secretions
of the stomach may yet be expelled by combining
with purgatives such preparations of antimony as
have an emetic operation. Consistently with these
views it would appear that the most perfect evacua-
tion of the whole canal must be that procured by
combining medicines of each class, and accord-
ingly we find the purgatives in most general use
so constituted. When full purging is required to
allay fever or lessen arterial action, no practice is
more common than to give at night a suitable dose
of extract of colocynth or of aloes, which are
simple aperients, combined with calomel and an-
timony, medicines that expel mucous secretions,
and followed next morning by a saline purgative,
which, while it accelerates the operation of the
previous dose, produces also copious watery stools.
When these latter are not required, but yet a state
of disordered intestinal secretion is manifested, it
is often expedient to correct this latter gradually,
the nature and activity of the cathartic employed
being suited to the particular design ; and whether,
it consist of colocynth, calomel, and antimony, or
of rhubarb, blue pill, and ipecacuan, the same
principles govern its administration, and similar
effects, differing only in degree, are produced.
With these principles to guide the employment
of purgative remedies, they may be so adminis-
tered as to prove most powerful auxiliaries of
bloodletting in the several stages of relative ple-
thora. In the earlier stage, simple aperients, com-
bined with mild doses of mercury and antimony,
are the most suitable. According as the febrile
stase succeeds, saline purges may be more freely
employed ; and when fever becomes active, or
local inflammations arise, these are indispensable.
In proportion as the mucous secretions are accu-
mulated or depraved — and they become signally
so whenever the earlier stage of relative plethora
has been of long duration — then must those com-
binations be employed which most effectually de-
terge the loaded membrane, and restore the secret-
ing vessels to their natural condition.

A consideration of the several changes that
take place in the body under febrile excitement,
and a more minute observation of the immediate
effects produced by increased arterial action on
the several secretory and excretory organs, will
show the value and importance of purgatives in
a still clearer point of view, and lead to a more
discriminative employment of them.

A certain degree of arterial action being neces-
sary to the healthy exercise of the secretory and
excretory functions, it might be reasonably sup-
posed that increase of such action would lead to
a more energetic performance of these functions,
and increased formation of what they respectively
secrete, — a supposition which the evidence of
facts amply confirms, one of the earliest effects
occurring in a state of febrile excitement being an
increased secretion of the natural mucus which
lines the stomach and intestines. Of the exist-
ence of such superabundant mucus during inflam-
matory complaints, sufficient proof is afforded in
the discharges brought off by appropriate evacu-
ants, or occasionally by the natural efforts. With
respect to the stomach, if the examination of its
rejected contents be superficial, it may mislead,
for the mucus, if of recent secretion, being clear

and colourless, is not readily distinguished from
the surrounding fluid. Its tenacity, however, fur-
nishes a ready means of detecting and demon-
strating it, for if a rod or wire of any kind be
drawn through it and elevated, it will raise from
the watery fluid, discharged by vomiting, the
mucus diffused through it, and sufficiently display
its dense and viscid nature. Similar secretions
go forward at the same time through the whole
intestinal canal, as evinced by the quantity of
mucus which a dose of calomel, or of calomel
and antimony, administered under these circum-
stances, expels. And to the power of these
medicines in dislodging such secretions is owing
much of the efficacy so long and so justly attri-
buted to them in the cure of acute diseases. The
increased secretions proceed immediately from the
greater activity of the secerning vessels. These
again derive their excitement from the greater
abundance and more stimulant quality of the
blood conveyed to them ; and the effect of their
increased action is to correct the stimulant pro-
perty of the blood, by disposing of the nutritive
constituents which render it unduly stimulant,
and thus to allay indirectly their own inordinate
actions. Hence the relief of the constitution by
means of the improved quality of the blood may
be fairly considered the final cause for which
these secretions are increased, for which febrile
excitement is generated. In this view we can
perceive the importance of purgatives, not only
as general evacuants, but also as specially pro-
moting those curative efforts by which nature her-
self endeavours to throw off redundancies and
minister to her own relief.

The want of sufficient attention being given t«
the peculiar effects produced by different purga-
tives may account for much of the -uncertainty
and indecision that have prevailed in the employ-
ment of them. This part of medical practice,
indeed, has been much improved of late years;
and the labours of several modern writers, of
whom Dr. Hamilton and Mr. Abernethy are pre-
eminently distinguished, have done much to assert
for it the importance due to it. Still much re-
mains to be investigated respecting it. If the
mucous matter be recently formed, and in no
great quantity, a common purgative will suffice
to remove it, together with all such feculent lodg-
ments as the bowels may contain. A source of
injurious irritation is thus removed, the various
secretory and excretory vessels are disencumbered
of an oppressive load, and left free to perform
their natural functions, or to renew their sanative
efforts; and the process of nature instituted for
the removal of redundancy and restoration of
health goes uninterruptedly forward. If the mu-
cous secretions be of older formation, consequently
more viscid and tenacious and less easily expelled,
the common purgatives fail to give relief, and a
doubt is thus often cast on the propriety of era-
ploying purgative treatment. The patients may
be misled, as many continually are, by false expe-
rience ; but the practitioner should not fall into
this error. The fault lies not in employing pur-
gatives, but in not suiting those given to the effect
required ; for if a suitable preparation of mercury
or antimony be in such case combined with the
simple aperient, the result will rarely occasion

PLETHORA.

5G7

disappointment. If saline purgatives be given
with the intention of cleansing the intestines at a
time when they are coated with viscid secretions,
the purpose will be very imperfectly answered,
while if persevered in when general evacuation is
no longer needed, and there is no febrile action to
call for their use, they fruitlessly exhaust strength
and do sensible injury. Even the powerful re-
medy which a combination of calomel, antimony,
and drastic purgatives supplies, may be misap-
plied, and if rashly given when the bowels are
irritable, with little mucus present, distress and
injury may result, and an useful remedy thus fall
into unmerited disrepute. In fine, by neglecting
to ascertain the precise nature of the evacuation
required, and to apply with accuracy the remedy
suited to effect it, we must ever run considerable
risk of disappointment in the effects expected from
purgatives, and of so misapplying them as really
to do injury in cases where purging, judiciously
regulated, is the best if not the only means of
cure. The quantity of mucus secreted in the
stomach and intestines under febrile excitement,
which implies a general increase of vascular ac-
tion, is often considerable. It lines the whole
canal, and when accumulated (and more especially
when inspissated by long retention) is the cause
of many powerful medicines passing through
without producing their ordinary effects ; for in
consequence of the interposed mucus, the medi-
cines come imperfectly or not at all in contact
with the living fibre on which alone they can act.
They pass, therefore, as if either the living fibre
were torpid or the medicine inert, when neither
supposition would be correct. This is signally
the case with respect to the stomach, the accumu-
lated mucus of which is often thrown off like a
dense membrane. In this state of stomach we
have oftentimes given tartarised antimony in grain
doses quickly repeated to the extent of twelve or
fourteen, ere vomiting could be excited, the matter
discharged furnishing abundant evidence why
such inordinate quantity was needed. We men-
tion the circumstance here in order to enforce the
expediency of judging on all occasions, not from
the quantity of medicine administered, but from
the effect produced ; and, as the principle applies
no less to the bowels than to the stomach, to im-
press the indispensable necessity of a constant
inspection of the alvine discharges, without which
it is impossible to form an accurate judgment
either of the propriety of purging, the selection
of purgatives specially indicated, the extent to
which their operation should be carried, or the
period for which their use should be continued.

It has been shown that the derangements of
circulation incident to a state of plethora, whether
absolute or relative, manifest an uniformity which
serves to mark the nature of the morbid changes
induced, and to illustrate the processes which
nature institutes in her endeavours to effect her
own relief. Redundancy of nutritive matter first
excites the healthy functions to increased energy,
tending to its appropriation by natural secretion :
when too much urged this energy abates, and
feebleness of arterial action ensues ; to this suc-
ceeds a state of general excitement, such as is
expressed by the term fever; and finally some
local congestion or inflammation occurs, producing

what is called a specific disease. From this view
the dependency both of the general fever and
local affection on the constitutional state is at
once perceived ; and the treatment by which
these are severally relieved acquires thence a
clearness and consistency which no speculative
theory of disease has ever yet imparted. For
absolute plethora in its simple state, it has been
shown that depletion and abstinence, the remedies
directly suggested by a knowledge of its cause,
are those which experience proves to be most
efficient, and which may alone give full relief.
For the active fever and local inflammation in-
duced by this condition, the same means are
essential, and are still the most powerful of all
Hhat can be employed ; though when these deriva-
tive maladies occur, other evacuations besides that
of blood are needed, it being here required to call
forth the energies of all the excretories of the
system in aid of those constitutional efforts by
which the febrile excitement is aroused. In rela-
tive plethora the morbid condition of the system
is less simple, yet it still corresponds with the
other throughout. Owing to the duration of
morbid actions antecedently to the occurrence of
febrile excitement, the constitutional derange-
ments are more extensive ; more functions are
depraved ; the difficulty of restoring these seve-
rally to a healthy state is increased ; and a longer
time is required to correct their aberrations and
renovate their powers. During this period, too,
various disturbances, originating in depravation
of nervous function, become intermixed with the
ordinary symptoms, complicating and obscuring
the whole. To these latter we shall have occa-
sion to advert more particularly by-and-by. In
absolute plethora the purpose is simple. If the
redundancy of nutriment be diminished, and a
fresh supply withheld — in other words, if blood-
letting and abstinence be carried to the requisite
extent, the powers of nature, thus relieved, are
amply sufficient to re-adjust all that is amiss, and
perfect health becomes restored.

No artificial stimulus is here needed to arouse
the natural powers ; but, on the contrary, the chief
care is to restrain them within salutary bounds.
In relative plethora, while depletion and adapta-
tion of diet are equally necessary as in positive,
more care is necessary for maintaining in due ac-
tivity the several secretories, and some degree of
stimulant treatment requires to be combined, in
order to excite and support those increased ener-
gies of the system by which alone this condition
can ever be thoroughly rectified. Ordinary stimu-
lants, however, which merely excite the heart and
larger vessels, are inadequate to this end. JVay y
they do mischief; for they lead to no effectual ex
ercise of power, and from that which they do ex-
cite, exhaustion rather than benefit results. The
creat deficiency of power which here prevails is in
the capillary vessels, and to depravation, abate-
ment, or suspension of their functions, may all the
coincident derangements of the frame be readily
traced. The two most essential processes of ani-
mal life are nutrition and excretion. These are
exclusively performed by the capillary vessels, on
the due energy of which they are dependent.
When from any debilitating cause these minute
vessels fail in power, or become obstructed, both

568

PLETHORA.

nutrition and excretion must become impeded ;
and hence we can understand why emaciation
often takes place, even when there is a redundancy
of nutritive matter in the general circulation, avail-
able for nutrition if the capillaries could so dis-
pose of it. It is hence also intelligible, how a de-
bilitating impression made on the system has,
through abatement or suspension of the capillary
function, the direct effect of throwing back upon
the mass of blood that which in ordinary course
the capillaries would have disposed of, and of
thus inducing a state of relative plethora. It is
clear from this view, that the object of treatment
in relative plethora is not merely to remove the
relative excess, although this demands its full
share of attention ; but also to renew the activity -
of the capillaries, in order, first to re-establish
their healthy functions as essential to the well-
being of the general constitution ; and secondly,
by thus providing for the just appropriation of the
nutritive matter supplied by the blood, to restore
that balance between appropriation and supply
without which health cannot subsist, and which
the occurrence of plethora, however induced, never
fails to disturb. We have stated that ordinary
stimulants, which produce but transient excite-
ment of the heart and larger vessels, are not the
remedies here needed. What we require is an
agency which, without exciting inordinately the
general circulation, is capable of acting on the
capillary vessels, and of arousing them to a re-
newal of their several functions both secretory
and excretory. Such a remedy we happily pos-
sess in mercury, which is singularly endued with
this peculiar property, and which, in consequence,
affords a powerful agency in relieving the larger
blood-vessels, when overcharged, from part of their
excessive load, by causing it to be diffused more
f.cely through their numerous and wide-spreading
ramifications ; and when the aggregate capacity
of the minute vessels thus expanded and restored
to the exercise of their natural functions, is esti-
mated, there will be little difficulty in comprehend-
ing how mercury proves so powerful an auxiliary
of bloodletting in relieving an overcharged state
of the general circulation, as well as in correcting
the congestions and other derangements to which
this state gives rise. If the effects of mercury on
the animal frame be examined, it will be seen
that, however diversified, they all correspond in
one respect — namely, in evincing increased action
of capillary vessels. Mercury has the effect of
increasing almost every secretion, and by capillary
vessels all secretion is performed. It promotes
transpiration by the skin, diuresis, and secretion
of bile ; it more especially excites the salivary
glands ; and there is reasonable ground of con-
jecture that it similarly affects the pancreas, to
the increased secretions of which gland mercurial
diarrhoea has been with some plausibility ascribed.
It increases the intestinal discharges independently
of its direct action on the bowels when taken in-
ternally, for mercurial frictions are well known
occasionally to purge. In every effect which
mercury induces this common character is observ-
able, that capillary action is more or less excited.
Now a renewal of capillary action is what has
been shown to be needful for correcting the de-
: ungenients incident to relative plethora, and

hence the inestimable value of this remedy when
judiciously administered, in restoring to health
those who suffer under such derangements.

In absolute plethora the febrile action aroused
suffices to impel blood into every extreme vessel
and thus to equalize circulation by extending it
to every part where nature requires its full activity ;
and to effect this seems to be the great end for
which febrile excitement is instituted by nature.
In relative plethora this effort is more feeble, the
natural powers being weaker, (indeed it is in this
natural weakness that relative plethora has its
origin ;) and as every day but adds to the labour
to be performed, while under the general deprava-
tion of habit the natural powers tend to further
decline, we have little difficulty in comprehending
why this state does not become aroused to those
energetic efforts which are so often witnessed in
the active fever of absolute plethora. To excite
such effects then by the peculiar stimulus of mer-
cury becomes an essential part of the treatment
of relative plethora ; and when in the correction of
this state mercury is used with the necessary dis-
crimination, and in aid of bloodletting, no course
of medical treatment can be more successful, nor
more strikingly illustrative of the principles by
which it is guided, than that which this combina-
tion of depletory and stimulant agency supplies.
The principle here adduced is confirmed by all
that we know of the action of mercury, whether
in its abuse or its use. Consistently with the
views here presented, this action ought to be salu-
tary only when the labour to be performed is not
beyond what the animal powers are capable of
sustaining. If the labour be too great, if inordi-
nate plethora prevail, then must the excitement
of mercury fail to effect its object, and the animal
powers, exhausted by the vain effort, must still
further decline. This operation of mercury cor-
responds exactly with the course of active fever
where no bloodletting is employed. The powers
exercised are in either case considerable, but the
labour is disproportionate, and they sink under it.
But if the labour be lightened by lowering the
nutritive quality of the blood, (and this can only
be effected with the necessary promptitude by
bloodletting,) then will both febrile action and that
of mercury accomplish all that is required from
them.

We must here call attention to a physiological
truth which requires to be borne in mind. When
nutritive matter is introduced into the blood, if it
find not an outlet by artificial bloodletting or
natural hemorrhage, it must go through the pro-
cesses of secretion and excretion ere it can be
again expelled. If it be so redundant as to re-
quire these functions to be inordinately exercised
in disposing of it, the respective organs lose
power, and from the over-excitement sink even
below the natural standard. Bloodletting, by
lowering the quality of the blood, and lessening
the proportion of its nutritive constituents, super-
sedes much of this inordinate and unnecessary
labour, and thus actually saves animal power in-
stead of expending it. In absolute plethora this
is all that is required, for the natural powers thus
relieved are fully equal to accomplish their own
work. But in relative plethora the case is some-
what different. Here, while the nutritive matter

PLETHORA.

569

of the blood is relatively redundant, requiring to
be reduced, the animal powers are also enfeebled,
and the several functions dependent on the capil-
lary vessels are all more or less depraved. In ad-
dition, then, to reducing the nutritive matter by
abstracting some blood, it is here necessary also to
excite both the general powers and the capillary
actions, in a way more effectual than simple febrile
excitement can accomplish. Here mercury comes
appositely and powerfully in aid, and by its direct
influence on the capillary vessels effects what the
natural powers, even when aroused into febrile
excitement, would under such circumstances be
unable to perform.

An analogy has been traced between the action
of mercury and febrile excitement; and if this be
followed up by closer observation, the respective
processes will appear little short of identical, the
only difference being in the excitant by which
these processes are instituted and maintained. In
absolute plethora the redundant nutritive matter
suffices to arouse the system to corrective efforts:
in relative this is inadequate, and the excitement
of mercury is needed for stimulating to due
activity the arteries, more especially in their mi-
nuter ramifications. This it effects in a way so
closely corresponding to febiile action, that when
the full effect of mercury is produced, it would be
difficult to show that its phenomena differ essen-
tially in any respect from those of fever. There
are induced a quick pulse, hot skin, white and
furred tongue, muscular debility, increased secre-
tions, attenuation, — in short all that characterizes
simple fever. And further, if this state be ne-
glected or maltreated, it passes into one which
exhibits the whole train of typhoid symptoms —
black and dry tongue, accumulation of sordes on
the teeth, prostration of power, high nervous ex-
citement, and finally death. These consequences
are attributable, not to any necessary effect of the
remedy, nor to any poisonous properties inherent,
but to the constitution not being prepared by sen-
sible depletion for its safe and salutary exhibition.
When mercury is administered in unreduced
plethora, and especially when its use is rashly
urged, the effects are precisely such as result from
febrile excitement, when, besides being inordinate
in degree, it fails in its corrective agency. The
excited powers, exhausted by their efforts, fall into
a state of collapse, the object for which they were
exercised is not attained, the capillary actions are
either not renewed, or if renewed they are over-
worked, and thus again enfeebled ; they are con-
sequently incapable of ministering to the general
restoration as they would do if their healthful
functions were re-established ; and the consequence
is, that the constitution is left in a far worse state
by the effort than if it were not made. Far dif-
ferent is the result when either febrile excitement
01 the action of mercury is regulated by the gui-
dance which sound principles supply. If plethora
be reduced, and a state of active secretion be
maintained, then may either febrile action, or that
of mercury, be rendered conducive to the restora-
tion of health, through renovation of functions
such as seen almost beyond the reach of other
influences.

The evils occasioned by neglect of the principle
here inculcated, are abundantly displayed in the

Vol. III. — 72 2l *

history of syphilis; and we believe that all expe-
rienced surgeons are now agreed on the danger of
administering mercury in an overcharged consti-
tution.

Enough has now been stated to display the
principles which should guide the employment of
mercury in the treatment of relative plethora, and
of the manifold diseases incident to this condition
of the frame ; and from long and extensive expe-
rience and close observation, both of diseases and
the operation of remedies, we can confidently
affirm, that if the principles here inculcated be
applied to the elucidation of diseased conditions ;
if in these the attendant state of constitution
be regarded rather than the specific disease, and
at all events in connection with it ; and if the
treatment indicated by the foregoing principles be
employed so as to correct the constitutional de-
rangements, many an apparently formidable ma-
lady will insensibly subside without requiring any
specific treatment to be directed towards it, its
surest corrective being the removal of the causes
in which it originated, and by which it was up-
held.

The practical application of these principles in
the treatment of relative plethora, is simple in the
extreme. If the diseased condition be of recent
occurrence, and the depravation of the capillary
functions slight, very moderate evacuations and
renewed activity of the secretory and excretory
functions, with regulated diet, will suffice to re-
store health. But if the plethoric state have con-
tinued so long as to deprave materially the general
habit ; if the capillary functions have been so long
inactive as to have become indisposed to a renewal
of their healthy energies ; if the secerning vessels
have, through their abortive efforts, become ob-
structed and powerless ; and if, through conges-
tion or subacute inflammation, structural changes
have commenced in any of the organs or tissues,
then these simple means must fail, and some con-
stitutional effort, such as is exerted under febrile
excitement, is necessary for restoration. But as
natural febrile action is in this case inadequate to
effect what is required, we here need the artificial
excitement which mercury supplies, to accomplish
the purposes which medical treatment has in
view. The indications by which the use of mer-
cury is to be guided, are neither obscure nor
equivocal. If there be the debility of incipient ple-
thora, moderate evacuations will relieve the vital
powers, and enable them to display their inherent
energies. When febrile action is thus aroused,
the course of procedure is clear, and if the powers
called forth be adequate to effect perfect restora-
tion, no artificial excitement can be needed. But
should it be, as in the larger proportion of such
instances will prove to be the case, that the natural
powers are feeble and inadequate to maintain the
curative processes by which a healthy state of
capillaries is to be renewed ; if the obstructions be
considerable, and the indisposition of the capil-
laries to a renewal of their natural exertions be
clearly marked, then is the stimulus of mercury
indispensable, and for this end there exists not, in
the wide range of medicinal agency, a remedy
possessed of powers so certain or so manageable.
We have medicines which emulate some of its
properties ; antimony promotes many of the capil-

570

PLETHORA.

lary secretions; iodine promises to afford much
valuable aid of a corresponding kind ; but so far
as our present knowledge extends, we have no
medicine entitled to rival mercury in the pro-
perties which the foregoing observations ascribe
to it. When a soft, calm, and firm pulse evinces
a healthful state of circulation ; when the several
secretories and excretories cease to display in their
products a morbid condition ; when under these
changes the general feelings improve, and health
progressively amends, it is quite needless to exceed
the means by which a change so favourable has
been effected, and far better is it to trust to this
slow but sure process of amendment, and await
the time necessary for completing it, than by over-
anxiety for more rapid progress hazard the disap-
pointment which too sedulous endeavours might
occasion.

But when the constitutional efforts do not make
perceptible advance in the removal of general in-
disposition and local derangement ; when the
pulse continues oppressed, the skin dry, the tongue
irregularly coated or otherwise unhealthy, the ex-
cretions morbid, the aspect sallow, and the general
feelings unrelieved, then if depletion have been
employed, and carried to the extent which sound
experience justifies, it becomes absolutely neces-
sary to resort to that agency which mercury sup-
plies, and to administer at intervals small and un-
irritating doses of this mineral, so as to excite the
animal powers to the efforts necessary for relief.

It occasionally happens that in this use of mer-
cury too much excitement follows, and from this
circumstance its inexpediency has been at times
somewhat hastily inferred. The occurrence may
no doubt proceed from the medicine being un-
suitable; but it may also take place either from
plethora not having been sufficiently reduced, or
from the medicine being too freely administered.
In these latter instances, further depletion and re-
duction of dose are what reason would direct.
Precipitately to withdraw the remedy under such
circumstances, without trial of the expedients here
proposed, would be little reconcilable with that
knowledge of the operation of mercury which all
should possess who venture to prescribe it. In
general, it is advisable to continue its use until
its constitutional effects are evidenced by slight
affection of the gums; but this is not indispensable,
for we have often seen its curative effects obtained
without any soreness of mouth being induced.
Much minute detail on what is called the altera-
tive effects of mercury, and the modifications
which its exhibition continually requires, might
here be introduced, but it would encumber an
article already too long, and it cannot be needed.

No morbid condition can more clearly illustrate
the operation of mercury than that which the ad-
vanced stages of continued fever present. Such
cases have often been consigned to us as hospital
patients when the early treatment had proved
unsuccessful. The phenomena of this stage of
the disease we need hardly describe. Great ema-
ciation, prostrate powers, a feeble and rapid pulse,
black and dry tongue, lips and teeth covered with
sordes, insensibility, with a train of corresponding
symptoms, characterise this stage. Yet, appalling
as is the condition here presented, we never des-
pair of it, provided no organ essential to life have

yet suffered irreparable injury. Stimulants to
recruit power are of course needed ; but the chief
agent for exciting the several secretory and excre-
tory vessels, and for renewing the activity of the
capillaries generally, is mercury. By small doses
of this, repeated at suitable intervals, the pulse is
rendered fuller and firmer, the secretions improve,
the tongue becomes moist and clean, sordes sepa-
rates from the teeth and lips, consciousness re-
turns, appetite revives, and sleep is restored.
Large doses are not needed ; from one to two
grains of calomel, given three or four times in the
twenty-four hours, will generally suffice. Aperi-
ents and nourishment are of course required, and
wine to such extent as the existing debility may
demand. This effect of mercury we have so often
witnessed that we can entertain no doubt either
of the correctness of what is here stated, or of the
agency to which the amendment is owing. No
subject in pathology can be more interesting than
the progressive development of power and im-
provement of function which such a case presents.
It has repeatedly occurred to us to see so much
reaction thus aroused as to require actual depletion
of blood at late periods of the disease to relieve
the local determinations which resulted. In the
same subject we have been obliged to apply
leeches alternately both to the head and chest, in
order to allay the respective local excitements.
That these resulted from the use of mercury wo
were well assured, but, instead of withdrawing it
under a false alarm, we relieved the local disturb-
ances by depletion, continuing a guarded use of
the mineral so long as its specific agency was re-
quired for the re-adjustment of the system.

The accordance of the principles maintained
throughout this article with the best established
doctrines of idiopathic fevers cannot fail to be
perceived by those who have given to this latter
any particular attention. Dr. J. Armstrong, in
his excellent treatise on typhus, distinguishes
three stages in the disease, namely, those of con-
gestion, reaction, and collapse. It is in confirma-
tion of his accuracy that a corresponding succes-
sion, differing only in the intenseness of each
stage, may be traced in every instance where sim-
ple inflammatory action arises, a circumstance
which claims for his theoretic views a high credi-
bility, by showing that the essential phenomena
of continued fever do not result from any pecu-
liarity of character imparted by its special cause,
but that they correspond accurately with the
successive processes which nature institutes in
the simplest febrile disturbances of the animal
frame.

Even the minuter observations which we have
made on the changes of the pulse, and which were
derived from the examination not of idiopathic
fever but of incipient plethora, correspond with
what Dr. Armstrong states as occurring in the
congestive stage of typhus, among the symptoms
of which he notices " a quick, low, struggling
pulse, changeable as to frequency, and even
irregular as to force." But the most impressive
illustration of the debility connected with internal
congestion, and of the effect of copious bloodlet-
ting in relieving it, is, perhaps, that which is fur-
nished by the epidemic, or, as it is commonly
termed, spasmodic cholera.

PLETHORA.

571

In the pamphlet published by the London
General Bo.ard of Health, by authority of the
Privy Council, the following passage occurs :
« But the remedy which is described to have been
most uniformly successful, when it could be used,
is bleeding, and this even in cases where the pulse
was scarcely perceptible at the wrist. This prac-
tice seemed to apply itself to the root of the dis-
ease, by relieving the congestion of the venous
system, which was invariably found loaded on
examination after death, and which congestion
(though only an effect of the first impression
made by the attack of the disease on the constitu-
tion) appeared to be the immediate cause of death.
In the lighter cases, or in those of a severe nature
which came under medical treatment before the
pulse at the wrist was lost, or had become flutter-
ing, bleeding was attended with the most decided
advantage. The oppression of the chest, the
burning heat of the pracordia, the spasms, the
vomiting and purging, are stated in some in-
stances to have ceased at once ; at others, on a
repetition of bleeding. In such as allowed a free
abstraction of blood, these effects very uniformly
occurred ; but even in some, when the pulse was
indistinct, bleeding was successful, if it could be
carried to the extent of eighteen, twenty-four, or
thirty ounces, the pulse rising in power and be-
coming more distinguishable in proportion to the
flow of blood. If the pulse in this state of feeble-
ness was distinct enough to give the finger the
feeling of oppression, bleeding was almost always
successful. The blood drawn was black, whether
procured from a vein or an artery, and flowed
with great difficulty, commonly first coming from
the vein in drops, and gradually in a stream ; but
before it could be induced to flow with freedom
the patient often required warm baths, frictions,
external and internal stimuli, to produce a suffi-
cient quantity for his relief. If a small quantity
only could be procured, the heart seemed to feel
the loss without being relieved, the bulk of the
blood actually circulating being reduced, while the
great mass of it, congested in the inferior and
superior vena cava, did not make its way to the
heart. The effect of bleeding was mechanical,
and acted only as removing an obstruction to the
passage of the blood from the distended venous
system; and if not carried far enough to remove
this impediment and allow the large veins to
empty themselves into the heart, such weakness
was produced as is occasioned by the loss of blood
in a constitution worn out by disease." This
statement of the Board of Health we adduce in
preference even to the authorities from which it
was derived. It was the result of deliberate and
mature consideration of all the information which
public records and private testimony could supply ;
it was issued to the public under a responsibility
which must have precluded all slovenly examina-
tion of facts, all influence of speculative theories;
and it hence carries authority as an announce-
ment of facts, which no individual testimony
could possess in an equal degree. It is difficult
to conceive a correspondence more complete than
that which subsists between the facts here recited
and the pathological principles which we have
endeavoured to illustrate throughout the present
article.

It cannot fail to be perceived how intimately
these principles are connected, not only with the
morbid conditions described, but also with the
whole course of medical practice. If such morbid
conditions of the frame have any existence, they
must more or less affect the progress and influence
the treatment of a large proportion of diseases.
Wherever they prevail it is obvious that the treat-
ment of specific maladies cannot be wholly inde-
pendent of them, and even where no plethora
exists, the negative can only be ascertained by a
familiar acquaintance with the phenomena which
denote its presence. Nay, so many specific dis-
eases depend wholly on the depravations of habit
noticed in this article, that when the constitutional
derangements are correct, the special diseases
spontaneously cease. On every account, then,
the doctrines of plethora, its rise, progress, and
treatment, must be allowed to constitute an essen-
tial part of medical science.

But of all sciences, that of physic is perhaps
the least simple. Its principles, individually con-
sidered, are clear deductions from well-established
facts, and, so far, simple in their nature. But it
very rarely happens that any one of them, how-
ever irrefragable, suffices for our guidance. Morbid
actions, however simple in their origin, become so
soon combined with others, whether derivative or
contingent, that the assemblage manifested in
every instance of advanced or specific disease
loses all character of simplicity, and requires for
its exposition a variety of knowledge, a clearness
of conception, and an accuracy of judgment ex-
ceeding perhaps what any other earthly pursuit
demands.

A most important complication of vascular
derangements is that which is derived from coin-
cident disturbance of nervous function ; and so
continually are these conditions intermixed, that
the consideration of plethora would be incomplete
if this source of complication were unnoticed. As
a matter of fact, it is familiarly known that in-
flammatory diseases of the same general character
and denomination present in different individuals
different phenomena according to the degree of
nervous irritability respectively attendant. The
predominance of this latter may proceed from pe-
culiarity of temperament, or from the influence of
stimulants particularly exciting the nervous sys-
tem, in operation antecedently to the special dis-
ease, and independent of it ; or it may result from
cerebral congestion or irritation incident to the
febrile slate which plethora is seen to induce. It
is further known that nervous irritability, when
in excess, is capable of producing derangements
which so much resemble those of pure inflamma-
tion as frequently to mislead practitioners into
employing active depletory treatment where this
is unsuitable, if not absolutely injurious. It is
time that these several conditions and their com-
binations should be more fully investigated and
better understood, were it only for guarding against
an error to which recent enquiries on this subject
seem to tend, — namely, that of regarding the in-
flammatory and irritative states as opposite and
contradictory ; so that where one state is proved
to exist, the other must, by implication, be con-
sidered as negatived. The truth of such a position
we would not admit ; and we are anxious to dis-

572

PLETHORA.

play the grounds of our persuasion in this respect,
entertaining as we do considerable apprehension
lest the views of nervous excitability which some
able and discriminating writers have of late years
presented, (or rather the practical evidences which
they have adduced of this being preponderant in
certain maladies which had been very generally
regarded as purely inflammatory,) should with-
draw attention from inflammatory action beyond
what the writers alluded to contemplated or would
have approved.

The morbid irritability which, simulating in-
flammatory excitement, gives rise to local disturb-
ances liable to be confounded with pure phleg-
masia?, and which, however it may be temporarily
alleviated by bloodletting, is eventually aggravated
by it, while it is relievable by opium and ammo-
nia, has been ably illustrated by the late Dr.
Gooch in his valuable »'< Account of the Peritoneal
Fevers of Lying-in Women," and also by Dr.
Marshall Hall in an " Essay on some Effects of
Intestinal Irritation," as in several other of his
works. In all that these judicious and eminently
practical writers have adduced respecting this con-
dition, and the treatment required for its relief,
we entirely concur; but in admitting fully the
truth of their statements, we are anxious at the
same time to impress that though the higher
degrees of irritability may exist independently of
plethora or of inflammation, — nay, may have their
origin in actual inanition or in excessive loss of
blood, the same nervous depravation is continually
found combined in every proportion with plethora,
inflammation, and congestion ; and that when it
is so combined, the treatment, to be safe and
effectual, must have relation to both sources of
disease. In proportion as plethora and inflamma-
tory action prevail, must depletory treatment take
the lead ; and according as irritability is exces-
sive, will opium and stimulants be needed. To
discriminate these respective conditions, then, so
as to assign to each its appropriate treatment, is
the point to which practical observation would be
most beneficially directed. And in this scrutiny
much advantage will result from founding diag-
nosis not on one or two prominent symptoms, but
on the whole assemblage ; among which, as was
remarked in a former part of this essay, such
harmony should subsist that no individual symp-
tom should be contradictory of what the others
proclaim. When such contradictions present,
then, instead of leaning exclusively to that side to
which the balance inclines, each class of symp-
toms should receive its appropriate consideration,
and be referred to the principles in which it ori-
ginates. In the morbid conditions under discus-
sion, it is not difficult to distinguish the purely
inflammatory cases from those in which excess of
irritability is combined. In the latter, while the
disproportionate degree of irritability should itself
excite suspicion, a scrutiny of symptoms will
show that these do not all in equal degree denote
such activity of inflammation as the prevailing
irritability would imply. The pulse, temperature,
and tongue do not present that correspondence of
derangement which is usually attendant on purely
inflammatory action. The pulse, however acce-
lerated, (and in such cases it is often inordinately
so,) wants the firmness which belongs to inflam-

mation. The temperature is not always in ac-
cordance with the high sensibility evinced by
particular parts of the frame ; and the tongue, in-
stead of being dry or furred, is oftentimes moist
and preternatural ly red. So endless, however,
are the varieties induced by the combinations
which occur, that it would be impossible to render
a distinct account of them by any description, or
to do more than to point out the sources of disease
to which the practitioner's own observation should
be directed.

For plethora and inflammation the appropriate
remedies, as we have often stated, are bleeding,
purging, and antiphlogistic treatment ; while mor-
bid irritability yields but to opium and other se-
datives, combined, as occasion requires, with cor-
dials and tonics. In proportion as either condi-
tion prevails, must its appropriate remedies be
combined in the treatment ; and on the accuracy
with which these remedies are severally adapted
does much of the success of medical practice de-
pend.

The subject is much too copious to be discussed
fully in this place, where our chief object for in-
troducing it is to impress a warning against hastily
inferring, that because irritability predominates,
inflammation or congestion is not co-existent.
Even where morbid irritability results from ex-
haustion or inanition, congestions continually oc-
cur which call for topical bleeding, however un-
suited depletion may be to the constitutional state
existing, and even though to sustain strength by
tonics and nutritive diet may be at the same time
required. This is well exemplified in a state of
disease of frequent occurrence, and with which
most practitioners must be familiar.

Females under too protracted lactation fall into
ill health, marked by exhaustion, and attended
with various nervous derangements. This state is
common among the poor, who, for various reasons,
are accustomed to suckle their children for long
periods, — even for two or three years. Pallid
aspect, disordered digestion, irregular bowels, and
acute pains of head, with prostration of strength
and great nervous irritability, are the prominent
features ; but the whole condition thus induced is
so peculiar and characteristic that they who are
familiar with it are at once led to a knowledge of
the cause by inquiries which they might otherwise
not think of making. Taught by experience, we
have oftentimes, among the out-patients of the
hospital, discovered the fact by direct inquiry
where there was nothing save the general charac-
ter of the disease to induce suspicion of the wo-
man being engaged in suckling ; there being either
no child produced, or one able to walk by its
mother's side. Weaning the child is here the in-
dispensable requisite ; and its effects are quickly
displayed. They are assisted by mild aperients
combined with sedatives, cordial remedies, and
sustenance. No state would appear on principle
less suited for evacuant treatment than this ; and
under this impression we were for a long time
averse to relieving the head by any direct deple-
tion. The inveteracy of the headach, however,
forced us to the application of leeches ; and the
prompt relief which they afforded soon removed
all scruples on this score. A few suffice ; six or
eight applied to the temples give in general all

PLETHORA

573

Me relief required ; but nothing can be more de-
cisive, or more strongly marked than the benefit
which they thus afford.

We do not say that all such cases require leech-
ing, but the attendant headach yields readily to
this remedy when all others fail to subdue it. The
only inference which we can draw is, that not-
withstanding the general debility and perhaps by
reason of it, the vessels of the brain become con-
gested and unable to unload themselves ; that the
topical bleeding, by lessening their contents, ena-
bles them to contract and recover their natural
diameter, and with it the power of carrying on the
circulation so tranquilly as no longer to disturb
the cerebral functions.

The above state only displays congestion as
coinciding with irritability and exhaustion ; but
the instances are of daily occurrence in which
morbid irritability is complicated in every variety
with relative plethora ; and when these states are
so combined, it is quite as necessary to correct the
plethora as to allay the irritation, the most effectual
way of restoring health in sdch case being, not to
pursue any exclusive system, but, guided by ex-
perience, to give to each derangement the consid-
eration which it specially claims, and to combine
the respective remedies as the prominent derange-
ments may severally demand. A knowledge of
the principles on which each class of remedies
should be employed furnishes the best guidance for
regulating those combinations which such complex
states of disease must ever require. One of those
conditions, at least, we have endeavoured to illus-
trate in the foregoing pages ; and however we may
have failed to do justice to the subject, it is hoped
that sufficient ground has been shown for pursu-
ing the inquiry, and a motive furnished for other
observers to complete what we must necessarily
leave imperfect.

Before concluding this article, it is necessary to
offer a few remarks on the vitiation of blood which
arises from redundancy of excrementitious matter,
regarding this in its simple state, unconnected
with the various degrees of plethora with which
it is so continually combined. In doing so the mo-
tive is not so much to designate the morbid con-
dition as likely on its own account to become an
express object of medical discipline, as to establish
the principles which should govern its treatment,
when, as continually happens, it is found com-
bined with other derangements. The general
phenomena which denote this condition are, a sal-
low aspect and dusky skin ; the pulse low, soft,
and compressible ; the surface of the body for the
most part harsh, dry, and obviously deficient in
natural transpiration ; the tongue moist, clear,
red ; the appetite capricious, often craving and
voracious, with an endless train of dyspeptic ail-
ments*; the alvine discharges inveterately foul,
dark, slimy, pitch-like, and exhibiting no trace of
heahhy faxes ; the urine high-coloured, depositing
more or less of dark, often fetid sediment : these,
with decline of flesh and strength, are the general
characteristics of this state. The condition itself
we believe to arise from the accumulation in the
blood of excrementitious matter imperfectly dis-
charged, and the depraved state of the several se-
cretions we regard as resulting from the laboured
though ineffectual efforts of the constitution to

accomplish, through their agency, its own purifi-
cation. It may give a clearer conception of this
condition to contrast its phenomena with those
which characterize nutritive plethora. In the lat-
ter the general aspect is more full and florid ; the
surface is hot and dry, or inclining to moisture ;
the pulse hard and frequent, or full, strong, and
bounding ; the tongue white and furred ; the
stomach inclining to nausea, with thirst ; the stools
feculent, though foul, and charged with mucus.

In specifying the symptoms of excrementitious
accumulations, it may be imagined that we have
included several which belong to the different
forms of hepatic disease. That they are fre-
quently regarded as evidences of diseased liver,
and treated accordingly, we are well aware ; but
that they are certainly to be met with where there
is no organic lesion of this viscera, nor any par-
ticular functional disturbance of it, we are fully
convinced. It is true that the functions of the
liver are, in common with those of the whole ali-
mentary canal, greatly depraved, but they are so
not from any primary defect or derangement of
their own powers, but from being required to act
inordinately on a vitiated mass which nature is
sedulous to purify.

According as nutritive plethora becomes more
or less combined with this state, the constitutional
efforts increase, and various degrees of febrile and
inflammatory excitement ensue. In proportion as
this excitement is energetic, and as measures of
suitable activity are employed for its relief, the
vitiated state of the blood becomes corrected, the
secretions and excretions improve, and the general
health and strength amend. The increased se-
cretions from the bowels seem to be the discharge
by which nature aims at getting rid of such im-
purities. To promote them, therefore, by suitable
purgatives, at the same time supporting the
strength by moderately nutritive diet, is the first
indication.

When relief, to a certain extent, is thus afforded,
the powers of the constitution rally, and a febrile
effort is made to assist in the work of purification.
According as this advances, depletion should be
more active and the diet less stimulating. When
sufficient excitement exists to warrant the em-
ployment of bloodletting, we may then consider
the curative process as in the most favourable
train. Perhaps the powers of the constitution are
hardly adequate to rectify any high degree of this
derangement without the extraordinary effects
which a state of febrile excitement supplies, and
hence we see experienced practitioners often hail
the appearance of febrile symptoms in chronic
maladies as announcing a more remediable form
of disease.

In every view that can be taken of this condi-
tion, it must be considered as intimately connected
with the state of cuticular excretion, from defect
of which it is more likely to arise than from any
other cause. When we reflect on the large
amount discharged by this excretory under a
healthy state of the system, and that, according to
accurate experiments, more than one-half the
ingesta is carried off by transpiration, it will be
readily conceived that great excrementitious accu-
mulation must result from impeded cuticular ex-
cretion. This matter being in consequence thrown

574

PLEURISY.

in inordinate quantity on the other excretories, it
can excite little surprise that their ordinary func-
tions should be thence disturbed, or that their
several secretions should present a morbid cha-
racter.

A constitution naturally feeble, especially if ex-
ercise be inadequately taken, sends the blood to
the surface too languidly for the exhalant arteries
to act with full power, whence excrementitious
accumulation commences; the effect of this being
directly debilitating, it serves to aggravate the
cause, and thus the foundation is laid for a broken
constitution and many inveterate chronic diseases.
The best preventive of this diseased condition is,
unquestionably, exercise, and in slighter degrees
of it this would also be the most effectual cure ;
but when great depravation of habit has already
taken place, there is neither the capability of
taking adequate exercise, nor would it alone,
under such circumstances, succeed. To be effec-
tual it should be carried to the extent of producing
some moisture on the skin, as the only sure evi-
dence of the blood being impelled with sufficient
force into the capillary vessels. The various forms
of warm bathing are of great value, especially
those which combine frictions and other means of
softening and detaching hardened cuticle. That
of the Russian vapour-bath, noticed by northern
travellers, and so accurately described by the late
Dr. Clarke, would appear eminently calculated
for establishing a healthy state of skin, and an
adequate activity of cuticular excretion.

E. Barlow.

PLEURISY, PLEURITIS. Gr. HAetop?™* from

xXcupa, the side, also the membrane that lines the
ribs, the pleura. Pleurisy signifies inflammation of
the serous membrane which lines the cavity of the
chest and invests the organs of respiration therein
contained. Modern pathology has narrowed the
application of this term, which, in the earlier ages
of medicine, was employed to express pain of the
side, no matter what tissue was the seat of the
uneasy sensation, provided it was acute in its
character and accompanied with fever. The fre-
quency of the complication of pleurisy and pneu-
monia led many to suppose that the former was
so essentially connected with the latter as to be
incapable of an independent existence. It is,
however, now clearly established that, although
the parenchyma of the lung, and its enveloping
membrane are often involved in the same inflam-
mation, still there is no necessary connection be-
tween the affection of the one and that of the
other.

If adhesions between opposite surfaces of serous
membranes are to be looked upon as evidence of
pre-existing inflammation, the frequency with
which we meet with this morbid phenomenon
between the pleural surfaces warrants us in as-
serting that no organ or tissue in the body is more
subject to inflammation than the pleura.

Pleurisy presents itself under so many varied
forms, that we shall find it difficult to exhibit it in
one general description. It may be acute or
chronic; it may affect one side of the chest or
both sides ; it may be general, involving the whole
of one side, or partial, only involving part of one
6ide ; it may be simple or complicated ; the com-

plication may be either accidental or essential,
and in the latter case the pleurisy and its compli-
cation stand to each other in the relation of effect
and cause.

I. Acute Pleurisy. — The anatomical cha-
racters which the pleura affected with acute in-
flammation presents, consist of change of texture
and change of secretion. We have also to con-
sider the changes which the lung, compressed by
the effused fluid, undergoes both in form, volume,
situation, and other relations.

The inflamed pleura exhibits numberless minute
capillary vessels carrying red blood ; these vessels
anastomose freely among themselves, and present
injected patches of various forms. Sometimes the
injection is so general as to appear like an ecchy-
mosis. Careful anatomical examination proves
these injected vessels to be situated in the subse-
rous cellular tissue ; and that what was considered
an actual thickening of the serous membrane in
the first stage of inflammation, is due to a serous
infiltration into this cellular tissue, as well as to a
loosening of the connection between the serous
membrane and the subjacent tissue by the in-
creased calibre of the capillaries, now carrying red
blood. In some cases we can peel off the serous
membrane, and thus prove the pretended thicken-
ing to be nothing more than what we have just
stated.

Inflammation of the pleura induces changes
both in the quantity and in the character of the
ordinary serous exhalation. The first effect of in-
flammation upon the exhalation of a serous sur-
face is, if not completely to suppress it, at least
to diminish it very considerably ; so that the dry
surfaces have no longer that easy gliding motion
which it is the physiological object of this lubre-
fying fluid to maintain. After an interval varying
from an hour to two or three days from the com-
mencement of inflammation, the serous exhala-
tion is much increased in quantity, or, to adopt
the language of pathology, the inflammation ter-
minates in effusion. Laennec objects to this
mode of expression, as calculated to convey an
erroneous idea as to the time when the effusion
begins to take place, as he is of opinion that in
serous membranes the inflammation and effusion
commence at the same moment, and proceed pari
passu. With this, we must confess, our expe-
rience does not agree ; and although in the larger
cavities, viz. the abdomen, heart, and chest, our
examination may not be capable of that degree of
precision which would enable us to pronounce
with certainty upon the point, still there are other
cavities in which the train of morbid phenomena
takes place more immediately under the cogni-
zance of our senses, and where we have an oppor-
tunity of recognising a determinate interval be-
tween the supervention of the inflammation and
the effusion ; for instance, the joints and the tunica
vaginalis testis. In iritis, we have ocular demon-
stration that it is some time after the pain has
announced the inflammation, that the increased
secretion of the aqueous humour takes place,
causing an unusual prominency of the cornea.

The fluid effused into the cavity of the chest,
in acute pleurisy, varies considerably in quantity ;
sometimes not exceeding an ounce, at other times
amounting to several pints. When it is consider-

PLEURISY.

575

able, and has exercised a pressure upon the yield-
ing parenchyma of the lung, reduced it to its
smallest possible dimensions, and pushed down
the diaphragm so as to cause the viscera placed
below it to be felt lower than their normal situa-
tion, viz., the liver on the right side, and the spleen
upon the left, it seems to be next directed against
the walls of the chest, and produces a change in
the form of the side, to which we shall have occa-
sion to advert when we come to enumerate the
physical signs of acute pleurisy.

The effused fluid presents itself under very va-
rious appearances. It may be colourless, transpa-
rent serum ; or we may find flocculi of lymph
floating in the serum without affecting its trans-
parency ; or, again, some of the lymph may be,
as it were, dissolved in the serum, and, rendering
it turbid, may impart to it an appearance resem-
bling unclarified whey. Again, it may be a
greenish fluid made up of serum and pus in vari-
ous proportions, and approaching to each of these
fluids in colour and consistence, according to the
proportions in which they enter into its composi-
tion. Or it may be unmixed pus, resembling in
its sensible qualities the matter of a phlegmonous
abscess ; and in this case the disease is ushered in
with a strong rigor, the ordinary announcement of
suppuration. Lastly, it may be either pure blood,
or the ordinary serous effusion more or less deeply
tinged with this fluid ; the blood in this instance
may be forced out either from the capillary vessels
of the pleura in a high state of orgasm, or from
the vessels developed in the organized false mem-
brane.

In a case of acute pleurisy, which we have had
recently under our care, and in which the urgency
of the symptoms required the immediate perform-
. ance of the operation of paracentesis thoracis, the
fluid drawn off was of a yellowish colour and oily
consistence, very much resembling in appearance
copal varnish. On remaining a short time in the
vessel in which it was drawn, it was converted
into a tremulous jelly, and after some hours re-
solved itself into two distinct parts, a thickish
crassamentum floating in a thin serum ; it in fact
very much resembled the blood without its colour-
ing matter. The fluid having collected again, it
became necessary, in the course of a fortnight, to
repeat the operation, when we found the effusion
to present very different sensible properties from
those of the original fluid ; it was of a greenish
colour, and though apparently of a homogeneous
consistence, on standing a short time, it separated
into a thick, purulent sediment and a thin, green-
ish, supernatant fluid. This operation afforded a
very temporary relief: the individual died in four
days, and on examination we found not less than
eight pints of thick purulent matter (such as is
met with in a phlegmonous abscess) in the left
side, and both pleura pulmonalis and costalis
densely coated with lymph. The difference pre-
sented by the effusion on three different occasions
constitutes the interesting feature of this case.
Andral, in the second volume of his Cliniquc
Medicale (Sur les Maladies du Poilririe,) men-
tions a case in which the fluid effused into the
pleura resembled the jelly of meat.

A portion of the fluid effused in pleurisy has a
natural tendency to pass to the solid state ; from

thence we have the false membranes, which pre-
sent so much variety in their organization, form,
extent, consistence, and thickness. The coa<»ula-
ble lymph is scarcely deposited upon the free sur-
face of the pleura when it becomes solid. In the
first instance it is a soft, whitish mass, exhibiting
no appearance of organization or vitality ; but
soon red points make their appearance in it, which,
elongating themselves into red lines, present une-
quivocal characters of vascular canals, and, pass-
ing beyond the lymph, — the matrix of their deve-
lopment, — proceed to inosculate with the vessels
of the pleura, and thus establish a communication
between the circulation of the false membrane
and the general circulation. It is impossible to
fix the time when organization takes place in these
false membranes ; nor is it easy to determine to
what special influences this process is subject, evi
dences of such organization being found in false
membranes, the result of pleurisy of a few days'
standing, and being wanting in others of as many
months' duration ; thus, at least, proving that
time is not the sole regulating circumstance.

The form assumed by the lymph deposited on
the pleura is very various ; sometimes it is depo-
sited in isolated drops, having either the appear-
ance of transparent vesicles or of miliary granules;
at other times they closely resemble tubercles. In
the differences presented by the lymph deposited
in this form, we recognise the grounds of the opin-
ion that hydatids are the form under which tuber-
cles first present themselves, the transparency of
these globular concretions countenancing such a
belief. In a case of cancer of the lung, in which
the cancerous matter presented itself in all the in-
termediate stages of development between harden-
ed scirrhous structure and soft, dissolved, encepha-
loid matter, we found lymph deposited in the form
of these isolated drops upon the pleura of the op-
posite lung, while the lung itself was quite free
from disease. We suspect that lymph is the ru-
diment, or matrix, of all these morbid growths,
which derive their special character from the pecu-
liar cachexy of the individual.

Sometimes the lymph covers a greater or less
extent of the pleura, in the form of concretions of
variable density. The surface of these concretions
is sometimes smooth and polished, sometimes it is
rough and unequal, and sometimes it has an areo-
lated, honey-comb appearance. In many cases,
these concretions are converted into cellular bands,
of variable length, connecting the two pleura, and
are often found traversing the effused fluid.
These bands acquire all the characters, both ana-
tomical and pathological, of cellular tissue ; they
are subject to dropsical infiltration, and in jaundice
present a yellow hue ; they are often the matrix
of morbid developments. That these bands do
not fetter the motion, or in any way interfere with
the function of the lung, is abundantly demon
strated by the fact of the frequency with which
we meet them, in our nccroscopic examinations,
where we had no reason to suspect them during
life.

The false membrane varies in thickness in dif-
ferent instances ; sometimes it can be removed
from the subjacent pleura in the form of a thin
pellicle, not exceeding the thickness of the pleura
itself. Most commonly the thickness of the fals«<

576

PLEURISY.

membrane greatly exceeds the natural thickness
of the pleura, and it seems to be made up of
several distinct laminae superposed. We have
seen this membrane an inch thick, and the lamina;
of which it was composed admitted of separation
like the different laminae composing the coagulum
of an aneurismal sac.

As the false membrane resembles cellular tissue
in its properties, it is subject to all the transforma-
tions of structure of which this latter texture is
susceptible ; thus it may be converted into carti-
lage, fibro-cartilage, or even into bone. It is this
membrane, converted either into cartilage or fibro-
cartilage, which, in phthisis pulmonalis, establishes
such an intimate union between the pleurae pul-
monalis and costalis as to defy our utmost efforts
to separate them.

The false membrane may be the matrix of dif-
ferent accidental developments, of which tubercle
is by much the most frequent. We often find the
surface of the membrane studded with small
miliary tubercles : at other times we find these
bodies in the substance of the membrane in their
different stages of softening. We have no pre-
cise data whereupon to average the time when
tubercles begin to form in the false membrane ;
and though we believe they may develop them-
selves within a very short period, we conceive the
work of tuberculization in general to be a slow,
insidious process, even in organs most essential
to life.

The lung of the side, when the effusion exists,
deserves our attention, both in reference to the
position which it occupies, and the changes which
it undergoes in its proper structure. In general
the effused fluid tends to press the lung into the
space beside the vertebral column, and when it is
in considerable quantity, the organ is reduced to
a thin lamina, so that sometimes it is not easy to
find it, and thence we have heard of its having
entirely disappeared. Adhesions will of course
modify the position of the lung, and protect a
portion of it from pressure. Sometimes the lung
is applied against the ribs by being pressed back-
wards and outwards; at other times it is com-
pletely suspended in the fluid. In general the
only change induced in the lung, pressed upon by
the effused fluid, is a diminution of size, the me-
chanical effect of the peculiar circumstances in
which it is placed. The air is squeezed out of it.
The organ becomes more dense and less crepi-
tating than natural ; it assumes very much the
anatomical characters of a foetal lung; it has a
smooth, uniform appearance, and does not tear as
a portion of hepatized lung will do ; its vesicular
structure has quite disappeared, and even the
blood-vessels are flattened and exanguious: the
bronchial tubes become contracted in their calibre.
Its resemblance to a portion of muscular tissue
which has been submitted to maceration has
procured for it the expressive term of carnifica-
tion.

Tubercles may form in the compressed lung,
and there undergoing their ordinary changes, will
modify the symptoms of the disease ; still it more
frequently happens that the tubercles already ex-
isting in the lung, in softening, perforate the
pleura, and give rise to that modification of pleu-
"isy which might with propriety be termed puo-

pneumothorax. (Tliov, pus, rrvitya, air, 8<Zpa%,
chest.)

General Symptoms of Acute Pleurisy. —

Acute pleurisy is well entitled to a place amon«
the Pyrexiae, from the symptoms of high febrile
excitement with which it is in general announced ;
to these symptoms are superadded pain in the
side, difficulty of breathing, a hard dry cough
and, usually, decubitus upon the unaffected side :
upon these follow, sooner or later, a dulness of
sound or absence of the ordinary resonance of the
affected side when percussed, a peculiar modifica-
tion of the voice designated aegophony, and bron-
chial respiration ; then the complete absence of
the respiratory murmur, and a palpable dilatation
of the affected side.

The febrile symptoms of acute pleurisy are not
marked by a uniform intensity. When the dis-
ease prevails as an epidemic, these symptoms par-
take more of a low typhoid type, and considerable
derangement of the digestive apparatus holds a
prominent place amongst them. The pain is un-
equivocally the most constant symptom of acute
pleurisy ; it is the one which especially attracts
the patient's attention, and which, from the ex-
pression of anxiety and suffering which it imparts
to the countenance, is seldom overlooked by the
physician : it is described as a sharp, lancinating
pain, increased by coughing, by inspiration, by
pressure in the intercostal spaces, or by lying on
the affected side ; its situation is generally referred
to near the mamma, and is felt in a very circum-
scribed space, no matter what may be the extent
of the inflammation. It is not easy to explain
why this should be the usual situation of the pain.
Morgagni attempted to account for it by the greater
mobility which this point of the chest presents, as
being equally distant from the apex and base of
the thorax, and from the sternum and spine.
Though the point mentioned be the most usual
seat of the pain, still it may be felt in any part of
the side, or even in the opposite side, without this
side participating in the inflammation.

When pleurisy depends upon tubercles in the
pulmonary tissue, the pain is felt in parts of the
chest corresponding to the situations of the forma-
tion of these foreign bodies ; hence in the early
or nascent stage of phthisis pulmonalis, we hear
the frequent complaint of pain under and above
the clavicle, in the hollow of the axilla, or be-
tween the shoulders, this pain indicating the ex-
istence of tubercles in the apex of the lung, the
usual seat of their earliest development. This
symptom of early phthisis is of much practical
value, as it assists our diagnosis at a stage of the
disease when the stethoscopic signs are equivocal,
and when treatment interferes with most prospect
of success.

When the pain is confined to the margin of the
ribs, it is not always easy to determine whether it
depend upon inflammation of the thoracic or of
the abdominal serous membrane, and the difficulty
is increased by the fact that jaundice has followed
upon unequivocal pleurisy by an extension of in-
flammation of the pleura lining the diaphragm.
Morgagni mentions a case in which Valsalva mis-
took the complication of jaundice for the primary
disease, and overlooked the less palpable signs of
a pre-existing pleurisy, proving how difficult it is

PLEURISY.

577

to establish a certain diagnosis when the situation
of the disease is a point where many organs are,
as it were, placed in the same parallel of latitude,
and when the disease itself is not marked by any
striking functional derangement. The pain is
seldom constant, but is brought on by every thing
calculated to impress the slightest motion upon
the affected side ; it sometimes assumes an inter-
mittent character, and returns with a regular pe-
riodicity.

In the first moments of acute pleurisy, the res-
piration is marked by a peculiar nervous hurry.
Nature is instinctively aware of the pain produced
by a full inspiration, and therefore avoids it ; she
compensates for the smallness of the volume of
air admitted at each inspiration by the frequent
repetition of the act, and hence the respiration is
short, hurried, and jerky (saccadee). When effu-
sion has taken place, the dyspnoea depends upon
a different cause, viz. the mechanical obstruction
to the expansion of the lung, and is in proportion
to the extent of the effusion and suddenness with
which it has taken place. This latter circum-
stance has much more effect in embarrassing the
respiration than the former, as we have known
cases where individuals were quite unconscious
of any thing affecting their chest, while at the
same time there existed unequivocal evidence of
extensive pleuritic effusion ; and this arose from
the organs having had time to accommodate them-
selves to the encroachment upon their functions.
Should the opposite lung be affected either with
bronchitis or emphysema, the dyspnoea will be
more distressing.

The characteristic cough of acute pleurisy is a
short cough, either dry, or accompanied with a
thin mucous expectoration : should the sputa be
more abundant or deviate from this character, we
may suspect a complication either of pneumonia
or bronchitis. The cough is often wanting alto-
gether, or is so slight as to attract the attention of
neither the patient nor the physician.

The difference of opinion which obtains among
systematic writers upon the subject of the decu-
bitus, or position of the patient in pleurisy, proves
at least that it is not constant, and therefore can-
not be exclusively relied upon as a diagnostic
sign ; still we may say that, as long as the acute
lancinating pain of the side continues, the aggra-
vation of it, caused by the pressure when lying
upon this side, makes the individual seek the
more easy position, either upon the opposite side
or upon the back. When the pain has ceased,
aiid extensive effusion taken place, the position,
before avoided, is now adopted ; because the effu-
sion, interrupting the function of one lung, and
placing it, as it were, hors de combat, a necessity
for greatly augmented action devolves upon the
other; and in order to favour this, nature instinc-
tively points to the position which allows the
easiest and most unembarrassed play to those
muscles whose province it is to dilate the unaf-
fected side of the chest, and this position is upon
the alfected side. It is only when the effusion
has been sudden and considerable, when the res-
piration has (if we may be allowed the expres-
sion) been taken by surprise, that nature seeks to
relieve herself by particular posture. It may hap-
pen that a fresh attack of inflammation in the side
Vol. III. — 73 2i

originally affected, or the lung hitherto free be-
coming involved, will produce the necessity for a
certain position, to which nature in the first in-
stance seemed to be indifferent.

Physical Signs, — In the earliest stage of
acute pleurisy, there is no physical sign to mark
its existence.

[Early in the disease, a rubbing, creaking, or
friction sound is heard, which may indicate that
the secretion from the pleura has been arrested by
the inflammation, or, what is more general, it in-
dicates that plastic lymph has been thrown out,
the consequence of which is the friction — frotte-
ment — which, however, may be so slight as
scarcely to merit the name of frolement, or "slight
grazing sound ;" but at other times is so loud as
to resemble the " leather creak" — bruit de cuir
neuf of the French. These signs, when com-
bined with the general symptoms, are valuable in
the diagnosis; but they are not of long duration,
and may not, therefore, be heard. Friction sounds
occur, also, in interlobular emphysema, and as this
pathological condition does not speedily change,
they persist longer. Recent researches, as re-
marked by Dr, Williams, (Lectures, SfC, on the
Chest, Amer. edit. p. 153, Philad. 1839,) would
seem to show, that, as in the case of peritonitis,
the sounds are not often produced in pleurisy,
unless the lung is at the same time pressed against
the chest by a tumour, or by effusion, or is par-
tially distended by emphysema or tuberculous or
other deposits. The sounds are generally most
audible in the central parts of the chest, owing to
the motion of the pleura? upon each other being
most marked in that situation ; and in order to be
heard, the patient should lie on his abdomen.]

When effusion takes place into the cavity of
the chest, its extent is marked by percussion of
the side yielding a dull dead sound, instead of its
ordinary clear tympanitic resonance. This dull
sound, it is true, may arise from other causes than
from fluid effused into the cavity of the pleura ; it
may be owing to solidification ot the pulmonary
tissue, the effect of pneumonia ; or to some mor-
bid growth formed in the lung ; still we can take
such advantage of this sign as will enable us to
determine upon what it depends ; for although
Laennec denies that fluid effused into the cavity
of the chest can change its place, and states that
it arranges itself between the lung and the walls
of the chest, the experiments and examinations of
Piorry on this subject, concurring with our own
experience both during life, and confirmed by ex-
amination after death, enable us to assert that this
fluid, being specifically heavier than the lung in
its natural state, will displace it, and gravitate to-
wards the most dependent part, and thus by
change of position of our patient shall we be en-
abled to change the results both of percussion and
auscultation. We believe the only internal limi-
tation to the displacement of the lung to be the
root of the organ ; and when the effusion is con-
siderable, and we examine the patient in the sit-
ting posture, the weakness, if not the complete
absence of respiration and dulness of sound, are
owing to the fluid having pushed up, and now
occupied the place of the lung; but as the root of
the organ is its fixed point, when the fluid rises
above its level, it is now that it presses upon it on

578

PLEURISY

all sides, and when it has filled the cavity, the
lung is, as it were, suspended in it, and, being re-
tained here, undergoes different degrees of com-
pression according to the extent of the effusion.
The analogy of the fluid in ascites, displacing the
Intestines, confirms the view that we have just
taken of the displacement of the lung by the pleu-
ritic effusion. Adhesions between the pleura pul-
monalis and costalis will prevent the fluid dis-
placing the lung ; and if we did not keep this fact
constantly in view in our examinations, we should
often be misled. We well remember the embar-
rassment which the usual phenomenon of distinct
bronchial respiration produced in a case of une-
quivocal pleuritic effusion, related by Dr. Graves
in the fifth volume of the Dublin Hospital Reports,
and which an adhesion between the pleurae pul-
monalis and costalis afterwards accounted for. It
is only when the dulness of sound and absence
of respiration present themselves when we see the
patient for the first time, that we can ever be at a
loss to determine whether they depend upon pleu-
ritic effusion or solidification of the lung; for the
short time in which the whole side, or even its in-
ferior half, will yield a dull sound, (sometimes oc-
curring within a few hours,) is conclusive of its
being due to effusion and not to hepatization,
which is a very gradual result, and is always pre-
ceded by the crepitating rale. We may state
generally that the sudden, equal, and uniform
absence of respiration and dulness of sound are
peculiar to pleuritic effusion.

When the effusion is very abundant from the
first moments of its formation, the respiratory
murmur ceases to be heard in any part of the
chest, except along the vertebral column, where it
is still perceptible for the space of about three
fingers' breadth, although more feeble than on the
opposite side. When, on the contrary, the effusion
is gradual, the respiratory murmur begins by be-
ing a degree fainter, and continues to diminish its
intensity until it is entirely lost. The respiratory
murmur will survive the dulness of sound some-
times for days. When it has ceased in all other
parts except beside the spine, it will often con-
tinue to be heard under the clavicle, in conse-
quence of the frequent adhesions between the
pleura pulmonalis and costalis in this situation
in phthisis. To the cessation of the respiratory
murmur or vesicular respiration succeeds a peculiar
modification of respiration, which, from its ap-
parent dependence on the air not penetrating
beyond the larger bronchial tubes, has been termed
bronchial respiration. As this same character of
respiration exists in solidification of the lung in
pneumonia, we may presume that it depends upon
the same cause in both cases, — namely, the pecu-
liar condition to which the pulmonary parenchyma
has been reduced, in one by the compression of
the fluid, and in the other by a deposition of
foreign matter into its proper structure ; so that
the phenomenon would seem to depend upon the
air entering the bronchial tubes, placed not in the
midst of their ordinary spongy medium, but of a
dense solid structure, and therefore better calcu-
lated to convey every modification of sound,
whether of voice or of the entrance of air ; furnish-
ing us in the former instance with bronchophony,
asd in the latter with bronchial respiration.

The voice, as heard by the stethoscope, is ob.
served to acquire a particular character in pleuritic
effusion, which led Laennec to regard it as one
of its most characteristic signs. From its resem-
blance to the shrill, jerky, tremulous sound of the
goat, he has termed it aegophony. (See Aus-
cultation.) This phenomenon is most per-
ceptible about the inferior angle of the scapula,
and in the space comprised between the posterior
margin of this bone and the spine, and is found to
exist only when the effusion has attained to a
certain extent, and to cease when it either goes
beyond or falls short of this : hence it is not met
with either in the very early or advanced stage of
pleurisy ; and when it has been present and disap-
peared, its return is hailed as indicative of progres-
sive absorption of the effused fluid. Laennec ascribes
it to the transmission of the voice through the com-
pressed lung and the fluid interposed between the
lung and the side of the chest. As we before
stated that our own experience, confirmed by
Piorry's experiments, made us question Laennec's
opinion of the stratum of fluid interposed between
the lung and side of the chest, of course we can-
not admit his rationale of the phenomenon, as far
as relates to the transmission of the voice through
this hypothetical interposed fluid. As the most
experienced stethoscopists allow that they can
with difficulty distinguish between aegophony and
bronchophony, we believe the former to be a mere
modification of the latter, and to differ only in the
structure of the lung not having undergone an
equal degree of compression : hence we see the
reason why, in the earliest stage of pleuritic effu-
sion, the compression has not been sufficient to
produce the phenomenon ; as the effusion in-
creases, the compression is greater, and the phe-
nomenon appears, the effusion increases still more,
and aegophony gives place to bronchophony ; as
absorption takes place, the compression becomes
less, and aegophony appears again ; hence we have
equal reason to hail the return of this phenomenon
as an indirect expression of the diminution of the
fluid, but an immediate result of the diminished
compression of the lung, and not of the diminished
interposed fluid through which the voice is trans-
mitted.

When the effusion is considerable and has
formed within a short space of time, the respira-
tion in the opposite lung becomes puerile. The
increased action which has devolved upon this
lung strongly predisposes it to disease, differing,
however, from the original affection; that is to
say, the lung is more likely to become consecu-
tively affected either with bronchitis or pneumonia
than with pleurisy. When pleurisy is double, the
two sides have become simultaneously affected,
and their respective affections proceed pari passu.

When the effusion has proceeded to a conside-
rable extent, it produces a change in the side, con-
sisting in an actual increase of its size and form.
It is remarkable how small a difference between
the two sides, as ascertained by actual measure-
ment, will strike the eye ; an increase of six lines
will have this effect. The change of form of the
side consists in its becoming more rounded, and in
the intercostal spaces being either effaced, or rising
beyond the level of the ribs. In these spaces fluc-
tuation can sometimes be detected. Change in

PLEURISY.

579

the form and dimensions of the side has been re-
cognised as a diagnostic sign of pleuritic effusion
since the dawn of pathology.

[The increased size, induced by effusion into
the chest, is observable early; — Laennec says
after two days' duration of the disease, — Andral
says, on the fourth or fifth day. The writer's ob-
servation, as stated elsewhere, {Practice of Medi-
cine, 2d edit. i. 389,) would lead him to fix the
appearance of this phenomenon at a later period.
It has been usually considered, that protrusion of
the intercostal spaces is always coexistent. But
this, as remarked by Dr. Stokes, ( On Diseases of
the Chest, 2d Amer. edit. p. 466, Philad. 1844,)
may be wanting. Moreover, dilatation of the side
may be absent, where even copious effusion exists,
owing to the displacement of the diaphragm. The
observer in making these comparisons must bear in
mind, that the right side, in health, is often larger
than the left. The average result of the most
accurate admeasurements of 20 chests of persons
not labouring under disease of the lungs gave, ac-
cording to Dr. Stokes, for the right side, 17.86
inches, and for the left 17.23, — or more than half
an inch in favour of the right lung. Of these, the
most capacious chest measured 22 inches for the
right, and 21.50 for the left. In one case only,
the left side was larger than the right ; and in
three the sides were symmetrical. In the case in
which the left side was more developed, the man
was left-handed. In the work already cited, the
writer has given the admeasurements of ten males
and ten females, taken by himself or under his in-
spection — none of the individuals labouring under
disease of the lungs. The average of these gave
16.92 inches for the left side, and 17.47 inches
for the right in the male, — being a difference of
about half an inch; 15.1 inches for the left side,
and 15.2 for the right in the female, — being a dif-
ference of not more than one-tenth of an inch.]

When the effusion is on the left side it will
have the effect of displacing the heart, and of
causing its pulsations to be heard either on the
right side or in the epigastrium ; hence, if we
miss the heart in its normal position, and perceive
its action in either of these situations, we have
very strong grounds to suspect, if not conclusive
evidence of. this lesion. [See article Empyema.]

M. Reynaud has suggested a mode of ascer-
taining the existence of fluid effused into the chest,
which consists in the application of the hand to
the side where the effusion is suspected, and then
making the individual speak, when the effused
fluid will be found to interrupt the vibrations
which the voice communicates to the walls of the
chest when the lungs are sound.

[By placing a hand under each scapula, pleu-
ritic effusion may, in this manner, be detected.
Dr. Stokes, {Op. cit. p. 462,) regarded this sign
as of far greater value than egophony. It does
not exist, however, in many cases of females and
of boys prior to the change of voice, — the vocal
vibrations in them, although audible, not being
sufficiently powerful to be felt by the hand.

The pectoriloquism of phthisis, and the ego-
phony of pleurisy are regarded as the least valua-
ble of the physical signs of these diseases ; still,
the presence of egophony with dulness on per-
cussion, enfeebled respiratory murmur of the

affected side, with absence of the crepitant rhon-
chus, and of the vibratory vocal fremitus, would be
a strong combination of evidence in favour of the
existence of pleurisy.]

Varieties of Acute Pleurisy. — Acute pleu-
risy may be double, that is, it may involve both
sides of the chest at the same moment. This is
by no means a common occurrence, and when it
does take place, and is speedily followed by ex-
tensive effusion into both sides, the sudden and
extensive mechanical interference with the func-
tion of respiration soon extinguishes life. Per-
cussion affords us no assistance in forming our
diagnosis in this case ; for as we have no absolute
standard of the degree of resonance which it
should yield, it is by comparison of the two sides
that we can alone judge ; but the effusion, pro-
ducing a dull sound in both sides, deprives us of
the value of this physical sign. However, if we
keep in mind the observations we before made
upon the differences between pleurisy and pneu-
monia, and apply them to the subject under con-
sideration, we shall have little difficulty in identi-
fying this affection, and distinguishing it from
the only modification of disease with which it
could by possibility be confounded. Double pleu-
risy, but of inconsiderable extent, often takes
place in the agony of acute diseases.

Partial or circumscribed inflammations of the
pleura are very common. They in general pro-
duce no fever or constitutional disturbance, and
are only announced by a pain more or less acute
in some point of the walls of the thorax : the pain
too is not a constant symptom. A slight exuda-
tion of lymph takes place, and this, in the course
of time, is transformed into a cellular band. This
is the history of those cellular adhesions which
unite the plura? pulmonalis and costalis more or
less intimately. Theae adhesions have often been
found in persons who, during life, never gave rea-
son to suspect any affection of the chest. Although
these partial pleurisies may exist alone, they more
frequently occur in cases of affection of the pul-
monary parenchyma. Phthisis pulmonalis is their
most fertile source, and hence arise the frequent
pains in different points of the side, of which the
subjects of this disease so often complain. These
painful points bespeak inflammation of the corre-
sponding portions of the pleura, and in our sub-
sequent examinations we find adhesive cellular
bands in these situations. The number of these
adhesive bands is, in general, in the direct ratio
of the number of tubercles, and they exist particu-
larly in points corresponding to those where the
tubercles are most abundant: hence their most
constant situation is between the apex of the lung
and the summit of the cavity of the chest ; the
adhesion here is sometimes so firm as to defy our
utmost efforts to break it.

Some partial pleurisies demand peculiar atten-
tion in consequence of the particular symptoms to
which they give rise. Inflammation of that por-
tion of the pleura which lines the diaphragm
claims our especial consideration upon this score.
Its characteristic features are, in addition to the
ordinary constitutional symptoms of acute pleurisy,
pain more or less acute of the cartilaginous border
of the false ribs, extending into the hypochon-
dria, and even to the flanks ; complete immobility

5S0

PLEURISY.

of the diaphragm in inspiration, which is per-
formed hy the elevation of the ribs ; orthopnoea,
with an inclination of the body forwards ; an inex-
pressible anxiety of countenance, maiked by a
sudden change of features ; the respiration more
hurried and jerky than in ordinary pleurisy ; the
voice low and interrupted, (entre-coupee ;) a fre-
quent desire to cough, but an obvious dread of it
from the pain which it causes. The intellect is
free at first, but when the case is aggravated, and
the constitutional symptoms run high, delirium
comes on. In addition to the symptoms enume-
rated, we have the ordinary physical signs of
pleurisy ; viz. in the first moments of the disease,
if the pain will allow us to employ percussion, we
find a disproportion between the sound it yields in
the inferior part of the chest, and the distinctness
with which respiration is heard in this situation,
the latter being feeble while the former is clear ;
in the course of a short time the sound here be-
comes dull, and the respiratory murmur ceases to
be heard, and these two phenomena extend up-
wards in proportion to the extent of the disease.
When the effusion takes place into the right ca-
vity of the pleura, it presses down the liver, and
causes it to be felt below the margin of the ribs ;
when it takes place into the left cavity, it produces
a similar change in the position of the spleen.
The signs which we have just enumerated may
be regarded as the most constant and unequivocal
of diaphragmatic pleurisy ; others are occasionally
present, viz. hiccough, nausea, vomiting, jaundice,
&c. It was the presence of jaundice that led
Valsalva to regard the accidental complication as
the original disease ; a mistake which might natu-
rally occur, if, as happens in many cases, the fea-
tures of the preceding pleurisy had not been
strongly marked. The risus sardonicus, to which
the ancients attributed so much importance as
characteristic of this modification of disease, has
not been found constant by modern observers.

There is a partial pleurisy which claims our
attention, in order to guard against a pathological
error into which we might fall did we not conduct
our investigation with care. We allude to inter-
lobular pleurisy, in which the cellular membrane,
the result of the present or of a former inflamma-
tion, connecting the lobes of the lung, may be-
come the nidus of an abscess, which a superficial
observer might easily mistake for an abscess in the
substance of the organ.

It is almost superfluous to observe that partial
pleurisies owe their importance to the extent of
surface which they occupy : the more extensive
they are, the more serious are the consequences.
Preceding pleurisies, in which adhesions have
been formed, limit the extent of future attacks ;
these adhesions, as it were, divide the cavity of
the pleura into smaller cavities, and thus circum-
scribe future pleurisies.

Inflammation may affect either the costal pleura
alone, or the pulmonary pleura, or both at the
same moment. In the first case, it is not always
easy to determine whether the affection be rheu-
matism of the intercostal muscles, or inflamma-
tion of the costal pleura ; we have in each the
same pain produced by the same causes, and the
same modification of respiration, in the perform-
ance of which the ribs seem to take no share.

When the pulmonary pleura alone is affected, the
pain is produced by the air inspired stretching this
membrane, and it is the effort to avoid this that
gives the short hurried character to the respiration.

There is a neuralgic pain of the side which is
sometimes mistaken for inflammation of the pleu-
ra, but which differs from it in being unaccompa-
nied with fever, and in the character of the pain,
which is represented as a burning or scalding
sensation, and not as a sharp lancinating pain.
The neuralgic pain differs from the pleuritic in
being relieved by pressure.

Causes of Acute Pleurisy. — These may be
divided into the predisposing causes and the occa-
sional or exciting causes. Among the first may
be enumerated congenital malformation, consisting
in narrowness of the chest ; a sanguine tempera-
ment ; irritability of the system ; weakened health
from previous disease ; convalescence from fever ;
the puerperal state. The exciting causes embrace
all mechanical injuries directly applied to the
pleura ; such as contusions, penetrating wounds
caused either by cutting instruments,* or by sharp
spiculae of fractured ribs ; extension of ulceration
from a softened tubercle in the substance of the
lung perforating the pleura, and giving rise to a
complication to which we shall have occasion to
advert ; cold applied to the surface when the cuta-
neous capillaries are in a state of excited action,
&c. The mode of operation of the cause last
mentioned is supposed to be by directing the
fluids from the circumference to the centre, and
thus determining their afflux to the serous mem-
brane ; and as this cause has also the effect of
producing a congestion of the parenchyma of the
lung, and, in consequence, a tension and stretching
of the investing pleura, it was supposed that in
this way it contributed to produce pleurisy. The
frequent complication of intermittent fever with
pleurisy further countenanced this idea. How-
ever, we cannot but consider the rationale of this
cause as too mechanical, and would rather con-
nect it with some physiological sympathy existing
between the skin and serous membrane of the
chest. Pleurisy is often found to depend upon a
certain intemperies of the atmosphere, winch
causes an epidemic spread of the disease ; and
like all epidemics, it then assumes a less sthenic
type than isolated sporadic cases do ; in this
modification of the disease, the digestive apparatus
is much deranged, and hence it has been designa-
ted bilious pleurisy. Metastasis of gout or rheu-
matism, or a repressed cutaneous eruption, may
be the exciting causes of acute pleurisy. Pneu-
monia, by an extension of inflammation, so
often induces pleurisy, that, as we before ob-
served, it was long thought that they could not
exist independent of each other. While patholo-
gy has controverted this error, it has shown us
that pneumonia more frequently produces pleurisy
than pleurisy produces pneumonia.

Pleurisy is said to be latent when it exists un-
announced by the ordinary symptoms which
usually accompany it, such as. pain of the side,
hurried respiration, dry cough, &c. We have
observed pleurisy supervene in this insidious way

* We have seen a fatal case of pleurisy produced by
perforation of the pleura in passing the nui'dle round 'he
subclavian artery for the cure of aneurism of this artery.

PLEURISY.

581

in the convalescence from fever : the patient, after
having made some advance towards recovery, is
observed to fall back again ; he makes no com-
plaint of his chest ; still on careful examination
we observe a slight hurry of the respiration, and
hear an occasional dry cough ; these direct our
attention to the chest, where we find unequivocal
evidence of pleurisy with effusion.

Complications of Acute Pleurisy with,
other diseases. — We may premise that acute
pleurisy is much oftener simple and uncomplica-
ted than chronic pleurisy. The frequency of the
coincidence of acute pleurisy and pneumonia
( pleuropneumonia) claims the first place in the
enumeration of the complications of acute pleu-
risy. The pneumonia may be either the cause
of the pleurisy, or it may be the consequence of
it ; or these two diseases may commence at the
same moment, being the independent effects of
the same morbid impression. In general, in
pneumonia, when the inflammation reaches the
surface of the lung, the contiguous portion of the
pleura becomes inflamed, and is coated with a
layer of lymph, usually thin, and often an exact
measure of the extent of the inflammation of the
lung. When the entire lung becomes hepatized,
we have often observed the whole investing serous
membrane covered with a more or less dense false
membrane, marked with parallel lines produced
by the impression of the ribs upon it. This com-
plication exhibits the most common case of what
has been termed dry pleurisy. We need hardly
observe that the pleurisy here is of very subordi-
nate importance : it is that, however, of which
the diagnosis would embarrass us most, had we
not seen the case at its commencement. The
pressure of the effused fluid may have the effect
of exciting inflammation in the lung : the ordi-
nary stethoscopic phenomena will disclose this
complication. The inflammation seldom goes
beyond the first stage of pneumonia ; and from
the repeated opportunities we have had of exam-
ining the bodies of those who died with pleu-
ritic effusion, and the few specimens we have
seen of pneumonia in the compressed lung, we
believe this complication to be very rare, and sus-
pect that the carnified condition of the lung has
been not unfrequently mistaken for the first stage
of pneumonia. Laennec remarks that the pres-
sure of the fluid has rather the effect of placing
the lung out of the pale of inflammation. The
third complication, or pleuropneumonia properly
so called, in which the proper tissue of the lung
and its investing membrane are simultaneously
affected, is recognised by its exhibiting the stetho-
scopic phenomena peculiar to each lesion. The
case is not very much aggravated by the compli-
cation ; Laennec even considers the danger less
than if either existed alone in a more considerable
degree ; for he is of opinion, as we above stated,
that the pressure of the fluid controls the pneu-
monia, and that, in return, the absorption of the
effused fluid is promoted by its being compressed
between the unyielding solidified lung and the
sides of the chest. This is a case in which the
fluid is interposed between the lung and the side
of the chest, in consequence of the lung, from
its increased density, not admitting of displace-
ment.

2t*

We have before adverted to the frequency of
the complication of pleurisy and tubercles in the
lungs, in which case there generally existed adhe-
sions between the pleurae pulmonalis and costalis.
However, it will happen that, in some instances,
nature will seem as it were to neglect the precau-
tion of establishing an adhesion between the op-
posite serous surfaces ; and softened tubercles
situated near the surface of the lung will, in obe-
dience to the pathological principles of purulent
matter seeking the easiest and shortest outlet, per-
forate the pleura, and immediately give rise to a
most intense pleurisy, marked by a very acute
pain of the side, most distressing difficulty of
breathing, and extreme anxiety. When we come
to examine the chest, we find all the physical
signs which characterize pneumothorax with effu-
sion, (vide Pneumothorax,) in which case we
know the lesion to consist of pleurisy and a tuber-
cular cavity into which a bronchial tube opens.
It may happen that the softened tubercle perfo-
rating the pleura will only give rise to simple
pleurisy, in consequence of its not communicating
with a bronchial tube.

Gangrenous ulceration of the lung and pleura
will cause either pneumothorax or pleurisy; in
addition to their respective signs, the sputa and
breath have an insupportable fetor.

Pleurisy of one side is not unfrequently com-
plicated with some disease of the opposite lung,
arising out of the increased duty that has devolved
upon it. This lung may either become emphyse-
matous, or the subject of bronchitis or pneumonia.
It is frequently attacked with sudden congestion,
which produces most urgent sense of suffocation,
and renders the patient's situation truly pitiable.
We have before alluded to the fact that when
pleurisy of one side exists, it seldom involves the
pleura of the opposite side, but leads either to
pneumonia or bronchitis ; and when pleurisy is
double, there is a fair start between both sides,
and their affections proceed pari passu.

Prognosis of A«ute Pleurisy. — Pleurisy is
ever a serious disease ; in many cases, however,
it terminates favourably. The danger is propor-
tionate, 1st, to the cause upon which the disease
depends : when it depends upon ulceration of a
tubercle, or upon superficial gangrene of the lung,
it is always fatal: 2d, to the extent of the inflam-
mation : double pleurisy is attended with more
danger than when the disease is confined to one
side ; and when the whole cavity of the pleura is
inflamed, the prognosis is more unfavourable than
when only part of it is affected : 3d, to the quan-
tity and nature of the effusion : 4th, to the time
during which the effusion has existed : 5th, to the
diseases which complicate the inflammation of the
pleura, or which exist along with it.

Previously to noticing the treatment of acute
pleurisy, we shall give the history of the disease
in a chronic state.

II. Chronic Pleurisy. — There are two dis»-
tinct kinds of chronic pleurisy : one, the continua-
tion, as it were, of the disease in its acute form ;
the other, to use the usual but paradoxical ques
tion, chronic from its commencement; that is to
say, at no period exhibiting either the intense
fever, the acute pain, or energy of reaction which
characterize an acute disease. When the diag-

582

PLEURISY.

nosis of diseases of the chest was less certain than
it has been since the acquisition of the stethoscope,
the first form of chronic pleurisy was much more
common than it is at present, for this reason, —
that formerly being without the means of appre-
ciating the physical signs of the disease, when the
pain, the most prominent symptom, had yielded
to antiphlogistic means, it was then conceived that
the inflammation was subdued and the cure com-
plete ; the patient then returning to his fonner
diet and resuming his usual occupations, was
often surprised by an attack more violent than the
former. Our improved mode of examination
teaches us that every symptom of inflammation
may have disappeared, every function apparently
be restored to its natural condition, and still there
may be considerable effusion into the cavity of
the chest : until this be entirely removed, we
never can feel secure about our patient. Pleurisy,
in its essential chronic form, creeps on very insi-
diously, without much acceleration of pulse or
heat of skin ; and when there is any unusual
sensation in the side, it does not amount to more
than a mere soreness : the difficulty or hurry of
breathing is sometimes so inconsiderable as not
to attract the individual's attention. An observer
is struck with the patient's unhealthy pallid ap-
pearance ; there is a loss of appetite and a languid
look, which emphatically tells us of some mis-
chief going on ; on close examination we find
that the absence of fever is not constant, but that
towards evening there is a febrile movement. A
dry cough, or one attended with scanty mucous
expectoration, and which has existed a considera-
ble time without any apparent dependence either
upon crude tubercles in the lungs or upon gastro-
intestinal irritation, should lead us to suspect the
possibility of chronic pleurisy.

The anatomical characters of chronic pleurisy
do not differ very widely from those of the acute
form, especially when it has been a mere transition
of one form of the disease into the other. In this
latter case, no matter to how distant a period the
disease may be protracted, the fluid effused retains
to the last its primitive character. As in acute
pleurisy, it is a straw-coloured serum, but more
consistent, apparently owing to its holding in sus-
pension a considerable portion of the fragments
of the false membrane, which, on the fluid settling,
sink to the bottom. These condensed fragments,
which, on opening the chest, are found in its most
dependent parts, constitute, according to Laennec,
a connecting link between the sero-purulent effu-
sion and the false membrane. In essentially
chronic pleurisy the effusion partakes more of a
purulent character : in this case the disease closely
resembles an abscess, the false membrane invest-
ing the pleura corresponding to the cyst, and en-
dowed with the physiological properties of absorp-
tion and secretion. If the constitution be imbued
with a scrofulous taint, (which is the habit in
which we most frequently meet with this morbid
condition,) the effusion will exhibit the ordinary
characters of scrofulous pus, viz. a thin, whey-
coloured matter, with flocculi of lymph floating in
it. When the effusion is mainly purulent matter,
mixed with a small proportion of serum, it is of
a greenish colour, and very much resembles an
effusion of tea to which a small proportion of

milk has been added. The effusion in chronic
pleurisy is not as exempt from smell as that in the
acute disease.

The false membrane in chronic pleurisy is not
essentially different from that in acute pleurisy ;
it is only firmer and more condensed, owing, per-
haps, to the longer time it has been under the
pressure of the effused fluid. It is capable of all
the transformations of which we stated it to be
susceptible in acute pleurisy ; and to its conver-
sion into fibro-cartilage, Laennec ascribes a partic-
ular change in the configuration of the chest, to
which we shall presently have occasion to advert.
It is more prone than in acute pleurisy to become
the matrix of morbid developments, especially
tubercle.

The lung is more compressed than in acute
pleurisy ; it is often reduced to a thin lamina, not
exceeding six lines in thickness, lying down along
the spine. There is also a more complete anni-
hilation of its vesicular structure. It was this
condition of the organ that led less careful exam-
iners to pronounce upon its entire removal. Tu-
bercles or other morbid growths may develop
themselves in it, and, undergoing their proper
changes, modify the symptoms of the original
disorder.

Diagnosis of Chronic Pleurisy. — The
physical signs of chronic pleurisy differ little from
those of acute, except in being more prominently
expressed ; and apparently for this reason, — that
the disease, from its insidious character, has ex-
cited little constitutional alarm, and therefore the
individual labouring under it has unconsciously
permitted it to go on without seeking medical re-
lief. In general, then, when it presents itself to
the physician it has existed for a considerable
time. The affected side is more rounded ; the
intercostal spaces are more dilated, and raised
above their natural level, in some cases admitting
of fluctuation being felt ; the integuments of the
side often become cedematous. When the disease
has existed for a long time, the spine is observed
to deviate from its natural direction, and to form
a curve with its cavity looking towards the affected
side. If the left side be the seat of the effusion,
the heart undergoes the same displacement as in
acute pleurisy.

The cedematous state of the integuments less-
ens, at least, the value of percussion as a means
of assisting our diagnosis. There is not only a
more complete absence of respiratory murmur,
but not even segophony or bronchial respiration
is present. Double chronic pleurisy is a very
rare form of disease.

Partial or circumscribed chronic pleurisy is
more frequently met with than the same modifi-
cation of acute pleurisy ; and although there arc
many circumstances connected with it calculated
to embarrass the diagnosis between it and pneu-
monia, especially our seldom having an opportu-
nity of observing it ab initio, still the marked
expression of the physical signs seldom leaves us
at fault. It sometimes happens that the circum-
scribed nature of the affection shows itself to the
eye by a distinct line of demarcation intersecting
the side of the chest. If it happens that the
pleurisy occupies the inferior part of the side,
(which is most frequently the case,) below this

PLEURISY,

583

line will be found the physical signs of pleurisy,
with dulncss of sound and absence of respiration ;
while above it, the only deviation from the ordi-
nary state of things is puerile respiration.

Pleurisy assuming a chronic character from its
commencement generally occurs in a cachectic
habit of body, or where the health has been
broken down by previous illness. We have met
with it more than once after fever, and usually
either in scrofulous habits, or in persons much
addicted to intemperance.

Prognosis of Chronic Pleurisy. — The
prognosis of chronic pleurisy is, generally speak-
ing, very unpromising ; however, if it exist as an
isolated affection, apart from any complication, it
may go on for months, nay, for years. If, as is
often the case, tubercles form and go through their
changes either in the compressed or in the oppo-
site lung, the complication will have the effect of
precipitating the fatal termination. In the ordi-
nary course of the disease, a slow, wasting fever
sets in ; there is a gradual emaciation ; the appe-
tite fails; the pulse is languid, although not much
quickened ; the legs swell, and the face becomes
puffed ; the expectoration often has a disagreeable
alliaceous smell. Upon these symptoms well-de-
fined hectic fever soon supervenes, and rapidly
wears down the patient.

Nature often takes the cure of pleurisy into her
own hands, and seeks to relieve herself of the fluid
effused into the chest in one of the following
ways: 1, by absorption ; or, 2, when the fluid is
purulent, by making a passage for it through the
pulmonary tissue into a bronchial tube, from
whence it is expectorated ; or though the walls of
the chest, from whence it flows immediately out;
or in some cases she adopts these two last ways at
the same moment.

When the disease has existed a long time, and
nature at length takes upon herself a slow, gradual
process of absorption, which she takes a consider-
able time to complete, we observe that remarkable
change in the form of the side to which we before
made allusion : this side, which was before per-
ceptibly longer than the opposite one, now becomes
less ; it is diminished in all its diameters, its cir-
cumference sometimes measuring less by an inch
than that of the opposite side. Its length is not
less encroached upon ; the ribs are approximated,
the shoulder becomes lower, and even the spine,
in some cases, assumes a lateral inclination from
the habitually bent position of the patient. The
muscles of the chest, especially the great pectoral,
seem to have lost half their volume. We shall
easily comprehend the nature of this change, when
we reflect upon the cause upon which it depends.
Laennec, who was the first to notice it, charged
it upon the fibro-cartilaginous nature of the false
membrane, which continued to oppose itself to the
lung's being restored to its original condition : it
interfered with its vesicular texture so as to render
it impervious to the air : the organ had, in fact,
virtually undergone a change of dimensions, in
consequence of which the relation between it and
its containing cavity was lost. The atmospheric
pressure acting upon the side, and not counter-
poised from within, causes it, as it were, to fall in
and accommodate itself to the altered condition of
the lung. We cease to wonder that the unyield-

ing bony case should have its form influenced by
this condition of the lung, when we reflect how
speedily an opposite state, or dilatation, will suc-
ceed to an emphysematous condition of the con-
tained organ. A cause mainly instrumental in the
contraction of the side is the atrophy of the mus-
cles from disease, respiration being exclusively
carried on by the opposite side.

When nature relieves herself of the accumula-
ted fluid by a passage through the pulmonary tis-
sue into a bronchial tube, the individual, who has
been for some time labouring under either a dry
cough, or one attended with scanty discharge, is
suddenly seized with an abundant expectoration
of greenish, purulent matter, which comes forth
with such a gush as to appear to be vomited rather
than expectorated. The discharge from the lungs
continues from day to day, the quantity gradually
diminishing till it ceases altogether. In proportion
as the matter is discharged, we perceive the ful-
ness of the side to give way, and to come down
to its normal dimensions. In this case a conside-
rable time will elapse before percussion and aus-
cultation yield their natural results, the sound
continuing dull, and respiration feeble; still the
function of the lung will ultimately be restored,
differing from the case of contraction of the side,
in which the dull sound and feeble respiration are
permanent.

The third expedient which nature adopts for the
discharge of the purulent fluid in the chest is to
give the pleurisy the character of an abscess,
making its way through the walls of the chest,
and pointing externally. When the apparently
small abscess on the side of the chest either opens
spontaneously, or is opened by art, it discharges a
quantity of matter quite disproportionate to its
size, and this matter is pumped out at each expi-
ration and cough. Sometimes the matter gets
vent both through a bronchial tube and through
the side of the chest at the same time. It is a
singular fact, that when the fluid' in the chest is
discharged through the lung, and consequently
through a communication estat lished between a
bronchial tube and the cavity of the pleura, pneu-
mothorax does not ensue, although it is previously
the same lesion that gives rise to this morbid phe-
nomenon ; the difference being only in the mode
in which this lesion takes place.

Treatment of Pleurisy. — If the energy and
activity of our practice in the phlegmasia; should
be in proportion to the importance of the part in-
flamed, there is scarcely any part in the whole
animal machine in which the inflammation de-
mands a more decided and uncompromising plan
of treatment than the pleura. If we temporize
in the treatment of pleurisy, the least evil we can
anticipate is a protracted convalescence ; whereas
if we meet it, in limine, with vigour, we often, as
it were, strangle it in the birth.

I. Treatment of Acute Pleurisy. The

treatment of acute pleurisy comprises all the
means usually employed to reduce constitutional
fever and local inflammation.

Bloodletting. — In the first stage of the disease,
when febrile excitement runs high, and is accom-
panied with much local distress, we should bleed
with an unsparing hand from a large orifice, and
in the manner most calculated to make the speed

584

PLEURISY.

iest impression upon the system. Should a sin-
gle bleeding, conducted in this way, fail to afford
very decided relief, we should resort to the opera-
tion again within a few hours, and repeat it at
more or less distant intervals, according to the
urgency of the symptoms and the capability of our
patient to bear further loss of blood. Some have
attempted to fix the precise quantity of blood to
be drawn in the cure of a pleurisy ; a generaliza-
tion to which nature will not submit, the effects
of bleeding differing in different individuals. It
would be to trust to a very fallible guide, indeed,
were we to depend upon the indications of the
pulse. In this, as well as in the inflammation of
all other serous membranes, the pulse, so to speak,
as often underrates as exaggerates the extent of
the mischief, being rather a measure of the consti-
tional irritability of the individual than of the ac-
tual amount of disease. The usually accompany-
ing pain is a symptom upon which we can place
more reliance, and the effects produced upon it
serve, in some measure, to guide us as to the ex-
tent of depletion ; but even it, so far from being
proportionate to the extent or intensity of the in-
flammation, is often absent when the inflammation
occupies a considerable extent of surface ; and
even when both sides are affected at the same mo-
ment, if it be present, it is often found not to
amount to more than a mere soreness. The dys-
pnoea, or rather the nervous dread of drawing in
a full breath, in many cases lasts for so short a
time, that we must see the patient in the first mo-
ments of the attack to have the value of this
symptom. Were we to lay down any general
rule, deduced from the common symptoms, as to
the limit to which we would carry sanguineous
depletion, we should be most disposed to regulate
this by the strength of the patient, and the relief
of the pain and consequent power of taking in a
full inspiration.

While we distrust the indications of the pulse,
which, in some cases, from its composure, is cal-
culated to mislead us as to the expediency or ne-
cessity of bleeding, so we should be equally on
our guard not to be betrayed into the opposite
error of considering an accelerated pulse, which
may be produced by the depletion we have em-
ployed, as the index of continuing inflammation,
and be thus led to push depletion still farther, and
thereby originate functional disorder ultimately
terminating in organic disease of the heart. We
have seen this mistake so often committed, that
we deem it necessary to subjoin this caution.

While we employ general bleeding, we may at
the same time seek to relieve the local congestion
by cupping and leeching. In the necessarily pro-
tracted operation of topical bleeding, we should
manage it with caution, so as not to run the risk
of exposing our patient to cold. Venesection
does not seem to be equally applicable to every
modification of pleurisy. Thus, when it prevails
as an epidemic, or develops itself in the progress
of fever, or occurs as a puerperal disease, — in all
these instances it assumes an asthenic type, when
it becomes very questionable if general bleeding
be at all admissible, or if we should not rather
confine ourselves to local bleeding, with such other
resources as art affords. This at least is certain,
hat in these cases bleeding should be employed

with extreme caution. In circumscribed pleurisy,
with which the constitution does not seem to
sympathise, the application of a few leeches to the
seat of the pain will often remove all uneasiness.
If, as in phthisis, in which partial pleurisy is so
common, the exhausted state of our patient will
not bear even so small an abstraction of blood, the
temporary application of a hot turpentine stupe
will often answer our wishes.

Purgatives. — The saline purgatives are especi-
ally suited to this first stage of pleurisy, as they
diminish the mass of the circulating fluid by
greatly increasing the secretion of the intestinal
mucous surface. We follow up this antiphlogistic
treatment by other means calculated to reduce
fever, by producing diaphoresis, or otherwise, viz.
the different preparations of antimony, tartar-
emetic in very minute doses, James's powder, Do-
ver's powder, &c.

Sedatives. — These are often very useful in
quieting the irritation of the cough, and thus pro-
curing the repose of the organ affected. With
such a view we derive much benefit from the use
of hyoscyamus, conium, lactucarium, &c. Some
recommend the use of opium in large doses after
bleeding, by which we continue, as it were, the
sedative impression of the bleeding, as well as
allay the irritation produced by the pain, and
soothe the cough.

Mercury. — The combination of calomel and
opium enjoys an established celebrity in the in-
flammations of serous membranes ; and after the
use of venesection, and where there exists much
pain, the remedy is invaluable. In such cases,
our object is to bring the system as speedily as
possible under the influence of mercury, by which
we as it were supersede the morbid action which
is going forward.

The treatment which we have just laid down
applies to the earliest stage of pleurisy. How-
ever, it often happens that the patient does not
present himself till the disease has existed at least
for some days, and the intensity of the symptoms
has in some degree abated, when the inflamma-
tion has assumed rather a subacute character, and
has partly terminated in effusion. It is now that
we have most reason to complain of the pulse not
intimating to us the extent of the mischief. We
now come to the long agitated question, — how
late in the progress of pleurisy are we warranted
in using the lancet 1 Without attempting to lay
down a general rule upon the point, we would say
that even now, notwithstanding the tranquillity of
the pulse which often exists, we expect decided
advantage from bleeding, inasmuch as we thereby,
1. check the further effusion of fluid; 2. promote
the removal of the fluid already effused, by in-
creasing the powers of the absorbing system at
the expense of the circulation ; 3. render the sys-
tem more susceptible of the influence of the me-
dicines we employ.

When the inflammation has nearly subsided,
and the acute pain given way to a mere sensation
of soreness, and we have the physical evidences
of effusion, the indications of cure now are dif-
ferent, our main object being to promote the re-
moval of the effused fluid. The means we era-
ploy for this purpose are either internal or exter-
nal : the former comprising those medicines which,

PLEURISY,

585

acting by way of derivation either upon the kid-
neys or bowels, thus indirectly affect the effusion ;
the latter comprehending the different modifica-
tions of counter-irritation, which, by stimulating
the absorbents, tend to produce the same effect
more directly.

Diuretics. — The popular combination of squill,
digitalis, and calomel, produces as speedy a diur-
etic effect as any we can employ. Laennec speaks
highly of the infusion of digitalis from experience
of its value in the particular case under considera-
tion. It recommends itself to our notice upon the
double grounds of its diuretic property and the
control it exercises over the circulation ; an im-
portant recommendation, when we consider the
proximity of the organ affected to the source of
the circulation, and the advantage from the blood
being driven into it with diminished impetus. We
may also employ, separately or in conjunction
with the above, the saline diuretics, viz. the nitrate,
acetate, and bitartrate of potash.

Purgatives. — If the strength of the patient will
permit, we may make use of the hydragogue ca-
thartics, viz. elaterium, jalap, scammony, camboge,
&c. ; but the operation of these medicines is at-
tended vvith so much exhaustion, that we can only
employ them occasionally.

Diaphoretic medicines afford us such very fee-
ble assistance at this stage of the disease, that
they scarcely deserve a place among our remedial
agents. We have not found tartar-emetic to sus-
tain its character of an active antiphlogistic agent
in uncomplicated acute pleurisy- ; but when the
lung is involved in the same inflammation, we
then find the advantage of associating it with our
remedies.

When we are endeavouring to affect the system
with mercury administered internally 7 , we may at
the same time employ mercurial friction on the
side, by which we assist the internal exhibition of
the mineral, while we stimulate the absorbents.

Stimulating liniments carry with them the ad-
vantages that we can regulate their irritating pro-
perty ad libitum, and that they do not unfit the
surface to which they are applied for any future
application.

When the milder counter-irritants, as auxilia-
ries to the internal means employed, have failed to
make any impression upon the fluid, we resort to
blisters. Andral's work (Sur les Maladies du
Poitrine) abounds in cases in which the removal
of the fluid seemed to date itself from the appli-
cation of a blister. A succession of blisters acts
more effectively than a single one of which the
discharge is continued by an irritating application.

As long as fever and inflammation are present,
we of course insist upon rigid abstinence. But
when these have subsided, and have left their ef-
fects alone behind them, the reasons for continuing
the same strict system are scarcely less cogent ; for
in this way we lower the circulation, and thus
establish a physiological ratio between its powers
and those of the absorbing system, whereby the
latter are much increased, and act with much more
avidity upon the fluid in the chest. We find it
extremely difficult to carry this part of our treat-
ment into effect; for our patient will regain a
degree of health, and feel very little if any incon-
venience from the fluid in the chest, and not being

Vol. III.- -74

able to reconcile our severe restrictions with his
sensible amendment, will become impatient of re-
straint, and, yielding to his improved appetite, will
in all probability bring on fresh inflammation.

Sometimes a considerable time will elapse before
any impression is made on the fluid, the system
seeming as it were to stand out against the opera-
tion of our remedial agents up to a certain point,
and then suddenly yielding, its removal rapidly
ensues. At other times our medicines begin to
take effect quickly, and remove the fluid gradually.
We recognise the effects of our remedies by the
side losing its fulness, by the reappearance of a?g-
ophony,* by the return of the respiratory murmur
and clear sound to situations where we before
sought them in vain. Percussion will continue to
yield a dull sound for a considerable time after the
return of the respiratory murmur.

It seldom happens that in acute pleurisy we
have to resort to the operation of paracentesis
thoracis ,- nor should we ever think of it as long
as we have any prospect of removing the fluid
otherwise ; still it may happen, from the other
lung becoming affected either with bronchitis or
pneumonia, or from having been already emphy-
sematous, that to relieve the urgent sense of suf-
focation we have no alternative. In almost all
these cases we find the operation to be attended
with no more than a mere temporary relief, the
fluid soon collecting again. It is an ascertained
fact that the operation is, in general, less success-
ful in acute than in chronic pleurisy, the reasons
for which we shall endeavour to explain when we
come to speak of the treatment applicable to the
latter form of the disease.

I. Treatment of Chronic Pleurisy. — The
treatment of chronic pleurisy, or of that modifica-
tion of the disease which from its commencement
exhibits some of the characteristics of an acute in-
flammation, is as different from that of acute pleu-
risy as the respective natures of the two forms of
the disease. Antiphlogistic means, whose activity
is measured by the intensity of the febrile symp-
toms and the strength of the individual, constitute
the treatment of acute pleurisy; and amongst
these means, bleeding, as we have seen, occupies
a most prominent place. In essentially chronic
pleurisy, we seldom, if ever, have occasion to re-
sort to constitutional bleeding. The weakened, if
not the vitiated habit of body in which it generally
takes place, will not admit of the exhaustion which
this operation would produce ; even local bleeding
must be employed with considerable caution. The
indications of cure are, to remove the fluid from
the cavity of the chest, and to improve the dilnpi-
dated state of the system. The means by which
we try to promote the removal of the fluid may
be divided into constitutional and local ; the for-
mer comprising those agents whose action is
directed to some organ or set of organs at a dis-
tance from the seat of disease, and which effect
the object we contemplate by establishing a coun-
ter-irritation and increased secretion at the expense
of the diseased secretion, which continues to take

* This effect was ascribed liy Laennec to llie transmis-
sion of the voice through a diminished stratum of fluid ;
hut we consider it to be rather due to a less compressed
state of the tun? from the diminution of the compressing
fluid.

586

PLEURISY.

place into the chest until it is as it were super-
seded.

Most of the means which we adverted to as ap-
plicable to the stage of acute pleurisy when effu-
sion has taken place, may be seasonably employed
in chronic pleurisy, qualified alone by the con-
sideration that in the latter form of the disease the
habit of body in general is not such as will bear
the operation of active medical agents. When we
employ mercury, we must manage its exhibition
with caution, and beware lest, in pushing its use
too far, we give rise to an irritative fever, which
would soon exhaust the weakened constitution in
which this modification of pleurisy usually pre-
sents itself: we should content ourselves with
slightly affecting the gums. When hectic symp-
toms show themselves, we should cautiously ab-
stain from the use of mercury altogether. We
employ the same diuretics as in the second stage
of acute pleurisy. We cannot, without incurring
the risk of weakening our patient too much, resort
to active purgation ; we must, therefore, be satis-
fied with the mildest medicines of this class, and
those whose operation draws least upon the sta-
mina, viz. castor oil, manna, &c. Diaphoretic
medicines lend us more aid in this than in the
second stage of acute pleurisy ; for instance, Do-
ver's powder, James's powder, &c.

Constitutional means or internal medicines, we
must in candour admit, do not assist very much
in the removal of the fluid.

[Iodine has been highly extolled, employed
both internally and externally. Dr. Stokes {Op.
cit.) advises, that Lugol's solution should be taken
freely ; and that from a quarter to half an ounce
of the compound iodine ointment should be
rubbed daily over the side. By others, the use of
iodide of potassium is preferred, and, in more
asthenic cases, iodide of iron.]

The external applications, and upon which we
place our principal reliance, comprehend the
different modifications of counter-irritation, viz.
blisters, setons, issues, stimulating liniments, &c.
Blisters are unequivocally the means most calcu-
lated to promote the absorption of the fluid secreted
into the chest, as well as to interfere with its
further secretion. We employ a blister commen-
surate with the extent of surface involved in the
inflammation, and repeat its application in pre-
ference to keeping the blistered surface open by
means of irritating substances, each repetition
having as it were the effect of renewing the
counter-irritation.

The next part of the treatment of chronic
pleurisy regards the improvement of the habit of
body and relief of the constitutional symptoms
which most commonly accompany this form of
the disease. We are not obliged to prescribe the
same restricted diet as in acute pleurisy, but would
admit a certain latitude, always taking care to
avoid such substances as are calculated to produce
febrile excitement, and consequent acceleration of
the circulation ; for, as we before observed, the
powers of absorption and circulation observe an
inverse ratio, and as we require the efforts of the
former to remove the fluid, we should defeat our
object did we not observe this caution. It is, be-
sides, an object of importance that as little blood
as possible should be transmitted through the lung

lying under the pressure of the fluid. In many
cases chronic pleurisy is attended with such slight
constitutional symptoms as scarcely to deserve to
be considered more than a local disease ; still in
most instances hectic fever sooner or later sets in.
At this stage of the disease, change of air is pro-
ductive of the most decided benefit, often effecting
an almost instantaneous amelioration in the symp-
toms: the night perspirations cease, the appetite
improves, and sleep becomes refreshing. In the
exhibition of tonics we have had reason to prefer
the infusion or decoction of bark, combined with
sulphuric acid, to the more concentrated sulphate
of quinine. We have found much advantage, in
these and similar cases, from the mineral acids in
decoction of Iceland moss. When our curative
means take effect, we recognise their success by
the physical signs of the disease gradually dis-
appearing ; by the side losing its fulness ; by the
intercostal spaces sinking down to their ordinary
level, and being less dilated ; and by the return
of a feeble respiratory murmur, and a less dull
sound on percussion ; and, in case of the left side
having been the seat of the disease, by the heart's
pulsation being felt in their normal situation ; and
by the liver ceasing to be felt below the margin of
the right false ribs when the disease has occupied
this side. But when, instead of these evidences
of the efficacy of our means, we find the fluid to
increase, and all the sensible signs of the disease
more marked, and in consequence the dyspnoea
more distressing, the operation of tapping the
chest is our last and only resource. We must
confess that the results that have usually attended
this operation are far from being calculated to
inspire us with encouraging anticipations, (see
Empyema ;) still even the few cases in which
either complete recovery or relief for a consider-
able time has followed it, prevent us from despair-
ing. It is impossible to judge what might be the
event were the operation undertaken earlier ; this
must be a matter of conjecture, as we must ever
look upon an operation, the unavoidable conse-
quence of which is the admission of air into the
inflamed cavity of the chest, as a serious matter,
and only warranted by the failure of other means
to produce the object we desire. We have similar
effects produced in chronic abscesses when opened.
As long as they had no communication with the
air, so long they produced no constitutional dis-
turbance ; but no sooner is the air admitted than
hectic symptoms quickly supervene. The cavity
of the chest affected with chronic inflammation
resembles a chronic abscess, both in its physiolo-
gical and pathological conditions. The failure of
success of the operation for empyema may be
ascribed to the following causes ; — to the irritative
fever which often follows immediately upon the
operation ; or to the condition of the lung, occu-
pied by tubercles in different stages, and giving
rise to constitutional symptoms ; or to the lung
having been so long pressed upon by the fluid as
to render its natural elasticity quite irrecoverable.
We have before observed that the operation, under-
taken under the most auspicious circumstances, is
not exempt from a certain share of danger.

[It must be borne in mind, too, that twenty
cases of complete and permanent recovery from
empyema, by absorption, have been recorded by

PLEURISY — PLICA POLONICA.

587

one author, Dr. Stokes {Op. cit. p. 481), so that,
as he properly remarks, the probability of a cure,
and the etficacy of remedies, is much greater than
has been supposed.]

We now come to consider if there be any case
so hopeless and desperate that we can promise
ourselves no advantage from the operation : if
such case there be, it is when there is extensive
tubercular development in the compressed lung ;
but even here Laennec does not hesitate to recom-
mend the operation, from his conviction of the
curability of phthisis even when there exists un-
equivocal evidence of a cavity in the lung.

Mr. Crompton has had considerable experience
of the operation for empyema and its results; and
of ten cases upon which he has operated, three
have been attended with complete success. After
operation, his practice is to inject a weak solution
of chloride of lime, which he finds to have the
effect of diminishing the discharge and of cor-
recting its character. (See Empyema.)

We have remarked that the operation of tap-
ping the chest is more likely to be successful in
chronic than in acute pleurisy ; that is to say, if
an untoward combination of circumstances de-
mands operation in the early stage of acute
pleurisy, such operation is more uncertain in its
result than the same operation undertaken in
chronic pleurisy at a period equally distant from
its commencement. This fact, established by ex-
perience, we would account for in one of two
ways ; either that the constitution sympathises
less, or suffers less irritation from the admission
of air into the cavity of the chest, covered with a
dense coating of lymph, as is the case in chronic
pleurisy, than from letting in the same fluid upon
the naked pleura unprovided with any such pro-
tection ; or perhaps it may depend upon inferior
susceptibility of inflammation in one case than in
the other. In chronic pleurisy, the older the dis-
ease is, the less likely is the operation to be suc-
cessful, because the more chance is there that the
lung is disorganized ; and the longer the lung has
remained under pressure of the fluid, the less
likely is it to recover its natural elasticity. The
more circumscribed the pleurisy is, the more pro-
mising is the prospect of a successful operation.

For further information on the subject of the
present article, we refer the reader to Emptema,
Perforation, Pneumonia, and Pneumotho-

nAX> Robert Law.

PLICA POLONICA, from plico, to knit to-
gether. This disease derives its name from the
manner in which the hair is plaited or matted
together, and, as its name also implies, is of most
frequent occurrence in Poland. It has, however,
been also observed in Tartary, among the Cos-
sacks of Russia, in Hungary, and in a few in-
stances in Switzerland and France. The people
of Poland believe that it was carried into their
country by the Tartars in the twelfth or thirteenth
century. Schlegel, a physician practising in Mos-
cow, who published a work on plica in 1806,
gives a singular account of its origin. The Poles
on the death of one of their kings, Miceslas II. in
1034, petitioned Pope Benedict the Ninth to re-
lease from his vows Casimir the son of Miceslas,
who had entered into a convent of Benedictines

in France ; the request was granted on certain
conditions, and one of the conditions required
was, that from that time forward the men of Po-
land should keep their heads shaved. Casimir on
his accession enforced the tonsure through all his
dominions, and to the present day a part of the
ceremony observed in assuming the national cos-
tume of Poland consists of shaving the head, a
single tuft of hair being left to grow from the top
of the scalp after the manner of the Tartar and
some Indian Hbes. The poorer inhabitants of
Poland being wretchedly lodged and clothed, and
exposed to the combined injurious influence of a
marshy soil and a damp variable climate, the ge-
neral cutaneous exhalation is at all times below
the healthy standard, and the secretion from the
scalp being still farther diminished by the custom
of keeping the head shaved, there is, according to
Schlegel, an increased compensating action thrown
upon the bulbs of the hair which has been al-
lowed to remain ; and hence arises the greatly
increased growth of this portion of the hair, and
the unnatural quantity of viscid secretion which
is at the same time thrown out.

The hair grows to a very unusual length, and
being not only plaited but matted together by a
viscid fatty secretion of an abominably fetid odour,
resembling the stench of rancid fat, and in most
instances crowded with vermin, presents an ex-
tremely disgusting picture of filth and disease.
The hair of the scalp is that generally affected,
but the disease is also seen in the axilla;, on the
breast, and the pubes. In a few rare instances the
nails are altered in their appearance, become livid
or yellowish, long, and crooked, so as to resemble
the talons of a bird of prey : this change is gene-
rally in the nails of the toes. The length which
the hair sometimes attains is almost incredible.
Cases are narrated of its reaching to the heels, of
its being in such quantity and of such a length
as to fall on the floor over all sides of the bed on
which the patient lay. In the museum of Dres-
den there is a specimen preserved nine feet long.
Not the least singular circumstance in the history
of plica is the extraordinary attachment the Poles
entertain for this dirty appendage. If the hair do
not become spontaneously matted and filthy, the
Poles spare no pains to make it so ; the men put
on dirty fur bonnets which have become coated
with viscid secretion from being worn by others
who laboured under the disease, or they interlace
with their own hair masses of old plica steeped in
beer ! The women wear their hair very long, and,
to encourage the growth of plica, refrain from
combing it, and fasten it in knots, and make it
adhere by glue or rosin. They will for years
willingly suffer the greatest torture in carrying or
dragging after them a mass of this matted hair,
and beggars who are fortunate enough to possess
a good plica cherish it with the greatest care as
the most certain means of obtaining alms. In
some parts of Poland the lower classes look upon
plica as a special favour from Providence, which
will preserve them from ham? and sickness; in
other parts it is viewed as an infliction coming
from a malignant spirit, but not the less cherished,
as it is then considered a protection from all other
misfortunes. Lafontaine, a physician resident in
Warsaw, who published a work on plica in 1792,

588

PLICA POLONICA.

relates the case of a pregnant woman who had
plica of four months growth on the pubes : during
that period the urine was allowed to filter through
the matted hair, and after labour commenced she
could not be persuaded to permit the plica, which
firmly resisted the protrusion of the child's head,
to be incised, until her life was in the most immi-
nent danger.

The prejudice in favour of plica is extended
even to inferior animals. Horses presenting an
appearance of the disease are valued beyond
others, and hence the jockeys of Poland have
learned to add another to the many arts practised
by their brethren of other countries. It is said
that in Poland, and in some parts of Russia, plica
is occasionally observed in sheep, dogs, wolves,
and foxes.

The physicians of Poland have not escaped the
contagion of prejudice. Kerckhoff,* whose ob-
servations were made during the stay of the
French army in Poland, relates a case illustrative
of this. The patient, a boy of about fifteen years
of age, complained of severe pains of his head.
He lay in a most filthy state, and his black hair,
knotted long and matted together, gave out an in-
tolerable stench. The Polish physician in attend-
ance strongly opposed Kerckhoff's suggestion of
cutting off the hair, on the ground that the hu-
mour exuded on the hair might turn in on the
brain and cause apoplexy. Kerckhoff entered
into a compromise with the Polish doctor; and
the hair was cut off in portions of two fingers'
breadth at intervals of two and four days. In
twenty days the whole scalp was cleared, and
then, by simply keeping the head combed and
washed, all the bad symptoms vanished.

Stories are related by some writers of the dis-
ease appearing very suddenly, and the hair pre-
serving for years the particular form of dressing
it possessed at the time of the seizure. These
stories are, however, treated as fables by the best
informed authors ; and a statement generally
made and believed in Poland, that the long hairs
of plica are acutely sensible, and are the seat of
great pain when touched, is equally void of foun-
dation. In some instances the bulbs of the hair
and the scalp are very sensible, owing to irritation,
and pulling the hair ever so slightly gives acute
pain ; but Larrey and all modern observers posi-
tively assert that the hair may be cut at any part
without causing the slightest pain, provided it be
done without dragging the bulbs.

Pathology* — On the nature of plica the most
opposite opinions are entertained. By some it is
pronounced as a disease " sui generis," having its
seat essentially in the bulbs of the hair, and re-
quiring very cautious treatment. Others as stoutly
assert that plica is merely the product of neglect
and dirt, and that it requires for cure nothing but
the shears and cleanliness. This difference of
opinion is not alone between foreign observers
and the physicians of Poland, but the latter them-
selves are divided on the question. Among those
who hold the firs? opinion are Lafontaine, who
asserts that he saw the disease in a new-born in-

* Observations Medicales par Jos. Rom. Louis Kerck-
hoff, Doctor en Medecine— Medecin de l'Armee des Pays
Mas, &c. Published in vol. vi. of Medical Transactions
of College of Physicians in London.

fant, and Robin, surgeon to Frederick the Great,
who relates the following experiment. He shaved
the heads of two boys on whom the disease was
just beginning to appear, and then paid particular
attention to the hair during its growth. His at-
tention was in vain, for the disease re-appearcd.
Schlegel agrees with Lafontaine and Robin ; and
more lately among foreign physicians, Chauraelon
and Mouton, who were attached to the French
army when in Poland during the late war, hold
the same opinion. It is further argued in support
of their view, that if plica owed its origin merely
to want of cleanliness, it would not be confined
to Poland, but should be equally found among
the Russian, Prussian, and Spanish peasants, who
are as dirty in their habits as the lower classes of
Poland ; that its appearance frequently constitutes
the marked crisis of some other disease ; that it is
accompanied with a peculiar secretion ; that the
nails, which are known to be merely a variety of
the same tissue as the hair, are in bad cases en
gaged by a similar diseased action ; and that the
bulbs of the hair exude a peculiar viscid secretion,
and are found swollen and acutely sensible. In
conclusion, it is asserted that plica cannot be sud-
denly removed without great danger to the pa-
tient. On the other hand, Davidson, a Scotch-
man, who was physician to one of the kings of
Poland, published a work in 1668, in which he
pithily observes of the disease, " Nullus habet,
nisi qui non velit carere," and declares that he
treated and cured more than 10,000 cases; that
he always, without hesitation, cut off the plica?,
and that no injurious consequences supervened.
Larrey, Chamsern, Gasc, Kerckhoff, &c, who had
opportunities during the late war of investigating
the disease in Poland, support the opinion pro-
mulgated so many years since by Davidson, and
assert with him that the fear entertained of cutting
off plica is a mere chimera. In support of their
opinions they point to the facts, that Polish re-
cruits are always cured by their hair being cut
and their habits changed after their entrance into
the army ; that the disease is almost invariably
confined to the lowest classes, and principally to
the Jews, who form an immense proportion of the
population of Poland, and are universally acknow-
ledged to be the filthiest people on the face of the
earth. They further state that strangers residing
in Poland never contract the disease unless they
sink so low as to approximate to the natives in
manners and dirt, and that the disease is disap-
pearing just in proportion as improved habits and
comforts are extending ; moreover, that in cutting
off a plica, as in the case related by Kerckhoff,
and which we have already noticed, the aggluti-
nated hair is found distinct and round at the roots.
To the last argument it is replied, and with jus-
tice, that the diseased action which produced the
plica having ceased, the hair which has continued
to grow will after a little time have pushed out
from the scalp the agglutinated mass of hair, and
hence that the soundness of the hair at the roots
is no proof that diseased action had not previously
existed. Larrey is further of opinion that the
urgent symptoms, as pains in the bones, joints,
&c, which occasionally precede or accompany
plica, owe their origin to a complication of syphilis.
Jourdan, the translator of Schlegel and Lafon-

PLICA POLONICA.

589

taine's works, and the writer of the article
"Plique" in the Dictionnaire des Sciences Medi-
rales, suggests that there should be a distinction
made of plica into true and false; true plica being
that form of the disease described by Schlegel, in
which the bulbs of the hair are inflamed, become
enlarged and acutely sensible, produce a rapid
growth of hair, and at the same time glue it to-
gether by a peculiar secretion which is poured out
from the skin and the hairy bulbs, and even forces
its way through the substance of the hair near the
skin. False plica Jourdan considers as a mere
accidental matting of the hair, dependent alto-
gether on external causes. This view would pro-
bably reconcile many of the conflicting statements,
but even in our investigation of the nature of
what, according to this classification, we may call
true plica, we meet with great difficulties. We
have not information before us sufficiently accurate
to enable us to say what is the precise source of
the fetid secretion which glues the hairs together,
—whether it is poured out by the bulbs of the
hair, the sebaceous follicles, or the general surface
of the skin. The surface of the skin where the
hair is affected is described as being in a state of
ulceration in some cases, but this may be an effect
of the state of the hair rather than a cause of it ;
and finally, the state of the scalp may, for aught
that we yet know, arise from the presence of
some ordinary eruption, the matting of the hair
and the viscid fetid secretion being complications
added by the influence of extraneous circum-
stances. Lafontaine asserts that hair presenting
shades of red is more liable to plica than hair of
other colours, but Schlegel states that he never
observed any difference of liability arising from
colour.

Alibert makes three subdivisions of plica, ac-
cording to the form it may chance to assume. He
calls his first species " plique multiforme," where
the hairs form a great number of ropes, hanging
round the patient's face like serpents round the
Gorgon's head ; his second species, " plique a
queue, ou solitaire," in which the whole hair is
united into one long plica or tail, principally met
with among females, and on those wearing their
hair after the national Polish fashion. He calls
his third species "plique en masse, ou larvee," in
which the hair is all melted into one cake, cover-
ing the head like a helmet. These subdivisions
arc, however, useless ; for the varied forms which
the hair assumes, appear to be merely the result
of external accidental circumstance.

The people of Poland believe that plica is con-
tagious, but there does not appear to be satisfac-
tory ground for this belief. Kerckhoff inoculated
children and himself with the viscid secretion, and
failed to propagate the disease ; and Davidson,
who had ample experience, is also a disbeliever
in its contagion. Alihert, on Robin's authority,
states that a Polish nobleman who kept a seraglio,
of which four of the inmates had plica, never con-
tracted the disease. On the other side, Lafontaine
and some of the French observers of plica believe
that it is a contagious disease.

Symptoms. — The premonitory symptoms of
an attack of plica, according to those who look
upon it as a peculiar disease, are pains in the
back and limbs, vertigo, lachrymation, with vio-

2z

lent itching sensation of pricking, and increased
sensibility of the hairy scalp, followed by a copious
secretion of a peculiar viscid sweat, of the con-
sistence of honey, which speedily glues the hairs
together. On the appearance of this secretion, the
previous symptoms disappear. It is said in Poland
that one of the most usual forerunners of an attack
of the disease is a perverted appetite, and hence
there is a saying, " Srcpe sub plica, latet seu fcetus
seu plica." Of all the symptoms, however, none
give a certainty of the approach of the disease ex-
cept the breaking out of the viscid sweat. Cases
are given by Alibert, Lafontaine, Schlegel, &c,
of plica appearing as a crisis of, or alternating
with internal diseases ; according to their ac-
counts, the internal affection was alleviated when
the plica secretion was abundant, and vice versa.
When the hair is cut very close, in what we may
call true plica, a brownish fluid frequently exudes
from the bulbs of the hair, and the appearance of
this fluid has given rise to the belief that the hair
poured out blood.

Treatment. — The directions for treatment, of
course, vary as much as the opinions on the na-
ture of the disease ; those who look upon the dis-
ease as the product of dirt, directing us to cut off
at once without dread the matted mass, and after-
wards trust for a cure to soap and combing ; and
on the other hand, those who see in the cutaneous
affection the elimination from the system of a
poison, which they call "virus trichomaticus,"
warn us in the strongest language not to meddle,
lest we turn the poison back on the brain or
lungs, &c. Lafontaine extends the supposition
of the existence of a peculiar virus so far as to
direct us, when any symptoms appear which we
suspect are premonitory of the approach of plica,
to hasten its appearance by warm cataplasms,
sinapisms, &c. to the scalp. Under whatever
view we regard the disease, the supposition of the
existence of a virus is a mere assumption, and the
advice to force the eruption is only an illustration
of the prevalence of the same bad principle which
of old so erroneously directed us to force out the
virus of other eruptive diseases, as small-pox or
measles. Mouton, to whose opinions we have
already alluded, says we may without fear cut off
plica if it be dry, and if it be united to the scalp
by hair sound near the roots, which he says indi-
cates that the diseased action which had produced
the plica had ceased ; but that we ought not to
interfere as long as the bulbs of the hair are in-
flamed and sensible, and continue to pour out a
viscid secretion, keeping the hair matted at its
roots. Various remedies are recommended in
Poland. Lycopodium is much used by the peo-
ple, who use it both as an external application
and an internal medicine ; but there does not
seem to be any settled rule or principle of treat-
ment. Preparations of mercury, antimony, sul-
phur, zinc, baths, emetics, diaphoretics, and nar-
cotics, have all in turn been recommi
Among these, the golden sulphuret of antimony
is probably the remedy on which most reliance is
placed. Patients who are debilitated or advanced
in life require, it is said, the administration of
tonics ; and it is scarcely requisite to observe that
an occasional application of strong mercurial oint-
ment to the hair is requisite to destroy the vermin,

590

PNEUMONIA.

which breed in it with immense rapidity. It is
unnecessary to say any thing on the management
of false plica, in which the matting of the hair,
arising from neglect, is present without any dis-
ease of the bulbs. D j CoRR1GAN-

PNEUMONIA, (■nvtvjiovia') ; peripneumonia,
or peripneumony, (xcynrvcvuovia) ; pneumonitis,
pulmonitis, peripneumonia vera, (from vvliyuny-
ovos, pulmo, a lung, or the lungs,-) are names
given to an inflammation of the parenchyma of
the lung, which is the most common of all the
dangerous inflammations.

Peripneumony and pneumonia are the names
applied by Hippocrates, Aretseus, Celsus, and
ether ancient writers on medicine, to most of the
acute diseases of the chest without severe pain ;
those connected with this symptom being termed
pleurisies. Many succeeding authors have not
admitted this distinction ; and inflammations of
the lung have been as often described under the
name of pleurisy as under that of pneumonia.
The earlier cultivators of morbid anatomy, Val-
salva and Morgagni, were the first to prove the
distinct existence of the two diseases, but they
gave no means of distinguishing them before
death. Hence Cullen, although he makes pleu-
risy a species of the genus pneumonia, expresses
his belief that the term pleurisy might with pro-
priety be applied to every case of the disease. It
is only through the aid of auscultation that pneu-
monia and pleurisy have been recognised as dis-
tinct diseases, and it is therefore only in the wri-
tings of those who have employed this method of
diagnosis that the truly distinctive characters of
pneumonia can be found.

Cullen's generic definition of pneumonia more
frequently holds good than his specific distinctions,
on the correctness of which, as we have just re-
marked, he does not insist. Fever, pain in some
part of the chest, difficult breathing, and cough,
which he ascribes to the genus pneumonia, are, in
the greater number of instances, present in both
pleural and pulmonary inflammation ; but there
are cases of both kinds in which each of these
symptoms is absent. The specific definitions of
pleurisy and pneumonia are still more frequently
at fault; thus the softer pulse, duller pain, con-
stant dyspnoea, and livid face, are as much the
characters of severe bronchitis as of pneumonia,
to which he ascribes them ; and the hard pulse,
acute pain, increased on inspiration, painful de-
cubitus on the affected side, painful cough, first
dry, and afterwards with expectoration, often
bloody, the assigned characters of pleurisy, indi-
cate pleuro-pneumonia as much as pleurisy, and
are sometimes presented by bronchitis or peripneu-
mony joined with pleurodyne.

The following is the character which we
would give as most generally applicable to pneu-
monia : — Fever, with more or less pain in
some part of the chest ,- accelerated and some-
tunes oppressed breathing,- cough, with viscid
and rusty-coloured expectoration,- at first the
crepitant rhonchus, afterwards bronchial respira-
tion, and bronchophony, with dulness of sound
on percussion in some part of the thorax. In
this, however, as in many other diseases, patholo-
gy is the only sure basis of definition : pathologi-

cally, therefore, pneumonia consists essentially of
an inflammation of the parenchyma of the lungs,
occasionally but not necessarily extending to the
pleura investing them ; which inflammation,
although it usually occasions a certain combina-
tion of general symptoms, is not so essentially
connected with these symptoms as to receive from
them an infallibly pathognomonic character.

The pathological and anatomical characters of
pneumonia, as well as its relation to general
symptoms, have been industriously and success-
fully investigated by the French pathologists, par-
ticularly by Laennec and Andral ; and it is to
them we owe the most important matter of the
following history. Andral calls the disease pleu-
ro-pneumonia, from the circumstance of some
part of the pleural covering of the lung being in-
volved in the inflammation : we do not deem it ne-
cessary to deviate from the example of Laennec,
who confines this term to that form of the disease
in which the pleura is affected in a sufficient de-
gree to modify the pulmonary inflammation. This
will be noticed among the complications of the
disease.

I. General History or Pneumonia.

Symptoms. — Like other severe inflammations,
pneumonia is accompanied by a pyrexia, which
often commences in a rigor, prior to any other
symptom. Sometimes this shivering fit does not
occur until after the establishment of pain, dys-
pnoea, and other symptoms ; and in some cases,
especially where the pneumonia succeeds to a
bronchitis, or when the first attack is felt in bed,
it is not observed at all. Frequently, a feeling
of great depression and languor, with pains in the
back and limbs, and a disordered state of the sto-
mach and bowels, precede the attack; then a
shivering fit comes on, followed by a violent reac-
tion, with great heat of the skin, and during this
hot stage the local symptoms of heat, pain and
oppression in the chest, with more or less cough,
are developed. The pyrexia is generally very in-
tense, and in plethoric individuals is accompanied
by great flushing of the cheeks, injection of the
conjunctivae, headache, and other signs of local
determination of blood. This general fever may
precede by a day or two the local symptoms, some-
times diminishing in intensity when they appear ;
and sometimes continuing and masking them.
The pain in the chest, which when present is
generally an early symptom, varies greatly in de-
gree, being sometimes very intense, sometimes
diffused and dull ; frequently it is a deep-seated
feeling of heat and weight rather than of pain.
Most commonly it is deep-seated in the anterior
parts of the chest, below the sternum or below the
mamma, sometimes under the scapula ; acute pains
are more common in either of the sides. Andral
says that there is never any pain without an ex-
tension of the inflammation to the pleura ; (Cli-
nique Medicale, torn. ii. p. 327 ;) Laennec asserts,
on the contrary, that there is frequently pain, and
sometimes a point of sharp pain when no pleurisy
is present, (De 1' Auscultation Mud. torn. i. p. 432;)
this is more in accordance with our own observa-
tion, and it is remarkable that in several of the
cases described by Andral, where there were vari-
ous degrees of pain, no mention is made of any
inflammatory appearances on the pleura on ex-

PNEUMONIA

591

amination after death. (Op. cit. obs. 29, 38, 43,
46.) There is commonly a cough at this time,
which aggravates the accompanying pain, or
causes a feeling of pain when none is otherwise
present. It is generally at first either dry or ac-
companied with simple catarrhal expectoration,
and short, not occurring in paroxysms, and is by
no means proportionate to the intensity of the in-
flammation ; it is sometimes so slight as scarcely
to be noticed by either patient or attendants. The
shortness of breathing or dyspnoea, which is com-
monly an early symptom, is a better measure of
the extent and severity of the disease; hut we
should be mistaken if we always trusted to the
feelings of our patients as to its presence or de-
gree. In its slighter degrees they are not sensible
of it, a supplementary quickness of breathing re-
moving the sensation of dyspnoea ; but an atten-
tive observer readily discovers this quicker and
shorter respiration, and the more perceptible ele-
vation of the ribs and depression of the diaphragm
that attend it. The number of respirations in a
minute, which is in health about twenty in the
adult, may now be counted at thirty and upwards,
and in severe cases it occasionally exceeds sixty.
In some examples, especially where the attack
has been sudden, the dyspnoea is greater and more
obvious, causing the patient to assume one parti-
cular posture, on his side, or on his back with his
shoulders elevated ; and from their sensibly in-
creasing his oppression, he avoids all exertions of
movement and speech ; this difficulty of breathing
continues to increase as the disease advances. The
pulse is quick, and in most instances sharp. With
respect to its hardness, it is subject to great diver-
sity, but in many cases it is (notwithstanding Cul-
len's definition) both hard and full at the com-
mencement of the disease. This character, how-
ever, rarely continues long, and often the pulse is
weak and small from the beginning. Under the
febrile excitement the urine is more highly co-
loured than in most other symptomatic fevers ; and
there is more or less of the thirst, white or brown
fur on the tongue, loss of appetite, pain in the
head and limbs, depression of the strength, &c,
than usually characterize them, and blood drawn
generally exhibits a bulled and concave crassa-
mentum. This fever may affect particular organs
especially, with the production of other symptoms ;
as the brain with delirium, the stomach with sick-
ness, &c. ; but these complications will be better
considered hereafter.

The symptoms usually continue in this state
from twenty-four to forty-eight hours. At a pe-
riod varying within that space, the cough, which
was hitherto dry or with the expectoration of com-
mon bronchitis, becomes accompanied by the ex-
pectoration of a very characteristic kind of sputa.
They are of a yellow-reddish or rusty tinge of various
shades, semi-transparent, tenacious, and running
together into one mass. At first this expectora-
tion scarcely exceeds the tenacity of the white of
an egg, resembling in all but its colour the sputa
of acute bronchitis, and, when poured out, falls in
glutinous strings; but it often becomes so viscid that
inverting the vessel and even shaking it in that
position will not detach it. The same tenacity
sometimes imprisons in the mass a multitude of
little air bubbles, which may produce a spumous

appearance. The colour may vary in numberless
gradations from a light reddish or greenish yellow
to a deep orange red or rusty hue. All these
tints proceed from various proportions of blood
intimately combined with the secretion of the
bronchial membrane. This new feature added to
the other symptoms is quite characteristic of the
disease. The dyspncea is frequently increased
at this period, the inspirations being obviously
short and quick ; and if the disease is extensive,
oppression becomes very urgent. The pain, on
the other hand, is commonly diminished ; some-
times it remains and prevents the patient from
lying on the affected side. The most common
posture is therefore on the back, as lying on the
same side would restrain the supplementary ex-
pansion which is required there. Often connected
with this posture, one of the cheeks is flushed,
but there is no constant correspondence, as Dr.
Stack has observed, between this and the side
affected.

The disease may go on in favourable cases to
the third or fourth day, and then decline in con-
sequence of the resolution of the inflammation,
which is indicated by a general alleviation of the
symptoms. The pain and dyspnoea are consider-
ably relieved ; the cough becomes looser and less
distressing; the expectoration less viscid and
rusty-coloured, more abundant, and resembling
the sputa of bronchitis. The pulse loses its sharp-
ness, and more gradually its frequency ; the skin
becomes cooler, and sometimes moistened with
perspiration ; the urine is increased in quantity,
and deposits a sediment. Sometimes this ame-
lioration is a speedy process, and restores the pa-
tient to a state of convalescence in six or eight
days ; but it is sometimes more protracted, slight
exacerbations recurring every evening, and some
of the symptoms remaining stationary, and ex-
tending the duration of the disease to a fortnight
or three weeks. The quickness of the pulse, and
dyspnoea, sometimes with cough, are the symp-
toms most apt to linger, with a temporary recur-
rence of the sanguinolent tinge of the sputa ; and
although there is a great improvement in other
respects, they are to be regarded as signs of a
lurking disease which a slight cause may be suf-
ficient to aggravate into a severe relapse.

The increase of the disease in more formidable
cases manifests itself on the third or fourth day by
an augmentation of the dyspnoea, which becomes
so urgent as to oblige the patient to have his head
and shoulders raised ; and the inspirations short,
forced, and amounting to from forty to sixty in a
minute, are effected by sudden elevations of the
ribs and depressions of the diaphragm ; in some
cases the side not affected obviously partaking dis-
proportionately in the respiratory effort. The
cough is sometimes more frequent, but this is not
constantly present in aggravated cases. The vis-
cidity and colour of the expectoration more exactly
correspond with the increase of the disease ; the
tenacity reaches its acme, so as to adhere strongly
when the vessel is inverted, and even shaken in
that position ; and the colour is more deeply
tinged with blood. The pulse becomes quicKer,
and often weaker and smaller. There is great
depression of the bodily powers; and the patient's
attention is engrossed by efforts to breathe under

592

PNEUMONIA.

the weight and oppression which he feels at the
chest. The tongue is often loaded and dry : the
skin sometimes continues harsh and hot ; in other
instances there are partial perspirations and cold-
ness of the surface. Occasionally the features are
livid ; but this is less common in pneumonia than
in severe bronchitis. Sometimes there is delirium
or coma; these are dangerous symptoms, especially
in old persons ; and when present, they frequently
disguise the character of the disease. We have
known a case of delirium occurring in a supposed
idiopathic fever, and another of delirium tremens,
which proved fatal through an inflammation of
the lung, which was only discovered after death.
Hippocrates noticed the danger implied by this
symptom ; and succeeding authors have confirmed
his remark. Laennec describes comatose affec-
tions, the result of sanguineous congestions in the
head, as of much more unfavourable import than
fierce delirium.

When the disease terminates favourably, the
amendment is generally marked by some critical
evacuation, such as perspiration, diarrhoea, expec-
toration, or a lateritious deposit in the urine. Of
these Laennec considered the last to be the most
common : Frank and Andral describe perspiration
as more frequent ; from our own observation we
should say that these two are commonly conjoined ;
and there seldom occurs in pneumonia a perspira-
tion that can be called critical, without at the
same time a deposit in the urine. The latter,
however, sometimes takes place when there is no
manifest increase of the cutaneous perspiration.
A copious expectoration does not occur so fre-
quently as it is described by Sydenham and Cullen
to have done ; and it is probable that the character
of the disease has in some measure changed since
their time; for, as Laennec remarks, there are
some epidemic forms of pneumonia which very
commonly terminate by free expectoration, and
which generally go on favourably after this is
once established. Other critical phenomena hap-
pen more rarely ; as epistaxis, hematuria or some
other hemorrhage, the menstrual discharge, &c.
The commencement of the amendment is general-
ly pretty obvious, and usually occurs in the morn-
ing. The observations of Andral have in some
measure confirmed the opinions of Hippocrates
and other authors, ancient and modern, that there
are certain days in the duration of the disease in
which there is a greater tendency to amelioration.
Of ninety-three cases, he found twenty-three give
way on the seventh, thirteen on the eleventh,
eleven on the fourteenth, and nine on the twen-
tieth days. The recoveries in the remaining cases
commenced on twelve out of forty-two non-critical
days, as many as eleven being ascribed to the tenth
day. (Clin. Med. t. ii. p. 365.) Thus the re-
coveries on critical days averaged as high as four-
teen, while those on non-critical scarcely exceeded
three.

In cases of favourable issue, after continuing
with greater or less intensity for the various periods
just mentioned, and generally on the occurrence
of some of the critical phenomena before named,
the symptoms become mitigated, and a notable
amendment takes place. The dyspnoea becomes
less oppressive ; the cough less constant ; the ex-
pectoration less viscid and sanguinolent, and more

free ; and the pulse less frequent, often with an
increase of fulness. The fever generally diminishes
with the inflammation ; if a critical perspiration
have not already appeared, the skin soon becomes
soft and moist ; the tongue gets cleaner, and the
thirst abates. Generally the patient is fully sensi-
ble of his real improvement ; he feels each day a
great accession of strength, and advances rapidly
to convalescence. Some dyspnoea and quickness
of pulse generally linger after the other symptoms ;
and there is sometimes a cough with an expectora-
tion of bronchitic mucus, which in some cases
remains for some time, but more commonly is
carried off with those changes in the sputa which
are observed in acute bronchitis. The breathing
and pulse in some instances do not assume their
natural slowness until after the patient has entered
on a tonic and restorative method of treatment.

Relapses are by no means uncommon in reco-
very from pneumonia ; and they are marked by a
recurrence of the characteristic symptoms, — pain,
shortness of breath, cough, and viscid sanguino-
lent expectoration. The fever has seldom so
sthenic a character as at the first attack, and fre-
quently it is decidedly adynamic, the strength
having been reduced by the previous disease and
treatment. Hence a relapse, if a serious one, is
often more dangerous than the first attack.

The progress of fatal cases of pneumonia is
marked by a continued aggravation of the dys-
pnoea, with increasing failure of the strength.
The cough becomes less capable of expectorating
the sputa, which sometimes retain their viscidity
and sanguinolent hue as long as any are voided.
In the greater number of instances there is a total
suppression of the expectoration for some hours
before death ; but in others it is still excreted, but
of a different character. Sometimes it is merely
pituitous, transparent, or of a dirty tinge ; some-
times it is a semi-opaque dirty mucus ; occasion-
ally purulent specks of a yellowish white colour
are visible in it ; more rarely it is purulent, with
streaks of blood, or in opaque nummulary forms
of a yellowish white colour, consisting of pus
and a little mucus. Not unfrequently various
mixtures of these different kinds are seen to-
gether ; but the whole sputa in the latter stages
of the disease are generally scanty. Andral de-
scribes sputa of a very remarkable kind as occa-
sionally occurring in the last stage of pneumonia :
they consist of a slightly glutinous liquid of a
reddish brown colour, resembling liquorice-water
or thin syrup of prunes. Rarely, sputa of a
mixed greenish and dirty red or grey colour, and
putrid fetor, are the last observed. With any of
these changes in the expectoration the state of the
patient puts on a worse aspect ; the pulse becomes
thready and intermittent ; the countenance pallid,
cadaverous, and bedewed with a cold sweat ; the
lips livid, the breathing gasping and convulsive,
with a rattle in the throat ; the sensorial functions,
if entire before, now give way, and the patient
dies asphyxiated.

Such is the general type of pneumonia as it
presents itself to the semeiological observer. This
appears to be the proper place to enumerate his-
torically the causes which have been observed to
excite the disease, or favour its production ; and
we shall afterwards proceed to scrutinize more

PNEUMONIA.

593

closely the various changes which constitute its
pathological history. Unfortunately the principal
part of our knowledge of these changes has been
derived from a study of their effects in the dead
body. It will, therefore, give better ground to our
pathology, if, after enumerating the causes, we
describe the anatomical characters of pneumonia.

[Pneumonia and acute rheumatism are diseases
in which the increase in the proportion of the
fibrin of the blood has been the greatest. In 84
bleedings, practised by M. Andral, (Hematologic
Putkologirjue, p. 87: Paris, 1843, or Amer. edit.
1844,) on the course of well-marked pneumonia,
there were only seven in which the proportion
oscillated between four and five in the 1000 ; in
the 77 others, it exceeded this ; — maintaining
itself, in eleven cases, between five and six ; in
nineteen between six and seven ; in fifteen be-
tween seven and eight ; in seventeen between
eight and nine ; in nine between nine and ten ;
and in six it rose as high as ten, and even ex-
ceeded thi's a little.]

Causes. — The previous occurrence of the dis-
ease seems more than any other circumstance to
predispose to pneumonia. Rush describes the
case of a German living in Philadelphia, who had
the disease twenty-eight times. Andral gives a
case in which it recurred the sixteenth time within
eleven years. (Clin. Med. t. ii. p. 192.) Dezo-
teux treated seven times a pneumonia in a subject
who had suffered from it fifteen times, (Diet, des
Sciences Med. t. xliii. p. 396); and Chomel al-
ludes to its recurrence the tenth time in the same
individual. (Diet, de Med. Art. Pneumonic)
Perhaps the only other circumstance that can be
fairly viewed as a predisposing cause, is the pre-
sence of tubercles in the lungs. It has been said
that the adult age, the male sex, a sanguine tem-
perament, and certain occupations, as those of
singers, street-criers, public speakers, &c. predis-
pose to the disease; but if it occurs more fre-
quently in persons under such circumstances, this
is to be referred to their being more exposed to
the existing causes, rather than to any constitu-
tional predisposition. [M. Grisolle, (Traite Pra-
tique de la Pneumonie, &c. Paris, 1841,) has,
indeed, found that when males and females are
equally exposed to field and other open air labour,
the proportion attacked with the disease is the
same. In infancy, too, females suffer as much as
males.] With regard to age, it has not been
found, since the disease has been accurately dis-
tinguished, that any age is particularly exempt
from it. The symptoms are generally more pro-
minent in middle life, and it is therefore more
readily distinguished ; but infancy and old age
appear to be equally liable to it. M. Guersent
reports the disease to be very common and fatal
among children ; and that of the deaths among
those in the hospital of sick children in Paris,
before the completion of the first dentition, three-
fifths occur from pneumonia, chiefly latent. (Ibid,
t. viii. p. 96.) From our own observation we are
inclined to consider young children as more fre-
quently the subjects of pneumonia than adults.
Of fifty-five cases attended by Mr. Byam and the
writer during one year, at a dispensary in the
parish of St. Marylebone, thirty-two were of the
age of six years or under. Neither Laennec nor
Voi. III. — 75 2z *

Chomel concurs with Stoll and Auenbrugger in
considering persons of sedentary modes cf life,
such as tailors, the most liable to pneumonia.
Masons, porters, out-door labourers, and carpen-
ters, present the greatest number of examples ,
which is plainly to be ascribed to their being more
exposed to the exciting causes. The same cir-
cumstance is, as M. Chomel observes, the reason
why men suffer more frequently than women.
Out of ninety-seven cases which occurred in the
wards of La Charite, under his care, seventy-
three were men, although the number of patients
of either sex was nearly the same. (Diet, de Med.
t. xvii. p. 211.)

