A Dictionary of practical medicine v. 4

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DICTIONARY

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PRACTICAL MEDICINE.

VOL. I.

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** *0 Blot fip«X^» 4 ^^ *'^X*^ fi«u^» ^ M mup6« &f^, ^ M ««cp« a^aktp^, ^ ti Kplmi x^<"^« ^<^

9(m$W," HlPPOCKATES.

** Man it born onto trouble at the tptrki fly upwards.*'

Job.

" Honour a physician with the honour due unto him, for the uses which ye may have of him :
for the Lord hath created him.

" For of the most High cometh healing, and he shall receive honour of the king.

** The skill of the physician shall lift up his head : and in the sight of great men he shall be in
admiration.

"The Lord hath created medicines out of the earth ; and he that is wise will not ablior tliem.

*'Then give place to the physician, for the Lord hath created him : let him not go from the«,
for thou hast need of him.

" There is a time when in their hands there is good success."

EccLBsiASTicus, chap. xxxviii. y. 1 et seq.

*<Qafle regio in terris noatri non plena laboris? *'

ViRQIL.

'* Multorum disce exemplo, qnn fi^ta sequaris, qax fugias."

Cato.

((.

Mentem sanari, corpus ut aegrum,

Cemimus, ct fleet! medicina posse videmns.*'

LUCRBTIUS.

*<To ignorants obdnrde, quhahr wilftDill errpur lyis,

Nor tit to curious folkt, quhllka carping doit deject thee.
Nor zit to learned men, quha thinkt thame onelie wyis.
But to the docile bairns of knowledge I direct thee."

James I. of Scotland.

" Man is all symmetric.
Full of proportion, one limbe to another,

And all to all the world besides ;
Each part calls the furthest brother.
For head with foot hath private amitie ;
And both with moons and tides.*'

Grorgb Hrkbbrt.

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TO

WILLIAM FOTHERGILL COOKE, ESQ.

OAKLAKDB, HANTS
TO

PETER DICKSON, ESQ.

UFFBS BBOOK 8TBBET
TO

HENRY JOHNSON, ESQ.

CBUTCHED FBIABS
TO

DANIEL LOUTTIT, ESQ.

FULTENEY TOWN, CAITHNESS
TO

PATRICK PANTON, ESQ.

BDSNBAMX, BOXBUBOHSHISB
AND TO

THOMAS GODFREY SAMBROOKE, ESQ.

EATON PLACE, BBLOBAYIA

THK AUTHOR DEDICATES THIS WORK

WITH

ATTECTION AND OBATITUDE

rOE THEIE

XONG AN-D INTIMATE FBIEND8HIP.

OU BurUngioH Street.
Jtiiy 1858.

//79f

PREFACE.

L Th£ Author deeply regrets the long period he has required to com-
plete his undertaking : hut circumstances^ which he could neither prevent
nor control, obliged him to bring out the early Parts of it sooner than he
desired, and delayed the subsequent Parts, which he was anxious to eze«
cote in ft manner commensurate with the character and success of those
which were published.

A work requiring for its satisfactory performance an acquaintance
with, and a frequent recourse to the best authorities, and a constant re-
gard to the results of the Author's observation and matured experi-
ence— to his written notes, as well as to his repeated recollections-*
could not be completed in a few years. The frequent interruptions
arising out of public and private medical practice ; the fatigue of body
and mind which this practice involved; the calls required from him,
the visits made, and the letters written to him, by those in his profes-
sion who claimed his attentions ; the anxieties resulting from the more
intimate relations of life ; the disappointments and losses which often fall
the most severely where they are most intensely felt — all have combined
to delay the completion of an undertaking commenced with enthusiasm,
and, notwithstanding numerous discouraging and retarding circumstances,
prosecuted with perseverance.

Daring the many years theT Author has devoted to this work, he has
employed the time 'vt^ch his more active professional duties during the
day allowed him, in making notes, in referring to authorities, and in com-
paring the descriptions of the individual cases which had come under his
care — of their histories, progress, course, complications, and treatment ;
whilst he has employed some of the hours usually given to repose, in digest-
ing the results of his observations and studies into the following per-
formance. Accustomed from early age to much endurance and applica-
tion, endowed with a strong and a sound constitution, and enjoying
through life uninterruptedly good health, for all which he cannot be
sufficiently grateful to an almighty and gracious Providence, ho has been
enabled to pursue his avocations, notwithstanding the interruptions
alluded to, with much less loss of time in the restoration of the powers of
nature in sleep than is generally required.

Thus endeavouring to economise and to regulate his time between the
active duties of practice, and the not less important duties of teaching,
orally and by his writings, the Author believes that he has succeeded in

A 4

PREFACE. si

stadjiDg the remoter relations, and the more intimate connections of
disease, as well as their differences in seat, character, nature, and form.
Also, when enumerating symptoms, references to those which are indica-
tire of danger, or even of a fatal issue, cannot be overlooked, especially as
they constitute the division of General Prognosis, comprised by the more
comprehensive department of Symptomatology ; Special Prognosis — or
the prognosis of individual diseases — being discussed as a part of the
pathology of these diseases, and in due connection with them.

A full consideration of the states and manifestations of morbid actions
cannot be limited to the discussion of Symptomatology, and the sympa-
thetic relations of disease. These subjects are merely the indications or
outlines of general principles, which require to be filled up and illustrated
by the more precise descriptions of the forms, courses, and complications
of diseases, as they are observed in practice, in different seasons and
climates, in different epidehiics, and in different races. The diagnosis and
the alliance of morbid conditions, although furnishing opposite indications,
also require to be duly estimated, in our endeavours to obtain precise and
specific information as to the natures and tendencies of diseases. It is not
only the features of disease, but also the expressions of these features,
which require to be studied in the investigation of the seats and vital
relations of morbid action, and of the extent to which the blood and the
tissues may have become contaminated and altered : and in our attempts
to form a prognosis of disease, not only should these features and their
expressions bo duly studied, but also the extent to which they are affected,
and the character of the change produced, by the means of cure which
have been employed. During the course and treatment of disease, the
very important diagnosis between the changes which may be imputed to
the natural procession of morbid phenomena, and those which result from,
and are the actual effects of, the medicinal agents which have been taken,
is too frequently either neglected, or altogether unknown ; and the ig-
norance, more than the neglect, of this diagnosis has been the cause of
more serious mischief than can well be credited, unless by those whose
enlightened experience and habits of close and unbiassed observation
enable them to form an opinion.

To the diagnosis of the effects or symptoms produced by the usual
causea of diseases, and by the action of medicines when given in excess,
may be added the diagnosis of the operation, or, in other words, a due
recognition of the modes of action of causes in developing morbid condi-
tions. Thus, owing to numerous causes, more especially to original and
acquired diathesis, to habits of life, and to modes of living, to indulgence
in animal food beyond the wants of the economy, to the abuse of fer-
mented and distilled fluids, to the many causes of debility and exhaustion,
the organic nervous force is lowered, digestion and assimilation are
impaired, secretion and excretion are diminished, nitrogenous and other
excrementitious matters, the extreme products of animalisation, accu-
mulate in and contaminate the blood, occasion numerous diseases, espe-
cially gout, rheumatism, cutaneous eruptions, visceral inflammations, &c.,
and require for their removal and for their counteraction or prevention,
an early recognition and diagnosis of them ; and, as shown by the Author in
the early Parts of his work (published 1832-7), a recourse to means which
may increase the secretions and excretions, may depurate the blood, and

FBEFAGE. xUi

and with whicli dynamic states are also associated. The specific perver-
sions or infections, for instance, characterising small-pox^ scarlet-fever,
hc^ are associated either with an exalted, or with an impaired state of
vital force and of vascular action at different periods of these maladies.
These perversions maj be manifested by both the organic nervous system
and the vascular systems and fluids, in various grades in different cases,
and may be so great as to occasion danger or death, even independently of
the dynamic states of action. In these, cases, it is not only the dynamic,
but also the specifically perverted, conditions -— the latter more par-
ticalarly — against which the physician must direct his agents, internal,
external, and emotional, appropriately to these conditions, endeavouring,
at the same time to counteract, to neutralise, and to remove those more
material and manifest alterations which, while they are the results of these
perversions, become the most influential agents of their increasing and
exterminating effects.

VIL General Thbbapsutios may be viewed as the capital of the
column which the medical teacher has erected in honour of that science,
to the study of which he has devoted his life. It is attempted in this
work to point out the several causes which combine to retard, if not
to arrest, the progress of therapeutical knowledge. The Principles of
Therapeutics are next stated, and divided into the Fundamental, into
the General, and into the Special ; these being severally illustrated and
enforced by practical precepts and indications, having due reference to
the states of vital force, of the circulating and secreted fluids^ and of al-
tered structures. The Author has endeavoured to developcj'^under this
head, the principles and intentions which should guide the student and
the practitioner of medicine in the application of the knowledge they have
acquired of other departments of science to the grand objects of curing
and of alleviating diseases. This most important subject is concluded by
a classification of hygeienic and therapeutical agents, according to their
modes of action and to their effects— according to their physiological ope-
ration and to their curative influences.

YIIL From the commencement of his lecturing on the Principles of
Pathology and the Practice of Medicine, the Author adopted a Classifica-
tion of diseases based on the Vital Force, as manifested by the several
systems and organs of the body. He viewed disease, especially in its early
states and stages, to be the result of causes affecting the conditions of this
force in one or other of these systems and organs ; these conditions either
passing into the healthy state, under the influence of this force, or extending
to and deranging other allied systems and organs, thereby perpetuating or
complicating disorder, until important changes supervene in the fluids,
or in the structures, or in both fluids and structures. Conformably with
this doctrine, and after a due consideration, 1st, of the causation of morbid
conditions ; 2d, of the nature and genesis of these conditions ; dd, of the
changes ihey occasion ; and 4th, of their mutations, metamorphoses, and
terminations, — subjects fully discussed under the heads, Disease, Blood,
Csisxa, ExcBETioK, Irritation, Sthpatht, and Sympathetic Associa-
tions OF D18SA8B, and forming a system of General Pathology, — the
Author entered upon the study of the special forms of disease, commencing

PREFACE. zv

until ihe secretions^ the circulating fluids, the excretions, and the struc-
tures become contaminated and organically altered, and capable, as respects
certain specific maladies, of communicating the same morbid actions to
healthy bat predisposed and susceptible persons, exposed to the emanations
proceeding from them.

Li our examination^ of the sources and causes of several of the maladies
which are often most prevalent, and which prove most destructive to the
human race, ^heir connection with epidemics, or epizootics, in the lower
animals' has been too generally overlooked. That diseases, originating and
hecoming prevalent and fatal in the lower animals, often extend to, or
infec^ Ihe human species, and that they may be recognised in this species
bj appearances and symptoms as nearly allied as the different circum-
stances of man and the lower animals are capable of manifesting, have
been satiafactorily demonstrated in respect of more than one of the exan-
thematous diseases. Established facts of this nature suggest further re-
searches into the concurrent causes and the phenomena not only of these,
but also of other infectious and contagious diseases, and more especially
where such a connection may be presumed to exist ; for if disease may
thus originate on any occasion, it may on others, and thus the evil may be

moItipUed, or even perpetuated.

X. The descripHons of diseases are based chiefly on the Author's
own obeeryation. His experience had demonstrated to him, what others
had either overlooked, or not ventured upon, that the very difierent
conditions and manifestations of morbid action, and the diversified
characters of local and specific diseases, caused by circumstances not
always manifest or even recognisable, but exerting nevertheless a more
or less powerful influence on the state, course, and issue of these dis-
eases, required due consideration, in respect both of their pathological
relations, and of their treatment ; he, therefore, has endeavoured, not only
to describe the more usual forms and courses of diseases, but also to notice
and to distinguish these modifications and differences, to assign them to
their specific or influential causes, and to point out the means of cure most
appropriate to each.

The nature of the predisposing and exciting causes ; original constitu-
tion, temperament, and diathesis; endemic and epidemic influences, cli-
mates, and states of season and weather; secret habits and vices; the
emotions and passions ; the deficiency, superabundance, and the nature of
food ; overcrowded places of resort ; a foul and too frequently respired
air ; infection and contagion in their various modes of transmission ; pe-
culiarity of race and varieties of the species, and the prevailing epidemic
constitution^ are severally, and in their diversified combinations, con-
sidered by the Author, with reference to the forms, states, the course,
and issue of diseases. These circumstances, modifying, diversifying, or
altogether changing the characters and states of local, or even of specific
maladies, he has extended his descriptions so as to comprise the different
forms thus produced, whether simple or complicated, and he has considered
them with reference to their modifying and appropriate causes, as fully as
his limits would admit.

Having viewed diseases as they are influenced, modified, or altogether
changed by the above causes, or by their various combinations acting on

PBEFACE. xTii

slight difficulty : and this difficulty is greatl/ augmented by the desire of
conyeying accurate views in concise, appropriate, and forcible language,
without unnecessary amplification or repetition. Our perceptions of diseased
actions may be distinct and accurate, and our conceptions of their causes and
tendencies may be lively, or even forcible in our own minds ; but to con-*
Tey these with equal accuracy and force to the minds of others-* to place
them before the mental vision of the reader, as we have seen and con-*
sidered them — and to render them objects of that amount of interest
which their importance and tendencies demand, cannot always be accom-
plished, so as to fully satisfy the mind of the describer, and the wants of
those whom he endeavours to instruct. To fail in accomplishing an object
of 60 great difficulty— -a difficulty of which an idea can be formed only by
making an attempt to overcome it — may not attach to it greater blame
than may be imputed to all attempts which, from the nature of the
object, preclude perfect success. But, although this has not been reached
bj the Author, yet he cannot divest himself of the hope that his effi^rts
have not altogether failed, and that close observers and candid judges will
allow that he has endeavoured to describe faithfully what he has carefully
observed ; and to elucidate, neither irrationally, nor unprofitably to the
reader, the sources, the natures, and the issues, of the numerous maladies
which his undertaking comprised.

XL The pathology and treatment of Fevers and Pestilences are
fully entertained. The Author has endeavoured to adduce all that has
appeared to him deserving of description and elucidation,* and to re-
move much error of long existence as to their nature and treatment. He
lias fully considered their causes, both those which primarily influence the
vital force and its several manifestations, and those which affect the con-
stitation of the circulating fluids. Certain of these causes, especially
specific infections, have been supposed to act primarily on the blood ; but
the long periods often existing between the impression made by the causes,
and the manifestation of their effects, as well as the character, course, and
issue of these effects, render it more probable that the morbid impression
is directly and primarily made upon the organic nervous system, the vital
force of which is changed conformably with the nature of this impression ;
the consecutive changes being a series of effects more or less slowly evolved,
ontil, after various periods, these changes break out into more or less acute
disorder implicating the whole organisation. If the phenomena of all in-
fectious fevers — the typhoid, the exanthematous, the malignant, and the pes-
tilential— ^be closely considered, it will be found that the infectious agent
may instantly and sensibly impress the body so as to produce a feeling of
sinking at the epigastrium, often followed by nausea, vomiting, or retching,
by manifest disorder of the organs supplied with the organic or ganglial
nervous system, and by changes of the secretions, the excretions, the cir-
culating fluids, especially the blood, and ultimately of the vital cohesion
and physical conditions of the several structures. That the morbid
impression is primarily made upon that portion of the organisation
especially devoted to secretion, assimilation, and the growth, nutrition,
and^velopment of the body, is shown by the permanence of certain of its
effects, — by the circumstance of the constitution being rendered insuscep-
tible of the impression of the same morbid agent for ever after, and by the

VouL •

PBEFAGE. ui

should be attached to an idiopathic or primary malady. But it is not easy,
or even possibloy to determine^ in every case^ the primary or the consecu-
tive nature of a complaint ; and when the former cannot be ascertained at
once, means should be used to mitigate the symptomatic disorder, which,
by its severity, may mask the original lesion. Disorders also referred to
the same seat may be either primary or symptomatic, and hence should be
praclically viewed and treated as either condition is inferred. Moreover,
the complaint, although obviously symptomatic, may attach to itself the
importance' and the means of cure which a primary disease would suggest.
Many also of the disorders usually denominated as symptomatic are, from
their severity and pathological relations, complications rather than pro-
minent symptoms ; they are, on this account, and owing often to their
severity, practically viewed by the Author with all the interest which is
attached to idiopaUiic diseases.

XVUUL At the present day the practice has grown up (and prospered as
a trade) of viewing diseases, both those which are chiefly internal, and
those more external or local, and of exhibiting them to the public as
being better understood from being specially professed. But man, al-
though furnishing the most wise, the most complex, and the most wonder-
ful of all machinery, is not an inanimate machine, but is endowed with
vital force distributed to, and actuating numerous systems, organs, and
parts, and evincing functions and offices duly connected with and in-
fluencing each other, so that the conditions of each are manifested by all,
in various modes of action, of existence, and of change. Hence the state
of one organ or pa^ cannot be considered in practice, either correctly or
safely, diaconnectedly from the rest of the economy ; and hence an inter-
ference with a single organ may, without due reference te the state of the
whole body, endanger the life of the individual. Whoever attempts to
cure an external sore, an eruption, or even certain internal or local
auctions, without considering the relations of these affections to visceral
disorder, may either, by effecting what he professes, occasion a most
severe or fatal malady ; or he may fail in his attempts, or even aggra-
vate the disease by an incompetence to estimate correctly the sympathetic
and the symptomatic relations of the affected organ, and of the disease
of which it is the seat. All parts of the frame are bound together by the
vitality which endows them ; and the meddling or ignorant interference
with one part, without duly considering the existing conditions and re-
lationa of the others, and the contingencies which may arise from such
interference, is more likely to extend or to perpetuate, than permanently
to remove disease.

The medical or the surgical specialist may err, not only by suppressing
a discharge, or by healing an eruption or a sore, which have become
safety-valves to a morbid constitution, or have warded off a disease to
which an internal organ is predisposed ; but he may err still further by
his ignorance of the operation of medicines which, when given in exces-
sive doses or too long continued, may produce effects much more serious
or even dangerous than the affection for which his vaunted treatment was
employed ; and, moreover, he may be, as he often is, most comfortably un-
conscious of the evil he has occasioned, by his being completely ignorant
of the symptoms by which these bad effects are indicated, and of his

a3

I

PREFAOE. zzlii

^ii to be assigned to more than one cause i but there is no cause half so
inflaentiid in occasioning this calanuty, as that secret vice, which has
been denounced in several parts of this work/ from a knowledge of its
great prevalence among young persons of both sexes^ and of its most in-
jorious influence on the healthy conditions of both mind and body. The
iafiimity of mind and the extreme credulity which it induces, before it
completely prostrates the faculties, render those addicted to self-pollution,
those of itke male sex more especially, the weak and drivelling victims of
a class of unqualified, unfeeling, and imposing pretenders, from whose
miarepresentationB the laws furnish no protection, and upon whom no re-
strictiflDs are imposed. The great importance of guarding against this
most vile and degrading vice has not been sufficiently recognised by
medical writers, especially systematic writers ; but, as it can be shown
that a large proportion, if not the majority of cases, of chronic diseases and
of the infirmities of mind and body in both sexes, arises from this vice,
practised at a period when the structures of the body are advancing to or
are assuming their full development, a due regard should be directed
to means of preventing it» inasmuch as it has become a most prevailing,
a most debasing, and a most destructive physical and moral evil.

XX. P018OK8 have been ably investigated by modern medico-legal
writers, chiefly, however, as regards the lesions they produce and the
methods of detecting them in the digestive canal and structures of the
body. The chemical and the medico-legal investigations of poisoning are
not entertained, because they do not come within the scope of this work.
Bat poisons are individually considered as respects their acute, and their
chronic or slow operations and effects, each poison producing, according
to its nature, specific effects, and therefore requiring an appropriate
treatment. The chapters on the nature^ operation, and treatment of
individual poisons are prefaced by an account of the modes in which
poisons are used and the varied circumstances in which they are had
recourse to. Without this information, the accidental or the felonious
nse of them may be mistaken for the course and issue of natural dis-
eases or even of puerperal maladies. The exhibition of poisons also
during disease, either singly or added to the medicines which the patient
has been taking, has often not been sufficiently recognised or even sus-
pected by the medical adviser ; and hence there is reason to believe that
many persons have been destroyed without the cause having been recog-
nised, and the effects of acute as well as of chronic or slow poisoning
hare been mistaken for the course and issue of natural disease. In order
that this view of poisoning should not be overlooked, that the symptoms
may be more clearly determined, and that the treatment should be both
suitable and successful, the Author has fully considered the modus operandi
or the physiological action of individual poisons, and has arranged them
ikceording to the more prominent characters by which their operation is
manifested. The treatment advised for each poison has been as fully de-
scribed as the limits of this undertaking could admit, both as respects the
employment of antidotes, and as regards the selection of means for the
removal of the injurious effects they may have produced.

The serious effects, as well those of acute as of chronic poisoning, and
their diagnosis from natural maladies, have been fully described, and the

a 4

PBKFACS. uWi

hive inoreMed. BeaideSi the single observer should &oi suppose that the
whole sphere of correct medical information can be embraced bj himself,
or that his own extent of acquirement should constitute a sufficient amount
of knowledge.

It is unnecessary to allude further to particular departments of this
work, or to subjects which have received especial attention and develop-
ment It is desired, and, indeed, most ardentlj desired, that every part
of this difficalt undertaking should be closely, but candidly, scrutinised ;
for, although the Author has been a student during his life, he is not too
old to learn and to derive advantage from judicious criticism.

XXIV. The Author may be permitted to state the incentives to his un-
dertaking, and the sources of the hopes he has entertained of being enabled
to accomplish it. When he entered upon the study of these departments
of sdenoe, which are the bases of practical medicine, he felt the want of
a work which would supply students and practitioners of medicine with
that amount of knowledge which the due and conscientious discharge of
their duties required. He had had the advantages, at that time too
seldom enjoyed by medical students, of having pursued, during four
years at the University of Edinburgh, those studies which form the best
introduction to the attainment of medical knowledge, and not only of
having assiduously attended the lectures, but also of having possessed
the acquaintance^ and he may say, the friendship of men whose names
will long live in the annals of literature, science, and philosophy, — of
DuvB^B, RrroHiE, Lbslie, Platvaib, Stewart, Jamibsok, Hope, Niell,
and Flexino, — names he now recalls with all the happiness connected
with the best of his early reminiscences. After having devoted eight years
to preliininary and professional education, he closely observed, during two
years, the diseases which prevailed in France and Germany soon after the
peace of 1815. He subsequently extended his field of observation and ex-
perience to the most unheidthy intertropical countries ; and on his return
to England, he was required^ from the commencement of his practice,
to exert his powers of observation and discrimination in the treatment of
diseasea of difficulty and danger, and in examining critically the merits
of thoae medical writings which were produced in this country and on
the continent of Europe.

Having been engaged in writing on scientific and medical subjects from
1819 until the present day, and in lecturing on Pathology and Practical
Medicine from 1824 until 1842 ; having from the earliest of these dates
enjoyed as extensive opportunities in public and private practice, as he
could use with advantage to his patients and to the advancement of his
own knowledge ; and being fully impressed by the truths which extensive
fields of observation and mature experience had disclosed, he has ventured
to state his opinions with the confidence inspired by a firm belief of their
accuracy. To hesitate in conveying instruction, and in employing reme-
dial means, betrays insufficient knowledge, and has never been rewarded
by more than accidental success ; but a firm conviction and expression
of the truth of what is stated or advised, will generally produce belief in
the mind of the reader or hearer. Hesitation rejects, where it fails in
suggesting, further investigation : confidence commands belief, even when
further research is required, and obtains success as its reward.

PREFACE. xxix

emnstances and contingencies which few could have endured. He has
receired no assistance in furtherance of his undertaking, nor with his
knowledge of human nature would he have accepted any. Some inac-
curacies are inevitable in a work so extensive and laborious as this is ;
bat the Author believes that thej are not many or important, inasmuch
as every line of it was written by his own hand, and all the proofs were
carefully read and corrected by himself.

Of the manner in which he has conveyed his ideas, his doctrines, his
dsseriptionsy and his instructions, it does not become the Author to venture
a confident opinion. He has endeavoured only to be clear, forcible,
and condensed. He has avoided a parade of scientific and technical terms
and of foreign words and phrases, and has preferred English expressions
wherever they were admissible, and the instances were rare in which they
were not only appropriate, but even preferable.

Thirty years of his life have been devoted to this work by its Author.
He has laboured on it alone and unassisted. He has, however, been en-
couraged to persevere to its completion by the friends to whom in grati-
tude he has dedicated it, and by the indulgence and liberality of his
Poblishers. He feels with becoming thankfulness the kindness of many
in the profession throughout the three kingdoms, who have confided in his
medical knowledge and have thereby enabled him to provide for the day
which was passing over him, and for those dear and nearly related to
him, whom misfortune and death have left to his care. And he expresses
his heartfelt thanks, not only to those friends, but also to others, who,
quite unknown to him as the authors, have been favourable, kind, and
considerate reviewers of the parts of the work as they successively,
although tardily, appeared. Entertaining no mean opinion of the legiti-
mate exercise of the healing art *, viewing his profession in the light in
which it was held in ancient, and even in more modern times, and estimating
his work according to the experience and the research, to the time he has
devoted to it, and to the amount of labour and the sacrifices it has cost him,
he feels assured that he has not laboured in vain ; and he cannot doubt that
it will be of essential service to many, — that sufiering humanity will be
benefited, and rational, learned, and scientific medical practice advanced
by it " For his name and memory, he leaves them to men's charitable
speeches and to foreign nations, and to the next age."

* Bacoh vindicated the dignity of the healing art by appealing to the example of Christ,
ud reminded men that the Great Fhyaician of the soul did not disdain to bo also the physi-
cian of the body.

** Katqoam enim l^mus miraculum aliquod ab eo patratum circa honores, ant pecunias,
led tantiim circa cofpns humanum, ant conservandnm, ant sustentandnm, aut persanandum."

JDe AugmentiSf Sfv., Lib. IV. ch. 2.

CLASSIFIED CONTENTS.

Prdiminary Remarks, — ^An Arranged Contents of his work is attempted by the Author with the otject
of enabling the student of medicine, and the medical practitioner, to peruse what he has advanced as
the results of his obsenration^f his practical experience — and of his reading, with the most advantage,
and in the most suggestive manner. Information is useful not only as respects its amount, but also as
regards what it may suggest to the mind of the reader calculated to lead to further investigation and
illustration, than the limits allotted by the Author to the many subjects and topics which have come
under his consideration could allow. He has endeavoured to arrange these subjects, both pathological
and practical, in such an order as may enable the information first afforded, or successively obtained, to
contribute to the elucidation, and to the more complete comprehension, it is hoped, of what ia sabse-
quently discussed.

It may be necessary to premise that the Classification of diseases here attempted is, as fur as the
Author is concerned, altogether original, although it was first published in the ** London Medical
EqwsUoiy,*' in 1822. Notwithstanding that this attempt was made at so early a period of his praotice,
ho had then enjoyed extensive opportunities of observation in this country, on the continent of £urope,
and witliin the tropics. This classification and the pathological principles here stated are the same as
were then published. Comprehensive and close observations, the sources of true experience, which he
believes himself to have possessed, as well as to have exerted, have confirmed him in the belief, that
bis arrangement is the most useful, practically or therapeutically, inasmuch as it is founded upon, and
has constant reference to, the conditions of vital force — to that power which actuates the whole human
organisation, and to which a continued regard must necessarily be had, and a constant reliance placed,
in our efforts to alleviate or to remove disease. During the many years, in which the Author waa en-
gaged in lecturing on the Principles of Pathology and on Practical Medicine, he adopted this classi-
fication, and he believes that it was then conducive to the acquisition of practical knowledge by his
pupils.

This arrangement being thus based upon the states of vital force and upon the unquestionable fiicts,
that disease, especially in its slightest and earliest deviations fVom health, is a deranged manifestation
of life in some tissue, organ, or system ; that this de\iation is followed by a succession of changes, until
alterations of the fluids, secretions, and structures supervene ; that the existing change has been in-
duced by that which preceded it, often aided by^the persistence of the exciting cause or causes and by
the concurrence of additional influences ; and that it will itself occasion still further changes, if not
arrested by science or art, or by the efforts of nature, or, in other words, by the resistance which the
vital force or power may be enabled to oppose to successive or imfavourable changes, — it follows that a
due recognition of the simplest and earliest manifestations of disorder, a correct estimate of existing
changes, and an accurate view of future contingent alterations and results, are of the utmost importance,
not merely as respects the places assigned to them in the classification, but still more as regards the
adoption of indications of alleviation or of cure, and the selection of means by which these indications
may be fulfilled. Of the essence of life itself we know nothing further, than that it is associated with,
and manifested by structure, the simplest and lowest structures displaying its simplest, but yet its moat
generally diffused functions or properties, the more complex organisations, its higher manifestatioos,
the highest and most perfect of created beings alone possessing its highest faculties.

The lowest formations which evince vitality possess organic nervous corpuscles and digestive and
circulating systems ; and as we ascend the scale of animal creation, the organic ncr\'ous system rises,
from rudimental, through more perfect developments, to the most complex and complete, as displayed
in the highest order of animals. Over the two latter systems — the assimilating and the circulating— the
aiyjuucally sensitive presides ; each of these reciprocally aiding and contributing its functions to the
(Aer^ and thereby supporting and increasing the \'ital force, whilst this force itself preserves the

CLASSIFIED CONTENTa

XXXI

organic dements in which it U aMOciated, and developa them into specific fonna, more particularly
wiMD nbjected to the influences which excite it into activity. Thna it will be seen that these three
prime fattan of life, viA., the organic nervous globules and their conformation into ganglia and ganglial
Dcrres, the circulating systems, and the digestive apparatus, which is more especially subsidiary to
Um others, have certain organs— respiratory, assimilating, secreting, excreting, &c.-^which are sub-
servient to the life of the individual— to the maintenance of vital force or power ; other organs, as
tfaoie of voluntary motion, of sense, and of the intellectual and moral powers, for holding conmiuni-
calion with the rest of the species and of creation ; and superadded organs, intended to perpetuate
tbeepcdeSb

CLASSIFIED CONTENTS.

GENERAL PATHOLOGY.

L PirrsioiiOOicAi. Pathoukjt : —

Absorption, §| 1, et aeq. - - - i 23
Age, Its i>hysiological and pathologi-
cal rdaUons ----- 88—45
Asphyxy, §§ 1, e< «qf. - - - — 128

Asphyxy of new-bom infants 134

Asthma, physiological relations of, §§

^-$ — 186

Blood, physiological pathology of, §§

Blue disease — 199

Climate, physiological and pathologi-
cal effecU of, §Cl7— 42 342

Cold, physiological and morbid effects
of, §§ 1—16 — 854

Cnaea, nature and ori^n of • 448

Excretion and Excretions, the physio-
logical and pathological relations
oC SI 1—14 - - 840

Mind, instinctive affections and intel-
lectual manifestations of, arranged
and noticed, ^ C6, et aeq. - - ii. 443

Insanity, physiological pathology of,
|J8^-3& - - - -—497

Imtability, physiological and patho-
logical relations of, §§ 1—20 599

Irritation, the physiological and mor-
bid relations o^ §§ 1—25 605

Menstruation, physio-pathological
sUtes o(, §§ 4—18 - 832

PoUntionf^ remarks respecting, §§
1 — 14 - - - - - - iii. 441

Preenanor, changes consequent upon.

Puerperal states, remarks as to, §§
l-ST — 482

Pulse, physiological pathology of the,
§§ 1—16 — 648

Sensation and sensibility, forms and
modes of — 40

Sleep, physio-pathological states o^
iSl— 16 • • - - - — 802

Spasm, §§ 1—16 - - - - — 844

Spleen, structure and physiological
pathology of the, §§ l-^fS 889

Supra-renal bodies, the structure and
physiol<^cal and pathological re-
lations (Tthe, f§ 1—13 - - 1423

Sympathy, physio-pathological rela-
tions of, §§1—145 - 986

Tranar,§§l,dM9. - - —1084

Urines pbyaiologicju and pathological
relations of the^ §§ 1-^ - — 1199

Voice and speech - - • - — 1860

Vomiting and retching • 1866

Worms, considerations connected with,

^ §§1-86 1375

Bee Bibliography and References to
these several i^cles.

n. ^TIOLOOr, OR THB CauSATIOK OP

DiSBASB (Art, Disease), §§ 1
— 62 - - • . . i^ 55g
ffeahh and Disease defined, §§ 6, 6 - — 657
The intimate relation of the subject
to the doctrine of life,— to the states
of TiUl force, §§ 1— 6 - - . — 555
General view of the subject, and with
reference to the nature, operation,
and arrangement of the causes of
disease, §| 7—9 - - 558

A, The preoispoeing causes of disease

arranged and described, §§ 10—37 — 559

B, The exciting causes, arranged,

described, and tbeir operation
explained, §§ 88—54 664

C, The specific causes of disease, de-

scribed, &c, §§ 65—60 669

D, Tlie determining and consecutive

causes, their operation, &c, 4s
61-63 - . . ' . '^!_570

Abstinence, its morbid effects, %i,et eeq 26

Absorption, in relation to the causation

of disease, §§ 1, el jeg^ - . _ 23
Arts and employments, as causing dis-
ease, esipeciallv considered,§§ 1, et teq, — 122
Climate, its influence in occasioning

disease, §§ 17— 41 - - ^388-49
Cold, its operation in producing dis-
ease, §§ 1-17 - - - — 364-8

Drunkenness i. 685

Endemic influences^ especially con-
sidered, §§ 1, ei teq, - - - 756

Epidemic influences and constitu-
tions, &c., §§ 1, et seg. - - - — 767
Infection, its sources, transmissions,

and modes of operation, §§ 1, et aeq. ii. 345
Irritations, §§ 1, et seq. - - - — 606
Lactation, excessive, and as a cause

of disease, §§678 - - - _ 673

Shock, §§ l,et9eq, - - - iii. 785

Bibliography and references to
.Okioiogif, i. 601; to Arte and
Emphymentty i. 128 ; to CHmaie^
i. 863i to OM, \, 860; to En-
dtmie and Epidemic Influences, i.
764. 781 ; and to Infection - i. 36d

III. Pathogeny, or the Doctrine of

Disease (see Art, Disease), § 63 — 671
Remarks on the ojperation of the causes
on the vital rorce and its several
manifestations, §§ 68 — 65 - - ibid.

i. 572

^

xxxii CONTENTS

L Tns CniEF States of Vital Force
OR Influence, §§ 66 — 92

A. 7^ Dynamic State* of Vital

ManifisteUiotUf §^ 67 — 86
(a.) Impaired yitai force, or De*
bilityj primary, consecutive,
and complicated debility,
)athoIogical relations, &c^
j§ 68—70, i. 573 ; and §§ 2,
et»Bq. - - - —473-86
Bibliography and references
to Debiuty • - - — 486
(6.) Excitement or reaction of the

vital force, §§ 69—86 578

B. Perverted States of Vital Force, §§
87-92 - - - - — 578

(a.) Perversion with reaction of

vital force, §§ 87—92 - ibid,

(6.) Perversion and depression or
exhaustion of vital power,
§§87—92 ' - ' ibid

ii. Disease of the Fiatids and So-
lids ORIGINATING IN ALTERED

Conditions of Life, and gene-
rally IN these already dis-
cussed, §§ 93—151 - - - — 580

A, Alterations arising chiefly from im-
paired organic Nervous Force, §§
93—151 - - - . 580-594

a. Diminished and otherwise altered
exhalation and secretion, §§
94—110 - • - - 582

b. Imperfect chymification, chylifi-
cation, and sanguification —
Anosmia, §§ 34 -47 - - —172-5

c. Impaired elimination and excre-
tion, or depuration, S§ 99—102 — 582

(L Contaminations of the blood from

this cause^ §§ 115, et seq. - — 188
€. Imi)erfect nutrition — Atrophy,

§§ 1, et seq., i. 154 ; § 108 583

Tabes, &c.,

§§ \,et9eq, ' - - iii. 1009
/, Venous congestions, Art. Con-
gestion of Blood, 1, §§ 1,
et seq. - - - - i. 401

0. Asthenic ILkmorrhages, § 12 it 64
A. Impaired vital cohesion, and flac-
cidity of the tissues — Soften-
ing of Tissues, §§ 1, et seq. - iii. 841
t. Diminished vital resistance to con-
taminating agents, §§ 1, et seq. ibid.
See more fully the pathology of

the Art. Debiuty, §§ 1, e< seq. 473
Bibliography and references to
Arts. Debiuty, i. 486 ; and to
Softening of Structure • iii. 844

B, Alterations proceeding from irregu-
larly distributed or increased Or-
ganic Nervous or Vital Force.

a. Vascular plethora, §§ 13—23 - i. 169

b. Gencrallv increased vascular ac-
Uon, ^§ 82—86 - - — 676-8

c. Local determinations of blood and
vascular erythism, §§ 25—83 171

d. Increased exhalation and secre-
tion, |§ 95—102 - 581

e. Sthenic iLehorrhaoes - - ii. 64
/. Sthenic Inflammations 367

C, Alterations caused by Perverted or by
Exhausted Organic Nervous or

Vital Force,
a. Alterations affecting chiefly the

Blood, §f 78—160 - — 180-8
(a.) Alterations of the blood in
disease, proved and insisted
upon, §§78^137 - — 180-97

— Pathoobnt.

- —187

- —188

- —100

191

- —192

— 195

- —196

(5.) Changes as respects the chief
constituents of the blood,
§§ 81—91 - - i 181-8
(r.) Vitiations of the blood by
the fluids which supply its
waste and which form it,
§§111-114 .
(d,) Imperfect performance of
the functions of depuration
a chief cause of the vitia-
tion of the blood, §§ 115—
124 - - .

Illustrations, §§ 126—

131 ...

(e.) Contamination of the blood
by putrid or by septic
matters applied to the tis-
sues, §§ 120—134 -
(f.) Contamination by causes
affecting the nerves supply-
ing the vascular so'stem,
§§ 134—142 -
(<7.) The absorption or passage of
morbid matters into the
blood from the veins —
Lymphatics, §§ 143—145
(A.) Phenomena depending upon
a vitiated state of the blood,
§§ 145—151 -
(t.) Connection of morbid action
and of organic lesion with
states of the blood, § 148 - — 198
Bibliography and rererences
to alterations of the Blood — 199
6. Alterations of the secretions and

excretions, §§ 93— 109 - —680-4
(a.) The simpler alterations of
exhalation and secretion,

§§ 94—103 - 680

(ft.) Preternatural exhalation and

secretion, §§ 104—109 688

(c.) Secretions and productions
adventitious to the situa-
tion, § 108

and to the economy, §§

125—136
c. Adventitious productions owins
to constitutional taint ana
perverted action, &c., | 141
Scrofulous and tubercular de-
posits, &c. - - - ilL 748-56
Atheromatous, suetty, fatty, 06-
sific, &c., deposits, or trans-
formations, &c.

d. Destruction of organised

parts, § 147

e. Connection of morbid ac-

tions and organic lesions
with states of the blood,
§§ 148—151
Urinary deposits and calcu-
lous formations • - ill. 1206-23
c. Alterations chiefly of sensation
and motion, see Art. Para-
lysis, ^% 3,etseq. - - - iiL 11
(a.) Alterations of sensibility, §§
6—14 - - - -
(b.^ Pains, &c., of various kinds
,c.) Loss of sensation, &c.
V/.) Impaired or lost motion
Je.) Irregular motions — Paraly-
sis agitans — Tremor —
Spasmodic motions, &c
Alterations of the fluids, and of
sensitive and irritable parts af-
fecting more or less the func-
tions, and tissues of the oeco-
^otaj, §§ 145, et seq. L 195—97

- —684

- — «NN>

— 691

- i. 119

" L 693

- i. 693

f;

s;

— 11

— 12

— 24

CONTENTS — Structural Lesions.

XXXlll

See abo Fevers, Peatilences, and
oth«r Diseases arising from
niissmato anU specific infec-
tions, &c.

(a) The procession of morbid

phenomena, §§ 152 — 154 - i. 594

(6.) Grades of morbid actions,

§ 154 - - - - — 595

(^.) Of the types and forms of
disease — Perio Jic — Con-
tinueii, §§ 155—157 - - ibid,

(<£) Duration of morbid actions
— the terms acato, sub-
acute, chronic, §§ 158, 159 — 59G

(f.) Of crises and of ciitical davs — 448

(/.) Of the terminations and is-
sues of disease, §§ 160—162 — 597

(p.) Of the relations, successions,
and complications of dis-
ease, §§ 163—171 - — 697-9

(A.) The metastasis, or change,
migration, &c., of disease,
§ 172 - - 699

(£.) Circumstances modifying the
form, complications, dura-
tion, and termination of
disease, § 177 - - ... 601
Bibliography and references
to Art. DisEASK - — 602

IV. LKSiotars of SriiucruHE okweratxy

PEOCEEDIXO FROM ONK OR MORS

OF niE Morbid States alrgl.vdy

ABDCCED.