Cold, excessive exertion of the lungs by violent
exercise or by the voice, the inhalation of irritating
vapours and asphyxiating gases, wounds of the
lungs and blows on the chest, the bite of the rat-
tlesnake, and the action of some other poisons, as
fungi, may be named as exciting causes of pneu-
monia. To these may be added several diseases
on which this inflammation occasionally becomes
engrafted ; such as bronchitis, hooping-cough, pul-
monary apoplexy, phthisis, the exanthematous,
continued, and sometimes traumatic fevers, parti-
cularly those supervening on extensive injuries or
operations. It is so frequently complicated with
hooping-cough, small-pox, and measles in chil-
dren, that we consider the danger of these affec-
tions in a great measure to arise from this compli-
cation. In common with other inflammations, it
may be occasioned by the suppression of habitual
discharges, as the catamenia, hemorrhoids, and
other hemorrhages, and issues or ulcers of long
standing. The inflammations of gout, rheuma-
tism, and cutaneous diseases, are sometimes trans-
ferred to the lungs by metastasis.

The influence of cold in producing inflammation
of the lungs is sufficiently apparent in the much
greater prevalence of the disease in cold seasons and
cold climates. Of ninety-seven cases recorded by
Louis in Chomel's wards at La Charite during
five years, eighty-one occurred between February
and August, and only sixteen in the remaining
five months of these years. Of the cases described
by Andral, the number occurring in March and
April amounted to a third of the whole; the few-
est took place in May, October, and November,
and the remaining months had an equal share.
Of two hundred and forty-three cases which were
treated at the Edinburgh New Town Dispensary
during three years, ending September 1, 1824,
sixty-seven occurred from 1st September to 1st
December ; one hundred and four from 1st De-
cember to 1st March; ninety-four from 1st March
to 1st June ; and sixty-eight from 1st June to 1st
September. We have observed in London nearly
an equal prevalence of the disease from the begin-
ning of December to the end of April, and a con-
siderably smaller proportion in the remaining
months ; but it appears generally that the latter
winter and early spring months are most fertile in
producing pneumonia in these climates.

[Recent statistical observations show, that three
times as many cases of pneumonia have been ob-
served in the French hospitals in the first six
months of the year as in the last, and such was
nearly the proportion in the Pennsylvania Hospi-
tal during the years 1840, 1841 and 1842,-39

594

PNEUMONIA.

cases having been received in the first six months, [
12 in the last]

Pinel and Brichctau consider the most frequent |
cause of pneumonia to be the sudden exposure of
the heated body to cold after violent exertion,
especially that of the voice. (Diet, des Sc. Med.
t. xliii. p. 396.) Laennec remarks on this point
that cold long-continued, or applied when the
body is only moderately heated and covered with
perspiration, is much more powerful as a cause
of pneumonia, than when cold succeeds to an ex-
cessive heat, and is not long continued : " the
Russian who rolls himself in the snow after com-
ing out of a hot bath, or the baker who goes from
his heated oven, almost naked, into an atmosphere
of a temperature below the freezing point, is not
liable to attacks of the disease ; while the porters,
whose occupation leads them to stand for a length
of time at the corners of the streets, are frequently
affected by it." (Dr. Forbes's Transl. 3d edit. p.
225.) It is certain that cold winds or cooling in-
fluences long applied, are more sure to produce
the disease than mere changes of temperature ;
and the perspiring body must obviously suffer
more as it is exposed to the additional cooling
agency of evaporation. Transitions of tempera-
ture of short duration are more effectually resisted
by the body ; and if the reaction from them pro-
duce any inflammation, it is generally one of the
mucous membrane, a coryza, a cynanche, or a
bronchitis : it is when the cold has penetrated
deeply that the parenchymatous inflammations
more frequently follow. Hence, besides cold
winds, any kind of exposure at a low tempera-
ture, as on horseback, sleeping in the open air,
&c, occasionally excite pneumonia. Rarely it
has been produced by drinking cold liquids when
the body is in profuse perspiration, and sometimes
by intemperate indulgence in alcoholic liquors.

The cause of the greater number of cases is,
however, either unknown, or of the obscure cha-
racter in which epidemic and endemic influences
are involved. Of seventy-nine cases investigated
by Chomel, fourteen of the individuals had been
exposed to cold ; five had taken an excess of wine,
one had been over-fatigued, one had suffered great
mental excitement, one had breathed for some
length of time the fumes of charcoal, and the re-
maining fifty-six could assign no cause for their
complaint. (Diet, de Med. t. xvii. p. 213.) The
epidemic occurrence of the disease is clearly
proved ; and such has been its extent, that a con-
tagious nature has been ascribed to it. Laennec
remarks that epidemic pneumonia is probably
often owing to deleterious miasms, suspended in
the air, entering the circulation and operating par-
ticularly on the lungs, as the poison of the rattle-
snake and of some fungi is said to do : hence many
persons are seized in their very chambers in spite
of the utmost care taken of their health. (Op.
cit. p. 225.) In many epidemics it is difficult to
decide the amount of influence which known
physical causes, such as changes of temperature
and moisture, may have in determining the pro-
duction of morbific effects on the body ; but no
meteorological observations have ever discovered
ir lie physical conditions of the air a sufficient
cause for the remarkable prevalence of this disease,
which occasionally constitutes a third, or even a

half of the acute complaints of our hospitals. In
one of these epidemics, it was observed by Hux-
ham that the disease showed itself in the form of
bronchitis in low and damp situations, while at a
short distance, on elevated spots, it prevailed as a
peripneumony. Elevated districts are perhaps the
more liable to pneumonia because they are more
exposed and colder ; whereas the humid air of low
valleys, whilst it diminishes the intensity of the
cold, relaxes more the mucous surfaces, and ren-
ders them the weaker points of the circulation.
The account of Hippocrates would not seem to
coincide with this statement, as he describes pneu-
monia as common in marshy districts, (De Aere,
&c.,) but that he probably includes severe bron-
chitis also under this name. Hoffmann ascribes
to pneumonia an endemic character in some parts
of Westphalia, Sweden, Pomerania, Denmark, and
Russia ; but the physical climates of these coun-
tries is a sufficient explanation of its prevalence,
and Britain may as fairly be added to the list. Nor
are the milder climates free : at Nice, Genoa,
Pisa and Florence, the disease prevails greatly,
and cuts off a good many of the inhabitants.
(Clark on the Influence of Climate, 2d edit. p.
121.) The neighbourhood of Mount Vesuvius is
remarkable for the frequency of its occurrence :
here it may more properly be called endemic, as it
may reasonably be attributed to the noxious ex-
halations which prevail there. (Vivenzi Epist. ad
Haller. iv. Bouillet, Mem. sur les Pleuro-pneu-
monies Epidem.)

[In the United States, it is a very common dis-
ease, and in some parts of it more common than
in others.]

II. Anatomical Chahactebs of Acute
Pneumonia.

We owe the most accurate information which
we possess on the morbid anatomy of this disease
to the researches of the French pathologists, par-
ticularly those of Laennec and Andral. There
are, however, many doubtful points relating to the
essential seat and effects of the inflammation
which still remain to be cleared up before our pa-
thology of pneumonia can be considered accurate.

Laennec arranges the general effects of inflam-
mation on the lungs into three stages or degrees,
each of which is distinguished by marked charac-
ters : The first degree, or engorgement ,• the second
degree, or hepatization ,■ the third degree, or pu~
rulent infiltration. These are the common effects
which inflammation in its general course produces
in the lung. Abscess and gangrene are of uncom-
mon occurrence, and to be viewed as exceptions,
rather than as regular events.

In the first degree of inflammation, the en-
gorged or obstructed state, the lung is externally
of a dark or livid red colour, to which a slight,
whitish opacity of the pleura sometimes gives a
violet hue ; it is heavier and more substantial to
the touch than a healthy lung : when pressed, n
yields less of the crepitating sound and feel, and
instead of generally collapsing under the pressure,
and partially -rising on its removal, it receives and
retains the impression of each finger, giving the
feeling of a liquid contained in cellular substance,
as in an oedematous limb. On examining it
closely through the transparent pleu.u, there are
seen numerous little round bubbles of air without

PNEUMONIA.

595

the angularity of the natural vesicular structure ;
and the septa, which are commonly very visible,
are scarcely to be discerned. On cutting into the
lung in this state, a bloody serum, containing nu-
merous minute air-bubbles, flows from it ; some-
times in great abundance and almost clear, some-
times more scanty and sanguinolent, or turbid, and
with various proportions of the spumous bubbles.
The substance thus cut into is of a red colour, of
various shades; crimson, dark red, brown red,
chocolate red, or of a livid puce colour, approach-
ing to black. The vesicular texture of the lung
can still be discerned, particularly after the serum
has drained from it ; and by pressing it gently and
washing it repeatedly, the natural colour, appear-
ance, and elasticity may in some degree be re-
stored. There are varieties in this state of en-
gorgement, some of which depend on the degree
or duration of the inflammation, and others on in-
dividual peculiarity. The progress which the
inflammation has made is pretty accurately repre-
sented by the defect of air in the tissue ; in the
slightest degree, there being a good deal of air, the
lung feels still crepitous, and the serum which
flows from it is very frothy. The quantity of
serum indicates rather the intensity of the inflam-
mation than its duration ; but, as far as we have
observed, it partly also depends on the coagulability
of the blood. In recent severe inflammations,
which have proved fatal in the first stage, it is ge-
nerally very copious ; but in those which have en-
dured for several days, it is seldom as abundant
even in points where the second stage has not
commenced. The progress towards this second
stage is marked by a paler colour, a diminished
quantity of both liquid and air, and an increasing
solidity of the tissue. There is another variety of
the inflammatory engorgement, probably depend-
ing more on the state of the blood than on the
degree of inflammation : the lung presents an ex-
treme lividity, and when cut, instead of yielding
serum, exudes slowly a dark, grumous blood in
greater or less quantity. This appearance is no-
ticed by Chomel, (Diet, de Med. t. xvii. p. 235,)
as occurring particularly in cases of pneumonia
complicated with other acute affections, as fevers ;
and we have repeatedly observed it. The writer,
together with Mr. Byam, recently examined the
lungs of a child of eighteen months, affected with
chronic hydrocephalus, who was carried off by an
attack of pneumonia : both lungs were partly he-
patized, and partly of a very dark red colour, ap-
pearing of a livid purple through the pleura; some
parts of this inflammatory engorgement still con-
tained a good deal of air, and, when pressed, exu-
ded merely a little grumous blood, mixed with
bubbles. Other parts of the lung were hepatized.
The child had repeated attacks of convulsions
during the two days before his death, and between
four and five ounces of serum were found between
the membranes and in the ventricles of the brain,
which was uncommonly voluminous. But what
we think most worthy of remark is, that the blood
was fluid in all the vessels examined, and this we
apprehend to be the cause of the peculiar charac-
ter of this inflammatory engorgement of the lung.
This was probably the case, also, in the complica-
tions noticed by M. Chomel, for a fluid state of
the blood is very commonly observed in typhoid

fevers after death. We consider that these cir-
cumstances render it probable that the separation
of the serum in the engorged lung is more a cada-
veric than a pathological process; and that, as the
blood coagulates in the distended vessels, its serum
transudes into the vesicular structure. Where, on
the other hand, the blood does not coagulate, it is
too thick a fluid to exude into the cells, or to flow
freely as serum does when the lung is cut. We
do not maintain that there is no interstitial serous
effusion during life ; the analogy of other inflamed
parts renders it probable that it does take place,
but, we suspect, by no means to the extent which
is commonly found in the engorged lung after
death. We shall revert to this point when speak-
ing of the pathology.

The colour of the lung inflamed to the first
degree depends on the blood in it, in some cases
deepened or modified by the black pulmonary
matter : in the lungs of old people the abundance
of this matter gives the inflammatory infarctus a
blacker or more dingy hue ; whilst in children
the colour of the blood entirely prevails. Al-
though very much heavier than was natural, a
portion of lung in this state retains enough air to
prevent it from sinking in water. Another re-
markable change wrought in the lung by the
most considerable degrees of inflammatory en-
gorgement, is a diminution in its molecular
cohesion, so that the fingers break through or
tear its substance much more readily than in a
healthy lung. This effect was first described by
Andral, (Clinique Medicale, t. ii. p. 307,) and
afterwards by Chomel, (Diet, de Med. loc. cit.)
Andral formerly considered this softening of the
tissue a test by which inflammatory engorgement
might be distinguished from that produced by
gravitation, the mechanical hyperemia ; but he
has since abandoned this opinion, and, as did
Laennec in his clinical lectures, referred the more
easily lacerable state of the lung to the physical
effect of an unusual proportion of blood in it.
" The reason of this fact will be readily under-
stood if we reflect that when the lung contains a
much larger proportion of air than of blood, the
parietes of the bronchia, when pressed by the
finger, press in their turn on the compressible
fluid they contain, and in this way, by com-
pressing or expelling the air, retire before the
pressure of the finger, and so escape being rup-
tured. But when the lung contains a larger
proportion of blood than of air, the former fluid
being almost wholly incompressible, the pulmo-
nary tissue cannot recede from under the finger,
and is therefore easily ruptured." (Andral's Pa-
thological Anatomy, translation, vol. ii. p. 510.)
Chomel, however, in his article before quoted,
published in 1827, still maintains the applica-
bility of this test; he says that the merely con-
gested lung preserves its natural consistence ; but
the inflamed lung in great measure loses it, inso-
much that it requires very little force to make the
fingers break through its substance. Our own
examinations have led to conclusions somewhat
different from those of both these authors. We
are convinced that both inflammatory and me-
chanical engorgements tend to diminish the cohe-
sion of the parenchyma more than the mere in-
crease of liquid in it can explain, and for the

596

PNEUMONIA.

following reasons: 1. if a portion of the healthy
tissue adjoining an engorged portion be pulled
gently, a laceration takes place in the latter be-
fore the healthy portion is stretched to the utmost,
and with a much smaller degree of force than is
required to tear this healthy portion : 2. the fra-
gility of the tissue is not always in proportion to
the quantity of liquid in it : 3. an engorged
portion of lung does not lose its greater friability
when the blood has been gently pressed and
washed out of it. We have never been able to
discover any physical difference between the first
stage of marked inflammation and that engorge-
ment supposed to be a mechanical congestion in
the most dependent part of the lung occurring
shortly before and after death ; and it would
appear from the observations of Laennec, that the
resemblance between the latter state and pneumo-
nia is not confined to the anatomical appearances ;
for where the agony, or moribund state is pro-
longed, points of hepatization are formed in the
most congested portion of the lungs ; so that this
author was led to class them as the results of real
inflammation, which he called pneumonia agoni-
zantium. (Op. cit. p. 241.) In these remarks
he is confirmed by Louis. (Recherches sur la
Phthisie, p. SO.) Whilst, therefore, we are led
to recognise softening of the parenchyma as the
pathological result of hyperemia or sanguinous
congestion, we find in it no distinction between
active idiopathic inflammation and that congested
state of lung which supervenes, in some measure
mechanically, on an obstructed state of the pul-
monary circulation.

The second stage, hepatization, (the red soften-
ing of Andral,) has very distinctive characters.
A lung in this state is solid and elastic to the
touch, of the consistence and weight of liver, and
portions of it sink in water : it is no longer crepi-
tous, neither does it, when cut, yield bubbles of
air, but when pressed, a bloody fluid exudes
sparingly from it. Its friability is generally
greater than in the first stage, the fingers readily
breaking through its substance ; and if a portion
be pressed between the fingers, it is reduced to a
red homogeneous pulp. A hepatized lung ap-
pears to be more voluminous than is natural, but
this depends on its being solid, and not collapsing,
as a healthy lung does, on opening the thorax.
Externally its colour is seldom so deep as in the
first stage, and when cut into, it is also lighter,
presenting shades varying from a blood or livid
red to a light pinkish purple or colour of muscle,
and various degrees of these colours are sometimes
seen mottling the lungs so as to resemble some
kinds of marble. Scattered through the hepatized
portion various lines are visible, of a lighter colour,
and specks almost white; a close examination
discovers the former to be portions of the interlo-
bular septa, less affected with inflammation, and
the latter sections of bronchi or blood-vessels, whose
coats have entirely escaped. There is generally in
a hepatized lung another character, which be-
comes apparent on a close inspection, and more
plainly with the aid of a lens. On a portion
being cut, a number of little points can be dis-
tinguished, looking like grains of a somewhat
lighter colour than the intervening spaces ; and if
the surface be wiped or lightly scraped, these

grains appear slightly elevated, as if they consist
of a more solid material. They may be made
still more obvious by tearing the hepatized lung;
they are then seen as little ovoid bodies, and may
be detached singly from the tissue. In most in-
stances these grains are closely pressed together
so as to constitute the chief substance of the dis-
eased part; but sometimes there are interstices of
a darker colour, and in some cases the granular
appearance is entirely absent. This uniform non-
granular solidification of the lung, described by
Andral (Path. Anatomy, vol. ii. p. 510,) and
Chomel, (Diet, de Med. t. xvii. p. 237,) is not re-
cognised by Laennec, who considered the granular
appearance as an essential character of hepatiza-
tion ; but from having seen the condition observed
by the other authors as an indubitable result of
inflammation, we do not hesitate to describe it as
a variety of hepatization. This state of the lung
differs from common hepatization in the absence
of the granules, and a consequently darker and
more uniform texture : it is sometimes softer, and
bears a considerable resemblance to the substance
of the spleen, whence it has been called splcniza-
Hon. In appearance it resembles that condition
of the lung produced in pleuro-pneumonia, called
by Laennec carnijication, which we shall allude
to hereafter ; it differs, however, from this in being
more friable. Andral was, we believe, the first
writer who ascribed the granular appearance of a
hepatized lung to the individual vesicles; and in
this opinion he is followed by Laennec and Louis.
In the second volume of his " Clinique Medicale,"
(p. 312) he describes the inflammation in pneu-
monia as occupying the air-vesicles, the internal
surface of which secretes a viscid mucus, which,
accumulating so as to fill their cavities, produces
the granular bodies in question. In confirmation
of this opinion, Louis asserts that this appearance
can be imitated by gently injecting the bronchi.
(Recherches sur la Phthisie, p. 9.) Laennec
says that these little bodies " are evidently air-
cells converted into solid grains by the thickening
of their parietes arid the obliteration of their cav-
ities by a concrete fluid." (Transl. p. 201.)
Many minute examinations which we have made
of hepatized lungs have convinced us that the
granulations contain no viscid mucus, nor does
their appearance by any means confirm the opin-
ion of Andral. They appear rather to consist
simply of the little bunches of vesicles, (in which,
according to Reisseissen, each minute bronchus
terminates,) whose membranous tunics have be-
come so swelled by the deposition of a soft albu-
minous matter in them, as well as from the in-
creased size of their blood-vessels, that their cavi-
ties are obliterated. Both from the uniformity of
their appearance when examined, and from the
absence of any such matter in the sputa before
death, we have long doubted that there is any ef-
fusion into the cavities of the air-cells, as supposed
by Laennec ; and Andral, in his latter work,
seems to take a somewhat similar view, which he
illustrates by the appearance presented by an in-
flamed lung when carefully dried. When the
lung is in the first stage of inflammation, "the
only morbid appearance it presents when dried is
a reddish, yellow, or brown tinge in the parietes
of its capillary bronchia and air-cells ; and in

PNEUMONIA,

597

some cases even this shade of colour is wanting,
and the lung, which before being dried presented
a remarkable degree of congestion, when dried
differs in no respect from a healthy lung. When
the experiment of drying is tried on a hepatized
lung, the parietes of the capillary bronchia and
of the air-cells present invariably a red colour, and
are, moreover, considerably thickened, so as to
cause in some points a remarkable diminution,
and in others a total obliteration of their cavities."
(Path. Anat. vol. ii. p. 511.) The same saga-
cious pathologist refers the absence of granula-
tions in the variety of hepatization before described
to the greater degree of tumefaction which the
air-cells undergo, by which they are approximated
so closely as to be confounded together. This
explanation does not seem to accord well with the
darker hue of this variety ; and we are inclined
to hazard the opinion that the inflammation and
swelling are in this case chiefly in the vessels and
interstitial tissue between the cells and the bronchi,
without involving the membrane which princi-
pally constitutes these cells, and which analogy
would point out to be of the nature of mucous
membrane. We propose this explanation merely
as a question, and it is one of some interest ; for
if it should be confirmed by further observation,
it would open a more important inquiry whether
such variety in the seat of the inflammation is
distinguished by any peculiarity in the pathologi-
cal history of the disease. The discrimination
between the minute elementary tissues of the
alimentary canal, in relation to disease, has not
been without its practical utility ; and there can
be little doubt that inflammation of the lungs
would exhibit some variation in its signs or course
according to the parts of the parenchyma which
it affects.

[The average weight of the healthy lung is
about 235 grammes. M. Grisolle (Op. cit.) has
found the organ, in the state of red hepatization,
to weigh 2500 grammes, — considerably more than
ten times the natural amount.]

The advance of a hepatized lung towards the
third stage is marked by its becoming lighter in
colour and less humid. The change in colour
seems to be produced by a substitution of more
of the yellowish white semi-solid albumen for the
red particles in its substance, by which the deep
red or dull red of hepatization passes into a
salmon-colour or a dingy pink, variously marbled
in the degree of its progress, as well as by the
mixture of black pulmonary matter. It is at this
period that a hepatized lung attains its greatest
degree of solidity ; when gently pressed, a turbid
red liquid exudes scantily from it : very little ad-
ditional pressure crushes its substance into a thick
pulp ; for although its compactness is increased
by the effusion into its substance, its molecular
cohesion is greatly diminished.* A close in-
spection will generally discover that the granula-
tions are the lighter points, and sometimes minute

*This character led M. Andral to call hepatization red
softening; but the objectionable nature of this term is
sufficiently apparent from the fact that Laennec misun-
derstood its meaning (op. cit. p. 206, note); and Chomel
described the state in question as a hardening of the
lung (endurcisscment rouge, Diet, de Med. loc. cit.) An-
dral meant friability.

yellowish-white specks can be discerned in them,
which are the first development of pus.

The lung affected with the third degree of in-
flammation, or rather its third effect, purulent in-
filtration, presents a still further change of cha-
racter. It generally changes the red tinge for a
yellowish drab or stone colour, which is still varied
with red in parts less advanced, and with grey,
blue, or bluish green, from the admixture cvf
black pulmonary matter.j- At first the lung re-
tains the weight, compactness, and granular tex-
ture which characterize hepatization, the change
being confined to the colour ; whence this state
has been called yellow hepatization, hepatization
grise, and by Andral, ramollissement gris,i from
its increased friability. On cutting into it, no
matter exudes in this early stage of suppuration,
because the cohesiveness of the texture is still
sufficient to retain it ; but very slight pressure re-
duces it to a thick purilage, in which pus obviously
constitutes a principal part. In a more advanced
degree the colour is of a straw or sulphur yellow,
which begins in patches and spreads through the
mass : on cutting into the lung, no granular tex-
ture can be seen ; but a yellowish, opaque, puru-
lent matter oozes in greater or less abundance,
according to the progress which the suppuration
has made. The solid matter obviously diminishes
as the pus is secreted ; for after squeezing this out,
what remains in the hand is a mere debris of the
pulmonary tissue, with a few granulations in
which the suppuration has not advanced. Except
in particular cases, the matter thus formed has a
much fainter odour than that from an ordinary
abscess. The softness of the lung in this state is
so great, that even the slight pressure of a finger
readily makes a cavity, which immediately fills
with pus ; and both Laennec and Andral remark
that this may be inadvertently produced in the
course of examination, and mistaken for an ab-
scess. In the most advanced stages of purulent
infiltration, a lens will sometimes enable us to per-
ceive that the only remnant of texture is a course
irregular network, composed chiefly of vessels,
bronchi, and the septa of lobules.

The purulent infiltration just described is the
form of suppuration to which pulmonary inflam-
mation tends ; the matter is rarely collected in a
focus, and still more rarely in an encysted abscess.
Laennec and Andral have recorded a few instances

f These appearances are beautifully and faithfully de-
lineated in the first number of Dr. Hope's coloured illus-
trations of morbid anatomy, the inspection of which will
be more instructive to the student than any verbal de-
scription; see especially fig. 4. From the blue shades
which slight admixtures of the pulmonary matter pro-
duce. Dr. Hope supposes that this matter is sometimes
blue : we believe, however, that this colour depends oil
a property which all whitish semitransparent bodies pos-
sess of transmitting the yellow and red, and reflecting
the blue rays, so that, when the light transmitted tlinmyli
a thin transparent film is absorbed by a dark body under
it, the blue rays are reflected from the film. Nothing
illustrates this more perfectly than opal glass, through
which dark objects appear blue, and light ones orange ;
and an example of the same optical effect more in point
may be given in the superficial veins, which through the
skin appear blue, although they contain nearly black
blood.

I This word gris is not here to be translated grey, a
mixture of black and white, but drab or stone-coloured,
like light brown paper, which in France is called prqncr
gris.

598

PNEUMONIA.

where the suppuration had in one part become
complete, and contained pure pus, whilst the ad-
joining parts were in a state of purulent infiltra-
tion quite diffluent on the margin of this sort of
abscess, but firmer as they receded from it. This
event has generally occurred in cases of partial
peripneumony ; and it appears to be no more
than a completion of the process of suppuration,
of which ordinary infiltration is only the begin-
ning. The reason assigned by Laennec is proba-
bly correct ; — that abscess of the lung is rare, be-
cause cases of partial peripneumony usually yield
early either to nature or art, while an affection
of greater extent produces death before the tissue
can be removed by absorption. He cites a case
in which a cavity lined with a strong false mem-
brane, and capable of containing a pint and a half
of fluid, existed in the middle of the right lung ;
the pulmonary pleura was destroyed to the extent
of more than six square inches, and the wall of
the cavity on this side was formed by the costal
pleura, which adhered closely to the lips of the
excavation. Several bronchial tubes opened into
this cavity. (Op. cit. p. 208.) As there were no
signs of tubercles, Laennec considers the cavity to
have been caused by an abscess. A similar case
occurred to Dr. Chambers at St. George's Hos-
pital, and the lung is preserved in the museum
there. A case of encysted abscess was shown to
the Academy of Medicine by Dr. Honore in 1823.
It was filled with pus, as large as a middle-sized
apple, and surrounded by a hepatized state of the
lung. The general testimony of the latest patho-
logical anatomists is in support of the opinion of
Laennec, that the termination of pneumonia in
abscess is of rare occurrence. Broussais says
that he only met with it once ; and in this case
the inflammation was produced by a musket-ball,
lodged in the lung for six years. (Hist, des
Phlegm. Chron. torn. ii. p. 111.) Andral con-
siders it extremely rare, and questions the accuracy
of Laennec's statement, that in the year 1823 he
met with more than twenty cases of partial peri-
pneumony terminating in abscess. If we com-
pare these opinions with the writings of Mor-
gagni, Baillie, or, in fact, any writer on morbid
anatomy prior to the last twenty years, or with
the notions of the less informed of the present
day, we shall be surprised at their discrepancy
with the frequent mention of abscess of the lungs
by these latter. The common error has been to
mistake tubercular vomicae, which are of very
common occurrence, for abscess ; and it is not
always easy to avoid the mistake, even in the
present state of our knowledge. Laennec says
that tubercular cavities are to be distinguished by
their containing some remains of the tubercular
matter, or by the coexistence of tubercles in other
parts of the lungs ; but these remains may have
been eliminated ; and where a rounded vomica,
containing only pus, is found singly in an in-
flamed lung, it may readily be mistaken for an
abscess. Such examples show how uncertain are
the anatomical distinctions between vomica and
abscess ; and perhaps any absolute boundary be-
tween these lesions is not to be met with in na-
ture. We may recur to this subject when speak-
ing of chronic peripneumony.

Abscesses of the lungs have sometimes been

met with unattended with any marks of inflam-
mation ; the pus being apparently secreted in
some other part of the system, is merely deposited
in the lungs. We remember to have seen several
abscesses of this kind in the lungs of a woman at
the hospital of La Charite at Paris, who died
with diffuse cellular and venous inflammation and
suppuration of the leg and thigh. They were
small, round, full of pus, and lined by recent
coagulable lymph, the adjacent pulmonary tissue
being quite crepitant. The liver, the spleen, and
one of the kidneys presented similar abscesses in
their parenchyma. Many other examples are on
record of both circumscribed deposits and infiltra-
tion with pus after great surgical operations, (An-
dral, Path. Anat. vol. ii. p. 540. Dr. Hope's
Illustrations, &c. part i. fig. 10, 11, 13); but as
these are not connected with pneumonia, we need
not describe them here.

Gangrene of the lung is rarely a consequence
of inflammation. That it is so at all is questioned
by Laennec, who considered this lesion as idio-
pathic, like hospital gangrene or anthrax, and as
exciting rather than following the inflammation,
which he says is by no means of an intense kind.
It has, however, been fully proved that gangrene
of the lung does occasionally succeed to inflam-
mation of the organ, although, as in the case of
abscess, it likewise occurs independently of it.
Inflammation may be so intense as to destroy the
vitality of a part, as mechanical injuries or chemi-
cal decompositions do ; and of the occurrence of
this event in the lung, there are a few instances
on record. (Andral, Clin. Med. t. ii. p. 295. Dr.
Hope's Illustrations, part i. fig. 4.) As a conse-
quence of acute inflammation, gangrene is com-
monly diffuse, surrounded by purulent infiltration
or hepatization, and bounded by a deposit of
lymph. The colour of the gangrenous part is a
greenish brown, a dirty olive, or a dark brown,
which a certain admixture of purulent and black
pulmpnary matter in some parts changes into a
greenish grey. It is about the consistence of the
lung in the third stage, except in some points
where the sphacelus is more advanced and difflu-
ent, and a turbid or greenish sanies runs readily
from it. It is, however, the putrid fetidity which
most distinguishes gangrene, and this test enables
us to discover the presence of slight degrees of
gangrene where it is not sufficiently extensive to
affect the colour. Where the tissue is in the
third stage, the colour as well as the odour readily
characterizes it, but the hepatized lung bordering
on gangrene can only be detected by its odour.
We have sometimes found portions of hepatized
lung very fetid, and although not materially al-
tered in consistence, and only a little darker in
colour than usual, we have been induced to think
that the gangrenous process had commenced in
them. M. Chomel describes a gangrenous condi-
tion of the lung, which is seen in the bodies of
those who have died after some days' illness in
consequence of being exposed to the effluvia of
cess-pools or sewers. The lung is found almost
black or greenish, full of a sanious, greenish, and
extremely fetid liquid, softened in many places,
and in some falling into deliquescence. Chomel
thinks this lesion marks the passage of the first
stage of inflammation into gangrene. The same

PNEUMONIA.

599

pathologist supposes the possibility of a whole
lung being destroyed by gangrene in the case of
its being compressed and rendered impermeable
to air by an extensive pleuritic effusion ; and he
quotes a case, which he conceives to be of this
kind, from the Opuscula Pathologica of Haller,
in which the left lung had entirely disappeared,
and the pleural sac was filled with a quantity of
fetid albuminous liquid, in which the large vessels
and bronchi terminated as if they had been cut
off. (Diet, de Med. t. xvii. p. 240.)

Circumscribed gangrene, if the result of inflam-
mation at all, follows only the chronic kind ; being
apparently caused by the obstruction to the circu-
lation which chronic inflammation sometimes pro-
duces in the lung. This form of gangrene more
frequently occurs independently of inflammation,
as the result of various septic influences present
in the system, and answers more exactly to Laen-
nec's opinion respecting pulmonary gangrene in
general. For an account of the relations of gan-
grene to these causes and to inflammation, we
refer the reader to the article Mortification.

We have hitherto described the general type of
the several consequences of inflammation of the
lung as detected by anatomical investigation. It
remains for us now to notice the different varieties
which individual cases present with regard to
combination, extent, and complication of these
inflammatory lesions.

Pneumonia is called lobar, lobular, or vesicular,
according as it affects whole or continuous parts
of lobes, or certain polygonal subdivisions of
these, or single bunches of vesicles. Lobar in-
flammation is the most common, and may be
limited to an irregular portion of a lobe, or it may
involve a whole lung, or a great part of both
lungs. When the inflammation is extensive, it is
commonly found in different degrees of advance-
ment. The most frequent of these combinations
is the engorgement or first stage, with the second,
hepatization ; and the gradual transition of one
into the other may here be very distinctly seen.
The greatest advancement is commonly at the
lower parts and margins of the lobes, (which are,
according to Laennec, the most usual seats of
peripneumony,) where we have the solid, airless,
liver-like state of the second stage. In receding
from this towards the less inflamed portions, the
lung is more livid, softer, and moister, but still
does not crepitate on pressure, and, except in
some spots, does not pit, but breaks under the
finger. Further still, there is some crepitation,
but the lung feels heavy and yielding to the touch,
and is of a dark red colour. In the slighter de-
grees of inflammatory engorgement, the colour is
brighter and the crepitation more distinct, and the
serum that flows on incision is very frothy. There
is frequently around the inflamed part an cedema-
tous state of the tissue, the colour of which is
natural, but a yellowish frothy serum flows from
it on incision. The third stage can also generally
be traced in progressive degrees from the hepatized
portions, lightening them by marbled shades of a
paler or yellower hue, which sometimes take the
shape of the polygonal lobules, and sometimes
pass continuously over the interlobular partitions
without distinction. Where these transitions of
colour are abrupt, and mottled with black pulmo-

nary matter, there is produced that appearance
which Laennec compares to some kinds of granite,
with its red and yellow felspar, grey quartz, and
black mica. Combination of these three degrees
may affect the whole of both lungs ; and this to
the extent that the whole of one lung, and more
than half of the other, are solidified ; but it is
obvious that they cannot be so far involved in the
second or third degrees, as life must be destroyed
long before they could be rendered so totally im-
pervious to air.

The anatomical evidence as to the parts of the
lung most frequently affected by pneumonia is not
entirely in accordance with that furnished by cli-
nical observation. Hence we find Morgagni,
Frank, and Broussais, who draw their conclusions
from dissections, assign the upper lobes as the
most frequent seat of inflammation ; while Laen-
nec and Andral, who included cases of recovery
in the calculation, found the lower lobes to be
most commonly inflamed. The reason of this dis-
crepancy is, that inflammation of the upper lobes
is the most frequently fatal ; hence Chomel,
although out of fifty-nine dissections he found the
inflammation occupying the apex in thirteen, the
base in eleven, and the whole or central parts in
the other cases, does not withhold his assent from
the decision of Laennec. That the right lung is
more frequently inflamed than the left, is agreed
on by all writers, and is proved equally by exami-
tion of the physical signs and by dissection.

[From the combined observations of several dis-
tinguished pathologists, it would appear, that in
1430 cases, the right lung was concerned in 742 ;
the left in 426 : and in 262 the pneumonia was
double, or affected both lungs. It is probable,
however, as has been suggested by Dr. Stokes,
(On Diseases of the Chest, 2d Amer. edit. p. 272,
Phil. 1844,) that the proportion of cases of double
pneumonia is under-rated in this estimate. It is
very much more common in young children, and
in old persons, than in adults. Of 128 cases, ob-
served in infancy, — according to MM. Valleix and
Vernois, — the disease occurred in the right lung
in 17 cases ; in the left, in no case ; and the pneu-
monia was double in 111 cases. Of these 111
cases, the disease predominated on the right side
59 times; on the left 10 times; and in 42 cases
it was equal on both sides. (Rilliet and Barthez,
Traite Clinique et Pratique des Maladies des
Enfans, torn, i., Paris, 1843.)]

Inflammation not unfrequently attacks single,
or a few isolated lobules, being abruptly limited
by the interlobular cellular tissue, so that lozenge-
shaped or polygonal patches of red, engorged or
hepatized tissue are found in the midst of healthy
structure. The same distinction is sometimes ex-
hibited in the degree to which the inflammation
has advanced, some lobules of light, purulent infil-
tration appearing in a livid engorgement. The
inflammation in lobular pneumonia seems to origi-
nate in several points at once, and not to be suffi-
ciently intense to traverse the barrier of the inter-
lobular membrane. It is this form that supervenes
frequently to great surgical operations or severe
accidents, and it is common in children.

Andral has distinguished another variety of
acute peripneumony, which, as he supposes it to
affect individual air-cells or vesicles, he calls vesi-

600

PNEUMONIA.

r.ular. This presents itself to the anatomist in the
form of little red spots, varying in size from that
of a pin's head to that of a hemp-seed, and in
colour from blood red to livid red : they are often
more fragile than the rest of the tissue, which is
sometimes quite healthy, but in many instances
contains the miliary granulations of Bayle. This
form of inflammation is not common, and requires
a light colour of the lung to make it distinct ;
but we have observed it sufficiently to enable
us to follow M. Andral in recognising it as a
variety.

A considerable variety in the anatomical charac-
ter of pneumonia is produced by the age of the
subject. The lungs of young children are natu-
rally more membranous and vascular than those
of adults ; and from this circumstance, and be-
cause the bronchi and vesicles are smaller, the
texture is less light and crepitating to the feel.
These characters are to be borne in mind when it
is examined in an inflamed state, for they render
the absence of crepitation and lightness, produced
by this lesion, less apparent than in the adult. On
the other hand, the colour, naturally light, of a
pink, buff hue, makes the red appearance of in-
flammation more visible at this age. Pneumonia
is seldom found so far advanced in children as in
the adult. After many days' duration, it is often
found only in the first stage, and its existence for
weeks frequently does not bring it beyond the
stage of hepatization. The division of the lungs
into lobules is more apparent in children, and in
the young of all animals than it is afterwards ;
which fact is an example of the progressive incor-
poration of elementary parts, which marks increas-
ing perfection in the scale of organization. This
anatomical difference appears to be the cause of
the frequency of the lobular form of pneumonia
in early life, and of the greater immunity from the
inflammation which the interlobular texture often
exhibits. The margins of the lobes are not un-
commonly the only portions found hepatized in
the lungs of children who have died of pneumo-
nia supervening on hooping-cough.

[Instead of lobular pneumonia being confined
to a single lobule, it often extends over many,
constituting what has been termed lobular pneu-
monia generalized. As in the pneumonia of the
adult, the morbid appearances may be divided into
three stages. In the first, according to MM. Ril-
liet and Barthez, the cut surface of the lung is
marbled with spots of a greyish rose, and red co-
lour ; these spots are more or less circumscribed,
and are more readily torn than the healthy tissue,
but they float in water; yield liquid, mixed with
air, when pressed ; and still crepitate. The second
stage is the one most commonly met with, and
resembles the hepatization of the adult ; the third,
or that of suppuration, requires careful examina-
tion to detect it — the substance of the lung having
regained the greyish colour which belongs to its
healthy state ; but, by careful attention, some
lobules are observed more prominent than the rest :
they are not flaccid, like those around them, and,
on pressure, they discharge a purulent fluid.

The appearances left by vesicular pneumonia
may readily be confounded with the effects of
phthisis. They have been accurately described

by MM. Rillict and Barthez. The lung is sofl
and flaccid, and is more or less collapsed, accord-
ing to the extent of the lesion. Its section pre-
sents a great number of granulations of a yellow-
ish-grey colour, and of about the size of millet-
seed. These granulations differ in physical pro-
perties, as well as in nature, from crude miliary
tubercles ; the former containing a liquid — the
latter forming solid masses. If the former be di-
vided, they collapse immediately, giving issue to a
drop of puriform fluid. MM. Rilliet and Bar-
thez propose the term vesicular bronchitis, which
they think, expresses the nature of the affection
better than its usual name, vesicular pneumonia.
They consider the disease to be seated exclusively
in the extreme bronchia ; a certain number of
pulmonary vesicles becoming inflamed, filled with
pus, and dilated, without the surrounding cellular
tissue being implicated. It is not easy to see,
however, how these minute tubes can be inflamed
to suppuration, without the inter-vesicular cellular
tissue being more or less concerned. This, indeed,
as elsewhere said, {Practice of Medicine, i. 397,)
is, probably, the mode in which lobular pneumo-
nia is produced.]

In old people, the prevalence of the black, pul-
monary matter, and the rare, light, and often em-
physematous texture of the lung, affect the cha-
racter of the inflammatory appearances, the first
two stages being darker and more dingy in colour,
and the structure more readily disorganized and
infiltrated with pus. Hence, whilst in children we
see the suppurative process retarded by the densi-
ty of the structure and the compactness of the
effusion, in old people we sometimes find pus
secreted in the second and even in the first stage
before the red particles are removed ; and this
collusion of degrees is the more common where
the pneumonia is of the congestive kind, as in
typhous fever. Dr. Hope has given a drawing of
a portion of lung from an old woman who died
of typhous fever, which exhibited all the physical
characters of purulent infiltration except the co-
lour, which was a deep opaque chocolate. He
says that he has frequently met with this state in
the peripneumony of exhausted and cachectic
subjects, especially after typhous fever.

Before describing anatomically some remarkable
complications of pneumonia, we would stop for a
moment on the question — what is the essential
seat of pneumonia ? Some pathologists, and among
them Andral, place it in the air-vesicles and minute
bronchi ; others consider it to be in the interstitial
cellular texture between these ; whilst a third
opinion supposes it to occupy all these indis-
criminately. The writer, some years since, thus
expressed his opinion : " Our knowledge of mi-
nute anatomy does not permit us to specify with
certainty the exact and essential seat of this in-
flammation ; but I am disposed, from a considera-
tion of the signs and of the effects on the tissue,
to refer it principally to the plexus of vessels and
submucous tissue surrounding and uniting the
minute extremities of the bronchi. It may, and
usually does, extend to the mucous membrane of
these extremities, and of the smaller bronchial
tubes ; but this is, strictly speaking, rather a
bronchitus attendant on the parenchymatous in-

PNEUMONIA.

601

flammation, than a part of the pneumonia."* We
have, since writing this, made many minute exa-
minations of the lung in various forms of inflam-
mation, and if they tend at all to modify this
opinion, it is to the effect that the plexus of ca-
pillary vessels rather than any distinguishable
texture, is the essential seat of pulmonary inflam-
mation. On inspecting, by the aid of a simple
lens, the margin of a slightly inflamed spot of
lung, numerous vessels may be seen, distended
with blood, passing across, around, and between
the vesicles, with very little regard to their form
or disposition ; and as the scrutiny is extended to
a part more inflamed, these vessels are so multi-
plied and confounded with each other as to be no
longer separately discernible. In this state it is
impossible to distinguish whether the tunics of
the cells, or the tissues which connect them are
most affected, for they all appear one mass of red-
ness, in which are seen the cells irregularly
diminished in size, and containing bloody serum
with bubbles of air. The interstitial cellular tex-
ture, where it can be separately discerned, namely,
between the lobules and around the larger bronchi,
is generally less vascular and of a lighter colour
than the other parts, and in some instances ap-
pears to be nearly free from the inflammation.
The lining membrane of the minute bronchi, al-
though generally of a deep red colour, is some-
times bluish red, as if from redness under it rather
than in it ; and on tracing these tubes higher, the
presence of this inflammatory character is very
uncertain. These examinations and some patho-
logical considerations induce us to consider the
capillary ramifications of the pulmonary artery
and veins to be the proper seat of pneumonia, and
that these may involve more or less of the tissues
through and around which they pass. Thus
through them the tunics of the air-cells, parti-
cularly the sub-mucous, commonly become the
scat of inflammation ; whence are formed the
granulations of ordinary hepatization. When,
again, the inflammation is confined more to the
inter-vesicular plexus and tissue, which appears
to he the case in the more congestive form of in-
flammation, where vessels larger than capillaries
are involved, the uniform non-granular form of
hepatization which we have before described, is
produced. + If, as is commonly the case, the in-
flammation extends to the extremities of the
bronchial arteries, which are said by anatomists
to anastomose with the pulmonary, the mucous
membrane lining the vesicles and minute bronchi
partakes of the inflammatory action, and exhibits it
in the manner peculiar to mucous membranes by
the secretion of a viscid mucus, and afterwards of
pus. So, likewise, when the inflammation reaches
the surface of the lung, it is generally, but not

• A Rational Exposition of the Signs of Diseases of
Hie Lungs and Pleura, by Charles J. 13. Williams, M. D.

p. 80.

* An uncommon effi'ct of pneumonia has, since writing
the above, been brought under our notice by Dr. Stokes
inareeent number of tin: Dublin Medical 1 Journal. A
part of the lung was in the third stage; and tile sup-
puration, instead of prevailing most in the tunics of the
bronchi and vesicles, had scarcely affected them, but had

ed the interstitial tissues, so that the vesicles
presented the appearance of bunches ol little grapes or
berries We need not remark how much this tact con-
firms the view which we take of the occasional diversity
i" the principal seat of pneumonic infiammation.
Vol. III. — 76 3a

constantly, propagated to that portion of the pleura
which invests it and derives its vessels from it ;
and this extension of the inflammation may add
another character to such instances of the disease.
But it is its seat in these extensive capillaries of
the lungs through which the blood of the whole
system is continually passing, — it is this affection
of so considerable and important a portion of the
circulatory system that causes the severe and in-
tense character of pneumonic inflammation ; and
the more constantly we hold this in view, the
better shall we understand the pathological history
of the disease, and its important relation to reme-
dial measures.

We have just mentioned the extension of in-
flammation to the pleural covering of the lung ;
this occurs so frequently that some writers have
used the terms pneumonia and pleuro-pneumonia
as synonymous. But in the ordinary cases of
pneumonia the pleuritic affection is so slight that
it scarcely modifies the disease, and like the in-
flammation of the bronchi, which is as usual an
accompaniment of pneumonia, is to be viewed as
incidental rather than essential in the disease. In
these cases the pleuritic inflammation will show
itself to be modified by the seat and extent of the
pulmonary disease. When this is partial, that
portion of the pleura which covers it has upon it
an albuminous deposit, which is generally thin,
and if the disease has been of sufficient duration,
shows signs of organization. The corresponding
portion of the costal pleura frequently presents a
similar deposit ; an instance of that propagation
of inflammation by contiguity which seems to as-
similate the proximate cause of inflammation to
something more subtle and mobile than the com-
mon properties of texture, and to bring it into
close analogy with electric agencies. These al-
buminous effusions are the basis of false mem-
branes, which form adhesions between the lung
and the costal pleura. Underneath them the
membrane exhibits points and patches of red, as
in ordinary pleurisy. When the pulmonary in-
flammation is of small extent, there is commonly
a small sero-purulent effusion into the pleural sac;
but extensive hepatization prevents this from tak-
ing place, by filling the pleural cavity with its
own unyielding substance, and the lung is then
partially covered with a thin false membrane,
which is thicker along the edges, in the inter-
lobular fissure, and occasionally at some points
where the inflammation was first extended to the
pleura. (Transl. of Laennec, p. 487.) These
circumstances prove the greater intensity of the
pulmonary inflammation, and constitute the reason
given by Laennec for not calling such a compli-
cation a true pleuro-pneumony.

There is another remarkable combination of
pleurisy and pneumonia, in which the former,
with an abundant liquid effusion, has the predo-
minance, and signally modifies the effect of the
inflammation on the tissue of the lung. The
pneumonia is generally circumscribed, sometimes
lobular, and is often seen in several distinct spots
at the lower parts of the lung. Laennec de-
scribes the hepatization under these circumstances
to be much more flabby and less solid than in
simple pneumonia. It is of a red or livid rtd
colour, and destitute of granulations or other trace.

602

PNEUMONIA.

of air-cells ; but the vessels and bronchial tubes
are still conspicuous in it. It contains no air, and
not more moisture than muscle ; from its resem-
blance in compactness and suppleness to this tis-
sue, Laennec distinguishes it by the term carnifi-
cation. In a case of this kind, which we have
recently seen, we could not but recognise in this
carnified state of the lung the uniform, non-
granular hepatization which we have described
as that in which the interstitial plexus and tissue
are the only seat of the inflammation ; and this
variety of consolidation, which is arrested or re-
strained by the pressure of the pleuritic effusion,
appears to be another proof that the essential seat
of pneumonia is not in the air-cells. It exhibits
the essential effects of pneumonic inflammation in
colour and solidification, without the granulations
and humidity which are fortuitous and dependent
on effusion extending to the walls of the yielding
air-cells. As it might be expected, the progress
of this form of pneumonia is slow, and rarely
reaches the suppurative stage ; but Laennec says
that in subjects who had died in from one to three
weeks after the subsidence of inflammatory symp-
toms, he has found "the affected portions of the
lung flabby, dry, and yellowish, with the vesicular
texture discoverable in some places, but the vesi-
cles apparently filled with a half concrete pus."
It has been remarked by Dr. Stack that this com-
pressed state of the lung is sometimes perpetuated
by false membranes, the product of the pleurisy,
binding it down. (Dublin Hospital Reports, vol.
iv. p. 90.) This we have seen exemplified more
than once : in one case illustrative of such an
effect of a false membrane, a pneumothorax had
supervened on the absorption of the liquid effu-
sion. (Rational Expos. &c, p. 143.)

Laennec calls that only true pleuro-pneumonia
in which both diseases are extensive, there being
copious pleuritic effusion, with a considerable ex-
tent of peripneumonia. Such a combination is
of rare occurrence, and as there is only a differ-
ence of degrees, it does not appear why this alone
should be entitled to the compound name.

The anatomical characters of resolution or cure
of peripneumony are worthy of remark ; they are
particularly described by Laennec. When re-
covering from the first stage, the pulmonary tis-
sue becomes drier and more filled with air, but
for some time retains its red colour, as if dyed.
Sometimes the texture continues for a while to be
cedematous. A hepatized portion in progress to-
wards cure assumes a paler hue, passing through
shades of red grey and reddish flax colour, until
it become a little redder only than natural. The
texture at the same time becomes more yielding
and moister, containing a frothy serum, which
abounds more and more in air as the resolution
advances, the granulations giving place to the
development of the air-filled vesicles. These
changes begin at several points, and, when ad-
vanced, often leave others still hepatized. When
the tissue resumes its natural dryness and colour,
it remains firmer, more elastic, and heavier for
some time after. The first signs of restoration
from the third stage are the yellow tinge becom-
ing lighter, and the pus more liquid by the inter-
mixture of serum; air-bubbles afterwards appear
and continue to increase, while the pus is reduced

to small specks. As the vesicular texture returns,
it resembles the first stage of engorgement in all
respects but colour, which appears on incision to
be dirty yellow or greenish, and this continue*
even after the complete reabsorption of the serum
The anatomical history of the process of cure of
gangrene of the lungs will be found in the article
Mortification.

III. Pathological HisTonr of Pneumonia.
Operation of Causes. — Pneumonia is the
most frequent of all the parenchymatous inflam-
mations. This in part proceeds from the very
vascular structure of the lungs, which renders
them very susceptible of inflammation ; but we
also see a reason in the nature of their function,
which peculiarly exposes them to suffer from the
various influences that injure the balance of the
circulation. Whatever view is taken respecting
the generation of heat, it is sufficiently established
by experiment that the function of the lungs is
intimately connected with it, and that the appli-
cation of any cooling influence to the body makes
a demand on an increased activity of this func-
tion. As, under such influence, the blood returns
freely to the lungs in a state more highly venous
than usual, there is a greater necessity for respira-
tion, and both this increased flux and the conse-
quent augmented activity bring this organ into a
condition peculiarly favourable to the development
of inflammation. If the application of cold be
not long continued, the pulmonary congestion
may soon be removed by the due oxygenation of
the blood, and consequent restoration of the bal-
ance of the circulation, before the tonicity of the
pulmonary vessels has materially suffered ; some
minor part of the circulation, as that of the bron-
chial membrane, occasionally alone being the seat
of inflammatory reaction. But if the cold be se-
vere and long continued, if a large portion of the
body, especially the chest, be exposed to it, the
pulmonary vessels suffer not only from their in-
creased task and the congestion consequent on its
imperfect completion, but likewise from the seda-
tive influence of the cold directly affecting them ;
hence, whenever reaction is established, they are
the parts most likely to suffer from its effects.
The manner in which excessive exertion and the
inhalation of asphyxiating gases and vapours ex-
cite the disease is obviously likewise by the con-
gested state which they occasion in the vessels,
which, if sufficiently continued, only requires tliu
addition of a subsequent reactive excitement to
convert it into inflammation. Alcohol and its
various compounds also act as occasional exciting
causes of pneumonia by their narcotic influence
on the nervous system, by which the sensation of
want of breath that excites the respiratory act is
blunted, and a congestion of blood takes place in
the lungs in consequence of their insufficient
action. How far in these several instances the
stasis of highly venous blood in the pulmonary
vessels may contribute to injure the tenacity of
their coats, and thus to render them peculiarly

obnoxious to the consequent reaction, is only a

matter of conjecture, not unsupported by analogy.

The presence in the body of various poisons,

as that of the rattlesnake and deleterious fungi,

may lead to the production of pneumonia partly
in the same way, but probably also from a speci-

PNEUMONIA.

603

fically injurious influence on the pulmonary ves-
sels. There is no organ in the body so intimately
exposed to the influence of the blood as are the
lungs ; the whole circulating mass passes rapidly
through their fine vascular filter, and if there be
a noxious ingredient in the blood, it may be rea-
sonably expected here to show its effects. Hence
the origin of pneumonia, not only from the poi-
sonous influences just named, but probably also,
as Laennec has surmised, from the more subtle
ones of an epidemic nature. The inflammations
arising in the course of various febrile and exan-
thernatous diseases may owe their existence in
some degree to a similar mode of influence ; but
the tendency of the phlogistic reaction to localize
itself in parts predisposed to inflammation in many
of these disorders, is likewise a link in the chain
of causes, which must not be withheld from our
recollection. In eruptive fevers particularly, it is
common, as Andral has remarked, (Clin. Med.
torn. ii. p. 287,) to see a great degree of dyspnoea
precede the appearance of the eruption, and gene-
rally cease, as if by magic, when this fully takes
place. In some cases, however, and especially
where the eruption recedes or is not fully thrown
out, the dyspnoea continues, and assumes the
character of a more permanent disease. This is
obviously a congestion persisting and becoming
converted by general vascular excitement into an
inflammation. The deficient resonance of the
chest, remarked by Avenbrugger and Corvisart at
the commencement of eruptive fevers, is a physi-
cal indication of this pulmonary congestion.

The intercurrence of pneumonia with other in-
flammatory diseases of the lungs and neighbour-
ing parts will admit of a more direct explanation :
it is an extension of inflammation by contiguity,
and arises from some additional external cause, as
when bronchitis or pertussis becomes a pneumo-
nia in consequence of exposure to cold ; or from
an additional internal movement, as when, in con-
sequence of a checked excretion or a too well
nourished mass of blood, such slight or mem-
branous inflammation spread and infest the more
considerable circulation of the parenchyma. The
remarkable tendency which is exhibited among
children to such a propagation of inflammation is
dependent on the greater proportion of membrane
and vascularity of the lungs, as well as on the
higher activity of their function at that early age ;
facts pointed out by Magendie and Laennec, and
strictly corresponding with the rapid progress of
diseases of these organs at that period. The fre-
quent intercurrence of pneumonia with hooping-
cough appears to depend not merely on a propa-
gation of inflammation ; the congested state of
the lungs induced by the cough and imperfect
oxygenation of the blood has likewise its share in
favouring the development of inflammation.

The metastasis of the inflammation of gout
and rheumatism occasionally falls on the lungs,
but seldom without some predisposition to disease
in the organ, from previous attacks of inflamma-
tion; and there is nothing in these instances
which tends to throw new light on this obscure
point of pathology. Whether these, and likewise
the cases of pneumonia supervening after severe
accidents and surgical operations, noticed by
Guthrie, Bell, Dupuytren, and others, are con-

nected with an altered condition of the circulating
fluids, is a question which cannot at present be
placed on any other than the ground of con-
jecture.

Tubercles and apoplectic engorgements in the
lungs may excite inflammation both by their
irritating influence, and likewise, if they are nu-
merous or extensive, by the obstruction which
they occasion in the circulation, and which leads
to the congested state which we have so frequently
observed to favour the development of inflamma-
tion. The points adjoining tubercular excava-
tions are likewise occasionally attacked with
inflammation. It is to be remarked of these and
other inflammations which originate chiefly from
mere local irritation, that they are much less
severe and permanent than those in which the
system at large is more concerned, and the in-
flammation is as it were the focus of a general
derangement. Accordingly it is observed that
such intercurrent peripneumonies are commonly
slight, and, if recognised, yield readily to treat-
ment. But their latent character constitutes their
worst feature, their symptoms being merely a
slight exacerbation of those of the pre-existent
disease ; and unless detected through the aid of
their physical signs, they may speedily prove
fatal.

In reviewing the pathological relations of the
causes of pneumonia, we cannot avoid noticing
the important link which congestion of blood in
the lungs forms in the development of the inflam-
mation. In by far the majority of cases this con-
gestion is immediately determined by the operation
of the exciting cause, and precedes what may be
termed the irritative stage of the inflammation.
Such we have seen to be the effect of cold exten-
sively applied, of violent and long-continued
exertion, of certain poisonous influences, (which,
by diminishing the sensibility of the nervous sys-
tem, impair that sensation of want of breath which
excites the respiratory act,) and of the congestive
stages of various febrile diseases. The connection
of congestion with inflammation is still more
forcibly illustrated in the pneumonia of the mori-
bund, in which the blood, imperfectly oxygenated
through the failure of the respiratory forces, accu-
mulates in the pulmonary vessels, which even
then become the seat of inflammatory action, and
if the agony or change of death be of long dura-
tion, produce those changes which are recognised
as the results of ordinary pneumonia. This point
has been fully established by Laennec and Louis.
The latter found signs of partial inflammation in
22 out of 1 12 cases which died of various chronic
diseases, and in which the inflammation could
have existed only a few days before death. (Rech.
sur la Phthisie, p. 39.) Laennec not only found
proofs in the dead body, but likewise repeatedly
discovered signs of this inflammation supervening
during the failure of the powers before dissolution
in various diseases. Seeing, then, the close rela-
tion which simple congestion, or passive hypere-
mia, (as Andral terms it,) of the lungs bears to
inflammation, so close that their anatomical dis-
tinctions cannot be discerned, it remains for
inquiry what is the additional pathological move-
ment which gives to inflammation its character
and permanency, and renders it more than simple

604

PNEUMONIA.

hyperemia. In answering this question by
asserting tnat it is a reaction of the neighbouring
arteries and of the heart, we only describe a phe-
nomenon which does succeed and which is the
next of a series of actions constituting the disease
in question. This is the irritative stage, and is
in most examples posterior to the formation of a
congested state of the vessels. In some instances,
however, as where inflammation succeeds to a
wound or other mechanical injury of the lung or
other irritation in its substance, the afflux of
blood is posterior to the irritation, which is then
the starting point of the pathological changes.
In the article Irritation we have already de-
scribed an afflux of blood as generally following
an excitement of a part, and it does so the more
certainly and fully in proportion as the organ is vas-
cular and freely supplied with blood ; hence the
lungs are peculiarly liable to the congestion of irri-
tation, and if the cause be applied for a sufficient
length of time, this congestion may become in-
flammation. We do not here stop to trace the
progressive changes and reaction which accom-
pany the development of inflammation in general ;
these are sufficiently dwelt upon in the article on
that subject ; but in considering the lungs as an
object of inflammatory action, it cannot escape
our observation that their vicinity to the heart,
their great congeries of vessels through which
the whole blood of the body passes, their spongy
and yielding texture, all tend greatly to increase
the delicacy of the balance of their circulation,
and render any disorder of this balance peculiarly
liable to those reactive processes of the principal
circulation which form a part of inflammation and
fever.

Physical Signs of Pneumonia. — Through
the aid of auscultation and percussion we obtain
a better knowledge of the pathological process of
pneumonia than can be obtained in any other
way, for through their means we in a measure
apply our senses to the very seat of the disease;
but there is still some degree of doubt about the
precise mechanism of certain of these signs, and
this obscurity leaves us uncertain as to some
minute points of the pathological progress of the
disease, which we have already found not clearly
determined by their anatomical history. We
shall, however, describe the signs as they have
been accurately observed, and afterwards state the
view of the pathology to which they, together
with the anatomical characters of the disease, ap-
pear most rationally to lead.

On the first invasion of inflammation of the
lungs, contemporaneously with the earliest of the
general symptoms before described, the ear un-
aided, or through the stethoscope, will perceive in
some part of the chest a peculiar sound accompa-
nying the usual respiratory murmur : it is a fine
crackling or crepitating sound, like that produced
when kitchen salt is thrown on a heated iron ; or
like the crepitation which occurs when a healthy
lung is pressed between the fingers. A pretty
correct idea of the sound may also be obtained in
a readier manner by rubbing between the finger
and thumb a lock of one's own hair close to the
ear. This is the crepitant rhonchus, and was
considered by Laennec to be pathognomonic of
the first stage of pneumonia. The space where

it can be heard is often at first very limited, some
times not extending more than an inch or two ;
but when more advanced, it may occupy nearly a
whole lung. The parts where it is most com-
monly first heard are, below the inferior margin
of the scapula, below the axilla, or about the
lower margin of the pectoral muscle, points corres-
ponding with the lower lobes of the lungs, which,
as we have before noticed, are the most frequent
seat of inflammation ; but it is occasionally met
with in other parts of the chest. At the com-
mencement of inflammation, the crepitation is
merely an addition to the ordinary respiratory
sound, which is still distinct ; but as the disease
proceeds, the crepitant rhonchus prevails more
and more, until it is the only sound heard in that
spot during the respiratory movements.

At this period the part begins to sound a little
duller on percussion than the corresponding op-
posite point, particularly if this be practised me-
diately, with M. Piorry's plate, or even on one of
the fingers of the left hand pressed closely on the
chest. The progress of the inflammation is marked
by the minute crepitations constituting the rhon-
chus becoming less continuous and regular, and
being confined principally to the end of each in-
spiration ; and as the lung begins to pass into the
state of hepatization, they are heard only on cough-
ing or on deep inspiration, and at last cease en-
tirely. If the disease is extensive, in proportion
as the crepitant rhonchus diminishes, the respira-
tion in the sound part of the lungs becomes louder
than usual, and like that of children, whence it is
called by Laennec puerile respiration. In the
second stage of pneumonia, if the disease is exten-
sive, the sound emitted on the percussion of the
part of the chest corresponding with the hepatized
portion, is quite dull, and yields no more reso-
nance than the region of the liver. On applying
the ear, neither the ordinary respiratory murmur,
nor the crepitant rhonchus of the first stage is
heard ; but sometimes another kind of sound is
substituted for them, and this occurs most com-
monly in proportion as the hepatization approaches
the middle parts and root of the lobes, and extends
to the surface. This is a whiffing sound, resem-
bling that produced by blowing through a crow's
quill, and it is occasionally so loud as almost to
amount to a whistle. This is the bronchial re-
spiration of Andral and Laennec, and in its acute
and defined character forms a remarkable contrast
with the dull diffused murmur of natural respira-
tion. It is often heard most distinctly during the
forcible respiration of coughing. A peculiar re-
sonance of the voice, called by Laennec broncho-
phony, is less commonly observed at the same
points. The voice resounds at the end of the ste-
thoscope in a modified tone, as if it came through
little tubes. It does not, as in perfect pectoriloquy,
appear to originate in the stethoscope, and it is
not heard in distinct words, but in notes of vari-
ous continuance, not always synchronous with the
words uttered by the mouth, and at intervals is
alternated with what may be called whiffs of the
bronchial respiration. With these several sounds
there is often mixed a mucous rhonchus or fine
gurgling, but this seems circumscribed and does
not obscure the others.

[M. Hourmann has pointed out another pheno-

PNEUMONIA.

G05

menon which, as suggested by M. Chomel, (Did.
de Med. 2d edit. xxv. 173,) might be useful in
cases in which the feebleness of the patient's voice
might not permit bronchophony to be heard, and
which consists in a greater resonance of the ob-
server's own voice, (ret entisse merit autophonique,}
when he speaks with his ear accurately applied to
the chest opposite the seat of the hepatization.
(See Ausccltatiox.)]

The puffing or blowing sound of bronchial re-
spiration sometimes gives the auditory sensation
of a person blowing into the ear through a narrow
tube ; and as this sound is sometimes interrupted,
and occurs in irregular puffs or whiffs, it gives the
impression of a movable veil or loose curtain
fluctuating under the impulse of the air.

[At times, solidification occurs rapidly, without
being preceded by the usual signs, — the lung pass-
ing, in the course of a few hours, from apparent
health, according to every physical sign, to solidi-
fication. Signs of sudden solidification, without
preceding crepitating rhonchus, have been re-
garded pathognomonic of pleurisy with effusion,
yet they are equally indicative of the condition
just described. The principal diagnosis be-
tween this typhoid solidity and a pleural effusion,
as remarked by Dr. Stokes, (Op. cit.), is, that
with the dulness and absence of respiration ac-
companying a considerable effusion, the signs of
excentric displacement are wanting ; the heart is
not displaced ; the epigastrium and hypochondria
are concave, and the intercostal muscles unaffected.]

In the third or suppurative stage, in addition to
the dulness on percussion observed in the second
stage, there is sometimes a coarse mucous rhon-
chus, heard especially at the root of the lungs or
about the lower axillary or mammary regions:
this is the only physical sign of the termination
of the inflammation in this stage ; and when it is
observed to commence in a part where bronchial
respiration and resonance have been previously
heard, it may be taken as a pretty certain proof of
the supervention of this change. Sometimes,
however, the bronchial respiration and resonance
continue without this sign, and there is then no phy-
sical indication of the occurrence of the third stage.

If the suppuration becomes complete, by the
formation of an abscess in any portion of the
lung, no physical indication of this event presents
itself until the purulent matter has been partly
expectorated. In that case a gurgling or cavern-
ous rhonchus will be heard in the corresponding
point ; and when the evacuation of the liquid con-
tents of the abscess has been further completed,
this rhonchus will give place to the hollow cavern-
ous respiration or pectoriloquy, indicating a ca-
vity communicating with the bronchi. If, how-
ever, the abscess is very large, it may leave a
cavity in which the metallic tinkling or ampho-
ric resonance is produced, precisely as these phe-
nomena are developed in phthisis after the evacua-
tion of the contents of tubercular vomica;. The
gangrenous termination of peripneumony will an-
nounce itself by the putrid fetor of the breath and
of the matter expectorated ; and in case the gan-
grenous portion is detached, whether in a circum-
scribed slough, or in a diffused deliquium, the
same signs of a cavity may be produced as in ab-
scess of the lungs.

3a*

Such are the physical signs which the most ac-
curate observers have concurred in attributing to
peripneumony and its consequences in their sim-
pler forms. We shall better understand their na-
ture as well as the varieties to which they are sub-
ject, if we examine them more rationally, in rela-
tion to the other symptoms, and to the effects of
the inflammation anatomically discovered in the
tissue. With respect to the crepitant rhonchus,
there can be no doubt that its seat is in the
minutest order of bronchi and air-cells of the
lungs, since it is only diseases which affect these
parts that present this or any sound resembling it.
But the precise manner in which they are affected
in order to produce this sound is not quite so cer-
tain, and different opinions upon it have been en-
tertained. M. Andral considers the crepitant
rhonchus to be nothing more than a finer modi-
fication of the mucous rhonchus ; the latter becom-
ing crepitant when its seat is in the minutest
bronchi and air-cells, the narrow dimensions of
which render the bubbles which compose it finer
and more equal. Hence he asserts that the cre-
pitant rhonchus is produced by the intermixture
of air and liquid in the air-cells and smallest
bronchi in other diseases as well as Si pneumonia,
and that it occurs in acute bronchitis whenever
the inflammation and excessive secretion extend
to these parts. Although he absolutely denies the
accuracy of this statement, Laennec does not ap-
pear to have clearly made up his mind as to the
cause of the crepitant rhonchus of peripneumony.
Speaking of this sound in one place, he says :
Besides the sound of crepitation, a sensation of
humidity in the part is clearly conveyed. We feel
that the pulmonary cells contain a watery fluid as
well as air, and that the intermixture of the two
fluids produces bubbles of extreme minuteness." —
" In respect of the size of the bubbles in the differ-
ent rattles, they may be estimated as very large,
large, middling, small. The last term is especially
applicable to the crepitous rattle of peripneumony,
in which it seems as if an infinity of minute
equal-sized bubbles, formed at once, were thrilling
or vibrating, rather than boiling on the surface of
a fluid." (Dr. Forbes's Translation, p. 52.) In
another place, however, he says that at the inva-
sion of the inflammation, the crepitation «' conveys
the notion of very small equal-sized bubbles, and
seems hardly to possess the character of humidity."
(Op. cit. p. 212.) These opinions are equally
inconsistent with each other, and with his obser-
vation on the certitude with which he strenuously
insisted that simple acute bronchitis never pre-
sented this sign ; for truly, if the intermixture of
air and liquid in the minute bronchi were the only
elements of the crepitant rhonchus, this disease as
well as pituitary catarrh, which certainly present
this condition, ought in an equal degree to pro-
duce this sound. Such, however, was the fine
accuracy ofLaennec's observation, (as, during the
last year of his life when he was most perfect in
his art, we had personally ample opportunities of
proving,) that we do not hesitate to receive his
testimony on this point as the most exact, what-
ever inconsistency may appear in his reasonings
upon it ; and therefore, although we cannot pre-
tend to such a perceptive acumen as to be able
always to distinguish the crepitant from the mu-

606

PNEUMONIA.

cous rhonchus in all their modifications and gra-
dations, we assume the authority of the great aus-
cultator as a proof in addition to others, that these
two sounds are essentially different in their na-
ture, and owe their characters to peculiarities in
the mechanism which produces them.

It is agreed on by all auscultators, that oedema
of the lungs and the margins of haemoptoic en-
gorgements may produce a rhonchus of the crepi-
tant kind, and it naturally occurs to us that these
lesions resemble pneumonic engorgement in the
pressure to which they subject the vesicular paren-
chyma. If we compare with these instances the
very close representation of the crepitant rhonchus
which the simple pressure of a healthy lung will
produce, we are led at once to an explanation of
the mechanism of this sign. By this pressure the
air is expressed from the tissue, whilst the tubes
and cells are so narrowed by the pressure that it
can only pass out of them in successive bubbles,
the escape of each of which produces a minute
crepitation : this sound Laennec tells us differs
from the crepitant rhonchus only in being not so
strong ; here no preternatural fluid is present in
the air-cells. In cedema, or in effusion of blood
into the substance of the lungs, we have the in-
terstitial effusion and narrowing of the minute
air-tubes, and cells, and from the nature of the
expectoration we may conclude that there is also
an increase of liquid within them ; the rhonchus
that accompanies them is accordingly described
by Laennec to consist of moister and somewhat
larger bubbles than that of peripneumony, and he
terms it subcrepitous. Lastly, we have the peri-
pneumonic engorgement, in which anatomy assures
us that there is the same narrowing of the air-
tubes and cells by the swelling of the interstitial
blood-vessels, whilst the observation of the sputa
leads us to conclude that the interior of these
tubes and cells is lined with a viscid secretion ;
this produces the drier and stronger sound of the
genuine pneumonic crepitation. This is in prin-
ciple the same explanation which we advanced
some years since in the following passage : " The
distended vessels, and the serous effusion in the
interstices, press on the minutest bronchial ramifi-
cations, and partially obstruct the ingress of air
into the cells to which they lead ; whilst the viscid
secretion of the mucous membrane simultaneously
inflamed, filling the calibre of the tubes thus nar-
rowed, only yields to the air in respiration forcing
its way through it in successive bubbles. This
bubbling passage of air through a viscid liquid
contained in an infinity of tubes of equally dimin-
ished calibre, causes that regular and equable
crepitation which constitutes the true rhonchus
crepitans." (Rational Exposition, &c. p. 81.)
We were led to doubt the accuracy of the expla-
nation of Andral and Laennec, from the circum-
stance that the character of the expectoration in
pneumonia does not countenance the supposition
that there is during life any other secretion into
the air-cells than the characteristic viscid secretion
of the mucous membrane which lines them. In
a former article we have pointed out the tendency
which the natural respiratory movements have to
throw all superfluous secretion from the smallest
t *onchi into the larger until they are brought

under the influence of the act of expectoration.
(See Expectoration-.) Now if, as those who
found their opinions solely on morbid anatomy
maintain, there were a serous effusion into the
air-cells in the first stage of pneumonia, there
ought to be more or less of this serum mixed with
the sputa as in some cases of pulmonary cedema :
this is not the case, for the expectoration is a glu-
tinous mucus from the onset of the inflammation,
and instead of becoming more serous, increases
in viscidity as the inflammation becomes more
vehement. Moreover, we venture to follow the
example of Laennec in asserting that there is a
mucous or liquid rhonchus of the fine bronchial
ramification, the character of which is sufficiently
distinct from the rhonchus of pneumonia to merit
its separation in kind as well as in degree from
the latter sign. This fine mucous rhonchus, which
we have observed in pituitary catarrh, and in the
general bronchitis accompanying continued fever,
occupying the base of the lungs, the common seat
of the crepitant rhonchus, is distinguished from
this latter in the greater inequality of the bubbles
which compose it ; they appear to roll through a
liquid without breaking with that regularity which
distinguishes the crepitation in pneumonia; there
are, besides, little hissing or whistling sounds
mixed with them, which convey to the mind the
impression of a movable proportion of air and
liquid in the tubes. If this mucous rhonchus is
to be distinguished from the subcrepitant of pul-
monary cedema and apoplexy, it is by the greater
irregularity of the minute sounds which constitute
it ; but we cannot pretend to assert that this dis-
tinction is always possible from the nature of the
sound, nor can we deny that there are gradations
and combinations of the two rhonchi which en-
tirely baffle our power of discrimination. But
we do maintain that the crepitant rhonchus of
peripneumony is, with few exceptions, sufficiently
characterized by its pure equable crepitation, un-
mixed with hissing or any sounds of liquid, to
render it a valuable and available means of distin-
guishing this disease in its earlier stages.

In conceiving the mechanism of this rhonchus
according to the explanation given above, we
must take into account the force with which the
air passes through the narrowed tubes, and we
shall then perceive why the bubbles crepitate drily,
and the liquid is not carried before the air passing
to and fro, as it would be were its viscidity less
and its quantity greater. It has been asserted that
the crepitation of peripneumony may be imitated
by the bursting of bubbles on the surface of fluids
of the tenacity of serum, and hence it is con-
cluded that the crepitant rhonchus depends on the
mixture of air with such a fluid in the lungs;
but the cases are by no means analogous: in the
one, the bubbles rise and burst merely from their
own levity ; in the other, an active moving force
is constantly driving and breaking them through
an infinity of minute tubes. On the whole, then,
the more we have examined and reflected on the
subject, the more we are convinced that the phy-
sical cause of the crepitation of peripneumony is
the forcible passage of air through narrowed pas-
sages lined with a viscid liquid ; and if we modify
at all the explanation formerly given, it would be

PNEUMONIA.

607

that we have not the ground to confine the crepi-
tation to the minute tubes only, but that it proba-
bly occurs in the air-cells likewise.

We can readily perceive how the various de-
grees of this rhonchus become an accurate mea-
sure of the progress of the inflammation. Thus,
when this is most moderate, the air enters many
tubes still without obstruction or crepitation, and
the natural sound of respiration is heard together
with the crepitant rhonchus ; but when the nar-
rowing of the tubes and cells and the viscid secre-
tion lining them, become more universal in the
part, no air enters there without this crepitation
being produced, and this rhonchus is then heard
pure and unmixed. The next change is the gra-
dual diminution of these crepitations, owing to
the increased swelling of the coats of the air-cells,
or of the interstitial tissues. Anatomical investi-
gation teaches us that at this period there is a de-
position of a semi- solid lymph or albumen ; this
appears to cause such a successive obliteration of
the tubes and cells as entirely to obstruct the entry
of air into them. Accordingly, as the lung passes
from the first stage of inflammation into the hepa-
tized state, the crepitations become fewer, are
heard only at the acme of inspiration, or during
the forcible efforts of coughing, and at length cease
altogether.

The physical cause of the bronchial respiration
and resonance is more obvious. The deposition
of albuminous matter in the parenchyma of the
lung has the effect, as we have just seen, of ob-
literating the spongy structure, and converts it
into a solid mass. In the healthy state, the dif-
ferent density of its materials (air, membrane,
and liquid) prevents the transmission of sounds
from the interior to the surface ; but now that
this density is rendered uniform, it propagates the
sound of the air passing to and fro in the larger
bronchial ramifications of the interior; and during
the exercise of the voice, its resonance also tra-
verses the hepatized substance in a similar man-
ner. It is obvious, therefore, that the extent and
intensity of these sounds must greatly depend on
the number and size of the bronchial tubes in-
volved in the hepatized portion ; hence they are
most distinct when the inflammation occupies the
summit, root, or central parts of the lung, and
extends to the surface ; but when the lower, the
central, or the superficial portions are alone af-
fected, they may be altogether wanting. When
the principal part of a lung is hepatized, including
the central portions, which contain many consider-
able bronchi, a noisy resonance of the voice, al-
most amounting to pectoriloquy, is heard in the
scapular region, in the central parts of the axilla,
or about the lower margin of the pectoral muscle,
but it may be generally distinguished from imper-
fect pectoriloquy by its more diffused character,
and from that of the perfect kind by the indis-
tinctness of the words uttered. The puffing or
fluctuating sound of bronchial respiration and
bronchophony, which we have mentioned as some-
times met with, is referred by Laennec to a thin
portion of healthy and crepitant lung immediately
on the surface and between the hepatized portion ;
and if this observation is exact, the cause of this
irregular puffing seems to be the air entering or
leaving this healthy portion, and thereby changing

the degrees in which the sound from the interior
is transmitted through it.

We have mentioned the supervention of a liquid
mucous or gurgling rhonchus as the only physical
indication of the occurrence of the third or suppu-
rative stage. This sign is the proof of that soft-
ening and deliquescence of parts which mark the
process of suppuration in all its forms, but we do
not obtain from it any further light on the inti-
mate nature of this termination of inflammation.
The more liquid form of the expectoration gene-
rally corresponds with the presence of the mucous
rhonchus ; sometimes, when there is little or no
expectoration, the bronchial respiration and bron-
chophony continue in this stage.

The physical signs of abscess and gangrene
sufficiently explain themselves ; they apply only
to the cases where a cavity has been produced by
the more or less perfect evacuation of the gan-
grenous or suppurated parts; and are, first, the
coarse bubbling rhonchus, and afterwards, more
rarely, the cavernous respiration and resonance,
or pectoriloquy, which are described as the signs
of tubercular cavities in phthisis. (See Tcber-
culak Phthisis.) In the uncommon case of a
large abscess, there may be the metallic tinkling
instead of these signs. In the work formerly
quoted will be found the only explanation that
has been given of this sign, and this explanation
has enabled us to generalize with success on the
cases of its production, but it has too little con-
nection with our present subject to require an
exposition here. (Rational Exposition, &c, p.
136.) If the abscess or the sloughy portion of
the lung has not been evacuated, auscultation
teaches us nothing of the presence of either.
Fetidity of the breath, especially in coughing, and
of the expectoration, is the only physical sign of
gangrene of the lungs. This may occur, how-
ever, in simple bronchitis, and it is only where
auscultation has detected signs of pneumonia that
it can be admitted as a proof of the death of a
portion of the pulmonary tissue.

We have hitherto considered the general type
of the physical signs of pneumonia in its most
simple state, and we need say little on the varieties
contingent on the situation or extent that the dis-
ease occupies. If it be confined to the central
part of the lung, the spongy tissue of the surface
may prevent the various sounds generated in the
inflamed portion from reaching the ear ; and this,
we apprehend, happens far more frequently to
auscultators in general than it did to Laennec,
who states that he only met with one case of
pneumonia where the stethoscopic signs were
wanting ; that he could detect a central spot of in-
flammation, not exceeding the size of a filbert, by
the distant deep-seated crepitation, or bronchial
respiration, heard beyond the pure murmur of
the surface. It requires a very fine ear and con-
siderable experience in auscultation to discover
these signs at all in many cases of central pneu-
monia ; and we believe, with Dr. Forbes, who
made a similar comment, that it is expecting too
much of auscultation to suppose it infallible in
detecting every degree of pulmonary disease.

It has always appeared to us, that the more the
student in auscultation holds in view the patholo-
gical state on which the signs depend, rather tha-t

608

PNEUMONIA.

those signs themselves, and habitually reflects on
their physical mechanism, as far as it is known,
without empirically dwelling on names or bare
descriptions of sound, the more surely will he
estimate the value of this method of diagnosis,
and the more instruction will he receive from it.
He will thus see that central peripneumony may
be so situated as to yield sometimes no physical
symptom, and at others those to be discovered
only bv a very careful examination ; and hence
he will see the impropriety of a partial method of
diagnosis, and the great importance of attending
to the sputa and other indications. When the
inflammation is extensive, all these difficulties
vanish, and the more intense and puerile respira-
tion in the sound portions of the lung, depending
on the more rapid and forcible passage of air in
them, further shows the infringement that has
been made on the proper function of the organ.

It is not uncommon, especially in partial peri-
pneumony, to observe the signs of the several
stages of inflammation co-existent in different
parts of the lung. Generally, the base or lower
lobe, the part most liable to inflammation, presents
its greatest degree, being hepatized, and yielding
no sound of respiration or resonance on percus-
sion ; a little higher are heard the bronchial respi-
ration and resonance, and above that the crepitant
rhonchus, which mixes with and gradually gives
place to the puerile respiration which occupies the
upper parts of the lung. More rarely this order
is reversed, the upper parts being the first and
most affected. Bronchial respiration is particu-
larly obvious when the hepatization affects the
root or middle portions, without extending to the
margins of the lobes ; and the obvious reason of
this is that there is still a passage of air through
them to the sound parts.

The resolution or cure of peripneumony is
marked by the reappearance, in a reversed order,
of the signs which attended its progress. If the
inflammation has reached only the first stage, en-
gorgement, the resolution announces itself by the
return of the respiratory sound, mixed with the
crepitant rhonchus which before prevailed, and
this pure vesicular murmur increases, whilst the
crepitation diminishes, as the tissue becomes more
free to the passage of the air. If the disease has
proceeded to hepatization, the same recurrence of
symptoms is observed ; thus, in a spot where no
sound of the ingress and egress of air had been
heard, or perhaps only a bronchial respiration, a
slight crepitation begins to be distinguished at the
end of each inspiration, apparently produced by
the air once more gaining admission through some
of the fine bronchial tubes, whose calibres have
been partially restored by the reabsorption of mat-
ter effused in and around their parietes. This
sign, the rhonchus crepitans redux of Laennec,
increases in intensity as the resolution proceeds ;
the bronchophony and bronchial respiration are
diminished as the lung reacquires its spongy tex-
ture, and becomes a worse conductor of sound :
after a while the natural respiratory murmur is
heard mixed with the crepitant rhonchus, and as
the texture becomes more permeable to the air, this
increases as that diminishes, and the healthy state
of the lung is thus gradually restored. It must
oe remarked, however, that this returning rhon-

chus differs slightly in character from that of in-
cipient pneumonia, in its being less even in its
crepitations ; and as it increases in intensity, it
gives more the sound of bubbles, resembling the
mucous rhonchus, with which at this period it
often becomes obviously mixed. The nature of
the expectoration in retroceding pneumonia ex-
plains this difference, for we see in its diminished
tenacity and more bronchitic character the reason
why the crepitation ceases to be dry ; and after a
while, when their proper calibres are restored to
the tubes and cells, the continuance of this secre-
tion produces a simple mucous or bubbling rhon-
chus. We commonly, however, hear some crepi-
tation in a part which has been inflamed, for some
time after the resolution has apparently taken
place ; and this seems to indicate an cedematous
state of the part, which we know in other in-
stances to succeed to inflammation. If the in-
flammation has been of long continuance, espe-
cially if hepatization has existed for some time,
the returning rhonchus is less regularly crepitant
in its character ; and if there be bronchial respi-
ration present, this, instead of becoming dimi-
nished, is sometimes in a measure increased at
first by the resolution. This fact, which has been
also remarked by Drs. Graves and Stokes, (Dublin
Hosp. Rep. vol. v.) seems to depend on the in-
creased passage of air attending the reopening of
the hepatized tissue before this has lost its good
conducting power. The progressive change which
supervenes, however, soon disguises this sound,
not only by the tissue again becoming a bad con-
ductor of sounds, but also by the bubbling or
mucous rhonchus which generally occurs in a
greater or less degree in the tubes which were
before the seat of bronchial respiration. This
change, compared with the free expectoration
which commonly attends the resolution of pneu-
monia, exhibits a direct evidence of the interest-
ing manner in which nature clears away effused
matter from a tissue by free secretion from the ad-
jacent membranes. When the hepatization has
continued stationary for many days, the returning
crepitant rhonchus is never so regular in its cha-
racter as in more recent cases ; and whilst in some
points this rhonchus has appeared and already
given place to one of a mucous kind, in others
there is only a faint crepitation indicating a re-
markable inequality in the progress of the resolu-
tion ; some of these we should be disposed to view
as cases of lobular pneumonia, in which the in-
flammation had commenced at several distinct
points simultaneously ; but in referring to the
anatomical characters of the resolution of peri-
pneumony before described, it will be seen that
the restoration of the tissue to the healthy state is
there seen to be also irregular and unequal, being
probably modified by the degree of inflammatory
orgasm in the different periods rather than by its
absolute duration.

It is less easy to define whether any peculiar
sign marks the restoration from the third stage,
since we have no certain mark of the superven-
tion of this stage. The coarse mucous rhonchus,
which in fatal cases goes on increasing until it
becomes tracheal and terminates the existence of
the patient, in favourable cases becomes finer and
less bubbling, in consequence of the free expeo

PNEUMONIA.

609

(oration of the matter ; and as this is secreted and
cleared away, the air finds its entrance into the
smaller bronchi and vesicles with a mixture of the
mucous and crepitant rhonchi ; these, in process
of time, again yield to the natural vesicular re-
spiration ; but as may be expected from the degree
to which the disease has attained, this restoration
is very slow, and a subcrepitant rhonchus, de-
pending on an oedematous state of the parts, often
lingers for weeks after the other signs seem to in-
dicate a removal of the peripneumony. The pro-
cess of cure, after the formation of abscess, consists
in the evacuation of its contents and its subsequent
cicatrization. The signs of a cavity, the gurgling
or cavernous rhonchus, or respiration, or pectori-
loquy, therefore, gradually diminish until they
nearly cease altogether ; but there is generally
left some dulness of the respiratory sound and of
the resonance or percussion in the spot, often ac-
companied with a bronchial resonance, after the
signs of cicatrization have appeared to be com-
plete ; and this is a natural consequence of the
permanent modification which the disorganization
has produced in the texture of the part. Laennec
states that in several instances of abscess from
partial peripneumony, which he observed in 1823,
the cicatrization was completed within a period of
from fifteen to forty days. In another patient who
had pectoriloquy and cavernous rhonchus, over a
space of three square inches on the lower part of
the right lung, three months elapsed before these
signs completely disappeared ; and in another
case, where a much smaller abscess existed in the
top of the left lung, they did not entirely disap-
pear until after .six months ; long before this,
however, both these patients had recovered their
flesh and strength, and considered themselves
completely cured. In the few instances in which
gangrene of the lungs has terminated favourably,
similar symptoms have been observed ; in fact,
after the removal of the gangrenous portion, a
cavity is left, which must be cicatrized precisely
as that produced by an abscess.

Physical Signs of Plenro'Puenmonia, —
The extension of the inflammation of the lung to
the pleura, (an event, as we have seen by the
anatomical history, very common in pneumonia,)
sometimes adds to the physical signs of the latter
disease others of a novel character, which it is of
importance to record. They depend exclusively
on the presence of a liquid effusion, for as far as
we have observed, we have been unable to recog-
nise the affection of the pleura by physical signs,
unless where this effusion has taken place. Some
recent writers have indeed asserted that a creaking
sound of friction is produced when the pleurae are
coated with freshly effused lymph, but this state-
ment we have been unable to verify. The liquid
effusion of a pleuro-pneumonia may declare its
presence by producing of itself new physical signs,
and by modifying those of the inflammation of the
lung. Where tho pleuritic effusion is not ex-
tensive, which is the common case, there may be
so little liquid effusion that its presence can
scarcely be detected, or it is discovered only by
the greater deficiency of sound on percussion in
the most dependent parts of the thorax, which
parts regain a portion of their natural resonance
when a change of posture raises them higher in

Vol. III. — 77

relative position. Together with such a degree
of effusion all the ordinary signs of pneumonia
may present themselves without perceptible modi-
fication. But if the liquid effusion be greater,
and sufficient to cover a considerable portion of
the lung, it will disguise these signs, by rendering
the crepitant rhonchus less distinct, while the
sound on percussion is quite dull wherever the
liquid reaches. If the pneumonia have attained
the state of hepatization with bronchophony, and
the point presenting this phenomenon be covered
with liquid, the tone of the local resonance will
become changed, — it will assume a cracked or
bleating character, or rather a sound of this
description will accompany the bronchophonic
resonance. This combination of aagophony and
bronchophony Laennec compared to the squeak-
ing voice of punchinello ; but besides the buzzing
and squeaking combination of noises which this
comparison represents, there is a tremulous or
vibratory character in this morbid sound which
seems alternately to approach and recede from the
ear in sudden jerks. We have heard the voice
otherwise modified by this combination of disease,
as if it came through little cracked brazen trum-
pets ; but, as far as we have observed, it is the
undulatory or tremulous character which most
constantly depends on the presence of the liquid,
and is therefore the surest indication of the exist-
ence of a pleurisy. The most common seat of
this phenomenon is the same as that of broncho-
phony, in the interscapular regions, but it may
extend, especially when the effusion is abundant,
through the whole of the segophonic region, that
is, in a band about three inches broad running
from below the inferior margins of the scapula, in
the direction of the ribs, to the sternum. It is
most purely segophonic in the anterior regions,
there being commonly a noisy bronchophony be-
hind. (See Pleurisy.) We have yet supposed
the effusion only extensive enough to push aside
slightly the lung from its apposition to the walls
of the chest, and the sounds of pulmonary respira-
tion are still heard pretty distinctly, modified by
the inflammation, in the first stage into the crepi-
tant rhonchus, and afterwards into the bronchial
respiration and resonance ; but there are some
cases which we have described anatomically, and
in which a copious pleuritic effusion has suddenly
increased during a pneumonia, and has com-
pressed and pushed aside the lung in such a
manner that the sound of respiration can only be
heard in the form of a crepitant rhonchus towards
the root of the lungs, that is, in the scapulary,
axillary, and infra-clavicular regions. This is the
form of disease which produces the state before
described anatomically under the name of carni-
fication, and the pneumonia may in most of these
cases rather be considered as secondary in exist-
ence as well as importance, and it is sometimes
confined to a few lobules ; but Dr. Stack inclines
to the opinion that even in these instances the
pneumonia is primary. (Dublin Hosp. Reports,
vol. iv.) The pathological as well as the ana-
tomical characters of pleuro-pneumonia lead to
the belief that where one inflammation has greatly
the predominance, the other is of trifling import,
and that where both exist to a considerable extent,
the complication, instead of presenting a more

610

PNEUMONIA.

aggravated case, rather mitigates the severity of
both diseases, and this from a cause purely me-
chanical. The pressure exerted by the pleuritic
effusion moderates the inflammatory action of the
lung ; and, again, the lung, in some degree con-
solidated by the inflammatory process, and not
yielding to the encroaching effusion, sets limits to
its accumulation. If, however, the intensity of a
pneumonia is diminished by a coexistent pleurisy,
its duration is probably prolonged; for the pro-
cess of resolution is always much slower in this
than in the simple case. This is because the
interstitial effusion is more solid, and less mixed
with the serous exhalation produced by common
inflammation, and which cannot but assist in the
discussion of the denser products. On the other
hand, a pleurisy coinciding with a pneumonia
will be of easier and speedier cure, inasmuch as
the effusion is less abundant. The dry state of
the carnified lung, taken together with the still
constant production of the crepitant rhonchus in
the course of the inflammation thus modified,
affords an additional proof that this sign owes its
existence to interstitial pressure on, rather than to
any liquid effusion within, the air-cells.

Pathology of the general symptoms of
Pneumonia. — Having made ourselves acquaint-
ed with the essential pathology of this disease, we
may with advantage review the general symptoms
in relation to it ; we shall thus complete the circle
of its history, and appreciate duly the value and
importance of the various signs and symptoms.

In idiopathic pneumonia, arising directly from
the application of an exciting cause, the inflam-
mation commences before the febrile process be-
gins ; hence, during the period of general uneasi-
ness, languor or depression, which are sometimes
felt before an attack of pneumonia, the ausculta-
tor will generally discover a crepitant rhonchus in
some part of the chest ; sometimes there is a sense
of fulness, soreness, or oppression about this part,
or a stitch in the side ; but these are often wanting
until the supervention of fever, which first dis-
guises, then develops the various general symp-
toms. At this time the pulse is commonly small,
occasionally not altered in frequency, but gene-
rally accelerated. This is the latent stage of the
inflammation, in which we cannot but point out
its resemblance to the first effects of various me-
chanical injuries on a part of the body, which we
have already shown to be produced according to
a general law in the system. (See Irihtation.)
A cause has here been applied which has de-
stroyed the balance of the circulation, and so
affected the vessels of the lungs that their tonic
power has suffered, and they become the seat of a
congestive load of blood. This is the local in-
jury, and first exerts its noxious or depressing
influence on the system precisely as a crushed
limb or a severe contusion would do, the local
symptoms being more apparent in these latter in-
stances because the animal sensibility of these
parts is greater than that of the lungs. Hence
the first symptoms of this, as well as of other
inflammations, may be those of prostration or
ii regular reaction ; and accordingly we find syn-
cope, pallidity of the surface, vomiting, hiccup,
&c, occasionally to precede the febrile stage of
pneumonia. Rigor is, however, the more com-

mon symptom of commencing reaction, and it is
the harbinger of that series of vascular move-
ments which constitute the general and local
character of phlegmasial pyrexia. After the rigor,
which is accompanied by its usual smallness and
frequency of the pulse, contracted coldness of the
surface, and general depression of the powers,
soon succeeds an increased action of the heart and
arteries, indicated by a pulse of greater force and
fulness, with more or less of the hard and sharp
character of sthenic irritation ; the surface be-
comes flushed and hot ; and all the internal
organs, the mucous surfaces, and secreting glands
suffer from the febrile reaction in the interruption
or perversion of their various offices. Under this
influence the tendency of particular constitutions,
or the morbid disposition of individual organs is
discovered. In some the gastro-enteric mucous
membrane especially feels the effect of this vascu-
lar excitement, and we have great thirst, scanty
and high-coloured urine, tenderness of the epigas-
trium, irritability of the stomach, with a reddened
tongue and fauces, and the various sympathetic
signs of gastric fever. In another the fever
assumes more of the bilious character, with bilious
vomiting, turbid, saffron-coloured, and ammoniacal
urine, and occasionally a jaundiced tinge of the
skin. It is a rarer case for the head to suffer, but
cases are not wanting in which great intolerance
of light and sound, with delirium, have accom-
panied the symptomatic fever of pneumonia. In
others, especially those of a plethoric habit, the
fever is congestive ; and besides the accumulation
of blood in the focus of inflammation, there are
other local determinations caused by the general
vascular excitement; hence the head, the liver,
the stomach, and the bowels may suffer, at once
or singly, from the irritation extending its influence
to a whole system of loaded vessels. It is during
the development of this general reaction, which
may thus vary in kind as well as in degree in
different subjects, that the local symptoms declare
themselves in the most prominent manner. Thus
the same point of inflammatory congestion, with
its crepitant rhonchus, which was perhaps the
only local indication of disease, now increased and
developed by reaction into active inflammation,
becomes the cause of cough, pain, and dyspnoea
in the various degrees that accompany the in-
creasing period of pneumonia. It is not easy to
define the cause of the variety in these symptoms
which different cases exhibit ; — why some patients
should suffer scarcely any cough, while others are
greatly harassed by it ; why the breathing may
in some be accelerated to a great degree without
the patient being sensible of it, while others com-
plain much of oppression when there is but a
moderate encroachment on the function ; and why
some suffer acute and distressing pain, while
others are scarcely conscious of any uneasiness. In
a general way we must refer these differences to
the state of the nervous system, the sensibility of
which in these varying instances is sometimes
exalted and sometimes depressed, either by indi-
vidual peculiarity, or by some complication which
the accompanying fever may produce. Thus,
when there is a congested state of the vessels of
the brain, sensibility is blunted, and the patient
approaches the verge of suffocation without com-

PNEUMONIA.

611

plaining of either dyspnoea or pain. When, on
the other hand, the inflammation is more concen-
trated within the chest, leaving comparatively free
the sensorial functions, the exalted sensibility de-
pending on inflammation is more easily felt, and
this more especially when a part liable to tension,
as the pleura, is involved in the disease. The
urgency of the cough may also in a measure de-
pend on the degree in which the bronchial lining
membrane is inflamed ; for if it is not affected, its
sensibility will probably, through derivation, be-
come lower than usual. Cough is occasioned by
affections of the larger order of bronchial ramifi-
cations more powerfully than by those of the
vesicular structure ; and there is often, therefore,
little of this symptom until the inflammation is
eitended to the lining of these tubes. From the
absence also of the bronchial inflammation, there
is often no expectoration at this early period ; and
cases occasionally present themselves in which it
does not occur throughout the disease. The
pathology of the secretion of the bronchial mem-
brane, those viscid rusty sputa that so signally
characterize peripneumony, is interesting. As in
simple acute bronchitis this secretion becomes
more tenacious in proportion to the intensity of
the inflammation, so in this secondary bronchitis,
when the vascular action of the membrane is
augmented to its greatest degree, being as it were
backed by the inflammation of the adjoining im-
portant and extensive vascular plexus, the secre-
tion acquires still greater viscidity, and, in addition
to this, becomes tinged by colouring matter from
the mass of surrounding blood. When it is con-
sidered that this secretion proceeds from the im-
mediate vicinity of the diseased part, it would
appear that it must tend to relieve the inflamed
vessels, and the inflammation, when very slight,
may be terminated through this relief; but in the
greater number of instances the relief thus af-
forded is too trifling to arrest the inflammation,
and the viscid secretion, by still further obstructing
the tubes and aggravating the dyspnoea, augments
the danger of the disease, and this it does the
more in proportion as its tenacity is greater.

The obstruction which the inflammation thus
causes to the functions of pulmonary circulation
and oxygenation of the blood now reacts in a new
way on the circulating powers ; the pulse, which
at the commencement of the pyrexia had shown
the heart to be vigorously contributing to the re-
action, now falls in strength and hardness, whilst
it commonly increases in frequency ; and the ste-
thoscope often discovers that there is a spasmodic
briskness in the heart's contraction which seems
to struggle vainly against the obstacle. Fre-
quently this irritable contraction of the heart
amounts to palpitation ; and when we consider
hdw its compartments must suffer from the injured
balance of the circulation, this irregular action is
readily explained. Owing to the obstruction in
the lungs, the right side of the heart is unduly
charged with blood, and subjected to the stimulus
of over-distension ; while the same obstruction
prevents the left side from receiving its proper
supply, and that blood which it does receive is but
imperfectly arterialized. This pathological view,
which is nothing more than a statement of ob-
served phenomena, explains equally the violence

and intensity of the inflammation in the pulmo-
nary vessels, which are under the immediate influ-
ence of an over-stimulated right ventricle, and the
weakness and failure of the general circulation,
which depends for its support on the left ventricle.
The depression thus occasioned by the failure of
the general circulation, and by the imperfect ox-
ygenation of the blood, is sometimes so great as
to resemble typhous fever, whence such forms of
the disease have obtained the name of pneumonia
typhodes. Dr. Mackintosh has stated his opinion,
in which we partly concur, that these varieties de-
pend on the extent of the inflammation and ob-
struction to the pulmonary function, or on a com-
plication with local congestions, and not on any
thing specific in the pneumonia itself. The same
writer thus expresses himself: "There is un-
doubtedly such a form of pneumonia, but I object
to the adjunct typhodes, as expressing erroneous
ideas of the pathological condition of the body.
This form of pneumonia was very prevalent during
the war, among troops stationed in exposed situa-
tions along the coast, and in large garrisons where
the duty was severe. The soldiers were often
seized with it when exposed at night as sentinels;
instead of walking about, they frequently stand
shivering in their sentry-boxes, the surface con-
tinues long chilled, and, with a view to fortify
themselves and to produce warmth, they are in
the habit of drinking ardent spirits in considerable
quantity. In the strongest subjects I have seen
the disease under such circumstances ran its
course to a fatal termination in from forty-eight
to sixty hours." (Elements of Pathology, &c. ;
2d edit. vol. i. p. 420.) This sketch is well wor-
thy of notice, as it illustrates the powerful effect
in aggravating the disease, of two causes already
noticed — long-continued cold and intoxicating
liquors.

There is another complication of pneumonia
which is very apt to give it an uncommonly de-
pressed or typhoid type ; this is, with severe bron-
chial affections, whether of the acute inflamma-
tory character or of the asthenic kind, which goes
under the name of peripneumonia notha. We
have elsewhere described the peculiar prostration
accompanying advanced states of these diseases,
and have there referred this feature to the circula-
tion of an imperfectly arterialized blood in the
system, (see BitoNCHrTis;) and we can readily
conceive how serious such a complication must be
in pneumonia. In persons advanced in life, and
in frames debilitated by excesses or by a cachectic
habit, the pneumonic inflammation is often accom-
panied by an early sinking of the powers ; such
individuals, after a few hours only of pain, cough,
or acute symptoms, become lethargic or insensible,
with a weak intermitting thready pulse, pallid
skin, partial sweats, cold extremities, and, after
lying in that state for some days, sink often with-
out any of the prominent general symptoms of
diseases of the lungs. This is a latent form of
pneumonia which is far from uncommon; and
although after death a large portion of the lung
may be found in the second or third stages, none
but a very attentive examination could have de
tected from the general symptoms the real situa-
tion of the fatal disease. Auscultation would
have indeed furnished a much readier means of

612

PNEUMONIA.

discovering such an extensive organic lesion ; but
we have known cases to have deceived practition-
ers, competent and versed in the use of this method
of exploration, from the circumstance that their
attention had not been drawn to the thoracic vis-
cera, all prominent symptoms having ceased before
they had an opportunity of seeing the patient. In
these and other latent forms of peripneumony, to
which we shall presently revert, although no ob-
vious dyspnoea be present, the frequency of the
respirations may be detected on a close inspection,
and the hand placed on the chest will often per-
ceive the vibration of a liquid gurgling in the
bronchi ; these circumstances may lead to a sus-
picion of the existence of the disease, but it
can be recognised with certainty only by aus-
cultation and percussion : it is unnecessary here
to detail this class of signs, as their distinctive
characters will again come before us under the
head of diagnosis.

[Typhoid pneumonia is exceedingly common
in the eleemosynary institutions of many parts of
the United States; and is often an intercurrent
affection. It is apt to be mistaken or overlooked
unless the physician is well aware of the physical as
well as of the general signs.]

In its simpler forms, when the disease is exten-
sive and has reached the second and third stages,
the whole symptoms commonly show an abate-
ment of the pain, fever, and other indications of
exalted organic and animal sensibility, whilst
there is an increasing injury and embarrassment
of the function of the affected organ. The orgasm
of the inflammation has in a measure expended
itself in the effusion, and the general pyrexia
sinks under the depressing influences of an in-
jured function, with which the whole frame sym-
pathises. This change in the character of the
symptoms is of the highest practical importance,
as it is a signal to modify the treatment in a ma-
terial degree. The discontinuance of the more
intense degree of inflammatory action is moreover
evinced by the expectoration, which, losing its
extreme viscidity and sanguinolent tinge, now
bears more the character of a serous exhalation,
or of a disordered mucous profluvium. The puru-
lent and albuminous matter and bloody streaks
that are sometimes seen in the advanced stages of
pneumonia, are rather to be ascribed to the accom-
panying bronchitis than to the breaking down of
the tissue of the lung : when the latter does hap-
pen, in the much rarer cases of abscess or gan-
grene, the expectoration is commonly very copious,
that from an abscess being distinctly puriform,
whilst that from gangrene contains pus, or mucus
with a dirty brownish or greenish sanies, occa-
sionally with portions of sloughy tissue, all cha-
racterized by an intolerable putrid fetor. The
suppression of the expectoration which commonly
occurs in fatal cases arises usually from the failure
of the respiratory forces to effect its expulsion,
and not from a cessation of the secretion. Hence
by auscultation we hear a mucous or bubbling
rhonchus, which goes on increasing and extend-
ing to the larger bronchial tubes, until it becomes
tracheal, when it is audible to the by-standers,
and constitutes the death-rattle, long known as a
Harbinger of death. Expectoration, as we have
posewhere shown, (see Expectoration,) so far

depends on a free exercise of the organs of respi-
ration, that unless air is carried beyond the accu-
mulated matter, the expulsion of this matter can
scarcely be effected. The short gasping bread]
drawn when a large portion of the pulmonary
tissue is hepatized cannot accomplish this : the
cough, when present, can scarcely reach the ob-
structing matter, and not (infrequently the sympa-
thetic sensibilities and muscular powers on which
this forcible respiratory act depends, are so much
reduced that it ceases altogether.

In reviewing the symptoms of a favourable
termination of pneumonia, the first class of phe-
nomena w-hich claim our attention are the critical
evacuations. These, together with the preference
which they show for particular days, are among
the obscure laws which govern the human frame,
and which must be the subject of far more ex-
tended observation before we can hope to explain
them by reference to any of the simpler vital or
physical influences. When Broussais ascribes
critical evacuations to a predominance of a second-
ary irritation in a secreting organ over the primary,
he only substitutes a new and unsatisfactory form
of words for a simple declaration of the fact ; for
the salutary effect of the evacuation is much more
explicable than the cause which determines its
presence and its kind. Besides, the word irrita-
tion seems not a very appropriate one to apply to
the influence which changes the skin from hot,
harsh, and dry, to soft and perspiring, the urine
from scanty, high-coloured, and scalding, to co-
pious and less acrid, and the expectoration from
very viscid and sanguinolent to an abundant,
simple, and more liquid mucus. For the present
we would prefer viewing critical evacuations
rather as signs than as causes of improvement ;
for although in a free expectoration or a hemor-
rhage we can at once perceive a rational mode of
relief, yet the cases of perspiration, diarrhoea, or a
lateritious deposit in the urine, may with equal
reason be viewed as a consequence of the diminu-
tion of the disease, which restores to the skin, the
bowels, or the kidneys, such functional powers as
enable them to carry off from the system matters
accumulated during a period when the powers
were more or less paralyzed or perverted by the
general febrile derangement ; and the fact that
such evacuations do sometimes take place without
proving critical is another reason for leaning to
this view. The subject involves more conjecture
than would be consistent with the design of a
practical work, and we therefore abstain from en-
tertaining it further than to remark, that no close
observer of nature can refrain from the conclusion
that, in one way or another, primarily or second-
arily, a disordered state of the fluids forms an im-
portant link in all extensive febrile and inflamma-
tory diseases.

The tendency to evening exacerbation in this
and in other diseases is another phenomenon
more observed than explained. We remember to
have heard M. Andral cite in his lectures the per-
sonal experiments of a physician, which illus-
trated forcibly the effect of periodic habit on the
body: for several nights in succession during the
winter, at a particular hour, he plunged into a
river, returning immediately to his bed. On in-
termitting the practice on certain days, a shivering

PNEUMONIA.

613

jit came on at the customary plunging hour, and
was followed by the usual reaction, as if the
plunge had not been omitted. Perhaps the even-
ing exacerbations of this and other inflammatory
and febrile diseases may be partly referred to the
same law of habit, of which this is merely a pro-
minent illustration. The addition of nutrient
matter to the blood, together with the accumulated
excitements of the day, produce a tendency to a
febrile movement in the evening, and these causes
are so regularly applied that their effect becomes
a habit, and persists even when they are removed.
With a few, the morning is the time of exacerba-
tion, and with such persons this may be deter-
mined by a slight habitual disturbance, which is
common at that period in dyspeptic individuals.

The rapid general improvement which com-
monly attends the progress of recoveries from
pneumonia indicates rather the restoration of the
healthy balance of functions than the entire re-
moval of all local disease ; for some dyspnoea and
quickness of pulse often remain up to an advanced
period of convalescence, and by means of auscul-
tation we discover a cause in the still diseased
state of portions of the pulmonary tissue- A
bronchial respiration, a resonance of the voice, or
a crepitant rhonchus, with some dulness on per-
cussion, remains as a proof that the effects of in-
flammation are still present, and, amidst other
signs of apparent recovery, these require time and
care to secure their restoration. Sometimes, as
we have seen anatomically, points of hepatization
remain for a considerable time, and may become
a focus for the rekindling of the acute disease by
any error of diet or regimen ; or, if left unsubdued,
the inflammation may continue there in a chronic
form. It is a commoner case that a crepitating or
rather subcrepitant rhonchus persists ; this, if there
is no lingering fever or considerable cough, and if
the expectoration has lost its red or yellow tinge
and viscidity, is to be considered as the effect of
oedema rather than of inflammation of the tissue,
and is removed most effectually by a mild tonic
combined with expectorants and diuretics.

Pathological Varieties and Complications
of Pneumonia. — We have already noticed the
complication of pneumonia with bronchitis, and
the effect that it commonly has of increasing the
depression attendant on the disease, and thereby
disguising its inflammatory nature. Drs. Graves
and Stokes (Dublin Hosp. Rep. vol. v.) have judi-
ciously remarked that in the treatment of this
combination the first remedies and a single bleed-
ing produce such relief to the bronchitis, that a
practitioner may be led to suppose that the whole
disease is overcome ; whereas auscultation disco-
vers, by a remaining crepitant rhonchus, that the
most formidable affection still remains to be sub-
dued. There are, however, a few instances in
which this combination puzzles even the auscul-
tator. The pneumatic crepitation is sometimes
so masked by a loud and general mucous rhonchus
that even an attentive examination may fail to de-
tect it: this happens especially when the pneu-
monia is central and towards the root of the lungs,
and does not extend to the surface. Laennec in-
deed asserts that a deep-seated crepitant rhonchus
can always be distinguished, by those practised in
the stethoscope, from any mixture of sounds pro-

3 B

duced nearer to the surface; but we now think
that to insist, as we once did, on the possibility
of this distinction, would be to reckon too much
on the infallibility of auscultation. The presence
of a rusty tinge in portions of the expectoration
will more frequently declare a latent peripneu-
mony ; and in the progress of the disease the ex-
tension of the inflammation to the surface will
make it more easy of recognition. Pneumonia
may arise in the course of either acute or chronic
bronchitis, and such an event is of great import-
ance in both cases. Acute bronchitis is most
liable to pass into peripneumony in young sub-
jects ; and the habitual chronic catarrh of old
people sometimes takes a similar course. Andral
remarks that this accident is not an unfrcquent
cause of the kindling up of fever and increase of
dyspnoea in aged asthmatic subjects ; and these
symptoms may erroneously be ascribed to an ag-
gravation of the habitual senile disease ; this in-
creases the danger of the complication, and for
causes that we have just explained, the diagnosis
must often rest on uncertain general symptoms.

There are two modifications of bronchial in-
flammation which occasionally exhibit a strong
tendency to pass into pneumonia, pertussis and
the influenza or epidemic catarrh. The violent
fits of coughing frequently coexisting in these
complaints with considerable fever, appear to us
to have a great share in extending the inflamma-
tion to the great pulmonary plexus of vessels.
These paroxysms of cough determine a great de-
gree of congestion in the lung, and we have al-
ready seen how easily such a congestion may be-
come inflammation. Of such a termination of
hooping-cough we have witnessed numerous in-
stances, proved in some by anatomical inspection,
and in many by the addition of a crepitant rhon-
chus to the physical signs of pertussis. In many
of the latter cases the fever had been so gradually
increased, and the general peripneumonic symp-
toms had been so mixed up with those of the ag-
gravated pertussis, that but for auscultation the
more serious disease might have escaped detec-
tion. This complication is most common in very
young and delicate children, and during winter
and spring, the usual peripneumonic season. Of
the supervention of pneumonia on influenza we
have seen several instances during the epidemic
that has lately prevailed to so great an extent, and
from the effects of which the country is still suf-
fering (May, 1833). It was at the time of its
greatest prevalence, when the weather was cold
and changeable, that the disease in occasional ex-
amples put on this decidedly inflammatory type.
In two instances we resorted to free bloodletting
with immediate relief; and it is worthy of remark,
that the patients suffered less from weakness than
many others where no depletory measures were
adopted.

[In children especially, in whom no information
from the sputa is attainable, bronchitis often masks
pneumonia. In them, too, the sounds afforded on
percussion may be alike on both sides, as the af-
fection is rarely confined to one lung. Previous
to six years of age, the symptoms and progress
of the disease differ somewhat from those of u
later period. It would seem, according to Messrs,
Gerhard, Rufz, and Rilliet and Barthez, to occu.

614

PNEUMONIA.

then as a secondary lesion ; and it has been con-
ceived to be owing to a stagnation of blood in the
lungs, which acts as a foreign body as it were,
and concurs in producing an alteration in the
pulmonary tissue with which it combines, and
becomes identified, so as to form hepatization of
the lungs. Although, however, in very many
children, the disease is generally secondary, in
other cases it attacks those in perfect health, and
runs its course in a brief space of time, — occa-
sionally in forty-eight hours. Howsoever this
may be, it is certain, that in younger children, the
diagnosis between pneumonia and bronchitis is
not easy.]

We have before described the combination of
pleurisy with pneumonia. Next to bronchitis, it
may be said to be the most natural concomitant
of the parenchymatous inflammation, for its con-
tiguity exposes it to be involved in an extension
of the disease. As we have said before, it may
considerably modify its course, but instead of, as
bronchitis, disguising the seat of the complaint, it
often declares it more openly by adding the pro-
minent symptoms of pain or stitch in the side, and
a catch in the breathing. These obvious symp-
toms are not, however, the constant concomitants
of pleuro-pneumonia ; and cases sometimes pre-
sent themselves in which this and every other
variety of the disease require the fullest investiga-
tion of both physical and general signs to ascer-
tain their nature with precision. As far as we
have observed, a pleurisy supervening on pneu-
monia aggravates the case most when it is attended
with a sharp pain and catch in the breathing ; for
it then keeps the patient in a distressing struggle
between pain and suffocation, and unless the pain
yield soon, it may in this way prove fatal. Gene-
rally it soon subsides, the active orgasm being de-
rived to the pulmonary tissue, which on account
of its greater vascularity is more obnoxious than
the pleura to the inflammation. For this reason
it is not common for the pleurisy to gain on the
pneumonia, and it is usually limited to the points
where the latter reaches the surface.

[It is maintained by some pathologists, as by M.
Valleix and Dr. Gerhard, (Lectures on the Dis-
eases of the Chest, p. 88, Philad. 1842,) that
inflammation of the pleura rarely complicates the
pneumonia of children. By others, however, the
complication has been found to be common, the
pleura being unaffected in the observations of
MM. Riiliet and Barthez, (Op. cit.) in ten cases
only. Evidences of acute pleurisy existed in one
third of the children from two to five years of
age.]

Peripneumony frequently attacks phthisical
subjects in both the early and the advanced stages
of tubercular disease. Miliary tubercles in the
lungs may be viewed as causes both predisposing
and exciting ; they render persons more liable to
inflammation on exposure to cold or any other
exciting cause ; and during a febrile state of the
system, their presence and mechanical irritation
may localise in this organ a general inflammatory
diathesis. In several instances of subjects who
have died of continued fever with pneumonia, we
have seen numerous tubercles in the inflamed
lung, and similar cases are recorded by Andral
and others. The liability of phthisical subjects to

intercurrent peripneumony has been noticed by
Laennec, Louis, and Andral. It is not generally
severe, and is often spontaneously cured ; which
illustrates a remark which we have before made,
that pneumonia excited by a local cause is never
so severe as that which arises from an extensive
impression on the circulation. Nevertheless, the
similarity of its symptoms to those of the phthisi-
cal disease often screens it from notice, with the
effect that its treatment is neglected, and if it does
not at present endanger life, it accelerates the pro-
gress of the other fatal disorder. Hence, as Laen-
nec recommends, it is important to examine from
time to time the chests of consumptive patients,
particularly when there is any sudden feverish
attack or decrease of the strength. Andral asserts
that intercurrent peripneumony, from being over-
looked, frequently occasions the death of phthisi-
cal subjects.

We have had occasion to speak of the occur-
rence of pneumonia in the course of various
febrile disorders, and it is the more important, as
the inflammation here commonly takes a latent
form. This is especially the case in severe
small-pox and erysipelas, and in fevers of the
congestive kind. In a considerable proportion of
the fatal cases of these diseases, this inflammation
seems to be the cause of death. During the pre-
valence of a peripneumonic epidemic, and in the
winter season, Laennec remarks that in patients
suffering under these disorders, any marked in-
crease of fever'in the young and robust, and any
sudden prostration of strength and loss of con-
sciousness in the aged and debilitated, are gene-
rally the result of a pneumonia supervening, and
it is frequently accompanied with neither dyspnoea,
cough, expectoration, nor any of its usual symp-
toms. The frequent occurrence of a latent pneu-
monia in continued fever is a fact too well known
to morbid anatomists ; it has already been noticed
in the article Fever continued. A harsh state
of the skin, fetid excretions, and sordes on the
teeth and tongue coming on in subjects worn out
by cancer or other severe chronic diseases, ac-
cording to Laennec, frequently indicate pneumo-
nia, which soon ends with coma, tracheal rattle,
and death. The bronchial affection of measles
sometimes passes into pneumonia, especially if
the eruption is repressed or disappears suddenly ;
but in this case the symptoms are commonly
urgent and sufficiently characteristic. Endemic
fevers sometimes determine an inflammation of
the lungs, which is frequently latent. Broussais
records this of the intermittent fevers which at-
tacked the military in the hospitals of Bruges.
(Hist, des Phlegmasies Chron. t. i.) The same
has been remarked of malaria fevers of other
kinds, and of the pestilential cholera. The latter
disease sometimes shows a remarkable tendency
to pneumonia in the stage of reaction, and this
event seems to be favoured by the great conges-
tion which occurs in the pulmonary vessels during
the period of collapse. The reaction of intermit-
tent febrile diseases has been sometimes observed
to be so regularly accompanied by pneumonic
symptoms that some authors have given the name
of intermittent peripneumony to these affections.
Thus Broussais has noticed the quotidian returns
of inflammation both of the lungs and of the

PNEUMONIA.

015

pleura at the time of the febrile paroxysm. But
it must be remarked that in these cases either the
pulmonary affection must have been exceedingly
slight, or it must have continued during the apy-
rectic period, and merely have been more fully
developed by the excitement of the paroxysm.

Pneumonia is sometimes produced in gouty
and rheumatic subjects, and this may occur either
vicariously, so that the limbs are relieved, or con-
jointly with the affections of these. In the first
case, the pulmonary affection is generally appa-
rent; in the latter, it is sometimes latent. P.
Frank has remarked that in rheumatic subjects
pneumonia sometimes terminates without any
expectoration, with a copious discharge of clear
urine, amounting to twelve pounds and upwards.
This curious fact is another sign of the connec-
tion which subsists between rheumatic and gouty
affections, and a diseased state of the fluids of the
body.

Hypertrophy of the heart modifies the pulse in
pneumonia in a manner that deserves notice. In-
stead of falling in strength as it generally does,
and becoming small and frequent, from the causes
that we have before explained, the pulse in some
degree retains the hard vibrating character pecu-
liar to hypertrophy. This is the case, however,
only when the left ventricle is affected. Hyper-
trophy of the left ventricle predisposes to pneu-
monia, and generally aggravates its form. In
pneumonia complicated with any disease of the
heart, the pulse becomes more fallacious "than
ever ; and neither its frequency nor its strength
bears any relation to the extent of the inflamma-
tion.

Inflammation of the mucous membrane of the
stomach and bowels is by no means an uncommon
accompaniment of pneumonia. It generally gives
a more adynamic type to the disease, and mani-
fests itself by the peculiar state of the tongue,
which is at first very red, and afterwards parched
and brown, with great thirst, vitiated excretions,
and frequently tenderness at the epigastrium.
Various other diseases may combine themselves
with pneumonia, and although they may manifest
themselves by their peculiar groups of symptoms,
yet the complication generally increases the ob-
scurity of the case, and the difficulty of its treat-
ment.

[In children, from the age of two to sixteen,
there would appear to be six diseases in the
course of which pneumonia is apt to occur in very
large proportion. Thus, according to M. Grisolle,
(Op. cit.) secondary pneumonia occurs in seven-
eighths of all cases of cramp ; in five-sixths of
all cases of cancrum oris ; in one-third of all
cases of enteritis, measles, and hooping-cough ;
and in one-fourth of all cases of small-pox. Ac-
cording to the same observer, intercurrent pneu-
monia was seen in one-seventh of all cases of
continued fever ; one-sixth of all cases of acute
affection of the brain ; one-fourth of cases of pul-
monary tubercles ; one-fourth of cases of disease
of the heart ; and in about one-sixth or one-
seventh of all cases of cancerous disease of the
viscera ; organic diseases of the liver— especially
cirrhosis, Brights' disease, &c. It is likewise a
frequent complication of glanders, phlebitis, &cj

Several surgical writers have noticed the occur-
rence of pneumonia after amputation and other
great surgical operations, and likewise after exten-
sive wounds ; and it has been supposed that this
disease is frequently the cause of death in these
cases. This is a very interesting subject, and one
that requires further investigation. The disease
of the lungs in these instances appears to be quite
of the latent kind, and sometimes it only declares
itself by the dyspnoea and rattle a short time
before death. We cannot speak from personal
observation on this subject ; but from the descrip-
tion given, it would seem that these cases of pneu-
monia may be ranged in two classes : those which
partake of the character of the pneumonia of the
moribund, which has often been alluded to in this
article, and which seems to be a concomitant
rather than a cause of the changes of death ; and
those which supervene during a febrile reaction,
and are disguised by other local and general symp-
toms. The latter class occurs most commonly in
the subjects of amputation, or where a great
change has been wrought in some part of the cir-
culation, leaving the heart vigorous and disposed
to sthenic reaction. The former comprises cases
of bad wounds or unfavourable operations, where
the powers fail under the local injury, and as a
part of this failure, a congestion takes place in the
lungs, which is, by a partial reaction, converted
into inflammation.

[From a table of forty-one deaths, following
various injuries and diseases, in the surgical wards
of University Hospital, London, — in which an
account of the state of the lungs was kept, — these
viscera, according to Mr. Erichsen, (London Medi-
cal Gazette, Feb. 1841,) were found in twenty-
three cases to be in the first or second stages of
pneumonia. On this account it has been sug-
gested to defer operations, when practicable, dur-
ing the prevalence of an epidemic pneumonia.]

It will be perceived that, in describing these va-
rious complications, we have comprehended nearly
all the varieties of pneumonia which have been
described by authors ; and we apprehend that the
pathological views of these varieties with which
modern researches have so fully furnished us, so
clearly expose the real nature of the greater num-
ber, that it is unnecessary to consider them further
in a separate form. The false or bastard perip-
neumony, (peripneumonia notha of Sydenham,)
does not require notice here, for it has been alrea-
dy described under its proper head, Bronchitis.
The bilious peripneumonies described by Stoll
and other writers of his time, do not appear to
constitute a real pathological variety of the dis-
ease : for they were either cases of bronchitis in
which the sputa were tinged with bile from a
simultaneous affection of the liver; or, what is
more probable, they were ordinary cases of pneu-
monia attended with the characteristic expectora-
tion, which is often yellow or greenish, from the
admixture of various proportions of the colouring
matter of the blood, and which these writers hy-
pothetically ascribed to an intermixture of bile.
Lacnnec says that he has frequently met with
these greenish sputa where there existed no bilious
complication : he admits that he has sometimes
seen them disappear after bilious evacuations ; but

616

PNEUMONIA,

this circumstance can be viewed in no other light
than that these evacuations were critical, and co-
incided with a resolution of the inflammation.

Diagnosis of Pneumonia. — We have de-
voted so much space to the consideration of the
signs of this disease, that we have now only to
recall the most characteristic, and compare with
them the distinctive signs of a few other maladies
with which they may be confounded.

The manner of attack, the dyspnoea, the pulse,
the pain, the cough, and the side of the decubitus,
although in the manner in which we have de-
cribed them, they contribute to form the general
character of the disease, yet are quite incompetent
to distinguish it with certainty from other acute
inflammations of the chest, particularly bronchitis
and pleurisy. Still these symptoms are not to be
disregarded, for, taken in conjunction witli the
physical signs, they often assist us much in the
diagnosis. Of all the diagnostic signs of pneu-
monia, the characteristic form of the expectoration
is the most infallible ; and when it does occur,
there can be no doubt of the existence of paren-
chymatous inflammation ; but it is sometimes en-
tirely absent ; frequently it does not appear until
after the disease has existed for two or three days,
and it generally ceases as the inflammation reaches
the second and third stages. It may moreover pass
by such insensible gradations into the colourless
form of bronchitic sputa, so that it is not always
easy to determine whether it partakes of the pneu-
monic character or not. The crepitant rhonchus,
when it occurs distinctly or unmixed, and in con-
junction with the general signs of pneumonia,
may be considered as quite pathognomonic ; and
as its presence is much more constant than that
of the expectoration, it may be considered as the
more available diagnostic sign. Laennec consi-
dered it the most important of all physical signs,
" inasmuch as it is invariably present, and from
the very invasion of the disease ; and exists in no
other case, except in oedema of the lungs and pul-
monary apoplexy, two diseases which are easily
distinguished from this by their own peculiar
signs and symptoms. M. Andral is mistaken in
saying that the crepitous rattle sometimes exists
in acute bronchitis, (Clin. Med. torn. 2. p. 333,)
and I think this is evident from his own cases.
From its constant presence in this disease, I re-
gard it as the most practically useful of all the
stethoscopic signs, inasmuch as it points out, in
its very earliest stage, one of the most severe and
most common diseases, and thereby enables the
physician to apply his means with much more
chance of success than he could have done even
a few hours later." (Dr. Forbes's Transl. p. 213.)
M. Piorry has lately questioned the pathognomo-
nic relation of the crepitant rhonchus to pneumo-
nia, not from observation of disease, but from the
circumstar.ee that a crepitation like it may be pro-
duced on applying the stethoscope to a lung out
of the body. (Gazette des Hopitaux, t. 6. No.
116.) Such an hypothetical objection cannot,
however, be entertained, in opposition to the mass
of evidence in corroboration of Laennec's opinion,
and we have already explained how the artificial
crepitation in question is produced. (See page
606.)

The preceding characters will be quite sufficient

to distinguish recent pneumonia from pleurisy.
In the latter the sound of respiration is unaccom-
panied with a rhonchus, and is only rendered
weaker, first by the pain restraining the respiratory
movements, and afterwards by the liquid effusion
pushing aside the lung. There is sometimes dul-
ness on percussion in the early stages of both
diseases; but in pneumonia this dulness will be
found to be fixed in the spot where the crepitant
rhonchus is heard ; in pleurisy, on the other band,
it generally occupies the most dependent part, and
changes with a change of posture. This lust
criterion, which is very easily applied, is sufficient
to discover moderate pleuritic effusions in every
case except in that of the effusion being limited
by adhesions of the lung to the ribs. This
a?gophonic resonance of the voice, when perfect,
is another sign equally distinctive of pleurisy ;
but as for its production there must be only a
certain thickness of the layer of fluid, its presence
is often of short duration, and it may thus escape
detection. The diagnosis between these diseases
is much more difficult in their advanced stages,
particularly when they are extensive. Thus it
may happen that we are called to see a patient
who has been ill for a considerable number of
days, and who has had more or fewer of the equi-
vocal general symptoms which are applicable to
either pleurisy or pneumonia; by auscultation we
find no sound of respiration in one side of the
chest, which is also quite dull on percussion.
The question then presents itself — is the case one
of pneumonia, with the whole lung in a state of
hepatization, or is it a case of pleurisy, acute or
chronic, with a very extensive effusion ? These
difficulties have been sagaciously pointed out by
Dr. Stack, (Dublin Hosp. Rep. vol. iv.) and we
admit them to be sufficient to mislead any but a
very careful observer. But an attentive consider-
ation of the previous history, and a minute exam-
ination of the physical and some general signs,
will, we believe, always furnish us with a correct
diagnosis. We have in two instances been mis-
taken, but we refer our error rather to the insuf-
ficiency of our examination than to an absence
of diagnostic signs ; and these cases, which oc-
curred in dispensary practice, presented a rare
combination of deceptive circumstances. The
most obvious distinction between a hepatized lung
and copious pleuritic effusion is the constant oc-
currence, in the former case, of a loud and almost
pectoriloquous bronchophony under the scapula,
along the spine, and below the clavicle, and the
general absence of this sign in the latter. This
test would have been sufficient to distinguish the
case cited by Dr. Stack as one of peculiar diffi-
culty ; the absence of this resonance clearly
proving it to be pleurisy and not pneumonia.
The presence of this bronchophony is not, how-
ever, an equally sure proof that the lung is hepa-
tized. In one of the instances before alluded to,
with a perfect deadness of sound on percussion
over the whole of the right side of the chest, a
bronchophony and bronchial respiration were
heard between the scapula and spine and below
the clavicle on this side, from which we too
hastily concluded the disease to be pneumonia;
on dissection it proved to be pleurisy, the right
thorax being full of serum and lined with a dense

PNEUMONIA.

617

false membrane ; the lung was compressed by the
affusion into a mass which adhered by solid pil-
lars to the upper part of the cavity under the
clavicle and to the posterior part exactly in the
points where the bronchophony had been heard.
These adhesions were obviously the cause of the
sign which misled us ; and as the possibility of
their occurrence in other cases must detract from
the certainty of its indications, we must seek for
further means of distinction. In copious pleuritic
effusion there are commonly several signs of dis-
placement, which are absent in hepatization of
the lung. Thus the affected side is commonly
enlarged, as can be ascertained both by inspection
and admeasurement. By viewing or feeling both
sides of the chest at the same time, if there is no
obvious enlargement, it may be perceived that the
affected side does not partake, equally with the
sound side, of the respiratory movements ; it re-
mains stationary in a fixed state of distension,
and this in a more remarkable degree than occurs
with a hepatized lung. The intercostal spaces
are also more prominent on the affected side,
which gives it a more rounded appearance ; this
character readily distinguishes pleuritic effusions
from hepatization in thin subjects, but it fails
where the integuments are fat or cedematous. Dr.
Stokes has pointed out some other means of dis-
tinction, founded on the same circumstance of
displacement, which occurs exclusively in pleu-
risy. (Dublin Med. Journal, March, 1833.) If
the disease occupy the left side, a copious pleuritic
effusion will generally displace the heart, which
will be heard and felt pulsating, not in its usual
place, but to the right of the sternum ; in pneu-
monia the pulsations are not displaced, but they
arc uncommonly audible throughout the affected
side. If the disease be on the right side, an effu-
sion will push down the liver, and make it per-
ceptible below the false ribs; it will also press
aside the sternal mediastinum, so that the whole
sternum would sound dull on percussion; in
hepatization of the whole right lung there is
neither displacement of the liver nor of the me-
diastinum ; and as the resonance of the sternum
on percussion depends on portions of both lungs
beneath, its right half would yield a dull and the
left a clear sound. By some or other of these
distinctive marks we may venture to assert that a
pretty certain diagnosis between pneumonia and
pleurisy may always be obtained. For further
particulars on this point we refer to the articles
Pleurisy and Empyema. The distinction of
slight degrees of pleurisy accompanying pneu-
monic inflammation will depend on the circum-
stances that change of posture modifies the sound
on percussion, rendering the dependent parts the
least sonorous, and that the bronchophony is ren-
dered bleating or vibratory whenever a thin stratum
of liquid is interposed between the pleura. Pleu-
risies circumscribed by adhesions are scarcely to
lie recognised unless when sufficiently extensive
to cause a fulness of the intercostal spaces. But
as we have before remarked, the pleurisies super-
vening on pneumonia generally are of secondary
importance, and their detection is not an object of
great interest.

Bronchitis in its severer forms is frequently
confounded with pneumonia ; it is often by the

Vol. Ill — 78 3 B *

physical signs only that they can be distinguished
with certainty; and even these sometimes fail to
detect a latent pneumonia in combination with
bronchitis. In pure bronchitis no crepitant rhon-
chus occurs, but there may be a variety of mucous,
sibilant and sonorous rhonchi. The distinction
of these from the pure crepitation of peripneu-
mony is sufficiently obvious, but it is not so easy
to distinguish this crepitation when it is mixed up
with the other rhonchi. In these difficult cases
we must look more to the expectoration, progress
of the symptoms, and state of the countenance.
With respect to the latter indication, as a diag-
nostic mean in bronchitis, pleurisy, and pneumo-
nia, we have received some valuable hints from
Dr. Stack, (Dublin Hosp. Rep. vol. iv. p. 90, et
seq.) although we can scarcely accede to his
opinion that it is generally more sure than the
physical signs. In pleurisy, either the face is
flushed, and the lips are florid, or their appearance
is not changed from that of health. In humid or
severe bronchitis, the parts of the face usually
coloured and the lips are more or less blue or
livid, according to the extent of the bronchial
membrane affected, and the quantity of secretion
in them, which prevents the oxygenation of the
blood. The flush of pneumonia is different from
either, being an intermediate shade of purplish
red. There is no correspondence between the
flush often observed in one cheek and the side
affected, and the flush often shifts from side to
side. In pleurisy and bronchitis, the colour in
the lips and cheeks is commonly circumscribed,
the other parts being uncommonly pale ; but in
pneumonia the redness, when present, is more
suffused over the whole countenance. These
variations of colour, which seem to depend on the
degree in which the functions of arterialization
and circulation of the blood are respectively affect-
ed, may assist us in doubtful cases in forming a
diagnosis, but we have seen them fail too often to
place implicit reliance on them. In the advanced
stages of pneumonia, bronchial resonance and re-
spiration and the perfect dulness on percussion
sufficiently distinguish it from bronchitis, in which
the mucous rhonchus and a considerable clearness
of sound on percussion persist until the last. Dr.
Stack, indeed, cites a case of humid bronchitis, in
which, a few hours before death, the chest yielded
no resonance ; but no such example has been else-
where described, and the anomaly must be at-
tributed to the moribund state of the patient, and
the imperfect entrance of air into the lungs at
that period.

The physical signs of extensive pulmonary
apoplexy sometimes approach closely to those of
peripneumony, there being in the spot affected a
dulness of sound on percussion and absence of
the respiratory murmur, surrounded by a crepitant
rhonchus. The absence of fever, however, and
the presence of hemoptysis will generally be suffi-
cient to characterize the former disease; and, by
referring to its history, it may be perceived that
there is commonly much difference in the origin
and progress of the two complaints. An inflam
mation of the tissue of the lung is sometimes
engrafted on apoplexy of the organ, and it will
then be more difficult to distinguish; but the
access of feverish heat, the increase of the crept

618

PNEUMONIA.

tant rhonchus, and the viscidity of some portion
of the sputa, will generally give evidence of the
complication.

Combinations of several affections of the chest
will sometimes, more closely than simple diseases,
simulate pneumonia. (Edema of the lungs com-
bined with pleurisy or even pleurodyne, may
produce physical signs resembling the first stage
of peripneumony, and a similarity in many of the
general symptoms increases the difficulty of the
diagnosis : the different character of the expecto-
ration, and the history and progress of the case,
are the means of distinction most to be relied on,
and an attentive examination of these will seldom
fail to lead to a correct decision. It is sometimes
more difficult to distinguish between chronic indu-
ration of the lung, whether from chronic peri-
pneumony, agglomerated tubercles, or melanose
formations, and the hepatization of local acute
inflammation supervening on phthisical disease.
If the case has been watched, the attack of the
Jatter affection must have been marked by some
augmentation of the fever and dyspnoea, and the
physical signs of the first stage would have further
characterized it ; but if the hepatization is com-
plete before the first time of examination, we
must remain for a time in doubt. These local
hepatizations are sometimes formed and reabsorbed
without much aid from treatment, and it is there-
fore less important to distinguish them than the
inflammatory stage which precedes them, and
which is, as we have just observed, cognizable by
its peculiar signs.

In fine, we would recommend the student to
found his diagnosis as much as possible on a
knowledge of the true characters of disease, rather
than to any detailed distinctions which can be
comprised in a treatise. The varieties and com-
plications of diseases are too numerous to be
capable of adaptation to any fixed rules of diag-
nosis ; but when the mind of the observer is fully
imbued with the principles of a true pathology,
his judgment will find in any combination of
phenomena some means of distinction less fallible
than the memory can ever .'.urnish from the most
minute exposition of possible cases.

Prognosis* — The remark which we have just
made on the subject of diagnosis may with nearly
equal force be applied to the prognosis, or estimate
of the severity and p.obable issue of the disease.
Our study of the pathology will lead us to form a
correct opinion more surely than any enumeration
of good or bad signs. The prognosis of this dis-
ease is always serious, and even in favourable
cases must be spoken of with caution, for cases,
which are slight at first, sometimes take an un-
favourable turn ; and in progress towards recovery,
as long as the disease lasts, there is a chance of a
relapse, which may throw the patient into new
and peculiar danger. The circumstances of the
pathology of a case which affect the prognosis, are
the degree of the inflammation, its extent, its seat,
its complication with other affections, and the
condition of the various functions of the body.

[The average duration of pneumonia is from
twelve to twenty-four days. At times it continues
only two or three days ; at others, it may go on
for thirty or forty. Of 78 cases observed at the
Hospital La Charite, Paris, between the years 1821

and 1827, twenty -eight, according to M. Louis,
proved fatal.]

As is the case with other inflammations of im-
portant organs, the continuance of the diwaM
increases its mischief and danger as it injures the
organization of the part ; hence the prognosis is
more serious if hepatization has taken place, and
still more so if the signs seem to indicate the
supervention of the third stage. The duration of
these stages varies very considerably according to
the effect of the treatment and the age of the sub-
ject. Laennec states the average proportion to be
as follows : " The obstruction, or first stage, usu-
ally lasts from twelve hours to three days before
passing to the state of complete hepatization : this
lasts from one to three days before spots of puru-
lent infiltration make their appearance ; and the
period of suppuration (from the time when the
concrete purulent infiltration is distinctly percepti-
ble until this is completely softened into a viscid
fluid) varies from two to six days. Bloodletting,
derivatives, and resolvents or stimulants of the
absorbent system, obviously retard the progress
of the disease, and consequently prolong the
period of the first two stages. Convalescence is
rapid in proportion as the inflammation is of small
extent and has been early checked." (Op. cit.
p. 211.)

We have already had occasion to remark that
in children the inflammation continues for a much
longer period in the first stage ; after some weeks'
duration, presenting only some hepatized points
at the margin of the lung or in isolated lobules.
Laennec has observed the same peculiarity in
certain epidemics, as in the grippe of 1803, when
he noticed the first stage to continue for seven or
eight days, sometimes affecting the whole of one
lung, and part of the other, and proving fatal be-
fore any distinct hepatization occurred. We have
before mentioned, on the other hand, the remark-
able tendency of the inflammation in old and
debilitated subjects to pass rapidly to the state of
purulent infiltration ; the author just named de-
scribes this to take place sometimes within thirty-
six or even twenty-four hours. Recovery is some-
times affected by resolution and reabsorption from
every degree of pneumonia, but the chances of
this favourable termination are very small when
the signs of hepatization have continued for such
a length of time that purulent infiltration has
probably occurred. Even simple hepatization re-
quires time and favourable circumstances for its
removal ; for besides that the deposited matter
obstructs the due function of the part, and thereby
prevents the restoration of the balance of health,
it likewise remains as an irritating cause, giving
a proclivity to the recurrence or continuance of
inflammatory action. Unless, therefore, the ten-
dency to this be kept in a state of subjection, and
the process of absorption be perceptibly gaining
ground, the prognosis must continue to be doubt-
ful. The supervention of gangrene will always
increase greatly the danger of a case. If the
gangrene is extensive, it must inevitably prove
fatal ; and where small and circumscribed, if the
powers of the system are weak, they can scarcely
be sufficient to support life until the noxious dead
matter is thrown off; if, however, the pulse and
muscular system show still considerable strength,

PNEUMONIA

619

this process may be happily effected, and there
are recorded instances of recovery even from the
gangrenous termination of pulmonary inflamma-
tion. An interesting case of this kind recently
fell under the observation of the writer in conjunc-
tion with Dr. Chambers and Mr. Jay of Sloane-
street, and was watched with great interest during
a doubtful period of several days ; the inflamma-
tion in the second state affected the right lung,
and signs of excavation (concluded to be gan-
grenous from the odour of the expectoration) were
heard at the inferior angle of the scapula ; the
case was greatly aggravated by the sudden super-
vention of a pleurisy on the left side, excited pro-
bably by the irritation of gangrenous matter in
the circulation. This new attack, and the deple-
tions necessary to subdue it, greatly increased the
danger ; but the powers of life ultimately pre-
vailed ; the expectoration became less fetid, more
purulent and abundant, and after some time gra-
dually ceased under the influence of a mineral
acid; the cavity progressively diminished was at
length cicatrized, and the patient, in three weeks
from his worst state, was quite convalescent.

The extent of the inflammation, as may be
anticipated, greatly affects the danger of a case.
A double pneumonia affecting both lungs at once
is frequently fatal, even in the first stage ; and
whenever the whole of one lung is involved, there
is much peril of an unfavourable issue. Cases do
occur, however, although rarely, in which the
gravity of the case does not bear proportion to
the extent of the inflammation ; and these ano-
malies in great measure depend on the natural
capacity of the function of respiration in the indi-
vidual, and its power to bear abridgment. Thus
we sometimes see a pneumonia of small extent
occasion orthopncea and other symptoms of a
severe case ; whilst in another example ausculta-
tion may indicate that nearly a whole lung is
involved, yet the patient is scarcely sensible of
dyspnoea, and the other functions are not greatly
disordered.

Inflammations attacking the superior lobes and
root of the lungs are more fatal than those con-
fined to the base or lower lobes ; and this circum-
stance explains the discrepancy of authors, before
noticed, respecting the comparative frequency of
inflammation in these different parts. The cause
of the difference appears to be, that disease of the
upper portions and root of the lungs obstructs the
passage of blood and of air in the larger vessels,
so that the peripheral parts unaffected with in-
flammation do not receive their due supply.

The complication of pneumonia with other
affections generally increases the danger of a case :
thus peripneumonies supervening in the course of
fevers and the exanthemata are generally of a se-
rious nature ; and the more formidable because
they are often latent. Inflammatory affections of
the gastro-intestinal canal, coinciding with pneu-
monia, render it less tractable and more danger-
ous; and the same may be said of bronchial, peri-
cardial, meningeal, and peritoneal inflammations.
Pleurisy, as we have seen, may diminish the in-
tensity of the inflammation, if it is on the same
side; but if it attacks the opposite cavity, it must
aggravate the functional disorder. Pneumonia
occurring in the course of phthisical disease is

seldom severe in itself, but it has a tendency to
accelerate the development and softening of the
tubercles. This inflammation is more than usu-
ally fatal during pregnancy and in the puerperal
state. It is especially dangerous at the extremes
of life, more particularly in weakly infants and in
cachectic old people, and those exhausted by habi-
tual excesses ; and the fatality is much greater
among the lower classes than among those well
and regularly fed and clothed. Mr. Chomel ob-
serves that the mortality in hospitals amounts to
a fourth of the cases, which is considerably more
than what occurs in private practice. The same
physician gives the following statement respecting
the influence of age in the mortality of pneumo-
nia : in seventy-nine cases, of thirty-three at ages
between 18 and 30 years, three died; of nine aged
from 30 to 40, two died ; of eleven aged from 40
to 50, five died ; of fifteen aged from 50 to 60,
eight died ; of eight aged from 60 to 70, four died ;
and the three cases which occurred beyond the
age of 70, all terminated fatally. (Diet, de Med.
t. xvii. p. 233.)

The state of the functions in pneumonia, al-
though it is not sufficiently constant to be of
much use in determining the diagnosis, is often
an important guide to the prognosis of individual
cases. Thus a severe degree of dyspnoea, when
constant, increasing and unyielding to treatment,
may justly excite our serious alarm ; and the more
so as it is conjoined with a state of the circulation
which betokens a continued predominance of irri-
tation, or a failure of functional strength. Thus,
when in a case of severe dyspncea the pulse is
very quick, as above 120, without much strength,
there may be reason to fear that the system may
not bear the treatment necessary to arrest the
course of the disease, and our opinion must be in
a proportionate degree apprehensive: the know-
ledge, through the physical signs, that the inflam-
mation in its second stage is the cause of this
state of the symptoms, will diminish our hopes, as
we know it to be then less within the power of
medicine ; and when the pulse becomes small,
weak, and intermitting, the danger may be consi-
dered imminent. There may, however, be exten-
sive and serious disease without exciting this com-
bination of symptoms; and although their presence
positively indicates danger, their absence does not
always represent safety. An obstinate cough, with
scanty or difficult expectoration, is an unfavourable
symptom, both because it indicates that there is no
vicarious relief from the bronchial mucous mem-
brane, and because the very exertion of coughing
never fails to aggravate the disease and wear the
strength. The character of the expectoration is
one of the most valuable indices which we possess
for the estimation of the gravity of a case. In
simple pneumonia the viscidity and rusty tinge
of the sputa are in exact proportion to the inten-
sity of the inflammation, and their increase in
quantity and diminution in tenacity and colour
are the common attendants of its resolution.
Scantiness or absence of expectoration, when
other signs prove the existence of a considerable
inflammation, is a bad sign, for the reason before
mentioned. Dirty or brown watery sputa, and
those containing pus, import great danger, inas-
much as they indicate the probable supervention

620

PNEUMONIA.

of the third stage, and a gangrenous odour gene-
rally implies a state of great peril. The indica-
tions of the expectoration are rendered less certain
when bronchitic or catarrhal disease is combined
with the pneumonia ; and the same remark may
be applied to the complication with phthisis. The
sudden suppression of expectoration is generally
an unfavourable symptom ; it is peculiarly so
when auscultation discovers a general mucous
rhonchus in the chest, because it proves that the
muscular powers are inadequate to expel the ac-
cumulating matter from the bronchial tubes ; and
a suppressed secretion of sputa, unless it is the
obvious result of a diminution of the inflamma-
tion, generally tends to increase it. Pneumonia
is frequently resolved without any increase of the
expectoration ; but when this increase does occur,
it always has a favourable influence, and contri-
butes greatly to the cure. A dry harsh state of
the skin often attends bad cases complicated with
gastric disease, with a loaded parched tongue,
great thirst or sickness, and tenderness of the epi-
gastrium. A moderately perspirable skin is the
most favourable state ; profuse perspirations some-
times occur in fatal cases. The same has been
remarked of diarrhoea ; yet, as we have before
mentioned, both these discharges occasionally
prove critical ; it is expedient therefore to hold in
view, what we have before suggested, that they
are to be considered as critical only when they
accompany a manifest improvement in the other
symptoms. A copious deposit in the urine may
generally be viewed as a favourable sign ; and the
observation of Hippocrates seems to be commonly
true, that if, after having been turbid, the urine
becomes clear before the fourth day of the inflam-
mation, a fatal tendency may be apprehended.
Delirium is generally considered to be a symptom
of great danger, and it is the more so when it is
constant, and not merely the temporary effect of
the nightly febrile exacerbations; but in hyste-
rical females it is often the effect of the treat-
ment, and portends no evil. A comatose or
lethargic state is an equally fearful case, as it
shows that the functional disorder has already
greatly encroached on that strength which is re-
quired to bear the treatment necessary for the re-
duction of the inflammation. The continuance
of the various symptoms of inflammation without
abatement, notwithstanding the administration of
the proper remedies, is always a just reason for
apprehension as to the issue.

[Statistical investigation has shown, that pneu-
monia proves fatal in an increasing proportion
after the 20th year, infancy being excepted. Cho-
mel (art. Pneumonie, in Did. de Med. xxv. 200,
Paris, 1842,) found the mortality of persons below
20 to be, at the Hotel Dieu, in a period of ten
years, from 1832 to IS 12, in persons from 15 to
20 years of age, 2 in 59, and in both of the fatal
cases the individuals were enfeebled by anterior
diseases ; but between 20 and 40 it rose to 1 in 8 ;
and between 40 and 60 to 1 in 5. It would seem
that females are much less favourable subjects for
the disease than males, — the mortality in the
former being, in the experience of M. Grisolle,
(Op. cit.) from one-third to one-half greater.]
IV. — Treatment of Pneumonia.

In our examination of the pathology of this

disease we found ample proofs that it is an inflam
mation largely affecting the system of blood-ves-
sels, and that, whatever share nervous irritation
may have in exciting or supporting it, the
sels are its peculiar seat, and through them is
produced its peculiar mischief. We have more-
over seen that in the greater number of cases ;i
congested state of these vessels is the immediate
effect of the application of the exciting cause,
and precedes that complication of nervous and
vascular motions which constitutes reaction and
inflammation : we have likewise had many occa-
sions to perceive the serious relations which the
disease when formed bears to the two functions
most essential to life, respiration and circulation ;
and the result of all these investigations is to lead
us rationally to the recommendation of that mode of
practice which the experience of ages has already
sanctioned. Pneumonia in its acute form may be
called an exquisite type of inflammation, and it
is, more than most other inflammations, the proper
object for those measures which are called anti-
phlogistic, and of which bloodletting is the chief.
The treatment of other inflammations may require
modifications and qualifications because the ves-
sels which they affect may be related to a secretory
function, or they may be small and unimportant,
or there may be more of nervous irritation than
of vascular orgasm, or there may be a coexisting
depressing influence in the system ; and thus it is
that in inflammations of the mucous membranes,
of glands, of cutaneous and muscular tissue, of
tendons, fasciae, and nerves, and, in some cases, of
serous membranes, bloodletting is less effectual,
and requires more limitation than in the disease
which we are now considering. This measure,
it is true, is not all-powerful in pneumonia, but
there are few practitioners who do not admit it to
be by far the most important in the early stages :
we shall see the limits of its efficacy in rationally
examining the subject. Every one who has
studied the phenomena of inflammation must be
aware that they do not depend entirely on the
quantity of blood in the system ; and although
we greatly reduce this, we may still leave unaf-
fected the state of the inflamed vessels, which re-
mains as a present cause of disorder to the func-
tion of the part, and the focus of a speedy return
of inflammatory reaction. This may be said of
pneumonia even in the first stage ; but the second
is obviously still less under the control of blood-
letting, which, although it may act favourably in
preventing an increase of inflammation and in
reducing the mass of fluid to pass through the dis-
abled organ, has little or no effect on the solid
effusion which now constitutes the organic mis-
chief. Here, then, we have to seek for other
remedies to aid the operation of bloodletting, and
to resort to where its beneficial operation ceases ;
and it is an advantage, which modern medicine
has to boast of, that it does possess means which
are of considerable efficacy in fulfilling these in-
tentions. We are not sufficiently assured of the
mode of operation of some of these remedies to
be able to class them with certainty as fulfilling
specific therapeutic indications, and we shall there-
fore act more safely by adopting a more empirical
course ; first describing them under their respective
names, and afterwards considering their com-

PNEUMONIA.

621

binod application in the treatment of individual
ca»es.

bloodletting. — Almost all medical writers, an-
cient and modern, concur in their testimony as to
the advantages of this measure in pneumonia ; so
that even Laennec, who depended on it much less
implicitly than most others, said that " its em-
ployment had been proscribed only by some few
theorists and medical heretics." (Dr. Forbes's
translation, second edit. p. 244.) But there is a
considerable diversity of opinion as to the extent
to which it ought to be carried, the period of the
disease during which it is beneficial, and the best
method of practising it. Many ancient physi-
cians, and Galen among the number, recommended
the bleeding in pneumonia to be carried to syn-
cope, whatever be the period of the disease ; and
this practice has been followed by many of the
present day, especially in this country. Cullen
advises that blood be drawn either until there be
remission of the pain and relief of the respiration,
or, if these do not appear, until symptoms of a
commencing syncope come on. This, we believe,
is the plan most commonly pursued in this coun-
try, and at this first bleeding a quantity varying
from sixteen to forty ounces of blood may be taken
before either of these effects is produced. By
some practitioners a much larger quantity has
been taken without inducing syncope, even to the
amount of seventy or eighty ounces ; but we con-
sider it doubtful whether it is ever advisable to
exceed the highest quantity before stated. Cul-
len observes that a first bleeding, however large,
will seldom prove a cure of the disease, and as the
pain and other symptoms recur, the measure must
be repeated, even in the course of the same day,
to as full an extent as before ; and although its
greatest efficacy is in the first three days, this re-
currence will make a repetition of the measure
proper at any period of the disease, especially
within the first fortnight. With this practice may
be contrasted that of many continental physicians,
who never take more than twelve or sixteen
ounces daily, and limit the bleeding to the first
two or three days, under the apprehension that
larger and later depletions interfere with the natu-
ral crisis of the disease. We even find Pinel and
Brichetau strongly deprecating the free use of the
lancet, and inculcating the precepts of Hippo-
crates, Stahl, Boerhaave, and Van Swieten, to treat
mild peripneumonies only by diluents, expecto-
rants, fomentations, pediluvia, and abstinence ;
and declaring that one or two bleedings at the
commencement are all that are generally useful in
the severer cases. It is a satisfactory proof of the
superiority of the English method of practice to
find that the best authorities in France now advo-
cate free depletions much more than formerly.
AnJral and CI omel recommend bloodletting to
sixteen or twenty ounces, practised, if necessary,
two or three times a day during the first days of
the disease, and more moderately afterwards.
Some of their countrymen still more recently have
prescribed two or three pounds to be drawn every
welve hours at the commencement of the inflam-
mation, and if the dyspnoea continues, eight to
twelve ounces daily afterwards. We may remark,
as a partial excuse for the tardy adoption of these
more energetic measures by continental practi-

tioners, that probably many of the mild peripneu-
monies, described formerly as cured without bleed-
ing, were in reality cases of bronchitis, and that
an improved pathology and method of diagnosis
have proved to them what pneumonia really requires.
We now know fully, and we are indebted prin-
cipally to our foreign brethren for this knowledge,
that pneumonic inflammation tends much more
strongly to effusion and disorganization than to
resolution ; and our study of the pathology has
pointed out, in a very striking manner, that the
spontaneous relief of an extensive plexus of ves-
sels gorged with blood, and under the immediate
influence of an irregularly excited heart, is too
improbable an event to be thought of otherwise
than as an exception, the general rule being to an
increase of the engorgement, and a progressive
encroachment on the proper state and office of the
organ. Expectant medicine, in such a case, is
therefore both irrational and dangerous.

There are, we presume, no practitioners in this
country who question the superior utility of free
bloodletting, as early as may be after the develop-
ment of the inflammation ; and it is generally ad-
mitted that the measure is more effectual when the
blood is drawn from as large an orifice and as
speedily as possible. Tho impression on the cir-
culation is thus more readily produced, and at less
expense of blood, than where the aperture is
small and the detraction more gradual, scantier,
and more frequently repeated. With a view to
this effect, Aretasus advised that a vein in each
arm should be opened simultaneously, and this
plan was adopted by Huxham and Husson.
There is, however, a limitation to the advantage
of this sudden impression on the system ; and
this limit seems to us to depend on the degree in
which the disease has become fixed in the pulmo-
nary vessels. In the first hours of the inflamma-
tion such a sudden loss of blood in the semi-erect
posture as will make the pulse soft and weak, and
induce some feeling of faintness, will often restore
the balance of the circulation, and enable the in-
flamed vessels to recover their wonted calibre ; so
that, although some general reaction follows the
approach to syncope, the seat of the disease does
not suffer from its effects. But if the inflamma-
tion has subsisted longer, the inflammation is
rarely thus cured by a single bleeding ; the vessels
of the lungs remain distended although syncope
be induced, the depressing effect of the depletion
is of short continuance, and the returning reaction
brings back the inflammation in its former charac-
ter. On this account, when the inflammation has
lasted more than twelve hours, we are distrustful
of a syncope induced by a small bleeding, and we
have generally found it necessary to repeat the
venesection sooner and more frequently than
where more blood has been drawn at first, and
only a tendency to faintness produced. Cullen
has justly remarked that many persons faint even
upon a small bleeding, and as this may prevent
the drawing as much blood at first as a pneumonic
inflammation may require, it is the more necessary
in these cases to repeat the measure more largely
afterwards. Early fainting should therefore bo
rather avoided than desired, and if the patient
feels it approaching when only a few ounces have
been extracted, and little relief is manifested in

022

PNEUMONIA.

the symptoms, it is expedient to stop the orifice,
and to let the patient lie down for a few minutes,
which, with the aid of a little cold water and a
smelling-bottle, will restore the circulation to a
state in which it will bear the necessary depletion.
The quantity to be drawn may vary in different
adult subjects according to the age, constitution,
extent of the inflammation, &c, from twenty to
forty ounces. If it is known that the patient
bears bleeding well, the larger the orifice and the
speedier the loss of blood the better ; but nervous
subjects, and those liable to palpitation and faint-
ing fits, must be coaxed more gradually to bear a
full depletion, and guarded from a fictitious syn-
cope by the horizontal posture. If these precau-
tions are neglected, the disease will continue to
gain ground in spite of the apparent impression
on the circulation, and each hour lost will dimi-
nish the beneficial influence of subsequent deple-
tory measures. Much discretion is required in
determining the quantity of blood to be drawn,
and this determination can never be satisfactorily
made beforehand ; within the limits just named,
therefore, the immediate effect of the operation is
the only sure guide. In the first stage of the in-
flammation, whilst the crepitant rhonchus prevails,
and there is little or no dulness on percussion,
bloodletting shows its greatest efficacy, and the
more so even when this stage is recent. Hence,
as we have already remarked, one full, speedy
bleeding of thirty ounces, or thereabout, instituted
within the first few hours, will often prove suffi-
cient to destroy the orgasm, and relieve entirely
the dyspnoea and pain ; the remaining quickness
of pulse and cough yield to subsequent milder
treatment; and the knowledge of its superior effi-
cacy at this time may authorize us to carry the
depletion beyond the point of producing relief to
the symptoms, and even to the verge of syncope.
After the first twelve hours have elapsed, and
when the stethoscope discovers no remains of re-
spiratory murmur mixed with the crepitant rhon-
chus of the affected part, there is little chance that
a single bleeding will prove sufficient ; and al-
though, when well borne, it may be carried to
forty ounces, more regard must be paid to avoid
syncope than in the first instance. This is the
more necessary when the crepitant rhonchus is on
the decline and becomes mixed with bronchophony,
and the part sounds dull on percussion, signs
which prove the transition to the second stage.
As this becomes formed, as the disease obtains a
physical hold of the part, full and sudden impres-
sions on the circulation lose much of their benefi-
cial influence ; and they are to be sought for only
when the first stage of inflammation still prevails
and spreads in another part of the pulmonary tis-
sue. If we are called to a patient with a lung
already hepatized, and on whom bloodletting has
not yet been practised, it is generally advisable to
bleed, but not with an expectation of complete re-
lief to the symptoms, or with a view to reduce the
pulse ; the solid effusion constitutes a material
cause of the dyspncea, which no bleeding can re-
move ; and the heart, although sometimes quieted
by diminishing the load which it has to propel
through an obstructed organ, often becomes more
irritable, and rises both in force and in frequency.

If the bleeding is carried to syncope at this stage,
it is commonly succeeded by a reaction, which
aggravates the dyspncea and adds to the disorder
of the hurried circulation. Bloodletting is not
the chief remedy in this stage, and, even where
used for the first time, it should be restricted to
the object of aiding other measures, and not
pushed to the length of inducing syncope.

All the advocates of bleeding in pneumonia
admit the necessity of repeating the measure in
case of the continuance or recurrence of the
symptoms of inflammation, and it is in the steady
and discreet perseverance in this measure, not-
withstanding a variety of phenomena which may
seem to oppose it, that the scientific and expe-
rienced physician shows his skill and proper
firmness. . The temporary relief afforded by the
first bleeding may have given place to an aggra-
vated dyspncea, and the pulse may have become
weak, contracted, and very quick ; symptoms of
great debility may have shown themselves ; and
the patient may express feelings of faintness and
exhaustion, which seem to be further evinced by
his indisposition to any exertion or movement
unconnected with his efforts to breathe. This
array of discouraging indications deters the timid
practitioner from again resorting to the lancet, and
he finds in certain authors a sanction for a supine
course, in their cautions, that if the bleeding be
pushed far, the disease will become typhoid, the
expectoration arrested, and the frame thrown into
a state of hopeless debility. As long, however,
as the physical symptoms indicate the continuance
of the first stage of inflammation, except in a few
cases to be presently noticed, there should be no
hesitation freely to repeat the bloodletting any
number of times until the symptoms are relieved ;
and it has been proved by ample experience that
this treatment, instead of giving rise to a typhoid
state, and facilitating effusion, prevents these
events by arresting their real cause, the inflamma-
tion and its extensive injury to the respiratory
function. These are far more formidable and
deadly than the consequences of even an immo-
derate loss of blood, and we can add our testimo-
ny to that of Dr. Mackintosh when, after cau-
tioning against excess in the use of this measure,
he says, " nevertheless I am persuaded from ex-
perience in treating the disease, and from exam-
inations after death, that much more mischief is
done by bleeding too little than by bleeding too
much." (Practice of Physic, vol. ii. p. 424.) It
is the delay or insufficient application of this mea-
sure at first, that often throws the disease into
that apparently typhoid form which has deceived
so many as to its real cause ; and nothing but the
actual experience that the pulse frequently rises
in force and fulness, the breathing becomes easier,
the lethargy or sinking and the anxiety of the
countenance become diminished, and the strength
increased, as the pernicious oppression of the
respiration is relieved by repeated bleedings, can
impress the mind fully with the safety and expe-
diency of the measure. " How often," says An-
dral, " have we not seen bloodletting employed
with the greatest advantage in individuals in whom
the pulse was small and contracted, the face pale,
the extremities nearly cold, the genera) debility

PNEUMONIA.

623

apparently very great, but in whom at the same
time the respiration was greatly oppressed."
(Clin. Med. t. ii. p. 380.)

We do not maintain that there are no cases in
which the disease is from the beginning connected
with a truly adynamic form of fever, and in which
bleeding, even to a small extent, and however
carefully managed, causes faintness without relief.
This occurs sometimes in those whose vascular
system has been greatly debilitated by excess in
ardent liquors, and in those of a strongly scorbu-
tic diathesis; it sometimes prevails epidemically
at the same time as other typhous diseases, and
changes the character of the peripneumonies that
may then happen to prevail. It may be almost a
question whether in these cases the local disease
in the lungs is not rather a congestion of blood
in an altered state than an inflammation, and it
is very commonly the sequel rather than the
cause of the fever. At all events, the impropriety
of the free use of bloodletting is obvious from its
effects, and our chief reliance must be on other
measures.

With regard to the time in which it will be-
come proper to repeat the measure, much will
depend on the severity of the case and the success
and extent of the first bleeding. If this was co-
pious, and produced signal relief to the dyspnoea
and pain, its full effect will not be apparent for
four or five hours, during which time further
benefit may follow from the use of other remedies ;
at the end of that time the patient should be seen
again, and if he should be found still to suffer,
and especially if there have been any increase of
dyspneca, the bleeding must be repeated with free-
dom, either until some relief be manifest, or till
an impression be produced on the circulation. If
the first bleeding failed from the speedy superven-
tion of syncope before much blood was drawn, it
will be necessary to repeat the visit in an hour or
two, and again to make trial of the measure, when
the patient will often be found to bear a much
larger bleeding than at first, and with proportion-
ate and more permanent relief to the symptoms.
The pulse furnishes a much less certain indication
for the use of the lancet than the state of the
breathing, which is the function which we should
be most anxious to relieve. In the first stage it
rarely happens that bleeding will not produce
some immediate relief of this kind as well as of
the attendant pain, and this effect may generally
guide us in the extent to which we may carry the
measure. If, however, although the bleeding
seems little affected, during the flow of the blood
at this repetition of the practice the pulse becomes
very weak, quick, and running, it is expedient to
stop the bleeding and trust to local depletion and
other remedies. It cannot be denied that this in-
tolerance of bleeding shows itself in some rare
instances from the very commencement of the
disease, giving to it the real typhoid type ; this
character, however, has been ascribed to a greater
number of cases than deserve it, and we cannot
be too careful in our endeavour to distinguish the
real from the false cases of vascular debility : the
distinction can seldom be so satisfactorily made as
by the cautious trial of venesection itself. Laen-
nec has, it is true, pointed out one test, which is
sometimes of great use and certainty, in the state I

of the action of the heart as investigated by the
stethoscope ; when, amidst symptoms of general
debility, the pulsations of the heart are heard and
felt more strongly in proportion than the arterial
pulse which they not unfrequently are, especially
under the sternum, there can be no fear of bleed-
ing, however weak the pulse may seem ; but if
they are both weak, the detraction of blood will
almost always occasion complete prostration of
strength. (Op. cit. p. 249.) There is an excep-
tion to this rule in the complication with hyper-
trophy of the heart, in which the pulsations con-
tinue to be apparently strong when the circulation
is really very weak. The palpitation of reaction
after loss of blood in nervous subjects may like-
wise be mistaken for the strong pulsations of
Laennec ; and this error is the more to be avoided
as this reaction often accompanies a state of the
circulation which will not bear bloodletting.* A
good auscultator may distinguish the palpitation
of reaction by its louder sound and more abrupt
but less forcible impulse than those attending the
really sthenic pulsations of the heart; but some
experience in auscultation is required to make
this distinction available in practice. Although,
therefore, this test is very useful in deterring us
from venesection in some cases of real debility,
yet where it seems to indicate the use of this
measure, it must not make us neglect the careful
study of the effects as the blood flows from the
vein.

In the second stage of inflammation, when dul-
ness on percussion and the absence or the bron-
chial character of the sound of respiration indicate
hepatization of the lung, bloodletting loses that
efficacy which entitles it to the foremost place in
the remedies for pneumonia. Some writers, in-
deed, proscribe its use at this period, as injurious
and interfering with the curative process. The
ancient physicians generally renounced bleeding
after the fifth day if the expectoration was abun-
dant, for fear of checking it, and their caution
was followed by most practitioners until the end
of the last century. We can readily perceive that
the efficacy of bloodletting must be very much
abridged by the permanent form which a solid
interstitial effusion has now given to the organic
disease, and therefore it is no longer to be expected
that its repetition, however copious or frequent,
can at once remove the dyspnoea or lower the
pulse ; but in a more moderate degree it is still
useful, inasmuch as it reduces the quantity of
blood which is to pass through the lungs, and
tends to prevent the progress of the inflammation
to the third and more hopeless state, purulent in-
filtration. We find, accordingly, many excellent
practical writers, Stoll, Cullen, Frank, De Haen,
Andral, Chomel, and even Laennec, recommend
the repetition of venesection during the second
and even the third stage, whenever the state of
the breathing, the pain, or the fever seem to re-
quire it. Laennec thought that to bleed to syn-
cope might produce the evil effect of checking the

* In hysterical females especially, this and otliersymp-
tonis of nervous excitement, as pain, delirium, and con-
vulsions, often occur and deceive the unwary as to their
rial cause; they are not dependent on the disease, but
on the loss of blood, and belonging to the class of irrita-
tions of reaction, require sedatives rather than further
depletory measures. "(See Irritation.)

624

PNEUMONIA.

expectoration, apprehended by former writers, and
in this opinion our own experience disposes us to
coincide. If venesection has been freely practised
before, the occasional loss of eight or ten ounces
from the arm, conjoined with local depletions, is
generally as much as is borne well or proves use-
ful, and the further relief of the disease must be
left to other means. In some instances this quan-
tity may be exceeded with advantage, even at this
period, when the stethoscope discovers the develop-
ment of inflammation in a new part. If, like-
wise, bleeding has been neglected, or only sparingly
used before, a larger abstraction is often service-
able, even in the second stage, to remove that
relative plethora into which the obstructed state
of the lungs converts the ordinary fulness of the
vascular system, and hence the great relief that
even at this period general bloodletting sometimes
affords. Here, it may be perceived, there is no
reason for a large orifice or a speedy abstraction
of blood, and these should be the rather avoided,
as the syncope which they may induce is not a
desirable event.

[It is maintained by M. Louis, (Researches on
ike Effects of Bloodletting in some Inflammatory
Diseases, &c, Boston 1836,) from the results of
numerical observations, that the influence of bleed-
ing, when performed even within the first two
days of pneumonia, is less than has been supposed,
and that in general its power is very limited ; that
its effect, however, on the progress of the disease
is found to be happy, and that patients who were
bled during the first four days recovered — other
things being equal — four or five days .sooner than
those bled at a later period. The researches of M.
Louis gave occasion to numerical investigations,
as to the effect of bloodletting in pneumonia on
this side of the Atlantic. (Dr. James Jackson, in
Translation of Louis on Bloodletting, cited above.)
Of 31 cases, treated at the Massachusetts General
Hospital, in three, bloodletting was practised on
the first day of the disease. The average duration
was 131 days. The number of bleedings in each
case was four ; and the average quantity of blood,
abstracted in each, 611 ounces. In 15 cases,
which were bled for the first time, on the first,
second, or third day, the average duration was
12*- days. The same thing was true, with a
slight difference, of 21 cases in which bleeding
was practised on or before the fourth day. In five
cases bled for the first time after the fourth day,
the average period of convalescence was 13i days.
In these 26 cases, the average duration of the
disease was 121 days. In five cases, bloodletting
was not employed, except in one in which six
leeches were applied. The mean duration of
the disease was 14| days. So far, therefore, as
these cases go, it would seem that the effect of
bleeding, on or before the fourth day of pneumo-
nia, is to shorten its course nearly one day, when
compared with the cases in which it was not em-
ployed until after that period. Compared with
those who were not bled, it was shortened a little
more than 2| days. These results are certainly
confirmatory of those of M. Louis, which led him
to infer, that bleeding does not exert so powerful
an effect on pneumonia as is generally believed;
but they are not sufficient to induce us to discard
Ais important remedy, or to place as little reliance

upon it as has been done by some. It is ques-
tionable whether it ever succeeds in cutting the
disease short. The remarks of M. Louis on this
point are very explicit. His conclusion is ; —
"that we cannot cut short pneumonia by blood-
letting, at least during the first days of the disease."
It must be admitted, however, from the testimony
of most observers, that in strong and vigorous
subjects, general bleeding is an important remedy ;
yet it must be equally admitted, from the same
testimony, that it ought not to be practised at all
periods ; and that after the stage of engorgement
has passed into that of solidification, and, a fortiori,
when it has entered that of interstitial suppura-
tion, it may be a very questionable or improper
agent. When the practitioner is called early, a
copious bleeding, which exhibits its effects upon
the morbid manifestations, but short of inducing
syncope, may be sufficient. One single venesec-
tion of this kind, carried to the extent of relieving
the pain in the chest, of permitting the patient to
take in a deep inspiration, and of converting the
small, rapid and oppressed pulse into one that is
large and full — has been found more efficacious
than four practised at a later period. In 180 cases,
according to Dr. Most, (art. Pneumonia, in Ency-
clop, der Gesammt. Medicin. und Chirurg.
Praxis,) it was found necessary in two only to
repeat the bloodletting on the same day, or at the
next exacerbation. Dr. Stokes, too, states, (On
Diseases of the Chest, 2d Amer. edit. p. 307, Phi-
lad. 1844,) that he has found the bold and re-
peated use of the lancet to be unnecessary, and he
is convinced, that, in general, a single bleeding, or
at the most, two bleedings will be sufficient. Out
of many hundred cases he has had only one in
which it was necessary to bleed oftener than twice :
in that instance, there was hypertrophy of the
heart.]

We have said nothing respecting the bufly coat
of the blood as a criterion of the propriety of vene-
section, because we have not observed any con-
stant relation between this sign and the intensity
or even the existence of inflammation. When
the crassamentum is buffed, cupped, and firm,
early in the disease, it may confirm us in perse-
vering in the measure; but in the after stages, the
separation of the fibrine from the colouring matter
may proceed as much from irritation or the use
of mercury as from inflammation, and it is at this
time only that its indications are wanted.

Local bloodletting. — It is obvious that, in the
greater number of cases, the abstraction of blood
from the integuments of the chest can produce but
little impression on a disease that occupies so
considerable a portion of the vascular system as
that extensive tree of vessels which conducts the
smaller circulation ; and accordingly local deple-
tion is but a subordinate measure in the treatment
of pneumonia. [Dr. Stokes, however, (Op. cit.)
considers it the principal remedy.] Many prac-
titioners, however, often employ leeches or cup-
ping as subsidiary to phlebotomy at the com-
mencement of the disease. Thus Andral tells us
that Lerminier often ordered the painful side to be
covered with leeches during the flow of blood from
the vein. This method, it may be remarked, is
better adapted to an hospital, where there are
plenty of experienced assistants, than to private

PNEUMONIA.

625

practice, where one of these operations is enough
at a time : but we have found great advantage in
prescribing local bloodletting in the space of an
hour after general, especially where a stitch in the
side indicated the extension of the inflammation
to the pleura. From twenty to forty leeches fol-
lowed by a large cataplasm, or from ten to sixteen
ounces of blood drawn by cupping, often not only
have the effect of relieving a pain which greatly
aggravates the difficulty of breathing and cough,
but also in some degree prolong the depression
resulting from the general depletion, and prevent
the bad effects of a reaction which sometimes suc-
ceeds to this depression. In aged and exhausted
subjects, and in those cases of real adynamic pneu-
monia which do not bear venesection, this local
bloodletting becomes a principal remedy, and al-
though much inferior in efficacy, and less worthy
of our confidence, it must often be our resource
when the strength would sink under general de-
pletions. In infants the bleeding from leech-bites
is equivalent to a general bloodletting, and below
the age of two years is very commonly substituted
for it. It may be suggested, however, that about
and above this age, when, in the early stage of the
inflammation, the symptoms are pressing, it is bet-
ter to use venesection ; and if there should be any
difficulty in bleeding from the arm, from four to
eight ounces may be taken from the jugular vein
with great advantage ; but if depletion be again
necessary, that by leeches will be generally suffi-
cient. It is sometimes recommended to apply a
leech or leeches to the foot or arm of infants, suf-
fering under inflammatory diseases, because the
bleeding can better be controlled in those parts;
but the greater benefit produced by the depletion
near the affected organ leads us to apply them in
preference close to the sternum, or under the cla-
vicle of the affected side ; we have never experi-
enced any difficulty, when it became necessary,
in stopping the hemorrhage by a compress and
bandage or slips of adhesive plaster. In adults,
when leeches are used as local depletories, the in-
tercostal spaces nearest to the point of pain are
the best place of application ; for contiguity, inde-
pendently of vascular communication, affects the
removal as well as the propagation of inflamma-
tion.

In the second and third stages of pneumonia
local bloodletting may sometimes be substituted
for venesection, on any return of pain or slight
increase of dyspncea which seems to demand more
immediate relief than can be obtained from the
internal remedies or blisters. In slight limited in-
flammations, such as those attacking phthisical
subjects, it is often the only kind of bloodletting
that is necessary.

Tartar-emetic. — Next to bloodletting this remedy
is perhaps the most powerful that we can employ
for the cure of acute pulmonary inflammation. Its
utility in emetic and in nauseating doses had long
recommended it in pectoral complaints, but its
power of subduing acute inflammations independ-
ently of its emetic, nauseating, or diaphoretic
effects, has been only of late years developed.
Rasori of Genoa was the first who established it,*

muMi we yield thus much to a foreigner, we must
ovvr a just claim to priority in practice in ft-
Dr Marrvat of Bristol, who dierl in 17D3. In the

* Althoug]
not pass

vour of Dr. Marry a l .
last edition of his - Therapeutics," published in 1,90, is

Vol. III. — 79 3c

and besides the testimony of many of his own
countrymen in its favour, it has received the high-
est and most unqualified praise from the illustri-
ous Laennec, whose sanction, after the great light
which his labours have thrown on the pathology
of this disease, cannot but command our atten-
tion. Althugh it may fall short of the sanguine
hopes held out by the advocates of this practice
abroad, the experience of many distinguished phy-
sicians in this country tells much in its favour,
and we believe justifies the opinion expressed at
the beginning of this paragraph. The success
which has attended the treatment of peripneumony
by repeated emetics, as recommended by Riverius
and Stoll, probably in part depended on this pecu-
liar action of tartar-emetic ; under this practice in
the hands of Dr. Hellis of Rouen, and some others
in France, the proportion of deaths was consider-
ably less than usual, not exceeding one in nine ;
while the average mortality of the disease, when
treated by bloodletting and derivatives, amounts to
one in six or eight, (Laennec, p. 261) ;'and in hos-
pital practice, and among the lower ranks, it is often
greater. The efficacy of the emetic treatment in
croup, advised by Dr. Cheyne, and in ophthalmia
and in hernia humoralis, probably partakes of the
same principle, and is less dependent on the emetic
than on the contro-sti?nulant or anti-injlammatory
effect of the tartarized antimony. As the subject
of large doses of tartar-emetic has been already
described in the article Inflammation, we shall
here only speak of its application in the treatment
of pneumonia.

Rasori, with whom the regular introduction of
this practice commenced as long ago as the year
1808, gave the medicine in the following manner.
Usually after one or more bleedings, but some-
times without this measure, from twelve to twenty-
four grains, or in severe and advanced cases, from
a scruple to half a drachm were given during the
day, and the same repeated in the night ; these
doses were daily increased until they amounted to
a drachm or several drachms in the twenty-four
hours. The result of this extraordinary practice
was, that out of 832 cases of pneumonia 1 73 died.
Out of 115 cases treated in the same way by
Tomassini of Bologna, only 14 died ; and several
other equally favourable reports are made by other
physicians of Italy. There are, however, counter-

the following passage, in which both the febrifuge virtue
of tartar-emetic, and the tolerance, of the system in re-
gard to it are described. " Any fever may be soon ex-
tinguished by the use of the following powders :— Take
of tartarized antimony five grains, white sugar (or nitre)
a drachm ; let them be well rubbed in a glass mortar, and
divided into six powders ; one to be taken every three
hours, notwithstanding the nausea the first may possi-
bly occasion. If these are taken, (which is commonly
the case) without any manifest inconvenience, let then-
be seven grains in the next six powders ; and in the next
ten. Here I beg to retract what I said in some former
edition of this work, viz. that till sickness and vomiting
were excited, this noble medicine was not to be depended
upon. For I have since seen many instances wherein a
paper has been given every three hours, (of which there
have been ten grains in six powders,) without the least
sensible operation, either by sickness, stool, sweat nr
urine, and though the patients had been unremittingly
delirious for more than a week, with subsultus tendinum
and all the appearances of hastening death, they have
perfectly recovered without any medical aid, a clyster
every other day excepted. I have lately seen a great
many cases similar to the above, and the tartarized an-
timony has invariably produced t lie same effect." — Se»
Medico-Cliirurg. Review, No. 31. p. 253.

626

PNEUMONIA.

statements to oppose to these ;• and, as we had
occasion to observe when speaking of the neglect
of bloodletting, we have no certainty that all the
cases here enumerated were in reality pneumonic.
At all events, later experience has proved that
there is no advantage in the excessive doses here
used, and, on the contrary, that greater success
has resulted from more moderate quantities. The
uncommonly small mortality of only two in fifty-
seven, which Laennec asserts to have attended his
method of exhibiting tartar-emetic, warrants our
quoting his own account of his treatment, which
will likewise show how much confidence he
placed in the measure.

" As soon as I recognise the existence of the
pneumonia, if the patient is in a state to bear
venesection, I direct from eight to sixteen ounces
of blood to be taken from the arm. I very rarely
repeat the bleeding, except in the case of patients
affected with disease of the heart or threatened
with apoplexy or some other internal congestion.
More than once I have even effected very rapid
cures of intense peripneumonies without bleeding
at all ; but in common I do not think it right to
deprive myself of a means so powerful as vene-
section except in cachectic or debilitated subjects.
In this respect Kasori does the same. I regard
bloodletting as a means of allaying for a time the
violence of the inflammatory action, and giving
time for the emetic tartar to act. Immediately
after the bleeding I give one grain of the tartar-
emetic dissolved in two ounces and a half of cold
weak infusion of orange leaf, sweetened with half
an ounce of syrup of marsh-mallows or orange-
flowers ; and this I repeat every second hour for
six times, after which I leave the patient quiet for
seven or eight hours, if the symptoms are not
urgent, or if he experiences any inclination to
sleep. But if the pneumonia has already made
progress, or if the oppression is great, or the head
affected, or if both lungs or one whole lung is
attacked, I continue the medicine uninterruptedly,
in the same dose, and after the same intervals,
until there is an amendment not only in the
symptoms, but also indicated by the stethoscopic
signs. Sometimes even, particularly when most
of the above-mentioned unfavourable symptoms
are combined, I increase the dose of the tartar-
emetic to a grain and a half, two grains, or even
two grains and a half, without increasing the
quantity of the vehicle. Many patients bear the
medicine without being either vomited or purged.
Others, and indeed the greater number, vomit
twice or thrice, and have five or six stools the first
day ; on the following days they have only slight
evacuations, and often, indeed, have none at all.
When once the tolerance of the medicine (to use
the expression of Rasori) is established, it even
■very frequently happens that the patients are so
much constipated as to require clysters to open
the body. When the evacuations are continued
to the second day, or when there is reason to fear
on the first that the medicine will be borne with
difficulty, I add to the six doses to be taken in
the fwenty-four hours, one or two ounces of the

* See an interesting and valuable note by Dr. Forbes,
in bis translation of I.aennec, third edit. p. 269. It con-
tains a succinct history of the new mode of exhibiting
tartar-emetic, and some very judicious comments upon it.

syrup of poppies. This combination is in opposi-
tion to the theoretical notions of Rasori and Tom-
masini, but has been proved to me by experience
to be very useful. In general, the effect of tartar-
emetic is never more rapid or more efficient than
when it gives rise to no evacuation ; sometimes,
however, its salutary operation is accompanied by
a general perspiration. Although copious purging
and frequent vomiting are by no means desirable
on account of the debility and hurtful irritation
of the intestinal canal which they may occasion,
I have obtained remarkable cures in cases in which
such evacuations had been very copious. I have
met with very few cases of pneumonia where the
patient could not bear the emetic tartar ; and the
few I have met with occurred in my earliest trials ;
insomuch that this result now appears to me to
be attributable rather to the inexperience and
want of confidence of the physician, than to the
practice. I now frequently find that a patient
who bears only moderately six grains with the
syrup of poppies, will bear nine perfectly well on
the following day. At the end of twenty-four or
forty-eight hours at most, we perceive a marked
improvement in all the symptoms. And some-
times even we find patients who seemed doomed
to certain death, out of all danger after the lapse
of a few hours only, without ever having ex.
perienced any crisis, any evacuation, or indeed
any other obvious change, but the rapid and pro-
gressive amelioration of all the symptoms. In
such cases the stethoscope at once accounts for
the sudden improvement, by exhibiting to us all
the signs of the resolution of the inflammation.
These striking results may be obtained at any
stage of the disease, even after a great portion of
the lung has undergone the purulent infiltration.
As soon as we have obtained some amelioration,
although but slight, we may be assured that the
continuation of the remedy will effect complete
resolution of the disease, without any fresh re-
lapse ; and it is in regard to this point more par-
ticularly, that the greatest practical difference
between the emetic tartar and bloodletting con-
sists. By the latter measure we almost always
obtain a diminution of the fever, of the oppression
and the bloody expectoration, so as to lead both
the patient and attendants to believe that recovery
is about to take place : after a few hours, how-
ever, the unfavourable symptoms return with fresh
vigour, and the same scene is renewed, often five
or six times, after as many successive venesec-
tions. On the other hand, I can state that I have
never witnessed these renewed attacks under the
use of tartar-emetic. In these cases we observe
only in the progress towards convalescence, occa-
sional stoppages. And this is more particularly
the case in respect of the stethoscopic signs ; as
we find that between the period when the patient
experiences a return of his appetite and strength,
and fancies himself quite cured, and the period at
which the stethoscope ceases to give any indica-
tion of pulmonary engorgement, — more time fre-
quently elapses than between the invasion of the
disease and the beginning of the convalescence.
It is necessary to observe, however, that this re-
mark is still more frequently applicable to the
disease when treated by bloodletting; and more-
over, that the patients subjected to the antimonial

PNEUMONIA.

627

method never experience the long- and excessive
debility which too often accompanies the con-
valescence of those who had been treated by re-
peated venesections." (Dr. Forbes's Translation,
p. 255.)

M. Peschier, of Geneva, appears to have given
tartar-emetic much in the same way as Laennec ;
and with such success that, according to his re-
port, he speedily cured almost every case without
the aid of bloodletting, although he never ex-
ceeded fifteen grains in the twenty-four hours.
(Biblioth. Univ. Juin, 1822.) Of those who have
written favourably of the remedy on this side of
the channel, we may name Dr. Mackintosh, of
Edinburgh, and Drs. Graves and Stokes, of Dub-
lin ; but these physicians differ from its foreign
advocates in making tartar-emetic a remedy se-
condary to bleeding. The experience of the for-
mer leads him to conclude that vomiting is more
speedily produced by a small dose dissolved in a
large quantity of water, than a large dose of the
drug mixed with a little sugar; but in the latter
case the nausea is more severe and of longer con-
tinuance than in the former. (Practice of Physic,
vol. i. p. 426.) Drs. Graves and Stokes begin
with a mixture containing six grains for the first
twenty-four hours, and add to this two or three
grains each day afterwards, as the severity of the
case may require, until fifteen grains are given
daily; beyond this quantity they think it unne-
cessary to go. They use general and local bleed-
ing freely, and in case of an increase of the symp-
toms, resort to it without trusting to larger doses
of the tartar-emetic. They consider the treatment
by this medicine as most eligible in strong consti-
tutions in the early stage of inflammation, during
the prevalence of the crepitant rhonchus, and be-
fore there is any dulness on percussion ; when
hepatization has taken place, it loses much of its
efficacy. Any symptom of gastritic disease they
consider as counter-indicating its use ; and they
find that the tolerance of the remedy is sometimes
more readily established by applying leeches to
the epigastrium. (Dub. Hosp. Rep. vol. v.)

Our own experience in the use of tartar-emetic
leads us to agree pretty closely with these obser-
vations. In truly sthenic cases of pneumonia,
we have generally found that it perpetuates the
impression produced by the lancet more promptly
and decidedly than any other remedy, and in a
proportionate degree ensures the relief of the pa-
tient, at a smaller expense of blood and strength
than the ordinary method of treatment, even with
the aid of mercury. But we cannot assent to the
opinion of Rasori, in which Laennec seems to
join, that the remedy has no depressing effect ex-
cept in regard to the inflammation, which it di-
rectly reduces; for we have very commonly found
that it lowers the strength, and sometimes the fre-
quency of the pulse, before its beneficial effects on
the inflammation are perceptible, and occasionally
even when these do not ensue. It may have
specific effects on the inflamed vessels, but it like-
wise sometimes exerts a sedative action on the
general circulation. This is not always apparent,
and its absence may result sometimes from the
local irritation of the medicine counteracting its
depressing influence, and in some cases from the
system being capable of resisting its effects. Cer-

tain it is, that in a few instances, principally in
children, its administration has been followed by
a more rapid sinking, and seemed to hasten the
fatal termination. These were, it is true, cases
of advanced disease, in which, after death, the
lungs exhibited extensive marks of unconquered
inflammation. We think it more necessary to
point out this depressing operation of tartar-
emetic, because Laennec takes no account of it,
but considers cases of debility as particularly
adapted for its use. Nevertheless we have seen
aggravated instances of pneumonia advanced to
the second, if not the third stage, and accompanied
with great apparent exhaustion, recover under the
influence of tartar-emetic and blisters, when blood-
letting had ceased to bring relief and was no longer
practicable. Unless, however, in case of failure
of the action of other remedies, we should not be
disposed to give tartar-emetic in any case where
the circulation is really weak ; and it should like-
wise be withheld where it appears to depress
greatly without improving the state of the respi-
ration.

A very important point in the exhibition of this
medicine is to establish the tolerance, which means
an insusceptibility of the stomach and bowels to
its emetic and purgative effects. Rasori supposed
that the presence of an inflammation in the sys-
tem is the cause of the drug having a different
operation from usual, and that the stimulus of
this inflammation must be neutralized by the di-
rectly sedative or contro- stimulant property of the
medicine before the body can be made sensible of
its common emetic effects. But, as Laennec has
observed, this is not consistent with the fact, that
after the tolerance is once established, ten, twenty,
or thirty grains may be taken and continued daily
throughout the period of convalescence without
any sensible effects. We have seen patients
recover their strength, appetite, and power of
digestion when they were taking twelve grains
daily. The experience which we have that the
most inflammatory and plethoric cases are those
in which this medicine is most successful, indi-
cates indeed its peculiar power over excited vas-
cular action, but its occasional utility over more
advanced forms of pneumonia and in hernia hu-
moralis proves that it likewise possesses a sorbe-
facient power. (See Dr. Mackintosh's Experi-
ments, Lancet, vol. ii. p. 536.) The directions
which we have quoted from Laennec with regard
to the best mode of exhibition to ensure the tole-
rance of the medicine,, are those which we have
generally found most successful. It is desirable
to vary the vehicle according to the taste of the
patient, and to choose that which is most grateful
to his stomach. We have often found the " king's
cup," a weak infusion of fresh lemon-peel sweet-
ened according to the liking of the patient, convey
the medicine very comfortably, but it is best not to
give more than a wine-glassful with each dose, as
in our experience a larger quantity is more apt
to produce vomiting. The first dose generally
produces this effect however given, and frequently
the second more slightly ; the third commonly
merely nauseates, and the tolerance is then estab
lished. This is the common average of the ope-
ration of the medicine. If the vomiting continue
after the second dose, or be very violent then, i

628

FNEUMONIA.

will be expedient to take some measures to dimi-
nish the irritability of the stomach and bowels.
Where there is a diarrhoea as well as vomiting,
instead of the syrup of poppies recommended by
Laennec, we prefer the addition of three or four
drops of the liquor opii sedativus, or of the solu-
tion of muriate of morphia, to each dose of the
medicine, and this may be advantageously given
with an effervescing mixture, as recommended by
Dr. Tweedie in the article Feveh ; but it is neces-
sary that the alkaline carbonate should be accu-
rately neutralized, otherwise it would decompose
the tartarized antimony. Where the vomiting
becomes obstinate and urgent, we can confidently
recommend the addition of a drop or two of hy-
drocyanic acid to each dose of the medicine, as in
the following form :

R. Antimon. tart. gr. iss. ad gr. iiss.

Aquae destill. f.^i.

Acid, hydrocyan. mi.

Aq. cinnamomi, (vel flor. aurant.) f.^iii.

Syrup, tolutan. f.gi. Fiat haustus.
This may be given every second, third, fourth, or
sixth hour, according to the severity of the case.
The draughts should not be made long before
they are used, as they soon become decomposed,
and the oxide of antimony is precipitated. For
this reason it may be sometimes useful to pre-
scribe the tartarized antimony in a powder, to be
dissolved at the time of exhibition in a wine-glass-
ful of lemon-peel infusion, to which, if necessary,
the hydrocyanic acid may be added. We deci-
dedly prefer the exhibition of the medicine in a
liquid form to that of a powder, as we consider it
to be more safe and efficacious. Where, notwith-
standing the combinations just mentioned, the
vomiting still continues, a few leeches to the epi-
gastrium, or, what is more efficacious, a mustard
poultice applied there for a few minutes, will
sometimes effect the tolerance of the remedy. If,
notwithstanding all these precautions, the vomit-
ing persists, it must be left to the discretion of
the practitioner whether the medicine is to be
continued or not; and in deciding this he will
have to balance between the beneficial influence
already produced by it, and the distress and injury
likely to ensue from so violent an operation still
continued.

It seldom happens, however, that this intoler-
ance of the medicine does remain where its con-
tinued exhibition would be safe ; and unless the
remedy should be producing a marked improve-
ment in the pulmonary symptoms, we may gene-
rally consider obstinate and violent vomiting or
diarrhoea as an indication to desist from its conti-
nuance. We are further warned from its use in
all cases where there is a florid red, or brown and
parched state of the tongue, with great thirst, and
tenderness and tension in the epigastrium, or over
the whole abdomen. We do not find that a moist
furred tongue, whether white or brown, gives any
contra-indication, and we have often seen this
state removed by the first operation of the medi-
cine. In continuing the medicine we must be
guided more by the physical than by the general
signs of the disease ; and it should not be hastily
discontinued, for it does not appear, like mercury,
to produce a permanent effect on the system. As
long as there is a rusty tinge and viscidity in the

sputa, and distinct crepitation, or absence of the
respiratory sound in the seat of disease, the medi-
cine should be continued, three times a-day at
least. It is an advantage of this remedy that it
may be combined with others, adapted to the
various stages of the disease ; and, although such
combinations speak equivocally as to its indivi-
dual powers, in some of the severest cases in
which the treatment was most signally successful,
we have joined the tartar-emetic with genond
bloodletting at first, with blistering and mercury
afterwards, and lastly with the decoction of senega
or some slight tonic.

Mercury and opium. — The exhibition of these
drugs as an antiphlogistic remedy, first practised
by Dr. Robert Hamilton, (Medical Commentaries,
vol. ix. p. 191,) and afterwards revived and
warmly recommended by Dr. Armstrong, (Prac-
tical Illustrations of Typhous Fever, &c. p. 453,)
is now pretty generally resorted to in this country,
and as it has been fully noticed in several pre-
ceding articles, need not here long occupy our
attention. Like tartar-emetic, it is to be generally
considered only as a measure secondary to blood-
letting, and the salutary effect is particularly
shown when the latter remedy has reduced the
inflammatory orgasm, and can be carried no fur-
ther. The efficacy of this combination depends
in a great measure on its being given to such an
extent as to affect the gums ; but its beneficial
operation is often manifest before this effect is
produced, and in some cases, especially in chil-
dren, without its occurring at all. But there is
seldom that obvious improvement from the first
doses which is often apparent in the exhibition of
tartar-emetic ; the operation of mercury is more
gradual, and, as may be expected, when once the
system is under its influence the effect is more
permanent. It is therefore especially adapted to
the advanced stages of the disease in which the
continued operation of a remedy is required to
resolve a solidification of the lung; and in effect-
ing this, and in preventing those remains of in-
flammation which lay the foundation for destruc-
tive chronic disease, mercury is pre-eminently
serviceable. Some doubt has existed whether the
mercury or the opium is the principal agent in
subduing inflammation. Dr. Hamilton considered
it to be the calomel, and he combined opium with
it to relieve pain, and to prevent it from passing
off by the bowels. Dr. Armstrong held that the
opium was a powerful means of subduing inflam-
mation after bleeding had made a decided impres-
sion on the general vascular action. In pneumo-
nic inflammation, however, we cannot but admit
that both medicines have their beneficial effects
each by its own influence, and by modifying the
action of the other. Thus the opium acts as an
anodyne in subduing the pain and cough, and as
a sedative in relieving that nervous irritation
which often follows both bleeding and the free
use of mercury, and which tends to the re-estab-
lishment of inflammation ; whilst the injurious
stimulant and restringent operation of the drug
is prevented by the previous bloodletting and the
mercury. The latter medicine, again, besides this
corrigent effect, more gradually exerts that specific
antiphlogistic and sorbefacient action which has
established its value in many diseases, and of

PNEUMONIA

which the treatment of iritis frequently affords a
visible illustration. If we adopt this view as a
guide in the application and management of these
combinations, we shall find that it leads to the
rules which experience has already sanctioned.

Calomel is the form of mercury which is gene-
rally preferred in acute inflammations, and as its
purgative effect is not an object, there is the
greater need to combine it with opium. Dr. Arm-
strong, indeed, considered the purgative operation
of a first full dose of calomel to be salutary, by
brushing away the coat of mucus from the intes-
tines, and thus opening the absorbents for the
specific action of the medicine : this may with
advantage be practised in pneumonia, and espe-
cially where a disordered or torpid state of the
excretions indicates a purgative. With this view,
from five grains to a scruple of calomel may be
given immediately after the first bleeding ; but as
a continued catharsis is seldom desirable, espe-
cially where there is free expectoration, the opium
should be added to the subsequent doses. With
respect to the quantity and frequency of these,
some difference must be observed according to the
form of the disease. In the most sthenic cases
uncomplicated with idiopathic fever or gastric af-
fection, large doses of calomel, of from six to
twelve grains, or even more, may be given three
or four times a-day with better effect than smaller
doses more frequently repeated. The proportion
of opium must likewise be varied according to
circumstances. Where after a full bleeding the
pain is considerable, with little fulness in the
pulse, and especially if there are signs of nervous
irritation, from a grain to a grain and a half of
opium may be added to every six grains of calo-
mel; but if the action of the heart is still strong,
half or a third of that quantity will generally be
sufficient to prevent the mercury from irritating
the bowels, which is in that case the principal
object of the opium. We have generally pre-
ferred Dover's powder, or a simple combination
with ipecacuanha to the opium alone ; for while
the anodyne powers of the drug are not impaired,
its stimulant quality is thus considerably dimin-
ished. In a few instances the sulphate of mor-
phia has been substituted for the opium, and ap-
parently with good effect, but our experience on
this point is too limited to enable us to speak
with certainty. In less sthenic cases, and espe-
cially where there is much gastric derangement,
or a fever which assumes more of the idiopathic
character, with a dry loaded tongue, hot skin, and
vitiated excretions, the calomel is with greater ad-
vantage given in more divided doses, and fre-
quently ; as from gr. iss. to gr. iii., with two or
three grains of Dover's powder every second or
third hour. In some instances, particularly where
there is an irritative diarrhoea, the hydrargyrum
cum creta. may be advantageously substituted for
the calomel, double the quantity being generally
given. The remedy, in whichever of these va-
rious ways it is given, should be continued until
it either produces a decided impression on the
disease, or affects the gums. Generally these
effects take place simultaneously, and the improve-
ment is seldom permanent and progressive until
the influence of the mercury on the system is
manifest in the gums. It is a favourable sign

3c*

when this takes place readily, for the most obsti-
nate and formidable inflammations counteract the
specific influence of mercury ; and if, after saliva-
tion has been produced, the inflammation becomes
rekindled, the gums get well, and the breath loses
its mercurial fetor. As soon as the mercury has
shown decided effects, it may be diminished to
two or three moderate doses in the day ; but when
the disease has advanced to hepatization, it is
proper to keep up its influence in a minor degree
for some days. Mercurial inunction is sometimes
practised to accelerate the introduction of the
metal into the system, but this is too slow a pro-
cess to be of material assistance where so much
promptitude is required.

[Opium alone, or in the form of morphia or
other of its preparations, the writer has found a
most valuable remedy in active pneumonia after
bloodletting ; and in asthenic cases where blood-
letting has not been indicated. In such cases, it
must be given in full > doses. The objections,
urged against its use in this and other inflamma-
tory affections, have been canvassed elsewhere
(See Narcotics). To its value in pneumonia
other observers have equally deposed. (Christison,
Dispensatory, p. 684, Edinburgh, 1842. See
also, art. Pneumonia, in Encyclopdd. Worterb. der
Medicinisch. Wissensch. xxvii.71 2, Berlin, 1S42.]

Counter-irritants. — It is generally agreed,
among medical writers, that blisters are not ad-
missible in the early stage of pneumonia, and not
a few deny their utility altogether in the acute
disease. There are two objections against their
use: one is, that whilst the inflammatory fever
lasts, then stimulus adds to it, and thus reacts in-
juriously on the inflammation ; and the other, in
our estimation scarcely less important, that they
prevent the use of those means of examination
of the chest, which, as we have seen, are neces-
sary to inform us accurately of the state of the
pulmonary disease, and of the effect of more
powerful remedies upon it. The last objection
does not apply to blisters on the legs or some dis-
tant part, which are recommended by some phy-
sicians even in the early stage. M. Lerminier
applies two to the legs immediately after the first
bleeding ; as soon as they are dry, he repeats them
on the thighs, and does not use them on
the chest until the disease has taken on a perfectly
chronic character. Unless, however, in case of
complications with cerebral disease, in which dis
tant revulsion may prove salutary, the effect of
this measure is too trivial to be relied on, and the
practitioners of this country seldom trust to
counter-irritation on any other part than the
parietes of the chest, but reserve its application
till the active character of the disease has been
subdued by other measures. In slight cases they
may often be advantageously applied immediately
after the first bleeding ; but in the severer disease
both the objections which we have just stated
would deter us from using thern until the pulse is
soft, and the heat of the skin moderate. Whilst
the disease remains acute, blisters from six to tea
inches square are to be preferred to smaller ones,
as they scarcely irritate more, and their salutary
derivative and evacuant effect is much greater.
When the disease, after having reached the stage
of hepatization, is proceeding towards cure, smaller

H30

PNEUMONIA.

blisters, repeated one after another in different
parts of the chest, are of considerable utility, and
enable the patient to bear a slightly tonic treat-
ment, which is often very salutary at this period.
It is at this time only that other means of counter-
irritation can well be substituted for blisters. The
friction necessary for the application of the tartar-
emetic ointment or solution constitutes an objection
to its use during the pain, cough, and oppression
tf the acute stage ; but as a safeguard against re-
lapse, and as a means of countervailing the internal
irritation and of promoting the sanative process,
this method of counter-irritation reaches deeper
and is more permanent than repeated blistering.
(See Counter-irritation.) Rubefacient plas-
ters, as those containing a small proportion only
of cantharides, are sometimes sufficient, and pro-
duce considerable benefit on the same principle;
but they should be of full size, and renewed with
sufficient frequency to insure their continued
activity.

Evacuants. — We may comprehend, under this
title, emetics, purgatives, diuretics, and diapho-
retics, all of which are occasionally useful, but it
is generally agreed that they are remedies of minor
importance, and require some judgment in their
application. From the success which has attended
the treatment of pneumonia by emetics, in the
hands of some physicians, as Stoll, Riverius,
Dumangin, Hellis, and Good, we cannot doubt
that these remedies are sometimes decidedly useful;
and probably they may be so, in the early stage
of the disease, by breaking that chain of morbid
action by which the incipient congestion becomes
converted into inflammatory fever, as well as by
their relaxing and derivative effect. They are,
however, generally considered as violent and un-
certain remedies, and enough of their peculiar
effect may be obtained in the ordinary operation
of the large doses of tartar-emetic, of which the
ulterior action has a higher claim to our con-
fidence.

Much difference of opinion exists as to the em-
ployment of purgatives in pneumonia ; some
practitioners, particularly those of this country,
using them freely, not merely to evacuate the
bowels, but also as depletories to reduce the action
of the heart and arteries. Dr. Pring recommends
them with this view, and considers them of equal
power with bloodletting in subverting inflamma-
tory action. (Principles of Pathology, p. 208.)
The general objection against their use is, that
they tend to check the expectoration, which is a
natural means of relief to the disease ; but proba-
bly they are likewise injurious in exciting in the
mucous membrane of the alimentary canal an in-
flammatory state, which gives to the disease that
typhoid tendency in which we have recognised
one of its most dangerous forms. These conside-
rations deter us from exciting any thing like a
continued discharge from the intestines, but we
consider that their daily evacuation is a safe and
expedient measure, and if this is not effected by
the medicines given with another object, it must
be excited by a colocynth pill or senna draught,
or, where there are signs of gastric excitement, by
castor oil or a laxative enema.

Diuretics are indicated chiefly where there is a
simultaneous effusion into the pleura; but we

have likewise found them useful in combination
with tonics in the decline of the disease, to remove
the oedema which commonly lingers in the lungs
and sometimes affects other parts of the body after
the active inflammation has subsided. Nitre, in
doses of a scruple or half a drachm in the former
case, and the same, or the spirit of nitric ether in
the latter, generally answer as well as any other
medicine, and their effect is commonly increased
by the mercury, digitalis, squill, or other medi-
cines given to fulfil other indications. A diapho-
retic operation also often results from the use of
the tartar-emetic or calomel and opium when these
are given ; when they are not, a great heat of skin
often renders it expedient to give James's pow-
der, or antimonial or ipecacuanha wine, with a
view to determine to the skin ; and in children
especially, the warm bath sometimes proves useful
in the same way ; but these remedies are too un-
certain and trivial in such a disease as pneumonia
to withdraw our principal trust from other more
important measures. In some cases, profuse
sweats come on, which weaken the patient without
relieving the symptoms, and require the exhibition
of a mineral acid to restrain them.

Sedatives. — The remedies of this kind which
have been held in greatest repute in pneumonia
are opium and digitalis. We have already no-
ticed the former in conjunction with calomel, but
it is likewise employed alone with a view to quiet
vascular action. Dr. Armstrong recommends at
least three grains of opium to be given immedi-
ately after bleeding to syncope or approaching
syncope, and its effect is to preserve the reduction
which the loss of blood has already effected in the
pulse. This is a point particularly to be observed
in the administration of opium. As long as the
vascular action is strong, this drug will stimulate
and prove injurious; but when reduced by a full
depletion, it seems to paralyse those powers of re-
action by which, after this temporary reduction,
irritation and inflammation are rekindled. We
have repeatedly seen the utility of opium in this
way ; but it has been generally in the first stage
of the inflammation ; and although we do not
hesitate to give it in the full dose recommended,
we judge it to be always safer to combine it with
calomel and ipecacuanha. Where there is much
pain, from twenty to forty minims of the liquor
opii sedativus, given immediately after the bleed-
ing, act more speedily and satisfactorily than solid
opium. In the after-stages, when the antiphlogis-
tic remedies have reduced, as far as may be,
the inflammatory action, opium often proves of
the greatest benefit in relieving the cough, which
frequently continues troublesome and obstinate,
even in the decline of the disease. With this
view it is generally combined with expectorants,
which we shall presently have occasion to notice.
Hyoseyamus, conium, extract of lettuce and of
belladonna, are sometimes used with the same in-
tention, and, where opium is ill borne, may prove
serviceable ; but, although they may at all times
be given with less risk, they are generally much
inferior to it in efficacy. These medicines, besides
reducing the excess of irritability on which the
act of coughing depends, seem in some degree
likewise to relieve the oppressed state of the
breathing, which occasionally remains after the

PNEUMONIA.

631

active disease is subdued, and this they probably
effect by diminishing those changes in the blood
by which it is rendered venous, and thereby light-
ening the task of the function of the lungs. (See
Dyspnosa. The action of digitalis is considerably
different, being principally on the vascular system,
and it does not possess any anodyne qualities. It
has been much extolled as an aid to bloodletting
in reducing inflammatory action ; but although it
occasionally shows considerable efficacy, its opera-
tion is far too uncertain to entitle it to our confi-
dence. Its exhibition is moreover not unattended
with danger, for when given largely to affect the
pulse, it sometimes develops its effects suddenly
in syncope and extreme reduction of the heart's
action. We trust to it more in the decline of the
disease ; and in the dose of ten to twenty minims
three times a day, combined with an opiate in an
expectorant mixture, we have found it of great
use in reducing the pulse and easing the respira-
tion. Some practitioners speak highly of larger
doses, frequently repeated, until an impression is
produced on the circulation : but we have not
seen enough advantage in this plan to induce us
to recommend it, and unless watched with the
closest attention, we cannot consider it a safe prac-
tice. Colchicum may be used with the same in-
tention, but it is more apt to pass off by the bow-
els, and should therefore be combined with opium.
It is most suited to the pneumonia of rheumatic
and arthritic subjects, and may be given in the
dose of £i of the wine with a few grains of car-
bonated alkali. Hydrocyanic acid does not appear
to deserve the encomiums that have been passed
upon it, and except to quiet an irritable state of
•he stomach, we have not seen it useful in pneu-
monia.

Expectorants. — During the active stage of the
inflammation, whilst the pulse is sharp and the
skin hot, the secretion of the bronchial membrane
is not within the influence of any of those medi-
cines which are called expectorant. The general
measures which reduce the inflammatory orgasm
of the great pulmonary vessels are then the best
means of relaxing those of the bronchi, and this
effect may afterward* be kept up by small doses
of antimony or ipecacuanha. In an advanced
state of the disease, however, the promotion of
expectoration becomes an object of great impor-
tance, as on its accomplishment may depend the
life of the individual. Where the inflammatory
symptoms have entirely given place to those of
weakness with a great embarrassment of the
breathing, the carbonate of ammonia becomes
a most valuable remedy, and we have more than
once seen it apparently turn the scale in imminent
cases. It may be given in doses of five grains or
more every hour or every two hours, or more fre-
quently if the sinking state of the patient seem to
require it. The decoction of senega is in these
cases a good vehicle for it, and great advantage
has sometimes resulted from the addition of the
tincture of the lobelia injlata, which, although an
uncertain remedy, often shows great powers in
facilitating expectoration and relieving dyspnoea
in several advanced forms of pulmonary disease.
The first dose of the medicine should not exceed
'en minims; but unless it produces sickness, it
may be increased by three or four minims in each I

successive dose. Different individuals bear it
very variously: we have known a drachm taken
at a dose, with great relief to the breathing, and
without inconvenience ; in another instance eight
minims produced such sickness and giddiness that
it became necessary to discontinue its use. When
the urgency of the symptoms which indicated the
use of ammonia has ceased, it may be of impor-
tance to keep up a free secretion from the bronchi,
in order to assist in the resolution and dispersion
of the solid effusion in the tissue of the lungs, and
for this purpose expectorants of less stimulating
quality are to be preferred. We have generally
found a combination of tincture of squills and
ipecacuanha, in the dose of ten minims of each,
■answer very well ; if the cough is troublesome, a
few drops of liquor opii sed. or forty or more of
the compound camphor tincture should be added.
The vehicle for these medicines may be the
almond" emulsion, with a little liquor ammon.
acetat. when the expectoration is thin and scanty;
but when it continues viscid, we have found
great benefit result from the exhibition of expecto-
rants in an alkaline vehicle, which is the only
form in which the alkali treatment, so much ex-
tolled by Sarcone and Mascagni, has appeared to
us useful in peripneumony. Ten or twenty
minims of liquor potasste, or the same number of
grains of carbonated alkali, may be given with
the above-named expectorants in water, camphor
julep, or any simple vehicle, or in the more asthe-
nic cases, with decoction of senega. In the
course of recovery from pneumonia we often find
it useful, whilst any pulmonary symptoms remain,
to join some expectorant with the tonic that is
employed.

[There is no class of remedies more uncertain
in their action than expectorants, and certainly
none that require more caution as regards their
administration in pneumonia. Let it be borne in
mind, that there is no article in the Materia
Medica, which is an expectorant under all cir-
cumstances. Expectorants are altogether indirect
agents ; hence we find an expectorant effect
equally from depletives and from tonics and exci-
tants ; from narcotics and from counter-irritants;
from nauseants and from emetics. (See Expec-
torants.)]

Tonics and stimulants. — In ordinary pneumo-
nia this class of medicines is out of the question
as long as any signs of active inflammation re-
main. When, however, depletions do no further
good, and the pulse is weak, the skin cool, and
the expectoration no longer rusty and tenacious,
then, although some dyspnoea and cough still
remain, considerable benefit is sometimes derived
from the exhibition of a mild vegetable tonic,
such as the decoction of senega, or a weak infu-
sion of calumba. We have already named the
first of these as a vehicle for carbonate of ammo-
nia to promote expectoration, but it seems also to
prove useful from its slightly tonic property, and
as a stimulant to the absorbent system. In the
state which we have just described, we have often
seen the symptoms remaining stationary, without
tendency to improvement, until this medicine was
given, and then in a few hours the pulse has be-
come slower, the breathing more free, the tongue
cleaner,, and the strength somewhat improved.

632

PNEUMONIA.

By auscultation, also, we have found in a return-
ing crepitant rhonchus or other vesicular sound,
a proof of the impulse which this treatment gtves
to the absorption of the effused matter. When
the active stage of the inflammation has been
subdued by tartar-emetic, it is a good plan to con-
tinue to give it three or four times a-day in this
decoction, as there is nothing inconsistent in the
action of the two medicines. After the mercurial
treatment it is even more useful, and may gene-
rally be given soon after the gums are decidedly
affected. The infusion of calumba we have
thought better adapted to cases in which there
had been much accompanying gastric disorder,
and in these it has sometimes cleansed the tongue,
which had continued foul in spite of the preva-
lence of mercurial action in the system. In the
exhibition of either of these tonics, however, a
close attention must be paid to prevent the re-
kindling of the inflammatory disease, anil they
must be discontinued on the appearance of any
sign of reaction. They are most safely employed
in conjunction with an external counter-irritation
on the chest; and it is under these combined
measures that the most rapid recoveries take
place. In the more typhoid forms of the disease,
especially those complicated with adynamic fever
from the beginning, tonics and even stimulants
are required more frequently, and with less limi-
tation. In some of these cases, where bloodletting
is not borne, bark and camphor may be given
even in the early stages of the disease, for the
pneumonic affection is really more a passive con-
gestion arising from an extremely atonic state of
the vascular system, with probably an altered
state of the blood, than a true inflammation.
Laennec says that he has, with success, given
both bark and wine in certain epidemic peripneu-
monies, particularly in one which prevailed among
the troops in 1814. He also recommends these
to be administered towards the termination of the
disease in old persons, and in debilitated and ca-
chectic subjects, when, after the suppurative stage,
the fever passes off and resolution goes on very
slowly. He considers cinchona the best remedy
in gangrene of the lungs, even when there is
extensive hepatization around the eschar ; but to
be effectual it must be given to the extent of an
ounce of the powder daily, or an equivalent por-
tion of sulphate of quinine. Except in case of
complication with intermittent fever, where the
specific operation of bark is required, we are dis-
posed to trust at first to opium, camphor, and
ammonia, in the typhoid pneumonia, combining
them with calomel, and to resort to the bark only
if the general strength seems to require it after-
wards.

Application of the Treatment. — We have
only to point out here the manner in which the
several remedies which we have described may be
combined in the treatment of individual cases.
Where the case is at all severe, the treatment
with tartar-emetic, or with calomel and opium,
should be commenced immediately after the first
bleeding, and continued uninterruptedly until an
impression shall have been produced on the dis-
ease. It is not safe, however, with either of these
remedies to lay aside bloodletting ; if sensible re-
lief does not ensue in the course of five or six

hours after the first full bleeding, this measure
must be repeated as before recommended. In the
most acute and inflammatory cases, uncompli-
cated with gastric disease, we have sometimes
combined the mercurial with the antimonial treat-
ment, by giving a pill containing from six to ten
grains of calomel, with from half a grain to a
grain and a half of opium every four or six hours-,
and the tarter-emetic draught before prescribed,
in the middle of that interval ; and where the
tolerance is established soon, the effect of this
treatment is very powerful. If the bowels are too
much acted on, the hydrargyrum cuin creta in
double quantity may be substituted for the calomel.
When an amelioration takes place in the symp-
toms, the mercury may be omitted, and the case
left to the tartar-emetic, and whatever depletion
or counter-irritation may be required. If the
attack of pneumonia is very recent, and accom-
panied with a sharp stitch in the side, or catch in
the breathing, a full dose of opium immediately
after a large bleeding, as recommended by Dr.
Armstrong, will sometimes be found sufficient to
cut short the disease. This plan can only be
adopted where the bleeding has been so copious
as to produce a great and real impression on the
heart's action, almost, if not quite, amounting to
syncope. The dose of opium should be large ;
three or four grains of the aqueous extract, or if
the pain and tendency to reaction are urgent,
from 30 to 60 minims of the liquor opii sed., are
the preparations to which we give the preference.
Even in this case we think it advisable to give
from six to twelve grains of calomel, or from ten
to twenty grains of blue pill, with, or soon after,
the opium ; the mercury does not interfere with
the sedative operation of the latter, and by preserv-
ing the balance of the secretions, it prevents those
functional derangements which sometimes follow
the use of opium even in this way. If the disease
has in any degree passed into the second stage,
and even if the first has lasted more than twenty-
four hours, there can be little hope of stifling it
with opium, and we must then resort to the alte-
rative powers of tartar-emetic or mercury, with
whatever bloodletting the case may bear. Blisters
can seldom with advantage be resorted to, until
all fulness and hardness of the pulse and heat
of skin have subsided ; and either these symp-
toms, or even the continuance of a fixed pain,
would counter-indicate the use of the decoction of
senega, or any of the mild tonics which prove use-
ful in the decline of the inflammation.

If, from the copious expectoration of pus and
the physical signs of a cavity in the lungs, it is
probable that an abscess has been formed, it may
be necessary to support the strength by a stronger
tonic, as the sulphate of quinine or bark with a
mineral acid ; but the expediency of this must de-
pend on a complete predominance of the symptoms
of weakness over those of inflammation. In case
of gangrene, some of the medicines of a supposed
antiseptic power may be given. Drs. Graves and
Stokes, in a case of this kind, gave the chloride
of lime in the dose of three grains with one of
opium three times a-day, with the effect of re-
moving the fetor from the expectoration, and for
a time improving the symptoms. We have seen
the same medicine in solution apparently produce

PNEUMONIA.

C33

the same result ; but we cannot expect much
from the operation of such agents. The principal
object in case of gangrene is to support the general
strength, and counteract the noxious influence of
the (lead matter, until it can be thrown oil from
the system.

The great fatality of pneumonia among chil-
dren renders it necessary that its treatment should
be directed with the greatest care and promptitude.
This fatality does not arise so much from the
course of the inflammation, as we have seen that
this is less rapid than in adults ; but from the
latency of the local symptoms, and the tendency
of the disease, under this disguised form, to pass
the period in which bloodletting is most effectual.
Hence, many of the cases of infantile pneumonia
which we have to treat, especially in the lower
classes, are already in a sinking state ; the de-
pressing influence of the injured function of the
lungs, which at this age ill bears any abridgment,
having already removed the sthenic character of
the disease. This circumstance represents to the
mind the importance of physical examination of
the chest in all the febrile diseases of children, in
order that, if any crepitant rhonchus be disco-
vered, the fit remedies may be promptly applied.
In this early stage bloodletting is highly effica-
cious, but when used after the disease has lasted
for several days, it sometimes produces convul-
sions and sinking, without relieving the respira-
tion. The same observation may in some degree
be applied to tartar-emetic, and yet these are the
most effectual remedies which we possess for in-
fantile pneumonia, and if used together at the
commencement, seldom fail to subdue it. Mer-
cury with difficulty produces its specific action on
infants, but it is still of great effect as a purga-
tive; and when bloodletting is no longer borne,
calomel, in doses of half a grain up to two grains,
according to the age of the child, every hour or
second hour, is the remedy on which we have
principally to depend. Unless where there is an
irritative diarrhoea, opium can seldom be used
with advantage ; in that excepted case, Dover's
powder is the best form. Although mucous or
bloody stools imply an undue irritation from the
calomel, and ought to be checked, yet copious
evacuations of green bile are essential to the suc-
cess of its operation, and seldom produce in the
pneumonia of children the bad effects which re-
sult from purgation in the adult. It would seem
that expectoration, as it is a less natural process
in early life, so its importance as a vicarious dis-
charge is of inferior moment, and does not prohibit
purgatives and other measures that may arrest it.
Counter-irritation with tartar-emetic ointment or
solution is of great efficacy in the after stages of
pulmonary inflammation in children, and should
especially be persevered in where there is any
sign of a phthisical tendency. This, together
with a sedative linctus to quiet the cough, and a
light tonic if required, constitute the chief part of
the treatment most eligible in the decline of the

In aged persons the disease is often very in-
tractable, in consequence of the great debility
which accompanies it. The mere circumstance
of age should not, however, restrain us from the
use of the lancet, where the state of the breathing

Vol. III. — 80

and pulse, and heat of skin seem to indicate it.
Frank bled an octogenarian pneumonic patient
nine times with a happy effect. It must be con-
fessed, however, that the period in which bleeding
is useful in old people is short, and the frequent
complication of a pituitous catarrh with pneu-
monia still further restricts its utility. Expecto-
ration is in these cases a most important process,
and when bleeding weakens so much as to be
likely to interfere with the performance of this
act, it must be abandoned. In some cases cup-
ping may be substituted, but blisters of ample
size are more effectual, and may be employed
much earlier than in younger subjects. The in-
ternal remedies may be administered as usual, but
it is often necessary to resort soon to the tonics
and stimulants before described.

We know of no reason why the sex of the
subject should materially modify the treatment
of pneumonia. The presence of the catamenia
ought never, in cases of any severity, to interfere
with free depletory measures, for the influence of
this relief on the system is trifling, compared with
the progress of a dangerous inflammation. The
case may be different in slight examples and to-
wards the decline of the disease, and stimulating
pediluvia may be used, if the circumstances indi-
cate it, to promote a natural crisis of this sort.

The complications of pneumonia with other
diseases will require that the treatment should in
some measure combine the indications of these
various affections. Thus in the complication with
bronchitis the power of bloodletting will be more
contracted, whilst the antimonial treatment of
blistering will claim more confidence. In pleuro-
pneumonia, local bleeding, in addition to venesec-
tion, becomes a very useful remedy, and if the
pleuritic affection be extensive, or accompanied by
much pain, calomel and opium will form the most
eligible remedy. In the treatment of pneumonia
occurring in continued fever, [and in all forms of
typhoid pneumonia,] the probable duration of the
latter affection must be held in view, and deple-
tions practised in a more cautious manner. The
mercurial treatment is generally the best here like-
wise, especially if the fever partakes much of the
gastritic character; and the hydrarg. cum creta,
with ipecacuanha or Dover's powder, is the pre-
ferable preparation. When any of these fevers
take on the typhoid or adynamic form, stimulants
and tonics will sometimes be required, and must
be given, notwithstanding the pulmonary disease.
It must be confessed that medicine has often very
little power in these cases ; but as far as our ex-
perience goes, stimulants judiciously given when
the heart's action is very feeble, and the musculai
powers are very low, have appeared to relieve the
pulmonary affection, as well as for a time to re
store a portion of strength ; and it is only by over-
stimulating the heart that there is a risk of aggra-
vating the inflammatory disorder. They must
therefore be carefully watched, and diminished ot
withdrawn as soon as any sharpness or hardness
is perceptible in the pulse. Besides those before
enumerated, we may mention musk, which is
highly recommended in the typhoid form of pneu-
monia by M. Recamier, who gives it in doses of
from 24 to 30 grains, with an effect which he
considers almost specific. It seems to us ques

634

PNEUMONIA.

tionable, whether the affections which have been
called intermittent peripneumonies, and said to
have been cured by bark, are really inflamma-
tions : it is more probable that they consist in a
simple congestion of the lung, determined by the
febrile paroxysms, just as simple congestions are
more familiarly known to take place in the spleen,
liver, &c. ; and from the near pathological affinity
between the two, it is not surprising that such a
congestive state should produce many of the local
phenomena of pneumonia. Although there can
be no doubt of the power of bark and arsenic over
these intermittent diseases, yet even here the op-
pression of the affected organ during the paroxysm
is occasionally such as to require the aid of blood-
letting. Neither should this measure be withheld,
from fear of suppressing the eruption, in the pul-
monic affections coming on at the commencement
of the exanthemata : the internal affection is a
present and dangerous evil, not to be neglected
on account of other imaginary ones.

In the peripneumonies supervening on hooping-
cough and influenza, it is sometimes a chief indi-
cation to give sedatives to allay the cough, which
appears often to have a considerable share in pro-
ducing the parenchymatous inflammation. Be-
sides bleeding, therefore, to the extent that the
case may require, large doses of the tincture of
hyoscyamus (Jss, and upwards, or, in hooping-
cough, the extract of belladonna, in doses of half
a grain to the adult, and one-sixteenth to children
below two years, these being gradually increased)
will be found of much efficacy in counteracting
the inflammatory tendency of these affections.
Local depletions and counter-irritation will gene-
rally be sufficient to arrest the inflammations in-
tercurrent on phthisis ; and we have found the
tincture of digitalis very useful in these cases.
Where an inflammatory state of the mucous or
serous membranes of the alimentary canal accom-
panies pneumonia, it is of great moment that the
treatment should extend to these complications,
for they greatly aggravate the case, and render it
less tractable. Free leeching of the abdomen
must be included in the depletory measures, and
the hydrargyrum cum cre'a, with Dover's powder,
will be the best antiphlogistic alterative. Purga-
tives must be at first rigidly proscribed, and the
bowels merely evacuated by laxative enemata or
suppositories. In the progress of recovery, a tea-
spoonful of castor oil daily, and infusion of ca-
lumba with dilute nitric acid, or some such light
tonic, will often contribute greatly to restore the
healthy functions of the membrane.

Diet and Regimen. — No one can question
the propriety of a strictly antiphlogistic regimen
in ordinary cases of pneumonia. A total absti-
nence from all solids must be enjoined during the
inflammatory stages of the disease, and the liquids
taken should be of the mild mucilaginous kind,
suiii as barley-water, tea, lemon-peel, and other
simple vegetable infusions. It is generally re-
commended to give these beverages warm : but
unless large draughts are taken, we see no objec-
tion to their being given cold if the patient pre-
fers it. We have heard Professor Hamilton of
Edinburgh express his decided belief that liquids
are injurious in pneumonia by adding to the mass
of blood, and thus counteracting a principal good

effect of bleeding ; and so far docs he carry this
opinion, that he considers that even pediluvia
may do harm by throwing more liquid into the
system through the absorbents. Although a
zealous advocate for a dry diet in some other com-
plaints, the writer is not persuaded of its utility
in the present disease, except in cases where the
dyspnoea is urgent. In such cases we have seen
the breathing distinctly become worse after copious
draughts of liquid, and with a view to keep the
mass of blood which passes through the lungs as
rich in quality and as small in quantity as possi-
ble, a paucity of drink may here be reasonably
recommended. The antimonial treatment gene-
rally requires a certain degree of abstinence from
liquids ; for until the tolerance is completely es-
tablished, a large draught is almost sure to pro-
duce vomiting. M. Chomel has pointed out a
very important exception to the utility of an abso-
lutely antiphlogistic regimen, in the case of those
addicted to excess in wine or spirits. The great
fatality of pneumonia in these subjects when
treated in the usual way is Well known ; and ob-
serving that one man accustomed to such excess,
who continued to take a pint and a half of wine
daily throughout his illness, speedily recovered
from the disease after only one bleeding, M. Cho-
mel afterwards prescribed a certain quantity of
wine in similar instances, and with a success that
encouraged him strongly to recommend the prac-
tice. These may probably be included in the
class of malignant cases, in which Laennec says
that both wine and bark are beneficial. After the
active stage of inflammation has been subdued,
the moderate return to nourishing food, as the
appetite craves it, is desirable. It should, how-
ever, be confined at first to farinaceous liquids,
light puddings, and the weakest chicken or veal
broth ; these may be gradually improved in nutri-
ment, and in the course of a few days a little
white fish may be allowed ; and the return to
ordinary animal food made by degrees and with
circumspection. In case of gangrene or extensive
suppuration, as manifested by fetid or copious
purulent expectoration, with great prostration of
strength, a more nutritive diet, such as beef-tea
and animal jellies, will be required ; and these are
cases in which wine may sometimes be cautiously
administered ; but too much attention cannot be
paid to watch lest this regimen should re-excite
an active state of inflammation.

In the progress of convalescence from pneu-
monia, we may say of nutritious food what we
have remarked of tonics, that it must be watched
in its effects, and that its tendency to rekindle the
local disease may be safely restrained by the si-
multaneous use of counter-irritation on the chest.

Patients labouring under peripneumony should
be kept in an airy room of moderate temperature,
(about 60°,) being protected on the one hand
from an accumulation of heated or impure air,
and on the other from draughts of cold air. These
points require the physician's attention, and are
too important to be left to the sole discretion of
the attendants. Much covering can seldom be
borne, and it is therefore the more necessary to
guard against the effects of accidental cold ; whilst
the oppressed state of the breathing still requires
that the air should not be close or impure. It is

PNEUMONIA.

635

of some importance likewise, in the severer cases
of inflammation of the lungs, that the chest should
be raised above the level of the lower part of the
body. The best method of doing this is by a bed
chair, which by means of a notched rack can be
raised to different angles with the level of the bed ;
but the same object may in a measure be attained
by propping the back with pillows. This posture,
besides that it facilitates the breathing and expec-
toration, prevents the gravitation of the blood to
the lungs ; and from the close connection which
we have frequently noticed between the mechani-
cal and the active hyperemia of the lung, the
importance of this last point is obvious. The
exertion of the lungs required in talking is inju-
rious, and must be avoided, and the bodily efforts
should be confined to necessary acts. Muscular
movement hurries the circulation, and that which
does this in the disabled state of the lungs neces-
sarily causes that injurious congestion in the
organ which we have so frequently noticed in its
connection with inflammation.

In enumerating the causes of pneumonia, we
had to remark that nothing so strongly predisposes
to the disease as its previous occurrence in the
individual. Hence prophylactic measures become
of great importance, and the more so in propor-
tion as the attack has been frequently repeated.
The necessity is obvious in such cases, of protec-
tion from the various exciting causes, by warm
clothing, by avoiding exposure, exertions of the
voice, and violent exercise of any kind, by ab-
staining from excess in diet, and by living on that
quantity and quality of food which support the
strength without inducing depletion, and by such
diet and regulated exercise, or if necessary by
proper medicines, ensuring the due performance
of the secretory functions. Among the most
essential articles of warm clothing, we may men-
tion a flannel waistcoat next the skin, and during
the prevalence of cold weather, a wash-leather
vest over it: these will be found more effectual
and less cumbersome than a larger quantity of
outer clothing, and should never be neglected by
the pulmonary invalid. We cannot inveigh too
strongly against the pernicious practice of females
liable to pulmonary inflammations subjecting
themselves with their necks and chests bare to
the trying changes of temperature inseparably
attendant on evening visiting. In cases where, in
spite of all precautions, the complaint recurs re-
peatedly at every return of cold weather, and ren-
ders the individual a constant invalid, a change
of residence during the winter and spring months
to a more genial climate becomes a desirable
measure. Torquay and the Undercliff of the Isle
of Wight in our own country, and the south-west
of France, the coast of Egypt and Barbary, Ma-
deira, and some of the West India Islands may
be named as generally the most eligible places of
resort; but the circumstances of the individual
case must in great measure determine the choice.
(See Climate.) The most efficacious remedial
measures which we know of to counteract this
tendency to the reproduction of pectoral inflam-
mation, is a continued counter-irritation, by means
of tartar-emetic, or a seton or issue, on the chest.
We give the preference to the former; and we
have seen patients under its influence regain a

degree of robustness and hardiness which they
had not known for months. When this measure
seems to be no longer necessary, the mild irrita-
tion of a pitch plaster may be substituted. Those
persons in whom there is only a proclivity with-
out any symptoms of real disease, should habituate
the pulmonary circulation to regulated impressions
of cold and healthy reaction, by sponging the
chest with vinegar or salt water, at first tepid, and
afterwards cold, and using vigorous friction with
a rough towel afterwards.

V. Chroxic Pertpkeumoitt.

Laennec commences a section under this head,
with a question as to the existence of such a dis-
ease ; and although he adduces a few examples,
which he admits to be of chronic inflammation,
he views it as " hardly probable that an organ so
vascular, so mobile, and so essentially living as
the lungs, can remain long in such a state of slow
and inactive inflammation, as we know to be the
condition of organs less necessary to life." (De
l'Auscult. Med. t. i. p. 475.) But this argument
is hardly tenable on a comparison with other
organs equally vascular, and is inconsistent with
the existence of chronic pneumonia to the extent
in which he admits its existence. The form of
disease considered by him to be chronic peripneu-
mony is a hard compact kind of hepatization,
sometimes found around gangrenous excavations
and ha?moptoic engorgements, and very rarely
also around tubercular cavities and between tuber-
cles. The lung thus affected creaks when cut, is
more livid or grey than ordinary hepatization, and
presents a more distinctly granular form, so that
it resembles the eggs of certain insects closely
pressed together, without any intervening sub-
stance. This may reasonably be considered the
chronic form of granular hepatization. But as
we have found the acute disease occasion a con-
solidation of the lung without the appearance of
granules, so it may be reasonable to expect that
the chronic inflammation may present us with a
corresponding uniform kind of induration. Ac-
cordingly, we find Andral, Chomel, and Louis,
describing other non-granular forms of chronic
solidification. It is sometimes found of a bright
red or a buff colour, but more frequently it is livid
or grey, being variously modified by the quantity
of blood and the black pulmonary matter in it.
It exudes little or no fluid when pressed, and is
quite solid, sometimes approaching to cartilage in
density. The red kind is most commonly a se-
quel of the acute disease imperfectly cured ; the
grey kind is more frequently found in the lungs
of phthisical subjects with miliary tubercles scat-
tered through it or surrounding tubercular vomi-
cae. The resemblance between the substance of
this miliary tubercle and this grey uniform indu-
ration, and the circumstance that yellow tubercu-
lar matter is frequently found in the tissue thus
indurated, led Laennec to the belief that this
induration was only a diffused form of the same
accidental tissue which he called a first stage of
tubercle. The resemblance is certainly very
strong, and as we often see an indurated hyper-
trophy of the interlobular septa, (See Dr. Hope's
coloured illustrations, figs. 3 and 5,) so a close
inspection will generally detect that the solid

636

PNEUMONIA,

state of the lung is owing to the same deposition
in the interstitial tissue of a matter more or less
dense, which we know in other parts to follow
chronic inflammation. As far as it is connected
with phthisical disease, this matter will be fully
treated of under the head Tubercular Phthi-
sis ; but we cannot refrain from repeating the
opinion (which is nearly that of Andral also,) that
the miliary and diffused indurations considered by
Laennec as the first stage of tubercle, are the
effect of chronic inflammation of the interstitial
tissues of the lung. The length to which this
article has extended prevents us from entering on
the question of the relation of inflammatory to
consumptive disease ; but we cannot refrain from
expressing our belief, that if tubercle is not gene-
rally produced by chronic inflammation termina-
ting in an irregular form of suppuration, extended
pathological research proves more and more that
an absolute line of demarcation cannot be drawn
between the indubitable result of inflammation,
and the various forms of what is now called tu-
bercle.

We have just adverted to the resemblance be-
tween the texture of miliary granulations and cer-
tain forms of chronic inflammation ; and those fa-
miliar with pathological anatomy will acknow-
ledge that there is no constant line of distinction
between purulent and tubercular matter; and that,
although they are generally different, yet cases
frequently present themselves in which they so
completely pass into each other that no physical
characters appropriate them to either kind of le-
sion. That tubercle may sometimes be developed
without any inflammatory process, is sufficiently
proved by the examples in which it occurs in va-
rious parts of the body at once, apparently as a
modification of the ordinary nutritive secretion of
the part under the influence of a peculiar diathe-
sis ; but the prevalence of this diathesis in a lower
degree, although insufficient in itself to produce
tubercle, may give a tuberculous character to the
products of any inflammation that may arise, and
this the more effectually as the inflammation is
asthenic and defective in the energy of its orgasm.
Although we thus express our conviction of the
connection of this subject with that of pulmonary
consumption, we must not entrench on the article
devoted to that disease, and we will close these
remarks by quoting from the little work before
noticed the conclusions to which we were then
led, as they develop what we consider still to be
the full extent of the relations of inflammatory to
tubercular disease. "The lungs may become in-
fested with tubercular matter : — I. by the tuber-
cular suppuration of the indurations, whether
granular or diffused, which we have been induced
to consider chronic inflammations of the pulmo-
nary tissue, this being the natural termination of
such inflammation ; 2. by tubercular suppuration
of other inflammations of the tissue ; this effect
being determined by the prevalence of the tuber-
culous diathesis :* 3. by secretion in tissue bearing
no marks of other lesion, the tubercular matter
being here deposited through excess of the tuber-
culous diathesis," modifying the common nutri-

* See Dr. Alison, on the Origin of Tuberculous Dis-
ease, Trans, of the Medico-Chir. Soc. Edin. vols. i. and

tive secretion of the part. (Rational Exposition,
&c. p. 160.)

The symptoms of chronic pneumonia superven-
ing on an acute attack partake of the general cha-
racter of this modification of inflammation. Thus,
although the general fever abates, and the func-
tions are in some degree restored, yet the pulse is
still quick, the breathing short, the cough remains,
the expectoration often assumes the characters of
that of chronic bronchitis, and the patient, although
he recovers in some degree his appetite and
strength, looks ill, and does not advance beyond a
certain degree of amendment. Percussion and
auscultation will discover the remaining disease by
the dull resonance of the corresponding part of the
chest, and the absence or bronchial character of
the respiratory sound. The solid state of the lung
which causes these signs, if it be not removed by
the sanative processes of nature aided by reme-
dies, will gradually induce other disorders : either
it may terminate in suppuration, and, if extensive,
it will endanger life by the unmanageable decay
in which it involves the lung, and which, if not
identical with tubercular disease, bears to it a
strong resemblance in its symptoms and course ;
or remaining a solid obstruction to the circulation
and respiration, it occasions dropsy and that
cachectic state which we find induced by chronic
pleurisy, pulmonary emphysema and other local
diseases which permanently infringe on these vital
functions ; and here again a condition is produced
which is on all sides admitted to be most favour-
able for the development of genuine tubercular
consumption. In fact, however we study the
relations of inflammation and tubercle, whether
rationally or from evidence, whether at the bed-
side or in the dissecting-room, we are continually
meeting with proofs of proximity between them,
which are far too constant and regular to be as-
cribed to accident. Were we to describe the
symptoms of pneumonia originally chronic, we
should only have to state phenomena which are
detailed in another article. See Tubercular
Phthisis.

Treatment of Chronic Peripnciimony.
— If this disease is so exceedingly rare as it is
supposed by Laennec to be, we might pass over
the subject of the treatment entirely, as he does;
and if, as we believe, it constitutes a form of con-
sumptive disease, we must refer to the article on
Tubercular Phthisis for its fuller consideration.
We would, however, make one remark to recon-
cile views which may otherwise appear conflict-
ing ; that because tuberculous disease may be
developed and hastened by a form of inflamma-
tion, it does not follow that consumption is to be
treated by depletions and abstinence. We have
often seen that these measures do not restrain the
asthenic and chronic forms of inflammation, while
they may injure the general power of the consti-
tution, and that the combination of treatment most
useful in these cases is a mild tonic and nutritive
regimen, with external counter-irritation and what-
ever alterative the case may suggest. We believe
these to be the most successful measures in the
disease in question, which may in addition require
expectorant and other remedies for particular
symptoms, and the removal of the occasional
causes by resorting to another climate. We have

PNEUMOTHORAX.

637

known a case of chronic solidification of the lung,
which had already begun to exhibit the commence-
ment of a phthisical career, cured under a course
of iodine internally, with external counter-irrita-
tion, and careful protection from transitions of
temperature. The prospect of a cure will be in
proportion as the disease is limited in extent, and
the constitution strong and free from that diathe-
sis which we have noticed as the cause of the
worst form of consumptive disease.

C. J. B. Williams.

PNEUMOTHORAX. — This term (com-
pounded of -vevna, aros—duipri^) signifies a collec-
tion of aeriform fluid in the cavity of the pleura.
As such a pathological state had not attracted
notice till modern times, it remained undistin-
guished by any proper appellation till the begin-
ning of the present century, when the word pneu-
mothorax, invented by M. Itard, was adopted to
designate it. It has been objected at various
times to this term that its etymological composi-
tion is incorrectly formed, but closer examination
into the analogies of Greek derivatives proves this
to be unfounded ; and, moreover, it appears now
to be so well established on the basis of authority
and general adoption, that any change would be
both improper and impracticable.*

Gaseous collections have been frequently noted
as occurring in some of the serous cavities as well
as the other tissues of the body. It had been
often observed that air escaped on opening the
thorax in necroscopic examinations, and the at-
tention of surgeons was occasionally arrested,
during the operation for empyema, by a rush of
air through the canula preceding the flow of mat-
ter. The effusion of air consequent on laceration
of the lung by fractured ribs was known, but was
classed with emphysema, and called emphysema
thoracis. Those casual observations had not been
reduced to any digested form, nor did they lead
to investigation of the true origin of the elastic
fluid, as it was universally assumed that the latter
was extricated by decomposition from the puru-

* We find that Dr. Ellintsnn, in his lectures, has re-
produced the objection of Piorryto the term pneumotho-
rax (Lancet, 1 Dec. 1832, p. 305.) He states that these
compounds are always made from the dative singular,
and that the word should he pneumatothorax. With un-
feigned deference we would submit that the majority of
these compounds are not formed from the prolonged da-
tive, as a'tpaTi, vSart, but from the nominative a\fia,
vow/), by changing its termination into o,— for example,
hemorrhage, hydrothorax, &c. Pneumothorax, formed
according'to tiiis analogy, is a more perfect hellenism,
and (as will be easily conceded) much more euphonious
than the other formation. Its true signification also is
" air in the thorax," and not "lung in the thorax ;" for
it will be observed that if this were necessarily its mean-
ing, it would follow, by the same analogy, that hydro-
thorax signifies, not " water in the chest," but " hydra
in the chest," and to represent the firmer it should be
h'Jilatothorax Professor Elliotson has permitted himself
tooverlook his own principles in saying that pneumo-
thorax means 'lung in the thorax," for even if, as he in-
rie formation from the dative were followed (as
9e acknowledge it has been in a few jnstapces), it is im-
mediately apparent that "lung in the thorax" would be
Pneumonot/wrax, ^jupr, puluio, ovoi, on. In arranging
'he terminations of these compounds the ancient Greeks
:"-ial regard to the euphony, but this does not
seem to have been the ease with their successors who
lived at the decline of the language, for to these are cer-
tainly to be referred the few compounds in afo, as hsama-
•bcele, pneumatocele. The last word was even changed
Irom the original pneumocele: vide Laennec.de 1 Aus-
cultation torn. ii. P- 241, " ulc - Edllnm lf ~ >t3 -

3d

lent matter. It was not, therefore, till 1803, when
M. Itard published his dissertation, that air in the
pleura came to be considered as not a mere acci-
dental complication in some rare cases of empyema,
or as only occurring after death, but to constitute
in itself an important pathological condition. Al-
though thus much appears to have been esta-
blished by the researches of this author, the insuf-
ficient advances which morbid anatomy had made,
and the incorrect notions which prevailed as to
the pathology of thoracic diseases, prevented him
from going much further. His views corresponded
with the old crude idea of the chemical decompo-
sition of pus. He regarded it as always conse-
quent to and depending on a latent phthisis, and
ascribed the production of the air to the decay of
the lung by means of a chronic suppuration, and
the long retention of the pus in a shut cavity,
which caused a partial absorption of the stagnant
liquid, and its decomposition into an aeriform
fluid : this was the state of knowledge on the sub-
ject till the time of Laennec, for whose labours
it was reserved to investigate its true nature, and
to give it its proper place in nosology. His re-
searches have attached to pneumothorax the high-
est degree of importance, and we do not think that
the genius and industry of this great physician
have been more signally displayed in any of their
achievements for thoracic diseases, than in the
comprehensive illustration which he has given of
the pathology and diagnosis of this affection.

Two sources are recounted by which air in the
cavity of the pleura may originate. It has been
said to be generated within that membrane, and
it may be introduced from without. The former,
we have seen, is the origin to which M. Itard as-
cribes it in every case, and Laennec assents to
this manner of explaining the six cases which he
cites. In all these instances the pneumothorax
was accompanied by a pleuritic effusion, the con-
sequence, as they relate, of phthisis ; and the lat-
ter author is of opinion that the gaseous develop-
ment was caused by a decomposition of part of
the albuminous matter suspended in the puriform
effusion. This, he adds, is rendered probable by
the odour of sulphuretted hydrogen which the air
exhaled. Neither this nor any of the other cir-
cumstances by which they were attended would
incline observers at the present day, furnished
with precise and more extended information on
the subject, to agree to this method of explaining
it. On the contrary, the examination of their
details exhibits sufficient evidence to authorize us
in referring them to a cause (the admission of air
from without) which will be hereafter mentioned,
as by far the most frequent of all. It has never
been satisfactorily proved, and it seems to us an
extremely problematical circumstance, that pneu-
mothorax ever occurs by the putrefactive decompo-
sition of a pleuritic effusion. The other processes
by which air may be developed within the pleura,
as recounted by Laennec, will be afterwards ad-
verted to. It may be here stated that some of
them are only conjectural ; for the experience of
one individual could not supply well-ascertained
facts sufficient to establish by observation all its
causes and their relative frequency, particularly
as he had to bring to maturity his own discovery
of the method of exploring them.

638

PNEUMOTHORAX.

It may be laid down as proved by the recorded
experience of medical men, that where pneumo-
thorax exists the air has been introduced from
without ; for cases of an opposite description are
so rare that they must be considered as exceptions
to the rule. This position will not be called in
question, we apprehend, by any one who has de-
voted some attention to this subject. Air, then,
may enter the serous membrane and form a lodg-
ment in the sac of the pleura, either from the
lung and bronchial tubes, or by the thoracic parie-
tes through the skin and intercostal spaces. An
example of the former is afforded by the rupture
of the pleura from the bursting of a tubercular
cavity communicating with the bronchial tubes,
and of the latter by the opening of an anthrax of
the intercostal spaces through the costal pleura,
or by the pneumothorax consequent on penetrat-
ing wounds of the chest, whether accidental or
artificial. We proceed now to expose the phe-
nomena of this affection ; but as most of these
are common to it from whatever source it arises,
it will be found advantageous to consider them in
a description of it as resulting from one particular
cause ; namely, the first which we shall mention.

Pneumothorax produced by the bursting of a
tubercular abscess into the pleura. — This species
of the affection is, beyond all comparison, more
frequent than all others. If we were to conclude
from the experience of the medical men in Dublin
who have given most attention to the subject, it
might be asserted that it constitutes fully nine-
tenths of the cases of pneumothorax, with the
exception of the traumatic variety ; and this, or
even a greater proportion, is established by the
cases found in medical writings since the publica-
tion of Laennec's work. This great comparative
frequency, together with the importance which it
derives from its connection with the history of
phthisis, have concentrated upon this form nearly
the whole interest which the malady possesses.

Pathology. — The cavities which the progres-
sive stages of aggregation and softening of tubercles
form in phthisis are situated almost invariably in
the superior lobe of the lung, and it is at the very
summit of this that in general the excavation is
largest. While the pulmonary parenchyma dis-
appears before the expanding walls of the abscess,
a remarkable circumstance is observed in examin-
ing the manner in which this tissue is destroyed,
which shows that nature was making at least
some struggle against her too powerful enemy. It
is found that the bloodvessels are not engaged in
the ulceration, but become obliterated, and traverse
the empty cavity, as solid chords. The bronchial
tubes, on the contrary, are involved in the de-
struction, and their divided ends preserved open,
levelled to the surface of the parietes of the sac,
and forming a part of them. This double provi-
sion has obviously for its ultimate end to prevent
sudden hemorrhage, and to allow of the evacua-
tion of the tubercular matter. (See Phthisis.)
While the latter is accomplished, it is manifest
that the same passage which permits the matter
Jo escape admits the inspired air to fill the space
which it occupied. If life be prolonged, the parie-
tes are always enlarging their limits, and thus,
although slowly, marching towards the surface of
the lung. Those centrally situated do not often

arrive at the surface, but others, originally devel-
oped more superficially, extend in their progress
to the serous membrane, which at length becomes
in contact with the membrane forming the wall
of the cavity. Here the spreading further is
generally restrained by the throwing out of lymph
and the formation of adhesions, but not uniformly,
for in many instances the pleura is perforated.
The immediate consequence of this is that the
contents of the tubercular abscess, including
softened tubercle, muco-purulent matter, and air,
are precipitated into the cavity of the pleura.
The reception of these contents into the pleura
could not take place if the lung were to remain
as in its natural state, in perfect apposition with
the costal parietes, but a new condition is induced
on the occurrence of perforation which permits it.
In the physiological condition the lung is retained
in a state of distention beyond its mean capacity
by the expansion of the thorax, a condition which
its highly elastic structure allows. It is, even at
the extremest expiration, we believe, still kept
more expanded than its elasticity would allow if
left to itself, and not counteracted by the atmo-
spheric pressure. The latter force, however, cer-
tainly stretches it during inspiration, when the
capacity of the thorax is much enlarged ; but
when perforation of the pulmonary pleura takes
place, the pressure becomes equalized on the ex-
ternal and internal surfaces of the lung, and now
the elasticity is permitted to act, which it imme-
diately does by producing the recession of the
lung from the costal pleura. By this means a
space is left and instantly filled with air from the
bronchial tubes, which have now, by the interven-
tion of the phthisical cavity, a free communication
with the sac of the perforated pleura. Such is
the mechanism by which the atmospheric air gets
ingress in this variety of pneumothorax.*

To physicians who have opened many subjects
that have died of phthisis, it would at first only
seem a surprising circumstance that pneumothorax
is not a more frequent occurrence. They are ac-
customed to find very frequently at the summit of
the lung phthisical cavities, bounded merely by the
pleura itself, or with so thin a plate of lung inter-
posed that it is scarcely any protection to it. Yet
it is well ascertained that perforation rarely or ever
takes place at the summit, where we so frequently
meet with so slender a barrier to prevent it. The
explanation of this is found in the fact that the
summit of the lung in which large cavities exist
is always covered by a dense cap of false mem-
brane, which effects its firm adhesion with the
opposed costal pleura. It would seem that, as

* It will be observed that we have adopted Dr. Car
son's views with respect to the agency of the elasticity
of the lung in respiration. We think 'that, so far as we
have stated them, they are consistent with our experi-
mental knowledge on the subject, but we are not igno-
rant that many think them contradicted by the pheno-
mena of wounds of the chest, where hernia of the lung
succeeds. It is almost certain that the latter is caused
by a vital irritability, and not by mere elasticity, as we
see that the invariable action of the latter in the dead
subject is to contract the lung when the internal pres-
sure i9 removed. The forces which act on the lung are
by no means sufficiently investigated ; the experiments
which have been made on the eighth pair seem quite
inconclusive on this subject, and until it be further elu-
cidated, many phenomena connected with asthma,
hysteria, protrusion of the lung, and its re-expansion
after collapse, must remain unexplained.

PNEUMOTHORAX.

639

the parictes of the cavity approach the surface at
the summit of the lung, an effort of nature is
made to intercept the escape of the contents of
the tubercular cavity, by the formation of these
adhesions. A chronic inflammatory action in the
pulmonary tissue always surrounds the cavity for
a lesser or greater extent, and, as it were, precedes
its progress towards the surface. The effect of
this is visible in the plates of lung often found to
intervene between the cavity and the surface,
which are generally in a state of dark-grey hepa-
tization. It is by this same inflammation that the
false membranes are thrown out which effect the
adhesion of the pleural surfaces, — those, we mean,
which are met with covering the summit of the
lung in phthisical patients. It is found that in
the same proportion as the cavity advances to the
summit, the cap of false membrane becomes more
strongly organized and thicker, and forms thus an
effectual protection against perforation as far as
those adhesions extend.

It is important to remark, with respect to those
dense membranous cases, that as it is in the sum-
mit of the lung that cavities usually exist, so this
part is much more favourably circumstanced for
adhesion than any lower part ; for the sliding mo-
tion of the lung on the costal pleura is greatest at
the diaphragm, and diminishes in proportion as
we ascend to the summit, where it is little if at all
moved by the respiratory action. A constantly
quiescent apposition of the two surfaces is that
which most advantageously promotes the forma-
tion of adhesions, and, as we have just stated, this
is possessed only by the summit, and decreases as
we descend from this. These considerations ex-
plain the observation, well known to all conver-
sant with phthisical dissections, of the existence
of the membranous coverings at the summit of
the lung. They moreover show the reason, that
while it is in this place tubercular cavities gene-
rally first attain the surface, perforation of the
pleura most seldom occurs here, and they also
lead us to anticipate the fact that the perforation
does generally take place just below the line to
which the adhesions extend.

The rupture may occur in any of the lobes of
the lung, but the inferior part of the upper lobe,
and the superior part of that beneath it, is the
place where it has been most usually observed.
In a great majority of cases it has been found to
tappen on a line with the third rib, posteriorly
iUut the costal angle, and, as we have said, just
under the reflection of the false membrane by
which the superior lobe is so generally adherent.
But although this is its usual situation, it is ob-
vious that it may happen at any part of the pul-
monary surface. It has even been known to hap-
pen at the base of the lung lying on the diaphragm;
but this must be a very rare situation, both because
adhesions are common here from the apposition
being little disturbed, and because tubercular
cavities are uncommon at the base of the lung.

The existence of a large cavity, or even of nu-
merous tubercles, is by no means necessary to the
production of pneumothorax. We have known
it to occur where the cavity which caused the per-
foration was smaller than a nut. Andral and
others have met with cases where only five or six
tubercles existed in the lung in which it hap-

pened, and Dr. Townsend had one remarkable
case where it followed on the bursting of one
single tubercle, which was unfortunately deve-
loped immediately under the pleura, while the
whole of the lung beside, as well as the other
lung, was perfectly free from them.

The inevitable consequence of the escape of
the contents of the cavity and of the air into the
pleura is the immediate accession of an acute
pleuritis of a more or less intense character.
This supervenes when scarcely any thing but
atmospheric air is received into it, for this proves
as decidedly irritant to the membrane as any other
of the foreign substances which enter together with
it, a fact which appears demonstrated by viewing
the false membrane which follows the pleuritic
effusion. The latter is found to be as thick and
well organized at the superior and middle parts
of the pleural sac, (where it could only receive
the irritant impression from the air,) as the base
of the sac upon which the fluid contents of the
cavity are emptied. The lung being separated
from the costal pleura at the first moments of the
perforation, (as we have described,) becomes now
compressed both by the air and the pleuritic effu-
sion, so that, unless it be retained in points by old
adhesions, the compression against the spine and
mediastinum leaves a large proportion of the
pleural cavity filled with air and fluid, constitut-
ing the double lesion of empyema and pneumo-
thorax.* (See Empyema.) If the consequences
of the perforation be not speedily mortal, the
lymph effused by the pleuritis soon becomes or-
ganized, and forms a factitious membrane over-
laying the whole surface of the compressed lung
and costal pleura, where the air has been able to
penetrate. This false membrane is not to be de-
scribed, as some have done, as a thickening of the
pleura. Even in its most perfect state of organi-
zation it may be perceived to be a deposition upon
the pleura, which membrane lies under it, (al-
though incorporated with it,) of its natural thick-
ness. The lung itself lies compressed and flat-
tened against the spinal column and mediastinum.
In cases which have lasted some time, its diminu-
tion of volume proceeds generally till it is reduced
to about one-fourth, and then, if its substance be
cut into, the bronchial tubes and vessels are so
matted up in its condensed tissue as to present
the appearance called carnified lung. (See Em
ptema.)

While the false membrane forms a general
lining for the sac of the pleura, the orifice of the
perforation is spared, and the communication be-
tween the bronchial tubes and this cavity pre-
served. The perforation becomes converted into
a fistulous opening with a smooth round edge.
This orifice has a tendency to increase in diam-
eter, and often attains the size of the tubercular
cavity which originated it, but it rarely passes the
size of a shilling. We lately had an opportunity
of examining three fistulae which afforded exqui-
site examples of the state of those perforations
when they attain to a chronic condition. Their
surface extended nearly across the cavity whose
bursting formed them, and was covered with a

* This constant complication of pleuritic effusion Willi
pneumothorax has given occasion to some to denomi-
nate it pleuro-pneumothora.\.

640

PNEUMOTHORAX.

smooth membrane of a serous aspect similar to
that forming the general empyematous sac. They
had the appearance of a shallow cul-de-sac about
a line in depth, and the largest of them had the
diameter of a shilling. On examining a little
closely, a probe passed under the circumferential
rim of the apparent cul-de-sac into a bronchial
tube which communicated with a larger cavity.
The disposition of the fisturce here described is
very common, viz. the perforation formed by the
remains of a very small tubercular cavity, and the
latter connected with other larger cavities by
means of bronchial tubes.

The closer anatomy of these fistula; presents
circumstances which are particularly worthy of
attention. The bronchial tube by which com-
munication is maintained between the orifice and
larger cavity is almost invariably found to open
upon the face of the fistula towards the sac in an
oblique manner from above downwards. This
disposition is noticed as occurring in some of the
cases detailed by Dr. Duncan in the 28th number
of the Edinburgh Medical and Surgical Journal,
and we have witnessed it very strikingly displayed
in cases which lasted for a certain period after the
perforation. The effect of this is to convert the
orifice of the opening into a valvular structure,
and as it were to aid in the accomplishment of
this object, the superior rim of the opening is
sometimes observed to be prolonged downwards
for a short space over it. The method by which
this structure is produced it is difficult to explain,
but the end which it is intended to accomplish
appears more obvious: at least an attentive ex-
amination of it in a strongly marked instance
satisfied our minds that it results from an attempt
at obliteration of the fistula by a process of nature.
On the smooth face of the opening in the case
alluded to, there were five small depressions which
appeared to be stopped-up bronchial tubes, and
the fistula which remained at the upper part was
far advanced in the valvular structure. It seemed
to us that those tubes were obliterated whose
smallness and direction afforded the greatest obsta-
cle to the entrance of air, while that which re-
mained pervious was of the largest size ; but what
we would particularly advert to as explaining its
resisting the process of obliteration, is the nearly
vertical direction which it had with regard to the
lung. According to our view, this position favours
remarkably the entrance of air in such a case, as
it lies directly in the line of the action of the
diaphragm, by the contraction of which, almost
solely, the air is drawn into the cavity in pneumo-
thorax. Another circumstance bearing on this
subject which was noticed in the same dissection*
should not be omitted. ' The lining of the bron-
chial tube which formed the fistulous communica-
tion, a track of about two inches, was quite
changed from the character of mucous mem-
brane; it was no longer pulpy and soft like the
latter, but partook more of trie serous character,
and there were remarked all along it firm granu-
lations of considerable size. The same change
was observable in the large excavation from which

* For an account of this dissection we refer to the
May number of the Dublin Journal of Medical and
Chemical Science.

the fistula led ; its lining was more like the lining
membrane of the heart than the usual soft mem-
brane which forms the secreting surface of phthisi-
cal cavities. (See Phthisis.) These observa-
tions go some length in explaining the mechanism
of these oblique fistulse, and we think they furnish
also an intelligible and just account of the object
which they are intended by nature to subserve,
which we are led to conclude is an attempt to
obliterate the fistulous orifice.

The general membrane of the sac is a highly
organized secreting surface, and appears to be
peculiarly susceptible of inflammation and its con-
sequences. It must, indeed, be supposed to be in
a continual state of chronic irritation, from the
presence of the atmospheric air to which it is
constantly exposed. There are frequently found
upon it more or less organized albuminous con-
cretions, the result of acute attacks of inflamma-
tion. These exudations are either general over
the whole sac, or partial. They sometimes sur-
round the aperture in the lung so as to narrow it,
and cases have been observed where it has been
closed altogether by them. The latter event
would be most likely to occur]- where the fistula
is small and recent, or, on the other hand, where
the valvular structure is far advanced. Another
result of inflammatory action which it is not un-
common to find on the sac, is the existence of
small erosions with a dark and irregular base and
circumference, which resemble small gangrenous
eschars more than they do common ulceration.
These exhale generally a fetid odour which gives
them also the character of spots of gangrene ;
and it is a fact which is confirmed by experience,
that the sac is much more liable to gangrenous
inflammation in empyema with pneumothorax
than in simp e empyema. The erosions just de-
scribed sometimes penetrate the sac and pleura,
and at other times they are not so deep, but go
no further than the thickness of the false mem-
brane. Their existence cannot but suggest the
idea that perforation may occur by the ulcerative
process originating in the pleura, and being propa-
gated to the lung and bronchial tubes, as well as
the contrary way, which we are considering in
this section. The occurrence of pneumothorax
originally in this way is, however, extremely rare;
but we believe that, when it has already for some
time existed, additional fistulse are occasionally
formed in this way.

The contents of the sac are in every case air
and purulent matter. In the early stages of the
affection the latter fluid is the secretion of the
pleura itself, the effect of the acute pleuritis which
follows the eruption of the air. When it has
advanced to a more chronic duration, the adven-
titious membrane thrown out by the pleuritis be-
comes itself the secreting surface whence the fluid
is derived. Its characters vary considerably, (see
Empyema, Pleuritis,) and are influenced by
the duration of the disease, vigour of the patient,
and other circumstances. For the most part it
is found to be a greyish turbid serum, through
which homogeneous pus is mixed, and having an

fWe are persuaded that this has been the state of
things in many of the cases of pneumothorax on record,
where it has been reported that examination failed to
discover any fistulous communkot ou.

PNEUMOTHORAX.

641

abundant stratum of soft albuminous coagula at
tbc bottom.

We have already marked the error which pre-
vailed long after the discovery of pneumothorax,
in supposing that the air was formed by the
putrefactive decomposition of the pus. Such a
decomposition of this fluid does*not take place,
but, on the contrary, it is generally remarked that
it is inodorous, and free from any evidence of such
a process. It is true that in some cases both air
and fluid exhale a fetid odour, but in these we
must search for other causes than the putrefaction
of the fluid ; for if this happened in one instance,
it should happen in all, as the laws of chemistry
do not alter or suspend their action, which would
be implied by this hypothesis. In the instances
in which we have noted the contents of the
sac to be fetid, there was always a gangrenous
state of the pleura to which the fetor was evi-
dently to be ascribed; and as we have shewn
that gangrenous ulcerations of the sac are not
uncommon in pneumothorax, we are inclined to
believe that they will be always found where the
putrid odour is exhaled by the purulent matter.*
The absence of the chemical decomposition of the
pus is a fact which is now fully proved by expe-
rience ; but when we consider the conditions to
which it is subjected, it appears to be nothing
wonderful that the idea was so long entertained,
but rather remarkable that it does not invariably
happen. It is constantly exposed to a warm tem-
perature and to atmospheric air, which, together
with moisture, are the essential promoters of the
decomposition of organic compounds. Yet we
have witnessed a case where these conditions ex-
isted for a year and a half, in which the pus was
quite free from odour, and in all its qualities
unchanged by the atmospheric contact. We are
unable at present to go any length in discussing
the cause of this curious circumstance, but we
would observe that rest is a condition favouring
chemical decomposition, which is absent in the
present case. Some have considered that it is
sufficiently explained by the fresh supply of ani-
ranliscd fluid, which the surface of the sac is sup-
posed to maintain, by a continual secretion and
absorption. The blood, when effused into the
pleura, has been sometimes observed to remain
fluid. We are not ignorant, as we have said, of
the explanation of these facts, but they seem to
prove that animal fluids have some power of re-
sisting the laws of chemistry while preserved in
contact with the living solid.

The air enters the sac through the fistulous
opening during inspiration. When allowed to
escape by a puncture of the thorax, it generally
proves to be an inodorous gas, or possessed of a
slight sharpness, but, generally speaking, it differs
little from the atmospheric air whence it was
originally derived. The same gaseous elements
have been found to make up its chemical consti-
tution, which has been examined by Dr. John
Davy, (Philosophical Transactions, 1824,) and
Dr. Apjohn, (Transactions of Association of Col-

* The fetidity which the bronchial rnucus is often
Known to possess in phthisical patients may be another
Muse imparting bad odour to the contents of the sac in
Hteumothorax, as il has generally free access to it
brougn the hstulc.
Vot.HI.- 81 3d*

lege of Physicians, Dublin, 5th vol.) The fol-
lowing was its composition in Dr. Apjohn'a
analysis, which is the more recent of the two.

Carbonic acid g

Oxygen io

Nitrogen 82

100
This coincides nearly with the composition of
expired air as deduced from the investigations of
Allen and Pepys, and it is by no means improba-
ble that the surface of the sac acts on it in a
similar manner with the air-vesicles of the lungs.
Such an action has been, indeed, proved to have
existed in Dr. Davy's case, in which analyses of
the air were made at different periods. By a
comparison of the latter, an interesting fact was
deducible. It was found that the quantity of
carbonic acid increased as the strength of the
patient decreased, and the air which was col-
lected twelve hours after death contained a dou-
ble proportion of this gas.

In the great majority of instances the air, al-
though free to enter the cavity, is either partially
or totally prevented egress during expiration,
owing to the valvular disposition of the fistulas
which we have adverted to above. When expi-
ration takes place, the air of the cavity, com-
pressed by the contracting thorax, forces the sides
of the fistula together, and thus closes it, exactly
in the same manner as the valve of the bellows
prevents the air from going out by the aperture
through which it entered. The consequence of
this is, that the air exerts a pressure within the
sac which is always increasing as long as the
communication remains open. This compression
is fully sufficient to account for the reduced size
and flattened appearance of the lung which has
been described above, and for the dilatation of the
intercostal spaces, which is equally a phenomenon
of pneumothorax. It has been a debated point,
what part the air, and how much the fluid, con-
tributed to the production of this internal pressure.
To us it seems evident that the compression must
be nearly altogether attributed to the air, and that
the purulent matter exerts pressure only as it is
itself acted on by the elastic fluid. The force
with which the latter escapes when a small punc-
ture is made in the parietes of the thorax, even
some hours after death, (when a diminution of
the pressure certainly takes place,) is well known.
A fact which occurred in Dublin illustrated in a
decisive manner the pressure which the fluid re-
ceives from the air. Paracentesis was performed
on a man who laboured under pneumothorax
with empyema, and the puncture of the chest was
made below the level of the fluid, the evacuation
of which was considered the chief object. Imme-
diately on the entrance of the canula, the matter
was projected through it with surprising force and
to a great distance. Its forcible exit continued
until it was nearly all evacuated, diminishing,
however, towards the end of its flowing. This
projection of the matter was undoubtedly to be
ascribed to the great compression under which
the elastic fluid existed. With respect to the re-
lative proportions of the air and fluid there is the
greatest variety. In the majority of cases the
space filled by the air is much greater than thit

642

PNEUMOTHORAX.

which the fluid occupies. The nearest ratio might
be set down as two-thirds air and one fluid.
These proportions, however, vary not only in dif-
ferent cases, but also in the same at different
periods. We are enabled often to ascertain that
the fluid gains on the air, and sometimes, though
seldomer, that the air increases at the expense of
the fluid. In an interesting case detailed by Mr.
Smeal, (Med. Chir. Review, July, 1831,) the fis-
tula became obliterated from the formation of a
coagulum, and speedily afterwards it was observed
that the air became absorbed, and the fluid pari
passu increased. This fact proves the manner in
which the proportion of the elastic fluid is pre-
served, and moreover shows the power which the
adventitious membrane possesses of absorbing air,
as Nysten's experiments had already done for the
pleura.

History and Diagnosis. — As the species of
pneumothorax which we now describe is the con-
sequence of phthisis, the history of an individual
case, if it be investigated with due precaution and
diligence, will almost universally demonstrate that
cough, hemoptysis, emaciation, night-sweats, &c.
(see Tubercular Phthisis,) have existed be-
fore the signs peculiar to pneumothorax betray its
presence. It happens generally that phthisis has
gone on to a very advanced stage ere this distress-
ing complication is brought under the observation
of the physician. This is, however, not entirely
owing to its invariably occurring at a late period.
Somewhat of it is attributable to the circumstance,
that the means of its diagnosis have been hitherto
scantily disseminated amongst the mass of prac-
titioners, and to their not being used with suffi-
cient confidence by those whose education has
embraced them. Auscultation and percussion are
now, indeed, daily becoming more practised and
relied on, and as this advances it is accordingly
found that many more cases are discovered, and
moreover it is occasionally detected in the com-
paratively earlier stages of phthisis. From what
has been related in the foregoing section as to its
being known to result from very minute cavities,
or even from a single tubercle, it follows that it is
an accident which may occur in the earliest
periods of the history of phthisis, even when the
phenomena of the latter are so transiently marked
as to be doubtful, and to allow of fallacious hopes
of recovery. This, which we should anticipate
from acquaintance with its pathology, has been
observed in actual practice ; its supervention has
been witnessed at the very commencement of
phthisis as well as at its close, so that what expe-
rience teaches is, that while the later stages are
more exposed to its occurrence, it may happen at
the period at which only the faintest suspicion of
phthisis has as yet existed.

The means for the diagnosis of pneumothorax
are the rational symptoms and the physical signs.
We shall consider these separately, comprehend-
ing under the latter the signs derived from suc-
cussion, percussion, and auscultation. In the first
place it is to be remarked that at the first occur-
rence of the pneumothorax, a striking change
takes place in the entire class of symptoms and
physical signs. Before this event there have been
present, in a more or less perfect state, the phe-
nomena of phthisis, but afterwards those which

we proceed to describe as the characteristics of
pneumothorax. This change, then, we would
call attention to as in itself an important com-
mencement of the chain of symptoms. The mo-
ment of this change is generally perceptible to the
patient himself, # and when this is the case, he
dwells much upon it in his description to his phy-
sician. He sometimes feels, in fact, the air pars-
ing into the pleura at the moment of the rupture,
as also the rupture itself. This sign did not
escape the observation of our older physicians, al-
though they were unacquainted with the patholo-
gical conditions which gave rise to it. Morgagni
recite= a case in which this sensation was accu-
rately described, as observed by Willis and Lower:
" Casurn habes in sepulcreto descriptum adoles-
cents qui se Willisio ac Lowero curandum tra-
didit. Is post immodicas equitationes, aliasque
corporis diuturnas exercitationes cum aliquandiu
in sinistra thoracis parte eum sensum habuisset,
qui esse sine interna compressione non poteral,
ibi tandem sensit disrumpi quasi vas quoddam ;
indeque per semihorse spatium in regione istd ub
alto in pectoris fundum cadentis stillicidium non
tantum ub eo percipi, sed etiam ab adstantibus
audiri potuif." (De Sed. et Causis Morborum,
Epist. xvi.) This sensation has been, if possible,
still more appositely depicted since the pathology
of pneumothorax has been cleared up. We find
the following description in Louis's forty-first
case : " La malade eprouva tout-d-coup, du cote
gauche de la poitrine, une sensation pareillc a
celle qui eut ete produite par un gaz qui aurait
circuit: de bas en haut dans toute cette partie du
thorax."* This actual perception of the perfora
tion by the patients is an element of the diagnosis
which it is so desirable to possess, that the practi-
tioner should never omit to inquire after it, yet it
is one which he must learn to dispense with, as
many cases occur in which no such sensation has
been felt, while in others, in which a certain period
has elapsed, it escapes the patient's memory.

Empyema being invariably an accompaniment
of this variety of pneumothorax, the symptoms of
the latter are necessarily mixed up with those of
the former. This circumstance demonstrates the
insufficiency of the rational symptoms in detect-
ing it, and partly accounts for the long ignorance
which reigned on the subject. We find the symp-
toms of empyema set down as dyspnoea and pain,
cough and expectoration, decubitus on one side,
dilatation of the side, displacement of the heart,
and depression of the diaphragm, hectic fever.
These are found amply discussed as constituting
the disease of empyema under its proper head
(See Empyema.) The same catalogue precisely
makes up the rational symptoms in pneumothorax
It now devolves on us to consider them in this
regard, and we shall find that accurate observation
has been enabled to discover several peculiarities
in them as belonging to pneumothorax, which
render an account of them quite indispensable to

* Rechorches Aiiatoniicc-PatholopriMes snr la Phthisie,
p. 461. The sensation, as related in a case of Dr. Stokes's,
strikingly resembled the description of Morgagni ; the
patient, " while in the act of coughing, had a sensation
as of a sudden crack, extending from the shoulder down-
wards, and felt as if a quantity of liquid was shed out
into the left side of the chest." Trans, of Assoc. Dublin
College of Physicians, vol. v. p. 337.

PNEUMOTHORAX.

643

its history, and give then, some importance as
auxiliaries in its diagnosis.

a. Dyspnoea and pain. — These symptoms are to
be considered at two periods. First, as they exist im-
mediately on the occurrence of pneumothorax, and
secondly, as present during the whole of the remain-
ing duration of the disease. The dyspnoea and pain
which follow immediately on perforation are nearly
simultaneous with the sensation which we have
above described, but they are still more constantly
present, and therefore of more value in its diagno-
sis. The researches of Louis (Op. citat.) have
called attention in a particular manner to these
circumstances. He regards the sudden superven-
tion of acute pain and overwhelming dyspnoea as
a constant attendant on perforation of the lung,
and as always indicating the period of its occur-
rence. They are, indeed, symptoms which are
so rationally suggested by a knowledge of the new
pathological conditions (viz. the sudden perfora-
tion of the lung, its collapse, and the effusion of
air &c. into the pleura) which ensue, that they
might have been anticipated by a priori reason-
ing, "et a raison de la similitude qui existe entre
les circonstances qui accompagnent la perforation
de I'intestin grele, et celle des poumons, on aurait
encore pu, ce nous semble, les soupconner par
voie d'anlagie." (Ibid. p. 476.) Louis relates
seven cases, in all of which they were present ;
and we know that in one of them at least they
occurred in the presence of the medical men, who
were enabled to pronounce on the supervention of
pneumothorax from this single circumstance. Their
value has been also confirmed by the reiterated
observation of them in the experience of others
since his publication. We are, then, to regard a
sudden access of violent pain in the chest, and of
greatly aggravated dyspnoea, as symptoms of the
greatest weight, and wherever they supervene in
the course of phthisis, the occurrence of pneumo-
thorax should be suggested to the mind of the at-
tendant physician, who should immediately have
recourse to other and less fallible means of explo-
ration. Louis observes that the pain, although
generally very acute, yet admits of varieties of in-
tensity, and that it is not always in proportion to
the sudden breathlessness which the perforation
induces ; and we find that in one of his cases he
notes that the pain was entirely absent.

But here we must not omit to state that in-
stances are not wanting which prove that neither
singly nor collectively can these signs be referred
to as decisive tests of perforation. Dr. Townsend
records a case of pneumothorax from this cause,
the commencement of which was marked by nei-
ther violent pain nor sudden dyspnoea. (Trans,
of Assoc, of Dublin College of Physicians, vol. v.)
We have also had a case in which the most care-
ful investigation of its history could not determine
the period of perforation from the sudden super-
vention of these symptoms. (Dublin Journal of
Medical and Chemical Science, No. 3.) In esti-
mating them, it is moreover to be remembered
that the dyspnoea of phthisical patients is not un-
commonly increased by other obscure causes ; and,
also, vvc should be on our guard against mistaking
for such an occurrence pleuritic pains, which arc so
common in phthisis, and sometimes are of more

than ordinary sharpness, without being by any
means connected with perforation.

The dyspnoea which exists during tne general
duration of pneumothorax is deeper and more dis-
tressing than that of simple chronic empyema.
This is, doubtless, partly occasioned by the co-
existing sources of irritation of the pulmonary
circulation which phthisical patients possess. A
cause of equal efficacy and more uniform exist-
ence is found in the resistance which the elasticity
of the air affords to the great pressure under which
it exists in pneumothorax. This causes such a
condensation of its volume before it produces the
compressing effect of a liquid effusion, that even
the greatest expansion of the thoracic parietes can
but partially overcome its reaction, so that the
dyspnoea resulting from their compression is but
partially mitigated by the deepest inspiration.
Such a condition is not present in simple empyema,
as it is obvious, from the non-elastic nature of the
fluid, that deep inspiratory efforts may expand the
thorax beyond the limits of its compressing action,
which therefore does not maintain a constant em-
barrassment of breathing, as it does not react (like
the elastic fluid) on the immediate compression
being temporarily withdrawn.

This appears to be the rationale of the aggra-
vated character which the dyspnoea of pneumo-
thorax possesses. The slightest exercise produces
great oppression if the patient be able to walk, but
ascending stairs causes particular distress. Even
the motion of turning or raising himself in the
bed leaves him often speechless from breathless-
ness for a short time. In the latter case we might
conjecture that the fluid is in large proportion, as
its mere weight has great influence on the breath-
ing in changing the posture.* If the duration of
the disease permits it to assume a chronic charac-
ter, the dyspnoea rather diminishes than increases,
although the internal compression shall not be
mitigated. This is attributable to that surprising
power of adaptation to circumstances which the
animal economy enjoys, and which is possessed in
an especial degree by the respiratory and circula-
tory organs. However, whatever fluctuation it
may undergo during the course of the affection, as
in all thoracic diseases, it becomes aggravated at
its close.

The acute pain which ushers in its commence-
ment generally subsides in a short time, and after
wards it runs its course without marked suffering
from this cause. But more usually, if the patient
lasts, he is subject to violent recurrences of pain
which have been traced in some instances to re-
cent inflammations of the sac, and also to the
establishment of new fistula?. These attacks of
pain are in themselves additional sources of the
dyspnoea ; it follows, however, of course, that no
secondary occurrence of inflammation, nor open-
ing of new fistula?, can produce the same degree

* This remark as to dyspnoea produced by sudden
change of posture, is a valuable diagnostic of fluid eflil.
sions of any kind in the chest, particularly where these
complicate pneumothorax. The description which Mor-
eagni gives of it in what was anciently called convul-
sive asthma, must be appropriated to such cases, and
particularly to that which we treat of. " Statim anhelt
fir.bant, ac velut moribuntli respirabant, cum retrorsum
caput moverent, aut supini," &c. De Sed. et Causis
Morb. Epist. xv.

644

PNEUMOTHOKAX,

of pain or overwhelming dyspnoea which ensues
upon the original perforation.

b. Cough and expectoration. — These symp-
toms, which are more or less present in every pul-
monary disease, form no essential accompaniment
of pneumothorax. No case indeed is altogether
free from them, but they are rather to be classed
with the signs of phthisis which has preceded it,
or with those of the pleuritis which accompanies
it, than to be referred to the affection itself. On
more than one occasion we have been enabled to
mark their connection with bronchitis supervening
in the opposite lung. Even a slight degree of
cough is harassing to the patient, and in the rare
cases where it remains frequent it causes extreme
anguish. It is performed in a very laborious man-
ner, in which an instinctive endeavour to refrain
from agitating the contents of the thorax is per-
ceptible to the medical observer. This gives to it
a peculiar expression, so that we find sometimes
set down, in accurately taken cases, " dry, husky,
ringing," as the character of the pneumothorax
cough. It has occurred to us, while observing it,
that it resembled very closely the cough of a
broken-winded horse. The distress which it oc-
casions makes it important to attend to this symp-
tom, and an acquaintance with its peculiar charac-
ter may assist in distinguishing the affection. It
is, however, sometimes nearly entirely absent. In
a case of Dr. Stokes's, the dissection of which we
attended, a complete cessation of both the cough
and expectoration took place simultaneously with
the occurrence of pneumothorax, but they re-
turned with severity when tubercles in the other
lung began to soften.

The expectoration is for the most part scanty,
and possesses no peculiar characteristic, but in
some rare cases it happens that the fluid contents
of the pleural cavity make way through the bron-
chial communication. When this occurs, the
evacuation of the matter is attended with terrible
dyspnoea, threatening, when it is copious, sudden
suffocation.

It is known that the patients who are operated
on for empyema sometimes acquire a power of
assisting the expulsion of the matter which col-
lects posterior to the operation, through the wound
of the side, by forcible expiratory efforts and
coughing. We mention this to notice the case
of a porter at the Meath Hospital, affected with
pneumothorax and empyema consequent on per-
foration of a tubercular abscess. This man pos-
sessed an analogous power of expelling at will
the fluid of the cavity through the fistula in the
lung. He was accustomed to exert this whenever
it accumulated to a certain quantity, by leaning
over the bedside so as to invert the thorax, and
thus decant it through the mouth, aiding its escape
by some efforts of coughing. Another singular
circumstance worth noticing was remarked in Dr.
Stokes's case just referred to. When the irrita-
tion of the opposite lung caused a return of the
expectoration, the patient was sometimes unable
to raise it out of the trachea, but was sensible of
losing command over it when it ascended as far
as the top of the sternum. In fact he felt con-
vinced that it used to drop down the bronchus
leading by the fistula to the pneumothorax cavity.
c. Decubitus. — If the fluid contents of the

pleural cavity be very small in quantity, the pa-
tient may recline indifferently upon either side or
upon the back ; but in the majority of accurately
observed cases he has been found to lie in prefer*
ence on the affected side. This is the conclusion
that our inquiries have led us to ; but different
statements are found in authors on this subject.
It is stated by Schmalz, (Vcrsuch einer Mcdizi-
nisch-Chirurgischen Diagnostik, Dresden und
Leipsig, 1825, p. 99,) and other writers, that the
decubitus is invariably on the sound side in pneu-
mothorax, and that this affords a striking mark
of distinction between it and empyema. We
cannot help suspecting that this opinion has been
originally rather conceived from theory than de-
duced from observation, and we the more readily
make this remark from observing the occasion and
the manner in which Dr. Duncan (Edin. Med.
and Surg. Journal, No. 28, p. 327) announces it.
" The change of decubitus," says he, describing a
case, " is exactly the reverse of what it ought to
have been, for in empyema the patients commonly
lie on the affected, and in pneumothorax, on the
sound side." The reasoning, too, with which
this has been advanced (See Med. Chir. Review,
July 1830, p. 455) is only applicable to the in-
finitely rare case of simple pneumothorax, and not
to that which results from perforation, for this is
always accompanied by empyema. It is true that
in empyema the dyspnoea is caused by the pres-
sure of fluid alone, and it is chiefly for the pur-
pose of relieving the mediastinum and opposite
lung of its weight and pressure that decubitus
takes place on the affected side. (See Empyema.)
But in pneumothorax the compression of the in-
ternal organs is as complete, if not more so, al-
though caused by air, and if the weight of even
an inconsiderable quantity of fluid should be added
to them already suffering under this great com-
pression, it will be an object with the patient in-
stinctively to obviate this by lying on the affected
side. As far as our experience goes, this position
has been, caeteris paribus, always preferred. How-
ever, it not unfrequently happens that the violence
of the pleuritic pain forces the patients to turn to
the sound side in spite of the increased oppression
which the change induces. We have witnessed
a case in which the struggle between the pain
augmented by lying on the affected side, and dysp-
noea aggravated by changing to the opposite, was
extremely distressing ; but here the want of breath-
ing triumphed over the pain, and compelled the
poor patient to endure the latter as the lesser evil.
When the intensity of the pain has passed, if a
change has taken place during its continuance,
decubitus on the affected side is usually resumed.
d. Dilatation of the side. — On a comparison of
the two sides of the thorax, it is observed that the
side in which the pneumothorax exists is faintly
or not at all elevated during inspiration, and on
being measured it is generally found to be larger
than the opposite. These differences may be ob-
served at a very early period after the perforation,
but for the most part they are greatest at the ad-
vanced periods of the affection. The average
amount of the dilatation is from one to two inches,
as in empyema. The enlargement of the inter-
costal spaces and their occasional protrusion be-
yond the level of the ribs are also '.iservable in

PNEUMOTHORAX.

645

both, so that, from the mere contemplation of the
phenomena of dilatation, there exists no distinc-
tive mark between them. It is said, however, that
where they are very conspicuous in pneumotho-
rax, the side is more what the French denominate
» bombe" than in empyema. The cedema of the
integuments of the side which sometimes attends
the latter is not observed, although Louis and
others have remarked an cedematous state of the
corresponding arm.*

Many instances of pneumothorax are on record
in which no difference whatsoever existed in the
dimensions of the two sides of the chest. It may
be observed that in cases where the air can pass
out during expiration from the non-existence or
imperfect formation of the valvular arrangement
of the fistula before described, the chief source of
dilatation, namely, the accumulating pressure of
the air, is absent. This valvular structure has
not been hitherto much attended to ; it has, how-
ever, been remarked that in some of the cases
where there was no dilatation, the fistulous orifice
was very large, rendering it probable that egress
from the cavity as well as ingress remain unob-
structed. But it must be acknowledged that this
suggestion is by no means sufficient to explain
the absence of dilatation of the side in many well-
authenticated cases, in which the air was proved
to have been subjected to very great pressure, evi-
denced by displacement of the thoracic viscera and
other phenomena.f

We had an opportunity of demonstrating that
the dilatation of the side varies considerably, and
that it may even give place to contraction. At an
interval of six months between two measurements
of a case, it was found that the pneumothorax
side (measuring from the centre of the sternum to
the spine of the vertebra?), from being one inch
wider had become half an inch narrower than the
other. And further, on measuring five months
afterwards, it was found to have returned to its
former dilated dimensions. We believe that we
were enabled to connect this temporary decrease
of dilatation with a partial closure of the fistulous
communication, and an attempt at cure, as hap-
pens when empyema is removed by absorption.
The progress of the case, however, (during which
other fistula? formed,) and its termination, did not
allow us to confirm this anticipation ; but notwith-
standing this, the nearly total departure of the tin-
tement coinciding with the contraction and other

* It appears, from Morgag'ni, that this cedema of the
arm has been frequently noted by the older physicians
in pneumothorax. " Verum pra:terquam quod hrachinm
alterum, quod dolebat, oedemate habebat tuniidiim (qua-
lem tumorem in thoracis hydrope Fantonus pater, et
Buchnerus, aliique, et in his Valsalva noster intcrdum
aj}nota.ru nt) cum ad thoracis motum diceret fluctaticnem
in eo sentire" S(C. Morgagni de Sed. et Causis Morb.
Kpfet. xvi. s. 36.

tSec Dr. Duncan's tenth case, Edin. Med. and Sur.
Journal, No. 'JH.; Dr. gtokes'scase, Trans. Assoc. Dublin
College of Physicians, vol. v. ; and five of Louis's cases,
marked " Etat extcrieur, de remarquable," which
amounts to evidence of no dilatation, for this exact ob-
server has noted it particularly in the cases where it
"as present. In Dr. Duncan's case a method of opening
'he thorax was practised by Dr. Cullcn, which is worth
'elating. Instead of penetrating the sac at once, which
i« Usually done, he dissected back the ribs and intercos-
l»li for a considerable space, so as to expose the external
surface of the pleura, whirl, rose up distended and elastic.
This way is somewhat more troublesome, but it is very
advantageous for estimating and displaying the pressure
which the air exerts

phenomena left little doubt that such was really
the case. (Dublin Journal of Med. Science, Nos.
3 and 8.)

Schmalz says, (Op. citat. Ibid.) » If both sides
be engaged, the chest exhibits nearly a cylindrical
form." Of the occurrence of double pneumotho-
rax the only two cases recorded that we know of
are those in Laennec's work. In the first of these,
observed by M. Recamier, the chest is described as
" vaste, bombe," terms which have probably sug-
gested the description of Schmalz. Notwithstand-
ing the extreme rarity of both sides being in-
volved, it may not be useless to retain in memory
this symptom of general dilatation, as in such a
case many of the other signs must be of no avail,
inasmuch as they require the contrast which is
afforded by the opposite side remaining sound ; and
it is of the greatest importance to be able to re-
cognise this terrible affection at once, in order to
attempt the relief of the dyspnoea by performing
paracentesis, the only means which art suggests
to prevent speedy suffocation.

e. Displacement of heart and depression of
diaphragm. — It appears that less compression is
requisite to affect these conditions than to produce
dilatation of the side, for the latter has been ab-
sent in cases where the heart has been thrust con-
siderably out of its place, and a sensible fulness
produced in the corresponding hypochondrium by
the depression of the diaph.agm. It is here a pro-
per place to remark the singular fact that perfora-
tion of the lung and its consequences, in the great
majority of cases happens on the left side. Seven
of eight cases, which occurred to Louis, were on
this side, and we believe that in the cases which
have come to our knowledge nearly an equal pre-
ponderance existed. So great a disproportion
must have been in some degree accidental, for in
eight cases described by Laennec the number on
each side was equal. However this may be, it is
certain that it occurs oftener on the left, and this
circumstance makes displacement of the heart a
very common and striking feature in pneumotho-
rax. In cases of extreme displacement, the heart's
action is both felt and seen beyond the cartilages
of the opposite side, but the average extent is not
farther than the opposite half of the sternum, or
below the ensiform cartilage ; for it is found to
move downwards as well as laterally when the
displacement occurs from left to right. When
the pneumothorax exists in the right side, the
heart's displacement, for obvious reasons, will be
less, but the depression of the diaphragm will be
more easily perceived from the protrusion of the
liver which follows it. This prominent state of
the liver is as truly an effect of depression of the
right side of the diaphragm by an aeriform collec-
tion as by an empyema; and, as in the latter, it
might at first view lead the observer to conclude
that the oppression of the respiratory organs was
connected with a visible hepatic enlargement.
This has been adverted to tn the article Empvkiia ;
but in a paper on the diagnosis of the latter (See
seventh number of Dublin Journal of Medical and
Chemical Science) by Dr. Stokes, since published.
there are some additional signs furnished, which
contribute much to the elucidation of this point of
diagnosis. We shall notice here but one of these,
which is as applicable in pneumothorax as it is in

646

PNEUMOTHORAX.

empyema. It has, moreover, a peculiar propriety
in the former, as it is a palpable sign, and ad-
dresses the eye at the first examination ; because
we apprehend that the effects of pneumothorax
and enlargement of the liver could be confounded
only where a defective exploration had at first
produced an erroneous impression, unless the air
be very small in quantity and the fluid copious, in
which case the difficulties connected with empye-
ma recur. Dr. Stokes, however, has observed,
that where the diaphragm, depressed and rendered
convex downwards by the contents of the pleural
sac, causes the descent of the liver, there is a sul-
cus evident to the sight and touch in the right
hypochondrium. This is produced by the two
convex surfaces of the diaphragm and liver, re-
spectively terminated anteriorly by the edge of the
latter and by the inferior margin of the false ribs.
It is manifest that such a sulcus cannot be pre-
sent in the mere enlargement of the liver, let it
take place to any extent, as it requires the opposed
convexity of the diaphragm for its formation, and
this condition is only produced by a liquid or
gaseous effusion.

f. Fever. — Whatever has been the condition of
the circulation before the escape of the air by per-
foration, the fever of pleuritis sets in speedily after
this event takes place. Its character is necessa-
rily modified by the previous state of the patient's
system, but it always conspires to aggravate his
sufferings. Much, indeed, of the dreadful distress
which ensues is to be ascribed to the increased
febrile action which occurs almost simultaneously
with the accident. This will be conceived when
it is recollected that while one of the lungs is by
rapid compression nearly deprived of its function
of respiration, the excitement of the heart's action
increases the demand for aeration, so that this
combination of circumstances often produces a
degree of dyspnoea under which the patient rapidly
expires. Such an effect of the fever is not more
likely to occur in debilitated individuals than in
those of robuster stamina ; for in the former, al-
though the constitution be more exhausted, this
seems fully counterbalanced as regards the effects
in question, by the diminished quantity of blood
which circulates in the system of emaciated
phthisical patients.

If the immediate consequences be not fatal, the
Ifcver subsides into the same type which existed
before perforation occurred. This is the hectic
of phthisis, in which the pulse seldom sinks below
1 10, and is exacerbated in daily paroxysms. We
are, however, led to believe, that if the opposite
lung be not already the seat of tubercular deposi-
tion, or even if this be not in an advanced or pro-
gressive state, the phthisical hectic which attended
the disease of the lung that has suffered perfora-
tion, is diminished by the supervention of pneu-
mothorax. We have witnessed one case and
heard of another in which the hectic pulse and
night sweats could be traced to have actually
ceased from this period. In both instances, it is
true, the cessation was but temporary, but we had
unequivocal evidence that their return was con-
temporaneous with the occurrence of disease in
.he opposite lung.

The foregoing is a detailed account of what
ure called the rational symptoms. Their study

is of great importance in understanding the dis-
ease, and it must be acknowledged that several
amongst them are valuable diagnostic signs. We
proceed now to describe the physical signs. It
would be a needless task, at the present day, to
use much earnestness in insisting on the import-
ance of these in the exploration of any thoracic
disease, for it is fully recognised. We must re-
mark, however, with respect to pneumothorax,
that just in proportion as the practitioner has
attained to a masterly facility in their application,
will he be enabled to decide with certainty as to
its presence or absence. The very existence of
this affection in nosology is so intimately con-
nected with its physical signs, that until these
were discovered it lay still unnoticed, and correct
notions on the subject advanced as they were
developed and improved. Hippocrates laid the
foundation for its future diagnosis by the practice
of succussion, and had he pushed its application
a little further, he must himself have arrived at
its real signification, as it appears, from some of
his remarks on its use, that he was partially aware
of some of the conditions necessary for its pro-
duction. Corvisart and Bayle, masters of per-
cussion, had glimpses of its nature, and remarked
its existence in the dead body. Laennec, whose
merit in this instance was as great in perfecting
and applying the other two signs as in adding his
own famous discovery, was the first who detected
it on the living body. He brought its diagnosis
to perfection by assigning to the physical signs
their value separately and in combination ; and
if any additional light be thrown on its history or
symptoms since his time, even this must be as-
cribed almost wholly to the greater facility and
confidence with which it is now recognised by
the employment of these means. These consider-
ations are sufficient to show the great importance
which attaches to these physical signs in pneu-
mothorax : upon them, in fact, rests its diag-
nosis, and he who is skilled in their application
may truly pronounce upon this affection, which
has remained for so many ages of medicine in
obscurity, in as positive a manner (as Andral
speaks of these principles applied to thoracic dis-
eases in general) as the surgeon can "of the least
complicated dislocation, or the simplest fracture."
(Clinique Medicale, Avantpropos, p. 6, tome ii.)

a. Succussion. — Whenever air and fluid exist
together in the sac of the pleura, if the trunk be
shaken abruptly, the splash of the liquid against
the walls of the thorax is often distinctly heard
by the patient, or by any one who places their ear
on or near the chest. There is no stronger evi-
dence of pneumothorax than this sound, for it is
only produced where both air and fluid are pre-
sent ; if either be absent, no splashing sound is
heard.

In the writings of Hippocrates this method of
exploration was taught as a means of ascertaining
the existence of purulent matter in the pleura.
Distinct directions are enjoined as to the manner
of performing the succussion, and even observa-
tions added from which it is apparent that the
author could estimate by this means the quantity
of pus contained in the pleura: " Among the
patients affected with empyema, those who pro
duce most sound, when shaken by the shoulder

PNEUMOTHORAX.

647

have less pus in the chest than those who yield
less sound, and who are more flushed and breath-
less: in respect of those who do not yield any
sound, but who have the nails livid and a great
dyspnoea, they are full of pus, and their case is
desperate." These remarks contain much truth,
and implying as they do considerable acquaintance
with the phenomena, it is a most remarkable cir-
cumstance that they did not conduct their author,
or his admiring commentators for so many ages
afterwards, to the knowledge of the real condition
which they indicate. Laennec points out the
reason why, while such close approximations as
that quoted from Hippocrates appeared as it were
to leave only another step to unfold the truth,
they remained as far removed from it as ever until
a very late period. It consisted in a fundamental
error as to the natural state of the lungs and
pleura. The early notions were a mass of con-
fusion on this subject, but for the most part it was
conceived that a vacuum existed in the thorax.
This absurd hypothesis precluded the necessity
for the presence of air to cause the sound of fluc-
tuation, and being handed down from age to age
prevented the truth from reaching the mind even
of such men as Morgagni. It is obviously in-
ferrible, from the quotation which Laennec makes
from the latter, that this great pathologist believed
that the fluid of an empyema was poured out into
an empty space in the pleura, which, after a cer-
tain quantity of effusion, became filled. In the
quotation which we now insert, this opinion is
not left to inference, but alleged in the most ex-
plicit terms, and even adduced as the only way
of explaining the sound of the fluid in a case of
pneumothorax. Referring to the " stillicidium
cadentis humoris," which we formerly quoted from
him, Morgagni says, " Res non ita facilis explicatu
iis qui inter pulmones et thoracis parietes negant
sputii quidquam inter reder -e ,• vera tamen, ut
postmodum comprobavit humoris, in eo latere
congesti, cum Jluctualio in agitatione corporis
ab ipso, ab aliisque evidentissime percepta]" 1 &c.
(Praenot. Coac. ii. 432. Forbes's translation of
Laennec, p. 507.) On such an hypothesis the
sound of fluctuation should have been heard in
every case of empyema, instead of being, as we
now know it to be, confined solely to the case
where this is combined with pneumothorax. It
is very probable, then, that its abandonment is to
be attributed to its having failed to detect simple
empyema, which it could never have done. It is
moreover certain, from the description, that the
cases designated by Hippocrates as "full of pus,"
and which Morgagni would have embraced under
those "qui ad summum pervenerunt," were cases
of simple empyema, and it shows that, although
these great physicians were prevented from seeing
its true cause by a false hypothesis, they observed
with accuracy and fidelity ; as in such cases no
sound of fluctuation is heard, the " space being
filled up," as Morgagni said.