L Altbratioxs usually termed Is-

FLAXXATORY, OR CONSEQUENCES

OF IxFLAMMATioN — See Art. In-

FLAxuATioir, § 1, et itq. - - IL 3G6

A, Tke Phenomena etntstiiuting Sthenic

Infiammatioji, their Coitrae and

lirmhuUimu, §§ 4—60 - — 867-77

a. Aeate sthenic inflammation, §§

6-29 . - - . —367-73
h. Sab-acate and chronic inflamma-
tions, ^ 30—35 - 373

e. Complications of sthenic inflam-
mations, §§ 36—38 - - — 374
d. Terminations and conseonences
of inflammation : — exudations,
effusions, suppuration, ulcera-
tion, thickening, induration,
§J|39— 50 - - - —375-7
i>. Ai^aunUf Morlnd and Reparative,

%\,eiteq, i. 32-6

a. Between cellular and serous tis-
sues, § 11 • - • . -.34
h. Between mncoos surfaces, § 15 • — 35

c. Bibliography and references - — 36
C ^Awesses, Descn^rfNm 0/, §§ 1— 53 —12-18

a. Encysted, dmosive, chronic, §§

8—20 —14

h. Symptomatic, conaccutive, §§ 20

—29 —10

t. Course and terminations of, §§

SO— 63 — 17

d. Pus, descriptions of - - - iit. 657
c Bibliography and references - i. 18

A Modi/ieatioMS and Vdrietie$ of lu"

ftamtiuaion,^ 51^70 - - il 377

0. Modifications as to activity and

grade, |§ 51—63 - 378

^> Modifications owing to impaired
Tital force and morbid states of
the blood — Asthenic inflam-
mations, &c, §§ 54—67 — 379-82
c. Asthenic inflammations, their pro-
gress, complications, and con<*
sequences ^ Disorganizations
Vot- I.

— Ichorous and sanions exu-
dations — Ulceration — Spha-
celation, §§ C8— 77 - - ii. 381

Softening of structures, inflam-
matory, § 43 - - - - — 37G

Softening, different states and
forms of, Art. Softening, § 1,
eteeq. iii. 841

Consecutive inflammations, vary-
ing with tlio states of vital
power and of the blood, § 112 iL 390
/. Secondary inflammntions, owing
to the passage or absorption of
morbid matters, &c., §§ 114 —

e.

120

— 391

- — 39:)

8

- i. 584
See Art,

154

— 154-6
See also

684

ii. 257
t id.

g. Opinions as to the nature or the
pathology of inflammations, §§
136—171
• A. Gangrene caused by inflamma-
tions. See Art, Gangrene,
§§6—15 . - - -

t. Reparation of tlie consequences of

inflammation, §§ 172—176 - — 405

h. Bibliography and references — 268, 421
ii. Alterations, occurring gene-

&.VLLY independently OF IN-
FLAMMATION, OR OWING TO Mor-
bid States of Secretion and
Nutrition, § 110, et teq.

A, Atrophia*, Nature, §"0., of.

Atrophy, §§1—13 -

a. Simple atrophy, § 1 -

h. Complicated atrophy.

Lesions of several tissues with
deposits of greasy, suctty, or
fatty matters, § 108

B, Hypertrt^ies, Naturf of. See Art.

Hypertrophy, §§ 1 — 6

a. Simple hypertrophy, § 1 -

b. Complicated hypertrophy. See al-

so Art, Scirrhous and other
Tumours, §§ 47—74 - - iii. 714
Bibliography and references to
Atrophy and Hypertrophy

i. 154 ; ii. 258

C, Hardening of TYssues, |r<r. See Art,

Induration, ^§ 1—7 - 344

D, Alterations, chiejly of Nutrition, §§

103—124 i.682

a. Metamorphosed and transformed

nutrition, §§ 110—124 - — 684-8
h. Arrangement and description of,

§§ 130—137 - - - - — 589
e. Morbid secretion associated with
morbid nutrition, or secretions
susceptible of organization —
Adventitious productions, §§
138—146 - - 690

d. Serous and other cysts, also Hy-

datids, § 114 - i. 585 i ii. 251

e. Of the origin of entozoo, § 145 - i. 592
/. Of the destruction of Organized

parts, § 147 - - 593

g. Gangrene occurring indepcndentiv

of inflammation, §§ IC— 5G 'ii. 11-21
Bibliography and • references to
Art. Disease, i. COl ; and to
Art. Gangrene - - - ii. 26

E, Non^malignaut and Malignant Growths

and Productions, §§ 77—99 iii. 704-24

a. Elements of morbid growths, &c.,

§§7—40 - - - —704-12

I:, Chemical composition, &c., §§ *
31—40 - - . - —710-22

e. Non-malignant growths and tu-
mours, §§ 47— 74 - - —713-18

d. Melanosis, description and rela-
tions of, §§ 1—18 - - - ii. 828
b

XXXIV

CONTENTS — Structural Lbsions.

t. Origin and nature of, §§ 19—21 - ii. 830

/. Fungoid, or fungo-bsematoid dis-
ease, §§ 1—20 - - - i. 1049

g, Scirrho-cancer, carcinomatous
and other malignant growths,
§§ 1—21, i. 282 ; and §§ 41-6 iii. 712

h. Pathological relations of scirrhous
and other growths, §§ 76—99

iii. 718—24
Bibliography and references to
Art. Disease ; to Cancer ; to
Fungoid Disease ; to Mela-
nosis ; and to Scirrhous and
other Tumours.

V. Structural Alterations of the
General Systems.

i. Lesions of the Nervous Systems,

§§ 2—14 ii. 869

A. Alterations as to size, &c., §§ 2 — 4 ilnd,

B. Changes in consistence, &c., §§ 5, 6 ibid,

C. Various other alterations, S 7, et aeq. — 870

Z). Inflammatory lesions, § 24 872

E. Tumours of nerves, §§ 20—32 873

Bibliography and references 874

ii. Lesions of the Vascular Systems.
Ist. Alterations of the Arterial

System, §§ 88—72 - L 116-121

A. Lesions consequent upon inflamma-

tion, § 23 - - - - — 114

B. Lesions of the individual coats of *

arteries, §§ 88—44 - - - — 117

C. Changes of Uie structure and cali-

bre of arteries — Various kinds

of aneurism, §§ 45 — 50 - - Hid.

a. Dilatation of arteries, § 45 - ibid.

if. Narroidng or constriction, § 51 — 118

r. Obliteration of arteries, § 63 - ibid.

D. Morbid matters and deposits in ar-

teries, § 68 - - . 119

a. Albuminous exudations, false

membraneo, pus, &c., § 68 - ibid.

b. Atheromatous, suetty, or fatty

matters, S 59 - - - ibid.

c. Osseous, calcareous fonnations,

&o., §§ 61—66 - 126

Bibliography and references - — 122

J?. Lesions of the Aorta - - - — 70

a. Changes consequent upon in-

flammation, §§ 13 — 15 71

b. Aneurisms of the aorta, varieties

and results, §§ 18—30 72

e. Bupture, constrictions, oblitera-
tion, &c. §§ 62—54 - - — 78
Bibliography and references - ibid.

2nd. Alterations of the Venous

.System, § 1, rt se^r. - - iii. 1304

A. Alterations caused by inflammation

of veins and sinuses, § 19 - - — 1806

a. Inflammatory lesions observed

in the external veins, §§ 20 —

28 - - - - —1306-8

b. Changes caused by inflamma-

mation of the vena porta, vena
cava, and other internal veins,
§§ 29—33 -..--_ 1808

c. Lesions caused by inflammation

of the sinuses, § 30 - - ibid.

B. Alterations consequent upon phle-

bitis, afiecting the blood, §§ 58—

02 — 1314-1315

C. Lesions of the individual coats of

the reins, §§ 62—69 - — 1315-16

^- Changes of the calibre — dilatation

--- contraction — contraction —
obliteration^ §§ 70—78 -

181G

E. Ossific, calcareous, &c., formations,

§74 ui. 1817

F. Fatty, atheromatous, and cancerous

formations, &c., §| 76-.^ - ibid.

Bibliography and references - • ibid.

8rd. Alterations op the Lympha-
tic AND Lacteal System - ii. 793

A, Appearances after inflammation, §§

18—15 — 796

B. Alterations of structure, &€., §§

20—28 — 797

a. Lesions of the calibre and of the

coats of these vessels, §§ 24 — 32 ibid.

b. Morbid contents of these vessels,

§§ 83-40 - - 798

C. Alterations of lymphatic and lacteal

glands, § 47 - - 800

a. Lesions caused by inflammation,

§§47,64,67 - - - ibid.

b. Changes, chiefly organic, §§ 65

—68 - - - - —801-8
(a.) Enlargement, scrofulous
enlargement, &c, §§ 66
—60 - - - —801-2
(6.) Malignant and other alte-
rations, §§ 61—78 - — 802-8
Bibliography and references 803

iiL Structural Changes of the Adi-
pose AND Cellular Tissues L 36, 298

A, Alterations of the Adipose Tissue,

§§1-8 - S6

B. Alterations of the Cellular Tissue,

%l,etseq. - - - - — 298

a. Inflammatory changes of, §§

8—6 — 299

b. Infiltrations, hsemorrhages, and

morbid growths in the, §§

6—8 ibid.

e. Appeariinces after diflVisive in-
flammation of, §§ 20—22 - — 802

d. Induration of the cellular tissue,

^Uetseq." - - - — 306

e. CEucmatous hardening of the,

e§8-6 -' - - ibid,

f. Induration chiefly of the adipose

tissue, §§ 4—7 - - - — 307
a. Bibliography and references

— 87, 306, 309

iv. Organic Lesions of the Fidrous

Tissues — 1040

A. Lesions of Fibrous Membranes, § 1,

etseq. i. 1041

a. Changes consequent on inflam-

matory action, §§ 2 — 9, i.

1042; §§15,10 - - - iiL 64

b. Adventitious productions, §§

9—12 i.l043

B. Alterations of the Fibrous Structure

of Joints,'^ 13, 14 1048

D, Bibliography and references,

i. 1044; and iii. 66

V. Alterations of the Muscular

Structure, § 17 - - - ii. 865

A. Alterations consequent on inflam-
mation of, §§ 17—21 866

B. Non -inflammatory changes of, §§
23—37 ibid.

a. Of the size, colour, consistence,
&c.,§§23— 28 - - - ibid.

b. Fatty or adipocerous degenera-
tion of, § 29 - 867

c. Other organic lesions and dege*

ZZXVl

CONTENTS — Organic Lksionr op Organs.

(o.) Enlargement of Ibe liver, §§

212. 218 - . - - iL 752

P
9-

«. Lesions of the large intestines
consequent on inflammation, §§

37—41 il 676

< Lesions consequent on acute ileo-
colitis, § 42 - . - - — 677
g. Changes caused by sub-acute and

chronic ileo-colitis, § 48 - — 578
(a.) Pseudo-membranous exuda-
tions on tho raucous sur-
face, §§ 61-3 - 579

(6.) Complicated lesions conse-
quent on enteritis, § 54, et teq. ibid.
(r.) Ulcerations, peritonitis, and
other lesions caused by en-
teritis, §§ 72—83 - — 588-C
h. Spasmodic constrictions of the in-
testines, § J 14 - - - — 693
t. Thickening and permanent con-
traction of a portion of intes-
tine, § 126 - - 696

k» Scirrhous and other malignant
formations in the intestines, §

128 ibid.

/. Softening of the tissues of the in-
testines, § 131 - 697

m. Alterations, consisting chiefly of
strangulations, introsuscep-
tions, &c., § 37, et »eq. - - i. 367
n. Bibliography and references,

i. 666; and ii. 698
o. Alterations of the caecum and of

its appendix - - •> - i. 278
(a.) Inflammatory lesions of the,

§§ 17, 27—33 - 280

(A.) Lesions of the appendix csBci,

§§ 27—33 - 281

Lesions of the colon • - - — 384
Alterations of the rectum and

anus .... ill. 689-608
a.) Malformations of the, § 6 - — 586
h.) Foreign bodies in, and lace-
rations of the, I 7 - - — 690
(r.) Inflammatory lesions of the,

§ 27 . - - - — 693

d.) Abscess of the, § 47 695

cl) Ulceration of the, § 56 - — 697

Fistula in ano, § 61 - - — 698

Fissures of the anus, § 71 - — 699

Prolapsus of the rectum, §76 — 601

(i.) Excrescences and polypi of

the anus and rectum', § 88 — 603
(A.) Contractions and strictures
of the rectum and anus,
§92 - - - 'Hid.
(I) Cancer of the rectum and

onus, § 109 - - - — 606
(m.) Bibliography and references — 608

il. Structuiial Alterations of tub
BiuARY Apparatus.

A. Lesions of the Liver - - ii. 727-751
a. Congestions of the liver, sangui-
neous and biliary, §§ 66—84 - — 727
(a.) Sanguineous congestions, §§

66—77 - - . —

(h.) Biliar>' congestion, S§ 78—84 —
/'. Hosmorrhage of tlie liver, §§

89—93

c. Alterations consequent upon acute
and chronic inflammations of
the liver, § 124 -
(a.) Abscess of the liver, §§

128 - 787

And §1 206—210
(6.) Softening, gangrene, and
other lesions, §§ 205, 211 -

(5

728
729

— 730

786

(dL) Induration, atn)ph}% &c., §

214 ... 753

f«.) Cirrhosis, &c., §§ 215, 217 - ibid.

d. Lesions from impaired vital

power and nutrition, § 218 - — 754
(a.) Fatty and oily deposits, &c,

§ 219 - - - - ihiJ.
(6.) Tubercular and cancerous

formations, §§ 222—230 - — 755
(c.) Simple cysts and acephalo*

cysts, &c, § 231 - - — 756

e. Bibliography and references, &c. — 7C0

B. Alterations of the Bile, Gall-Bladder,

and Ducts - - - ii. 1, & i. 392

a. Alterations of the bile, §§ 1 — 7 - ii. 1

b. Biliary concretions, &c., §§ 1, et

se^. L392

c. Bibliography and references - — 397

d. Changes, consecutive, of inflam-

mation of tho gall-bladder, 1 26 ii. 6

e. Changes in the biliary ducts, § 28 ibid,
d. Bibliography and references to - — 8

C. Morbid appearances most frtquenUy

seen in connection with Jaundice,

^ 18—26 - - 298

Bioliography and references - — 311

til Lesions of the Spleen, §§ 27,

76—97 iii. 893

a. Those consisting of congestion

and inflammation, &c., § 27 - — 891

b. Organic lesions of the spleen, §§

76—84 — 902

c. Enlargements and tumours, §§

88—89 — 903

d. Morbid formations, §§ 90—96 904

e. Haemorrhage into the spleen, § 97 — 005
/. Bibliography and references 90G

4

C

10

-740
761

ibid.

■iv. Lesions of the Pancreas -

a. Alterations consequent upon in-

flammation, §§ 12— 19 - • -

b. Those not necessarily depending

upon inflammation, §§ 23—86 -
e. Bibliography and references

V. Organic Lesions of the Mesen-
tery AND Mesenteric Glands,
%l,etseq. - ' - iJ. 853-5

a. Alterations of the mesentery con-

sequent on inflammation, § 6 - — 8o4
6. Lesions of the mesenteric glands,

■ §§ 8—12 - - - - — 856

c. Scrofulous and other lesions of

these glands, §§ 24, 36 - - — 857

d. Bibliography and references - — 862

vi. Structural Changes of the Uri-
nary Al'PARATUS.

A, AlieratiottS of the Kidneys, § 25, et

sea. ------ — 6,*?!

a. dhanges consequent upon inflam*

mations, §§ 26—38 • -. 631-4

lesions consequent upon gouty,
rheumatic, asthenic, and con-
secutive nephritis, §§ 49, 61,
64,66,69 - . . _G32-S

Appearances after death from ca*
chectic nephritis, or granular
disease of kidneys, §§ 99—109 — 645-7

Lesions consequent upon inflam-
mation of the pelvis and caliccs
of the kidnev, | 174, et seq. — 669-63

Alterations of the tissues snr-
rounding tlie kidnevs, §§
202-207 - - " . — 663-4

b.

c.

e.

X3CXY111

CONTENTS — Organic Lesions op Organs.

690

698

— 700
ibid.

e. Chronic tubercular peritonitis, pri-
mary and conficcutive, §§111
—lis iii. 82

/. Effusions and various formations

in the peritoneum, § 116 - — 83

g. Other organic lesions of the peri-
toneum, §§ 164—181 92

h. Bibliography and references 96

ix. Lesions of Serous and Synovial

Membranes, § 1, et $eq. - - — 786

A. Certain consecutive changes of their

le^iions, § 1. - - - - UficL

B. Alterations of synovial membranes,

§3 ibid,

C. Bibliography and references - - ibid.

s. Alterations of the Respiratory
Organs.

1st Lesions of the Lan/nx and Trachea,

%BO,etseq. - - - - ii. 689

a. Alterations consequent upon in-

flammation, §§ 80— 83 - - ibid.

(a.) Lesions of the epiglottis,

&c, § 76 - - - — 688

(^.) (Edema, puriform infiltra-
tion, ulceration, ossifica-
tion of the cartilages, ne-
crosis, fistulsB, &c., of the
larvnx and trachea, &c.,
§§81—84

b. Foreign bodies lodged in the la-

rynx, &c., § 112 -

c. Tumours, &c., compressing the

wind-pipe, § 124 -

d. Bibliography and references
2d. AlUrations of the Bronchi, §§ 2—25 i. 244

a. Alterations of the mucous mem-

brane, §§ 3— 8 - - - ibid,

b. Alterations of the secretions of

the air-tubes, §§ 9—14 246

c. Lesions of the cellular, fibrous,

and cartilaginous tissues of the
air-tubes, §§ 15—17 - - ibid,

d. Alterations of the calibre of the

air-vessels, §§ 18—20 - - — 247
(a.) Dilatation of the bronchi,

§§ 19. 106 - 266

(b.) Diminished calibre, § 18 247

e. Ulceration of the bronchi, § 108 - — 267
/. Bibliography and references 268

8d. Lesions of the Lungs, §§ 3, 27, et teq. ii. 761

a. Alterations consequent on sthenic

inflammation, §§ 3, 27—38 - — 765

b. Lesions following asthenic inflam-

mations, §§ 67—69 - - — 769

c. Changes following associated or

complicated pneumonia, §§ 69,
73—79 — 770

d. Emphysematous lesions of the

lungs, §§ 137, 155—159 — 781-4

e. CEdcnia of the lungs, §§ 166, 167 — 785
/. Atrophy and hypertrophy, &c,

§§170,171 - - - —786

g. Abscess and gangrene, §§ 172, 173 ibid,
h. Tubercles in the lungs, § 176, ii.

787, and §§ 1—7, et seq. - uL 1091
t. Malignant formations in the, §§

177—181 - - - - a 787
' k. Ilaemorrhage into the lungs, &c,

§§ 186—192 - - 788

/. Bibliography and references - ibid.
4th. lesions of the rkura, § 112, et seq. - iii. 284

A. Forms und seats of pleurisy, § 41,

et sea. - - - * - - — 271

B. Partial pleurisy with adhesions, §51 — 273
a Pleurisy with afitiaion, § 52 - - ibid.

D. Polmonaiy, costal, diaphnigmatici ^

and mediastinal pleurisies. § 54 - iii 374 •

E. Pleurisy connected with pneumonia

— Pleuro-pneumonia, §| 148 — 152 — 292

F. Double pleurisy, § 61 - 274

G. Chronic pleurisy and empyema, § 68 — 276
H. The early changes consequent upon

pleuritis, §§ 112—115 - - — 284

/. Consecutive products ofpleuritis, 1 116 -^ 286

a. Plastic organizable exudations,

§§116—117 - - - - iWi

b. Pnnilent or empyemio afiiision,

f § 118, 119 - - 286

c. Tubercular pleuritic products, §§

120,124 - 286,808

d. Sanguineous and gaseous pro-

ducts, §§ 121, 206, 207 - —287,808

e. Organization of pleuritic exuda-

tions and adhesions of oppo-
site surfaces, &c., § 123 288

/. Fatty degeneration of bands of
adhesions, and other alterations
in the pleura, §§ 100, 210 — 283, 308

0. Ulcerations, perforations, and gan-
grene, §§ 201—203 802

h. Waterv aad other afi'usions into

its ciavity, § 204 - 803

L Cartilaginous and osseous forma-
tions in the, § 208 - - iWdl

A. Malignant or cancerous degene-
rations, § 212 - 804

L Bibliography and references 806

xL Lesions of the Mediastinum, § 7,

etseq.- - - - - 11 826

a. Alterations consequent upon in-

flammation, §§ 7, 8 - - ibid,

b. Abscess of the mediastinum, § 9 — 826

c. Thickening and other organic

changes, §§ 15, 16 - - - ibid,

d. Bibliography and references - ibid.

xii. Alterations of the Diafhkaom,

% 12, et seq. - - - - i. 520

a. Lesions produced by inflamma-

tion, § 12 - - - - ibid.

b. Perforations of the diaphragm, §

17 — 521

c. Other lesions of, § 20 - - ibUi.

d. Spasm, ruptures, &c., §§ 19, 21 - tWd.

e. Bibliograpny and references 622

xiii. Alterations op the Heart and

Pericardium - - - ii 164

A. Lesions consequent upon Inflamma'

tion, § 65 - - * 180

a. Inflammatory lesions of the en-

docardium and valves, §§
65—67 - - - — 180-2

b. Lesions of the valves and ori-

fices caused by chronic in-
flammation, §§ 67, 68 181

c. Lesions of the pericardium caused

by acute inflammation, §§
85—88 - - 185

d. Lesions by chronic inflammation,
§§ 89—94 - - . . — 186

e. False membranes and adhesions,
§ 107 — 190

/. Inflammatory lesions of the sub-
stance of the heart, §§111 —
120 - ■ - - - — 191-3
g. Inflammatory lesions of the heart
and pericardium of children,

§ 150 — 200

Bibliography and references to
Inflammation of heart and peri-
cardium - - - - — 2pl

x\

CONTENTS — Symptomatology

tcrci] sensibilitv of involuntary |

partt, § 40 '- - - - iii. 943

B. H«flectea throngh the media of the

ganglionated roots of the spinal
nerves, nnd affecting the move-
ments of voluntary parts, § 41 - ibid,

C, Reflected through the medium of

the spinal chord, and inducing
morbid sensations or motions, or
both, §42 - - - - tWa.

/). Reflected through cither the me-
dulla oblongata or the brain, or
both, and causing various dis-
orders of sensation, of perception,
and voluntar}' action, &c., § 43 - iWrf.

ii. ClRGU3ISTANC'KS INFI.UKNX'IXG THE

CiiARAcTEit, Number, and Is-
TKXsiTY OF Sympathetic Phe-
nomena, § 44 - - - - ibid,
a. Race and temperament, § 45 - - — 944
h. Habit of body, § 47 - - - ibid,

c, 5^T, §"48 ibid,

d. Age, § 49 ibUL

c. Fhifsical power, § 50 - - - ibid,

f. Occupations, &c., § 51 - - - ibid

iii. SrECiAi. Consideration of Sy3I-

VATIIIEM AND OF ASSOCIATED

Moiinii) Piiknomena, § 52 - ibid.
1st. A$sociated Sympathies or Affec-
tions of the Digestive and Assimi-
lative Organs, |§ 63—62 - ~ 945-7

A. The symj'athy between the di-

gestive organs and the functions

of the heart and lungs, §§ 63—69 — 947-9

B. The svmpathies between the di-

gestive organs nnd the brain, and
organs of sense, § 70 - - — 949

C. IJetwecn the organs of motion and

the digestive organs, § 72 • - ibid,

D. The s}'mpathies or the repro<luctive

organs with the functions of di-
gestion, § 73 - - - - ibid
2d. The Sympathetic and Symptomatic
Phenomena resulting from the
states of the Circulating and J7e-
spiratory Org tn$, § 74 950

a. The organization of the blood

considered, §§ 76— 82 - —950,1

b. Sources of the contamination of

the blood, §§ 83—88 - — 951, 2

c. Sympathies resulting from the

states of the blood, § 92 - — 953

d. The sympathetic association of

disorder owing to the qualitv

of the blood, S§ 93—100 '- ibid.

e. Importance of observing morbid

conditions of the blood in con-
nection with states of the or-
ganic functions, §§ 97—100 954

/. The importance of considering
the quantity of the blood in
relation to the area of the
blood-vessels, § 101 - - ibid,
g. The sympathetic association of
disorder arising from the
quantity of the blood, — or
from the want of correspond-
ence between the mass of
blood and the area of the
• blood-vesficls and the state of

vital force, §§ 101—107 — 955-7

h. The several sources and condi-
tions from which alterations
of the vascular system and
blood proceed, causing mor-
bid sympathies and associated
djsesses, §§ 107—113 - - — 957

t. Maladies evincing these sources,
morbid conditions and asso-
ciations, §§ 114— 125 - iii.
k. Sympathetic complications of
' disease from organic lesions of
the heart, §§ 120—128
/. Sympathies between the states.
* of the circulation and the di-
gestive organ?, § 128 - —
m. Sympathies between the cardiac
' and pulmonary circulation and
the brain, § 130 -
n. Between the circulating, ner-
vous, and muscular systems,

§ 183 -

Bd, Sympathies of Sensation and asso-
dated states of Morbid Sensi-
bility and Motion, §§ 134—136
o. Assoi.*iatcd states of morbid sen-
sation, § 134 - - -
b. Sympathetic disorders of animal
motion, § 137 - - - -
4th. Sympathies and associated Dis-
otders evolved by the ReproduC'
tive Organs, § 1399
Bibliography and references

957-9

- 959

- 960
ibid,

- 961

ibid,
ibid,

- 9j2

963
964

VIII. Semeioi/kjy or Symptoma-
tology, COMPRISING General
Diagnosis and Prognosis, §§ 1
—220 - - - iii. 965— 1008

Preliminary Remarhsresi^trng Symptoma-
tology, or Semeiology, comprising
General Diagnosis and Prognosis,
§§1—4 - - - -, -—965
1. Signs and Symptoms appertaining to
the Attitude and Amearances of the
Body, and of the Animal Functions,
R§ 4_^i .... — 966-73

A, Of the attitude and general appear-

ance of the body, §§ 4—7 - - — 966

B, The expression of the face and state

of the features, §§ 7—16 - - — 968

C, The external examination of the

chest, §§1—9 - - - - i.809

a. Of deformities of the chest, §§

1—12 — 310

b. Of auscultation of the chest, §§

1—41 - - - - —167-68
2>. The external examination of the

abdomen, §§ 1—26 - 1-5

77. The states of the general surface of

the body, §§ 16—25 - - - iii. 969

F. The perspiratory functions, §§ 25—

36

G. The state of nutrition of the body,

§§36—41

H. The functions and organs of volun-
tary motion, §§ 4 1 — 55

ii. The Signs and Symptoms furnished
by the Senses and Nervous System
of Animal Life, §§ 65—95 - — 976-84

A, The signs presented by the eves,

§§ 66—74 - - - - ' 977

B, The signs furnished by the sense

and organs of hearing, §§ 74 — 76 — 979

C, By the sense of smelling, §§ 76— 78 —980

D, By the sense of taste, §§ 78—80 - ibid,

E, By the sense of touch, §§ 80, 81 981

F, The signs furnished bv sensation and

sensibility. §§ 81—88 - 981

a. Diminished and exalted sensa-

tion, §§ 81—84 - • - - 982

b. Perverted sensibility, §§ 84—87 ibid,
c Pain and its various modifications,

§§ 87—94 - - - - — 983

G, The signs evinced by the mental

manifestations, Ac, § 96 984

— 971

— 973

— 974

CONTENTS— General Therapeutics.

ill Tki Siffmt cud Sympionu of the
Vi^ettiee FtimcHons and drgana,
J§96— U7 - . . -iiKl)84

A. Of the mouth, toeib, and gums, §§

9:-101 ibid.

B. The aigns fornuhed by the tongue,

§§ 101—116 . - 985

C Bt the salivary secretioo, §§ 116 —

118 - - ^ - - - — 987
D. By the throat and faaces, §§118—

121 ibifl.

^ By deglutition, &c^ §§ 121—128 988

R By the desire of food and drink,

§§123-129 - - - - ibid.

C. The i}-niptoms connected with the

itofnacb, §§ 129—132 990

a. Of flatulence, eFOCtations, &c.

b. Retchings and vomitings 1366

//. Fomiihed by the intestinal func-
tions and eTacuations, §§ 132 —

147 — 990

/. Bt the state and appearances of the

alTine eracoations, §§ 147—152 992

bili

xli

laughing, &c., as signs of .

disease, §§ 206—208 - - iij. 1005
vi. Sign* and Symptoma furmthed by
the Urinary and Sexual OrganSy
§§209-218 - - - . ibid.

A. Signs furnished by the states of the

urine, §210 - . - - ibid.

B. Signs furnished by the excretion

of the urine, §§ 210—218 - - — 1006

C. Signs furnished by deposits and

- —994

— 994
i. 840
14-13

- —547

549

997

As respecta the biliary secretion
and excretion, § 154
h. As regarda the intestinal secre-
tions and excretions, §§ 156 —
158 - - . -
^ c. Excretion and excretions, § 1. -
A'. Criaea and critical days, described -

BiUiography and references to - — 449
iv. The Sigma and Symptoms connected
with the Circulating Sysiemt, §§ 159
170 iil995

A. The physical signs and f^inptoms

related to the heart, &c., § 160 995

B. Aucaltation of the heart and peri-

cardium, § 24, etaeq.- - - i. 160

C. Congestion of the cavities of the

heart, §162 - • - - iii. 996

D. Signs and svmptoms connected with

the arterial system, § 163 - - — 996

E. Semeioogical notices of the pulse, §§

16-37 - - -. 547

0. As to the development of the

pnlse. §§ 17-23 - -
6. As to the rhythm and frequency
of the pulse, §f 24—36 -
f' Signs connected with the venous

system, § 166
(**. Signa furnished by the lymphatic

vesaels and glands, § 169 -
V. ^ij^iu and Symptomt of the Betpi-
nOary Function, §§ 170—208 -

A. Of the signs furnished by the va-

rious states of respiration, §§ 170
185

B. Of the states, temperature, and

odour of the expired air, §§ 186

—188

C Of auscultation, of respiration and

voice, §§ 10—24
D, Signs furnished by the states of

expectoration, §§ 189—208 iii.' 1001-5
0. Mocua, mnoo-purulent, pus, and
ichorous matters, &c., §§190
—196 . - - - — 1002-^
h. Blood in various states and aaso-

ciaUons, §§ 197— 200 -
e. Fibrinous, membranous, and tu-
bular exudations, § 200

d. Earthy or calcareous concre-

tions, §201 -

e. States of expectoration in special

diseases, |§ 202—205 1004

/. The act and manner of expecto-
rating, § 205 - -*' - — 1005
g. Yawnfaig, sighing, sneezing,

ibid,
ibid.

— 998

— 1001

- I 158

1003
ibid.

1003

i.884
ibid

ibid.

886

other states of the urine. See
Ukine, § l,e^«cg. - - 1199—1233

2>. Signs furnished by the sexual or>

gans, § 218, et seq. - 1007

E. Bibliography and references to

Symptomatology - 1009

— and to Abdomen, Auscul-
tation, Chest, Pulse, Urine.

Syjiptomatolooy and Diag-
nosis are further elucidated by
an account of the Seceral Die-
eaeee tchich may be Feigned, and
of the means of their Detection
(see Art. Feigning Disease,

Sec.)

Feigning Disease ....
1. Pretended; 2. ArtifieiaUy excited; 3.
Exaggerated; and 4. ArtiJiciaJly
increased, diseases, §§ 1 — 5 -
Abdominal Tumours, Abortion, Absti-
nence, §§ 6 — 8
Blindness, Cachexia, Cancer, Catalep-
sy, Concretions, &f., §§ 9—13
Deafness, Deaf-dumbness, Delivery,
Dropsy, Dj'senteiy, and Chronic Di-
arrhoea, §§ 10—17 -
£pilep8>', I leces, incontinence of. Faint-
ing, f'evers, &c., S§ 19—22 -
Gastric Affections, Hicmorrhoids, Hie-
roorrhages from the Stomach or
from the Lungs, 6§ 23 — 25
Heart Affections, Hepatic Disorders,
Hernia, Hydrocele, H^-steria, §§ 26

—29

Jaundice, Insanity, Lameness, Neural-
gia and Rheumatism, Ophthalmia,

§§30—38

Palsies, Poh-pi, Pregnancy, Pulmonary
Diseases, Affections of the Rectum,

§§39—43

Rheumatism and Lumbago, Sight, dc-
fecta of, Sonmolency and Sopor, §§
44 — 46 - - r - . -
Tympanitic and Emphvsematons Af-
fections, Tumefied Leg, Sec, §§ 47, 48
Ulcers, Urine, incontinence o^ Bloodv
Urine, Urinary Calculi, and Gravel,
§§49-52 .....
Uterine Diseases, Varicose Veins,

Wounds, Sec, §§ 63—55
Bibliography and References

ibid

886

- — 887

ibid

— 888

889

890

891
ibid

— 892

ibid

— 893

GENERAL THERAPEUTICS, § 1,

etseq. - - - - iii. 1034-5

i. CiRCUMSTANCKS RETARDING THE AR-
RIVAL AT Just Principles in
Therapeutics, §§ 4—12 - — 1035-7

A. Limited views in pathologv, &c.,

§ 4 - - - - '- - — 1035

B. The neglect of the states of vital

endowment, § 5 - - - — 1035

C. Undue importance attached to

novel views, &c^ § 6 - - — 1035

D. Wrong estimates of particular me-

dicines and agents, § 7 1036

E. The licence allowed to imposture,
8 - - - - • • ibid.

zlii

CONTENTS — Arbanoement of Therapeutical Agents. :i

O. To paUiate urgent or di«tWMing ... i

symptoms, &c., § 67 - - - m. 1049 i*

P. To excite and direct the mental
emotions, to the prevention and

removal of disease, § 68 - - ^d, ;

JP,. The selfish policy of members of the

profession, § 9 - - - - iii. 1036

G. The neglect of the physiological

action of medicines, § 10 - • ibul

H. The prejudices of patients, Ac,

§11 - - - - - — 1037

/. Medical jealousies and contentions,

&c.. §12 »*M^

ii. Therapeutical Principles, &c.,

§18—69 - - - - 1037-49

Ist. Tlw fundamental Principles of The*

. rapeutics, §§ 13—24 - - — 1037-9

A. To endeavour to interpret aright

the operations of nature, § 14 1037

B. To ascertain the causes, the acces-

sion, the course, and the circum-
stances influencing the progress
of the disease, &c., §§ 16 — 22

C. To determine the pathogeny of

ibid.

disease, &c., § 28
all

— 1039

predisposing, ex-
concurring causes.

ibid.

— 1039

ibid.

ibid

— 1040

2). To remove
citing, and
§24

2d. General Therapeutical Principles

and Precepts, ^% 25-35 - —1039-41

A, Of indications and contra-indica-

tions in the treatment of disease,
§26

B, To employ the most suitable means

for the Ailfilment of intentions
of cure, § 26 -

C, To observe closely the states of

vital power and of vital mani-
festations, &c., § 27 -

I). To estimate the influence of tem-
perament, diathesis, and other
circumstances of the patient, &c.,
§28

E. To select the means of cure with
strict reference to their modes of
action, &c., §§ 29— 86 - - ibid.
3d. Special Therapeutical Principles, ^c,

^87 — 1041

A. The restoration of nervous and

vital power when primarily de-
pressed, &c., §§ 38-41 - — 1041-3

B. The promotion of the several se-

creting and excreting functions
of the depurating processes, §§
42—48

C. To equalise the viUl and vascular

actions throughout the Arame,
§49

D. To moderate or restrain excessive

secretion and excretion, ike, § 60

E. To moderate or allay nervous ex-

citement, unnatural function, or
irregular actions, § 52

F. To allay or remove vascular dis-

order, § 53

G. To prevent, correct, and counteract

morbid states of the blood, §§
66-7

H, To allay morbid irritation, &c.,
§68

/. To alter or correct diseased states
of individual structures, &c. § 69

K. To prevent or remove exhaustion
in its various forms, &c, § 60 -

L, To remove congestions of blood,
&c., §61

M, To support vital resistance to the
extension of disease, and to en-
able it to throw off parasitical
formations, &c., §§ 62 — 4 -

y. To restore impaired or lost func-
tions, § 66

iil The Principal Classes of Hr-
OBiEMic and Therapeutical
Agents - - - - —
(See in connection with these.
General Uyoeiene.)
Ist. Psychical or Mental Bemedial In-
fluences . - - - -

A. Those furnished through the

media of the senses

a. Affections of mind induced by

pleasant odours and tastes -

b. States of mind caused by vision
e. Affections of mind from sounds,

voice, speech, &c.
d. States induced by the sense of
touch - - - -

B. Influences produced by the in-
tellectual powers - - -

C. Influences arising from the moral
affections of mind - • -

2d. Hygeienic Agents and Influences -

A. Food and drink - - -

B. Air and locality - - -

C. Modes of exercise, &c.

D. Climate and change of climate -
3d. Medicinal Agents. — Medicines ap-
plied to the Frame - - —

A, Modes in which medicines are
employed, &c. _ - -

B, The action of medicines

C, The modes in which, and the
channels through which, me-
dicines act - - - -

2>. The general effects of medicines

Classification of Medicines ac-
cording TO their Special

— 1043

— 1045

ibid.

1046

U/id.

ilnd,

— 1047
ibid.

— 1048
ibid.

- — 1048

- — 1049

1060-4
— 1050

arid.
UM.

ibid.

ibid,
ibid,
ibid,
ibid.

1060-4
Odd.

— 1051
ibid.

Operations -

— 1061-4

Class I.— Abstracting the Animal
Heat, ok depressing the Ca-
lorific Process — Refri-
gerants

A. External refrigerants

B, Internal refrigerants

Class II. — Depressing, Suppress-
ing, &c. Involuntary and
Voluntary Motions — Seda-
tives, &c. - - - -

A. Mental sedatives - - -

B, Physical or medicinal sedatives

Class III.— Softening or Liquefy-
ing Agents — Dissolvants -

Class IV. — Astringing the Tis-
sues AND increasing THE

Vital Cohesion of the
Structures — Astringents
AND Tonics - - - -

A, Vegetable astringents. Sec

B, Bitter tonics - - - -

C, Astringent and bitter tonics

I>. Aromatic tonics - - -

E. Acid tonics - - - -

F. Alkaloid tonics

G. Metallic tonics - - -

CiJissV. — Irritating the Struc-
tures — Irritants — Corro-

1051
Srid,
ibid.

ibid
ibid,
ibid.

ibid

DANTS

A. Mineral irritants and corrodaats

ibid
ibid,
ibid,
ibid,
ibid,
ibid,
ibid
ibid

ibid,
ibid.

xliv

CONTENTS — SrjicUt Pathology and Thkrapbutict,

CHIEFLY OF IstPAIlUIENT OF

Vital Force.*

UI. I

ibid,
ibid.

OnuKR I Impaired Function of

THE Digestive Okoans.

Genus Ut Impaired Function chiefly

oftlu Stomach.

Spec. Ist. Relaxation of the uvula

and palate — Definition,

Symptoms and cau'^es

Treatment - - -

Spec. 2(L Indiccestion or dyspepsia,

defnition of - - ii. 326
Description of symptoms
and relations and conse-
quences of - 327

Causes and pathology of - — 832
Treatment of - - - _ 835
Various means of cure ad-
vised for - - - — - 337
Diet and regimen for - — 838
Bibliography and refe-
rences - - - — 8-43
Spec 3d. Gastric flatulence and
fermentation, definition
and description of - i. 1044
Primary and symptomatic

forms of - - - tW<i
Causes, pathology and

treatment of - - — 1045
Bibliography and refe-
rences of - - - — 1047
Spec. 4th. Kumination and regurgi-
tation of food, definition
of - - - - iii.657
History and symptoms of — 658
Causes and treatment of - — 659
Bibliography and refe-
rences to - -

and

and

Spec. 5th. Pyrosis, definition
'symptoms of

Diagnosis, causes
treatment of

Bibliography and refe-
rences - - -
Spec. 6th. Apcpsia, or complete loss
of appetite and of diges-
tive power, symptomatic
of many diseases -
Genus 2d. Disorder of the Intestinal
Function arising chiefly
from depressed vital
jwwer.
Spec. 1st. Duodenal indigestion, or

. impaired function of
the duodenum

Pathology of -

Treatment of -
Spec. 2d. Costiveuess and Consti-
pation, dtfinition. Sec,
of - - - -

Causes and pathology of -

Consequcnres and termi-
nations - . -

Treatment and remedies
for - - - -

Bibliography and refe-
rences - - .

— 660

— 562

— 563

— 665

Ufid,

i. 689

ibUl.

- 690

405
406

407

408

412

• Vital force, vital power, vital energy, are used ai sy-
nonymous terms ; nnu organic nervous force, power, and
energy imply the display of vital force by means of the
organic orgingllal nervous system. Vital functions are
lAe mat/ffcitatioas of vital force by the organs or struc-
eureg of the body, the discharge of the offices which are

eatlncd to bo performed by the organs and tisiuea of the
iiBe.