Thus this invaluable diagnostic fell into ne-
glect; there is no evidence of its having been used
after the time of the Asclepiades ; and even the
commentators appear to have esteemed it as use-
less, and to have alluded to it, as Laennec re-
marks, merely out of respect to Hippocrates. It
Was not revived till the true causes which pro-

duce it became fully explained, but since that pe-
riod it has been ranked as one of the most infalli-
ble signs by which any internal disease can be
recognised.

The Hippocratic method is still generally used
in the employment of succussion. While the phy-
sician places his ear to the side of the thorax, an
assistant shakes the patient smartly by the shoul-
ders, and thus the dashing of the fluid is heard.
It frequently happens that the patient is the first
to call attention to it by mentioning that as often
as he turns over in the bed he is sensible of this
sound himself. It is felt by him on descending a
stair, or, as we have known, when he makes a
forward step with greater quickness than usual.
Besides the little confidence which Morgagni
placed in it as an indication, he objected to the
Hippocratic method that many patients would not
suffer willingly the concussion of the trunk.
While this remark cannot have the effect which
he intended, yet it is worthy of attention. Laen-
nec denies that it is attended with any inconveni-
ence, but in the cases in which we have seen it
employed, a very considerable commotion was
caused to the patient before the fluid could be
heard. An intelligent man, who was under our
care for a very long period, was accustomed to
produce the fluctuation himself by making a jerk-
ing rotation of the trunk on the spinal column.
He was enabled to produce the sound with much
facility, and greatly preferred doing so himself in
this manner to being succussed in the ordinary
way by the hands of another. We can conceive
that in certain cases such a method would be as
impracticable as the former; we leave them both,
therefore, at the option of the practitioner, who
will of course choose that which causes least dis-
turbance to the patient.

This fluctuation might be also produced by an
enormous phthisical abscess half full of matter
and air ; but such a cavity as would be sufficient
to give rise to it is scarcely ever met with, hav-
ing occurred but once in the large experience of
Laennec. There is also a possibility of being de-
ceived as to the souree of the fluctuation, if the
stomach contain much flatus, and the patient has
recently taken drink. The other physical signs
will easily preclude the latter error ; but its infi-
nite rarity alone seems to be the only protection
from the former.

b. Percussion and auscultation. — Laennec has
demonstrated, from a review of the knowledge
which Avenbrugger, Corvisart, and Bayle pos-
sessed on this subject, that percussion alone was
insufficient for the diagnosis of pneumothorax.
When the side affected is percussed, an unnatu-
turally clear or tympanitic sound is returned, and
if this coincide with dilatation of the same side,
the evidence for pneumothorax is very strong.
From these data Bayle was enabled to recognise it
in the dead body in two or three cases ; and
doubtless, if its pathology had been understood in
his time, he would have detected it from the same
evidence on the living. But even in the hands
of the most experienced master of percussion these
signs might lead to a deep fallacy, for it might be
thought that the clear-sounding side was in a
healthy condition while the other was the seat of
either pulmonary engorgement or a pleuritic cllu

648

PNEUMOTHORAX.

sion, which produced the comparatively dull
sound ; and as to the dilatation of the side, it is
liable, when considered only in conjunction with
percussion, to lead to the same error; that is,
the dilated side might be mistaken for the sound,
and the latter regarded as in the state of contrac-
tion which results from chronic pleurisy (See
Pleuritis) ; and again, the converse of this
error is also possible, in which the contracted side
should be mistaken for the sound side, and the
latter considered as dilated and too resonant.
That these difficulties of diagnosis from these
means are not imaginary our own experience has
convinced us as well as the warnings of Laennec,
(Forbes's Translation, p. 497) ; they are, how-
ever, quite removed by adding to percussion the
results of auscultation. On applying the stetho-
scope to the pneumothorax side, it is found that
the respiration is as completely absent as if it was
an empyema ; but percussion has already proved
that, instead of the perfectly dull sound, which a
collection of liquid in the chest causes, we have
now a preternatural clearness of sound, which two
conditions, viz. nullity of respiration and clear
sound on percussion, never coexist except in the
case of air in the cavity of the thorax.

Although we have indicated the percussion
sound of pneumothorax to be exceedingly clear
and tympanitic, occasional deviations to a certain
extent from this general rule are met with. It
will be recollected that when pneumothorax takes
place, the expansion of the air vesicles of the op-
posite lung becomes much increased from having
to perform the compensatory respiration, and con-
sequently the clearness on percussion of this side
is simultaneously increased. This is one cause
why the contrast on percussion is not so striking
as might be anticipated, and it suggests how much
more valuable this sign would be were it possible
for us to contrast the sound of the same side be-
fore and after the period when pneumothorax
was supposed to occur. Another circumstance
which occasionally prevents the drum-like reso-
nance peculiar to this affection from being pro-
duced, is the existence of partial adhesions which
sometimes retain the lung in spots still in contact
with the costal pleura. In the points correspond-
ing to these the sound on percussion will still be
dull, while the clearness will be perceptible in the
intervening spaces. It is also to be remarked that,
although we have laid down nullity of respiration
as the rule, this is seldom absolute. Close atten-
tion will almost invariably discover a feeble bron-
chial sound at the root of the lung along the spi-
nal column, which may sometimes lead the ob-
server to imagine that he hears the puerile respi-
ration of tV opposite lung conveyed across the
spine. But besides this, if there be any points of
adhesion, they may cause a faint murmur to be
heard. These adhesions may exist at any part
of the lung, but as we have in a preceding part
shown that they are very common at the summit,
so we are not unfrequently enabled to discover,
immediately under the clavicle or in the supra-
spinal region of the scapula, the sound of respira-
tion generally of a cavernous character, and mixed
with a single bubble of gargouillement. These
latter signs may be considered as marking the re-
mains of a cavity (see Tubercular Phthisis),

and this is sometimes confirmed by the coexist-
ence of an obscure pectoriloquy.

The fluid which is contained in the cavity is
recognised by these signs with the same facility as
the air. By the absence of respiration we learp
that the lung is now displaced by either fluid or
air. This being established by auscultation, the
results of percussion enable us to appreciate the
space in the thorax which is occupied by the
liquid and gaseous fluid respectively. As percus-
sion is performed from above downwards, the
tympanitic resonance is perceived to give place
at a certain level to a total dulness of sound, and
where this change abruptly occurs is the line of
demarcation between the air and fluid. By mark-
ing from time to time the situation of this line, it
is manifest that we can ascertain whether the pro-
portion of the air and fluid remains stationary, or
if either of them increase at the expense of the
other. Finally, it may be instructive to examine
their relations unde7 changes of posture, to ob-
serve how the liquid obeys the law of gravity, and
the tympanitic sound shifts as the air moves to
occupy the space vacated by the heavier fluid.
Such investigations furnish data from which an
acute observer may form a conjecture as to the
existence of adhesions, the size of the cavity, and
even the amount of the compression sustained by
the viscera ; upon which points it may be of the
highest importance to obtain any additional light,
particularly if the idea of paracentesis be enter
tained.

The signs of pneumothorax derived from aus-
cultation and percussion, so far described, are al-
most purely of a negative character; but even
were the diagnosis necessarily confined to them,
there is but one disease for which it could possibly
be mistaken ; this is emphysema of the lung, or
dilatation of the air-cells, many of the characters of
which are, however, so clearly distinguished from it,
that it could only be confounded with it by a very
inattentive examination. They resemble each other
in the clear resonance which percussion gives out,
and also in the negative results of auscultation.
But the respiration is never totally absent in em-
physema of the lung, as in pneumothorax ; it is
only much weakened, and is moreover accompa-
nied by its peculiar rale, which strikingly opposes
them. The history and general phenomena are
quite distinct ; the emphysema is always a chro-
nic malady, and the patient is able to go about ;
although complaining much of difficulty of breath-
ing, it is more because it interferes with his occu-
pations than from the deadly anguish which over-
whelms the patient in most cases of pneumotho-
rax. If these considerations be not sufficiently
convincing, the presence of pneumothorax (from
perforation at least) may be decisively determined
by succussion and the metallic tinkling.

The inventive genius of Laennec was not con-
tent with these negative results of auscultation.
Apparently not long after he had laid the founda-
tion of its diagnosis in these, his perseverance was
enabled to add to them a positive sign, the tinte-
merit metallique. This is a metallic tinkling ot
ringing sound, heard in the pneumothorax cavity
at intervals. It is discerned equally well by the
naked ear or by means of the stethoscope, but to
examine it accurately and to mark its limits, the.

PNEUMOTHORAX,

649

latter instrument must be employed. It is so ac-
curately represented by the dropping of a pin into
a large wine-glass, or touching gently a sonorous
porcelain vase with a quill, that it may be recog-
nised without the observer having previously
heard it; by keeping this comparison in mind,
having been once heard, it is always remembered.
The metallic tinkling is audible during cough-
ing, speaking, and sometimes during respiration,
or it might be more correct to say after these
actions. Besides this, it is often heard independ-
ently of these, observing a certain periodicity, and
finer in its tone. That the finer tone which we
have just alluded to is the echo caused by the
occasional fall of a single drop of fluid from the
summit of the cavity on the surface of the liquid, we
only require to imitate it by letting fall into a large
wide-mouthed bottle, one-third full of water, one
drop of any liquid, to be fully convinced. This
variety of the tinkling is explained in this manner
by Laennec, who has also proved demonstratively
that the sort which results from speaking, cough-
ing, and inspiration, is produced by the air enter-
ing through a fistula into the pneumothorax
cavity. He did not announce more particularly
its proximate cause, and where this master did
not speak, it might become us to be silent. We
may state, however, without presumption, that we
never had any hesitation in explaining this variety
of the tintement on the same principles as the
other. It appears to us to be manifestly the echo
of the air forced into the cavity reverberating
against its hollow parietcs, and that the sound is
more particularly caused by the bursting of minute
air-bubbles at the orifice of the fistula, formed as
the air traverses the latter, by its entanglement
with mucus. It is more clearly audible in pro-
portion as the cavity is empty of fluid ; but its
distinctness and loudness are chiefly dependent
on the size of the fistulous communication. We
have been enabled to follow the gradual narrowing
of the latter by the diminution of the tinkling in
one remarkable case. It became so minute that
it was by the greatest stretch of attention scarcely
perceptible on respiration, and at length became
inaudible, but it still persisted on speaking and
coughing. At an after period the whole train of
symptoms became exacerbated, and the tinkling
was again manifest on respiration ; and by de-
grees, as the malady grew worse, it increased to a
louder and graver pitch than ever. This is indeed
the ordinary change which it undergoes ; in most
cases the fistulous orifice rapidly enlarging in
size, the tintement is heard more and more plainly
on respiration, and at length it becomes so deep-
ened in tone as to assume quite a different cha-
racter.

To the metallic tinkling altered thus by the
deepening of its sound, the name of bourdonne-
ment amphorique* has been given. It is so called
because it exactly resembles the sound produced
l)y blowing into a decanter or large bottle. When

* We u on M <rladly use English words, but cannot devise
any that would justly anglicise the above; we have,
therefore thou»ht it better to leave the expression which
the discoverer applied. Nothing can be better than me
tallic linklin-' hut it appears to us that " utricular buz
*ing," which i'« used in the valuable translation of Or
Forbes, although a correct synonym, is scarcely less for
M|D than the original.

Vol. III. — 82 3 E

this sound becomes evident, it is a sure indication
that the fistula is growing larger, and consequently
that the case is more hopeless.

In exploring for the metallic tinkling, there is a
source of fallacy which the physician should be
aware of. When the stomach is flatulent, it lies
high under the false ribs, and if in this state the
patient has lately taken drink, the tinkling may
be produced in the stomach, and lead the observer
to think he hears it in the chest. On the other
hand, an incident occurred to the writer of this
article, which shows that this source of deception
may be held too strongly in view. In examining
a case which at first view he had imagined was
empyema, the tinkling was evidently perceived ;
but finding the epigastrium tympanitic, it was dis-
regarded, from the conception that it was produced
in the stomach. On the second or third examin-
ation the sound was again heard, and now recog-
nized to be the true metallic tinkling.

The only other condition besides pneumotho-
rax which can give rise to this sign is the exist-
ence of a vast phthisical abscess, such as also pro-
duces the sound of fluctuation. Laennec relates
its occurrence in a phthisical abscess of such a
size that the whole lung was nearly involved in
it ; but such instances are so infinitely rare that
they will never embarrass the diagnosis.

The production of the metallic tinkling in a
phthisical cavity, we would remark, is a circum-
stance quite inconsistent with the views on the
subject which Mr. Guthrie has lately published.
This gentleman states that Laennec, and all who
hold, with him, that it " depends entirely on the
passage of air through a hole in the lung into the
cavity of the thorax," were mistaken ; and in op-
position to this he maintains that for its produc-
tion the air of the cavity must necessarily be com-
pressed. " I do not," says Mr. Guthrie, (London
Med. and Surg. Journ. for Jan. 12, 1833, p. 477,)
" deny the facts of the air, the hole in the lung,
or the fluid; but I believe that, to produce the
sound of the Jew's-harp (the metallic tinkling,)
the air in the cavity must be greatly compressed,
and that it essentially depends upon it." That
this latter opinion is unfounded, its occurrence in
large tubercular cavities, which has been observed
by most who are much conversant with phthisical
auscultation, sufficiently proves. In such the air
can suffer no compression. It is besides well
known to exist after the operation for empyema ;
and we have never heard it more audible than in
a case of pneumothorax caused by the bursting
of an anthrax of the intercostal spaces into the
pleura, in which the external fistula remained
open.

We have now concluded the account of the
diagnosis, but as we have been necessarily dif-
fuse on some of the points, we think it may
not be superfluous here to recapitulate, so as
to give at a glance the principal diagnostic
signs. By subjoining to each a word of valua •
tion, the reader will be able to calculate the
amount of evidence implied by the presence of
any one of them.

1. The sensation of something giving way
in the chest, and of air entering the
pleural cavity. — Very valuable, but often
absent or unnoticed.

650

PNEUMOTHORAX.

2. In a phthisical individual the sudden

supervention of overwhelming dyspnoea
and pain. — Rarely absent, therefore very
valuable; still more so if succeeding last
sign.

3. Comparison of auscultation and percussion.

Nullity of respiration over one side, to-
gether with tympanitic clearness of sound,
which below terminates abruptly in com-
plete dulness. — If accurately established,
amounting to positive certainty, but some-
times not easy to establish. iEgophony
rare.

4. Fluctuation on succussion. — Positive cer-

tainty, but should be unquestionably
verified.

5. Metallic tinkling. — Positive certainty, but

should be unquestionably verified.

Prognosis and treatment. On casting our
regards back on the pathology of this affection,
we cannot be astonished at any thing which ex-
perience can teach us, as to the rapidity and
certainty with which it is followed by a fatal
result. When we consider the prognosis of
phthisis, and add to this the aggravating circum-
stances of perforation and acute inflammation of
the pleura, together with the simultaneous priva-
tion of the function of one lung, the consequences
will appear to be so inevitable and immediate,
that our review of its pathology and symptoms
may seem to be a dissertation on a nice point of
morbid anatomy and diagnosis, or only useful so
far as an acquaintance with it may prevent the
physician from being taken by surprise by the
supervention of its fearful indications in a case of
phthisis. And, indeed, if all knowledge were
useless that did not immediately lead to practical
benefit, this would be in a measure true ; for it
must be confessed that at present it does little
more than unfold to us how soon we may expect
a period to be put to the patient's sufferings.
The result of Laennec's experience of it is more
fairly drawn from the statement which he makes
for the purpose of contrasting it with emphysema
of the lungs, than where he specially speaks of
its prognosis. " The effusion of air," he says,
" comes on suddenly, and cannot exist for any
length of time without giving rise to severe
symptoms, and even death. I have never seen
pneumothorax in any person who was not con-
fined to bed." (Forbes's Trans, p. 499.) Louis
only speaks of the result with a view of calculat-
ing the time which elapses between the period
of perforation and death. (Recherches sur la
Phthisie, p. 487.) Dr. Stokes relates his case,
which lasted five months, as the longest at that
time on record ; (Trans. Association, &c.;) and in
upwards of twenty cases witnessed by Dr. Town-
send, none, we believe, lasted so long a period.
In Louis's seven cases the fatal termination took
place at intervals of from sixteen hours to thirty-
six days after the perforation occurred ; and this
author adds, " it is difficult to give an account of
the circumstances which produce this difference,
and it is in vain to seek for the explanation in
the greater or less strength of the patients at the
time that the accident took place." (Louis, op. cit.)

The only question, then, which the prognosis
•droits of is, whether recovery in pneumothorax

from perforation by tubercle is barely possible.
Laennec, arguing from his observation of the
cicatrisation of tubercular cavities, is of opinion
that it must not be regarded as impossible even in
the severest cases. This opinion is shared by
some others, but it is to be regretted that the few
facts which are produced in its favour are drawn
from the older writers, who were ignorant of its
production in this manner. Some of them were
evidently, at first, cases of empyema, which, by
opening into the lung, gave rise to the pneumo-
thorax : and we believe that most pathologists
consider even the case related by Laennec, in
which the pneumothorax existed for six years,
was of this nature. But the progress of a case
detailed in the third number of the Dublin Journal
of Medical and Chemical Science (which has
been more than once adverted to in this article)
has induced us to believe that this case of Laennec
and some others may probably have resulted from
tubercular perforation, and to adopt his opinion as
to the possibility of recovery. In this case the
individual lived a year and a half after the estab-
lishment of the fistula, during which period the
dilated side became contracted, but ultimately
resumed its former dilatation. The patient's
general health and strength became so much
improved as to permit him to work as a bricklayer
for some months of this period, but this labour
exhausted him very much. His own imprudent
perseverance in working under exposure produced
an attack of severe and general pleuropneumony
in the opposite side, which his extraordinary
vigour enabled him to outlive, but he ultimately
sank under the effects of repeated acute inflamma-
tion of the other lung as well as of the pneumo-
thorax sac. The other medical men who saw it
with the author agreed with him in thinking that
this case might have lasted for a very long time ;
in fact that the contraction of the side, the im-
provement of health, and the disappearance of the
tintement metallique indicated a spontaneous at-
tempt at cure which was counteracted by the reck-
less neglect of proper caution on the part of the
patient. The contemplation of this case, with
some observations suggested by it, has, as we
have said, induced us to admit the possibility of
recovery, which, however, we by no means wish
to inculcate in a positive manner : before this can
be done by any one, a more enlarged experience
must be possessed, and the observer, who is de-
sirous of deciding the question by facts, has to set
out with the melancholy knowledge that not one
case proved by auscultation to have been of this
nature is on record in which ultimate recovery
took place.*

* For our opinion, as above stated, we have not ad-
duced arguments where facts are wanting; but a con-
sideration which weighed with us much, suggested by
the above case, may be mentioned here. If the first ef-
fects of the perforation be outlived, (which is rare,) it
does not appear that a worse condition exists in pneu-
mothorax than in empyema, provided the opposite lung
remains free from tubercles. It may be objected that
there remains the tubercular state of the coin;
lung. It is true; but we believe that the conditions
which make tubercles so fatally progressive in the lung
are absent in the latter ; we allude to its constant motion
and its great supply of blood. The motion and conse-
quent friction which the act of respiration constantly
maintains around a tubercle, appear to us to be a prin-
cipal cause of the irritation which it produces, and con-
sequently of the increase of its own bulk. Developed

PNEUMOTHORAX.

651

The resources of the healing art, it will ~be
anticipated, can contribute little of a positive na-
ture, if any thing, to promote a cure in this ca-
lamitous affection. Yet, as in all such extremities
the aid of the medical man will be eagerly sought,
he should be prepared to do something, although
he may regard it as ultimately certain to triumph
over human efforts. Few cases will present
themselves where some symptoms which aggra-
vate the patient's sufferings may not be removed
or alleviated by appropriate means. Proud science
may draw back from what seems to be beyond her
realm, but the physician has higher instincts to
obey and duties to perform here as in other hope-
less diseases, in attempting even the mitigation of
the pain and anguish which science informs him
he cannot altogether remove ; and this reflection
may be added, that where such motives actuate
him to exertion, he is seldom left entirely without
means, and never without the satisfaction which
obedience to them brings.

We would consider, then, whether any thing
can be done to allay the urgency of the symptoms
by which the patient is so usually oppressed im-
mediately on the occurrence of this species of
pneumothorax ; the dreadful dyspnoea, sinking,
and pain. We find on this subject no assistance
from books, for as the affection itself has been but
recently clearly understood, its detection at this
early period has been extremely rare ; and this,
we think, should suggest to all practitioners having
the care of phthisical individuals, the utility of
keeping in mind their liability to this event, in
order to be able to afford assistance with prompti-
tude should it occur. The indications for practice
appear to be sufficiently clear. If it has super-
vened in the last stage of phthisis, when the
patient is much emaciated, and already nearly
spent by hectic, the treatment must be little ener-
getic. Leeches should be applied in small num-
ber to the part where the pleuritic pain is most
acute. Afterwards a fomentation of strong decoc-
tion of poppy heads, or an anodyne poultice
should be used, and in twelve hours another ap-
plication of leeches might be had recourse to with
advantage. . The exhibition of a strong narcotic
internally will also tend to relieve the dyspnoea as
well as the pain, for this class of medicines has
the power of diminishing the sensation of want
of respiration as well as of lulling the general
sensibility of the brain. The use of anodynes
may have probably been habitual with the patient
before this occurrence, and in this case the usual
dose should be increased. We need not specify
the particular preparation, but may mention that
the "acetum opii" and the " black drop" are often
preferred by phthisical patients, and that it is pru-
dent to vary by times from one preparation to
another, by which means narcotics do not lose

in organs whose function docs not submit them to mo-
tion or friction, their progress is incomparably slower
Umn in the lung. Moreover, the great quantity of blood
which circulates in this organ, probably contributes to
its rapid progression. We would now observe, that in
the lung compressed by pneumothorax, the influence of
these causes is absent, as it lies against the spine in a
Hate of nearly perfect quiescence, and of comparative
amEinia. We would remark, also, that in the above
ate the hectic sweats ceased almost entirely from the
time of the perforation, and we refer to its dissect.on
for some particulars of the compressed lung.

their effect so soon, when the dose is not aug-
mented. If the individual be yet in the very early
stages before the perforation, then it would appear
to be a very rational proceeding to bleed him co-
piously, and to treat him with an especial regard
to the pleuritis, which speedily ensues. A large
bleeding seems to be a very proper measure in
such a case for the purpose of diminishing the
mass of blood in the circulation ; by this means
the opposite lung will be less oppressed by the
additional influx which takes place from the com-
pressed side ;* and this might be confidently ex-
pected to alleviate the aggravated dyspnoea of
which the latter condition is a principal cause.
The leeches can be used here in large number,
and the anodyne will follow the bleeding with
great propriety, co-operating to the same effect.
An assiduous application of these remedies, and
watching their effects, might do much to relieve
the urgency of these symptoms, which, if they
be not by some means arrested, grow hourly
worse.

But cases will occur where these means will
be insufficient to prevent the dyspnoea from in-
creasing to such a pitch as to threaten imminent
suffocation, and then the operation of paracen-
tesis is the only resource by which a longer space
may be added to the life of the patient. The
escape of the air effected by this means is almost
always followed by great relief of the symptoms,
abatement of the dyspnoea, and lowering of the
pulse. This is only temporary. After a period,
which is seldom long, although different in each
case, the patient sinks, being only saved from suf-
focation to die of the consequences of the opera-
tion. It is, however, justified in such extreme
cases by the prolongation of life which it effects,
and the alleviation of that most distressing of all
suffering which results from extreme dyspnoea.

In such a case, where the only question is
whether life shall be allowed to be extinguished,
the medical man has no alternative to balance ;
but if the urgent dyspnoea and pleuritic symptoms
have already passed over without destroying the
patient, and the case has attained a certain degree
of chronicity, is paracentesis advisable ? This
question is at once set at rest if the existence of
tubercles be proved in the other lung, as in such
a case not a shadow of hope could be entertained
of its success. Since Munro and Hewson advised
the operation, it has been occasionally advocated
without discriminating between the varieties of
pneumothorax ; but although the latter of these
writers made a sharp conjecture on the subject, it
is evident that neither of them had any adequate
notions as to that species of which we treat. The
chief, if not the only authority by which its per-
formance in pneumothorax from such an internal
cause can be supported, is a passage in Riolan,
and the case in which Munro advised it. On re-
ferring to the former it is impossible to form an
idea of what species of it his observations include ;

* We find this argument used by Andral in recom-
mending copious bleedings in the case of pleuritic effu-
sion. " Lorsque I'epanchement existe, on doit encore
avoir recours hardiment aux saignees, dans le double
but de s'opposer aux progres ulterieurs de l'inflaiinna
tion, et de diminuer la quantite du sang, qui dans un
temps donna doit traverser le poumon comprime." Clin
Med. t.ii. p. 582.

652

PNEUMOTHORAX.

but it is very plain that he speaks only of the pre-
sent relief which paracentesis procured, and not
of the ultimate consequences. The following are
his words : " Interdum flatus tarn violenter disten-
dit pulmones, ut prsefocationem, adferat, ni suc-
curratur aperto thorace per ipsam paracentesim,
quod sajpius factitatum Parish's, magno segrorum
emolumento, et thoracis levatione, etiamsi aquae
nullae effluxerunt, sed flatus cum violentia displo-
sus." (Riolan, Encheiridion Anatomicum. Lib.
iii. cap. 2. — Med. Obs. & Enq. p. 394.) Monro's
case, in which the operation was successful, is re-
corded with considerable accuracy ; and we think
that any one conversant with those matters, who
examines it, will at once deny that it belongs to
this class ; it seemed, in fact, very probable that
the air escaped into the chest by the rupture of
some of these distended subpleural vesicles, which
are not uncommon in emphysema of the lung,
under which apparently the patient laboured for
many years. (See Halliday on Emphysema, p.
49.) Universal experience of its failure, as well
as the great weight of authority, is against the
operation ; for no case has recovered after it, of
this variety of pneumothorax, since it has been
possible to recognise it by auscultation. Its fail-
ure appears to have for its cause the readiness to
take on a bad inflammation, which the false mem-
brane and pleura possess in this species, in con-
sequence of which it is very common to find a
gangrenous state of these membranes occurring
after the wound, propagated originally from its
edges. Notwithstanding its not having succeeded
hitherto, there is still a decided leaning to perform
the operation whenever a case occurs. This in
some measure is caused by the fact, that the old
ideas which connected fluctuation and simple
empyema are not yet perfectly exploded, and
partly from the too generally applied notion, « me-
lius est anceps experiri quam nullum," — an adage
which is sometimes erroneous, and founded on a
forgetfulness of the part which nature takes in the
removal of morbid action. The writer confesses
it to be his own opinion that the possibility of
cure which he has above professed to believe in,
lies not in the appliances of art, but in the opera-
tions of nature.*

This terminates the subject of pneumothorax
from perforation of the lung by a tubercular ab-
scess. We have purposely devoted the bulk of
this article to the consideration of this one species
for the convenience of arrangement, as well as
because it is incomparably more frequent than the
whole of the other varieties. To have discussed
the latter separately would have involved us in a
mass of tedious repetitions ; and it seems certain
that he who is acquainted with the species which
we have chosen for its description, can be at no
loss fully to comprehend its pathology and diag-
nosis, should he meet with it arising from other
sources ; or at least we trust that the foregoing ac-
count of it will place him in such a position that
he will be enabled to investigate them for himself.
In conclusion, we shall now briefly mention the

* If ever the perfecting of diagnosis shall arrive at
distinguishing the cases where pneumothorax is caused
by the bursting of a single tubercle, or of a small mass,
we conceive that in such a case the operation may be
yet practised with success.

other methods by which authors have described it
to arise.

Pneumothorax from gaseous secretion of the
pleura. — The pleura, according to Laennec, in
very rare cases takes on the secretion of air like
the other serous membranes. This may take
place singly, or the elastic fluid may accompany
an aqueous or puriform effusion. This variety
has not been decidedly established by the observ-
ation of other pathologists since the time of Laen-
nec, and we record its existence merely on his
authority, and on that of Andral, who relates a
case of it, in which, however, this origin was not
unquestionably proved. (Clinique Med. t. ii. p.
512.)

Pneumothorax from the opening of an em-
pyema into the lung. — The bursting of an em-
pyema into the lung is not a very unfrequent oc-
currence; and yet this is an extremely rare source
of pneumothorax. When it takes its origin in
this way, the empyema has generally been cir-
cumscribed. This variety of pneumothorax is
that in which the operation is fairly entertained
(See Empyema); and we believe that the cases
which recovered after it, where it was proved by
the fluctuation to have existed, must be referred to
it. We allude to the remarkable cases of Dr.
Archer (Trans. Dublin Association) and Dr.
Hawthorne, (Edinb. Med. and Surg. Journal, No.
61,) &c.

Pneumothorax from gangrenous perforation,
and from rupture of the pleura in emphysema
of the lung. — The first of these cases has been
occasionally remarked, but the latter is extremely
rare. Monro's case of successful operation was, as
we have before stated, very probably of this nature.
In it the rupture took place during a fit of cough-
ing, and it was succeeded by general emphysema
of the cellular tissue as well as pneumothorax.
Laennec thought that he observed its origin from
this cause in one caSe.

Pneumothorax from lesions of the thoracic
parietes. — We should mention under this head,
1st, that consequent on penetrating wounds and
lacerations of the lung by fractured ribs, called
hitherto by surgeons emphysema thoracis. Dr.
Hennen remarks that the fears which exist as to
its arising from these causes are greatly exagge-
rated, as it is in fact a very rare occurrence in mili-
tary surgery. (Hennen's Military Surgery, third
edition, p. 380.) 2nd. Where it is consequent
on the opening of an anthrax or abscess through
the intercostal spaces. Of the former we wit-
nessed an interesting case in the Meath Hospital,
in which all the phenomena were remarkably
perfect. To the latter belongs the singular case
described by Dr. Duncan, in which a diffuse ab-
scess spread from the arm to the chest, and pene-
trated the costal pleura and lung, upon which a
circumscribed pneumothorax formed, communi-
cating with the external abscess, and producing
elastic tumours on the side. (Trans. Med. Chi-
rurg. Society of Edinb.) 3rd. The species which
succeeds to the evacuation of the purulent matter
after the operation of empyema. This is an in-
variable consequence, but we believe that its pre-
judicial effects are too much insisted upon, as pa-
tients sometimes live many years with a fistulous
opening in the side, and enjoy a tolerable state of

PORRIGO.

653

health. The case of longest duration which we
are aware of is that related by Dr. Otto, in which
the individual daily discharged a small quantity
of purulent matter through the aperture formed
by the operation for seventeen years, and was en-
abled for nearly that period to take part in social
life. (Acta Nova Reg. Soc. Med. Havniensis,

vol. vii. p. 79.) T TT

' James Houghton.

POISONING.— See Toxicology.

POLYPUS OF THE UTERUS.— See Ute-
bcs, Diseases of.

PORRIGO. — Porrigo is the generic appellation
for several pustular diseases affecting the scalp
chiefly, but occasionally other parts of the body,
agreeing less in their symptoms than the species
of almost any other of the genera of cutaneous
diseases in the classifications of writers. It is
synonymous with the tinea of Avicenna and vari-
ous authors.

Porrigo is defined by Bateman, " an eruption
of straw-coloured pustules, concreting into yellow
or brownish crusts or cellular scabs;" but this de-
finition accords with three only of the species
usually arranged in this genus ; and, indeed, the
genus actually comprehends three diseased states
of skin, differing not only in their symptoms, but
requiring distinct modes of treatment. But as lit-
tle advantage perhaps would be derived from an
alteration of arrangement, or the division of this
genus into three distinct genera, we propose to
arrange the species so as to bring together those
that accord, and separate others the characters of
which are evidently distinct. They may be all
arranged under the three following sections.
Skit. I. Porrigo, true porriginous eruption,
comprehending —
Species 1 . P. larva/is ;

2. P. lupinosa ;

3. P. favosa.

II. EcZEMATOUS PoRRIGO.

4. P.furfuruns.

III. Anomalous Porrigo.

5. P. scutulata ;

6. P. decalvans.

I. True Porriginous Eruptions. — These
are characterized by the pustules assuming those
forms which have been denominated favus and
achor, and by being unaccompanied with fever.
The different forms may be regarded rather as
varieties than distinct species, as they sometimes
exist simultaneously on the same person. They af-
fect both sexes and all ages, but are most frequently
observed in infancy and youth. In many in-
stances it is difficult to trace them to any peculiar
predisposition ; but in general they may be re-
ferred to some deranged condition of the digestive
nrgans, to improper food, and occasionally to de-
pressing passions. None of the true porriginous
eruptions are contagious, nor does the treatment
applicable to all of them materially differ.

Species 1. Porrigo lurvalis ; milk scall or
mist.— This species of porrigo appears on the
forehead or cheeks, in the form of small, yellow-
ish, white, superficial pustules, upon a red surface,
in irregular groups. On breaking, they pour out
a greenish-yellow fluid, which concretes into thin
lamellated scabs, usually of a brownish hue. New
groups of pustules form in the vicinity of those

that have broken ; these break, and, as the former,
pour out their fluid, which encrusts in its turn ;
whilst the old scabs are thickened and extended
by the fluid continuing to ooze out from below
them, so that by degrees the whole of the face
becomes covered by these scabs, as if with a mask ;
thence the specific term larvalis. At this time the
crusts exhale a rank peculiar odour, which Ali-
bert likens to sour putrid milk. The eruption
varies in severity : sometimes the inflammation is
intense, the exuded humour very abundant, and
so acrid as to excoriate the cheeks and other parts ;
at other times it is moderate in quantity and mild
in quality ; the pustules are few, slow, and suc-
cessive in their development, and the crusts thin
and dry. Besides the forehead and cheeks,
patches appear behind the ears, around the mouth,
and upon the chin, yet they rarely appear upon
the nose and eyebrows. Small patches occasion-
ally break out about the neck and breast, and
sometimes even on the extremities. When they
rise upon the hairy scalp they assume a chronic
character ; the bulbs of the hairs sometimes in-
flame, and baldness, temporary or permanent, may
be the result. In whatever part the eruption is
seated, it is accompanied with itching, sometimes
with stinging pains, which are more severe, the
younger the patient is, and in infants not only
greatly disturb the natural sleep, but derange the
digestive function. This is particularly the case
in plethoric children, and especially when the
eruption spreads over much of the neck and
breast. The eyes and eyelids are often inflamed,
and discharge a purulent matter; when the dis-
charge on the scalp is absorbed, the parotid glands
swell. In strumous and highly irritable subjects
the mesenteric glands also inflame, and marasmus,
diarrhoea, and hectic may supervene and destroy
the patient. But this aggravation of the disease
is a rare occurrence.

When the disease is yielding, whether sponta-
neously or to remedies, the pustules form more
slowly, exude less, and the crusts fall off and are
not renewed, but they leave behind them a red,
tender cuticle, which is sometimes marked with
deep lines, and occasionally exfoliates several
times. Sometimes it appears as if about to yield,
and then returns with greater severity. In this
manner we have seen it vary during the whole
period of dentition, and yet, unless the nails have
been much at work, no cicatrices remain.

This species of porrigo is not contagious ; but
in a case mentioned by Alibert, in which an in-
fant was inoculated with it, the disease was taken.
It occurs in infants during the cutting of the first
teeth, and also in children during the second
dentition. We have never been able to trace it
to any state of the breast milk when it appears in
infants, but in every instance the stomach is in a
very irritable state, and much acid is present in it.
We have been able to trace it to the too free use
of acescent food, such as fruit-tarts and puddings,
sugar, and various articles of confectionary into
which it enters, in children of full and gross ha-
bits of body. Rayer says that it is less frequent
in the Parisian hospitals than the porrigo favosa,
the proportion being as seventy-one to nine hun-
dred and eight.

The disease most likely to be confounded with

654

PORRIGO.

porrigo larvalis is porrigo favosa ; but to careful
observers the circular depressed crusts of the latter
readily distinguish it from the former. None of
the other species of porrigo, except porrigo furfu-
rans, is likely to be mistaken for it ; but in por-
rigo furfur ans the crusts dry and become very
hard and greyish, which distinguish it.

In general the disease runs its course without
danger, but, as we have already stated, the mesen-
teric glands may be in a diseased condition, in
which case it becomes formidable, and may in-
duce diarrhoea, marasmus, hectic, and thus prove
fatal. The sudden cessation or repulsion of the
discharge is also said to indicate an increase of
some deeper-seated disease ; but our experience
has not led us to form such a conclusion. We
concur in the opinion of Dr. Underwood, (Trea-
tise on the Diseases of Children, 8th edit.,) that in-
fants who suffer much from the milk crust aP»
always healthy in other respects, and cut their
teeth remarkably well. Dr. Starck (Starck's Diss,
de Crusta Lactea Infantum, &c.) affirms that the
prognosis is always favourable when the odour of
the urine resembles that of the cat. We have not
seen this remark verified ; indeed, unless the dis-
ease occur in very young, ill-fed, and badly
nursed children, or in those of an hereditary stru-
mous constitution, our prognosis may always be
favourable.

Porrigo larvalis requires both constitutional
and local treatment.

When the disease appears in infants at the
breast or during the first dentition, it is essential
to allay the general irritability of the mucous
membrane, which is the source of the acescent
state of the stomach ; and as soon as that is ac-
complished, to aid the general powers of the sys-
tem by mild tonics. For answering the first of
these indications we have seen much benefit de-
rived from the hydrargyrum cum creta, in doses of
gr. iii. to gr. vi. given night and morning ; or in
older children, when the mesenteric glands were
enlarged, and the abdomen was tense and tumid,
from calomel, in doses of one-tenth of a grain
combined with one-fourth of a grain of ipeca-
cuanha and half a grain of the powder of conium,
given every eighth hour for a week. For fulfil-
ling the second nothing answers so well as a
combination of carbonate of soda, powder of ca-
lumba, and rhubarb, in doses proportioned to the
age of the child and other circumstances, given
twice or three times a day. Under such a plan
of constitutional treatment we have witnessed the
disease to yield in a very short time without any
local applications except those which cleanliness
requires. We have had no occasion to employ
sarsaparilla, cinchona bark, the rumex aquaticus,
nor the viola tricolor recommended by Dr. Starck.
(Ibid.) During dentition the warm bath at bed-
time is highly salutary, especially when the itch-
ing is so troublesome as to interrupt the sleep of
the little patient. Nothing is more important
than to examine the state of the milk : if this be
thick, the nurse should either be changed, or her
allowance of porter, animal food, and other stimu-
lant nutriment should be diminished. If the in-
fant be undergoing the uncertain experiment of
being brought up by hand, the food should consist
balely of milk diluted with an equal quantity of

barley-gruel, and sweetened slightly with lump
sugar. The quantity should be moderate, and
any thing like voracious appetite in the child re-
pressed.

In children of more advanced age, during the
second dentition, when the pulse is quick and full,
the face flushed, and the nights restless, it may be
necessary to apply a few leeches either behind the
ears or under the angle of the jaw ; and in very
obstinate cases to apply a blister on the nape of
the neck, or between the shoulders, and keep it
discharging for ten or twelve days. Gentle ape-
rients, merely to regulate the bowels, are neces-
sary, but we have never seen any advantage de-
rived from a course of purging.

With regard to local applications, if the erup-
tion occupy the scalp, it is scarcely requisite to
say that the hair must be removed by scissors, for
it seldom admits of being shaved ; after which the
separation of the crusts should be aided by a
dressing of the oxide of zinc or the subacetate of
lead-ointment on lint, covered with an emollient
poultice. If the discharge be considerable and
very acrid, the denuded surface should be washed
with a solution of gii. of bicarbonate of soda in
/.^viii. of bitter almond emulsion, or of milk
with the addition of /.£ss of hydrocyanic acid.
In very young children, however, it is advisable
to leave out the hydrocyanic acid. As soon as
the local irritation is subdued, if a return to the
healthy state of the scalp seems to be retarded
only by the crusts becoming dry, hard, and ad-
herent, their separation and cicatrization are fa-
cilitated by the unguentum hydrargyri nitratis,
diluted with six or seven parts of lard. We have
never met with a case in which lotions of the
hydro-sulphuret of potassa or sulphureous baths
were required.

In conclusion we may remark that we are ac-
quainted with no eruptive disease in which there
is so complete an obliteration of every thing that
could indicate the existence of the previous erup-
tion after the crusts fall ; and in none have we
perceived less mischief to result from checking
the eruption.

2. Porrigo lupirtosa ; lupine scull. — This spe-
cies of porrigo is distinguished by the achores,
which arise in small separate clusters, forming
when they break circular scabs of a yellowish
white colour, set deeply in the skin, with a central
indentation or depression, sometimes containing a
white, scaly powder. When seated on the scalp
or on the temples, they acquire nearly the size of
a sixpence, and there is sometimes an intervening
thin white incrustation, which exfoliates, or occa-
sionally forms an elevated crustaceous covering.
The eruption sometimes displays itself on the
shoulders, the thorax, the abdomen, and the ex-
tremities ; but in these places the scabs never
attain to the size which they do on the scalp.
The eruption exhales an offensive odour, not
unlike that of mice ; it affords a harbour for
pediculi in the crevices of the crusts ; and when
the acrid discharge is absorbed, the cervical glands
swell ; whilst long-protracted cases terminate in
baldness. When left to itself, the disease is very
long before it wears itself out, and even unde
proper treatment it is tedious of cure.

It is not contagious ; and it is the least frequent

PORRIGO.

655

of all the species of porrigo. Its predisposing
cause seems to be a low state of the habit, result-
ing from the miseries attendant on poverty.

The treatment of porrigo lupinosa consists
chiefly in the application of emollient poultices,
and soap and warm water; the mechanical re-
moval of the crusts ; and, after this is effected,
the assiduous use of an ointment made with two
drachms of the finely powdered seeds of the coc-
culus Indicus and one ounce of lard. In very
obstinate cases, the hard crusts may be touched
with diluted sulphuric or muriatic acid, or treated
with a lotion made with Kquoris potassse £j, olivse
olei^'i], aquas gj. When the crusts are removed,
and the surface appears red and covered with
numerous small ulcers, exuding a viscid, fetid,
yellowish fluid, the diluted ointment of the nitrate
of mercury is the best application to assist cica-
trization, and complete the cure.

3. Porrigo favosa ,- honeycomb scall. — The
eruption in this species of porrigo consists of
small, flat, soft, straw-coloured pustules, termed
favi, generally distinct, with an irregular edge,
and bounded by a slight inflammation. The
scalp is the chief seat of the eruption, but it
sometimes occupies the forehead, the temples, the
chin, the space behind the ears, the eyebrows, and
occasionally it extends to the trunk and the ex-
tremities. When it appears on the scalp, the
pustules are small, not very distinct to the naked
eye, and the minute drop of yellow fluid which
they contain does not escape, but dries within
them, and acquires a deeper yellow colour, and is
very adherent. The pustules, although they are
usually distinct, sometimes appear in groups, and
become confluent. When distinct, they are usually
on elevated bases, and each is frequently traversed
by a hair. In whatever manner they appear, they
are always more or less accompanied with itching.
If the crusts be removed by poultices, or by any
lotion, they do not return, the formation of new
pustules being necessary for that purpose. When
the disease is left to itself the crusts are very ad-
hesive, and remain in a dry, white, and brittle
6tate, sometimes for months and even years.
Sometimes as they assume this character in one
place, fresh pustules appear in another. The hair
separates with the greatest ease, sometimes leaving
the part permanently bald. As the disease pro-
ceeds, if great care be not taken to keep the parts
clean, pediculi harbour in the crusts, the itching
augments to an intolerable degree, and the erup-
tion exhales a most offensive odour. The exco-
riated surfaces, after the crusts are removed, exude
a fetid reddish fluid, which concretes into irregular
crusts. Occasionally they cause small subcutane-
ous abscesses and lymphatic swellings in the neck,
which slowly suppurate ; the axillary glands are
affected when the eruption appears on the upper
part of the trunk.

It is probable that the reticular tissue is the seat
of the disease ; although, owing to the bulbs of
the hair becoming affected in long-standing cases,
It has been supposed to originate there. It rarely
happens that the hairs are detached without being
diseased. The duration of the disease is uncer-
tain.

Porrigo favosa is asserted to be contagious ;
because, owing to the acrimony of the discharge,

it causes inflammation and scabbing on any sound
part with which a diseased part comes in contact ;
as for instance the breast with the chin, or the
hands and arms with the face in young children.
The breast of the nurse may become affected in
the same manner. It occurs at all seasons of the
year, and in both sexes ; but it is more common
in infancy and childhood. The strumous diathe-
sis, bad nourishment and poor clothing ; damp, ill-
ventilated houses, prisons, and the miseries of
poverty in all their forms, may be regarded as its
predisposing causes.

This species of porrigo may be readily con-
founded with porrigo furfurans ; but as the pus-
tules are found on different parts of the body in
every stage of their progress, it is easily recog-
nized. When the disease is of long standing,
the hairs are destroyed on the affected parts of the
scalp.

[It has been affirmed of late that the yellow
substance, which constitutes the crusts of this af-
fection, is an organic growth of simple structure
bearing a marked resemblance to the vegetable
bodies, collectively called mould. They have
been examined by Remak, Schonlein, Fuchs, and
Langenbeck, and Gruby, the last of whom states,
that the crusts are made up of aggregated myco-
dermata. It is very questionable, however,
whether these mycodermata be really vegetable ;
and it is certainly far more probable, that they are
very simple animal growths. — (E. Wilson, on
Diseases of the Skin, Amer. edit. p. 322, Philad.
1843.)]

Continental writers assert that porrigo favosa
requires little more than local remedies ; but we
have seen no case of the disease in which it was
not easy to trace it to some morbid condition of
the system. For this reason a gentle alterative
course is required, care being taken at the same
time to regulate the diet and exercise. The for-
mer should consist chiefly of light animal food,
with milk and farinaceous preparations ; the lat-
ter should be regular, but never carried to fatigue ;
and when the tepid bath can be employed, which
is always more or less serviceable, the exercise, in
dry and temperate weather, should be taken im-
mediately after using it. If the habit be decidedly
strumous, the glandular affections severe, and
much emaciation has taken place, tonics will be
found to be necessary. The chalybeates are the
most useful, and none possesses more power in
such cases than the hydriodate of iron, given in
doses of from one grain to three grains in a large
quantity of water three times a day. The sul-
phate of quinia and the muriate of baryta have
also been advantageously administered. In young
children we have seen much benefit derived from
the hydrargyrum cum creta, given every night in
doses proportionate to the age of the patient;
with a combination of cascarilla and subcarbonate
of soda, in full doses, given three times a day.
In adults a mild course of Plummer's pill with
sarsaparilla is occasionally requisite, in cases of
long standing which have resisted the usual mode
of treatment.

With respect to local remedies, the first object
is to free the scalp as much as possible from the
crusts, and to subdue topical inflammation. This
is accomplished by cutting the hair as short as

656

PORRIGO.

possible, or by shaving the scalp if the eruption
admit of it ; daily ablution with hot water and
soap ; and when the crusts are dry and very ad-
hesive, the application of poultices. After the
surface is pretty well cleared, an ointment con-
taining equal quantities of the unguentum oxidi
zinci and unguentum hydrargyri precipitati albi
may be applied to the inflamed parts ; or if the
inflammation be moderate, the unguentum hy-
drargyri nitratis will answer better. The com-
bination of the tar ointment, diluted with two
parts of lard, and one part of sulphur, forms a
useful application when the crusts are very ad-
hesive ; but the pitch-cap, which was formerly
much employed, is apt to excite a highly inflam-
matory state of the scalp, and a considerable
degree of symptomatic fever, consequently it
should be used with caution. In addition to
these topical applications, much advantage has
been derived from the introduction of a seton in
the nape of the neck or in the arm ; indeed we
have rarely witnessed the most obstinate cases
resist the beneficial influence of such a drain con-
tinued for a month or six weeks.

Of all the local methods of treatment, that pur-
sued by two brothers of the name of Mahon, in
the Parisian hospitals, has been found the most
efficacious ; and therefore we shall give a brief
sketch of it. The hair is first cut, so as to leave
it throughout about two inches long ; the crusts
are next cleared away as completely as can be
done by the aid of linseed-meal poultices and
soap and water, a part of the treatment which
occupies from four to five days. Having thus
prepared the scalp, the affected parts are next
covered with an ointment composed of chalk,
silex, alum, oxide of iron, a small quantity of
subcarbonate of potassa, some lime, and a little
charcoal rubbed up with lard, but in proportions
which are kept secret. This ointment is applied
on alternate days for upwards of a month ; whilst
on the intermediate days a comb is passed gently
over the parts to detach the loosened hairs with
as little pain as possible. At the end of this
time a powder, the same as that which was em-
ployed in forming the ointment, but without any
charcoal, is sprinkled over the affected parts ; and
after using the comb on the following day, the
former ointment is again resorted to ; and by con-
tinuing this method the disease yields, and the
skin again acquires its natural and healthy con-
dition. We have had no experience of this
method of treating this species of porrigo ; but
from its reputation in Paris we are of opinion
that it merits the attention of British practi-
tioners.

Many other local stimulants have been em-
ployed with various success ; for example, oint-
ments composed of powdered charcoal, peroxide
of manganese, and oxygenated lard ; cantharides
ointment, and pommades made with white pre-
cipitate, or calomel, or bichloride of mercury.
Different anodyne cataplasms also have been re-
commended, made chiefly with strong decoctions
of conium maculatum or of the twigs of dulca-
mara ; but at best these may be regarded simply
as palliatives to allay local irritation. In obsti-
nate cases, after removing the crusts, it has been
found useful to touch the raw surfaces with a

feather dipped in any of the mineral acids, and
then a few minutes afterwards to bathe the parts
repeatedly with cold water. The pain excited is
great ; consequently some degree of caution is
requisite in applying these caustics to children of
delicate habits.

When the eruption appears on the trunk of the
body, the ordinary warm-bath is found to be bene-
ficial, and still more so the sulphurous vapour-
bath.

[Alkaline ointments and washes ; weak solu-
tions of chlorinated lime or chlorinated soda or of
creasote may be employed ; and in some cases,
solutions of sulphate of zinc or of sulphate of cop-
per or of nitrate of silver have been of great ser-
vice. The citrine ointment, unmodified, or re-
reduced, according to circumstances, has been ad-
vised by many. In the author's experience more
good has been derived from the ointment of iodide
of sulphur than from any other application. Cod-
liver oil is likewise said to have been used with
advantage ; but it would be endless to enumerate
all the topical applications that have been advised.
(For a further detail see the author's Practice of
Medicine, 2d edit. ii. 126.)]

In conclusion, it is necessary to recollect that
in no cutaneous eruption is a change of measures
more necessary than in this species of porrigo ;
the employment of any single remedy, however
judicious, is not likely to be followed by success.

II. Eczematows Porrigo* — Species 4. Por-
rigo furfurans ; furfuraceous scall. — This is the
teigne amiantacee and teigne furfuracee of Ali-
bert ; the eczema de cuir chevelu of Biett, Rayer,
and some other French writers : but as there can
be only one opinion as to its pustular nature, it
cannot be regarded as a variety of eczema, although
it may be characterized as an eczematous porrigo.
The eruption most commonly appears on the nape
of the neck, at the margin of the hairy scalp, or
on the temples. It commences with a crop of
minute achores, the pus in which being unusually
transparent has led them to be mistaken for vesi-
cles. The discharge is moderate, and soon con-
cretes, forming thin, laminated, exfoliating scales,
accompanied with much itching and soreness
when the disease, as is most commonly the case,
is seated in the scalp and extends to the temples,
ears, and neck. The discharge is also viscid, and
exhales a nauseous odour ; it adheres to the hairs ;
and on drying forms a powdery scurf, which the
slightest friction separates ; and when confined
under these scales, it is absorbed, and the glands
of the neck swell and become painful. This also
occurs in old cases ; whilst the inflammation ex-
tending to the bulbs of the hairs, these fall off
and baldness appears.

This species of porrigo generally attacks adults,
females rather than males, and always those of a
lymphatic temperament. The eruptions with
which it is most likely to be confounded are pso-
riasis, and lepra when the latter affects the scalp.
We have seen it also assume the appearance of
impetigo. The pustular origin of the disease, as
it appears at irregular periods, enables us very
readily to form a correct diagnosis ; and independ-
ent of this, we observe no moisture nor ulceration,
nor any diseased condition of the hair in either
psoriasis or lepra ; nor are these eruptions conta-

PORRIGO.

657

gious, whilst porrigo furfurans is undoubtedly
communicable by contact.

Porrigo furfurans is usually treated solely by
topical remedies; but we have never seen it yield
without the employment of general means. We
have found much benefit by prefacing a light
alterative course, with one or two moderate bleed-
ings, and a full evacuation of the alimentary canal
by means of six or eight grains of calomel, fol-
lowed by a brisk saline purgative. We then
generally order ten grains of hydrargyrum cum
creta to be taken daily at bed-time, and twenty
minims of liquor potassae three times a day, gra-
dually increasing the dose until it reach to ninety
or one hundred drops. The best vehicle is milk,
which both covers the taste and sheaths the acri-
mony of the medicine in swallowing. We have
occasionally carried the dose to the extent of one
hundred and twenty minims without any incon-
venience to the patient.

With respect to the local treatment, the first
object is to free the scalp and the hairs from the
scurf, which is easily accomplished by cutting the
hair short, and using a solution of f.^iv of liquor
potassce, in f.^vss of bitter almond emulsion as a
lotion. The same lotion, more largely diluted,
may be applied, tepid, twice a day : it cleans the
scalp better than soap and water, and prepares it
for the application of a stimulant ointment, which
should be kept on, and the surface at the same
ime preserved in a moist state by an oil-silk cap
accurately fitted to the shape of the head. The
nature of the ointment must depend upon the
greater or less irritability of the affected surface.
When the scalp is very tender and moist, the
oxide of zinc ointment should be preferred ; or an
ointment prepared with two parts of finely pow-
dered cocculus indicus and eight of lard. In a drier
and less sensitive condition of the diseased parts,
the strong lotion may be used daily, or one com-
posed of Jiij of recently prepared sulphuret of po-
tassae, £i of soft soap, ^viij of lime water, and sjij
of rectified spirit ; or with a lather formed with
equal parts of soft soap and sulphur ointment in
hot water. Instead of the unguentum oxidi zinci,
either the unguentum hydrargyri nitratis, or un-
guentum hydrargyri nitrico-oxydi, or unguentum
acidi nitrici of the Edinburgh Pharmacopoeia
may be now used ; or, what in our opinion is pre-
ferable to all of these, a mixture of the common
tar and sulphur ointments. By the employment
of such means the disease usually yields, but as
the inflammatory symptoms frequently recur, it is
necessary, under such circumstances, to return to
the use of the milder applications. All salted
meats, pork, and fish should be forbidden during
the existence of the eruption.

III. Anomalous Porrigo. — This division of
porrigo contains chronic inflammatory affections,
of a contagious nature, characterized by extremely
minute circular groups of achores, which exude
a fluid that concretes into thin, slightly adhesive
crusts. In one of these species both the achores
and the crusts are so minute as to be almost micro-
scopic objects.

Species 5. Porrigo scutulata ,• ring-worm of
the scalp. This is the most difficult to manage,
and the most decidedly contagious of the whole
genus. The pustules, or achores, are generally

Vol. III. — 83

seated on the scalp, although occasionally they
appear on the forehead and neck in distinct, some-
what distant, circular patches. When these are
closely examined with a magnifying glass, they
are found to consist of very minute whitish-yellow
pustules, embedded as it were in the epidermis.
These break and are succeeded by thin crusts,
which are readily detached at first, but after a
short time harden, and become adhesive as they
accumulate. The first circular patch, after the
pustules break, is in a few days surrounded by a
circle of fresh pustules, which break and crust
in their turn, and are surrounded by a new crop
of pustules ; and by these repetitions the areas of
the patches extend, until the greater part of the
scalp is covered by them. The pustules are gene-
rally preceded by ery thematic patches, which itch :
when carefully examined, M. Biett says that, like
porrigo favosa, each pustule has a central depres-
sion, and is generally traversed by a hair ; and
when the crusts in which they terminate exfoliate,
the surface remains red, shining, and inflamed.
If the hair falls off, which generally occurs, the
new hairs are dry, woolly, and so little adhesive
that they may be detached with the smallest effort.
The various patches display different periods of
the eruption, and each is surrounded by an exter-
nal circle of recent inflammatory pustules. The
duration of the disease is very uncertain ; but under
every circumstance, even the most favourable, the
prospect of cure is always a distant one. When
the circles remain red, smooth, shining, dry, o
scurfy, the disease is still in progress ; but when
the redness and exfoliation disappear together, and
the hairs begin to cover the spots and assume
their natural appearance and colour, it may be
regarded on the decline.

With regard to the causes of this disease, it is
said to originate spontaneously in weak, flabby
children, badly nourished, and who are confined
to close ill-ventilated apartments ; but there is some
reason for thinking that it is one of those evils
which our oriental possessions has bestowed upon
us, (for we think that it is imported from India,)
and that its general propagation is due to its highly
contagious character. Its introduction into a
school is sufficient to fix it in the establishment
for years, in spite of the greatest vigilance and
attention on the part of the superintendents. It
occasionally, but rarely, occurs in adults.

The circular form of the patches, their manner
of extending, the minuteness of the achores, and
their contagious nature, readily distinguish this
species of eruption from all others. It may never-
theless be confounded with impetigo Jigurata
when this appears on the hairy scalp ; but there
are distinctive characters sufficiently evident to
separate the two : thus, the superficial, slightly
prominent psydracious pustules of impetigo Jigu-
rata, seated on a diffused red surface, differ essen-
tially from the imbedded pustules of porrigo scu-
tulata, surrounded by inflammation only at their
base. Impetigo Jigurata also seldom appears ex-
clusively upon the scalp, nor is it contagious.

If the spontaneous appearance of porrigo scutu
lata be true, it is evident that the tone and vigou'
of the constitution should be brought up where
that is deficient ; thence gentle alteratives, namely,
minute doses of hydrargyrum cum creta, with

658

POilfilGO.

decoction of bark, or the solution of hydriodate
of iron or other chalybeate preparations, are indi-
cated when the disease appears in cachectic habits.
When, on the contrary, it is communicated by
contagion to stout and healthy children, no gene-
ral treatment is required. In both, however, some
attention to diet and regimen is necessary ; all
crude aliments, raw vegetables, and sweetmeats,
or whatever is likely to prove acescent, should be
avoided ; and the surface of the body, particularly
the lower extremities, must be kept warm, so as
to maintain the balance of the circulation and
keep up the insensible perspiration. In a word,
every thing should be done to improve the general
health if that is defective, and to preserve it if it
do not require improvement.

The local treatment must be varied according
to circumstances. In the early stage of the dis-
ease, when the patches are inflamed and irritable,
soothing applications are indicated ; for example,
sponging with warm water, lime-water, or the ap-
plication of emollient poultices, after shaving the
head, which should be done at least once a-week ;
but we have seen more advantage derived from
the simple application of cold or iced water to the
patches, at this time, than from any warm or tepid
application. A light linen cap should be worn,
and changed daily, and every pains taken to pre-
serve cleanliness, and to prevent scratching or any
mechanical irritation of the scalp. As the inflam-
matory state diminishes, and a dry, harsh state of
the patches ensues, provided no fresh circles of
pustules rise, and produce tender, inflamed areolae,
stimulant applications are indicated. During the
irritative stage, Alibert recommends a cataplasm
of hemlock, which we have tried, as well as cata-
plasms of henbane and belladonna, without ob-
serving any decided benefit to follow their em-
ployment. The belladonna causes dilatation
of the pupils, blindness, vertigo, and other ner-
vous symptoms, and therefore it requires to be
used with caution, especially in young subjects.
If ointments are desirable at this period, those pre-
pared with cocculus indicus, calomel, white pre-
cipitate, oxide of zinc, the acetates of lead, or with
opium or tobacco, are chiefly recommended. De-
coctions of poppy heads or of tobacco have also
proved beneficial ; but the latter requires more
caution than the belladonna poultice. We have
seen it cause sickness, vertigo, and the most alarm-
ing degree of collapse.

When the inflammatory state is absent, every
stimulant that can be externally applied has been
used in this complaint. Ointments, formed of
metallic oxides and salts, namely, unguentum
hydrargyri nitratis, unguentum hydrargyri nitrico-
oxydi, and Banyer's ointment* containing calo-
mel ; sulphur ointments ; the tar ointment, or one
resembling it, made with petroleum instead of tar ;
ointments containing white hellebore, sabadilla,
mustard, staves-acre, black pepper, capsicum, galls,
rue, and similar vegetable excitants have been
employed, and each in some cases has proved suc-
cessful ; nevertheless all have occasionally failed.
In India, where the disease prevails, an ointment

* Banyer's ointment consists of lb.ss of litharge, 2 oz.
of burnt alum, 1 oz.ss of calomel, lb.ss of Venice turpen-
tine and 2 lbs. of lard, well rubbed together. It is too
iicrid for all cases, consequently it requires dilution with
more lard.

composed of 31. of powdered galls, ^i- of sulphate
of copper, and £i. of simple cerate is said to prove
successful. In this country the last application
in vogue is creasote ;j- we have witnessed its suc-
cess, but experience has yet to determine how
far it can be depended upon. In very dry, rigid
inert states of the patches, the nitrate of silver, the
strong mineral acid, the pure alkalies, and other
caustics have been applied, with the view of de-
stroying the morbid cuticle and setting up a new
action in the part. In some cases we have seen
this practice succeed : in many instances, however,
like other applications, it is useless. Although
none of these external remedies when singly relied
upon is permanently successful, yet all of them
when alternately employed or variously combined,
are productive of benefit. As far as our own ex-
perience has enabled us to form a judgment on
this subject, we are of opinion that more benefit
is derived from the use of the depilatory method
mentioned under the head of porrigo favosa than
from any other mode of management. It is un-
doubted that, whether the disease be seated in the
bulbs of the hairs, or whether these become mere
irritating bodies, the removal of the hairs is an
important step in forwarding the cure. When
these are once removed, the application of any
stimulant ointment, exciting a new action in the
diseased spots, aids the cicatrization of the pustules,
and the formation of a healthy cuticle. The best and
most certain evidence of the cure being completed is
the growth of healthy, good coloured hair on the
spots which were previously the sites of the pustules.

Species 6. Porrigo decalvans ,■ bald scall. —
This species, which is easily recognised from all
the other species, and indeed from every other
cutaneous disease, is the area alopecia of Celsus,
the alopecia areata of Sauvages, and the trichosis
area of Good. (See Alopecia.) It is character-
ised by patches of baldness in different parts of
the head, generally of a circular form, with the
naked part of the scalp smooth, shining, and white.
No crusts form on these patches, nor can any
achores be detected even when a good eye is aided
with the most powerful glasses. Sometimes the
patches enlarge, and run into one another so as to
produce baldness of the greater part of the scalp.

It is extremely difficult to trace the cause of this
curious disease. It seems to be some morbid condi-
dition of the secreting follicles of the hair, for

t As this substance has very lately been introduced to
the notice of the profession in this country, it may be
useful to give here some account of it. Creasote is a
colourless transparent liquid ; sometimes, however, it is
of a pale yellow colour. Its specific gravity is 1037. It
remains fluid at —17° and boils at 397° Fahrenheit. It
impresses a hot taste on the palate, followed by sweet-
ness ; its odour resembles that of Westphalia ham. The
antiseptic properties of pyroligneous acid are ascribed
to Creasote. It is soluble in eighty parts of water, and in
every proportion in alcohol, ether, and naphtha. It com-
bines with acids and alkalies, forming compounds solu-
ble in water: It coagulates powerfully albumen. Finally,
it is a compound of carbon, hydrogen", and oxygen.

Such are the physical and chemical properties of this
substance. It operates as an energetic excitant to the
animal system, and proves poisonous to fish when they
are introduced into aqueous solutions of it. As a thera-
peutical agent, it rapidly exhausts nervous energy, and
therefore displays a narcotic as well as an excitant in-
fluence. It has been administered internally in rheuma-
tism, hysteria, and several other diseases, and it lias
certainly been found useful as a topical remedy in ulcers
and several cutaneous diseases, but hitherto its adminis-
tration has been directed rather hy empirical than scien-
tific principles.

PREGNANCY AND DELIVERY, (SIGNS OF)

there are no achores apparent, nor any disease
of the cutis, unless we can regard the pale ex-
sanguine aspect of the bald spot to be the result
of some contracted state of the capillaries. There
jg a slight degree of itching, indicating nervous
excitement on the patches ; but this is not always
present. Dr. Bateman (Synopsis, p. 248) hints
that the disease is contagious : we have not seen
any cases in which it could be traced to commu-
nication. It occurs most frequently in children
of ten or twelve years of age ; but it is also occa-
sionally observed in adults.

With respect to the treatment of this species
of porrigo, we have seldom failed to cure it by
shaving to the extent of an inch round the bald
patches, and brushing them, at least twice a day,
with rectified oil of turpentine, diluted with two
parts of alcohol. As the new hair begins to
appear on the bald parts, it should be regularly
shaved off as long as it is softer and of a lighter
colour than the healthy hair of the individual,
the re-appearance of which is the proof of the
termination of the disease. No internal medi-
cines are indicated. A. T. THOMSON.

PREGNANCY AND DELIVERY, SIGNS
OF. — Few questions in legal medicine, whether
considered in a merely professional point of view,
or in reference to their relations with criminal or
civil law, impose on the medical examiner a more
delicate duty, or a more trying responsibility, than
the determination of the existence or absence of
pregnancy ; placed before him, as the question
generally is, under circumstances by which all its
natural difficulties are increased an hundred fold.
It usually happens in such cases that he cannot
rely on a single statement made by the individual
who may be the subject of examination ; but, on
the contrary, he must be prepared for every species
of falsehood and misrepresentation. And yet on
the correctness of his opinion frequently depend
the claim to fair fame, virtue, and honour ; — the
succession to property, and the rights of legitima-
cy ; — the judicious treatment of disease ; — and, in
criminal cases, the preservation or destruction of
the unborn innocent.

The instances which present themselves are un-
fortunately but too frequent, in which the unmar-
ried female, either yielding to the influence of
passion, or made the reluctant victim of the un-
principled seducer, and becoming pregnant, an in-
vestigation as to her real state is sought for, in the
hope of inducing marriage, or perhaps for the pur-
pose of influencing a jury in the assessment of

An attempt may be made to conceal pregnancy
by the unmarried, or even by the married under
certain circumstances ; as in the case of a wife's
separation from her husband or his casual absence,
in order to avoid disgrace in society, or to enable
her with impunity to destroy her offspring. On
the other hand, pregnancy may be feigned in
order to gratify the wishes of a husband or rela-
tives, to extort money, to compel marriage, to de-
prive the lawful heir of his just rights of succes-
sion, or to delay the execution of the sentence of
death.

By the law of this country, a woman con-
demned to death may plead pregnancy in bar of

execution, and medical men are appointed to de-
termine the question whether the culprit is really
with child or not ; and if she is, whether she be
quick with child, for pregnancy alone will not
save her. This rule, we may observe in passing,
is one of the most monstrous and barbarous fea-
tures of our penal code.* Infinitely superior both
in morals and in mercy is the law of France,
which ordains that if a woman be pregnant at all,
she shall not be executed until after her delivery ;
and formerly the privilege allowed under such cir-
cumstances was even greater : in 1795 a law was
passed which ordained that no woman accused of
a capital crime should be brought to trial until it
was properly ascertained that she was not preg-
nant, (see observations on Quickening in the
present article,) and in conformity with this, sev-
eral decisions were reversed where it appeared
that the female had not been properly examined ;
and in more than one instance the sentence of
death was annulled, because after the trial it was
discovered that the woman was pregnant at the
time of being put upon her trial. {Fodere, Med.
Leg. vol. i. p. 428, et seq.)

Connected with such investigations, some very
melancholy mistakes have occurred, by which the
lives of unborn infants have been sacrificed. Rio-
Ian relates the history of a woman named Gene-
vieve Supplice, who, after being hanged for rob-
bery, was publicly dissected by him at the school
of medicine, and was found pregnant of a child of
five months, contrary to the opinion of the sur-
geons and midwives who had examined her.
(Anthropog. lib. 6, ch. 2.) Mauriceau also men-
tions having seen at Paris, in 1666, a miserable
example of this kind in a woman who was hanged
and afterwards publicly dissected : she was found
to be pregnant four months, notwithstanding the
report of the persons who had visited and exa-
mined her by order of the judge before her execu-
tion, and pronounced that she was not pregnant,
being deceived by the fact of her continuing to
menstruate. This matter caused a great sensation
of disgust and horror, and was reported to the
king and his court, and in consequence a severe
censure was passed on the persons who, by their
ignorance, had caused the untimely execution of
the unfortunate woman, with whom had perished
also her infant, innocent of its mother's crime.
(Maladies des femmes grosses, torn. i. p. 71-2.)

A proceeding may also take place at common
law, " where a widow is suspected to feign herself
with child in order to produce a supposititious heir
to the estate, and defraud the lawful heir. In such
case the heir presumptive may have a writ de ven-
tre inspiciendo, to examine if she be with child or
not, and if she be, to keep her under proper re-
straint until she is delivered. But if the widow
be, upon due examination, found not pregnant,
the presumptive heir shall be admitted to the in-
heritance, though liable to lose it again on the

* Pregnant women have always been objects of much
regard and reverence. The Roman laws allowed then.
the same privilege as those of Fiance. The ancient*
even spared the life of the murderer who took refuge
under the roof of a woman with child. The kings of
Persia used to present two pieces of gold to each preg-
nant- woman. The Jews, who observed so rigorously the
Mosaic law, allowed them the use of forbidden meats,
lest the child might suffer from their longings.

660

PREGNANCY AND DELIVERY, (SIGNS OF)

birth of a child within forty weeks from the death
of the husband." (Blackslone, vol. iv. p. 394-5.)
A celebrated case of this kind, which attracted
great attention, occurred in the family of Sir
Francis Willoughby, who died, seised of a large
inheritance. He left five daughters, (one of whom
was married to Percival Willoughby,) but. not any
son. His widow at the time of his death stated
that she was with child by him. This declaration
was evidently one of great moment to the daugh-
ters, since if a son should be born, all the five sis-
ters would thereby lose the inheritance descended
to them. Percival Willoughby prayed for a writ
de ventre inspiciendo, to have the widow exa-
mined, and the sheriff of London was accordingly
directed to have her examined. He returned that
she was twenty weeks gone with child, and that
within twenty weeks fuit paritura. " Whereupon
another writ issued out of the Common Pleas,
commanding the sheriff safely to keep her in such
an house, and that the door should be well guard-
ed ; and that every day he should cause her to be
viewed by some of the women named in the writ,
(wherein ten were named,) and when she should
be delivered, that some of them should be with
her to view her birth, whether it be male or fe-
male, to the intent there should not be any falsity.
And upon this writ the sheriff returned, that ac-
cordingly he had caused her to be so kept, and
that on such a day she was delivered of a daugh-
ter."*

There is another case where the court has in-
terfered on proof -of the existence of pregnancy
being brought before it, and that is, where a female
in this situation is imprisoned. Thus in the case
of Elizabeth Slymbridge, (Croke's James, p. 358,)
" upon suggestion that she had been imprisoned
for divers weeks and was with child, and would
be in danger of death if she should not be en-
larged," Sir Edward Coke, the Chief Justice, ad-
mitted her to bail to prevent the peril of death to
her and her infant, and in giving his opinion he
quotes a similar case which happened in the 40th
of Edward III. The editor remarks that these
cases are cited as extraordinary instances. The
last case is mentioned in Coke upon Littleton, 289
a. — The record states: "Quia eadem Elena
pregnans fuit, et in periculo mortis, ipsa dimittitur
per manucaptionem ad habendum corpus," &c.

When proceeding to an investigation of this
kind, we must recollect that the signs or proofs
of pregnancy are to be collected from various and
very different sources, and, moreover, that of some
of them we can have no evidence except from the
report made to us, while of others we can judge
by the changes existing before us, and cognizable
by our senses. The following are the chief of
these signs : —

1. Certain affections of the constitution induced
by pregnancy, which are the result of the new
action which has commenced in the uterus ; such
as suppression of the menses, generally increased
irritability of the nervous system, evinced in
capriciousness of temper, or perhaps in the pro-
duction of erratic pains, as in the face and teeth,

* Croke's Elizabeth, p. 566. See also in the matter of
Martha lirowne ezpartc Wallop in Brown's Chancery
Cases, vol. iv. p. 90: and ezparte Aiscough. Peere Wil-
liams' Reports, vol. ii. p. 591.

greater activity in the circulating system, and es-
pecially in the exhalents, giving rise to oedema
and other forms of dropsical effusions; alterations
in the countenance from absorption of the fat, &c.

2. In consequence of the irritation induced in
the uterus, there are a train of sympathies excited
in other organs, affecting cither their phvsiccl
constitution or their peculiar functions : such, for
instance, are the changes produced in the breasts
by which their size is increased, with tingling
pains, the wreola formed, and milk secreted ; the
stomach is irritable ; vomiting ensues ; the appe-
tite becomes variable and capricious, and some-
times the salivary apparatus participates so de-
cidedly in the irritation that complete salivation
takes place.

3. The altered condition of the uterus itself,
which, increasing in size, ceases to be a pelvic
organ, and rises into the abdomen, which in con-
sequence becomes enlarged and prominent, and a
corresponding change is effected in the state of
the umbilicus ; while at the same time certain
alterations take place in the os and cervix uteri,
affecting their form, texture, &c. which we can
recognize by touch.

4. The contents of the uterus so enlarged ; the
presence of a foetus therein, and its motions,
which we endeavour to ascertain by manual ex-
amination, both externally through the abdominal
parietes, and internally per vaginam ; and also
by the adoption of auscultation to discover the
pulsations of the fetal heart and the placentary
sound.

5. Certain organized substances may, under
suspicious circumstances, be discharged from the
uterus, by a proper examination of which we may
be enabled to determine whether they are the
product of conception, and of course proofs of
pregnancy.

6. After death we may be called on to make an
investigation for a like purpose, and, by examina-
tion of the uterus and its appendages, to deter-
mine the question of actual pregnancy, or of pre-
vious impregnation. We shall notice the princi-
pal of these signs in detail.

Suppression of tlie Menses.— This is one
of the symptoms of pregnancy our investigation
of which must almost always be encumbered with
this difficulty, — that our knowledge must be de-
rived from the statement of the female herself, nor
can we have in general any certain means of dis-
proving or confirming her assertion. It is more-
over a circumstance which, notwithstanding its
general subjection to a fixed law, has been fully
proved by experience to be liable to very many
exceptions and deviations.

We are indeed quite justified in adopting as a
general rule that in healthy women, whose men-
struation has been established and continued regu-
lar, and who are not nursing, conception is fol-
lowed by a suppression of the menstrual discharge
at the next return of its period ; but then this
suppression may not so occur, and on the other
hand it may happen from a variety of other causes
altogether unconnected with pregnancy : for these
reasons we ought, whenever we come to consider
this sign, to weigh very fully all the possible cir-
cumstances of the individual case before us, and
view it in relation to the various exceptions which

PREGNANCY AND DELIVERY, (SIGNS OF)

661

experience has from time to time shown to exist.
Thus we must recollect that cases have occurred
in which conception took place previous to men-
struation. One instance of this happened under
our own observation, and a very remarkable one
is mentioned by Morgagni in these words : " I
was acquainted with a maiden of a noble family
who married before menstruation took place, though
the menses had been expected for some years;
nevertheless she became exceedingly fruitful. We
were the less surprised at this circumstance be-
cause the same thing had happened to her mo-
ther."* Frank had a patient who gave birth to
three children without ever having menstruated
or had lochial discharge, and he saw three others
who never had the catamenia, but were not defi-
cient in lochia after delivery. (De Morb. Horn.
Curand. art. Amenorrhcea.) A woman, 55 years
of age, very lately resided in Cornwall, who had
borne several children and always enjoyed good
health, but had never menstruated or had vicarious
discharge of any kind.f Capuron quotes several
cases of fecundity without menstruation, (Med.
Leg. relat. a l'accouchement, &c. p. 96-7,) and
Fodere assures us of the fact. (" J'ai eu occa-
sion de m'assurer completement de ce fait." torn.
L p. 395.)

Some women are very irregular in the returns
of their menstrual periods, having them prolonged
much beyond the usual interval. The writer
lately attended an unmarried woman of 40 af-
fected with polypus uteri, who assured him that
the returns of the catamenial discharge with her
had been frequently deferred for more than six
months without any accompanying circumstances
of ill health : instances of habitual suppression
for shorter periods are frequently met with.
Zacchias mentions that he attended a patient who
used to menstruate regularly, but who never con-
ceived until the discharge had been suppressed
for three or four months previously. A case
somewhat similar is related by Mauriceau, (Ob-
servation 556, torn. ii. p. 461,) who very justly
remarks that such cases not unfrequently give
rise to the supposition of protracted gestation.

At the period which is usually denominated the
change of life, it is very usual to have the
menses suppressed for two or three months and
then return profusely, giving rise to the idea of
pregnancy and abortion, both suppositions being
equally unfounded.

On the other hand cases occasionally occur in
which women have conceived after menstruation
had apparently ceased.

In married women, and others who have been
incurring the risk of pregnancy, suppression may
arise from a variety of causes altogether inde-
pendent of conception, such as different forms of
disease, exposure to cold and hardship, mental
emotions, particularly that of fear, the effects of
which latter we have had an opportunity of ob-
serving in very numerous instances, in some of

* De Causis et Sedibus Morborum, Epis. xlvii. 3. See
also Fodere, Med. Leg. torn. i. p. 395, and torn. ii. p. 437.
Desormeaux, Diet, de Med. torn, x, p. 393. And Mauri-
ceau, Obs. 393, vol. ii. p. 326.

t " Ego habui amicain laudahilis temperamenti et
complexionis qua? octo filios tulit consequenter, id est
ornni anno iinnm ; nunquain tanien visa una gutta san-
guinis menstrui." Low, p. 523.

3 F

our prisons, where young women constantly apply
to the physician in consequence of their menses
being suppressed, which they very often, and ap-
parently with great reason, ascribe to the alarm
and terror which they suffered when arrested and
carried to prison.

A woman may conceive while she is nursing,
without any previous return of the catamenia,
which, however, very usually happens in such
cases, as observed by Denman.

Here, then, we have a variety of cases in which
the absence of the menstrual discharge could not
be made a means of diagnosis, or, if assumed as
affirmative of pregnancy, would lead us into abso-
lute error.

It now remains to view the matter in another
light, and inquire, how far the presence of the
catamenia can be considered as evidence that the
woman is not with child.

We have met with several instances of menstrua-
tion occurring once after conception, and at this
moment we are in attendance on two ladies to
both of whom it happened ; and one of them who
has borne three children and is now a fourth time
pregnant, assured us that she always knew when
she had become with child by the unusual profuse-
ness of the next period. This is distinctly taken notice
of by Johnson, who says, " some have the menstrua
copiously at the first period." (System of Midwife-
ry, p. 100.) A diminution in the quantity under
similar circumstances has, however, been more fre-
quently observed. " I have seen," says Desor-
meaux, " some cases in which the appearance of
the menses in small quantity and at an unusual
time, was almost a certain sign of conception."
(Diet, de Med. vol. x. p. 394.) A similar remark
is made by Pjzos, Stein, and Gardien. (Traite
des Accouchernens, vol. i. p. 489.) An interesting
case, which confirms this remark, is detailed by
Dr. Dewees. (Compendium of Midwifery, p. 165.)
A gentleman, who had been obliged to absent
himself from his family for many months, returned
secretly and spent one night at home with his
wife, in consequence of which she conceived, as
the event proved, although the regular return of
her catamenia a week afterwards in their usual
quantity, had led her to expect that she had escap-
ed with impunity.

Again, there are individuals who menstruate
with regularity for more than one period after
conception. " It is well known," says Burton,
(New System of Midwifery, p. 285,) " by experi-
ence, that the menstrual discharge sometimes con-
tinues in its usual regularity for two or three
months after conception without any dangerous
consequences." Instances of this are not at all
unfrequent, and are quoted by all who have
written at large upon this subject^ It has been
asserted as an objection, that these discharges
are not truly menstruation ; but the discussion

+ Capuron, Med. Legale, p. C>3. Belloc, Quest. Med. Leg.

p. 02. Mauriceau, vol. i. p. 72, 155. Dewees, Compemli ,

p. 93, et seq. Desormeaux, Diet, de Med. vol, x. p. 394.
Gardien, vol. i. p. 489. Gooch, Diseases of Females, pp.
902-3. Van Swieten, Commentaries, vol. xiii. pp. 379,
468. Bech, Principles of Med. Jurisp. p. 76. Van Swieten
supposes such discharges do not proceed from the same
source as the regular menses, "but from the vessels
distributed about the vagina and the external surface o*
the neck of the womb." A similar opinion is maintain
ed by Hoffman, Med. Ration, et. Syst. torn. iv. part $■
cap. C23, and by Frank.

662

PREGNANCY AND DELIVERY, (SIGNS OF)

of that question does not concern us here. We
have only to consider whether there does not fre-
quently, during pregnancy, take place a coloured
discharge from the vagina, so closely resembling
menstruation in its periods, quantity, and duration,
that neither the woman herself nor the medical in-
quirer shall be able to detect any difference between
them ; and of this we must declare with Dewees
and Gooch, " there can be no doubt."

In still more rare instances, of which we have
ourselves never met one, but which are recorded
by writers of credit, women have continued to
have these discharges through nearly the whole
period of pregnancy. (Fodere, vol. i. p. 437.)
Dewees mentions an instance in which this hap-
pened to both mother and daughter, (Dewees,
Comp. Mid. p. 96,) who were in the habit of
menstruating up to the seventh month. " On a
vu," says Gardien, " chez des femmes jeunes et
plethoriques l'evacuation menstruelle continuer
pendant les trois ou quatre premiers mois, quelque-
fois meme pendant tout le cours de la grossesse."
(Traite des Accouchemens, torn. i. p. 489).

The last, and perhaps most remarkable excep-
tions to the general rule, to which it appears neces-
sary to allude, are those very singular cases in
which menstruation has either appeared for the
first time after conception, or in which it continued
only during pregnancy. Perfect's eightieth case
(Cases in Midwifery, vol. ii. p. 71) affords a very
satisfactory instance of the former ; and Daventer,
Dewees, and Baudeloque,* furnish us with exam-
ples of women whose habit it was to menstruate
only during pregnancy, and who did so through
the whole period of that condition, though never
at any other time.

There is a source of deception against which we
can hardly guard, and which we know to have
been resorted to by a young woman in one instance.
She apprehended that she was pregnant, but de-
ceived those about her by staining her linen at the
usual periods of menstruation : this completely
lulled the suspicion of her friends for two months,
but in the third a circumstance was discovered
which proved that she had incurred the risk of
pregnancy, and the writer was requested to see
her. On looking at her breasts, the areolae were so
distinct, and exhibited their proper characters so
perfectly, that he felt persuaded she was preg-
nant ; and perceiving that her breasts were marked
with the silvery lines observable on parts formerly
much distended, he told her his opinion that she
was then with child, and moreover that she cer-
tainly had been so before. This completely took
her by surprise, and she acknowledged that she
had given birth to a child about two years before,
and had suffered much from the distension of her
breasts during pregnancy. The event also proved
that we were correct in supposing her pregnant
then, as she was afterwards in proper time deliver-
ed of a full-grown child.

Belloc, p. 65, takes notice of this kind of im-
position, which he informs us was attempted on
himself by a girl three months advanced. " II
faut alors exiger que les parties soient Iavees avec
de l'eau tiede ; si le sang ne reparait pas, le cas

* Daventer, Novum Lumen Art. Ohst. cap. xv. p. 54.
Dewees, Comp. Mid. p. 97. Baudelocque, Art. d'Accouche-
merit, vol. i. p. 197-8. Ed. 1822.

est suspect." (Capuron, p. 81. See also Beck,
p. 76, and Mahon, Med. Legale, vol. i. p. 153.
Fodere, torn. i. p. 438.)

We should not forget that there are cases oc-
casionally met with, in which suspicions arise in
connection with a non-appearance of the menses,
the elimination of the discharge being prevented
by some adventitious structure or imperforate state
of some of the natural parts, especially of the
hymen. In such a case the secretion takes place,
but being prevented from leaving the body, accu-
mulates within, distending the vagina and the
uterus, and so giving rise to several of the sym-
pathies usually accompanying pregnancy. We
had very lately an instance of this under our care
in a girl of 17, who between the age of 15 and 16
began to exhibit the signs of puberty. When we
saw her, suspicions had been excited of her being
pregnant. The abdomen was enlarged, and the
uterus could be felt as high as the umbilicus, the
breasts were painful, and she had occasional
vomiting, and pain in the back and along the
thighs. Complete inability to pass water was
the cause of our being requested to see her, and
on hearing the above detail of symptoms, we con-
fess we had our suspicions too, but did not ex-
press them : on attempting to pass the catheter
we encountered a soft elastic tumour protruding
from the external parts, displacing the urethra,
and concealing its orifice. This rendered a closer
examination necessary, which detected the hymen
attached completely all around, and distended by
fluid from within : having relieved the bladder,
we punctured the opposing membrane and gave
exit to about three pints of a dark chocolate-
coloured fluid, without smell and uncoagu-
lated.

Frank (Epitome de Morbis Hominum Curan-
dis. Art. Amenorrhma,') mentions two such cases,
in one of which the abdomen was as much en-
larged as at the sixth month of pregnancy, and
the girl herself thought that she felt a foreign body
in the uterus, which, however, was found to con-
tain five pounds of a dark and thick blood, with-
out any offensive odour: in the other case the
girl was believed to be with child, and in con-
sequence suffered temporary loss of reputation,
but the hymen was found imperforate, and, when
punctured, gave passage to several pints of blood.

Madame Boivin (Memoire sur les Hemorrha-
gies internes de l'Uterus, p. 73,) has collected the
details of ten such cases, among which are two
much in .point. In one from Denman the girl
was submitted to examination from a belief that
she was with child : the uterus was as high as
the navel, and contained no less than four pounds
of blood of the colour and consistence of tar. (In-
troduction to Midwifery, p. 87. 5th ed.) The other
case occurred to Dr. Macauly, in a young woman
of 19, whom he supposed to be not only pregnant,
but in labour, as she had pains, and he felt what
he thought was " the membranes with the water
pushing low down." (Smellie's Cases in Mid-
wifery, vol. ii. p. 15.) On puncturing the hymen
there came away two quarts of thick black blood.
In a case of obstruction related by Dr. Dewees,
he mentions that he was fully impressed with the
belief that pregnancy existed, as he could dis-
tinctly feel the enlarged uterus, and even thought

PREGNANCY AND DELIVERY, (SIGNS OF)

663

he felt the motion of a foetus. (Essays on several
subjects, &c. p. 337.)

Such exceptions should always be taken into
account, to guard us against error, but on the
other hand absence of the menstrual discharge in
an otherwise healthy woman is always a circum-
stance of great importance, concerning which the
remark of Belloc is deserving of great attention.
« When a female," says he, " experiences sup-
pression along with other symptoms of pregnancy,
we may consider her situation as yet uncertain,
because these signs are common to amenorrhcea
and pregnancy. But if towards the third month,
while the suppression continues, she recovers her
health, and if her appetite and colour return, we
need no better proof of pregnancy. Under other
circumstances her health would remain impaired,
and even become worse." (Cours de Med. Le-
gale, p. 60.)

Nausea and vomiting. — In general, when
pregnancy has occurred, the stomach becomes
irritable, in consequence of which the woman is
distressed with nausea and vomiting, especially
in the early part of the day : in some this com-
mences almost immediately after conception. We
had once a lady under our care, in whom there
was reason to believe it began the day after mar-
riage, and the date of her labour corresponded to
such a belief: most frequently it occurs for the
first time between two and three weeks after con-
ception, in others not for as many months, and in
some not at all : of this we have now seen several
instances.

On the other hand, irritability of the stomach
may occur from a variety of causes totally inde-
pendent of pregnancy, and connected with disease
or disordered function, such as suppressed men-
struation, so that we must be slow to draw an in-
ference merely from the presence of such a symp-
tom : at the same time a proper degree of inquiry
will generally enable us to distinguish between
the two kinds. The vomiting of pregnancy is not
accompanied by any other symptom of ill health;
on the contrary, the patient feels perhaps as well
as ever in other respects, and may even take her
meals with as much appetite and relish as at other
times, but while doing so, or immediately after,
she feels suddenly sick, and has hardly time to
retire when she rejects the whole contents of the
stomach, and presently feels quite well again : in
some instances, however, the woman is distressed
by a perpetual nausea, and in a few rare cases
vomiting has been so excessive as to endanger the
life of the woman from inanition. (See Mem.
Lond. Med. Soc. vol. ii. p. 125. Med. Chir. Trans.
vol. iii. p. 139. Ashwell on Parturition, p. 194.)

Salivation. — By an extension of the sympa-
thetic irritation which in the stomach causes nau-
sea and vomiting, the salivary apparatus is in some
persons excited to such a degree as to produce
complete and copious salivation. This fact was
expressly noticed by Hippocrates as one among
the symptoms of pregnancy, (the passage is quo-
ted by Van Swieten, vol. xiii. p. 371,) and has
been observed by many others since. (See Gar-
dicn, vol. ii. p. 32. Burns, p. 237.) Dr. Dewees
records a well-marked instance of the kind, (Com-
pendium of Midwifery, p. 115,) and the writer
of this article was consulted about another in

which it occurred profusely in two successive
pregnancies, but ceased immediately on delivery.
Affections of tl»e Mammse. — When concep-
tion has taken place, and the menses have been
suppressed for one or two periods, the woman ge-
nerally becomes sensible of an alteration in the
state of the breasts, in which she feels an uneasy
sensation of throbbing, or of stretching fulness
accompanied by tingling pains felt about the cen-
tre of them and in the nipple. The breasts them-
selves grow sensibly larger and more firm; a circle
around the nipple becomes altered in colour and
in structure, constituting the areola ; and as ges-
tation advances, milk is secreted. But there is
considerable variety in the period of gestation at
which these changes may occur, as well as in the
degree of their development ; for while in some
instances they may be recognised very soon after
conception, in others they are hardly perceptible
until gestation is far advanced, or even drawing
towards its termination. In general, however, we
may expect to find these sympathies (except the
secretion of milk) established when two months
of pregnancy have been completed ; but any opin-
ion deduced from their existence must be modified
by several considerations. We must recollect that
these changes of form and size may be the result
of causes unconnected with conception. In many
women the breasts enlarge merely in consequence
of marriage and the habits thence arising ; in
others it may happen from the person becoming
fat ; it may be caused by accidental suppression
of the menses, or their retention by an imperforate
hymen, (see cases noticed under the preceding
section,) or by any cause capable of distending the
uterus. The enlargement from pregnancy may,
however, in general be distinguished from that
produced merely by fat, by the greater firmness of
the breast, which also feels knotty and uneven
when pressed by the hand. With some women
of an irritable habit, swelling and pain of the
breasts accompany each return of the catamenia,
especially if they are the subjects of dysmenor-
rhoea ; but under such circumstances the tension
and uneasiness suhside in two or three days,
whereas that caused by pregnancy continues to
increase, except when the ovum happens to be
blighted, in which case the breasts become flaccid,
and lose the characters which they had previously
assumed. On the other hand it not unfrequently
happens that in women of weakly and delicate
constitution very little change can be observed in
the breasts till pregnancy is far advanced. Gar-
dien (Traite des Accouchemens, torn. i. p. 490)
asserts that the swelling of the breasts is not ob-
servable in women who menstruate during the
early months of pregnancy ; and Mahon (Mede-
cine Legale, torn. i. p. 151) makes the same ob-
servation. It should also be recollected that such
a condition of fulness of the breasts may be natu-
ral to the individual, or it may take place at the
turn of life, when the menses becoming naturally
suppressed, the person grows at the same time fat-
ter, and the breasts under such circumstances
become full, and are not unfrequently painful, —
which circumstances concurring are often impro-
perly considered in the light of cause and effect,
and irritability of the stomach being at the same
time experienced, the woman believes herself preg-

664

PREGNANCY AND DELIVERY, (SIGNS OF)

nant. There is, however, one of those changes '
which, if carefully observed, is of the utmost value
as an evidence of pregnancy, which, according to
our experience, can alone produce it, — we allude
to the altered condition of the areola.

The Areola* — The alteration which takes
place in that part of the breast which immediately
surrounds the nipple, and is called the areola, ap-
pears to us not to have received that degree of
notice which its importance merits, as being one
of the most certain external indications of preg-
nancy, arising from the operation of sympathy.
On this, however, as on almost all other points
connected with this investigation, a very marked
difference of opinion exists ; for while some sup-
pose, with Denman, that the alteration in the are-
ola " may be produced by any cause capable of
giving to the breasts a state resembling that which
they are in at the time of pregnancy," many
others of equal authority maintain the opinion of
Smellie and William Hunter, who regarded it as
the result of pregnancy only : an opinion in which
we entirely concur, and think we shall be able to
show that much of the discrepancy of opinion on
this subject has arisen from want of sufficient care
in observing and accuracy in describing the essen-
tial characters of the true areola.

Most of those who have noticed this change ap-
pear, from their observations on it, to have attend-
ed to one only of its characters, — namely, its co-
lour, which is, in our opinion, the one of all
others most liable to uncertainty. We should
here, perhaps, except the description by Rcederer,
which is by far the most accurate we have met
with: — " Menstruorum suppressionem mamma-
rum tumor insequitur ; quocirca mammae crescunt,
replentur, dolent interdum, indurescunt : vena?
earum cccruleo colore conspicuse redduntur, eras-
sescit papilla, injlala videtur, color ejusdem Jit
obscurior, simili colore distinguitur discus ambi-
ens qui in latitudinem majorem expandilur, par
visque eminentiis, quasi totidem papillulis, tegi-
lur." (Elem. Artis Obstet. pp. 4C, 47.)

The several circumstances here enumerated at
least ought in all cases to form distinct subjects
of consideration, when we propose to avail our-
selves of the condition of this part as an indication
of the existence or absence of pregnancy. One
other we shall add as equally constant, which is a
soft and moist state of the integument, which, to-
gether with its altered colour, gives us the idea of
a part in which there is going forward a greater
degree of vital action than is in operation around
it; and we not unfrequently find that the little
glandular follicles are bedewed with a secretion
sufficient to damp and colour the woman's inner
dress. We must recollect also that these changes
do not take place immediately after conception,
but occur in different persons after uncertain in-
tervals : we must therefore consider, in the first
place, the period of pregnancy at which we may
expect to gain any useful information from the
condition of the areola.

We cannot speak very positively as to what
may be the earliest period at which this change
can be observed, but we have certainly been sat-
isfied of its existence at the end of the second
month, at which period the change of colour is
by no means the most distinct character to be ob-

served, but the turgescence of the nipple and the
development of the little glandular follicles are the
objects which should principally engage our atten-
tion ; the colour at this period being in general
little more than a deeper shade of rose or flesh
colour slightly tinged with a yellowish or brown-
ish hue. During the progress of the next two
months the changes in the areola are in general
perfected or nearly so, and it then presents the
following characters: a circle around the nipple,
whose colour varies in intensity according to the
peculiar complexion of the individual, being ge-
nerally much darker in persons with black hair,
dark eyes, and sallow skins, than in those of fair
hair, light-coloured eyes, and delicate complexions.
The extent of this circle varies from a diameter
of an inch to an inch and a half, and increases in
some as pregnancy advances, as does also the
depth of colour.*

In the centre of this circle the nipple is ob-
served partaking of the altered colour of the part,
and appearing turgid (Crassescit papilla, inflata
videtur, Rcederer,) and prominent ; and the part
of the areola more immediately around the base
of the nipple has its surface rendered unequal by
the prominence of the glandular follicles, which,
varying in number from twelve to twenty, project
from the sixteenth to the eighth of an inch ;| and,
lastly, the integument covering the part is ob-
served to be softer and more moist than that
which surrounds it, and the breasts themselves are
at the same time observed to be full and firm, at
least more so than was natural to the person pre-
viously. Such we believe to be the essential
characters of the true areola, the result of preg-
nancy, and that, when found possessing these dis-
tinctive marks, it ought to be looked on as the
result of that condition alone, no other cause
being capable of producing it.

But we cannot stop here and rest satisfied with
the knowledge of the distinctly affirmative part
of the<question only, without also looking to cer-
tain circumstances which will most materially
modify the certainty of our conclusions.

In the first place, then, pregnancy may exist,
and the areola remain deficient in at least one of
its usually essential characters, and that, the one
too generally supposed to be its most important
distinctive mark, — namely, the colour. Within
the last few months the writer saw two well-
marked instances of this ; one in a lady of very
fair skin, blue eyes, and light hair ; the other in a
lady of fair skin, but with black hair and very
dark-brown eyes : in both, the colour of the areola
was so slight as hardly to differ from that of the
surrounding skin, and certainly was less distinct
than we have frequently seen it in the virgin, but
all the other changes which we have enumerated
were well developed in both.

Again, we must recollect that a woman may be
presented to us for an opinion, who having per-
haps very recently miscarried, her breasts may
exhibit all the true characters of the areola, com*

* We lately saw the areola; on the breasts of a youns
woman, of very dark complexion, at the time of labour ;
they were of a very deep shade, and exceeded three
inches in diameter. In negro women the areola; is al-
most jet black.

t For a very full account of the structure of this part
of the breast, see Meckel's Anatomy, vol, iii. p. 05*2.

PREGNANCY AND DELIVERY, (SIGNS OF)

665

bined with several other circumstances really in-
dicating a state of pregnancy ; but if we do not
use great caution in giving our opinion, it will in
such a case appear falsified by the event, although
really correct. In nurses, also, the characters of
the areola are kept up and continue in a state of
considerable perfection.

Now, as to the colour alone, we may adopt this
belief— that where we find it of a deep and dark
brownish shade, forming a circle round the nip-
ple, even though unaccompanied with the other
changes natural to the part, it affords very strong
presumptive evidence of a former state of preg-
nancy ; but when so accompanied, it is a mark
of great value, and in our experience has never
yet deceived us : and we certainly never saw any
other condition of the part produced by disease
which could possibly be mistaken for it. At the
same time it should be observed that the areola
does not always, in pregnant women, present all
the characters we have described as belonging to
it. We have seen it at the time of labour pre-
senting the dark circle alone without the promi-
nence of the glandular follicles, but we never saw
an instance of their development, as already de-
scribed, without the concurrence of pregnancy :
their absence, therefore, ought not to decide our
opinion against the existence of that condition,
though their presence would be with us a very
convincing proof of previous conception : we should
also be cautious in being influenced by the condi-
tion of this part, before the period at which its
characters are in general developed and perfected,
as already described.

A case which occurred recently, while the writer
was lecturing on this subject, afforded a very
satisfactory illustration of the value to be attached
to this evidence of pregnancy. A young woman
came a considerable distance from the country to be
admitted into Sir P. Dunn's Hospital, the medical
men in the country not having succeeded in af-
fording her relief or restoring her health. A very
prominent symptom of complaint was amenorrhcea
of four months' duration, accompanied by uterine
pain, want of appetite, &c. A very intelligent
pupil suggested to the writer, after lecture, that he
thought we must be mistaken in our account of
the subject, as there was then in the house an
unmarried patient, labouring only under amenor-
rhcea, whose breasts presented the areola, with all
the characters we had described. We immedi-
ately saw her, and on examining her breasts we
pronounced at once that there was the true areola
of pregnancy — an announcement which she heard
with the most fiery indignation, declaring that
she would submit to any thing rather than lie
under so calumnious an aspersion, and even con-
senting to permit an examination per vaginam,
when proposed to her as the only thing which
could save her character. On making the exam-
ination we were distinctly able to feel the foetus
by ballottement. She afterwards acknowledged
that she had been " walking by moonlight with a
young man who had a great regard for her."

If a woman has been pregnant before, and par-
ticularly if she suckled or is nursing, it may
greatly embarrass our investigation. The colour
of the areola depends on the deposition of an
actual pigment between the cuticle and subjacent

Vol. III. — 84 3i*

skin. Of this we have satisfied ourselves by mak-
ing preparations of the part, one of which, show-
ing this very distinctly, is preserved in the writ-
er's museum. In some persons of fair complex-
ion especially, this colouring matter is removed
in some time after delivery, and the breast resumes
its virgin appearance ; in others the colour remains
permanent, and there is even a slight prominence
of the little glands to be observed sufficient to de-
ceive an inexperienced eye. It is also to be recol-
lected that it is peculiar to some young females to
have the areola assume a shade of colour resem-
bling that which we so frequently observe around
or under the eyes.

The conclusion which Gooch came to on this
subject was, that " darkness of the areola rarely
depends on other causes (than pregnancy), and
that, when it exists, it may generally be looked
upon as a sign either that the patient is pregnant
or has been so formerly." (Account of Female
Diseases, p. 205.) It seems remarkable that so
accurate a writer as Gooch should have confined
his description to the colour alone. Smellie's
account is more accurate, and he considers it as
the result of pregnancy only. (Treatise on Mid-
wifery, vol. i. p. 191.) William Hunter has not,
as far as we are aware, left us any description of
what he considered the true areola, but he pro-
fessed such faith in this sign as to assert that he
could always judge by it whether a woman was
pregnant or not, and on one occasion gave a
remarkable proof of his accuracy. Happening to
examine the breast of a subject brought to him
for dissection, he immediately pronounced from
the appearance of the areola, that the woman had
died pregnant : however, on examining the geni-
tals, the hymen was found entire, but Hunter per-
sisted in his opinion, declaring that the areola was
more convincing than the presence ot the hymen.
The body was opened, and an impregnated uterus
confirmed the justice of his assertion.

Since writing the above, a case has come under
the writer's observation which greatly strengthens
his reliance on this sign. We were requested to
see a patient affected with menorrhagia, arising,
as was supposed by her medical attendant, from
disease of the uterus. The history of the case
was briefly this : — the patient was near forty years
of age, and had borne five children ; in the May
preceding she had miscarried in the fifth month,
and the placenta was retained eight weeks. In
July she returned to her husband's bed, but her
health continued feeble, and she had at irregular
intervals of one, two, or three weeks, profuse and
foul uterine discharges, but had none of the usual
symptoms which used to accompany her preg-
nancy in former instances, so that she utterly dis-
believed in the possibility of her being then with
child. For two months previous to our seeing her,
her fears had been much augmented by the pre-
sence of a tumour in the centre and lower part of
the abdomen, which was almost constantly the
seat of severe pain ; and she had still the foul
uterine discharges. Under such circumstances
we entertained but little idea of the existence of
pregnancy, but on seeing her breasts we were re-
joiced to find them full, and exhibiting a very
perfect example of the true areola, with all its
characters so well marked that we did not hesitate

666

PREGNANCY AND DELIVERY, (SIGNS OF)

to declare our belief that she was pregnant, though
every other circumstance conspired to render it
more than improbable. The uterine tumour felt
as hard as cartilage, and knotty all over its sur-
face, was very painful, and exquisitely tender to
the touch; but the condition of pregnancy was
put beyond a doubt in less than a week after-
wards by her expelling a fetus of five months,
and along with it its placenta quite perfect, and
afterwards several pieces or fragments of a sub-
stance resembling decidua, mixed up with what
appeared to be portions of placenta and membrane,
but altered in their texture and consistence so as
to possess the toughness of leather.

Could these have remained in utero from the
time of the former miscarriage 1 They certainly
were totally different from any of the parts of
undoubtedly recent formation. The expulsion of
them went on for fully half-an-hour after the rest
of the process was completed, and portions con-
tinued to be discharged for some days ; after which
the patient recovered well, and at the end of a
month there was not a trace of uterine irritation
or discharge, and she considered herself in better
health than she had been for a year before.

[But although the state of the areola constitutes
one of the best single proofs of the existence of
pregnancy, it is obvious, that for accurate discri-
mination, it is necessary to be aware of the hue,
in each particular case, in the unfecundated state.
Moreover, instances are on record of a well-
marked areola in persons who were not pregnant,
as well as of an entire absence of areola in those
who were. Dr. Guy (Principles of Forensic
Medicine, p. 72, Lond. 1843) states, that Dr.John
Reid showed him a case of enlarged mamma?,
with distinct areolae and mucous follicles, in a
female, who had never been, and was not at the
time, pregnant. (See Dr. Reid, in Lond. Lancet,
Dec. 22, 1838.) The writer has had numerous
opportunities for appreciating the insufficiency of
these evidences when taken singly.]

Mil k in the Breasts* — The secretion of milk
in the breasts is popularly esteemed as an infalli-
ble proof of pregnancy, but nothing can be more
erroneous than such a presumption, which is con-
tradicted by facts, recorded on the best authority,
proving the possibility of its formation under cir-
cumstances totally independent not only of preg-
nancy but even of intercourse, and at ages ante-
cedent to puberty, and after the cessation of the
generative faculty.

Perhaps the most remarkable case on record is
that of the little girl of Alen^on, who was produced
by Baudelocque (Art d'Accouchement, torn. i. p.
188. ed. 1822) before the Royal Academy of Sur-
gery on the 16th Oct. 1783, where she milked
her breasts in presence of the members. This
girl was only eight years old, and the secretion
was caused by the repeated application of an in-
fant which her mother was suckling at the time.

Belloc (Cours de Med. Legale, p. 52) mentions
a servant girl, who, being obliged to have sleeping
in her chamber an infant which was being weaned,
and which by its crying disturbed her rest, be-
thought her of giving it her breast to appease its
clamour ; and the result was that in a short time
she had milk enough to satisfy the child. Fodere
mentions having seen a lady, who, in order to

escape being imprisoned, pretended that she was
a nurse when she was not, and she succeeded in
producing milk from her breasts. (Traite de Med.
Leg. vol. i. p. 440.)

The same phenomenon has occasionally occurred
in women advanced in years. The following
case is related by Mr. George Semple. (North of
England Med. and Surg. Journ. vol. i. p. 230.)
" Mrs. B. wife of John B reward, Simpson Green
near Idle, aged forty-nine, the mother of nine
children, the youngest of whom is twelve years
old, lost a daughter-in-law about a year ago, who
died in about a fortnight after giving birth to her
first child. On her death, Mrs. B. took charge of
the infant, a little puny, sickly baby. The child
was so fretful and uneasy, that Mrs. B. after several
sleepless nights was induced to permit the child to
take her nipple into its mouth. In the course of
from thirty to thirty-six hours she felt very unwell,
her breasts became extremely painful, considerably
increased in size, and soon after, to her utter asto-
nishment, milk was secreted and poured forth in
the same abundance as on former occasions after
the birth of her own children. The child, now a
year old, is a fine, thriving, healthy girl, and only
a few days ago I saw her eagerly engaged in ob-
taining an apparently abundant supply of healthy
nourishment from the same fountain which nearly
twenty years ago poured forth its resources for the
support of her father." Several other instances
still more remarkable are on record. (See Smith,
Forensic Medicine, p. 484 ; Beck, p. 75, note ;
Philos. Trans, vol. ix. and vol. xxxi. Capuron, p.
126.)

[The writer, in another work, (Human Phy-
siology, 5th edit. ii. 437, Philad. 1844,) has re-
ferred to many such cases ; and to several occur-
ring in the male. One of the most striking was
communicated to him by Professor Hall, of the
University of Maryland. The subject of it — a
coloured man, 55 years of age — was exhibited to
the obstetrical class in the year 1827. He had
large, soft, well-formed mamma?, rather more coni-
cal than those of the female, and projecting fully
seven inches from the chest, with perfect and large
nipples. The glandular structure seemed to the
touch to be exactly like that of the female. This
man, according to Professor Hall, had officiated
as wet-nurse, for several years, in the family of
his mistress; and he represented, that the secretion
of milk was induced by applying the children,
entrusted to his care, to the breasts during the
night. When the milk was no longer required,
great difficulty was experienced in arresting the
secretion. His genital organs were fully deve-
loped.]

Another source of deception might arise from
the fact that women sometimes after nursing re-
tain milk in their breasts for a great length of time.
The writer is at present in attendance on a lady,
who, after weaning her last child, which she
nursed for fifteen months, retained for nearly
three years so much milk in her breasts that she
was obliged to adopt precautions to prevent her
dress being wet by it. The child is now five
years old, and she can still express a little milk
from the nipples ; she has not conceived since the
birth of that child, but has always menstruated
regularly. Dr. Francis, in his edition of Den-

PREGNANCY AND DELIVERY, (SIGNS OF)

667

man, (Francis's Denman, p. 229,) mentions, on
the authority of Professor Post, that " a lady of
this city (New York) was almost fourteen years
ago delivered of a healthy child ; since that time
her breasts have regularly secreted milk in great
abundance, so that, to use her own language, she
could at all times easily perform the office of a
nurse. She has uniformly enjoyed good health,
is now about thirty-five years of age, and has
never proved pregnant a second time, nor had any
return of her menses."*

» We see," says Fodere, " women who have
milk in their breasts from one pregnancy to an-
other, and even for whole years together, although
they have not nursed." And he adds that he has
had repeated opportunities of observing the secre-
tion of milk take place on the cessation of the
catamenia at the turn of life, of which fact he
quotes two striking instances. (Medecine Legale,
torn. i. p. 440-1 and note.)

It has been already remarked that morbid causes
capable of distending the cavity of the uterus may
excite the sympathetic changes in the breasts, and
it appears that even the secretion of milk may be
thus induced, as happened in two cases mentioned
by Frank, where it occurred in one in consequence
of physometra, (Vol. iv. p. 50. French translation,)
and in the other from hydrometra. (P. 182, ibid.)
Notwithstanding, however, the exceptions esta-
blished by such facts as the foregoing, we should
attach great consequence to the presence of milk
in the breasts, and if found in connection with
others of the rational symptoms of pregnancy, it
ought to go a great way in confirming our belief
in the existence of that condition, especially if
occurring in a woman who had never, borne a
child or been pregnant before.

Quickening, and motions of the foetus.
— By quickening is generally understood the first
sensation experienced by the mother, of the life
of the child within her womb ; and a notion is
very generally entertained in society that it is on
the occurrence of this phenomenon that the child
becomes for the first time endowed with life.

It appears very unaccountable that such an
absurdity should have received not merely the
sanction of popular belief, but that it should form
the grounds of law in most civilized countries, our
own not excepted ; for the English law adopts
the distinction, and considers the foetus before
quickening as inanimate, or merely as portio vis-
cerum matris, but as afterwards endowed with
life ; and on this principle acts in the award of
punishment for crime. Thus in a law enacted in
1803, called the Ellenborough Act, it is ordained
that if any person shall wilfully or maliciously
use means to cause or procure abortion in a
woman not quick with child, he shall be declared
guilty of felony, and may be fined, imprisoned,
set in the pillory, publicly whipped, or transported
for any term not exceeding fourteen years ; but
if the offence be committed after quickening, it
shall be punishable with death.f In like manner,

* The last mentioned particular in this case is in ac-
cordance with the aphorisms derived from Hippocrates:
K mulier, qua: nee pregnans nee puerpera est, lac habet
ci menstrua defecerunt," which is, however, shown to be
incorrect by the perfect regularity of the catamenia in
the case under the writers observation.

t'fliis law has been, a*d I think justly, designated as

when a woman pleads pregnancy in bar or stay
of execution, the court orders an investigation as
to whether she is quick with child or not, for be-
ing merely pregnant will not be sufficient ;t and
if she be pronounced quick with child, execution
shall be stayed until either she is delivered, or
proves by the law of nature not to have been with
child at all. In France the law is at once more
merciful and more consistent with the laws of na-
ture and with common sense, when it provides
that " if a woman condemned to die states that
she is pregnant, and if it be proved that she is so,
she shall not suffer punishment until after her
delivery."^

It is perfectly monstrous and absurd to suppose
for a moment that the foetus does not enjoy vitality
from the first moment of its existence, and of
course long before the sensation of quickening is
felt by the mother ; and if it be asked why no in-
dications of life are given before the time at which
quickening generally takes place, the obvious
answer is, that the absence of any consciousness
on the part of the mother relative to the motions
of the child is no proof whatever that such mo-
tions do not exist. [| Of this fact the writer can
speak with certainty. A married lady, who men-
struated for the last time on the 10th of Novem-
ber, came to Dublin in March, on the 21st of
which month a consultation was held to determine
whether she was labouring under a disease of the
womb or not, as she had been previously assured
by her medical attendant that she could not be
pregnant because she had not sick stomach, nor
felt the child. On examination the writer dis-
tinctly felt through the abdominal parietes the
limbs of the foetus in motion, as did also Mr.
Cusack and Dr. Marsh, and yet the lady herself
had no consciousness whatever of any such sensa-
tion, nor did she quicken till the second week of
the following month, April, and was delivered of
a healthy boy on the 9th of August. 1

In attempting to make a knowledge of this
phenomenon available in any inquiry as to the
existence of pregnancy, even where there cannot
be supposed any intention or motive on the part
of the woman to deceive, we obviously labour un-

immoral, unjust, and irrational ; as tempting to the per-
petration of the same crime at one time which at an-
other it punishes with death ; while in the words of the
admirable Percival, "To extinguish the first spark of
life is a crime of the same nature both against our
Maker and society, as to destroy an infant, a child, or a
man ; these regular and successive stages of existence
being the ordinances of God, subject alone to his divine
will, and appointed by sovereign wisdom and goodness
as the exclusive means of preserving the race and multi-
plying the enjoyments of mankind." — Percival's Works
vol. ii. p. 430, 1.

J " Here again the law of the land is at variance
with what we conceive to be the law of nature ; and it
is at variance with itself, for it is a strange anomaly
that by the law of real property, an infant en ventre s'a
mere may take an estate from the moment of its concep-
tion, and yet be hanged four months afterwards for the
crime of its mother." Paris and Fonblanque, vol. iii.
p. 141, note.

§Code penal, art. 27. See Fodere. torn. i. p. 428. See
cases already detailed under the first section of this
article.

|| Vide Beck's Medical Jurisprudence, p. 137. Gardien,
Traite des Accouchemens, torn. i. p. 508.

IT It may be observed here that the facts of this case
are completely in opposition to the explanation of
quickening given by Dr. Royston and others, who sup-
pose it to be coincident with, and resulting from, the
sudden ascent of the uterus out of the pelvic cavity.

668

PREGNANCY AND DELIVERY, (SIGNS OF)

der this disadvantage, that except we are at the
time able to feel the motions of the child, we can
have no evidence except her statement as to the
fact of quickening or otherwise ; and nothing is
more certain than that she may be completely
mistaken on both sides of the question. We have
just mentioned a case in which motion of the
child perceptible to the hand of another was not
felt by the mother ; and a second instance of the
same kind has occurred to us lately in the wife
of a medical friend. On the other hand, the ex-
amples of women who have supposed and firmly
believed that they had quickened when no such
thing had occurred, are numerous even to no-
toriety. We remember being some years ago
called in great haste to see a lady, the mother of
seven children, who was said to be in premature
labour at seven months and a half, accompanied
with hemorrhage. On our arrival, her husband,
who was a physician, mentioned among other
things that she had quickened at four months and
a half, and had from that time continued to feel
the child as distinctly as in any of her former
pregnancies, adding that he had himself repeatedly
recognised its movements also ; on examination,
however, we could discover no child in utero, and
the case terminated in the expulsion of a few
coagula from the uterus without any foetus what-
ever. We do not, however, mean to have it in-
ferred that we should not pay any attention to
the statements of married women on this subject :
on the contrary, we should attach great value to
the assertion of a person who has already, and
perhaps repeatedly, experienced the sensation,
and has at the same time no conceivable reasons
for wishing to deceive ; but for the reasons already
stated, we cannot yield implicit credence to such
representations , they may be mistaken, or they
may have strong and powerful motives to misre-
present, known only to themselves. In cases of
criminal, or even ordinary legal investigations,
there is always a motive to influence the repre-
sentations made by the woman, and we can only
give credence in proportion as the account may
appear to us to correspond to other circumstances
or conditions of the case, of which we are satis-
fied. Should we be able to feel the movements
of the foetus, of course we could have no doubt on
the subject; but it must not be forgotten that
such an examination is liable to be unsatisfactory,
or even lead us into error if great caution be not
observed. It may be unsatisfactory, because it
not unfrequently happens that even in women
who have really quickened, and have been for
several weeks conscious of the motions of the
foetus, we are unable either to feel the child or
recognise its movements. The writer is at this
moment in attendance on a lady who quickened
more than six weeks ago, and is now in the sixth
month of pregnancy, and after repeated examina-
tions neither we nor her attendant physician have
been able to feel the foetus. In another case, in
which ascites was combined with pregnancy,
which had advanced to the seventh month, it was
found impossible to feel the child by any mode
of examination that could be adopted, though it
was made with great care, both internally and ex-
ternally, by the writer, and by one of the most
experienced practitioners in Dublin. This case

gave rise to great embarrassment, and recourse
was repeatedly had to the application of the
stethoscope in the most skilful hands ; but neither
the pulsation of the fatal heart nor the placentary
murmur could be heard, though it happened that
several times during our examinations the woman
assured us that she was at that moment sensible
of active movements of the child. Desormeaux
tells us of a patient of his who felt her child at
the ordinary period, and its movements continued
remarkably strong for three weeks, after which
they ceased for a whole month, and nothing could
excite them : the child was born alive and healthy.
(Diet, de Medecine, torn. x. p. 399.) On the
other hand we may fall into the error of supposing
we have felt these movements, when in reality the
woman is not pregnant at all. One such instance
we have already detailed, and more recently we
met with another. Dr. Dewees relates a very
marked instance of such an error occurring to
himself. A young lady had her menses sup-
pressed for several months; her belly swelled
very much, her breasts became enlarged, she had
nausea and vomitings in the mornings ; in short
she had all the usual symptoms of pregnancy.
" Examining the abdomen carefully," says Dr.
Dewees, « I found it considerably distended ;
there was a circumscribed tumour within it,
which I was very certain was an enlarged uterus.
While conducting this examination, I thought I
distinctly perceived the motion of a fastus."*
Another source of error would of course be found
in a power which it is asserted some women pos-
sess of simulating the motions of the child by
certain actions of the abdominal muscles. We
never met with any such case ; but Dr. Blundell,
who mentions the fact, tells us of "a woman who
was seen by the late Dr. Lowder and other
eminent accoucheurs, who simulated these move-
ments so exactly, that, had they judged from this
sign alone, they would have pronounced her
pregnant." (Lectures on Midwifery, p. 251.)

We must now turn our attention to the period
of pregnancy at which we may in general expect
that this phenomenon shall have occurred. Ex-
perience has shown that it happens from the tenth
to the twenty-fifth week ; but according to the
writer's experience, the greatest number of in-
stances will be found to occur between the end of
the twelfth and sixteenth weeks, or, adopting ano-
ther mode of calculation, between the fourteenth
and eighteenth week after the last menstruation.
And under ordinary circumstances, when quicken-
ing does occur, but especially if it happens in
conjunction with the sudden ascent of the uterus
out of the pelvis, the woman is apt to feel an un-
usual degree of nervous agitation, which not un-
frequently ends in faintness or even complete syn-
cope, after which she is sensible of a slight flut-
tering sensation, which from day to day becomes
more distinct, until she fully recognises the motions
of the child. The earliest instance of which we
were certain was in the case of a lady, who must
have conceived on the 10th of November, and she
quickened on the 28th of January, the interval
being eleven weeks and two days ; delivery oc-

+ Essays on several subjects connected with Mid-
wifery, pp. 337-8. The case eventually proved to be one
of accumulation of menstrual fluid in the uterus.

PREGNANCY AND DELIVERY, (SIGNS OF)

669

curred on the 17th of August. A very general
impression prevails in society, that quickening
takes place exactly at the end of four calendar
months and a half, whereas in fact the greater
number of instances occur two or three weeks
before that time has arrived, and many also not till
long after. We have already mentioned one such
case, and have by us notes of several others. At
this moment we are in attendance on a lady who
has in seven successive pregnancies felt the child
for the first time in the sixth month, and once in
the seventh. Baudelocque mentions that some of
his patients did not quicken until after the sixth
or seventh month, and, " in one of these women,"
he adds, "whatever we could do, and notwith-
standing the very obvious ballottement of the child
in utero, which we could perform by a finger in-
troduced into the vagina, its motions could not be
ascertained either by the mother or the accoucheur
who examined her, till the end of the seventh
month. (Art d 'Accouchement, ed. 1822, pp.
205-6.)

"There are some cases," says Johnson, "where
the motions are not felt till near the end of the
reckoning." (New System of Midwifery, p. 102.)

A fact much more remarkable than the occa-
sional postponement of this change is its total ab-
sence during the whole period of gestation, not-
withstanding the subsequent birth of living and
healthy children. Two instances of this kind
came under our own observation, and the fact is
mentioned by several writers of authority. Levret
speaks of a woman who felt no motion of her
child in two successive pregnancies. " I was sev-
eral times consulted," says Baudelocque, "about a
woman whose pregnancy appeared doubtful to her
till the last moment, as well as to the physician,
because the motions of the child could not in any
way be perceived ; and nothing that we could do
even at eight months and a half could excite them :
the child, however, was born healthy, and as
strong as usual." Gardien met with two such in-
stances ; (Traite des Accouchemens, torn. i. p.
509;) and Gooch says on this subject, " there are
cases, though rare, in which the child has not
moved during the whole of pregnancy, although

has been born alive and vigorous : of this I
nave known one instance, and read of others.*

When we wish to feel or excite the motions of
the child in utero, we may expect to succeed by
adopting either such a manual examination of the
abdomen as we are accustomed to make when ex-
amining for a tumour in that cavity, pressing with
the fingers backwards towards the spine, or from
each side towards the centre ; or applying one
hand firmly against the side of the uterine tumour,
we impress the opposite side quickly with the
fingers of the other hand.

Sometimes the simple application of the spread
hand over the front of the abdomen is sufficient
for our purpose ; at other times we shall best suc-
ceed by the sudden application of the hand pre-
viously rendered very cold by immersion in water,
or contact with a marble chimney-piece : this fre-
quently has the effect of making the foetus as it

* Account of Diseases of Women, p. 203. Dr. Dewees
also relates a similar case, " vvliere the motions of the
child were never perceived during the whole period of
uiero-gestaiion." Compendium of Midwifery, p. 105.

were start, and communicate a very distinct sensa-
tion of its movements.

It is obvious that there are two species of move-
ments of the fcetus which may thus be recognised,
one of which depends on the exertion of its mus-
cular power, and of course implies life; the other,
the result of mere change of place or situation,
effected by some external agency, and capable of
being recognised equally in the dead and the liv-
ing foetus : this latter, which is more properly mo-
bility than motion of the fcetus, may be most effec-
tually ascertained by a manoeuvre, which has been
named by the French ballottement, and which we
shall describe fully under the section which treats
of the state of the uterus.

Size of the Abdomen and state of the
Umbilicus. — An increase in the size of the ab-
domen being the necessary result of the develop-
ment of the uterus from pregnancy, a careful exa-
mination of that part will be essentially required
in every instance of an investigation as to the ex-
istence of that condition.

When conception occurs, and the ovum is re-
ceived into the cavity of the uterus, the organ in-
creases considerably in weight ; and its fundus
becoming at the same time developed, and so pre-
senting a broader surface for pressure from the su-
perincumbent viscera, it descends lower into the
cavity of the pelvis, and so will not, for the first
two months, or sometimes more, produce any en-
largement of the abdomen by its increased bulk.
Such an enlargement, however, is frequently ob-
served at this early period, but it will be found on
examination to arise from an inflated state of the
bowels, which very generally takes place soon
after the commencement of gestation, and continu-
ing for some weeks will cause the patient to look
as large or even larger in the second month, than
she will afterwards appear in the third or fourth.
This inflated state of the bowels generally subsides
after a month or six weeks, and then the patient
will not appear enlarged at all, but, on the con-
trary, the abdomen may be found flatter than is
natural to the patient, and the umbilicus under
such circumstances will sometimes be found more
depressed,f an ^ as ff drawn inwards and down-
wards, in which condition it is occasionally the
seat of an unpleasant and rather painful sensation
of dragging, the part being also at the time some-
what tender on pressure.

This state, however, soon begins to alter, and
before the end of the third month the enlargement
of the abdomen becomes obvious to the eye, and
from this period continues to increase gradually
from month to month in the same proportion as
the development of the uterus proceeds. In the
fifth month the depressed condition of the umbili
cus begins to diminish, and by the end of the
sixth month it is generally raised to a level with
the surrounding integument, and afterwards it in
many persons projects above the surface.

Such is the history of this change in the per-
fectly natural and healthy condition of the preg-
nant woman ; but as there is, on the one hand, a
host of causes which may produce enlargement
of the abdomen, and be accompanied also by sev-

t This change is noticed by Velpeau, vol. i. pp. 175-6
and also by others. The French have a proverb which
says, " en ventre plat enfant il a y."

670

PREGNANCY AND DELIVERY, (SIGNS OF)

eral others of tho symptoms of pregnancy when
it does not exist ; so also, on the other hand, a
woman may be with child, and yet the develop-
ment of the abdomen not correspond to the period
which has elapsed since conception.

When the enlargement proceeds from a gravid
uterus, and four months of pregnancy have elapsed,
if the patient be placed lying on her back, with
her shoulders a little raised, and the limbs at the
same time drawn upwards, so that the thighs shall
be in a state of semiflexion on the trunk, and the
abdominal muscles thereby relaxed, if the woman
be not very fat we shall be able to feel and trace
the outline of the gravid uterus, at a height in the
abdomen proportioned to the period of pregnancy,
as stated in the preceding section ; and even
though we should not be able, from the fatness of
the woman, the tension of the abdominal parietes,
or any other cause, to feel distinctly the uterine
tumour and define its circumstance, we shall at
least ascertain that the cause of the enlargement
is something which renders the abdomen much
more solid to the touch than is natural to that
part, and an examination per vaginam detects the
coexistence of the changes in the uterus, already
described as necessarily accompanying gestation ;
while at the same time the general health of the
woman is found unimpaired or unaffected by any
symptom of disease.

When the increased volume of the abdomen is
the result of morbid conditions, not affecting the
uterus, as disease of the liver, spleen, &c, an
ovarian tumour, or ascites, we shall, in general,
without much difficulty form our diagnosis from
the history of the case, the length of time the en-
largement has existed, which may have greatly
exceeded the whole term of gestation, the general
diseased condition of the system, the total want of
correspondence in the symptoms and conditions of
the case if it were pregnancy ; and, lastly, a vaginal
inquiry assures us that the uterus is not enlarged.

When the abdomen is distended by the accu-
mulations of fat in the omentum or in the integu-
ments, or by the inflated state of the bowels, the
very soft and yielding condition of the part under
the hand when pressed backwards towards the
spine, and the total absence of any solid tumour,
together with the non-existence of the ordinary
symptoms of pregnancy, will form a sufficient
basis for an opinion. Should there exist ascites,
that condition can hardly be overlooked or mis-
taken ; but it must not be forgotten that pregnancy
and dropsy may exist together, and, when they do,
they may present a combination of circumstances
of the most embarrassing description.*

Again, we must remember that there are women,
who, from their height or some peculiarity of
torm, exhibit their increase of size much less than
others, so that the abdomen will appear less at
seven months than it generally does in the fifth
month.-j- And it is still more important to recol-

*See case related in the section on Quickening and
notion of the foetus in the present article.

■fThe writer was once called on to attend a young un-
married female of respectability, whom he found in
labour, and he was assured by her mother that up to the
hour of her labour she never suspected that her daughter
was pregnant, not having perceived any alteration in
her size; and the young lady had danced all night at a
oall about a week before he« delivery: she had com-
pleted seven months.

lect, that although pregnancy should exist, if the
child die the development of the uterus will be
arrested, and the enlargement of the abdomen
will not continue to increase, but, on the contrary,
will sometimes diminish, the dead foetus being re-
tained in utero for several months, and the patient,
although really many months pregnant, may not
exhibit any increase of size beyond what is natural
to her ; or being near the end of her nine months,
may not be larger than she was at four or five.
The writer lately saw a case of this kind, which
gave rise to great doubt. In the month of May
he was requested to see a lady who considered
herself in the eighth month of pregnancy, and
was rendered miserably solicitous about her con-
dition because she had irregular discharges from
the uterus, and felt no motion of the child. On
examination her abdomen was found perfectly flat
and even depressed, and no tumour of any kind
could be detected in its cavity ; but the uterus felt
per vaginam was evidently enlarged and soft, and
the os and cervix uteri had undergone the changes
which accompany early pregnancy. The lady
had begun to experience the symptoms of that
condition in October, which continued till the be-
ginning of January, when they suddenly ceased,
and she became liable to vaginal discharges. All
doubt about the case was solved shortly after the
writer's visit by the expulsion of an ovum with a
blighted foetus, which had evidently not arrived
at three months' growth, and during its long
stay in the uterine cavity as an extraneous body
had become encrusted with a reddish calcareous
deposit.

With regard to the changes which take place
in the state of the umbilicus, it is to be observed
that any solid tumour enlarging the abdomen will
also be capable of effecting the elevation of the
umbilicus, which circumstance, therefore, of itself
can afford us no certain information that the dis-
tending agent is a gravid uterus ; but if, in a case
in which pregnancy is supposed to be advanced
to the seventh or eighth month, we find the um-
bilicus depressed and the belly flat, it will prove
certainly that gestation has not advanced to such
a period, although it will not be, as asserted by
Dr. Gooch, decisive evidence against the existence
of pregnancy, which may be present, but not suf-
ficiently advanced to effect the change, or the
uterine development may have been arrested by
the death of the foetus.

[State of the Vagina. — It has been affirmed
by Dr. Kluge, of Berlin, and by M. Jacquemin,
of Paris, that a bluish tint of the vagina, extend-
ing from the os externum to the os uteri, is a sure
test of pregnancy. According to the former, this
discoloration commences in the fourth week of
utero-gestation, increases until the time of delivery,
and ceases with the lochia. M. Jacquemin, on
examining the genitals of prostitutes, in compli-
ance with the police regulations of Paris, observed
the same peculiarity of colour in the same situa-
tion in those that were pregnant : he describes it
as a violet colour, or like lees of wine, and so dis-
tinct as never to deceive him, — being sufficient of
itself, and independently of the other signs of
pregnancy, to determine the existence of that
state. M. Parent Duchatelet (De la Prostitution
dans la ville de Paris, i. 217, 218, Paris, 1837,)

PREGNANCY AND DELIVERY, (SIGNS OF)

671

affirms, that he was present when M. Jacquemin's
accuracy in this matter was successfully put to the
test: in the investigation, he examined no less
than 4500 prostitutes. Dr. Montgomery, how-
ever, (An Exposition of the Signs and Symptoms
of Pregnancy, p. vi. Lond. 1837,) — from limited
observation, it is true — found, that whilst in some
cases the bluish colour was very obvious, in others
it was so slight as to be scarcely, if at all, percep-
tible. There is nothing more probable — as the
writer has remarked elsewhere (Human Physi-
ology, 5th edit. ii. 420, Philad. 1844,)— than that
the capillary circulation of the mucous coat of the
vagina may be modified along with that of the
interior of the uterus during pregnancy, so as to
give occasion to a change of colour like that men-
tioned by the above-cited observers ; but it may
be doubted whether the test can be often available,
especially in private practice.]

State of the Uterus. — Having thus carefully
investigated the circumstances of the case as far
as we can discover them either by the report made
to us, or infer them by the presence or otherwise
by the sympathies already enumerated, we pro-
ceed in the next place to an examination of the
uterus itself, having for our object to ascertain the
following points : — the state of the os uteri and
cervix ; the condition of the organ with regard to
development, and the degree to which it may be
enlarged ; the correspondence of such degree of
enlargement with the other circumstances of the
case; the cause of its increase, and the nature of
its contents.

1. State of the os and cervix uteri. — In the
unimpregnated condition of the uterus, its mouth
and the lower section of the neck, when examined
by the finger introduced into the vagina, can be
felt projecting into that cavity from a quarter to
half an inch. The part so projecting feels re-
markably firm, and about as large as the end of a
man's thumb, having in its termination in the
vagina a transverse opening, whose lips or mar-
gins feel firm and well defined. This may be so
far open as to allow the extremity of the finger to
be insinuated between them to the depth of an
eighth of an inch, sometimes a little more, some-
times not so much ; or it may merely communi-
cate a sensation of a slight depression almost
without a cavity, such as is felt when the tip of
the finger is pressed between the lateral cartilages
at the extremity of the nose. Sometimes the os
uteri differs very considerably from this descrip-
tion, being almost imperceptible from its diminu-
tive size, and perfectly circular.

When conception has taken place, all these
characters begin to alter ; the change from the
natural condition above described being distinct in
proportion to the period of gestation at which the
examination is made. In order to fit the uterus
for the reception of the ovum and its support,
there is, very soon after impregnation, a greater
supply of fluids directed towards it ; its vessels,
which before crept almost imperceptibly through
its dense structure, and with their calibre com-
pVtely constringed, become distended and carry
blood ; the cellular texture is loosened out, and
its interstices are infiltrated with a greater quan-
tity of fluid, and in consequence the organ be-
comes not only altered in texture, but increased

in size and weight. At this time, when the finger
is applied to its vaginal extremity, the cervix is
felt fuller, rounder, and softer or more springy
and elastic under the point of the finger ; and the
same alterations having taken place in the labia
of the os uteri, this part communicates a corres-
ponding difference in the sensation received by
the finger of the examiner: the margins of the
orifice feel tumid, but softer and much less dis-
tinct, having lost the well-defined edge, which in
the unimpregnated organ is natural to them ;
while the orifice itself, instead of seeming trans-
verse, feels as if it were circular, and admits the
tip of the finger more readily and to a greater
depth than in its former state. As pregnancy
advances, other changes in these parts may be
appreciated. During the sixth month for in-
stance, we ascertain that the cervix has not only
undergone the changes of structure already de-
tailed, but that it has lost somewhat of its length,
owing to a portion of its upper section, or that
which unites it to the body of the organ, becom-
ing dilated, and taken up as it were to form a part
of the distended cavity containing the child ; and
this obliteration of the cervix from above down-
wards continuing to be gradually effected, we
find, if we examine towards the close of gestation,
that the projecting cervix is no longer to be felt,
but in its place there is detected, at the upper ex-
tremity of the vagina, a globular tumour, which
is the enlarged uterus, with the head of the child
to be distinctly recognised through its parietes.
In like manner also the os uteri undergoes great
changes of form, structure, and position, as preg-
nancy advances.

During the greater part of the first three
months, besides the alteration already mentioned,
it is felt lower in the vagina, and not unfrequently
projecting a little forwards; but as soon as the
uterus begins to rise into the abdomen, and leaves
the pelvic cavity, as it does by the fifth month at
farthest, sometimes a month earlier, its fundus
leans forwards, and in consequence the os uteri
is directed backwards ; its margins are now felt
very soft and relaxed, and we distinguish very
generally within the circle of its orifice the cervi-
cal glandulse slightly projecting, and feeling like
little firm smooth vesicles rolling under the point
of the finger. We can now also introduce the
finger with great ease to a considerable depth into
the cavity of the cervix, owing to the very yield-
ing condition of the labia of the os uteri. From
this period, in consequence of the rapid develop-
ment of the uterus, and the shortening of the
cervix, the os uteri rises in the pelvis, and is of
course removed farther and farther from the ex-
ternal parts, while, at the same time, the anterior
projection of the uterus increasing, its mouth is
in the same degree directed backwards, so that, if
we examine in the eighth or ninth month, we reach
it with difficulty, and must expect to find it in tho
direction of the upper part of the sacrum. If
gestation be drawing to a close, the orifice will
often be hardly distinguishable, and when felt
gives only the impression of an opening in a
nearly flat surface, without any elevated margin,
or at most very little, and feeling as a mere rugous
opening in the mucous membrane of the uppet
part of the vagina.

672

PREGNANCY AND DELIVERY, (SIGNS OF)

But we must recollect, when we come to form
an opinion from the existence of such changes in
the os uteri, that there are other conditions of the
uterus besides pregnancy by which they may be
produced so as to assume almost exactly the cha-
racters of those that accompany the earlier periods
of gestation. Thus, for instance, the near ap-
proach of menstruation and the accompanying
irritation of the uterus may (and we have had
repeated proofs from examination that it does)
effect such a change in the form and texture of
the os uteri. The same thing will happen in a
more marked degree, when the organ becomes
from any cause enlarged either by an increase of
its substance, or still more remarkably when its
cavity becomes distended by an accumulation of
fluid within it, as of blood or water, or the pre-
sence of a diseased growth, such as a polypus or
hydatids.* Moreover, in some women, especially
those who have borne several children, the con-
dition of the os uteri is at all times such as may
but too easily impose on us. On the other hand,
however, there is one fact on the subject on which
we may rely, — viz. that inasmuch as pregnancy
must always be accompanied with the physical
changes of structure in the uterus already men-
tioned, should we find in a suspected or doubtful
case, especially if supposed to be of some months'
duration, the os uteri retaining distinctly the cha-
racters which belong to it in its unimpregnated
state, that is, its transverse orifice with well de-
fined and firm margins, we may conclude with
certainty that the woman is not with child.

2. Size of the Uterus, 3(C. — When conception
has taken place, the uterus almost immediately
begins to increase in size, generally in every part,
in consequence of the new action already described,
but especially at the fundus. Here the cavity
begins to increase its capacity, to enable it to re-
ceive and accommodate the ovum, which being
accomplished, the upper part of the organ con-
tinues to increase in size in proportion to the
growth of its contents. The fundus is first de-
veloped, then the body, and lastly the cervix ; the
latter part not being affected by the process of ex-
pansion until about the sixth month, as already
stated. During the earlier months, therefore, the
finger introduced per vaginam cannot reach suffi-
ciently far to arrive at and detect the development
which has taken place in the upper part of the
uterus ; and as the increase of size in the organ
is not as yet such as to prevent its being still ac-
commodated within the pelvis, it cannot be detected
by examining through the parietes of the abdo-
men ; wherefore, during this period, which ex-
tends through at least the first three months, the
development of the organ or its degree will be dif-
ficult to ascertain, but will become gradually more
easy of detection as pregnancy proceeds and the
uterus enlarges. In general, by the end of the
fourth month, the fundus of the uterus may be
felt, especially in a thin person, overtopping the
anterior wall of the pelvis. During the fifth it
rises to half-way between the symphisis pubis and
the umbilicus; and if an examination be made

* In introducing hydatids here, we do not mean to be
understood as considering them distinct from pregnancy,
from which we believe they always arise, but as distinct
from the natural conditions of that state, and from the
presence of a foetus.

per vaginam, we can detect the enlarged uterus,
which we encounter when we attempt to pass the
finger between the anterior part of the cervix and
the inside of the symphisis pubis, — a situation in
which, when a woman is not pregnant, and even
during the earlier periods of pregnancy, we are not
able to feel any" thing. At this period, also, we
may at the same moment feel the foetus by bal-
lottement, as described in another section. In the
sixth month the uterus rises as high as the umbi-
licus, which is now for the first time sensibly
affected and begins to rise to a level with the sur-
rounding integuments. In the seventh month the
fundus uteri may be felt half-way between the um-
bilicus and the end of the sternum ; and if an ex-
amination be made per vaginam, the finger readily
detects the globular tumour of the uterus resting
on the symphisis pubis, and within it the child's
head ; but the os uteri is now reached with greater
difficulty, both because it is raised absolutely higher
in the pelvis, and also because it is removed far-
ther from the external parts by being projected
more towards the promontory of the sacrum.

By the end of the eighth month the uterus has
risen as high as the ensiform cartilage, and fills
the whole abdomen, which is now very prominent
and tense, and the umbilicus is in general not
merely on a level with the integuments, but pro-
jects a little beyond them.

In the ninth month the uterus continues to en-
large, but the degree of its increase is not very
observable by an increased elevation of its fundus,
which on the contrary very generally falls lower
towards the close of the month, so that for a week,
or even two, before labour, the woman will appear
and feel smaller than she was previously. If at
this period we examine internally, the os uteri will
in most cases be touched with great difficulty from
its situation towards the upper and back part of
the pelvis ; there are in general no remains of the
cervix ; and the margins of the os uteri are felt
thin, soft, and so relaxed that the orifice would
receive with perfect ease the end of one's thumb,
and within its circle we may feel the membranes.

Now it is important to notice the different de-
grees of distinctness with which these changes in
the uterus may be recognised in different indivi-
duals, or in the same individual at different times,
and to speak of the best method of conducting
the examination.

In some women there is a natural stiffness and
tension of the muscles of the abdomen, which is
a great obstacle to an examination ; and this they
can produce or increase at pleasure, if they wish
to baffle us in our investigation. In this, how-
ever, we may defeat them, by engaging them at
the instant in conversation on some subject con-
nected with their case which will be likely to set
them talking. In other cases a similar difficulty
will arise from inflation of the intestines or their
distention by an accumulation of faeces ; or a still
more formidable bar may be found in a general
condition of embonpoint, when the omentum and
abdominal integuments may be so loaded and
thickened with fat, that we can no more feel any
thing through them than if we had a folded
blanket between our hand and the patient's abdo-
men. This is so remarkable in some fat women,
that we have found it impossible immediately

PREGNANCY AND DELIVERY, (SIGNS OF)

673

after delivery to ascertain by external examination
the degree of uterine contraction, although there
were other satisfactory proofs of its perfection.
We should not forget that this is a state of the
abdomen very apt to occur at the turn of life,
when, from the cessation of the catamenia, women
very often fancy or affect to think themselves with
child. On the other hand, the examination will
be most satisfactory in women of a spare habit,
and who have the abdominal parietes relaxed.

It was before stated that during the first three
months we cannot expect much information from
the altered size of the uterus, but that after the
lapse of another month, the change might be
ascertained both externally and also per vaginam ;
and it may be here added that in a case of doubt
we may make these two modes of examination
mutually confirmative of each other, by applying
the finger of one hand to the os or cervix uteri,
and pushing that part upwards, and then with
the other hand gently pressing down the tumour
felt in the abdomen. If we thus feel its descent
upon the finger in the vagina, it affords almost
certain proof that the tumour is the uterus in a
state of enlargement. But we must again recol-
lect that a certainty even of this will not be suffi-
cient to assure us of the existence of pregnancy,
because the enlargement may arise from other
causes than the presence of a foetus, such as hyda-
tids, polypus, dropsy, or accumulated menses with-
in the uterus, or scirrhous thickening of its sub-
stance. In the case of polypus or scirrhus, the
great solidity of the organ would at once unde-
ceive us ; but in other circumstances we might be
able to ascertain merely that the cavity of the
organ was increased in capacity without being
able to determine the exact course of its enlarge-
ment. At the same time the presence of several
of the symptoms of pregnancy might afford a very
strong moral conviction of the existence of that
condition ; while, on the other hand, we may dis-
cover such a want of correspondence between the
state of the uterus and the other symptoms ap-
parently indicating a certain period of pregnancy,
as would be sufficient to decide our opinion on
the negative side of the question.

We have already spoken of the mode of exam-
ining externally to discover the presence of a
foetus in utero, and alluded to another form of
examination per vaginam, to which we ought to
resort for this purpose. As we have no English
name for this mode of examination, it is still
designated by its French name.

Ballottementi— This mode of examination is
thus to be instituted. The patient may be exam-
ined in the upright position, or placed lying with
the shoulders much raised. One or two fingers
are then to be introduced into the vagina and
carried upwards until their points are applied to
the anterior section of the cervix uteri, and as
high up on that part as they can be conveniently
made to reach without using force, and they must
be carefully kept in constant contact with the
part to which they have been applied. The
other hand of the examiner is to be placed on the
abdomen over the uterine tumour, which should
be pressed downwards towards the cavity of the
pelvis ; instantly on our doing this, the fingers
which have been kept applied to the cervix should

Vol. III. — 85 3 a

be impressed against it with a quick and slightly
jerking motion upwards, when something will
be felt to have bounded away from the fingers,
upon which it will, in the course of three or four
seconds, be felt to drop again with a gentle pat.

Should this be distinctly felt, it is proof positive
of a foetus in utero, there being no other condition
or disease of the organ in which a solid body can
be felt in this way floating in its cavity ; and it
possesses this great advantage over many other
modes of investigation, that it is equally applicable
to the dead as to the living foetus. But we must
be prepared for occasional disappointment in this
test as in others, inasmuch as the most carefully
conducted examinations of this kind have failed of
success when there was really a foetus in the womb
of sufficient bulk to be thus felt, as we have our-
selves experienced. This difficulty may arise in
some cases from the foetus being unusually small,
or from the cervix being unusually long ; and in
some instances we were satisfied it has arisen
from the uterus lying too much beyond the reach
of the finger at the time of the examination.

The time at which we may resort to this ex-
amination with the best prospect of success is
generally said to be from the fourth to the sixth
month. Our experience leads us to say that it is
not likely to be satisfactory until after the end of
the fourth month, but from that till the end of the
sixth it will be found most available, and often
completely decisive.* In the earlier periods of
pregnancy the foetus is too light to be felt, and in
the more advanced its presence is ascertainable
by other means, and besides it is then too large
and too much confined to be made to float or
move about thus freely.

It is desirable that the bladder and rectum
should be quite empty when we make this exami-
nation, that the uterus may have as much space
as possible for its descent into the pelvis, and so
be brought as much as possible within reach of
the examiner's finger. We must be careful not
to mistake the movement of the uterus for that of
the foetus, an error into which we shall be particu-
larly liable to fall if we remove the fingers from
their contact with the cervix while making the
examination. In one instance of enlarged uterus
we knew the pulsation of one of the arteries to be
mistaken for the drop of the foetus on the finger.-j-

Application of Auscultation.— Since the ap-
pearance of the memoir of Dr. Mayor (Vide Bib-
liotheque Universelle, Nov. 1818) of Geneva, in
1818, and the subsequent observations of Kergara-
dec and Laennec, the application of auscultation
as a means of detecting pregnancy has been much
cultivated, and with results highly benefical to the
interests of science and our powers of making a
correct diagnosis.

The phenomena thus ascertainable are, the pul-
sations of the foetal heart, and a peculiar sound
audible in that part of the uterus to which the
placenta is attached, and hence called the placen-
tal sound or murmur (bruit placental™). We

* Gardien specifies four months and a half; Gooch
from the fifth to the seventh.

f On this subject see Eaudelocque, torn. i. p. 206.— Desor-
meaux. Diet, de Med. torn. x. p. 400.— Velpeau, Traite
des Accouchemens, torn. i. p. 185— Gooch, On Female Dis-
eases, &c. p. 215— Gardien, Traite Coniplet, &c. torn. i. p
507-10.— Malum, Mud. Leg. torn. i. p. 100. note by Fautrel,

674

PREGNANCY AND DELIVERY, (SIGNS OF)

shall first consider the modes of investigating
these, and then state the advantages which this
mode of examination enjoys above others, and the
defects under which it labours as a general means
of diagnosis.

The placcntary sound is the one first capable
of being examined, and may be heard as soon as
the uterus has become sufficiently developed that
its fundus shall have risen above the anterior wall
of the pelvis : this happens in the fourth month
of gestation, before which period we do not be-
lieve the placental sound can be ascertained. We
are aware that cases are recorded in which it was
supposed to have been heard so early as the tenth
week. If so, we have not been so fortunate as
others, although we have very many times indeed
carefully repeated our examinations, but never
succeeded until four months of pregnancy had
been completed.*

The characters of this phenomenon are, a low
murmuring or somewhat cooing sound, resem-
bling that made by blowing gently over the lip of
a wide-mouthed phial, and accompanied by a slight
rushing noise, (« Battement simple avec souffle."
— Kergaradec,) unaccompanied by any sensation
of impulse. This sound is in its returns exactly
synchronous with the pulse of the mother at the
time of examination, and varies in the frequency
of its repetitions with any accidental variations
which may occur in the maternal circulation. Its
situation does not vary during the course of the
same pregnancy ; but in whatever region of the
uterus it is first heard, it will in future be found,
if recognised at all, for it is liable to intermissions ;
at least we shall occasionally be unable to hear
it where we have already heard it a short time
before, and where we shall shortly again recognise
it. In relation to the regions of the abdomen, its
seat will of course vary in proportion to the pro-
gressive advance of the pregnancy. According to
our experience it will be most frequently heard
about the situation of the fallopian tube of the
right side, but it may be detected in any of the
lateral or anterior parts of the uterus.

[It is questionable, however, whether this sound
be ever produced except by pressure on the large
dorsal vessels of the mother. It is, indeed, posi-
tively affirmed, that the sound has been heard in
cases of uterine and other tumours where there
was no pregnancy. (Raciborski, Manual of Aus-
cultation, by Fitzherbert, p. 145, Lond. 1835. E.
Rigby, System of Midwifery, Amer. edit. Philad.
1842. Hope, Treatise on Diseases of the Heart,
by Dr. Pennock, Philad. 1842 : and Prof. Huston,
in Amer. edit, of Churchill's System of Midwifery,
p. 136 (note), Philad. 1843.) In one case of
fibrous tumour of the uterus, the writer heard it
distinctly.]

The other phenomenon differs in every one of
its circumstances from the placentary murmur.
It results from the contractions of the foetal heart,
which, when conveyed to the ear, are heard as rapid
pulsations without any of the murmuring sound of
the bruit placentaire. These pulsations vary in

* " Je ne l'ai rencontre que dans la seconde moitie de
la grossesse. Si Laennec et M. de Leus, qui disent
l'avoir reconnu avant la fin du troisieme mois, ne se
sont pas mepris, il me parait parcela seul impossible de
I'attribuer a la circulation utero-placentaire." Velpeau,
Traite des Accoucliemens, vol. i. pp. 190-1.

number from 120 to 160 in the minute, while the
mother's pulse at the same time may not exceed
the usual standard ; and should it happen to do
so, the pulsations of the foetal heart will not bo
found similarly affected. By this want of corre-
spondence, and permanently greater rapidity, they
are distinguished from the pulses of the mother.
The impulses of sound communicated to the ear
are in general very delicate and feeble, resembling
very much the ticking of a watch heard through
one's pillow at night.-j- This phenomenon is not
ascertainable, according to the writer's experience,
until five months of pregnancy have been accom-
plished, t and then requires for its recognition very
great attention on the part of the examiner, and
also a practised ear. As pregnancy advances, the
sound becomes more distinct. Its seat or source
being the heart of the foetus, and the foetus having
in most women a great disposition to change its
posture, the situation of the sound will conse-
quently be different at different times, espe-
cially from the sixth to the eighth month. It is,
however, most frequently and most readily heard
at one or other side, and at about the middle of a
line drawn from the umbilicus to the anterior and
inferior spinous process of the ileum, and more
frequently at the left side than at the right.

The mode of ascertaining the existence of
pregnancy has this great advantage over almost
every other, that it detects not only the presence
of a foetus, but proves its life also. On the other
hand, however, should life be extinct, auscultation
cannot possibly afford us any information; and
here lies the great defect under which its applica-
tion labours when compared with other modes of
examination, to which also it is inferior in not
being available during that period of pregnancy
which is most obscured by doubt. Again, from
the fact that both phenomena are occasionally in-
audible (see case related in the section on Quick-
ening, &c.) even in the case of a living and
healthy foetus, it will not justify us in giving a
negative opinion. The bruit de cceur once heard
is of course decisive, because there is no other
sound which can be mistaken for it ; but not so
with the placental murmur, which may be so
imitated, either artificially, as by pressure, or by
disease, that the nicest and most practised ear can-
not detect any difference. A case most strikingly
illustrative of this statement was not long since
under the writer's care, in which enormous en-
largement of the uterus, of that kind which has
been called vascular sarcoma, was accompa-
nied by this phenomenon in its most perfect con-
dition ; and in another case of abdominal tumour
(supposed to be of the spleen) pressing on the
aorta this sound was equally distinct : moreover,
it may at any time be imitated by pressing the
end of the stethoscope over the region of the iliac
vessels.

At all times this kind of examination requires
great care and nicety on the part of the examiner,
and complete silence around him, for the sounds
are very often almost imperceptible. We have

f "— semblable a celui que font entendre les batte-
mens d'une montre enveloppee de beaucoup de linges.'
Velpeau.

|"Ces pulsations s'entendent distinctement dei l«
sixieme mois, et quelquefois nieme un peu plus tnt."
Laennec, torn. ii. p. 457.

PREGNANCY AND DELIVERY, (SIGNS OF)

675

the very highest authority for believing that the
formation of a correct judgment by their means
requires more care, and is beset with greater diffi-
culties than are found in investigating all the dis-
eases of the chest.* We must recollect that, from
their occasional intermission, it may happen that
we shall not be able to give a satisfactory opinion
until we have several times repeated our examin-
ation. To make this examination, it is by no
means necessary that we should be practised ste-
thoscopists, or even use the stethoscope at all,
since the naked ear will detect the sounds sought
for with perfect accuracy ; but the use of the tube
is for many reasons preferable.

It appears not unimportant to mention here,
that our success will sometimes depend on our
making a proper degree of pressure with the end
of the instrument, 6ince the seat of the sound
which we seek to discover may not, and very often
is not, in contact with the surface on which we
apply our ear or our stethoscope ; and under such
circumstances the intervention of a fluid, such as
the liquor amnii, will effectually prevent the trans-
mission of the sound, until, by gently increasing
the pressure on the integuments, we carry them
inwards, and by displacing the intermediate fluid,
whether air or water, we bring them into more
immediate contact with the source of the sound,
and obtain a solid medium for its transmission. +

* "L'etude des phenomenes dont nous venons de par-
ler dans cet article demande incomparablement plus
d'attention que celle de tous ceux que presentent les ma-
ladies de la poitrine." Laennec, torn. ii. p. 4C6.

f The author of the article Auscultation in the first
volume of the present work, gladly avails himself of the
present occasion to correct some mistakes which he has
committed in respect to the appropriation of certain
opinions therein advanced.

In treating of the utero-placental circulation, with re-
ference to the variety of sounds which accompany it, we
gave it as Dr. Ferguson's opinion that " the most con-
slant variety is a combination of the bellows or sawing,
with the hissing sound, commencing with one of the
former and terminating with the latter ;" and in another
place we stated that " Dr. Ferguson had not observed
any variety of the sounds to be peculiar to particular
stages of pregnancy." Now the fact is that both these
remarks belong to Dr. Kennedy, and are taken from an
excellent paper by this gentleman, published in the fifth
volume of the Dublin Hospital Reports. In transcribing
the extracts which we had made, we inadvertently in-
serted Dr. Ferguson's name in place of Dr. Kennedy's,
and referred to a paper by the former gentleman in the
Dublin Medical Transactions, from which we also had
been making extracts. We are much obliged to Dr. Ken-
nedy for having enabled us to correct our mistake.

In respect of certain other statements made by us in the
same article, we most readiiy afford Dr. Kennedy the
opportunity of giving his own explanation by extracting
a passage from a communication with which he has
favoured us.

Eztract of a letter from Dr. Kennedy to Dr. Forbes:

"You appear to have misunderstood me when you
ftate'lhere seems little ground for believing with Dr.
Kennedy that the placental arteries themselves have a
share in the production of the sound any farther than by
their action promoting that of the uterine arteries.'
HOW if you will refer to p. 241 of my paper you will find
that I merely deem it possible that the passage of the
blood through the arterial tubes and cells of the maternal
?<M of the placenta may have some effect in producing
It; anil p. 244, in speaking of the possibility of its ope-
rating so, add that the point still admits of doubt. From
this it will be seen that I by no means commit myself,
either in the manner or to the extent „that your state-
ment implies. The fact is, that although my explanation
may not have been sufficiently explicit on this point, }«et
the manner in which I endeavoured to explain the ma-
ternal part of the placenta's assisting in producing the
soufflet (if it did so at all), was that which you more dis-
tinctly state, namely, by promoting the action of the
uterine arteries. But even of this I was not, nor am I as
yet quite satisfied. I however thought myself called upon
candidly to state facts and inferences as they presented

Substances expelled from the Uterus. —

The expulsion from the uterus of solid or orga-
nized substances, presenting occasionally very un-
usual or anomalous characters, excites not unfre-
quently suspicions of the existence of pregnancy
in the unmarried, and perhaps the perfectly chaste.
Under such circumstances we may be applied to
for an opinion as to the nature of the substance
expelled, and are expected to declare whether it is
or is not the product of conception. Inasmuch
as character and fair fame of the individual depend
on our answer, the greatest care will be required
in making such an examination, and the utmost
caution in forming or pronouncing an opinion.
To this duty no person can possibly be competent
if he have not previously made himself intimately
familiar with the appearance and structure of the
ovum, particularly in the earlier periods of its for-
mation ; and this knowledge he may take it for
granted he never will attain to by descriptions in
books or plates, nor by 3ny means except repeated
examinations of the structure itself under every
circumstance and condition in which it may be
found : more especially when it is altered in its
characters, as it usually is, by abortion.

The substances thus expelled may be, 1. an
early ovum ; 2. a mole ; 3. uterine hydatids ; 4.
the membrane produced in dysmenorrhcea ; to
each of which we shall now turn our attention.

1. An early Ovum. — When the product of
conception is expelled within a month from the
time of conception, the most careful and skilful
examination may fail in detecting its true character.
After this period its structure is sufficiently dis-
tinct to be recognised by any one well acquainted
with it, and who will take sufficient time to ex-
amine it ; for this also is absolutely essential to
the formation of a correct opinion. The ovum,
when thus expelled, is generally infiltrated with
firmly coagulated blood, and the pressure which it
sustains while it is forcing its way through the
contracted and rigid cervix of the uterus, so con-
denses its texture as to reduce it apparently to the
condition of a solid homogeneous mass. The real
structure of the body cannot be ascertained by any
examination instituted at the moment, but must
be gradually made out by first immersing the sub-
stance in water for a day or so ; and then, by agi-
tation and washing, the coagulated blood must be
removed, while with delicate blunt instruments
we gently separate the component parts of the

themselves to me on my investigation, leaving it to others
to draw what conclusions they thought proper from them.
" There is still another point to which I wish to draw
your attention, as, from the manner in which you quote
me, my meaning is very equivocally conveyed. You
say, 'Dr. Kennedy denies M. Ollivry's statement, that
the soufflet is immediately extinguished on the removal
of the placenta, the death of the foetus, and the tying the
cord, the sound becoming abrupt,' Sec. From this it
might be concluded that I stated the soufflet always to
continue after delivery, death of the foetus, &c. an infer-
ence widely at variance with the fact, and such as wa3
never intended by me. Y'ou will find, p. 244, Dub. IIos.
Rep. vol. v. the passage which you quote : it runs thus :
' Neither docs the sound (the soufflet) invariably cease, as
we might be led to conclude on the authority of Dr. Olli-
vry, on the separation or expulsion of the placenta ; but
provided the uterine arteries at this part, from imperfect
contraction of the uterus, continue pervious to blood, a
soufflet will still continue,' &c. Here you will at once
perceive how much the words 'immediately extinguish
ed,' in place of ' invariably cease,' affect the nature vf
the statement."

May, 1833. J. p. EdU.

676

PREGNANCY AND DELIVERY, (SIGNS OF)

mass under water, until at length we ascertain its
real character. This process may occupy us for
a time varying from three or four days to a week,
before we are able to satisfy ourselves perfectly.
Haste may completely defeat the object of the
examination.

If in the progress of such an investigation we
discover a foetus, or even a part of one, it would
of course be decisive ; but this may not be the
case, and yet we may recognise all the other com-
ponent parts of the ovum presenting several struc-
tures which are never produced by disease.*
First, we may have the decidua covering either
partially or completely the substance under exami-
nation, distinguished by its soft, rich, pulpy ap-
pearance and strong red colour, its external or
uterine surface rough and unequal, and, when well
freed from the coagulated blood, exhibiting nume-
rous small round foramina, (see Hunter's plates
of the gravid uterus, xxix. fig. 11, and also plates
xxviii., xxx., xxxiii., xxxiv.), capable of admitting
a pin : its internal surface is smooth, and exhibits
little or no appearance of these openings. This
coat may be found attached to the ovum, or en-
tirely torn away and separated from it during its
expulsion ; but in either case these characters
mark the true decidua, and are not found in the
products of disease. Within this outer coat an-
other is found immediately investing the mem-
branes of the ovum, the outer surface of which is
smooth, and its inner completely filamentous, re-
ceiving the beautiful arborescent villi which cover
and shoot from the surface of the chorion, forming
the bond of union between it and this inner de-
cidua. The discovery of these arborescent villi or
capillaries is proof positive of the nature of the
product, as they are never found presenting like
characters, except upon the chorion or uterine
surface of the placenta.

2. Moles. — With regard to those solid fleshy
masses called moles, which are occasionally ex-
pelled from the uterus, there is a great discrepancy
in the opinions of writers of authority, some of
whom maintain, with Mauriceau,-f" that they are
the result of conception alone, and of course posi-
tive proofs of pregnancy ; while others either think
this very doubtful, or deny it altogether, and sup-
pose that they are merely accidental formations
of a morbid character. " By the term mole," says
Denman, (Introduction to Midwifery, p. 124),
" authors have intended to describe very different
productions of, or excretions from, the uterus. By
some it has been used to signify every kind of
fleshy substance, particularly those which are called
polypi ; by others, those only which are the con-
sequence of imperfect conception when the ovum
is in a morbid or decayed state ; and by many,
which is the most popular opinion, every coagu-
lum of blood which continues long enough in the
uterus to assume its form, and to retain only the
fibrous part as it is properly called, is denominated

* See a case related by Mr. Lemon in the Edinburgh
Medical and Surgical Journal, vol. xi. p. 96. The writer
has in his museum more than one specimen illustrative
of this absence of the foetus where the other parts of the
ovum exist.

t " II est tres certain que les femmes n'engendrent pas
de moles ni de faux germes, si elles n'ont use du coit."
Maladies des Femmes, torn. i. p. 109. '• Massa carnea,
vasculosa, ex utero excreta. Ovum deforme." Vogel.

a mole." — "True moles," says Yoigtel, (Hand
buch der Pathologischen Anatomie, vol. iii. p.
501), "are distinguished from the false and other
growths of the uterus by their not deriving their
origin from the substance of the womb or its mem-
brane ; but by their being always the consequence
of conception." This is at once assuming that
conception is the sine-qua-non without which a
mole cannot exist, — an opinion which is support-
ed, to a certain extent at least, by the experience
of Mr. Burns, who says, " It is the opinion of
many that these substances are never formed in
the virgin state, and no case that I have yet met
with contradicts the supposition." (Principles of
Midwifery, ed. 7, p. 1 1 1). Fodere (Medecine Le-
gale, vol. i. p. 468) thinks that the true mole is
always the result of intercourse between the sexes,
and that those substances which are discharged
from the virgin uterus are merely condensed co-
agula of blood, which of course may form in the
chaste as well as others. Baudelocque (Art. des
Accouchemens, torn. ii. p. 367) considers the mole
and the false conception as one and the same.

On the other hand, we find the matter thus
stated by Dr. Smith : " Moles are disorganized
masses that form in the uterus; and continuing
for some time to increase, cause some of the symp-
toms of pregnancy. They have been found in
females who never had any intercourse with the
other sex." (Principles of Forensic Medicine,
p. 298). Ruysch makes a similar assertion, and
adds that he has seen them in women so advanced
in years as to be beyond the reach of suspicion.
A case came before the parliament of Paris in
1781, in which the female sued for damages for
seduction. Twenty months after this was alleged
to have been committed, she brought forth a mole.
The parliament decided against her on the score
of character, and they added that " the causes of
moles were as uncertain as the time of their ges-
tation, and that there were instances of girls, and
even of nuns, who had produced moles without
any previous criminal connection." Fodere, who
quotes this case, disapproves altogether of the view
taken by the court. (Medecine Legale, t. i. p.
478).

It is to be observed here that this is a mere
question of fact, of which different views have
been taken, and opinions formed by authors or
practitioners according to the opportunities afford-
ed them of judging. The writer does not feel
prepared to undertake to reconcile these conflict-
ing opinions, but it appears to him almost certain
that much of the discordance has arisen from sub-
stances of very different characters having been
indiscriminately classed together under the general
term of moles, some of which were undoubtedly
neither more nor less than diseased ova, or rem-
nants of such, while others were as certainly
either merely condensed coagula, or perhaps ute-
rine polypi. Hence Mahon (Mahon, Medecine
Legale, t. i. p. 274) appears perfectly justified in
making the folJowing remarks : — « The existence
of moles properly so called is extremely doubtful,
since they may all be referred to some one or other
of the substances of which we have spoken, viz.,
a placenta which had continued its growth, the
foetus having perished ; the degenerated remains
of the after-birth ; coagulated blood ; sarcomatous

PREGNANCY AND DELIVERY, (SIGNS OF)

677

tumours or polypi of the uterus. The two first
cannot exist except after sexual intercourse ; the
other three may be found independently of it.*
This is the distinction which it is of the greatest
importance to make in questions of legal medi-
cine, that we may not without cause compromise
the reputation of the unmarried girl or the widow
of irreproachable life and conduct."

In this view the writer entirely coincides, and
thinks the medical jurist would not be justifiable
in pronouncing any such mass expelled from the
uterus as proof of pregnancy, except he can detect
in it either the foetus or a part of it, or some other
of the component structures of the ovum.-(- In
the instances which have come under our imme-
diate observation, the women were all either mar-
ried or avowedly indulging in sexual intercourse,
and the masses expelled, when examined, were
found to contain the product of conception dege-
nerated or greatly altered by disease. The last of
these substances which came under our observa-
tion was expelled from the uterus immediately
after the discharge of a healthy ovum, containing
a well-formed fcetus of four months, at which pe-
riod of pregnancy the woman, according to her
own account, had arrived. The substance had
the external characters usually considered as those
of a mole, and was of the form and size of a large
orange. When opened, no trace of a fcetus could
be discovered, .but there was a small remnant of
an umbilical cord, which was ragged at its unat-
tached extremity : the fleshy envelope varied in
thickness from an eighth to half an inch, the
thickest part being that where the placenta was
situated, the internal surface of which exhibited
very remarkably the tubercular disease represented
in Denman's ninth plate. (It is preserved in the
writer's museum.) Morgagni (Epistles 48-9) re-
lates a similar case, and quotes Hartman and Gut-
terman. Mr. Lemon's case has been already re-
ferred to.

3. Uterine hydatids. — Of the nature of these
productions, and their necessary connection or
otherwise with conception, there exists, as in the
case of fleshy moles, a complete want of accord-
ance in the opinions of authors. Some maintain
that they are not necessarily the result of concep-
tion, while others as strongly, and, as it appears to
us, with much greater reason and truth, consider
them as the product of disease attacking the ovum.
Without entering into lengthened details on this
subject, it appears proper to quote a few of the
most respectable opinions on each side of this
question before stating the result of our own expe-
rience on the subject. Dr. C. M. Clarke (Obser-
vations on the Diseases of Females, part ii. p. 115)

* " Aussi sont-ce les seules productions que Ton ren-
contre chez les filles, et chez les femmes vivans dans l'e-
lat de chastite." Mad. Boivin sur la Mole Vesiculate,
&c. p. 18.

* It has been already remarked that these are not un-
freqiiently found without any part of a foetus. This is
noticed also by Voigtel in describing different species of
nioles. "In others," he observes, "from an originally
imperfect development of the ovum, or an injury to the
fetus at its first formation, it appears either as a shape-
tai mass, or the fatus itself is completely destroyed, and
only its membranes and the placenta continue to grow for
8 time and get thickened and fleshy, or filled with fluid
only, or form membranous, fibrous masses, or hydatids,
or assume other unnatural appearances." Voigtel, Op.
cit.

3g*

thus expresses himself: — « It is probable that the
existence of pregnancy is not necessary for the
production of this disease. It has been believed
to exist independently of this state ; and perhaps
a morbid condition of organized lymph may have
the power of originating this disease under certain
circumstances, but what these circumstances are
is not known." Gardien's opinion is that " hyda-
tids may be met with in girls as well as women ;
however, although they are independent of sexual
intercourse, they are much more frequently met
with in women who have borne children, and es-
pecially when they have arrived at the turn of
life." (Traite complet, &c. t. i. p. 559.) Den-
man says : — " These have been supposed to pro-
ceed from coagula of blood, or portions of the pla-
centa remaining in the uterus, and this opinion is
generally true : but there is sometimes reason for
thinking that they are an original production of
the uterus independent of such accidental circum-
stances, and sometimes the precursors of organic
disease in that part." (Introduction to Midwifery,
fifth edition, p. 121.) Of these opinions we think
we are justified in saying at least that there is so
much of conjecture in them that they weigh very
little in the determination of this point ; and it is,
moreover, to be observed that these writers admit
elsewhere, as indeed do all who have written on
the subject, that the existence of hydatids in utero
is always accompanied by the ordinary symptoms
of pregnancy. The weight of authority appears
to us very decidedly in favour of the necessary
connection between these substances and previous
conception. Beck declares that he " can find no
case on record where hydatids of the uterus have
been formed independent of sexual connection ."
(Elem. Med. Jurisp. p. 102.) Baudelocque and
Voigtel consider them merely as a variety of the
mole, and as such the result of impregnation.
(Locis citatis.) Desormeaux thus speaks of them :
" It is superfluous to say that the development of
these masses of hydatids is most frequently, if not
always, the result of conception : at first it is
impossible to distinguish this affection from preg-
nancy, or, to speak more correctly, pregnancy
exists with all its phenomena, and it is impossible
to discover when the degeneration into hydatids
takes place." (Article " OEuf humain," Diet, de
Med. t. xv. p. 387.) Velpeau is perhaps even
more decisive on the point : his words are, " the
mole and hydatids of the uterus being but the
products of conception degenerated, give rise to
the same phenomena as true pregnancy." (Traite
Elem. de l'Art des Aceouch. t. i. p. 217.) We
shall quote only one other authority, to which,
however, we attach very considerable value. Ma-
dame Boivin has published a very ingenious and
satisfactory pamphlet (Nouvelles Recherches sur
l'origine, la nature, et le traitement de la Mole Ve
siculaire ou Grossesse Hydatique, 1827) expressly
on this subject, in which she brings forward a vast
quantity of information connected with this affec-
tion, which she appears to have studied with unu-
sual attention ; and the result of her observations
she announces to be that hydatids in the uterus
are in all cases the result of conception. (Vide
pp. 15, 24, and 56, Op. cit.) She notices the fact
that these formations are not attached immediately
to the internal surface of the uterus, but are sur-

678

PREGNANCY AND DELIVERY, (SIGNS OF)

rounded by an investing membrane having all the
characters of the decidua vera,- and she main-
tains that the hydatids originate in the filamentous
vessels which spring from the external surface of
the transparent membranes of the ovum ; in re-
gard to both which points we coincide in her
views, and have in our possession preparations
showing both facts. Our own belief, then, is that
uterine hydatids do not occur except after sexual
intercourse, and as a consequence of impregnation.
We never met or heard of a case in which their
presence was not accompanied or preceded by the
usual symptoms of pregnancy ; (such also was
the experience of Dr. Gooch. See Account of the
Diseases of Women, &c. p. 242-3 ;) and in every
instance under our immediate observation, the
women supposed themselves with child, and when
the contents of the uterus were expelled, there was
found either a blighted foetus or some other part
of the ovum.

It may not be amiss to notice here an argu-
ment from analogy which has been brought for-
ward against this view of the question, viz. that
hydatids being formed in other situations, as the
brain, &c, why may they not occur in the uterus
also, independently of any such circumstance as
intercourse or conception 1 To this we would
reply, first, that the hydatids produced in the
situations alluded to differ, toto ccclo, in their
characters from those of the uterus ; and, second-
ly, that whenever hydatids are formed, it is always
in connection with serous membranes, which do
not exist in the uterus until the ovum is deposited
there, whose membranes are essentially serous.
Still it must be confessed that our knowledge on
this point is by no means sufficiently precise, nor
our collection of facts sufficiently extended, to
warrant us in pronouncing positively on the ques-
tion, or asserting decidedly, in a case of suspicion,
that a woman was pregnant merely because she
discharged hydatids from the uterus, except we
could detect along with them some constituent
part of the ovum, or in an examination after death
find in the ovary the true corpus luteum, which
ought to put an end to all doubt. It would be
presumptuous and absurd to maintain that, be-
cause we had always found them in connection
with one particular cause, there might not be
some other also capable of producing them ; and
as there may be a doubt, we must let the accused
have the benefit of that doubt. Again, in giving
an opinion we should be prepared to make allow-
ance for such a case as this : a woman loses her
husband by death or departure, when she is, per-
haps, in the third or fourth month of pregnancy ;
shortly afterwards she miscarries, and the placenta
or some other portion of the ovum is retained,
and gives rise to the production of hydatids. This
new product may be retained for many months,*
and being then expelled, might very unjustly
excite suspicion against a perfectly chaste person :
for, although the result of impregnation in such
a case, they might obviously be no proof of a

* In Madame Boivin's work, p. 74, there is a table
showing the number of months which intervened in
thirty-two cases between the commencement of preg-
nancy and the expulsion of the hydatids. Some inter-
esting cases are detailed by Nanche in a well-written
article on this subject. See Maladies propres aux
Femmes, partie i. p. 182.

pregnancy occurring subsequently to the absence
of the husband.

3. Membranes expelled- in di/sinenorrlura. —
The circumstances attending dysmenorrhoea have
sometimes given rise to a suspicion of pregnancy
and early abortion, because the female may havo
pains resembling those of labour, accompanied by
red discharge, and followed by the expulsion of a
substance somewhat resembling the decidua. But
it only requires a little examination and inquiry
into circumstances to detect the difference be-
tween these two products and the real nature of
the case. In the first place, we learn that such
occurrences are habitual with the person at every
menstrual period; the. symptoms of pregnancy
have not been observed; nor does the state of the
breasts correspond to the existence of that condi-
tion. Again, the substance expelled in such
cases will be found deficient in several of the
characters of the true decidua : it is thin, flimsy,
and very unsubstantial in its texture, and has not
the vascularity, nor the foramina for the reception
of the nutrient vessels from the uterus, which are
so distinctly observable in the decidua vera; and
lastly, the most accurate examination will not
discover within it any of the transparent mem-
branes of the ovum. We cannot more appropri-
ately close these observations on this membrane
than by quoting the opinion of Denman, who, of
all the moderns, has best described it. " As the
first cases in which this membrane was discharged
were those of married women, a doubt arose in
my mind whether it was not really a consequence
of early conception: but I have lately had the
most undoubted proofs that it is sometimes dis-
charged by unmarried women, and may be formed
previous to and without connubial communica-
tion ; and that the uterus has occasionally or
constantly, in some women, the property of form-
ing it at or in the interval between the periods
of the menstrual discharges. It seems particu-
larly necessary to establish this fact, as the appear-
ance of this membrane has more than once given
rise to erroneous opinions and unjust aspersions.
Nor is this the only circumstance in which some
women, at each period of menstruation, have
symptoms like those which accompany pregnancy
or parturition." (Introduction to Midwifery, pp.
161-2.)

Accidental Circumstances. — Under this
head it is intended merely to notice certain pecu-
liarities sometimes observable in pregnant women,
which, although generally deserving but little atten-
tion in such an investigation, may still be remem-
bered with advantage on account of the constancy
with which they occur in particular individuals, and
the assistance which they may consequently afford
in confirming or modifying our opinion. Such is,
for instance, the alteration so often observed to take
place in the features and expression of the face,
which has been made a subject of remark since the
days of Hippocrates, who mentions it. The features
of the face in general become sharper, especially the
nose, which seems as if it were lengthened, and
the mouth appears larger ; the eyes are sunk, and
often surrounded with a brownish or livid areola,
and assume a languid expression. A marked
change in the temper is very commonly observed
also, so that a woman who was under ordinary

PJREGNANCY AND DELIVERY, (SIGNS OF)

679

circumstances extremely mild anil sweet-tempered,
becomes, when pregnant, irritable and capricious.
Strange appetites and antipathies are well known
as frequent attendants on pregnancy in many per-
sons, some of whom will long to eat unusual and
even revolting articles, while others, immediately
after conception, are seized with an unconquerable
aversion to species of food which were previously
particularly agreeable to them. We have seen
several well-marked instances of this, and in par-
ticular one, in the case of a lady who assured us
that she always knew when she was with child
by feeling a violent antipathy to wine* and tea,
which at other times she took with pleasure. We
had an opportunity of observing the accuracy of
this indication in three successive pregnancies of
the lady alluded to. (See Gardien, torn. i. p. 485.
Burns's Principles of Midwifery, p. 231. Den-
man, p. 232.) The occurrence of pains in the
teeth, face, and other situations, are with some the
invariable accompaniments of pregnancy. In
some women the same condition develops very
singular idiosyncrasies, such as the occurrence of
dark, blotches over the face and other parts of the
skin, an instance of which is at present exhibited
in a patient under the writer's care. Lecat relates
the case of a woman whose face in three succes-
sive pregnancies became quite black. (See other
instances by Gardien, loc. cit.) Camper observed
the same circumstance. The occurrence of sali-
vation in consequence of pregnancy has been
already noticed. Some women always have vari-
cose veins during gestation, who are not subject
to such an affection at any other time. Mr. Ash-
well mentions that in some individuals frightful
dreams have been found a very good diagnostic
sign ; and he informs us that Dr. Haighton used
to relate the case of a lady under Dr. Lowder's
care, who was compelled to hire a nurse to awake
her when her countenance became very much
discomposed. (Treatise on Parturition, &c. p.
171.) A very curious case is recorded by Dr.
Bennewitz in Osann's Clinical Report for 1823,
of a young woman who in three successive preg-
nancies was affected with diabetes mellitus which
completely ceased after delivery, but always re-
turned when she again conceived. (Edinburgh
Med. and Surg. Journ. vol. xxx. p. 217.) In first
pregnancies we can gain little or no information
from such accidental peculiarities, but their con-
stant occurrence in successive instances ought to
give them value in our eyes ; the degree of value,
however, must depend altogether on the distinct-
ness with which we can ascertain their existence,
or the reliance which we can place on the sincer-
ity of those who report them to us. (See Mahon,
torn. i. p. 162.)

The Blood, Urine, and Pulse. — It is very
generally asserted that the blood of pregnant
women ulways presents the buffy coat and other
fharacters of inflammation, (see Blackhall on
Dropsies, p. 279-80. Scudamore on the Blood,
P- 148,) and this change in that fluid is even
noticed by authors as one among the rational
evidences of pregnancy. (Gardien, vol. i. p. 487.)
The very general belief in this as a fact established,

*This particular aversion is expressly noticed by
flippocratis as a sign of pregnancy, "vinum odio
habept cibos aversanlur." De infecundis, cap. 6.

has probably arisen from the circumstance that
pregnant women are seldom bled except when
labouring under some form of inflammatory dis-
ease ; but experience has fully taught us that no
reliance whatever can be placed on the condition
of the blood as an evidence of pregnancy. It is
quite obvious that a woman exhibiting many of
the symptoms of pregnancy, and yet not with
child, may have her system under the influence
of inflammatory action sufficient to cause the ap-
pearance of the blood frequently noticed in preg-
nancy ; and on the other hand the blood of
pregnant women will be very often found not
presenting the characters supposed to be peculiar
to it. This we have seen proved in several in-
stances, and perfectly recollect the first case which
particularly arrested our attention on this point ;
it was that of a very fat and robust woman who
was seized with puerperal convulsions, and her
blood exhibited not the least trace of inflammatory
character. We have observed the same absence
of such an appearance in blood drawn in the
earlier periods of gestation to prevent abortion ;
and within the last few days we witnessed a very
satisfactory instance of the same kind in the case
of a lady in the ninth month of pregnancy, whom
we judged it expedient to bleed for a very dis-
tressing cough accompanied with pain in the
chest and great irritation of the bladder; the
abstraction of blood gave her the most immediate
and decided relief, but it appeared in every respect
perfectly natural and healthy.

A peculiarity in the urine of pregnant women
has long been a matter of popular belief; and
Savonarola, who wrote in 1486, gives a minute
detail of the changes which that secretion under-
goes in the different periods of pregnancy : up to
about the sixth month, according to this writer,
" the urine is clear, and of a pale citrine colour,
with a cloud on its surface ; and about the middle
of the fluid, a deposit like carded wool ; but as
pregnancy advances towards its close, the urine
becomes redder and turbid when stirred." This
condition of the urine Fodere thinks entitled to
consideration, having, as he says, "verified the
accuracy of the observation." (Med. Legale, torn,
i. p. 435.) Still more recently M. Nanche has
brought this subject before the profession. (See
the Lancette Franchise; also the Lancet, No.
417, p. 765.) He speaks of it as a discovery of
his own, and does not appear to be aware of the
observations previously made by others : his words
are : " By allowing the urine of pregnant women
or of nurses to stand for some time, in thirty or
forty hours a deposit takes place of white, flaky,
pulverulent, grumous matter, being the caseum or
peculiar principle of milk formed in the breasts
during gestation. The precipitation is more rea-
dily procured by adding a few drops of alcohol to
the urine." To this observation he subjoins a
very strong case, in which he ventured to affirm
the existence of pregnancy in a woman who was
subsequently examined, both per vaginam and
with the stethoscope, by several medical men, and
pronounced not to be with child ; but her delivery
shortly afterwards evinced the accuracy of his
previous diagnosis. The editor of the Lancet in-
forms us in a note, that he had « applied the test
in one case, and found it perfectly correct." We

680

PREGNANCY AND DELIVERY, (SIGNS OF)

have ourselves tried it in several instances, and the
result of our trials has been this ; in some in-
stances no opinion could be formed as to whether
the peculiar deposit existed or not, on account of
the deep colour and turbid condition of the urine ;
but in the cases in which the fluid was clear, and
pregnancy existing, the peculiar deposit was ob-
served in every instance ; and we think its appear-
ance would be best described by saying that it
looks as if a little milk had been thrown into the
urine, which having sunk through it, had partly
reached the bottom, while a part remained sus-
pended and floating through the lower part of the
fluid, in the form of a whitish, semi-transparent,
filmy cloud. And in some cases in which preg-
nancy was suspected, but did not exist, no such
deposit was observed ; but it is superfluous to say
that there is such a host of accidental causes
capable of altering the condition of the urine as
ought to make us very cautious indeed how we
ventured to attach credit to a symptom so equivo-
cal.

We may apply the same observation to the
state of the pulse, which has been made a subject
of remark since the days of Galen. We shall
only observe that in pregnant women the pulse is
almost always stronger and more rapid than is
natural to the individual at other times ; but we
cannot tell in a particular instance what may be
the exciting cause of the increased action ; we
cannot even be sure that it is not natural to the
person, and at all events we are certain that there
are a thousand circumstances of disease or acci-
dent which may equally produce it.

[Although a difference has been found to exist
between the urine of an impregnated and that of
a». unimpregnated, female, it has not generally
been found distinctive. M. Donne, indeed, (Ga-
zette Medicate de Paris, 29 Mai, 1841, and Cours
de Microscopie, Paris, 1844,) affirms, that during
pregnancy it contains less uric acid, and phosphate
of lime, than in the natural state, — a difference
which may be accounted for, on considering the
elements that are necessary for the formation of
the organs of the foetus. The crystallization of
the salts of the urine is thus so remarkably modi-
fied, that by simple inspection, without examining
the females, he has, in more than thirty cases, re-
cognised the state of pregnancy at different periods.
Of late years, the urine of the pregnant female has
been found to contain a peculiar substance, which,
when it is allowed to stand, separates and forms
a pellicle on the surface. To observe this, the
urine must be allowed to stand from two to six
days, when minute opaque bodies are observed to
rise from the bottom to the surface of the fluid,
where they gradually agglomerate, and form a
continuous layer over the surface, which is so
consistent, that it may be almost lifted off the
urine by raising it by one of its edges. To this
pellicle, the name Kiestcin, or more properly
Kyestein (from kvuv, < to be pregnant') has been
given. It is whitish, opalescent, slightly granu-
lar, and may be compared to the fatty substance,
which swims on the surface of soups, after they
have been allowed to cool. When examined by
Ihe microscope, it has the aspect of a gelatinous
mass without determinate form : at times, cubical
crystals are observed in it, but this appearance is

only seen when it has stood for a long time, and
may be esteemed foreign to it. The kiestcin re-
mains on the surface for several days ; the urine
then becomes turbid, and small opaque masses
are detached from the kicstein and fall to the
bottom of the fluid : the pellicle then soon becomes
destroyed. Various experiments have been made
on this matter by Nauche (La Lancctte Fran-
gaise, and Land. Lancet, cxvii. G75 ;) Eguisier,
(Ibid. Fevrier 21, 1829, and V 'Experience, 25
Juillet, 1839;) Dr. Golding Bird, (Guy's Hos-
pital Reports, April, 1840;) Mr. Letheby, (Land.
Med. Gaz, Dec. 24, 1841 ;) Dr. Stark, (Eilinh.
Med. and Surg. Journ., Jan. 1842 ;) Dr. E. K.
Kane, of Philadelphia, (Amer. Journ. of the Med.
Sciences, p. 37, Philad. 1842;) and, by Drs.
McPheters and Perry, resident physicians at the
Philadelphia Hospital, (Amer. Med. Intelligencer,
March 15, 1841, p. 369.) They show, that when
taken in conjunction with other phenomena, the
appearance of the kiestcin is certainly a great aid
in the diagnosis of pregnancy. Mr. Letheby
found unquestionable evidence of it in 48 out
of 50 cases between the second and ninth months
of utero-gestation, and was unable to account
for its absence in the two exceptions. The result
of Dr. Kane's observations, which the writer
had an opportunity of examining from time to
time, and for the accuracy of which he can
vouch, is stated by Dr. Kane as follows : First.
kiestein is not peculiar to pregnancy, but ma)
occur whenever the lacteal elements are secreted
without a free discharge from the mammse. Se-
condly. Although it is sometimes obscurely de-
veloped, and occasionally simulated by other pel-
licles, it is generally distinguishable from all
others. Thirdly. Where pregnancy is possible,
the exhibition of a clearly-defined kiesteinic pel-
licle is one of the least equivocal proofs of that
condition ; and fourthly, when the pellicle is not
found in the more advanced stages of supposed
pregnancy, the probabilities, if the female be other-
wise healthy, are as 20 to 1 (81 to 4) that the
prognosis is incorrect. The writer has distinctly
noticed, in some of the cases, the cheesy odour of
kiesteinic urine described by Dr. Bird. (See, on
all this subject, Huter, Art. Schwangersckuft.
Geburtshuljiich, in Encyclopad. Worterb. dtr
Medicinisch. Wissensch. xxx. 577, Berlin, 1843,
and Prof. T. R. Beck, in Amer. Journ. of the
Med. Sciences, Jan. 1843, p. 112.)]

Usual Conditions of the Female. — Before
entering on the last division of our subject, which
will treat of the post-mortem examination, it ap-
pears necessary to advert to certain conditions in
which a female may become pregnant, and her
case be thereby rendered more obscure ; as when,
for instance, conception takes place, — 1. in early
youth or advanced age ; 2. during the existence
of disease, especially of a kind calculated to pre-
vent conception, or to render its occurrence very
improbable ; 3. without the woman being con-
scious of having incurred the risk ; 4. under cir-
cumstances not likely to be followed by such a
result, as where copulation was only partially ac-
complished, &c, &c.

1. The age of the individual.— -This may be
such as, judging from what we observe in the or-
dinary course of nature, would appear either to

PREGNANCY AND DELIVERY, (SIGNS OF)

681

preclude the idea of impregnation, or at least to
render its occurrence extremely improbable. The
limits of the generative faculty in women are
generally those of the function of menstruation,
but in some rare instances women have been
known to conceive before the catamenia had be-
gun to appear, (see cases referred to under the
second section of this article, [also, the writer's
Human Pfiysiology, ii. 350, Philad. 1844,] and
after their cessation.

Conception before the age of fourteen is very
rare, but it appears that instances of it have oc-
curred. Bruce mentions that in Abyssinia he
has frequently seen mothers of eleven years of
age; and Dunlop witnessed the same in Bengal.
(Beck's Jurisprudence, page 82, note.) La Motte
delivered a girl who had not completed her thir-
teenth year. (Traile d'Accouch. obs. xxiii. p. 52.)
Instances of conception at nine and ten years of
age are recorded by Jubert Schwrigius (see Smith,
p. 493, note, and Ballard, note on Metzger, p.
485) and others, but they scarcely appear deserv-
ing of credit ; yet we find Dr. Good expressing
bis assent to such relations, and quoting Haller
(Vide Blumenbach, Bibl. i. p. 558) and Professor
Schmidt (Act. Helvet. iv. 162. Eph. Nat. Cur.
dec. iii. ann. ii. obs. 172) in support of them.
(Study of Medicine, vol. v. p. 157.) The earliest
instance of pregnancy known to the writer was
that of a young lady who brought forth twins be-
fore she had completed her fifteenth year. Sir E.
Home knew two instances, in one of which a girl
of thirteen, and in the other a girl of twelve, gave
birth to children. (Philosophical Transactions,
1819, p. 61.)

So also pregnancy very seldom occurs after
fifty, especially in women who have not previ-
ously borne children ; but instances have from
time to time occurred at unusually late periods in
women who had formerly conceived. In the state-
ment sent to parliament by Bartholomew Mosse
when endeavouring to procure a grant for the
Dublin Lying-in Hospital, he mentions that eighty-
four of the women delivered under his care were
between the ages of forty-one and fifty-four; four
of these were in their fifty-first year, and one in
ner fifty-fourth. (Case of Bartholomew Mosse
presented to the House of Commons, 1755). The
succession to an estate was disputed in France
because the mother was fifty-eight years old when
the child was born : the decision was in favour
of the fact. (Mem. de l'Academie de Chirurgie,
torn. vii. p. 27). Colomb adduces a similar case,
and Knebel (V. pol. ger. ek. i. p. 161) two, one
of fifty-two years, and the other of fifty-four, v In
May, 1816, Mrs. Ashley, wife of John Ashley,
grazier, of Firsby near Spilsby, at the age of fifty-
four was delivered of two female children, which
with the mother were likely to do well." (Edin-
burgh Annual Register, vol. ix. part 2, p. 508.)

While writing these observations, an eminent
accoucheur of Dublin (Dr. Labatt) informed us
that he some time since attended a lady who was
married when forty years of age, and that after
remaining barren for ten years, she conceived for
the first time when she was past fifty, went to her
full time, and after a difficult labour bore a living
child.
Capuron (Mcdecine Legale, &c, p. 92-3, and
Vol. III.— 86

98) quotes several cases of child-bearing in ad-
vanced age, among which are the following: —
Pliny records the case of Cornelia, of the family
of the Scipios, who at the age of sixty bore a son
who was named Volusius Saturninus. Marra, a
physician of Venice, mentions that he treated a
woman for dropsy who was really pregnant, and
he was deceived by her age, which was sixty.
La Motte tells of a woman who refused to marry
until she was fifty-one, in order that she might
escape child-bearing; but she was disappointed,
and bore a child. Valescus de Tarenta mentions
a woman who continued to menstruate beyond
sixty, at which age she bore her last child : Capu-
ron adds that it was generally believed in Paris
that a woman in the Rue Harpe bore a daughter
at the age of sixty-three, and nursed it.

The occurrence of such cases, however rare,
should at least have the effect of making us ex-
tremely cautious in pronouncing against preg-
nancy, merely because the individual may have
exceeded by ten or fifteen years the period of life
after which the generative faculty ordinarily ceases
to manifest itself; or because the woman may have
lived for many years a married life without con-
ceiving, and then show symptoms of pregnancy.
A highly interesting case of this kind is, at the
moment of writing this, under our care. A lady
now in her forty-third year, who was married to
her present husband twenty years ago, remained
without any promise of offspring until within the
last few months; but having missed her menstrua-
tion in September last, and finding her size in-
creasing, the writer was requested to see her in
January, when she exhibited evident symptoms
of pregnancy : she has since under the writer's
care been delivered of a healthy boy after a natu-
ral labour of about four hours. Dr. Gooch relates
a case almost exactly similar, which occurred in
" a woman of forty-two years of age, and who had
been married twenty-two years without ever being
pregnant," when she at length conceived, and
brought forth a child at the full time.*

2. Complication with Disease. — Pregnancy not
unfrequenlly takes place in diseased states of the
system, which would, a priori, render its occur-
rence very improbable, and which, when it does
occur under such circumstances, give rise to an
unusual difficulty in recognising its existence.
From this circumstance have from time to time
arisen some very lamentable mistakes in practice.
Thus women who have been long labouring under
a general infirmity of health and with very irregu-
lar menstruation, or even a total suppression of
that discharge, may conceive, and under such cir-
cumstances the phenomena of pregnancy are likely
to be much obscured, or even their existence at
all rendered very doubtful. Such a case is men-
tioned by Professor James of Philadelphia, in
which a woman conceived after having had the
menses suppressed for nearly two years before.
(Hosack's Med. and Phil. Register, vol. iv. p. 422.)
Diseases which increase the size of the abdomen,
as they on the one hand often induce the supposi-

* Diseases of Women, p. 220. The following is insert-
ed in the Scots Magazine for the year 1709, vol. xxxi.
p. 279, under the head of" Births :" '" May. At Doncar
ney in Ireland, in the 85th year of her age, the wife of
one Rogers, a labouring man, of a boy ! ! 1"

682

PREGNANCY AND DELIVERY, (SIGNS OF)

tion of pregnancy when it does not exist, so on
the other hand they sometimes render its detection
a matter of great embarrassment. Several in-
stances have occurred in which women labouring
under dropsy, even when the complaint was the
result of serious organic disease, and had existed
for a long time, have proved with child, and from
the combination of circumstances thus produced
great doubt and difficulty are likely to arise, espe-
cially when the woman is not herself aware of her
condition, as happened to the wife of the king's
council mentioned by Mauriceau, who was treated
during seven months of her pregnancy for dropsy,
and then brought forth a child. (Tom. i. p. 73.)
In some instances very grievous errors have been
committed. Mauriceau relates two cases of this
kind, in one of which the woman had been nine
years affected with dropsy in an extreme degree,
but had during that time given birth to four chil-
dren. (Maladies des Femmes grosses, torn. ii.
obs. 70 and 249.) M. Chamsern had a patient
who was tapped one hundred and sixty-nine times,
and during the course of the disease she bore and
suckled two children, though during each preg-
nancy it was found necessary to tap her three
times.* Fodere mentions two women who, being
pregnant, were tapped under the idea that they
had dropsy ; (Medecine Legale, torn. i. p. 463-4.)
the uterus fortunately was not wounded ; but in
another case of distended bladder accompanying
pregnancy and mistaken for dropsy, the practi-
tioner tapped the patient ; " death was the conse-
quence, and on examination it appeared that the
trochar had passed through both sides of the blad-
der, through the uterus, and even into the head
of the child." (Lowder's MS. Lectures, quoted
by Gooch, on Diseases of Females, p. 240 and
note.) Capuron mentions that Marsa, a physi-
cian of Venice, treated a woman for dropsy, who
was pregnant, being deceived by her age, which
was sixty.-j- In a case which occurred to the
writer, pregnancy remained a matter of the utmost
doubt until the seventh month ; the woman died
two days after delivery, and the liver was found
tuberculated, hard as cartilage, and diminished to
about one-third of its natural size. " The bare
possibility of such cases," says Gooch, " is a strong
reason for never tapping a married woman with-
out having the uterus previously examined by a
person skilful in such examinations." Beck makes
the following observations on this subject : " The
most difficult case of concealed pregnancy that
probably can occur, is when it is accompanied
with ascites. The motion of the foetus cannot be
perceived ; and it is added by Fodere, that the
uterus does not take on its ordinary development.
Yet many cases are on record where females with
this disease on them have been delivered of healthy
children. In suspected cases the practitioner should
weigh the symptoms and ascertain whether they
are all referable to the disease. His medicines

* Quoted by Fodere from the Bullet, des Sciences Med.
(TEvreux, 1810, No. 18, p. 135. See also Mr. LangstafFs
case, Med. Chir. Trans, vol. xii. p. 372, and another by
Scarpa in the Quarterly Journ. of For. Med. vol. i.
p. 149.

t Avenzoar has left a confession that he was deceived
about his own wife, whom he treated as dropsical, though
she had passed her fourth month of pregnancy. See Paris
and Fonblanque, vol. i. p. 288.

should be mild, and patience exercised as to the
event." (Elem. Jurisp. p. 81.)

Enlargement of the ovary is another disease
which may either simulate pregnancy or coexist
with it,+ and the abdominal enlargement increas-
ing may be mistaken for the progress of the dis-
ease ; when both ovaries are affected, pregnancy
is of course much more improbable, yet it has oc-
curred. Morgagni declares that even in disease
of both ovaries, if there remain healthy a portion
containing one vesicle, the woman may conceive.§
A case very lately occurred in this city, in which
a lady with ovarian enlargement at both sides,
and of considerable size, became pregnant, and
her true condition was not recognized until preg-
nancy was very far advanced, when the applica-
tion of the stethoscope detected the pulsations of
the foetal heart. Under such circumstances a
proper examination of the uterus per vaginam
ought to enable us to detect the nature of the case.
On the other hand, the existence of such a disease
has repeatedly given rise to the suspicion of preg-
nancy. In the celebrated case of the Demoiselle
Famin, published at Berlin and Paris by Valentin,
in 1768, a charge of pregnancy and child-murder
was erroneously instituted in consequence of an
extreme case of ovarian dropsy.

The writer had once an opportunity of examin-
ing a very remarkable case, which presented a
combination that could hardly fail to be attended
with infinite doubt. A woman was received into
the Cork-street Fever Hospital in 1828, with
considerable enlargement of the abdomen. Her
history, as far as it could be learned, was, that
eight years before she had been in labour, which,
after continuing for two days, suddenly ceased,
and the child, as she expressed herself, rose up
into her stomach : no delivery followed. After
remaining, in bad health for about two years, she
again experienced the symptoms of pregnancy,
and gave birth to a child, which did not survive;
but the former child still remained in the cavity
of the belly, and during its continuance there she
bore three children, the last of whom lived. Ulti-
mately a fistulous opening formed near the umbili-
cus, which was enlarged, and the original child
removed ; it was in a state of wonderful preserva-
tion, measured twenty-two inches in length, ana
had attached to it about two feet of the umbilical
cord. || Some of the most formidable diseases of
the uterus have been found not incompatible with
conception, and even the completion of the full
term of gestation. Thus, instances of the concur-
rence of polypus, uteri, and pregnancy have been
several times witnessed ;f and in some cases the
placenta has been found attached to the polypus.**
The writer has a preparation in which an early

% See Gooch, p. 239. Merriman's Synopsis, pp. 58 and
228.

§ See case by Mr. Hewlett, Med. Chir. Trans, vol. xvii.
p. 226.

|| A notice of this case was published by Dr. O'Reardon
in the Medico-Chirurgical Review for October, J828.

IT SeeGardien, torn. i. p. 443,— Gooch, Diseases of Fe-
males, p. 290,— Dr. Beatty in Trans. Assoc. Coll. Pays.
Ireland, vol. iv. p. 1. London Med. and Phys. Journal,
vol. xxvi.

** See Glasgow Medical Journal, vol. i. p. 422. Bach,
Mayor de Polypis, quoted by Cooper in the Surgical Dic-
tionary, article Polypus.

PREGNANCY AND DELIVERY, (SIGNS OF)

683

ovum is thus connected. Levret,* Bach, Joerg,
and Dr. Macfarlane have recorded cases in which
the foetus reached its full time under such circum-
stances. Even cancer and fungoid diseases of
the uterus have been proved not to prevent the
occurrence of pregnancy ,f and a scirrhous cervix
has been found an obstacle in the time of labour,*
Gardien expressly states that numerous facts
within his knowledge have proved to him that
women may carry their children to the full time
although labouring under cancer in the ulcerated
stated

Women have been impregnated although af-
flicted with complete external prolapse of the
uterus. M. Guillemot has written a very interest-
ing paper on this subject, in which he has col-
lected from various sources nine cases of the kind,
the first two of which are particularly remarkable
as examples of gestation accomplished where the
prolapse was complete. (Quoted from, 1. Archives
de la Soc. d'Emulation. 2. Journal de Med. et de
Chirurgie for 1775.) In the third case impregna-
tion occurred while the uterus was completely
external. || Another of the cases happened in the
practice of the great Harvey, who gives us the
following account of the matter : " And now at
this time it was large and dangling between her
leggs. It grew at last bigger than a man's head,
being then a hard tumour, and hanging downe to
her knees did much pain her, so that she could
not goe but upon all foure. I did suspect it to
be a cancer of the wombe, and therefore did be-
think my selfe of a ligature and cutting it off:
but the following night an infant perfectly shaped,
of a span long, was cast out of that tumour, but
it was dead." (Anatomical Exercitations con-
cerning the Generation of living Creatures, p.
494.)

We have thought it advisable thus to enter
fully into the statement of such unusual condi-
tions, lest a proposition on our part against the
possibility of such occurrences should act un-
favourably, either by closing our eyes against the
evidence before us in extraordinary cases, or
making us less careful in their examination from
a pre-conviction that pregnancy could not under
such circumstances exist.

3. Conception without the knowledge of the
woman. — That a married woman, or any female
who has indulged in sexual intercourse, may be-
come pregnant without being aware of her condi-
tion, is a fact too notorious to require further

* M6m.de 1' Acad. Chir. vol. iii. p. 543.

t See case by Dr. Realty, Trans. Assoc. Coll. Pliys. vol.
i. New Series, p. ] 16-7.

{See Burns's Principles of Midwifery, 7th edition, p.
96, note, and p. 401. — Clarke on Diseases of Females,
part i. p. 213.— Dcninan's Introduction, &c. ed. 5. p. 363.
A most remarkable case of this kind has been recorded
l>y M. Neyzonis, in which the woman died undelivered;
the parietes of the uterus were found carcinomatous, and
three inches thick near the fundus. Diet, des Sciences
Med. torn. iv. p 237.

§ Traite d'Accouch. vol. i. p. 430.— See Raige Delorme,
Diet, de Med. torn. x. p. 464.

[From Chopart, Malad. des Voies Urinaires, vol. i. p.
3B9, note. Tho circumstances of this case were very
remarkable. The woman was married at twenty years
of age, and during twenty-one years " son mari fit des
tcni.itives infructueuses pour la rendre mere; enfin au
bout de ce terns-la, il paiyint a dilater l'oriflce de la ma-
trice qui 6toit hors des grandes levres, et consomma
IVBiivre de la generation." The account of the labour
and delivery, &c. are full of interest.

observation than the mere mention of it . the
question which we propose to consider here is, —
can a woman become pregnant in consequence of
intercourse, of the occurrence of which she was
not conscious, and so find herself with child with-
out being aware of having incurred the risk ?
Improbable or even absurd as such a supposition
may at first sight appear, the possibility of such
an accident is established by too many facts testi-
fied by high authority, to permit incredulity on
the subject. The belief that consent and pleasur-
able sensation on the part of the woman are con-
ditions necessary to conception is now universally
known to be without foundation in nature, and
of course no longer influences legal decisions :
formerly, however, it was otherwise, so that in
case of rape, if pregnancy followed, it was pre-
sumed to prove consent, and it was so laid down
by Dalton ; (Dalton, c. 160. See also, 2 Just.
190,) but Lord Hale says that this opinion of
Dalton seems to be no law. (I. H. H. 131. See
also, MSS. Sum 334.) « That so absurd a no-
tion as that conception evidenced consent should
in modern times have obtained amongst any
whose education and intellect were superior to
those of an old nurse, is indeed surprising ; at this
day, however, facts and theory concur to prove
that the assentation of nature in this respect is no
ways connected with volition of mind." (Burn's
Justice, tit. Rape.) « It is a fact," says Capuron,
" which experience has more than once confirmed,
that a woman may become with child while in a
state of hysteria, under the influence of narcotics,
during asphyxia, drunkenness, or deep sleep, and
consequently without being conscious of it, or
sharing the enjoyment of the man who dishonours
her ;" and in proof he mentions having attended
a young woman who was got with child while
totally unconscious, being buried in a deep sleep
produced by punch given her by her paramour.
(See Med. Leg. relat. aux Accouchemens, pp. 57,
84.) She became aware of her condition for tho
first time when she felt the sensation of motion in
the fourth month. Fodere expresses a similar
opinion, and quotes several instances in which
the occurrence took place, one of which is parti-
cularly remarkable. (Medecine Legale, torn. i.
pp. 497 et seq.) MM. Marc (Diet, de Med. torn.
xxi. p. 358-9,) and Raige Delorme (Diet, de Med.
torn. x. p. 465-6. See, also, Smith, Forens. Med.
p. 401,) speak of such a fact as established by
experience. Dr. Gooch says, " it is not necessary
that the woman should be sensible at the time of
impregnation," to which observation the following
case is subjoined : " A maid at an inn, who was
always thought to be virtuous, and bore a good
character, began to enlarge in a way which ex-
cited suspicions of pregnancy ; she solemnly de-
clared that she never had connection with any
man. At length she was delivered, and was
afterwards brought before a magistrate to swear
to the father ; but she repeated her former declara-
tion. Not long afterwards a postboy related the
following circumstances : that one night he came
late to this inn, put his horses into the stable, and
went into the house ;• he found all gone to bed
except this girl, who was lying asleep on the
hearth-rug, and without waking her he contrived
to gratify his desires." " This shows," he adds

684

PREGNANCY AND DELIVERY, (SIGNS OF)

« that impregnation may take place without the
knowledge of the female." (Compendium of
Midwifery, p. 81-2.)

In reference to this question Beck remarks, « In
females habituated to sexual connection, or where
sleep is unnaturally produced, there is no doubt
of its occurring ; whereas in the opposite cases the
probability is greatly lessened ;" (Elem. Med.
Jurisp. p. 92) ; and in a note on this passage he
quotes the following case : " A pregnant female in
her last moments solemnly declared that to her
knowledge she never had connection, but that a
person in the family some time previous had
given her some wine to drink, after which she
fell into a profound sleep. She was not, however,
conscious of any thing having occurred during
that state, but mentioned the circumstance as
probably explaining her situation." (Mierius in
Brendel, p. 99.) A case very much resembling
that related by Dr. Gooch has just been mentioned
to the writer by Mr. Cusack, which occurred under
his own observation. A servant woman at an
hotel in Neaugh proved pregnant, and solemnly
declared that she was not conscious of having had
intercourse with any man. Suspicion, however,
fell upon an hostler in the establishment, who
subsequently acknowledged that he believed he
was the father of the child ; that having found the
woman in a deep sleep from fatigue, caused by
long-continued exertion and being kept out of bed
two or three nights in succession, he had connec-
tion with her, and, as he believed, totally without
her knowledge, as she did not evince the slightest
consciousness of the act at the time, or recollection
of its occurrence afterwards ; the parties were
married with mutual consent.

We once attended a patient who even in her
dying hour protested in the most solemn manner
that she was not conscious of sexual intercourse;
and when we recollect that delivery has occurred
during sleep, we cannot doubt but that coition,
which is so much less likely to disturb, may be
consummated during sleep with a female accus-
tomed to sexual indulgence without her being
afterwards aware of it. That such an event
must be of very rare occurrence is certain, but we
cannot deny its possibility, and therefore we are
furnished with an additional reason for refusing
implicit assent to the statements of females, who,
as they will in ordinary cases of illegitimate preg-
nancy deny the possibility of their condition with
the most unparalleled effrontery and the most
solemn and imposing protestations, so should we,
on the other hand, recollect that impregnation
may possibly have been effected without their
knowledge ; so that, however highly we may
esteem their general credibility in other matters,
in this they may either try to deceive us or be
themselves deceived ; we must therefore form our
opinion not by what we hear, but by what we
can see and feel.

[Yet the cases adduced of conception without
consciousness of intercourse on the part of the
female are few, and by no means overwhelm-
ing. If, indeed, it be requisite, that through
venereal excitement, the Fallopian tubes must
embrace the ovary, in order that the sperm may
reach trie ovary and impregnate an ovum, it is
difficult to comprehend how conception can take

place without some feeling on the part of the
female.]

The following case is quoted by Bruhier,
Fodere, (Medecine Legale, torn. i. p. 500-1,) and
others, (Louis, Lettre sur la certitude des Signes de
la Mort,) from the Causes Celebres, to show the
possibility of conception during a state of complete
asphyxia or apparent death. " A young friar
being on a journey, arrived at a house where they
were about to bury a young girl, whom they be-
lieved to be dead. He proposed to pass the night
in the chamber with the coffin and watch the
body. In the course of the night, while examin-
ing the body, his passions were so excited by the
beauty still remaining, that he determined on
satisfying them even under such circumstances.
He departed early next morning, and in the course
of the day the apparently dead revived, proved to
be pregnant, and at the end of nine months brought
forth a child, to the great amazement of her friends
as well as her own. The friar returned to the
place about this time, confessed himself the father
of the child, and married the mother, having pro-
cured absolution from his vows, which he had
taken against his will."

4. Presence or absence of the hymen. — It seems
almost unnecessary to remark that the presence
of the hymen, however perfect its condition, can-
not be assumed or depended on as a conclusive
proof against the previous occurrence of impreg-
nation, for although it certainly ought to be con-
sidered as strong presumptive evidence in favour
of virginity, so many cases have been witnessed
and put on record by authors worthy of credit, in
which that membrane has been found coexisting,
not alone with pregnancy, but even with labour,
that the fact no longer remains a matter of doubt,
Meckel (Anatomie Descriptive, &c. vol. iii. p.
735,) remarks that " the hymen cannot be con-
sidered a certain physical sign of virginity, because,
on the one hand, it has been often found entire
not only in women who had frequently indulged
in sexual intercourse,* but even in some who
had brought forth foetuses advanced even so far
as the seventh month."f The writer was once
consulted by a young person whom he found to
be pregnant, but whose hymen was as perfect as
it had probably ever been ; but the opening through
it was such as to admit the finger to pass without
difficulty, and the girl acknowledged that she had
on more than one or two occasions enjoyed the
embraces of a very young gentleman, on whose
youth it appeared she had relied for immunity
from the usual consequences.} The existence of
the hymen at the time of labour has been detailed
by Ambrose Pare, Willis, Ruysch, Ncegele, Bau-
delocque, (Art des Accouchement, vol. i. ch. 3,)
Mauriceau,§ and many others : the cases related
by the last two are particularly remarkable. Dr.

* Osiander. Abhandlung iiber die Scheidenklappe, p
24. " Miles causes 6trangeres an coit penvent ledeiruire,
et que la copulation n'en determine pas toujours la rup-
ture." Velpeau, torn. i. p. 63. See also Metzger, by
Ballard, pp. 251-2.

t Tolberg de Varietate Hymenum, p. 14. Meckle say*
he has the part in his museum.

\ See Wm. Hunter's case in Observations on the areola
in the present article.

§ Maladies des Fcmmes Grosses, torn. ii. obs. 489, p.
405, and obs. 583.

PREGNANCY AND DELIVERY, (SIGNS OF)

685

Davis* also refers to more than one case of this
kind. Velpeau (Traite d'Accouch. torn. i. pp.
63-4,) mentions having met with the hymen entire
in the body of a woman of forty, " who had long
cohabited with her husband, but without having
children." The writer once witnessed a similar
case in an old lady of 80, who had been married and
lived thirty years with her husband without having
children: when visited by the writer, she had been
Borne years a widow, and examination of the parts be-
came necessary in consequence of an affection of the
urethra ; the hymen would not permit the passage
of the point of the little finger without difficulty.

On the other hand we believe it is a matter of
universal agreement, that there are many causes
besides sexual intercourse capable of destroying
this membrane, which there is also good reason
for believing may in some cases have been origin-
ally defective from imperfect conformation of the
part. (See Meckel, loc. cit.) In another part
of this article the imperforate hymen has been
noticed, and its effect in inducing suspicion of
pregnancy by preventing the discharge of the
catamenia. And it is scarcely necessary to ob-
serve here, that in such a case the mere discovery
of the obstacle would be proof positive against
the condition suspected. Among the Jews a dis-
charge of blood as the consequence of the lacera-
tion of the hymen in primis nuptiis, was consid-
ered so unequivocally the test of virginity, that it
was made a subject of legislation, and the woman
to whom this did not happen was liable to be
stoned to death. (Deuteronomy, chap, xxii.)
Gardien mentions that the Jewish custom prevails
to a certain extent at the present day amongst the
Bedouin Arabs ; and Mahon, on the authority of
Chappe, speaks of a similar custom as at present
existing in Siberia and in certain parts of Russia.
(Medecine Legale, torn. i. p. 123.) It has been
remarked by Fodere, Mahon, and others, that the
state of the hymen may vary much in the same
individual at different times and under different
circumstances ; and the latter mentions a case
where a man not finding it existing in his bride
took great offence, but afterwards finding a totally
different condition of the part, recognised his
error and was satisfied. (Loc. cit. p. 121.)
Marc has recorded a very remarkable case illus-
trative of this, and, as he says, " showing that,
when the hymen is of the semilunar form, it may
disappear for a time, and return again." (See the
statement of Buffon, as quoted by Mahon, torn,
i. p. 127-9.) "A young girl, not 13 years of
age, formed an illicit intercourse with a man, in
consequence of which she was severely affected
with syphilis, for the cure of which she was
brought to the hospital of La Pitie: on exami-
nation by Dr. Serres and others, there was found
extreme dilatation of the vagina, injury of the
external genitals, and total absence of the hymen :
she was cured, and then they were greatly aston-
ished to find all the physical marks of virginity
existing, especially a well-marked semilunar hy-
men. MM. le Doctcur Fournier, Pescay, and

* Principles of Ob9tetric Medicine, p. 104. See also
Omen's Compendium of Midwifery, p. 81, and Paris and
Fnnblannue, vnl. i. p. 203. Several similar cases are
mentioned in Merriman's Synopsisof difficult parturition,
see pp. 58 and 228, 4th ed. See also Smellie, Collect,
xxxi. case -JO, p. 62.

3h

Marc were appointed by the Medical Society of
Emulation to examine the fact." (Diet, de Med*
Art. Violation, by Marc. vol. xxi. pp. 353-4.)

As a suitable conclusion to this section we shall
notice a very remarkable case recorded by Nysten,
forcibly illustrating the necessity of attending. to
these unusual conditions, as not being incompati-
ble with pregnancy, which in the case alluded to
occurred in combination with several such. In
this instance, 1. the pregnancy was ovarian ; 2.
the girl was only thirteen years old; 3. she had
never menstruated ; 4. the hymen was perfect ;
5. the vagina so contracted that it would scarcely
admit the tip of the finger ; 6. the organs of
generation and the breasts like those of child-
hood." (Journal de Medecine par MM. Corvi-
sart et Leroux, brumaire, an 11. p. 144, et seq.)

Examination of tile Uterus and its ap-
pendages after death. — It is unnecessary to
repeat here what has been already particularly set
forth with regard to the state of enlargement in
which the uterus must be when containing the
product of conception. In relation to our present
subject, the first and most obvious fact to be
noticed is, that when an examination is made after
death, and the uterus found of its naturally dimi-
nutive size, it is proof positive against the present
existence of pregnancy. If, on the other hand,
we find the organ enlarged, and its condition ap-
parently corresponding to the period of pregnancy
supposed to exist, nothing but a careful examina-
tion of its contents, or other cause of enlargement,
can determine the question at issue. We will
here only observe that nothing less than the dis-
tinct and unequivocal detection of the ovum or
some of its component structures ought to satisfy
our minds, or justify us in giving an opinion in
the affirmative. (See section on Substances ex-
pelled from the uterus.)

Another condition of the uterus which may
present itself, is that in which it is found enlarged
but empty, exhibiting, however, several of the
changes which accompany gestation : these, how-
ever, upon examination will only afford evidence
sufficient to convince us that the organ has
recently been distended by something contained
within it, and which had been attached to its
internal surface by a vascular connection : the
substance expelled may or may not have been
the product of conception ; and the most careful
examination of the appearances remaining, or of
the structural changes effected, will not enable us
to pronounce safely on the precise nature of the
cause which had produced them. Thus, for in-
stance, in a case where hydatids have been ex-
pelled, we could not determine by examination of
the uterus alone, whether the conditions there
observable were the result of true pregnancy and
the expulsion of a foetus or ovum, or whether they
might not have been produced by some other
cause unconnected with conception : we may not,
in fact, be able to tell without further investiga-
tion whether the woman have recently conceived
or not, a question which it may be occasionally
of paramount importance to be able to answer •
we must therefore turn our attention in another
direction, and seek for proof of impregnation in
the appendages, particularly in that part of them
which is more especially the seat of conception.

686

PREGNANCY AND DELIVERY, (SIGNS OF)

This leads us at once to investigate the value of
that peculiar change in the ovary, by which, after
the vivification of the germ, there is produced a
new structure, to which has been applied the
name of corpus glandulosum, or more generally,
corpus luteum, — a production the presence of
which is by some considered incontrovertible
evidence of impregnation. Others, however, with
equal confidence discredit the value of its pre-
sence, and assert that its existence may be owing
to causes altogether accidental and independent
of sexual intercourse, and that consequently it
cannot be taken as certain evidence of conception.
It becomes, therefore, a matter of vital moment to
examine the truth of such assertions, and to deter-
mine, if we can, how far they coincide with or
depart from absolute matter of fact, which alone
can be the measure of their correctness, and con-
sequently of their value. In order to do this, the
first thing which appears to us essentially neces-
sary is, that we should have a clear idea of what
a true corpus luteum is, and of what is not a cor-
pus luteum.

If this inquiry should appear to any one super-
fluous, it is only necessary to turn to the gene-
rality of books in which it is mentioned, and then
compare the descriptions to be found there with
the object as it exists in nature, and we must be
convinced how faint is the resemblance between
the portrait and the original. We are inclined to
think that the naming of this substance has given
rise to much of the error which exists and is pro-
pagated on the subject, the colour being assumed
as the only characteristic necessary to constitute
the corpus luteum. Whenever small spots, or
even points, of a yellow hue are met with in the
ovaries, they are supposed to be true corpora
lutea. We recollect distinctly the first time our
attention was drawn to the subject was at a de-
monstration of the structure of the ovaries, when
two spots, each not larger than a grain of mustard-
seed, and of a yellow colour, were exhibited as
specimens of corpora lutea, and as proving that
the woman had, during her life, borne two chil-
dren.

A trial took place some years ago in Edin-
burgh, which, while it evinced the necessity for a
correct knowledge of this subject, which might
occasionally arise even under circumstances not
apparently connected with its existence, proved
but too plainly how little was known about it.
A prosecution was instituted against four medical
students for exhuming the body of a lady in Glas-
gow. The body was so disfigured that it could
not be identified : the ovaries were, however,
examined, and it was reported that there was in
one of them a perfect corpus luteum, which would
be sufficient to prove that the remains were not
those of the lady in question, who was a virgin,
and advanced in life. On the trial there was a
complete contradiction between the medical wit-
nesses, one-half of whom affirmed the appearance
in the ovary to be a true corpus luteum, while
the others maintained that it was not ; so that no
satisfactory inference could be drawn from the
fact. The body was afterwards identified by a
dentist producing a cast which he had taken of
the gums.

If we examine the ovaries of a woman who has

recently conceived, we observe that the one which
has supplied the germ differs In several remarkable
particulars from its fellow of the opposite side : it
strikes the eye at once as being larger and more
vascular ; to the touch it feels fuller and softer :
we perceive further, that this increase of size of
the one is not so much the result of an increased
development of the whole substance or body of
the organ, as of the addition to it at one part, of a
tumour projecting mors or less from its natural
outline, as we find in the eye, where the circum-
ference of the cornea projects from the outline of
the globe, the segment of a smaller circle being
superimposed on that of a greater.

When we examine this protuberance, we find
that the increased vascularity of the organ is
nearly confined to its limits, and very frequently
we perceive that the colour of this part is com-
pletely different from the rest of the substance,
giving the notion of deep or dull yellow seen
through a slightly reddish medium; and lastly,
we observe on some part of the external covering
of this prominent part a distinct cicatrix, or ap-
pearance as of a rent imperfectly united.*

We should observe here that these external
changes by which we recognise the existence of
the corpus luteum within, are to be seen most re-
markably in some of the lower animals. In cows
it is not unusual to see the corpus luteum project-
ing almost like a parasitic tumour from the side or
cud of the ovary ; the same may be said of the
sheep, and of animals which naturally have the
Graafian vesicles very prominent, as the hedgehog
or common sow, in which they absolutely project
from the surface : in this animal the ovaries after
conception appear literally like bunches of round
berries, from the great prominence of the nume-
rous corpora lutea.

Having satisfied ourselves of the presence of
the external characters, we proceed to examine the
internal structure ; in order to do which we should
make a section of the ovary, carrying the knife
through the centre of the prominent part so as to
divide the ovary into two longitudinal sections, by
which we expose the corpus luteum presenting
the following characteristic appearances.

In form and size it is almost always an oval,
with its longer axis varying from four to five
eighths of an inch, and the shorter from three to
four eighths ; its thickness is generally less than
its breadth.j-

Its texture is obviously and strikingly glandu-
lar, resembling a section of the human kidney ;
(see De Graaf, p. 177) ; or, as some one has said,
it is like a miniature of the particular sections of
the brain called by anatomists centrum ovale.
William Hunter describes it as " tender and fria-
ble, like glandular flesh." (Anatomy of the Gra-
vid Uterus, p. 14.)

*In the case examined by Sir E. Home and Mr. Clift,
where the woman died eight days after impregnation
was supposed to have taken place, " the right ovarium
had a small torn orifice upon the most prominent part
of its external surface. We slit it open in a longitudinal
direction, in a line close to the edge of this orifice ; the
orifice was found to lead to a cavity filled up with
coagulated blood, and surrounded by a yellowish or-
ganized substance." Philos. Trans. 1817, p. 254.

■f " Pene hemisphericum, :t vellante mole." Haller. —
" Longum quatuor lineas, latum ternas lineas, crassum
duas lineas." Rtzdcrtr.

PREGNANCY AND DELIVERY, (SIGNS OF)

687

It is very vascular, small vessels being very
frequently visible without any preparation ; but
if fine-coloured injections have been previously
thrown into one of the branches of the spermatic
arteries going to the ovary, the vessels of the cor-
pus luteum will be filled with the colouring mat-
ter, and are to be seen very distinctly running from
its circumference towards its centre.

Its colour is, as its name implies, a dull yel-
low, very similar to that of the buffy coat of the
blood ; exhibiting generally, when recently ex-
posed, a slightly reddish tinge, " ex Jlavo rubens,"
Haller.

Its centre exhibits either a cavity or a radiated
white cicatrix according to the period at which
the examination is made: if within the first three
or four months after conception, we shall frequent-
ly find the cavity still existing, and of such a size
as to be capable of containing a grain of wheat ; *
this cavity is surrounded by a strong white cyst,
and as gestation proceeds, the opposite parts of
this cyst approximate and at length close toge-
ther, by which the cavity is completely obliterated,
and in its place there remains a white cicatrix,
whose form is best expressed by calling it radiated.
Of this latter appearance it ought to be observed
here that it is visible as long as any distinct trace
of the corpus luteum remains, and forms an essen-
tial character, distinguishing this body from every
other that might be confounded with it.

After the period of gestation has been completed,
or the contents of the uterus prematurely expelled,
so that gestation ceases, the corpus luteum soon
begins to exhibit a very decided alteration in all
its characters, until at length it is no longer to be
found in the ovary. The exact period of its total
disappearance we are unable to state ; but we have
found it distinctly visible so late as at the end of
five months after delivery at the full time, but not
beyond this period ; and the corpus luteum of a
preceding conception is never to be found along
with that of a more recent, when gestation has
arrived at its full term ; but in cases of miscarriage
repeated at short intervals, it may. At the time
of delivery the corpus luteum is neither so large
nor so vascular as at the earlier periods of preg-
nancy, except the woman should happen at the
time of her death to be labouring under inflamma-
tion of the uterine system, in which case the cor-
pus luteum partakes of the turgescence of the other
parts, and very remarkably of their increased vas-
cularity.

In the ovary of a woman who died of inflam-
mation of the womb a few days after delivery, and
which is preserved in the writer's museum, the
white central cicatrix is very distinct, and exter-
nally the ovary continues to exhibit the superfi-
cial cicatrix and the alteration of form produced
by the projection of the part containing the corpus
luteum. In another preparation, which shows the
appearance of the corpus luteum in a woman who
died of pneumonia exactly five weeks after de-
livery at the full time, it is diminished in size to
about one-half of its original dimensions, is closer
in its texture, and its colour was becoming indis-

* "Cavea dimidiam lineam lata, non profunda," Haller.
We once met with this central cavity in the ovary of a
cow recently impregnated, large enough to receive the
end of the little linger.

tinct in numerous points, so that it appeared paler,
but the radiated central cicatrix is quite distinct ;
its vascularity also was diminished, as fine injec-
tion could not be got to pass into it : the external
surface of the ovary exhibits the greater size and
prominence of one part, and the fissure on it is
still well marked ; and it is particularly deserving
of remark here that there is only one cicatrix ob-
servable on each ovary, although the woman from
whom they were taken had borne six children.

In another specimen in our collection, taken
from the body of a woman who died in the twelfth
week after delivery, the external prominence was
greatly diminished, but was still sufficiently obvi-
ous to indicate the exact situation of the corpus
luteum, as was also the superficial cicatrix ; the
corpus luteum itself had lost much of its colour,
and what remained became, on immersion into
spirits, of a light grey shade ; the texture of its
substance was more condensed, and resembled that
of a cut apple ; and its dimensions, especially in
breadth, are reduced to about one-third or rather
less, but the central radiated cicatrix is still dis-
tinctly observable.

Lastly, in the case of a young woman who died
Jive months after giving birth to her first child,
the ovary retained very little of its increased size
or altered form ; the prominence was hardly to be
recognised ; but the external cicatrix was perfectly
obvious. When opened, the corpus luteum exhi-
bited its peculiar colour only in one very small
spot, rather larger than a mustard-seed, within
which is still observable the central radiated cica-
trix ; the yellow colour completely disappeared
when immersed in perfectly pure rectified spirit
diluted with water.-f- Beyond this period we have
never detected the existence of the corpus luteum :
the vulgar notion, however, is that it is a perma-
nent structure, and that consequently we have only
to examine the ovaries after death to enable us to
tell not only whether a woman has borne children,
but the exact number of her offspring, from the
number of corpora lutea existing in the ovary.
This is quite an error, and probably arose from a
misconception of the meaning of such an expres-
sion as that of Haller, when he says — " Numerum
credo eundem esse, qui est fcetuum," (Elem. Phy-
siologic, vol. viii. p. 36) ; or, as in another place,
" Numerus corporum luteorum est in ratione fce-
tuum." (Op. Min. vol. ii. p. 457.) By this expres-
sion, however, he only meant that their number
was the same as that of the foetuses lodged in
utero in one gestation, which indeed we find ex-
pressly stated by De Graaf, whose words are —
" Deteguntur, unus aut plures, prout animal ex
illo congressu unum aut plures foetus in lucem
edet." (DeOrganisMulierumGenerat. &c.p. 178.)
Hence, when there is only one fetus, there is only
one corpus luteum. In cases of twins or three
children, there will be a corresponding number of
these bodies in the ovary or ovaries, for they may
be all formed in one ovary only, or some in each.
This suggests a circumstance of very great im-
portance connected with the number of these
bodies which may be found ; which is, that occa-
sionally a corpus luteum may be discovered with-

f This does not happen when tin' corpus luteum, taken
during gestation, or just at the time of delivery, is place'.!
in contact with the same fluid:

PREGNANCY AND DELIVERY, (SIGNS OF)

out a foetus, or a greater number of them than
there are foetuses produced at the time. Thus, in
one instance we found two corpora lutea in the
ovary of a woman who killed herself by medicine
taken to produce abortion. She was reported to
have expelled but one ovum. Haller notices this
occasional occurrence, and explains it thus ; " Si
unquam absque foetu corpus luteum in ovaria re-
pertum est, quod est rarissimum, credibile est eum
foetum abortu perditum aut alio modo destructum
disparuisse." (Elem. Physiologix, vol. viii. p. 36.)
We have had several opportunities of verifying
this observation, and, amongst other instances, we
once found ten corpora lutea in the ovaries of a
sow, but only nine foetuses in the uterus ; but at
length, after a very diligent search, we discovered
in one of the cornea the remains of another foetus
which had been blighted and was in a state of
partial decomposition. Haighton also observed
this occurrence, but adds that " the uterus in these
cases has borne the marks of an early and recent
abortion," (Philosophical Transactions for 1797,
p. 166); and Cruikshank, as mentioned in another
place, speaks of the corpus luteum as a certain
mark of conception, " whether the embryo is visi-
ble or not." (Philosophical Transactions. 1797, p.
200.) We may remark that from such facts follows
of necessity this circumscription of the conclusion
to be drawn from what we may observe in the
ovaries, — viz. that the presence of a corpus luteum
does not prove that a woman has borne a child,
although it would be a decided proof that she had
been impregnated and had conceived ; because it
is quite obvious that the ovum, after its vivifica-
tion, may be, from a great variety of causes,
blighted and destroyed long before the foetus has
acquired any distinct form. But the converse will
not hold good. We believe no one ever found a
foetus in utero without a corpus luteum in the
ovary, and that the truth of Haller's corollary,
" nullus unquam conceptus est absque corpore lu-
teo," (Opera Minora, vol. ii. p. 458,) remains un-
disputed.

Considering the results constantly presented to
us by examination, we feel utterly at a loss to im-
agine what could have induced the following asser-
tion of Sir E. Home : « The remains of the cor-
pus luteum at nine months after impregnation of
the ovum, are so indistinct as hardly to be recog-
nised ; but in the opposite ovarium there is com-
monly a corpus luteum far advanced, forming an-
other ovum ; and it will be found that all the
preparations of corpora lutea taken from the ova-
ria of women who die in childbed, actually belong
to this new ovum not yet completely formed."
(Philosophical Transactions, 1819, p. 63.) Now,
our experience convinces us of the contrary of
every statement here made, and we think that one
question will be sufficient of itself to show their
inaccuracy : premising that we deny altogether
the statement that there is " commonly" found a
second corpus luteum, we ask, if this corpus luteum
always found in the ovaria of women who die in
childbed belongs to the ovum not yet completely
formed, how does it happen that we always find
on its surface the cicatrix through which the ovum
has already escaped 1

A similar and equally erroneous idea obtains
very generally with regard to the cicatrices on the

surface of the ovaries, which have been already
noticed as marking the situation of the corpus lu»
teum. These arc supposed by many to be perma-
nent and ineffaceable, and of course certain indi-
cations of the number of children borne by the
woman during her life, or of the number of times
she had conceived. But such is not the case; the
ovaries of women who have borne several children
will sometimes be found exhibiting only one or
two of these rents or marks on the surface, a very
distinct instance of which has been already no-
ticed ; the woman in this case having given birth
to six children, and yet the ovaries exhibited only
one cicatrix on each. On the other hand the
effects of inflammation, or the bursting of small
abscesses in the ovary, may produce cicatrices
which cannot be distinguished from those which
are caused by the escape of the impregnated ovum.
There is a passage in Beck's Jurisprudence which
evinces extremely little practical acquaintance with
the subject, implying one error, and distinctly as-
serting another. His words are, " Upon examin-
ing the ovaria, if it be done a short time after the
ovum has escaped from them, a corpus luteum is
generally found, which vanishes soon after, but
leaves a scar for life." (Medical Jurisprudence, p.
140.) Dr. Smith appears to confound the cicatrix
with the corpus luteum itself, in the following
passage : " In the place from which one of these
bodies (ova) had been conveyed, a cicatrix was
formed which received the name of corpus luteum."
(Principles of Forensic Medicine, p. 489. ed.
1821.)

Having thus far described the characters of the
true corpus luteum as accurately as repeated ob-
servations and dissections of a great number of
women, and a much larger number of brute ani-
mals, have enabled us, we wish to declare, first,
that we never in any one instance saw the corpus
luteum, having the characters we have described
as belonging to it, except in females who had pre-
viously been impregnated and had conceived ; and
our firm conviction is, that such a corpus luteum
was never found in a virgin animal.

As, however, different opinions have been en-
tertained on this subject, it becomes necessary to
examine them and ascertain their value. The
views entertained by those who deny the necessary
connection between the formation of the corpus
luteum and sexual intercourse followed by con-
ception, are principally two. According to the
one, the corpus luteum is a provision for concep-
tion, by which the ovum lodged within it is pre-
pared and fitted for impregnation. According to
the other view, the corpus luteum is properly the
effect of impregnation, but may also be produced
by other adventitious circumstances causing high
excitement of the generative apparatus indepen-
dently of sexual intercourse. The first of these
opinions is generally supposed to have originated
with the late Sir E. Home, but it is only justice
to say that he merely revived a theory which had
been exploded and lain dormant for a long series
of years, as appears very clearly from a passage
in Wrisbcrg. This writer, after stating that mul-
tiplied observations both in the human race and
in quadrupeds proved that the corpus luteum was
not to be found in the ovaries « ante congressum
foecundum et inde pendentem conceptionem,"

PREGNANCY AND DELIVERY, (SIGNS OF)

689

adds, " ruit itaque ingeniosum potius quam na-
turae congruum, de usu ct functione corporis Iutei,
latum judicium conceptionis materiem ex parte
sexus sequioris comprehendere et secemerc."
(Vide paper by Wrisberg, in Trans. Soc. Reg.
Goettingae for 1781.) The opinion here alluded
to was that of Malpighi, Santorini, Valisneri, and
Bertrandi ; and it is remarkable that Sir E. Home
should have promulgated it anew without even
noticing its former existence, and that he should
have done so on the data furnished to him by a
single case,* in which he examined the body of a
young woman who died a few days after concep-
tion, when he found an ovum in the uterus, and
a corpus luteum in one of the ovaries. From
this he concludes at once that this was the com-
mencing provision for a future conception, not
the result of the former ; but the reasons are not
stated.

It has been already shown that a similar notion
was entertained many years ago, and its accuracy
disproved by observation ; but it is not altogether
satisfactory, nor consistent with the spirit of
philosophic inquiry, to reject an opinion merely
because it has been already exploded, however
high may have been the authority for its rejection.
We must, therefore, examine this doctrine upon
its own merits, before we can refuse it our assent.
In the first place, then, if such a statement were
correct, corpora luta? ought to be found in* the
ovaries of almost all women examined just before
or during the period of life in which they are apt
for conception. No one has ever asserted that
this is so ; and in point of fact we know it is not
the case. In the second place, if such were the
relation of the corpus luteum to conception, it
ought to be found in a state of greater develop-
ment, as the distance of time from the former
conception increases : now we have demonstrative
proof that exactly the contrary happens. In the
third place we find that their number corresponds
to the number of foetuses which have been pro-
duced, as already explained. Such objections
might easily be multiplied, but those already
stated appear more than sufficient for our purpose.
The other assertion, that corpora lutea may be
produced independently of sexual intercourse or
conception, during periods of lasciviousness, or
from the stimulus of strong passions, or unnatural
enjoyments, requires a very careful examination,
inasmuch as, if it be really borne out by facts,
the presence of the corpus luteum in the ovary
would cease to be of any value whatever as a
proof of impregnation ; and believing, as we
think we have full grounds for doing from a very
long-continued examination of the subject, that
the real corpus luteum is the result of conception,
and of nothing but conception, we think we shall
be able to show that some of the assertors of this
doctrine which we impeach, have in some in-
stances merely repeated the statements of others
without examination ; while others have misre-
presented the opinions which they quote in their
support; and others, again, have mistaken for
true corpora lutea accidental formations in the
ovaries, having no one character, except the colour,
of the bodies which really deserve the name.

♦This he himself decU^s; vide Philos. Trans. 1817,
I'- 255 - o .

Vol. III. — 87 J H

Most of the writers who advocate the produc-
tion of corpora lutea without impregnation, pre-
mise as a powerful support in their favour the
opinion of Blumenbach, which is thus spoken
of:—" In the year 1788 Blumenbach showed that
corpora lutea may exist in the ovaries of virgins."
(See a paper by Mr. Stanley, in the Trans. Coll.
Phys. Lond. vol. vi. p. 421-2.) Now, before
proceeding to review any of the opinions or as-
sertions built on the authority of this great phy-
siologist, we must first examine what he has really
said on this subject. His observations are to be
found in a Specimen Physiologiae Comparalx,
(Trans. Soc. Reg. Goettingffi, vol. ix.) published
in 1788, and in our opinion are very far from
warranting the conclusion so generally taken for
granted to result from them ; first, because his
own definition of the corpus luteum renders it
extremely doubtful whether his observations apply
to the body really deserving that name, or merely
to the cicatrix on the ovary connected with it.
His words are: " Notum est post fecundum
coitum in muliere aliisque mammalibus femineis,
in alterutro ovario Jissuram reperiri cruentam, ex
ruptu sub cestrum venereum una. alterave earum
vesicularum quas Graafius pro veris ovulis vendita-
verat; idemquevulnusculum temporis progressu
in cicatricem abire cortice eleganter vasculoso
cinctam, atque Malpighii inde temporibus lutei
corporis nomine insignitam." (Op. cit. pp. 109-
10.) And, secondly, even if we are satisfied that
he there speaks of the true corpus luteum, which
we very much doubt, it is very remarkable that in
no one part of his paper does he speak as from
personal observation or examination of the subject
by himself, but confines himself to physiological
reasonings grounded on the facts observed by
others, (" Corpora lutea in innuptis observarunt
auctores." Op. cit. p. 113.) from the considera-
tion of which he declares his belief (" Et ita
corpora lutea in virgineo corpore oriri conjido,")
in one place, and his suspicion (" Non absimilem
originem suspicor," Op. cit. p. 113,) in another,
that the fact may be so, but he nowhere asserts
that he saw an instance of it ; and he adds that
all the cases his reading furnished him with hap-
pened in Italian girls, whose climate he appears
to suspect might have something to do with the
matter. The passage in which this is expressed
appears to us, even from its singularity, worth
quotation here; it is as follows: — " Num climati
quoque aliquod tribuendum, decidere non audio,
annotans tantummodo quotquot mihi hactenus
apud auctores occurrerunt ejusmodi haud infi-
ciendi casus eos non nisi in Italicis virginibus
observates fuisse." (Loco citato.) Meckel, also,
is by some asserted to have maintained this doc-
trine ; but it appears to us that so far as his ob-
servations go, they afford it very little if any sup-
port at all. He commences with these words : —
"The internal organs of generation are modified
not by the act of intercourse merely, but by con-
ception alone. There is developed in the ovary
a peculiar body called corpus luteum," (Anatomic
Descriptive, &c. p. 735,) which he then describes
as resulting from a change produced in one or
more of the vesicles of De Graaf; and adds, << the
influence of the male semen is the ordinary and
regular cause of this change, which, however, it

G90

PREGNANCY AND DELIVERY, (SIGNS OF)

appears, may be effected under the influence of
other stimuli, perhaps by the imagination or un-
natural enjoyments." Now it is, we think, quite
plain, from the language of the above passage,
that he is alluding to the opinions of others, and
not stating a fact of which he had assured him-
self; and accordingly he immediately subjoins,
" in truth, many of these rare cases, in which
corpora lutea have been found in unmarried wo-
men, and in girls having the physical marks of
virginity, allow the belief that the formation of
these bodies had been preceded by sexual inter-
course and fecundation." He afterwards makes
an observation which, if properly understood and
appreciated, would have prevented many of the
absurdities which have been promulgated on this
subject. " They speak," says he, " of corpora
lutea which have been found in new-born or very
young animals; but the obvious answer to this is,
that every yellow substance met with in the ovary
is not a corpus, luteum." (Anatomie Descriptive,
&c. p. 736.) What but the most complete mis-
take on this point could have induced an anno-
tator on Beck's Medical Jurisprudence to hazard
the following observation : — "A recent case has in
my opinion completely overthrown the theory,
that even strong passions are necessary to the
formation of the corpora lutea: the subject was
not above Jive years old, and the hymen of course
entire ; she died of tubercular disease in the
lungs, yet in her ovaries were numerous corpora
lutea as distinct as I ever saw them in the adult
impregnated female." (Beck, p. 103. Note,
signed Dutilop.) The only comment necessary
to make On this statement is, simply to remark
that one real corpus luteum, as it is found "in
the adult impregnated female," is fully as large,
or even larger than the ovary of a child five years
old, therefore it is impossible that there could in
such a case be several of them.

Dr. Bostock, in his very able and instructive
work on physiology, (Elementary System of Phy-
siology, vol. iii. p. 36 et seq.) gives a summary
of the opinions on this subject, but avoids hazard-
ing more than a mere hypothesis himself. It is
plain, however, that he inclines to the belief " that
corpora lutea are not the necessary result of im-
pregnation." (Note, loc. cit.) But we must
observe that he overstates the opinion of Blu-
menbach when he- asserts that he " decidedly
maintained" such a doctrine, which we have al-
ready shown he did not ; and he is equally inac-
curate in quoting Cuvier as a supporter of this
physiological heresy : it is only necessary to refer
to the passage quoted, (Lecons d'Anat. Comp. t.
v. p. 57,) to see that Cuvier is there not speaking
of the corpus luteum at all, but of the cicatrices
observed on the ovaries ; and throws out a ques-
tion, whether these may not sometimes be caused
by the passage of germs, under the influence of
unnatural stimuli. Dr. Seymour, in his very in-
teresting work on the ovaria, (Illustrations of
some of the Diseases of the Ovaria,) has given a
well-arranged summary of the conflicting opinions
and theories on this subject, to which he has
added some very judicious and pertinent remarks ;
but upon the particular question before us, he ex-
presses himself at least vaguely. He however
appears to believe in the possibility of the pro-

duction of corpora lutea without impregnation,
but nowhere asserts that he saw an instance of
the kind ; on the contrary, the result of his own
investigations, as stated by himself, is so strongly
against such a belief, that we mean to quote it in
his own words as a very strong fact in our favour.
" It has occurred to me," he says, " to have ex-
amined the ovaria in the human being;, and in
animals at the period of puberty in veiy many
instances ; many had ova ready for impregnation,
large, projecting, vascular, yet no corpora lutea
were visible." (Op. cit. p. 32.) Such, also, has
been the result of our examinations of a very
large number of bodies both of women and of
animals, and in no one instance did we ever find
a true corpus luteum except as the product of
conception ; and reasoning merely on the subject,
we would ask, if mere imagination or highly ex-
cited desires without intercourse are capable of
causing such a change in the condition of the
ovary, should we not expect to find corpora lutea
almost invariably in women who have been living
with their husbands, or otherwise enjoying con-
stantly the natural and perfect excitement of the
generative system without conception? Of the
non-occurrence of which consequence we can
speak in very decided terms, from numerous op
portunities of making examinations under such
circumstances.

We shall now proceed to state, as briefly as pos
sible, the opinions of those whose careful and re-
peated examinations of the subject fairly entitle
them to the highest degree of credit. De Graaf,
who is justly celebrated as an accurate anatomist
and physiologist, devoted much of his attention to
the generative system of the female, and in his
work on this subject published in 1672, (Dc muli-
erum organis generationi inservientibus tractatus
novus, Lug. Bat. 1672,) we find him thus speak.
ing: — " Quse vero secundum naturam, aliquando
tantum, in mulierum testibus inveniuntur ; sunt
globuli, qui glandularum conglomeratarum adin-
star ex multis particulis a centro ad circumfercn-
tiam recto quasi ductu tendentibus conflantur, et
propria membrana obvolvuntur. Hos globulos
non omni tempore in fcemellarum testiculis exis-
tere dicimus; quia post coitum tantum in illis de-
teguntur, unus aut plures, prout animal ex illo
congressu unum aut plures foetus in lucem edet."
De Graaf applied to this formation the name of
corpus glandulosum, which name it retained until
Malpighi changed it to that of corpus luteum on
account of its colour. The great Haller paid par-
ticular attention to this point, in the investigation
of which he sacrificed many sheep, goats, and
cows, besides great numbers of other animals ;
and by opening the bodies of several at gradually
prolonged intervals of time from intercourse with
the male, he traced the corpus luteum from iU
first commencement through all its successive
stages of increase and decline. (Vide Elem. Phy-
siologias, vol. viii. sect, xv.) He tells us, also,
that he had opened the bodies of upwards of a
hundred women, and met with the corpus luteum
about ten times, but never except in those who
were at the time pregnant, or had brought forth
children. (Vide op. min. vol. iii. p. 185, 186.)
"Quotquot feminae nullam fecundationem ante
mortem passse sunt, tot etiam incisa; nulla corpora

PREGNANCY AND DELIVERY, (SIGNS OF)

691

lutea ostendunt." Now it is to be observed that
Haller continued this investigation through many
years, and was perfectly well aware of the theo-
ries of Bertrandi, Valisneri, and Buffon, with the
latter of whom he corresponded on the subject,
and the result of his observations he embodies in
two brief but most important propositions : —
>■ Nullus unquam conceptus est absque corpore lu-
teo." (Op. min. vol. ii. p. 458.) « Corpus luteum
invirgineis animalibus nullum est, ex conceptione
oritur, neque prius paratum adest." The first of
these propositions has never been questioned, and
the truth of the second appears to us equally in-
controvertible. The observations of Blumenbach
were published in 1788, and nine years afterwards,
or in 1797, Dr. Haighton read before the Royal
Society the details of many experiments on the
subject of animal impregnation, (see Philos. Trans,
for 1797, p. 159,) and thus expresses himself on
this point : — " I may then say that no corpora lu-
tea exist in virgin animals, and that, whenever
they are found, they furnish incontestable proof
that impregnation either does exist or has prece-
ded." (Ibid. p. 163-4.) And again he says, "I
decline trespassing on your patience, and therefore
lay before you only the conclusion ; which is, that
in the great variety of experiments on brute ani-
mals which my physiological inquiries have led
me to conduct, as well as in the extensive oppor-
tunities I have had of observing the ovaries in the
human subject, I have never seen a recently formed
corpus luteum unattended with some circumstance
or other connecting it very evidently with impreg-
nation." (Ibid. p. 166.) In the same year Mr.
Cruikshank published his account of a series of
experiments also on this subject, and we find him
remarking as follows : — " These calyces, on the
expulsion of the ova, enlarge and become yellow,
projecting above the external surface of the ovaria,
and form corpora lutea, a certain mark of concep-
tion in all quadrupeds, and in women themselves,
whether the embryo is visible or not." (Phil.
Trans, for 1797, p. 200.) William Hunter and
his editor, Dr. Baillie, speak of the corpus luteum
as the product of conception, but do not even
mention the supposition of its possible occurrence
in any other way. (Description of Gravid Uterus,
1794, pp. 14-74.)

When Mr. Angus was tried in Liverpool, in
1808, for the supposed murder of Miss Burris,
great doubt arose as to whether the condition of
the uterus or its appendages was such as to prove
a pregnancy recently existing. " It was not until
after the trial that the ovaria was examined.
They were then divided in the presence of a
number of physicians, and a corpus luteum dis-
tinctly perceived in one of them. Mr. Hay took
the uterus and its appendages to London, and
showed it to the most eminent practitioners there.
He received certificates from Drs. Denman and
Haighton, Messrs. Henry Cline, Charles M. Clarke,
Astley Cooper, and Abernethy, all stating that it
exhibited appearances that could alone be ex-
plained on the idea of an advanced state of preg-
nancy. And it appears to have been universally
allowed that the discovery of the corpus luteum
proved the fact beyond a doubt." (See Report
of the trial; and Edinb. Med. and Surg. Journ.
vol. v p 220.) In addition to the authorities

here cited, we may be allowed to add the result
of our own observations, which have been now
continued through a period of more than six
years, during which time we never omitted a sin-
gle opportunity within our reach for examining
the bodies of women of all ages, and under all
the varying circumstances of virginity, after in-
tercourse, during gestation, and subsequent to
delivery at different periods from conception ;
these opportunities having been afforded by more
than one large hospital, as well as in private
practice. We have also dissected hundreds of the
inferior animals with reference to this point, and
have in our museum preparations of ovaries ex-
hibiting the corpus luteum in different conditions
in the human female, and also in cows, mares,
sheep, sows, goats, bitches, cats, hares, rabbits ;
and our firm conviction is of the truth of both
Haller's propositions, viz. that " conception never
happens without the production of a corpus
luteum," and that " the corpus luteum is never
found in virgin animals, but is the effect of
impregnation." And we think that those who
have supposed or asserted that they may exist
without impregnation, and of course be found in
the virgin ovary, have been led into the error by
confounding appearances and structures essentially
different, and in fact having only one character in
common, which is their colour, altogether forget-
ting that " every yellow substance in the ovary is
not a corpus luteum." (Meckel, supra citat.)
It is allowed by those writers that " the corpora
lutea of virgins may in general be distinguished
by their smaller size, and by the less extensive
vascularity of the contiguous parts of the ovarium."
(Mr. Stanley and Dr. Blundell.) Now we have
seen several of these virgin corpora lutea, as they
are unhappily called, and have preserved several
specimens of them, and according to our expe-
rience they differ from those of impregnation in
all the following particulars : — 1 . there is no
prominence or enlargement of the ovary over
them ; 2. the external cicatrix is wanting ; 3.
there are often several of them in both ovaries,
especially in patients who have died of tubercular
diseases ; 4. they are not vascular, and cannot be
injected ; 5. their texture is sometimes so infirm
that they seem to consist merely of the remains
of a coagulum, and at others appears fibrocellular
and resembling that of the internal structure of
the ovary, but in no instance did we ever see
them presenting the soft, rich, and regularly
glandular appearance which Hunter meant to
express when he described them as " tender and
friable like glandular flesh ;" (Description of
Gravid Uterus, p. 14,) 6. they have neither the
central cavity, nor the radiated cicatrix which re-
sults from its closure.

[Recently, however, Dr. William Davidson
(London and Edinb. Monthly Journal of Med.
Science, Dec. 1841,) has published three dissec-
tions of females — not one of whom was pregnant,
yet, in each, corpora lutea were found. They all
possessed the characters assigned them by Dr.
Montgomery, — a central cavity or fibrous coagu-
lum ; an oval shape, and a radiated white cicatrix
in the centre, just about the central body ; — the
body being at the same time immediately under
the peritonea} coat. This last point is dwelt upon

692

PREGNANCY AND DELIVERY, (SIGNS OF)

by Dr. Robert Lee, who maintains, that false
corpora lutea are never observed in immediate
connection with the peritoneum, a small portion
of stroma intervening. One of the females had
been in a weakly condition for some years, and
had no children ; another was unmarried, and had
menstruated three days previous to her death ; of
the third, there was no history, but all the organs
were healthy, and the Fallopian tubes and uterus
were in every respect natural. Dr. Davidson ex-
presses his confident opinion, that in none of the
cases had there been impregnation prior to the
appearance of these bodies; and he refers to Pro-
fessors Alison, Allen Thomson, John Reid and
Mr. Goodsir, in proof of the accuracy of his
statement, and of their perfect resemblance to true
corpora lutea. Dr. Davidson states, as the result
of his investigations, that he is led to believe, that
impregnation cannot take place without the ap-
pearance of a true corpus luteum, but that a true
corpus luteum may appear independently of im-
pregnation.]

Signs of Delivery.

An investigation into the proofs of delivery,
whether undertaken with reference to circum-
stances of a social, professional, or legal nature,
although not so frequently required, will be found
no less important in its relations to society, nor
less difficult in its details, than the examination
of the proofs of pregnancy, a very clear and ac-
curate knowledge of which latter is indispensably
necessary to enable us to arrive at a satisfactory
conclusion, when engaged in such an inquiry as
that before us. It may, and indeed frequently
does happen, that a woman with an enlarged
belly arising from some purely accidental or mor-
bid cause becomes an object of suspicion, and
afterwards the sudden reduction of her size may,
however unjustly, affix upon her the imputation
of clandestine delivery at least; and although
such charge may never be made the subject of a
legal or criminal investigation, its influences
would be alike unjustly prejudicial to the character
of the individual, and injurious to the moral in-
terests of society. The writer very lately saw
such an instance in the case of a woman separated
from her husband, who became affected with what
was considered ovarian dropsy, and which en-
larged the abdomen to the size of six months'
pregnancy, some of the other symptoms of which
state were also present. After an attack of in-
flammation, during which it is to be presumed
the parietes of the tumour formed an adhesion
with the upper part of the vagina, there took
place suddenly a discharge of gelatinous fluid
from that cavity, and the abdomen completely
subsided in the course of a day, and the pre-
viously entertained suspicion appeared to be con-
firmed beyond a doubt ; but on examination the
woman had not about her one of the signs of de-
livery ; yet had not the case been at once inves-
tigated, loss of reputation at the least would
have inevitably, though most undeservedly, fol-
lowed. In a very interesting case related by
Fodere, the life of an innocent woman was very
near falling a sacrifice to the law under circum-
stances somewhat similar. " A young woman
had her menses suddenly suppressed in conse-

quence of a fright, and sought every aid to reatore
them without effect : she was at length married
with a view to induce their retam, which aueceeded
after a time, and she discharged a great quantity
of fetid matters. This fact was proved by the
husband and the medical attendants. It so hap-
pened just at this period that two children were
found exposed and destroyed by cold ; suspicion
fell on this young woman, because she was known
to have had an enlarged abdomen, which had very
suddenly subsided. The judges of the district
ordered her to be arrested and examined by a phy-
sician, a surgeon, and two midwives, who reported
that they had discovered marks of delivery. In
consequence of this, the unfortunate woman was
condemned to death for concealing her pregnancy,
and making away with her children. An appeal,
however, was made to parliament against this
sentence; and in consequence of two consulta-
tions, held by several physicians and surgeons of
the greatest eminence, she was acquitted." (Med.
Legale, torn. i. p. 476.)

Delivery may be concealed with the hope of
saving shame, or still more criminally with the
intention of destroying the offspring ; and where
infanticide is charged, the law requires proof of
delivery, and the finding of the child. Or again,
delivery may be feigned for the purpose of obtain-
ing marriage with a paramour, to gratify the
wishes of a husband, or to wrest property from
the lawful heir. Perhaps the most singular case
of the kind on record is that related by Capuron,
(Med. Legale relat. aux accouchemens, p. 110),
in which a young woman, with a view to obtain-
ing marriage with her lover, feigned pregnancy
and then delivery, and so far succeeded completely
in her attempt; but after some time, being called
on to produce the child, and refusing to do so, she
was accused of infanticide, and brought before the
criminal tribunal, where she confessed the fraud
which she had practised, and the motives by which
she had been actuated ; but she was then called
on to prove that she had never been delivered, and
an investigation by medical examiners was order-
ed, the result of which was a report that they could
find no sign of delivery of either recent or ancient
date, whereupon she was acquitted and discharged.
A similar instance of pretended delivery appeared
not long since in a Berlin journal, as having oc-
curred at Sirakovo in the circle of Posen, where a
young woman, anxious to fulfil the ardent desire
of her husband to have an heir, pretended to have
been suddenly and unexpectedly delivered, and
stole an infant to support the falsehood : the case
was rendered more atrocious from the real mother
having in consequence of the theft been subjected
to the accusation of infanticide ; the fact was, how-
ever, happily discovered, and the culprit consigned
to the punishment due to her crime. (See Paris
and Fonblanque, vol. i. p. 250.) Dr. Male tells
us that a surgeon was called to a pretended la-
bour, and a dead child presented to him, but there
was no placenta ; he therefore proceeded immedi-
ately to examine the woman, when he found the
os tines in its natural state, nearly closed, and the
vagina quite contracted : the fact was that the
woman had never been pregnant, and the dead
child was the borrowed offspring of another : it
appeared that she was induced to practise the ar

PREGNANCY AND DELIVERY, (SIGNS OF)

693

lifice to appease the wrath of her husband, who
frequently reproached her for her sterility.

With reference to whatever object this inquiry
may be entered on, it is very important to consi-
der, in limine, what are the limits of time within
which the signs of ordinary delivery can be de-
tected, and also whether a woman who has given
birth to a child necessarily retains any mark or
symptom by which her delivery can be ascertained
after an interval of many months or years. With
reference to the first of these questions, it must be
recollected that there is a remarkable difference in
the effects produced by parturition on the system
of different individuals, as well as in the merely
physical changes made in the condition of the
parts more immediately concerned in that process,
arising partly from the greater strength or tonicity
in the constitution of particular persons, and the
consequent rapidity with which the parts restore
themselves to their original state, and partly de-
pending on the period of pregnancy, and the size
of the ovum or foetus which has been expelled.
As a general rule, however, it is agreed on by all
who have directed their attention carefully to the
subject, that the time within which we may ex-
pect satisfactory information has certainly expired
when ten days have elapsed from the time of de-
livery ; but we are not to assume this extension
of the time suited for the inquiry as implying that
we may safely postpone our examination so long,
or that up to the end of that period we can obtain
all the evidence we require : such is by no means
the fact, and experience will soon convince us that
in general within a week the condition of a
healthy woman who has not sustained any acci-
dent in delivery is so restored as to render the re-
sult of any such investigation a matter of much
uncertainty ; many of the most marked alterations
in the parts of generation disappearing, " so as to
leave no trace remaining eight days after delivery."
(Baudelocque, vol. i. p. 115. See also Fodere,
torn. ii. p. 17. Marc, Diet, de Med.tom. i. p. 228.)
Such also was the opinion of Bohn and Albert, in
conjunction with Antoine Petit and Louis, when
they met in conference on the case of a woman
of Nantes who was accused of infanticide, and
whom they pronounced innocent on the grounds
of her not having been examined as to the fact of
her delivery until after the expiration of a month.
We were not long since called on to examine a
woman five days after delivery at the full time,
and were particularly struck with the degree in
which the parts had restored themselves to their
natural condition, especially the os and cervix
uteri, which hardly differed from their natural un-
impregnated form and size. If the contents of the
Uterus have been prematurely expelled, the signs
of delivery, at whatever time investigated, will be
found indistinct in proportion to the immaturity
of the ovum ; so that, after abortion at an early
period, so little change is made in the condition
of the uterus and other parts, and the woman may
exhibit otherwise so few of the signs of pregnancy
even when examined within a day or two after
the occurrence, that it may be found impossible to
form anything approaching to a decided opinion,

* " Avant les deux premiers mow revolus de la grow-
er .urtout lorsqu'il ne s'agit pas d'nM P^'/'^'pa
ne presente aucuu moyen concluant de determiner par

excepting a very careful examination of whatever
substance may have been expelled, should that be
within our reach ; when, if the structures of the
ovum be satisfactorily detected, and we have suf-
ficient proof that such body was expelled by the
woman, there can no longer be any doubt. While
writing these observations we are in attendance
on a lady who miscarried a few days since, with
little or no pain, but with considerable hemorrhage,
at the close of the second month ; and in twenty-
four hours afterwards we found the os and cervix
uteri almost completely restored to their natural
state ; the vagina and external parts hardly if at
all dilated and very little relaxed ; the breasts ex-
hibited very imperfectly the appearances which
accompany pregnancy, the ordinary sympathetic
symptoms of which had been almost entirely ab-
sent. Now in such a case as this it would be
utterly impossible to arrive at more than a very
ill-established probability except by finding the
ovum, which in this case was expelled entire and
perfect, in which state we have preserved it.

As to the second point, or our being able to
ascertain by personal examination whether a
woman has ever at any former period been de-
livered or not : it is plain that we may be able to
establish the negative of the question from the
existence of some physical condition, such as a
perfect hymen, which would be incompatible with
the birth of a mature child ; this would not, how-
ever, prove that abortion had not taken place ;
but such a state of imperfect development or of
imperforation might be discovered, as would pre-
clude altogether the notion of either pregnancy or
delivery. But the question of most practical im-
portance is this, — supposing a woman to have
been a mother, does there remain any mark or
sign by which the fact of delivery can at any
future period be established ? The reply to this
question which experience warrants appears to be,
that in a very great majority of cases we should be
totally unable to discover any such certain indica-
tion of a former delivery ; for although in some
instances there are to be found appearances which
point strongly to a probability of such an occur-
rence having taken place, they are very seldom
indeed such as ought to be considered decisive of
the question ; while in other cases where parturi-
tion has occurred repeatedly, not one of the signs
usually insisted on is found to have continued
permanent. We very lately examined a patient
who had borne five children and nursed three of
them, the youngest being now five years old ; the
breasts were small, but neither flaccid nor pen-
dulous ; the nipples short, with not the least
shade of brown colour in the areola?, which ex-
hibited only the delicate rose colour so often
observed on that part of the virgin breast ; there
were neither lines nor spots of any kind on the
abdomen ; the os uteri was small and natural ;
the vagina contracted, and the fourchette perfectly
entire. It should be mentioned that this lady
never carried her children beyond the end of the
eighth month. But the remarkable case of Aimee
Perdriat, related by Fodere, (Tom. ii. 18,) shows
very forcibly that the lapse of a few weeks may
be sufficient to render impossible the detection of

Pexamen de la femme si un avortement a eu lieu." —
Marc, Diet, de Med. vol. iii. p. 193.

694

PREGNANCY AND DELIVERY, (SIGNS OF)

the signs of delivery : the facts were briefly these :
— On the 11th of June, early in the morning,
Aimee Perdriat left her master's house and went
to that of a friend named Rosina, living in the
fifth story of the house, begging permission to lie
down, as she was unwell with colic : in about an
hour afterwards a person living in the third story
heard an extraordinary noise in the water-pipe, as
if a heavy body was falling forcibly through it.
Aimee was not visited by any one except Rosina
and another young girl, who came to ask if she
wanted any thing. About five hours afterwards
Rosina observed blood on the stairs and on the
floor of the room, and Aimee remarked that her
menses were flowing very profusely. Suspicion
was excited, and on the l?th the privy was
opened, when a child, placenta, and two bloody
cloths were found. Two surgeons examined the
body, and reported that there were no marks of
violence present, except that the umbilical cord
was torn off; that it was a full-grown child, and
in their opinion had breathed after birth, and had
fallen alive into the place from whence it was
taken. Aimee was arrested on suspicion of being
the mother of this child, and the suspicion was
increased by her refusing to submit to the ex-
amination of a midwife, and having absconded
from Paris : she was brought back, and on the
15th, 17th, and 27th of July, being more than a
month after the supposed delivery, she was ex-
amined by Baudelocque, Dubois, Ane, Dupuytren,
and Lafarge, who declared that they could not
discover any sign indicative of delivery having
taken place at the time in question. In con-
sequence of this she was acquitted, the judges
leaning to the side of mercy ; but the circum-
stances of the case must impress us with a moral
conviction of the woman's guilt.

The presence of shining broken streaks, like
the remains of cracks, in the skin of the belly,
caused by the previous distension of that part
during gestation, and which when once produced
are permanent, is a sign very generally acknow-
ledged as of value ; but then we have just seen
that a woman may have been repeatedly delivered
without the formation of any such marks; and on
the other hand we know that any cause capable
of stretching the abdominal integuments to the
same degree may equally give rise to their pro-
duction ; a remarkable instance of which we lately
saw in a man labouring under general dropsy,
whose abdomen was literally covered with such
streaks, and there were also several on the thighs,
prepuce, and other parts of the body. It some-
times happens also, especially in young women
of a full habit, that when the breasts have been
greatly and rapidly enlarged during pregnancy or
after delivery, the skin covering them is in like
manner injured, and silvery lines are formed
which never afterwards disappear. We have
already related the particulars of a case in which
we discovered, by the presence of these marks, a
delivery which had taken place two years before ;
and this day, in consultation with Surgeon Co-
nolly on a case of doubtful pregnancy, where
previous childbearing was at first resolutely denied,
the recognition of these silvery streaks induced us
to press the party strongly on the subject, when

she confessed that she had given birth to a child
nineteen months before.

[These marks are sometimes accompanied by a
brown line, extending from the pubis to the um-
bilicus, (Montgomery, Signs and Symptoms of
Pregnancy, 6th edit. p. 171, Lond. 1842) ; and
accompanying this dark abdominal line, Dr.
Montgomery has, in a few instances, observed
another appearance of a similar kind, which con-
sists of a dark-coloured circle or areola, surround-
ing the umbilicus, extending in breadth about a
quarter of an inch all round that part, and in ge-
neral, but not always, varying in depth of tint
according to the colour of the hair, eyes, and skin
of the woman. Unlike the mammary areola,
there is no turgescence or elevation of it above
the surface of the surrounding skin, nor are there
any prominent follicles upon its disk.

Whether it is ever produced under circum-
stances unconnected with pregnancy, remains to
be determined by further observation. (Dublin
Journal of Medical Science, May, 1844, p. 298 ;
see, also, Dr. R. Turner, in Lond. and Edinb.
Monthly Journ. of Med. Sciences, Aug. 1842, and
Sept. 1844, and Dr. J. R. Cornack, Ibid. Feb.
1844.)]

It may be satisfactory to inquire here, whether
there is any other affection of the mamma? which
might give rise to such a condition of their sur-
face. The mere accumulation of fat we certainly
think would not, and the existence of diseased en-
largement would not be likely to give rise to mis-
take ; but there is one fact on this subject which
deserves to be borne in recollection, — namely, that
the application of leeches to the breasts as a means
of restoring the menstrual discharge, lately re-
commended by Dr. Loudon, (Edinburgh Med.
and Surg. Journ. vol. xxxviii. p. 61,) has been
followed, as he tells us, by these organs becoming
" swelled to an enormous degree ;" and as this
swelling takes place very rapidly, it seems reason-
able to suppose that it might produce a similar
disorganization of the integument ; but we have
no evidence from experience on the subject. We
have, on several occasions, when examining the
state of the os uteri in women who had borne
children, observed that its labia felt jagged, and
sometimes as if a portion had been torn and re-
mained separated from the rest: we should at-
tach some consideration to this state of the part,
because it is not likely to be produced by the ex
pulsion of any accidental formation from the
cavity of the uterus, and we have never met with
it except after childbirth. The value of the evi-
dence to be obtained from a lacerated state of the
perineum will be fully considered presently. Be-
fore proceeding to investigate in detail the present
circumstances of any case submitted to us for ex-
amination, we should endeavour to possess our-
selves as fully as possible of the previous history
of the woman, if that be not already known to us,
which may have been on the one hand such as
would greatly tend to render probable the occur-
rence of delivery, or on the other hand to dimin-
ish, or perhaps altogether forbid, our belief in its
possibility. We may, for instance, learn that she
had been for several months observed to be in-
creasing in size, and exhibiting other symptoms

PREGNANCY AND DELIVERY, (SIGNS OF)

C95

f pregnancy previous to the time at which dili-
ver y was suspected to have taken place ; or we
may have reason to know that she had been long
labouring under some form of disease, which,
while it rendered the occurrence of pregnancy ex-
tremely improbable, was at the same time such as
would be likely to induce many of its symptoms.
The age also of the individual may be such as
would tend greatly to confirm us in a negative
opinion ; and even supposing that we are satisfied
that conception had occurred, this may in no
measure facilitate our investigation, but may, on
the contrary, involve us in further difficulty. It
has been already shown that a woman may be
pregnant, and that the fruit of her womb may
be blighted at any period, but may be retained in
utero until the full time is accomplished, while
the size of the abdomen happening from some
other accidental cause to continue increasing un-
til the expulsion of the degenerated ovum occurs,
the woman may be suspected of having brought
forth a child ; nay, it may even happen, however
paradoxical such an assertion may at first sight
appear, that pregnancy and utero-gestation, even
when their full term has been nearly accomplished,
and the life of the foetus distinctly recognised, are
not necessarily followed by the birth of a child, as is
proved by the facts of the following very remarka-
ble case which the writer saw about three years ago
with surgeon Whitestone and Mr. Mulock. Mrs.
C. of Charlemont-street became pregnant for the
fourth time, and up to the seventh month matters
went on favourably ; but after that time she
ceased to feel the motions of the child, which had
been previously very active ; she, however, con-
tinued to increase in size up to the end of the
ninth month, when the membranes having pro-
truded into the vagina and ruptured, a great quan-
tity of horribly offensive fluid and gas made their
escape, but no child could be discovered : in a few
days afterwards the placenta and cord came away
completely macerated, and all the interstitial mat-
ter so completely removed as to present a most
perfect ready-made preparation of the umbilical
or placental vessels, even to the most minute ca-
pillary terminations, (it is preserved in the writer's
museum) ; but nothing remained of the child ex-
cept the bones, many of which were subsequently
discharged from time to time during the two
years which the patient survived. The facts of
this case appear to us sufficient in themselves to
demonstrate the imperfection of the rule of law
concerning concealment of birth, in order to prove
which it is held sufficient to ascertain that there
has been a pregnancy or a delivery ; for in this
case pregnancy was clearly ascertained, the mo-
tions of the child were strongly felt, and the full
term of gestation was accomplished, yet no child
was born. It may also be observed here, that
should such a case a.< this give rise to the suspi-
cion of infanticide, the accusation could not be
sustained, because, in order to do so, the existence
of the child must be proved and its body found ;
and in suspected cases, whether of concealed or
feigned delivery, we should very carefully exam-
ine the child if possible, for the purpose of ascer-
taining whether its state corresponds to the sup-
posed or pretended time of delivery, and to the
other circumstances of the case, as by so doing

the attempted fraud may sometimes be at once
detected. If, for instance, a woman feign to have
been delivered two or three days before, and pro-
duce as her own a child with the cord separated
and the umbilicus quite healed ; or, on the con-
trary, if delivery be asserted to have taken place
a month before, and the cord be found still attached
to the navel, such incongruities would be so far
decisive against the truth of the woman's account.
Other discrepancies, such as want of correspond-
ence between the development of the child and
the period of pregnancy accomplished, or the in-
terval after delivery, will readily suggest them-
selves, and ought to be very carefully attended to.
Having made these general observations, we have
next to consider in detail the individual signs by
an examination of which we may be enabled to
form an opinion as to the recent occurrence of
delivery, when such inquiry is instituted within a
proper time after parturition is supposed to have
taken place.

1. The face is generally a little paler than
usual, the eyes are somewhat depressed, and not
unfrequently surrounded by a slightly brownish
circle, and the whole expression of the counte-
nance resembles that of a person recovering from
a slight indisposition ; the pulse is more or less
accelerated, the skin softer and warmer than usual,
and relaxed with a moisture which has in many a
peculiar and sometimes very unpleasant odour.

2. The state of the breasts ought to be a sub-
ject of particular attention, especially if examined
about the third or fourth day after delivery, at
which time they are generally full, tense, and hard,
or even knotty under the hand, and if pressed or
drawn they yield a lactiform fluid ; the nipples
appear turgid, and the areolae are dark and other-
wise altered, as already fully described.

3. The abdomen is found full, and its integu-
ments greatly relaxed or even thrown into folds,
especially in those who have borne several chil-
dren ; and we recognise those light-coloured bro-
ken streaks or cracks already mentioned, which
are generally most numerous from the groins and
pubes towards the umbilicus ; and if the hand be
pressed pretty firmly over the lower or pubic re-
gion, we feel, — 4, the uterine tumour produced by
the volume of the imperfectly contracted uterus,
which is felt about as large as the head of a new-
born child, and rising three or four inches above
the brim of the pelvis, into the cavity of which it
can be traced by the hand, and lying towards one
or other side.

5. The state of the os uteri, vagina, and exter-
nal parts, next claims our attention. By an exa-
mination per vaginam we detect the enlarged state
of the uterus and its identity with the abdominal
tumour, and at the same time we ascertain the
condition of the os uteri, which in a recently de-
livered woman is found gaping open, so that two
or three fingers might be introduced into it with
ease ; its margins are flabby and very much re-
laxed, and not unfrequently feel as if divided by
several small fissures. If the examination hap-
pens to be made within a few hours after delivery,
the patulous state of this orifice is such that its
margins cannot be distinctly recognised, so that
we feel at a loss to distinguish between it and the
cavity of the vagina, of which it seems as if it

696

PREGNANCY AND DELIVERY, (SIGNS OF)

were a continuation. This latter part also is
greatly relaxed and dilated, in consequence of
which its internal surface is rendered smooth, its
natural rugoe being obliterated by the recent dis-
tension of its tissues. From the same cause, also,
the external parts are swollen, not unfrequently
contused or even torn, especially after a first or a
difficult labour, and partake of the relaxed state
of the internal parts; there is also found issuing
a peculiar discharge, to which we apply the name
of lochia.

6. Laceration of the perineum. When a wo-
man for the first time gives birth to a full-grown
child, it frequently happens that the thin fold of
integument constituting the anterior edge of the
perineum, and called the fourchette, is torn, and
sometimes the rent extending further backwards
divides the proper substance of the perineum to a
greater or less extent ; this, however, is merely a
contingency, which may or may not take place,
and is, in fact, of rather rare occurrence, except in
the simpler form first mentioned, but if recognised
in the greater degree, is a very strong proof of de-
livery having preceded.

7. The lochia. From the time of delivery, a
sanguineous discharge is eliminated from the geni-
tals, and continues to flow for a period varying
between four or five days to as many weeks, ac-
cording to the peculiar habit or constitution. In
general the discharge continues red for the first
three or four days, and then becomes nearly co-
lourless, or acquires a slightly brownish or dirty
greenish hue, from which it is sometimes vulgarly
called green waters, and after a week or eight
days it ceases altogether. This discharge has a
peculiar odour, (Marc, Diet, de Med. torn. i. p.
227 ; Fodere, t. ii. p. 13,) not easily named. Lo-
der compared it to the smell of " fish-oil ;" others
speak of it as a sour smell, but any one who has
been much about lying-in women, especially in the
wards of a lying-in hospital, must be aware of the
peculiarity of this odour, which Dr. Beck informs
us it has been found impossible by any artifice to
destroy. (Elem. Med. Jurisp. p. 94.)

Should such an assemblage of symptoms as are
here enumerated be recognised as at once existing
in the case submitted for examination, no doubt
could be entertained of the fact of delivery, there
being, to use the words of Chaussier, " no disease
or affection besides parturition which can possibly
produce the whole series of signs above described ;"
but we may not enjoy the advantage of having
before us such a satisfactory combination of proofs,
and may be under the necessity of forming our
opinion when only some of these signs can be de-
tected, and others are entirely absent ; and when
we come to examine them separately, we shall
find that they must be received in evidence with
very great caution, and with various modifications
of their value, by which the proofs which they
afford will be found little more than merely pre-
sumptive. Thus it is obvious that the expression
of the countenance, as well as the state of the
pulse and skin above noticed, may be induced by
any indisposition or exertion which may have de-
pressed the bodily strength of the woman, and
otherwise disordered the functions of her system.
The state of the breasts has been already very
fully considered in the former division of this arti-

cle, so that it appears only necessary to observe
here that, as on the one hand such a circumstance
as the expulsion of hydatids is capable of inducing
great functional activity in the mamma; and an
abundant secretion of milk, so on the other hand
it occasionally happens in weak, delicate women,
that little or no alteration is perceived in the
breasts after delivery ; and it was elsewhere re-
marked that in such persons a similar want of
sympathy is sometimes observable during preg-
nancy, so that the changes in the areolae are but
imperfectly established. Still we are fully war-
ranted in considering a full breast, with abundance
of milk about the third or fourth day after delivery
is supposed to have taken place, as a very strong
indication of such an occurrence. " It is possible,"
says Mr. Burns, " for this secretion to take place
independently of pregnancy, but not with the ap-
pearance just described."*

The fulness of the abdomen and relaxed state
of the integuments, as well as the appearance of
streaks or cracks, may all arise from any cause
capable of producing the same degree of disten-
sion as occurs in consequence of pregnancy, such,
for instance, as dropsy or enlarged ovary, or they
may be the result of a former pregnancy ; while,
on the other hand, they may not be found when
delivery has really and recently occurred. As to
the uterine tumour, we must expect to find it dis-
tinct or otherwise in proportion to the recency of
the delivery and the period of pregnancy at which
it took place, the fatness or tenuity of the abdo-
minal parietes, and the degree of activity with
which the contractile action of the uterine fibres
may have produced, from which results in a great
measure the difference in the degree of develop-
ment which this tumour presents in different per-
sons at the same interval of time after mature par-
turition, being smaller, and in consequence less
easily felt in some at the end of four or five days
than in others after double the time. Besides this,
a tumour may be felt so situated, and yet may not
be the uterus. To satisfy ourselves on this point,
we must conjoin the examination per vaginara
with that already made externally ; and even
when we have ascertained the exact nature of the
tumour, we must recollect that it may equally
arise from the organ having recently expelled a
mole, a large mass of hydatids, or even a consi-
derable accumulation of retained menstrual dis-
charge ; (see section Suppression of the menses,)
which accidental circumstances might also produce
the dilated and relaxed state of the os uteri, in
which the vagina and external parts would parti-
cipate. But from such causes as these there
would be found neither swelling, contusion, nor
laceration of the internal organs ; nor could the
os uteri be rendered patulous merely by increased
secretion, such as long-continued leucorrhoeal dis-
charge, which sometimes induces extraordinary
relaxation of the other parts. Laceration of the
fourchette, although a very common occurrence in
childbirth, does not always take place. We have

* Principles of Midwifery, seventh edit. p. 547. It ap
pears proper to notice here a remarkable discrepancy be-
tween the opinion of Mr. Burns, as above stated, ill liis
own words, and as quoted by Dr. Beck in his Elements
of Medical Jurisprudence, third edit. p. 94, where lie is
made to assert the exact contrary, the word impossible
being substituted for possible, as it stands in the text

PREGNANCY AND DELIVERY, (SIGNS OF)

already spoken of a lady who bore five children
without sustaining any injury to that part; and
within the last few days we examined a young
girl of sixteen, and of very diminutive stature,
who had home a full-grown child some months
before, and the fourchette escaped uninjured.
Many such instances as these have come under
our ohservation, (see also Marc, loc. cit. and
Fodere, torn, ii.) ; but should a laceration of the
perineum be discovered, it is a proof of immense
importance. We must, however, recollect that it
may present itself under conditions indicating a
more or less remote date as that of the delivery
which caused it : thus it may be found a fresh
unhealed wound, or the margins of the laceration
may be perfectly healed or even callous, but quite
disunited and separate from each other ; or, lastly,
complete union may have taken place, so that the
presence of a rigid cicatrix is the only evidence
remaining of the occurrence of the accident. Now
should we happen, in an examination of this kind,
to discover a fresh laceration of the perineum, in
connection with others of the signs we have been
considering, especially the relaxed and dilated state
of the os uteri, vagina, and external organs, and
the presence of the abdominal tumour, it ought to
be considered as decisive of the fact of recent de-
livery ; but neither of the other states of the parts
would be equally conclusive as proof of a former
delivery, because they might have been produced
by causes totally unconnected with childbirth, as
happened in the case of a girl who was romping
with a young man, and, losing her balance, fell
backwards on the point of the leg of a stool, which
tore through the perineum and entered the vagina,
causing a frightful laceration. Or it may have
been caused by some surgical operation on the
part, as in the case related by M. Berard, where it
was found necessary to divide the perineum in
order to accomplish the removal of a pessary which
had lain several years in the vagina. (Journal
Hebdomadaire, torn. i. p. 263.) About two years
ago a patient applied to the writer for relief, as she
was labouring under prolapse of the uterus and
incontinence of urine: on examination there was
also found extensive laceration of the perineum,
but none of these accidents were the result of de-
livery. The unfortunate woman had led an aban-
doned life, and was the victim of a horrid outrage
committed by three or four drunken ruffians, who,
having first violated her, forced a broken stone into
the vagina, which tore the perineum and the neck
of the bladder. The stone had been removed in
the hospital, but the lacerated parts never recovered
the injury. As to the lochia, we cannot expect
to obtain much information of a satisfactory kind
from that source, especially if the examination is
not made very soon after delivery. We have
known the discharge cease after the second day ;
and even when this is not the case, we must take
care that we do not confound with it some dis-
charge of a different nature, such as the menstrual,
or perhaps one of a morbid origin, from either of
which, however, a careful examination of the ute-
rus and external organs would almost certainly
enable us to distinguish it.

It appears to us that we cannot more appropri-
ately conclude this review of the ordinary signs
of delivery than by quoting the words of two very
Vol. III. — 88 3l

distinguished writers on such subjects. "The
relative value," says Dr. Paris, (Medical Jurispru-
dence, vol. i. p. 253,) «« which each of the signs
possesses will be better appreciated after we have
considered the diseases whose effects may resemble
them ; but as a general principle we are anxious
to enforce the necessity of always considering the
consecutive signs of parturition collectively, and
not individually ; under such circumstances the
practitioner can never be betrayed into an errone-
ous conclusion." « Other circumstances," observes
Mr. Burns (Principles of Midwifery, seventh edit,
p. 547), " may also concur in confirming the opi-
nion of the practitioner ; as, for instance, if the
patient give an absurd account of the way in
which her bulk suddenly left her, ascribing it to a
perspiration, which never in a single night can
carry off the great size of the abdomen in the end
of a supposed pregnancy.

Delivery without consciousness. — Having
in a former part of this article discussed the pos-
sibility of impregnation being effected without the
woman's knowledge, as during sleep, and having
alluded to the fact of delivery sometimes taking
place under similar circumstances as an argument
d fortiori in favour of the credibility of such an
occurrence, it seems necessary now to consider
briefly that question. That a woman may be de-
livered without being sensible of it, if she be at the
time labouring under cerebral oppression or de-
rangement, as in coma, in delirium, in puerperal
convulsions, stupified by narcotics, (as in the cele-
brated case of the Countess St. Seran, Causes
Celebres, Cause 259), or by ardent spirits (see
case by M. Deneux in the Diet, des Sciences Med.
torn. xxxi. p. 212), is a fact of repeated observa-
tion ; but it is not pretended that in such instances
the woman could be afterwards ignorant that she
had been delivered. The occurrence of delivery
after the life of the mother has become extinct,
and consequently effected by the independent con-
tractile power of the uterus, has been attested by
so many authors of established credit, that we
cannot refuse it our belief; having received the
testimony of Fodere (Med. Leg. torn. ii. p. II),
Buffon (see Gardien, vol. ii. p. 212), Lereux
(Obs. des pertes des Sang. Obs. xiii. p. 25), Le-
vret (Art des Accouchernens), Baudelocque (Art
des Accouchernens, torn. i. p. 123, note, ed. 1822),
Bichat(Anatomie Descriptive, torn. iv. p. 392, ed.
1829), and others* of equally high authority,
who have recorded instances of the fact, to which
for the present we shall merely refer, as below, and
proceed to notice two or three facts more directly
in proof of delivery during sleep or insensibility.
For the first of these the writer is indebted to Dr.
Douglas, one of the most experienced practitioners
in this city, and whose correct and ingenious ex-
position of the evolution (improperly called spon-
taneous) of the foetus is so well known to the
profession. In a letter to the writer, Dr. Douglas
states that he was called about six o'clock a. m.
on the 26th September, 1828, to attend Mrs. D.
of the county of W , but then residing in

* See Hartemann, Act. Nat. Curios. Dec. 11. an. 3
Diet, des Sc. Med. vol. xxxi. p. 212. Journ Univ. des S< .
Med. Aout 1817. Lond. Med. and Pins. Journ. vol
xlvii. p. 26. Dr. Planqve, Bibliotheque de Med. Cuuisie
vol. iii. p. 222.

698

PREGNANCY AND DELIVERY, (SIGNS OF)

Eccles-street. On his arrival he found the house
in the utmost confusion, and was told that the
child had been born before the messenger was
despatched for the doctor ; and from the lady her-
self he learned that about half an hour previously
she had been awakened from a natural sleep by
the alarm of a daughter about five years old, who
had slept with her for some nights before ; and
this alarm had been occasioned by the little girl
feeling the movements and hearing the crying of
an infant in the bed: to the mother's great surprise
she found she had brought forth her child without
any consciousness of the fact. Mrs. D. had had
several children with favourable labours. In the
London practice of Midwifery (Fifth edition, p.
87. See also Barlow's Essays on Surgery and Mid-
wifery, p. 182), a work generally ascribed to a very
distinguished practitioner, we find the following
account. " A lady of great respectability, the wife
of a peer of the realm, was actually delivered once
in her sleep : she immediately awaked her hus-
band, being a little alarmed at finding one more
in bed than was before." To these accounts we
wish to subjoin the details of a very remarkable
case, from a source which leaves no doubt of the
accuracy of the relation. " A fright produced by
the dangerous situation of her only son, when
eighteen months old, brought on in Mrs. Durant
an alarming illness attended with some singular
phenomena, the most singular of which respected
her memory. The illness happened in July ; she
was then advanced six months in a state of preg-
nancy, and was, when perfectly insensible, deli-
vered of a child. On awakening from the insen-
sibility, which had continued for three days, she
imagined it was the month of January. Her
mental powers were but slightly impaired, and soon
regained their former perfection ; nor was her me-
mory affected except as regarded the preceding six
months: of that time she had forgotten all the
events. Some accidental circumstance might after-
wards occasionally produce a train of thought,
which would bring an event of that six months to
her recollection. Several of the most important,
nowever, were never regained, nor could she, I
believe, to the hour of her death remember that
she had then been pregnant" (Durant's Memoirs
of an only Son, vol. i. p. 147.)

[A case of parturition without uneasiness, and
without the least exhibition of consciousness of
the child's expulsion, has been published by Mr.
Rawson, (London Lancet, Nov. 27, 1841 ; and
Dr. T. R. Beck, in Amer. Journal af the Med.
Sciences, April, 1842, p. 491.) The writer was
called, some years ago, to a female, who informed
him, that she awoke suddenly in the night, with
scarcely any uneasiness, and found both the child
and placenta extruded.]

Examination after Death. — Having else-
where described the signs of pregnancy which
may be discovered after death, it will not be neces-
sary now to say much in addition to the observa-
tions already made. In such an examination our
attention should be directed to the same objects
which we have been just considering as the proofs
of delivery which may be recognised during life,
almost all of which may be also ascertained after
death, provided, as before insisted on, the investi-
gation oe undertaken within a proper time : in

addition to these means, by opening the body we
are enabled to satisfy ourselves more precisely of
the exact condition of the uterus and its append-
ages. Should death take place during or imme-
diately after the act of parturition, especially from
hemorrhage, the uterus may be found lying in the
abdomen, a flattened flabby bag, from eight to ten
inches long, its mouth gaping wide open, so that
the hand would pass through it without resist-
ance ; its parietes are soft and relaxed, its cavity
often containing large coagula of blood, and its
internal surface covered with the soft and pulpy
remains of the decidua, which, if the part be im-
mersed in fluid, appear as flocculent processes ad-
hering to and springing from it in great numbers,
(see preparation No. 141 in the writer's museum,)
while the portion to which the placenta had been
adhering is distinguished by having less of these
deciduous flakes, the substance of the organ in
that situation appearing as if laid bare, and exhi-
biting several semilunar and apparently valvular
openings in its structure. But these conditions
will be greatly altered should the woman have
survived delivery a few days, so as to afford time
for the uterus to contract ; and the change pro-
duced will be in proportion to the time since deli-
very and the energy with which the organ may
have exerted its contractile powers, so that in some
instances it may be found as large at the end of a
week, as in others where the examination is made
within two or three days. It would therefore be
very difficult, if not impossible, to assign the exact
dimensions which the uterus will present at given
periods after mature delivery ; and should it have
occurred prematurely, these dimensions will of
course be thereby still further affected. When
delivery has taken place at the full time, and the
uterus has contracted perfectly, if an examination
be made within a day or two, it will be found
about seven inches long and four broad ; its exter-
nal surface having a vascular appearance, and not
unfrequently presenting patches of a purplish co-
lour ; its substance, divided by the knife, is found
from an inch to an inch and a half thick, of the
consistence, and nearly of the colour, of firm mus-
cular fibre, of which it appears to consist ; and
the cut surface displays the orifices of a great
number of very large vessels. Its internal surface
differs little from the description already given;
the Fallopian tubes and ovaria, or at least one of
the latter, are found turgid and vascular, and lying
more confined to the sides of the uterus. At the
end of a week the organ has diminished to a
length of between five and six inches, and after a
fortnight does not exceed five inches in length;
its vascularity is diminished, and the thickness of
its parietes reduced about one-third ; but the den-
sity of their structure is found increased in a like
proportion, so that the orifices of the vessels are
much less distinct, and the colour of the muscular
substance has become much paler. After this pe-
riod little information is likely to be obtained from
an examination of the uterus merely ; for although
it probably is not reduced to its original unimpreg-
nated condition before the end of the fourth week,
the alterations which can be appreciated towards
the conclusion of that period are too liable to have
been induced by contingent causes to allow of our
attaching value to them as proof of delivery

PROGNOSIS.

Tjnder such circumstances, our attention would be
more profitably directed to an examination of the
ovaries and the existence of the corpus luteum,
the value of which has been already so fully con-
sidered that it appears now only necessary to re-
mark, that although its existence is proof positive
of previous conception, it can be received as evi-
dence of recent delivery only when it is found in
connection with other circumstances indicative of
the occurrence of that event, (see report of the
trial of Charles Angus for the murder of Miss
Burns,) in which case it ought to be considered
as a very powerfully corroborative proof.

We may sum up the substance of these observ-
ations in the following general corollaries : —

1. The signs of delivery are most distinct after
the birth of a full-grown child ; and least so when
the uterine contents have been expelled at an early
period of pregnancy.

2. The proofs are more distinct in proportion
to the recency of the delivery, and any examina-
tion made after the lapse of ten days from the time
of the delivery is not likely to afford satisfactory
information, the most decisive signs in general
disappearing within a week.

3. The third or fourth day generally presents
the results of delivery very distinctly, the condi-
tion of the breasts being then most remarkable
from the active secretion of milk.

4. A first delivery is more easily detected than
subsequent ones.

5. We cannot safely rely on any of the signs
of delivery viewed separately, but must consider
them collectively, and their mutual relation and
correspondence with each other, and with the
other collateral circumstances of the woman's case
and history.

6. The chief points of attention ought to be
the state of the external parts and of the breasts.

7. There are certain physical signs which,
when present, are sufficient to establish a negative
decision ; such are, for instance, a perfect hymen,
or an imperforate state of the parts.

8. But, on the other hand, a woman may have
borne children, and no one mark remain by which
the fact of delivery could be proved after the
lapse of even a few weeks.

9. A woman may be delivered while in a state
of insensibility, or even during deep natural
sleep ; so that her child may perish merely from
want of attention, and without any moral delin-
quency on her part.

W. F. Montgomery.

PROGNOSIS, irpoywSw, foreknowledge. The
important place which in medical science is justly
assigned to the faculty of foreseeing and predicting
the future may be inferred from a consideration
of the objects which it embraces. The principal
of these are— the question whether a disease is
remediable— the degree of danger which attends
it— its probable duration — the circumstances
which may be expected to arise during its course
-its tendency to recur— and the probability of
other diseases supervening.

The necessity of ministering to that mstinctive
anxiety with which mankind contemplate the
prospect of life or death, of renovated health or
prot acted suffering, would of itself be sufficient

to rank the faculty of prediction among the most
essential qualifications of the physician. It, how-
ever, derives a stronger claim to this distinction
from its important influence in the treatment of
disease. Nor is there, perhaps, any one qualifi-
cation more adapted to produce confidence in the
patient and his attendants, and thus to insure
compliance with the injunctions of the physician,
than the power of predicting with accuracy what
will happen in the course of a disease. Again,
in a multitude of cases, how powerful an ally
does he obtain if he can inspire the patient with
hope by his cheering predictions ! On the other
hand, it often happens that, in diseases attended
with little danger, there is a temporary increase
of disorder and suffering. If this be foreseen and
cautiously announced, disappointment and de-
spondency, such as might retard or even prevent
recovery, will be avoided. There are, besides,
various circumstances incident to the progress of
maladies, such as the appearance of fresh symp-
toms, or the supervention of some new disease,
which, if foreseen, may be modified, or perhaps
wholly prevented ; while, in many acute affec-
tions, the anticipations of those periods and con-
junctures which experience has shown to be often
critical, may suggest means calculated to insure a
favourable and decisive effort of nature.

It is not, however, merely in its relation to the
treatment of disease that the art of prognosis is
important to the physician. He will find it an
influential and honourable means of promoting
his own reputation ; and, what he should still
more value, one that may often be made subser-
vient to the dearest and most momentous interests
of his patient. That he whose days are num-
bered by the progress of a mortal disease, should,
while his powers are adequate to the task, set his
worldly concerns in order, is a position which few
or none will call in question ; but the necessity
of preparation for another and an eternal state of
being can be duly appreciated by those only who
have a just perception of the awful nature of the
interests at stake. Such, however, may be the
physical or moral condition of the patient, or such
the nature of his malady, that the announcement
of danger might in many cases seem calculated to
accelerate the fatal event, and to counteract the
measures devised for his relief. Since, then, the
issue must often be foreseen by the physician
alone, the question of disclosing or concealing his
anticipations will frequently place him in circum-
stances of the most serious responsibility. It
would be foreign to the proper object of this arti-
cle to attempt the delicate task of establishing
general rules for the solution of such questions.
It will suffice to say that the judgment of physi-
cians would be more generally sound, and their
conduct more wise, in this as well as in other
parts of their professional duties, if their own
minds were more deeply imbued with the impor-
tance of the truths and obligations of religion.

[Should the physician, however, have any hes-
itation as to the propriety of communicating his
unfavourable prognosis to the patient, he ought
not to hesitate to put the patient's friends in full
possession of it.]

The qualifications and attainments which are
essential to the art of prognosis may, in general

700

PROGNOSIS,

terms, be said to comprehend all those which give
superiority in the other departments of medical
science. Some, however, are more peculiarly re-
quisite. As a foundation, the accurate discrimi-
nation of disease is obviously indispensable ; and
hence the necessity of those habits of close ob-
servation, and of that extensive knowledge of
pathology and of the signs of disease, upon which
success in diagnosis depends. But in a multi-
tude of cases the mere recognition of a disease is
a very inadequate guide to the prediction of its
future course and ultimate event. Something
beyond this is wanted ; and here we see remark-
ably exemplified that practical superiority which
is acquired by men of clear understanding and
natural good sense, who have had the advantage
of long experience and an extensive field for ob-
servation.

The difficulties which are inseparable from the
subject, and the sources of error and disappoint-
ment with which it abounds, are early forced, and
often painfully so, upon the attention of the phy-
sician. Before, however, experience shall have
taught him the lesson, he will do well to exercise
great caution in his predictions. Let him bear
in mind, on the one hand, that the most formidable
symptoms sometimes occur when there is no real
danger ; and on the other, that a moment of de-
lusive calm is often the prelude to the sudden
appearance of indications of approaching death.
Let him remember, that however accurate may be
his diagnosis, his estimate of what is expressively
called the vis vita? may and often must be most
imperfect. If such considerations as these have
their due influence on his mind, he will shrink
from a rashness of prediction no less injurious to
his own reputation than to the welfare of those
whose life and health are intrusted to his care.