Spec 3d. Inaction or imperfect vital
function of the c»cam,
described - - • L 275
Pathology of - - - ibid.
Symptoms of - - - — 276
Treatment of - - - *- 277
Spec. 4th. Torpor or atony of the

colon, d^nition, &c., of — 882

Pathology of - - - iHd.

Causes and consequences of — 884

Treatment of - - - ^ 9So

Spec. 5th. Colic, or flatulent colic,

definition, &C., of - - — 360
The varietv and states of,

describecl - - - — 861

a. Colic from flatulent disten-

sion - - - - tWifil

b. Colic from injurious ingesta ibid.

c. Colic from bilious or other

morbitl secretion - - — 862
c/. Colic from the poison of

lead - - 364

Symptoms and pathology
and symptomatic rela-
tions of these varieties — 861-6

Treatment of these varie-
ties - - - — 371-6

Bibliography and refe-
rences ' - - - — 381
Spec. 6tb. Tympanites — Flatulent
distension of the di-
gestive tube — Syno-
nvmes — Ddinition - iii. 1177

Pathology and causes of ilnd.

llie signs and symptoms
of - - - - — 1178

The treatment, indica-
tions, &c. - - - — 1179

Means for removing the
distension - - - ibid.

Treatment of the patholo-
gical states producing it i5fcl.

Bibliography and rde-

jences - 1180

Spec. 7th. Inaction of the rectum,
definition and symp-
toins of - 590

Causes, complications, and
treatment of - — 590-1
Genus 3c/. The Formation of Concre-
tions in the Intestines —
Alvine Concretions, §"c.,
definition of - -

Spec. let. Earthy, phosphatic, and
other concretions, de-
scribed, &c

Their causes and cflccts -

Their symptoms, &c

Treatment of -
Spec. 2d. Fatty and unctuous and he-
terogeneous concretions

Sources and nature of

Bibliography and refe-
rences

Genus Ath. Dqprcsged or exhausted Vi-
tal Function of the J5t-
liary Apparatus, inde-
pendently of previous
Organic Lesions.
Spec, Ut Torpor of the liver, or di-
minished secretion of
bile, definition and
symptoms - - - ii. 723

Causes of torpid liver 718

Treatment of torpor of
liver - - - - — 724
Spec, 2d. Inaction ol W\^ ^AV-XAtuSi-
det and dncX% — kRt>x-

i.397

— 398
ibid.

— 899
ibid.

— 400
ibid.

40;

xlvi

CONTENTS — Spicial Patholooy and Thbrapeutics.

— 175
ibid,

1879

— 880

— 883

Treatment of asthenic - iii. 850
Irregularities, complica-
tions, 8k., of menstrua-
tion - - 851

Bibliogr. and references - — 852
Spec 5th. Leucorrboea asthcnica —

Chronic leucorrboea 710

Treatment of - - - ibid.
Spec. 6th. Impotence and sterility of

the female - - - — 322

Causes and description of — 323

Treatment of - - - — 324

Bibliogr. and references 325

Order III. — Impaired Vital Forck

MANIFESTKD BY THE CIRCULAT-
ING AND HeSPIRATORY OrOANS.

Genttt lat. Depressed action of tJie

Heart, from lowered Or-

ganic Nervous Power.

Spec. 1st. Irregular action of the

Heart, independent of

any organic lesion, —

dfjifUtion, &c., § 39 - ii. 174

Description of enfeebled

and irregular action of

the heart - - -

Treatment of -

Spec 2d. Fainting, or full syncope,

definition and description

Causes and pathology of -

Treatment of -

Bibliogr. and references 884

Spec 3d. Depression and sinking
from physical and men-
tal shock and mental
emotions, definition and
phenomena - -
Var. a. Physical shock from in-
juries, &c. -

Var. b. Moral shock • - - —

Diagnosis and prognosis of —

Treatment of - - • —

Bibliogr. and references - —

Spec 4th. Faintness from inanition,

&c. - - • - i.
From aniemia - - —
From losses of blood,

&c -

Spec. 5th. Faintness from breathing
foul air, the odours of
flowers, or vapours, &c. —
Spec. 6tli. Symptomatic faintness, —
the derivation of organic
nervous force from the
heart to some other part,
as in impregnation and
pregnancy, &c. - - iii. 454
Genus 2d. Decent Vital Power of
the Respiratory Organs.
Spec 1st Asphvxy of new-born
and debilitated children,
owing to imperfect vital
expansion or collapse of
the lungs - - i. 129-34
Spec. 2d. Dyspnoea and Apnoea ge-
nerally symptomatic of
disease of the lungs,
heart, dropsical cfTu-
sions, oedema of the
lungs, bronchial disease,
bronchorrhoea - - ibid.
Spec 8d. Dyspnowi from impaired
\ital expansion of the
lungs in debilitated and
iJl-nouriBhed children - — 478

iii. 785

787
788
788
789
790

26
172

175

128

Spec 4th. Dyspnosa of aged, phleg-
matic, and nypochon-
driacal persons, owing to
deficient vital power of
the lungi - - - L 267
Var. a. Attended by relaxation of
the bronchial exhalanta
— Bronchorrhosa - - ibid,
Var. b. With general cachexia - ibid.
Diagnostic svmptoms - UmL
Treatment of - - - — 268
Spec 5th. Deformities of the thorax,

forms and states of 310

(a.) Lateral depression of

the chest 810

(5.) Depression of the ster-
num with lateral
prominence of ribs - — 811
Description and causes - ifttfi
Treatment of - - - — 812

Ordkr IV. — Deficient Vital Force
OF the Organic Nervous Sys-
tem ACTUATING THE CEREBRO-
SPINAL OkOANS and THEIR NER-
VOUS Productions — the Ner-
vous Ststebi of Relation —

AND influencing MORE OR LF.SS

THE Vascuijir Circulation of

THESE 0HO.VNS.

Genus Itt. Impaired Organic Nervous
Energy of the Brain.
Spec. 1st. ImpairMi organic nervous
force, with exalted mor-
bid sensations — Morbid
consciousness — > Hypo-
chondriasis— Synonymes
-^Definition - - ii 259

Grades and complications — 260

Duration and terminations — 261

Lesions of structure and
diagnosis of 262

Causes, predisposing and
exciting - 263

Pathology and prognosis
of - - - - ~ 265

Indications of treatment - — 266

Means advised commented
on - - 267

Kemedics advised by au-
thors - - 270

Bibliogr. and references 271

Spec. 2d. Impaired nervous force,
with disordered states of
mind — Insanity 432

Definition, and arrange-
ment of its forms, &c - — 432

A review of the indications,
signs, and symptoms of
insanity - 484

Classification of mental
disorders adopted by
writers - - - — 441

Classification of the mani-
festation and affections
of mind by the Author — 443

Arrangement of the special
forms of insanity fol-
lowed by the Author - ibiil.
Var. 1st. Partial insanity, or the

simpler forms of insanity — 444

a. Moral insanity, forms and

states of - - - ibid.

b. Partial disorder of the un-

derstanding • - — 449

r. A general view of partial

insanity - - - — 450

CONTENTS — Spicul Pathology and Thbrapbutics.

dL HTpochondriAc monoma-

siA - • ii. 451

c MeUncbolic monomania —

UeUnchoUa 452

/. Several varieties of par-
tial intanity described 454

Tir.2d. Mania, or madnese, cAa-

racierued, tec, 456

a. Acnte mania, sjmptonis

of - - - - ibid,

b. Course and symptonis of

chronic mania 458

Causes, diagnosis, and
pro^osis - > - — 459
Vsr. 2d. Amentia, or imbecility —

Chronic insanity - ' 460

DtfiMitum and description
of - - 461

a. First grade, or loss of me-
mory - - - - ibid.

h. Second grade, or irration-
ality - - - - Und,

e. Third degree, or incom-

preben^tion - - . ibid.

d. Fourth degree, or loss of

instinct end volition - ibid.

c Fifth ^rade, or fatuity, or
anmhilation of mental
power - - - — 462

Spec. 3U. A. Causes and diagnosis of

imbecility - - - ibid.

B. Complications of insanity — 463
Insanity complicate with

gtroeral panilysis - - ibid.

Compbcated with vertigo — 464

Insanity complicated with
epilepsy, or convulsions ibid.

Complicated with apo-
plexy - - - — 465

Compbcated with other
nervous and physical
disorders - 466

C. Terminations and dura-

tion of insanity - - ibid.
D. Prognosis of insanity - — 469
K. Relapses and recun-ences

of insanity - 470

F. Fatal jtermination, its pa-

thological causes - — 471

G. The alterations of struc-

ture connected with in-
sanity - - - — 474
(a.) Morbid appear-
ances in the head - ibid.
(Jb.) Alterations in the

thoracic viscera 480

(c.) Alterations in the

abdominal viscera - ibid.
H. Canaes of insanity - - — 481
(a.) Predisposing cau-
ses, fully reviewed
and considered - ibid.
(Jb.^ Exciting or effi-
cient causes 487

Certain moral emo-
tions - 488

Pln'sical causes of

insanity - - — 491

a. Social and political causes

of insanity - 495

b. Of tlie ph\- Biological pa-

iholog\' of insanity — 497

(a.) kemarks on mind

and organisation - ibid.
(A.) On modern ma-
terialism 499

(e.) Of phrenology, in

relation to insanity - — 501

L Of the connection of the
mind with the nervous
systems

K» Treatment of insanity

a. Introductory re-
marks on - -

b. Seclusion or separa-
tion of the insane -

c. Clothing, re^mcn,
and diet of the msane

d. Management of con-
valescents

e. Means of preventing
attacks, relapses, or
returns of insanity -

L, Treatment of special forms
of insanity - - - -
'(cu) Of partial insanity
J>.) Treatment of mo-
ral insanity -
(c.) Of melancholic

monomania -
(jd.) Of other partial
states of insanitv -
M. Treatment of general in-
sanity . - -

a. Of maniacal insanity

b. Treatment of dementia

and fatuity, chronic
states of insanity -
N. Treatment of the compli-
cated states of insanity
O. Review of the remedies for
insanity, with remarks
on the individual means
and plans advised

a. The moral treatment of

insanity - - -

b. Of the classification of pa-

tients and arrangement
of institutions, &c.
Spec. 4th. Connate or puerile in-
sanity, defined and de-
scribed - - -
(a.J Deficiency of intellect
lb.) Complete privation of
mental faculties —
Idiotcy - - -
Complications and causes
of imbecility and idiotcy
Treatment of imbecility
and idiotcy - - -
Spec. 5th. Puerperal insanity, de-
fined - - - -
Description of - -

a. Insanity during preg-

nancy - - -

b. Insanity after deliver}'

c. Insanity during or

after lactation
Diagnosis and prognosis

Causes of puerperal in-
sanity - - -

Pathological states and re-
lations of - -

Treatment of puerperal
insanity, with reference
to the period of its oc-
currence • - -

Diet, regimen, and moral
management
Spec. 6th. Suicidal insanity — Sui-
cide— Definition -

Occasions or causes of sui-
cide - - - -

Prcdisponcnt cLrcumstan
ces and causes

- u.

zlvii

605
511

ibid,

612

614

615

ibid,

ibid,
^fid,

616

617

619

519
520

522
623

- 624
635

- — 639

640
ibid.

541

542

543

643
ibid,

ibid.
544

ibid

545

646

547

548
649
560
661
. 667

XlvUI

CONTENTS — STpecial Pathology and Therapeutics.

Spec. 7th.

Spec. 8th.

Spec 9th.

Spec 10th.

Genua 2d,

Spec 1st

Spec. 2d.

Spec. 3d.
Spec. 4th.

Spec. 6th.

Genut Bd,

Pathology of suiddal in-
sanitv

Physiological consider-
ations as to suicidal in-
sanity - - -

Prognosis, &c.

Treatment — avoidance of
the occasions, &c.

Surveillance and restraint

Prevention and repres-
sion - - - -

Bibliography and refer-
ences to insanity -

Cretinism — definition
and description -

Treatment - - -

Bibliog. and references <•

Asthenic, ircak or serous
apoplexy — Apoplexy
from lowered organic
vital force - - -

Description, terminations,
morbid appearances

Pathological states of,
§ 115 -

Treatment of, §§ 148—
152 - - - -

Cerebral svncope, § 7

Causes and pathology of -

Diagnosis and treatment -

Bibliogr. and references -

NervQus Headach*, §
10 - - -

Causes and description of

Treatment and means ad-
vised, § 39 -

Deficient Vital Inunction
of the Organs of Sense,

Amaurosis, or loss of
sight from impaired
ftmction of the optic or
ophthalmic nerves, or
retina, &c., owing to ca-
pillary or venous con-
gestion, &c, definition,
&c, § 1

Causes and pathological
states, § 9 -

Svmptonis, grades, and
'forms, § 20 -

Diagnosis and prognosis -

Treatment, &c § 70

Bibliography - - -

Functional diminution or
abolition of the faculty
of hearing — Kervous
deafness

Symptoms and pathology
of - - - -

Treatment of -

Loss of the sense of smell

Impaired or lost sense of
taste - - - -

Anaesthesia, or loss of feel-
ing - - - -

Symptoms and pathology
of - - - -

Treatment of paralysis of,
§ 205 - -

Lowered Vital Power of
the Spinal Column

- ii. 561

5fi2
563

5G4
5G4

565

567

- i. 441
443

ibid.

80

81

97

102
880
S81
882
884

143
144

149

- 11.

i. 50
ibid,

- 62

- 67

- 68

- 02

- ii. 160

111.

ICl

ibid.

11

ibid,

12

ibid.

42

853

* Headacli is aicrtbed to altered' feniibUitv, or to
pain, arising from changes of the organic netTous en*
oowment of the brain or Iti membranes, caused either
by impaired capfllarf circulation, or by vascular con-
gestion or excitements or by organic lesion, &c. Se<'
art. Hbaoach.

Spec. 4th.
Genus 4th,

Spec. 1st. Flexures of the spine, § 29

Forms, causes, and conse-
quences of -

Treatment of -

Treatment advised by the
Author, § 48
Spec 2d. Venous congestion of the
spinal chord, its mem-
branes, &c., with or
without increased se-
rous effusion
Spec. 3d. Raehialgia, or nervous and
painful affections of the
Spinal Column, § 58 •

DeJinUion, description, and
varieties of -

Causes and nature of

Treatment of -

Bibliogr. and references -

Tabes dorsalis from ex-
haustion

Inypaired Vital Power of
the Nerves of Sensation
or Motion, associated with
altered, generaJly exalted,
Senstbility.
Spec. 1st Neuralgic affections, evin-
cing no sign of inflam-
mation or of organic
lesion - - -

Yarietiea and states of -

Causes and associations of

Terminations and prog-
nosis of - - -

Pathology of -

Treatment of -

Various plans and means
of cure - - -

Bibliogr. and references -
Spec 2d. Barbiers, definition and
symptoms -

Treatment - - -
Spec. 3d. Beriberi, definition, symp-
toms, and diagnosis

Causes and paUiology of -

Treatment of -

Bibliography -

iii. 857

— 858

— 859

— SCO

Soo

— 862

ibtj.
8G4
865

8.^7

1009

- IL

877

878
881

887
888
889

895

103
ibid.

IGl

IGo

ibid.

- — 1G<;

- 1.

Order V. — Impaired Organic Nkr-
vous OR Vital Force mani-

PRSTED BY THE BlOOD AMD HY

THE Vascular amd Absorbent
Systems, with more or less
Cachexia.

Genus 1st. Alterations of the Quantity

and Quality of the Blood, i. 172
Spec Ist. Morbid deficiency of blood

— anemia — d^nition - ibid.

Symptoms and pathology
of - - - - — 17:;

Complicated states of 174

Causes and treatment of - — 17.~i

Bibliogr. and references - ihi,t
Spec, 2d. Deficiency ,from losses of

blood - - - . ihitL

Morbid effects produced
by, on persons m health ibid.

Bvlarge Josses of blood 17G

The insidious effects from
repeated losses of blood — 177

Of excessive loss of blood
in diseases of excite-
ment - - - - t7>iV/.

Of the mode by which ex-
cessive loss may be pre-
vented or counteracted — 17S

CONTENTS — Spbcial Pathoi.ooy awd Therapibuticr.

643

(a.) Rachitis— Rickj:t8—

firet stage of - - ui.

(6.) Scorbutus — Scurvy

— first grade of - — 769

(c.) Purpura, early state

of - - - - - 651

Order YI. Oktbral Chronic Debi-
UTT, OR Impaired YrrAL Force,

MAKITBSTBD THROUGHOUT THE

FRAME — See Art, Debilitx.

Genus Ui, 8in^ general Debility,
without any manifest In-
fiammaiory or Organic
Quinge — D^nithn
Spec. Ist Primary debility '-

Causes of - - -
Treatment of - - -
Spec 2d. Consecutive debility,

Causes and pathology of -
Treatment of - - -
Manifestations of debility
Complications of debilitv
Pathological relations of -
Treatment of the several
forms and states of de-
bility -
Treatment of its various

associations
Of convalescence -
Moral and physical regi-
men, and other means -
Bibliogr. and references -
Spec. 3d. Climacteric decay — Defini-
tion - - - -

i. 478.

— 474
ibid.

— 482
_ 475

ibid,

— 483

— 477

— 481
ibid.

482

485
ibid.

486
486

336
i&tdL

337
ibid.

338

251
252

- — 254

255
256
257

S}rmptoms

Causes - - -

Treatment

Bibliogr. and references - —

Genus 2d. General 2>e5t&'(y, asso-'

dated with jTydatidic

and Verminous Forma-

tions and Devdopments.

Spec. 1st. Hydatids — Synonymes —

Dffiniiion - - - ii.
V Description of - - —

Pseudo-hydatids, or sim-
ple cysts

Remote and immediate
causes of hydatids

Symptoms and treatment

Bibliogr. and references
Spec. 2d. Worms — Intestinal Worms
— Yennination — Ento-
zoa — Definition - - iii. 1875

A. The origin of animal pa-

rasites - 1376

The emi|^tions and im-
migrations of - - — 1877

B. The classification of in-

testinal worms - - — 1380

a. Infiisoria — Description

of the trichomonas

and the denticola ho-

minis ... ibid.

h. Helmintha — ^Yermes —

General description of — 1381

Their general patho-
logy - - - ibid.

The general prognosis
of - - - - tMd

The principles of treat-
ment of - - - ibid*

C. Description of the 1st

Order, Platyelmia, of
the 2d Gass, Hehnintha U»id,
Generation, metamorpho-

-—1888

- — 18M

- — 1891 *

- — 18»

ibid.

/•

sif, and growth of tape- !,

worms • - -iii. 1882
The development of ces-
toidea, or cestode worms — 1887

a. Description of the bo-

thriocephalus latus - ibid.

b. Dttcription of t«nia so-

lium

c. Description of tenia

mealocannellata

Symptoms and diagnosis
of the mature cestoide*
occurring in the human
intestines -

Description of immature
tssnisB found in the hu-
man body exiemalfy to
the intestines

a. Of cjrsticercus tenui-

coUis - . -

b. Of echinococcns soolid-

pariens, and of £. al-
tridpariens - — 1892-41
The diagnosis, progno-
sis, and etiology of — 1894-6

D, Descriptionof trematoidea,

monostoma, and di-
stoma - - •• - — 1896
Seats, diagnosis, mnd al-
terations produced by - — 1890 -«

E, Description of nemi^-

mia — Nematoidea — ^
Thread'Worms — ^Bound-
worms - - - — 1897

a. Of tricocephalns dispar

—Trichina spinOis 1898

b. Of oxyuris vermicularis

— Locality — Symp-
toms and diagnosis - — 1400

c Of Strongyli gigas —

Locality and symp-
toms - - - — 1401
d. Of ancvlostomum duo- -

denale— Pathology of — 1401

F, Symptoms and altera-

tions observed after

death from 1402

a. Of filaria medinensis —

Synonymes and diag-
nosis - - - — lf08

b. Of ascaris lumbricoides

— Symptoms and
diagnosis - - - — 1404

A general view of . the
symptoms produced by
worms in the diges-
tive canal • 1406

The causes of worms - ibid*
The treatment of worms - iMA

a. The prevention of the

ingestion of their ova ibUL

b. The pi*evention of the

development of the
ova wncn ingested — 1407-8
K. The direct and curative

*- treatment of worms - — 1408

a. The treatment of tape-

worms ... ibid.
The several methods re-
commended - — 1409-15

b. Treatment of distoma,

oxyuris vermicularis,
of Strongylns gigas,
the . ancylostomum '
duodenale - — 1416-17

c. Treatment of filaria me-

dinensis and ascaris
lumbricoides - — 1417-19

G,

I.

lii

CONTENTS — Spbci.vl Pathology and Thbrapxutics.

parts of the brain,
causing a morbid in-
crease of certain emo-
tions and passions. See
Partial iNSAifiTy and
Acute Makia — I.
Class— Order IV. - ii. 456
Spec. 4tb. Tremor * — Definition - iii. 1084

Description ... ibid.

Causes and states of • — 1085

Diagnosis and prognosis

— 1086-7

Treatment - - - — 1087

Bibliography and refer-
ences - - - — 1088
Spec. 5tb. Delirium nvith tremor,
¥rith excited vascular
action^Definitinu - L 497

Symptoms, modifications,
and diagnosis - - — 498

Causes, pathology, and
prognosis • - - — 500

Treatment, &c - . -. 501

Bibliog. and references — 504
Spec. Gth. VerU^o * —D^nition - iii. 1857

Description of - • - t5id!.

Causes and forms of - ibid.

Diagnosis and morbid re-
lations of - 1858

Prognosis and treatment
of - - - - — 1859

Bibliography and refer-
ences - - - • — 1860

Gl

02
C3

Order II. — Irritahon or Vascular

EXCTTRMEMT OOCASIOMIlfO OR

folix>wbd by H^morrhaob,
chiefly from Mucous and
OTHER Surfaces — D^tnition ii.

A. Of the state of organic, nervous or

vital force in haemorrhage - —

JB. Of changes in the seats of hemor-
rhage - - - . . —

C. Of changes in the circulating organs

and vessels producing liaemor-

rhage — 64

D. Of the states of the blood in hae-

morrhage ....

E. Remote causes of htemorrhage

F. Symptoms, diagnosis, and prog-

nosis . - . - -
O, Classification of hemorrhages
If. Treatment of hemorrhages -
J. Remedies for, adduced and com-
mented upon ....
K. Regimen ana prophylaxis -
L. Bibliography and references -
Jf. Haamorrhages considered with re-
spect to their seats ...
A'. Bibuognphy and references «
Genut IsL H<emorrhage9 from the Di-
gettive CaiuiL
Spec. 1st Hemorrhage from the
mouth and throat
Description of seats and
states of hemorrhage -
Diagnosis and causes of -
Treatment of -
Bibliog. and references -

* Many cases of vertigo may lie referred to debility or

even to nnemia of the bmio ; others to congestion or to

active determination of blood to the brain, and others

io orjfa/iic )e$\on. The same remarks apply to Tremor^

which aho mnjr proceed from very oppoiite states of clr.

J^^/foa Jn the brain, or oren from structural change.

oeeCi.xa9lV, Order III. «

the

ibid.

- 65

- 66

- 67

ibid

- 68

- 70

- 71

- 72

- 73

- 77

Geuut

2d

ibid.

Si>ec

.1st

- 78

- 79

ibid.

Spec. 2d. Hemorrhage (Vom
CEsophagus -
(Rarely occurs unless
from mechanical in-
jury and organic le-
sions. Class IY.)
Treatment, &c - •
Spec. 8d. Hemorrhage firom the

stomach - • - —
Primary or simple -
Vicarious hematemesis - —
Hemorrhage from disease

of associated viscera
Hematemesis from organic
lesions of the stomach
or of its vessels - - —
Vomiting of black matter
Causes and symptoms - —
Morbid appearances and

pathological inferences —
Diagnosis and prognosis - —
Treatment durmg the at-
tack - - - - —
Treatment subsequently to
the attack - - • —

Bibliogr. and refierences

Spec 4th. Haamorrhage from the in-
testines imd melena
Definition and description

of . . . - —
Pathology and causes of - —
Diagnosis and prognosis of
Treatment of - - - •—
Bibliogr. and references -
Spec 5th. Hemorrhage from the
hemorrhoidal vessels —

UiKMORRHOIDS - • —

Definition and pathological
history ...

General character and de-
scription - .

Varieties of the hcBmor-
rhoidal tumours

Character, returns, amount,
and nature of the dis-
charge

The consequences and
complications of hemor-
rhoids ....

Diagnosis, causes, and
prognosis - . .

Treatment, constitutional
and pathological rela-
tions of - . -

Treatment of the hemor-
rhoidal discharges

Treatment of the hemor-
rhoidal tumours -

Treatment of the conse-
(^uences and complica-
tions ....

Re-establishment of sup-
pressed hemorrhoids - —

Bibliog^. and references -

Httmorrhage from the Bt"
Mpiratory Surface;

Hemorrhage from the nose
— Epistaxis — Defini-
tion oi- - - —

Phenomena and causes of —

Treatment and means ad-
vised - - . - —

After-treatment of - • —

Bibliogr. and references

Spec. 2d. Hemorrhage from the
bronchi — Hemoptysis —
Definition - - - —

Symptoms uniX ^\o^;rQ^ - —

. ii. 914

— 916

— 91
ibid.

— 92

i5idL

93

ibid.

94

95
96

97

98
99

Ofid.

100
102

ibid.
108

ibid.

- 122

ibid.

' 123

• 124

125

• 126
127

129

ibid,

130

- — 182

133
t6«dL

78
74

75
70
77

79

to

llT

CONTENTS — Spicul Pathology and Thbrapiutics.

G«n«ral ramftrkf on the
pathology of colic and
ileus - • - - i 870
Diagnosis and prognosis • ibid.
Treatment of tha sevaral
▼arietiei of coUo and
Ueiis - * • —871-7
Ofleadoolie - • * — 878
Ofconiralescenceftom • ii 876
Treatment of ileus • • ~ 876
Remedies and meins pre*

scribed - - —871-80
Bibliogr. and references - -• 881
Spec. 4tb. Spum of the rectum and
sigmoid flexure of the
colon - - « - Ui 604
Treatment of - - tUdL

(Spasm of these parts,
occasioning tenes-
mus, &c., often at-
tends irritation and
organic lesions,either
seated in them or in '
their vicinity. See
Arts. Dybehtbrt,
RsGTiTM, and Anus,
&c.)
Genus 2d, Spa§modie Afftttunu of
di§ Digetttpe OoiumI, with

ths ViUtma Smface,
Spec Ist. Spasm of the stomach,
with eructations of wa-
tery fluid — Ptbosis - — 862
(The disorder usually
termed pyrosis is
characterised, in some
cases, chiefly l^ pain-
ftil spasm previously
to the aqueous dis-
charge } and in others
by indigMtion, with
no pain and little or
no spasm, the fluid
being merely regur-
gitated firom the
stomach.)
Diagnosis, causes, and na-
ture of - - - — 568

Treatment and bibliogr. 664

Spec 8d. Spasmodio and painful ac-
tion of the stomach,
duodenum, and intes-
tines, with copious eva-
cuations and spasms of
the extremities — Cho-
LBBA*— Z^^ntCion - L 818
History and symptoms - ibid,

Var. a. Bilious cholera 819

6. Flatulent cholera - - — 820
c. Spasmodic cholera - - — 821
Diagnosis, causes, and pa-
thological stetes - —819-22
Treatment and remedies

prescribed - 822

Bibliogr. and references - — 824
GeuuiSd. SpMmodieAffBUioiuofthe
Urinarp and SexutU
Org€mM.

* The pbenomena characteri»iog Cholera vary much
with thr seat or spafm and pain,— with the severity of
tiie irritation of the organic Dervett-— and with the de-
gree of affection of the dmodemmm. When the spasmodic
action of thtt part is great the doets are implicated, and
the discharge of bile u arrested. The Irritation of the
organic nertes, being propagated to Che roou of the
spinal nerTet, oeeationt spatrnt of the voluntary muscles,
stated la the lint part of the work, pubUthed Sept.

Spec tst
Spec 2d.

Spec.8d.

Crefitis4M.
Spec 1st.

Spec 2d.

Spec8d.

Spec 4th.

Irritable urinaiy bladder - liL
Diagnosis of • - - —
Treatment of • - - —
Spasm of the urinaiy blad-

Diagnosis of • - - —

Treatment of -

Irritation of the uterus and
appendages^ with more
or less morbid sensibility
of these organa — Syno-
nymea-.%Z>2fSMlMm

Local and genanl symp-
toms • • . -

Diagnosis and prognosis -

Causes and nature of irri-
table uterus

Treatment of • - -
<S|pasfiiodie AffeeHong tm-
pScaiing dutfy ike Rt*
MMTvtorp Or^HMS.

Aneoting chiefly the dia-
phragm—Hiccup — Sin-
gultus — Synonymes —
h^fimtioH •

Causes —Various sources
of irritetion, &c, gene-
rally symptomatic

Diagnosis and prognosis -

Cough or xnitauon re-
flected chiefly on the
reepiratory muscles
generally— A qrmptom-
atio affeotioa produced
by varioos sources of
irritation •

Causes, sonross, and forms
of ... -

Tk«atment of, and means

of cure - - -

Bibliogr. and reforenoes -

Simple catarrh— Speciflc

irritation of the Schnei-

derian membrane and

adjoining surfaces, often

with a watoy discharge,

and slight symptomatic

fever towards nights

D^fhUiitm -

Cansee, prsdisposing and

excitixig . . •

Diagnosis, prognosis, &c -

Complications and nature

of - - -
Treatment and prescrip-
tions for - - -
Bibliogr. and reforences -
Hoopingoough— /'erfsMM,
s^onymesb and ci^/fat-
htm - • .
DeecripUont eonunenca*

ment, and couse -
Complicated pertussis
Appearance seen in &tal

1180
1181
1182

iUd,
1188
Und.

- —1240

ibid.
1241

ibid.
1242

- ii 634

Odd.
286

- L

486
ibid.

487

488

294

ibid,

. 296

• ^ 296

297
298

- U. 286

- 236
• 237

Nature and seat of per^

tussis - • - -

Diagnosis, prognosis, and

IVsatment of the simple

form - - - - ^
IVeatment of ooo^cated

hooping ooogh - • ^
Review of remedies ad-
vised - - - - —
Bibliogr. and references • —
Spec 6tli. Spasmodic croup - - L
(A vaiietgr of Cuour

240

ibid,

243

244

245

24S
260
468

Ivi

CONTENTS — Special Patbojlooy and Thirapsutics.

Edampeia and other va-
rieties of - -

Gonvnlflions in the puer-
peral states - • -

d, Px«monitory ** sjrmptoms

and complete seisure -

e. ConvnlsionB sympathetic

of several diseases

Diagnods, consequences,
and prognosis of con-
vulsions - - -

Bemote and efficient causes

Cleneral view of the treat-
ment - - - -

The means during the at-
tack - - - -

The prevention of the
seizure - - -

External means, regimen,
&c - - - -

Treatment of convulsions
in infants and children

Treatment of puerperal
convulsions -

Means required to termi-
nate the seizure -

Of the epileptic attack in
the puerperal state

Of the attack when caused
by losses of blood

Of the prevention of con-
vulsions - - -

Bibliogr. and references -

Spec. 3d. Tetanus and trismus —

Synonymes, de/inition,

&c. - - -

Description of the several

forms of trismus and

tetanus - - -

* a. Of trismus - - -

5. Of acute tetanus •

c. Of sub-acute and other
states of -
Duration and termina-
tion of tetanus -
Appearances in fatal

cases
Diagnosis of - -

<2, Tetanus infantum, or
trismus of new-bom
infants ...

Causes and appearances
after death . - -

Relations and alliances of
trismus and tetanus to
other diseases

The effects of muscular
contractions on the cir-
culation

Influence of the states of
the blood on muscular
contractions

Predisposing and exciting
causes - - -

The formative or incu-
bative period of tetanus

The prognosis, &c -

Pathological infiBrences
and remarks

Kemarks on the treatment
of - . •• •

The local treatment of -

The external means ad-
vised - - * -

Constitutional and in-
ternal means

Successive and combined
measares - - •

- 1.

418

ibid.

419

tlnd,

420
422

424

425

427

428

480

432

433

434

435

ibid,
ibid.

- iii. 1010

1011
ibid.
1012

1014

1015

ibid.
1017

1018
ibid.

1019

X

1020

ibid.

1021

1022
ibid.

- —1023

ill.

1024
1025

1026

1027

1031

The prevention of tetanus

or trismus -
Treatment of conva-
lescence . - -
Bibliogr. and references —
Spec 4th. Chorea — Chorea Sancti
Yiti — synonymes and
de^tfton ...
(Chorea, tremor, shak-
ing palsy, and va-
rious other affec-
tions characterised
by twitchinffs of the
muscles, and usually
viewed as states of
chronic or asthenic
spasm, may be con-
sidered as the results
of impaired or sup-
pressed nervous in-
fluence endowing the
muscles, and as not
legitimately belong-
ing to this order.)
Symptoms, duration, and

coraplicaticms
Terminations and appear-
ances after death
Diagnosis and prognosis -
Predisposing and exciting

causes
Nature of the disease
Of nervous diseases re-
sembling chorea -
Conspectus of the treat-
ment of chorea
Treatment reconunended

by the Author
Prescriptions advised
Treatment of the compli-
cate and irregtdar states
of chorea - - -
Bibliogr. and references -
Spec 5th. Catalepsy — Synonymes —
DefinUion - - -
Symptoms and relations of
Diagnosis and causes of -
Treatment of -
Spec. 6th. Cataleptic ecstasy — Defi-
nition - . - -
Description and termina-
tion - - - -
Causes and nature of
Treatment of -
Bibliogr. and references -
Genut 6f A. Spcumodic and Contminoe
Affection$ owing to Irri-
tation of the Female
Sexual Organs, extend-
ina thence to the Spinal
Chord, and often to the
Srain.
Spec 1st. Hysterical spasms, pains,
and convulsions — ^Hys-
terical AFFEGTIOirS —
Synonymes and de/S-
nition - - -

a. The milder and more re-

gular forms of - -

b. The severer forms of

c. The irregular and ano-

malous states of hysteria
described - . -

Complications of h^rsteria

Duration and terminations

Diagnosis, &c

Causen, predisposing and
cxciiiiig

- iu. 1033

ibid.
1033-4

- i. 327

- i. 328

— 329
ibid.

— 330
iid.

— 831

— 832

— 334

— 835

ibid.
886

290

ibid.

291

292

291

ibid.

292

ibid.

298

- ii. 272

— 278

— 274

— 275

— 280
ibid.

— 281

282

Iriii

CONTENTS — Spkcxal Patholoov and Tuirapbutics.

b.

c.

c/.

e.

a. Simple, or erjrthMiMtio - iii. 928
Simple stomatitis - • ibitL
Treatment of - - • Und,
Pseudo-membranoiu sto-
matitis • » • — 929
Causes and treatment - ibid,
Mercnrial stomatitis. See
PouOHS, §§ 662— 598 - Und,

Ulcerated stomatitis 930

Treatment of - - - — 931
Phagedenic stomatitis — -
Canerum oris — Symp-
toms of - . * ibid.
Diagnosis and causes of - — 932
Treatment, &c. - • ibid,
Bibliogr. and references - — 983
Spec. 2d. Inflammation of the tongue

— Glossitis —D^^Nt&m

&c. - - - - — 1077

a. Acute glossitis described - Md,
Conne and consequences

of - - - - ~ 1078
Abscess of the tongue - ibid,

b. Asthenic acute glossitis,

course and termination
of .... ibid.
Causes of acute glossitis - ibid,

c. Superficial and partial glos-

sitis - - 1079

(L Chronic superficial glos-
sitis ... - ibid.

Prognosis of inflammation
or the tongue - - — 1080

Treatment of acute glos-
sitis - - 1081

Treatment of chrooio glos-
dtis . • . • ibid.

Symptomatic and compli-
cated glossitis, treat-
ment of • - - ibid.

Treatment of partial and
of chronic glossitis 1082

Bibliogr. and references - — 1084
Spec. 3d. Inflanunation of the ton-
sils — TonsiUitU —
Synonymes and deJbU'
turn ' - - - — 1056

Symptoms and causes of - i&tdL

(jourse and duration of - — 1057

Abscess, enlargement, kc,
of * • - - iMdL

Treatment of acute sthenic
tonsillitis - 1068

Treatment of asthenic ton-
sUlitis - - - — 1064

Treatment of abscess of
the tonsils ... Und.
Spec. 4th. Inflammation of the palate
and fauces — Isthmitis
— Angina — Synonymes
and tkfiniHoH - - iiL 1

Symptoms and complica-
tions of - 2

Chronic and ulcerated sore-
throat ... ibid.

Treatment of acute, chro-
nic, and complicated
sore-throat - - - — 8

Bibliogr. and references - ibid.
Spec. 5th. Inflammation of the fences
and pharynx — Phaiyn-
gitis— See^ri Throat.

— Synonymes and dSe-
Jintiim of - 1057

Causes and description of — 1058
Mild, acute, and catarrhal ibid.
Forms, their complications,
snd terminations - - ibid.

a.

b. Chronic phaiyngitia - iii. 1059
c Pharyngitis with plastic
exudation — Diphthe-
ritis — Angina <» mem-
branacea - —1059

Description, and special
andconstittttional symp-
toms of - - - — 1060

Terminations and prog-
nosis of ... ibid.

Appearances after death - — 1061
d, Dinusiye inflammation of
the throat -« Asthenic
angina — Synonymes —
Ihfimtim^ - - - ibid.

Causes and symptoms - — 1062

Duration, termination, and
prognosis ... ibid.

Complications, && • - — 1063

Treatment of angina pha-
ryngea. See Tonsil-
litis - - - - ibid.

Treatment of angina mem-
branacea - - - — 1065

Treatment of diflhsive an-
gina .... arid.

Treatment of the compli-
cations of angina - - ibid.

Diet and regimen - - — 1066

Bibliogr. and references - — 1068
Spec. 6th. Aphthous inflammation of
the mouth, fauces, and
pharynx — Thrush —
AphthsB — Synonymes
KiA definition - - ibid.

Symptoms and character-
istic features - - — 1070

Nature of aphtha - - ibid.

Treatment — load, hygei-
enic, and medicinal 1071

Bibliography and refer-
ences ... ..1072
Spec. 7th. Inflammation of the oeso-
phagus — (EsophagilJs
— Synonymes and dlt-
finibon - - - iL 908

Causes and symptoms of
acute - - - • — 909

Terminations and appear-
ances in fatal cases - — 910

Sub-acute and duooic
oesophagitis • • ibid.

Consequences or lesions
produced by - - — 911

Stricture, ulceration, and
their symptoms - - tUef.

Prognosis or chronic oeso-
phagitis and of its con-
sequences - - - — - 913

Treatment of acuta csso-
phsgitis - - - tMdL

Treatment of snb-acata
and chronic, and of their
conseonenoes and com-
plications ' 914

Bibliogr. and refeteaces - — 917
Spec. 8th. Inflammations of the
stomach — Gastritis —
Synonymes, dtfimHom^
&0. - - - -iii

Causes, predisposing and
exciting ...

Description of the ferms
and states of - - —
a. The milder states of gas-
tritis - - - - —

Sttb-acnte gastritis -

a.

5.

c. Acute or severe gastritis -

911
ibid.

912

913

914

iind.

u

CONTENTS — SpBCUt Pathology and Tiibrapbutics.

tion or inflammation of
the mucous surikce
Treatment of these affec-
tions - - - -
e. Abscess of the rectum and

iii. 595
ihUL

— 596

— 597

— 598

— 608

A.

B.

anus - - - -

/. Several other conseouences

of proctitis described -

Treatment of abscess and
other consequences

Bibliogr. and references *

Genua 2d, It^flammaiion of ike BUkuy

Organs,

Spec 1st. Inflammation of the liver —

Hepatitis — Synonymes

ana d^nitum of - - ii. 781

Remarks on the seats*
states, and relations ci(
hepatitis ... ibkL

Acute and snb^acute he*
patitis described - - — 732
a, Wnen affecting chiefly the

substance of liver - ibid.

When seated chiefly in a
part of the surface - — 734

Chronic inflammation of
the substance and sur-
faces of the liver - - — 735

Consequences and termi-
nations of hepatitis - — 786

C, Suppuration or abscess in
the liver - - - ibid.

Pro^press, course, and con-
stitutional symptoms of
hepatic abscess - - — 787

Situations in which ab-
scess generally opens - — 788

Indications, sigos, and
symptoms of the point-
ing of hepatic abscess - ibid,

D, Chronic enlargement of
the liver - - - — 789

Complications of hepatitis

— with periodic fevers

— with d^nteiy —
with eastritis, &c. 740

Prognoeis of the several
states of hemititis - — 741

E, Treatment of acute and
sub-acute hepatitis - ibid,

a. The means of cure re-
viewed and commented
on - - 742

5. Of the use of mercurials

in hepatitis - - . — 748

c. The treatment of hqpatitis
in Europeans in warm
climates - - - — 745

d. Treatment of the compli-
cations of acute hepa-
Utis - - 746

e. Treatment of abscess of
the liver - - - — 747

/ The external opening of

abscess of the liver 749

g. Treatment of chronic he-
patitis ... ibid,
Bibliogr. and references - — 760
Spec 2d. Inflammation of the gall
bladder and ducts —
Definition, ^.of' - ii. 5
Symptoms and consecu-
tive changes - - — 6
Pathologiccu observations ibid.
Treatment, constitutional

andlood - - - — 7
Bibliography and refer-

COC68 - « . • — 8

Genus 8d, InflammaUon of ike Pan'
creas,

Pancreatis — Definitions ^, iii. 5

Symptoms, progress, diag-
nosis, ana difficulties of ibid.

Complications, conse-
quences, and termina-
tions - - N 6

Causes and treatment, &c — 6, 7
Genus iih, Infiammation of the Spken
— Splenitis,

Synonymes uiddefimtion of — 894

Causes and history of sple-
nitis ... - ibid,
a. Acute splenitis, descrip-
tion of - - - ibid.

Appearances after death
from - - - . ibid.

Abscess and other termi-
minations of acute sple-
nitis - - - - — 895
6. Asthenic acute splenitis,
generally consecutive
and complicated - - ibid,
c Chronic splenitis, s^'mp-
toms and consequences
of, in adults and m chil-
dren - - - - — 896

Diagnosis and pro^osis of
splenitis, ana of its com-
plicaUons - - • — 898

Treatment of acute sple-
nitis - - - - — 899

Treatment of sub-acute
and chronic splenitis - ibid.

Treatment of the conse-

Suences and complica-
ions - - - - — 900
Means advised by authors — 901
Bibliogpr. and references - — 906
Genus 5th, Inflammation of the Uri-
nary Organs,
Spec 1st. Inflammation of the kid-
neys — Nephritis — Sy-
nonymes and definition ii. 628
Yar. a. Inflammation of the vas-
cular and tubular struc-
ture of the kidneys.
Nephri^ propria — Causes^
occ. .... ibii.

Description of its several
forms and states - - — 629

S3rmptoins of acute and
sub-acute nephritis - ibid.

Symptoms of chronic ne-
phritis - 631

Consequences and termi-
nations ... Und,

Appearances observed after
death - - - - — 638

Diagnosis of simple states
of nephritis - - - — 634
5. Modified states of nephri*
tis — (a.) Oonty nephri*
tia - - - - — 685
(5.) Rheumatic nephri-
tis— S3'mptoms - — 636
(c.) Consecutive or as-
thenic n^hritis - tfrufl

Of the influence of ne-
phritis in producing
other maladies - - — 638

Complications and prog-
nosis of nephritis - - — 639

Treatment of the primary
and simple forms 640

Treatment of the modified
and consecutive states - — 641

Izii

CONTENTS — Spbcial Pathology and Thirapiutica.

*— Signi, BTinptoms,

.&& - - .m.1258

f. IniUimmatioii and absoess

of the Fallopiaii tubes

and cellular tinne - UmL

(a.) Causes, symptoins,and

progress of - - — 1254
(ft.) Terminations and

prognosis of - - — 1255
d Associations or complica-
tions of metritis - - UndL
e. Treatment of inflamma-
tion of the uterus and
appendages - - — 1257

(a.) Of inflammation of
the cervix and its
consequences - ibid,

(5.) Treatment of hyper-
trophj and indura-
tion of cervix -—1261
(c.) Of acute inflamma-
tion of the internal
surface and body of

the tttems 1262

(dL) IVeatment of chronic
metritis and en-
larged uterus 1268

(e.) Of inflammation and
abscess of the ute*
rine appendages - — 1264
/. Inflammation of the nterus
and appendix of a spe-
dile nature - - • ibid.
(a.) Gonorrhoeal inflam-
mation of these
parts - - - ibid,
(5.) ^»hilitic ulceration

<^^e cervix uteri — 1265
(e.) IVeatment of spedflc
inflammations of
these parts - - Hid
Bibliog. and reftrences — 1288
Spec. 8d. Inflammatfon of the uterus
and appendages in the
puerperal states — Puer-
peral metritis and ova-
ritis - - .

A. Symptoms of puerperal

metritis — Acute and
sub-acute ...
Course and terminations of —
Appearances on dissection

B, Symptoms of Inflamma-

tion of the oraria and
Fallopian tubes - - ibid

Course and terminations of Ufid

Diagnosis of pueiperal in-
flammation of the uterus
and appendaees - - — 580

Treatment or puerperal
metritis and ovaritis - — 588
GenuM 7th, InftammaHon of the Peri"
toneum, ajfeeting more
(rr leu wme portion
of iU expanrion^- Par-
&d or General Peri-
tonitie.
Spec Ist. Non-puerperal peritonitis
—Peritonitis mdepend-
entiy of the puerperal
states — Synonjrmes and

defhitionaf 66

A. Symptoms of acute sthenic

peritonitis* - - - — 67

o. Partial states of acute

sthenic peritonitis - ibid

fr. Peritonitis omentalis —

Omental peritonitis - — 68

- — 614

ibid.

515

ibid

B, Acute general peritonitis,
srmptoms ana course of
CAstnenic general perito-
nitis— Diflftisive perito-
nitis . - . •
Forms and states of, de-
scribed • . .
Conse<{uences and termi-
nations of acute general
peritonitis • . .
J), Chronic peritonitis, lite-
rary history of -
a. Pnmaiy cnronic perito-
nitis, symptoms of -
5. Consecutive chronic pe-
ritonitis . - .
S, Acute, snb-acute,'and chro-
nic peritonitis in chil-
dren - - - .
Chronic tubercular peri-
tonitis in children
J^. Complications of perito-
nitis, reviewed and com-
mented on - - -
G. Appearances on dissec-
tion — (a.) after acute
sthenic peritonitis
(6.) After acute asthenic

peritonitis
(e.) The lesions observed
after chronic peri-
tonitis ...
Diagnosis between peri-
tonitis and visceral dis-

ilL G9

— 70
ibid

— 71

— 72

— 78

— 74

^- 75

— 76

— 78

— 80

81

Prognosis of the several
states of peritonitis

Causes, predisposing and
exciting - . -

Treatment — (a.) of acute
sthenic peritonitis

— (5.) of acute asthenic
peritonitis - - -

— — (tf.) of chronic perito-
nitis . - - -

— (d.) of the complica-
tions of peritonitis

•^— (e.) of peritonitis in
enildren - - -

*— (/) of couTalescence
from peritonitis -

Bibliogr. and references -
Spec 2d. Peritonitis in the puerperal
states — Puerperal pe-
ritonitis . . .

Symptoms, course, and
terminations of -

Diagnosis and prognosis
of - - -

Treatment of - - -

Geniu 8<A. iii/faiMiiiatiofi of ihe Mt-

tenteryoMdofiiM Glamde.

Difficulties connected with
the diagnosis of dJseaaea
of these parts
Spec 1st. Inflamnution of the me-
sentery — mesenteritis
— IMinitiomf §v, -

Great mfficulty attending
the diagnosis of -

Symptoms and history of
Its several states -

Consequences and treat-
ment of - - -
Spec 2d. Inflammation of the me-
aenteric glands -

Difficulty of Its diagnosis

Recognised chiefly by its

- 84

- 85

- 86
ibid

- 89
ibid,

- 91
ibid

- 92

- 96

- 513
ibid

680-1

- 583

-11. 853
ilnti,

~ 854

ibid,

ibid,
ibid.

IxW

CONTENtS— 8»»ciAL Pathology and Thbrapkutics.

Predispoaing and exciting

- i. 267

Treatment of the several
states and stages of acute
bronchitis - - - UntL

Treatment of their com-
plications - - - — 260

Treatment of sub-acute
and chronic bronchitis — 262

Of inhalations, &c, for - — 264

Treatment of the compli-
cations of chronic bron-
chitis - - - - — 265

The regimenal treatment
of bronchitis - • — 266

Bibliogr. and references 268

Spec. 5th. Inflammation of the larynx

' and trachea — Laryn-
gitis — Trachitis — La-
rjmgo-tracheitis — Sy-
nonymes and definUion ii. 684

(Inflammation may be
seated chiefly in the la-
rynx or in the trachea,
but most frequently it
extends from Uie one
to the other, and not
unfrequently from the
pharynx to the larjmx ;
and sometimes also to
the trachea and larger
bronchi, especially in
angina memoranacea.^

A. Symptoms of catarrhal la-

ryngitis ... ibid.

B. Acute laryngitis, forms

and stages of - - Und,

C. Consecutive and compli«

cated acute laryngitis - — 685

D. Asthenic acute laryngitis — 686
K. Consecutive and compli

cated asthenic - - — 687
F, Chronic laryngitis, simple,
consecutive, and compli-
cated - - -. - — 688

Syphilitic chronic lar^-n-
gitis - - - ■ 689

Appearances after death
fVom sthenic, asthenic,
and chronic lar^-ngitis

— 68»-90

Diagnosis of acute, com-
plicated (laryngo-tra-
cheitis), and chronic
laryngitis - - - — 691

Prognosis of the several
forms, &c. • - - — 692

Causes of the forms, states,
and complications - ibid.

Treatment of acute sthenic
lamigitis - - - — 698

Of the complicated states
of the disease - - — 694

Treatment of acute asthe-
nic laryngitis - - — 695

Of chronic laryngitis - t&£i.

Local and constitutional
means advised for la-
ryngitis - - - — 697

Bibliography and refer-
ences - ... — 700
Genus 10^. Inflammation of tfte Mt-
aiastinum — Synonymet
— Definiticn.
Symptoms, causes, complica-
tions - - - - - — 825
Terminations in abscess, &c. • — 826

Treatment of inflammation and

abscess of the mediastinum ii. 826
BibUographv and references - ibid,
Oenut llth. Jt\flammaii(mi of the Heart
and Pericarmttm — 2>e-
^finiiion.
Division of, and remarks

on, this subject - - — 179
Spec 1st. Inflammation of the endo-
cardium — Endocarditis
— Synon3rmes and de-
fytidon - - . — 180

Instoiy ot, and appear-
ances, after death - ibid.

Symptoms and diagnosis
of the several stages - — 182

Syinptoms of lesions of the
different valves - - — 188
Spec. 2d. Inflammation of the peri-
cardium - - - — 184

Structural lesions in the
acute stage - - - — 185

Symptoms and diagnosis
of pericarditis and of its
consequences - - — 187*
Spec. Sd. Inflammation of the struc-
ture of the heart — True
carditis — Synonymes
Kaddefimtian . _ igo

Structural lesions in true
carditis - - . -. 191

The svmptoms and diag-
nosis of - - - — 198

The predisposing and ex-
citing causes of inflam-
mation of the heart and
pericardium - - — 195

Remarks on the patho-
logical states of - - ibid.

The diagnosis of inflam-
mations of the heart and
pericardium, and of their
complications 196

The prognosis, duration,
and terminations of in-
flammations of the heart,
&c. - - 197

The prognosis of the above
species ... gi^

The treatment of inflam-
mations of the heart and
pericardium - - — 198

Of the more acute states of ibid.

Of the sub-acate and chro-
nic states of - - — 199

Treatment of other states,
complications, and re-
lapses ... ibid.

Causes, s3'mptoms, and
treatment of carditis
and pericarditis in chil-
dren - - - - — 200

Bibliogr. and references • — 201
Gentif 12th, Jnftammation of the C^trcu-
leUiny Systeme.
Spec 1st Inflammation of arteries —
Artereitis — Synonymes
and defnition - - i. 112

Pathology, causes, and
lesions of artereitis - — 113

Symptoms of acute arte-
reitis - - 114

Of chronic artereitis, and
of the complications - — 115

Diagnosis and prognosis
of - - - - — 110

The treatment of acute

Ixvi

CONTENTS — Special Pathology and Thbrapkutics.

1.

Of pundeDt ophthal-
mia in infants -
CauMB, symptoms and

progress of -
Terminations and prog-
nosis •
Treatment and means

of care -
Purulent ophthalmia

in adults
Causes and oontagion
of - - -
Symptoms, diagnosis,
prognosis, and con-
sequences of -
Local and general
treatment of the
states and grades
of
(e.) Gonorrhooal ophthal-
mia, progress and
consequences of
Diagnosis, pn^piosis,

and causes of
Treatment of -
(d.) Pustular and scro-
fulous ophthalmia,
causes, symptoms,
and course -
Diagnosis, conse-
quences, &c. -
Treatment, regimen,
&c. - - -
(«.) Exanthematous oph-
thalmia, forms, ap-
pearances, &c., of -
Treatment of -
S. Inflammation of the proper
coats of the eye — 2>c-
JinUum - - -
(a.) Symptoms, course,
and effects of
Diagnosis and prog-
nosis of - -
Treatment of the acute
states, general and
local
Of the suh-acute and
chronic states
(ft.) Rheumatic, catarrho-
rheumatic, and ar-
thritic ophthalmia
— Symptoms and
course of - -
Treatment of -
(e.) Inflammation, acute,
sub-acute chronic,
and scrofulous, of
the cornea — Cor-
neitis - - -
Treatment of these
states of corneitis -
C. Inflammation of the in-
ternal parts of the eye -
(a.) Inflammation of the
anterior chamber -
Treatment, &c., of -
(ft.) Inflammation of the
iris — Iritis -
Causes, symptoms^ and

grades of iritis
Diagnosis, prognosis,
and consequences -
Treatment of -
The pathology, con-
nections, and treat-
ment of sympa-
thetic iritis 874

D.

852

UAd,

853

854

855

- — 867

a

e

^s

. — 858

i

- — 861

ibid,
862

868
864
ibid.

865
866

itid,

ibid.

867

ibid,
868

E,

Spec. 2d.
a.

b,
e.

\, 875

ibid
ibid

-—876

Und.

877

ibid

878

ibid

— 737

— 738

— 739

ibid

— 740

— 741

ibid

— 742
ibid

Genua 15M.
Spec. UL

Ufid
869

Spec 2d.

ibid.

870

ibid

ibid.
871

ibid,

872

873
ibid

Spec. 8d.

Genu$ IM.

Spec Ist

Inflammations of the in-
ternal coats of the eye

— Internal ophthalmia
(a.) Inflsmmation of the

retina, acute and
chronic — Symp-
toms and course <»
Treatment of -
(6.) Inflammation of the
choroid coat, its
symptoms andtreat-
ment - - -
(c.) Arthritic, and other
forms of inflamma-
tion - - -
Treatment of - —876-7
Inflammation of the whole

eye — JDefinition -

Symptoms, diagnosis,

course, and consequences

of . . - -

Treatment of its stages

and forms •
Bibliography and refer-
ences - - - -
Inflammation of the ear

— Otitis — IkfvidtioH -
Symptoms of external and

internal acute otitis
Consequences and lesions
Symptoms of chronic otitis

— otorrhcea

Consequences and lesions

Prognosis and causes

Treatment of acute ex-
ternal and internal otitis

Treatment of chronic otitis
and otorrhcea

Bibliogr. and referances -

InficKMmixtioH ofMutadar
and Fibrous Sirueturet,

Inflammation of muscular
structure — Myositis —
Definition - • -

Causes, symptoms^ and
consequences

Suppuration, gangrene,
Induration • - -

Treatment of myositis

Bibliogr. and references -

Inflammation and suppu-
ration of the psos mus-
cles — Psoitis ^D^/ini'
tion$ - - - iii. 467-5

Causes, symptoms^ and
diagnosis or

Diagnosis of psose abscess
and prognosis

Treatment of psoitis and
of psoa abscess -

Bibliogr. and references -

Inflammation of fibrous
tissues

Causes, states, and conse-
quence - - -

Alterations produced by

Inflammation of fibrotts
tissues of joints -

Bibliogr. and references - — 1044
[See also Gout^ Shew
fnatiunf ^. J

Injiammation of the Pe^
rkateum and Sonet,

Inflammation of the peri-
osteum — Periostitis —
Definition -

Symptoms of acute and
sub-acute perioetitis -

ii. 865
ibid,

— 866
ibid.

— 868

ibid,

4C8

— 469

— 470

- i. 1041

ibid.
— 1042

1043

- uu

63
ibid.

Izviii

CONTENTS — Special Pathology and Thkrapkutics.

Diagnosis and prognosu

of gout - - - iL ^40
Causes, predisposing and

exciting - - • — 41-5
The patnological condi-
tions of gout - - — 48
The states of the blood,
and of the depurating
functions - - - — 44
D, Treatment, the opinions

of the ancients as to the — 45
a. Treatment of the pa-
roxysm of acute gout - — 47
Treatment by renal and
other depurants of the

blood - - 49

Local treatment of the

parox3rBm - - — 60

Of diet and regimen, and

of convalescence - - — 61-2
The empirical treatment

of acute gout 68

h. Treatment of chronic goat — 64
The local treatment of - — 65
c. Treatment; of irrsgolar

gout - - - « i6tc£.
Of retrocedent gout - Und.
Of misplaced gout -> - — 67
Of mineral and thermal
* waters in gout - - — > 68
The prevention of gout - — 69
Bibbography and refer-
ences - - — 69 — 61
Spec. 2d. Rheimiatism— Synonymes

-^DefuikUm - - ilL 608
^.^Description — a, of acute
and sub 'acute rheuma-
tism - - - - _ 609
6. Of chronic rheumatism - — 611

Chronic of the joints 612

Of the seats of acute and
chronic rheumatism - — 614
c. GonorrliQBal rheumatism - — 617
Of the complications, ex-
tensions, or metastasis
of rheumatism - - — 618
Of the sUtes of the blood
and excretions in rheu-
matism • - - — 620
Diagnosis and prognosis — 622-S
Remote causes, predis-
posing and exciting — 628-4
B, The nature and pathology

of rheumatism - - — 624

a. Treatment of acute

and sub-acute rheu-
matism - - - — 627
Means advised by writers ibid.
Treatment advised by the

Author - 681

b. Treatment of the chronic

states of rheumatism - — 688
Review of remedies for,

with comments - - ibid.
Review of various means
recommended for the
several forms - - — 685
Of several external means — 636
Of mineral waters and
baths, and physical
training - -' . -. C38

c. Treatment of the compli-

cations of rheumatism - — 639
dL Of gonorrhoeal rheumatism — 641
Regimen, diet, and change

of air - • - - ibid,
Bibllogr. and references — 641-8

SuB-OiiUBB. — Imflammatoby Diseases

OF THE brrEOVXBMTB.

G€HU9l9t. DemuUiieM timpHcu —

Eczemata — J>^iMititm - iit 795

Spec. 1st. Erythema — Synonymes —
JMUution and varieties
of, described - • ii. 836
Causes and dia^osis of - — S38
Treatment of its varieties Hid,
Bibllogr. and references - ibid.
Spec 2d. Rose-rash — Roseola —
Synonymes and dtfitd'
tumot' - - -lit 652
Description of its varieties ibid.
Diagnosis and causes - — > 654
Treatment and Bibliogr. - ibid.
Spec 8d. Nettle-rash — Urticans ~

Synonymes and ile/iniium — 1287
DMcriptionofitsvsrieUes ibid,
Assodationsydiagnosis, and

prognosis - 1238

Causes, treatment, and
bibliography - - — 1289
Spec 4th. Lichen — Licfaenons-
rashes — Synonj^mes —
D^nitiam - - - iL 718
Description of its varieties ibid.
Diagnosis, treatment, and
bibliography - - — 761
Spec 6th. Prurigo — Synonymes —

D^nitum - - -iii. 463
Description of its varieties ibid.
Diagnosis^ prognosis, and

causes - 464

Treatment of its varieties
and bibliography - — 465
Spec 6th. Eczema — Synonymes and

d^nkioH ' - - L 747
Description of its states

and varieties - - ibid.
Diagnosis, prognosis, and>

causes of - - - — 748
Treatment of its varieties
and biblicMrrapb^, &c - ibid.
Spec 7th. Herpes — Herpetic erup-
tions — Synonymes —
DefinitioH . . - li. 230
Description of its varieties — 231
Causes and diagnosis of - — 282
Treatment and biblio-
graphy, &c - - - — 233
GenMM 2d. DemuUitet Squamotct,

Sponymes— l>e/Siuti(m - ilL 796
Spec 1st Pityriasis — Synonymes —

U^udtum • - - — 258
Description of its varieties ibid.
Diagnosis, prognosis,

causes, and complica-
tions - - - - — 261
Treatment, bibllogr., &c —262-3
Spec 2d. Psoriasis and lepriasis —
Synonymes and cfe/Ent-
tum ' - - - — 470
Causes, predisposing and
exciting ... ibid,

A, Description of the varieties
of psoriasis - » — 471

B, Description of the varieties
of lepriasis - • - — 474

C, Of sy^nilitic psoriasis and
lepriasis - - - — 475

Diagnosis and prognosis - ibid.
The pathology w scaly

emptions - • - — 477
Treatment and thera-
peutical intentions • ibid.

Ixx

CONTENTS — Spscial Pathology and Therapeutics.

Of convalescence, regi-
men, diet, &c - - L 946

Bibliogr. and references - ibicL
Spec. 2d. Bemittent, or exacer-
bating foyer — D^fim-
Hon .... ibid.

Predisposing and exciting
causes of - « . Hid,

A. Description of mild remit-

tent - - 947

B. Of inflammatory remittent ibid^

C. Of bilio-inflammatory re-

mittent - 948

2>. Of the ad3mamic, or ma-
lignant - - - ibid,

E, Complicated remittents - — 949
Terminations and ap-
pearances after death - — 950

The diagnosis of remit-
tents, and distinctions
between the yellow re-
mittent and hicmagas-
tric fever - - —950-1

Treatment of the several
varieties of remittent - — 952

Treatment of the compli-
cated states of - - — 954

Notices of means for vari-
ous states of the disease — 955

F. Of chronic, obscure, or re-

lapsing remittents - ibid,

Svmptoms and course of » 956

Treatment of, and regi-
men, and change of air

for - - 957

Spec 8d. Remittent fever of chil-
dren - - - - iJbid,

Description of the acute,
adynamic, and chronic
forms of - - - ibid.

Diagnosis, terminations,
and prognosis of 959

Treatment and regimen of
the several varieties of — 9G0

Bibliogr. and references to
remittent fevers • - — 961
Spec 4th. Hectic fever— Synonymes

and defimtUm - - ibid.

Description of the early
qrmptoms of - - — 962

Causes, pathological, &c tfttcf.

Prognosis, pathology,
post-mortem appear-
ances, and nature of - — 964

Treatment of the several
forms - - - - — 965

Diet, regimen, &c - - — 966

Bibliogr. and references - »5ui.
Genus 2d, Continued fetsen — Syno-

fiymes — Definition of 967

Remarks on the division
of continued fever - ibid.

Review of the prognostic

symptoms of 968

Sub'Oen, 1st. Non-infectious Con-
tinued fevers.
Spec Ist Ardent fevers — characters

of - - 972

A, Ephemeral fever— Symp-
toms and diaiposis of - ibid.

Treatment and biblio-

eraphy of - 972-3

JB, Inflammatory fever — Sy-
nonymes and definition

of - - 973

a. Mild inflammatory fever,
symptoms and history
o/" - - - - ibid.

974
975

Complicated states of - i.
h. Severe inflammatory fever —

Complications, termina-
tions, and diagnosis of 976

Prognosis, duration, and
post - mortem appear-
ances of - - - — 977

Causes, predisposing and
exciting . - . ibid.

Of the nature of inflam-
matory fever - - — 978
C, Treatment during the

stage of excitement - — 980

Treatment in the stage of
exhaustion or collapse - — 1017

Bibliogr. and references - — 983
Spec 2d. Bilio -gastric fever — Sy-

nonprmes and definition ibid,

Descnption of its usual
course - - - - — 984

Of its modifications and
complications - - ibid.

Duration, terminations,and
diagnosis - 985

Prognosis and causes of - — 986

The indications and means
of cure - - - it^

Bibliogr. and references - — 987
Spec 8d.Mucou8 or pituitous fever —

Synonymes— D^nttion — 988

Symptoms and diagnosis
of - - - - iWA

Duration, terminations, and

prognosis - - - ibid.

Appearances on dissection,
and causes of - - — 989

Treatment and intentions
ofcure - - - ibid,

Bibliogr. and references - — 990
Spec 4th. Influenza— Catarrhal fever
— Synonymes — Defini'
Hon - - - -

History of its epidemic
appearances

Sjrmptoms and complica-
tions of - - -

Progress, duration, se-
quelsB, &c, of - -

Diagnosis and appear-
ances in fatal cases

Remote causes and nature
of influenza

Treatment of simple and
complicated

Bibliography and refer-
ences - - - -
Sub- Gen, 2d. ConHnued Fevers which
are Infectious, when cir-
cumstance favodr In-
fection,
Spec 1st. Sweating fever — Syno-
nymes — DefiniHon

History of its occurrences
and epidemic preva-
lence - - - -

Symptoms of its mild,
severe, and complicated
or malignant forms

Alterations of structure,
diagnosis, prognosis, and
causes

Treatment of its several
forms - - - -

Bibliogr. and references -

Spec 2d. Common continued fever

— Synochoid fever —

Synochus — D^nUion - ibid,

A, Description of simple con-

u.

423
ibid,
425
426
429
UAd,
431
432

- 1. 990
ibid.

' 991

- — 992

ibid.
993

Ixxii

CONTENTS — Special Patuoiooy anu Thbrapbutics,

Spec. 1st Erysipelas —The rose —
Synonymes — De^nithn
— Infections in circum-
stances favoaring infec-
tion - - - - L 818

General description of * - Ond,

Particular description of
the forms and states of — 819

Division of the forms - — 820

Simple erysipelas - -> — 821

Complicated or}*sipelas,
states and grades of - ibid.

Lesions observed in fatal
cases - - 824

Diagnosis and prognosis - ibid.

Causes, predisposing and
exciting - - - — 825

Epidemic erysipelas, —
mostly adynamic and
infectious - 826

Erysipelas of infants - — 827

Treatment of simple or
mild erysipelas 828

Treatment of the several
associated and compli-
cated states of erysipelas — 829

Of the constitutional treat-
ment of - - - — 880

Of the local treatment of — 883
• Treatment of erysipelas

in infants - - > — 834

The regimen, diet, and
treatment of conva-
lescence - - - — 835

Bibliogr. and references — 835-6
Spec 2d Glanders — />^m£Mm - ii. 30

Description of simple acute
glanders in the human
subject - - - — 81

Appearances after death - ibid.

Description of acute finrcy
glanders - - - — 32

The chronic forms of
glanders ... ibid.
' Nature of the disease - ibid.

The prognosis of acute and
chronic glanders - - ibid.

Treatment and bibliogr. of — 33
Sub.' Gen. The Exanthemata which
ffeneralfy infect the hu-
man frame only once,
and dettroy the autetpti-
bUity of the organic
nervouM eyttem, to be
again affected by their
retpective causes - - i. 839

(It may be considered that
true or exanthematic
typhus should be com-
prised under this head,
on account both of the
eruption characterising
it, and of the infre-
quency of its occurrence
oftener than once in the
same person. It, how-
ever, iumishes a link in
the chain which con-
nects the several species
of fever— continued and
eruptive, mild and ma-
lignant, or pestilential
— ^with each other^
Spec. 1st Measles — Morbilli— bjrno-

nymes and definition iL 812

Description of the several
stages of the regular
form •■ - - - — 818

Modifications, complica-
tioDS, and irregularities
of measles - - - ii. 814

The terminations and se-
quelie of measles - • — 817

Appearances observed in
fatal cases * 819

Pathology, diagnosis, and
prognosis - - - — 820

The specific and predis-
posing causes, and ori-
gin of measles - - — 822

The treatment and indi-
cations - 823

— — of the modifications,
complications, and irre-
gulariUes - 824

Bibliogr. and references 824-5

Spec 2d. Scarlet fever— Scarlatina
— -Synonymes — Defini-
tixm - - - - iiL 665

Historical remarks - - Sbid.

A. Description of the stages

of regular scarlatina • — 666

B. Of the types and irregular

forms of - 667

a^ Of the appearances of the

eruption of • - - - 668
b. The forms of scarlatina
depending upon the
states of vital power, &c. — 669
(a.) Mild or simple scar-
let fever « - - ibid,
(6.) Infiammatory, or an-

ginous scarlatina - ibid.
(c.) Malignant scarlet

fever - - - — 670
(dL) Scarlatina without

the eruption - - — 671
(e.) Latent or suppressed

jscarlet fever - - — 672

C. Complications or promi-

nent affections of scarlet

fever - - - -

2>. Seoueln of scarlet fever

described - - -

State of the blood and

urine in scarlatina
Appearances in fatal cases
Diagnosis and prognosis
The specific and predis-
posing causes
Of susceptibility and im-
munity, and period of
incubation - - -
Pathological inferences -

E, lYcatment — Preservative

measures - 690

Curative treatment of

simple or mild scarlatina — 691
Of innammator}' or angi-

nous scarlatina - - — 692
Of malignant scarlet fever — 698
Of scarlet fever without

the eruption > 694

Of latent, suppressed, or

masked scarlatina - — 695
Treatment of the several
complications or pro-
minent afiections - — > 696

F. Treatment of the sequelsD

of scarlet fever - - — 697
Remarks on the remedies

recommended for 698

Regimen, diet, &c. - - — 702
Bibliography and refer-
ences - - - -.702-8
Spec 8d. Scarlatina rheumatica —

. 678

• 676

- 680

• 682
> 684

- — 685

687
689

Ixxiv

CONTENTS — Special Pathology axd Thbrapeutics.

Treatment daring con-
valesoence - - -iii. 186

Bibliogr. and references — 186-7
Spec 2d. HaBmagastric pestilence —

Synonymes and d^m^ion -~ 187

Introductoiy remarlu * - Und.

Description of hsmagas-
trie or continued ydiow
fever - - 188

Of the several forms of the
disease ... Und,

Of the stages of the ma-
lady - - - - — 142

Appearances afUr death 143

Diagnosis of the forms of — 144

Prognosis and mortality of — 147

Predisposing and deter-
mining causes - - — 150

Infectious nature of this
disease demonstrated 151

This pestilence is different
from remittent yellow
fever - - - • — 165

This malady attacks the
same person only once - — 167

Observations on Uie pro-
pagation, orinn, and
nature of this oisease 174

Questions proposed as to
the sonrces and nature
ofit - - - - tWA

Pathological inferences de-
ducibie from the above — 177

Treatment of the grades
and forms of hiemagas-
tric pestilence - • — 180

Treatment of the stages - — 182

Remarks on various me-
thods and means of cure •— 188

Of the use of spirits of tur-
pentine, camphor, cap-
sicum, &c. - - - — 185

External remedies and
treatment of conva-
lescence - 187

Bibliogr. and references — 187-8
Spec 3d. Septic or glandular pesti-
lence — Plague — Sy-
nonvmes — D^flmtiont 189

Introductory remarks - — 190

Description of its symp-
toms and grades - - — 192

Of its stages and states of
plague - - - — 194

Appearances after death - — 196

Diagnosis and prognosis - — 197

Causes of plague - - — 198

Is plague caused and pro-
pagated by infection ? 199

That it is thus propagated
appears demonstrated 200

Proofe of its infections
nature - 202

Opinions of contemporary
writers referred to - — 206

Of the origin of plague -— 212

Arguments of anti-infec-
tionlsts disprove - — 215

Circumstances favouring
and determining infec-
tion • - 219

Of insect lifs as a cause of
pestilence - - - — 222

Conclusions as to the
causes and propagation
of plague - • - — 223

The nature of plague 225

Treatment of plBgue • — 226

The local treatment of

The diet, regfmen, and
management of conva-
lescence

Bibliogr. and references •
Spec 4th, Dysentery * — Inflamma-
tory dysentery — Syno-
nymes — Definitions

Seat and forms of -

Description of acute sthe-
nic, or inflammatory
dysentery -

Hyperacute, or dysentery
of Europeans removed to
hot climates

Complications of inflam-
matory dysentery

Snb-acute and chronic dy-
sentery - - -

Complications of chronic
dysentery - - -

Terminations and prog-
nosis - - - -

Appearances in fatal cases

Diagnosis of ...

Pathological inferences -

Hepatic complications
considered . - -

Of Relapses, &c

Treatment of acute sthenic
dysentery - . -

Of Europeans in hot cli-
mates - - - -

Treatment of complicated

Of the sub-acute and
chronic ...

Treatment of certain con-
tingent states

Review of remedies ad-
vised by authors -

Diet, regimen, and pro-
phylactic means -

Bibliogr. and references —
Spec 5th. Asthenic dysentery — Epi-
demic dysentery — Ma-
lignant dysentery — In-
fectious— Definition

Causes, predisposing and
exciting

Forms and s^ptoms of

Dysentery m the dark
races - - - -

Epidemic dysentery - -

Types and course of the
disease

Intermittent, remittent, or
continued types, accord-
ing to the causes

Complications of asthenic
dysentery - . -

Complicated with scurvy

Prognosis of -

Diagnosis of asthenic and
its complications -

Appearances of fatal cases

Pathological conditions -

Treatment of the asthenic
forms - - - -

In the dark races -

Complicated with scurvy,
treatment of

Treatment of other com-
plicated states, and con-
tingent consequences

- iii. 229

— 230
-230-2

i. 693
ibid.

- — 695

— 697

— 705

— 707

— 708

— 709

— 710

— 712

— 718

— 716

— 717

ibid.

— 719

— 721

— 723

— 725

— 727

— 783
734-5

698

698-9

- 700

- 702
702-3

- — 704

ibid.

— 705

— 706

— 709

— 711
ibid.

— 714

— 719

— 721

- — 722

— 722-6

* Dysent«r7. i^ asthenic or adjnaioic form especially,
and In the dark races, or when epidemic, often at^fimfi
an Infectious and pestilential character.

Izzvi

CONTENTS — Special Pathology and Thirapbutics.

Tenninations and prog-
nosis - - . -

Appearances in fktal cases
c. Inflammation of the ute-
rine appendages -

Symptoms and termina-
tions of - - -
Spec. 2d. Congestive or synochoid
puerperal fever •

Symptoms with reference
to its origin or seat, or
prominent affection

Symptoms and coarse of
uterine phlebitis -

Consecutive affections upon
uterine phlebitis -
Spec dd. Malignant or putro-ady-
namic puerperal ferer -

Periods of its occurrence
and symptoms

Complications of -

Of symptoms marking the
forms and complications

The appearances of the
blood in malignant
puerperal fever -

Appearances after death

Kesults of post-mortem
researches by others

A. Pathological inquiries re-

specting the several

species of puerperal

fevers - - - -

Diagnosis of these species

Prognosis of these species

Pathological inferences -

B, Treatment of puerperal

fevers - - - -
a.' Of the inflammatory states
6. Of the congestive or syno-
choid forms
Means of cure advised
c. Treatment of malignant
or putro-adynamic puer-
peral fever - - -
Means employed by the
author - - -

Remarks on several means
of cure - - -
Prophylactic measures -
Bibliogr. and references -

Class IV. — • Organic Lesions not

ADMITTINO OF AURAMOKMKNT
UNDKR THE PRKCBDING ClASSKS,
ALTHOUOU CON8E<2UENCKS OF

THE Diseased Conditioms cha-
racterising THESE Classes. —
The Three former Cijisses
COMPRISE Primary Diseases,

THIS C1.ASS EMBRACES STRUC-
TURAL Changes.*

Order I. — Organic Lesions of the
Digestive Organs.

Structural Oumges of the AU'
maUary (ktnal.

1st Of the mouth and throat
The causes and symptoms

of lesions of the mouth
Treatment of them -
Organic lesions of the tongue
described -

iiiSU

— 616

ibid,
ibid,
ibid,

— 616

— 617

— 618
ibid.

— 619

— 620

— 621

— 628

— 624

- — 627

ibid.

— 629

— 631

— 682

— 633
ibid.

ibid.

— 684

— 686

— 637

— 688

— 641
—641-3

1.

2d.

ill 931
— 932

- —1082

* Th«>ie leijons «re enamernted fullir in ihat |mrt of
the ClMKifled ConteiiU « Inch refcrc to the deccription of
Morbid Structures ; therefore h brief reference to their
cuuset, their lymptumi, and to their treauneiit, can oulj
be admitted under thi« clnsi.

907

911

913
917

018

919
920

ibid.
921

922

924

-—925

691
692

ii.

Symptoms and diagnosis iiL 1082
Treatment and Bibliogr. — 1083-^
8d. Structural changes of the
tonsils and throat de-
scribed - 1060

Treatment and Bibliogr. - — 1068
4th. Structural changes of the

oesophagus described - it
S^'mptoms and diagnosis

of - - - - —
Treatment - - - —

Bibliogr. and references

6th. Organic i lesions of the
stomach, comprising the
cardia and pylorus, de- ^
scribe - - - ill.
Symptoms of ulceration,

&r. - -

Treatment of -

Symptoms of softening
and other lesions of its
coats - - - -

Treatment of -

Symptoms and causes of

malignant disease of

Treatment of - - - —
Other organic lesions,
their symptoms and
treatment -
6th. Structural changes of the

duodenum described - L

Treatment for -

7th. Several organic lesions of
the intestines — Causes
and symptoms of - - ii. 596
Treatment of - - — 696-8
(See, further, Art». Colic
and lusus ; Colon, Di-
oBsnvE Canal^ and
Dtssmtery.)
8th. Organic lesions of the rec-
tum and anus iii. 595-608
Description of each lesion,
and the causes and
symptoms of each — 596-608
Treatment of the several
alterations of structure ibid.
AUerationt of Structure of the
Btliary Afparatue.
1st Organic lesions of the liver IL 751

A. Lesions consequent upon

inflammation - - ibid,

B. Alterations not arising

from this cause - - — 754

Diagnosis of structural
changes of the liver - — 750

Treatment of organic le-
sions of liver - - — 758

Mineral waters, regimen,
diet, &c. — Bibliogr. — 759-60
2d. Alterations of the gall-
bladder and ducts

Description, treatment, and
bibliography
Sd. Lesions of the biliarv ap-
paratus attended 'by
jaundice — D^mtkm - — 296

Description of its states

and symptoms - - f6tdl

Remote causes and morbid
appearances - - •— 298

The pathological relations
and forms of jatmdice
individually described - — 800

Prognosis and proximate
causes of - 806

Treatment, remarks on the — 807

llie indications and means

6

- — 6-«

Ixxriii

CONTENTS — Special Pathology and Thkrapiutics.

BATORY A2n> ClBOTTLATIMO Or-
QAMB. -

(The lesions consequent npon inflam-
mation of these organs are de-
scribed as such in the sections of
the respective articles, in which
inflammations, their conseqnenees,
and their treatment are described.)

i. Strueiural Changes of tks JU-
aoiraUtry Funages and
Organ*,
1st. Lesions of the mnoous sur-
iacQ of the nostrils —
OzaaiA^Deftmtwnoi ii. 931
Ulceration of the nasal

mucous membrane - ibid.
Description and prognosis — 932
Treatment and biblio-
graphv • - - ibid,
2d. Lesions of the larynx and

trachea - 686

Treatment of - - - — 697
Foreign bodies in the - — 698
Diagnosis, prognosis, &c.,

of the - - - — 698-9
Treatment of - - . — 700
Of tumours external to
and compressing the la-
rynx or trachea - - ibid,
3d. Stmctural alterations of the

bronchi - - - i. 244
Alterations of the mucous

membrane of the - - ibid.
False membranes formed

on - - 246

Alterations of the other
structures of the air-
tubes - - - - ibid.
Alterations of the calibre

of the tubes - - - — 247
Dilatations of the bronchi — 266
Treatment, &c. - • ibid
Ulceration of the bronchi — 267
Treatment of - - - ibid.
4th. Organic lesions of the lungs ii. 781
Emphysema of the lungs UAd,

Symptoms and diagnosis - — 782
Progress and prognosis - — 783
^ Treatment of emphysema — 78d

(Edema of the lungs - t6idL
Symptoms and treatment Utid,
Hypertrophy and atrophy

of the lungs - • — 786
Abscesses and gangrene

of, symptoms of • - ibid.
Treatment of gangrene - ibid.
Tubercles and malignant

diseases - - - — 787
Melanosis of the - - ibid,
5th. Structural changes of the
pleura, not necessarily
arising from inflamma-
tion - - - - iii. 802
Description of - - - ibid.
Symptoms anfd signs of - — 304
Treatment of organic le-
sions of - - - — 306
il. Structural Changes of the Heart
and Pericardium — JDe-
JiniHon - - - ii. 220
1st Hypertrophy of the heart,

description - - • ibid.
The causes and nature of- — 203
Complications and conse-
quences of - " - — 205
Symptoms, signs, and
diagnaaia of" - - -. 207

— 210
ibid,

— 210

— 211

— 212

ibid,

213

214
ibid.

Treatment of - - - ii 208
2d. Dilatation of the chambers
and orifices of the heart

Description of - -

Remote and pathological
causes- - - -

Signs and symptoms of -

Progress and terminations

Treatment of dilatations
of the cavities and ori-
fices - - - -
8d. Atrophy of the heart, de-
scriptions of - -

Causes, signs, and symp-
toms of - - -

Treatment of - - .
4th. Contractions of the cavities
and orifices of the heart
described ... ibid.