Of the grounds of Prognosis* — The first
and most obvious means for predicting the event
of disease is derived from an attention to the in-
crease or diminution of its more prominent symp-
toms. But although common sense and experience
sufficiently attest the general value of this guide,
a very limited extent of observation will show that
the cases in which it is an imperfect or fallacious
one are numerous and important. So far, indeed,
is it from uniformly indicating the ultimate event
of death or recovery, that it often fails to resolve
the immediate question, whether the patient is
getting better or worse. Experience has taught
us that the most conspicuous and distressing
symptoms of many diseases are, at least in part,
the result of what is termed an effort of nature to
obtain relief, and that their disappearance merely
announces the approaching fatal termination of
the struggle. Thus the anasarca which sooner
or later attends most organic diseases; the sputa,
colliquative sweating, and diarrhoea of phthisis;
and the saccharine urine of diabetes, often cease
in the extreme stage of those maladies, but cease
only to give place to death. We may perhaps
refer to the same class of facts that delusive calm,
sometimes accompanied by an appearance of
revival, Avhich so often precedes the fatal issue of
acute diseases, as, for example, of encephalic in-
flammation, yellow fever, and puerperal peritonitis.
Experience further shows that the disappearance

of one set of symptoms is often a mere precursor
of others of equal or greater severity. Thus the
cold stage of ague is presently replaced by the hot ;
and the cessation of spasmodic asthma and of
scrofulous disease of the cervical glands is fre-
quently but the forerunner of pulmonary con-
sumption. On the other hand, in acute diseases,
a marked increase in the severity of the symptoms
is a common prelude to a salutary crisis; while
the crisis itself consists in the appearance or ag-
gravation of some circumstance which, either in
kind or degree, is essentially morbid.

As we thus find that the apparent increase or
decrease of a malady cannot be by any means
uniformly relied upon as indicating its event, we
must have recourse to those materials which ex-
perience has collected for our guidance. In its
application to the prognosis as well as to the treat-
ment of diseases, experience presents itself in a
twofold character ; first, as entitling us to infer
that a certain event will result from certain exist-
ing circumstances, merely because it has been
ordinarily found to follow them ; and, secondly,
as the foundation of those generalizations and de-
ductions which constitute the science of pathology.
From the age of Hippocrates to that of Morgagni,
the art of prognosis, or at least what was valuable
in it, was almost exclusively founded upon the
former kind of experience ; for whatever was
derived from pathology was always hypothetical
and mostly erroneous. The writings of our own
illustrious Sydenham strikingly exemplify the
contrast between the value of accurate observation
and the fallacy of mere speculation, however in-
genious.

The cultivation of pathology in modern times
has unquestionably produced an important in-
fluence upon prognosis, as well as upon every
other branch of practical medicine. It would be
foreign to the immediate object of this article to
inquire how far that influence has been beneficial,
or to what extent its benefits have been associated
with mischief. It may, however, be asserted in
general terms, that while, on the one hand, pa-
thology has given an increased precision to our
views of the nature, and consequently of the event
of many diseases, especially of those which we
call organic, yet, on the other, a propensity to
generalize from inadequate data, and to attribute
to the science a perfection which it has by no
means attained, has unquestionably led to much
error. And there can be no doubt that in the
present state of medical science he who combines
a simple and accurate observation of individual
circumstances with an enlightened but cautious
application of pathology, will be found the most
sagacious in prognosis as well as the most suc-
cessful in practice.

The application of experience to prognosis is
greatly facilitated by the aid which nosology af-
fords in creating abstract notions of disease apart
from the peculiarities of individual cases. Hence
arises a natural division of the subject into two
parts. The first embraces prognosis as considered
in its relation to diagnosis, and comprehends
those general conclusions as to the future which
are drawn from the known history and tendency
of any given disease. The second comprehends

PROGNOSIS.

701

hose particular circumstances which belong to
he individual case, not being included in the
abstract notion of the disease itself.

The value of an accurate diagnosis as an index
of the future is often indisputably great. In many
affections it at once informs us whether we must
regard the disease as curable or incurable, and
whether death or recovery may be expected.
Thus, when the existence of hydrophobia on the
one hand, or of hysteria on the other, is clearly
ascertained, we are able to predict the ultimate
event with a confidence little short of certainty.
If a case be identified with tuberculous phthisis or
schirro-carcinoma, we at once perceive that the
probability of recovery is extremely small. The
great majority of diseases, including fevers gene-
rally, and indeed most acute affections, are, how-
ever, in their own nature, neither essentially
curable nor incurable, fatal nor free from danger ;
and hence, in order to predict the result, we must
take into account the circumstances of each in-
dividual case : and even when the ultimate event
may be learnt from the diagnosis alone, we must
still have recourse to them to determine many
questions of great interest both to the patient and
the physician, as the duration of the disease, the
event of particular symptoms, the expectation of
new ones, &c. Numerous cases also occur in
practice, to which diagnosis is wholly or in a
great measure inapplicable ; and although in
judging of the future some light may be derived
from their apparent analogy to known diseases,
much will necessarily depend on a consideration
of individual circumstances. But not only is
diagnosis in many cases unattainable, it is also
often unnecessary. How much of that tact which
experience gives is independent of any pretensions
to accuracy in referring a case to its nosological
position ! This is remarkably exemplified in the
anomalous affections of young females ; and fre-
quently also in those which attend the final dis-
appearance of the menses.

It is to be observed that the limits between the
two divisions under which it is proposed to arrange
the several materials of prognosis are by no means
always precise. It may often be doubtful whether
a particular symptom is an essential character of
the disease in the abstract, forming part of its
diagnosis, or merely an accidental circumstance,
influencing our judgment of the event. And it
not unfrequently happens as a consequence of
this uncertainty, that a symptom which was
formerly referred to one of these two heads, is in
the progress of pathology found to belong to the
other.

I. Of the Prognosis of Disease as deduced
from its Diagnosis.
The prognosis of particular diseases will of
course be included in the articles allotted to them
in the present work. It will be our more appro-
priate object here to generalize the subject as
far as is practicable, by considering diseases as
grouped together in natural families. In adopting
a classification for this purpose, the point to be
chiefly aimed at is its facility of application, and
as no pretension is made to a perfect nosological
arrangement, it is unnecessary to enter into a
defence of that which will be employed in the

following pages. It will be sufficient if the reader
be advertised of the sense in which words em-
ployed to designate the several families of disease
are used, and if the same words be always used
in the same sense.

In the progress of this attempt to apply patho-
logy to the subject of prognosis, the imperfect state
of that science, or at least its limited applicability
to questions of a practical nature, will often be
apparent. In many diseases, and perhaps even in
the majority, it may adequately account for their
tendency and ultimate event ; but in many others
our knowledge of these points is matter of simple
experience, admitting as yet neither of useful
generalization nor of explication by any known
laws of pathological science.

We propose to consider the different families
of disease in relation to the following objects of
prognosis: 1. their curability; 2. their danger;
3. the particular circumstances which may be
expected to arise in their progress ; 4. the super-
vention of new diseases; 5. their duration; 6.
their liability to recur.

1, Curability. — The question whether a dis-
ease is remediable or not is in its nature quite
distinct from that of the degree of danger which
attends it. It is true that in many affections, as,
for example, hydrophobia, the former appears al-
most solely determined by the latter, so that we
have little or no reason for judging a cure to be
hopeless further than our experience of the in-
compatibility of the disease with the preservation
of life. Such cases, however, more properly be-
long to the next head.

Some diseases appear to be absolutely irreme-
diable either by nature or art ; in others, on the
contrary, a cure may be almost certainly predicted ;
and between these extremes we meet with every
shade of difference.

Many cases of disease which, to speak with
pathological accuracy, must be called irremediable,
inasmuch as the structure of the affected part can-
not be perfectly restored, are yet, in a practical
sense, sufficiently curable, because the alteration
of structure, though permanent, is productive of
no inconvenience. This is well illustrated in in-
flammations of serous membranes leading to ad-
hesions of moderate extent.

Of the various forms of idiopathic fever (using
the words in their ordinary acceptation) no one
variety can be considered as in its nature incur-
able, since it is their general character to have a
more or less determinate course and duration, and
thus to cease spontaneously when they are not
destructive of life. Some varieties, as the plague
and yellow fever, (and perhaps the present epide-
mic cholera ought to be classed with them,) must,
however, be deemed in a high degree incurable,
because in a large proportion of cases they prove
fatal, and as such they will be considered under
the next head. In others, as the ordinary con-
tinued fevers of this climate and intermittents,
(when they are not inveterate, and their local
cause can be avoided,) general experience justifies
a pretty confident expectation of recovery. The
prognosis in remittent fevers is generally good in
proportion as the remissions are distinct, or as the
affection approaches to the character of an inter-
mittent. As to symptomatic fevers (among which

702

PROGNOSIS.

almost all of those which are called hectic, and
probably also infantile remittent fever, must be
included,) their very designation implies that the
question of their curability is contingent upon that
of the primary disease to which they owe their
origin.

It may be said of acute inflammations as of
idiopathic fever, that none of them is, per se, in-
curable. In some, however, as for example acute
hydrocephalus and laryngitis, the hope of cure is
greatly diminished by the danger which attends
them. In many others there is a tendency, more
or less strong, to results which constitute organic
disease, and which are often wholly irremediable.
One of the principal of these results of inflamma-
tion is the deposition of coagulable lymph or fib-
rine, constituting what are called false membranes.
These are most frequent in the serous membranes,
where they generally cause adhesions between the
opposing surfaces, and become eventually orga-
nized, and often even secreting tissues. In such
an advanced state their removal is certainly be-
yond the reach of art or nature ; and even in their
earlier stages there is no evidence of absorption
ever taking place, while expulsion is of course out
of the question. Although adhesions of serous
membranes are thus irremediable in a pathological
sense, yet in a practical point of view they are
ordinarily scarcely to be recognised as constituting
disease. In the pleura and pericardium they are
not unfrequently found to have been almost uni-
versal without having produced any appreciable
inconvenience. The same may be said of the ad-
hesions which are artificially produced by stimu-
lant injections for the cure of hydrocele. Owing
to the mechanism of the abdominal viscera, adhe-
sions between different portions of the peritoneum
appear more often to interfere with their functions,
but by no means uniformly so. Inflammation of
mucous surfaces exhibits much less tendency to
the production of false membranes, and when they
do take place, the prognosis is widely different ;
for by the conjoined operation of muscular con-
tractions and mucous secretion, the membrane
when formed is commonly detached and expelled,
unless, as is often the case in croup, its presence
has speedily caused death. Hence permanent
and incurable adhesions are of rare occurrence.
According to the views of Laennec, the hepatized
state of the lungs consists in effusion of coagula-
ble lymph into the air-cells, and he seems to re-
gard it as removable by the powers of nature in
every stage of its progress. It is, however, proba-
ble that the consolidation thus produced is often
permanent and irremediable. In iritis there is a
great tendency to the formation of organized ad-
hesions, for which a surgical operation is the only
resource. Those effusions which take place in
the cellular and white fibrous tissues in inveterate
gout and rheumatism, appear to be almost wholly
incurable. The submucous cellular tissue is pro-
bably the seat of the thickening which constitutes
permanent or organic stricture. When this is
recent, mechanical pressure has some power in
producing absorption; but more commonly its de-
struction by caustics, &c. is the only effectual
remedy.

Ulceration, when it is the result of acute inflam-
ai»tion and does not destroy life, may be regarded

as curable, though probably the integrity of the
organization of the part is never perfectly restored.
The deficiency is, however, very rarely discovera-
ble, the eye being the principal exception, and that
by no means a constant one. Suppuration, an-
other result of acute inflammation, occurs in two
forms. In the one it is merely an altered secre-
tion from the surface inflamed, and unless it take
place to such an extent as to be destructive of
life, admits of cure. In the other it assumes the
form of abscess, and, when not fatal, is remediable
in various ways, as by absorption, by ulceration
and the evacuation of its contents, or by the aid
of surgery. Among the occasional effects of acute
inflammation, softening and gangrene may be in-
cluded. The former, which is principally met
with in the cerebral tissue and mucous membrane
of the alimentary canal, appears to consist in a
disorganization wholly or in great measure irreme-
diable. In gangrene reparation is utterly hope-
less ; although, when life is preserved, nature some-
times effects what may be called a cure by the
separation of the diseased part. It is possible that
some other alterations in the condition of parts
occasionally result from acute inflammation. They
will, however, be more conveniently considered
under the general head of organic changes and
lesions of structure.

Inflammation seems in general to be more in-
tractable when it attacks parts of low organization,
as bone, cartilage, white fibrous tissue, and conse-
quently joints. Chronic inflammation is also com-
monly less under the control of remedies than
acute, and more peculiarly so when, as is often
the case, it is connected with a cachectic habit of
body, as in scrofula, syphilis, mercurial erethism,
&c. It is probably owing in part at least to the
scrofulous habit with which acute hydrocephalus
is so commonly connected, that every mode of
treatment is found ineffectual in a considerable
number of cases.

Under the term profluvia may be comprehended
all those cases of mucous or muco-purulent dis-
charge which cannot properly be referred to in-
flammation. It will thus include many forms of
bronchial catarrh, diarrhoea, and perhaps dysen-
tery, catarrhus vesicae, and leucorrhcea. None of
these is in itself incurable, but every one of thern
may be and often is so, from being symptomatic
of some organic disease, and even when idiopa-
thic they are often very unmanageable.

Hemorrhages, if not so profuse as to be fatal,
may be considered as remediable, except when
they are symptomatic of organic disease, as hae-
moptysis attending tuberculous phthisis, and hae-
matemesis and melaena when referable to disease
of the liver or other abdominal viscera. In those
forms of hemorrhage in which the effused blood
finds a ready exit, the integrity of the part is left
untouched ; but when the effusion occurs in the
substance of an organ, the case is widely different.
Not only does a coagulum remain, but its pre-
sence is necessarily accompanied with a dilacera-
tion or compression of the substance of the organ ■
and though the coagulum is often ultimately re-
moved by absorption, the structure of the organ
may be irreparably injured. Here, however, as
in regard to the organic results of inflammation
already adverted to, we must bear in mind that

PROGNOSIS.

703

w hat is pathologically incurable may be unattend-
ed with any appreciable morbid effects. Thus, in
the cases of cerebral hemorrhage occurring in
hemiplegiac attacks, every symptom of inconveni-
ence sometimes disappears, not only before cica-
trization of the breach has been effected, but even
before the coagulum is absorbed. On the other
hand, cases are not wanting in which the palsy
has been permanent, though absorption and cica-
trization had taken place. Pulmonary apoplexy,
which Laennec refers to effusion into the air-cells,
is considered by that pathologist to admit of per-
fect restoration of the healthy condition of the
organ. The hematemesis of young females, and
other hemorrhages which appear to be vicarious
of the menstrual discharge, are striking examples
of a favourable prognosis being justified under
circumstances apparently the most alarming. The
hemorrhagic disposition in scurvy being peculiar
in its cause, is no less so in its prognosis, which
wholly depends upon the power of changing the
diet and other circumstances to which the disease
owes its origin.

The peculiarly intractable character of most of
the forms of dropsy is well known. Though this
is chiefly, it is by no means wholly to be explained
by the dropsy being merely symptomatic of some
organic disease ; for chronic hydrocephalus and
ascites are often, and hydrocele is almost always,
idiopathic, yet they are commonly but little influ-
enced by medical treatment. Anasarca and hy-
drothorax are much more manageable, and even
when symptomatic of organic disease, may often
be removed for a time by the use of diuretic and
other remedies. The powers of medicine in hy-
dropericardium and oedema pulmonum are not
much known, principally because the diagnosis
of those affections is very obscure. Many forms
of dropsy admit of temporary relief by surgical
means ; hydrocele alone (or almost so) of a per-
manent cure, namely, by the artificial excitement
of inflammation in the serous membrane, which
leads to universal adhesion of its opposing sur-
faces. Ovarian disease can hardly in strictness be
recognised as a form of dropsy, and if it be, it is
very far from affording an exception to the gene-
ral intractable character of the family.

Under the designation of cachexise it will be
convenient for our present purpose to include
several diseases which have little in common ex-
cept the impossibility of assigning them a local
seat. Some of them are very little amenable to
treatment. This is almost proverbially the case
with scrofula in its various forms, among which
may be included tuberculous disease generally.
Lues and mercurial disease, when inveterate, are
very difficult of cure ; and diabetes, which may
properly be noticed here, is well known to offer
an almost hopeless prognosis. In chlorosis, on
the contrary, and in scurvy, (when the circum-
stances which engender and maintain the disease
can be reversed,) the prospect of recovery is gene-
rally good. . .

Under the head of organic disease, lesions, and
other changes of structure, may be comprehended
all those deviations from the natural organization
of parts which are not distinctly referable to in-
flammation, or at least not commonly so. As a
whole, they are very little remediable, though m

the following enumeration many exceptions will
be noticed. In hypertrophy and atrophy the prog-
nosis varies greatly with the tissue affected ; thus,
by the judicious employment of remedial means,
great changes may be effected in the bulk of the
adipose tissue, and possibly of the muscles of loco-
motion; whereas in the hollow muscles, as the
heart and urinary bladder, which present the two
most common and well-marked instances of hy-
pertrophy, such means seem to avail little or no-
thing. The contrast of the two cases perhaps
countenances the opinion of some pathologists,
that hypertrophy of the heart is essentially differ-
ent from that increased bulk of voluntary muscles
which results from their increased use.

The development of the natural tissues of the
body in parts into the healthy structure of which
they do not enter, is an occurrence which rarely
if ever admits of remedy. Such are ossifications
(with which may be conjoined exostosis and an-
chylosis) and cartilaginous degeneration. The
fatty degeneration of the heart and liver may per-
haps be included with them.

New formations are either organic or inorganic.
According to most pathologists, tubercles are to
be enumerated among the latter. Though the
absorption of these bodies is generally admitted to
be impossible, there is a mode in which nature
has provided for their removal, namely, by the
process of softening, or, as it is often called, ul-
ceration ; and from recent investigations it appears
that the cavities which are thus produced in the
lungs are occasionally obliterated by a kind of
cicatrization. Of course this, in a pathological
sense, is a very imperfect mode of cure, since there
is no restoration of the pulmonary substance ; and
not only is it both rare and imperfect, but owing
to the continued deposition of tuberculous matter
in other parts of the lungs, it is commonly in the
end unavailing.

The occasional expectoration of tubercles is far
too rare and partial to modify the general prog-
nosis of the affection. Other varieties of inor-
ganic formations are melanosis, the contents of
encysted tumours, gouty concretions, and urinary
and bilious calculi. The first is in no way reme-
diable ; the others are occasionally got rid of by
expulsion or ulceration, but more often not with-
out the aid of surgery. In the opinion of Andral,
medullary sarcoma is an inorganic deposition, not
a degeneration : it appears to be wholly beyond
the reach of remedies.

The organized new formations, as sarcomatous
tumours, polypi, and hydatids, though occasionally
removed by spontaneous ulceration, are in general
wholly inaccessible to remedies, if we except those
which surgery provides. Perhaps ovarian disease
may properly be placed here. As has been al-
ready observed, it is unaffected by medicine ; tap-
ping affords but a very temporary relief; and ex-
cision is scarcely practicable except in that early
stage of the disease in which it occasions far too
little inconvenience to dispose the patient to sub-
mit to a formidable operation.

The organic diseases which seem to consist
rather in a change or degeneration of the natural
structure of the part than in any new formation,
such as scirrho-carcinoma miu some visceral in
durations, softening of the brain and spina 1 cord,

704

PROGNOSIS.

mollities ossium, cataract, &c. do not admit of
cure unless by surgical operations ; and even then
the prognosis is often bad, as in scirrho-carcinoma,
and still more in medullary sarcoma, (regarded
by some pathologists as a degeneration,) because
the disease, though extirpated from one part, may
already exist, or is liable to make its appearance
in another, implying not a merely local malady,
but a morbid state or tendency of the system. In-
durations of the liver and spleen, occurring in in-
veterate ague, appear to be very little under the
influence of remedies. If bronchocele and sarco-
cele properly belong to this division, they afford
well-known exceptions to the ordinary incurability
of this class of organic diseases.

Dilatations of the hollow muscles and canals,
when produced by mere distension, are generally
curable (supposing the cause removed) in an in-
verse proportion to their duration, as is seen in
the urinary bladder and passages, and in the colon.
Even where the dilatation is rather the effect of
want of tone or contractile energy the case does
not seem to be hopeless ; at least Piorry alleges
that he has watched the gradual diminution of
dilatation of the cavities of the heart; and we
know that varicose veins are sometimes reduced
in size by the effects of pressure. There is rea-
son to believe that a tympanitic state of the sto-
mach and intestines is sometimes caused by mere
want of tone, and admits of cure by proper treat-
ment. The pathology of ileus is imperfectly
known ; but if, as Dr. Abercrombie inclines to in-
fer from his researches, the only essential circum-
stance is a dilatation of some portion of the intes-
tinal canal, it may properly be noticed here. The
danger that attends this severe affection is well
known to be great, but it cannot be regarded as
incurable. Dilatation of the bronchi and enlarge-
ment of the air-cells (the pulmonary emphysema
of Laennec,) are, as far as is known, incurable.
Aneurism rarely consists in mere arterial dilata-
tion : such, however, appears to be occasionally
the case, especially in the aorta ; and it is more
particularly in this form of the disease that, in
the estimation of some writers, the mode of treat-
ment proposed by Valsalva produces a beneficial
result.

Permanent strictures of canals, from effusion of
lymph, have been already noticed among the
effects of inflammation : those which depend on
muscular contraction only are in a considerable
degree remediable by mechanical means. Of per-
manent contractions of the hollow viscera we
know little.

Breaches in the solids. — The reunion of frac-
tured bone is generally practicable, unless in some
particular states of the constitution, as pregnancy,
lues, and scurvy. The only alleged ordinary ex-
ception is the neck of the thigh bone. Lacerated
white fibrous tissue, as ligaments and tendons,
also readily reunites. The reunion of torn muscles
appears to be effected by cellular tissue, not by
the reproduction of muscular fibre. It is probable
ihat the hollow muscles and muscular canals
would be generally repaired in the same manner,
were not their rupture mostly attended by fatal
consequences ; and the same may be said of the
solid viscera, as the liver, &c. In the case of
olood-vessels being torn or cut through, a peculiar

provision is made for the repair of the injury.
The separated ends are not reunited, but the cir-
culation is carried on through collateral branches.
Divided nerves are said to be reunited by nervous
tissue. Excretory ducts, the pulmonary cells,
and the cutaneous and cellular tissues are all sus- ■
ceptible of reunion.

Ulcerations generally admit of repair by the
processes of granulation and cicatrization ; but
least so when the system is under the influence
of any of the affections already mentioned as
cachectic, especially scrofula and syphilis. Of the
peculiarly intractable character of ulcers in the
former of these, we have instances in the articular
cartilages, and in laryngeal and tracheal phthisis.
With regard to excavations formed by the remo-
val of morbid depositions, we know that healthy
abscesses, when emptied, readily heal, and that
even the less manageable ones are to a considera-
ble extent curable. It has been already stated,
that when life is preserved for a sufficient time,
the powers of nature are occasionally adequate to
the reparation of the tuberculous excavations of
the lungs, and hemorrhagic cells in the brain. In
some of the congenital breaches, as the hare-lip
and imperfect palate, a cure may be effected by
operation. In spina bifida, all attempts to cure or
even palliate the affection have commonly failed ;
and in the case of unnatural communication be-
tween the cavities of the heart, no means can
possibly be of avail.

Displacements. — The prognosis in dislocations
of the joints is mostly good, provided the attempt
at reduction be not too long delayed. Though
the lateral curvature of the spine is often, at least
in its origin, merely a displacement of certain por-
tions of the column, it is far from being uniformly
a curable affection. The angular curvature rather
belongs to the head of diseased structure than to
that of displacements. When invagination of the
bowels is from above downwards, and no adhe-
sions have been formed, there is good reason to
believe that replacement is often spontaneously
effected : when, however, adhesions have taken
place, the cure must be all but hopeless. The
prognosis appears to be also very bad in every cir-
cumstance of that rare form of intussusception
which is from below upwards. External herniae,
when not strangulated, are mostly replaceable
either spontaneously or by taxis ; and when stran-
gulated, often admit of cure by the division of the
stricture. Even in cases which from adhesions
or other causes cannot be relieved in this way, a
sort of cure is occasionally effected, either sponta-
neously or designedly, by the formation of what
is called an artificial anus. Diaphragmatic and
other internal hernise are wholly inaccessible to
the resources of art. Prolapsus of the uterus and
anus, when not inveterate or of great extent,
generally admits of cure or relief, either by means
directed to increase the tone of the parts, or by
mechanical support. In the latter affection, when
both these means fail, excision of the protruded
portion is often resorted to with success. Retro-
version of the uterus is almost peculiar to the im-
pregnated state of the organ, its immediate cause
being generally distension of the urinary blad-
der; and when this is removed, the womb rea-
dily recovers its proper position, either spontane-

PROGNOSIS.

705

ously or by manual assistance. Inversion is per-
haps never relieved except by the latter means.

When fluids escape from their natural seats by
ulceration or disruption, the prognosis is very va-
'ious, depending on particular circumstances.
That of air into the cellular tissue, constituting
external emphysema, generally ends favourably,
either by spontaneous absorption or by the aid of
punctures. Pneumothorax and abdominal tympa-
nitis are much less curable, being almost always
the result of organic lesions. The same may he
said of effusions of urine, in which, however, re-
markable instances of the curative resources of
nature, when aided by the prompt and judicious
interference of surgical art, are occasionally met
with.

Under the general designation of functional
disorders may be included all those which are not
constantly and necessarily associated with visible
changes in the condition or organization of parts.
Hence, while in most of the preceding classes of
disease, pathology throws more or less light upon
the question of curability, in the present it almost
wholly fails us. Indeed in many of the most in-
tractable and fatal cases of these affections no
morbid appearance whatever can be found after
death, or at least nothing beyond slight changes
in the vascularity of the part whose functions had
been disturbed, and which are considered by the
best pathologists rather as effects than causes of
the disorder. It is true that the functional disturb-
ance is sometimes associated with, and apparently
dependent upon, inflammatory or organic disease ;
and where the existence of this can be known, it
must of course materially influence the prognosis.

In reviewing these disorders, it will be most
convenient to arrange them according to the
organs or functions most prominently disturbed ;
and so widely do they differ in regard to their
prognosis, and so insusceptible are they of any
satisfactory generalization, that it will be necessary
to speak of most of them individually.

Functional affections of the nervous system,
including disorders of sensation and of the mus-
cles of voluntary motion. — Two of these, viz. teta-
nus and hydrophobia, the pathology of which is
extremely obscure, are so fatal, that in the former
a cure is comparatively rare, and in the latter
almost unknown. The convulsions of infants,
though much less commonly fatal than the prece-
ding, are a source of great mortality in the first
years of life. In those of puerperal women there
is generally a tolerably good prognosis, except
where they have been produced by very profuse
hemorrhage. Apoplexy is another affection often
incurable by reason of its immediate fatality; and
even when it does not destroy life, but disappears
either spontaneously or by the use of remedies,
the ultimate prognosis is greatly influenced by its
known tendency to recur. Palsy and insanity,
though not of themselves very frequently mortal,
are often wholly incurable, and commonly but lit-
tle under the influence of remedies. Palsy, at
least in two of its forms, viz., hemiplegia and pa-
raplegia, is more often connected with visible or
organic changes than any other affection of this
class. Yet even were the existence of such
changes more certainly ascertainable than it can
be, it would be necessary to use great caution in
Voi. III. — 89

drawing inferences as to the prognosis. Thus we
have the testimony of Dr. Abercrombie, that in
cases of hemiplegia, the effused blood may be ab-
sorbed and even cicatrization effected, and yet the
paralysis occasionally remain ; while in other cases
the paralysis may disappear before absorption has
taken place. While so much obscurity hangs
over the pathology of these affections, it need not
surprise us that remarkable and unlooked-for in-
stances of recovery, even from inveterate palsy,
sometimes occur ; and hence we properly draw the
distinction between a bad and a hopeless progno-
sis. If aphonia be considered as a form of para-
lysis, it affords a striking instance of the uncer-
tainty of prognosis in such affections ; since, on
the one hand, our anticipations of success from
the use of remedies should be any thing but san-
guine, while, on the other, we know that sudden
and complete recovery not unfrequently takes
place even when the affection has existed for
years.

The prognosis in epilepsy is on the whole bad,
the malady often resisting every mode of treat-
ment, even in cases in which after death no patho-
logical cause can be detected. On the other hand,
hysteria, which sometimes very nearly resembles
it, is generally curable ; as in fact are most dis-
eases which depend upon a disordered state of the
menstrual function. Catalepsy is probably but a
modification of hysteria, and like it generally ad-
mits of recovery ; as also does chorea. Delirium
tremens too often ends fatally to allow in general
of a very sanguine prognosis. Hypochondriasis,
which seems to be intermediate between dyspepsia
and insanity, partaking in some measure of the
characters of both, is probably on the whole less
curable than the former, and more so than the
latter.

With regard to morbid sensations, pain, though
commonly but a symptom of other affections, con-
stitutes of itself the whole character of one family
of diseases, the neuralgise. Like the functional
disorders just spoken of, they are sometimes con-
nected with organic or other appreciable disease
of some part of the nervous system, but more
often not, even when they are found utterly in-
curable. The neuralgise, though often irremedia-
ble by any mode of treatment, do not on the whole
justify a very unfavourable prognosis. It must,
however, be much influenced by the particular
seat of the pain. Thus the tic douloureux, many
forms of head and back-ach, gastrodynia, and an-
gina pectoris, are in general far less remediable af-
fections than pleurodynia, sciatica, and lumbago.
With regard to the pains of the chest, chiefly oc-
curring in females, and referred to the intercostal
nerves, the pathology is obscure, but the prognosis
generally good.

With regard to functional affections of the
thoracic organs, the cases ordinarily designated
spasmodic croup most commonly end favourably.
Some authors, however, deny the existence of the
disease. Spasmodic asthma, even when appa-
rently independent of organic disease, is confess-
edly a very intractable affection, the prospect of a
perfect cure being on the whole but faint. The
same may be said of palpitation and angina pec-
toris, even in the absence of organic disease ; and
when, as is often the case, they are associated

706

PROGNOSIS.

with it, there can be little or no hope of re-
covery.

Of the various modifications of functional dis-
order of some one or more of the digestive organs,
there is none which can be regarded as in its
nature incurable, though many, perhaps most of
them, are often very obstinate.

The ischuria renalis, though but a functional
disorder, is so often fatal that the prognosis is far
from good. An exception must, however, be
made as to those cases in which it is a symptom
of hysteric affection. Two other morbid condi-
tions of the renal function, namely, the secretion
of albuminous urine, and the phosphatic diathe-
sis, are perhaps mostly connected with organic
disease ; at any rate they are commonly very in-
curable maladies. Diabetes has been already no-
ticed as being rather a constitutional disease than
a mere local affection of the urinary organs.

In amenorrhcea, when it is not symptomatic
of some other disease, the ultimate prognosis is
generally good, though the affection is often very
tedious and unmanageable. Dysmenorrhcea is
perhaps even more so.

Congestions. — Although either a general or
partial derangement of the balance of circulation
between the arterial and venous systems may
mostly form one link in the chain of circumstances
which constitute diseases, it is very doubtful whe-
ther any one which is recognised in nosology can
be said essentially to consist in such a state. If,
however, it be otherwise, we may safely assume
with respect to prognosis, that though the de-
rangement may be sometimes destructive of life,
or may eventually lead to irremediable changes
of organization, it cannot constitute a disease in
its nature incurable.

Parasitic animals are chiefly intestinal worms
and hydatids : the former are mostly accessible to
the powers of medicine; but the latter, being
rarely in open canals, cannot be expelled by such
means; so that the question of curability very
much resolves itself into that of the practicability
of a surgical operation.

2. Danger to Life. — A large number of dis-
eases are in themselves neither so entirely desti-
tute of danger as to cause no alarm, nor so gene-
rally fatal as to excite it in a very high degree.
The estimate of danger in these affections must
therefore depend on the particular circumstances
of each individual case, a subject which forms the
second part of the present article. There are,
however, other diseases which occupy the two
extremes of the scale, some being very commonly
fatal, and others as commonly devoid of danger.
It properly belongs to a general view of the sub-
ject of prognosis to attempt an analysis of the
circumstances which determine the location of a
disease in either of these two extreme classes.
As we have already seen that the light which
pathology throws upon the question of curability
is frequently very imperfect, so will that science
be often found an inadequate guide to the dis-
covery of the extent of danger. It may be pre-
mised as a general position, that the ultimate
issue of disease, whether in death or recovery,
can be less certainly foreseen in acute than in
chronic affections.

A Diseases, invariably or very commonly

fatal, may be thus classified in relation to the
circumstances which seem to determine the dan-
ger.

a. Those in which the whole system receives a
sudden and overwhelming shock, most apparent
in the disturbed balance of the circulation, and
commonly attended with a morbid state of the
circulating fluids. In this way certain forms of
epidemic fever, especially the plague and yellow
fever, (and the spasmodic cholera ought probably
to be included,) are very often fatal in their first,
or, in the language of Dr. Armstrong, their con-
gestive stage ; and sometimes even before the
manifestation of any local or characteristic symp-
toms. It is apparently in an analogous way
(though the nervous system is then often more
prominently affected than the vascular) that life
is sometimes suddenly extinguished by violent
accidents or the agency of certain poisons.

b. Those in which organs of great importance
to life, or having very extensive sympathies, are
affected with inflammation or other considerable
disease. Thus encephalic inflammation generally,
and especially acute hydrocephalus, apoplexy,
carditis, pericarditis, and organic disease of the
heart, extensive phlebitis, croup, laryngitis, as-
phyxia, peripneumonia, peripneumonia notha, and
severe or extensive disease of the gastro-intestinal
mucous membrane, may all be regarded as dan-
gerous affections. In many of them, and perhaps
more particularly in those which are seated in the
encephalon, even if we were always able during
life to ascertain the extent and degree of the local
disease or disorganization, we should have a very
uncertain guide for the prognosis of danger, since
the researches of pathology show that these bear
no definite relation to the fatal tendency. The
amount of functional disturbance probably affords
a better criterion. The cases of cerebral abscess
related by O'Halloran strkingly exemplify the
occasional retention of life when disorganization
of an important organ has proceeded to a very
great extent.

c. The tendency to a fatal event seems in some
diseases to be rather owing to the kind of morbid
change or to its extent, than to the importance of
the organ affected. Of the first kind of cause
we have examples in strangulated hernia, in
gangrene generally, in cynanche maligna, and
perhaps in ileus ; of the second, in fevers when
fatal after reaction, in confluent small-pox, diffuse
inflammation of the cellular tissue, and extensive
peritonitis.

d. Diseases which are fatal by gradual ex-
haustion, including the greater part of mortal
chronic diseases, as phthisis pulmonalis, laryngeal
and tracheal phthisis, chronic bronchitis, empyema,
tabes mesenterica, psoas abscess, some organic
diseases of the liver, scirrho-carcinoma, medullary
sarcoma, peritoneal accretions, ovarian disease,
diabetes, &c. It is to be observed, however, that
few chronic diseases terminate fatally without the
supervention of disease in the bronchial or gastro-
intestinal mucous membrane, especially the latter ;
and such a complication must undoubtedly have
an important influence in determining the fatal
event, and also affords a ground for predicting its
approach. Profuse hemorrhages may be classed
among diseases which are fatal by exhaustion

PROGNOSIS.

707

The most common examples are, the rupture of
aneurisms, wounds of arteries, and puerperal
hemorrhage. In some forms of apoplexy internal
hemorrhage seems to be, in part at least, the im-
mediate cause of death.

e. Intense pain, though not often of itself
fatal, seems to be occasionally so. Gastrodynia
perhaps affords the most frequent and decisive
examples.

/. In some affections the prediction of death is
rather founded upon the high probability that
another and fatal disease will supervene than upon
the danger which immediately arises from the
existing one. The termination of ischuria renalis
in apoplexy or coma is perhaps the most consid-
erable instance.

g. The fatal tendency of puerperal peritonitis
seems to be much more explicable by the peculiar
condition of the system at large immediately after
parturition, than by the seat or intensity of the
local affection.

h. There are two diseases, namely, hydrophobia
and tetanus, in a very high degree dangerous to
life, yet so obscure in their pathology that it seems
impracticable to unite them with any other class
of mortal diseases.

B. Diseases which in themselves are rarely
fatal may be thus classified : —

a. Those in which, although there be general
disturbance of the nervous and circulating sys-
tems, it is moderate, and unattended by any con-
siderable local affection, such as the ordinary in-
termittent and continued fevers of this country.

b. Inflammations of parts not essential to life,
or not having extensive sympathies with other
parts of the body ; such as those of the eye, ton-
sils, parotids, mamma?, testicles, prostate, urethra,
vagina, joints (including articular rheumatism
and gout), lymphatic glands, and cellular tissue.

c. Organic affections of similar parts, as cata-
ract and many other affections of the eye, bron-
chocele, hydrocele, sarcomatous and encysted
tumours, and hydatids. The principal exceptions
are when these affections are such as are con-
sidered specific, as scirrho-carcinoma and medul-
lary sarcoma.

d. Certain functional disorders, as epilepsy,
catalepsy, chorea, hysteria, insanity, hypochon-
driasis, the neuralgise in general, spasmodic asthma,
nervous palpitation, dyspepsia, amenorrhcea, and
most of those disorders which are connected with
it, as chlorosis and vicarious hemorrhages. No-
where is the imperfection of pathology, as a guide
to prognosis, more apparent than in relation to
this class of affections ; for example, it is by ex-
perience only, and an experience which does not
admit of generalization, that we judge of the
wide difference in respect of danger between
epilepsy, hysteria, and syncope on the one hand,
and hydrophobia and tetanus on the other.

3. Circumstances which may he expected
to arise in the course of a disease* — Al-
though a distinction may properly be made be-
tween the appearance of new symptoms during
the progress of a disease, and the supervention
of new diseases, it must necessarily often be
arbitrary, and sometimes obscure ; since it wholly
depends upon the fact of such symptoms or cir-
cumstances being or not being recognised by

nosologists as separate diseases. Those which
are not generally admitted as such may be arranged
under three heads, critical, non-critical, and in-
termediate, that is, such as are critical in a lower
degree, denoting merely a temporary alleviation
of the malady.

Critical. — It is to be premised that, though a
particular circumstance may in one disease be criti-
cal, it may in another, or even in a different stage of
the same, be non-critical. Thus profluvia, hemor-
rhages, and tumours, which towards the termina-
tion of fevers are often critical, are mostly not at
all so in the earlier periods of their progress.
Whether critical circumstances be the cause, sign,
or effect of the termination of the malady, is a
question of little moment in relation to prognosis,
though it may be one of much interest with re-
gard to practice.

In treating of critical circumstances, we find a
distinction of much practical importance, namely,
as they indicate the permanent removal, or
merely the temporary disappearance of a disease.
The former are chiefly seen in continued fever
and acute inflammations. Why, in such affec-
tions, one symptom or circumstance is critical
rather than another, is a question involved in
much obscurity. What has been called the con-
stitution of the season appears to have considera-
ble influence. Thus in some epidemics, fevers
most commonly terminate by sweating ; in others,
by purging; though perhaps the most frequent
mode is by copious urinary deposits. In other
cases the crisis is marked by hemorrhages, ab-
scesses, buboes, or carbuncles. There seems in
fact little beyond mere experience of the prevail-
ing tendency, to guide us in the anticipation of
the particular circumstance which is likely to
mark the solution. The constitutional predispo-
sition of the individual has, however, probably
some share ; and also the characters of the dis-
ease, in regard to the organs or functions which
are most prominently disturbed. It might in-
deed be conjectured that when the function of an
organ has been interrupted by disease, it would,
at the cessation of that disease, be renewed with
augmented energy. And perhaps, as a general
position, this has some foundation in truth. It
seems to be in degree illustrated in the spasmodic
cholera, in which affection, while the force of the
disease falls very much upon the organs concerned
in digestion, healthy bilious secretion often marks
its favourable termination. The position must,
however, be received with considerable limitation.
Thus, as Laennec states, peripneumonia much
more often terminates with urinary deposits than
with copious sputa.

In those affections which are characterized by
accessions or paroxysms returning at intervals,
the termination of the paroxysm is very commonly
marked by some critical circumstance. Such is
the sweating of ague, the expectoration in some
forms of asthma, vomiting in pyrosis, perhaps the
swelling of the foot in regular gout, sleep in epilep-
sy, and the secretion of lithic acid in some of those
painful affections of the loins which are too indis-
criminately called fits of stone or gravel, there
being often no evidence whatever of the passage
of such concretions.

Intermediate. — In many diseases we can predict,

7U8

PROGNOSIS.

with more or less certainty, the occurrence of cir-
cumstances which, though they by no means
denote the cessation of the malady, commonly
imply a certain measure of relief. Such are
dropsical effusions and hemorrhages in organic
diseases and chronic inflammations of important
organs, as the brain, heart, lungs, and liver. It is
true that such an occurrence may itself constitute
a more troublesome or immediately dangerous
disease than the primary one which it tends to
alleviate ; and perhaps this is more particularly
the case in regard to the brain, owing to the
mechanism of the cranium. But even there we
have strong reasons for supposing that hemorrhage
occasionally, and serious effusion more often,
serve to mitigate existing diseases. Effusion into
the joints and neighbouring tissues, in gout and
articular rheumatism, is also generally attended
with some alleviation of suffering. In hectic and
in remittent fevers, sweating, urinary deposits,
and other secretions, make an imperfect solution ;
and this is observable, though in a less degree, in
the daily history of even continued fevers.

Non-critical. — Under this designation may be
comprehended all those circumstances, whether
they be pathological changes or functional de-
rangements, which make up the history of a dis-
ease, and which consequently may be predicted
when that history is known. It is evident that
prognosis of this kind is chiefly available in those
affections which have a more or less determinate
course and regular succession of events, the oc-
currence of which may be foreseen from the com-
mencement. Such is the series of events which
constitute a fit of ague, and the succession of
symptoms in acute exanthemata, gout, syphilis,
yellow fever, and epidemic diseases in general.
The following may be instanced as some of the
more considerable examples of non-critical circum-
stances whose occurrence may be predicted in
certain kinds of disease.

a. In fevers and febrile affections generally,
daily exacerbations and remissions in the symp-
toms may be looked for, commonly more or less
nearly corresponding with the hours of sunset and
sunrise. These are most conspicuous in the
fevers called remittent, (as indeed their designa-
tion implies,) including infantile remittent fever,
and in hectic fever, in which latter some authors
distinguish two daily exacerbations, namely, about
noon and sunset. Among acute inflammations,
rheumatism and gout present these daily variations
most conspicuously. In many cases of neuralgic
affections and chronic rheumatism, the daily acces-
sions occur at very different hours from those
above named, governed by circumstances which
are wholly unknown, and as to which it is impos-
sible to generalize.

b. In inflammations, certain pathological re-
sults, varying with the tissue or organ affected,
may be more or less confidently predicted. Thus
inflammation of the mucous membranes, the skin,
and cornea, is most liable to pass into ulceration ;
that of the former also often leads to softening,
and occasionally, as in croup and diphtheritis, to
effusion of coagulable lymph, or false membrane.
Serous effusion, and the formation of false mem-
brane resulting in adhesions, are the most com-
mon effects of inflammation of serous membranes.

Erysipelatous inflammation frequently tends to
gangrene ; so also, in the opinion of Dr. Abercrom-
bie, does inflammation of the muscular tissue, as in
the enteritis of Cullen, and in ileus. Inflamma-
tion of the cellular tissue, kidneys, tonsils, mamma;,
and, in India, that of the liver, ends chiefly in
suppuration and abscess. In gout and rheuma-
tism there is a tendency to those effusions into
the white fibrous tissue which cause stiff joints,
and in gonorrhoea, to the thickening which pro-
duces stricture. The pathology of phlegmasia
dolens is yet involved in much obscurity ; but as
a point of prognosis, it deserves notice that its ap-
pearance may be often foreseen when much pain
is felt in the groin soon after parturition.

c. Certain organic affections have a pathologi-
cal course peculiar to themselves. Thus tubercles
pass through the process of softening ; scirrhus
goes on to carcinoma ; medullary sarcoma to he-
morrhage ; and ulceration of the articular carti-
lages to abscess and sinuses in the surrounding
parts.

d. In diseases which cause long confinement to
bed, and are attended with much emaciation and
general loss of vital power, the occurrence of bad
sores is to be apprehended. Hence they often ap-
pear in protracted fevers, phthisis pulmonalis,
inveterate lues, the worst cases of insanity, &c.
Somewhat analogous to this is the tendency of
punctures in anasarcous limbs to cause gangrene.

e. Perhaps in most fatal chronic diseases, and
certainly in phthisis pulmonalis, the appearance
of slight delirium may be expected to precede
death.

f. Lastly, some individual diseases are liable to
circumstances peculiar to themselves, and not ad-
mitting of being generalized. Thus the disappear-
ance of cynanche parotidcea is very commonly
attended by swelling of the testes or mamma? ; and
inveterate ague produces indurations of the liver
and spleen.

4. Supervention of new Diseases. — There
are many varieties as to the mode in which this
occurs. Thus the disappearance of the primary
affection, and the development of a secondary one
may be simultaneous ; and if the nature of both
diseases be the same, the substitution of one for
the other is called metastasis or translation. Again,
there may be an interval between the cessation
of the first affection and the appearance of the
second, as is sometimes observed when phthisis
pulmonalis follows measles. Or, lastly, the two
may coexist. It is to be observed, that although
some diseases always supervene in the same way,
this is by no means the case with all : thus disease
of the heart and pericardium may either replace
articular rheumatism or coexist with it. It may
perhaps be assumed as a general position, subject,
however, to exceptions, that when the primary
disease is acute, the supervening one commonly
supplants it; but when it is chronic, they go on
together.

The circumstances under which new diseases
supervene upon previously existing ones may be
thus generalized :

a. A great degree of vascular disturbance of the
system at large is very prone to end in local in-
flammation, its particular seat being apparently in
great measure determined by the predisposition of

PROGNOSIS.

709

the part. Thus local inflammations very often
occur in the course of fevers and acute exanthe-
mata ; and hysteritis or peritonitis follows profuse
puerperal hemorrhage. Perhaps the frequent ap-
pearance of encephalic inflammation after violent
concussion may be referred to the same head.

b. It has been already observed that chronic
diseases of important organs, as the lungs, heart,
brain and its membranes, liver, and mesentery,
very commonly lead to disease of the gastrointes-
tinal and bronchial mucous membranes.

c. Diseases attended with great exhaustion, as
protracted fevers, phthisis pulmonalis, diabetes,
diarrhoea, and hemorrhages, generally induce ana-
sarca. In organic diseases of important viscera,
not only does dropsy take place in the cellular
tissue, but also often in the cavities ; and as a
general though not universal rule, more especially
in those with which the diseased viscera are more
particularly connected. Thus hydrothorax and
hydropericardium are found to supervene upon
diseases of the heart and lungs ; ascites upon those
of the liver and abdominal viscera generally ; while
most organic affections of the cncephalon sooner
or later cause serous effusion into the ventricles,
or between the membranes.

d. Many cases of supervening disease seem re-
ferable to the relation or sympathy which subsists
between different tissues of the same organ, and
between the external and internal parts of the
same region of the body. Some of these cases are
strictly metastatic ; in others, the primary and
secondary diseases coexist. We have examples
in inflammation of the brain and its membranes
ensuing upon erysipelas of the face and scalp,
upon injuries of the latter, and upon otorrhoea and
ophthalmia ; in pleurisy occurring in peripneu-
mony and phthisis ; in the alternation of abdomi-
nal dropsy with diarrhoea or dysentery ; perhaps
also in anasarca following scarlatina, though in
other exanthematous affections little or no ten-
dency of this kind is observed.

e. Continuity of tissue, together with close alli-
ance in function, is a cause of secondary diseases,
most conspicuously seen in the mucous mem-
branes. Thus, stricture of the urethra and dis-
ease of the prostate are apt to lead to disease of
the bladder ; and the latter, including vesical cal-
culi, to disease of the kidneys. Common catarrh
is often followed by an analogous affection of the
rectum and urinary bladder, and by an herpetic
affection of the upper lip ; the diphtheritis of Bre-
tonneau is very prone to pass into croup ; and
cynanche maligna, and occasionally pertussis, into
bronchitis. An American anatomist states that
he has traced the continuity of the white fibrous
tissue of the limbs with that which enters into the
structure of the pericardium, and thence deduces
an explanation of pericarditis supervening upon
rheumatism. A more simple and natural expla-
nation appears to be that rheumatism is a disease
which attacks muscles and fascia? generally, and
therefore, among the rest, occasionally affects the
heart and pericardium.

/. The supervention of a new disease seems
sometimes to arise from a peculiar sympathy or
relation between parts which are neither contigu-
ous, nor immediately connected in function. We
have examples in the chylopoietic viscera and en-

* OK.

cephalon : thus encephalic inflammation not un-
frequently ensues upon hepatitis ; while the latter
is sometimes produced by injuries of the head. So
in fevers, meningeal inflammation is found to fol-
low that of the gastro-intestinal mucous mem-
brane, or the reverse. Again, infantile remittent
fever is often the precursor of acute hydrocepha-
lus.

g. When a constitutional predisposition or dia-
thesis, such as the scrofulous or tuberculous, sub-
sists, various diseases will either call it into acti-
vity for the first time, or, if it had previously been
developed in an organ in a latent and unsuspected
state, make its presence manifest. This latter is
perhaps often the case in regard to the apparently
exciting causes of phthisis pulmonalis. Thus all
diseases which occasion great prostration of
strength, as protracted fevers, exanthemata, diar-
rhoea, diabetes, and chlorosis, are apt, in the pre-
disposed, to lead to tuberculous disease or external
scrofula. So also inflammations or other diseases
of the organs most liable to these affections will
often call them forth j thus pneumonic inflamma-
tion, bronchial catarrh, and sometimes pleurisy,
will pass on to phthisis pulmonalis ; and inflam-
mation of the mucous membrane of the small in-
testines into tabes mesenterica. Perhaps the fre-
quent termination of spasmodic asthma in phthisis
may be properly classed with the preceding facts.
If the constitutional diathesis be already mani-
fested in one organ or tissue, there will be much
reason to suspect its present latent existence, and
future development in others. Thus external
scrofula is often the precursor of phthisis pulmo-
nalis and tabes mesenterica ; acute hydrocephalus
has been observed to supersede threatened con-'
sumption ; and Dr. Baron states that accretions
may be expected to take place in the pleura, when
they already occupy the peritoneum. So, also,
the extirpation of medullary sarcoma in one organ
is commonly unavailing, owing to its existence
or development in others.

h. The disappearance of a morbid action or se-
cretion of a part, or the absence of its accustomed
return, is very often followed by disease in some
other parts; more especially if the constitution
had been long habituated to the preceding affec-
tion, or if that affection had suddenly disappeared.
Cases of this kind constitute a numerous family,
apparently very capricious in their individual cha-
racters, and little susceptible of useful generaliza-
tion. Thus the disappearance of cutaneous dis-
eases, profluvia, hemorrhages, purulent discharges,
&c. may give rise to internal diseases of all kinds
and localities, the particular nature and seat being
of course very much influenced by the patient's
age, habits, &c. as is illustrated by the well-known
liability of aged persons, under such circumstances,
to apoplexy and palsy. The following cases may
be enumerated as of most frequent occurrence,
and consequently of most practical importance
in regard to prognosis : — the various forms of
irregular gout, which (whatever be our view of
the pathology of the disease) may be fairly con-
sidered to be caused by the absence or premature
recession of the disorder from the extremities ;
hysteria and vicarious hemorrhages, resulting from
amenorrheca ; the various diseases to which women
are subject when they cease to menstruate, of

no

PROGNOSIS.

which scirrho-carcinoma is the most important, if
not the most frequent ; apoplexy and palsy, follow-
ing the suppression of hemorrhoids in the aged;
the alternation of gout and gravel ; the occurrence
of hernia humoralis, when gonorrhoea is hastily
stopped by astringents ; the termination of ischu-
ria renalis in fatal coma ; and the occurrence of
some general and fatal disease after extirpation of
a merely local one, as scirrho-carcinoma of the
breast.

i. The obstruction of excretory ducts by the
impaction of concrete matter frequently gives rise
to disease. Thus jaundice is often caused by
biliary calculi lodging in the ductus communis;
and it occasionally happens that both the ureters
are obstructed by calculi so as to induce ischuria
renalis.

k. It is more particularly in regard to the brain
and nervous system that we meet with instances
of one functional disorder passing into another ;
though, as is often the case, both may be inde-
pendent of any vascular or organic change. Thus
epilepsy and chorea occasionally lead to fatuity,
and mania to complete amentia.

/. There is a question of much practical interest
in regard to prognosis which is entitled to some
notice in this place ; namely, whether there is a
general tendency in functional disorders to pass
into inflammation or organic disease. Notwith-
standing the statements of Dr. Wilson Philip, the
general experience of physicians seems to furnish
a negative answer to this question, as it respects
the most common of all functional disorders, —
those of the digestive organs : and the same may
be said of palpitations of the heart. In some of
• the functional disorders of the brain and nervous
system, especially mania and epilepsy, pathologists
have however, in a large proportion of cases, noted
appearances of vascular derangement, and in
many, even of disorganization ; as especially
Wenzels, in regard to epilepsy. Unnatural vascu-
larity of the spinal cord is also said to be com-
monly found in fatal cases of tetanus and hydro-
phobia, and even in those of spasmodic cholera ;
but it is very doubtful whether it constitutes any
important part of the pathology of these affections.
Perhaps the same may be said of the morbid vas-
cularity generally found in the kidneys in fatal
cases of diabetes.

5. Duration of Disease. — The distinction
between acute and chronic diseases of itself implies
some sort of prognosis of their duration, yet ne-
cessarily a very imperfect one, not only because
the limits of the two classes admit of no precise
definition, since the same kinds of disease some-
times belong to one, sometimes to the other ; but
also because there is a wide range of duration
among diseases referred to the same class, as for
example between a twenty-one days' fever, and
the worst forms of plague and spasmodic cholera.
Fevers in general are considered acute affections ;
the only considerable exception being those which
are symptomatic of organic diseases, and which
mostly assume the form of hectic. Inflamma-
tions, with very few exceptions, may be either
acute or chronic ; and so difficult is it often found
to determine to which class a given case ought to
De referred, that many modern pathologists have
esorted to the expedient of distinguishing a

third and intermediate class, which they call sub-
acute.

Profluvia, hemorrhages, and dropsies, diseases
which have much natural affinity with inflamma-
tions, are, like them, both acute and chronic ;
mostly assuming the latter form when they are
symptomatic of organic affections. The cachexias
are in their nature chronic ; and it is well known
that when inflammation occurs in persons whose
constitutions are infected with scrofulous or tuber-
culous disease, it commonly assumes a chronic,
and at most a subacute form. Organic changes
and structural lesions are necessarily chronic. Of
functional disorders, some are essentially acute, as
apoplexy, hydrophobia, and tetanus ; others almost
always chronic, as dyspepsia and hypochondriasis;
many, sometimes one, sometimes the other, as
paralysis and the neuralgia? ; and, lastly, some
are of an intermediate or anomalous character,
being chronic as a whole, but acute as to the suc-
cessive paroxysms, as epilepsy and spasmodic
asthma.

However uncertain the prognosis of the dura-
tion of diseases may commonly be, it is, as a
general rule, much less so in acute than in chro-
nic affections ; and in some of the former it is in
a considerable degree determinate. Of these we
find examples in certain endemic or epidemic
fevers, as well continued as intermittent and re-
mittent ; in some of the exanthemata, especially
small-pox and measles, and some varieties of
herpes ; in acute inflammations in general, includ-
ing hydrocephalus acutus ; in acute profluvia, es-
pecially when epidemic, as catarrh and dysen-
tery ; in hydrophobia, tetanus, and perhaps ischu-
ria renalis. The acute diseases, whose duration
can least be calculated upon, are such as are as-
sociated with the scrofulous or tuberculous dia-
thesis, or with secondary syphilis ; those inflam-
mations in which the inflammatory action is but
slight, as pertussis ; and such as are prone to shift
their seat, as especially rheumatism.

Of course in proportion as the nature of the
disease itself throws little light on the question of
its duration, we are obliged to have recourse to
the particular circumstances of each individual
case, and in chronic diseases these constitute al-
most our sole guide.

A subsidiary-means of predicting the duration
of some acute diseases is derived from the know-
ledge of what are termed critical days. They
have been chiefly observed in fevers, and in this
work are properly treated of under that head. A
general notice of the subject is all that can be
attempted here.

Critical days are those on which experience has
shown that fevers most commonly terminate. Au-
thors have more particularly noted as such the
third, fifth, seventh, ninth, eleventh, fourteenth,
seventeenth, and twentieth, being separated in the
earlier stages by periods of two days, in the later
of three, and perhaps even more. Supposing the
distinction to be founded in truth, we are thus
able to predict with more or less confidence, at
any period of a fever, that it may terminate on
the next critical day or on any subsequent one,
but that its cessation is not likely to occur at any
intervening time.

The term critical days properly denotes nothing

PROGNOSIS,

711

more than the fact of termination, without any
reference to its being favourable or the reverse.
As to this point some authors have, however,
made a distinction of days in regard to fevers
generally, and with more appearance of truth as
to some particular diseases. Thus Sydenham, in
his admirable description of small-pox, has noted
the eighth day in the distinct form, and the elev-
enth in the confluent, as those on which the dis-
ease is most apt to terminate fatally.

It is obvious that the mere knowledge of the
existence of critical days can be of little avail for
prognosis if there be no means of predicting on
which of them a disease is likely to terminate.
This has been supposed to be in some degree fur-
nished by certain intervening days called indica-
tive, because the occurrence of particular symp-
toms on them is considered to denote the termi-
nation of the affection on the next critical day.

The law which determines the series of critical
days in fevers of a continued type seems to be a
modification of that which regulates the periodical
recurrence and termination of the paroxysms of
intermittents, and the less definite course of remit-
tents. It seems indeed as though the existence
of critical days was most discernible, and conse-
quently most available for prognosis, in proportion
as fevers tend to the remittent character : and it
is probably owing to the slight tendency to this
chaiacter in the common continued fevers of our
own country that the subject so little either occu-
pies our attention or influences our practice.*

6. Liability to recurrence or relapse. — By the
former of these words is properly meant the re-
appearance of a disease after an interval of exemp-
tion from it; by the latter, its renovation during
the period of convalescence. There are very few
diseases that may not, and that occasionally do
not, recur when circumstances favour their pro-
duction. With some, however, it very rarely hap-
pens: such are, 1. diseases which are almost uni-
formly fatal ; 2. those epidemic fevers which ap-
pear to be partly propagated by infection or con-
tagion, as plague, yellow fever, and typhus, and
also rubeola, scarlatina, variola, pertussis, influ-
enza, and perhaps spasmodic cholera. It is to be
observed that diseases which are manifestly con-
tagious, without being epidemic, such as syphilis,
are by no means indisposed to recur. 3. Diseases
which are almost peculiar to infancy and child-
hood, or the adult age, are of course not likely to
recur in after life: such are infantile remittent
fever, convulsions, porrigo, chorea, chlorosis, and
perhaps epistaxis. 4. The organic results of some
diseases seem to oppose an obstacle to their re-
currence. Laenncc asserts that this is the case
with extensive adhesions from pleurisy, and it is
certainly so with hydrocele when cured by excit-
ing adhesive inflammation.

The diseases which most frequently recur may
be distinguished into two classes, according as the
recurrence is regular and periodical, or irregular
and as it were accidental. Those which ordina-
rily belong to the first class are few m number,

wSsasffJSS s£5 SUA

1818.

the principal being intermittent fevers. In these,
the type being once known, we are able to foretel
the appearance of the next fit. The prognosis
must, however, be formed with some limitation,
since not only may art interfere, but there appears
to be very often a natural tendency in these fevers
to cease spontaneously after a certain though va-
riable number of paroxysms. Some neuralgic
affections, especially headach, frequently assume
a periodical character, observing the ordinary pe-
riods of intermittent fevers, and that even when
they cannot be referred to malaria. The only
other diseases which are often observed to return
periodically are gout and spasmodic asthma, and
in these the periods of recurrence form no part of
the general character of the disease, but vary in
each particular case. There are besides numerous
other affections which occasionally observe very
exact periods of return. The principal are hemor-
rhages, especially hemorrhoids; profluvia, as diar-
rhoea ; and some functional disorders, as mania,
epilepsy, and jaundice. But as these peculiarities
belong to the individual, and not to the disease,
they are of no general interest in prognosis.

The liability of diseases to return irregularly
and accidentally may in general terms be ascribed
to the continued influence of some circumstance
which stands in the relation of a cause, cither pre-
disposing or exciting, but more commonly the
former. Such causes ma; be thus classed :

a. Organic disease frequently gives rise to the
repeated recurrence of othei diseases, and these
may affect either the part in which the organic
disease is seated, or others mcfre or less remote.
Of the former we have examples in the liability
to repeated attacks of pleurisy, peripneumony,
bronchial catarrh, and hemoptysis, which attends
the presence of tubercles in the lungs ; in the ten-
dency to spasmodic stricture, where permanent
stricture exists ; in the frequent occurrence of par-
tial peritonitis and ascites, when the liver is
organically diseased ; of menorrhagia, in cases of
scirrhous uterus ; and of affections of the intestinal
mucous membrane, in disease of the mesenteric
glands. We have examples of organic disease in
one part causing repeated morbid affections of
other parts, in the anasarca and various hemor-
rhages which attend diseases of the heart, and in
hsematemesis and melasna accompanying that of
the liver.

b. Nearly allied to the preceding description
of cases is the well-known tendency of chronic
affections to assume more or less frequently during
their progress an acute character. Perhaps this
is most conspicuously seen in the serous mem-
branes, as in the pleura, peritoneum, and arach-
noid membrane.

c. In many cases the liability to a particular
disease on the application of slight exciting causes
seems referable to some defects, not amounting to
notable disease, in the vascular or nervous appa-
ratus of a part, the result of previous attacks.
It is most conspicuously seen in affections of the
skin and mucous membranes, as for example in
ophthalmia, cynanche tonsillaris, catarrh and bron-
chitis, diarrhoea and dysentery, gleet and leucorr-
hoea, diseases which, if they have once occurred,
often leave a manifest tendency to their reproduc-
tion. In numerous other cases, however, the

712

PROGNOSIS.

tendency in a disease to reappear seems to admit
of no such pathological explanation, nor indeed of
any other satisfactory one, however we may at-
tempt to conceal our ignorance by the use of such
terms as mobility, excitability, and the like. In
many of these affections the vascular system is
prominently disturbed. Such are erysipelas,
biliary calculi and jaundice, gout, rheumatism,
hemorrhoids, puerperal hemorrhage, amenorrhcea,
dysmenorrhoea, phlegmasia dolens, and calculous
affections of the urinary organs. In others, as
palsy, epilepsy, insanity, neuralgia, palpitation,
angina pectoris, spasmodic asthma, hiccup, dyspep-
sia, colic, and hysteria, the nervous system seems
to be most affected.

d. Repeated attacks of the same disease often
originate in the presence of some constitutional
diathesis or depraved state of the general health.
Hence the frequent recurrence of constitutional
syphilis and of scrofolous affection of the glands
and joints, the formation of successive crops of
tubercles in the same or different organs, and the
liability to scirrho-carcinoma, medullary sarcoma,
carbuncles, &c.

e. Affections peculiar to certain periods of life
are liable to recur during those periods, as epis-
taxis in childhood, and cerebral hemorrhage in old
age.

f. Affections which may be traced to the inter-
ruption of some function, as hysteria and vicarious
hemorrhages to suppression of the menses, may
of course be expected to recur as long as the inter-
ruption continues.

The practical application of our knowledge of
the liability to the recurrence of disease under the
several circumstances now enumerated, consists
chiefly in the avoidance of the occasional and
exciting causes, since the permanent and predis-
posing ones are for the most part beyond our
reach.

By the term relapse is properly signified the
renewal of a disease during the period of conva-
lescence, or before the effects of the preceding at-
tack have entirely disappeared. Hence it is
almost exclusively applied to acute diseases, es-
pecially fevers and febrile affections generally, in-
cluding acute inflammations. The liability to
relapse may be said in general terms to be in an
inverse proportion to the completeness of the
recovery. In epidemics it appears to depend in
part upon their prevailing character and tendency,
being much greater in some than in others; and it
seems to be a general rule that when an affection,
which ordinarily terminates by some marked
crisis, has receded without such an occurrence,
or when it has disappeared early and suddenly,
without running its usual course, there is a more
than common danger of relapse. It is also laid
down as a maxim by Hippocrates and other writers
who treat of critical days, that when fevers end
on non-critical days the patients are peculiarly
liable to a relapse.

II. Of the Prognosis of Disease as deduced

FROM THE PARTICULAR CIRCUMSTANCES OF

INDIVIDUAL CASES.

Our judgment of the future in many cases of
disease is greatly influenced by the consideration
of their being primary or secondary, idiopathic

or symptomatic. The question of the curability
and probable duration of a secondary or sympto-
matic affection is commonly very much involved
in the prognosis of the primary one. This gene-
ral rule, however, requires some limitation. Thus
dropsical affections, which are symptomatic of
organic disease of the heart, are not unfrequently
removed, at least for a time, though the primary
affection be wholly incurable. There is, however,
in such cases, as has been formerly observed,
great liability to a recurrence of the secondary
malady.

The principal cases in which prognosis is in-
fluenced by the secondary or symptomatic char-
acter of the disease may be classed under the fol-
lowing heads.

a. Fever which is symptomatic of local inflam-
mation of an acute character cannot be removed
while the inflammation subsists. With regard,
however, to the febrile state which attends local
diseases of a more chronic and passive nature,
and which often assumes the form of hectic, the
same position cannot be assumed, except with
considerable modification. Here we not only often
meet with great spontaneous variations, the causes
of which are mostly but little known, but we even
find the hectic fever, to a certain extent, under the
control of remedies. Thus the power of sul-
phuric acid to diminish the sweating is generally
admitted, and the influence of bark is attested by
high medical authority.

b. When local inflammation or other disease
arises during the progress of continued fever, it is
by no means necessary that the primary aflection
should cease before the secondary one can admit
of removal. Indeed, when the local affection
does not proceed to disorganization, it more com-
monly disappears before the cessation of the pri-
mary fever. It may perhaps be assumed as a
general rule that the symptoms of a local aflec-
tion arising in fever are more prominent and severe
than those of an idiopathic affection of the same
character and tendency. The treatment of fever
appears to be generally influenced by this rule,
and its bearing upon the question of prognosis is
obvious.

c. What has been above stated in regard to
hectic fever is also applicable to other affections
which are symptomatic of organic diseases; that
is to say, the secondary affections are not only
subject to great spontaneous variations, but may
often be mitigated or removed by medical art,
though the primary disease be permanent and in-
curable. As illustrations of this we may cite
those symptomatic affections which are common
to organic diseases in general, namely, hemor-
rhages, dropsies, and affections of the bronchial
and gastro-intestinal mucous membranes, and
many others which are more proper to particular
ones, as pleurisy and peripneumony to tuberculous
phthisis; dyspepsia, pyrosis, gastrodynia, and
obstipatio, to organic diseases of the stomach
dysentery, to those of the liver ; and dysuria,
tenesmus, &c. to diseases of the urinary and
genital organs.

d. Affections which are symptomatic of a dc
ranged or interrupted function are mostly very
unmanageable till the latter is restored. The
most remarkable examples are furnished by the

PROGNOSIS.

713

various diseases which attend amenorrhoea, such
as hysteria in all its forms, regular and irregular,
hajmatemesis, obstinate vomiting, suppression of
urine, &c. While the menses are absent or de-
fective, these affections are very little under the
control of remedies ; but though they often as-
sume a threatening aspect, experience teaches us
that there is very little danger to life. For our
knowledge of the great and extensive influence
of derangements of. the digestive organs in pro-
ducing or maintaining various morbid affections,
wc are very much indebted to the sagacity of
Abernethy. These affections sometimes present
a formidable aspect, such as violent palpitation of
the heart or interruption of its action, angina
pectoris, palsy, and even a state like apoplexy ;
others, though less alarming, are very distressing,
as neuralgia and asthma ; and all of them, how-
ever generally exempt from actual danger, can
only be treated with success by means which act
upon the primary disorder.

e. Besides the above principal varieties of
symptomatic affections, there are some more
anomalous ones which deserve notice ; especially
worms and teething, which give rise to convul-
sions and various other diseases of children ; and
pregnancy, the origin of a long list of disorders,
as vomiting, indigestion, costiveness, &c. These
are all more or less subject to the general rule,
that the removal of the symptomatic affection is
in a great measure dependent upon that of the
primary one.

/. When one disorder succeeds to or takes the
place of another, the prognosis does not appear to
be in general different from what it would have
been if the secondary affection had occurred pri-
marily. Dr. Cheyne, however, states that hydro-
cephalus supervening upon and displacing enteric
disease, is more dangerous than when it occurs
primarily. On the other hand, insanity is found
much more often to admit of recovery when it is
induced by some preceding affection, as fever or
pregnancy, than when it arises spontaneously.

g. When primary and secondary diseases sub-
sist together, the complication generally makes
the prognosis additionally unfavourable ; as, for
example, when ulceration of the intestinal mu-
cous membrane is superadded to phthisis pulmo-
nalis. Sometimes, however, the fatal termination
of a disease appears to be retarded by such com-
plications, as in the well-known case of mania
suspending the progress of phthisis.

In many kinds of disease the prognosis is much
influenced by the nature of the exciting causes.
The following may be noted as some of the more
prominent examples of this kind :

It seems to be a general rule that epidemic dis-
orders are more tedious, unmanageable, and dan-
gerous, than affections of the like nature and in-
tensity which appear sporadically, and arise from
some known causes peculiar to the individual,
such as exposure to cold, intemperance, &c. This
is very observable in regard to affections of the
bronchial and gastro-intestinal mucous mem-
branes. There seems to be an exception to this
rule in some diseases which are traceable to the
influence of marsh miasmata; as, for example,
neuralgic affections, which are then more curable,
Voi. III. — 90 3 k.*

supposing the future action of the cause be avoid-
ed, than when they arise from cold, &c.

Local inflammations, abscesses and ulcers, when
originating from an external injury or other cause
which affects the part only, generally afford a
much better prognosis than when they appear
spontaneously ; because in the latter case they
have generally a constitutional origin, often of the
nature of a cachectic diathesis. Tetanus, how-
ever, is more fatal when the affection is produced
by a local injury than when it is referable to a
cause acting on the system at large, as cold. We
may here advert to the well-known fact, that in
fractures or other severe local injuries, the progno-
sis is more unfavourable when the violence done
to the part is accompanied with a general shock
to the system.

In some affections of the nervous system, the
prognosis appears to be partly influenced by the
nature of the exciting cause, though in a way
which cannot easily be explained. Thus epilepsy
and insanity are said to be peculiarly intractable
when they have been first brought on by fear or
terror.

The mode of invasion is a point of much im-
portance in the prognosis of many acute diseases,
as fevers and febrile disorders generally, including
the exanthemata. The first shock is sometimes
so violent, or the progress of the disorder so rapid,
that before remedial means can operate, life is ex-
tinguished, or irreparable disorganization produced.
This is often seen in severe epidemic diseases, as
plague, spasmodic cholera, &c. ; and, among local
inflammations, in meningitis and ophthalmia. If
we except cases of the above description, it may
be laid down as a general rule, that in proportion
as the first invasion of an acute disease is well-
marked and decisive, it will be found not only
more controllable by remedies and shorter in dura-
tion, but also less likely to terminate fatally, or to
cause permanent disorganization. On the other
hand, where a disease is insidious and imperfectly
developed in its commencement, remedies are ge-
nerally less efficacious ; and even were it other-
wise, the early diagnosis is often so obscured as to
prevent their being resorted to with sufficient
promptitude and energy. Chronic affections are
generally more or less indistinct at their com-
mencement, and are very often so much so as to
baffle all attempts at precise diagnosis. In pro-
portion as this is the case, the prognosis is com-
monly unfavourable, the efficacy of remedies being
mostly less decisive, and the event often revealing
an extent of disease little suspected in its earlier
stages.

Regularity or irregularity of progress, as a
guide to prognosis, is applicable only to disorders
which have a pretty marked and determinate
course, as especially to the exanthemata. In these
affections, any considerable deviation from the ac-
customed course, as a premature disappearance of
the eruption, furnishes an unfavourable augury ;
such cases not unfrequently ending fatally, even
where there has been no peculiar severity of
symptoms, or other circumstances, to excite alarm.
Gout is another disease in which irregularities are
often the precursors of dangerous and sometimes
of fatal consequences. There is one disorder
which affords an apparent rather than a real es

714

PROGNOSIS.

ception to the preceding rule. It is well known
that, in intermittent fevers, changes in the accus-
tomed hours of access of the paroxysms, whether
they occur spontaneously or are caused by the use
of remedies, often predict the approaching cessa-
tion of the malady.

In many diseases, especially those of a chronic
character, the prospect of recovery is much influ-
enced, and in general unfavourably so, by the
length of their past duration. This influence
seems to result from various causes, of which what
may be called the force of habit is perhaps the
most considerable. Its operation is conspicuously
seen in many of those affections which are chiefly
referrable to the nervous system, as well as in
others in which the occurrence of some secretion
or other form of evacuation indicates disorder of
the vascular apparatus of the part affected. Of
the former we have examples in epilepsy and the
neuralgia? ; of the latter in hemorrhoids and leu-
corrhcea ; while spasmodic asthma and gout are
cases of a somewhat mixed character. In all
these affections, and in many others of the same
kind, the hope of recovery is in general small in
proportion to their duration, and to the influence
of habit which that duration implies. Another
cause which renders the duration of a disease un-
favourable to the hope of recovery, is its tendency
to produce changes in the organization of parts.
Perhaps all the affections commonly called nerv-
ous have more or less of this tendency, as, for ex-
ample, epilepsy and asthma. It is, however, more
conspicuously seen in some other diseases, as
ague, gout, and rheumatism ; in all of which the
inveteracy of the affection is found to be increased
by the production of organic changes. A third
mode in which diseases become more intractable
by continuance, is by diminishing the vigour of
the system, and consequently its powers of resist-
ance. This is illustrated in many kinds of chronic
discharges.

The cases in which the prospect of recovery is
improved by the duration of the disease are chiefly
those in which it is observed to have a natural
tendency to exhaust itself after long continuance.
Examples are furnished by some of the chronic
cutaneous diseases, as porrigo, and perhaps lepra.
A tendency of the same kind is in some instances
connected with age. Thus external scrofula and
dyspepsia, however intractable during the earlier
periods of life, are often found to diminish or dis-
appear in mature and middle age.

With regard to the influence of the duration of
disease upon its danger, it is obvious that all those
affections which have a tendency to destroy life,
either by inducing fatal disorganization, or by ex-
hausting the vital powers, become increasingly
dangerous in proportion as their continuance is
prolonged.

Of particular Symptoms* — In the infancy
of pathology a great number of symptoms which,
either singly or in conjunction, are now known
to indicate certain kinds of disease, merely served
as guides to predict the event of individual cases.
Thus, much of what Hippocrates has said on the
subject of prognosis more properly belongs to that
of diagnosis ; and it is probably in a great measure
owing to the change above noted in the relative
position of these two branches of medical science,

that while the latter increasingly occupies the at-
tention of physicians, and has given birth to many
valuable systematic works in our own times, the
former has, for the last half century, almost ceased
to be the subject of distinct treatises.* That part
of prognosis which is independent of diagnosis
being thus restricted in its materials, will not re-
quire a large proportional space in this article. It
will be found that in local affections generally the
most prominent symptoms are essentially diag-
nostic, and therefore foreign to our present object.
In affections of a more general nature, such espe-
cially as fever, the case is different; and numerous
symptoms present themselves which do not ap-
pear to be diagnostic of any particular state of
disease, but which greatly influence our judgment
of the event. These will necessarily occupy a
prominent place in the following enumeration. It
must, however, be borne in mind that in many
cases our knowledge is too imperfect to enable us
to determine with certainty what symptoms are
properly diagnostic, and what are merely prog-
nostic.

It is a general rule that the disappearance of
the several morbid circumstances in the condition
and functions of the body which constitute disease
marks the approaching return of health ; and, in
fact, great part of the prognosis of particular dis-
eases, as stated in systematic works, is of this
kind. It seems, however, useless to extend an
article like the present by an enumeration of points
so self-evident. The chief exceptions to the above
rule are to be found in the disappearance of one
or more morbid circumstances while others re-
main. Indeed, in a large proportion of cases of
disease, the prognosis is rather deduced from a
general consideration of all the symptoms than
from changes in particular ones ; and hence
arises an imperfection inseparable from this
branch of the subject.

As the consideration of every individual morbid
symptom would be at once tedious and unprofit-
able, it will be sufficient to particularize those
which are most important and of most general
application to the subject of prognosis.

Symptoms chiefly referable to the nervous
system. — Delirium being one of the most com-
mon symptoms of fevers and febrile disorders
generally, cannot in itself be considered unfavour-
able. In two of its forms, however, it indicates a
threatening state of disease : namely, the delirium
ferox, which perhaps mostly implies meningeal
inflammation ; and the muttering delirium which
is one of the characters of typhus and adynamic
fevers. An access or increase of delirium some-
times precedes a crisis in fevers ; and, on the
other hand, its cessation, though a favourable oc-
currence when conjoined with other marks of
lessening disorder, is not unfrequently but the
commencement of stupor and coma, or a part of
that delusive calm which has been already adverted
to as sometimes taking place before the fatal ter-
mination of many acute affections. In encephalic
inflammations generally, including acute hydro-

* In a list of fifty works appended to the article Pro-
vostic. in the 45th vol. of the Diet, des Sciences Medica-
tes, which was published in 1820, thirty-five are of dates
prior to 1700, (a majority of them being rather comments
on Hippocrates than original treatises,) fifteen between
1700 and 1777, and none later.

PROGNOSIS.

715

cephalus, the violence and duration of the delirium
is one measure of the severity and consequent
danger of the disease. In acute pulmonary affec-
tions and also in jaundice, the occurrence of deli-
rium has always been regarded as more or less
alarming. That which frequently follows some
local injuries does not appear to denote peculiar
danger. In chronic diseases generally, particularly
in phthisis pulmonalis, its occurrence is one of
the most unequivocal indications of the approach
of death.

Besides delirium, there are other modifications
of mental disorder very common in fever and
encephalic inflammations, which, when they are
prominent, generally denote a severe and formida-
ble disease. Such are, an expression of great
confusion in the countenance, corresponding con-
fusion of thought, and want of any recollection
of things said or done immediately before.

The expression of great anxiety in the coun-
tenance and manner is a very unfavourable symp-
tom in acute affections ; while hope and cheerful-
ness, when not arising from delirium, are of good
omen, being at once a cause and an indication of
amendment. In many chronic affections, how-
ever, these indications are reversed. Thus in
dyspepsia, jaundice, hypochondriasis, &c, anxiety
and depression of spirits by no means imply any
well-founded alarm ; while, on the other hand, in
phthisis pulmonalis there is often confidence of
recovery even to the last period of existence.

A strong presentiment or anticipation of death
is at all times ominous, since, apart from every
consideration of its foundation, it often appears to
be the cause of its own fulfilment. The same
may be said of a confident anticipation of re-
covery, whatever be its source ; for whether con-
nected with religious impressions, or excited by
the prognostics of pretenders to the healing art, it
often produces the most extraordinary effects.

The opposite states of preternatural suscepti-
bility and complete insensibility of the organs of
the external senses are alike unfavourable symp-
toms in fevers and febrile diseases. Hence, a
very contracted or dilated and immovable condi-
tion of the pupil, as well as strabismus, and that
state of the eye in which it remains constantly
half closed with only the white part visible, have
always been considered of bad omen in such af-
fections. It is, however, to be observed that deaf-
ness is a frequent occurrence during convalescence
from fevers ; and that extreme sensibility of the
eyes and of the whole surface are not uncommon
in hysterical affections, and of course of little
moment.

In febrile disorders, sensibility to suffering,
with complaint of pain, are generally favoura-
ble, while the total absence of both is always a
bad symptom. Severe attacks of local pain are
not unfrequently the precursors of a crisis ; and
a peevish sensibility to uneasiness of any kind is
proverbial as an indication of approaching con-
valescence.

In acute inflammations severe pain in the af-
fected part cannot in general be considered as
alarming. The principal apparent exception is
found in enteritis ; in this case, however, the
severity of the pain seems chiefly owing to a spas-
modic affection of the muscular coat of the in-

testine. Throbbing pain is a well-known precursor
of suppuration.

With regard to local p a i ns , severe headach is
an unfavourable symptom in peripneumonia notha,
and perhaps in pulmonary affections generally.
A sudden and violent attack of pain in the head,
preceding apoplexy, den&tes a very dangerous
form of that disease. Very severe pain in the
loins has been observed to precede the confluent
form of small-pox, and at the invasion of febrile
disorders in general, mostly portends an attack of
considerable violence.

Pains which are prone to shift their seat, as in
acute rheumatism, are generally less manageable
than such as are fixed.

The sudden disappearance of pain, without
any known or satisfactory cause, is always alarm-
ing, as is seen in ileus, enteritis, and hernia, al-
though in these cases it has been too exclusively
regarded as an indication of commencing gan-
grene.

The sensation of pricking in palsied limbs often
precedes the recovery of their power.

In fever, constant lying on the back, with the
legs drawn up, a continual tendency to sink down
in the bed, or general rigidity of the trunk and
limbs, are all unfavourable symptoms; while re-
cumbency on the side, with occasional changes
of position, and a flexible state of the muscles,
are of good omen. In peritoneal inflammation
great retraction of the lower extremities upon the
trunk indicates a severe affection ; while their oc-
casional extension, together with the capability
of sitting upright, are sure signs of the subsidence
of the inflammation.

Convulsions and spasmodic affections are much
worse symptoms in the advanced than in the early
stages of fevers, and are generally less alarming
in women and children than in adult males. In-
deed, in young children (as Sydenham remarked
in small-pox) their occurrence at the invasion of
febrile disorders is often rather favourable than
otherwise. In general it is not so much their
severity as their continuance and frequent recur-
rence which imply danger. Among the different
forms of convulsive movements, subsultus tendi-
num, picking at the bed-clothes, &c. ; tremoursof
the hands and lips, and grinding of the teeth, are
more peculiarly alarming, as being common indi-
cations of approaching dissolution.

A propensity to keep the hands and ftet out of
bed, and the trunk uncovered, commonly denotes
a state of severe disease. Any form of paralysis
occurring in fevers and acute inflammations is
generally more or less alarming. Severe rigors
are not ordinarily unfavourable in acute affections,
as they tend to produce speedy reaction. In
chronic diseases they are much more often so,
mostly implying internal suppuration.

Extreme debility, or loss of muscular power,
almost always justifies alarm.

Somnolence, occurring at an advanced stage
of febrile affections, if it be associated with other
indications of their decline, and especially if it
follow some form of crisis, is highly favourable.
In other circumstances, however, it is often but
the beginning of a state of torpor, eventually
passing into fatal coma. Sleep which is hurried
or disturbed by convulsive startings, or in which

716

PROGNOSIS.

the eyes are half open, showing the white part
only, or in which the lower jaw drops, is of bad
omen. Constant wakefulness is always an un-
favourable symptom.

Of all the indications of approaching death,
and of all the forms in which it takes place, per-
haps none is more general than coma. Yet coma
does not invariably portend death. In fevers at-
tended with much cerebral disorder, and in idio-
pathic affections of the encephalon, more particu-
larly in children, it is not unfrequently recovered
from. In pulmonary affections it is almost always
a fatal symptom.

Circulating system. — The prognosis deduced
from the action of the heart and arteries varies
greatly in different diseases and under different
circumstances. Extreme weakness, with great
frequency, and perhaps irregularity of the pulse,
is one of the most constant precursors of death.
The principal exception is found in cases of pro-
fuse hemorrhage, when the pulse often remains
full and vibrating, almost to the last moments of
life. A very great degree of frequency, such as
any excess above 150, is of itself almost invaria-
bly indicative of danger; and under some cir-
cumstances, especially after parturition, a pulse
even above 100 justifies the apprehension of im-
pending mischief. In cerebral affections more
particularly, the pulse is liable to great variations
of character, and these are sometimes valuable for
the purposes of prognosis. Thus in apoplexy,
the transition from a small, weak, and rapid pulse,
to a full, strong, and labouring one, is always
alarming. Mere irregularity or intermissions,
especially when met with in advanced life, are
by no means so alarming as is popularly sup-
posed ; and the most vehement palpitations of the
heart, alternating with protracted intermissions,
are met with in those sympathetic affections of
the organ which experience shows to be attended
with little real danger.

Syncope is chiefly an alarming symptom when
it is connected with disease of the heart and
larger arteries, or is the result of extreme exhaus-
tion, as from profuse hemorrhage.

With regard to morbid conditions of the blood,
the separation of a thick and tenacious coat of
fibrine, with great contraction of the coagulum
and concavity of its surface, though mostly indi-
cative of active local inflammation, or of a general
inflammatory diathesis, cannot in itself be regarded
as an indication of danger. The dark, grumous,
or pitch-like blood, which is commonly met with
in the first or congestive stage of severe febrile
disorders, and in some other affections, though a
much more formidable appearance, does not by
any means necessarily imply great danger, since
it often disappears after one or more bleedings, as
in diabetes and fevers. That dissolved and watery
state of the blood in which it resembles claret, and
is scarcely or not at all coagulable, such as is
often seen in purpura, is much more alarming
than either of the two preceding.

The prognosis of hemorrhage, when considered
as a separate disease, has already been adverted
to. As a symptom of other diseases, it is often
an important guide to their prognosis. In febrile
disorders it is presented under two very different
aspects ; in the one appearing as a critical symp-

tom, and denoting the favourable termination of
the malady, in the other constituting an occurrence
of much danger. The distinction between the
two must of course be drawn from the circum-
stances under which the hemorrhage takes place.
The modifications of hemorrhage in which the
characters of the effused fluid are widely different
from those of natural blood, such as the black
vomit of yellow fever, and the alvine discharges
in mekena, are always alarming. Hemorrhages,
when occurring in chronic affections, as in tuber-
culous disease of the lungs, scirrho-cancer, organic
disease of the heart, &c. though often producing
some temporary relief, must always be considered
as very unfavourable in relation to the ultimate
event.

Respiratory system. — There is scarcely any
more certain indication of severe and dangerous
disease than great disturbance of the respiratory
function, if we except those cases in which it is
referable to some spasmodic affection of the organs,
of which asthma is the most considerable example.
Slow, labouring, and irregular, or hurried and
feeble respiration, is one of the most common pre-
cursors of death ; and where an audible rattle in
the throat is also heard, that event may almost
invariably be pronounced near at hand. Spasmo-
dic asthma is almost the only case in which ortho-
pncea does not imply a formidable state of disease.
Stertorous breathing, which is in a great measure
peculiar to severe cerebral disorders, is always
more or less alarming. Extremely fetid breath in
fever is unfavourable.

Deep sighing is sometimes one of the most
prominent indications of such a degree of exhaus-
tion after hemorrhage as leaves little hope of rally-
ing. Moaning is chiefly observed in children,
especially in acute hydrocephalus, and is an un-
favourable symptom.

In chronic diseases which are attended with
cough and expectoration, these symptoms ate
commonly observed to cease before death. In
aged persons, the disappearance of an habitual
bronchial affection is always an alarming circum-
stance, being generally a prelude te some fatal
attack, as of apoplexy. The prognosis to be
drawn from the character of the sputa varies with
the nature of the existing disease. Thus purulent
expectoration, when associated with tuberculous
disease, is always alarming ; in chronic bronchitis
it is less decidedly so, and in acute bronchial affec-
tions supervening upon fevers, &c. the prognosis
is often good, even though the excretion be of an
alarming extent and duration. This is perhaps
still more strikingly observed in abscess of the
liver communicating with the bronchial tubes.

Notwithstanding many occasional exceptions,
it cannot be doubted that the frequent appearance
of blood mingled with the sputa must be ordinari-
ly regarded as a very unfavourable circumstance.
Fetid and black sputa are always alarming.

Hiccup occasionally precedes a favourable re-
action in some cases of acute disease, as for exam-
ple in the epidemic cholera ; but much more com-
monly it appears in the advanced stages of both
acute and chronic diseases as one of the indica-
tions of approaching death. In fevers, hurried or
inarticulate and scarcely intelligible speech is gen-
erally an unfavourable symptom.

PROGNOSIS.

717

Organs of digestion—Perhaps there is no one
single circumstance indicative of approaching con-
valescence of such general value as the return of
the tongue to its natural state ; and, on the other
hand, its various deviations from that state are
among our best guides for judging of the severity
and probable danger of disease. A perfectly dry
tongue, whether its surface be polished, of a livid
red or mahogany colour, or covered with a rough
coating of brown or blackish fur, is at all times
indicative of severe and commonly of more or less
dangerous disease; while a natural degree of mois-
ture almost always justifies a favourable augury,
except in affections which are attended by hectic
fever. Redness of the tip and edges, with un-
naturally prominent papilla?, is too commonly met
with in acute diseases of most kinds, especially
those in which there is much irritation of the
gastro-intestinal mucous membrane, to be regarded
as unfavourable, unless when it is peculiarly vivid;
but in chronic affections, continued redness of the
tongue commonly justifies apprehensions. Pale-
ness is not a threatening symptom, except when
it is one of the results of alarming hemorrhage.
The temperature of the tongue may be said in
general terms to furnish the same indications as
that of the surface of the body. An extreme
degree of coldness has lately excited much atten-
tion, as being one of the characteristic symptoms
of the present epidemic cholera in its worst form.
The opposite states of tremour and of rigidity with
retraction of the tongue, have been noted as un-
favourable symptoms in fevers and other acute
diseases.

Brown or black sordes on the lips, gums, and
teeth, always denote more or less of danger.
Bleeding of the gums, when it occurs late in fever,
as part of a general hemorrhagic disposition, is an
unfavourable symptom. The lips, more than any
other part of the body, indicate, by their livid or
purple colour in severe affections of the organs of
respiration and circulation, that want of arteriali-
zation of the blood which is almost always an
alarming symptom. Coldness of the lips and
dropping of the under lip and jaw are among the
features of the well-known facies Hippocratica.
Salivation has been occasionally noted as critical
in fevers, but its value in prognosis is chiefly seen
in those cases in which mercury is given with a
view to produce its specific effect. In these its
appearance often warrants the anticipation of a
favourable change. An aphthous state of the
mouth and fauces is generally alarming, but more
decidedly so in chronic than in acute affections,
and in adults than in children.

An unnatural degree of appetite is sometimes
observed to precede the development of severe in-
flammation of the gastro-intestinal mucous mem-
brane ; but it is chiefly in relation to convalescence
that the appetite is a guide to prognosis, for its
return, after a period of more or less complete
anorexia, is, one of the surest marks of returning
health. Its sudden manifestation by a craving for
some particular kind of food, after severe and pro-
traded cases of fever, has been often noted as the
first indication of a recovery which had previously

been despaired ot. ,..',«

In febrile disorder*, intense thirst always im-
plies a severe affection ; but its apparent absence,

under circumstances in which it is ordinarily pre-
sent, is a far more dangerous symptom, as being
one of the indications of a general loss of physical
sensibility.

Difficulty of swallowing, when it results from
loss of muscular power in the oesophagus, as in
the advanced stages of fever, hydrocephalus, apo-
plexy, and palsy, is always an alarming symptom.
When it arises from some mechanical obstruction,
the prognosis of course varies with the nature of
the particular cause.

Vomiting at the commencement of fehrile dis-
orders cannot be considered as unfavourable, un-
less it be very severe and protracted. In acute
affections of the gastric mucous membrane, as well
as in chronic diseases of the stomach, it may fur-
nish some kind of index, though certainly no con-
stant or sure one, of their severity and danger.
Though vomiting is popularly associated with the
very notion of cholera, it is of itself no guide to
our prognosis in that affection, being sometimes
very inconsiderable in its most severe form. In cere-
bral affections, unless it recur very frequently, it is
often rather a favourable symptom, indicating the
continuance of physical sensibility. Thus, after
concussion, it is one of the marks which distin-
guish a temporary suspension of the cerebral func-
tions from a state of perfect coma. Vomiting of
black matter, as in yellow fever, and sometimes in
melasna, — of putrid, as in some very bad forms of
fever, — and of faeces, as in ileus, are all alarming
symptoms. There is one case in which the most
protracted and uncontrollable vomiting can hardly
be considered dangerous, — namely, when it is
merely a symptom of hysteria. In pregnant
women, especially in the earlier months of gesta-
tion, it is often peculiarly obstinate, without giv-
ing just occasion for alarm.

Diarrhoea, like other evacuations in febrile af-
fections, occurs under two circumstances widely
differing in their relation to prognosis ; being in
the one case critical, in the other a cause of ex-
haustion, often connected with severe disease, or
even disorganization of the intestinal mucous mem-
brane. Diarrhoea is also critical in some other
affections, especially those in which there is much
congestion in the abdominal viscera ; it also often
marks the solution of colic and ileus. Black and
pitchy stools are sometimes met with in critical
diarrhoea ; but when evacuations of this kind, in-
stead of marking the solution of an acute disease,
assume a more chronic character, as in melaena,
the prognosis is mostly unfavourable. Hemor-
rhage from the bowels is sometimes critical in fevers,
but is more often one of the results of a general
hemorrhagic tendency which rapidly exhausts the
patient's remaining strength. Involuntary pas-
sage of the faeces is under all circumstances alarm-
ing. Diarrhoea, when it occurs in the course of
chronic affections, commonly renders the progno-
sis increasingly unfavourable, because it mostly
implies the extension of disease to the intestinal
mucous membrane. In such cases it ve.y often
ceases for some hours before death, being one in
dication of the approach of that event. Great
insensibility to the action of emetics and purga-
tives is an alarming symptom in many cerebral
diseases, especially the acute hydrocephalus.

A tympanitic state of the intestines generally

718

PROGNOSIS.

denotes danger, though, as Dr. Abercrombie has
shown, it is sometimes recovered from, even after
enteric inflammation. A hard and tumefied state
of the hypochondria and neighbouring parts has
been long noted as an unfavourable symptom, ex-
cept when, as is sometimes the case, it precedes a
critical diarrhoea. Great depression of the abdo-
men, so as to make the hips and false ribs promi-
nent, is indicative of a threatening state of things.

If we except some severe affections of the biliary
system, met with in tropical climates, a copious
secretion of healthy bile is generally a favourable
occurrence. It was found very commonly to in-
dicate recovery in the epidemic cholera of India.
Jaundice supervening upon cerebral affections is a
dangerous symptom, and in all circumstances that
form of it in which the skin is of a green hue
justifies a much worse prognosis than the yellow
variety.

Urinary organs. — A complete, or nearly com-
plete cessation of the renal function is always
dangerous (unless when it is part of an hysteric
affection), being very commonly followed by fatal
coma, both in children and adults. Retention of
urine from insensibility of the bladder is an unfa-
vourable symptom in fever ; its involuntary dis-
charge is still more so. Bloody urine is occasion-
ally critical ; but more often, like other hemorrha-
ges in the advanced stages of fever, it implies
danger. Of all the occurrences which mark a
crisis or favourable turns in fevers and inflamma-
tions generally, none is more common in our own
climate than a copious deposition in the urine,
sometimes of bilious matter, but more often of
sediments chiefly composed of lithic acid and its
compounds. In fact, when these are found in the
urine, the prognosis is almost always good, except
in cases attended with hectic fever; whereas the
presence of the earthy phosphates as commonly
denotes a dangerous state of disease. Albuminous
urine is decidedly unfavourable, unless perhaps in
cases of acute dropsy.

Sexual organs. — Amenorrhcea is a common
attendant of many chronic diseases, generally oc-
curring when they have made some progress, and,
consequently, giving a more unfavourable aspect
to their prognosis.

[Diseases which occur during menstruation,
and especially during pregnancy, are esteemed
to be more severe, and, as a general rule, such is
the case. Moreover, in the latter condition, they
may induce abortion or premature delivery, and
thus add to the dahger. Yet certain affections
seem to be masked, if not arrested, in their devel-
opment by pregnancy, — tuberculosis of the lungs,
for example, which appears, however, to run its
course with more fearful rapidity after delivery.
The puerperal state adds likewise to the danger
of serious maladies.]

The skin and subcutaneous tissue. — As to
colour ; a livid, purple, or leaden hue of the lips,
cheeks, and surface generally, is a symptom indi-
cative of danger. Sudden and frequent variations
of colour, a circumscribed flush of the cheeks,
extreme pallor, or its opposite, a very high degree
of redness (when not from an exanthematous
affection), are all unfavourable symptoms. In
erupiive disorders, the imperfect development of
the eruption, an unnatural colour of it, or its pre-

mature recession, are circumstances generally more
or less alarming.

As to temperature : the opposite extremes of
intense heat and death-like coldness are both
alarming. Partial and unequal distribution of
heat, especially that sense of burning which is
often felt in the palms and soles in chronic dis-
eases attended with hectic fever, and also frequent
variations of temperature, are unfavourable. Cold-
ness of the extremities is one of the most familiarly
known precursors of death.

Moderate perspiration, if diffused over the body,
attended with warmth, and not of long duration,
is almost never unfavourable, and often critical.
The extremes of dryness and moisture, like those
of heat and cold, are dangerous ; but especially
moisture when combined with cold, as in the cold
clammy sweats which often denote approaching
death. Partial sweating, as of the head, chest, or
extremities (as in phthisis pulmonalis), is always
unfavourable. Perspiration of a fetid, cadaverous,
or urinous odour, is an alarming symptom, unless
it belong to hysteria. Sydenham observes that
sweating in the eruptive fever of small-pox de-
notes that the disease will assume the distinct form.

Petechiae, vibices, ecchymosis, and oozing of
blood from the skin, are always unfavourable
symptoms, though in various degrees, depending on
the particular circumstances in which they occur.

When oedema or anasarca appears towards the
termination or after the cessation of acute diseases,
it is rarely alarming, and sometimes even critical.
On the contrary, in chronic and organic diseases
it always confirms a prognosis already unfavoura-
ble ; and in these cases its disappearance, especially
when sudden, is often among the indications of
approaching death.

Abscesses and buboes are analogous to excre-
tions, inasmuch as they are sometimes critical, and
at others complications, which increase the patient's
sufferings and accelerate his death.

Emaciation, even to a great degree, is rarely
alarming when it is the result of acute disease. In
chronic diseases it almost invariably renders a
prognosis otherwise doubtful decidedly bad. To
this head may be referred most of those well-known
features which together make up the facies Hippo-
cratica ; namely, the pointed nose, sunk eyes,
shrivelled ears, hollow temples, and pale, black,
livid, or lead-coloured complexion.

Besides those circumstances which form part of
the disease itself, there are others pertaining to the
individual affected, the climate which he inhabits,
the season of the year, &c, which often materially
influence our prognosis of the future. An attempt
to estimate the value of all these with any degree
of exactness would involve an extension of this
article much beyond the limits assigned to it ; a
brief review of some of the leading facts is, there-
fore, all that can be attempted.

Sex. — The influence which sex has on progno-
sis is chiefly referable to affections of«the sexual
organs, especially of the female. It has been
already observed that the various morbid affections
which are apt to occur about puberty, or for a few
years after, when the menses are absent, such as
hemorrhages, disorders of the digestive organs,
different modifications of hysteria, &c, though
often and apparently threatening, scarcely eve

PROGNOSIS.

719

justify alarm, unless they are complicated with
fixed local disease, as tubercles, &c. The sudden
suppression of the menses, as from cold or terror,
is very apt to be followed by severe and often
tedious disorders of various kinds. Morbid affec-
tions occurring about the time of the natural ces-
sation of the menses often assume a very formida-
ble character, resulting in scirrhus of the womb or
breast, or organic disease of other kinds. The
various local affections which immediately depend
on pregnancy, as vomiting, hemorrhoids, oedema,
&c., may of course be expected to cease with their
cause. Affections which partially or wholly dis-
appear when conception takes place, such as
phthisis and mania, may be expected to return
with equal or increased energy after parturition.
The prognosis is considered more unfavourable in
pregnant females than in others, after severe inju-
ries and surgical operations. It may perhaps be
assumed as a general rule, that in the pregnant
state local affections are attended with symptoms
more severe than those which would accompany
them under other circumstances. If this be the
case, a better prognosis will commonly be justified
than would otherwise be admissible.

Age. — The difficulties and sources of error
which are inseparable from the art of prognosis
under all circumstances, are found to be peculiarly
great in relation to the diseases of infants and
young children. In them the powers of life are
easily overwhelmed or soon exhausted, so that af-
fections comparatively slight are often rapidly and
unexpectedly fatal. On the other hand, if those
powers are adequate to sustain the shock of dis-
ease till its violence is past, recovery commonly
takes place with peculiar rapidity, and often under
circumstances apparently the most desperate.
[Nil desperandum should be the maxim of the
physician in such cases ; for, to use the language
of Chomel, (art. Prognostic, in Did. de Med. xxvi.
120, Paris, 1842,) childhood is the age of resur-
rections.] If there be one class of affections
more peculiarly dangerous than others in the ear-
liest periods of life, it is severe injuries of the
skin. Hence burns, even of very inconsiderable
extent, and small blisters, are often speedily fatal.
As children are much more constitutionally dis-
posed to convulsive affections than adults, their
appearance is in general proportionately less
alarming; yet violent, or rather protracted con-
vulsions, are very frequently the cause of death in
infants. In childhood, the prognosis of surgical
operations is commonly better than at other
periods of life, not only from the activity with
which nature carries on the work of reparation,
but from the absence of those depressing moral
causes which at a more mature age so often par-
alyse the physical powers of the system.

[Yet under two years of age, owing to the great
impressibility of the nervous system of the infant,
there is greater danger of convulsions from opera-
tions.] . . „

In many affections the prognosis is greatly
modified by the advance from childhood to puberty
and from puberty to manhood and old age Ot
the former we have illustrations in rickets, exter-
nal scrofula, epilepsy, chorea, and unnary «kfr
lus, disorders which, when most intractable ■ »
childhood, often spontaneously improve and dis
appear about puberty, or in the approach to man-

hood. On the other hand, some of these very
affections, especially epilepsy and chorea, not un-
frequently make their first appearance about
puberty. Indigestion arising from irritability of
the gastric mucous membrane, a very common and
troublesome affection in youth and early manhood,
often gradually diminishes with the approach of
middle age. The influence which age has upon
prognosis in regard to many disorders of females
has been already considered in connection with
the subject of sex.

The circumstances of very advanced age are in
some respects analogous to those of infancy, in
others conspicuously different. The vital powers
being feeble, as in infants, are easily overwhelmed ;
and thus comparatively slight attacks of bronchial
inflammation, vomiting, purging, hemorrhage, &c,
often rapidly carry off old people. But unlike
the early stages of life, the power of reparation
being no less feeble than that of resistance, many
diseases, not in their nature directly fatal, admit
of very imperfect recovery, and often lead to
gradual exhaustion. Fractures and ulcers of the
surface are examples familiar to every one.

[On these points, much light has been thrown
by statistical observers, to which a brief allusion
only can be made here. It is well known, that
more males are born than females ; yet there are
manifestly, during the early stages of life, agencies
operating to reduce the proportion of the male sex.
(Quetelet, Sur V Homme, i. 43, Paris, 1835, and
Burdach's Physiologie, u. s. w., i. 587, Leipz.
1835, cited in the writer's Human Physiology,
5th edit. ii. 406, Philad. 1844.) The investiga-
tions of Dr. Emerson (Amer. Journ. of the Med.
Sciences, for Nov. 1835, p. 56) exhibit clearly
that the greater liability of males to accidents does
not furnish a sufficient reason for their greater
mortality ; — the deaths reported in the Philadelphia
bills, under the head of casualties, constituting
but a small proportion of the whole mortality ;
and this, when burns and scalds are included—
being more considerable in the case of the female.
The gross male mortality under the twentieth
year, for the ten years from 1821 to 1830 inclu-
sive, exceeded the female in the ratio of 7.94 per
cent. The diseases which seemed to be particu-
larly obnoxious to the male sex, were, according
to the Philadelphia bills, the following, arranged
in the order of their decreasing mortality. — In-
flammation of the brain ; inflammation of the
bowels ; bronchitis ; croup ; inflammation of the
lungs ; fevers of all kinds, except scarlet fever ;
convulsions; general dropsy; dropsy of the head,
and small-pox. To these sources of mortality
may be added those under the head of casualties,
and others vaguely designated debility, decay, &c.
The few cases in which the deaths of females
predominated were — consumption, dropsy of the
chest, scarlet fever, burns and scalds, and hoop-
ing-cough. The excellent reports of the Registrar
General of Births, Deaths, and Marriages m Eng-
land, contain much valuable information on these
heads.]

Constitution, &c. — In persons of vigorous
constitution, whether of the sanguine or melan-
cholic temperament, acute disease, though often
vehement and proportionately dangerous, is com-
monly more under the control of active remedial
measures than in those of an opposite habu. Weak

720

PROGNOSIS.

ness and exhaustion not only predispose to in-
flammatory affections, but also render their occur-
rence more dangerous, even though they may not
assume a very intense or vehement aspect. Per-
sons of delicate form, lax fibre, and great physical
and moral susceptibility, whether their tempera-
ment be sanguine or melancholic, are so liable,
under various and even opposite circumstances, to
become the subjects of tuberculous or other incu-
rable chronic affections, that in them the prognosis
of the ultimate event of even slight disease is
generally more or less doubtful.

In almost all circumstances of disease, a calm,
equable, and cheerful constitution of the mind
tends to render the prognosis more favourable.
In cases of severe local injury, and after surgical
operations, it is found to be of the greatest im-
portance.

With regard to habits of life, the peculiar dan-
ger of almost every severe malady, and often of
trivial ones, to gluttons, drunkards, debauchees,
and those whose constitutions are broken down
by alternations of excess and privation, is fami-
liarly known. This partly explains the frequent
extreme fatality of epidemic diseases in armies,
especially when moral causes of a distressing na-
ture are superadded.

[Yet when fatal epidemics threaten, the aban-
donment of long-cherished habits — even if in-
trinsically objectionable — may render the indi-
vidual more liable to their attacks, and the super-
vening disease more dangerous.]

In connection with facts of this kind may be
mentioned the far greater mortality of infants in
foundling than in lying-in hospitals; no advan-
tages of cleanliness, ventilation, and care, com-
pensating for the deprivation of that mode of
sustenance which nature has provided for the first
months of existence.

A marked constitutional tendency to any form
of disease, whether it be hereditary, or common
to the members of a family of the same genera-
tion without the suspicion of inheritance, or pe-
culiar to the individual himself, generally makes
the prognosis decidedly more unfavourable.

Climate often influences the prognosis of dis-
ease. In tropical countries acute diseases are
commonly more vehement in their attack, more
rapid in their progress, and more apt speedily to
cause irremediable disorganization, than in tempe-
rate regions. Hence the prognosis is generally
more unfavourable. On the other hand, temperate
climates, being most commonly variable, are more
apt, by the repeated irritation which frequent and
sudden changes in the atmosphere produce, to
render chronic affections, and especially those of
the respiratory organs, incurable and ultimately
fatal. It is perhaps from a similar cause that
syphilis is generally found to be a more tractable
and less dangerous disease in warm than in cold
and variable climates. Convulsive affections, par-
ticularly tetanus, are observed to be not only more
common, but also more fatal in hot countries. It
is hardly necessary to state, that in all diseases
which arise from local causes, such as marsh
miasmata, the prognosis must be proportionately
bad while exposure to the influence of those
causes continues.

Season. — The season of the year is a circum-

stance of some importance in the prognosis of
many diseases. This is in general better in
spring and summer than in autumn and winter;
and more particularly so with regard to scrofulous
and tuberculous affections, and diseases of the
pulmonary organs, among which measles may be
enumerated. It has been noted from the time of
Hippocrates downwards, that autumnal intermit-
tents are both more severe and more intractable
than vernal ones ; and perhaps the observation is
generally applicable to continued fevers, though
subject to much exception.

The varieties of form and character assumed
by diseases in different years, or at different
periods of the same year, and which mark what
Sydenham calls the constitution of the season, of
course involve corresponding varieties in the prog-
nosis. The experienced tendency of particular
epidemics is indeed often found to be a more cer-
tain guide to our judgment of the future than
could be derived from a mere consideration of the
symptoms ; a point which has been justly insisted
on by Dr. Gooch in relation to puerperal or peri-
toneal fever.

[The special prognosis, in case of epidemics,
will be regulated, to a certain extent, by the gene-
ral prognosis. At the incursion of certain epi.
demies, as of cholera and scarlatina, the prognosis
is, at times, exceedingly unfavourable ; but after
awhile the disease becomes milder, and often — it
must be borne in mind — not owing to improved
treatment. Such was the fact with the cholera
especially, which not unfrequently on its first ap-
pearance destroyed almost all that were attacked
by it ; and afterwards became much mitigated ;
yet, under all treatment, the mortality from it was,
on the whole, much the same every where. (See
Choeeba.)]

Tlie effect of remedies previously tried,
whether in the same person under a preceding
similar attack, or (as in the case of epidemics) in
other persons similarly affected, is often an im-
portant aid to our prognosis of their operation,
and consequently of the event of the malady.

Edward Ash.

PROLAPSUS UTERI. See Uterus, Dis-
eases OF THE.

PRURIGO, (from prurigo, itching,) is ar-
ranged by Willan, Alibert, Rayer, Biett, and
others, as a papular affection of the skin ; but the
eruption is generally very obscure. There are
several varieties of prurigo. The chief character-
istic of all of them is severe itching, augmented
by sudden exposure to heat. Where any erup-
tion appears, and this seldom occurs except when
the spot which itches is rubbed or scratched, the
papula; are of the same colour as the adjoining
cuticle. The disease is either general or local,
and as such only shall we regard it, as we are
decidedly of opinion that the three general species
designated by Willan, under the terms mitis,for-
micans, and senilis, are merely modifications of
the same affection, depending on the state of the
individual, and the changes that age produces in
augmenting the severity of all diseases, more espe-
cially those of the skin. The propriety of sepa-
rating the local from the general pruriginous af-
fections requires no comment. No age, no sex is

PRURIGO,

721

exempt from the attacks of prurigo ; it is observed
to make its appearance in all seasons, and to find
its victims in every rank of life.

1. General Pruriginous Affections.

When the disease assumes that mild form which
Willan has denominated prurigo mitis, the itching
is first experienced upon the shoulders, the breast,
the loins, the arms, and the thighs. No papula;
appear to the naked eye ; but if the finger is
passed lightly over the affected parts, they are felt
soft and large in the skin ; as a consequence
of itching, small thin black scabs are here and
there, conspicuous, and the cuticle between them
is slightly reddened. Constant friction occasion-
ally produces inflamed pustules, but these must
always be regarded as incidental. This variety
usually appears in young and otherwise healthy
individuals, and commonly makes its attack in
spring and summer. In the more severe form of
the disease, the prurigo formicans of Willan, the
papula are larger, but less obvious than in the
milder variety of the disease. It affects the whole
of the body except the face, the palms of the
hands, and the feet; but they are chiefly seated
on the loins, the back of the neck, and the thighs.
The same small scabby points are also scattered
over the affected parts as in prurigo mitis. It
occurs more generally in adults than in the young,
and is not more prevalent at one season than at
another. The duration of both varieties is con-
siderable, but the formicans is the most lasting
and difficult of cure : it sometimes continues for
two or more years. The pertinacity of the disease,
however, is most striking in the third variety, the
prurigo senilis, which differs from the two former
only in the greater magnitude of the papulae : this
variety often continues for the remainder of life,
rendering it truly wretched.

In all the varieties the itching is intolerable,
augmenting in comparative severity according to
the age of the patient. Thus in prurigo mitis,
although severe, it is supportable, but it is much
aggravated by sudden exposure of the naked body
to the air, at the times of dressing: and undressing;
it is also increased by exercise and heat. In for-
micans the itching is more incessant, and often
accompanied by the sensation of ants stinging the
skin, whence the appellation formicans ; but this
feeling is usually more like hot needles running
into the skin than the stinging of ants. In the
senilis the itching is insupportable and more per-
manent than in either of the other varieties, tor-
menting the patient to a degree almost sufficient
to cause phrenzy ; but it is sometimes surpassed
by the stinging in formicans, which often causes
cramps and contractions of the extremities in a
remarkable manner.

When great cleanliness is neglected in any of
the varieties of prurigo, pustules and vesicles some-
times appear among the papulae ; and when the
disease has been of long continuance, the skin
acquires a preternatural thickness, the cuticle
separates in a scaly scurf, and rhagades form. In
these conditions of the surface, in dirty persons,
pediculi are observed to infest. the fissures of the
altered cuticle. These appearances of pustules
and other changes during the continuance of pru-
rigo have led to the erroneous opinion that the
milder variety may be converted into itch and
Vol. III. -9 J L

impetigo. The disease may be complicated with
these affections, but its conversion into them may
be fairly doubted.

The causes of prurigo, whatever form it assumes,
are obscure. Its appearance, however, is often
preceded by morbid affections of the stomach,
sickness, gastrodynia, cephalea; sometimes it su-
pervenes upon particular kinds of diet, namely,
salted meats, shell-fish, and even other kinds of
fish, namely, mackerel, herrings, and salmon : it
has also followed the free use of fermented liquors
and spirits, and, occasionally, excess in the use of
vinegar and condiments and pickles made with it.
We have witnessed an instance of a temporary
prurigo from the use of the crystallized citric acid,
in the formation of the effervescing draught, al-
though no such effect was produced when recent
lemon-juice was employed. It often appears
among the lower classes of society, when they are
lodged in damp and ill-ventilated apartments,
badly nourished and ill-clothed. It is also ob-
served to attack most frequently persons of spare
habits, with sallow complexions, subject to vis-
ceral diseases, who are reduced in strength by
over-fatigue or watching, or lowered in vital
energy by mental affections. But although these
may be regarded as predisposing causes of pru-
rigo, yet the condition of the nervous system that
renders it morbidly excitable, and which really
constitutes the disease, is still unknown. It is
easy to conceive that, as age advances, the secre-
tions must necessarily become more acrid ; and
this may account for the greater severity and per-
tinacity of the disease in old people ; but as it
appears in all ages, there must exist some peculiar
state either of the secerning system, which sup-
plies the acrimony that may be supposed to act on
the cutaneous nerves and capillaries to produce
the disease, or some altered condition of the ex-
treme nerves that renders them more susceptible
of impression from ordinary agents than in the
healthy state of the system. What either of these
states consists in we have yet to learn.

With respect to the diagnostic symptoms that
enable us to recognise prurigo from other cutaneous
diseases, the chief are undoubtedly the obscure, or
almost invisible, character of the papulae, and the
degree of itching attending them. It might be
confounded with lichen ; but the papulae are larger,
softer, and less apparent than those of lichen,
which also never display the minute black crusts
that often appear in prurigo ; and the itching in
the former disease is much le^s both in degree and
in permanence than in the latter. With itch it is
not likely to be confounded by those who are
familiar with the appearance of that loathsome
disease. Itch is, besides, a vesicular affection, and
the vesicles being acuminated and filled with a
pellucid lymph can scarcely be confounded with
the soft flat papulae of prurigo : the site of scabies
also differs from that of prurigo ; the former occu-
pies chiefly the fore-parts of the arms and the
under pirt of the thighs, the spaces between the
fingers and the axillae and the flexures of the
limbs; the latter, regarded as a general affection,
has its seat mostly on the shoulders, the back,
and the fore-part of the thighs. Scabies is conta-
gious, prurigo is not communicable by contact.
It is scarcely possible to confound it with ecthyma,!

722

PRURIGO.

eczema, impetigo, or any other cutaneous erup-
tion.

The prognosis in prurigo must always be un-
certain as far as respects the continuance and
curability of the disease, even when it assumes its
mildest form. In old age and in worn-out con-
stitutions it may be considered as incurable.

The treatment differs according to the variety
of the disease. The mildest form, prurigo mltis,
is benefited by a steady perseverance in the use
of the tepid-bath, even when the disease is ap-
parently for a time augmented by its employment.
(Lurry, de Morb. Cutan. cap. iii. art. ii. par. ii.)
When the bath cannot be procured, the skin
should be regularly washed twice a day with warm
water. We have observed much benefit to follow
the daily use of the vapour-bath obtained in the
manner of the Hindoos, namely, by seating the
patient naked upon a chair, and after placing be-
side him a bucket of boiling water, enveloping his
person and the apparatus within a large blanket,
closely pinned round the neck, so as to prevent
the escape of the hot vapour. The body should
be gently rubbed by the hands of the patient
whilst he remains in the bath ; and when the
temperature of the vapour falls, a hot brick should
be dropped into the bucket to restore it. Mild
soap or small quantities of the pure alkalies may
be added to the water, when the body is immersed
in the bath. We have not observed any ad-
vantage derived from the addition of sulphureous
compounds.

In prurigo mills, bleeding and active purging,
followed by the internal use of sulphur and car-
bonate of soda or of nitre, have appeared to
mitigate the itching, particularly in young and
otherwise healthy subjects. If saline purgatives
be employed, they should be combined with either
the diluted sulphuric or the nitric acid. In pru-
rigo formicans the same general means are ne-
cessary, with the addition of light tonics, such as
decoction of sarsaparilla or serpentaria, or the so-
lution of sulphate of quinia with the addition of
diluted sulphuric or nitro-muriatic acid in doses
of a fluidrachm, if the constitution of the patient
be enfeebled or naturally weak. No benefit results
from courses either of purgatives or diaphoretics.

We have little to propose respecting the gene-
ral treatment of prurigo senilis. In most instances,
the disease seems connected with a worn-out
languid state of the habit, and requires the aid of
a chalybeate, either natural or artificial ; we pre-
fer the former, but when it cannot be obtained, we
consider the solution of the hydriodate of iron, in
small doses largely diluted, as the best substitute.
Some benefit has occasionally been derived from
the Harrogate waters, employed internally and
externally at the same time. When the itching
is very severe, the warm-bath affords a temporary
alleviation, and the warm sea-water bath should
always be preferred to the fresh-water bath when
it can be procured. When neither can be readily
obtained, much benefit has followed the employ-
ment of a lotion of the bitter almond emulsion,
containing one grain of the bichloride of mercury
in each fluidounce of the emulsion, and one flui-
drachm of hydrocyanic acid. When pediculi in-
vest the skin, the most effectual mode of destroying
them is the fumigation with cinnabar, which acts

promptly and effectually ; or, where this is ob-
jected to, an embrocation with one part of the oil
of bitter almonds, one part of the oil of turpentine,
and six parts of olive oil, will be found useful :
the fumigation, however, is more decidedly useful
than the embrocation, as it not only destroys the
living insects, but their ova, which often escape
the action of the embrocation as they lie in the
rhagades.

2. The local prnriginous affections re-
quire a separate notice, as they have scarcely any
affinity with the general diseases which we have
just described. Two of them, namely prurigo
prseputii and urethralis, are objects rather of
surgical than of medical treatment, and therefore
do not require to be noticed here; and a third,
prurigo pubis, arising solely from the presence of
pediculi, is cured by whatever destroys the insects
that cause it. The ointment of the white preci-
pitate of mercury of the pharmacopoeia, or an
ointment made with equal parts of mercurial and
sulphur ointment, answers every indication.

Prurigo podicis is sometimes a very trouble-
some and very obstinate disease. It generally
occurs in aged persons and those of sedentary
habits ; and although it sometimes depends on
hemorrhoids, chronic inflammation of the rectum,
or ascarides, yet it appears independently of those
local diseases. The itching is intense round the
anus and along the perineum, extending to the
scrotum, which often appears changed in colour
and consistence, becoming brown, thick, and
scaly. The irritation increases at night, and
varies greatly, according to the diet of the patient.

Prurigo podicis requires a different treatment
according to the degree of irritation and the habit
of the patient. When it is severe, and there
either exist hemorrhoids or a tendency to them,
local bleeding is necessary ; and this is best ac-
complished by cupping over the sacrum. Emol-
lient cataplasms, composed of bread soaked in a
strong decoction of poppy-heads in vinegar and
water, also afford much relief to the itching at
night. Rayer recommends the gelatino-sulphure-
ous lotions proposed by M. Dupuytren, especially
when the parts are excoriated by friction. We
have no experience of this application, and would
rely more on local bleeding, and the zinc or diluted
tar-ointment; or on an ointment composed of sjss
of acetate of lead, ^i of sulphate of zinc, f.^iv of
tincture of opium, and ^iss of lard. We have
seen much comfort derived from the daily employ-
ment of the warm hip-bath at bedtime, and the
cold hip-bath in the morning. Little internal
medicine is requisite : the secretions should be
improved by the administration of very minute
doses of calomel, namely, one-sixth of a grain
combined with three grains of extract of conium
at bedtime, and half a drachm of the solution of
ioduret of iron, equal to gr. iss of the salt, in a
large glass-full of water twice a day. In old worn-
out habits, the fluid extract of sarsaparilla, in doses
of a table-spoonful in half a pint of milk three
times a day, has proved useful. But it must be
acknowledged that this troublesome affection often
resists every treatment that has been suggested.

Prurigo scroti resembles prurigo podicis in
many particulars, and seems to originate in similar
conditions of the habit. It requires nearly the

PRURIGO — PSEUDO-M ORB ID APPEARANCES.

723

same treatment. Lotions made with calomel or
bichloride of mercury and lime-water, without be-
ing filtered, have been found useful. When the
disease arises in plethoric individuals from violent
exercise in hot weather, nothing more is necessary
than daily ablutions with tepid soap and water,
regulating the bowels, and avoiding stimulant diet.

Prurigo muliebris differs little from the last-
mentioned varieties, except as regards the nature
of the parts affected and the sex of the patients.
It is frequently connected with leucorrhoea, espe-
cially when it appears after the cessation of the
catamenia. In some instances the itching and
irritation about the labia and os vagina is so in-
tolerable as to drive the patients from society, and
sometimes to excite a degree of nymphomania.
In such cases leeches to the vulva, and cooling
saturnine emollient and narcotic lotions are in-
dicated. On the continent much confidence is
reposed on bleeding in the feet or ankles, but we
are of opinion that more benefit is derived from
relieving the affected parts than by any revulsive
measures. Whatever local applications are em-
ployed should be frequently changed, and thus
the following may be alternately used ; the ordi-
nary black-wash ; the orange-wash, composed of
two grains of bichloride of mercury and a fluid-
ounce of lime-water ; equal parts of the solution
of the chloride of soda of Labarraque and water ;
and a lotion composed of two fluidrachms of
liquor potassre, a fluidrachm of hydrocyanic acid,
and eight fluidounces of bitter-almond emulsion.
In one very obstinate case, the writer of this
article found much benefit from pencilling the af-
fected parts with a solution of nitrate of silver, in
the proportion of two grains of the nitrate to a
fluidounce of distilled water, acidulated with two
minims of diluted nitric acid.

It is scarcely necessary to remark that, in every
local pruriginous affection, much heat should be
avoided, and a firm mattress instead of a feather-
bed, adopted. As the irritation is always most
severe in the night, much comfort may be pro-
cured at that time by applying the sedative lotions
cooled in ice. If possible, friction of every kind
ought to be avoided. It is also of importance to
refrain from the use of all seasoned food, aroma-
tics, coffee, wine, and fermented and alcoholic
liquors, during the continuance of the disease.

A. T. Thomson.

PSEUDO -MORBID APPEARANCES.—

There are three conditions in which any tissue or
organ of the body may be found, between which
it is necessary to discriminate with accuracy, in
order to form correct inferences in morbid anato-
my. The first of these is the natural or healthy,
which we find to present certain varieties either
of colour or density, according to the age of the
subject. The second is the abnormal or morbid,
and is to be regarded as the result either of some
perversion of the development of a part, or of the
influence of disease upon it. The evidence of
this condition is derived in the one case from some
congenital malformation, and in the other from
certain appearances which the texture of the part
exhibits, and which vary in aspect and extent ac-
cording to the duration and violence of the dis-
ease : these are the morbid appearances. Ihe

third condition differs from both of those above-
mentioned, yet in some points resembles the mor-
bid. This condition is in general produced by
causes which come into operation after death ;
sometimes, however, they may partially take effect
a short time before death ; and sometimes it may
owe its rise to other causes, hereafter to be no-
ticed, and only in action during life. The appear-
ances which characterize this condition of the tis-
sues of the human body may be denominated
pseudo-morbid appearances, as being liable to be
confounded with and as it were simulating those
which are morbid.

Although the attention of pathologists has been
a good deal directed to this subject of late years,
we find but little written upon it, and the term
pseudo-morbid in limited use. Dr. Yelloly, in a
paper published in the fourth volume of the Medi-
co-Chirurgical Transactions, was the first to point
out that the mucous membrane of the stomach
may exhibit an increased degree of vascularity
under certain circumstances, independently of in-
flammatory action. In France, the extravagant
assertions of Broussais, who, in order to establish
a favourite hypothesis, pronounced every increase
of redness to be indicative of inflammation, had
the good effect of inducing anatomists to inquire
whether other causes than disease could similarly
alter the aspect of the tissues. By the researches
of Trousseau and Rigot, (Archives Gen. de Med.
October and November 1826, and July 1827,)
and also of M. Billard, (De la Memb. Muqueuse
Gastro-intestinale,) — [see, also, Devergie, Med.
LJg. 2d edit. i. 288, Paris, 1840,] — much light
has been thrown upon the post-mortem changes
which occur in the body, and which give rise to
appearances often very similar to those of inflam-
mation. We are likewise indebted to John Hun-
ter, Allan Burns, and more recently to Dr. Cars-
well and Orfila for much interesting and valuable
matter, which we shall presently have occasion to
notice.*

It may be well to state our reasons for the adop-
tion of a hybrid term, pseudo-morbid, in prefer-
ence to others more generally in use. Let it be
observed that we employ the term in question to
denote those appearances in any given tissue
which might be mistaken for the effects of morbid
action in that tissue. To apply the terms cada-
veric or post-mortem to such phenomena would
be to limit their number and causes ; whereas it
will appear in the sequel that some tissues of the
body may present appearances which must be re-
garded as pseudo- morbid, and which result from
the action of causes operating before death. We
are not aware that the term is employed by any
writer except the author of an analysis of MM.
Trousseau and Rigot's papers above-mentioned,
which is to be found in the twenty-eighth volume
of the Edinburgh Medical and Surgical Journal,
and Dr. Christison, in his very valuable and ela-
borate work on Poisons. Under this denomina

* Although distinct treatises on this subject are tare,
we must not omit to state that it has received due atten-
tion in several modern works, either on morbid anatomy
in general, or on particular parts of it. We need hardly
refer to Andral's invaluable Treatise on Pathological
Anatomy. Iii Laennec's work, also, and in those of
Bertin and Hodgson, constant allusion is made to appear-
ances supposed to be cadaveric or produced in the agony
of death.

T24

PSEUDO-MORBID APPEARANCES.

tion, then, we would be understood to include all
appearances in the dead body which might be
mistaken for morbid appearances, whether they
arise from the action of causes antecedent to death,
or whether they be strictly such as are now gene-
rally spoken of as cadaveric or post-mortem ap-
pearances.

In the great majority of cases, a more or less
gradual diminution of the vital powers precedes
dissolution. The influence of life in preserving
the integrity of the membranes of the body, whe-
ther it act through the nervous system or in any
other way, gradually diminishes, and a correspond-
ing change is manifested. This is most conspicu-
ous in the capillary circulation, which becomes
impeded to a variable extent in several places, the
vessels being less capable of resisting the force of
gravitation. This disturbance of the capillary cir-
culation may be noticed in almost every tissue in
the body. In the agony of death, the same cause,
it is natural to expect, will operate to a greater de-
gree, and at the same time the occasional muscular
contractions, which often mark the final struggle,
must mechanically cause irregular distributions of
the blood in the sanguiferous system. The extent
to which these irregularities take place is in gene-
ral proportionate to the strength of the patient
(inversely), to the duration of the struggle, and
in some cases, we conceive, to the degree of fluid-
ity of the blood itself (directly). Any one who
has ever watched a patient in the last stage of ty-
phus fever will not want further testimony in fa-
vour of the accuracy of the preceding statements.
The general cutaneous hyperscmia of the back
and dependent parts indicates that the laws of gra-
vitation have begun to operate to a much greater
extent than during the state of health. (See an
interesting essay by Bourdon, entitled " De l'ln-
fluence du Pesanteur sur quelques Phenomenes
de la Vie." Paris, 1823.) We may also adduce
the pneumonie des agonnisans of M. Laennec,
the engouement de position of Andral, or the
pneumonie hypostatique of Piorry, as additional
corroborative evidence.

But even when life is in full vigour, local san-
guineous determinations may occur independently
of the immediate operation of disease on the part
in which they appear. Thus the performance of
peculiar functions may cause an afflux of blood
to the particular organs ; as for example, while
the function of digestion is going on, we find that
a marked change is produced in the colour of the
mucous membrane of the stomach. Again, if any
obstacle occur to the free return of the venous
blood, there is in general formed a congestion of
the capillary system to a greater or less extent ;
this is more conspicuous where the veins are des-
titute of valves, as in the mesenteric veins, the
pulmonary veins. Hepatic disease, by compress-
ing one or more ramifications of the vena portse,
and some forms of disease of the heart, are very
frequent causes of the local determinations to
which wc allude.

With the cessation of life is removed all oppo-
sition to the full scope and play of gravitation and
chemical affinities, the former of which was par-
tially in operation during life. The manner in
which the fluids seek the dependent parts is clearly
%o be attributed to the action of gravitation. In

fact it has been proved to be so caused, over and
over again, by the simple experiment of turning
the body occasionally, so as to change the depen-
dent parts ; in this case the blood is invariably
found to leave the vessels that were before lowest
to seek those that now are so. Bodies being usu-
ally placed supine after death, the integuments on
their posterior surfaces are uniformly found con-
gested, but if the body be placed immediately after
death on the face and abdomen, a similar conges-
tion will present itself in the integuments covering
those parts.

The effects produced by the operation of che-
mical affinities are apparent in the alterations in
the texture, the density, and the specific gravities
of the tissues : gases are evolved, new fluids are
formed, and the membranes are often considerably
discoloured ; in short, in the action of these affini-
ties consists the putrefactive process, whereby new
compounds are formed, and the former constitu-
ents of the body almost wholly vanish. We find
considerable variation in the period of commence-
ment and rapidity of course of this process, not
only as regards different bodies compared with
each other, but also with respect to particular parts
of the same body. The age and habit of the in-
dividual, the quantity of the fluids, the kind of
death, as well as the circumstances which preceded
it, the season of the year, climate, state of the at-
mosphere, are so many circumstances which exert
a powerful influence on the rapidity of the pheno-
mena of this process, as must be familiar to every
one who has studied anatomy even in the most
superficial manner.

To the action of these same chemical affinities,
we think, may be fairly attributed, at least in part,
a very evident cadaveric phenomenon ; namely,
that increased porosity of the membranes by which
the contained fluids are allowed to transude
through the coats of the canals or sacs which hold
them. We say increased porosity, for it must be
admitted as the result of recent experiments, that
transudation may take place to a slight degree
even during life. (See the experiments of Fodere
on absorption ; of Dutrochet ; and the Observa-
tions of Bouillaud on Dropsies.) Life, then,
must be supposed to operate in limiting this poro-
sity, by preventing the action of the chemical affi-
nities ; when life ceases, these affinities come into
play, and there takes place a separation of the
molecules of the tissues to a degree proportionate
to the extent of action of the same affinities.
There is no part of the body in which we do not
observe this phenomenon ; it is not confined to
sacs with simple parietes, but extends also to those
of which the walls are compound ; we observe it
to take place through the coats of vessels, through
the walls of any or all of the membranous viscera,
and even through serous membranes.

The alterations which are produced, then, on
the several organs or membranes of the body by
the action of the agencies above detailed, may be
stated in general to be — 1. such as affect the co-
lour of parts ; 2. such as alter their density or
consistence ; 3. such as alter the contents of a
natural cavity, as for example a serous sac, by
increasing or diminishing the quantity, or altering
the nature of fluid in it.

We proceed to consider these effects as they

PSEUDO-MORBID APPEARANCES.

725

manifest themselves in the different parts of the
body, and we shall adopt the order usually fol-
lowed in making a post-mortem examination, com-
mencing with the external integument and the
cellular tissue, then proceeding to the contents of
each of the three great cavities, head, thorax, ab-
domen ; and, finally, to the arterial and venous
tissues.

1. The external Integument. — The altera-
tions in colour which the skin presents after death,
are almost the only phenomena which it exhibits
liable to be mistaken for those of disease ; and
even they are so distinct in the mode of their
formation, that any mistake must arise from a
very superficial examination. Spots of various
degrees of redness, and also varying in extent, are
almost uniformly observable on the dead body.
In general they are of a dark red, which increases
in depth of colour with the length of time that
has elapsed from the death of the subject. As
this cutaneous discoloration is principally owing
to the influence of gravitation, we find it uniformly
on the most dependent parts, the occipital portion
of the scalp, the posterior surface of the neck, the
back, nates, posterior parts of the thighs and legs.
That it is confined to the skin may be seen by
cutting into the corion where the redness exists.
It is moreover to be observed that this redness is
vascular, and that the surface of the skin presents
the appearance of a ramiform distribution of ves-
sels. This is important, as characterizing the kind
of discoloration arising from gravitation, and dis-
tinguishing it from that which may be the result
of the pressure of ligatures or vestments, &c. on the
surface before death ; for in this latter the redness
will be found to be diffused and uniform, without
any appearance of vessels.

But cutaneous discolorations or lividities may
occur in situations not dependent, and at a more
advanced period after death, being phenomena
purely cadaveric. When decomposition has fully
set in, and gases are being disengaged in the sto-
mach and intestines, the surface of the skin of the
face and neck becomes of a livid colour ; the su-
perficial veins are full, and streaks of a dark colour
indicate the course of most of them. This con-
gestion Chaussier attempted to explain by attri-
buting it to the compression of the right auricle
of the heart by the diaphragm, which was pushed
up by the stomach disfended with gas ; and he
states that by producing a similar distension of
the stomach artificially, viz. by the introduction
of a fermenting mixture into it, he was enabled to
exhibit similar effects on the cutaneous capillary
system. The compressed right auricle causes in
the blood a retrograde motion from venous trunks
to branches, from the branches to the capillaries,
which is the more easily done, as at this period
the blood has to a considerable degree resumed its
fluidity. To this fermentation and gaseous de-
velopment may be attributable, as Chaussier fur-
ther observes, the passage of pieces of food from
the stomach into the pharynx, larynx, and bron-
chi, the passage of worms into the bronchi, nasal
fossa; or mouth. (Chaussier, Medecine Legale,
and Table des Phenomenes Cadavenques.)

2 The Cellular Tissue.— The subcutaneous
cellular tissue is generally more or less discoloured
in the neighbourhood of or immediately beneath

the cutaneous discoloration. Here, however, the
change of colour takes place from a two-fold
cause,— the gravitation of the fluids in the vessels,
as well as the transudation of the serous portion
of the blood through the vascular parietes. These
two causes generally reduce the subcutaneous tis-
sue to an anasarcous condition, which of course
increases with the progress of decomposition ; the
serous portion of the blood, too, becomes more and
more tinged by the colouring matter. We need
hardly refer to the common appearance of the cel-
lular membrane under the integuments of the
back, with which every student of anatomy is
familiar, in proof that this is the ordinary condi-
tion of that membrane, and that too within a very
short period after death, as the effect of gravitation
and transudation. But as putrefaction advances,
and the blood resumes its fluidity, we observe
ecchymoses to form in the subcutaneous tissue,
the distinction of which from the effects of con-
tusions before death is sometimes an important
task for the medical jurist, and is rendered more
difficult by the fact that these ecchymoses do not
seem to be formed under the influence of gravita-
tion, being found even in elevated parts. Although
it does not strictly come within the range of this
article, it may be proper to mention that the fol-
lowing circumstances, noticed by Orfila, will assist
in distinguishing these cadaveric ecchymoses from
such as may have been formed by violence or
otherwise before death: — 1. Their situation, which
will generally be found in those localities where
the cellular tissue is very lax and distensible, as
in the occiput, loins, eyelids, and scrotum ; 2. the
general evidence of an advanced stage of putrefac-
tion presented by the dissolving condition of all
parts of the body ; 3. the uniformity of colour pre-
sented by these ecchymoses. which is not usually
observed in those made during life. (Orfila,
Lecons de Medecine Legale.)

Subcutaneous ecchymoses, however, may be
produced by direct violence applied to the body
shortly after death, as has been proved by experi-
ment by Dr. Christison, and as may often be seen
in the dissecting-rooms. Effusions of blood into
the intermuscular cellular tissue, it is important to
bear in mind, may likewise be produced by vio-
lence to the body after death. During the winter
1830-31, we had occasion to notice this fact upon
bodies which, from the then imperfect state of the
laws regarding dissection, were conveyed to Lon-
don tightly packed in boxes from distant parts of
the country. In such bodies extensive extravasa-
tions of blood into the cellular membrane between
the muscles of the back were uniformly present.
This fact had been likewise previously well ascer-
tained by the happily devised experiments of Dr.
Christison on the occasion of the murders com-
mitted at Edinburgh. (Ed. Med. and Surg. Journal,
vol. xxxi. p. 243.)

We do not find any induration of the cellular
tissue of a pseudo-morbid character ; but it may
be remarked, although the fact cannot have escaped
the most superficial observer, as a post-mortem
result, that this tissue is frequently emphysematous,
and, indeed, always so after a certain period in
the work of decomposition, but sometimes very
soon after death, as in some low and putrid fevers,
&c.

726

PSEUDO-MORBID APPEARANCES.

3. The Head. — On opening the cranium, the
attention is first directed to the quantity of blood
contained in the small venous trunks which are
seen ramifying on the surface of the dura mater
and in the sinuses. It was long ago noticed by
Vicq d'Azyr, and subsequently by Marc, that the
straight sinus and torcular Herophili uniformly
contain coagulated blood, in consequence of the
blood when fluid flowing to that dependent posi-
tion. On the same principle we may expect to
find the superficial veins of the dura mater more
distended towards the posterior portion of that
membrane. With respect to the general appear-
ance of the dura mater, the anatomist has only to
take care that he attributes a condition of hypere-
mia of it, whether local or general, to its proper
cause : in consequence of the fibrous character of
this membrane, it is not liable to a diffuse discolo-
ration, such as some of the other tissues are, nor
do we find any alterations of its consistence which
are at all likely to be mistaken for morbid ones.
In fact it resists the putrefactive process for a con-
siderable time, as do all membranes of the same
nature. It is proper, however, to remember that
a hyperxmia of this membrane may be developed
in the progress to decomposition, by the disengage-
ment of gas in the stomach, and the compression
of the right auricle, in the same manner as Pro-
fessor Chaussier supposed some cutaneous lividi-
ties to be produced, as already alluded to.

When the dura mater, with its adherent layer
of arachnoid, has been slit up, so as to expose the
visceral layer of the latter membrane, and in fact
to open into the arachnoid sac, the anatomist ge-
nerally looks first for some effusion between this
membrane and the subjacent pia mater. We fear
that in general too much stress is laid upon the
occurrence of effusions between the arachnoid and
pia mater. Hence what is really a natural condi-
tion is very apt to be mistaken for a morbid one ;
and, on the other hand, the total absence of effu-
sion is too often regarded as indicating a state of
health, when such a conclusion can be by no
means constantly deduced. The interesting dis-
coveries of M. Magendie relating to what he has
termed the cephalo-spinal fluid, deserve more at-
tention than seems to have been bestowed upon
them by most practical pathologists. The princi-
pal conclusions at which he has arrived are the
following: — 1. That in the state of health there
exists a fluid between the visceral layer of the
arachnoid and the pia mater, both of the head and
spine ; the quantity of which is never below two
ounces in the adult, and often amounts to five in
subjects of large stature, and whose cranium is
not of small dimensions; — that the fluid contained
in the spine communicates with that in the head,
and vice versa., so as to pass freely from one cavity
to the other ; — and that a portion of the same fluid
is found in the lateral, the third and fourth ventri-
cles of the brain, which communicate with the
space between the arachnoid and pia mater by an
opening situated at the inferior extremity of the
fourth ventricle, between the upper part of the
spinal marrow and the valve of Vieussens. 2.
That this fluid may be demonstrated in full quan-
tity either during life, or at a short time after
death ; but after a period of little more than
twenty-four hours it becomes absorbed, and there-

fore diminished in quantity, or altogether removed:
if after that period sub-arachnoid effusion of this
kind exist, it is to be considered either as entirely
a post-mortem appearance, or tho remains of the
natural effusion, to which had been added a quan-
tity of fluid, the result of morbid action. 3. That
a diminution as well as an increase in the quantity
of this fluid is capable of producing serious dis-
turbance in the functions of these important por-
tions of the nervous system. It is plain, therefore,
from the above abstract of Magcndie's discoveries
respecting this cephalo-spinal fluid, that it would
be always difficult, and often impossible, to decide
whether a sub-arachnoid effusion be a natural, a
morbid, or pseudo-morbid phenomenon. Unless
the effusion be very considerable, and have been
found very shortly after death, we cannot with
certainty pronounce it to be the effect of disease.
But those which are found forty-eight or seventy-
two hours after death are for the most part pseudo-
morbid, being caused by the transudation of the
serous part of the blood through the vascular pa-
rietes, so much so that, in opening a body two or
three days after death, we may invariably expect
to find sub-arachnoid effusion to a greater or less
extent. We conceive that a due attention to
these facts connected with the cephalo-spinal fluids
will sufficiently account for the surprise or disap-
pointment which some have expressed respecting
the want of coincidence between the severity of
symptoms and the extent of effusion.

The degree of colour of the pia mater is often
increased by the same causes which we have
already enumerated as influencing post-mortem
sanguineous determinations ; in this case it will
always be found that the other tissues within the
cranium which admit red blood are similarly con-
gested. In some cases this congestion may go so
far as to produce extravasation ; and if the body
has lain long after death, the serum effused between
the pia mater and arachnoid will be more or less
tinged with the red particles of the blood. We
may here remark further, that sanguineous extrava-
sations from apoplexy, if extending into the cavity
of the ventricles, will communicate their colour to
the cephalo-spinal fluid, provided the natural com-
munication of the internal cavity of the brain with
the sub-arachnoid cavity be not interrupted.

With respect to the encephalon itself, it may
be stated that in general (such obvious cases as
apoplectic clots, abscesses or tumours being except-
ed) it is extremely difficult, nay, often impossible,
to decide between the morbid and pseudo-morbid
states of this organ. This latter state is such as
manifests itself by a change in the colour and
consistence of the cerebral tissue. As to colour,
we find it, here as elsewhere, influenced by the
quantity of fluid blood in the viscus: in the corti-
cal substance, from its much greater vascularity,
that discoloration is most likely to appear ; and it
is of the first moment to distinguish it from the
redness of inflammation, because we find that the
same colour may be the result of an active determi-
nation of blood to the brain, as well as arise from
a mechanical congestion of its membranes and sub-
stance. To determine this question it will be
necessary to note accurately certain collateral cir-
cumstances — the condition of the arterial and
venous system of the head generally — the degree

PSEUDO-MORBID APPEARANCES.

of plentitude or vacuity of the heart, whether it
afford any obstacle to the free return of the blood,
or by an increase in its propelling power magnify
the momentum of the columns of blood to the
head— the position in which the head of the indi-
vidual has been laid since death — and also whether
putrefaction has begun, or the degree to which it
has advanced.

The alteration in consistence, by a diminution
of it, (softening,) is the most constant and obvious
change which the brain and spinal marrow present.
This softening is equally the result of disease and
of the tendency to decomposition. Before proceed-
ing to indicate the distinctions between these two
kinds of softening, it may be well to notice that
in the state of health different parts of the cerebro-
spinal axis present a marked difference as to con-
sistence. Thus, in the adult, the spinal marrow
is softer than either the cerebellum or cerebrum ;
the cerebellum than the brain ; both these parts
softer than the pons Varolii. In the child the
spinal marrow is firmer than the brain, and more
resisting than in the adult.*

The morbid and pseudo-morbid softenings pre-
sent many characters in common, as to situation,
colour, smell : indeed, we have no sign sufficiently
free from ambiguity to indicate either of these
conditions with certainty : both attack the grey
substance most frequently, and before the white ;
both exhibit the same varieties and shades of colour
—with this exception, that in the morbid softening
we often see the affected part of a bloody tinge,
arising from a slight sanguineous effusion: some-
times a purulent infiltration is found, which is
obviously decisive. In the extent of these two
forms of ramollissement, we have a more certain
indication of their cause ; the pseudo-morbid will
generally be found to pervade the whole cerebral
mass, varying perhaps in degree according to the
above-mentioned scale of natural variations of con-
sistence, but the morbid ramollissement is almost
invariably circumscribed. We say almost, because
a morbid ramollissement has been met with of
unusual extent, occasionally in the adult, but
more frequently in the new-born infant. A state
of general ramollissement of the brain is met with
in cases of general anasarca, and differing very
much from morbid softening. It arises from the
infiltration of the brain by the fluid effused in the
cranium and beneath the arachnoid. It can be
produced in the dead body by injecting water
through a small opening made in the head ; the
whole fluid injected will not be found in the serous
membrane. (Gendrin, Hist. Anat. des Inflamma-
tions, vol. i. p. 188.)

M. Orfila suggests the propriety of pronouncing
with caution on a morbid ramollissement merely
from its locality being defined, because the cadave-
ric softening does not begin at the same time in
all parts; the fornix, septum lucidum, and walls
of the lateral ventricles, being the situations in
which it first shows itself.

* Orfila, Exhumations Juridiques, torn. ii. p- 2p5;
Such is undoubtedly the case at the usual period after
death when post-mortem examinations are made. But
we are disposed to think with Calmeil, that immediately
after dissolution the spinal marrow is of firmer consis-
lonce than the brain. The Essays of his author on the
Anatomy and Physiology of the Sp«"al Manow areweU
worthy the readers attention. Vid. Journal de Progres
des Sciences Med. torn. xxxi.

727

The spinal marrow is remarkable for the rapidi-
ty with which it softens. Every anatomist knows
that in order to dissect that organ satisfactorily he
must obtain it from a body quite recently dead,
and that even then a short exposure to the air
causes a rapid diminution in its consistence. The
internal grey substance seems more prone to this
diminution of consistence than even the white,
and hence the great diversity of opinion among
anatomists respecting its exact form and characters
in a state of health. However, in this organ there
does not appear, so far as we at present know of
its morbid states, any difficulty in distinguishing
the pseudo-morbid softening from that which is
caused by disease ; for the circumscribed locality
of the latter, with the augmented vascularity of
the surrounding portion, and slight sanguine tint
of the softened part, will in general be sufficiently
characteristic. We are not aware that such a
decidedly pathological general ramollissement of
the cord has been found as we have noticed in the
brain.

4. The Thorax. — On opening the chest in the
usual way, the membrane of the pleura first at-
tracts notice. After the lapse of some time from
death, an effusion is invariably found in this
serous sac, which is liable to be mistaken for a
morbid one. The subserous cellular tissue and
the pulmonary substance being abundantly per-
vaded by fluids, it follows that a transudation of
them must necessarily occur after a certain period,
and of course they will be collected into the sac
of the pleura. The bloody colour of this fluid, its
serous character, the absence of any organizable
matter such as serous membranes are prone to
secrete, are sufficient to prove that this is not a
morbid phenomenon ; moreover, it will seldom be
found except in a body examined at least forty-
eight hours after death, and its quantity will be
in proportion to the condition of the body as to
decomposition. Sometimes, but rarely, gaseous
effusions take place in the pleural sac ; they are
in general complicated with old pleuritic effusions,
and result from their decomposition, thus consti-
tuting one of the species of pneumothorax de-
scribed by Laennec. Whether this disengagement
of gas takes place before or after death is not easily
determined ; probability is in favour of the latter,
but the experiments of Gendrin seem to indicate
the presence of a variable quantity of gas in the
chest in very acute pleurisies, appearing just when
the inflammation seems to have arrived at a cer-
tain degree of violence.