Treatment of - - - ibid.
5th. Alterations of the consist-
ence and ccdonr of the
heart - - 215

The signs and symptoms
of - - - - tWi

Treatment of - - - — 216
6th. Serous and sanguineous in-
filtrations of the heart - ibid,
7th. Fatty degenerations and

obesity of the heart - ibid.

Description, and signs and
symptoms of - - — 217

Treatment of - - . ibkU
8th. Adventitious formations in
the heart and pericar-
dium described - - ibid,

Signs and symptoms of - — 218
9th. Polypous concretions in the
cavities of the heart
described - - - — 220

The signs and symptoms
of - - - - — 221

Prognosis and treatment
of - - - - — 222
10th. Ruptures of the heart - ibid.

Seat and history of - ibid^

Pathological causes and
descriptions of - - — 223

Symptoms and diagnosis
of « - - - ^ 224
11th. Alterations of the blood-
vessels of the heart de-
scribed - - •> — 225
12th. Ossific deposits, or other
changes in the arteries,
with softening, fatty de-
generation, or atrophy,
of the structure of the
heart — Angina Pectoris
— Synonymes — Deftni-
Hon - - - - L 62

Symptoms and causes of 68

Diagnosis, prognosis, &c. — 64

Opinions as to it^ proxi-
mate cause - - - — 65

Treatment during the at'
tack - - - - — 66

Treatment during the in-
tervals - - - — 67

Review of means recom-
mended - - - — 67-9

Bibliogr. and references - — 69
13th. Communications between the

sides of the heart - ii. 225

Signs and symptoms of - — 226

Blue disease— Cyanosis —

Definition - - - L 199
The pathology of - - t&id

CONTENTS — Special Pathology and Thbrapxutic&

Ixzix

- — 118

- — 119

80.

121
72

ibUL

' — 78

74

75
77
78

ilfid.

' iiL 1313

Symptoma, progreis, and

tenniiiAlioiu - - i 200
Ctnaes - - - - — 201
Treatment and bitliogr. - ibid.
14th. Diqftlacemcnti^ &G. of the

heart - - - - ii. 226
Bibliography and refer-
ences - - - —227-230
Hi StntetMnd AlUrationB of drcu-

Ut Morbid Btmctore of arteries — 116
Lesions of the coats of - — 117
Aneurisms described — 117-18
Narrowing and oblitera-
tion of - -
Other alterations de-
scribed
Treatment of morbid
Btroctures of - -
2d. Organic leaiona of the aorta
I>i]atation of the, and
aneurism of, described •
Lesions connected with

aneurism of*
Conse^oenoee and termi-
nations of -
The causes, signs, and

diagnosis of •
Treatment of - -

Rnptnre of the aorta
Constriction and oblitera-
tion of ...
Structural alterations of
Tsins • - -
Description and patholo-
gical relations of - — 1818-17
4th. Stractaral changes of lym.
phatics and lymphatic
glands ...
DMcription of changes in

the lymphatic system - iL
AlteiaticMis of lymphatic

glands described -
Loions produced by
BibliogT. and references -
iv. Ntm maHgtuwni GromtkM or ISmovn
mokdneH/tlmg on Morbid
Tabd.
UL firoochocele^SyBonymes

^D^idtion - - L 269

Cansea and morbid rela-
tions • • . ibid.
Diagnosis - - - — 270
IVeatment and bibliogr. — 270-1
Inflammatory and organic
enlargements of the pa-
rotid gland
Caoses and history of
IVeatment of . - -
Enlargement and indura-
tion of the prostate
gland . - -
Canses»&c. of - •
T^eatmentof • . -
4th. Yarioos morbid and fatty

growths described — 718-17
Treatment of - - — 726-9

Diet and regimen 729

Bibliography and refer-

•• • - • ibid.

ibid,

797

— 801

— 803
ibid.

2d.

Bd.

iii 61

— 62

ibid.

— 460

*- 461

ibid.

Obdib iy«— Oboavio LsnoKs, with
Hamokrhaoic or SBBotrs Effq-
nom.

Soa-osont I<— Oboamio LnBoi»cAV9-
aa HsKOBBaAOic ExuDAXiom

I, Qmseeutive or Structural ^Lenons
of the Digestive OrgauM, eome-
timee ccataing the Ifffumon of
Blood,

Arrangement of organic lesions
causing hemorrhages -
Ist. From changes in the mouth
and throat ...
Treatment of . - -
2d. Haemorrhage from the
oesophagus - . -
Treatment of - - -
8d. Organic lesions causing
hemorrhage from the
st(»nach ...
Appearances on dissection
Diagnosis and prognosis
Treatment of, and oibliogr.
4th. Lesions causing haemor-
rhage from the intestines
and melona
Appearances on dissection
Treatment, &c - -
6th. Structural changes pro-
ducing hasmorraoids -
Diagnosis of -
Treatment, constitutional
and local •
ii Structural AlteratioHM of the Uri-
nary and Sexwd O^ne often
oauabui Exudatione of Blood.
Ist. From the urinary organs^
Hsmaturia
The blood being retained

in the bladder
Diagnosis of -
Treatment ...
2d. Alterations of the ntema
and appendages causing
haemorrhages
Treatment of -

A. Poljrpi uteri producing

hsDmorrha^e
Treatment of « ~

B. HsBmorrhage caused by

tumours of the uterus -
Treatment of -
d HaBmorrhage from cancer,
&c - - - -
Treatment of - - .
iii. Organic Leeione of the Ctrcu"
kiting Organe aom^imes causing
Effumonqf Blood.
UL Obstructive disease of the
heart causing haenlor-
rhage ...

A, Producing hssmoptysis, or
pulmonary apoplezv —
B» Causing apoplexy and pa-
ralysis. See the patho-
logy and treatment of
these diseases
Belations and complica-
tions of • - -
Treatment of - - -
2d. Alterations of the heart
and pericardium, caus-
ing effusion of blood into
the latter - - -
Causes, symptoms, and
diagnods of - -
Bibbography and refer-
ences - - - -
Sd. Structural changes of ar-
teries canaing efiusion of
blood • • -
Aneurisms, ruptures o^
atheromatous, fatty, and

ii. 67

.- 78

— 79

— 914

— 916

— 92

— 96

— 96

— 98

— 100

— 102

— 103

— 128-6
— 127

- 129-33

- — 106

ibid,

— 106

ibid.

iii. 1266

— 1267

— 1273
1273-4

— 1276

— 1277

— 1280

— 1282

ii. 81
■ 83, 788

- 1.

94

ii. 82
— 87

222

— 224

— 229

- L 116

Ixzx

CONTENTS — Special Pathology and Ths&apbutic&

• ossific deposits in, ar-
teries - - - - I. 117
Treatment of - - - — 121
4tb. Iiesions of veins sometimes

causing hemorrhage - iiL 1316
Treatment, as in the above
states - - ibicL

iv. Orffame or Ootueeuihe Lesions of
the ReapircUory Organs ocea-
SMnatty faUowed hjf Effuuon
of Blood,

1st From and into the bronchi
and lungs— Pulmonary
Apoplexy - - - ii. 788
Terminations, &c. - - Und.
Treatment of - - - tWdL
2d. Hnmonrhage into the
pleural cavity — Hsema-
thorax • - - - iii 803
Symptoms of - - - — 804

Treatment of - 305

V. Organic AUeratums of]ike Brainy
Spinal Chord, and thin Mem-
branes, sometimes followed by
Effudon of Blood,
1st. See the forms of CerAral
Apoplexy and of Para'-
lysis, attended by effu-
sion of blood - i 84, 216 ;

iu. 12, 15
2d. Spinal Apoplexy — Symp-
toms of - - - iii 888
Treatment of - - - — 884
Bibliogaphy and refer-
ences - - - — 889

SUB-ORDEB II. — ObOAHIO LeSZOKS

GAusmo Sbbous OB Dbofsical
Effusions.

L General View of Dropskal Effw

tions - - - - i. 603

A, Pathology of dropsy - - ibid,

a, Histoncal sketch of

opinions of - . - Und,
5. The causes of dropsies - — 604

c. Appearances observed on

dissection - - - — 605

d. The chief pathological

states causing dropsy - — 607
(a.^ Acute or sthenic in-

nammatoipr dropsy * — 608
(5.^ Asthenic or passive

aropsy - - - iJi^d,
^c.) Consecutive or symp-
tomatic dropsy - - — 609

B, Principal lesions, causing

consecutive, chronic, or
passive dropsies - - iUd,
o. Dropsy from obstructive

lesions of the heart • HAd,

b. From disease of the veins

and lymphatics - - Qnd,

e. Connected with the lungs

and pleura - - - — 610

d Dropsy from organic dis-
ease of the liver - - — > 611

e. Dropsy from disease of the

kidneys - - - — 612

/. From msease of the kid-
neys and heart - - UmL

g. From disease of the ovaria

and uterus - • - ibid,

C, Of the state of the urine

in dropsies • . • ibid,

D. Treatment of dropdes - - ^ 618

a. Ofacntedrop^ - - Ond,

b. Of sub-acute - - • L 614
€. Of asthenic or passive - Und,

E, Treatment t>f consecutive

dropsies . - - ibid,

a. When consecutive of car-

diac disease - - — 615

b. When owing to disease of

the veins or absorbents ibid.

c. Connected with pulmonaiy

or pleuritic disease 616

if. When owing to disease of

the liver or spleen - Stid,
e. When caused by disease

of the kidneys - <- ibid,
f When caused by ovarian

or uterine disease - — - 617

F, Indications of treatment, and

means recommended for
ilropsies ... t5uiL

a. To remove the irritation

or vascular action caus-
ing dropsy — Means,
&c - - - - Und,
An -enumeration of the
various means advised — 618

b. To remove obstructions to

the circulation, and to
promote absorption - ^ 619
A.review, with comments,
of the numerous medi-
cines, purgatives, diu-
retics, and depurants, re-
commended - - - ibid.
Biblipg. and references — 626
11. Dropsy of the abdomen — Or-
ganic lesions producing — 627

A, Synonymes, definition^ and

causes- ... ibid.
Pre-existing diseases^ or
pathological states^ pro-
ducing ... UAd,
Forms and complications

of - - - - — 628
Appearances in fiital cases — 629
Diagnosis and prognosis - tUi.
Treatment of acute and

sub-acute states - - — 680
Of the asthenic or passive ibid.
Treatment of the consecu-
tive and complicated - -> 631
Of paracentesis abdominis — 632

B, Puerperal ascites, pathology

of - - - - — 633
Treatment of, aocording

to the puerperal states - ibii,
Bibliogr. and references - — 634
iiL Encysted dropsies — Synonjrmes

—Defini^on^ 652

Causes remote and proxi-

imate .... Hid,
Prognosis, treatment, and

seats of - 653

Var. A, Dropsy of the ovarium - .i— 654
Definition and pathologyof ibid.
Causes, symptoms, and

progress - - - — .655
Diagnosis and prognosis - — 656
Treatment, general and
local - - - - — 657
Var. B, Dropsy of the Fallopian

tubes . . . . jMdL
Var. C Encysted dropsy of the

uterus- - - - — 658
Var. i>. Encysted dropsy of the

peritoneum ... ibid.
Treatment of . - • ibid,
Var. E, £n<78ted dropsy of the

liver > - • • iind.

Ixxxii

CONTENTS — 8t»xciAL Pathology and Thsrai'KUTics.

Genui i, 8qfltmw0 of the Brain and
8pmai Chord.
1st Softening of the itructuro of

the brain • - - i. 241
STmptomsy direct and indi-
rect - - - -—241-2

• ••

m.

Treatment of -
Bibliogr. and references -
Sd. Softening and other leaions
of the epinal chord
DoubtAil diagnoeia of
Treatment of -
BibUography and refer-
ences
Gentif ii. ApopUctie and Parafytie
Mahdiet,
Ist. Apoplexy — Sjnonymes —
hefinitioni *
A. Description of the states
of - - - -
«L The premonitory signs of

b. The symptoms constitut-

ing the attack

c. Simple and primary apo-

plexy - . - -
Appearances on dissection

d. Gradoally increasing or

ingrarescent apoplexy —
Appearances after death -

e. Apoplexy complicated

with, or followed by,
paralysis - - - —
Morbid appearances, &c -

/. Apoplexy commencing
with, or following,

paralysis -

Morbid appearances, &c. -

S. The phenomena of apo-
plexy not depending
upon its separate forms —

C. The relations of the symp-

toms to certain ports of
the brain, &c - - —

D. Diagnosis and prognosis - —

E. The causes, predisposing

and exciting

The modus operandi of the
causes -

Consecutire and compli-
cated apoplexy -

F. The pathoiogi(»d states

constituting
Inftrences respecting

G. IVeatment of apoplexy >
a. Means intended to prevent

the attack . - .
6. Treatment of the attack -

c. Of depressed states of the

seiaure ...

d. Remedies admissible in the

sthenic or asthenic states
c. Treatment of the consecu-
tive and complicated
states . - .
/. Treatment subsequently to
the attack, or during
convalescence
Bibliogr. and references -
Apoplexy of new-born in-
fants described -
Treatment advised -
2d. Paralysis — Palsy— Syno-
nymes — D^nitum
A. Paralysis of sensation
a. Loss of the indivldoal
senses - . - -
(a.) Lossof sight^Amau-
rosis in the sequel

242
243

BS2
886
887

889

- i. 79

ibuL
Sfid,

- — 80

ibid,
ibid.

82
ibid.

84
ibid.

86
ibid.

87

88
89

. — 91

- — 98

ibid.

> 96
97
98

— 99

— 100

^ 102

— 103

- — 104

106
ibid,

107
ibid.

- UL

11

ibid,
ibid.

' i. 60

(e.) Defect or loss of feel-
ing— Anasthetia - lii.

B. Paralvns of motion -

a. The local or partial states

of palsy - - -

b. Hemiplegia, modes of oc-

currence, &c - - —
e. Paraplegia, description of —

C. General paral3Yis

a. Pathological relations of - -^^

b. Symptoms and complica-

tions -

D. Pttalysis in new-bom in-

fiuits and children

E. Shaking palsy described -

F. Paralysis from poisons -

a. From lead ...

b. From arsenic, mercury,

monkshood, &c -

G. General history of the

various disorders attend-
ing palsy
The associations or com-
plications of

12
ibid,

ibid.

15
16
19
20

- — 22

ibid.
24

25
ibid.

ibid.

26

a. With apoplexy
ipilepsy, i
tions of tne brain, &c -

b. With epilepsy, jnflamma-

c. With insanity, Ac -

d. With disease of the heart,

and other morbid states

Diagnosis of the lesions
causing palsy - - -

Consequences, terminations,
and prognosis
• Caoses, predisposing and ex-
citing - - - -

Of certain points in the
pathology of palsy •

Of reflectedactions, ttc

On the forms and modes of
sensibility

The mechanism and func-
tions of the spinal cord -

JP. Treatment of palsy

a. Of paralysis of sensation

b. Of palsy of motion, local

and hemiplegic -

e. Treatment of paraplegia -

d. Of paralysis or infants and

children . . .

c. Of shaking palsv -
/. Of palsy caused by poisons
g. Of the complications of

palsy - - - -
G. Appreciation and appropri-
ation of remeoies for
palsy . - - -

a. Of internal medicines

b. Of external means -

e. Of regimen and diet
Bibliogr. and references -

Sd. Amaurosis — > Synooymes —
Definition -

A. Seats of amaurosis -

B. Causes, predisposing and

exciting - - -

Efficient or pathological

causes- « . -

C. Symptoms, promss, &c -

D. Stages, grades, and

forms -

E. Diagnosis and prognosis -
i^. IVeatment — 0. Of func-
tional amaurosis

b. Of congestive amaurosis -

c. Of the inflammatory states

of the internal parts of
the eve ...

27
ibid.

28
29

do

. ol
h2
33

84

39

40

41

42

a»id,

43
41

45

46

ibid.

ibid.

- I.

47
ibid.
49
50
51

:>u

ibid.

ibid.

51
52

54

. 57

58
CO

ibid.

IXKX'lV

CONTENTS— Special Pathology and TirKaArKtrus.

a.

6.

PHiLts, may also be classed here.
See Class III. Order I.
Sub-Order II.— Structural Diseases
caused bt a cokstxtutional
Taikt or Diathesis
Genvs i. Not MaUgnanL

Ist Scroftila and tubercles —
Synonymes, and dtfini-
lion of- - - " iii. 730

A, The scrofulous diathesis,

or taint, described 731

B, The causes of the stru-

mous taint, and of ex-
ternal and internal tu-
berculosis - 732

a. Causes appertaining to the

parents - 783

b Caus^ acting during early

life - - 786

e. Aiding or determining

causes - - — 742

C, The pathology of scro-

fula and tubercles - — 743
ITie structure of tubercu-
lar and scroAilous mat-
ter - - - - ibid.
Structure of tubercles dis-
played by the micro-
scope - - - - — 747

c. The chemical composition
of - - 748

d. 'Hie pathogenesis of scro-
fula and tuberculosis - — 749

e. The identity of scrofula
and tubercles - - — 752

/. The relations of the scro-
fulous taint with other
diseases - - - — 763
g. The complications of scro-
fula and tubercles - -r 755
h. The comparatiyo mani-
festations of tuberculosis — 75G
1). The prevention of scrofula

and tuberculosis - - — 758
E, The medicinal treatment of — 759

a. Of the scrofulous taint,
devoid of local lesion - ibid,

b. Of the more developed
states of tuberculosis - — 760

r. The means advised for

scrofula and tuberculosis — 761

d. Change of air, mineral
waters, local means, re-

S'men, &c. - - - — 765
iogr. and references — 707-8
2d. Tubercular consumption —
Phthisis — Synonymes
and definitims - - -— 1088
Origin, &c of - - — 1089
A, Description of tubercular

phthisis - - - — 1090

a. Of the more usual form of — 1091
(a.) Of the signs and

symptoms of the first
stage - - - itid,

[b.) Of tlie second sUge • — 1093
[c) Of the third stage - — 1095

b. Signs and symptoms di-
agnostic of phthisis - ibid,

c. The forms or modifica-
tions of phthisis 1102

(a.) The ktent form of - ibid,
(6.) Primary acute, or

rapid phthisis 1103

c.) Consecutively acute — 1105
^^d,) Protracted phthisis — 1106
,e.) Phthisis in infants
and children - - ibid.

I

I

(/.) Phthisis in the dark
races - - - - iii.
d. The atatcs of the blood in
phthisis -

B. Complications of tubercu-

lar phthisis - - - —

a. With hasmoptysis - - —

b. With bronchial irritation

and inflammation

c. With disease of the lar}*nx

and trachea - - -

d. With partial inflamma-

tion of the lungs - - —
a. With inflammation of the

pleura - - -
/. With various alnlominal

lesions - - - —

C, The pathological anatomy
of pulmonary tul>erclc8 —

The eeat and distribution

a,

of tubercles in the lungs •

b. The lesions of the lungs

af^sociatedMrith tubercles

c. Softened or liquefied tu-

bercles

d. Tubercular cavities and

vomiciB described - ■

r. The absorption and heal-
ing processes of,describeil -

D. Tuberculosis of the bron-

chial glands - - ■

E. Duration and prognosis of

phthisis

F. The causes of tubercular

phthisis
Classification of the causes
of tubercular consump-
tion -

a. Causes appertaining to

the parents

b. Causes acting during in-

fancy and childhood

c. Cau£cs acting during and

subsequently to pubert}'

d. Contingent or concurring

and aiding influences,
&c.

e. Pathological causes of

phthisis
/. The modes of operation of

the causes -
(j. The treatment of\ tuber-

cular*consumption
{(. Historical sketch of the
treatment recommended
by authors
(a.) Means advised by

the ancients
(5.) By physicians in the
15tli, 16th, and 17th
centuries
(c.) By authors of the

18th century - - -
(rf.) Bywritersof the 19th
century
//. The prevention of tuber-
cular phthisis
/. The treatment when

phthisis is threatened - -
A". Treatment of the usual
form of phthisis -

a. Of the first stage of

b. Of the second stage of - -

c. Of the third stage of

L. Treatment of the latent
form of phthisis -

-V. Of the primary acute, or
rapid lunn of

1107

1108

1109
1110

ibid,

ibid.

nil

i'id.
1112
1113
1114
ibid,
1115
1116
1117
1118
1120
• 1121

1122

ibid,

1125

-1126

1127

-1133

1133

ibid,

ibid,
1136

1137

1139

1142

1145

1147

1148
1149
1153
1155

1156

1157

CONTENTS— Poisoss, tHWr Sprcial Efpjbcts and Trbatment.

Ixxxvi

I. The Modes nr which Poisoitnio tares

PLACE, S§ 2—10 - - - lii. 312
The 8everaiway$ in which poisons may

be exhibited or emph^ - —312—814

II. Of the Action of Poisons, § 11 - — 814
i. Of the local and primary action of

poiaons, §§ 12 — 15 ... aid,
iL Of the remote or consecutive action

of poisons, § 16 - - - - — 815

III. Of the Media or Chanrels by

wincH Poisons act, § 18 - - ibid,
L The nature of the local and primary

action of poisons, §§ 19 — 23 "- ibid,
ii The sympathetic operation of poisons

considered, § 24 - - - — 316

ill. The organic action of poisons, § 25 - ibid,
iv. Their chemical action noticed, § 27 - — 317

IV. The General or l'sual Effects of

Poisons, § 28 -
L Depressing or sedative effects, §§ 28 —
30

ii Exciting or stimulating effects.

§31
ill. Exnausting organic nervous force.

ibid,
ibid,
ibid.

— 318
ibid

•

ibid,
ibid.

— 319

and sensorv and motive functions,
§32 - '-
iv. Perverted or morbid actions of poi-
sons, § 33 -

V. The Special Operation of Poisons,

§34

L Depressing or refrigerating action,
§35

ii. Benumbing or destroving sensibilitv,
§36 - - -" ' - -

iiL Impairing the irritability and paraly-
sing voluntary actions, § 37 - - ibid,

iv. Diminishing vital cohesion, and pro-
ducing a septic action, § 39 - - ibid,

V. Exciting ganglial, spinal, and sen-
sory nerves, &c., §§ 41 — 44 - - ibid,

vl. Astringing and irritating the tissues,

J[ 45 — 320
ecting and perverting the irrita-
bility of contractile tissues, § 46 - — 321
viii. Acting on the secretions and excre-
tions, § 47 - - - - - ibid,
iz. Substances irritating, altering, &c.,

the parts, § 49 - - - - ibid,

VI. The Circumstances whictt modh-t

the Effects of Poisons, § 51 - — 322

L The states of the poisonous sub-
stances, &c, § 52

ii. Combinations, admixture, and chemi-
cal conditions, §§ 53—55 -

iii. The nature of the parts to which they
are applied, ^§ 55—57

iv. Habitual use, i(iio8yncrasy, and moral
and physical states of the recipient,
§§ 58--60 — 323

VII. Circumstances which should sug-

gest Suspicions of being Poi-
soned, § 61
i. The sudden occurrence of severe
symptoRis, especially after taking
any substance, &c, §S 61 — 64
ii. The state of the patient s spirits and
feelings, &c., § 65

VIII. Matters requiring Attrntiox

•when Suspicions are excited,

§ 66 — 324

IX. The Symptoms caused by Poisons,

§67 ibid,

L The characteristic symptoms, &c,

^es — 325

ibid,
ibid,
ibid.

ibid.

ibid,
ibid

ii. The duration of the s^m^toms, 1 70 - iii. 325
a. Acute or rapid poisoning, § / 1 - ibuL
h. Chronic or slow poisoning, § 72 - ibid.

X. The General Diagnosis of Poison-
ing, §§ 73—90 - - - — 326—380
t The general diagnosis of poisoning

during life, § 73—77 - 326

it The diagnosis furnished by post-
mortem examination, €§ 78—87 - — 327

d moral cir-

329

iii. By chemical analysis an
cumstances, §§ 88—90

XI. The Diagnosis of Poisoning during

Disease, §§ 91—97 - 330

L General review of, and remarks re-

8pecUng,§91 - - - - ifridL
ii Diseases and states of disease, in

which poisoning may result from

ignorance and heroic practice,

Jll 92—5 - - - - iWA

onions poisoning during disease,
and the puerperal states, § 93 - Und,

XII. The General Princtples of Treat-

ment for Poisoning, §§ 98 — 105 — 331
i. The prevention of the action of

poisons, §§ 99—102 - - - ibid,
ii. The counteraction of the operation of

the poison, § 103 - - - — 832
iii. Removal of the pro^essive effects of

poison, and opposing the tendency

to death, §10o - - - - ibid.

Xin. Classification of Poisons, § 106 - — 333
L Arrangements proposed by writers,

§106 ibid,

ii. Arrangement adopted by the Author ibid,

XIV. Of the Spf,cial Effects and

TREATMFJfT OF POISONB, § 108 - — 334

Class I. — Acrid and coRROsn's Poi-
sons, § 109 - - - - ibid,
i. Symptoms and Diagnosis of corro-
sive poisoning, § 109 - - ibid,
ii. Acids.—- ^. Acetic acid, concen-
trated, § 125 887

B. The mineral acids, the
hydrochloric, the ni-
tric and sulphuric
acids, § 132 - - — 338
a Oxalic acid, § 159 - — 842
iii. Alkalies and their carbonates, § 167 — 344

iv. Antimony, chloride of, § 175 845

V. Iodine and bromine, § 179 - - ibid,

vi. Lime, unslaked, § 189 - - - — 847

vii. Phosphorus, § 192 - - - ibid.

viii. Salts — Alkaline corrosive, § 196 - ibid.

A, Bichromate of potash, § 197 - UM.

B. Binoxalatc of potash, $198 848

ix. Salts — Metallic corrosive, ^199 - t6tdL

.<4. Of antimony, §200 - - ibid.

B. Bismuth, trisnitrate of, S 201 ibid,

C. Copper, preparations of, € 205 ibid.
V. Gold, chloride and iodide of,

§211 - - - -—849

E, Mercury, bi-chloride of, § 216 t5tdL

Nitrates, bicyanide, and
some other preparations
of, § 226 - 350

F, Silver, nitrate of, § 229 851

G, Tin, the chlorides of, § 231 - ibid.
H, Zinc, chloride and sulphate

of, § 232 - - 852

X. Vegetable acrids, § 234 - - ibid.

a. Anemone, the poisonous species

of, §235 - - - 'ibid.

b. Arum maculatum and A. dra-

cunculus, § 236 - - - ibid.

Ixxxviii

CONTENTS — Til K Phkvkntion of Djskasb.

i. Remarks on various septic poison!^,

§688 iii. 434

ii. The bites of various poisonous ser-
pents, § 690 - - - - — 435

iii. The stings of insects, &c, § 702 437

Bibliography and references — 488-9

HYGEIENE, OH THE PREVENTION OF

DISEASE.

i. Remarks respecting the prevention
of the diseases to wbicli tlic
several epochs of life are most
liable, in the ^rf. Age - - i. 38
Bibliography and references - — 49
ii. The causes of, and the means of
averting, the maladies resulting

from Akts and Employmknts 122

Bibliography and references 128

iii. Tlic influence of Climate in caus-
ing, in preventing, and in curing
disease - - - - - — 838

Bibliograpby and references 853

iv. Tlie means of preventing and of
counteracting the bad effects of

Cold — 358

Bibliography and references - — 869
v. Description of the causes of dis-
ease, and of their avoidance
and prophvlaxis — See Di5E.vse,
§§ 7—62 ' - - - - — 558 ,
vi. Of preventing the production of I

£ndp.3iic Causes of disease, and I

of counteracting their cfTects
Bibliography and references
vii. Causes of EriDRMics, and infer-
ences respecting them
Bibliography and references ^ -
viii. The prevention and counteraction
of the causes of Fevkr, §§117

—122

ix. The sources of Infection, their
modes of communication and
operation, their effects ; and the
means ^vliich protect from Ix-
1- ECi'ioN, and counteract its im-
pression and operation - ii. 345
Separation of the infected, disinfec-
tion, &c. - - - - - — 359
Precautions against infection - — 362
Treatment of the early symptoms

of infection - . - 363

Bibliograph}' and references — 364-6

X. PllOTECTION FROM PESTILENCES,

and from other dangerous dis-
eases ----- iii. 232
Sources of pestilential and other
diseases referred to, their effects
stated, and their removal in-
sisted on - - • ill 97, 234
A. The protection of the commu-
nity ----- ibid,
llic prevention of animal ex-
cretions and remains from
accumulating - - - — 234
The prevention of other do-
mestic causes by sanitao'
measures, &c. - - - — 235

— 762

— 764

— 767

— 781

— 920

Protection from foreign pesti-
lences and infections —
Quarantine - - - iii. 237
B, The arrest of pestilential dis-
eosesjwhen introduced or pre-
vailing - - - - — 240

a. When tney appear in a popu-

lous city or town - - ibid,

b. Measures advised when such

diseases arc introduced into

armies or garrisons - - — 341

c. When introduced into ships,

transports, and ships of war,

&c — 24.3

" C. Protection of individuals, fami-
lies, or classes from prevail-
ing pestilences or other infec-
tious maladies • - - — 214

a. Departure from the sphere of

infection, or strict seclusion,

Ac. ibuL

b. Restrictions imposed on those

departing from an infecte<i
locality, and on their clothes iliJ.
v. Protection by means which
enable the * constitution or
vital force to resist infection — 24 >

a. Various medicines, &c., ad-

vised with this object *" 2lu

b. Regimen and diet recom-

mended with this intention - UmL

Bibliography and references 247

xi. Of Vaccination as a protection

from small -pox - - ^ 1290

Of revaccination, and of the evi-
dence in its favour - - - — 1 293
Bibliograph}' and references - — 1 294
xii. Prevention of TiniHtcULAK Con-
sumption - - - -
a. The efficient prevention
h. llie conditional prevention of
xiiL The prevention of Scrofula and

TUBERCUI/>SIS - - -

xiv. The prevention of Scurvy -

a. B V vegetable?, fruits, aud 1 i mc -
juice - - - - -
h. By tar-wrtter and various fer-
mented liquors - - -
f. By spruce beer and vegetable
acids - - - - -

d. Bj fresh meat, sugar, &c.
XV. Ilygeienic TuKKArKUTics -

.^. The removal of all predispos-
ing, exciting, and accessary
causes . - - -

B. To excite and direct the mental

emotions to resist the causes
of disease - - - -

C. Ilygeienic agents and influences

enumerated - - -
(The preventive or hygeienic
treatment of the niost im-
portant diseases is generally
considered when treating of
these diseases; and the
avoidance and counteracting
of the causes constitutes
prophylactic or hygeienic
indications for all diseases.)

114J
1146
ibid,

7.'»8
77vS

ibiJ.

78n

ibid.

781

lOStl

ibid,

1049

io:.i»

/

2 ABDOMEN — l^vtsTioATiojf op, in Disease.

difTerence in its nze. Thus, il is somewhat chanced
in severe diseases of the respiratory pai»!«age8, when
the entrance of air into the lungs i» obstructed j the
epigastrium and hypochondria being then pressed
inwards and upwards : whilst in some morbid
states of the liver and gall-bladder, of the spleen,
and of the ovaria, an unusual prominence in
their respective regions \^ frc(|uently observed.
But the most remarkable changes in the form of
the abdomen is met with wlien the iize of the ca-
vity is also altered. It is scarcely ncce^ary to
allude to examples ; but, in nil those diiHMi.^os at-
tended witti enlargement or diii)inuti<m of the bulk
of this important part of the body, either in one of
its regions, in severul of them, or in all, ins{)cction
fihould always l>e {KTformed : it gives greater pre-
cision to manual examination ; enables us to com*

traction of the muscular parietcs. In entering
upon the examination, care should be taken not to
excite the ulaim of the patient. The hand ought
to be applied at first in the gentlest manner pos-
sible. l!y ob;x^rving this, three very important
objects will be best obtained ; namely, a know-
ledge of the form, of the temperature, and of the
sen>iliiiity of the surface of the abdomen.

i). As much more information tlian this is
required from manual examination, the patient
iihould be directed to place himself in a favour-
able position for a more general and complete •
investigation, lie should l>e placed on his backt
with the liead and shoulders slightly and com-
fortably elevated, and the thighs drawn nearly to
a right angle with the trunk. If the bladder be
full, it should be emptied. When proceeding to

pare the bulk of u nrgiou with the corresponding examine, the patient should be told to relax all
region on the other side, and with others in its "
and impresses uiion the memory the

vicmity ; and mipresses ujion the memorj'
changes whicii the part mny experience during
the progress of di^H^aso. It shuuM, therefore,
never be neglected in all tlie forms of nlxlominal
dropsy ; in peritonitis, chronic or acute ; in in-
flammation of tiie stomach, liver, spleen, and

the mwfclcs, particularly the abdominal musclei.
Commencing, therefore, with the utmost centle-
nes!>, and passing the hand slightly over the ab-
domen, we should slowly increase the precsure,
with the view of ascertaming the followmg con-
! ditions : — 1st, Its temperature ; 2d, Its form and
j eize; 3d, Its sensibility: 4th, Its degree of ten-
bowels; in the diflferent kinds of colic, in fevers, ' sion and Hrmnoss; 5th, The existence of enlarge-
in uterine and ovarian diseases; in affections of | ment», tumours, 6lc.; ()th, The presence of effuiied
the kidneys and urinary organs ; in all disorders | fluids ; 7ih, The probable existence of accnmu-
accompanied witli obstruction to the excretions ; I lated secretion^) and fscal matters ; 8th, Hernial
and, in short, in all chronic maladies. It ought ' protrusions and displacements. On each of these
never to be overlooked in the diseases of infancy I proceed to offer a few reniarks.
and childhood, of whatever nature they may be. 10. 1st, The temperature of the abdomen for-

7. Besides, however, attending in those diseases I nishes most important indications as to the nature
to the form and size of the abdomen merely, tlie of disease. It is gcncndly always higher than

mtttions which it presents ought not to be neglect-
ed. When rightly interpreted, they often furnish
important diagnostic and therapeutic hints. But
they require to be viewed in connection with the
motions of the thorax, and state of the heart's ac-

natural in diseases of increased action ; and is also
ofti>n higher when the patient is actually com*
plaining of cold, particularly at the commence-
ment of fevers. In many fevers and inflammaliou
of the abdominal viscera, particularly those of «

tion. In diaphragniitis, pel itonitis, gastritis, enter- dangerous or malignant character, the increased
itis, and certain states of hepatitis, the motions of , tempeniture i« accompanied with a peculiar acrid
the abdomen are slight or obscure, whilst the ac- ' pungency to the sen.'^ation of the examiner; a
tions of the thorax are incretised. On the other I phenomenon which indicates the utmost risk of
hand, in several severe diseases of the respiratory j rapidly supervening disorganisation. Diminith^
organs, particularly in croup, laryngitis, bronchi- , temiterattire of the abdomen Ls met with in the
tis, several varieties of asthma, pleuritis, pncu- I (>cnod of depression, or cold stage at the com-
monia, &c., the parietcs of the chest are nearly ; mencement of fevers, but very seldom at their
motionless; whilst the movements of the abdomen, I termination, even in death, unless in the most
especially at the epigastrium, in croup and asthma, ' malignant or liquescent forms. It is also met
are remarkably increased, or lal>orious. The I with after injuries of the abdomen, particularly

motions of the abdomen, also, are often not li-
mited to tha«<e caused by respiration ; but in some
cases, particularly inorganic changes of the heart,
pericardium, aorta, btc, and even in certain nerv-
ous disorders implicating these oi^ans, comprise
those occasioned by the action of the heart, in-
creased by the state of the large abdo:iiinaI vessels,

blows on the epigastrium, in ana>mia, chlorosiSi
and other disorders of debility.

II. 2d, The J'onn and she of the abdomen are
frequently altered, as already noticed (§6,7.);
but, in order to ascertain the nature of tlie alter-
ation, various mciins of investigation are generally
required, particularly those which remain to be

and by the emaciation or other morbid conditions considered. When proceeding with the manual

of the patient. i examination of the abdomen, it is necessary very

8. II. Manual Examination of the ab<lo- | gently to increase the pressure, and, when acute

men is one of the most important means of dia- ' i)ain is not complained of, to make it in varioiu

tigation, the temperature of the hand of the prnc- not csca]>e detection, but be accunilely asceT"
titioner at the time of making it should be attendi-d taine<l und estimated ; and the examination should
to, in the grout majority of diseases ; both as a always be made with a careful observation of iti
moderate warmth of the Iiand is neces.sary to the cfTecis upon the expression of the countenance of
greatest delicacy and accui-ncy of touch, and as the patient. It will also often be requisite to per-
its application to the surface of the abdomen will ' form the manual examination, now with the points
j)ot in that stale occasion any di»tuibunce or cou- ' of several lingeis, now v\ith the whole of one, or

ABDOMEN— -Investigation op, in Disease.

rnn of both hands; and occasionally, at the
■aw time that a full inspiration is being made.
Bot it riiould always be performed with attention
to the aeoMtioas of the patient, particularly as
cipiutaul by the countenance, and to the feelings
sad ideaa it may eicite in our own minds. Even
the stale of action in which the abdominal muscles
sre often thrown by the examination ; the degree
if picaMue occasbning such action ; and the cir>
nuDslaDce of tension of those muscles preceding
the ezaminsition, or being excited by it j as well as
tlie eoatnmanoe of their contractions, and the pe-
riods and occasions of their relaxation, are all im-
poftaat matters in our estimate of the state of the
viseera underneath,— > more particularly in the
tarious states of ioflammation seated in the peri-
toaeom, in the alimentary canal, &c.

12. 3d, The $emtibiUty of the parietes of the
abdomen is most intimately associated with that
of the contained or^ns, both in health and dts-
eaK. The sensibility of the epigastric region
varies moat widely in different persons. It is fre-
ouendy, even in tolerable health, Very great in
deHcato and thin females. It is always so in
inflammation of the viscera, more particularly
when the aeroua membranes are affected; and
the more saperfidal the inflammation, the more
leader is the sarface. In order to obtain an ac-
cance idea of the state of the sensibility of the
shdooMB. pressure should be commenced in the
gcntleat manner, and with the fingers and palm
ii the open hand. When the patient cannot
endure the slightest touch, the aisease is then
commonly in the parietes, or in the serous mem-
brune ledected over them. When the cause exists
more deeply, the tenderness is less acute, and the
muscles are almost instinctively brought into
actuQ, even before pressure is made, in order to
protect the diseased viscera from it.

13. When sdper6cial tenderness is absent, the
eramination may be made with increased pres-
8«re, in order to ascertain the presence of tender-
nen, psin, or soreness, in any degree or at any
part, fiut caution in thus iocreasiog the pressure
B always necessary when the parenchyma of an
organ, paiticniarly of the liver or spleen, is enlarged
or otherwise affected ; for many such affections
may be very serious, and yet the sensibility of the
dbvased part not much increased. I have known
raptore of an enlarged and softened spleen occa-
noned by the rudeness of the examination ; and
writen have mentioned nmilar accidents to have
eecarred to the liver.

14. 4th, The Umnon ond firmmn of the abdo-
Bwn require attention, and due estimaiion of their
sctual amovnt ; and in eonnection with the other
diagnostic indications furnished by the examin-
uioo. Thus, when the tension is associated with
uifrrased temperature and sensibility, inflamma-
tion of one or more organs underneath, particularly
of the peritoneum, may be predicated. The tu-
mcfrclion, degree of sensibility, position of the
padcttt, &c. will farther prove the accuracy of
the diagnosis. Tension and firmness are always
present in the diffferent forms of peritonitis and
inflammations of the subjacent viscera, but not
cnifbrDly throughout all their stages. Even in
the worst or most malignant forms of peritonitis,
%* those met with in puerperal females, these
*ymptoms are often either almost altogether wnnt-
ini;. or they exist for a short time only. When

effusion of a serous or sero-purulent matter occurs
in peritonitis, or when suppuration has followed
inflammation of the enveloped viscera, tension as
well as firmness- disappear. They are generally,
however, both present, even when the sensibility
of the parietes is not much greater than natural,
in chronic peritonitis with the formation of false
membranes, or the agglutination of the opposing
surfaces of the viscera.

15. Sth, The pretence of tumourt or other mor-
bid growths, or the fact of their absence, has also
to be ascertained by a manual examination. This
information can be obtained only by this mode of
investigation, carefully conducted. If we detect
any degree of unusual tumefaction or hardness,
we should endeavour to ascertain its exact site ; its
form, size, connections; its consistence, degree of
sensibility ; and whether it is fixed or moveable,
soft and yielding, or hard ; pulsatile or not. The
situation of the tumour ; its size, form, and degree
of fixedness, will enable us to form an idea of the
part affected : whilst the absence or presence of
morbid sensibility in it, of fluctuation and puls-
ation, and the manner in which the nearest parts
of the abdominal parietes are affected by it, will
furnish important indications of its nature. When
tumours or unusual circumscribed indurations are
detected in any part of the abdomen, we should
bear in mind that their sources and kinds are nu-
merous: that they may be formed in the liver,
pancreas, spleen, stomach, pylorus, mesentery,
omentum, caecum, kidneys, uterine organs, &c. ;
that their nature may be extremely various ; and
that they may consist either of accumulations of
some fluid contained in a cyst, or infiltrated in the
substance of an organ, ur enclosed in its natural
cavity, the outlet of which has been obstructed ;
or of a deposition of some morbid structure, the
nature of which can only be known by a com-
parison of numerous symptoms, and the history
of the disease. Care should be also taken that
the accumulations of faecal matters occasionally
formed in the caecum, and in various parts of the
colon, or that an unusual anterior protuberance
or curvature of the inferior dorsal or lumbar ver-
tebre, be not mistaken, as have sometimes hap-
pened, for morbid growths; and that unusually
large collections of the natural secretions in their
cysts, as of tlie bile and urine, owing to temporary
obstruction to their discharge, be not treated as
morbid formations of a very difl^erent kind. I have
known eases in which distension of the gall-blad-
def, from great accumulation of the cystic bile,
was mistaken for abscess of the liver; and an
enormously distended urinary bladder was viewed
as dropfty.

16. 6lh, Tlie pretence of fluids effused into
the peritoneal sac is best ascertained by placing
the patient in the erect posture. If this cannot
be aone, and if he cannot even sit up, the
shoulders and limbs should be placed low ; and,
whether in the erect or recumbent posture, the
palm of one hand laid with a gentle pressure
upon one side of the abdomen, whilst we tap,
somewhat smartly, with the other hand, on the
opposite side. The impulse occasioned by the
stroke will occasion, if fluid be effused, a vibratory
undulation or shock which will be felt by the
other hand, and which constitutes the diupnostic
symptom in diseases of the abtloiuen attended
with effusion.

B 2

6

^DoGEs.) Or they may be divided into the pre-
disposiog, exciting, and cflicient causes*^ It vdll
be necessnrv to consider the causes with some
relation to these distinctions.

4. i. PredispMing cauut, — The disposition to
abortion is, in some females, so strong that the
slightest exciting cause will produce it ; in other
females the most serious injuries, and the most
violent mental and moral impressions, arc insuffi-
cient to occasion it. Some of the predisposing
causes arc referable to the mother, others to the
foetus and its appendages.

5. A, The predisposing causes referable to the
mother are numerous, and consist of' certain states
of the uterus, and particular conditions of the
habit and constitution, influencing either the
uterus or the embryo itself.

6. The conditions of the uterus favouring abor-
tion are great rigidity of it« fibres, and an un-
yielding state of its parictes, op[>o»ing too great
« resistance to the dilatation which the organ
must necessarily experience ; too great sensibility
and contractility of the uterus, in the former of
which states the other oi^rans of generation often
also participate ; too great a flow of blooil to the
uterus and ovaria, either proceeding constitution-
ally, or from causes which excite the nerves of
tliesc organs or parts adjoining; feebleness and
relaxation of the neck of the uterus — a condition
of the parts which M. Deso rmf.au x states he has
frequently asccrtninetl to exist in females subject
to'aborUon ; and atony of the uterus itself, eitlier
from original constitution or long-continued Icu-
corrhoea, or from a severe or protracted labour,
a cause which may be conjoined with the one pre-
ceding it. The foregoing causes are chiefly pro-
ductive of those abortions which occur at the same
period of pregnancy, and which have been called
periodic by some authors.

7. To the above may be added, as strictly re-
ferable, a condition of the organ called by Peu
immoderate heat of the uterus, which is attribut-
able to an excited condition of the nerves of the
organ, and a chronic inflnmmatonr or irritative
state of its ve^iscls ; also scirrhus, fibrous, fleshy,
stcatoniatous tumours of the uterus; polypus,
dropsy, the presence of several children, and the
too rapid or too great dilation of the organ thereby
occasioned ; tumours of, and fluid effusions into,
the substance of the ovaria ; and inflammation of
the ovaria and parts adjoining.

8. The causes chiefly referable to the consli-
tutum and huhit of the mother are certain states
of the atmosphere, to which only can be attributed
those fre(iuent abortions sometimes observed,
which have even assumed an epidemic form, acd
of which Hippocrates, FrsciiER,TESsiER, Desor-
MEAux, and others, have made mention; the san-
guine and irritable temperament ; plethoric habit ;
a constitutional disposition to hajmorrhage inde-
pendently of, or connected witli, the foregoing
states ; habitual menorrhagia ; irregular menstru-
ation ; great debility of body ; excessive sensibi-
lity, susceptibility, and mobility of the nervous
and mu^icular systems; hystencal states of the
nervous system ; the syphilitic and the mercurial
poisons ; a cachectic condition of the frame ; pain-
ful and chronic diseases; addiction to ma.sturb-
ation in early life ; curvatures of the spine ; mal-
formations of the spine and pelvis; hereditary

disposition} an acquired disj)osition arising from

ABOUTION — Causes op.

previous abortions caused by accidental circam*
stances; marriage or impregnation late in life;
deficient or improper nourishment ; too dose
cinctures of the biKly ; worms in the inteatinal
canal; conception at a too early period after
delivery, or after a previous abortion ; the atonic
state of plethora generated by luxurious indul-
gences, by sleeping in soft and too warm beds, by
indolence, a too full diet, &c.; local plethora,
or excitement of the uterine organs, occasioned
and kept up by sensual gratifications; and the
constitutional and local commotion occasioned
by infectious, exanthematous, pestilential, mod
febrile diseases.

10. B, The causes which depend upon tkefeeha
are referable either to the foetus itself or to its
appendages. They operate either by favonriog
the deatn of the foetus, which acts then ai a
foreign body in the uterus, exciting the organ to
expel it ; or by impeding its growth, so that it doM
not consume, or does not afford a ready circula*
tion to, the blood sent to the uterus ; thus occawMi-
ing an accumulation of this fluid in the uterine
vessels, and consequently congestion, terminating
in hiemorrhage and the expulsion of the erobiyo.
Owing to these circumstances, abortion is favoured
by debility, or imperfect development of tbe
foetus; by monstrous conformation, and dinceie
affecting it at some period of its early growth;
by the imperfect adhesion of the placenta to the
surface of the womb, or its implantation over Ike
neck of the organ ; by disease of the placenta,
as inflammation, apoplectic haemorrhage into ill
substance, calcareous deposits, fatty degeneia-
tion, scirrhous or cartilaginous induration; the
formation of serous cysts, of hydatids, eneuriiffl,
or varices of this organ ; by atrophy, hypertrophy,
or disproportionate size of the placenta ; by a too
short or a too long umbilical cord ; by twitting
of the chord around the neck or one of the limbe
of the foetus ; by diseased structure of the choni
itself, as extreme tensity or softness, the formation
of tumours or hydatids in it, by knots or adb^
sions preventing or impeding the circulaticNi
through it ; great tenderness of the* mcmbranee of
the ovum ; inflammation, thickening, opacity, and
irregularity of the membranes ; the presence of
too much or too little amniotic fluid, and oolleo*
tions of serum, or of a sanguineous fluid, bo*
tween the chorion and amnion ; adhesions formed
between the placenta and parts of the surface of
the foetus; and, in the more advanced periods
of gestation, constitutional diseases, particularly
eruptive and infectious diseases, or continued
fevers, extending from the mother to the embiyo*

10. ii. The occasional eicitiug causes are eX"

tremely numerous. It may be even said that there

is scarcely an occurrence in life which may net

be occasionally concerned in producing abortioik

(Desohmkai'x.) The chief causes of this claa

are acute diseases; such as fevers, scariatiaBf

; measles, small-pox, and inflammations, particM>

larly of tlie uterus, ovuria, pelvic peritoneiin,

colon, &c. ; the irritation of adjoining viscera;

I diarrhoea, dysentery, tenesmus, colic, conitipation,

I hsraorrhoids ; hysterical and epilecUc convnU

I sions ; syphilis ; violent pain ; disappointment and

j anxiety of mind ; anger, fright, excessive joy ;

' the impression of various odours; threatenea ee-

phyxia, particularly from the vapour of carbon ;

violent exertions and fatigue ; dancing ; nding oa

6

ABORTION — Causes of.

(Ddoks.) Or they may be divided into the pre-
disposing, exciting, and efficient causes. It will
be necessary to consider the causes with some
relation to these distinctions.

4. i. Prediipoiing causes. — The disposition to
abortion is, in some females, so strong that the
slightest exciting cause will produce it ; in other
females the most serious injuries, and the most
violent mental and moral impressions, are insuffi-
cient to occasion it. Some of the predisposing
causes are referable to the mother, others to the
foetus and its appendages.

5. A, The predisposing causes referabU to the
mother are numerous, and consist of certain states
of the uterus, and particular conditions of the
habit and constitution, influencing either the
uterus or the embryo itself.

6. The conditions of the uterus favouring abor-
tion are great rigidity of its fibres, and an un-
yielding state of its parietes, opposing too great
a resistance to the dilatation which the orean
must necessarily experience ; too great sensibility
and contractility ot the uterus, in the former of
which states the other organs of generation often
also participate ; too great a flow of blood to the
uterus and ovaria, either proceeding constitution-
ally, or from causes which excite the nerves of
these organs or parts adjoining; feebleness and
relaxation of the neck of the uterus—- a condition
of the parts which M. Desormeaux states he has
frequently ascertained to exist in females subject
to' abortion ; and atony of the utenii itself, either
from original constitution or long-continued leu-
corrhoea, or from a severe or protracted labour,
a cause which may be conjoinea with the one pre-
ceding it. The foregoing causes are chiefly pro-
ductive of those abortions which occur at the same
period of pregnancy, and which have been called
periodic by some authors.

7. To the above may be added, as strictly re-
ferable, a condition of the organ called by Peu
immoderate heat of the uterus, which is attribut-
able to an excited condition of the nerves of the
organ, and a chronic inflammatonr or irritative
state of its vessels ; also scirrhus, fibrous, fleshy,
steatomatous tumours of the uterus; polypus,
dropsy, the presence of several children, and the
too rapid or too great dilation of the orgfan thereby
occasioned ; tumours of, and fluid emisions into,
the substance of the ovaria ; and inflammation of
the ovaria and parts adjoining.

8. The causes chiefly referable to the consti-
tution and habit of the mother are certain states
of the atmosphere, to which only can be attributed
those frequent abortions sometimes observed,
which have even assumed an epidemic form, and
of which Hippocrates, Fischer, Tbssier, Desor-
meaux, and others, have made mention ; the san-
guine and irritable temperament ; plethoric habit ;
a constitutional disposition to hemorrhage inde-
pendently of, or connected with, the foregoing
states ; habitual menorrhagta ; irregular menstru-
ation ; great debility of body ; excessive sensibi-
lity, susceptibility, and mobility of the nervous
and mu^ular systems ; hysterical states of the
nervous system ; the syphilitic and the mercurial
poisons ; a cachectic condition of the frame ; pain-
ful and chronic diseases; addiction to masturb-
ation in early life ; curvatures of the spine ; mal-
formations of the spine and pelvb; hereditary
disposition; an acquired disposition arisiog from

previous abortions caused by accideBtal eircam*
stances; marriage or impreg[iiation late ia life;
deficient or improper nourishment ; too eloae
cinctures of the body; worms in the intestiiuil
canal; conception at a loo early period aflc*r
delivery, or alter a previous abortion ; the atonic
state of plethora generated by luxurioos indul*
gences, by sleeping in soft and too wann beds, b j
indolence, a too full diet, &c.; local plethora,
or excitement of the uterine organs, occaaioned
and kept up by sensual gratifications; and the
constitutional and local commotion oecaMooed
by infectious, exanthematons, pestilential, aikd
febrile diseases.

10. B, The causes lokieh diejfend,^pan tk§feetu$
are referable either to the foetus itself or to ita
appendac'es. They operate either by favonriDg
the death of the foetus, which acts then aa a
foreign body in the uterus, exciting the organ to
expel it ; or by impeding its growth, so that it does
not consume, or does not afford a ready circula*
tion to, the blood sent to the uterus ; thus occaaoD*
ing an accumulation of this fluid in the nterino
vessels, and consequently congestion, terminating
in hemorrhage and the expulaon of the embryo.
Owing to these circumstances, abortion is faroured
by debility, or imperfect development of the
foetus; by monstrous conformation, and disease
afifectine it at some period of its early growth ;
by the imperfect adhesion of the placenta to the
surface of the womb, or its implantation over the
neck of the organ ; by disease of the placenta,
as inflammation, apoplectic hsmorrfaage into its
substance, calcareous depottts, fatty degenera-
tion, scirrhous or cartilaginous induration; the
formation of serous eyats, of hydatids, anenrisia,
or varices of this organ ; by atrophy, hypertrophy,
or disproportionate size of the placenta ; by a too
short or a too long umbilical cord ; by twisting
of the chord around the neck or one m the limbs
of the foetus ; by diseased structure of the chonl
itself, as extreme tensity or softness, the formation
of tumours or hydatids in it, by knots or adhe-
sions preventing or impeding the eirenlation
through it; great tenderness of themembFanas of
the ovum ; inflammation, thickening, opacity, and
irregularity of the membranes; the presence of
too much or too fittle amniotie fluid, and collec-
tions of serum, or of a sanguineous flnid, be>
tween the chorion and amnion ; adhesions formed
between the placenta and parti of the suriiace of
the foetus; and, in the more advanced periods
of gestatbn, constitutional diseases, particularly
eruptive and infectious diseases, or continued
fevers, extending from the mother to the embryo.

10. ii. The occasional exciting causes are ex-
tremely numerous. It may be even said that there
is scarcely an occurrence in life which may not
be occasionally concerned in producing abortion.
(Desoriieavx.) The chief causes of this class
are acute diseases; such as fevera, scarlatina,
measles, small-pox, and inflammations, particn*
larly of the uterus, ovaria, pelvic peritonenm,
colon, &c. ; the irritation of adjoining viscera ;
diarrhoea, dysentery, tenesmus, colic, constipation,
hemorrhoids; hysterical and epilectic oonTuU
sions ; syphilis ; violent pain ; disappointment and
anxiety of mind; anger, fright, excessive joy;
the iinpression of various odours; threatened as-
phyxia, particularly from the vapour of carbon ;
violent exertions and fatigue ; dancings nding on

8

ABORTION— DiAONOSu of.

breasts, sometimes with a slight discharge of seram ;
a Bow of a saoious, then of a saDguineous, fluid,
and afterwards of blood, either in a fluid or gru-
moos state, from the vulva ; diminished motion of
the child, soon afterwards followed by perfect
cessation of motion ; lessened bulk, of the abdo-
men or of the hypogastrium ; uterine pains, which
become more and more frequent and severe ; pro-
gressive dilation of the uterine orifice, and pro-
minence of the membranes ; and, lastly, expulsion
of the amniotic fluid and foetus, followea, at an
indefinite time, by the placenta. Most frequently
the discharge of blooa does not cease until the
placenta is expelled. (Desormeaux.)

16. Abortion proceeding from the more ener-
getic exciting causes is sometimes preceded by

1>ains, and an unusual sense of weight in the
oins and at the lower part of the vagina; by
horripilations or rigors, by general uneasiness, and
cardialgia or nausea. From the first there is often
an appearance of blood, followed by the discharge
of a sanguineous serum, which soon passes into
serious hiemorrha|;e. In other cases the action
of the cause is instantly followed by a large
eflfusion of blood, which continues until after the
expulsion of the foetus and its appendages. Fre-
quent lancinating pains dart through the abdo-
men, chiefly in the direction of the umbilicus and
vulva : the uterus makes efforts at expulsion, and
the foetus is expelled. The more advanced the
term of pregnancy, the nearer do the symptoms
approach to those of delivery at the full time ;
and the nearer also do its consequences assimi-
late to those following upon a natural confine-
ment, as the lochial (Oschai^, after pains, milk-
fever, &c.

17. It is sometimes observed, even up to the
middle period of utero-gestatioo, that the foetus is
expelled enveloped in its membranes. But it
sometimes also occurs in the first months, that,
after the rupture of the membranes, the foetus and
placenta are retained, decomposed, and discharged
m the form of a brown foetid sanies. In other
cases the placenta is not expelled until several
weeks after the foetus, either m the state now de-
scribed, or in that of a putrid mass. It occa>
sionally is observed that the placenta continues
attached to the uterus, and is nourished, increas-
ing in size, and assuming the appearance of a
fleshy mass, in which are sometimes found simple
cysts, or cysts conuininr hydatids. This latter
occurrence takes place eiUier when the foetus had
been expelled, or had died at an early period of
its formation ; and, whilst it was yet small and
nearly gelatinous, being dissolved during the pro-
cess of decay in the amniotic fluid, or preserved
in it.

18. This change in the placenta forms what
has been called by Desormeaux and others the
moU of pneration ; the chief character of which
is that It possesses a cavity lined with a smooth
membrane, the remains of the amnion. Fre-
quently, at the more advanced periods at which
abortion takes place, the foetus is expelled alive ;
but the duration of its life subsequently depends
upon its age, and the circumstances attending its
abortion. It sometimes also is dead before it is
expelled, occasionally for a considerable time;
although it mav have reached the age of several
months. Its death does not necessarily lead,
althoogh it does generally, to its expulsion. In

some cases it is retained even up to the full perio 1
of utero-gestation, and is then thrown out in a
state of peculiar softening and maceration, but
without putrefaction : this only occurs when the
membranes have remained entire, and air been
excluded from the interior of the uterus. In other
instances it is converted into a substance resem*
bling adipocere, or the fatty substance generated
during the decomposition of animal matter. In
rarer cases the foetus and envelopes become hard*
ened, and even converted into a bonv or petrous
state, and retained till the natural death of th«
mother ; or, in the course of some months, or even
years, occasion inflammation of the uterus, and
suppuration. Sometimes, in cases of this latter
description, a portion of the uterus forms adhesions
to the parts oppo6ite4 the abscess which is formed
extending in (hat direction, and opening on the
surface of the abdomen, or in the interior of the
intestinal canal, or into the vasina, and giving
issue to purulent matter, mixed with a foetid sanies,
and portions of bones arising from the decompo-
sition of the textures of the embiyo. But these
latter consequences of abortion are rarely met
with unless in cases of rupture of the womb, or
extra-uterine impregnation.

19. In some cases of abortion the hamorrhage
from the uterus continues to a serious extent for
several days. This may be the case at Tarious
epochs of pregnancy ; and may result from the
detachment, partial or general, of the placenta,
and its retention along with the foetus in the ute*
fine cavity, owing to imperfect action of the uterus
to eject it. It may also proceed from the expul-
sion of the foetus, and the retention of the placenta,
either altogether or partly separated from the ute-
rus. In some cases the presence of the placenta,
or of a portion of the membranes in the womb, or
in the os uteri and upper j^art of the vagina, by
the irritation thereby occasioned, may have the
eflect of keeping up a constsnt and exhausting
hsmorrhase. In a case of abortion to which I
was recenUy called, the practitioner in attendance
stated the foetus to have come away two or three
days previously. Upon inquiring as to the dis-
charge of the appendages, I was led to recommend
an examination per vaginam; when they were
found lodged pairtly in the vagina and os uteri.
After tlieir removal the patient rapidly recovered.

20. III. Diagnosis. — The diagnosis of abortion
should be directed to three objects : 1st, its cause ;
2dly, to the possibility of preventing its occur-
rence; and, odly, to ascertaining the stage or
development of the process. The causes of abor-
tion are generally readily recognised, and admit
of an easy explanation. There are two, however,
to which Professor Desormeaux has particularly
directed attention ; namely, rigidity of the fibres
of the fundus and body of the uterus, and laxity
of its neck. The former of those is generally con-
nected with a similar state of the whole system,
and accompanied with scanty or painful men*
struation. In the first impregnations abortion
takes place at an early period ; but in suboe*
quent impregnations the period of gestation ap*
preaches more nearly the natural epoch, the
female at last bearing children to the full time.
When the abortion is referable chiefly to laxity
of the neck of the uterus, a result contrary to the
foregoing takes pUce ; the period of abortion ap*
preaching nearer, in successive coDceptions, to

10

ABORTION — TnEATMEKT or.

general plethora or excitement, rather cooling
Uian otherwise, and such as may promote, ratiier
than retard, the natural actions of the bowels.
Lemonade, imperial, barley-water, toast- water,
&c., are amongst the best in this class of coses.

29. Much will depend upon the perseverance
with which this plan may be followed, particu-
larly in cases of habitual or precedent abortions ;
where it ought to be rigorously enforced and con-
tinued for months, or, at least, for a long time
after the period of gestation at which tlie former
abortion occurred. If the threatened abortion be
accompained with pains, or by any degree of
discharge, an opiate should bo given at bed-time^
and, in every case where we nave conceived it
requisite to abstract blood, either generally or
locally, even as a preventive measure, the oper-
ation should be followed by a dose of opium.

30. Attention to the bowels is indis^Kinsable ;
but great discrimination is necessary in the choice of
laxatives when the l)owels are constipated. These
should be of tlie most cooling and gentle descrip-
tion. The soluble tartar, and cream of tartar m
the form of electuary, or with confection of senna,
particularly in cases of plethora, are very eligible.
Castor oil, with a very few drops of laudanum,
which will not retard its operation ; or small
doses of the bi-sulphate of potash, are also suitable
laxatives.

31. When, from our knowledge of the state of
the ovum, in previous abortion, we suspect a
repetition of it, we may endeavour to prevent it,
by usinrr those means which are most successful
in imparting energy to the constitution, and,
through it, to the generative functions ; so that the
process of foetation may proceed to a successful
issue. This is, perhaps, best accomplished by
change of air ; the use of the tonic mineral
waters, both internally and in the form of baths ;
by the mineral acitU given in the infusions of bit-
ter tonics, or with the solutions of the salts of iron :
as the tinctura ferri sesquichloridi ; the tinctura ferri
stherea (see Appendix) ; by the sulphate of zinc,
witli the compound infusion of rosct; ; by the ex-
hibition of the various balsamic and terebinthinnte
medicines, combined with the pulvis cinchona:,
or the pulvis rhri, and the carbonates of die
alkalies, or magnesia; and by attention to the
state of the bowels, to diet, and gentle but regular
exercise. The btiUams most surviccable in oises
of this description, as well as in all those cha-
racterised by weak and imperfect uterine function,
arc the baUams of Peru, of Canada, of Chio,
and of copaiba ; the tereliinthiiia vulgaris, and
T. Veni'tii. SiKDOi.o recommends thebulsnmum
vita; IIoHmanni (K. 317.), a medicine which
enjoys great reputation on the Continent in many
diseases of debility. The h>ins may be rubbed
night and morning, for some time, with the lini-
mentum saponisct camphoric comp. ( I'\30(j.), the
linimentum terebinthinv cnmpositum ( 1^*311.),
or the liniineiit. anod vnum ( F. 298. ). The appli-
cation of the cmplnstruin cumini, the empla-itrum
picis compositum, or the emplnstrnm rouorans
(F. 118.), to the loins will also prove of service.

32. When diarrhoea occurs (luring the ])eriod

of utero-gestation, and more e.^pocially if it be

accompanied with tenesmus, in dolic^ito female^.

or in those w)io h}\\ii exporioncL-d j)rtviou!* abor-

/i'ons, it should be fnuneili.itcly checked or Ics^ned.
la these cnaea clhtordcr is chiedy confined to the

colon and rectum, which should be sootbed by
small emollient and anodyne enemata, or by the
use of suppositories of lead plaster, and cpiiim.
Whilst, however, we thus prevent the irritatioii
from being extended from the large bowels to tha
uterus, we should take care to prevent the reten-
tion of hardened feces in the cells of the colon,
by which irritation will be perpetuated ; and to
remove them, when we suspect their presence, by
the use of gentle laxatives, and emollient ani
aperient injections, avoiding the use of saline
purgatives and cathartics.

33. In cases of threatened abortion in debili-
tated constitutions, the mineral acids, particularly
the sulphuric, either with or without small doses
of laudanum, or combined with small doses of
colchicum, or of digitalis, are extremely useful.
Where the circumstances of the case permit the
horizontal posture to be dispensed with, the pa-
tient may be allowed very gentle exercise, for
short iperiods, in the open air, avoiding all exer-
tion and local excitement. She should live ab-
stemiously, yet not too low. In many cases of
this description a glass or two of li^^ht wine may
be allowed daily, and in several a still more tonic
treatment is required. When this is the case, the
infusion of calumba, or of quassia, with the car-
bonate of soda, and tincture of hyoscyarous, lias
seemed to me very serviceable ; and the patient
has been. allowed the occasional use of the swing,
or a gentle ride in a carriage. The tepid and
cold liip-bath, particularly with sea«water, are
often of^ use in cases of this description, as well
as the treatment recommended in a preceding pa-
ragraph. The necessity of abstaining from sexual
intercourse, in all cases of threatened abortion,
is most evident.

34. In cases accompanied with incipient dis-
charge, either the cold hip-bath, or B|)onging the
hips, thighs, and lower pnrUt of the trunk with
cold water and vinegar ; or by squeezing a large
sponge filled with cold water, bo that its contents
may fall in a scattered stream from some height
upon the hips and pelvis ; will sometimes be ser-
viceable. Injections of cold or iced water, or cold
astringent solutions yter vaginam, or a lavement of
cold water, will sometimes arrest the accession of
hicmorrhage.

35. It will occasionally be observed that weak,
nervous, and delicate females are often irritable and
dispirited from a tedious confinement, during gesta-
tion, audevennhortowingtothis cause ; obviously,
in many cases, from the effect produced upon the
uterus, and upon the nutrition and health of the
emhiyo. This should be anti<>ipated, and pre-
vented by a timely relaxation of the plan, and by
allowing the patient ns much exercise, amusement,
tS:c., and by ndnpiing as much of the trcatmetit
recommended above {§ 33.), as may be consistent
with the accomplishment of or.r end. When, in
the^ cases, the nervous symptoms predoniinate*
the use of antispasmodics, with anoiiynes, and
their combination with vegetable bitrers, chaly-
beates, &c., are often required. Hie diet should
also be nutritious, but ea<:y of digestion, and not
too heating and stimulating.

36. 'J'he forc[!oing plan will often succeed in
pres(;rving the infant, uiik-ss the di.-yc'hargc con-
tinues or becomes more copious ; the uterine
pains, with the other symptoms of commcnciDg
abortion, sVvW ^ctsasV. ox met^^n^ *, «h.ii<\ vVk^ Nionnaa

12

ABSCESS — Patholooical DocrniNB of.

~ Jaaerintt De Abortu. Vien. 1777. — Mauer, AphorUml
de Caiuu Abortum ^rovocantibui, ito. Franc. 1780. —
Becker^ De Abortu. Got. 1798. — Gregortni, De Ilydrope
Uteri et Hydatldibus. HaL 1795i -> U Roy, Sur les Pertes
dc Sang pendant la GroMease. et tur lea fauaaca Couch^.
Paris, 1801. —SUwartt On the Caucea which deatroy the
Foetus in Utero, in Medical and Chirurgical Ttanaactlona,
vol. V. p. 144. — EI, ». Siebold, Von den Fnihgeburten in
dcasen Handb. sur Erkenntniaa und Heiluns der Frauen-
simmer ikrankheiten, ii. U u. S. Frank. lBSS.—De»or-
fneaugy art Avorlement, Diction, de M6decine, t iii.
p. 177. : et art fEitf. Ibid, t xv.^Btundelit Lecturea
on Midwifery, &c. Lancet, vol. xiii. — Goat, Study of
Medicine, vol. v. p. 174. — £/f. v. Siebold^ art. Abortus,
Encyclopadtachea Wfirterbuch der Mediciniaeben Wia-
aenschaften, &c. erster Band, Berlin, 18S8. — Rpan,
Manual of Midwifery, 19ma Lond. 1831, dd ed. — Dvges,
in Revue Medicale, 1824, t. iii. p. 74. ; et Manuel dea
Accouchemena. Paria, 1930. — Atidry, Sur le Maladiea
du Foetus et aca Annexea, in Joum. dea Frogria dea Scien.
M6d. 2d ser. t L p. 1S6. —Dewees, In Cyc of Pract
Med. and Surg. edit, by J. Hayt, Part i. Philadclph. 8vo.
1833. — R. Lee, in Cyc. of Pract Meil. Part 1. Lond. 8vo.
1832.— Z)itfff«, in Diet, de M^tL et de Chirurg. Prat
torn. iii. Paris, 8vo. 1829. — Brit and For. Med. Rev.
vol. vi. p. 81.

ABSCESS. Syn. Ahtcesnu (from ahtcedere, to
depart, to separate), Apottema, Abtcessio, Vo'
tnicUf Imposthuma, Auct. Lat. Awoo^n/AM,
Or. Abets, Fr. Die FAterbeuU, Ger. EJder-
bjftd, Dao. Bulning, Swed. Ettergetwel, Dut.
Aiceiso, Ital. Abscesso, Span. AbMceuo, Port.
Abtceu, Impathume, Eng.

Classxf. — See Inflammatiox.

1. Defin. a collection of purulent matter formed
or deposited in the strticture of an organ or part.

2. An abscess is never an origioal disease, but
is constantly the effect or termination of inflam-
matory action, in some form or grade, or of irri-
tation of the part in which it is seated. This may
not seem to be in accordance with certain phe-
nomena connected with tlie formation of purulent
collections, in parts at a distance from those in
which inflammatory action originates, and where
pus is originally formed : but I shall have occa-
sion to show that it is not opposed to sound
views as to this topic, or, at least, that the excep-
tions to it are few.

3. Without noticing further than to enumerate
them, the older distinctions of abscesses into the
warm, phlegmonous, or inflammatory, the cold
or congestive, and the acute and the chronic, I
shall have to show that, instead of proceeding
from difl^erent sources, they are equally the result
of a certain state of inflammatory action, modiiied
into a variety of forms according to the degrees
of vital energy and action of the part, and of the
system generally, the organisation of the part af-
fected, and the peculiarity of constitution and
diathesis. In the present article, a general view
will be taken of the pathology and medical treat-
ment of abscess, the consideration of the difTerent
kinds of abscess: their various seats, and relations
to other diseases, fall under diflTerent heads, where
they are more advantageously discussed.

4. I. Of the Pathological CiiARAcrERs of
Abscess. — 1st, Of abscess proceeding from acute
injiammation, with integrity of the constitutional
energy. — When a part becomes inflamed, the vi-
tality of which has not been previously injured,
as respects either its individual state, or constitu-
tional relations, its temperature becomes increased,
and iU veswls are injected with a greater quantity
of the circulating fluid than in health, and gene-
rully in proportion to the violence of the irritation
upon which thb aflflux of fluid depends. At first
the fluid does not extend beyond the vessels in

which it has passed ; but, in proportaon as it dis«
tends them so as to exhaust their tone and power
of reaction, and as the vital cohesion of their
extremities, and of the tissues which they rapply,
is weakened, a portion of the more flaid oonsti-
tuents of their contents escapes into the texture
of the part affected; infiltrates, and combines
with, its constituent elements, and renden it, at
first, more compact and dense. But, at the same
time that the inflamed part undergoes thia change,
it loses its vital elasticity, is more friable or ta-
cerable, so as to break down more readily from
foreign pressure, or upon the application of a
firm ligature.

5. If the inflammatory action stops not here,
the tissues affected by it undergo further changes.
They pass, more or less rapidly, from a dense but
friable state to that of softening ; and tfaia quickly
but insensibly assumes a pulpy condition, owing
to its continued and increasing infiltration with
the more fluid parts of the bl(K>d, and even with
more or less of its colouring particles ; the mole-
cules composing the tissues of the part being so
combined with, and separated by, the infiltrated
fluid, that all distinct traces of proper oi^ganisation
are lost. From this pulpy state, to which the
central portion of the inflamed structure is re*
duced, the transition to pus proceeds rapidly. Dut
it is not to be understood that the tisanes them-
selves are converted into this fluid. The flaid
poured out from the extreme capillaries gradually
distends the surrounding parts, and partially dis-
solves the softened and dUorganised tiasues in
which it is effused. The coagulable lymph, which
the tonic or unexhausted vital energy of the ad-
joining vessels form in the surrounoing texture,
confines the effused fluid, and prevents it from
extending beyond the barrier it opposes; whilst
the impaction of the cellular tissue, occasioned
by the increasing quantity of purulent effusion,
and the pressure it produces in all directions, with
the thickening, and the continued deposition of
1 vmph in the parietes of the abscess, tend still fur-
ther to fulfil this end, and thus to limit the mis-
chief, and to prevent the contamination and
disorganisation of the adjoining structures; con-
sequences which not infrequently supervene, when
the vital energies of the frame and the state of
local action are insafiicient to admit of the form'
ation of coagulable lymph, and to throw up this
barrier against the extension of disease.

6. The first step of the suppurative process is
the dissemination, particularly m the softest, in the
first and most intensely inflamed part, of minute
collections of a sero> albuminous or sero-sangui-
neous matter. By degrees, thb fluid becomes more
abundant. These minute collections enlarge, sp-
proach each other, and, at last, the partitions of
softened tissue between them are altogether dis*
organised and disappear; the whole, at last,
forming o&ly one cavity of variable extent. As
this process advances, the effused fluid cban^
from a thin albuminous lymph into pus ; which
becomes more thoroughly elaboratea, losing its
colouring matter which it had derived from the
blood, and diRsolviog the shreds or dibris of the
disorganised tissues m which it had formed : aad
when the suppurative process is matured, the pas
forms an homogeneous fluid, presenting ccrtaJD
characters distinguishing it from all other aoioisl
fluids.

14

ABSCESS — Diffusive, its Pathologt.

not limited to a particular part, or within dbtinct
bounds ; and the duid which is poured out from
the inflamed vessels is not circumscribed, or con-
fined to the centre of the inflamed part. The
inflammation which produces this unhealthy and
imperfect form of abscess is always characterised
by that state of asthenic or ataxic action, local
and general, which is incapable of producing co-
agulable lymph from the blood, tnat roav limit
both the morbid action and the efl'used fluid.
(See art. Inflammation.)

14. This kind of abscess not infrequently
forms in erysipelas ; or after wounds, inju-
ries, and punctures ; and from the inoculation
of an animal poison. The characters of the suc-
cession of morbid actions it presents are want of
vital power aod resistance, and a speedy solution
of the vital cohesion of the affected tissues. It
would seem that the iofluence of the ganglial
nerves supplying the capillaries of the part is ra*
ptdly, or almost instantly, destroyed by the cause
of the disease ; and that the vessels, thus deprived
of a great proportion or the whole of their vitality,
allow the escape of the more fluid parts of the
blood, and the infiltrutiou of the tissues. The
vessels pass rapidly, and without the previous
grades of healthy inflammation, into that state
which admits of the efliision of a watery or puri-
form sanies. The state of vital energy, and the
deficient crasis, or unhealthy condition, of the
blood itself, probably contribute to this result ;
and, with the effect of this eflPusion on the diseased
part, promote the rapid exhaustion of the remain-
ing action of the capillaries.

15. Diff'usive absce'ses generally commence in,
and spread rapidly in the direction of, the cellular
tissue. They affect also, in a very marked man-
ner, the other structures placed in their way.
They seldom commence in the internal viscera,
as the liver, lungs, &c. ; but when they do thus
originate, as is occasionally observed in the latter
stages of malignant or ataxic fevers, in exhausted
states of the frame, 6cc., they nearly approach
the characters they assume in the cellular struc-
ture. In almost every case of this disease, the
constitutional disturbance is very remarkable;
and the powers of the nervous system, particu-
larly that^residiog over the organic and assimilat-
ing functions, are uncommonly depressed. Local ly ,
the eflfusion of a watery, or sero-albuminous, or a
sero-sanguineous fluid, is nearly coeval with the
affection of the cellular tissue and congestion of
its capillaries. The vital cohesion of the inflamed
texture is rapidly dissolved ; and the fluid, abun-
dantly poured out in its areolae or cellules, distends
the part, diminishes its vital functions to the
lowest grade, and, at points, lacerates its tissue,
thereby partially cutting off its connection with
the adjoining structures. Thus the fluid is effused
from the congested capillaries of the affected part
in numerous places : in some, forming consider-
able collections; in others, mere inflltrations.
Parts of the cellular tissue itself, and, in rare in-
stances, as the mischief proceeds, portions of ad-
joining or intermediate textures, are deprived of
all vitality, sphacelate, and mix with the fluid
effused.

16. In many cases the integuments participate
but imperfectly, and often not at all, in the mor-
bid actions, whilst the process, as now described,
is going forward ', and the great effubion into, and

partial destruction of, the cellular tissue, have
enormously distended the limb or part in a dif-
fused manner, and to a great extent, and given it
*^ hoggy or imperfectly fluctuating character. At
a later period, parts of the more attenuated or dis^
coloured integuments vesicate, ultimately bursty
and give issue at first to a discoloured purifonn
secretion, which afterwards becomes offensive and
otherwise modified. When the skin is affected, it
generally presents a dark or livid hue : its tem^
perature is seldom above (excepting, sonetixneSy
at the very commencement of the antecedent in-
flammation), and frequently sinks below, the
tural standard.

17. With respect to the appearance of the
cretion in this form of absoeai, 1 mav state, that
it not only varies remarkably in different case«,
but also at different stages of the same case. At
first, the fluid effused and infiltrating the cellular
structure consists cliiefly of a limpid, reddened
serum, which readily flows from the divided struc-
tures; in a more advanced stage, the effused mat-
ter is less fluid, often high-coloured, but without
the whiteness and opacity of purulent matter.
Afterwards, the cellular membrane is engorged
with a white semifluid matter, which separates the
particles of fat and cellular tjtoue at an unusual
distance from each other. In subsequent stages
it continues opaque; but often becomes reddish,
greenish, and more fluid. At a still more advanced
period, the infiltrated cellular and adipose tissue
are entirely broken down, and the sphacelated
portions hanging into, or mixed with, the parifurm
matter ; which sometimes now presents the appear-
ance of a brownish, purulent sanies, sometimes n
greenish pus, and at other times a sero-pnruleot
matter of^ various shades of colour and degrees of
consistence. At no period of the disease is the
matter contained in any circumscribed cavity, but
is gradually and irregularly lost in the surround-
ing cellular tissue; without any demarcation, or
appearance of coagu labia lymph about the cir-
cumference of the diseased part. In general, the
purulent secretion speedily assumes an offensive
odour, aod its sensible qualities are otherwise
altered, and often variously, upon the adaussioa
of air to tlie diseased surface.

18. The muscular structure, and other parts in
contact with the puriform matter, and iu tne way
of the spreading disease, is generally much disco-
loured, softened, easily torn, and sometimes par-
tially destroyed. In some cases the muscles are
paler ; in others, darker, and more livid, than na-
tural. In rarer instances, the adjoiomg bones
and more resistant structures are also affected.
(See INFLAMMATION, Diffusivt.y

19. 3d, Abicesses eomequent npon inflammatum
of lower grades of intensity. — ^The more slow and
obscure the progress of inflammation, the l€«9
marked are the signs of irritation preceding and
accompanying abscesses. It is not uncommon to
observe, in lymphatic and phlegmatic tempera-
ments, fluctuating tumours of various sixes, both
superficial and deep-seated ; without any consider-
able pain or increase of animal heat, either ante-
cedent or subsequent to their formation. Purulent
collections, of a chronic and indolent character,
generally proceed from a low but continued state
of irritation, or from reiterated excitation of so low
a grade as scarcely to influence tho sensibility of
liie part ; and occur in constitutions of weik vital

16

ABSCESS — Consecutive, its Patiioloot.

tomatic of ioflatnmation and ulceration of bones
or cartilages is generally greyish, thin, mixed with
albuminous flocculi, minute clots of blood, and
portions of phosphate of lime. It exhales a nau-
seous odour: but this characteristic is present only
after the opening of the tumour, and when the air
has access to the cavity.

26. If we examine the cavities of symptomatic
abscesses, and trace them from their origin to
their outlet, we shall find, in the former situation,
the cartilages and bones profoundly changed : the
bones are softened, friable, changed to a greyish
black, partially absorbed and carious, and their
periosteum destroyed. From this origin of the
disease is formed a channel or sinus, traversing
the cellular structure frequently in the course of
the large vessels or muscles, and terminating with
the external outlet of the tumour. The whole of
this canal or sinus is usually surrounded by a
softened, friable, or lardaceous state of the tex-
tures; and lined with a smooth, thick, firm, cel-
lular, or fibro-cellular membrane, which in some
cases is of a fibro-cartils^inous structure. At the
lower part, the canal generally dilates into a con-
siderable cavity, sometimes irregular or sinuous
in its form, and lined with the membrane usuallv
found in the more chronic kinds of abscesses.