In the mucous membrane which lines the air-
passages, from the larynx and trachea to the mi-
nutest bronchial ramification, discolorations occur
from various causes, which are extremely likely
to deceive even a practised eye. In the larynx,
trachea, and larger bronchi, this discoloration is
not so variable. We here find a passive hyperse-
mia from the gravitation of the blood, in which
case the mucous membrane is only partially con-
gested. We also find here a congestion from ob-
struction to the circulation generally, dependent
on disease of the heart; but in the minute bron-
chial ramifications we find not only the influence
of gravitation or transudation after death produc-
ing alterations in the aspect of the membrane, but
likewise these causes are apt to take effect in the

728

PSEUDO-MORBID APPEARANCES.

struggle of death, or even some time before death
in very debilitated persons. The progress of pu-
trefaction in general produces a very marked and
diffuse brown colour of the mucous membrane,
much more intense in the smaller tubes. To be
able to decide upon any one of the above species
of hyperemia of the bronchial membrane will re-
quire a careful consideration of coexisting circum-
stances. In the latter instance the general condi-
tion of the pulmonary and the other tissues as to
their state of preservation, will materially assist;
in the other cases the injection is ramiform, and
the membrane does not appear so uniformly dyed,
the redness being chiefly limited to dependent
parts ; and the state of the heart or great vessels
will assist further in deciding upon the true nature
of the redness. These circumstances will direct
us in discriminating any of these different forms
of redness not only from the others, but also from
that which is produced by inflammation. Inflam-
matory redness, it should be remembered, is often
accompanied with some secretion, either a viscid
and adherent mucus, or a pseudo-membranous
exudation, or even purulent fluid, all which are
unequivocal proofs of the morbid nature of the
colour of the membrane.

In examining the pulmonary tissue itself, we
experience considerable difficulty in distinguishing
between its pseudo-morbid and morbid conditions.
We can say with confidence, from tolerably ex-
tensive opportunities for studying the subject, that
there is no one point in morbid anatomy more
difficult to pronounce upon with certainty, than
whether a hyperemia of the lung be inflammatory
or not. Every one must have experienced how
unsatisfactory are the signs of the second stage of
pneumomia — the engouement of authors. It is
obvious that this difficulty is greater the longer
the period which may have elapsed since the death
of the subject. It however rajely happens that a
patient dies in the first stage of pneumonia ; most
frequently we find that the disease has in one por-
tion of the lung advanced to its second stage {red
hepatization), and very frequently the third stage
{grey hepatization) is exhibited in the same lung
along with the two preceding. Where either of
the forms of hepatization exists, there can be little
doubt as to the nature of the congestion in any
other part of the lung. Moreover, we may remark
that the inflammatory congestion affects the upper
as well as the dependent parts. The following
observations from Andral will show how he
estimated the difficulty of laying down any dis-
tinction between inflammatory and the pseudo-
morbid hyperemia. "It is," he says, "in the
lungs as in the intestines, where a local accumu-
lation of blood may be found in the dead body,
which has had no share in producing any of the
morbid phenomena observed during life; but was
formed during the last moments of existence, or
after life ceased altogether. Hence it follows that
the existence of a simple congestion, especially
when it occupies the most dependent portions of
the lung, is not sufficient to prove that a process
of irritation or inflammation had been going on
there during life. Does an alteration in the con-
sistence of the part afford a more certain criterion
to judge by in such cases'! For a long time I
was of opinion that when the lung was red and

gorged with blood at its posterior portion, ann al
the same time was softer and more easily broken
down than natural, it was a proof that the hvper-
a:mia was caused by inflammation ; but I have
since altered my opinion, and am now convinced
that whenever the sanguineous congestion is so
great that the lung contains a larger proportion
of blood than of air, the pulmonary parenchyma
is invariably soft and friable. The reason of this
fact will readily be understood if we reflect that,
when the lung contains a much larger proportion
of air than of blood, the parietes of the bronchi,
when pressed by the finger, press in their turn on
the compressible fluid they contain, and in this
way, by compressing or expelling the air, retire
before the pressure of the finger, and so escape
being ruptured. But when the lung contains a
larger proportion of blood than of air, the former
fluid being almost wholly incompressible, the pul-
monary tissue cannot recede from under the finger,
and is therefore easily ruptured." (Andral's
Pathol. Anatomy, by Townsend, vol. ii. p. 508.)
And in another section he remarks, " as the ana-
tomical characters of the hyperemia are precisely
the same in both these cases, it follows that, in
this instance at least, the true nature of the lesions
found on dissection can only be known by the
nature of the symptoms observed during life."
(Op. cit. vol. ii. p. 509.)

We can hardly suppose it possible that gan-
grene of the lung and any post-mortem congestion
of it could be confounded together. The peculiar
smell from a gangrenous spot is a certain indica-
tion of its true nature. However, if any condi-
tion do appear closely to resemble gangrene, by
carefully washing the suspected portion of lung
in clean water we shall in general succeed in ex-
hibiting the sound pulmonary texture.

In the pericardium the signs of disease are so
very obvious that we know of no phenomenon
which that membrane can present which could
be considered pseudo-morbid. There is found,
however, in its cavity, after a certain time, a sero-
sanguinolent effusion in small quantity, which,
like a similar one above noticed in the pleura, is
to be regarded as a cadaveric result. (See Hx-

DnO-PERICARDIUM.)

Except after the lapse of a considerable time
from death, we have never seen any post-mortem
condition of the substance of the heart which
could be mistaken for a morbid one. We not
uncommonly meet with softening of the muscular
texture of the heart ; and this may arise from so
many different causes, that Andral has enumerated
six varieties of it ; with any of these may be con-
founded a true cadaveric softening, which, how-
ever, generally does not appear for a long time
after death. The best criterion of the true nature
of a softening of the heart's parietes may be
formed from the state of the internal membrane;
if that membrane be healthy, or do not partake in
the diminished consistency of the heart's parietes,
then the great probability is in favour of this con-
dition being the result of disease. But when the
internal membrane is of a deep red colour, and is
more or less softened, while at the same time
there is no appearance of any lymph or other pro-
duct usually resulting from inflammatory action,
then we consider it impossible to determine with

PSEUDO-MORBID APPEARANCES.

729

certainty to what cause the softening is to be at-
tributed. In some instances the blood has been
known to transude through the walls of the heart,
and form ecchymoses either between the fibres or
on the external surface. Such ecchymoses will
want the regularity of form which those formed
during life would possess, and rarely, if ever, take
place except in an advanced stage of decomposi-
tion. We have twice seen numerous ecchymosed
spots on the hearts of patients who died of pur-
pura hemorrhagica ; but these should be consi-
dered as morbid, and attributable to the same
cause as the cutaneous ecchymoses.

The internal membrane of the heart often pre-
sents an obviously pseudo-morbid alteration in its
colour. When the examination of a body does
not take place for forty-eight hours after death, or
in very warm weather for a longer period, we
may invariably expect to find this membrane of a
red colour to a greater or less extent. That por-
tion which lines the dependent parts of the cavi-
ties will always be found so, and to a greater de-
gree than the rest, because the colouring matter
sinks through the coagulum so as to come imme-
diately in contact with the internal surface of the
heart ; and this will account for the fact, that ex-
cept at a very advanced period in the cadaveric
decay, this redness generally appears in patches,
and those most intense which are most dependent.
A precisely similar redness will occur under cir-
cumstances which can leave no doubt that it took
place during life; but as this subject is closely
connected with the appearances of the internal
coats of arteries, we shall defer any farther remarks
upon it till we come to that section of our article.
The fibrinous masses which are almost uni-
formly found in the cavities of the heart are not
to be considered in every instance as morbid pro-
ductions, as the older pathologists thought ; in
general they are formed after death, or immedi-
ately before it, and merely form the natural dispo-
sition of the fibrine to assume the solid form.
However, some of these coagula have been found
organized, some containing pus, others with
pieces of bone on them or in them ; whence we
must conclude that these fibrinous masses may
be formed before death, and produce considerable
disturbance of the circulation.*

5. The Abdomen. — Of all the serous mem-
branes, the peritoneum is most liable to morbid
effusions. But in this cavity, as well as in that
of the pleura, we generally find a post-mortem
effusion after thirty or forty hours ; which, like
that of the pleura, is in general coloured by more
or less admixture of blood. This fluid will al-
ways, except it be in very great quantity, be found
in the pelvic portion of the peritoneum. In the
serous membrane itself, we know of no pseudo-
morbid appearance likely to occur, except we name
that softening produced by contact with the acid
contents of a perforated stomach, which we shall
presently notice more fully. The discoloration
arising from contact with the gall-bladder is too
evident to be mistaken for disease.
In examining the exterior of the intest.nal tube

*Dr Harty has given a very elaborate narration of
the svmntomVof two cases, which in his op.ninn vvcre
iroffi by these so-called polypi of the heart. Dub.
Med. Transactions, vol. i.

Vol. III. — 92

as the intestines lie in the abdominal cavity, we
observe appearing through the serous coat vascu-
lar ramifications more or less numerous and more
or less filled with blood. Here we observe well
illustrated the effects of gravitation on the blood
within the vessels of the intestines ; those coils
which are lowest, namely those which hang into
the cavity of the pelvis, always presenting the
deepest colour, and also the most depending por-
tions of all the parts of the canal.

There is no membrane of the body which pre-
sents pseudo-morbid coloration arising from so
many different causes, as the gastro-intestinal
mucous membrane: we speak now of the colour
which results from particular distributions of the
blood in its vessels. In the first place, we may
notice that the act of digestion produces an in-
creased degree of redness of the mucous mem-
brane of the stomach as well as of the small
intestine. The effect produced by digestion on
this membrane has been well noticed by Gendrin ;
he says that the membrane becomes of a rosy hue,
deeper in young than in old subjects ; and that it
is owing to the action of this function may be
very well inferred from the fact that only that
portion of the membrane is coloured which is in
contact with the chymous mass. It is also re-
marked round the portions of digested' matter
which are found in the lower part of the small
intestine. It appears, too, that the degree of
colour depends very much upon the quality of the
food, being less intense when the food is of a
bland nature. This has been proved upon two
dogs, to one of which milk only had been given,
to the other an equal quantity of rich broth highly
seasoned ; the mucous membrane of the latter
was of a deep red colour, while that of the former
was very slightly altered. Fasting also has the
effect of altering the colour of this membrane,
giving it a rosy hue in its whole extent; in this
way differing from the effects of digestion, which
produces only a partial colouring.

A third cause of alteration of colour results
from " the passive hypcrfflmia," to adopt the lan-
guage of Andral, " which has always a tendency
to take place in the last moments of life in the
parts abounding with capillaries." In this case
the colour is generally of a darker hue, and the
greatest quantity of blood is found in the vessels
of the depending portions of the intestines.

Any obstacle to the free return of the venous
blood, whether it reside in the liver, or from com-
pression of the vena porUe itself, or whether it is
to be found in the heart, will produce increased
vascular injection of the mucous membrane; the
blood in such cases will be of the venous kind,
and the injection extensive, and even universal ;
varying, however, according to the period before
death at which the obstruction commenced.

Such are the circumstances which operate be-
fore death in producing pseudo-morbid colouring
of the mucous membrane. In the true inflam-
matory redness, there is generally some degree of
thickening of the membrane, as well as a viscid
mucous secretion in variable quantity. The red
ness, too, is not affected by position, being equally
great on the upper as in the depending portions,
and in a more advanced stage of the inflammation
there may be lymph or purulent matter.

730

PSEUDO-MORBID APPEARANCES.

After death, we find the blood accumulating
with greater rapidity, and in a more marked man-
ner in the depending parts. This phenomenon
may be observed as to the mode of its occurrence,
by removing a coil of intestine, tying it at each
extremity, and hanging it up ; after some time the
blood will be seen to leave the upper part, and
accumulate in the lower portion of the intestine.
If there be much blood in the capillary system of
the mucous membrane, we observe another cada-
veric phenomenon, after the body has Iain for
some time : the mucous membrane, and of course
the villi, are gorged with blood, which presently
begins to ooze out upon the surface, and to pass
into the cavity of the intestine. This we lately
saw well exemplified in the case of a young gen-
tleman who died of fever, and whose body we
could not obtain permission to examine till five
days after death. All the upper portion of the
small intestine was free from sanguine congestion,
but that part of it which lay in the pelvis was
found to be of a dark red hue externally ; the
mucous membrane being gorged, especially at its
inferior part, and the cavity of the intestine full
of fluid blood. This phenomenon is easily ex-
plained if we consider how freely the blood passes
from the large mesenteric veins to the villi, which
moreover, from the researches of Ribes, appear to
contain more veins than arteries ; it is also fur-
ther accounted for by the great facility with which
an intestine may be inflated by blowing air into
its principal venous trunk. Contact with the
spleen produces a redness of a different kind,
being more of a uniform stain or tinge of the
membranes in its vicinity. This obviously arises
from transudation of the blood from this vascular
body through its coats. After a certain period we
find the blood to transude through the coats of
the larger vessels of the stomach and intestines so
as to produce a more or less continuous stain, or
extravasation of blood in the cellular membrane
on each side of the trajet of the vessel. This
appearance must be familiar to every one who has
examined a stomach in an early stage of decom-
position ; the stain is distinctly visible on the
mucous surface, and may also be noticed on the
peritoneal surface. The period at which this
transudation may take place will very much de-
pend on the season, the temperature of the room,
and perhaps the state of the blood.

There are two other causes of discoloration
which it is well to remember, although the ap-
pearances they produce may not be very apt to be
mistaken for morbid ones. One of these is the
.presence of gases in the cavity, which may alter
in various ways the colour of the blood collected
in the coats of the intestine. The action of the
bile too, by soaking into and combining with the
mucous membrane, produces a very obvious
change in its colour, and this may even extend
into the stomach. There is a third cause of dis-
coloration resulting from the action of the gastric
acid on the blood, which we shall notice more
fully after considering the other effects of that
acid.

In inspecting the alimentary canal, we should
not neglect to observe accurately the nature of its
contents, for sometimes some coloured fluid may
be found among them which may impart its

colour to the membrane. Dr. Christison quotes
a case in which a suspicion of poisoning had
arisen from the inspector hastily referring the
altered colour of the inner membrane of the
stomach to inflammatory action. It was ascer-
tained that the deceased was in the habit of taking
a strong infusion of corn poppy, (papaver rhxa-
dos,) which, when administered to dogs, produced
appearances identically the same. The inference
was obvious. (Vide Christison on Poisons, p. 121.)
It will thus appear, that in attempting to form
a judgment as to the precise nature of any co-
loration of the alimentary mucous membrane,
there are numerous sources of fallacy which it is
important to avoid. It is in the stomach that
most of these pseudo-morbid appearances occur,
but many of them likewise are to be met with in
the intestines. They may be classed as follows:
1st, those which are produced antecedent to death,
and 2d, those which are strictly post-mortem or
cadaveric. Under the former are comprehended,

1, those produced by the stimulus of digestion ;

2, those resulting from long abstinence ; 3, the
result of passive hyperemia toward the close of
life ; 4, such as arise from a disturbed state of the
circulation owing to a retardation in, or obstacle
to, the free return of the venous blood. Under
the cadaveric may be enumerated, 1, that arising
from post-mortem hypostasis, which is sometimes
accompanied with cadaveric hemorrhage ; 2, that
produced by contact with a vascular body like the
spleen ; 3, those stains or streaks resulting from
transudations of the blood through the coats of
the larger vessels, more especially of veins; 4,
that produced by the action of gases evolved into
the cavity of the intestine, upon the blood con-
tained in its vessels; 5, that from imbibition of
the bile ; 6, that from contact with some coloured
fluid in the intestine forming part of the ingesta;
and, lastly, that produced by the action of the
gastric acid, of which we have yet to speak.

Attenuation or thinning of the mucous mem-
brane is occasionally met with as a morbid phe-
nomenon. We sometimes, however, find it caused
mechanically by a continued distension of the
tube. Thus Billard relates a case in which he
found a mass of lumbrici in a portion of small
intestine, which was so distended by them that it
almost equalled the coecum in volume, and its
wall was so thin as to permit the worms to be
seen coiled up in its interior. We lately ex-
amined the body of a young girl, in which the
ccecum was distended with faeces to such a degree
that it extended across the upper outlet of the
pelvis to the left iliac region. From the excessive
attenuation of the wall of the intestine, the faeces
were distinctly visible through it.

Softening of the mucous membrane is an alter-
ation of texture which equally takes place under
the influence of morbid causes as of others of a
different nature. Nobody denies the existence
of softening of the gastro-intestinal mucous mem-
brane consequent upon inflammation ; but it may
reasonably be doubted whether it arises from that
cause so frequently as has been supposed. Nei-
ther can this alteration of consistence be con-
sidered as a frequent result of the putrefactive
process, for unless the membrane be exposed to
air, we find that it softens slowly. Andral has

PSEUDO-MORBID APPEARANCES.

found its consistence unimpaired eight or ten days
after death, and in bodies which exhibited abund-
ant signs of advanced putrefaction. Even when
exposed to the air it softens slowly, as Billard did
not perceive any change till the sixth day of the
exposure of a portion of mucous membrane, and
in a situation where the sun's rays could exert
their full influence upon it. Hence we may with
reason reject putrefaction or decomposition from
the list of causes of this alteration, seeing that
the majority of post-mortem examinations take
place within forty-eight hours after death.

To John Hunter we are indebted for the first
notice of what must be considered a very im-
portant fact, viz. that in the body of an individual
dead soon after digestion has commenced, the
mucous membrane of the stomach, the great end
especially, may be found dissolved, and even the
wall of that viscus perforated, and this through
the solvent power of the gastric juice, « that men-
struum which the stomach itself has formed for
the digestion of food." (Hunter's Animal Econo-
my, p. 231.) Without inquiring into the grounds
on which so many subsequent writers or experi-
menters attempted to refute or deny Hunter's
hypothesis, we shall content ourselves with refer-
ring the reader to Dr. Carswell's very able paper
on this subject, (see Edin. Med. and Surg. Journ.
v. 34, p. 282,) in which he will find the opinions
of Jseger, Laisne, Gairdner and others, fully dis-
cussed, and pass on to state the facts which
appear fully to establish the original opinion of
the great British physiologist. The first circum-
stances in favour of this opinion are those related
by Hunter himself, viz. the fact of having found
a solution of the stomach in two persons killed
suddenly and shortly after having taken food ;
the frequency of the solution in fishes, which gene-
rally died of violence and with the stomach full,
and in other animals killed violently and during
digestion.

Spallanzani, Adams, Cooper, and Carlisle after-
wards confirmed these experiments. Some fail-
ures, however, occurred in the attempts to produce
this phenomenon at pleasure in animals, and hence
the confidence of subsequent experimentalists was
somewhat shaken. Some observations strongly
corroborative of the Hunterian doctrine were pub-
lished by Allan Burns ; he found the stomach
dissolved and perforated, and not only this, but
every viscus with which the fluid that escaped
from the stomach came in contact was also soften-
ed in its walls ; and as a still further confirmation,
he observed, on examining the body two days after
his first inspection, that the solution had extended
considerably. Recently Dr. Carswell, in the paper
above referred to, has fully succeeded in proving
that this softening takes place in healthy animals
killed during digestion, and that, in whatever part
of the stomach " this function was going on most
actively, or an accumulation had taken place of
the products of secretion, there the organic altera-
tions had also occurred." Finally, a case has oc-
curred to Dr. Sharpey, as related by Dr. Christi-
son, precisely analogous to that of Mr. Burns.
"On proceeding to open the body of a child for
the purpose of dissecting the nerves, he remarked
that the stomach was perforated and gelatinized
but the adjoining parts uninjured. He then sewed

731

up the body in order to show the appearances to
some of his friends next day. By that time the
peritoneal surfaces of the spleen and left kidney
were found much softened and pulpy where they
lay in contact with the hole in the stomach."
(Christison on Poisons, p. 127.)

Such, then, is the evidence upon which we
would attribute a form of softening (and perhaps
the most frequent) of the mucous membrane of
the stomach, to the action of the gastric juice, and
it may be added that this action may go on to
produce a perforation of the wall of the stomach.
The softening is generally observed at the most
depending part, most commonly the great sac :
here the membrane appears like jelly, yet hardly
so firm. " When raised between the fingers the
coats crumbled to pieces like a recent pseudo-
membrane," and often the serous coat is similarly
softened. The only alteration of colour in the
mucous membrane is that of being rendered rather
whiter than the natural hue. The perforations
resulting from this cause of course vary in extent
according to that of the softened tissues ; we find
them, therefore, of all sizes, sometimes so great
as to involve a considerable portion of the sto-
mach. The margins appear half dissolved, fringed,
and generally formed of the serous membrane, and
for a considerable distance round the mucous
membrane is gelatinized. Moreover, as has been
first noticed by Dr Carswell, the blood-vessels dis-
tributed on the softened parts and also on every
part which had come into contact with the fluid,
were altered in colour, so as to form brownish,
brownish black, or pure black arborescences.
When the fluid could not come in contact with
the membrane, the vessels exhibited their natural
colour. It may be stated further that the fluid
found in these stomachs at once reddened litmus.
In the instances of this form of perforation which
have occurred in the human subject, no symptoms
whatever of gastric disease were present before
death, the patients having died of disease of some
other organs or by violence. Thus, according to
an abstract which we take from Dr. Christison's
work, it has been found in women who died of
convulsions after delivery, in children who died
convulsed or of hydrocephalus, after death from
suppuration of the brain both idiopathic and trau-
matic, from diseased mesenteric glands, from nerv-
ous fever, and after sudden death from fracture of
the skull and hanging.

The softening of the mucous membrane thus
formed is to be distinguished from that which is
the result of morbid irritation during life, as weli
as of that produced by the introduction of irritant
poisons. Cruveilhier has described a condition of
this membrane in the stomach of children, which
he calls •' ramollissement gelatin/forme." This
softening, like that above described, extends to the
other coats of the stomach, and even causes perfo-
ration. In short, this affection described by Cm
veilhicr has the strongest possible resemblance to
the pseudo-morbid softening of Hunter ; but the
evidence adduced in favour of its morbid charac-
ter is derived from certain symptoms supervening
a short time before death. We know of no means
whereby we can distinguish between these two
alterations, except, perhaps, the dark colour of the
blood contained in the vessels of the softened part,

732

PSEUDO-MORBID APPEARANCES.

which, if the alteration described by M. Cruveil-
hier were the eiTect of morbid irritation, would not
be likely to occur. On the whole, however, we
are strongly disposed to the opinion that the ramol-
lissement gelatiniforme of Cruveilhieris a pseudo-
morbid phenomenon, and identical with that
caused by the action of the gastric juice.

In a true pathological softening there are uni-
formly present some additional signs of inflamma-
tion ; thus, we sometimes have redness of the
membrane, and generally an increased opacity and
a thickening of the submucous tissue ; and it may
be indifferently found on all parts of the stomach,
even where the gastric juice could not come in
contact with it ; moreover, here likewise we have
not the black discoloration of the blood which is a
remarkable character of the softening by the gas-
tric juice.

The perforation which results from this soften-
ing must be distinguished from that caused by in-
flammation or by rupture. The existence of signs
of inflammation in the serous membrane would be
unequivocal evidence ; but sometimes the perfora-
tion or rupture occurs at too short a time prior to
death to allow of the production of peritoneal in-
flammation, in which case the appearance of the
margin of the opening, the state of the surround-
ing membrane, and of the submucous tissue, will
assist in forming a conclusion.

We have alluded to the effect which the gastric
fluid produces when brought into contact with the
blood in the vessels of the stomach. The effect is
nearly similar to that produced in the case of
poisoning by acetic acid, related by Orfila in
the Annales d'Hygiene for July, 1831, namely,
a black or brownish black discoloration of the
blood, without affecting the coats of the vessels.
In the instance under consideration, however, the
discoloration is not so extensive as in that of poi-
soning by the acid, the quantity of acid in the
gastric juice being so small. But we sometimes
meet with a brownish black discoloration from
morbid action, which may be distinguished chiefly
by the fact of its occupying the villi of the mem-
brane, and by the gradation through which the
colour passes from red to brown, and from brown
to black ; to which we may add that the discolora-
tion by the gastric juice is most conspicuous in
the large trunks. The absence of all appearance
of transudation, as well as the state of the other
tissues, will sufficiently indicate that the black
colour is not caused by putrefaction.

In the parenchymatous viscera of the abdomen
there are no pseudo-morbid appearances worthy
of notice; they are chiefly such as are produced
by mechanical obstacles to the free course of the
blood, or such as are caused by the operation of
the principle of gravitation. In some bad states
of the blood the liver and spleen have been found
softened in their texture to such a degree that
they almost appeared to be thus altered by putre-
faction ; however, in general, the effect of putre-
faction is to diminish the size of those organs,
while the reverse often takes place in the case to
which we allude.

G. The Blood-vessels. — It is not uncommon
to find considerable -/ascularity of the cellular
membrane forming th3 external investment of
arteries; The minute vessels ramifying in this

tissue, called vasa vasorum, are minutely injected,
and form beautiful arborescences freely anastomos-
ing over the surface of the arterial tube. These
often are produced as a mere mechanical effect, or
as the result of gravitation. The alterations of
colour which the internal coat of arteries exhibits
deserve particular attention. Every one must
have observed that if an artery be slit open, its
coagulum or blood removed, and its inner coat
exposed to the air, it quickly acquires a bright red
colour. Again, if the blood remain fluid for some
time after death, if its fibrine be less contractile
than in the healthy state, the inner coat of the arte-
ries will be generally found to be deeply coloured.
In examinations made when putrefaction has fully
set in, a similar colouring of the same tissue will
uniformly be seen. Again, if a coagulum exist
in an artery, and the colouring matter have sunk
to its most depending part, that portion of the
inner coat will be coloured which is in contact
with the colouring matter of the clot. Finally,
by inclosing some blood in an artery, and keeping
it there by ligatures, we are able to produce a red
colour in its internal membrane. Such are the
different ways in which a red colour or stain of
the inner coat of arteries may be produced, very
similar to that which is the first indication of in-
flammatory action in it. In veins similar disco-
lorations, and from the same causes, are observed
and in them those arising post-mortem take place
much more quickly than they do in arteries. The
red colour of the inner membrane of either arte-
ries or veins can be but little depended on as a
sign of inflammation ; nor, indeed, can we derive
any conclusion from it at all unless it be accom-
panied with an albuminous exudation or other
unequivocal product of inflammatory action.

In the preceding detail of the various pseudo-
morbid alterations which are to be met with in
the principal tissues of the body, our design was,
not to exhibit to the reader the difficulties in the
way of forming a correct estimate of the condi-
tion of any structure, but to convince him, and in
the most practical way, of the necessity for and
utility of observing great caution in deciding upon
the presence or absence of disease. We shall
bring this article to a close by stating a few con-
clusions suggested by the consideration of the sub-
ject, which may serve as useful directions in mak-
ing or recording post-mortem examinations.

1. Before proceeding to examine a body, the
inspector should invariably ascertain, with as much
accuracy as possible, the length of time which
may have elapsed since the death, and it should
be noted in the record of the inspection. The
neglect of this has rendered many apparently va-
luable cases, noted in some of our standard works,
utterly inconclusive. We allude more especially
to cases in which serous effusion has been found
round the brain or spinal marrow. 2. The reporter
of post-mortem inspections should in no case con-
tent himself with merely stating what he conceived
to be the state of a tissue, as, for instance, " that
such a membrane was inflamed," but he should
be careful to note, as clearly and as concisely a&
may be, the appearances which presented them-
selves, and any concomitant circumstances calcu
lated to unfold the true nature of those appear-
ances, whether morbid or pseudo-morbid. Tim

PSORIASIS.

r33

precaution need not, however, preclude any re-
marks as to the impression conveyed at the time
of examination, but it is obvious that it will have
the advantage of recording a plain statement of
facts, from which each reader may have equal
means of deriving a conclusion. 3. There are
some points respecting the examination of certain
parts worthy of attention. In every case of sus-
pected disease of the spinal marrow, the spinal
canal should be opened before the head, in order
to form an estimate of the precise quantity of fluid
that may happen to be effused. The advantage
of this is apparent from what we state respecting
the free communication between the two portions
of the cephalo-spinal fluid. The brain should not
be removed from the cranium until the ventricles
have been examined, that as little as possible of
the fluid may escape. Of course this is only ap-
plicable where the head is opened before the spine.
As to the manner of opening the head, we have
generally preferred to do so by sharp and strong
blows of a hammer, so as to crack the skull round,
the head being supported by the other hand, and
not placed upon so unyielding a fulcrum as a
table or block. We have found this method pre-
ferable to that of sawing, which, we conceive, dis-
turbs the parts more, and, unless the saw be very
sharp, is always extremely tedious ; not to men-
tion the difficulty of preventing the saw from in-
juring the dura mater, or even the substance of
the brain itself. „ -r> rp„ „„

K. D. 1 ODD.

PSORIASIS. — The termpsoriasis (scaly tetter;
dartre squameuse,) from \pwpa, a scab or itch, was
first employed by Dr. Willan to denote a cutaneous
disease, which consists essentially in a greater or
less degree of inflammation of the rete mucosum
and contiguous surface of the cutis ; and in the
( secretion of an unhealthy epidermis, forming itself
into scales which exfoliate, and are renewed with
greater or less rapidity. The natural transpiration
through the affected parts is almost completely
interrupted, and its place supplied by the exuber-
ant growth of a morbid cuticle. Psoriasis is so
closely allied to lepra that some writers (Plumbe,
On Diseases of the Skin ; Duffin, in Edin. Med.
and Sur. Journ. 1826, on Squamous Diseases.)
have proposed to conjoin them under one head,
which in a practical point of view would be attended
with no inconvenience. Both are well-marked scaly
diseases, and the difference between them consists
in the more perfect circular regularity of lepra, its
inflamed margin, raised scaly circumference, and
usually depressed centre; while the outline of the
patches of psoriasis is irregular, and their centre
rather elevated than depressed. Yet the connec-
tion between the two diseases is so intimate, that
we sometimes observe both forms of eruption in
the same individual; spots of lepra being intermix-
ed with the more irregular and extended patches
of psoriasis. . . ,

The elementary character of psonas.s is a scaly
surface with inflammation of the subjacent vascular
tissue ; but to these are generally superadded the
formation of fissures and excoriations, discharging
a thin fluid, which concretes into crusts, intermin-
gled with or formed upon true scales; and m
severe and protracted cases there also occurs over-
growth of the cutis, which acquires unnatural

thickness and solidity. This affection is attended
with heat and itching, which, although seldom
altogether absent, become at limes more intense
and distressing : during the exacerbations the in-
flamed skin flushes with heat, and swells up into
ridges like an erectile tissue.

Psoriasis varies much in the rapidity of its pro-
gress : it generally appears first in the form of
small, red, shining spots which become covered with
scales ; and under these other scales are formed,
while the first loosen and fall off. Thus the
scales thicken, the spots multiply, enlarge, coalesce
one with another, and form large patches. In
other instances of this disease, considerable portions
of the integument are affected at once, becoming
rough, harsh and chopped. Psoriasis is usually pre-
ceded by languor, lassitude, and loss of appetite:
and is accompanied in its early stage by more or
less of febrile disturbance, which is always most
strongly marked in those cases where the disease
is suddenly developed. It is very often periodical
in its attacks, disappearing and recurring with
marked regularity at certain seasons of the year.
In the case of a lady, whose leg has for many
years been affected with a large patch of psoriasis
inveterata, the disease uniformly disappears during
pregnancy, leaving a pale, wrinkled surface similar
to the scar of a burn.

Causes* — Psoriasis is not generally believed to
be contagious ; but Dr. Willan, (Bateman, Synop-
sis, p. 38,) it appears, had observed psoriasis gut-
tata to occur among the children of the same
school or family at the same time : and we remem-
ber to have been consulted by two ladies having
this disease on their necks, who were impressed
with the belief that they had received it from their
female attendant. Its hereditary nature is gener-
ally admitted ; and several instances in proof of
this opinion are known to us. Psoriasis is more
frequently seen among the lower than the upper
classes of society, and oftener among females than
males, occurring especially during disorder of the
uterine functions, as in chlorosis and after parturi-
tion. Persons of a full habit and dark complexion
are most subject to this disease ; and a distinct
tendency to it is indicated by a dry and husky
state of the skin, with languor of the circulation.
It is more especially a disease of cold climates,
and its occurrence is much promoted by the keen,
dry winds of spring, and the sudden alternations
of temperature which take place both at that sea-
son and in autumn. Hence it has been observed to
recur particularly at these periods for successive
years, and to be then most aggravated ; but we
have known psoriasis to be most severe during
the heats of summer.

Various occasional causes appear to give rise to
this disease; such as chilling the stomach by
large draughts of cold water while heated, (Fal-
coner, Memoirs Medic. Soc. London, vol. hi,) ; the
sudden exposure of the body to cold after violent
exercise, acid and indigestible substances taken
into the stomach. In children psoriasis appears
sometimes to originate from the irritation of denti-
tion ; and in adults it has been observed to arise
during great mental anxiety, grief, and apprehen-
sion (Bateman, Synopsis, p. 38,) — most probably
from the influence which these states of the mind
exert over the digestive organs. There is reason

734

PSORIASIS.

to believe that Loth gout and urinary calculus are
connected with psoriasis, not as causes, but con-
curring consequences of the same disordered con-
dition of the stomach and bowels. Numerous
local irritations are productive of psoriasis affect-
ing the hands and arms, as in washerwomen,
bakers, and others.

Dr. Willan* has mentioned that both psoriasis
guttata and psoriasis diffusa are sometimes the
sequel of lichen and prurigo; and we recollect
an instance where psoriasis inveterata appeared
to have been the consequence of eczema rubrum.
We have observed also the disease last named de-
generate under our eyes into psoriasis guttata.

Psoriasis has been divided by Dr. Willan into
numerous species, of which only four deserve par-
ticular consideration ; the rest being regarded as
mere varieties, for which a brief notice will suffice.

1. Psoriasis Guttata, (drop-like scaly tetter.)
This appears in the form of irregularly shaped
spots, some no bigger than a pin's head, others
nearly as large as a sixpence ; which multiply,
extend, and coalesce into patches, all of them co-
vered by white glistening scales, excepting those
in the face, where they appear merely as red spots,
rough and slightly elevated. It is seldom attended
with much inflammation of the skin. Its type is
sometimes acute, at others chronic ; the former is
most frequent in children, in whom it occasionally
overspreads nearly the whole body in a few days ;
the latter is usual in adults. When the progress
of psoriasis guttata is rapid, it is always accom-
panied by general feverish disturbance, and in
many cases preceded by muscular pains. It ap-
pears most frequently in spring, and sometimes
recurs annually at that season for several succes-
sive years. This is the most common form of
psoriasis, constituting, according to Rayer, (Mala-
dies de la Peau,) three-fifths of all the cases which
are met with.

2. Psoriasis Diffusa, (diffuse scaly tetter.)
The character of this species is considerably more
inflammatory than any of the others, and it is
more nearly allied to impetigo and eczema ; indeed
Alibert has described one form of it under the
name of dartre squameuse humide.f The skin
affected by this eruption is much more hot, red,
and tender, more frequently presents fissures and
excoriations, and is much less closely covered
with scales, which differ frem those of the fore-
going species in being occasionally of a brownish
tint, more irregular in their form, and placed more
edgewise on the surface. Diffuse psoriasis some-
times appears at once over a large extent, the skin
becoming harsh, cracked, red, and scaly : at other
times its progress can be traced from the formation
of minute, elevated spots, covered with distinct
scales, which after a time are connected by the
inflammation of the intervening spaces ; these in
their turn become scaly, and the whole is at length

* On Cutaneous Diseases, vol. j. p. 156. To the works
of Dr. Willan, and of his pupil and follower Dr. Bate-
man, the writer of this article gladly acknowledges the
heavy debt which he owes. Not to have drawn from the
rich treasures left us by those distinguished physicians,
would have been at once discreditable to himself and
unjust to his readers.

t Maladies de la Peau, PI. 13. Another form of the
same species has been named by him dartre squameuse
vrbiculaire. PI. 14.

changed into one continuous eruption. Again,
in other cases, the disease appears in small sepa-
rate patches, which may remain distinct, but are
also apt to extend and coalesce, acquiring ulti-
mately the characters just described. The cuticle
becomes rent into fissures, which discharge a thin,
serous, and sometimes bloody fluid, while the
cutis, which is always more or less turgid from
inflammation, at length suffers a real overgrowth.
The development of this disease is usually attend-
ed with constitutional disturbance, which is after-
wards maintained by the continued irritation of
the inflamed skin. The heat and itching are often
very troublesome, and any additional excitement
from increased temperature, or the friction of the
clothes, produces a distressing aggravation of the
symptoms. In children this is particularly re-
markable, for in them diffuse psoriasis appears in
a severe form, generally from the age of two
months to two years. Dr. Willan (vol. i. p. 170)
was led to erect this into a distinct species (pso-
riasis infantilis) in consequence of the affection
of the mucous membrane of the nostrils which
usually accompanies it, and the intermixture of
scaly patches with smooth shining elevations,
which in the cleft of the nates often assume the
appearance of moist flattened condylemata. But
we have seen this occur in other squamous dis-
eases, apparently from the mere action of heat
and moisture preventing the scales from forming,
and increasing the morbid turgescence of the af-
fected spots. The disease in this altered form is
more amenable to treatment, the flattened eleva-
tions yielding in general readily to the application
of sulphate of copper.

When diffuse psoriasis continues its progress
unabated, it either destroys the patient by the
effects of cutaneous irritation, and of the accompa-
nying morbid condition of the alimentary mucous ,
membrane ; or more frequently it degenerates into
the inveterate form (psoriasis inveterata). But
the severity of the disease is usually limited to a
few months, after which it becomes greatly ame-
liorated or disappears altogether, again to recur
during the variable weather of spring or autumn,
most frequently the former, but sometimes at both
seasons.

The causes of this species of psoriasis are the
same as those already enumerated ; but it appears
oftener to originate from the application of irritat-
ing substances to the skin, and exposure to sud-
den alternations of temperature : hence arise the
local varieties which occur in washerwomen,
bakers, shoemakers, workers in metals, and cooks.
The first of these is often very severe, affecting
the hands, wrists, and fore-arms, particularly about
the part up to which they are usually immersed
in the washing-tub. It arises from the irritation
of the soap, and the alternate exposure of the skin
to hot water and cold air, and is most frequent in
spring and winter.

The baker's itch (psoriasis pistoria) is con-
fined chiefly to the back of the hand, where the
skin is more tender than in the palm, and where
it is exposed both to the irritation of the flour and
to the strong heat of the oven. We have also
observed a cutaneous affection somewhat similar
on the hands of cooks, arising from exposure to
the scorching heat of the fire.

PSORIASIS.

735

3. Psoriasis Inveterata (inveterate scaly
tetter; dartre squameuse lichenoide). This, as
its name imports, is the most obstinate of all the
forms of the disease, sometimes originating in the
diffuse species, at other times being the conse-
quence of prurigo senilis or of eczema rubrum.
It is characterized by an exceedingly thickened
state of the cuticle, which appears in firm layers
of a glistening white colour, resembling the shining
bark of a tree, or the skin of a dried fish ; divided
not into the mosaic of ichthyosis, but by transverse
lines and fissures : it often encases a part or the
whole of a limb, and sometimes extends over the
greater part of the body, leaving unaffected a por-
tion of the face, or perhaps the palms and soles.
The edges of the divided cuticle are usually
curled inwards, and these chinks open and close
with the motions of the body, which in such cases
are not unfrequently attended with a rustling or
slight crackling noise. A quantity of thin fluid,
sometimes tinged with blood, oozes from the fis-
sures, and occasionally large portions of the
thickened cuticle are detached, leaving a bright
red and exceedingly tender surface, at first dis-
charging copiously a watery liquid, and then be-
coming covered with a hard dry epidermis, which
separates from time to time in large plates. The
formation of scales and flattened crusts is so rapid
in this disease, that great quantities are found
every morning in the patient's bed, (Willan, on
Cutaneous Diseases,) resembling in this respect
the decline of mercurial eczema, in which, how-
ever, the appearance is produced by the drying of
the serous discharge rather than the formation of
true scales. When the cuticle is thus extensively
and deeply diseased, the nails participate in the
change, becoming thickened and brittle, frequently
separating and being renewed.

4. Psoriasis Gyrata, (serpentine scaly tet-
ter). This very rare species of psoriasis is chiefly
remarkable for the red waving ringlet-like stripes
which it presents on the back or breast of the
patient ; the figures on one side of the spine, or
on one breast, often bearing a near resemblance to
those on the other. It is unnecessary to describe
minutely the fantastic shapes which it sometimes
exhibits ; suffice it to say that the red colour of
these tortuous stripes is partly shaded by a thin
covering of light branny scales, which are con-
stantly being thrown off and renewed. It is dis-
tinguished from herpetic and impetiginous erup-
tions, to which it bears a remote general resem-
blance, by the absence of vesicles and pustules.
Like other species of psoriasis, it is much in-
fluenced by the weather and the seasons of the
year — subsiding in summer, and becoming more
intense in spring and autumn.

Such are the great divisions of psoriasis founded
on its peculiar forms and the degree of its severity,
and under them, especially the diffuse species,
may be ranked all the local varieties which have
been described by Dr. Willan and others. The
most important, and perhaps the most common of
these varieties, is that which affects the palms ot
the hands, (psoriasis palmaria .- dartre squameuse
centrifuge) : it is characterized by inflammation
and thickening of the skin of the palm, with
scales dispersed over the surface; and very often
fissures, from which thin fluid oozes, attended

with heat, itching, and sometimes considerable
pain on extending the fingers. Patches of the
same description appear also on the inside of the
wrist and on the sides of the fingers ; the nails
likewise are affected in protracted cases, becoming
thickened and opaque, and mouldering away or
being cast off. This is often observed to be an
hereditary disease, and in those disposed to it the
nails usually possess an unnatural brittleness
which makes them snap under the scissors. In
such individuals the exposure of the hands to a
cold dry wind, or frequently moistening them, is
almost sure to induce some degree of psoriasis.
The same affection is seen also on the soles of the
feet, but in a less severe form, and rarely accom-
panied with fissures, as the feet are much better
protected from cold, and very seldom exposed to
the air while moist.

Diffuse psoriasis is sometimes seen on the scalp,
producing an inflamed state of the skin, and a
copious formation of white scales : in some in-
stances the bulbs of the hairs become affected, and
baldness is the consequence. The skin around
the different natural apertures of the body is also
subject to psoriasis, which, from the movements
of the parts, is almost always productive of pain-
ful fissures. Thus it is met with on the edges of
the eye-lids (psoriasis ophthalmica), the lips
(psoriasis labialis'), the nostrils, and on the verge
of the anus and prepuce (psoriasis preputialis).
When the lip is affected with psoriasis, it is most
commonly the prolabium of the under lip : its
causes are obscure, but Rayer (Maladies de la
Peau, t. ii. p. i. p. 35,) states that he has twice
observed it in persons who were great talkers, and
addicted to the practice of biting their lips. The
scrotum is likewise subject to this disease, and
that generally in the inveterate form (psoriasis
scrotalis).

Treatment. — The treatment of psoriasis is
rendered of much greater importance than that
of many other cutaneous diseases by the severe
suffering which in many of its forms it produces ;
by its long continuance, sometimes for a lifetime ;
and by the obstinacy with which, after an appa-
rent cure, it returns on a change of season, or the
application of some slight occasional cause. It
very seldom exists to any considerable extent
along with a general healthy state of the frame :
the system is usually either oppressed by the
effects of a luxurious and indolent mode of life,
or enfeebled by bad health, or by scanty nourish-
ment and clothing, neglect of cleanliness, and the
other concomitants of poverty. In both of these
cases a change in the mode of living and in the
state of health must be accomplished before we
can hope to derive permanent benefit from the
employment of remedies. A strict regimen, ex-
tending to every particular of diet, clothing, and
exercise, suited to the peculiarities of the individual,
must be the first step in our treatment. Should
much irritation exist, and the strength of the
patient permit, blood should be taken by venesec-
tion or cupping ; and in the local varieties, such
as the palmar and ophthalmic, leeches in the
vicinity will be found useful. A general anti-
phlogistic regimen should be pursued, the use of
spirituous liquors abandoned, and even wine and
ale very sparingly, if at all, allowed ; pickles, sour

736

PSORIASIS.

fruits, vinegar, shell-fish, baked meats, pastry,
highly seasoned dishes, and other indigestible
food, should be carefully avoided. The bowels
ought in every instance to be freely opened and
kept in regular order : in many cases a sustained
purgative treatment by calomel and saline medi-
cines has succeeded in effecting a cure. In the
hands of M. Biett (Schedel et Cazenave, Abrege
pratique des Malad. de la Peau,) this mode of
treating psoriasis has proved highly advantageous;
but it has been strongly opposed by Willan and
Bateman, whose opinion on this subject has tend-
ed in no small degree to prevent British practi-
tioners from making a fair trial of its efficacy.
Of this practice our own experience does not
enable us to speak with confidence ; but we be-
lieve that it will be found to be suited only to those
cases where there exists a tendency to plethora.
Psoriasis, we have already stated, is sometimes
combined with an opposite condition of the sys-
tem, as it is met with in delicate chlorotic females.
In these a course of tonic medicines, consisting
of the preparations of cinchona and steel, will be
necessary, if not as the immediate means of cure,
at least for the purpose of preparing' the body
for the successful employment of other^ remedies.

Mercurials as well as purgatives have been
denounced in general terms by Willan and Bate-
man, (Willan, vol. i. pp. 183, 184; Bateman,
Synopsis, p. 43,) as unsuited to the treatment of
psoriasis ; and it must be admitted that the full
action of mercury in this disease is positively in-
jurious, as Willis (De Medicin. operat. Opera, p.
292,) long ago discovered. But it will not be
denied that this remedy, when judiciously ma-
naged, in small and alterative doses, possesses a
great power of correcting many of the disordered
states of the digestive organs, and of restoring to
the skin a soft and perspiring condition. The
mercurial pill, mercury with chalk, Plummer's
pill, and corrosive sublimate, have in our hands
proved very serviceable, both in psoriasis and other
scaly affections. One of the numerous remedies
which have been employed internally for the cure
of this disease is sulphur : it may be considered
to act both as a revulsive, and by its immediate
effect on the skin, through the pores of which,
even under scaly disease, it is exhaled in the form
of hydro-sulphurous gas. Among the different
modes of exhibiting this popular remedy, may be
enumerated the sulphureous mineral waters, sul-
phur conjoined with soda, with magnesia, or with
cream of tartar; and, lastly, the diluted sulphuric
acid, which was given by Dr. C. Smyth in very
large doses, and, according to his report, with
excellent effects. (Smyth, in Medical Communi-
cat. vol. i. p. 191.) It is proper here to remark,
that the sulphuric acid, when taken diluted, un-
dergoes decomposition in the alimentary cavities ;
and that by its continued use the body becomes
impregnated with sulphur, just as when that sub-
stance itself has been administered.

We are furnished with still more powerful re-
medies of a revulsive character in the tincture of
cantharides and the different preparations of arse-
nic. The former of these was first recommended
by Dr. Mead* in cutaneous diseases ; and since

*Medicina Sacra, cap. ii. Although Dr. Mead's re-
marks refer professedly to the leprosy of the Jews, he

his time its reputation has undergone many vicis
situdes. Dr. C. Smyth, Dr. Falconer, and Dr.
Willan, speak of the tincture of cantharides as
altogether inefficient in the treatment of scaly dis-
ease ; but M. Biett, (Schedel et Cazenave, Abrege
pratique,) at the Hospital St. Louis, has revived
the use of this medicine in psoriasis, and found it
to possess great efficacy. Our own experience
has convinced us of its utility, but we have been
repeatedly obliged to relinquish its employment in
consequence of its effects on the urinary and ge-
nerative organs. Arsenic, which was first intro-
duced by Dr. Fowler in the treatment of squamous
affections, has maintained its character among
British practitioners with little or no interruption,
and has even gained a place in the estimation of
the physicians of France, notwithstanding the
denunciations of the school of Broussais. M.
Biett uses the solutions of Fowler and Pearson,
and has also introduced into practice the arseniate
of ammonia, of which he speaks very favourably.
He employs, likewise, with advantage, the arse-
nical pill formed of the protoxide and black pep-
per : each pill contains one-thirteenth of a grain
of arsenic, and two daily are considered by him
as the maximum dose. Iodine is another medi-
cine of the revulsive class, from which we anti-
cipate very beneficial results in the treatment of
psoriasis, but as yet our limited trials do not
enable us to speak of its effects with confidence.
Before taking leave of these powerfully acrid sub-
stances, it is necessary to caution the younger
portion of our readers against employing them
during the existence of constitutional disturbance
or irritation of the digestive organs, and to point
out the necessity of attentively watching their
effects, that any inflammatory movement or dele-
terious influence on the stomach or brain may be
immediately counteracted. In some cases, when
the appearance of such symptoms has obliged us
to suspend these medicines, great benefit has been
obtained from bloodletting, both in allaying the
irritation which they had caused, and subduing
the cutaneous affection.

There remain to be noticed some other remedies
of the revulsive tribe which possess a certain de-
gree of efficacy in scaly diseases. The tincture
of white hellebore (veratrum album), and pitch
given in large doses in pill, are both highly recom-
mended by Dr. Bateman : from the latter we have
seen beneficial results. The liquor potassse has
occasionally proved useful in psoriasis, as we have
repeatedly experienced ; and when this disease
exists along with the lithic diathesis, as in gout
and calculus, (no unusual combination,) its pro-
perty of correcting acidity affords a prospect of
decided benefit. (See the case of Horace Wal-
pole, Phil. Trans, vol. 50, p. 206.) The bitter
sweet (solanum dulcamara) has likewise obtained
considerable reputation for the cure of psoriasis ;
its effects are rather narcotic than revulsive ; but
its sensible action, in the doses usually prescribed,
is seldom very obvious. The belief in its efficacy
as a remedy for scaly eruptions rests on unexcep

appears to have had in view scaly diseases; for he
describes, as an instance of leprosy, the case of a coun-
tryman, whose skin was glistening like snow with white
scales, which, when rubbed off, left a raw surface ex-
posed. This individual seems to have laboured under
psoriasis inveterata.

PSORIASIS,

737

tionable authority ; (Crichton, in Willan on Cu-
taneous Diseases, p. 145) ; and the remarks of
Dr. Gardner (in Med. and Phys. Journ. May,
1830) on the defective mode in which the decoc-
tion is usually prepared may serve to explain
much of that disappointment which has of late
been experienced in its exhibition.

Psoriasis being remarkable for the severity of
its local effects, we are naturally led to attempt its
cure by means of topical remedies ; and although
these alone will rarely prove effectual, it must be
acknowledged that, without their judiciously di-
rected aid, we shall rarely if ever succeed in ob-
taining a satisfactory result. We are often ena-
bled to relieve the patient's sufferings by such
applications, as infusion of almond meal or of
bran, decoction of poppy-heads, weak spirit lotion,
emulsion of bitter almonds, lotions containing hy-
drocyanic acid, cream or fresh butter, neat's foot
or almond oil, [or cod-liver oil]. A still more
soothing effect on the whole frame will be pro-
duced by the use of a tepid or moderately warm
bath, to which a quantity of bran or a little car-
bonate of soda or potass has been added. A
favourite remedy among the French for the same
purpose is a bath of greasy dish-water (eau de
vaissclle grasse) — rather an unseemly application.
After due attention has been paid to the state of
the general health, and when the severity of the
local irritation has somewhat subsided, we may
proceed to employ the warm bath, from 96° to
104°, with such friction as can be easily borne, in
order to stimulate and soften the skin, and detach
the scales. The simple vapour-bath, or this com-
bined with sulphur or iodine, affords still more
powerful means of softening the surface and ex-
citing the skin to a healthy performance of its
functions, and the secretion of a sounder cuticle.
Such baths certainly form a valuable addition to
our means of curing every variety of scaly disease,
and often enable us to subdue affections which
would formerly have resisted all our remedies.
(Rapou, Traite de la Methode fumigatoire.) But
tire vapour-bath, in its different modifications, is a
remedy which always demands the watchful care
of the physician : its excitement not unfrequently
proves too great, requiring its suspension, or even
the abstraction of blood. Baths of mineral waters,
especially those impregnated with sulphur, have
long been resorted to with benefit for the cure of
psoriasis ; and similar baths, formed artificially by
means of the sulphurets, will often be found of
great service, provided the disease is not in too
active and irritated a state. In the slighter forms
of psoriasis, as when it is confined to the face and
forehead, a sulphurated lotion, prepared by infus-
ing sulphur in boiling water, has often proved
highly advantageous. The internal use of the
sulphureous mineral waters, or of corresponding
medicines, may be beneficially conjoined. Saline
mineral waters and sea-water have likewise been
employed in this disease, and from the latter we
have seen excellent effects ; but chiefly we believe
from the influence of sea-bathing in improving
the general health. In one very aggravated case
of diffuse psoriasis, where the disease was in an
active and increasing state under the use of the
arsenical liquor, the patient commenced sea-bath-
in- and anointed the eruption merely with fresh

Vol. III. -9?

butter : a speedy amendment followed, and the
affection almost wholly disappeared in about a
month, but it was not eradicated.

Although the transpiration from the affected sur-
face is much obstructed in psoriasis, it is not
wholly suppressed ; and there are still left many
interstices from which an insensible perspiration is
exhaled. By covering the part with oiled silk,
we retain this and preserve the skin in a continual
vapour-bath, which softens it, and tends to restore
it to a healthy state. The benefits of such a prac-
tice have been long known in the treatment of
several local forms of psoriasis, as that of the
palms ; and the plan may be usefully extended
even to cases where a large part of the body is
affected. Great benefit is also derived from merely
protecting the patches of psoriasis from the action
of the atmosphere, which is remarkably evinced
in that of the lips, nostrils, and eyelids. Any
mild adhesive cerate will answer the purpose; but
it is usual to employ one containing a very small
proportion of the nitrate, or the white precipitate
of mercury. Dr. Willan states that in psoriasis
of the lips, nothing but the mildest cerate or plas-
ter can be borne ; and that its ..onstant use is in-
dispensable to a cure.

But ointments are employed in psoriasis, not
merely to protect and soften the surface, but as
strong topical stimulants, to excite the healthy
actions and remove the thickening of the skin.
Those in most common use are, the ointment of
nitrate of mercury, the pitch ointment, and one
composed of equal parts of these two. We are
indebted to M. Biett for the introduction of reme-
dies of vastly greater power, formed from the pre-
parations of iodine. Of these the most efficient
are the ointments of the iodides of mercury and
sulphur,* which we have found fuily to merit the
praises he has bestowed on them. It is necessary
for the success of these stimulating ointments that
they should be well rubbed into the spots and
patches at bed-time, washed off with soap and
water in the morning, and if the situation of the
eruption permit, again rubbed in, and the same
process gone through twice daily. In cases of
solid thickening, both of the cuticle and cutis,
sometimes seen, particularly in the knee and elbow,
where even these powerfully stimulating ointments
prove unavailing, we have derived great benefit
from the application of strong acetic acid. The
agency of this liquid in removing the most obsti-
nate horny warts, and thinning the cuticle, when
vinegar and sponging have been long employed,
first directed our attention to it as a remedy in
psoriasis ; and the result of our trials has been
highly satisfactory — the diseased cuticle separating
in flakes, and a new surface being exposed of a
much more healthy character. The application
of the acid, which requires to be repeated, is hot
and painful, especially when there are excoriations
or fissures, but these ought to be protected by
some mild cerate. Blisters have likewise been
had recourse to in obstinate states of psoriasis, and
with marked benefit ; but their effects appear to

* Recipe. — P. tenuiss. proto iodid. hydrarg. gr. xii. —
sc. ii. Axung. purific. oz. i. m. nt liat un{f.

Recipe.— P. tenuiss. deuto iodid. liydr. gr. xii.— sc. iss.
Axung. purif. oz. i. m. ut fiat ung.

Recipe. — P. tenuis?, iodid. sulphuris, sc. i. — sc. lss,
Asung. purif. oz. i. m. ut fiat ung.

3m

738

PSORIASIS — PTY A LISM.

be less permanent than those of the acetic acid.
When there is oozing of fluid from the patches of
psoriasis, advantage will be derived from the use
of astringent lotions, as the liquor alum, compos,
and solutions of corrosive sublimate, or of sulphate
of copper ; and when the effusion of moisture has
thus been dried up, and the parts are a little hard-
ened, which readily takes place, some mild adhe-
sive cerate may be applied at bed-time and washed
off in the morning. By steadily persevering in
this plan, very troublesome cases of the local
forms of psoriasis have been completely cured.
In some of these obstinate varieties, particularly
that of the scrotum, fumigations with sulphur and
with cinnabar have effected a cure.

[Recently, anthrakokali and fuligokali, simple
and sulphuretted, have been recommended both in-
ternally and externally. (See the writer's New
Remedies, 4th edit. p. 57 and p. 321, and Mr. E.
Wilson, A Practical and Theoretical Treatise on
Diseases of the Skin, Amer. edit. p. 351, Philad.
1843.) Cantharides have likewise been employed
externally. Dr. Davidson (Land. # Edinb.
Monthly Jour n. of Med.. Science, Dec. 1841) noted
the comparative effect of iodide of sulphur, and
the acetum cantharidis of the Edinburgh Phar-
macopoeia in an inveterate case of several years'
standing, in which a variety of remedies had been
tried in vain, and found the latter more efficacious.
(See Lepra.)]

The long list of remedies which has now been
reviewed, furnishes in itself abundant evidence of
the intractable and rebellious nature of psoriasis ;
but it is not without reason that they have been
enumerated, for it is well known to those familiar
with chronic diseases of the skin, that a change
of remedies is frequently required ; and that one
will at length succeed when all others have failed.

Should our efforts to effect the cure of psoriasis
have proved unavailing, it will be proper, if the
patient's circumstances and general health permit,
to recommend his removal to a more genial or
even a warm climate, when the habitually increased
activity of the cutaneous functions, and the change
which his constitution is likely to undergo, may
render successful the modes of treatment which
were previously without effect.

When the cure of psoriasis is about to be ac-
complished, the scales rapidly drop, and soon cease
to be reproduced ; the thickening and inflamma-
tion of the skin gradually yield ; at length the
affected parts appear as if slightly depressed, hav-
ing a somewhat darker tint than the healthy skin,
and occasionally we observe around these cicatri-
ces a pale or white border. The completion of
these changes on the diseased surface affords satis-
factory evidence of the cure of psoriasis; and
without this cicatrization, the mere absence of
scales amounts only to a temporary amendment.

W. Cumin.

[PTYALISM, or SALIVATION. — An in-
creased secretion of saliva may arise from various
causes and is frequently altogether symptomatic, —
as in children, during dentition. When it occurs as
a symptom, it will be described under the primary
affection.

Ptyalism may be considered under two heads —
the first embracing that which arises spontaneous-

ly, often without any obvious cause, and the second
that which is produced by mercury.

1. Spontaneous Ptyalism. — Salivation occa-
sionally occurs, especially in children, with all the
characters of mercurial salivation, when not a
particle of mercury has been administered. It is
essential to bear this fact in mind, inasmuch as
blame is frequently attached to the medical practi-
tioner, where such symptoms arise, under the idea
that he has been administering mercurials to an
objectionable extent. Salivation may be induced
by various articles, — as by iodine, the preparations
of gold, copper, antimony, arsenic; and it is said,
by Dr. Watson, (Lectures on the Principles and
Practice of Physic, Amer. edit. p. 434. Philad.
1844,) that it has followed the employment of
castor oil, digitalis, and opium. Cases are on
record, in which it has occurred to a profuse
extent, without any obvious cause. Thus, one is
related in which two or three pints of saliva were
discharged daily, for some time. The affection
ceased under the use of gentle cathartics. Many
similar examples are on record.

Treatment. — Should such a case present itself,
it will be important to examine, whether there be
inflammation, or irritation, from carious teeth or
otherwise, in the mouth. Should no adequate
cause be discoverable, the disease must be referred
to some constitutional or local affection of the
glands, which gives rise to secretory irritation, and
consequent hypercrinia.

Certain of the remedies, recommended under
the next form of ptyalism, may be found serviceable.

2. Mercurial Pttalism. — Diagnosis. —
The symptoms of mercurial salivation are well
known ; but fortunately, not so much so as former-
ly, in consequence of the comparative unfrequency
of the affection, owing to our improved knowledge
of the therapeutical effects, and modus operandi
of mercury. Prior to the supervention of full
ptyalism, phenomena present themselves, which
indicate that the mouth is touched by the mercury.
A disagreeable coppery taste is experienced, ac-
companied by a painful feeling or soreness in the
mucous membrane of the mouth, and in the teeth,
which appear to be loosened in their sockets ; to
these phenomena succeed swelling of the gums,
inner surface of the cheeks, tongue, and soft palate,
which become hot and painful, and, where the
cheek and tongue are pressed upon by the teeth,
they are found indented. The gums now fall
away from the teeth, and at the edges a whitish
secretion is poured out, which has an albuminous
appearance. This secretion seems, indeed, to invest
the mucous membrane of the mouth, which conse-
quently does not appear to be as red as the symptoms
would indicate. The parts that are the most swollen
and subjected to pressure soon begin to ulcerate,
and the ulcers spread, and present a greyish,
flabby and fungous appearance, blood readily
flowing from them. The lymphatic ganglions,
situate between the parts affected, and the centre
of the lymphatic system, now become swollen
and painful ; and, at times, the patient is unable
to separate his jaws, and almost to swallow, owing
to the excessive tumefaction of the parts. From
the very commencement, the breath has a peculiar
fetor, and this augments, so that at the height of
the disease it is strong and disagreeable. As sooi

PTYALISM.

739

as the mouth is touched by the remedy, the flow
of saliva, and of the mucous secretions of the
mouth becomes so much augmented, that the
individual is compelled to eject the fluid continu-
ally, and where complete ptyalism has set in, the
quantity evacuated is occasionally enormous.
Eight pounds in the 24 hours have been mention-
ed by M. Andral, (Cours de Pathologie Interne,)
but this is not the limit. Sixteen pounds are said
by Most, (Art. Pttalismus, in Encyklopad. der
gesammten Med. und Chirur. Praxis, Leipz.
1837,) to have been discharged in this way ; the
average quantity in health not exceeding four
ounces, according to Mitscherlich, (Rusfs Maga-
zin, xxxvi,491; see also, Rullier etRaige-Delorme,
Art. Digestion, in Did. de Med. 2de edit. x. 300,
Paris 1835.) This increased flow may exist — to
a greater or less extent — for many days or even
weeks.

At one time, the effect of the remedy in syphilis
was measured by the quantity of saliva discharged:
—if the disease were of a certain duration, the pa-
tient must spit a quart ; if of a longer, two quarts,
and so on : but now, since the conviction of the
practitioner is, that salivation is rarely or never
necessary, and that it is rather to be deplored, —
inasmuch as the increased discharge exhausts and
irritates, without being of itself beneficial, — the
practice has been abandoned, and if we meet with
excessive ptyalism, it is generally in those who
are easily affected by mercury and in whom the
affection supervenes rapidly ; or in those in whom
the remedy has, by accident, been persisted in for
a longer period than was contemplated. The
books were formerly filled with descriptions of
the horrible accidents induced by mercurial ptya-
lism, some of which the author has witnessed ; —
as extensive sloughing, loss of teeth, caries of
jaw bones; protrusion of the tongue from the
mouth ; adhesions of the tongue and cheeks, &c.
&c. ; with, at times, excessive febrile irritation,
marasmus, and death. This last event was, how-
ever, uncommon. Usually, after a tedious con-
valescence, the sufferer was restored to health, but
occasionally the system received an injury from
which it never wholly recovered.

Although the plan of exciting profuse saliva-
tion for the cure of syphilis may now be con-
sidered as generally and properly exploded, and,
therefore, these cases of ptyalism are compara-
tively rare, we still now and then observe the
deplorable effects of mercury pushed with equal
incaution for the treatment of many of our bilious
and other fevers. Not many years ago, an in-
teresting case fell under the author's care, in
which the lower jaw became firmly closed in con-
sequence of the formation of ligamentous bands,
and of the contraction that had occurred during
the cicatrization of mercurial ulcers of the mouth ;
the bones of the jaw were carious, and portions
of them exfoliated ; yet, by careful management,
-improving the general habit, and separating the
jaws gradually by an instrument contrived for
that purpose, they became movable. Within the
lust few years, the writer has known of othe
similar cases, the subjects of which had sought
Philadelphia for surgical relief under their de-

formities.
Causes.

The term mercurial ptyalism suffi-

ciently indicates the exciting cause ; but a few
remarks are necessary on predisposition. Un-
questionably, age has its influence. It is almost
impossible,— wholly so, perhaps, in most cases,—
to salivate a child under two years of age. There
is something in the peculiar evolution of organs
at this age that prevents it ; yet, after the age of
two, children become very susceptible of mercurial
influence, and remain so, although not perhaps to
an equal degree, throughout the remainder of
existence. There is, likewise, a marked difference
in individuals as to their susceptibility to the ac-
tion of mercury, — some being affected by the
smallest quantity, whilst it is impossible to salivate
others by any amount. Temperature has some
effect, and exposure to cool air. In hot weather,
especially if the individual take exercise, the mer-
cury appears to pass off by the cutaneous trans-
piration ; and, on the other hand, the repression
of the transpiration frequently induces ptyalism.
Constipation also appears to favour the action of
mercury, as diarrhoea usually prevents or re-
tards it.

It is difficult to account for the action of mer-
cury in inducing ptyalism. It obviously enters
the blood, for it has been detected in that fluid ;
and, in this way, probably, it excites a new action
not only in the salivary glands, but apparently,
in almost all the secretory organs of the economy.
M. Andral (He'matologie Pathologique, Paris,
1843,) examined the condition of the blood in
some cases of mercurial stomatitis, but did not
discover any difference between it and the blood
of other inflammatory affections. He never wit-
nessed a diminution of fibrin, as is supposed to
follow its use by those who prescribe it in certain
diseased conditions to diminish the plasticity of
the blood, as in diphtheritis, and, indeed, in in-
flammatory affections in general.

Treatment. — If the febrile and inflammatory
symptoms run high, blood-letting — general and
local — may be demanded ; but this can seldom
be the case. It is a favourite remedy, at the com-
mencement, with one distinguished individual, M.
Cullerier. Generally, it is best to administer saline
cathartics, which act in a twofold manner, both
as depletives and revellents.

They should be given to the extent of pro-
ducing at least two or three liquid evacuations in
the twenty-four hours, for the first two or three
days, unless their use is contra-indicated. The
preparations of sulphur — sublimed sulphur, and
sulphuret of potassium — combined, or not, with
sulphurous baths, have been long prescribed ; un-
der the idea, that the sulphur would exert some
chemical agency in modifying the action of the
mercury. Few entertain this opinion at the pre-
sent day : sublimed sulphur is, however, a gentle
and pleasant laxative, and may be given with
that view.

In the early period of the disease, emollient and
warm collutories are found to be the most sooth-
ing. These may consist of mucilage of gum
arabic, flaxseed tea, infusion of the slippery elm,
and similar mucilaginous articles ; but, in the
after stages, greater advantage is derived from
agents of a more excitant character. Various
astringents have been used for this purpose, such
as the acetate of lead, the sulphate of zinc, and

740

PTYALISM — PUERPERAL DISEASES.

the sulphate of alumina and potassa. The author
thinks that he has derived as much benefit from
the solution of chlorinated lime, and from that of
creasote, as from any other agents. It must be
borne in mind, however, that the art of medicine,
in the generality of cases, does not appear to pos-
sess much power over the disease, and that what-
ever internal or external remedy is employed,
time is an essential element in the cure. A col-
lutory of chlorinated lime not only appears to
diminish, in many cases, the excessive secretion
from the salivary glands, but speedily mitigates
the sense of burning in the mouth, induces the
healing of the erosions of the mucous membrane,
and corrects the mercurial fetor. If either this,
or the creasote wash, should be too stimulating,
it must be reduced by the addition of water.

By many, the internal use of iodine has been
highly extolled ; yet, in the experience of others,
its efficacy has been doubtful. It may be given
in the form of the tincture, (ten drops, three times
a day, in gruel.)

If ulcerations exist, and they resist the local
management above directed, they may be treated
upon the plan advised under the head of Stoma-
titis. M. Ricord prefers applying strong muriatic
acid to the ulcerations, repeating the application
every day, or every other day, — the bleeding of
the surface presenting no obstacle. The acute
pain it produces soon ceases, and nothing, he
thinks, equals its beneficial effects. Should the
pain be so severe as to preclude rest, opium or its
preparations may be freely administered.

Recently, a case of mercurial ptyalism, occur-
ring in a child four years of age, which had con-
tinued for two months and a half, and had resisted
all the usual remedies, yielded to warm baths
acidulated with equal parts of nitric and muriatic
acid, prescribed by Dr. Baumgartner.

The diet, throughout the severity of the dis-
ease, should consist of farinaceous substances ;
but, later on, milk, broths, and the lighter pre-
parations of animal food, may not only be permit-
ted, but be advisable. „ t-. ,
R.OBLEY DUNGLISON.J

PUERPERAL DISEASES.— The object of
this article is to present a general view of the par-
turient and puerperal states, and of the various
diseases which may occur, singly or combined, in
their varied circumstances. Such views of an
important class of morbid affections are frequently
of more practical value than the most laboured
treatises on individual diseases. But the present
class is one of peculiar moment : no other is so
complicated in itself, and none excites such deep
interest in the minds both of friends and of the
physician.

The class of puerperal diseases must be viewed
as embracing all those morbid affections which
arise out of the state of pregnancy, — the act of
parturition, the complicated condition of the system
and organs which immediately follows parturition,
and the function of lactation.

In the early period of pregnancy, several organs,
but especially the stomach, sympathize with the
new condition of the uterus, and suffer severely.

In the later periods of pregnancy several causes
combine their influence especially to endanger the
6tate of the brain. It is upon the conjoined and

separate operation of these causes that our atten-
tion should be particularly fixed, in regard to the
diseases of this period ; for it is frequently by their
co-operation alone that their morbid influence upon
the brain is brought into activity, whilst it may
occur, afterwards, that one or even several of these
causes may be removed, and yet a remaining one
may renew or continue the morbid effect upon the
brain, which they had conjointly began. The
causes which co-operate in the last period of utero-
gestation, in inducing a morbid state of the brain,
are chiefly uterine and intestinal irritation, con-
curring with the actual pressure of the gravid
uterus upon the various viscera and vessels situated
behind it, and the state of plethora of the vascular
system especially, occasioned by this pressure.

During parturition, the contractile efforts of the
uterus and of the abdominal muscles add another
source of danger to those already mentioned ; and
it is at this period that the brain is most subjected
to fulness and pressure, and that convulsions or
even apoplexy are apt to occur.

Several sources of danger are removed when
delivery has taken place ; and yet this is not
always sufficient to protect the patient from an
attack of convulsion, for this terrible affection has
first occurred even after delivery had been effected.
In this case, especially, we suspect that a state of
intestinal load and irritation has been the exciting
cause of the convulsion. This observation con-
firms the remark already made, that when several
causes have co-operated to induce a state of dan-
ger, some may be removed, and yet, if one remain,
it may lead to the most disastrous events. This
peculiarity in the study of puerperal diseases can-
not be pointed out too often or too strongly.

Convulsions do occasionally occur after delive-
ry, even although the system be in a state of ex-
haustion from hemorrhage. The state of gene-
ral exhaustion is not, we believe, incompatible
with a state of fulness of the brain ; but this kind
of convulsions will be found, we think, frequently
to involve also a state of intestinal load and irri-
tation.

The danger may arise, however, immediately
after delivery, more directly and simply, from a
state of inanition and exhaustion, the effects of an
emptied condition of the uterus and abdomen, of
abstracted pressure upon the viscera and vessels
along the spine, and perhaps of loss of blood.

To these sources of danger after delivery must
also be added the effects, perhaps, of protracted
suffering, of violent pain, of mental alarm, and of
what may be termed the "shock" of parturition.

There is another series of puerperal affections
which do not occur for the most part until some
hours at least after delivery. These affections
consist principally of uterine, peritoneal, or venous
inflammation, of the effects of intestinal irritation,
of the effects of loss of blood, or of two or more
of these combined. There are two other sources
of irritation in the condition of the mammae, and
occasionally of the uterus ; and there is that terri-
ble disease, the epidemic puerperal fever.

Considering the important and sudden change
which takes place in the condition of the uterus
in parturition, we cannot be surprised that this
organ should frequently be the subject of inflam-
mation in the puerperal state. Neither can it be

PUERPERAL DISEASES.

741

matter of surprise that its appendages, the adjacent
viscera, and the peritoneum at large, should not
{infrequently participate in this morbid condition.
Arid when we further consider the degree of vio-
lence to which the brain has been subjected during
parturition, we must be led to expect that this im-
portant organ should be left by that process in a
state of proneness to inflammation ; and this is
precisely the case : for next to the viscera of the
abdominal cavity, the brain is perhaps the organ
which is most apt to become affected by puerperal
inflammation, though in fact puerperal phrenitis
is a far more rare disease than has been supposed.

We have further to consider the peculiar condi-
tion of the internal surface of the uterus after par-
turition. M. Cruveilhier has compared it to that
of a wound. However this may be, phrenitis and
inflammation of the absorbents are among the
most formidable of puerperal diseases, diseases
arising from this peculiar state of the internal sur-
face of the uterus.

There is another not less fertile source of puer-
peral disease in the state of the alimentary canal
after delivery. This state consists, in general, of
a loaded or disordered condition of the large intes-
tines, but is sometimes also induced by improper
things taken into the stomach. It is most import-
ant to observe that the effects of stomachal or in-
testinal irritation are very similar to those of in-
flammation, as it affects the head or abdomen ; for
on the just diagnosis of these cases depends the
proper application of the remedies.

Similar observations apply to the effects of loss
of blood when these are of the remote character,
and attended by the phenomena of reaction.

In this case the head is apt to be so affected as
to lead to the idea of inflammation of the brain ;
and the heart, so as to present the symptoms of
disease of this vital organ.

But it is rare that these sources of disease act
thus distinctly ; it is far more usual to observe
them co-operating to produce mixed cases. One
of the most frequent of these is puerperal mania.
It is in such complicated cases that all the atten-
tion and energies of the mind are required to ap-
preciate the influence of each, and to adapt the
remedies to this complicated form of disease.

There is not unfrequently, also, a source of irri-
tation in the state of the uterus itself. A certain
degree of after-pain is usual in almost every case ;
but a state of irritation and pain is frequently kept
up by the presence of clots of blood, and the efforts
for their expulsion. This state of the uterus is
full of dangers ; not in itself, but by masking and
concealing the beginning of dangerous diseases :
pain of an inflammatory kind is too apt to be ne-
glected, under the impression that it is but the
usual after-pain.

A similar remark may be made in regard to the
irritation excited during the establishment of the
secretion of milk. This process is apt to be at-
tended by pain, fever, and affection of the head,
which frequently mask the beginnings of puerperal

disease. , ,

Both these sources of irritation concur to add
complexity to the character, and difficulty to the
diagnosis of puerperal diseases, and to constitute
that peculiarity of this study to which we have
already alluded

The first of these classes of disease might per-
haps be denominated parturient, whilst the second
might be distinguished by the epithet puerperal;
the former occurring chiefly in or near the act of
parturition ; the latter usually some hours after-
wards. There is a third class of morbid affections
which follow still more remotely upon child-bear-
ing, and which consist principally of the more
continued effects of intestinal disorder or of loss
of blood, and issue, for the most part, in an ina-
bility to support the drain occasioned by lactation.

A fourth series of puerperal maladies, using this
term in its most extended sense, arises out of un-
due lactation itself. They consist in the various
forms and effects of exhaustion, and constitute a
most important and interesting subject for renewed
inquiry ; for we believe them not to be at present
by any means fully understood.

There is still another consideration which is full
of interest in regard to puerperal diseases, — namely,
the state of health of the patient previous to her
confinement. That which most frequently modi-
fies the puerperal state is disorder of the general
health, which may possess very various characters.
It frequently occurs, from such a state of general
disorder, that the recovery after confinement is
tardy, the secretion of milk scanty, or even morbid,
affecting the health of the infant ; and that there
are many local affections, especially of the head or
of the heart, which are full of pain and suffering.

We have now taken a rapid survey of the prin-
cipal causes of puerperal diseases. It may be
truly said that many of these causes co-operate in
everv case ; but it is also true that each puerperal
disease is to be referred to one or two of these
causes more especially. Every case of puerperal
affection may, therefore, be considered as a case
of modified disease, requiring that the mind of the
physician be active and comprehensive, so as to
embrace the numerous circumstances of the dis-
ease. This is true in a degree which scarcely
obtains in any other class of diseases ; and it is on
this account that we have represented the study of
puerperal diseases as requiring peculiar habits of
inquiry and investigation.

Of the morbid affections which occur in the
parturient slate. — The term parturient is .adopted
to express the condition of a person just before,
just after, and during the act of parturition A
brief notice of the morbid tendencies of this state
is a necessary introduction to the more detailed
account of some of the morbid affections which
occur in that which may perhaps be more properly
termed puerperal. The distinction between the
parturient and the puerperal states will be found
to be at least of great practical utility.

We have already cursorily alluded to the prin-
cipal causes of apoplexy and convulsions, as they
occur in the last stage of utero-gestation, and in
the act of parturition. It is our present object to
enter into this important question with somewhat
more detail.

The first cause enumerated as conducing to
these affections of the brain was uterine irritation.
That this species of irritation does indeed dispose
to disease of the brain, is sufficiently obvious from
the occasional occurrence of convulsions in cases
even of dysmenorrhcca or painful menstruation.

A second excitine cause of affection of the

742

PUERPERAL DISEASES.

brain, probably not very different in its nature
from the former, is found in the parturient efforts
of the uterus when labour has begun. The effects
of labour-pain upon the vascular system of the
head is sufficiently seen in the flushed state of the
countenance ; and the attack, or the recurrence of
convulsion, not unfrequently takes place with each
uterine effort.

With the uterine efforts must, however, be
conjoined those of the abdominal and other mus-
cles, in our estimation of the influence of labour-
pains upon the state of the brain.

The third cause of affection of the head in the
parturient state is stomachal or intestinal load or
irritation. It appears almost unnecessary to ad-
duce any example of the influence of these causes
upon the vascular system and nervous origins
within the head. The presence of indigestible
substances in the stomach, and of indurated or
otherwise morbid faecal matters in the large intes-
tines, are amongst the most usual causes of apo-
plexy and convulsions in those who are predis-
posed to (hese affections, and especially in the
puerperal state. The late Dr. John Clarke pub-
lished an interesting and important paper, to which
we shall have occasion to revert hereafter, upon
the morbid influence of oysters, taken at this pe-
riod, upon the brain ; and it cannot be doubted
that other indigestible substances have frequently,
perhaps unsuspectedly, produced the same delete-
rious effects. One of these effects was convul-
sion. And it is to be particularly remarked that
the cases published by Dr. Clarke all occurred
after delivery, and of course even after some of
the predisposing causes of puerperal convulsion
had ceased to operate.

But a still more frequent concurrent cause of
convulsion or of apoplexy in the parturient state
is a loaded condition of the large intestines. The
operation of this cause is frequently made obvious
by the effects of purgative medicines and enemata
in these cases, both in the relief they effect in the
symptoms of affection of the brain, and in the
character of the alvine evacuations : the quantity
of scybalous faeces which have thus been evacuated
in some instances would appear incredible, were
not the torpid and dilated condition of the intes-
tine taken into the account.

Nor can there be any doubt that the gravid ute-
rus itself acts by its size and by its pressure upon
the descending aorta, in inducing fulness of the
vessels of the brain in the last period of utero-ges-
tation. It is on this principle that delivery fre-
quently secures the patient against the recurrence
of the fit of convulsion. When the pressure of
the gravid uterus falls more particularly upon the
vena cava, the effect of interrupted circulation is
of course observed in the lower extremities, chiefly
under the form of oedema, but perhaps of phleg-
masia dolens.

It usually happens, as we have observed already,
that apoplexy or convulsion occurs in the partu-
rient state from the conjoined operation of several
of these causes; and it is only by an attentive
consideration of all of these sources of danger,
that the attack is to be prevented in the first place,
and its recurrence in the second.

It is important also, with the view of preven-
tion, to consider the probable condition of the en-

cephalon itself immediately leading to an attack
of convulsion or apoplexy. . It is doubtless one
either of irritation or of fulness. Every cause of
these morbid states of the brain must therefore be
carefully removed and avoided, whilst their effects
are combated by the most vigorous remedial mea-
sures.

This is the more important, because each re-
currence of convulsion is not only attended by im-
mediate danger, but aggravates the morbid condi-
tion of the brain and augments the tendency to
the repetition of the paroxysms of convulsion.
The same observation may be made of each con-
tractile effort of the uterus and abdominal muscles
during parturition, which, like the fits of hooping-
cough in other circumstances, has in some in-
stances led to convulsion.

The state of the system which obtains immedi-
ately after delivery is in many important circum-
stances different from that which exists during
pregnancy and in the act of parturition. The
emptied state of the uterus and abdomen consti-
tutes in itself a source of inanition ; and there is
usually more or less of loss of blood, and some-
times even an extreme degree of hemorrhage, so
that the system in general must be considered to
be in a state of exhaustion. There can be no
doubt that this very exhaustion alone has in some
instances induced convulsion ; but it is probable
that in many, some of the causes of this terrible
affection which have been mentioned, and espe-
cially a state of uterine, stomachal, or intestinal
irritation, have concurred to produce this effect.

The more usual immediate consequences of
delivery and of uterine hemorrhage is a state of
syncope ; this is more or less severe and alarming
according to the degree of loss of blood and of the
susceptibility to its effects, and varies from the
slightest degree of faintishness to such a state of
syncope as may endanger life.

Similar effects are sometimes to be attributed to
the protracted sufferings of a lingering labour, in
other cases to the violence of pain, and in others
to alarm and dreary apprehensions and anticipa-
tions on the part of the patient. These circum-
stances sometimes lead to sudden death, an event
which may occur immediately upon delivery. In
such cases, cordials given during the last stage of
labour, the recumbent position guardedly pre-
served, and the immediate and careful application
of the abdominal bandage, may save the patient.

Perhaps the condition of the system under the
influence of some of the circumstances of parturi-
tion cannot be better expressed than by the term
' shock ;' and it may be aptly compared to a simi-
lar state under very different circumstances, and
especially those of a painful operation. This
state of shock seems to consist of a partially sus-
pended power and action in the system. It may
be suddenly fatal, or it may yield to reaction,
which may or may not pass the boundary of
health ; or, lastly, after some feeble efforts, it may
lead to a gradual but irretrievable sinking of the
vital powers. This subject has not been suffi-
ciently noticed in medical writings, especially in
connection with the parturient state.

One of the influences of shock still requires to
be mentioned. Many causes of disorder may long
remain dormant, or may be affecting the system

PUERPERAL DISEASES.

743

in the most gradual manner only, until they are
called into a more active operation by some kind
of shock. This is particularly true in regard to
intestinal irritation. This cause of disorder may
long subsist in an inactive state, until, by the oc-
currence of some shock to the system, it is brought
into but too effective operation. It is for this rea-
son that the effects of intestinal irritation are so
frequently observed in the puerperal state and
after various accidents, without which this cause
of constitutional derangement might have long
remained inoperative, or at least insufficient for
the production of acute disease.

In the treatment of apoplexy or convulsions be-
fore delivery, and even after delivery, except in
cases of profuse uterine hemorrhage, the principal
remedy is bloodletting; the second object is the
removal of all those exciting causes of the disease
which have been mentioned ; and the third is cup-
ping of the occiput and neck.

In the case of hemorrhage, the remedies are
still the removal of the exciting causes and cup-
ping.

A state of exhaustion from loss of blood gene-
rally from the system, does not protect the brain
from a state of vascular fulness. This is abund-
antly proved in the excellent paper of Dr. Kellie,
in the Medico-Chirurgical Transactions of Edin-
burgh, and by the fact of the occurrence of con-
vulsions, and even of apoplexy, in this state of
exhaustion It is in this very case that cupping
of the occiput is so strongly to be recommended.
The brain, in some cases of exhaustion, is relieved
by the topical abstraction of a very small quantity
of blood ; and this relief is not only obtained by a
less expenditure of blood, but is more permanent
than similar relief by general bloodletting.

[The signs of determination of blood, which often
supervene on excessive hemorrhage, are, however,
often owing to the irregularity of vascular action
induced through inordinately and irregularly ex-
cited nervous erethism in the stage of reaction —
and, as the writer has said elsewhere, {General
Therapeutics and Materia Medlca, ii. 150, Phi-
lad. 1843,) they are best treated by a full dose
of opium, sufficient to allay the nervous excite-
ment, after which the vascular tumult speedily sub-
sides.]

The next point in the treatment is the removal,
not of one or two, but of all sources of irritation —
of all the possible exciting causes.

A point not less important than the treatment
of these affections is their prevention. No means
would conduce so much to this purpose as the
invariable administration of copious warm-water
injections at some period before or during labour.
The large intestines would thus be relieved of
their load, and a great and fertile source of future
disease would be removed. And this remark ap-
plies not to affections of the head only, but to
many other puerperal diseases.

Of the Morbid Affections which occnr in
the Puerperal State.— The morbid affections
Which occur in the puerperal as distinguished
from the parturient state usually commences at
such a period after delivery as may have given
space for reaction to take place, after the state of
inanition and exhaustion which usually obtains
immediately upon parturition.

It should be observed, however, that there is
scarcely a disease of the puerperal state which
does not occasionally show itself before delivery.
In these cases the disease usually remains sta-
tionary, or nearly so, until parturition has taken
place, and then assumes its exasperated form.

In some instances, and those of the most seri-
ous kind, puerperal disease supervenes insidiouslv,
and makes a slow and probably an unheeded and
fatal progress.

Even of those puerperal diseases which com-
mence by marked symptoms, the more serious are
not always the most unequivocal in their mode of
attack. Pure inflammation is, for example, less
marked by rigor, heat, and other obvious symp-
toms, than are the effects of intestinal irritation.
This is a point which requires to be enforced upon
the attention of practitioners ; for, in inflamma-
tion especially, it is of the utmost importance to
detect the disease in its very origin.

The effects of intestinal irritation and of loss
of blood are apt to produce symptoms of increased
action resembling those of inflammatory disease,
and prompting the use of evacuant remedies.
This proceeding is attended by two sources of
error: in the first place the symptoms are fre-
quently relieved in the first instance, — a state ot
faintishness taking place of that of reaction, — and
the physician is apt to judge that the remedy had
relieved, but was used in too mild a degree to
subdue the disease, and is thence led to a repeti-
tion of the measure : in the second place, after the
first and second moderate use of the lancet, for
instance, the reaction returns in a still more vio-
lent degree than before ; and it is then imagined
that the disease, though relieved, was not only
not subdued, but had been suffered to make a fear-
ful progress ; the lancet is therefore again used,
until it may be that the powers of the system
yield, and sinking takes place of reaction ; or,
if the last bloodletting be considerable, the scene
may be closed by a sudden and unexpected disso-
lution.

We now proceed to treat of each particular
form of puerperal disease.

Of Puerperal Inflammation within the
Abdomen. — Inflammation within the abdomen,
as it occurs in the puerperal state, may be di-
vided into three kinds ; that which chiefly affects
the uterus and its appendages; that which ap-
pears to be general over the peritoneum ; and
that which is confined to a portion of this mem-
brane.

A distinction of still greater practical impor-
tance is that between the acute and the insidious
forms of puerperal inflammation of the abdomen.
Sometimes the attack is distinctly characterized
from the beginning ; at other times it is of the
most insidious character, perhaps to be referred
back to a date anterior to parturition, or even ap-
parently issuing out of mere labour-pain. These
are points which require to be deeply impressed
upon the mind of the young physician, in order
that they may induce in him that degree of
watchfulness in regard to these diseases which
they so imperatively demand.

Inflammation within the abdomen, of whatevei
kind it may be, is only to be ascertained by th»
presence of pain, induced or aggravated upon

744

PUERPERAL DISEASES.

pressure. This is the pathognomonic symptom
of the disease. All the other symptoms are only
accessory ; and they are all, without exception,
inconstant. In some insidious cases of abdominal
inflammation, the tenderness even is only dis-
covered by a careful examination ; and there is
sometimes pain under pressure when there is no
inflammation.

These remarks will, we trust, lead to the most
careful examination of the abdomen, and of the
symptoms in general, in every case of puerperal
disease.

The acute attack of puerperal inflammation
ivithin the abdomen is frequently marked by
rigor. This is frequently in the worst cases only
slight. We cannot sufficiently enforce this fact
upon the attention of our readers. Some have
imagined that there could be no puerperal inflam-
mation of the abdomen without severe rigor ; and
they have generally supposed that severe rigor
necessarily supposes an attack of inflammation.
We can most unequivocally attest that both these
opinions are erroneous, and contradicted by facts.

We would make precisely the same observa-
tions in regard to great heat of surface or fever.
We have known many instances of acute puer-
peral inflammation within the abdomen unat-
tended by heat of skin, and many cases re-
sembling inflammation, but not in reality inflam-
matory, in which the heat of surface was
extreme.

Frequency of the pulse is not a less uncertain
indication of inflammation. 'We are enabled to
say, from careful observation, that the pulse is
but little accelerated in many cases of puerperal
inflammation within the abdomen, whilst it is ex-
cessively and even alarmingly frequent in some
cases in which inflammation does not exist.

In regard to pain and affection of the head,
they are by no means essential attendants upon
puerperal inflammation of the abdomen in its
first stages, but, on the contrary, appear to denote
another and different kind of morbid affection,
which may exist alone or as a complication of
inflammation.

Pure puerperal inflammation of the peritoneum
is to be ascertained by an attentive examination
of the abdomen. There is either pain increased
upon pressure, or tenderness discovered upon
pressure ; and this is either general over the abdo-
men, or confined to the hypogastric region ; or,
lastly, in cases of partial peritonitis, to some other
part of the abdomen. With the pain or tender-
ness there is frequently either general tumidity
of the abdomen, or a local hardness ; in the lat-
ter case it is frequently such as to denote an en-
larged and inflamed condition of the uterus, but
it occasionally arises from an affection of the
ovarium, or from partial inflammation and suppu-
ration of the peritoneum.

There are sometimes, and only sometimes, sick-
ness and vomiting ; there are also, in some in-
stances, a suppression of the lochial discharge,
and a flaccid state of the mammae. But we do
not think the precise cases in which these effects
do or do not occur, have been distinctly ascer-
tained by the observation of a sufficient number
of facts.

In pure puerperal inflammation of the abdomen

there is not necessarily much rigor, heat of skin,
load of the tongue, affection of the head, or great
frequency of the pulse ; there is, on the contrary,
in many instances, only a slight degree or even
an entire absence of rigor, little or no heat of
surface, or whiteness of the tongue, little fre-
quency of the pulse, and no affection of the head.
But the countenance, manner, and respiration,
usually become highly characteristic.

Puerperal inflammation within the abdomen is
marked by an expression of extreme pain and
anxiety in the countenance ; the brow is con-
tracted, and the upper lip is drawn upwards in a
peculiar and characteristic manner, and bound
round the teeth or rather gums. These appear-
ances are increased on pressing upon the abdo-
men, or they are observed at that moment if they
had not been manifest before. The countenance
is generally pale and rather sunk, but with partial
heats.

The manner of the patient is much changed,
and has become expressive of suffering and anxie-
ty. The movements of the body are attended by
pain, and are therefore suppressed; or if performed
at all, it is with an expression of suffering in the
countenance, and of caution in the manner; and
there is an appearance as if the body had become
heavy and helpless.

The respiration becomes rather hurried and
anxious, and it is performed principally by move-
ments of the thorax, those of the diaphragm and
abdomen being more or less, sometimes complete-
ly, suppressed, — a circumstance which gives great
peculiarity to the appearance of the breathing.
Sometimes there is considerable heaving of the
chest, with some hurry, some noise from the in-
gress and egress of the air, and sometimes with a
sort of blowing: this state of the respiration is
attended by the utmost danger, being frequently
one of the first symptoms of the sinking state, of
which we shall have to speak immediately, and
to which we wish earnestly to call the attention
of our readers.

The general surface is usually a little increased
in its temperature, and there is frequently perspi-
ration.

The pulse is at first only moderately frequent,
but gradually becomes more so, and it is often
small and apparently feeble.

We have already alluded to the occasional
occurrence of sickness and vomiting. The abdo-
men is frequently tense and tumid, as well as
tender under pressure : this is an affection to be
anxiously watched; it sometimes increases to a
state of complete tympanitis. The state of the
bowels is very various; there is by no means
always constipation ; sometimes there is diarrhoea,
with or without the discharge of mucous stools.

Instead of general tumidity of the abdomen,
there is frequently a distinct tumour with tender-
ness in the region of the uterus, in the iliac region,
or in some other region of the abdomen, leading
to the suspicion of an especial affection of the
uterus or ovarium, or of a partial inflammation
and suppuration of the peritoneum.

We have thus described the most usual form
of puerperal inflammation of the abdomen in its
commencement. It does not seem either possible
or profitable to divide the disease into distinct

PUERPERAL DISEASES.

stages. But it is quite incumbent upon the prac-
titioner to trace the usual changes which are ob-
served in this disease: these are, first, a gradual
amendment; secondly, a gradual exasperation of
the disease; and thirdly, the supervention of the
state of 'sinking.'

Little can or need be said upon the two first
of these changes. Every appearance of a return
to a healthy state of the functions and general
appearances of the patient will raise our hopes;
but there are no points of so much importance to
be watched as the expression and condition of the
countenance, the manner, and the state of the
abdomen.

No apparent amendment is to be at all de-
pended upon unless it has continued and been
progressive for four-and-twenty hours ; this is a
caution of great importance to the young physi-
cian, in guiding him in his expressions in regard
to the prognosis. And even in the most favoura-
ble cases the further progr&ss towards recovery is
to be watched with the utmost care and precau-
tion.

In the less favourable cases the countenance
becomes more and more altered, the pulse more
and more frequent, the abdomen more tender and
tumid ; the muscular powers of the patient appear
overwhelmed ; the respiration becomes more heav-
ing, and, as we have usually termed it " blowing,"
being somewhat audible, — a condition of the
breathing always attended by the utmost danger.
At this period, too, there is often some degree of
delirium, alternating perhaps with slight dozing,
and there are generally restlessness and jactita-
tion, and the patient cannot bear the arms to be
covered.

At this period, too, the tongue is frequently
loaded and more foul, and sometimes dry ; the
bowels are variable, frequently flatulent and
loose. The mammae are flaccid, the lochia sup-
pressed ; the skin is clammy and wet, if not cold;
the hands and wrists are often livid, and the feet
cold.

This description of symptoms applies to the
case of general inflammation of the peritoneum.
The more partial cases of peritonitis continue
longer, and affect the constitution less and less
rapidly. In some instances the integuments over
the seat of the inflammation have become tumid
and inflamed, and an issue has at length been
effected for the subjacent pus; the abscess has
afterwards collapsed and healed, and the patient
has slowly but finally recovered. This opening
frequently takes place about half-way between the
umbilicus and spinous process of the ilium. In
other instances the matter has been evacuated by
the rectum, and in some rare examples by the
bladder. In other cases the abscess has not been
evacuated during life; but the patient has become
gradually emaciated, and the health and strength
have tailed ; there have been great frequency of
the pulse and hectic, and the disease has at
length, though perhaps very slowly, proved fatal.
It has, however, occasionally happened that the
effused fluid has been re-absorbed, and the fatal

event averted. , ...

But the acute form of puerperal peritonitis
sometimes issues in a state of sudden sinking of
the vital powers. The change and symptoms ar

Vol. III. -94

745

such as have frequently led to the suspicion of
gangrene having taken place ; but no such appear-
ance is observed after death.

This state of sinking is usually rather abrupt in
its manifestation. The patient may be left not
without hope the preceding night, but on being
visited on the ensuing morning is found to have
passed into a state of hopeless sinking. The pain
has ceased, but the tumidity of the abdomen is
augmented ; the breathing is attended by heaving
and blowing ; the skin of the arms and hands is
cold, clammy, and livid, the livid colour only
partially disappearing on pressure ; the pulse is
thready and excessively frequent ; the countenance
is altered and sunk ; the patient may be roused,
but is then, perhaps, unconscious of pain, and
expresses herself as being relieved ; the hands are
kept out of bed ; sometimes there is cough, and
the feet are livid and cold.

The morbid appearances usually induced in
cases of inflammation of the uterus and of the
peritoneum are well known.

In inflammation of the uterus there are, in dif-
ferent instances, exudations of serum, of coagulable
lymph, and of pus, or it is the seat of distinct
abscesses ; and its internal surface is frequently
morbidly red, and the source of various discharges.
The appendages of the uterus are frequently the-
seat of similar morbid appearances.

The peritoneum when inflamed pours out serum,
coagulable lymph, or pus ; and its different surfaces
are apt to be variously glued together. Frequent-
ly the intestinal canal is found distended to the-
utmost, as before death, by fetid gases.

In some intances pus is effused and deposited
in various parts of the peritoneum, being confined
by the adhesion of contiguous portions of this
membrane.

There is no part of the peritoneum, and no
viscus in the abdomen, which may not become
the seat of puerperal inflammation and of the con-
sequent changes of structure. The parts most
frequently affected by puerperal inflammation,
however, are the organs contained within the
pelvis, — the uterus, its appendages, the rectum,
the bladder, and the peritoneal lining of the pelvis;
and then the peritoneum in general. In an inter-
esting case, published by Dr. Ley, the spleen was
found to be a principal seat of disease.

We now proceed to state the treatment of puer-
peral inflammation, and we must observe, in the
first place, that nothing can be trusted to to save
the patient but the most ample bloodletting, and in
the second place, that nothing should preclude the
use of this remedy but the actual existence of the
state of sinking.

In regard to the measure and the repetition of
the bloodletting, many points must be taken into
consideration. The earlier and the more fullv
this remedy is employed, the more efficacious anil
the safer it is, and the safer is its full repetition.

There is one point which we would particu
larly impress upon our readers. It is, that the
bloodletting should in this disease always be per-
formed when the patient is in the erect position ;
and it may then in general be safely carried to
deliquium. We do not recommend this mode
of proceeding with the view of producing deliqui-
um merely, but also that this deliquium may serve

3 ic

746

PUERPERAL DISEASES.

us as a guide in judging of the extent to which
we may carry the depletion. If the patient be
sitting upright, and faint by the loss of blood, we
have a security and remedy against any danger
from this event in laying the patient low ; but if
deliquium be induced by bleeding the patient in
the recumbent position, we cannot say that we
think it will be always without danger. We
think the plan which we have proposed at once
far more safe as well as far more efficacious in
subduing this disease. If it were requisite, the
patient's head might be laid even lower than the
rest of her body, should deliquium supervene.

The same rule may apply for the repetition of
the bloodletting. If the fullest effect is desired
which the patient can safely bear, let her be bled
to syncope in the erect posture. She will faint
from losing a larger or a smaller quantity of blood
precisely in the inverse proportion of the previous
exhaustion ; the state of syncope will not only
warn us to desist from drawing more blood, but
will arrest the flow of blood itself just at the point
when the patient can bear to lose no more.

This is a most important criterion for the em-
ployment of a most powerful remedy. We do
not by any means wish it to be understood that it
is always safe to bleed to deliquium in the erect
posture ; but that, when it is determined to bleed,
it is important to have the boundary, which it
would be unsafe to pass, at least clearly defined.

Sometimes the patient will faint on being
merely placed upright ; is it then, ever, and in
what particular cases, safe to bleed !

The next question is in regard to topical blood-
letting, and we think there is one important rule
for the adoption of this remedy. It may of course
be enjoined to be done immediately after general
bloodletting ; but it is particularly useful in those
cases in which the system is obviously subdued
by the general bloodletting, and yet the inflamed
part remains tender under pressure. In such
cases leeches, or, still better, cupping, if it be pro-
perly and tenderly performed, will prove a most
useful remedy.

It is quite unnecessary to state the utility, or
rather the necessity, for the administration of
purgative medicines in this disease. There is
good reason to suppose that some cases have been
subdued even by this remedy alone; and the
efficacy of purging in conjunction with bloodlet-
ting is quite undoubted. A constant catharsis
should be kept up, indeed, until the disease is
completely subdued.

In cases in which there is great tympanitic dis-
tension of the abdomen, an injection of warm
water sometimes succeeds in inducing evacuations
of flatus, which greatly relieve. We have some-
limes thought that still more effectual relief of the
same kind might be obtained by the introduction
of a flexible tube, properly pierced, high into the
large intestine.

Much and important relief may also be afforded
in some cases in which suppuration has taken
place, by giving exit to the pus when it plainly
fluctuates and approaches the surface.

Blisters are also of great service in those cases
of this disease which are not attended by much
heat or irritability ; but in other cases they have
appeared to us to add to the patient's sufferings,

to prevent sleep, and to do harm by leading to a
state of exhaustion.

There are still three other powerful remedies
of which a cursory mention must be made in this
place. The first is vomiting, which is well known
to have been so successful in the hands of M.
Doulcet of Paris. The second is the spiritus
terebinthinaj, recommended by Dr. Brenan of
Dublin. The third is the attempt to induce a
state of ptyalism by mercurial medicines and in-
unctions.

Emetics, like purgative medicines, but especi-
ally the spiritus terebinthina;, have doubtless been
used successfully in many cases ; but we much
suspect that many of these cases were not inflam-
mation, but intestinal irritation.

Ptyalism would seem to deserve a trial ; it is
one of those measures which are most powerful,
and yet generally unattended with risk, and it
would by no means preclude the adoption of
every other more prompt and efficient mode of
treatment. If adopted early, it might prevent
some of those protracted states of the disease
which occasionally occur and wear out the pa-
tient.

During the existence of inflammation the pa-
tient should be allowed absolutely nothing but tea
or gruel in the smallest quantities.

In some cases in which the pain is not severe,
but the tension of the abdomen great, continued
but extremely light frictions of the abdomen have
done great good. They may be followed by the
application of a cold lotion and by fomentation of
the feet.

In cases of pure inflammation the use of opium
is not desirable. The pain must be subdued by
bloodletting ; and every thing that by masking the
pain can divert our minds from the use of this
remedy involves danger to the patient. And
there are seldom those symptoms of constitutional
irritation which require the use of opium until
the inflammation has subsided. In mixed cases
we think the use of opium, especially after blood-
letting, may be both necessary to subdue constitu-
tional irritation, and beneficial in the cure of the
disease. [Under Peritonitis and Nahcotics,
the value of opium in this and similar phlegmasia
has been fully investigated.]

Of tlie effects of Stomachal and Intesti-
nal Irritation. — Some of the effects of intesti-
nal irritation may be observed before parturition ;
but it is far more usual to find them developed
afterwards. They generally take place rather
suddenly, about forty or fifty hours after delivery ;
but the puerperal state appears so to dispose to
this affection that the presence of any cause of
stomachal or intestinal irritation cannot always
be borne with impunity for many days even after
delivery.

This affection may, for the facility of descrip-
tion, be divided into the acute and the insidious ;
each of these forms manifests itself with general
symptoms only, or with some predominant local
affection.

The acute form of intestinal irritation is gene-
rally ushered in by a violent rigor. This is an
important fact ; for rigor, as we have already ob-
served, has been considered as denoting puerperal
inflammation, and essential to the latter disease.

PUERPERAL DISEASES.

747

Neither of these suppositions is true ; for puer-
peral inflammation may occur in a severe and fatal
form without rigor ; and the severest rigor may
only portend an attack of the effects of intestinal
irritation ; and in general the latter disease is at-
tended even with a severer rigor than the former.

In the attack of intestinal irritation there is
usually, after the rigor, great heat of the surface.
We have already observed that this is by no
means an essential part of puerperal inflamma-
tion ; indeed we do not think that it properly
belongs to the latter disease, but that, when it
does occur with inflammation, it denotes a mixed
case and the coexistence of intestinal irritation.

In the attack of the effects of intestinal irrita-
tion there is usually earlier and even greater fre-
quency of the pulse than in cases of puerperal
inflammation ; the pulse is also usually fuller
than in the latter disease.

Intestinal irritation induces symptoms which
are similar to those of the most acute phrenitis.
or to those of the most acute peritonitis. This is
a remark of the utmost practical importance ; for
the remedies in these different cases are totally
different ; and we should say that in the former
the freest bloodletting must be aided by purgative
medicines, whilst in the latter the freest and fullest
evacuation of the intestines must be aided by
bloodletting.

A mistake in either case would, in our opinion,
endanger the life of the patient ; and it is a foolish
and idle remark to say that it is better to mistake
irritation for inflammation than inflammation for
irritation. It is of the utmost importance to
attend to the distinctions which we have made
between inflammation and intestinal irritation in
regard to the treatment ; for, although both blood-
letting and purging are to be used in every case,
yet the former is the remedy in inflammation, and
the latter in intestinal irritation. If the cure of
inflammation be trusted even chiefly to purgative
medicines, we think it will frequently proceed to
the destruction of the patient ; and if bloodletting
should be chiefly employed, in like manner, in
intestinal irritation, we believe it would leave the
disease unsubdued, and eventually plunge the
patient into a state of irremediable exhaustion.

The affection of the head and that of the abdo-
men frequently coexist or alternate in the same
case ; but sometimes one of them exists to the
exclusion of the other, or supervenes upon the
cessation of the other ; and in the latter case the
affection of the head usually succeeds that of the
abdomen. The diagnosis is much confirmed by
this conjunction of the two affections.

In the affection of the head from intestinal irri-
tation there is frequently the severest pain and the
Utmost intolerance of noise, light, and disturbance
of every kind. It is in these cases principally
that the pavement is covered with straw, the
knocker tied, the patient's room kept dark and
still, so that these very external circumstances
speak a significant language to the physician.
To the symptoms which have been enumerated
are frequently added wakefulness and even deli-
rium, j. , . • , • i

When the abdomen is affected from intestinal
irritation, there are general pain and tenderness
upon pressure, and frequently tumidity, combined

with the general symptoms which we have already
enumerated.

Much is effected and learnt in this case by the
exhibition of large injections of warm water and
of active purgative medicines, a careful examina-
tion of the evacuations, and a studious observation
of the effects produced upon the disease. The
faeces will be found to be scybalous, or at least
offensive and dark-coloured, and in large quantity;
and the relief obtained, or the return of pain, will
be found to depend upon the evacuated or neglect-
ed state of the bowels.

Another point of great importance is an atten-
tive inquiry into the diet of the patient ; this in-
quiry frequently reveals the mystery of an attack,
and of course immediately leads to the adoption
of an important remedy.

In regard to the course of cases of intestinal irri-
tation, we imagine that under judicious treatment
this would always be one of progressive recovery.
When a contrary event occurs, we think it is to
be attributed to the misuse of remedies, and espe-
cially of bloodletting. In this manner some of
the symptoms which are detailed in the succeed-
ing section are superinduced, and sometimes a
sudden dissolution has overwhelmed the practi-
tioner with consternation.

One of the characteristics of intestinal irritation
is the susceptibility to syncope upon bloodletting.
This is of course much more remarkable upon a
second or third bloodletting than upon a first use
of the lancet. No dependence can be placed upon
the appearance of the blood drawn. This may
be much buffed and cupped in the puerperal state
without the existence of inflammation, and in
cases of the most decided inflammation these ap-
pearances of the blood may be but little observed.

We have scarcely had an opportunity of ex-
amining the state of the internal organs after
death ; for in general the patients affected by in-
testinal irritation have recovered. But no doubt
that such an examination would illustrate the fol-
lowing important remark of the late Dr. Denman :
— " We have been told that in the dissection of
some who are said to have died of puerperal fever,
no appearances of inflammation have been disco-
vered ; but I should suspect that in such cases
some important appearances had been overlooked,
or that errors had been committed as to the nature
of the disease, and probably in its treatment." A
due consideration of the effects of intestinal irrita-
tion will also serve to elucidate other cases of
morbid affection, in which the appearances of in-
flammation were looked for on dissection, but
were not found. This observation applies par-
ticularly to affections of the head, heart, and ab-
domen. In several cases of this morbid affection,
which we had the opportunity of examining many
years ago, no morbid appearances were found on
the most careful inspection. We have already
sufficiently alluded to the causes of this affection
They are for the most part obvious sources of
gastric or of intestinal irritation ; the former chiefly
affecting the head, the latter both the head and
the abdomen, either together or separately.

In the treatment of the effects of intestinal irri-
tation, we would by no means exclude the use of
the lancet. Bloodletting may be useful in such a
case, for the same reason that it is useful in sini

748

PUERPERAL DISEASES.

pie fever. But we repeat that this remedy is only
subsidiary to the full and free evacuation of the
bowels, and, if necessary, of the stomach. If it
■were trusted to alone, or with only a moderate
attention to the state of the alimentary canal, or
if it were used in the manner which is required to
be efficient in puerperal inflammation, we are per-
suaded that the patient would die of exhaustion,
before the symptoms would yield.

The remedies of intestinal irritation and its ef-
fects we would enumerate and arrange in the fol-
lowing order : — first, the full evacuation of the
intestinal canal ; secondly, bloodletting ; thirdly,
some soothing anodyne ; fourthly, leeches, cup-
ping, a lotion, a liniment, or a blister, according
to the circumstances of the case, for the topical
affection ; fifthly, the mildest nutritious food ;
sixthly, the most absolute quiet, and the most
perfect security from light, noise, disturbance, and
every other source of excitation ; seventhly, great
coolness, and free ventilation of the sick-room ;
and lastly, a constant watching over the patient
during sleep, to avoid the injurious effects of tur-
bulent dreams on the one hand, and of too long
sleep and fasting on the other. Upon each of
these points we proceed to make such observations
as we have learnt from practice to be of import-
ance.

In regard to the state of the alimentary canal,
it is quite obvious that an emetic is the proper
remedy when the symptoms can be attributed to
any indigestible substance taken ; and we would
recommend this remedy, even although it might
appear, from the lapse of time, unlikely that the
injurious substance should still remain in the
stomach.

When the case originates from intestinal irrita-
tion, we would earnestly recommend that the first
remedy should be an enema, consisting of three
or four pints of warm water, very slowly and
gently forced into the bowels. This should be
followed by an active purge ; and this should, in
due time, be followed by a repetition of the in-
jection. The evacuations should be immediately
carefully examined, and the effects upon the symp-
toms of the disease be watched.

To abate the general heat and excitement of
the system, to relieve the head or the abdomen,
and to ensure perfect safety, the patient should,
in cases in which the strength is not particularly
impaired, be raised into the erect posture, and be
blooded until faintishness be induced. This effect,
also, should be carefully watched and observed.
If it occur from the loss of a small quantity of
blood, it confirms the diagnosis ; if it do not oc-
cur until much blood have flowed, it should sug-
gest the suspicion of more than mere intestinal
irritation, — of one of those mixed cases which so
frequently occur, and of which we propose to
treat in a subsequent section.

We do not imagine that this decided use of the
lancet can ever be attended with danger, if there
have been no previous loss of blood or other cause
of exhaustion. But it could not be repeated with
impunity. It would lead to exhaustion with the
symptoms of reaction, to the state of sinking, or
even to sudden dissolution ; and if the case be
really one of intestinal irritation, and the other

remedies have been duly applied, such repetition
of bloodletting will not be required.

It is an observation of great importance, that in
inflammation repeated bloodletting is required, and
is borne with safety ; in intestinal irritation, on
the contrary, the repetition of bloodletting is nei
ther necessary nor safe.

This free evacuation of the bowels and detrac-
tion of blood are very apt to be followed by symp-
toms of hurry and alarm in the system. These
effects are frequently prevented by the timely ad-
ministration of an efficient and kindly anodyne;
and we believe no anodyne is possessed of those
qualities in a higher degree than Battley's liquor
opii sedativus. Of this excellent medicine a full
dose may be given, and, if necessary, repeated in
five or six hours.

If this plan do not perfectly relieve the topical
affection, some local remedy must be applied. In
cases of cerebral affection, leeches may be applied
to the temples, or cupping, or a blister, to the nape
of the neck, a cold lotion over the whole head, and
fomentation to the feet. Leeches, a fomentation,
a liniment, or a blister may be applied, if there be
affection of the abdomen.

Before the patient falls asleep, we should re-
commend some mild food to be taken, as gruel or
panada. This plan prevents exhaustion, and fre-
quently relieves the local symptoms by securing a
more refreshing kind of sleep. For the same rea-
son the utmost quiet must be preserved in the
patient's room. The least disturbance greatly
agitates the patient, and prevents the good effects
of the remedies which have been employed.

Some other circumstances have been before
enumerated which claim our attention in the treat-
ment of this morbid affection ; but, in order to
prevent repetition, we postpone the remarks which
we have to make upon these points to the next
section, — upon the effects of loss of blood ; in
which case an attention to them is, if possible, still
more necessary than in that under our immediate
consideration.

On tlie Effects of loss of Blood in the Pu-
erperal State. — The effects of Loss of blood
usually present themselves to our notice in rather
an insidious manner ; they are not generally intro-
duced by rigor, or heat, or any other acute symp-
tom ; though there may be exceptions to the last
part of this rule. It is an important remark that
the remoter effects of loss of blood are frequently
developed in cases in which there is also intesti-
nal irritation in a dormant form, but that they
very rarely occur in conjunction with inflamma-
tion ; the effects of loss of blood, when they do
occur in cases of inflammation, generally denote
that the inflammatory action has been subdued.

We have already observed that there is rarely
either rigor or heat of surface: there may be tran-
sient chills and flushes, and slightly augmented
temperature ; but the countenance, and especially
the prolabium, is generally pallid, and the skin is
in a natural state.

The case is usually denoted by a throbbing ful-
ness with moderate frequency of the pulse, throb-
bing pain of the head and palpitation of the heart,
which is apt to alternate with a state of syncope
on slight exertion, or on assuming the erect pos-

PUERPERAL DISEASES.

749

raie ; and there is usually a degree of panting.
There is a characteristic susceptibility to fainting
on taking a very small quantity of blood.

We have repeatedly known the effects of loss
of blood to be mistaken for inflammation of the
brain on one hand, and disease of the heart on the
other. We consider this an important remark, as
suggesting at once two characteristics of this affec-
tion, and the necessary caution in the diagnosis in
puerperal diseases.

When the head is affected from loss of blood,
there are much beating and throbbing of the tem-
ples, pain, a sense of pressure, or vertigo, with
rushing or cracking noises.

When the heart is affected, there are great flut-
tering, beating, or palpitation, starting during
sleep, hurry and alarm on awaking, sometimes
with faintishness, a feeling of sinking or of im-
pending dissolution, &c, and with the palpitation
there is frequently beating and throbbing of the
carotids, and sometimes of the abdominal aorta,
perceptible to the touch or even to the eye. These
affections sometimes recur in the form of attacks
which are attended by much hurry and alarm.

Besides these more marked affections of the
head and heart, which render it so necessary to
distinguish this affection from inflammation or dis-
ease of those organs respectively, there are many
symptoms which occur in a less marked degree or
form.

There is frequently an inability to bear noise or
disturbance, or even the act of thinking with at-
tention ; but there is rarely intolerance of light ;
the last symptom usually denoting a state of intes-
tinal irritation.

There are frequently vertigo or faintishness on
any exertion, or on assuming the erect posture ;
and when these two are combined, there has some-
limes been a sudden and unexpected fatal termina-
tion of the patient's sufferings. In many cases
there are great faintishness and urgent demand
for the smelling-bottle, for the fan, or the fresh air,
and for cold applications to the face or temples,
and a feeling of impending dissolution. The re-
spiration is affected in different cases with panting,
hurry, sighing, heaving, blowing, moaning, gasp-
ing, catching, &c. There is in some cases an irri-
tative cough in violent fits, or in the form of per-
petual hacking, apparently arising from an affec-
tion of the larynx or trachea. The stomach is
liable to be affected with retching, vomiting, hic-
cup, and eructation ; and the bowels, even in cases
in which they were not previously disordered,
become variously deranged, with constipation,
diarrhoea, and flatulency. There are frequently,
in severe cases, urgent restlessness and jactitation.
In some cases there are various spasmodic affec-
tions. In other instances there are catching pains,
which are apt to be mistaken for inflammation.
There are frequent changes, sudden attacks oi
alarming symptoms, a sense and fear of impend-
ing dissolution, urgent messages, &c, which be-
come characteristic of this affection.

Another characteristic consists in the faintish-
ness, gasping, or feeling of dissolution, which
sometimes follows even a slight bloodletting; an
awfully sudden death has immediately ensued
upon a R Hand mistaken bloodletting at this cr>-
ffjjriod! Even the operation of purgative

medicine has sometimes induced a degree of faint-
ishness.

Every source of disturbance, of anxiety, or of
alarm, and every kind of effort either of mind or
body, is apt to be followed by a return or exaspe-
ration of the symptoms, and cannot be said to be
free from danger. We have already remarked
that an effort of the muscles and assumption of the
erect posture have proved suddenly fatal. This
sad event occurred to a lady who raised herself in
bed in this exhausted state to make water ; she
fell down and expired. But when the fatal event
from loss of blood is not sudden in this manner,
the state of reaction sometimes yields to one of
fatal sinking.

The symptoms of exhaustion with excessive re-
action may gradually subside and leave the patient
feeble, but with returning health ; or they may
yield to the state of sinking. This term is adopt-
ed not to express a state of negative weakness
merely, which may continue long and issue in
eventual recovery ; but to denote a state of posi-
tive and progressive failure of the vital powers at-
tended by its peculiar effects, and by a set of phe-
nomena very different from those of exhaustion
with reaction.

If in the latter the energies of the system were
augmented, in the former the functions of the
brain, the lungs, and the heart are singularly im-
paired. The sensibilities of the brain subside, and
the patient is no longer affected by noises as
before ; there is, on the contrary, a tendency to
dozing, and gradually, some of those effects on
the muscular system which denote a diminished
sensibility of the brain supervene, as snoring, ster-
tor, blowing up of the cheeks in breathing, &c. ;
instead of the hurry and alarm on waking, as ob-
served in the case- of excessive reaction, the pa-
tient in the state of sinking requires a moment to
recollect herself and recover her consciousness, is
perhaps affected with slight delirium, and is apt to
forget the circumstances of her situation, and, in-
attentive to the objects around her, to fall again
into a: state of dozing.

Not less remarkable is the effect of the state
of exhaustion with sinking on the function of the
lungs ; indeed, the very first sure indication of this
state is, we believe, to be found in the superven-
tion of a crepitus in the respiration, only to be
heard at first on the most attentive listening ; this
crepitus gradually becomes more audible, and
passes into slight rattling, heard in the situation
of the bronchi and trachea ; there is also a degree
of labour or oppression, sighing, hurry, and blow-
ing, in the breathing, inducing acuteness in the
nostrils, which are dilated below and drawn in
above the lobes, at each inspiration ; in some cases
there is besides a peculiar, catching, laryngeal
cough, which is especially apt to come on during
sleep, and awakes or imperfectly awakes the pa-
tient. The heart has at the same time lost its vio-
lent beat and palpitation, and the pulse and arte-
ries their bounding or throbbing. The stomach
and bowels become disordered, flatulent, and tym-
panitic, and the command over the sphincters is
impaired. The last stage of sinking is denoted
by a pale and sunk countenance, inquietude, jac-
titation, delirium, and coldness of the extremities.
We now propose to detail the principles of the

750

PUERPERAL DISEASES.

treatment in cases of the effects of loss of blood
in the puerperal state.

In the first place the state of exhaustion from
loss of blood, with or without reaction, by no
means precludes the possibility of congestion
within the head ; and it is no less certain that the
application of leeches to the temples, or of the
cupping-glass to the back of the neck, relieves the
symptoms of affection of the head, arising from
loss of blood, in a remarkable manner. In a case
given by Mr. Hey, which we regard as being of
this character, and to which we shall have occa-
sion to revert hereafter, urgent symptoms of affec-
tion of the head were twice relieved by the ab-
straction of but three ounces of blood from the
temporal artery. This mode of treatment must
not, therefore, be neglected except in the most ex-
treme cases, in which the loss of even so small a
quantity of blood, and that from the head even,
might prostrate the remaining powers of the pa-
tient.

The next point of practice which requires to be
mentioned is the state of the stomach and bowels.
If these were free from all disorder before the oc-
currence of the loss of blood, yet the state of
exhaustion ever induces a deranged state of the
alimentary canal. The state of the bowels must,
therefore, claim our attentive consideration in
every case of symptoms arising from loss of blood.
Their functions and tone must be carefully re-
stored by every means in our power, while we as
carefully avoid any fresh source of exhaustion.
The bowels must in particular be carefully eva-
cuated daily. This may perhaps be best done by
means of the warm-water injection so often recom-
mended by us already, with or without the aid of
a draught containing an ounce of the infusion,
and two or three drachms of the compound tinc-
ture of rhubarb, and of manna.

By these means the state of irritability which
is so apt to affect the system, and especially the
head and the heart, in cases of exhaustion from
loss of blood, is greatly obviated. But for this
affection it is frequently also necessary to give
some mild but efficient anodyne. The tinctura
opii, the tinctura hyoscyami, the spiritus ammonia?
aromaticus, &c. are extremely useful remedies in
this affection. But perhaps the best are Battley's
liquor opii sedativus, or the extract of poppy,
given in efficient doses.

When the head, the heart, and the alimentary
canal have been thus relieved, and even during
the exhibition of the medicines which have been
enumerated, it is of the first importance to attend
to all the following points : viz. nourishment,
fresh air, quiet, soothing, sleep, &c.

It is difficult to give fixed rules for the ad-
ministration of nourishment; but the first rule is
to ascertain that the bowels have been properly
evacuated, otherwise food will only oppress the
stomach ; the second is to give the nourishment
itself in such forms as will prove light and easy
of digestion ; the third is that it should be taken
at first very slowly and in small quantities.
Arrow-root in water, beef-tea, panada, sago, &c.
may be given frequently.

The best restorative we possess is, we believe,
Jresh air ; but it is especially the best in the cases
under consideration. The warmth and closeness

of a lying-in room must therefore bo forthwith
exchanged for free ventilation, only observing the
due precautions against giving cold.

Nothing is more essential than quiet both of
body and mind. Bodily exertion leads to still
further exhaustion, and perhaps even to unex-
pected dissolution ; and every kind of mental
effort or hurry not only exhausts the patient's
strength, but is extremely apt to lead to those
attacks of symptoms of irritability of which we
have given so full a description.

The patient should be soothed and lulled in
every possible way ; and it is of the utmost im-
portance to procure sleep. But it should be ob-
served, in regard to sleep, that too long a sleep is
apt to exhaust or overwhelm the patient. This is
especially true if it be not preceded by nourish-
ment. The sleep is also apt to be injurious by
leading to turbulent dreams, which have the same
bad effects as waking hurry of mind ; the sleep
should, therefore, be watched, and it should be
interrupted if the patient is observed to suffer from
agitation : this is best done, we think, by offering
nourishment, for the patient is immediately col-
lected, on awaking, from knowing what is doing.

There is one point which we have not hitherto
mentioned as it deserves ; it is the efforts made
by the patient to suckle her infant. Nothing is
so injurious in all puerperal diseases. These
morbid affections have often appeared to be first
induced by the attempt to nurse ; and they have
still more frequently been exasperated by it. Thi«
attempt especially involves within itself almost
every thing which can be injurious in a state of
exhaustion ; the drain, the muscular effort, the
mental excitement implied in the act of suckling,
are all of the most injurious tendency in this af-
fection.

Of mixed cases, and especially of Puer-
peral Mania* — Perhaps the cases which most
frequently present themselves to our notice in
practice are of a character distinct from those
which have been described in the preceding sec-
tions, differing from them principally by blending
two or all three of those cases in an individual
patient.

Our systems of nosology have, we are per-
suaded, greatly erred in attempting to separate
diseases from each other, and describe them as
distinct, when they far more frequently occur in
conjunction; so that the mind of the medical
student is not at all prepared for the cases which
most frequently occur to him when he first enters
upon practice. A little experience teaches him
the difficulty, nay the absurdity, of attempting to
give each individual case a name, or to put it
down in a list of diseases. Each patient, on the
contrary, presents to him a new congeries of
symptoms, a new complication of diseases or dis-
orders.

To apply these remarks to our present subject,
it may be truly said that puerperal cases are more
complicated than any. But we have already in-
sisted upon this point; and we now proceed to
illustrate the various combinations of inflamma-
tion with intestinal irritation, or of either or both,
with the effects of loss of blood.

Some cases have conjoined the most decided
symptoms of intestinal irritation with those of in-

PUERPERAL DISEASES.

751

flammation, and, having proved fatal, have pre-
sented all the traces of inflammatory action on
examination. It has already been shown that in
many cases of inflammation there are none of the
symptoms which denote intestinal irritation ; there
is an absence of rigor, of heat, of affection of the
head, &c. ; but the effects of inflammation are
found upon dissection. On the other hand, there
have been all the symptoms of intestinal irritation,
as rigor, heat, hcadach, with pain, tenderness, and
tension of the abdomen, without a trace of the
effects of inflammatory action on examination
after death. The conclusion from these separate
statements is obvious ; inflammation and intes-
tinal irritation may exist separately, but they may
also exist together.

The effects of loss of blood are frequently ob-
served in cases of inflammation, when the primary
disease has been perfectly subdued. But they are
still more apt to concur and to assimilate them-
selves with those of intestinal irritation, when
there has been much loss of blood by hemorrhage
or by bloodletting.

This subject, as well as the interesting question
of the diagnosis, might be illustrated by a reference
to the valuable treatise of Mr. Hey upon puerperal
fever. This author, as well indeed as almost
every writer upon this subject, appears to us to
have combined in one description all the three
different cases of which we have treated. It is
not, therefore, wonderful that their works should
involve many inexplicable discrepancies in the
symptoms and in the treatment. Some cases
have occurred without rigor, heat, or headach ;
others have combined all three with or without
affection of the abdomen. Some have been cured
without the lancet ; others have not yielded to the
most judicious and most ample bloodletting. It is
doubtless a most important question, — how can
these discrepancies be explained ?

Other difficulties and other discrepancies have
arisen from the addition or superinduction of the
symptoms of loss of blood, in cases of inflamma-
tion or of intestinal irritation. This is a mixed
case which frequently occurs, and causes much
embarrassment to the young and inexperienced
physician ; and it has too frequently happened
that the lancet has been prescribed under a false
impression of inflammation ; and that great danger
and even immediate dissolution have ensued.

There is a mixed case which shows itself un-
der a still different form from any which have
hitherto been described ; it is puerperal mama.
We believe this disease to result, in general, Irom
all the circumstances following parturition com-
bined, but chiefly from the united influences ot
intestinal irritation and loss of blood. We pur-
pose to pursue this subject hereafter. In ine
meantime, however, we would observe that we
are persuaded that real puerperal phremtis is com-
paratively a rare disease; that puerperal mama
seldom of an inflammatory character, and ha
is especially to be treated by those measures wheh
are suited to the mixed case ot mtestinal i nUtion
and exhaustion. This opinion is conhrmed by
the fact of mania occurring from undue lactation
as we 1 a 1 from the circumstances of the puerperal
statT W are inclined to attribute much more
to the combined influence of irritation and ex-

haustion than to the mere "state of the sexual
system which occurs after delivery," which has
been assigned as the chief cause of this morbid
affection by Dr. Gooch, in a most interesting pa-
per upon this subject in the sixth volume of the
Transactions of the College of Physicians, p. 280 ;
although we would by no means exclude the in-
fluence of this principle altogether. There is
ample evidence in Dr. Gooch's cases of the in-
fluence of intestinal disorder; and the events of
labour and the circumstances of lactation ever
add to this a state of exhaustion. This view is
the more important, because it directly suggests
the proper mode of treatment, which consists in
restoring the system to a state of due health by
every means in our power, whilst we adopt every
measure which can soothe and allay the morbid
irritability of the nervous system.

We are confirmed in this view of the nature of
puerperal mania not only by a careful investiga-
tion of its causes and the good effects of the reme-
dies which we have mentioned, but by having
met with the symptoms of intestinal irritation as
a prelude to those of mania.

There are frequently also many of the appear-
ances of disorder of the general health, sometimes
jaundice even ; and the state of the complexion
and of the alvine evacuations leaves no doubt as
to the influence of the morbid condition of the
intestinal canal. Bloodletting plunges the patient
into a state of danger, perhaps into one of irre-
trievable sinking.

Puerperal mania is, in fact, in the most empha-
tic sense a mixed case : previous derangement of
the health ; intestinal irritation ; loss of blood ;
the pain and shock, and anxiety attendant on
parturition ; the subsequent morbid state of the
genital organs ; — all these may combine with pre-
disposition to induce the maniacal attack.

But our attention must be chiefly directed to
the degree of exhaustion which obtains, to direct
us what remedies to employ and what measures
to avoid.

On being called to a case of puerperal mania,
we have long been in the habit of asking whether
the patient has or has not been bled ; on this
greatly depends the event of the case : if blood
has been freely taken, the patient will probably
die ; if otherwise, most puerperal cases of mania
issue well.

It must be admitted in this place, however, that
puerperal mania may possibly be combined with
inflammation, especially of the uterus, its append-
ages, or the peritoneum. This is to be ascertained
by a careful examination. In such a case blood-
letting must be used, and in such a case it can be
borne.

Puerperal phrenitis is certainly a rare disease.
This opinion was early expressed by the writer
of this article, and it is confirmed by Dr. Gooch.
The same remark may be made in regard to the
most influential cause of puerperal mania, and the
danger of bloodletting in that disease.

The symptoms in puerperal mania occur in the
most insidious manner : there is a little excite-
ment during the day, and sleeplessness at night,
then something bordering on delirium ; then ac-
tual delirium; and then confirmed mania.

The most important parts of the treatment aru

752

PUERPERAL DISEASES— PULSE.

extreme quiet of mind and of body ; a regulated
state of the bowels; a mild, light, but nutritious
diet ; a cold lotion to the head ; fomentations to
the feet ; every soothing plan ; careful watching ;
and time. It too frequently happens that the
friends undo in one day what the physician's care
has effected in many: visitors intrude ; the infant is
brought ; conversation, excitement are permitted.
The treatment consists, in fact, much more in
avoiding sources of harm than in positive reme-
dies. Bloodletting is replete with danger ; every
depleting means, by adding to the exhaustion, adds
to the malady. The cure depends more upon
nursing than upon the materia medica. It is pro-
per, however, to state that the mildest opiates have
lulled and soothed, and obtained rest, and allayed
the disease. The progress of puerperal mania has
also been controlled by administering mercury so
as to induce ptyalism, and avoiding its effects on
the bowels. [See the article Insanity.]

We have thus given a rapid sketch of those
puerperal diseases which are of most frequent oc-
currence and greatest practical interest. But there
is another series of puerperal diseases of a still
more terrible character, of which a sketch must
now be added. They consist of softening of the
substance of the uterus, inflammation of the lym-
phatics, and phlebitis.

The first of these may be suspected whenever
there are, after rigors and fever, with uterine pain
or tenderness, and suppressed lochia, symptoms
like those of the sinking state, the countenance
becoming collapsed, the pulse extremely frequent
and small, the respiration hurried and anxious, the
strength prostrate.

The symptoms in inflammation of the lympha-
tics are very similar, and of a typhoid character ;
these are usually conjoined with those of perito-
nitis, and occasionally with pleuritis. But there
are not the secondary abscesses observed in the
disease to be next mentioned.

The important distinction in regard to uterine,
as in the other forms of phlebitis, is between the
adhesive and the suppurative. In the former the
effects are localized. Uterine phlebitis of the ad-
hesive character is attended by local pain and ten-
derness. The occurrence of crural phlebitis seems
to constitute the disease formerly termed the phleg-
masia dolens. This disease is distinguished by
pain in the situation of the iliac and inguinal
veins, with tension and swelling, afterwards pur-
suing their course down the thigh. The femoral
vein is white, tense, elastic, painful, and tender.

The suppurative phlebitis is a far more formida-
ble and fatal disease. It is denoted by the occur-
ence of terrific typhoid symptoms, and by external
suppurative inflammation of the integuments or
of the eye ; whilst abscesses form internally in the
brain, the lobules of the lungs and liver, in the
spleen, in the joints, in the muscular substance,
&c. It is usually unattended by peritonitis.

Of the treatment of softening of the uterus, and
inflammation of the lymphatics, and of suppura-
tive and diffused phlebitis, little is known; and it
would be foreign to the object of this sketch to
rnter upon any discussion of the subject.

Marshall Hall.

PUERPERAL FEVER.— See Feter [Puer-
peral.]

PULSE. — The stroke or beat of an artery, as
recognised, for the most part, by the finger applied
to the integuments lying over it, is denominated
the pulse ,- by the Greeks it was termed c<pvyn&s ;
by the Latins pulsus, whence our English term is
derived.

We propose to divide the following article into
three parts, which may be regarded respectively as
historical, physiological, and pathological. The
first will consist of a brief historical account of
what was known on the subject of the pulse by
the ancients, as well as the opinions that have been
entertained respecting it by the moderns. In the
second place, we shall inquire into the cause of
the pulse. We shall endeavour to explain its dif-
ferent varieties, and shall point out their connection
with the other parts of the animal economy.
Lastly, we shall offer some remarks on the morbid
conditions of the pulse, and inquire into the de-
gree in which they may enable us to judge of the
seat and nature of disease, so as to assist us in
forming our diagnosis and prognosis, and in
directing our practice.

1. History of the opinions that have been
entertained respecting the pulse. — We have
a distinct notice of the pulse in the writings of
Hippocrates ; it is mentioned, however, incident-
ally, and in a few passages only, and he appears
to have attached scarcely any importance to it,
either theoretical or practical. It is commonly
supposed that he is the first writer who employed
the term pulse (<r0uy/idj) to denote the natural and
ordinary beating of the artery. It would seem
that the ancients usually applied the term to what
we should call pulsation, i. e. the beating that is
felt by the individual himself, in a part that is in-
flamed, or otherwise morbidly affected, without
applying the finger to it. But although there are
certain passages in the writings of Hippocrates
where the word is used in the more correct and
restricted sense, yet it must be admitted that these
are few in number; a circumstance which is the
more remarkable, when we consider with what
minute accuracy he detailed the other symptoms
of the diseases of which he has left us a distinct
account. We may farther notice, that from the
manner in which he refers to the pulse, he seems
to have made little or no use of it, either in regu-
lating his practice, or in forming his diagnosis.
Where, for example, he gives a detailed account
of the phenomena of fever, he states with great
minuteness the temperature of the patient, the
state of the respiration, of the secretions and ex-
cretions, and indeed all the circumstances to which
the most judicious modern physician would direct
his attention, except the pulse. The only use
which Hippocrates made of the pulse was to assist
him in forming his prognosis ; but even here we
meet with little of that acuteness of observation
which, on most occasions, characterizes the wri-
tings of the great father of medical science.*

It is generally agreed that Herophilus was the
first physician who was fully aware of the import-

* Hippocrates enumerates a peculiar state of the pulse
among the signs of disease in his treatise ' Ue Ilumori-
bus;' also, in various parts of his ' Coaca; Fraiiiotiones.'

PULSE.

753

ance of the pulse, and paid particular attention to
its various conditions. He was one of the most
distinguished ornaments of the Alexandrian school,
and is especially celebrated for his knowledge of
anatomy, into which science he introduced many
great improvements. The fame of Herophilus is
principally supported by the authority of Galen,
who expressly notices his merits on this point.
(See his treatise De Diff. Puis. lib. ii. c. 10.) We
learn, however, from Pliny (Hist. Nat. xxix. 1),
that he was supposed by some to have introduced
into practice a number of unnecessary and even
fallacious distinctions concerning the pulse, and
that, for the most part, his opinions were derived
more from hypothesis than from actual observa-
tion.

The author whom we shall next notice is Cel-
sus. The judicious manner in which he treats
his subject, the candour which he displays in re-
ferring to the opinions of others, together with the
elegance and purity of his .diction, have caused
him to be regarded as one of our highest classical
authorities. This is more especially the case on
all questions of literary history, as he appears to
have aimed more at giving a correct view of the
state of medical science at this age, than a mere
transcript of his own observations and experience.
In his account of the pulse, he has been supposed
to revert to the doctrine of Hippocrates. When
giving directions for the treatment of fever, he
remarks upon the great importance of obtaining a
correct criterion of the presence of the disease,
and in this connection he introduces the following
observation : " We principally trust to the veins,
a thing which is most fallacious, for they are fre-
quently too slow or too quick, depending on the
•.ge, the sex, and the peculiar nature of the body."
He goes on to inform us that there are various
cases in which the pulse is affected by circum-
stances quite unconnected with any morbid condi-
tion of the body, and where we should fall into
the greatest mistakes were we to suffer our judg-
ment to be influenced by the state of the pulse.
(Lib. iii. cap. 6.) The multiplied and varied ex-
perience of the modern practitioner has proved
that the precautions of Celsus, although not with-
out some foundation, were carried to an unrea-
sonable length ; and that, although the pulse is
affected by most if not by all the extraneous cir-
cumstances mentioned by him, yet that it still
leaves us the most valuable indications of the state
and nature of disease.

We now arrive at the period of the celebrated
Galen, a man whose talents and acquirements
were of the first order, and who from other causes
obtained an ascendancy over medical opinions
more considerable and more durable than had been
acquired by any of his predecessors ; and we may
venture to add, than will be ever again obtained
by any individual. There is scarcely any topic,
connected either with medicine or pathology,
which Galen has not investigated; and the pulse
is one on which he bestowed a peculiar degree of
attention. He has devoted to this subject no less
than six different treatises, some of considerable
length, in which he investigates m the most ela-
borate manner everything concerning the use of
the pulse its causes, its different varieties, the
method of distinguishing these varieties, the prog-

Vox.lU. — 96

nostics to be deduced from them, and other anal-
ogous subjects.*

A characteristic feature of the writings of Galen
is the methodical arrangement, and the numerous
technical divisions which he introduces into almost
all the subjects which fall under his notice. He
proceeds on this principle when treating of prog-
nostics, which he classes under the three heads of
those which relate to the concoction of the hu-
mours, to the absolute removal of the disease, or
to particular crises of various kinds. Again, he
supposes crises of all kinds to be derived from
three kinds of powers or actions, arranging them,
according to their origin, under the denominations
of natural, vital, or animal ; the pulse he regards
as principally indicative of the different kinds of
vital actions. It would carry us far beyond all
reasonable limits, were we to follow our author
into his speculations concerning the causes of the
pulse, and the mode in which its different actions
manifest themselves, so as to give rise to a most
complicated system of minute distinctions and va-
rieties, which it is difficult even to comprehend,
and of which few only have probably any actual
existence.

With respect to the cause of the pulse, Galen,
according to his ordinary custom in such cases,
attributes it to a specific faculty, inherent in the
heart and vessels, which he names pulsative, by
which their alternate contraction and dilatation is
produced. As the pulse is an effect resulting from
the action of the vital faculties, it affords us one
of the most correct indications by which we may
judge of the strength or weakness of the vital
powers in general, and of the consequent tendency
to life or death, and thus constitutes one of our
most valuable means of prognosis. Hence the
extreme importance of making ourselves acquainted
with all its variations, and connecting them with
the state of the other actions and functions of the
animal economy.

The use of the pulse was supposed to be to
maintain the heat of the body, and to remove the
excess of excrementitious matter from the blood ;
by considering the condition of the vital powers,
in relation to these supposed processes, he lays
the foundation for the differences in the pulse
which he endeavours to establish. These differ-
ences he first arranges under the two heads of
simple and compound, which he again subdivides
into numerous varieties, depending partly upon
the supposed quantity of motion in the vessels,
the nature of this motion, the length of time
which it occupies, the space which intervenes be-
tween the pulsations, the force of the vital action,
and the particular disposition of the artery. Pro-
ceeding upon these principles, he forms all the
supposable combinations of these different circum-
stances, and from them he deduces a great num-
ber of varieties, to which he gives distinct appel
lations, but which it would be useless to attempt
to describe, or even to enumerate.

Those who are curious to obtain farther inform*
tion on this point may especially consult his dis
sertation " On the Varieties of the Pulse," a work

* The following are the Latin titles of Galen's Trea-
tises on the Pulse : De Pulsuum Usa ; Introdiictio in Pul-
sus; De Differentiis Pulsuum, 4 lib.; De Cognoscendia
Pulsibus, 4 lib. ; De Causis Pulsuum, 4 lib. ; De Praecog-
nitione ex Pulsibus, 4 lib.

754

PULSE.

of considerable length, which is exclusively de-
voted to this particular object. It may be regarded
as one of the most learned of Galen's perform-
ances, and as peculiarly characteristic of the me-
thodical and technical manner in which he treats
his subjects.

After the age of Galen we have little to detain
us until the revival of medical science by the Ita-
lians in the sixteenth century. Medicine was, in-
deed, very assiduously cultivated by the successors
of Galen, during what are termed the dark ages;
and among the Arabs especially, we meet with
various individuals of great eminence for their
learning. But their attention was almost entirely
confined to the writings of the Greeks, and parti-
cularly to those of Galen, which they regarded as
standards of excellence ; these they translated
and republished in various forms, and illustrated
by almost innumerable commentaries and disserta-
tions, adding very few original observations, and
making scarcely any advance in the principles of
the science. This system prevailed to so great an
extent, that it has been asserted, and, as it would
appear, without exaggeration, that for more than
one thousand years after the death of Galen,
scarcely a single improvement in medicine or
physiology was made which has been thought
worthy of being transmitted to posterity.

In tracing the history of science among the na-
tions of antiquity, we seldom think it necessary
to go beyond the limits of Europe, or the period
of Grecian literature ; yet it is generally admitted
that the Greeks were not themselves the inventors
or the originators of the arts in which they so
much excelled. It is a question of very difficult
decision, what was the country in which they took
their rise, whether in Egypt or in India, or in
some other part of the East. It is, however, cer-
tain that the Oriental nations made very early ad-
vances in various departments ; and that, while
Europe has been undergoing numerous revolutions,
and been gradually advancing to its present state
of improvement, Asia has remained much more
stationary ; so that, in many cases, we have rea-
son to believe that it exhibits at this day nearly
the same condition which existed perhaps two
thousand years ago. This is most remarkably
the case with the Chinese, both in regard to their
early civilization and to the little change it has
experienced ; and it hence becomes a subject of
great interest and curiosity to inquire into the
opinions and practices of this remarkable people.

We are furnished by the missionary Jesuits
with a minute account of Chinese medicine, and
particularly of their opinions respecting the
pulse. It appears that they paid great attention
to it, and supposed that it afforded them indica-
tions of almost every change to which the body is
subject, as well salutary as morbid. Thus, among
other notions, it was conceived that the different
organs produced by their derangement different
effects upon the pulse, some of which were to be
detected by examining the pulse of the right side
of the body, and others that of the left. They
farther imagined that from the state of the pulse of
a pregnant woman, the sex of the foetus might be
ascertained. They arranged the different parts of
the body under three divisions, upper, middle, and
l.'iver, in conformity with their respective situa-

tions ; and they conceived, that according as one
or other of these parts was affected, so a corre-
sponding state of the pulse was to be recognised.
(See especially the " Description de la Chine," by
Du Halde.) We might be the more disposed to
inveigh against the futility and absurdity of these
opinions, were we not aware that they but too
much resemble some of those which were sup-
ported by the most enlightened and learned phy-
sicians of Europe scarcely a century ago.

At the revival of letters, when the human intel-
lect began to rouse itself from its long repose, the
mathematical sect of physicians sprung up. Their
reasonings were, for the most part, founded upon
erroneous principles, and were almost exclusively
derived from physical deductions, which were in-
applicable to the phenomena of the living body.
Still these labours were not entirely without their
use, by stimulating the mind to exertion, and by
indirectly leading it to those subjects which are
more connected with the principles that ought to
guide us in our inquiries. It is on this account
chiefly that we notice the name of Bellini, a
learned professor of Pisa, who flourished in the
beginning of the seventeenth century, and wrote
a treatise on the pulse. (De Urinis ct Pulsibus,
1683.) Although the fundamental principles of
the sect to which Bellini belonged were, in many
respects, essentially erroneous, yet they led to a
closeness of reasoning which was more favourable
to the progress of knowledge than the completely
hypothetical method of their rivals the chemists.

It was not, however, until the immortal disco-
very of Harvey was generally recognised, and its
importance duly appreciated, that any considera-
ble progress could be made in our knowledge of
the laws of the circulation, or that we could expect
to form any just conception, either of the theory
of the pulse, or of the circumstances that might be
supposed to affect it. The general turn for ob-
servation which now became prevalent in all the
departments of philosophy, of which the discovery
of Harvey itself may be regarded as one of the
most splendid results, gave rise to various investi-
gations respecting the cause and nature of the
pulse, varying much in their respective merits and
importance, but all of them professing to be de-
rived from observation or experience, and contri-
buting more or less to the establishment of the
principles of a correct theory.

Among the first of these productions which
will require our notice, is a work which appeared
early in the seventeenth century, in many respects
peculiar in its style and in the opinions which the
author adopts, but of real value, as possessing the
merit of pointing out a precise mode of ascertain-
ing with accuracy the rate of the pulse, by means
of an instrument adapted for measuring short in-
tervals of time. This was done by Sir J. Floycr,
in " The Physican's Pulse Watch," published in
1707. The instrument which he describes is
indeed awkward in its construction, and must
have been inconvenient in practice, but it deserves
to be recorded, as being the first step of an im-
portant improvement.

In the year 1731 a singular work made its ap-
pearance, written by Solano, a native of Lucca,
but who passed the greatest part of his life in
Spain ; it was entitled " Lapis Lydius Apollinis."

PULSE.

755

In the course of his practice he had met with
some cases of what is termed the rebounding
pulse, and being struck with its peculiarity, and
with the symptoms which succeeded it, he was
led to pay particular attention to the various
states of the pulse, and to the morbid changes
which appeared to be connected with them. He
accordingly directed his attention almost ex-
clusively to this function, and he is said to have
arrived at an inconceivable degree of acuteness in
predicting the event of disease by the peculiar
indications of the pulse. The result of his expe-
rience, real or supposed, forms the subject of his
volume, which obtained, at the time of its publi-
cation, a considerable degree of celebrity.

The investigation was zealously pursued by
Nihell, an English physician, who likewise re-
sided in Spain, and who undertook to give to the
world the principles of Solano under a more
intelligible form, and divested of a degree of
obscurity which is attached to the original. Ac-
cordingly, in the year 1745 Nihell published his
" New and extraordinary Observations concerning
the Predictions of Crisis by the Pulse."

A few years after the appearance of Nihell's
treatise, a work of a similar kind was published
in France by Fouquet ; who, proceeding upon
the plan of Solano, endeavoured to point out the
connection between certain peculiar states of the
pulse and the affection of peculiar organs of the
body.

The subject was still farther prosecuted by a
learned countryman of Fouquet's, Bordeau, who,
in the year 1756, published his " Recherches sur
le pouls par rapport aux crises." In this treatise
he proceeds upon the method of Solano ; but he
goes even beyond him in the minuteness of his
distinctions, and the apparent accuracy of his dis-
criminations ; and from these he professes to draw
a system of indications and prognoses, which,
although in some of its parts it may not be alto-
gether without foundation, is generally admitted
to be derived from subtile and over-refined dis-
tinctions, which it is impossible to recognise, and
which, for the most part, can have no real exist-
ence. It does not appear that in this country the
system of Solano ever had any considerable num-
ber of adherents, while in France the learning
and ability exhibited in the work of Bordeu,
aided also by his reputation as an able and suc-
cessful practitioner, contributed to give a degree
of weight and authority to his opinions, greater
than was due to their intrinsic merit. Even in
the present day, we observe in the French school
an attempt at nice discriminations of the pulse,
which are conceived by the English to be altogether
imaginary, a state of things which may probably
be traced, in some degree, to the writings of
Bordeu.

For the opinions which have been, of late
years, generally embraced in this country re-
specting the pulse, we are probably indebted in no
inconsiderable degree to two short, but very valu-
able treatises; the first consisting of an essay,
which was read by Dr. Heberden before the Col-
lege of Physicians in the year 1768 ; the latter
of the " Observations respecting the Pulse, by
Dr Falconer, published in the year 1796.