27. 5th, Of consecutive abteesut ; or eoUeetions
of matter found in situationt consecutively to its
formation in distant parts, between which there ex-
ists no communication. — - It has been not infre-
quently remarked, that inflammation of a part has
taken place, and has gone on to suppuration; that
the matter thus formed has been absorbed ; and
that it has subsequently formed in some other
vise us, generally in an internal organ. The nature
and procession of the morbid phenomena now
enounced have led to some inquiry, particularly
in recent times. The circumstances in which
consecutive abscesses occur in practice are the
following : —

Inflammation of the internal surface of the
uterus, or of its veins, or of both the substance
of the uterus and veins, occasionally takes place
after child-birth, and terminates the life of the
patient. On dissection, purulent infiltrations or
distinct collections of pus are found, in one case,
in the lungs ; in another, in the liver ; in a third,
in the substance of the brain ; in a fourth, in the
capsules of the joints ; and, in a fifth, in both the
lungs, liver, and perhaps, also, in the joints. A
man, from injury of the head, has inflammation of
the sinuses of the brain, followed by all the symp-
toms of a vitiated state of the circulating fluid,
terminating in death : after which, abscesses, or
purulent infiltrations, are found in the liver or
lungs. A similar procession of phenomena oc-
casionally results from phlebitis consequent on
blood-letting, or other causes; also during the
suppurations following amputations, particularly
when the matter is confined on the face of the
stump, by the adhesion of the integuments which
had been drawn over it. A child is seized with
severe or confluent small-pox ; and during, or sub-
sequently to, the secondary fever, fluctuating
tumours form in the joints from matter accumu-
lated in their capsules. Upon dissection, the
cartilages are found eroded ; and, in other rare
cases of this kind, purulent collections are found
in the internal viscera. In other instances,
abscess disappears from external parts ; the patient

sinks with low fever ; and, upon dissection, col-
lections of pus are found in internal organs. In
cases of this description, the following require
notice : — Ist, I'he state of the vital energies pre-
ceding or during the occurrence ; 2d, Tl^ symp-
toms characterising the progress of the pheDomena ;
and, 3d, The nature of the results.

28. Ist, The energies and vital resistance of the
system are generally greatly impaired, either from
pre-existing or concurring causes, in cases where
consecutive abscesses form. (See article on /r-

flummatioH of Vkins.) 2d, Tne depression of the
powers of life increases as the disease advances.
The nervous system is seriously aflTecied ; the cir-
culating fluid betrays change in its appearances
after its emission, or after death ; the soft solids
lose their vital elasticity and cohesion ; the sarfiace
of the body and countenance become dusky and
livid ; and low delirium, rapid and weak circula-
tion, &c. take place. 3d, The purulent matter is
generally eitlier infiltrated into the parenchyma-
tous structure of some organ, or collected into
one or more distinct abscesses, or it is effused into
the cavity of one or more joints. When the mat-
ter is infiltrated into the texture of an oivan, the
infiltrated structure is very frequently abo soft-
ened. The purulent collections that are found in
other cases generally have no distinct cyvt, and
the surrounding substance of the organ seldom
presents any marked redness or injection of its
vessels, or indeed any remarkable change, except-
ing in some instances a slight softemng. 'ihe
matter is usually found in several distinct ab-
scesses or collections, varying from the sixe of a
small seed to that of an egg, or even larger.
Sometimes the immediately surrounding structure
seems impacted around the abscess, but not other-
wise changed. The purulent matter itself varies
but little from that which is observed in the ab-
scesses described in the first section. ($ 6, 7, B.)
It is occasionally of a darker or greenish hue,
particularly when found in the liver.

29. As to the Origin of these purulent collec-
tions, some doubts may be entertained. That they
are very intimately connected with the primary
inflammation and formation of matter in other
parts of the system, cannot be doubted, but in
what way cannot be so readily stated. It seems
to me extremely probable, from the attentive ob-
servation of the progress of a number of such
cases which have come before me in practice,
that, owing to depressed vital energy, and defi-
cient resistance of the frame, purulent matter
passes into and vitiates the blood ; that the morbid
condition of the circulating fluid, thus induced,
depresses still lower the already weakened nervous
powers; and that the irritating matters carried
into the circulating current change the state of the
capillaries of parenchymatous and some other
organs, so that they secrete purulent matter
without any evident sign of previous or accom-
panying inflammation. Several French pathologists
suppose that the purulent matter conveyed into
the blood circulates without conbinin^ with it,
and is merely deposited by the capillaries, or
separated by them, from this fluid in parts; the
vessels and texture of which are most disposed to
permit its elimination, or the best constituted to
admit of its deposition. It is difficult to deter-
mine in which of those ways the consecutive
abscess is formed. Indeed, both may approximate

20

ABSCESS— PftOONosis or.

becomes more elevated, prominent, and soflened
at the centre of the surface. The redness and
tension undergo a similar change. The circum-
ference of the mflamed surface is restored in some
degree to the natural state ; but the more promi-
nent part acquires a dnrk red tint, afterwards a
bluish hue, and yields more and more to the pres-
sure of the subjacent pus. For some time pre-
vious to this stage the tumour evinces a more or
less distinct fluctuation when suitably examined,
and this sign becomes more manifest as the abscess
advances to the surface*

48. When an abscess forms in deep-seated parts
or viscera, particularly those protected by solid
envelopes, or by thick and unyielding structures,
the diagnosis rests entirely upon the nature of the
constitutional disturbance, and the disorder in the
functions of the affected organ or part, and here
the physician should seize and appreciate the
slightest difference taking place in the pulse, the
animal heat, and the state of all the natural and
organic functions. In these cases he requires the
most exquisite tact for examination, in order to
arrive at an accurate opinion. The symptoms
which should guide him in cases of this descrip-
tion will be stated when I treat of the diagnosis
of the different kinds of visceral abscess. I may,
however, remark at this place, that, even in parts
much less deeply seated, when the cyst or an
abscess is greatly distended and very tense, fluc-
tuation generally is extremely obscure, or even
not to be felt, although its contents may be very
fluid. Also, when the purulent matter is con-
tained in no distinct cyst, but is disseminated
through the textures, or infiltrated between
fascia) or muscles, or is confined beneath apo-
neuroses, great incertitude may exist as to its form-
ation. The parts in such cases present more of
a diffused osdema than of a fluctuating tumour ;
and if fluctuation can be at all felt, it is only ob-
scurely.

49. It must be evident that the more feeble
and latent the phenomena of the precursory in-
flammatory irritation, the more difficult is it to de-
termine the period at which the elaboration of pus
commences. We frequently observe in practice,
particularly after phlebitis, injuries of the head,
fractures, and capital surgical operations, abscesses
form in the liver, mediastinum, lungs, kidneys,
or ovaries, preceded merely by obscure and occa-
sional pain, and furnishing no certain symptoms
of a local kind, by which we can decide as to their
formation, until the time that they appear exter-
nally, or are detected upon post mortem examin-
ation. In cases of this description, the constitu-
tionsl symptoms are our chief guides ; but even
these are often so uncertain and so imperfectly
developed as to leav« us in doubt. The accession
in this obscure unAner of internal abscess is
particularly remarkable as respects those which
supervene to inflammatory disease existing in other
parti, particularly to phlebitis, and which I have
denominated consecutive abscesses. (See Veins
— injiammation of.)

50. Symptomatic abscesses generally escape
detection until they advance externally. Previous
to this, pain, uneasiness, tumefaction, &c., are only
felt chiefly in the part originally affected. But
the symptoms already noticed ($4(> — 48.), espe-
cially the unhealthy aspect of tlie surface, the
state of the febrile action and of the pulse, the

I night perspirations, the disorder of the respiratory
and alvine functions, will generally serve, in con-
junction with the changes in the part to which
symptomatic abscesses extend, to indicate the
nature of the mischief.

51. It is important, as M. Dupuytakn has
very justly remarked, to take into account, whea
determining the existence of abscess, tbe greater
disposition inherent in some constitutions to form
purulent matter. In some persons, the least irri-
tation is followed by the suppurative process.
This is particularly the case in persons of a pale
visage, of a soft flaccid state of the different
structures, and of the lymphatic temperament.
It is also remarkable in those whose vital ener-
gies have been lowered by previous diaetse; by
chronic affections of the digestive mucous sur-
faces ; and by those diseases which require the
performance of amputation, or other important
surgical operations. When the suppurative pro-
cess has continued for some time, and has after-
wards been suddenly stopped by an operation, or
any other active treatment, the disposition to form
abscesses b generally remarkable. A similar re-
mark may be extended to the sudden suppression
of any accustomed secretion or discharge. The
most familiar instance of this kind is noticed in
the breasts of nurses, which ate extremely liable
to suppuration upon interruption to the secretion
of milk. These considerations should have Itheir
due weight with us when estimating the 8igU3 of
the existence of internal abscess. Those symp-
toms which are peculiar to collections of matter
formed in each of the internal vbcera are pointed
out in their respective articles.

52. IV. Op THE Proonosis op Aascirsa. The
danger from abscess is in proportion, 1st, to the
extent of their internal surface ; 2d, to the depth
at which they are seated ; 3d, to the indolence of
their action, or the deficiency of vital action ac-
companying them ; 4th, to the severity and
danger of the disease by which they have been
occasioned ; 5th, to the sinking or deficiency of
the constitutional powers under them ; and, 6th,
to the severity of the symptoms accompanying
them, or produced by them. I'hese poaitiooa are
so obvious, that no remarks need be offered in
support of them. I may, however, observe, that
abscesses seated in internal viscera are always
attended with danger ; but the degree of danger
will depend upon numerous circumstances con-
nected with their seat, the direction which they
take, the state of the vital energies of the frame
durmg their progress, the chances of their evacu^
ation, and the means of reparation and renovation
the constitution may still possess.

53. The prognosis of chronic, symptomatic,
and consecutive abscesses depends as much upon
the nature of the preceding disease, as upon the
state of the abscess itself. In chronic abftoev,
the danger is in proportion to the extent of the
surface of its parietes, and to tbe grade of consti-
tutional vice. In symptomatic ahscesi, the dangt r
depends almost wholly upon tbe nature and extent
of the original disease, ^f which it is the conae-
ciuence, and upon thelargeneasofsurfoceeztendtog
thence to the ultimate limiu of suppuration. In
consecutive abscess, the danger is extreme; owing,
in many cases, to tbe nature of the primary dis-
ease, the depressed state of the constitutional
powers, and to tbe vitiation of the circulating

22

ABSCESS— Tit£ATiinrr ot.

Emollient and astringent appUcatbns should also
be constantly employed. These will generally
reduce the inflammation of the surrounding tissue,
favour the resolution of the parts not yet suppu-
rated, limit the quantity of the morbid secretion,
and favour the maturation of the abscess, so that it
may be opened with the best hopes of success.
In some cases» the use of these antiphlogistic mea-
sures will give rise to the absorption of the puru-
lent matter, even after thb had been attempted to
no purpose by means of revulsants.

oO. It should be recollected that the surfoces
of abscesses are tbe constant seat of two kinds of
action ; one of exhalation or secretion, the other
of absorption ; and that whatever excites or irri-
tates them increases the former, and whatever
soothes or diminishes this irritation lessens it, and
favours the latter action. This consideration
should lead us strenuously to adopt a continued
antiphlogistic and soothing treatment of the aflTect-
ed part, until the thinning of the skin at the most
prominent part of the tumour indicates the neces-
sity of opening it.

61. In symptomatic abscesses, the treatment
should chiefly be directed to the primaiy seat of
disease ; for as long as the mischief continues or
advances there, the purulent collection increases,
and diminishes as it subsides. Thus, the abscesses
that point near the anus or crural arch, in conse-
quence of disease of the vertebne, will sometimes
disappear after the use of active means directed to
the, original malady, and judiciously adapted to
the state of the patient.

62. Consecutive and spreading abscesses re-
quire a very difierent management from that now
pointed out. These generally occur in persons
of an unhealthy habit of body, or who have been
weakened by acute disease; or they are the
result of an adynamic or ataxic and spreading
inflammation occasioned by a specific or poison-
ous agent; and they are not infrequently the
consequence of the inflammation of veins, or of
the presence of morbid secretions or purulent
matter absorbed into the circulation (§§ 25 — ^28.),
or of the transfer of iiritation from a distant part.
But from whatever cause they may proceed, — and
thev may, and occasionally do, proceed from
either of those sources, — deficient constitutional
energy, and vital resistance to the influence of
the exciting cause, with a marked disposition of
the structures to be invaded by it, and to partici-
pate in the morbid action it excites, are their
constant concomitants; requiring the energetic
use of those means which are the best calculated
to rouse the powers of the frame i to restore the
deficient tone of the capillary vessels, and to thus
enable them to form coagulable lymph, by which
the spread of the local mischief may be limited.
Instead, therefore, of having recourse to anti-
phlogistic remedies, the state of local action, and of
constitutional power, requires a tonic, stimuhiting,
and restorative treatment; conjoined with the
means best calculated to promote the functions of
all the abdominal viscera, so that morbid matters
may be eliminated from the circulating current,
and healthy nutritious elements conveyed into it ;
and with a pure air to perfect the changes which
it undergoes during respiration, and which are
requisite to the continuance of the functions of
life. The treatment necessary in such cases is
fully detailed in the articles on Intlamm atxon of

Vxms, on Sprsai>ino Inflahiiation of the
Cellular Tissue, and on the treatment of Ani-
mal Poisons.

63. 2d, Of opming aWocnes.—- When we &il
in procuring the absorption of the purifonn mat-
ter, its artificial discharge will, sooner or later, be
required, when this can l>e accomplished. Ceriaio
abscesses require a more immediate performance
of this operation tban others, and more particu-
larly the following : — 1st, Abscesses proceeding
from the escape, mto the substance of any orgmn
or part, of irntating secretions or excrementorial
matters, as the urine, or fecal substances, 2d,
Abscesses preceded by very acute inflammatory
action, and occurring in cellular or adipose struc*
tures, as the margin of the anus, the sides of tbe
neck, or the groins. 3d, Purulent collections
deeply seated, or confined under fiucis or apooeu>
roses. 4th, Abscesses formed in the parietes of
the splanchnic cavities, in order to prevent the
chance of thdr breaking internally. 5th, Ab-
scesses formed in parts through which large nerves
and blood vessels pass, and on which the purulent
matter occasions a painful and injurious pressure ;
as abscesses in the neck, and underneath the
stemo-mastoid muscle, at the top and inside of tbe
thighs and arms, &c. 6th, Abscesses which em*
barrass the respiratory organs, and which press
upon the lar^rnx, pharynx, or trachea, or which
endanger the integrity of those parts.

64. In all these the strict antiphlogistic treat-
ment will be requisite, unless they are of the
diffusive or consecutive kinds, with emollieDt
applications, in order to limit the extent of the
inflamed parts, to diminish their size, and to hasten
their maturation ; and in many cases this mode of
treatment must bo continued for a considerable
time after the discharge of the matter, in order to
limit or prevent its re-accumulation, and to pro-
mote the collapse and diminution of the parietes
of the abscess. The cases where it will be fre-
quently necessary to retard the period of dis-
charging the purulent collection, are chiefly those
in which it is formed in the internal viscera, as the
liver, spleen, kidneys, lungs, &c«; respecting
which I have treated fully under their appropriate
heads.

65. Chronic abscesses should be opened as
soon as it is shown that their absorption cannot
be accomplished ; or when they augment in bulk
under the discutient and derivative treatment.
Symptomatic abscesses also require to be opened,
when we find that the means which we have
directed to the original seat of disease fail of limits
ing their extension, or lessening their bulk. Con-
secutive abscesses require to have their contents
immediately discharged, when their situation
admits of this being done ; for the morbid state of
the matter they sometimes contain, and the weak
vital resistance opposed by the surrounding parts,
and by the constitution, favours the contaminatioD
of the adjoining structures, and, indeed, of the
whole frame. But this intention can seldom be
fulfilled, owing to tbe seat of the purulent collec-
tion ; and, when it is put in practice, it should be
followed by as complete an exclusion of the
atmospheric air as possible.

66. It does not come within the scope of this
work to notice, at this place, the different modes
of opening abscesses, and the treatment with
which the operation should be aooompanied and

24

ABSORPTION—- ITS Pathological Bblations.

have reason, moreover, not only to infer that the
more material causes of disease are absorbed from
the surface of the lungs, when inhaled into them
with the atmosphere, in the moisture of which they
are dissolved, or otherwise combined ; but, also,
that the foreign gases, which sometimes mix with
the air, act m some measure through the same
channel.

6. The or^nisation of the respiratory surfaces,
the nature of the circulating functions on these
surfaces, and the more immediate relation subsist-
ing between the air in contact with, and the blood
circulating in, them, will readily explain the rapi-
dity with which foreign matters floating in the
atnioi«phere are frequently conveyed into the cir-
culation. Besides, we have strong reasons to infer
that several of the gases, and of the soluble sub-
stances which float in the air, are carried directly
into the blood from the surface of the lungs, with-
out passing along absorbent vessels. The experi-
ments of Professor Mayer, and of Drs. Lawrence
and CoATEs, as well as those of MM. Segalas,
FoDERA, &c., fully confirm this inference ; whilst
those performed by MM. Magekdie, Sbiler,
FiciNus, Tiedemann,Gmeun, and several others,
show, that even in the alimentary canal, and espe-
cially when capillary vessels are divided in any of
our tissues, the function of absorption is not con-
fined to lacteal or lymphatic vessels, but is fre-
quently extended to the venous capillaries, which,
in respect of certain substances particularly, chiefly
perform this function. Hence I may conclude
that foreign substances dtESolved in, or combined
with, the moisture of the air, or mixed with this
fluid, may, when inspired, be carried from the sur-
face of the lungs into the blood, independently of
the absorbent vessels; although, doubtless, these
vessels perform their appropriate functions in this
as in other parts of the body.

7. b. The rapidity of absorption in the lungs, and
the ready access to the blooa which foreign mat-
ters find through them, are suflicient to vindicate
their importance as channels through which to
convey our means of cure, not only in those ma-
ladies to which they are liable, but also in a num-
ber of diseases affecting the i^hole frame, or par-
ticular parts of it. General suggestions on this
subject are all that can be advanced in this place ;
the particular recommendations for its use are
given in their appropriate places. Those gaseous
bodies which possess active medicinal powers ; all
those remedies which are more or less volatile, or
are soluble in aqueous vapour ; and many medical
substances which may be rendered volatile or
soluble in water, when combined with other bodies
that do not destroy altogether their remedial powers,
may be prescribed advantageously through the
medium of ihe lungs. Chlorine, the nitrous oxide,
dilute oxygen gas; the vapour of iodine, or the
sulphuret of iodine ; the vapour of turpentine,
camphor, of the common, the aromatic, or the py-
roligneous vinegars ; tar vapour ; the chlorides or
chlorurets of lime or of soda ; ai^ueous vapour hold-
ing the active principles of opium, henbane, hem-
lock, belladonna, digitalis, colcbicum, &c. in so-
lution ; the volatile principles of various salt$, the
aroma of a number of vegetable bodies, — all exert
powerful effects upon the system when administered
m this way.

8. c. Through this channel a number of fevers,
especially those ivhicli arc characterised by great

depression of the powers of life, or which rapidly
pass into this state ; various clironic aflfiectioos of
the lungs themselves, which are unattended by
acute inflammation, but consist chiefly of a mor-
bid state of the respiratory nerves, and are accom*
panied with spasm, and a morbidly increased
secretion ; the different kinds and forms of as-
phyxy ; the diseases which threaten life by inter-
rupting the respiratory functions; and various
maladies in which the blood is vitiated, and where
it becomes important to act in a direct and de*
cided manner on this fluid, and on the circulat-
ing organs generally, may be sueceasfully com-
bated.

9. d. The knowledge that we thus acquire re-
specting the channels, through which the causes
of many diseases invade the system, and the re-
medies for removing ihem may be efficaciously
administered, furnishes us with important indica-
tions as to the employment of prophylactic mea-
sura, and rational plans of reffimen and hygiene.
Miasmal or contafrious fevers furnish us with nu-
merous opportunities of proving the justness of
these views. Observation shows us that the
causes of this class of disease act upon the system
chiefly from their presence in the air we breathe :
it further enables us to decide that these canoes
invade the system chiefly through one of two, or
perhaps by both routes : viz. by the nerves sap-
plying the respiratory organs, or by the paitial
absorption of the causes themselves, from the
pulmonary mucous surface, into the circulation.
From the same source, or from the collateral evi-
dence of experiment, we know that foreign sub-
stances do not so readily enter the cireulation,
when its functions proceed with energy, and the
vital resistance is perfect, as when they act feebly
and imperfectly ; and that the depressing eauncs
of disease have less power over the nervous in-
fluence of the respiratory organs, and of the system
in general, when the vital actions which take
place in the lungs are performed with due acti-
vity. The same sources of observation make us
acquainted with the important facts, that the dilu-
tion of the atmosphere, which contains the causes
of febrile diseases floating in it, by free ventil-
ation ; that the destruction, or neuiraJisation, or
counteraction, of these causes, by the evaporation
of certain disinfectant and stimulating agents ;
and that a due energy of all the vital and secret-
ing functions, with an equable state of tlie mental
powers and manifestations, and with a steady con-
fidence, are the most successful means of prevent-
ing the attack and diffusion of those malames.

10. By combining these facts as to the source,
mode of operation, and methods of counteraction,
of the chief causes of a most important class of
maladies, and by directing the measures they sug-
gest as far as may be according to the peculiari-
ties of individual cases and diseases, we are thereby
enabled to furnish persons, and even whole com-
rnunities, with instructions and means calculated
either to counteract or to lessen the dangers to
which they are exposed.

1 1 . 3d, Of absorption Jrom the atmentary canai,
in connection with the causation of disease,'-^ a. It
may be received as a pathological axiom, that the
rapidity and extent with which deleterious mat-
ters are absorbed from the digestive mucous sur-
faces, as well, indeed, as from the respiratory,
and other organs of the body, are nearly in pro-

ABSORPTION — ITS Kslatiovs to Disease.

25

pertion to the depression of the nervous ener-
t.K9 and Yital leautance of the system. The
tnath of this is evinced in respect not only of the
tcdoas proceeding on the mucous surfaces, but
&].«o of those taking place in the different organs
dsd strnctures. It is necessary to allude here to
lb Deraerous agents which cause, counteract, or
maove disease, by their being absorbed from the
ikteotary canal. Whilst many agents produce
iW effects chiefly by modifying the states of the
aerve& and mucous tissue of this canal, others
ict principally from bong absorbed, either by the
iacteaU, or bv the venous ladicles, and carried
JQto the drcolation ; and a still more numerous
ci«i-9 seem to operate through both channels, im-
P'es£«Dg immeoiately the nerves and tissues to
whicb they are applied, and subsequently beiog
»b^rbed mto the blood, where they produce im-
portant effects not only upon this fluid, and on
liK vascular system, but also upon the functions
of various secreting organs, especially those by
which they are eliminated from the body.

12. A very large proportion, therefore, of the
inzesta, whether alimentary, medicinal, or poi-
boaous, thus acting upon the system chiefly
tbrough the medium of absorption, the importance
cf direciiog a considerable portion of attention to
uis faoction in our pathological investigations, as
Veil a» in the appropriation of medicinal means,
^s'istbe apparent. Besides these more obvious
rcbtioas of the subject, there are others which
Wnbeeo either imperfectly investigated or entirely
CTcriooked. To tnese I can merely allude : but
aswngst the most interesting are the absorption of
■JSKbolesome and imperfectly digested chyle from
ib« iatesdnal surftbce ; the absorption of a portion
of the vitiated secretions which occasionally acou-
BoJaie in the alimentary tube, particularly in the
ececQiD and cells of the colon ; the absorption of
some part of the fscal matters, when they are long
retained in the above situation, as evinced by the
seiuible qualities of the perspiration, foul state of
the 4in, &c., or of the obstructed and accumu-
lated uriaary secretion, as proved by similar phe-
Domcna ; the passage of bile into the circulation,
when It has been retained in the liver, the biliary
dacift, or gall-bladder, from torpor or obstruction
v( these pails, or when it is secreted in lai^
qoaotity, and does not readily pass off" with the
e^sta. All these are very fruitful sources of
disease ; and, although generally connected with
«oine degree of pre-existing disorder, or of torpid
ftioctioo, they are often the chief aggravatmg
csvMs of many of the maladies we are called
upon to treat, from the constitutional and visceral
^tuibance they occasion and perpetuate.

13. There are few disorders which implicate
the ffigestive and chylopoietic organs, and very
£e« febrile diseases, which do not, at some period
of th^ course, evince si|;ns of the absorption into
the drcttlation of a portion of the morbid secre-
tioos or fecal fluids retained in the alimentary
canal, when due evacuations are not practised.
Therefore, besides the other effects produced by
medicines of this class, the due evacuation of these
Kcrtuoia and faecal matters from the prima via is
one of the best offices they perform.

14. b. It is nnnecesMry to do more than to
kllode to the advantages that accrue to the
Kieotific practitioner from some knowledge, — al-
tboogb, in the present state of medicine, necessa-

rily imperfect, — of the remedies which act by being
absorbed, either altogether or in part, from the
alimentary canal. Most of those substances which
are found by experience the most efficacious in
promoting the actions of the different secreting
viscera, and in producing amfirked and permanent
change of the general state and functions of the
economy, operate after having been absorbed into
the circulating current, and conveyed through
this channel to vital and secreting organs ; and,
although, during the healthy performance of the
secreting functions, or whilst the vital energies
are not far reduced, these substances seldom accu-
mulate in the blood so as to be detected in it by
chemical analysis, owing to the balance which is
preserved between the rapidity of absorption and
the activity of elimination, yet their passaee
through it is proved by the fact, frequeoUy
observed in regard of all of them, of their being
found in the secretions of the eliminating or de-
puratory organs. This fact was established by
experiments performed by myself,— -some of them
as far back as 1819, — and published in several
periodicak in 1821 and 1822.

15. 4th. Of abtarptionfrom diteaud organs and
structures, — a. When morbid secretions are gener-
ated, or accumulated in any organ or texture, or
when any part is changed m such a manner as to
secrete a matter different from the healthy consti-
tuents and fluids of the body, the matter formed
is generally, after a while, absorbed into the
circulation, and contaminates, in a more or less
marked manner, acoordins to its nature, the other
fluids, and the soft solids, and thereby at last
destroys life. Illustrations of this procedure
are furnished us in the pathological history of in-
ternal and deep-seated abscesses ; in some morbid
states of the uterus ; in scirrho-cancer, fungous
hsmatodes, and other nuUignant diseases. The
celerity with which the absorption of the morbid
matter and the contamination of the frame pro-
ceed, is generally according to the principle al-
ready recognised ($9.), — in proportion to the
diminution of the vital energy and resistance of
the constitutional powera.

16. 6. The commencement of the contamination
can scarcely be determined by an appreciation of
symptoms: but the experienced observer will
readily recognise, in the colour of the surface of
the body ; in the state of the heart's action, and
of all the circulating functions, as well as in the
blood itself; in the failure of the energies of life ;
in the morbid condition of the nervous functions
and of the powers of the stomach, and indeed of
the whole aigestive canal, sufficient proofs of the
early, as well as of the advanced progress of dis-
ease, arising from the absorption of morbid mat-
ters from the primary seat of morbid action, and
the consequent viUation of the circulating fluids,
of the sort solids, and of the secretions and ex-
cretions of the body. (See Art. Blood.)

1 7. In many of the more chronic diseases which
either commence with or terminate in the malig-
nant state, this contamination is frequently first
evinced by the tumefaction and pain of adjoining
lymphatic glands, owing to the irritation produced
by tne morbid fluid convened into them : the in-
flammation or obstruction thus produced in them
becoming an obstacle to the rapid transit of the
morbid matters from the original seat of disease
into the circulation. But in many cases this is an

36

ABSTINENCE— MoMiD Eyncn or.

insufficient btriier ; Vkd in othen, tliese matteis
seem to pa« onwards, either without circulating
throueh lymphatic glands, or without occasioning
irritation, obstruction, or inflammation in them ; or
are almost directly conveyed into the venous circu-
lation. Whatever q^y be the channel of oonvev-
ance, there can be no doubt of the fact — the
practical importance of which is very great — that
' the rapidity of the absorption of morbid matters,
and extent of their hurtful effects on the constitu-
tion, are in proportion to the depression of the vital
eneigies of the frame, — this depression being fre-
quently the cause of their absorption, particularly
in respect of puriform fluids ; or at least the cir*
cumstance which more especially favours its oc-
currence, and the rapidity of its proness.

Bnuooa^PHT. — Gdj^orrf, Siir lei Muadiei Putridei,
&c. in M. Magendie*s Joum . de Physiol., t. li.— ^. Copland^
in London medhcal Repository, vol xvii. for May, 18SS;
and in his Notes and Appendix to M. MekertuuPs £le>
menu of Physiology, Lood. 1824 and l9S9.^Magemdte,
art. AbMorptum, in Diet, de MM. et Chirurg. Prat. t. i.,
Paris, l899.'-'Podtra, Archives Qbait. de MM., til.
p. 57. — FioUet, R%rw MM., W36, 1. 1. p. 165.

ABSTINENCE. Its Morbid EffieU. Syn. Ab-
stinentia, lAt. A$tintnta, Ital. Die Enthal
tung, Ger. Absttti§ne€f Fr. Starvatian from
Hunger,
Classiv. I. Class, V. Ordeb {Author, see
Clamjieation in the Preface),
1. It does not come within the scope of this
work to enter upon the consideration ofthe thera-
peutical relations of abstinence ; but that the prac-
titioner should be acquainted with the states of
disease which it occasions, and wiih the best means
of treating it, is extremely important ; more espe-
cially as, when it is too rigidly enforced dunng
the treatment of several diseases, it not infre-
quently gives rise to effects of a serious nature,
which not infrequently have been mistaken for
the spontaneous course of the malady.

2. 1. Of THE Morbid Effects of Abstinence.
Abstinence has been long employed as a means of
cure, and generally as a part of the antiphlogistic
r^men, in a very great number of diseases, par-
ticularly in fevers and inflammatory affections.
Very great difference, however, exists both among
writers and practitioners as to the extent to which
it should be carried, and the maladies in which
it ought to be prescribed. As to its applica-
bility to the class of diseases now noticed, there
is no doubt : but in disorders of debility, or of
irritation merely, particularly those which occa-
sionally simulate chronic inflammation, and in
various nervous affections, it is extremely injuri-
ous ; and I believe that it has been carried to a
hurtful extent in many of these affections, particu-
larly by Broussais and his followers, as indeed
has been recently well shown by JNIM. Piorky
and Bar R AS. A case of this description, which
had been long under the care of M. Brovssais,
very lately came before me, with many of the
morbid effects of this practice, which had been
carried to a hurtful extent. There can be no doubt,
however, that it is extremely beneficial, when
carefully watched and regulated, in many of the
diseases of the stomach and its associated viscera ;
but the fact is equally incontrovertible, that it will
often produce effects very nearly resembling those
for which it has been prescribed. The importance,
therefore, of keeping these eflSscts in recollection,
when treating several diseases, particularly those
of irritation and debility, must be apparent.

8. In appreciatiii^ the umal eileets of abstiiMiice
it is extremely requisite to be awane of two things :
1st, That the efiects vary with the state of the
patient at the time that abstinence is endured ; 2«l ,
that they differ materially according to the sud-
denness with which it is entered upon, the extent
to which it is carried, and the circumstances witb
which it it associated. By very corpulent and
plethoric persons, abstinence is generally borne
well for a long period, and by those labouring
under febrile or inflammatory excitement ; smd it
is, in them, one of the most necessary means to
diminish the one and lower the other. In these,
particularly the latter, total abstinence uaty be
endured for many days ; whilst, if carried to the
same extent in healthy persons, its efiects would
be fatal, or nearly so. Abstinence, also, is longer
endured by persons of the middle or matured
epochs of life, than by those of an early age.

4. That the absolute or sudden deprivation of
food should be productive of more npidly serious
effects is very obvious ; but it is not so well known
that there are circumstances, which modify the
effects of the less absolute^states of abstinence, and
which, when thus combined, give rise to very im-
portant and dangerous diseases. In order to place
the subject more clearly before the reader, I will
Jirtt notice the effects of abstinence simply, and
unassociated with other causes of disease; and
next, the morbid conditions, which its association
with certain influential egeots usually occacioD.

5. 1st, The morbid efeeU of simple absthunee
— Keeping in recollection the modifications de-
pending upon the extent to which deprivation of
nourishment is carried, and the age and state of the
person at the time of its adoption, I may briefliy
describe the morbid effects ot abstinence as fol-
low. — Paleness and langour of the countenance ;
muscular debility and emaciation; a weak and
small pulse ; thirst ; at first quickness of intel-
lect, constipation, and flaccidity of the muscles.
To these succeed increased frequency of pulse,
palpitations, alternating with leipothymia, or even
full syncope ; headach or delirium ; flashes of
light before the eyes ; tinnitus aurium ; slight
amaurosis ; parched state of the throat, and thirst ;
pains in the stomach ; great wakefulness, followed
by delirium, sometimes mild, but in other caaes
furious, or at first mild or muttering, and afterwards
strong or furious ; sinking of the animal heat, or
alternate coldness and burning in parts of the
body ; and lastly, morbid sensibility of the organs
of sense and surface of the body, and greatly
depressed temperature, followed by insensibility,
stupor, or coma, terminating in death.

o. It is obvious that the severity and doiation
of these symptoms will vary in different cases,
according to circumstances peculiar to each.
But it is not so well known that they will be
actually produced by pursuing a too rigid absti-
nence m the treatment of various diseases, and
particularly when the nature ofthe disease n uk.
taken : as when the irritative symptoms frequently
sttendant upon diseases of debility, or on nervous
affections, are viewed as resulting from inflamma-
tion. Many cases have occurred to me in the
coune of practice, where the antiphlogistic regi-
men, which had been too rigidly pursued, was
itself the cause of the very symptoms which it
was employed to remove. Of these symptoms, the
affection of the head and deKrittv are the most

ACNE.

a?

lOMfkaUt. tad the moit veadily miitaktii k>r an
•etvtl dmmt requiring abftineoce for its remoYal,
A case of Uiti deacriptioQ lately occurred to me.
A pnlesBonal man wu seiied with fever, for
mivh a too rigid abstinence was enforced, not
mIt daring its oontinoance, but also during con-
nicKence, Delirium had been present at the
bdtt of the fever, and leourred when convales-
ffd. A physician of eminence in maniacal cases
m called to him, and recommended him to be
iwovtd to a PfivAte asylum. Before this was
earned into eoect, I was requested to see him.
AifribeBt treatment and regimen, with a gra-
dul increase of nourishment, were adopted, and
he vaa wdl in a few days, and within a fortnight
ittnnnd to his professional avocations.

7. Tht morbid appeamncm observed after fatal

caaa of deprivation of food poaaeM some interest.

TIk most remarkable are the emaciation and ab-

lorptiini of every particle of fetty matter : the

paknes, fiabbinesa, softening, and emaciation

fi the rolnntary mnjcles, and of the substance

uf the hMrt ; an exsanguined and pale state

of the riseera ; slight atrophy of the liver and

iyitea; iinnmMhArf riie of the stomach and

»<oii ; and particulaTly the increased vascularity

of die bfatn, and oometimes of the membranes

ii«, eonpared with the other viscera. It would

itXQ that a very large proportion of the blood

cmtsnei, ss in many cases of great vaAnilar de-

ph:^ to be sent to the brain to the very last.

Tb» B obviously o'wing to the pressure of the

ar 00 all parts of the body, from which the

^"v^piialoo is guarded by its unyielding case.

Is addition, also, to the vascularity of this part,

a faipid serous effasion between the membranes,

bfia tie ventricles, is sometimes met with.

8. 2d, Oftkt morbid effects of ahgtmena token
'^ n tmcmted with 4)lker hurtful agents. — These
^tcts are occasionally presented to medicdl men
uder a variety of circumstances, and from a
mied eombinataon of causes ; bat in the great
i&ajoritj of instances they result from deficiency
uf Wl merely, rather than from a rigid abstinence,
eonjoiaed with the depressing in6uence of cold or
=^dent clothing, great or continued exertion,
cr wkh a moist and unwholesome atmosphere.
7h«i we find the aasociation of then causes, par-
^icnlsriy insaiBcient or unwholesome food, labo-
rjms cscrtioo, mental depression, a moist, cold, or
•^wholesome atmosphere or locality, not infre-
'{oently give rise to purpura haemorrhagica,
^^ryy, scorbutic dysentery or diarrhoea, low or
Tphoid fevers, affections of the brain and nervous
Tstea, emaciation, with chronic ulcerations, &c.
—effects which have received a particular notice
a their respeetive articles.

9. The best illustration of the effects of this
^«*ociatiGD of other agents with a continued defi-
fVKj of food is famished by the diseases which
Vpeared a few years ago in tlie Milbank Peniten-
tiary. Hie prisoners confined in this prison were
•^'^AuAj put upon a diet from which animal food
■•u nearfy altoeether excluded, excepting in as
^ as it entered into the composition of a weak
^««p. They were at the ssme time subjected to
* low grade of temperature, to considerable ex-
^ftmi. and confined within the walls of a prison
'itvale in the midst of a marsh which is below
the level of the adjoining river. The conse-
•l«Qnccs were, fira, the loss of colour, of flesh and

strength ; subsequently, diarrhoea, dysentery, scor-
butic dysenterv, scurvy; and, lastly, low ataxic
or adynamic fevers, or headach, vertigo, con-
vulsions, delirium or mania, apoplexy, &c. The
smallest loss of blood producea syncope or lei-
pothymia, and fatal results. Yet, in the great
majority of the fatal cases, independently of the
lesions observed in the mucous surface of the
digestsre tube, or in other -situations, increased
vascularity of the brain and its meninges, fre>
quently with effusion of fluid in the ventricles or
between the membranes, was found upon examin-
ation after death.

10. II, The TnEATMENT of the morbid efiects
of abstinence is very obvious, yet considerable
care is necessary to its successful issue in very
urgent cases. Nourishment should be adminis-
tered cautiously, in a very sniall quantity at a
time at first, but frequently. It ought to be
bland and farinaceous : animal food may be en-
tered upon subsequently, and the quantity gra-
dually increased. The animal warmth should be
promoted, at the same time, by the usual exter-
nal means — by frictions and warm applications ;
and the bowels assisted by the occasional use of
bland enemata. Soups may be allowed early in
the treatment, but in a small quantity at a time.
Milk is often prejudicial, unless diluted and made
into gruel witn some of the farinaceous articles of
food. Internal stimulants are seldom required,
unless when symptoms of cerebral or nervous
irritation exist, when they may be given ; parti-
cularly the preparations of ammonia, the aithers,
camphor, vegetable bitters and tonics, at first in
very moderate doses, in conjunction with small
Quantities of an anodyne, as the extract of hop,
tne extract of hyoscyamus or of opium, the
paregoric elixir ; and by warmth, frictions, and
stimulating applications to the cutaneous surface
and lower extremities. These means will gene-
rally succeed in removing the effects of simple
abstinence whilst they admit of removal. Uhe
treatment of the effects resulting from the con-
junction of other causes with the one now discussed,
19 considered under their respective heads.

BiBLiOGRAPUV.— CtfrriV, Medical Rcport8,'4to ed., vol. i.
p. 904.— muan. Miscellan. Worki, by A. Sjmtk, p. 4cr7.
— Barroi, TraiU tur let Oantralgiet ct les Entcralgies,
&c., 3d ed. 8ro, Parit, 1829. — Piorryt Proc§tlc 0|>6rati)ire
dans rExploration des Organee, &c. &c.,8vo, Pariii, 1831,
p. :j68.'— p. M. Latham. On the Diseases In the Milbank
Penitentiarv, 8vo, I.ond. 1824. — ilm/ro/, Precis d'Ana.
ton. Patholog., L ii. p. 769. — Ro^an. Diet de Med» t. i.
p. 154— Cft. Londe, Diet, de M6d. et Chir. Prat., t. i. p.103.
Cottard de Martignjf, in MagemUt*» Joum. de Physiol.,
ftc., k. viii. pi l&S.

ACNE. *Aani. Derived, according to Cas.ViU9
(Nat. et Med. Quest., &c., Prob. 33.), from
oMfuin. SvN, lov^dof, Gr. Fonur, Lat. Psy-
dracia Acne, Sauv. Gutta Bcsea, Darwin.
lonthuSf Good. BouUm, Couperose, Fr. Die
JPffifitfn, Ger. Carbuncle, Stme-pock, Whelk,
Classiv. 3. Class, Diseases of the San-
guineous Function ; 2. Order, Inflamma-
tion (Good) ; 7. Order, Tubercles ( Willan
and Bateman). IV. Class, IV. Order
(Author, see the Classification),

1. Depxv. Hardfinjlamed, tubercular tumours,
suppurating very slowly, occurring chiefly in the
face ; sometimes, also, on the neck and shoulders,

2. I. Description. One or more, sometimes a
number, of these tubercles appear, generally in
successiott, in the face, and sometimes on the neck.

28

ACNE — Simplex -^Indubata — Rosacea.

sboulders, and breast, but never lower ; remain
permanent for a considerable time ; and suppurate
slowly and imperfectly, leaving a dark or livid
mark, which gradually disappears. They occur
chieBy in persons of the sanguine temperament ;
commencing at the period of puberty, and gene-
rally disappearing after thirty or thirty-five. They
are common to both sexes, but are most frequent
and numerous in the male sex.

3. This is one of the meet constant and unva-
rying in its characters of any of the affections of
the skin ; but writers upon this class of diseases
differ widely in respect both of its particular cha-
racter and seat. Willam, Plemck, Batemak,
and Thomson consider it a tubercular affection;
whilst Alibert, Biett, and Rayer view it as
pustular. I believe, however, that both opinions
are in some resfects correct ; and that in cer-
tain forms or states of acne the tubercular change
is predominant, little or no suppuration taking
place, but a state of slow inflammation giving
rise to a continued exfoliation of the cuticle, or
formation of thin scabs on their apices ; and thus
they slowly disappear ; whilst in others the pustu-
lar character is very distinct, but always preceded
by the characteristic tubercular hardness. This
affection may be viewed, therefore, as forming an
intermediate link between the tubercular and pus-
tular eruptions.