Dr Heberden has the merit of having freed the

subject from most of the subtile and over-refined
distinctions which had been introduced into it, in
the first instance by the followers of Galen, and
afterwards by those who adopted the opinions of
Solano. He informs us that his object was to
direct the attention of the practitioner to " such
circumstances of the pulse, in which they could
neither mistake nor be misunderstood." He con-
tinues : " what I mean is, the quickness or fre-
quency of the pulse, which, although distinguished
by some writers, I shall use as synonymous
terms." Proceeding upon this principle, he gives
us the valuable results of his own observation on
the respective frequency of the pulse at different
ages and in different states of the constitution,
and points out various circumstances in which the
frequency of the pulse, considered by itself, with-
out reference to other symptoms, was found to be
a very inadequate criterion of the nature and de-
gree of disease.

Nearly a similar view of the subject was taken
by Dr. Falconer. Referring to the essay of Dr.
Heberden, he has the following remark. " It has
been reserved for the good sense and clear under-
standing of a physician, who does honour to our
own country, to free the study of the profession
from many needless incumbrances of this kind,
and to direct the attention of practitioners to the
only circumstance respecting the pulse which is
capable of communicating accurate and distinct
ideas, or of affording decisive indications." He
further agrees with Dr. Heberden, that the quick-
ness and frequency of the pulse are to be regarded
as synonymous terms, and characterizes the fre-
quency " as the only circumstance respecting it
(the pulse) of which we can form any clear or
determinate idea, and which we can be assured
conveys the same information to others that it
does to ourselves ;" while he speaks of the other
distinctions as fanciful or whimsical, and as
serving to perplex and embarrass the practitioner.

With the greatest respect, however, for these
individuals, who may be justly regarded as among
the most enlightened and candid physicians of
modern times, we conceive that they have at-
tempted to simplify the subject too far, and that,
in discarding a mass of erroneous notions, they
have fallen into the opposite extreme. But what-
ever we may think of their opinions on this point,
the facts and observations which they have adduced
are of the highest importance, and rest upon au-
thority which can never be called in question.

It will be scarcely necessary to pursue the his-
torical part of this article below the termination
of the last century, for although we have many
very valuable observations on the pulse of a 'ater
date, they are either contained in works princi-
pally devoted to other topics, such as general his-
tories of medical science, and accounts of par-
ticular diseases and individual cases, or they are
written for the express purpose of establishing
and elucidating some physiological position, which
will be more conveniently discussed in the second
part of this article.*

* For a more minute account of the opinions respect
ing the pulse, we may refer especially to the histories o<
Le Clerc and Sprcngel, and to Haller, El. Phys. lib. G,
sert.'.>; also to the art. Pouls, in the Diet, des Scieu.
Med.

756

PULSE.

H. Physiology of the Pulse. — In treating
of the physiology of the pulse there are various
points that present themselves for our considera-
tion. In the first place we must inquire into the
cause of the pulse, and when we have ascertained
the cause, we shall be prepared to investigate the
exact nature of the effect, and what relation it
bears to the other functions of the animal eco-
nomy.

Since the immortal discovery of Harvey, it is
universally admitted that the pulse depends im-
mediately upon the action of the heart, which, by
its contraction, expels a portion of blood from its
cavities into the great arteries. The contraction,
or, as it has been termed, the systole of the heart,
must therefore correspond, in point of time, with
the stroke of the artery, while, during the diastole
of the heart, the artery returns to its quiescent
state. But although there can be no difference
of opinion on this point, there are various subor-
dinate questions, which have been the subject of
warm and protracted discussions, some of which
remain still undecided.

Of these, one of the most important is, whether
the arteries themselves possess any contractile
power, by which they are enabled to co-operate
with the heart. The contractile power of the
arteries has been supported by direct experiments,
and especially by those in which the blood was
found to be propelled along the vessels after the
heart was removed from the body ; while, on the
contrary, this property has been denied by other
physiologists, because, in experiments made for
the express purpose, the artery could not be made
to contract by the application of those agents
which are known in ordinary cases to stimulate
the muscular fibre. There is certainly some diffi-
culty in reconciling the apparently discordant
results ; but, upon the whole, the weight of evi-
dence is in favour of the contractile power of the
arteries ; for it appears almost impossible to ex-
plain various phenomena without admitting this
power, while the negative results that have been
adduced against this opinion are explicable upon
other principles. We may therefore assume it as
an established point, that the blood is propelled
along the vessels by the joint power of the heart
and arteries.

Proceeding, however, upon this position, that
when the heart contracts, a certain impulse is
propagated through the artery which causes it to
strike the finger, it still remains to be ascertained
what is the exact nature of this impulse. We
may inquire whether the vessel be actually dis-
tended, so as to have its diameter increased, or is
it merely extended in length, or displaced ? or
without having its size actually augmented, or
being removed from its situation, is it only ren-
dered more tense or firm, or what other change
does it experience? When we estimate the bulk
of the blood sent into the aorta at each contrac-
tion of the heart, and compare this with the
quantity of blood previously contained in the ves-
sels, although we might theoretically suppose that
the diameter of any particular artery was actually
increased, it must be admitted that the increase
of bulk would be much too small to be perceived
1'V the finger, or to produce the sensation which
i? conveyed to us by the pulse. Hence we may

conclude that the terms systole and diastole are
scarcely applicable to the different states of the
artery; for although we may conceive them to be
technically correct, when considered as a question
of theory, we cannot admit of their actual exist-
ence in any sensible or perceptible degree.

As to the extension or displacement of the
artery, it appears certain that when the jet of
blood is forcibly projected into a flexible tube, like
that, of which the artery is composed, there will
be an effort produced to straighten it and to di-
minish its flexures, and at the same time to extend
it in a longitudinal direction, as far as the texture
of the organ itself and its connection with the
neighbouring parts will permit. There is, how-
ever, reason to believe that these changes, although
they may actually take place to a certain extent,
do not exist in sufficient degree to produce all the
effect which is experienced, and we are therefore
induced to search for some other cause of the
phenomena.

The solution of the problem was attempted by
Dr. Parry,* who, after proving the insufficiency
of all the former modes of explanation, proposed
a new view of the subject. We shall quote the
words of the author, as they express, in a short
compass, the fundamental positions on which the
hypothesis rests. " In the larger arteries there is
no sensible dilatation or contraction, — therefore
the pulse cannot depend on this alternation. —
The chief cause of the pulse is a strong and
predominant impulse of distension from the sys-
tole of the left ventricle, given by the blood as it
passes through any portion of an artery forcibly
contracted within its natural dimensions." The
pulse is felt when the motion of the blood is im-
peded by the compression of the artery, and it is
the resistance to this obstruction which produces
the pulse. We feel much disposed to acquiesce
in Dr. Parry's opinion, at least it may be asserted
that there is no other which gives a sufficient ex-
planation of the phenomena, while at the same
time there is nothing in the hypothesis either re-
pugnant to the laws of the constitution, or incon-
sistent with the structure and properties of the
organs in question.

It will follow as a consequence of this opinion,
that the pulse must be progressive, i. e. the im-
pulse must be made on the different parts of the
artery at different times, corresponding to their
distance from the heart. But although this may
be theoretically true, it has been questioned
whether the difference be really perceptible, and
many very accurate observers have not hesitated
to affirm that they have been unable to recognise
it. There are, however, physiologists of the first
eminence, who inform us that they can perceive a
difference in point of time in the beat of the dif-
ferent parts of the arterial system. Considering,
therefore, that a positive fact, where the authori-
ties are equal, is to be preferred to a negative one,
we must admit that the progressive beat of the
arteries is perceptible.

Another question which, like the last, must be
answered partly from theory, and partly from ob-
servation, is whether the force of the different
parts of the arterial system always maintains the

* Experimental Inquiry concerning the Arterial Pulse,
1816; with additional experiments by his Son, 1819.

PULSE

757

same relation to that of all the other parts, and to
the action of the heart. If the action of the heart
be increased in a certain ratio, is that of every
artery increased in the same ratio, or is the same
ratio observed in every increase or diminution of
action which may occur in any part of the arterial
system 1 If the heart were the sole impelling
power, this equality of ratio must necessarily be
preserved ; but if the arteries themselves partake
of this action, and co-operate with the heart in
the propelling power, it will follow that a local
cause may produce a local effect ; and this we in
fact find to be the case.

If we suppose that the arterial system derives
its power ultimately from the force of muscular
contractility, and that this is exercised conjointly
by the heart and the arteries, we may inquire to
what change of properties or of constitution are
the parts concerned in this operation obnoxious,
which may produce an actual or perceptible effect
on the pulse ; and further, what is the nature of
the changes which would be thus produced.

The mechanical structure of the parts we may
conceive to remain unchanged, but the force of
contractility is perpetually varying. And although
we may suppose that the heart and arteries are
not under the direct influence of the nervous
power, yet we are disposed to acquiesce in the
doctrine of those physiologists who maintain that
they are indirectly affected by it, in the same
manner with the involuntary muscles generally,
so that we have here another source of variation
in the pulse.

The function of respiration exercises a most
important influence over the circulation. The
essential object of this function is to produce such
a chemical change in the blood as to enable it to
maintain the contractility of the muscular parts,
and among others, that of the heart itself. Any
interruption to this change in the nature and con-
stitution of the blood will necessarily impede the
action of the heart, independently of any direct
change in its susceptibility, while a still more
material change in the circulation will be produced,
if both the nature of the blood and the power of
the heart be simultaneously affected. The func-
tion of assimilation is still more immediately con-
nected with the process of sanguification, and con-
sequently with the quantity and quality of the
blood, so that we have here two direct and imme-
diate causes always in operation, which, either
separately or conjointly, may contribute to affect
the state of the pulse. From these considerations
ir will appear that, independent of any external
agency, wo shall have a sufficient number of
changes in the powers or actions connected with
ihe circulation, to account for all the actual va-
rieties that are observable in the state of the
pulse, and to serve us as a basis on which to con-
struct a theory of the cause and nature of these
variations.

Let us now attempt to apply these observations
to explain the phenomena of the pulse. We may
arrange all its varieties under the three relations ot
time/force, and equality, considered either simply
or in combination. Thus the strokes of the artery
may be in the simple relation of frequent or rare,
strong or weak, regular or irregular or we may
have the combined relations oi frequent and strong,

weak and regular, & c . It will be a question,
however, for consideration, whether all the varie-
ties that can be actually detected are reducible to
these three simple or combined relations ; and in
order to elucidate this point, it will be necessary
to determine what are the characters of the pulse
which can be clearly recognised, and are generally
allowed to exist.

The first is that which depends upon the sim-
ple relation of time, constituting the frequent or
rare pulse, indicating merely the number of strokes
in a given period. The next variety is the quick
or the slow pulse, including something beyond the
mere number of beats in a given time, and taking
into account the period occupied by each indi-
vidual pulsation. From what has been stated in
the first part of this article, it will appear that it
has been questioned by physiologists and physi-
cians, whether it is possible to distinguish between
these two states of the pulse, or rather, indeed,
whether this difference actually exists ; whether,
for example, a pulse can be at the same time both
rare and quick, or frequent and slow. This point
formed the subject of a very warm discussion be-
tween the celebrated rivals Stahl and Hoffmann,
about the beginning of the last century, the
former maintaining the affirmative, and the latter
the negative opinion. We have seen above, that
the high authority of Heberden and Falconer is
in favour of the opinion of Hoffmann, yet we have
also high authorities on the other side of the
question ; and proceeding upon the same princi-
ple as on a former occasion, we do not hesitate to
decide in the affirmative. It may indeed be im-
possible to discriminate between a quick and a
frequent pulse where the frequency is considera-
ble ; yet in cases of less frequency, we conceive
that a difference may be detected. These are the
only simple relations of time.

With respect to the second class of relations,
that of force, we have first the most simple cha-
racter of strong and weak, depending directly upon
the degree of force with which the heart propels
the blood into the arteries. It may be doubted
whether there be any state of the constitution in
which the contractility of the heart is increased or
diminished, without the action of the arterial sys-
tem, taken in its whole extent, being likewise in-
creased or diminished ; nor, if this condition
should exist, are we in possession of any method
of detecting it through the medium of the pulse.

We may conceive a state, in which the contrac-
tility of the heart may remain unchanged, but in
which the nervous energy may be increased or
diminished, in which case an indirect effect may
be produced on the pulse, giving rise to two pos-
sible variations, the one depending on an increase,
the other on a diminution of nervous power.
Then again, conceiving the muscular and the
nervous powers to be derived from different
sources, and not necessarily dependent on each
other, we have the farther possible modifications
of increased contractility, while the sensibility is
either increased or diminished, and the reverse.
But although some of these may be regarded as
possible and even not unfrequent occurrences, it
does not appear that wc have any means of recog-
nising their effects on the pulse, or of distinguish-
ing them from each other. The only characters

758

PULSE,

of the pulse which belong to the relation of
strength, besides that of the simply strong and
weak pulse, is the hard or soft, and what is per-
haps nearly the same, or differing from it by a
minute shade only, the quality which has been
termed tension, where, without the actual bulk of
the artery, or the force of the heart being in- |
creased, a sensation is communicated to the finger
cf great firmness or density. It is probable that
under one or other of these characters may be
comprehended all the essential variations of the
pulse which are connected with the simple relation
of force.

[Most of the theories of the pulse take the con-
tractility of the artery too little into account. In
pathology, where we have an opportunity for ob-
serving the pulse in various phases, we have sen-
sations communicated to the finger which it is dif-
ficult to explain upon any theory, except that of
the compound action of heart and arteries. The
arterial system is manifestly more or less affected
by the nerves distributed to it: it may be stimula-
ted by irritants applied to the great nervous cen-
tres, or to the nerves passing to it ; and this is,
doubtless, the cause of many of the modifications
of arterial tension which we notice in disease.
No inflammation can affect a part of the system,
for any length of time, without both heart and
arteries participating, and affording unequivocal
signs of such inflammation.]

We must next speak of those variations of the
pulse which proceed upon the relation of equality.
These naturally arrange themselves under the two
heads of equality as to time, and equality as to
force. The first constitutes the regular or the
irregular pulse, and the irregularity may be of two
kinds ; when one beat among a certain number
of strokes is omitted, as in the intermitting pulse,
or when the beats generally bear no uniform rela-
tion to each other. With respect also to the irre-
gularity of force, we have, in like manner, two
varieties ; the first, where there is a general ine-
quality in the strength of the pulsations compared
with each other ; the second, that state of the
pulse where a weaker and a stronger beat succeed
each other, with at least a certain degree of uni-
formity. One variety of this has been termed the
rebounding pulse, and there are others, much in-
sisted upon by the older writers, and perhaps not
altogether without an actual existence, where this
change of force is continued through two or three
strokes, constituting a kind of increasing or de-
creasing series, to which the terms inciduus and
miurus (iiuovpos') have been respectively applied.

If we now bear in mind the three general causes
which we have supposed to affect the circulation,
the vital powers of contractility and sensibility,
and the state of the circulating fluid, we shall per-
ceive that the relations of time, force, and equality
may be, each of them, supposed capable of being
influenced by the third of these causes, which will
give rise to an additional set of combinations, of
possible, perhaps some of them of frequent occur-
rence. Thus, what is termed the full or small
pulse probably depends upon an excessive or a
deficient quantity of blood in the vessels. That
peculiar slate of the pulse in which the sensation
conveyed by the artery to the finger has been
'ikened to that of a thread, a wire, or a cord, may

be supposed to depend upon the small quantity of
blood in the vessel, combined with an increased or
diminished contractility of the heart, while the
contrary state of a sluggish or an oppressed pulse,
and the like, may be attributed to an unusual ful-
ness of the vessels, the vital powers of contractility
and sensibility not being increased, or even one or
both of them being diminished.

The varieties in the pulse which have been
enumerated above, are supposed to be derived from,
or to be dependent on, the general or ordinary ac-
tions of the animal economy, and to be explicable
by a reference to the principles which influence
these actions. There are, however, many other
variations which profess to be the result of observ-
ation and experience, but which are admitted to
be altogether empirical, and of which no explana-
tion is attempted to be given. Some of these were
referred to in the first part of this article. Such
are, for the most part, the different states of the
pulse pointed out by Solano and his followers, and
especially by Fouquet and Bordeu. The greatest
part of these we may unhesitatingly pronounce to
be altogether without foundation ; there are, how-
ever, some of them which are supported by such
numerous and learned authorities that it would be
improper to pass them by without noticing them a
little more particularly.

It has been a favourite notion with many physi-
ologists, ancient as well as modern, that diseases
of the different regions of the body, for example,
of the upper, the middle, and the lower, might be
recognised by corresponding differences in the
state of the pulse. But we may venture to assert
that this doctrine is erroneous. The mere local
situation of a disease can have no effect on the
pulse, except as far as regards the distance of the
organ from the centre of the circulation ; while,
on the contrary, wherever the morbid part be
situated, it is easy to imagine that the function to
which it is subservient, or even its texture and
composition, may materially affect the condition
of the circulation, and that this may possibly be
detected by the state of the pulse. Antecedently
to all experience on the subject, we might expect
that an inflammation of any part connected with
the brain or an organ of sense would produce a
different effect upon the pulse from an inflamma-
tion of the lungs, and this again from a similar
affection of the stomach or the intestines. We may
farther conceive that an inflammation of a mucous,
a serous, a muscular, or a membranous texture,
would respectively impress a specific character on
the circulation, as manifested by the pulse; but
this will be altogether independent of the mere
locality of the organ, and must be referred to a
totally different principle. The idea which was
long prevalent of there being a connection between
the diseases of each side of the body and the pulse
of the same side, would appear, in like manner, to
be entirely without foundation.

There is, however, another set of causes which
materially affect the pulse ; these may be divided
into internal and external. The internal are con-
nected with the original powers or constitution of
the body, or with its natural and ordinary pro-
gressive changes. Such are age, sex, tempera-
ment, and peculiar idiosyncracies, the states of
sleep and watching, of repletion and inanition,

PULSE.

759

mental emotions of all kinds, and the revolution
of the diurnal period. All the above are within
the limits of health, and the catalogue is to be
augmented by the long and melancholy train of
morbid affections. Among the external causes
are climate, temperature, various atmospherical
changes, peculiarities of diet, modes of life, certain
occupations and acquired habits. All these cir-
cumstances more or less affect the pulse, and
cause it to deviate from what may be regarded as
its medium or standard condition, and they are all
of them objects of especial attention to the judi-
cious and intelligent physician. The further con-
sideration of these may, however, be more conve-
niently referred to the third division of this ar-
ticle.

III. Pathology of the Pulse. — After having
made ourselves acquainted with the physiology of
the pulse, we shall be prepared for entering into
the consideration of its pathology, and for inquir-
ing into the degree in which it may serve us as
an indication of the nature and seat of disease.

We have had ample occasion to remark upon
the great difference of opinion that has existed on
this latter point among the most eminent men
both in ancient and modern times. While Hip-
pocrates and Celsus paid but little attention to the
indications of the pulse, Galen, on the contrary,
full into the opposite error, and aimed at what
was considered, even by some of his contempora-
ries, as an excessive and over-refined minuteness.
Among the moderns, the prevailing disposition
has been to regard the pulse as one of the most
important means of ascertaining the nature and
progress of disease ; and it may be asserted gene-
rally, that the pulse is among the first objects to
which the practitioner directs his attention. Yet
even among the most enlightened and candid of
the moderns, we have opinions promulgated which
must diminish the confidence we might otherwise
be disposed to feel on this subject. We have seen
above, that Dr. Heberden limits the characters of
the pulse, which are available by the practitioner,
almost to its different degrees of frequency ; and
with respect to its indications generally, the ten-
dency of his observations is to show that the pulse
is, in many cases, a very inadequate guide in en-
abling us to form our indications, and that not
unfrequently it would lead us to absolutely erro-
neous conclusions.

In this state of uncertainty it may be useful to
recur to first principles, and to endeavour to unite
theory with experience and observation. If there
be a state of the system in which the muscular
contractility and the nervous energy are one or
both of them increased, we might expect that an
increased action of the heart would be the conse-
quence, and that this increased action would be
communicated to the arteries, and would, accord-
ing to circumstances, produce a full, a hard, a
frequent, or a quick pulse, or any combination of
these conditions. If, on the contrary, the force of
the heart be diminished, either directly by the
diminution of its contractility, or indirectly by that
of the nervous influence, the blood will be pro-
pelled with less force into the arteries, and will be
moved with less facility along them. The pulse
will then become languid or oppressed, feeble,
small, intermitting, or irregular, according to the

quantity of blood in the vessels, and the relation
of this to the vital powers.

Proceeding, then, upon the united basis of
theory and observation, it may be useful to consi-
der, first, what characters of the pulse are the most
distinctly perceived and clearly discriminated ;
and, secondly, to inquire what conditions of the
vital powers or of the functions may be supposed
capable of producing a distinct and specific change
in the state of the pulse.

But before we proceed to examine into the re-
lation which these various states of the pulse bear
to the different morbid conditions of the body, it
will be proper to offer a few brief remarks on the
effect of the circumstances alluded to above, which,
independently of disease, are supposed, in a greater
or less degree, to influence the circulation.

The first in point both of order and of impor-
tance is the age of the subject. The pulse of a
newly-born infant is 130 or 140 in a minute,
nearly twice as frequent as that of an adult ; but
its frequency soon begins to diminish, its mean
rate during the first month being about 120.
During the first year it falls to about 110 ; during
the second year to about 100 ; from the third to
the sixth year it may be estimated at about 90 ;
and by the tenth or twelfth year it arrives at the
state in which it remains for the greatest part of life.

[More accurate observations have indicated
conditions of the pulse in the different ages that
had been overlooked. In infancy, it is generally
irregular and always rapid ; and in old age, con-
trary to the views generally embraced, it often
certainly becomes more rapid than in the adult.
Researches by MM. Hourmann and Dechambre
(Archiv. general, de Medecine, 1835) on 255
women, between the ages of 60 and 96, have
shown the average number of the pulse to be
82-29. M. Rochoux, however, (art Pouls, in
Diet, de Med. 2d edit. xxv. 614, Paris, 1842;
see also Piorry, Traitede Diagnostic, § 555,) still
considers that, as a general rule, the pulse dimin-
ishes in frequency in the progress of age ; and the
same inference has been drawn, it will be seen, by
Dr. Knox. It is important, also, to remark, that Dr.
Gorham (Lond. Med. Gaz. Nov. 25, 1837,) found
the mean number of the pulse, from five months to
two years old, to be 130; and 107.63 from two
to four years old; from which time until the 10th
year, the number continues almost the same.
Unless these facts be borne in mind, that velocity
of the circulation, which is healthy, may be re-
garded as morbid. (See, on this subject, Trous-
seau, in Journ. des Connaiss. Med. Chir. Juillet
and Aout, 1841, or Amer. Journ. of the Med.
Sciences, Oct. 1841,p.458,and Jan. 1842, p. 199.)]

Numerous observations have been made for the
purpose of fixing the average rate of the pulse in
the healthy adult. This subject was particularly
attended to by Dr. Falconer, and we find in his
essay a copious collection of observations made
by himself and others, in order to ascertain this
point; the number which he fixes upon is 75,
and there appears sufficient ground for acquies-
cing in his conclusion. It is further to be re-
marked that the pulse is more irritable in youth
than in more advanced age, being more affected
both by external and internal causes.

With respect to the two sexes, it is generally

760

PULSE.

admitted that the pulse of the fejiale is more fre-
quent than that of the male, perhaps eight or ten
beats in the minute ; it likewise resembles the
pulse of youth in its liability to be affected by all
those circumstances which influence the state of
the circulation. An analogous observation may
be made with respect to temperaments ; in the
sanguine temperament, where the constitution
more resembles the state of youth and of the
female, the pulse is more frequent and more irri-
table than in that of an opposite character. With
respect to idiosyncrasies, it is obvious that no
general remarks can be made ; but it is important
for the practitioner to be aware that individuals,
who may resemble each other in all that respects
age, sex, or temperament, may still have a differ-
ent rate of the pulse, and this independent of
any apparent morbid condition or assignable
cause.

[In some individuals in health, the number of
beats is singularly few. The pulse of a healthy
adult, known to the author, was, on the average,
36 per minute. Not unfrequently, on the other
hand, it exceeds 100 in health. Strange to say,
the pulse has been known to be wholly absent,
without the health being interfered with. Such
a case has been related by Professor Jackson, of
Philadelphia, {Principles of Medicine, &c. p.
492, Philad. 1832); and for other cases, see the
writer's Human Physiology, ii. 164.)]

The states of sleep and watching, and more
generally of rest and motion, very considerably
affect the pulse. The observations that have been
made on the pulse during sleep are not altogether
uniform, but they tend generally to the conclu-
sion, that the pulse becomes slower during this
state. With respect to the effect of motion,
every one is aware how much the pulse is in-
creased in frequency by exercise of any kind ; the
degree of this increase being partly in proportion
to the degree of exercise employed, and partly to
the previous state of the constitution or the ordi-
nary habits of the individual. On this subject,
as well as on many other points connected with
the mechanism of the pulse, we have a number
of valuable observations by Bryan Robinson, a
writer whose facts appear to be correct and worthy
of our attention, although his physiological hypo-
theses are, for the most part, discarded. (Trea-
tise on the Animal Economy, 1732.)

[Dr. Guy (Guy's Hospital Reports, April,
1838, p. 92. See, also, Dr. John M. B. Harden,
in Amer. Journ. of the Med. Sciences, for April,
1843, p. 340)', from numerous observations, found
the pulse in healthy males, of the mean age of
27 years, in a state of rest, 79 when standing, 70
sitting, and 67 lying ; the difference between
standing and sitting being 9 beats ; between sit-
ting and lying, 3 beats; and between standing
and lying, 12 beats. When all exceptions to the
general rule were excluded, the numbers were, —
standing 81 ; sitting 71 ; and lying 66, — the dif-
ference between standing and sitting being 10
beats ; between sitting and lying 5 beats ; and
between standing and lying 15 beats. The effect
produced upon the pulse by change of posture,
Dr. Guy ascribes to muscular contraction, whether
employed to change the position of the body or to
maintain it in the same position. In children the

difference between the pulse in the sitting and
lying posture is often very marked. In a boy, six
years of age, the writer found it to amount to
fifteen beats ; and Dr. Evanson (Treatise on Dis-
eases of Children, by Drs. Evanson and Maun-
sell, Amer. edit, by Dr. Condie, p. 19, Philad.
1843) states, that he has often found the pulse, —
which at night, during sleep, was 80, full and
steady — up to 100 or even 120 during the day,
small and hurried, and this in children six or
seven years of age, and in perfect health.]

The state of the system with respect to reple-
tion or inanition very materially affects the pulse.
The taking of food increases both its frequency
and its fulness, and that often in a very considera-
ble degree. After a : meal which cannot be re-
garded as excessive or intemperate, the pulse
may be increased by one-fifth of its average num-
ber of beats, while its strength and fulness are
almost equally augmented. When abstinence is
carried to a great and unnatural excess, the pulse,
although much diminished in strength, appears to
be increased in frequency ; but this occurrence
can seldom be observed without the presence of
some other disease, which is the immediate cause
of the abstinence, and which would probably of
itself affect the pulse.

Every one is aware how much the circulation
is affected by mental emotions of all kinds. If
we arrange them, according to the ordinary dis-
tribution, under the two great classes of exciting
and depressing, we shall find that they, each of
them, increase the frequency of the pulse; the
former, however, for the most part, have the effect
of also increasing its force, while the latter, on
the contrary, render it more feeble.

It is generally admitted that the pulse under-
goes a kind of periodical revolution during the
course of the day, and this independent of any
of those circumstances, external or internal,
which might be supposed to affect it. This sub-
ject has been attended to by various physiologists,
and among others by Bryan Robinson and Fal-
coner, who have given us tables of the results of
their observations. We are, however, scarcely
able to draw any conclusions from them, except
that the pulse is less frequent in the morning, and
that it has a general disposition to become more
frequent as the day advances ; but it appears very
difficult, if not impossible, to determine in what
degree this increased quickness is to be attributed
to food, exercise, or to other exciting causes.

[From observations made by Dr. Knox (Edinb.
Med. and Surg. Journ. April, 1837), he has
drawn the following deductions on this subject,
which accord greatly with those of Dr. Guy on
the same subject (Ibid. Jan. 1841, p. 90): 1.
The velocity of the heart's action is in a direct
ratio with the age of the individual, — being quick-
est in young persons, slowest in the aged. There
may be exceptions to this, but they do not affect
the general law. 2. There are no data to deter-
mine the question of an average pulse for all
ages. 3. There is a morning acceleration, and
an evening retardation in the number of the
pulsations of the heart, independently of any
stimulation by food, &c. 4. The excitability of
the heart undergoes a daily revolution ; that is,
food and exercise affect the heart's action most

PULSE.

rei

in the morning, and during the forenoon, least in
the afternoon, and least of all in the evening.
Hence it must be inferred, that the pernicious use
of spirituous liquors must be greatly aggravated
in those who drink before dinner. 5. Sleep does
not farther effect the heart's action than by a ces-
sation of all voluntary motion, and by a recum-
bent position. 6. In weak persons, muscular
action excites the action of the heart more power-
fully than in strong and healthy individuals ; but
this does not apply to other stimulants, to wine
for example, or to spirituous liquors. 7. The
effects of the position of the body, in increasing
or diminishing the number of pulsations, is solely
attributable to the muscular exertion required to
maintain the body in the sitting or erect attitude :
the debility may be measured by altering the
position of the person from a recumbent to a sit-
ting, or to the erect position. 8. The most pow-
erful stimulant to the heart's action is muscular
exertion. The febrile pulse never equals this.]

We are still less able to draw any general con-
clusions respecting the operation of the external
causes, which were enumerated above as liable to
affect the pulse; it is less easy to observe their
distinct and separate action on the system, and it
may be apprehended that the operation itself is
in most cases less uniform. If there be any ex-
ception, it is with respect to external temperature,
which seems very generally to increase the fre-
quency, and in most cases the strength and ful-
ness of the pulse. Temperature, however, like
all other stimulating agents, if carried beyond j
certain limits, either as to quantity or duration, I
exhausts the vital powers, and produces a state
of weakness, which may be recognised by the
pulse. Excessive cold exercises a directly debili-
tating power over the system, and produces a
corresponding effect on the pulse. There is,
however, a considerable diversity in the accounts
which we have on this subject, in consequence
of the difficulty there is in ascertaining the point
at which cold may be considered as exceeding the
limits of the salutary action which it exerts when
in a moderate degree only. With respect to the
other external causes which affect the pulse, we
may remark that they are all of them points to
which the practitioner should direct his attention,
in order that he may learn to distinguish between
the effects which proceed from these causes, and
those which belong to the diseases under treat-
ment.

To return from this digression to consider the
characters of the pulse, the following may be enu-
merated among those which are the most distinct
and unequivocal. In the relations of time, tho
pulse mav be frequent or rare, quick or slow ; in
the relations of force, it may be strong or weak,
hard or soft, full or small, free or compressed : in
the third relation, of equality, we have the irregu-
lar pulse with respect both to time and force, wit i
the varieties of each, the intermitting, the rebound-
ing, the fluctuating or wavering pulse, &c.

In considering the changes that may be com-
municated to the pulse by a change f in the act on
of the heart, we may remark that, of the two vital
powers which contribute to this action, the m -
vous power is the one the most liable tc vanat on*
and the most under the influence of external

Vox.. III. -96 3o *

agents ; we therefore assume that, in most cases
of increased or diminished action, the change
originates in an affection of the nervous system.
It hence becomes necessary to consider what are
the laws which regulate the actions of the nervous
system — at least what are the changes in this
action which are especially applicable to the case
in question. Now there are two states of the
nervous system recognised by physiologists, which
must influence the action of the heart in such a
way as to affect the frequency of the pulse ; the
first condition, which has been termed the in-
creased mobility or excitability of the nervous sys-
tem, the other a sedative operation, tending directly
to diminish its action. The effect of the increased
mobility of the nervous system is to render a part
under the influence of the nerves more susceptible
of action, while the force of the action is not pro-
portionably increased ; the operation of a directly
sedative agency is to diminish the action of the
parts in all respects, both as to susceptibility and
to force. The diseases of hysteria and apoplexy,
or rather the tendency to these diseases, may be
cited as affording us, respectively, types of these
two states of the nervous system ; the former giv-
ing rise to frequent and irregular contractions of
the muscles, the latter tending altogether to de-
stroy their contractility. Hence we observe a
foundation for what at first view might appear a
contradiction, that a debilitating cause, acting on
the heart, may in one case cause an increased,
and at another time a diminished frequency of the
pulse.

It is generally admitted by physiologists, that a
principle analogous to what has been described as
occurring in the nervous system exists also in the
muscular; that absolute force and susceptibility
of action bear no necessary relation to each other,
but that each of them may be increased or dimin-
ished without a corresponding change in the con-
dition of the other. With respect to the pulse,
however, it is admitted that we are, for the most
part, unable to distinguish between the affections
of the muscular and the nervous systems ; conse-
quently all that we can aim at is to ascertain in
what manner or in what degree the morbid cause
acts generally upon the powers which increase or
diminish the susceptibility or force of the contrac-
tions of the heart.

It will be scarcely necessary to offer any re-
1 marks on the mode of feeling the pulse. We
have, indeed, in some of the older writers, many
minute directions on this subject, and in some
French works, even of recent date, the " explora-
tion" of the pulse is treated of in detail, as an ela-
borate art of difficult attainment. It no doubt re-
quires accurate observation and minute attention
to appreciate all the changes to which the pulse is
liable, but there appears to be nothing in the sub-
ject of peculiar dilficulty, or which will not be
overcome by a due familiarity with the phenomena
of disease. The anatomical structure of the part,
and its practical convenience, render the artery at
the wrist, in a great majority of cases, the most
eligible part for ascertaining the state of the pulse;
we may occasionally find it necessary to examine
the artery in the neighbourhood of a part which is
supposed to be the immediate seat of the disease,
and in some instances we compare the action of

762

PULSE— PURPURA.

different arteries with each other ; but these are
points which scarcely require or admit of general
directions.

What has been stated above bears immediately
upon the second point which we proposed for
consideration, viz. to inquire what condition of
the vital powers or of the functions may be sup-
posed capable of producing a distinct and specific
effect upon the pulse, and what are the diseases
which derive their distinctive characters from the
changes consequent on these conditions. Now
we shall find that the diseases in which the action
of the heart is more immediately or directly con-
cerned are those which we referred to the great
class of febrile affections. These may be ar-
ranged under the two divisions of fevers that ori-
ginate in, or are essentially connected with, in-
creased action of the vital powers, and those which
originate in a diminished action of these powers ;
the first constituting what is popularly termed in-
flammatory fever, the synocha or cauma of sys-
tematic writers ; the latter the low or nervous
fever, the typhus of the nosologists. If to these
we add a third class of diseases, which depend
upon a directly sedative operation on the nervous
system, nearly corresponding to the anaesthesia? of
the nosologists, we shall have three great divisions,
to which we may refer all the various changes in
the state and condition of the pulse which can be
easily reduced to any general principles.

We are now arrived at that part of the subject
to which all the rest ought to be subservient, and
which alone gives it its value — the practical appli-
cation of our theoretical principles ; yet, import-
ant as it is, on this occasion it must necessarily be
passed over with a very slight notice. All that
can be accomplished in an essay like the present,
is to establish and illustrate certain general posi-
tions, which may be applicable to each particular
disease, or even to each individual case, — a detail
which would be inconsistent with the nature and
the limits of our article, but which will be amply
supplied by the other parts of this work.

The object of the practitioner is to ascertain, if
possible, in the first instance, what is the ordinary
state of the pulse of each individual, as depending
upon his peculiar constitution or habits ; and, se-
condly, how it may be supposed to be affected by
the circumstances, either external or internal,
which were enumerated above, and which are in-
dependent of the disease in question. In the third
place, he must ascertain the state of the pulse with
respect to its three principal relations of time,
force, and equality, considered either simply or in
combination, and endeavour to trace their connec-
tion with the supposed cause of the disease, and
with the derangement which has been induced in
the various powers and functions of the system.
These he will probably find it convenient to refer
to one or other of the three great classes mentioned
above, and he must regulate his practice, and form
his diagnosis and prognosis by still farther viewing
them in connection with the other symptoms of
the disease. The result of this process will be,
that by referring to the physiological principles
which we have attempted to establish, the practi-
tioner will frequently be enabled to explain what
would otherwise be obscure and unintelligible;
yet it must be acknowledged, on the other hand,

that he will meet with numerous anomalies which
he will find it impossible to reduce to his system,
and which can only be duly appreciated by a care-
ful and diligent observation of the phenomena of
disease, and by steadily preferring the result of
experience to the deductions of any theory, how-
ever plausibly formed or ingeniously supported.
[See on the whole subject of the pulse, Piorry,
TraiU de Diagnostic, § 537.]

John Bostock.

PURGATIVES.— See Cathartics.

PURPURA The terms purpura, [or por-

phijra] purpura hemorrhagica, and haemorrhaea
petechialis, are employed to denote that affection
which was formerly distinguished in medical
writings by the designations of morbus maculosus
hsemorrhagicus, petechia? sine febre, phcenigmus
petechialis, (Sauv.) &c. This disease is charac-
terized by an efflorescence on the skin, occurring
independently of primary fever, consisting of red,
purple, or livid spots of various sizes, (termed
petechias, vibices, and ecchymoses,) and in its
more severe form accompanied by hemorrhage
from various parts of the body, chiefly from the
mucous membranes. The spots are seldom elevated
above the level of the surrounding cuticle ; they
are unattended by itching or any uneasy sensa-
tion ; and on division of the cuticle by a scalpel
they are found to consist of minute effusions of
blood. They are therefore essentially different
from every form of rash or other cutaneous erup-
tion ; and are properly considered as the result of
a cutaneous hemorrhage.

[In consequence of the appearance of the skin,
purpura has been commonly classed amongst
cutaneous diseases. Willan has treated, under
the head of purpura, of the land-scurvy, and of
the petechial spots of malignant fever, — petechia
contagiosa; yet he has omitted sea-scurvy, — an
affection almost identical with land-scurvy. They
are all — as a general rule — dependent upon a
similar depraved condition of the fluids and solids ;
are true cachexies, in other words ; and have ac-
cordingly been treated of, by the writer, under
Scorbutic Cachexia. (Practice of Medicine, 2d
edit. ii. 632, Philad. 1844.)]

Petechias (a name introduced into nosological
language from the Italian petecchia, and supposed
to be originally derived from their resemblance to
flea-bites) have been long noted as a symptom in
continued fevers and other febrile diseases, in which
they have been supposed to indicate peculiar ma-
lignancy. (See the article Feveii.) From their
constant occurrence in certain epidemic fevers,
these were considered as constituting a specific
exanthematous disease, which was described in
nosological systems and practical writings under
the names of petechia;, febris petechialis, febris
purpurata, &c. The occurrence of petechia? in
continued fever, no less than in small-pox, measles,
&c. is now universally allowed to be a contingent
symptom, and most commonly arises from the in-
fluence of foul air, a hot regimen, the neglect of
purgatives, or similar errors in treatment. It is
accordingly much less frequent than formerly.
Petechial fever is the " purpura" of Sauvages'
nosology ; a term which had previously been used

PURPURA.

763

in the same sense by Kiverius, Diemerbroeck, &c.
By others of the old writers it had been employed
to signify affections totally different, viz. various
forms of papulous eruptions and rashes, as red-
gum, lichen, miliaria, nettle-rash, measles, and
scarlatina. (Willan on Cutaneous Diseases, p.
452. — Bateman, Synopsis, p. 103, third edit.)
We must therefore take care not to apply their
observations to what is now termed purpura.

We owe the name of purpura in its present
acceptation to Dr. Willan. In his nomenclature
of cutaneous affections it is used as a generic
term, to include every form of petechial eruption,
febrile or non-febrile. He therefore includes under
it, as a species, purpura contagiosa, the petechial
eruption in continued fevers ; a name every way
objectionable, as it would tend to perpetuate the
ancient errors of the idiopathic nature and specific
contagion of those petechia. Under the names of
P. simplex, P. hemorrhagica, and P. urticans, he
describes " three striking varieties" of petechial
eruption independent of primary fever, — varieties
which confessedly differ chiefly in degree, and
which, under the general name of purpura, form
the subject of the present article.

Purpura, considered by Willan as an affection
of the skin, was ranked by him under the order
" Exanthemata," or rashes, of his arrangement ;
to which it bears some affinity in external appear-
ance only, but even in this respect does not agree
with his definition of the order. Rayer has more
correctly classed purpura (under the somewhat
quaint name of hemacelinose, — from aipa, blood,
»»j'\f?, spot, voaa, disease; Rayer, Malad. de la
Peau, t ii. p. 158,) under « Cutaneous and Sub.
cutaneous Hemorrhages." But purpura cannot
be correctly considered as merely a cutaneous dis-
ease, since, as Dr. W T atson has well observed, " the
effusion of blood (which, strictly a hemorrhage in
all parts, takes the form of red or purple spots
where the quantity effused is but a drop) is not
confined to the skin nor to the subcutaneous tis-
sues, but is observed occasionally on the internal
surfaces also, and in the parenchymatous surface
of the viscera. The disease, therefore, is properly
a hemorrhage, but it is not properly, or merely, a
cutaneous hemorrhage."

Purpura, considered as a hemorrhagic affection,
is a most interesting subject of pathological in-
quiry, and demands peculiar attention from the
danger which attends it, and from the obscurity
which attaches to its nature and mode of cure. It
has, therefore, ever since it was first distinguished
from typhoid fever, attracted much notice from
medical writers. For its earlier literary history,
the reader must be referred to Dr. Willan's work,
where he will find it amply detailed. Reference
to the old writers can be of little avail for patho-
logical and practical purposes. The first syste-
matic account of the disease, under the name ot
hemorrhoea petechialis, was given in this country
by Dr. Adair, in his thesis published in 1/8J.
Dr. Bateman, in his inaugural dissertation pub-
lished in 1800, described it under the jame ap-
pellation. The description of purpura by W illan
in his Reports of the Diseases ^ LonJon > T^
subsequently in his great work on Disease, .0 the
Skin is given with his usual perspicuity, but he
was p actically unacquainted mth the severer

cases of the disease, never having met with one
which proved fatal. He considered the disease as
nearly if not quite identical with scorbutus, and to
be combated by similar remedies. These views
were disputed by Dr. Parry and Dr. Harty, and
were considerably modified by Dr. Bateman in
his Synopsis. Since that period a succession of
valuable and instructive cases have been published
in the Edinburgh Medical and Surgical Journal,
and a few in other periodical works.* Yet much
remains to be done ere the pathology of purpura
or its treatment can be considered as satisfactorily
fixed on scientific principles.

Phenomena of the disease. — These may
be referred to — 1. appearances on the skin; 2.
hemorrhages ; 3. constitutional symptoms ; 4. pro-
gress and duration of the disease ; 5. circumstances
noticed respecting the blood and the urine; 6.
morbid appearances on dissection.

1. We have already given a general description
of the efflorescence on the skin characteristic of
purpura. There are three different forms of it,
(well represented in plates xxviii. and xxix. of
Bateman's " Delineations,") viz. the P. simplex,
P. haemorrhagica, and P. urticans of Willan. The
P. senilis of Bateman (figured in his 30th plate)
is a nearly local form of ecchymosis, unattended
with fever, hemorrhage, or other constitutional
symptoms; we shall therefore refer to the "Deli-
neations," and to the third and subsequent edi-
tions of the " Synopsis," for his account of it.

In the purpura simplex, the petechia? are
described by Willan and Bateman as occurring
with little constitutional disorder. " They are
most numerous on the breast and on the inside
of the arms and legs, and are of various sizes, from
the most minute point to that of a flea-bite, and
commonly circular. They may be distinguished
from recent flea-bites partly by their more livid or
purple colour, and partly because, in the latter,
there is a distinct central puncture, the redness
round which disappears on pressure." (Bateman,
Synopsis, p. 104.) Purpura simplex is chiefly
noticed in women and delicate children. It is
thus described by Heberden : — "Cutis puerorum
interdum ubique distinguitur maculis purpureis,
similibus earum quae in febribus nascuntur. Tamen
cum his adversa valetudo nulla est, neque praeces-
sit, neque subsequitur. Alia? pustulse (scil. ma-
culae) vix sunt semine milii majores, alia? sunt ties
pollices ampla?. Post paucos dies cuncta?, sine
medicamentorum auxilio, sua sponte plerumque
recedunt. In quodam puero sic affecto, si modo
digitus leviter cuti imprimeretur, continuo sanguis

* Duncan (senior), Medical Cases, Edin. 1781, p. 90.—
Rogert, Acta Soc. Keg. Med. Haft), torn, i.— Adair, Diss.
Inaug. Edin. 1781. — Ferris, Med. Facts and Observat.
1781. — Tattersall, Med. Comment, vol. xx. (1795.) —
Walker, Annals of Med. vol. ii. (1797.) — Bateman, Diss.
Inaug-. 1800.— Willan, Reports on Diseases of London.—
Willan on Cutaneous Diseases.— Bateman's Synopsis. —
Bateman's Reports on Diseases of London. — Parry,
Edin. Med. Journ. v. 7. Bateman, ibid. vi. 224 and 374.
—Jeffreys, ibid, vi ii. 435. — Walsh, ibid. ix. 161. — Harty,
ibid, ix: 186. — Ibid, xiii. Wi. — Combe, ibid. xvii. 83. —
Johnston, ibid, xviii. 402. — Duncan (junior), ibid. 405.—
JYkholl, ibid, xviii. 540. — Darwall, ibid, xxiii. 53.— Magee,
ibid. xxiv. 2.07 —Kift, ibid, xxvii. 71.— Blackall on Drop
sirs, p. 150. — Yeats, Medical Transactions, iv. 429.-
Oairdncr, Edin. Medico-Cliirnr. Trans, i. 671. — Wood,
ibid. 680. — Fairbairn, ibid. ii. 157. — Latham, Med. Ga
zette, i. 514.— Watson, ibid. vol. vii.— Mackintosh's Pract
of Physic, vol. ii. — Bayer, Malad. de la Peau, torn. ji.
p. 168.

764

PURPURA.

ex vasis vicinis exiit, et sugillatio, tanquam in
collisis, facta est." (Heberden, Comment, cap.
Ixxviii. de maculis purpureis.) The latter cir-
cumstance is more frequently noticed in the next
form of the disease.

In purpura hemorrhagica " the petechia? are
often of a larger size, and are interspersed with
livid stripes and patches, resembling marks left by
the stroke of a whip, or by violent bruises. They
commonly appear first on the legs, and at uncer-
tain periods afterwards on the thighs, arms, and
trunk of the body, the hands being more rarely
spotted with them, and the trunk generally free.
They are usually of a bright red colour when they
first appear, but soon become purple or livid ; and,
when about to disappear, they change to a brown
or yellowish hue ; so that, as new eruptions arise,
and the absorption of the old ones slowly proceeds,
this variety of colour is commonly seen in the
different points about the same time. (See Delhi,
plate xxviii. fig. 2.) The cuticle over them ap-
pears smooth and shining, but is not sensibly
elevated : in a few cases, however, the cuticle has
been seen raised into a sort of vesicles, containing
black blood .... The gentlest pressure on the skin,
even such as is employed in feeling the pulse,
will often produce a purple blotch like that which
is left after a severe bruise." {Bateman, Synop-
sis, p. 105.) The nature and seat of the small
effusions of blood which constitute the petechioe,
from which the vibices and ecchymoses differ
chiefly in magnitude, are well explained by the
anatomical researches of Rayer. " On dissecting
the skin," he observes, " it is found that the
petechia? and ecchymoses do not all occupy the
same situation. Some are very superficial, and
seated on the surface of the rete mucosum ; others
occupy the alveoli of the cutis ; the largest and
darkest-coloured have their seat under the skin in
the cellular tissue. In these the blood is found
coagulated, but it is fluid in the smaller and more
superficial effusions. The vascular ramifications
contiguous to these minute ecchymoses are in
their natural state. The blood is easily removed
by washing or maceration." {Rayer, Malad. de
la Peau, ii. 162.)

The variety termed by Willan and Bateman
purpura urticans, is comparatively rare. It is
characterized by " rounded and reddish elevations
of the cuticle, resembling wheals, but which are
not accompanied, like the wheals of urticaria, by
any sensation of itching or tingling." These
little tumours gradually dilate ; but within twenty-
four hours or somewhat longer, subside to the
level of the neighbouring cuticle. They are com-
monly situated on the legs, where they are inter-
mixed with petechia? ; (see Delineat. plate xxix. ;)
they also appear on the thighs, breast, arms, &c.
The spots are not permanent, but fade, while
others appear in succession in different places.
The duration of the complaint varies from three
to five weeks. Willan never observed it to be
attended with hemorrhage or fever ; he states that
it generally occurs in summer and autumn, and
attacks those who are exposed to daily fatigue,
&c, or young women who live luxuriously and
take little exercise. Some cedema of the ex-
tremities usually accompanies it, and it is occa-
sionally preceded by stiffness and pain in the |

legs. ' (Willan on Cutaneous Diseases, p. 461. —
Bateman's Synopsis, p. 116.)

2. The hemorrhages attendant on purpura take
place from the mouth, nostrils, bronchial tubes,
stomach, intestines, bladder, uterus, — in short,
from every part of the mucous membranes. They
also in some cases occur from the skin ; at least
this singular hemorrhage bears in some cases a
close analogy to purpura. In all these cases the
effect produced on the system is from the loss of
blood ; but where the hemorrhage is strictly in-
ternal, as from the serous membranes or the
parenchymatous substance of the viscera, the mis-
chief is done by the mechanical compression or
destruction of the texture of organs essential to
life. Both cerebral and pulmonary apoplexy may
thus occur and destroy the patient; of which
there are several cases on record.

The most frequent hemorrhage, particularly in
weak subjects, and where there is an approach to
what has been termed the scorbutic diathesis, is
that from the mouth. The gums are tender, and
easily bleed on being touched. The lining mem-
brane of the inside of the lips and cheeks, the
investing membrane of the tongue, and also in
some cases that which covers the tonsils and con-
tiguous parts, present dark-coloured spots, which
are usually elevated and distended with blood,
which they pour out either spontaneously or on
the slightest pressure. In some very unfavourable
cases, as that related by the late Dr. Duncan,
(Edinburgh Med. Journal, vol. ix. p. 405,) these
spots degenerate into gangrenous ulcerations.

The tendency to the several kinds of hemor-
rhage varies at different periods of life : according
to Rayer, epistaxis is the most common in children,
as might be expected ; uterine hemorrhage in
women ; and pulmonary or intestinal hemor-
rhage in male adults. The quantity of blood lost
is often very considerable ; and, as in other cases
of hemorrhage, it is very apt to recur, and to be-
come periodical. A case is mentioned where it
returned daily at the same hour for a considerable
period.

3. We have already stated that the constitu-
tional symptoms are usually but slight in the
varieties of the disease termed P. simplex and P
urticans. In both of these forms, occurring with-
out hemorrhage, considerable febrile excitement
has been observed in some cases. With regard to
P. hajmorrhagica, the following account of the
preceding and accompanying symptoms is given
by Bateman : « This singular disease is often pre-
ceded for some weeks by great lassitude, faintness,
and pains in the limbs, which render the patient
incapable of any exertion ; but not unfrequently
it appears suddenly, in the midst of apparent good
health. It is always accompanied by extreme
debility and depression of spirits ; the pulse is
commonly feeble, and sometimes quickened ; and
heat, flushing, perspiration, and other symptoms
of slight febrile irritation, recurring like the pa-
roxysms of hectic, occasionally attend. In some
patients, deep-seated pains about the pracordia,
and in the chest, loins, and abdomen, have been
felt. In others, a cough has accompanied the
complaint, or tumour and tension of the epigas-
trium and hypochondria, with tenderness on pres-
sure, and a constipated or irregular state of thfl

PURPURA

765

bowels. But in many cases no febrile symptoms
have been noticed ; and the functions of the in-
testines are often natural. In a few instances
frequent syncope has occurred. When the dis-
ease has continued some time, the patient becomes
sallow, or of a dirty complexion, and much ema-
ciated ; and some degree of oedema appears in the
lower extremities, and afterwards extends to other
parts." (Bateman, Synopsis, p. 107.) This is
a very faithful general account ; but in several of
the cases which have been recorded, the febrile
symptoms, and those indicative of internal affec-
tions of the congestive or inflammatory kind, have
been much more considerable than we should
collect from Dr. Bateman's statement. Such af-
fections are considered by Rayer as always con-
stituting an "accidental complication" of purpura;
and he says that it is only in such cases of acci-
dental complication that he has seen it present
the characters of active hemorrhage. (Op. cit. ii.
167.) On the other hand, it is to be observed
that the mode of treatment which has been directed
to the relief of the internal symptoms, has in
several well-marked cases procured the cessation
of those proper to purpura ; an effect which has
also not unfrequently occurred from a profuse
eruption of the catamenia, (Bateman, Reports of
Diseases of London, p. 130,) or from a hemor-
rhage which has appeared to be, in the language
of the schools, critical. This subject, however,
will more properly come to be considered under
the heads of pathology and treatment.

4. " The purpura hemorrhagica," observes
Willan, " has not any regular or stated termina-
tion. It was protracted, in the cases under my
own observation, from fourteen days to twelve
months and upwards. The disease did not, in
any of these cases, prove fatal." (Op. cit. p.
457.) In some cases the disease has proved fatal
from internal or external hemorrhage, or the vio-
lence of the febrile symptoms, or prostration of
the vital powers, in a shorter time, considerably,
than the former period mentioned by Willan. In
others it has assumed a completely chronic form,
and either recurred periodically, or as to some of
its symptoms been more or less constantly present.
Several well-attested cases are recorded where it
has appeared to be linked in an inexplicable man-
ner with the mode of existence of the individual,
and put on the character of what are properly
called " constitutional hemorrhages." (See He-
morrhage.) In such cases, it has existed for
years without impairment of the general health.
A boy is mentioned by Bateman on the authority
of the elder Dr. Duncan, whose skin for severa
years was constantly covered with petechias, and
exhibited vibices or purple blotches on the slight-
est blow ; yet he was in other respects in good
health, and capable of active exercise. Pulmo-
nary hemorrhage at length supervened, and car-
ried him off: (Synopsis, p. 108.) A case ,s re-
lated by Adair, where the symptoms of purpura
recurred regularly for six succeeding summers.
(Diss. Inaug. p. 16.)

K 5. We have not been .be to meet with any
account of the chemical analysis of the .Hood .m
a case of purpura. Its sensible qualities, how-
ever and nfode'of coagulation have been carefully

noted in several cases. Dr. Watson asserts that
" in many, perhaps in all instances of the disease,
in which it can be examined, the blood is found
actually to have undergone a change, and not
merely a change which may be ascertained by
nice or elaborate chemical research, but such an
alteration of its sensible qualities as is evident to
the eye, and forces itself upon our notice." (Wat-
son's Lumleian Lecture, Med. Gazette, vol. x. p.
499.) The inquiry into the state of the blood is
certainly one of the highest interest, both with
regard to the pathology of this disease in particu-
lar, and as it bears upon the general doctrines of
pathological science. But in pursuing it we must
be careful to keep in view the causes which, inde-
pendently of any primitive alteration in the state
of the blood existing as the cause of all the phe-
nomena of purpura, may materially affect the
condition of that fluid. The coexistence of fever
or inflammation will, of course, give rise to those
alterations in the blood which are proper to those
morbid states ; accordingly we find it stated by
Dr. Parry, that in both his cases the blood was
highly buffed, the crassamentum firm and cohe-
sive, but bearing a small proportion to the serum.*
In other cases where the blood has been examined,
there had previously occurred either very profuse
or long-continued hemorrhage, which necessarily
altered the quality of the blood by diminishing
the quantity of the red globules as well as of the
fibrine of the blood in proportion to the serum.
Our conclusions ought, if possible, to be derived
from the examination of blood drawn at the height
of the disease, when no excessive hemorrhage
has preceded, and in cases where there are no
decided marks of inflammation or other disease
coexisting with purpura.

Some of the most remarkable results of the ex-
amination of the blood in purpura have been the
following. In the case of a sea-captain, a pletho-
ric subject with a full pulse, the state of the blood
obtained by a second venesection, and when pur-
gatives had been prescribed, and two pounds of
blood previously lost by epistaxis, is described by
Dr. Jeffreys as follows : " The blood drawn yes-
terday shows an inflammatory buff" on its surface,
at least an inch and a half in thickness, firm and
yellow, far exceeding any thing I ever saw in
rheumatism or pneumonia, but not at all cupped ;
in fact, the whole serum looks like a corrupted
coat of coagulable lymph. The crassamentum
appears in a very dissolved state, of nearly a black
colour, and much less in quantity than usual."
(Edin. Med. Journal, viii. 435.) This patient
was again twice bled, the blood presenting the
same appearances ; he ultimately recovered. In
a case related by Dr. Johnston, of decidedly febrile
character, and which rapidly proved fatal, the
blood did not separate into serum and crassamen-
tum ; it had little consistence or tenacity, but
traces of coagulable lymph were diffused through
it. (Edin. Med. Journal, xviii. 402.) In Dr.
Duncan's case, which has been already quoted,
the blood, while flowing slowly from the vein, was

*Eilin. Med. Journ. v. 8. In a case related by Bate
man, (Reports on Diseases of London, p. 131,) of purpura
occurring in a stout farmer, with a sharp and frequent
pulse, the blood also exhibited a firm burly coat.

7GG

PURPURA.

observed to be florid and semi-transparent, resem-
bling diluted arterial blood. It slowly formed a
loose coagulum, from which no serum was sepa-
rated ; the coagulum was like jelly, tremulous,
transparent, and colourless, the few red globules
having subsided to the bottom. In this case
much blood had been previously lost by hemor-
rhage. (Ibid, xviii. 405.) In Dr. Combe's case
the'blood was pale, coagulated slowly, separated
no serum, and was not buffed. (Ibid. xvii. 83.)
In Dr. Gairdner's the blood first drawn by the
lancet seemed, four hours after, to coagulate very
imperfectly into a homogeneous mass. On the
following day it resembled a tremulous jelly, the
top of which was of a greenish buff colour with
brownish spots like tadpoles. What afterwards
oozed from the puncture resembled turbid lymph,
or a watery fluid containing colouring matter in
suspension ; the cloths taken from the arm ap-
peared as if stained with bloody water. (Edin.
Medico-Chir. Transactions, i. 671.) In Dr. Fair-
bairn's case the blood first drawn resembled that
described by Dr. Duncan and Dr. Combe; on a
second bleeding it presented the same appear-
ances ; but on the third it showed the buffy coat,
coagulated somewhat more firmly, and separated
a portion of serum. (Ibid. ii. 671.)

[These facts do not accord with the recent
views of Andral, (Hematologic Pathologique,
Paris, 1843, or translation by Drs. J. F. Meigs
and A. Stille, Philad. 1844,) that the fibrinous
element of the blood is probably depressed beneath
its normal proportion in every case of purpura
hemorrhagica.]

The state of the urine has been less attentively
noticed, or at least less frequently. We possess,
however, the accounts of two cases in which the
urine has been analyzed. At the conclusion of
Dr. Combe's case, which we have just referred to,
the results of the analysis of the urine are stated,
at the height, during the decline, and after the
cessation of the disease. At the height of the
disease, and previous to venesection, the urine was
found to contain a large proportion of serosity
and of the phosphates, no free acid, and but a
small proportion of urea. When the force of the
disease had been broken, and the hemorrhage had
ceased, there was no longer any albuminous mat-
ter, but a free acid, and but a small proportion of
urea. Finally, when the patient was convalescent,
the analysis of the urine detected no ingredients
differing from its healthy condition. In Dr. Gaird-
ner's case, also above referred to, the urine, on
analysis by Mr. Murray, showed a deficiency of
urea and an excess of albuminous matter. For
the chemical details we must refer to the original
cases. In Dr. Blackall's work on Dropsy, several
cases are related " resembling land-scurvy," two
of which, at least, are clearly cases of the hemor-
rhagic purpura, in which the attack was sudden
and attended with febrile symptoms. In both
these cases the urine was albuminous, and Dr. B.
states his opinion that « venesection would have
been their appropriate remedy ; in the early stage,
probably a successful one."

6. The appearances which are exhibited by the
skin on examination after death have already
been noticed. Of the morbid alterations disco-
vered in the internal organs we possess a tolera-

ble number of histories, recorded with various
degrees of minuteness.*

The chief morbid appearances which have been
noticed in the three great cavities have been tho
following :

In the head. In a case transcribed by Rayer
(Obs. 174,) from Stoll, the meninges of the brain,
especially on the left side, were spotted with seve-
ral large ecchymotic maculse ; some ecchymoses,
resembling clots of extravasated blood, from the
size of a lentil to that of a bean, were also found
in the convolutions of the brain. The surface of
the ventricles, and that of the cerebellum, were
covered with innumerable small petechia; ; the
left ventricle was distended with straw-coloured
serum. The girl who was the subject of this
case had died comatose, having previously suf-
fered severely from headach (which chiefly af-
fected the left side); she had high fever, petechia;,
and hemorrhage from the mouth. In Dr. Walsh's
case (Edin. Med. Journ. vol. ix.) of a soldier pre-
viously in good health, who died apoplectic on the
fourth day from the supervention of purpura he-
morrhagica, besides the impression of petechial
spots on the pericranium, and an ecchymosis of
the right temporal muscle, a considerable coagu-
lum (a table-spoonful) was found pressing on the
brain, and the vessels of the pia mater were turgid
with black blood. In Mr. Wood's case (Edin.
Medico-Chir. Trans, vol. i.,) the pericranium and
dura mater were covered with petechial spots,
and « in the right temporal region a fine coagu-
lum, floating in bloody serum, had forced its way
through the broken-down brain into the ventricle."
Similar effusions of blood on the brain were ob-
served in two cases by Dr. Watson. (Med. Ga-
zette, x. 502.)

In the chest the following appearances are no-
ticed by Rayer as characteristic of this disease.
" The outer surface of the lungs is commonly
speckled with numerous ecchymoses, which are
the more distinctly visible, that the surface of the
lung in the intervals retains its natural hue. Be-
neath each of these ecchymotic spots the tissue
of the lung is of a uniform brownish-red colour,
is firmer in its texture than the surrounding
healthy lung, and presents a circumscribed en-
gorgement, from which, on pressure, black blood
is squeezed out — a morbid alteration quite analo-
gous to the hemoptysical engorgements described
by Laennec." Similar petechial spots are also
found on the surface of the heart, on the pleura,
&c. The other morbid changes noticed in the
thorax are not so characteristic, being common to
other diseases. Such are the effusions of serous
or sero-sanguineous fluid very commonly found in
the cavities of the pleurae or pericardium, or in
the cellular tissue of the lungs. In one case (Dr.
Johnston's) the heart is stated to have been small,
pale, and easily lacerable. In some cases it has
contained fluid blood, or pink-coloured gelatinous
coagula in some of its cavities. The pericardium,
in one case, and the inner membrane of the aorta

* Raymann, Acta Nat. Cur. apud Ailair, diss. ilMUg.
p. 14. Edinburgh Med. Journal, vi. 374. Ibid. ix. 164
Ibid. Xiii. 40-2. Ibid. xiii. 40.3. Ibid, xxvii. 71. Edin-
burgh Medico-Chir. Trans, i, 981. Ibid. ii. 181. Rayer
Malacl. de la Peau, tome ii. observ. 171, n-2 173 174
175. Cases 173 and 174 are transcribed from Stoll R»
Medendi. '

PURPURA,

in another, showed a blush of redness. In a boy
who died ten days after the supervention of pur-
pura, Dr. Bateman found a large firm tumour
occupying the situation of the thymus gland ; this
tumour, which must have been of slow growth,
had not perceptibly affected the respiration or im-
paired the general health. Tubercles of the lungs
were found in a case mentioned by Rayer, (Ob-
serv. 171) ; and pulmonary tubercles, and the
marks of chronic inflammation of the substance
of the lungs, were met with in another case in a
child seven years old. But this case, in which
petechial spots and epistaxis supervened only on
the day of the child's death, and as a symptom
of impending dissolution, ought not to be taken
as a fair instance of purpura.

In the abdomen, petechial and ecchymotic spots
are often found throughout a considerable tract of
the mucous membrane of the alimentary canal,
especially in the stomach, duodenum, and upper
part of the small intestines, but sometimes also in
the colon. Similar spots are also met with un-
derneath the serous membranes, as betwixt the
folds of the mesentery, and under the peritoneal
covering of the viscera. Dr. Fairbairn found the
cardiac extremity of the stomach emphysematous,
(which did not arise from putrefaction,) the liver
and spleen somewhat softened, and a bloody fluid
could be squeezed from their substance ; one
kidney was also softened. A case is related by
Dr. Bateman, where the spleen had been felt
during life nearly as low as the spine of the
ileum, and after death was found enormously
enlarged. (Synops. p. 112.)

[Under another head (Spleen, Diseases of
the) reference is made to " splenic cachexia," as
it is termed in India, which is accompanied by
all the signs of purpura, and which is evidently
connected with, and perhaps dependent upon,
hypertrophy and atrophy of that viscus. Not
long ago the writer had a fatal case of this form
of diseased spleen under his care, in which the
organ was greatly enlarged, and encephaloid in
certain portions. All the signs of purpura
hemorrhagica supervened, with hydropic infiltra-
tion of the lower extremities, under which the
patient died. In another case of purpura, that
fell under his care, the spleen was sound, but the
liver was scirrhous, and incurable jaundice pre-
ceded the fatal termination.]

Predisposing and exciting causes. — Pur-
pura generally may be stated to be rather a rare
disease; it is especially so in its more severe
forms. The purpura simplex most commonly
affects children ; cases resembling purpura urti-
cans, but often presenting anomalous symptoms,
occur chiefly in young women. Of seventeen
cases of purpura hemorrhagica, which were all
that Dr. Willan had met with, two only were
men, nine women, three boys, and three infants
under a year old ; four of the women were above
the age of fifty. The proportion of male adults
is considerably greater in the cases which have
been recorded subsequently to the publication of
Willan's work, especially in the severe and fatal

cases.

Willan, Bateman, and Rayer agree in stating
that purpura chiefly occurs in indmduals of deli-
cate habit, or enfeebled by their occupations or

mode of life ; by confined, low, or damp habita-
tions, scanty food, hard labour, grief, anxiety,
fatigue, and watching ; or who have suffered from
acute or chronic disease. In a case mentioned by
Willan, it ensued on excessive drinking of undi-
luted ^spirits. (Reports on Diseases of London,
p. 167.) In a fatal case which occurred to Bate-
man, it came on during a severe salivation, acci-
dentally induced by a few grains of mercury.
(Synopsis, p. 110.) A remarkable case is related
in the appendix to Adair's Thesis, of a Hamp-
shire farmer, aged 34, who was hereditarily pre-
disposed to insanity, and becoming affected with
religious melancholia, refused all food and drink
except bread and water. After having some time
subsisted on this diet, symptoms of purpura or
scorbutus supervened ; viz. petechia? all over the
body, accompanied by remarkable roughness of
skin, a large ecchymosis above the right ham,
gums tender, swollen, and bleeding, legs cedema-
tous, pale dejected countenance, great debility,
stiffness of the joints, (which preceded the
petechial eruption,) oppressed respiration, bowels
costive. This patient recovered under the use of
vegetables and ripe fruits, for he could not be per-
suaded to take animal food.

On the other hand, purpura frequently occurs
where no causes of a debilitating or depressing
nature can be supposed to have existed ; in per-
sons in the prime of life, in the easy and opulent
classes of society, breathing a pure air, and enjoy-
ing the necessaries and comforts of existence.
" This circumstance," observes Bateman, " tends
greatly to obscure the pathology of the disease ;
for it not only renders the operation of the alleged
causes extremely questionable, but it seems to es-
tablish an essential difference in the origin and
nature of this disorder from that of scurvy, to
which the majority of writers have contented
themselves with referring it. In scurvy, the ten-
derness of the superficial vessels appears to rise
from deficiency of nutriment, and the disease is
removed by having recourse to wholesome and
nutritious food, especially to fresh vegetables and
to acids ; while in many cases of purpura the
same diet and medicine have been taken abun-
dantly without the smallest alleviation of the com-
plaint. In other cases, where a residence in the
country, and the circumstances of the patients
necessarily placed them above all privation in
these respects, the disease appeared in its severest
degree." (Synopsis, p. 110.)

Pathology of Purpura. — If the opinion
just adverted to of the identity of purpura with
true scurvy were admitted, it would not be neces-
sary to enter into any particular inquiry respect-
ing the pathology of the former disease, as dis-
tinct from scorbutus. Dr. Willan seems to have
entirely acquiesced in that opinion. " I consider
it (purpura), under all the forms described, as
pertaining to the scurvy ; though it is not always
attended with sponginess of the gums and a dis-
charge of blood from them, according to the defi-
nition of scorbutus in nosology." (Willan, p.
466.) Into the nature and causes of scorbutus
we are not to enter in this place ; not only be-
cause we can say nothing satisfactory of a dis-
ease which we have never seen, and which is
now happily rarely to be met with ever bv naval

PURPURA.

practitioners, but because it will form the subject
of a separate article in this work. We are, how-
ever, inclined to acquiesce in the opinion of
Bateman and of most succeeding writers, that
purpura (at least many cases of it) is distinct in
its nature, causes, and mode of treatment, from
the true scurvy described by Lind, Trotter, &c.
and as we conceive there can be no doubt of the
truth of Cullen's doctrine, " that there is one dis-
ease only entitled to the name of scurvy ; that it is
the same by land as upon the sea, depending every
where upon the same causes," (First Lines, sec.
1790,) it appears to us that the name of land-
scurvy, as a synonym for purpura, (Good's Study
of Med. vol. ii. p. 875, and Syst. of Nosology, p.
268,) is improper, and calculated to lead to an
erroneous notion of the latter disease.

The late Dr. Duncan enumerates the following
as the possible modes in which he conceives the
phenomena of purpura might be produced: — 1. in-
creased tenuity of blood, allowing it to escape from
the extremities of the capillary arteries ; 2. dilata-
tion of the mouths of these arteries, allowing na-
tural blood to escape ; 3. tenderness of the coats
of the minute vessels, giving way from the ordi-
nary impetus of the blood; 4. increased impetus
of the blood, rupturing healthy vessels ; 5. ob-
struction in the vessels causing rupture ; 6. two
or more of these causes acting simultaneously or
successively. But he acknowledges that he can-
not reconcile any of these suppositions with the
phenomena of the disease. (Edin. Med. Journ.
ix. 410.) Other recent writers equally confess
their ignorance of its true pathology. Of the in-
timate nature of the process by which the blood
is poured out at once from the capillaries of the
cutaneous surface, and of the internal organs, we
must probably be content to remain ignorant, until
the physiological action of that important part of
the vascular system shall be better understood
than it is at present. Many processes, both natu-
ral and morbid, are not more explicable than the
occurrence of petechia?, either as a symptom of
fever, or from other causes ; and especially the
process of hemorrhage by exhalation, of the close
connection of which with the phenomena of pur-
pura there can be no doubt.

The most striking peculiarity of purpura, con-
sidered as a hemorrhagic disease, is the univer-
sality of the hemorrhagic tendency, whereby the
blood is poured out not only from the various
mucous membranes, at least from several of these
outlets, simultaneously or in succession, hut is
also effused into the textures of the skin and cel-
lular membrane, forming petechial spots, and oc-
casionally into the serous cavities or the texture
of the solid viscera. It is, therefore, a very pro-
bable, if not a certain conclusion, that the imme-
diate cause of these phenomena is one affecting
the whole system ; and none seems so probable,
or so well accords with the phenomena, as an
alteration in the composition and vital properties
of the blood. When we take into consideration
the analogy which subsists between the pheno-
mena of purpura and those of petechial fever on
the one hand, and of cachexy, passive hemorrhage,
and scorbutus on the other, it is highly probable
that a similar cause is in operation in all these
cases. In scorbutus it is generally admitted that

the composition of the blood is vitiated. That a
change both in its composition and its vital pro-
perties is intimately concerned in the production
of the phenomena of fever, is a conclusion the
proofs of which are rapidly accumulating upon
us. (See the articles Feveii, and Morbid States
of the Blood, in the present work.) We have,
therefore, strong analogical grounds for believing
that a like cause is productive, at least in some
cases, of that assemblage of symptoms to which
we give the name of purpura. The proofs of this
opinion will be found fully and very ably developed
in Dr. Watson's Lecture on Purpura, (Medical
Gazette, vol. x. p. 498,) to which we refer the
reader.

The third hypothesis suggested by Dr. Duncan,
viz. weakness or frangibility of the coats of the
capillary vessels, has several facts to support its
probability, and especially the tender state of the
gums, and the readiness with which blotches and
ecchymoses are produced in some cases by the
slightest pressure on the skin. Such a state may
coexist with a primary diseased condition of the
blood, and may be induced by the circulation of
such blood through these vessels, which is not
improbable ; though, as Dr. Watson has suggested,
the relation of cause and effect may be different
from this : " It is easy to imagine that some de-
rangement (of the nature of which, supposing it
to exist at all, we know nothing) in that part of
the circulating system which is strictly capillary,
and in which those changes take place whereby
the blood, from being scarlet or arterial, becomes
purple or venous, should modify or interfere with
the change itself, and so come to affect the quality
of the blood." (Medical Gazette, vol. x. p. 499.)

But to whatever conclusion the pathologist may
come on these points, it cannot affect the practical
fact, that purpura is not unfrequently connected
with a state of the system at large, or of particular
organs, which not only will bear, but requires de-
pletory measures for its removal, and which ren-
ders the use of tonic and stimulant remedies im-
proper and dangerous. Of this the recorded cases
of the disease supply abundant evidence. " The
rapidity of the attack," observes Dr. Bateman,
" the acuteness of the pains in the internal cavi-
ties, the actual inflammatory symptoms that some-
times supervene, the occasional removal of the
disease by spontaneous hemorrhage, the frequent
relief derived from artificial discharges of blood
and from purging, — all tend to excite a suspicion
that some local congestion or obstruction is the
cause of the symptoms in different instances."
(Synops. p. 111.)

Diagnosis. — The diseases with which pur-
pura is most likely to be confounded are, typhous
fever attended with petechia?, and scorbutus.
Where the symptoms denoting purpura are ac-
companied by febrile symptoms of some intensity,
it may become a question whether the purpura or
the fever be the primary disease. The origin and
course of the complaint, the period at which the
petechia? appear, the extent and the variety of the
accompanying hemorrhages, will enable the prac-
titioner to judge of the nature of the case. With
regard to scorbutus, that disease is now fortunately
seldom if ever to be met with in its genuine form.
Cases of petechial efflorescence attended with he-

PURPURA.

769

morrhage and signs of great general debility, with-
out any febrile or inllammatory symptoms, may be
considered by some practitioners as properly belong-
ing to scurvy ; and if they occur in patients who
have been much exposed to the influence of de-
bilitating causes, the tonic treatment appropriate
to that disease, and especially pure air and an im-
proved diet, will generally be beneficial.

Prognosis* — In the milder cases of purpura,
which are unattended by hemorrhage, by any con-
siderable febrile symptoms or organic disease ; or
where the hemorrhage is slight, or attended with
amelioration of the symptoms; a favourable prog-
nosis may be formed. But when much blood is
lost by the profuse occurrence or long continuance
of hemorrhage, or where there are symptoms of
serious internal congestion or inflammation, high
fever, or great depression of the vital powers, the
prognostic is unfavourable. Even in chronic and
constitutional cases a guarded prognosis should
be given, and the danger of the supervention of
fatal hemorrhage should not be lost sight of.

Treatment. — While the older doctrines pre-
vailed, which ascribed the symptoms of purpura
solely to debility of the solids and attenuation of
the blood, a tonic and invigorating treatment was
universally recommended. The mineral acids,
cinchona, and wine, comprehended the whole me-
dicinal treatment ; these, however, were acknow-
ledged to be often merely palliative, and to have
little effect in producing a radical cure. (Adair,
Diss. Inaug. p. 18.) The same remedies are
alone mentioned by Willan, who at the same time
insists strongly on the importance of pure air, ex-
ercise, good diet, and whatever may tend to pro-
duce cheerfulness and serenity of mind. ( Willan,
Reports, p. 93; Cutan. Dis. p. 461.) Willan's
experience of this disease had not been extensive;
and in particular its more severe and fatal forms
had not occurred to him. The publication of his
opinions respecting this disease and its treatment
called forth the observations of Dr. Parry on the
utility, in some cases, of venesection. (Edinb.
Med. Journ. v. 7.) Dr. Harty and Dr. Bateman
subsequently called the attention of the profession
to the benefit to be derived from the employment
of purgative medicines. Dr. Harty having expe-
rienced a complete failure in a case of purpura
hemorrhagica which he treated strictly according
to the plan of Willan, with every advantage of
country air, nourishing diet, and tonics, had his
attention turned to the functions of the alimentary
canal in this disease. In a seemingly very unfa-
vourable case of purpura hemorrhagica, in a tedious
and obstinate case of purpura simplex attended
with fever and headach, and in nine others, he
employed brisk purgation with decided success.
(Edin. Med. Journ. v. ix. p. 186.)

Dr. Bateman, after admitting that in slighter
degrees of purpura, occurring in women and chil-
dren who have been under the influence of close
air, want of exercise, and other debilitating causes,
the tonic plan, as recommended by Willan, may
be adequate to the cure of the disease, adds :—
"But in adults, especially those already enjoying
the benefits of exercise in the air of the country,
and who have suffered no privation in respect to
diet ; or when it appears in persons previously
stout, or even plethoric ; when it is accompanied
Vol. III. — 9 7

with a white loaded tongue, a quick and somewhat
sharp, though small, pulse, occasional chills and
heats, and other symptoms of feverishness, however
moderate ; and if at the same time there are fixed
internal pains, a dry cough, and an irregular state
of the bowels, — symptoms which may be pre-
sumed to indicate the existence of some local
congestion, — then the administration of tonic me-
dicines, particularly of cinchona, wine, and other
warmer tonics, will be found inefficacious, if not
decidedly injurious. In such cases, free and re-
peated evacuation of the bowels, by medicines con-
taining some portion of calomel, will be found
most beneficial. The continuance or repetition
of these evacuants must, of course, be regulated
by their effects on the symptoms of the complaint,
or on the general constitution, and by the appear-
ance of the excretion from the intestines. If the
pains are severe and fixed, and if the marks of
febrile irritation are considerable, and the sponta-
neous hemorrhage not profuse, local or general
bloodletting may, doubtless, be employed with
great benefit, especially in robust adults." (Bate-
man, Synops. p. 1 14.) We have given Dr. Bate-
man's practical directions at length, because little
has been added to them by subsequent writers,
except in the way of illustration. We apprehend
that in very few cases will tonics be requisite or
admissible, at least at the commencement of the
disease. We have seen them do evident mischief,
even in children of delicate frame, in whom the
cautious but effectual employment of laxatives and
a mild antiphlogistic regimen have afterwards
effected a cure. From the manifest success of
purgatives, and especially calomel, in the conges-
tive form of typhous fever attended with petechia;,
practitioners have learned not to be deterred by
the symptoms of apparent debility from employing
this most useful class of remedies in such fevers ;
and in purpura, notwithstanding similar signs of
prostration of strength, they are no less efficacious.

Venesection is a more hazardous remedy, and
requires greater discrimination as to the cases and
period of the disease in which it probaly may be
employed with safety and advantage. In the cir-
cumstances pointed out by Bateman, and especi-
ally where there is hardness of pulse and fixed
local pain, there can be no doubt of the propriety
of having recourse to it, especially at an early pe-
riod of the disease. But we must be very cau-
tious not to push it too far, or employ it too late
to be of benefit. Dr. Mackintosh informs us that
he lost a patient some hours after she had been
bled; and the subject of Dr. Fairbairn's case,
though a strong man in the prime of life, never
rallied after the third bleeding. Dr. Fairbairn
candidly confesses that he doubts whether the
bleeding was not carried too far. In other cases
which have been treated by venesection, but
where, from the symptoms of debility or supposed
putrescent tendency, wine and other stimulants
have been administered, it is much to be suspected
that these have proved injurious, and that if a mild
antiphlogistic regimen had been trusted to, the re-
sult might have been more satisfactory.

In conclusion, we may sum up by observing
that, in the treatment of cases of purpura, we are
not to be guided by the name or the external ap-
pearances of the disease, but by diligent attention

3p

770

PURPURA — PUS — PYROSIS.

to the symptoms, and especially to the state of the
functions, and the habit and constitution of the
patient. Where high excitement prevails, with
strength of pulse and vigour of constitution, and
we have reason to suspect inflammation, or an
approach to it, venesection and free purging, with
a suitable antiphlogistic diet, are the appropriate
remedies. Where a quite opposite state exists,
extreme languor and debility, pale cachectic com-
plexion, small and weak pulse, and much hemor-
rhage has occurred, all active depletion must be
abstained from, and the strength supported by
beef-tea and other mild nutriment, while sulphuric
acid, and perhaps divided doses of quinine, may
be resorted to. In intermediate cases, a mixed
treatment must be adapted to the exigencies of the
particular case by the discrimination of the prac-
titioner. It will be often much safer in such cases,
where any doubt exists as to the proper plan of
treatment, to adopt one almost purely negative, as
saline diaphoretics and a mild antiphlogistic diet,
(paying due attention to the bowels,) than to have
recourse to any extreme measures.

Local hemorrhage, when trifling in its amount
and occurring early in the disease, it may not in
all cases be advisable to interfere with. It has in
several well-attested cases appeared to be a salu-
tary effort of nature, and has removed the symp-
toms of the disease. Where the hemorrhage is
protracted, or dangerously profuse, the usual
means (pointed out in the article Hemorrhage,
and in those which treat of the individual hemor-
rhages) must be had recourse to to arrest it; and
of these there is none so generally efficacious as
the application of cold.

Some particular modes of treatment have befn
recommended in this disease, of which we cann >t
speak from experience, and therefore we sh&il
i ly refer to them. The oil of turpentine w&s
employed with success by Dr. Nicholl in several
cases of purpura unattended with fever, and which
he conceived to depend on mere relaxation of the
extreme vessels. A successful case of its employ-
ment has since been published by Dr. Magee ; but
it should be noticed that both these physicians
employed it in combination with laxatives. Dr.
Mason Good and Dr. Mackintosh recommend the
vegetable acids in purpura, in preference to the
mineral ; the latter especially speaks in favour of
" fresh lime-juice, not only taken internally, but
applied externally." Spirit-lotions, or a solution
of chloride of lime, or cloths dipped in vinegar
and water, are advised by Rayer to be applied to
those parts of the skin which are spotted with pe-
techia and ecchymoses ; we confess we do not
understand on what principle.

Dr. Belcombe, physician to the York County
Hospital, has recently applied with success to this
disease the principles of treatment which Dr. Ste-
vens has advocated in certain diseases conceived
by him to depend on a morbid deterioration of the
blood, and especially in the fevers of hot climates
and in epidemic cholera, namely, the administra-
tion of neutral saline remedies, not intended to act
as cathartics. In a decided and severe case of
purpura hemorrhagica, in which Dr. Belcombe
adopted this treatment, according to the formula
of Dr. Stevens, (bicarbonate of soda gss, muriate
of soda 9 i, chlorate of potass gr. vii. ;) the result

was the recovery of the patient ; and in two other
cases of petechial eruption which have since oc-
curred to him, he has had recourse to it with the
same success. George Goldie.

PUS, (from nvov, matter,) a yellowish-white,
bland, cream-like fluid, having a sweetish taste
and faint smell, heavier than water, (Sp. gr. about
1.03,) found in abscesses, on the surface of ulcers,
and occasionally deposited on free surfaces, or in
the tissue of organs.

An account of the various opinions entertained
of its formation, as well as a description of its
physical and chemical properties, will be found
under Abscess, Inflammation, and Suppuba-

TI0Ir - A. TWEEDIE.

PYLORUS, DISEASES OF THE. — See
Stomach.

PYROSIS, (Gr. irvpwcts, burning, inflamma-
tion ; from T«p<Sa>, to burn ; th. wup, fire.) — This
is the generic name of a disease adopted into their
nosological classifications by Sauvages, Sagar, and
Cullen, and, according to the definition of the last
mentioned writer, synonymous with the cardialgia
sputatoria of Linnajus and Mason Good. Sauv-
ages has defined it, " Sensus ardoris in ventriculo
et cesophago sine febre acuta ;" and Sagar, " Ardor
oesophagi ad ventriculum usque extensus sine fe-
bre, vulgo soda dicitur ;" both corresponding to
the character of soda in the system of Vogel, for-
merly a common but now obsolete name for heart-
burn. But the peculiar combination of symptoms
which the early writers on medicine had included
in their general descriptions of gastric disorder,
particularly under the term cardialgia, and which
previous nosologists had classed as one of several
species of the same genus under the generic name
of pyrosis, Cullen was the first to consider as the
indications of a distinct idiopathic disease, which
he separated accordingly, and placed in his class
Neuroses, and order Spasmi, with the following
definition, " epigastrii dolor urens cum copia hu-
moris aquei, plerumque insipidi, aliquando acris,
eructata." Such has been the general and limited
acceptation of the word pyrosis in this country
since the time of Cullen, and the signification we
attach to it in the present article.

This form of disease is known in England by
the popular name of black-water, and in Scotland
by that of icater-brash. It is most frequently to
be observed amongst the poor, but sometimes,
though rarely, in persons of more fortunate condi-
tion in life. In Scotland, Lapland, and Iceland,
it has been observed to be endemic, and probably
is a prevailing disease in many other countries ; in
England it is strictly sporadic. The subjects of
it are most commonly persons under middle age ;
it seldom appears before puberty, and very rarely
in advanced life. Females are more often affected
with it than males, sometimes during pregnancy,
and occasionally it seems incidental to this state,
subsiding when it terminates, and recurring with
its repetition. It most frequently, however, occurs
in the unmarried, and of the married, most fre-
quently in those who have never been pregnant :
in many instances it appears when leucorrhcea has
been present. Having once taken place, it is apt
to return for a long time after ; and though often

PYROSIS.

771

eitremely difficult to cure, is seldom if ever di-
rectly attended with danger to life.

The Causes by which it has been induced have
never been satisfactorily determined ; but the facts
of its endemic occurrence, its almost exclusive
prevalence einong the lower classes of the com-
munity, even where it is only sporadic, as in this
country, and regard to the functions of the parti-
cular organ which appears to be chiefly implicated,
have raised a prevailing belief that the ingesta
have a powerful influence on its production. It
was remarked, however, by Cullen, that he had
not observed its connection with any particular
diet, and that persons using animal food were
subjects of it, although he thought more frequently
those whose subsistence was milk and farinaceous
substances. In Scotland, however, (the field, be it
remembered, of Cullen's observations,) unfer-
mented meal forms the bulk of the diet of the poor;
and up to the present time the same substance
in the form of oat or barley cake has stood as an
article in the diet of the great mass of the people,
in the same relation as wheat bread to the diet of
the people of this country. The similar use of
other articles of food defective in its nutritious
quality, and difficult of digestion, has been com-
monly observed to precede its occurrence, and in
those whose idiosyncrasy predisposes them to be
so affected, (a condition of which we acknowledge
our entire ignorance,) all those circumstances
which obstruct the natural functions of the sto-
mach are, more or less, conducive to the develop-
ment of pyrosis.

In some instances the use of indigestible sub-
stances has appeared to us to have been an excit-
ing cause of the attack ; but those which are most
generally considered so, are suddenly diminished
temperature, particularly in' the application of cold
to the feet, and extraordinary emotions of the
mind.

The paroxysms of pyrosis, according to Cullen,
(whose description of the symptoms has been con-
sidered most faithful,) usually come on in the
morning and forenoon after food has been ab-
stained from for some hours, though in our expe-
rience the period has not uncommonly been two
or three hours after dinner : its first symptom is a
pain at the epigastrium, described as that of ex-
treme heat (emphatically called by the French fir
chaud,) with a sense of constriction, as if the sto-
mach were drawn towards the back, the pain be-
ing greatest when the body is in the erect posture,
and causing it to be bent forwards; it is often
very severe, and after continuing for some time is
followed by an eructation of thin fluid, varying in
quantity, but in appearance always resembling
water ; to the taste it is often absolutely insipid,
but sometimes extremely sour. Though appa-
rently the occasion of a sense of extreme heat in
the stomach and oesophagus, the ejected fluid in
passing through the mouth occasionally impresses
it with an opposite sensation of cold in a very re-
markable degree. The eructation is frequently
repeated, and the pain which preceded it does not
immediately cease, but does so after a time, and
terminates the paroxysm. These paroxysms vary
in their duration, both in the same and in differ-
ent individuals, recurring often successively every

day for a consi

idcrablc time, and sometimes inter-

mitting for one or several days, but always with
great irregularity. Cullen has declared that pyro-
sis is often unattended by any symptoms of dys-
pepsia, but the remark is not only inconsistent
with his own definitions of the two diseases and
his observations upon them, but (we presume to
say) with general experience. That the symp-
toms vary in number and degree we doubt not,
but their entire absence we conceive to be ex-
tremely rare : one which has appeared to us to
have been almost invariably present has been pain
at the epigastrium immediately consequent to
swallowing any ordinary food. We are, more-
over, without proof or reason of probability that
the morbid condition of the stomach which gives
rise to pyrosis differs in any essential degree from
that which occasions some other forms of dyspep-
sia, certain variations in the phenomena of which
are as much beyond our explanation, as the spe-
cific distinctions by which they are severally cha-
racterized. The distinguished writer we have so
frequently had occasion to cite, seems indeed to
have been unconscious of the approximation of
his own ideas on this point in reference both to
dyspepsia and pyrosis, having defined the proxi-
mate cause of dyspepsia, " an imbecility, loss of
tone, and weaker action in the muscular fibres of
the stomach," and spasm (which can be viewed
in no other light than a consequent condition,
and of the same structure), as the proximate cause
of pyrosis. " It seems," says he, " to begin by a
spasm of the muscular fibres of the stomach, which
is afterwards in a certain manner communicated
to the blood-vessels and exhalants, so as to in-
crease the impetus of the fluids in these vessels
while a constriction takes place on their extremi-
ties. While, therefore, the increased impetus de-
termines a greater quantity than usual of fluid
into these vessels, the constriction upon the extre-
mities allows only the pure watery parts to be
poured out, analogous in every respect to what
happens in diabetes hystericus." Another and
opposite view has been suggested by Mason Good,
who considers that in some instances pyrosis may
be induced by a peculiar paresis or inactivity of
the proper absorbents of the stomach, — an hypo-
thesis founded on some experiments of Magendie,
proving the rapidity of the absorption of fluids
from the stomach in a state of health, even when
its pyloric orifice has been encircled by a ligature ;
but the absorption of other fluids, and the regur-
gitation only of the morbid product, reflect a de-
gree of improbability on this conjecture. We are,
indeed, without any evidence that the latter is
actually secreted by the stomach, and it has been
surmised, from the resemblance between the natu-
ral secretion of the pancreas and the ejected fluid,
that it may be derived from this source : the writer,
however, is not aware that the latter has been
submitted to chemical analysis, but the result-of
this process promises means of comparison whereby
the supposition would be further confirmed or in-
validated. A priori it appears impossible that a
fluid so uncongenial to the sensibility of the sto-
mach should be admitted into it by an inversion
of the natural action of the duodenum without
more violent efforts than are manifested, or that
the fluid itself proceeding from this source should
appear entirely free from any admixture of bilo

772

PYROSIS.

[The writer is disposed to regard it as a form
of gastrorrhoea. In some persons, the secretion is
so copious, that they can eject at pleasure consi-
derable quantities of fluid, especially in the morn-
ing before taking food, — or they possess what has
been termed the faculty of vomiting at pleasure.
(See the article Ixdtgestiojt, vol. ii. p. 639.)]

Prognosis. — Pyrosis in its simple form is
never attended with danger to life, nor does it
commonly even prevent the sufferer from pursu-
ing his ordinary occupation. The physician, how-
ever, is frequently baffled in his attempts to cure
it, and even when there has been a reasonable
hope of the remedial means having been success-
ful, a recurrence of the watery eructation has not
unfrequently exposed its fallacy.

Treatment. — The doubt in which our know-
ledge of the pathognomonic causes of pyrosis is
involved, obscures the indications on which the
method of treating it should be grounded and pur-
sued with a rational anticipation of success; nor
has observation even up to the present period in
any satisfactory degree supplied the deficiency.
Opium will certainly relieve the paroxysm ; and
its various preparations, as well as other anodynes
and antispasmodics, as hyoscyamus and conium,
with camphor, the compound spirit of sulphuric
ether, and the aromatic spirit of ammonia, vari-
ously selected and combined according to the pe-
culiarities of the circumstances of the patient, will
all be found useful for this purpose, but relief of
the paroxysm appears only to be a temporary ad-
vantage: to render it permanent, the intermediate
state must be the object of our more particular
consideration. We have the warrant both of rea-
son and experience for concluding that digestion
cannot be perfectly accomplished whilst the func-
tions of an organ so important to it as the stomach
are subject, whether primarily or secondarily, to
the frequent interruptions occasioned by the ac-
cessions of this disease. A morbid state of the
pancreas we know also will materially obstruct
this process. The regulation, therefore, of the
diet is a most essential point in the plan of treat-
ment; all substances which are likely to ferment
are difficultly digestible, and manifestly productive
even of temporary discomfort or uneasiness, and
the farinacea should as far as possible be avoided.
It might be even advantageous, and especially
when the disease is endemic, to effect an entire
change in the articles which have constituted the
general diet, so regulating the quality and limiting
the quantity as if the cure of indigestion, whether
evident or not, were the object to be effected.
Any deviation from the natural state in the func-
tions of the liver or alvine canal should be cor-
rected by remedies appropriate to their particular
condition ; but in the special plan of the treatment
of pyrosis, it will be found advantageous occa-
sionally to produce a laxative effect on the latter,
and for this purpose aperients which occasion a
sense of warmth in the stomach have been found
most suitable ; such, for instance, as the compound
decoction of aloes, combinations of the powder of
rhubarb with magnesia, the compound tinctures
of rhubarb and cardamoms, and peppermint-water,
the powder and compound tincture of rhubarb,
with carbonate of ammonia and camphor mixture,
Sec. It has further been the practice pursued to

attempt to restore the supposed loss of tone in the
muscular fibres of the stomach, and at the same
time to neutralize the acid secretions which are
commonly present. The particular medicines used
with this view have been various combinations of
the vegetable tonics with aromatics, and large doses
of alkalies and the alkaline earths; of the former,
particularly the carbonate of ammonia and its
preparations. Tonics of the same kind with the
mineral acids, particularly sulphuric, have also
been recommended for this purpose. The various
preparations of iron and zinc have also been had
recourse to, but we believe it to be the result of
general experience, as it has been of our own, that
however such means may have counteracted any
other coexistent symptoms resulting from dyspep-
sia, or have mitigated or suspended the painful
accessions which constitute this affection, its re-
currence has too often taken place as usual.

Cullen distinctly states that all the remedies for
the cure of indigestion have been applied to it
without success, and the late Dr. Baillie has left
it on record that, consistently with his experience,
it had been little benefited by medicine. He add-
ed, however, that a drachm of compound tincture
of benzoin rendered miscible with water by tritu-
ration with mucilage, he had found the most effi-
cacious of any. (Lectures and Observations on
Medicine, by the late Matthew Baillie, M. D.,
1825.) We know it to have been also a favour-
ite prescription of another experienced eminent
physician in the treatment of pyrosis. Astrin-
gents, such as the compound powder of kino given
three times a day in doses of ten grains, have been
considered serviceable in cases of dyspepsia in
which pyrosis has been a prominent symptom.
Linnsus, who had frequent opportunities of wit-
nessing the disease, recommended the nux vomica
for its relief, in doses of ten grains three times a
day ; but this has been regarded, and doubtless is,
a very hazardous quantity to commence with.
We are not aware that strychnine has been sub-
stituted for it ; but the preceding recommendation
points it out as worthy of trial, in doses of from a
twelfth to a sixth of a grain every eight hours.
The subnitrate of bismuth, suggested as a remedy
in cases of gastrodynia and other painful affections
of the stomach by Dr. Odier of Geneva, and fa-
vourably reported of by Dr. Marcet in the fifth
volume of the Memoirs of the London Medical
Society, in similar cases, was particularly recom-
mended as a useful medicine in the cure of pyro-
sis by Dr. Bardsley of Manchester, in his " Medi-
cal Reports of Hospital Practice," published in
the year 1807. His recommendation is accom-
panied with a detail of several cases in which its
use was successful ; and with the comment, that
in pyrosis and disorders of the same kind it exerts
a local and specific action upon the organs of di-
gestion, restoring the stomach to a state of vigour
and consequent healthy secretion, essential to the
removal of the symptoms of acidity, spasm, and
pain. Dr. Bardsley prescribed it in doses of five
grains with from fifteen to twenty grains of com-
pound powder of tragacanth, two or three times
in the day ; a mode which we have found useful
in similar cases. Dr. A. T. Thomson speaks
highly of it in combination with extract of hops,
having found it, as he states, extremely beneficial

RAPE.

773

in pyrosis, gastiodynia, and some other varieties
of dyspepsia ; and when there has been merely
atony of the digestive organs without organic mis-
chief, almost universally successful. Mason Good
has spoken in high commendation of the internal
use of soap in pyrosis, combined with opium if it
should be attended with much pain ; he refers the
efficacy of the former to its decomposition allow-
ing the alkali to unite with the acrid secretion,
whilst the oil defends the stomach from the action
of any acrimonious matter which may be present.
He has not, however, mentioned the quantity or
form in which he has prescribed it ; but from the
benefit we have known it to produce with rhubarb
and extract of gentian in some of the modifications
of dyspepsia, we should be inclined to adopt a simi-
lar combination in prescribing it for the cure of
pyrosis. On the principle of allaying irritation,
and thereby favouring a slower, and consequently
more healthy gastric secretion, hydrocyanic acid
lias been recommended for the relief of pyrosis ;
but experience is yet required to determine whether
it possesses any lasting power over it. The de-
cided advantage derived from its use in cases ap-
parently allied to pyrosis, leads us to anticipate
that it will be found a valuable medicine in the
treatment of the latter affection. Commencing
with a dose of two minims, we may gradually in-
crease it to five ; and it will be suitably prescribed
diluted with an ounce and a half of water and a
drachm of tincture of calomba every eight hours.
In conclusion, we refer the reader to the article
Indigestion, in which the various disorders of
the stomach commonly classed under the term
dyspepsia have been fully discussed, and particu-
larly to the third section of that article, which de-
scribes pyrosis in relation to them, under the head
of irritable gastric dyspepsia.

William Kerr.

RAPE. — The high value set upon female purity,
and the heavy penalty incurred by its loss, in the
banishment of the delinquent from society, have
led most civilized countries to inflict the severest
punishments on the individual guilty of a forcible
violation of the weaker sex. When we consider,
on the one hand, the condition of a virtuous female
thus plunged into an abyss of misery, a release
from which by death has been voluntarily sought
by many; and, on the other, contemplate the
number of profligate persons who are found in all
countries and societies, whose chief occupation
seems to be the corruption and debasement of the
female sex; we cannot fail to rejoice that the
strong arm of the law should interpose its pro-
tecting shield, and visit with its severest judgments
one of the grossest crimes that vice can perpetrate.
By the law of England, rape is defined to be the
caftial knowledge of a woman against her will,
and death is its penalty. All classes of females
are equally protected, the virgin, the married wo-
man, and even the common prostitute is included,
because she may at the very time have determined
en a reformation of her former habits. In Scot-
land the ravisl.er is exempted from the pains ol
death, only in case of the woman s fubsequen
consent, or her declaration that she yielded of her
own free will; and even then he is to suffer an
arbitrarv punishment either by imprisonment, con-

fiscation of goods, or a pecuniary fine. (Edin. En-
cyclop, vol. xi. p. 823.) In the state of New York,
death was formerly the punishment for committing
a rape on a married woman or a maid ; and it was
also ordained at the same time, that if a woman
had been ravished, and afterwards consented to
her ravisher, her husband, father, or next of kin,
might sue by appeal against such offender. These
laws, however, have been repealed, the punishment
altered, and appeals of felony abolished. The acts
now in force prescribe the punishment of impri-
sonment for life in the State-prison, of the offender
and his accomplices, if he have any, for ravishing
by force any woman-child of the age often years
and upwards, or any other woman. An assault,
with an intent to commit a rape, may be punished
by fine and imprisonment, or both.

[It has also been enacted that every person who
shall have carnal knowledge of any woman above
the age of ten years, without her consent, by ad-
ministering to her any " substance or liquid," which
shall produce such stupor or such imbecility of
mind or weakness of body as to prevent effectual
resistance, shall, upon conviction, be punished by
imprisonment, in a State -prison, not exceeding
five years.

In Massachusetts, Rhode Island, Delaware, and
South Carolina, it is a capital offence. In Con-
necticut, Georgia, Illinois, Indiana, Ohio, Maine,
New Hampshire, New Jersey, Vermont, Pennsyl-
vania, Virginia, and Michigan, imprisonment for a
term of years, or for life, is directed ; in Louisi-
ana, imprisonment and hard labour for life ; and
in the States of Missouri and Arkansas, the pun-
ishment is castration. (Beck's MedicalJur impru-
dence, 5th edit., i. 160, Philad. 1833.)]

In the case of adults, it is necessary, in order
to constitute a rape, that the act shall have been
committed against the will of the female ; but in
the case of children, in whom the power of judg-
ing between right and wrong is not supposed to
exist, the matter of consent is of no moment, and
the deed is equally criminal whether it be obtained
or not. " A female infant under ten years of age
is in law deemed incapable of consenting to any
act, much less to her dishonour ; the carnal know-
ledge of such infant, whether she yield or not, is
therefore virtually a rape ; but whether if the child
be above ten years of age, it be also a felony, has
been questioned. Sir Matthew Hale was of opin-
ion that such profligate actions, either with or
without consent, amount to rape and felony, as
well since as before the statute of Queen Eliza-
beth ; but in his Summary, the learned judge ap-
pears to have altered his opinion ; and the present
practice is, that if the child be under ten years of
age then it is felony by the statute ; but if she be
above ten and under twelve, then it is no rape if
she consented, but only a misdemeanour." (Pa-
ris and Fonblanque, Med. Jur. vol. i. p. 419.)
The French code extends the period to fifteen
years, and punishes the crime committed on a
child of that age by hard labour for a limited
time. (Capuron, p. 1.) "In New York the
carnal knowledge of a woman-child under ten
years of age is punished by imprisonment in the
State-prison for life. In Massachusetts and Illi-
nois, death is the punishment. In Virginia, New
Hampshire, Connecticut, and New Jersey, impri

774

RAPE

sonment either for life or a long term of years is
directed. All these specify the period of ten years.
The law in Vermont varies from this. It directs
that whenever any individual over the age of fif-
teen shall abuse any female under eleven with or
without her will, he will suffer fine and imprison-
ment." (Beck, p. 60.)

[It would appear that the punishment of death
is awarded for this offence in only one State of the
Union — Massachusetts. In Virginia, Connecticut,
New Hampshire, Maine, New Jersey, Illinois,
Ohio, Michigan, and Tennessee, the punishment
is either imprisonment for life, or a term of years,
or fine, or imprisonment, or both. All these spe-
cify the period of ten years. In Indiana, the age
of the female is extended to twelve years, and the
punishment is imprisonment for a term of years.
In Missouri, a rape on a female under the age of
ten years is punished by castration. In Delaware,
the law directs a fine, standing in the pillory for
one hour, sixty lashes on the back, — well laid on,
— imprisonment for not more than two years, and
afterwards to be sold as a servant for a term not
exceeding fourteen years. (Beck, op. cit. i. 153.)]

By the ancient law of England, the woman
was required to make her accusation immediately
after the commission of the outrage. At a subse-
quent period she was allowed forty days as the
utmost limit; but by the law as it at present
stands, there is no time of limitation fixed. How-
ever, although there is no limit fixed by law, pub-
lic opinion demands an early discovery ; and an
accuser who has postponed her complaint for any
unreasonable length of time, is listened to with
great caution by a jury. In fact, this is a crime
so easily charged, so hard to be proved, and so
much harder to be rebutted, that it is of the utmost
importance that no time shall be allowed for con-
cocting a malicious tale, particularly if medical
testimony is to be adduced, as a few hours are
often sufficient to efface appearances that might
have been evident on an early examination.
Indeed, in all cases, the greatest caution is neces-
sary in judging of the guilt of an accused party.
There is generally no witness to confirm the direct
testimony of the accuser as to the fact ; the whole
case turns upon the woman's assertion, and unless
there is strong collateral evidence, such as a speedy
disclosure to her friends and the authorities, and
an early medical examination, we are of opinion
that it should require the clearest and most un-
shaken testimony on the cross-examination to gain
credence with a jury. It is better that ten guilty
should escape than that one innocent man should
suffer: and however we abhor the crime, and
would wish the heaviest punishment to overtake
the guilty, we cannot help offering this caution to
medical men and jurors, knowing as we do the
depravity of the human heart, and the lengths to
which it will sometimes go to accomplish the ends
of malice or revenge. It is not impossible, nay, it
has sometimes happened, that a woman who has
freely consented to surrender her virtue will after-
wards turn round on her paramour, and denounce
him as her ravisher. This becomes a case of the
greatest intricacy from the fact of the principal
feature (that of the venereal congress having taken
place) being true. It now passes out of the hands
of the medical jurist, and becomes a question with

the jury whether they believe the deposition of fire
woman as to consent or not. This, it must bo
confessed, is a most difficult question to solve, and
it requires all the ingenuity of the bar to sift to the
bottom all external circumstances which may con-
tribute to prove the negative. Cases of a mixed
kind are also sometimes met with ; as when a
woman will at first resist the advances of a suitor,
and even continue her resistance for a time, but
afterwards, from the excitement of passion or some
other cause, yields to his desire. This is a case,
if possible, more puzzling than the former, because
marks of violence on the limbs of the female, from
her previous struggling, may be evident, which
would naturally lead to the supposition that the
act had been accomplished by force. We confess
that we should be inclined to deal hardly with a
man under such circumstances, from the difficulty
of understanding what constitutes consent. The
act is committed in secret ; there are no witnesses;
the woman is bruised on the limbs and body ; and
her person is violated : it is not likely that a for-
mal question of "Will you consent 1" has been
put, followed by an answer of yea or nay ; and
yet, after the employment of so much force, the
man defends himself by saying the woman con-
sented, which she denies. The jury alone can
determine which is to be credited ; but, as we
already said, appearances are strongly in favour of
the woman, and a struggle of such violence and
duration, followed by coition, amounts, in our
opinion, if not to a legal, at least to a moral rape.
Having spoken thus generally of some of the dif-
ficulties attending the investigation of accusations
of rape, we proceed to consider some of the points
upon which medical testimony is more particularly
required.

Of the physical Signs of "Violation. —
These are the absence of the signs of virginity,
marks of violence, tumefaction, or laceration of
the pudenda, with effusion of blood, and bruises
on other parts of the body, particularly on the
breasts, arms, and thighs. It must be evident that
the most important of these, that is, the want of
the attributes of the virgin state, together with
the injuries inflicted on the genital organs, as
evidenced by inflammation and tumefaction, can-
not apply to all women, but only to virgins ; for
in married women, or those previously in the
habit of sexual intercourse, the negative signs are
of course of no value, and the positive are not
likely to occur. And this narrows our present
observations to the signs of rape committed on
virgins.

The investigation of this subject must be pre-
ceded by an exposition of the signs of virginity.
This is a question which has occupied the atten-
tion of anatomists and physiologists from an early
period ; but it does not appear that any very
accurate conclusions have been agreed upon.

The existence of the hymen is the sign upon
which the greatest stress has been laid by some
authors, while, strange to say, its presence has
been esteemed by others, among whom we find
Ambrose Pare, Columbus, Dionis, and Buffon,
as an unnatural formation. However, at the
present day, it is generally considered as an at-
tribute of the human virgin. The hymen is a
membranous or membrano-carneous structure.

RAPE.

775

•which is situated at the entrance of the vagina,
and serves to form a boundary between that pas-
sage and the external genitals. It is formed by
duplicatures of the lining membrane of the vagina,
and is usually of a crescentic form, leaving an
opening into the vagina at its upper part. This
opening serves as an outlet for the menses, and
in the average of adult subjects is large enough to
admit the index finger sufficiently high up into
the vagina, to effect an examination of the os
uteri, without injury to the hymen. Dr. Davis
states that in breech presentations he has some-
times introduced his finger into the vagina of the
infant without injuring this membrane. The
shape of this membrane, however, is various and
uncertain. In some cases it is more or less cir-
cular, presenting through its centre a round aper-
ture of three or four lines in diameter. At other
times only a part or exclusive portion of the orifi-
cial extremity of the vagina, sometimes the su-
perior, at other times the inferior poTtion of it, is
seen to be veiled over with this structure. In
some rare cases the hymen is an imperforate cir-
cular membrane attached to the edge of the orifice
of the vagina in every part, so as to close the
canal completely. We have already alluded to
some of these cases in the article Impotence.
Another form of the hymen is, when there are
two crescental portions attached to the more car-
neons structure of the external orifice laterally.
The structural tissue of the hymen seems in some
measure to vary in different instances. " In most
foetal subjects it seems to be distinctly mem-
branous, whilst in some others it partakes also of
a carneous character. Hence, probably, the very
different descriptions given of it by different
authors. By Soranus it is accordingly described
as being membranous ; by Avicenna as veinous
and ligamentous; by Riolanus as carneous; by
Berengarius as retiform, consisting of vascular and
delicate ligamentous tissue; by Columbus as a
thick substance ; and by Spigelius as partly car-
neous and partly nervous." (Princip. and Pract.
of Obstet. Med. by Dr. Davis, p. 100.) In order
to see this membrane in the living subject, it is
necessary to separate the labia and even the thighs
to a considerable distance from each other; for
the opening into the vagina is quite closed up by
the external parts in the ordinary positions of the
body. The hymen is usually torn by sexual in-
tercourse, and its rupture is attended by an effu-
sion of blood; an appearance upon which so
much reliance was placed by the Jews as a test
of virginity, that the nuptial sheets were con-
stantly exhibited to the relations on both sides,
and preserved by the friends of the woman as
evidences of her chastity. In case this token of
virginity was not found on them, she was to be
stoned to death at her father's door. After the
rupture of the hymen, its remains shrivel towards
their base into several small excrescences at the
orifice of the vagina. These are thick, red and
obtuse at their extremities, and from their fancied
resemblance to a myrtle-berry, have been called
caruncuUc myrtiformes. They generally ' d.sap-

p. 17,) remarks that the carunculffi may be found
when the hymen is entire. Dr. Davis (Loc. cit.
p. 101,) observes that the greater part of the circle
at the basis of the hymen when that structure
remains, and at the same locality when it has
suffered rupture, may occasionally be seen studded
with caruncles of different origin ; such extra
caruncles in some cases being few and small, but
in others large and numerous. He alludes to one
case, which was that of a young lady of unques-
tionably good character, who, in consequence of
some irregularities imputed to a gay husband, to
whom she had been recently married, became the
subject of a professional examination : there pre-
sented at the orifice of the vagina on either side,
and in immediate contiguity to the carunculous
remains of the hymen, two large multifoliated
masses of structure, disposed in parallel layers in
such a manner as scarcely to fail to suggest the
idea of a pair of epaulettes. These are the forms
under which the hymen is usually found ; but it
should be borne in mind by the medical jurist
that it is liable to certain malformations, with
which he should be acquainted. It is commonly
a thin membrane, easily ruptured by any large
body introduced into the vagina. But it some-
times occurs that it is possessed of so much firm-
ness as to resist the intromission of the penis
This unusual degree of thickness and strength
may belong to a hymen composed of one uniform
membrane ; or to that conformation of it termed
cribriform, from its being pierced by a number of
holes. In this latter condition the membrane is
commonly exceedingly strong, and capable of
resisting the ordinary means of rupture. It is a
state, however, that does not prevent impregna-
tion, some cases of which are related by Dr. Davis ;
and as they relate to an important medico-legal
point, we refer to them, in addition to those al-
ready mentioned in the article Impotence. One
of these cases of cribriform hymen we transcribe
in consequence of its great interest : " It was
usually narrated in his peculiarly terse style by
the late Dr. Haighton, in his lectures on mid-
wifery in Guy's Hospital. The subject of it had
been the lady of one of the physicians to that or
to the neighbouring hospital of St. Thomas. It
was become matter of post-mortem history even
in the time of Dr. Haighton. The hymen was
perforated by many small apertures ; but it never-
theless was so strong that it had resisted all the
efforts of the husband to effect its rupture. That
gentleman, however, concealed his chagrin ; nor
did he take any means to accomplish artificially
what he had failed to do by the ordinary means.
Under these circumstances the lady drooped and
became unhappy ; but she also, at no distant pe-
riod, became the subject of faintings and sickness,
and eventually of great abdominal enlargement,
and of anasarca of her lower extremities. During
the urgency of those symptoms she was advised
to go to Bath for the benefit of the waters and of
the other good things to be obtained at that cele-
brated city. No remedy was found, however,
even there for the lady's dropsy, and the symp-
toms became more and more urgent every day.
Finding no relief at Bath, and giving up all hope
of recovery any where, she determined, after a
residence of some weeks at that place, to return

77G

RAPE

to London, in order that her remains might the
more conveniently be deposited in the monumental
vault of her family. Whilst on this journey,
which she was performing in a post-chaise, she
was seized with a severe abdominal pain, which
she naturally enough ascribed to a spasm of the
intestines. This colic, which was moderate and
bearable at the commencement, became so ex-
tremely violent in its progress that she was obliged
to stop suddenly at an inn on the road, where in
less than an hour she was radically cured of her
dropsy by becoming the mother of a well-grown
living child. The hymen was then ruptured
without the assistance of art." (Op. cit. p. 104.)

We have alluded to these cases to show that it
is possible for all the moral guilt of a rape to be
incurred without the conditions necessary to satisfy
the law upon the point, namely, intromission of
the penis, &c. Besides these sources of difficulty
presented to the medical jurist in malformation of
the hymen, there are some cases, and probably not
a few, in which this membrane has never existed
at all ; or having been at first formed of great
tenuity, has been ruptured and destroyed in early
life. Accidental circumstances may also serve to
obliterate it, such as disease, improper practices, or
acrimonious discharges ; and instances are not
wanting where it has been destroyed by the pres-
sure of the confined menstrual fluid. From the
cases alluded to above, it appears that impregnation
may take place without rupture of this membrane,
but in these instances perforation is not supposed
to have occurred. It is, however, stated by Zac-
chias that intromission may be effected when a
disproportion exists between the organs, when the
hymen does not exceed the ordinary size, but is
thick and hard, and when connection has taken
place during the presence of menstruation, or fluor
albus, without damage to this membrane. Gavard
(Fodere, Med. Leg. t. iv. p. 340,) found it perfect
in a female thirteen years of age, who was labour-
ing under the venereal disease. Ruysch (Observ.
Anat. Chirurg. xxii.) has said, that if coitus take
place during or immediately after the menstrual
excretion, this membrane is often not ruptured.

From these several circumstances of variety in
the original formation and appearance of the
hymen, its power of resisting the natural means
of rupture in some cases, and its yielding in others
to the slightest force, we are inclined to think that
the accuracy necessary in forming a medico-legal
opinion cannot be attained by looking to this sign
alone. We must, however, agree with Dr. Beck
(Elem. of Med. Jur. by Darwall, p. 52,) that it
would be difficult to support an accusation of rape
where the hymen is found entire, although its
presence cannot be considered as an unequivocal
proof of virginity ; for, as we have stated, it has
been asserted by good authority that it is not
always ruptured in coitu. An instance is related
by Dr. Smith (Prin. of For. Med. p. 410,) in
which an accusation of rape fell to the ground in
consequence of the presence of this membrane.
This occurred in the case of a man named Stew-
art, who was tried at the Old Bailey in 1704 for
ravishing two female children. The evidence
being at variance as to the fact of penetration, the
children were sent out of court to be examined, and
the eldest was found to have the signs of virginity.

The state of the vagina is the next point worthy
of consideration. In young subjects it is extremely
small ; but as the female advances towards puberty,
it becomes increased in its dimensions. In a
healthy adult virgin the parietes of the vagina are
remarkably firm and substantial, and from the only
function it has to perform, that of giving exit to
the menstrual excretion, it is rigid and narrow.
The internal surface is lined with a mucous mem-
brane which is remarkable for the peculiarity of
being much wrinkled or folded together into shal-
low irregularly transverse rug©, the peculiar use
of which is to qualify the passage for being inde-
finitely developed during parturition. These folds
are removed by frequent sexual intercourse, and
nearly obliterated in women who have borne one
or two children. The dilatation of the vagina,
and smoothness of its internal surface, are not,
however, to be taken as unequivocal proofs of
want of chastity, for these appearances may arise
from other causes. There are disorders of which
the tendency is to render it so, as fluor albus,
chlorosis, or menorrhagia ; and certain malprac-
tices will also occasion the same dilatation as sex-
ual intercourse ; and, on the other hand, coitus
may have taken place, and the vagina afterwards
reassume its contracted condition.

Generally speaking, in virgins the external labia
are thick, firm, elastic, and internally of a bright
red colour, with their edges so opposed as to ex
elude the entrance into the vagina ; while in mar-
ried women, or those accustomed to coition, they
are soft, pale, and have an interval of greater or
less extent between them. But these signs will
be found to vary according to the age, tempera-
ment, and state of health of the individual. Thus,
in persons of a sanguine temperament, although
in the habit of venereal enjoyment, the colour,
firmness, and thickness of these parts will be pre-
served ; and virgins of advanced age and weak
leucophlegmatic habit of body, or those afflicted
with leucorrhoea or menorrhagia, may present ap-
pearances which, if he above signs were sup-
posed to be valid, would lead to a conclusion of
an opposite character. The same observations
will apply to the state of the fraenum labiorum, or
posterior commissure of the pudenda. Some
authors have esteemed the integrity and rigidity
of this part as a proof of virginity, but no positive
conclusion can be drawn from it, for it frequently
remains untouched even after parturition.

From the observations just made, we feel our-
selves compelled to acknowledge that there are no
anatomical signs by which we can attest the pre-
sence of virginity. Taken singly they are all fal-
lacious, and even viewed in connection, they can
only favour the conclusion as to the chastity of
the female ; but the converse is not established by
the absence of these signs, as they may be all ab-
sent from causes already enumerated, although
their absence may serve to corroborate the oppo-
site opinion in suspected cases.

[M. Devergie (Mcdecine Legale, 2de edit. i.
345, Paris, 1840) has entered at length into an
inquiry, founded on numerous examinations, as to
the normal condition of the genital organs, in
young children ; in young girls near the period
of puberty ; in women who have had sexual in-
tercourse ; aud in those who have had children ;

RAPE

777

and he lays great stress on the circumstance, that
there is a considerable separation between the
labia at their upper part in young children ; — the
reverse occurring after puberty, and especially in
those who have had sexual intercourse.]

Signs of Defloration. — In this inquiry it is
necessary to take into account the age, strength,
and state of mind of both persons concerned. The
sexual organs of both should be examined, and
this as speedily as possible after the alleged as-
sault, for if the woman have reached the period
of puberty, no satisfactory information can be ob-
tained by a professional examination unless made
immediately after the commission of the act. In
children, from the great disproportion of the parts,
the violence is greater, and the effects consequently
remain for a longer time ; but in a subject of full
organic development, the appearances consequent
to connection are very fleeting. If the examina-
tion be made early, and particularly if the female
have been a virgin, besides the state of mental ex-
citement in which she may be found, there may
be physical signs consisting in local marks of vio-
lence. The parts are found lacerated, tumefied,
and bloody or inflamed, and painful to the touch ;
the hymen most commonly ruptured ; and some-
times the presence of semen can be detected.
Besides these marks upon the genitals, there are
usually bruises or ecchymoses on other parts of
the body, particularly on the arms, thighs, nates,
and breast. In children the local appearances are
more evident, from the greater injury the parts
have received ; and the inflammation is sometimes
so great as to incapacitate them from walking.
But in married women, even a very speedy ex-
amination will fail to afford much assistance, from
the previously dilated condition of the parts. It
should be borne in mind that the female genitals
are liable to diseases which may imitate the ap-
pearances just pointed out. Of this fact, a case
related by Dr. Percival (Medical Ethics, p. 103
and 231) is a striking example. A girl, four
years of age, and in good health, was suddenly
seized with inflammation of the pudenda, and
symptoms of defloration, with pain in making
water. She had slept two or three nights in the
same bed with a boy fourteen years old, and had
complained of being very much hurt by him dur-
ing the night. The symptoms increased in vio-
lence, and the child died on the ninth day. An
inquest was held on the body, and Mr. Ward,
under whose care the patient had been in the
Manchester Infirmary, deposed that death was
caused by external injury. A verdict of murder
was returned against the boy, and he was accord-
ingly taken into custody. A very short time
afterwards, however, several similar cases occurred
in the same neighbourhood, in which there was
no ground for supposing that violence had been
offered. Fortunately for the boy, h.s trial had
not come on, and Mr. Ward now informed the
authorities of the mistake he had committed, and
the prisoner was discharged. This kind of dis-
ease appears to be to a certain extent epidemic, and
is very fatal. Thus, out of twelve cases mentioned
by Mr. Kinder Wood, (Med Ch.rur. Trans .
vii p 84,) only two recovered. It is usually pre-
ceded by febrile symptoms for two or three days,

Vol. III. — 98

and when the genitals are examined, they are
found inflamed and swollen. The colour is dark,
and ulceration with gangrene quickly follows
The fever assumes a typhoid character, and death
shortly takes place.

The presence of the venereal disease in the
female, when its invasion corresponds with the
period at which the outrage is stated to have oc-
curred, that is, in from three to eight days after-
wards, is a very strong corroborative proof of de-
floration, if the aggressor is found on examination
to be afflicted with the same disease. This is not
uncommonly the case in young children, in con-
sequence of a very prevalent notion entertained
by the lower orders, that connection with a virgin
is a certain cure for the disorder. Appearances
resembling gonorrhoea, however, should be looked
at with a very scrupulous eye, as it is now per-
fectly well known that children, particularly those
of strumous delicate constitutions, are liable to
purulent discharges from the vagina, which very
much resemble the consequences of impure con-
nection. These discharges take place during den-
tition, or from the presence of worms in the intes-
tinal canal, and are also sometimes observed in the
male sex from the same causes. We are indebted
to Sir Astley Cooper (Lectures on Surgery) for
the following energetic observation on this pecu-
liar affection. " There is a circumstance on which
I am exceedingly anxious to dwell — I allude to a
discharge from young females, and I hope that
there is not one here this evening but will be
strongly impressed with the importance of the
subject. Children from one year old, and even
under, up to puberty, are frequently the subjects
of a purulent discharge from the pudendum,
chiefly originating beneath the preputium clito-
ridis ; the nymphse, orifice of the vagina, and the
meatus urinarius, are in an inflamed state, and
pour out a discharge. The bed-linen and rest of
the clothes are marked by it. It now and then
happens to a nervous woman to be alarmed at
such an appearance, and she suspects her child of
having acted in an improper manner ; and perhaps
not quite clear herself, she is more ready to suspect
others, and says, dear me, (if she confesses,) it is
something like what I have had myself. She goes
to a medical man, who may unfortunately not be
aware of the complaint I am speaking of, and he
says, ' your child has got a clap.' I can assure
you a multitude of persons have been hanged for
such a mistake. I will tell you exactly what takes
place in such cases ; the mother goes home and
says to the child, ' who is it that has been playing
with you 1 who has taken you on his knee lately V
The child innocently replies, « no one, mother ,
nobody has, I declare to you.' The mother then
says, * Oh, don't tell me such stories ; I will flog
you if you do.' And thus the child is driven to
confess what never happened, in order to save her-
self from being chastised ; at last she says, ' Such
a one has taken me on his lap.' The person is
questioned, and firmly denies it; but the child,
owing to the mother's threats, persists in what
she has said. The man is brought into a court
of justice ; a surgeon who is ignorant of the nature
of the discharge I am now speaking about, gives
his evidence ; and the man suffers for that which

778

RAPE.

he never committed. The mother is persuaded,
if there be a slight ulceration on the parts, that
violence has been used, and a rape committed.

" If I were to tell you how often I have met with
such cases, I should say that 1 have met with thirty
in the course of my life. The last case I saw was
in the city ; a gentleman came to me, and asked
me to see a child with him who had a gonorrhoea
on her. I went, and found that she had a free
discharge from the preputium clitoridis. 1 said that
there was nothing so common as this. There was
considerable inflammation, and it had even pro-
ceeded to ulceration, which I told him would soon
give way to the use of the liquor calcis with calo-
mel. ' Do you tell me so ?' he replied ; < why, sus-
picion has fallen on one of the servants ; but he
will not confess. If he had appeared at the Old
Bailey, I should have given my evidence against
him; for I was not aware of what you have just
told me.' I told him that if the man had been
hanged by his evidence, he would have deserved
to be hanged too. I am anxious that this com-
plaint should be known by every one present, and
that the remarks which I have made should be cir-
culated throughout the kingdom. When a child
has this discharge, there is a heat of the parts,
slight inflammation ; and this sometimes increases,
and goes on to ulceration. This disease some-
times occurs in children at the time of cutting their
teeth."

In the year 1831 a man was arrested in the city
of Dublin on a charge of a rape committed on a
child ; the only evidence of which was the pre-
sence of a purulent discharge from the pudendum.
Popular opinion, as is usual in such cases, ran
high against him ; and it was only through the
positive opinion of an intelligent surgeon that the
case was explained, and the man liberated. A
case of a somewhat similar nature lately came
under the observation of the writer. A lady and
gentleman came to his house one evening in a
state of great alarm and excitement, accompanied
by their child, a girl of four years old, whom they
stated to be afflicted with a terrible disorder, com-
municated to her by some person in their employ-
ment. They had previously shown the child to
an apothecary, who confirmed their worst appre-
hensions, and at once declared that the girl had
got a clap. On examination, the parts were found
in a state resembling that just described, with a
free purulent discharge ; and it was with no small
degree of pleasure the writer was able to console
the parents by assuring them that their child was
labouring under no uncommon affection, and that
a few days would set all to rights. It has rarely
fallen to his lot to witness a more sudden transition
from grief to joy than this announcement effected.

Dr. Ryan (Med. Jur. p. 185,) mentions the
case of a delicate girl, aged 11 years, who had a
purulent discharge from the external genitals, and
accused a young man of eighteen, whose genitals
were developed in an extraordinary degree, of
having violated her person. Two apothecaries
swore the girl had been violated, a rape committed,
and gonorrhoea communicated. Dr. Gordon Smith,
Mr. Whitmore, and Dr. Ryan were of a different
opinion. The case was grievously mismanaged
for the prisoner; the only evidence produced in
his favour was Dr. Smith's, which was contrasted

with that of the two medical witnesses for the pro-
secution, who had refused to examine the person
of the prisoner, although assured that he had no
discharge from the urethra, and had not had any
for six months previously. The man was found
guilty at the Middlesex sessions, and sentenced to
six months' imprisonment, and lectured by the
chairman on his good fortune that he was not
hanged. The mother of the child confessed to
Dr. Smith that she had had the discharge since
she was five years old.

[In a recent article (hond. and Edinb. Monthly
Journal of Med. Science, Sept. 1844, p. 760,)
Dr. J. R. Cormack has described similar cases
which lead him to the practical conclusion, "that
a variety of causes, constitutional and local, may
(either singly or in conjunction with one another)
give rise to discharges, which cannot be distin-
guished from those occasioned by impure coitus,
to which the name of gonorrhoea is commonly
applied."]

From these and other similar instances, we can-
not too strongly urge the necessity of an early
examination of both parties. By following this
course, it has happened that the man has been
acquitted where marks of disease were discovered
in the female, because no signs of gonorrhoea have
been detected about himself. A case related by
Sir Matthew Hale (Paris and Fonblanque, Med.
Jur. vol. i. p. 418,) furnishes an instance where an
innocent man might have been saved from a mali-
cious prosecution, to the hazard of his life, by this
precaution. Fodere (Med. Leg. vol. iv. p. 363,)
mentions two cases from Zacchias, where the false-
hood of an accusation was determined by a com-
parative inspection of both parties. Besides the
presence or not of disease, there are other points
to be determined by examination. Thus it may
happen that the man is impotent ; the penis may
have been lost by sloughing, accident, design, or
cancer ; the female organs may be so constructed
as to prevent the possibility of penetration ; in all
of which cases an inspection of both parties can
alone give grounds for conclusive opinions. It has
been remarked by a writer in a celebrated periodi-
cal work, with reference to the purulent discharge
of what we have just spoken, that "we must take
care not to run into the opposite error of ascribing
inflammation, ulceration, and discharge in cases
where violence has been alleged, to this disease
without sufficient grounds ; for it is extremely im-
probable that diseases which occur so rarely should
happen to appear in a child to whom violence was
offered, unless that violence had some effect in
producing it." (Edin. Med. Surg. Journ. vol.
xiii. p. 491.) On this point we think it right to
observe that the laceration, tumefaction, and in-
flammation consequent to the violation of a child
are very different from the disease under considera-
tion, and could scarcely be confounded with it. Its
great resemblance is to true gonorrhoea ; and that
point can be settled by a personal examination of
the man accused. Dr. Dewees (Treat, of Children,
pp. 236, 435.) states that when this disease arises in
very young subjects, it almost always proceeds
from a neglect of cleanly attention to these parts,
either by withholding a frequent use of lukewarm
water, or permitting the child to remain too long
wet. Children, however, of a more advanced age

RAPE.

779

have also discharges of a purulent character, that | Lord Coke, Sir Matthew Hale, and Hawkins held

seem to arise from a morbid action of the mucous
membrane of the vagina. This frequently shows
itself about the fifth year, and may continue, if
neglected, to almost any period. It should be re-
collected that violence has been sometimes inflicted
on the external genitals for the purpose of sustain-
ing an accusation against an innocent person. A
remarkable case of this sort is related by Fodere.
A female at Martigues, in 1808, accused eight or
ten of the principal persons of the place of having
violated her grand-daughter, aged about nine years
and a half, at an inn. She laid her complaint
before the judge de paix,and stated that she would
withdraw it provided the accused would accommo-
date the matter with her. She had procured a
daughter of the inn-keeper, aged sixteen and an
idiot, as a witness. As the charge was obstinately
persisted in, Fodere, with two officers of health,
was ordered to examine the child in presence of
the judge ; and suspicion was immediately excited
from the delay used in admitting the visitors. On
examining the parts, he found the hymen un-
touched, and the vagina extremely narrow. Around
the pudenda, however, a red circle about the size
of a crown was observed, which appeared to have
been induced recently ; and this was indeed the
fact ; for at the end of half an hour the circle had
decreased in size, and the redness disappeared

that there must be both penetratio and emissio
seminis, and this appears to have been the decision
of Skynner, C. B. Gould, Willis, Ashhurst, Nares,
Eyre, and Hotham, against Lord Loughborough,
Buller, and Heath ; Lord Mansfield, though pre-
sent, having given no opinion of his own. The
argument is stated to have turned on the words
carnal knowledge, to which the majority contended
that emissio seminis was absolutely necessary.
(Paris and Fonblanque, Med. Jur. vol. i. p. 433.)
This state of the law rendered cases of rape ex-
tremely difficult to prove ; for in virgins it is not at
all likely they would be conscious of any such cir-
cumstance having taken place, particularly when
we consider the state of fright, pain, and weakness
into which they are necessarily thrown ; and even
in married women it does not appear that they are
always conscious of emission — indeed, we should
be inclined to suppose the reverse. Judge Buller
stated, in giving judgment on a case in 1787, that
he recollected a case where a man had been in-
dicted for a rape, and the woman had sworn that
she did not perceive anything come from him ;
but she had had many children, and was never in
her life sensible of emission from a man. Again,
in the case of children, it is manifestly impossible
that evidence of emission can be obtained ; and,
as has been well remarked by Dr. Paris, if it be

Had this been the effect of great violence, it is na- true that certain eunuchs have the power of erec-

tural to suppose that it would have increased in
intensity of colour. A report was prepared, stat-
ing the above facts ; and the consequence was,
that the accuser was put in prison, and finally
ordered out of the city.

The chief point in an accusation of rape, neces-
sary to be proved, is the act of coition ; but as
considerable difference of opinion has existed as to
what legally constitutes this act, it is necessary to
make some observations upon it. Some authorities
have maintained that simple penetration was suffi-
cient, while others have judged that without emis-
sion the crime is not complete. In the case of
Russen, the schoolmaster, who was tried for a rape

tion, and consequently of penetration, they may
morally ravish without incurring the punishment
of rape; for it is certain that they can have no
emissio seminis ; or a man may have perpetrated
all the more atrocious parts of his crime, and yet
being interrupted in the least voluntary constituent
of it, escape the well-merited vengeance of the
law ; while it is evident, on the other hand, that
the innocent victim has suffered in body, mind,
and reputation, as much as if the crime had been
legally completed. (Loc. cit.) It has been stated
in defence of this practice of requiring proof of
emission, that it is quite necessary to make the
proof of the crime difficult in order to avoid false

committed on a girl under ten years of age, it was accusations, for it often happens that the only
proved by two surgeons on behalf of the prisoner,
and corroborated by four others who had examined
the girl, that the hymen (which they considered
an indubitable mark of virginity) was whole and
unbroken, and that the passage was so rm rr ° w
that a finger could not be introduced. But Mr.
Justice Ashurst, who tried the case, left it to the
jury whether any penetration were proved ; for
if there were any, however small, the rape was
complete in law. The jury found him guilty, and
he received judgment of death. But before the
time of execution, the matter being much discussed,
the learned judge reported the case to the otner
judges for their opinion, whether his directions
were proper ; and upon a conference it was unani-
mously decreed that the directions of the judge
were perfectly right. They held that, in such
cases, the least degree of penetration was suffi-
cient though it may not be ""ended with tl e de
privation of the signs of virginity It w *A«»
fore, properly left to the jury by tl e judge, and
accordingly the prisoner was executed. This oc
according, « F Q the other hand,

curred in the year j / < >•

chance an innocent man has is the cross-exami-
nation of the prosecutrix ; if, therefore, it be ne-
cessary to prove all the circumstances, including
emission, it follows that there is a greater likelihood
of the witness tripping in her evidence.

The question with respect to requiring proof of
seminal emission in cases of rape has been recent-
ly settled by an act (9 Geo. IV. c. 31, passed June,
1828,) which cites "that upon trials for the
crimes of buggery and of rape, and of carnally
abusing girls under the respective ages hereinbe-
fore mentioned, offenders frequently escape by
reason of the difficulty of the proof which has
been required of ihe completion of these different
crimes ; for remedy thereof be it enacted, that it
shall not be necessary in any of these cases to
prove the actual emission of seed in order to con
stitute a carnal knowledge, but that the carnal
knowledge shall be deemed complete upon proof
of penetration only." By the same act the crima
of rape, or of the abuse and carnal knowledge of"
a girl under ten years of age, is punishable by
death. Abuse and carnal knowledge of a girl

790

RAPE.

between ten and twelve years of age is considered
a misdemeanour only, punishable by imprison-
ment, with or without hard labour.

In Philadelphia, where the law is the same as
with us, it has become common of late years to
indict for an attempt to commit a rape, rather
than for the crime itself, and chiefly from the diffi-
culty of proof. Emission, however, is not con-
sidered essential in Pennsylvania (according to
Judge Cooper) ; and properly, he adds, for it is
not the essence of the crime, and it may happen
without being perceived in cases of violence. In
Illinois it is expressly enacted that so much of the
/aw regulating the evidence in case of rape as
makes emission necessary, is hereby repealed.
(Beck, p. 67.)

[In the United States, the disposition, almost
universally, is, to consider penetration alone to be
sufficient evidence as to the carnaliter cognovit ;
and recent English decisions are to the effect, that
the least possible introduction of the male organ
within the orifice of the vagina, — even short of the
rupture of the hymen, and without the emission
of sperm, — constitutes a rape, provided it be done
forcibly, and against the will of the female. (See
5 Carrington dj- Payne's Reports, 321 ; and Ibid.
August 27, 1838; Regina v. Hughes, 1841, in
Ibid. 9 : cited in Guy's Principles of Forensic
Medicine, p. 52, Lond. 1843.)

Of late years, great stress has been laid upon
spots or stains on the linen of the accused, or of
the woman ; which, according to M. Devergie,
(op. cit. i. 358,) afford, at times, the strongest
proofs of violation. These spots are of two kinds,
and occupy two different positions — the one on
the anterior part of the chemise, and the other on
the posterior. This, at least, is their most com-
mon situation. The spots on the front of the che-
mise present all the characters of sperm. They
are of a greyish-white colour ; circumscribed,
roundish, and terminated at their circumference by
a greyish line of a deeper colour. The linen is
stiffened ; and, if the effort to violate has been re-
cent, the spots, even when dry, may exhale a
spermatic odour; and, when subjected to analysis
and microscopic examination, may furnish all the
characters of sperm. The spots on the hind part
of the chemise are most commonly formed of
blood ; but they usually occur under two different
forms : the one, of a deep red, smaller, rich in co-
louring matter, and of an equal degree of colour
over their whole surface ; the other, of a much
brighter red, or rather of a reddish yellow : larger
than the first ; paler at the centre, and bounded
at the circumference by a circle of red colouring
matter, deeper than the rest of the spot. The for-
mer are produced by pure blood extravasated at
the time of the sexual union ; the latter by a
bloody serum, a sero-sanguineous oozing, less and
less coloured, and altogether like that which flows
from wounds made by a cutting instrument, when
they cease to discharge blood. This respective
position of the spots, M. Devergie adds, is not so
constant but that spots of blood, or of sanguine-
ous serum, may exist on the front of the chemise,
and some drops of sperm on the back : but still
they are more frequently seen under the circum-
stances described above.

Mr. Taylor (Manual of Medical Jurisprudence,

p. 579, London, 1844) affirms, that cases of rape
have hitherto been tried without reference to this
species of evidence ; and that it is not easy to
perceive how this can be necessary to the proof of
the crime, when the present law of England de-
mands only proof of penetration, and not of
emission. "Thus" — he says — "a rape maybe
legally completed without reference to emission ;
and, medically speaking, it appears quite possible
that there might be emission without any penetra-
tion. Admitting that certain stains of this de-
scription are found on the clothes of an accused
party, is this to be taken as an undeniable proof
of the legal completion of rape 1 It appears to
me that it cannot be so taken, and, therefore, that
the affirmative evidence from the miscroscope is
as liable to lead to error as that which is purely
negative. Besides, if such evidence were either
required or received, it is impossible to set a limit
to the mistakes and fallacies into which a court of
law might be led. It could only escape from these
by receiving evidence from a practised microscopi-
cal observer. Among the reports of numerous
trials for rape, in our courts, I have never yet met
with a single instance in which such evidence was
required, or would have been of the least utility."
(P. 580.)

Great caution would, doubtless, have to be used
in admitting such testimony : yet it is easy to see,
that the fact of blood upon the clothes might be
prima facie evidence of violence, and the pre-
sence of sperm strongly indicate the object of
such violence.

It need scarcely be said, that care must be had
not to confound spots of blood with the stains
produced by the menstrual discharge. Menstrual
blood contains but little fibrin, and does not co-
agulate. It is probably, also, darker than that
which would flow as the result of violence. By
introducing a plug into the vagina, it could be dis-
covered that the blood proceeds from high up that
canal ; which would at once show that it was not
the result of violence, if any doubt previously ex-
isted. In case of suspected spots of sperm, by
infusing the linen in water, and placing the fluid
in the field of a microscope, if spermatozoa be per-
ceptible, there will be no difficulty in arriving at a
decision. Dr. Dewy (Edin. Med. and Surg.
Journ. iv. 15) affirms that he observed them in a
seminal stain which had been kept eighteen days;
and still more extraordinary cases are on record.
(Devergie, op. cit. iii.347, and Guy, op. cit. p. 61.)]

This crime may be committed on a female at
any period of life after she has passed mere in-
fancy. We have already mentioned the law as
applied to children. In this case the charge of
violation requires the most accurate inquiry, be-
cause the material evidence in other cases, that of
the sufferer herself, is wanting, from her being in-
capable as a witness in consequence of her youth.
" If the rape be charged to have been committed
on an infant under twelve years of age, she may
still be a competent witness, if she hath sense and
understanding to know the nature and obligation
of an oath, or even to be sensible of the wickedness
of telling a deliberate lie ; nay, though she hath
not, it is thought by Sir M. Hale, that she ought
to be heard without oath, to give the court infor-
mation ; and others have held that what the child

RAPE.

781

told her mother or other relations may be given in
evidence, since the nature of the case admits fre-
quently of no other proof. But it is now settled
by a solemn determination of the twelve judges,
that no hearsay evidence can be given of the de-
clarations of a child who hath not capacity to be
sworn ; nor can such child be examined in court
without oath ; and there can be no determinate
age at which the oath of a child ought either to
be admitted or rejected ; but their admissibility de-
pends upon the sense and reason they entertain of
the danger and impiety of falsehood, which is to
be collected from their answers to questions pro-
pounded to them by the court." (Paris and Fon-
blanque, vol. i. p. 421.) Females, before they
reach the time of life at which menstruation com-
mences, are generally ignorant of the consequences
likely to result ; and this, coupled with want of
physical power, may often tend to facilitate the
commission of rape. But at the age of puberty
it has been doubted whether a woman of ordinary
strength may not successfully resist the attempts
of a single man.

Farr, in speaking of this subject, expresses
himself in the following terms: — "But the con-
summation of a rape, by which is meant a com-
plete, full, and entire coition, which is made with-
out any consent or permission of the woman,
seems to be impossible, unless some very extraor-
dinary circumstances occur. For a woman always
possesses sufficient power by drawing back her
limbs, and by the force of her hands to prevent the
insertion of the penis, whilst she can keep her re-
solution entire." (P. 41.) Dr. Beck quotes the
following answer given by the medical faculty of
Leipsic to the question whether a single man could
ravish a woman : " Si circumstantias quae in actu
coe'undi concurrunt consideramus, non credibile,
nee possibile, videtur, quod unus masculus nubi-
lem virginem (excipe impubem, teneram, delica-
tam, aut simul ebriam puellam) absque ipsius con-
sensu, permissione atque voluntate vitiare, aut vio-
lento modo stuprare possit ; dum feminse cuilibet
facilius est si velit, penis immissionem recusare,
vel multis aliis modis impedire, quam viro eidem
invitac plane intrudere." (Valentini Pandects,
vol. i. p. 61.) It is necessary, therefore, to be ex-
tremely cautious in admitting the truth of accusa-
tions, unless the bodily power of the man far ex-
ceeds that of the complainant. At the same time,
however, we should not entirely agree with the
positive opinions just quoted, for we think it pos-
sible that by long-continued violence, intimidation,
or other circumstances, the man may ultimately
prevail.

The question naturally arises here, can a female
be violated without her knowledge? in which
case the crime would be equally great, for it would
be still without her consent. There are different
ways in which we may suppose this to be effected,
as during natural sleep, or stupefaction caused by
inebriation or narcotics, or during a fit. As to the
possibility of rape being committed on a virgin
during natural sleep, we are very much inclined
to doubt it, notwithstanding the decision of the
faculty of Leipsic, " Dormientem in sella virginem
insciam deflorari posse." (Valentius, Novelke Med.
Leg cas 1 ) When we consider the violence in-
flicted, and the pain that attends a first intercourse,

3 a

we think it scarcely possible that any natural sleep
could be so sound as to preserve the woman un-
conscious of what was going forward. The case
is not exactly the same with married women, in
whom from previous sexual intercourse the parts
are more dilated. In such case we must admit
the possibility, but not at all the probability, for
even in them natural sleep, however heavy, would
be most likely broken by the attempt at violation.
That a female, whether virgin or not, may be
ravished during the insensibility attending intoxi-
cation, the administration of narcotics, or disease,
will be readily granted. As the sufferer can give
no direct testimony as to the fact, the only corro-
boration to be obtained is from a personal exami-
nation ; but as we have already mentioned, this
can be of no use alone in the case of her being a
virgin. There is reason to think that narcotics
have not been unfrequently administered for the
purpose of facilitating the commission of rape,
which circumstance is justly considered a great
aggravation of the offence, and, when proved, is
sure to draw down the heaviest punishment on
the perpetrator. A case occurred in Dublin, in
April 1831, in which a gentleman was tried for a
rape, and convicted, chiefly in consequence of an
impression made on the minds of the jury, that
some soporific had been administered by him to
the young lady, by means of which he was ena-
bled to effect his purpose. (Dublin Morning Post,
April 20, 1831.) There is another mode in which
this crime may be committed, wherein, although
the woman is not unconscious, she makes no re-
sistance, neither does she consent : that is, when
a man obtains admission to the bedroom of a mar-
ried woman, and imposes himself on her as her
husband. This constitutes a case of rape, and
subjects the offender to the usual penalty. The
same holds good in the case of forcible abduction,
where a woman is compelled to marry and is after-
wards violated by force.

[Dr. Guy (op. cit. p. 64,) states, that in the
year 1840, he was consulted by a poor woman,
who, after mentioning other complaints of little
importance, stated, that she was somewhat alarmed
by the fact of her sleep being so heavy, that she
was with difficulty aroused. She added, by way
of illustration, that her husband had assured her
that he had frequently had connection with her
during sleep.]

The fact of sexual intercourse being proved or
admitted, it now remains to be ascertained whether
the woman consented or not. If she be dead,
which sometimes happens from the violence em-
ployed, the most material part of the evidence, her
own testimony, is of course wanting, unless she
have lived long enough to give information before
her death. In the well-known case of Abraham
Thornton, who was tried some years ago, in Eng-
land, for the murder of Mary Ashford, (a case re-
markable for being the last in which a wager of
battle was offered, such right having been imme-
diately afterwards abolished by the statute 59 Geo.
III. c. 46 ;) the prisoner admitted having had cai-
nal knowledge of her, but stated that it was with
her own consent ; and although the general tenor
of the evidence was in opposition to this assertion,
the death of the unfortunate woman rendered it
impossible to ascertain the truth. It was formerly

782

RAPE.

imagined that the occurrence of pregnancy after
violation was evidence of the consent of the wo-
man. This opinion was maintained by Dr. Bartley
(P. 43,) and Dr. Farr (P. 43,) on the supposition
that women under the influence of the depressing
passions, such as fear, terror, &c. could not con-
ceive. It is said by Mr. Dalton, that if a woman
at the time of the supposed rape do conceive with
child by the ravisher, this is no rape, for (he says)
a woman cannot conceive unless she doth consent.
Such an opinion was founded on the idea that a
certain amount of enjoyment on the part of the
female is necessary towards conception. But it
has been clearly ascertained that this is not the
case, and the process of impregnation may go for-
ward, totally without the will, consent, or enjoy-
ment of the female. " That so absurd a notion
as that conception evidenced consent, should in
modern times have obtained amongst any whose
education and intellect were superior to those of
an old nurse, is indeed surprising : at this day,
however, facts and theory concur to prove that the
assentation of nature in this respect is no ways
connected with violation of mind." (Burn's
Just. tit. Rape.) Such is the opinion of all medi-
cal jurists ; and it is supported by the many facts
on record, of impregnation having taken place in

consequence of connection had with females dur-
ing insensibility from disease or the influence of
narcotics.

It was ruled, in the case of the king against
Fleming and Windham (Leach's C. L. p. 996,
and Paris and Fonblanque, vol. i. p. 439), A. D.
1779, that if the party be dead, the deposition of
the girl, taken before the committing magistrate
and signed by him, may after her death be read in
evidence at the trial of the prisoner, although it
was not signed by her, and she was under twelve
years of age ; provided she was sworn and ap-
peared competent to take an oath ; and all the
facts necessary to complete the crime may be col-
lected from the testimony so given in evidence.
But, as is the practice in other criminal cases, it is
not necessary that the female should be sworn, if
her testimony is given while she is dying, she
being conscious of her state at the time ; for it is
considered that the awful situation in which she is
placed is as sure a guarantee of the truth as any
form of oath could be. At the same time it is
quite necessary to have proof of the soundness ot
her understanding at the time, for without this the
solemnity of the occasion, and the anticipation oi
death, may not have a sufficient impression on her
mind.

T. E. Beatty.

END OF THE THIRD VOLUME

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