4. In respect of the particular tissue in which
this disease is seated, some difference of opinion
also exists. The greater number of writers on the
pathology have considered this disease to be
seated in the proper structure of the cutis vera ;
many of them admitting, at the same time, an
affection of the sebaceous follicles very nearly
resembling it. Mr. Plumbs, however, attributes
it entirely to obstruction and chronic inflammation
of these follicles. I believe that this opinion is
too restricted ; and that, whilst one form of acne
evidently depends upon this cause, others are es-
sentially disease of tne cutis vera.

5. Spec. i. Acne Simplex, Simple Acne, Syn.
Gutta BMea Hereditaria, Darwin. Dartre
Puttuleute MHiare, Alibert. lonlhue vartte
simplex, Good.

Simple aene affects most frequently young sub-
jects at the period of puberty, and particularly
females. They generally appear on the forehead,
shoulders, and upper part of the thorax, and are
liable to recur at the menstrual periods, especially
in cases of dysraenorrhoea. Many of these vari
do not proceed to suppuration, but slowly subside.
They are very commonly developed in succes-
sion -f commencing with small, hard, and inflamed
tubercles, of the size of a pin's head. These
continue to enlarge for three or four days, and the
inflammation becomes more apparent. In seven
or eight days they have reached their greatest
size. They are then dark red, smooth, prominent,
shining, hard, and slightly painful to the touch.
After two or three days a small speck of matter
appears on the apices of some of them; and
when these break, a thin humour exudes from the
tubercular induration, and dries on its surface,
forming a thin scab, which adheres firmly ; but,
after a few days, is loosened at the edges, and falls
off*; the tubercular hardness and livid redness gra-
dually subsiding, and disappearing after three or
four weeks.

6. In some penons this eruption recurs fre-

quently at short intervals, the vari being more or
less numerous ; in others it is more extensive, and
never altogether disappears, although it is more
troubleBome at one time than another. When
the vari are numerous, many of them undergo no
suppuration ; but the sebaceous glands aze often
excited, giving the skin a greasy appearance. In
many of these cases, several of the vari ^tnnnw
the characters of the next species.

7. Spec. ii. Acne Induhata, ^/unc-podlc.

The tubercles are larger, more indurated and
permanent than the foregoing ; and are appaiently
the consequence of a slower and more deepseated
inflammation. They often appear in conadereble
number, of a conical or oblong-conoidal form ;
some of them assuming a roseate hue, and tend-
ing to suppuration at their apices ; others remmin-
in^ in a hard, elevated state for a very long time.
without any appearance of the suppurative pro-
cess, or disposition towards it. In some cases, two
or even more of them coalesce, and occasionally
suppurate at their respective apices ; but one only
may undergo this change. As they continue
they become more purple or livid, particularly
when they have no tendency to suppurate. When
thev experience (his process, the same process of
scabbing and exfoliation, already described (§ 5.),
is gone through ; but it sometimes happens that
when they experience any irritation they may
suppurate a second time. As they very slowly
subside, they leave a purple or livid discoloration,
and, occasionally, a slight depression, which is
long in wearing off", and which sometiines never
altogether disappears.

8. This species of acne generally is moat fre*
(juent and numerous along the rami of the lower
jaw, on the temples, the nose, and cheeks ; alto
on the back and neck. They are frequently ac-
companied by a greasy state of the skin, from
an excited state of the cutaneous follicles; are
commonly sore and tender to the touch; and,
when numerous, are in every stage of progresct,
giving the surface a spotted and variegated ap-
pearance,— owing to the prominence and redness
of some at their commencement, to the yellow
points in those that are suppurating, to the scaly
crusts covering those which have undergone this

f process, to the lividity of those that have exfo-
iated or are subsiding, and to the discoloured
depressions which others have left after them.

9. The general health seldom suffers mate-
rially from either the simple or the indurated
acne, excepting as far as regards some pre-eaiating
and concomitant disorder of the digestive func-
tions. If fever, or acute disease, attack peiaons
aflTected with these eruptions, the vari generally
disappear ; but they frequently also re-appear upon
its subsidence, becoming in some respects a critl*
cal eruption.

10. Spec. iii. Acns Rosacea, Raiy-«irap,
Svn. Gutta K4Mea,Auct. var. Gulte Rawta
Hepatica, Darwin. lamlhui Coeymbifrr^
Good. Dartre Ptutuleuee Couperoae, Alibcvt.
Goutte Roee, C&uperate Raugeurt, Fr. Kup^

ferbandel, RotK-fWie, Ger. Carbtmtled l^ac»y
Eng.
The Jirtt and second species, described above,
might have been, with propriety, viewed as varie-
ties of the same species ; out this is a very dis-
tinct species from the preceding. It consists of
small, slowly suppurating tubercles, accompanied

30

ACNE — Taeatmemt op.

and excitement, or an imperfect performance of
the uterine fuDcdons ; by constipation ; by torpid
conditions of the liver; and by the injurious ad-
diction to onanism.

17. V. Treatment. — In the treatment of these
aflTections, our chief attention ought to be directed
to their pathological relations and causes. These
latter must be removed as far as may be done ;
and the former should both guide our indications,
and direct our means of cure. The apprehensions
entertained by the older writers, of producing
internal disease by the sudden repulsion of the
eruption, were founded on the results of observ-
atioD, although explained by partially inaccurate
or unsound pathological views. Affections of
the stomach, bowels, chest, and head, have been
thus induced, and been relieved upon are-appear-
ance of the eruption : but such consecutive dis-
eases are more common after the repulsion of
other eruptions. We should, however, as being
both the safest and the most permanent method
of cure, direct our remedies to the constitutional
or internal relations, as well as to the external
manifestations of disordeit

In the treatment of this, as well as many other
diseases, the causes, the state of the habit and
constitution of the patient, its morbid relations,
and its duration, are severally to be kept in recol-
lectbn.

18. 1st, Treatment of aene timples. — In deli*
cate constitutions, the chief attention should be
directed to the state of the digestive functions.
These should be promoted by gentle aperient*,
combined with tonia, and the functions of the
skin promoted, by preserving a free transpiration
on its surface. With this view, nUphur may be
combined with magnesia, or with cream of tartar,
and confection of senna, and taken in a sufficient
dose, at bedtime, to procure a full evacuation in
the morning, or any one of the formulas (Av.
Nos. 82. 89. 98.) may be had recourse to. These
may be occasionally changed for a powder with
rhubarb, sulphur, and magnesia, or for the ex-
tract or decoction of taraxacum, with carbonate
of soda or sulphate of potash. If the functions of
the liver are torpid, tne following may be taken
for a few nights : —

No. 6. B PiluL Hydrirg. Chloridl Comp. aj. ; Fellla
Tauri IntpiM. gr. xv. ; SoDonu CmUI. gr. x. ; £xtr. Ta-
raxdci 3 J. 31. Fiant Piluls xviii., quarum capiat binaa
▼el tres hor& somnl.

After the bowels have been evacuated, and the
secretions brought to a healthier state, the dilute
mineral acids, either alone or with bitter infusions,
may be taken through the day.

19. When the eruption occurs in young ple-
thoric persons, and when it is in females attended
with scanty and difficult menstruation, small blood-
lettings may be practised ; in the latter, by the
application of leeches to the superior and internal
parts of the thighs. « In more delicate females the
functions of the lower bowels are to be promoted
by the pilula aloes cum myrrfaa, combixied either
with pilula ferri eomposita, or with the extractum
gentians. When the eruption is obviously con-
nected with imperfect and painful menslmation,
the use of the warm salt water hip-bath, or of the
hip vapour bath, or warm salt water pediluvia,
after the application of a few leeches to the in-
sides of the thighs, will be extremelj serviceable.
In such cases, the internal exhibition of the bi-
berate of soda, «ith«r in the foraa of pill or draught,

combined with camphor, the extractum tanizaei,
or the extr.rutsB, or, as directed in Form. Nos. 93.
184. 209. 254. will be found of great advantage.

20. In addition to these internal remedies,
which require to be varied according to different
patholo^cal relations of the eruption, external
applications will be necessary; and when con-
joined with the above treatment, or employed
subsequently to it, no dread may be entertained
of any injurious consequences from them. The
ancients, particularly Cblsus, Pliny, Ames,
Paulus, Actuarius, &c recommended lotions
and liniments with vinegar and honey ; and these
sometimes combined with turpentine, emulsion of
bitter almonds, myrrh, alum, soap, Cimoltan
earth, the bruised roots of the lily, the cyclaonen,
narcissus, and the fruit of the wild vine; the
most of them calculated to be advantageous in
many states of the common forms of acne.

21. If the tubercles are much inflamed, and
inclined to be pustular, mildly stimulating appli-
cations are most serviceable, as dilute spirit, or
the pyrolignoous acetie add, or lufucr amtnoni^
aeetatis, with rose or elder-flower water. In the
more indolent cases, or when the skin can bear
an augmented stimulus, Willan and Batess an
recommend from half a grain to a grain, or more,
of the bichloride of mercury, in each ounce of the
vehicle ; or a dniehm or more of the liquor potanee,
or of the hydrochltyric acid, in six ounces : and
Thomson advises that the emulsion of bitter
almonds, containing ten minims of hjfdroevanic
acid to each fluid ounce of the emulsion, anonld
be the vehicle adopted. The solution of the
sulphuret of potauium, in the proportion of a
drachm to twelve or sixteen ounces of water, may
also be employed; and, in the more obstinate
cases, the baths directed in Form. No. 14 — 17.
may be had recourse to. The solution of the hy^
drochlorate of ammonia, either alone or with the
bichloride of mercury, is often serviceable.

22. The lotion (torn which I have derived the
greatest advantage in practice, and which I have
found the most geneially applicable, is a solution
of the biborate of soda in rose or elder-liower
water, or in water which had been poured in the
boiling state over sulphur, and allowed to infase
for ten or twelve hours. The borax may also be
dissolved in equal quantities of elder-flower water
and honey, and lised as a lotion in the moi«
chronic cases.

23. 2d, Treatment of aene indurate.— In yonng
and plethoric subjects, or in females, when the
eruption is accompanied with a scanty and pain-
ful menstruation, the treatment already pointed
out ($ 19.), should be put in practiee. When
we suspect that sexual irritation or maatnibation
is connected with the causation of the eruption,
earl^ rising, mental occupation, the use of gentle
cooling aperients, of soda combined with amalt
doses of camphor, soda water, sulphur with aoda
or antimony, are the most serviceable internal
remedies. After these, the mineral acids, the
sulphureous mineral waters, and gentle vegetable
tonics, will be useful. Where the eruption is de-
pendent upon torpid function of the stomach, or
liver, or bowels, mild alteratives, exhibited at bed-
time, as the pills already prescribed (§ 16.), and
Sntle tonics through the daT« will be required,
a most obstinate case» which some time ago
came befoie me m a lady, whom ell the pt«c«

84

ADHESIONS — Morbid.

rery quick, and the powers of the Utter fail, thi^t
much dreaded state of the frame, which is insuf-
ficient for the formation of coagulable lymph,
may be considered as approaching, if it be not
actually present In all cases where blood-ves-
sels are liable to be inflamed, this state of the
constitutional powers, owing to the risk of the
blood being vitiated, is particularly to be guarded
against. Having advanced as much as belongs
to my province respectiag the reparative states of
adhesion, I proceed to state briefly the doctrine
of Morbid adhesions. The particular morbid ad-
hesions are noticed under the articles on the
pathology of the parts in which they form.

10. Adhesions in some one of the states de-
scribed above {§ 1—4.) are liable to occur, as a
consequence of certain grades of inflammation, in
the following situations: — 1st, In the cellular
tissue ; 2d, Between serous surfaces ; 3d, Be-
tween mucous surfaces ; 4th, Between synovial
surfaces ; 5th, In the internal surfaces of blood-
vessels ; and, 6th, Between the surfaces of morbid
or accidental formations.

11. A, AdhuioM of Cellular 7iMii«.— The
first step of the process is the exhalation of a
quantity of yellowish serum and of coagulable
lymph mto the cellules of this tissue, which ulti-
mately agglutinates them together, upon the
absorption of the former, and the concrescence
of the latter. The consequence of this is, that
the product of inflammation formed in the centre
of the inflamed cellular tissue, consisting chiefly
of the more fluid and least concrescible portion of
the exhalation, is prevented from permeating the
agglutinated cellules, and a barrier is set up
against it. If resolutioo takes place and the pu-
rulent matter is absorbed, the surfaces of the
cavity become united, and the medium of union
is changed, as in cases of recent wounds, and in
the manner described above ($ 6.). If the parts
p> on to the evacuation of the matter, adhesion
IS also effected, as in the case of eomecutive re-
storative adh^on ($ 7.) ; leaving, however, a
cicatrix, which is gradually diminished, formed
of the cellulo-fibrous medium of union. In all
cases of inflammation of cellular tissues, adhesion
of the cellules, from the exudation of a concres-
cible lymph, takes place ; and it is this adhesion
which forms the fibrous cysts to abscesses, iso-
lates their contents from the surrounding struc-
tures, and in some respects excludes them from
the economy. Adhesions of the cellules of this
structure also strengthen the cysts of aneurisms,
and form sero-fibrous cysts around foreign bodies
that are accidentally lodged in it.

12. B. Adhesions between mrous surfaces are
the next most common; being fonned through
the medium, either of a more or less thick and
firm inorganic albumen, in the form of a false
membrane, or of this substance advanced to a
more or less organised state, and assuming either
the appearance of cellular tissue, with a surface
partaking of the serous character, or one of the
states alMut to be noticed. The organised nature
of those adhesions has been denied by some ; but
the observations of Stoll, Hunter, Dupvy-
TRiN, Baillib, Mxokxl, Homb, Lobstxin, Cru-
vxiLHiBR, Gendrin, Baron, Rud Others, who
have traced blood-vessels in them, have put the
question at rest. Adhesions occur most frequently
Mweeo the pleurs, next in the peritoneusi, and

next to these in the pericardium. They are com-
paratively rare in the tunica vaginalis ; and in
the arachnoid they are still more tare.

13. It is not necessary to the formation of ad-
hesions between opposite seioua surfaces, that the
pre-existing inflammation shall extend continue
ously to both. When the coagulable lymph is
thrown out upon one of the two inflamed surtaces,
— as, for instance, on the peritoneal surface of the
small intestines,*-4t seems to act as an irritant to
the opposite part of the omentum, with which
it is brought in contact, inducing inflammation
of that part only, and leaving the intervening
surface both above and below it unaffected. The

f>art thus irritated by the contact of the coagu-
able Ivmpb, poured out by the part primanly
affected opposite to it, becomes also mflamed,
and exudes this concrescible fluid; and the
inflammation thus secondarily induceid in a part
of the omentum, may advance to the external
surface of the omental duplicature, and, by means
of the exudation of this product of inflammation
in that situation, excite a similar state of action
in the directly opposite part of the peritoneum
reflected over the abdominal parietes. Thus the
inflammation and its consecutive adbcsioDs may
proceed, without the disease having affecUid any
of the continuous surfaces intervening between
them. A similar circumstance is sometinaes ot>-
served in respect of the convex surface of the
liver and peritoneal surface of the diaphragm.
Inflammation, commencing in a part only of the
former, will excite it in the part of the latter
exactly oppositet and be followed by adhesion;
and the inflammatory action, not infrequently ex-
tending upwards through the diaphragm to the dia-
phragmatic pleura, will be further followed by the
exudation of^ coagulable lymph on its free surface,
which, irritating that portion only of the pulmonic
pleura opposite to, or in contact with it, wdl infUme
that part, and form adhesions with it, without
affecting the continuous surface intervening be-
tween, and surrounding the sdherent parts. The
unadhering cavity, however, not wfreqnently
contains a turbid or flaky serum, with patches of
fslse membrane, arising from a less acute state of
inflammatory action in those parts of the serous
surisoe immediately adjoining the adhesions. Thus
it is not unusual to find, in cases of acute inflam-
mation affecting either the peritoneum, pleura, or
arachnoid, and limited to a particular pert, a
similar state of disease, and the same product,
formed only in the parts opposite, and most nearly
in contact; whilst the continuous snrfiMes sar^
rounding them are either altogether sound, or
much less affected ;-— most commonly only so
far as to give rise to a serous exudation, or abght
albuminous coating, in their immediate vicinity.

14. From this it will appear, that the near
approach, and more espeoally the imnediale
contact, of opposite surfaces, and the want of
motion between the one surface and the other,
will favour the formation of adhesions: thus they
are most frequent at the superior parts of the
pleura, between the convex surfiice of the liver
and the diaphragm, and the serous suiiaces of
parts included in heraim. Thedifierant species
of medis, by which adhesions of serous wnhceB
are affected, are the following, according to hi.
CaovxiLBixa :— An inorganised false membrane ;
a filaasntouB adhesion, and a cellalar mdhakm.

36

ADIPOSE TISSUE— MoRDXD States of.

This may be viewed as the primary form of their
adhesions, and its usual results. When, how-
ever, suppuration takes place in their inleroal sur-
face, the adhesion is formed consecutively in the
manner described above ($7.) ; or the primary
may pass into the consecutive form of aahesioo,
particularly when the false membrane is insuffi-
cient to fill up the entire canal of the vessel.

19. Adhesions take place more readily in veins
than arteries ; are proauced in both, and in lym-
phatics also, in the manner now stated, generally
m consequence of inflammatory action, attended
with sufficient power of the constitution to form
concrescible lymph (see the articles on Arteries
and on Veins) ; and sometimes, even after a very
slow and slight grade of this action, when the
opposite surfaces of the vessels are pressed toge-
ther by any tumour existing exteriorly to them.
When artificially excited in arteries, as by the ap-
plication of ligatures, the inflammatory state which
prodaces the adhesion is not so prone to extend
along the axis of the vessel, or to occasion dan-
gerous eflTects, as when it is excited in the same
way in veins. When thus produced in these lat-
ter vessels, fault of constitution, an unhealthy
habit of body, unwholesome state of the atmo-
sphere, &c., or the other causes above assigned
($8.), will generally interfere with the process,
and occasion that state of morbid action, and of
its products, which will vitiate the current of the
circalation, and even destroy life. (See Veins
—'Inflammation of.)

20. F. Adhesions of the internal surfaces of
cysts, and other morbid formations, sometimes
take place from a consecutive state of inflamma-
tion extending to them. Large cysts, which in
consequence of their situation cannot be removed,
may be obliterated by their puncture, and the

J>roduction of inflammation of their internal sur-
aces, so as to procure their adhesion.

21. G. Adhesions may also form between
parts of the cutaneous surface, when deprived of
the cuticle, and kept in close contact. This is
not infrequent after scalds and bums, and is pro-
duced in a similar manner, as I have explained,
in respect of adhesions taking place prmiarily,
and without suppuration, or subsequently to the
occurrence of this process in the cellular and
mucous tissues. Adhesions also occur in other
situations, as between the iris and capsule of the
crystalline lens, &c. ; but I have noticed those
which more especially belong to my province.

BiSLtooKAPHT. ~ BicAaf, Anatomie G<n#rale, t It.
pasUm. — J. Cmtand, Lond. Med. Repot., t. xv. p. S7S.<—
Scoutetten^ Archives G^n^r. de MM. t. lii. p. 497., t. it.
p. 386., t. y. p. 597- Lond. Med. Repot, yol. xxH. ,p. S3:}.
'^RenatUdin, art. Adkirruoei, in Diet, dct Sdcn. M£d.
1. 1. — Brneket^ art. Adherence*, in Diet de MM. t. i.

?. 340. — JSnroit, On TuberculHtcd Accretions of Scroui
f ctnbranct, 8vo. 1819 ; and Ilhiitrationt of Tuberculou*

Diteatct, 1«22 CruveilMuT, Etiai tur I'Anat. Pathol.

t. i. p. 144. i et art. AdA^sions, in Diet, de M6d. et
Chirurg. Pratique*, t. i. p. 317. — Meekelt Anatomic
Oinfr. et Patholog. t. iii. pastim. — Gendrim^ Hiitoire
Anaton. det Inlamniationt. S t 8ro. Paris, 18S7. —
AndraL Archive* Ote. de Med. t. iii. p. 246. ; cc Clini.
oue Medlcale, ftc t iii. et iv. pasHmj et Anatomic
Path(4ogique, passim. —Craitift On General and Pathol.
Anat. passim. (See alto Biliiog, and Btferenees to art.
Ikflammation.)

ADIPOSE TISSUE.— TtU adipota, Lat. TUiu
gntisteux, Fr. Dat Fett, Germ.— Its Morbid
States.
Classif. — IV. Class, IV, OfiosR (Author,
see th$ Prrface)*

1. The adipose substance is frequently either
diminished or increased far beyond the healttiy
standard. — A. Excessive diminution of this sub>
stance, atrophy, occurs naturally in very aged
pereons ; and there seems to be, even in early
life, a tendency to it hereditarily in certain con-
stitutions, particularly in those of a peevish ^
anxious, and irritable temper. It is ofteo met
with as a consequence of, or conjointly with,
pulmonary and other organic diseases, particu-
larly those which interrupt assimilation and the
supply of nutrition. But it is also a symptom
of aJl diseases, which impair the vital eneigies by
morbidly increasing the secretions and evacu-
ations ; as in diabetes, diarrhoea, and dysentery.
It also necessarily proceeds from long abatinence,
&c.

2. Atrophy of this substance may be temporary
or pennanent. It is nsually the former in early
or middle life, and continues merely as long aa the
causes which occasioned it. It is usually perma-
nent in advanced life, and in those of an active,
peevish, restless disposition. In every case the re-
moval of the fatty matter is produced by abeorptiois;
and, according to the experiments of Maoknoic,

TlEDEMANK, UMEUN, MaYER, &C., this pfOCCAS

may be ascribed, at least in part, to the minute
veins. The circumstance of fatty and oily mat-
ter being constantly found in the blood, but in
variable quantity, as shown by Trail, Babing-
TON, Lb Camu, &c., seems to support this view ;
for, if taken up by the absorbents, it may have been
changed or assimilated in its passage through the
absorbent glands before it could have reached the
blood.

3. B, Excemve deposition or hypertrophy of thi^
substance {adiposis} is very common, aflfectan''
the body generally, but sometimes locally only.
Persons have weighed as much as 500 or 600 lbs.
owing entirely to this state of hypertrophy. Thi?
tissue is naturally abundant in females and
eunuchs. Its hypertrophy is frequently occa-
sioned by excessive venereal indulgences, particu-
larly in early life, and when conjoined with high
living and mdolence. It generally is attended
by 'a weak languid circulation, weak digestion,
with craving appetite, defective secretions and
excretions, and aisinclination to active mental or
physical exertion. It also evinces a marked here-
ditanr character. Full living, particularly on food
which abounds with the elements of the mtty sub-
stance, as sugar, spirituous and malt liquors, &c.,
tend greatly to promote it. The connection of
this morbid state with deficient assimilation ap-
pears fully proved. It would seem that in persons
whose vital energies are diminished, whilst the
appetite remains unimpaired, or is excited by t^i.
mulating liquors, 6cc., the sanguifaction of chyle
does not take place so rapidly nor so perfectly as
in health ; that a large portion of this fluid assumcst
an oily or fatty character, and is deposited in the
adipose tissue, which thus becomes one of the
emunctories of the frame, in which a substance
that cannot readily be carried out of the circu-
lation by any other organ is set apart for the
purpose of future absorption, assimilatioOp ao'J
nutrition, as the wants of the system may requtr«.
and to prevent its hurtful accumulation in the
circulating fluid. Thus, in persons otherwise ap-
parently healthy, the excessive accumulation of
fat is often one of the earliest and moat remark-

AFTER-PAINS — Symptoms and Duonobis.

37

able sgnt of diminution of the vital energies of
the frnne. (See art. Obesity.)

4. C. In many instances, when the powers of
t}te coctttitution are either greatly reduced or other-
wise perverted from the healthy state, the adipose
i&a:tcr is also changed in coUnLr, composition, and
rynsiaence, becoming remarkably pale, or dark,
reddtth, or gelatinous. It may likewise be, par-
limlarij ia cachectic persons, uncommonly
«uery, soft, smeary, or jelly-like ; and, on the
contrary, bat more rarely, hard, waxy, or even
iKHny.

5. D. It may be a question whether or not this
trtRure 18 liable to iuflammation. Considering it
merely as a modification of the cellular structure,
chiefly in as far as it contains the fatty substance
of the body deposited in its areols, the containiog
a«ue only must be looked upon as that which is
li&Ue to inflammation or any other disease ; the
fat or contained matter beiog entirely passive, and
mocfified only by the morbid states of the tissue
vbch secretes and contains it. There seems little
doabt that the adipose tissue participates in the
ranons states of diffuse inflammation ; whether
t^ attending upon certain forms of erysipelas, or
bllowing accidents, or the inoculation of morbid
matter. When thus inflamed, it rapidly passes
lato a state of sloughy and fetid suppuration ;
W|e portions of it being not infrequently con-
verted into an ash-coloured, semifluid pulp, mixed
«ith ikreds of cellular tissue and albuminous
fsaoo-. or becoming entirely sphacelated.

6. E. Effuaian of blood into the adipose tissue
nrcwB ander smilar circumstances to those con-
nected with hemorrhage into the cellular sub-
^aoce, but much less frequently. This change
lias been occasionally noticed by Huxiiah, Cleg-
hoe?!, Caiiioic, and by myself and others, in
ft:orbutns, purpura hsmorrhagica, and in the
r<que9cent or malignant forms of remittent fever
ia warm or unhealthy climates.

7. F. Of the tumoun most frequently developed
i^i this tissue, the most remarkable are — a. Adipose
ureoma, which is surrounded by a thin capsule of
cellular tissue condensed around it, and consists
of an unusual accumulation of fatty matter in
cells, tike component fibres of which are so firm
St) to give consistence to the tumour : it closely re-
sembles a local hypertrophy of the adipose tissue,
excepting that it is surrounded by a capsule -, and
It may have either a broad or narrow base ; — b.
Steiitomatous tumours are chiefly a peculiar modifi-
cation of the fatty secretion, which is accumulated

, surrounded by a spheroidal cyst : they

m

are not formed of cells, in which the fatty matter
U deposited, but consist of a simple semifluid sub-
stance secreted by the inner surface of the cyst :
tk#y occur more frequently in the cellular, than in
the adipose tissue ;-— r. Atheromatous and melice-
Tov$ tumours are either modifications of the steato-
matoiu, or proceed from the change ioduced in
^mall chrcmic abscess; but they are most com-
icoaly the former when seated in (his tissue.

8. O. MeUiumd deposition is sometimes found in
Loth the internal and external adipose substance.
It may be either disseminated in the form of small
Uiky spots, or accumulated in spheroidal masses ;
or found in a semifluid state and brownish black
colour, surrounded by a cyst' formed by the con-
^Uf-risatioo of the contiguous cellular tissue. As
to the state in which this peculiar matter is formed,

great diversity of opinion exists. Laennec sup-

f»osed that it is first secreted in a solid form, and,
ike tubercular deposits, afterwards becomes soft.
I am, however, inclined to adopt the opposite
opinion ; viz. that it is secreted in a fluid or semi-
fluid state, and that it afterwards becomes firm by
the absorption of its more fluid parts. The observ-
ations of Drs. CuLLEN and Carswell, and of
M. Cmomel, seem to confirm this opinion.

BiBLtoaaAPHY — Art.Grix«s«e, CormUence, and ObHUit
in Diet, dea Sciencei Medicate*. .— Gragjcy in Journ. fUr
Chirurg. und Augenheilk. b. ix; p. iii. p. 2ffJ. — Grunct.'De
Sani et MorboaA Pingucdinis in Corpore Secretionc, 8vo.
Ber. 18S6. — Oito, in Selt. Beot»cht. b. il p. 166. — Cho-
met, Nouv. Journ. de Mi^d. t. iii-p. 41. — Craigie, General
and Patiiological Anatomy, p. 62,

AFTER-PAINS. Syn. Parodynia Secundaria
DoUrrosat Good.
Classif.-«>5. Class, 3. Order (Good). II.
Class, III. Order {Author),

1. Defin. — Pains, more or less severe, either
continuing or supervening ihortly after the expul-
sion of the placenta in ehild'birth,

2. I. Symptoms and Diagnosis. — Attacks of
pain in the abdomen are usually experienced in
the early part of the puerperal state. They pro-
ceed, when very severe, from the contraction of
the uterus, irregularly excited by the presence of
coagula. They usually soon follow delivery,
are least severe after a first labour, are increased
upon the application of the child to the breast,
and last for a day or two. They are generally
aggravated by flatulence and costiveness.

3. It is extremely requisite for the young prac-
titioner to be on his guard respecting the nature
and seat of pain after delivery, as the commence-
ment of the most fatal diseases to which the sex
are listble may be mistaken, if not carefully ob-
served, for after-pains. These latter are the
result of the natural contractions of the womb,
and of its return to its former state ; and are dis-
tinguished from disease, particularly inflamma-
tions of the uterus, ovaria, or pelvic peritoneum,
by their remissions, and by the absence of tender-
ness or tension of the abdomen, especially on
pressure. The uterine discharge, also, is not
obstructed ; the milk is secreted \ there is no
shivering nor vomiting ; and the pulse is seldom
increased in frequency.

47 When the patient's bowels have been neg-
lected previously to confinement, and when
much flatulence existo, the after*pains are often
complicated with colic, or they assume a colicky
character. In cases of this kind, the abdomen is
often somewhat more tense and distended than
usual ; the fits of ^ain are severe, with complete
remissions ; the patient complains of flatulence ;
the bowels are constipated : but the pulse is not
much aflected ; the skin, particularly of the
trunk, is not hot ; the tongue is moist ; and the
feet are often cold ; in a few cases there is retch-
ing. It is important to attend carefully to the
character of puin consequent upon delivery, and
to consider it in relation to the attendant symp-
toms, particularly the states of the pulse, and of
the abdomen. We ought, therefore, to inquire
into its exact seat, examine the pained part care-
fully with the hand ; and, having ascertained in
what manner it is aflfected by the examination,
we readily arrive at just conclusions as to its
nature. When it is felt in the regions of the
I uterus and ovaria, and accom ponied by great fre-

D 3

38

AGE— 1t« dipterent Pfhiods,

bv removinj; flatus, and promoting the restoration
0^ the uterus tn its nntuml state. In the more
urgent ca.«e«. anodynes may be conjoined to the
fore;;oin<r means ; for, when thus associated, they
will not act in prevcntin*^ the contractionA of the
uterus. (For H\>tkralc:ia, and the variout dis-

quency of pu1«e, ditorder of the lochlal discharge,
tenderneM, and fulnew of the hypoiiJi-tric region,
&c., the existence of the inflammatory di9ea«i>s of
the uteruit, and of its iipncnda;;e5, are to be in-
ferred. If it be complained oif about the groin,
it may lie the forerunner of phlegmasia dolen« ;
and if it be felt about the hip, or in the muscles | eases of the ulcru«* in the puerperal and unimpreg-
of the pelvis, alnlomen, or thiglw, it may Im: nated stales, see Uterts.)

rheumatic, owing to the application of cold in
■ome form or other. The painn of rheumatism
are readily recognised from their Feat, their ach-
ing or gnawing cliHracter, the manner of their
affecting the motions of the part, and the attend-
ant symptoms. The diagnosw, however, of these
diseases is fully poiuted out under their respective
heads.

5. II. Treatment. — The exhibition of an ano-
dyne, with attention to the f:tate of the bowels
subsequently, has generally been considereil suf-
ficient for the relief of after-|>ains. In the more
■evere cases, an anodyne linmient has been re-
commended to be applicl to the abdomen, in
addiuon to the exhibition of a dose of laudanum
internally ; and, in protractetl cases, Dr. Burns
advises a purgative — certainly the best part ot
the treatment usually resorted to. I am, how-
ever, of opinion, from remarking the results of
this practice, that the common or le-^s urgent
cases would have been better left to nature ; and
that friction of the abdomen merely with any of
the liniments in the ApficndiT (F. 297, 298.), or
friction followed by a purgative, or an enema, is
all that is necessary. We ought to recollect that
these pains are merely the result of the healthy
tonic contractions of the uterus upon the con-
gested veins, and the coaguia remaining in it,
occasioning their expulsion, and the discharge of
the blood accumulatetl in its sinuses ; and that
the more effectually these ends are accomplished,

Earticularly in unhealthy situations, and lying-in
ospitals, the less risk there will be of the occur-
rence of dangerous forms of puerperal disease.

6. Whilst, however, anoflynes allay the morbid
sensibility of the uterus, they tend to dimioi^th its
tonic contraction, to induce a congested and re-
laxed state of Its parieles and mouth, and to
favour the admission of air into its cavity. Air,
when admitteti, particularly under certain circum-
Ktancea, Is productive of the must dangerous re-
sults, from its effects upon that portion of the
surface of the womb to which the placenta was
attached. Impressed with the justness of this
view, I have usually recommended frictions with
liniments over the region of the uterus, and a
purgative, or purgative injection, which will tend

^ essentially to favour the contraction of the uterus,
and the expulsion of the cause of irritation.

7. In cases complicated with flatulency and
colic ($4.), the above means are still more re>
quisite ; but much will depend u|}on the choice
of purgatives. My own experience, derived en-
tirely from consultation, is decidedly in favour
of a draught, consisting of half an ounce of the
oleum terebinthinie, combined with the same
quantity of oleum ricini ; or an enema, contain-
ing the same medicines. The combination, also,
of a purgative with assafteiida, or any other
antispasmodic, and an injection, consisting of in-
fusion of valerian, or containing assafoptida, with
M due jiroportion of any aperient meilicine (see

K J30. 135. 138.), will seidom fail of giving relief.

BiBi.io<:HAniY DmmaH, Introduction to the Prac-
tice of Midwifery, Ac. I«nnd. IHlfi, 5th t>il i t. — O.-irrfirn,
Traite complct d'Acrouchifmenf et ilea MalaJiet dm
Femine<, &c. t. iii. rarU, l«vir>. — JinrnM, Friiicipica of
Midwifery, Kc. LjmhI. lhv.'4, p. -VJo. — Good. Study of Me-
dicine, vol. ▼. — Hjfan, Manual of Midwifery, 3d edit.
Loud. 18J1.

AG E. — Svy. — /Etai, Lat. Das Alter, Ger. Agi,
Fr. EtUy Ital.
Classif. — Pathology and Tiikrapeutics.

1. In the succinct view I purpose to take of the
pathological and theraiieulical indications which
this subject w.ll naturally suggest to the mind of
the practical physician, I purpoM*, ,/ifr»(, to sketch
the successive epoch-* of life, and thus consider
the word in its generic acceptation. When I ar-
rive at those periods of existence to which the
word af^e is s]K'citicRlly applicable, the changes
which take place in the human fnime, in respect
both of organisation and function, with the ad-
vanced progrts-* of years, — with age in its ipecific
acceptation, will be fully stated, as furnishing
important data for practical indications in the
treatment of diseases of this epoch.

2. I. Or AoF rv it«* okniric Acceptation,
— or different KpDchx of Life. — Before I proceed
to consider the subject in its enlarged point of
view, 1 may briefly advert to the periods into
which the u.^ual natural duration of human exist-
ence may be divided. Without occupying my
limits with the divisions adopted by ancient and
modern writers, I shall adopt that arrangement
of the different epochs of life which has been
suggcnted to my own mind, from observing the va-
rying manifiMttation^ of life and function, and the
modiHcations of di>cHsed action with advancinfi
age. I'ho division which I have thus adopted
may require more to be said in support and illafl<
trafion of it, particularly in respect of its physio<
logical relations, than 1 am willing to adranoe
on a subject which may be considere^l as nearly
verging on the s{)cculative. Leaving, therefore
out of sight many of the physioloj^ical and psy*
chological views, which would arise out of as
extended investigation of the subject, I shall
merely briefly advert to topics of practical im-
portance ; — those which concern the medicil

! jurist fall not within the *icope of this work. (Foi
epo<?h of ftvtal lij'et see Futus.)

3. Before proceeding to consider the different
}>eriods of age individually, it may be useful to
exhibit a view of the arrangement I intt d to
follow : —
i. Period, or that of Infnncy.

1st Kpt)ch, to the commencement of the fini

dentition.
2d KfhKht from the commencement, to the
completion, of the flrst dentition,
ii. Perioo, or tJutt of CliiUUtood.

Kxtcnding from the completion of the fint t(
the coiiipU'tiim of the second dentition,
iii. Pfnion, or liouhiXHl — Girlhood,

From the seventh or eighth \'ear to the com*
mencemcnt of puberty.

AGE^Infakoy.

39

▼• PxmiOD, or Adoltiewnet*

Commencing with the first appeanmce of
puberty, and extending to adult age.
V. Peuod, AduU Age.

1st Epoch, or early adalt agCi or confirmed
Tirility.

SdfjMcft. or mature age.
tL PaaiOD, Deetining Age,

let Epoch, declining age.

2d Epoch, advanced age.
vii. Pbbiod, OU Age.

let Epoch, ripe old age.

Sd Epoch, decrepitiide— second infiancy.
4. L PmaiOD, or that of Infanct, (Infantia,
from the privation of tpeechO commences with
birth, and eiteods to about the end of the second
year, when the first dentition is completed. It
nay be divided into two epochs ; the fir^ begin-
ain^ at birth, and extending to the sixth or
seventh month, when dentition is fully com-
maiced ; the teeond proceeding from this age to
the end of the perioa, the completion of the first
dnititioa, when the relations of the young being
vhh the external world are fully established by
the developement of the s^psorial and locomotive

5. A. Daring the fir ft epoch, or that preceding
the coamenoement of dentition, all the structures
vt merely in the course of developemeot ; par-
(kohrly the osseous system, the cerebro-spmal
B9vi»s system, and the organs of locomotion.
The fiincdons are only acquiring activity, and
srreral of them have not yet appeared. The
vit^ phenomena gain strength, whilst certain of
ibose fdncboos, by which the young being is to
bold convene with the objects around him, either
begin to dawn, or have not yet merged into
existence. The manifestations of life are chiefly
T^^tative, and the movements automatic or sym-
pathetic. The attitwiei are generally without va-
riety, and the changes of the countenance express
merdy pleasure and. pain to the spectator ; but.
to the medical observer, they convey important
information, and often all that he can obtain re-
fpectiDg the maladies incidental to this period of
lift. At this epoch, the position of the limbs, the
chancier of their motions ; the cry, and its nu-
merotis varieties ; and especially the changes of
the coontenance *, the state of tlie eyes and eye-
Fids ; the openness, contraction, &c., of the eye-
brows; the appearance of the lips and nostrils,
cff the mouth, gums, and tongue; — all furnish
means of ascertaining the nature and progress
of disease.

6. «. At this age the organs of digestion are
anauHed to any other food than that derived from
the breast of the mother ; and so little capable
are they to assimilate any other, even of the
blandest and most digestible kind, or the milk of
other animals, that very few, not more than one
in six or seven, ever arrive at the more advanced
periods of life who are deprived of the kind of
aonrisbraent nature intendc»d for this epoch. At
dui sge the system is extremely susceptible of
ezteraal impressions acting upon the lungs, sur-
face of the body, and digestive organs ; and par-
ticularly to the influence of cold. Recently re-
moved from a constant and unvaried warmth,
sad having heretofore existed vrith all the mucous
surfues mot from the action of foreign agents,
the yovDg infint hnptiativeiy Teqaires to be pre*

served, nartieularly during the first months of
this epoch, from the influence of a low range of
temperature, and from its sudden changes. The
disposition to increased action in all the mucous
membranes, and the great susceptibility of the
respiratory nerves, require the surface of the
boay, and particularly the organs of respiration^
to be guarded from atmospheric vicisstudes ; the
chief source of the diseases which are so preva-
lent and fatal at this age. A similar suscepti-
bility of the digestive mucous surface also exists,
and is but too frequently evinced by the slightest
change in the milk of the mother, or addition of
articles of food unsuited to the state of the diges-
tive organs. Much of the mischief, however,
which improper ingesta are calculated to produce,
is guarded against by the copious secretion of
mucus, with which the internal surface of the
stomach and bowels is covered, particularly in
very early life.

7. The susceptibility of the mucous tissues to
stimuli and irritants, and their proneness to in-
flammatory action at this age, extend also to the
cutaneous surface, as shown by the frequency of
acute exantbematous diseases, and of chronic
eruptions. The intimate sympathy existing be-
tween both these structures is very strikingly
evinced, by the frequent association of inflam-
matory excitement of the mucous surfaces, par-
ticularly of the digestive canal, with a similar
afleclion of the skin. The co-existence and close
connection of inflammatory irritation of the di-
gestive mucous surface, and an analogous state
of disease of the brain and its membranes, or the
supervention of the latter on the former, are also
often observed. During the first months of ex-
istence, vascular action in the brain is promi-
nently developed, and engaged in perfecting the
organisation of this organ : and partly owing to
this circumstance, as well as to the quantity of
blood sent to it, compared with the rest of the
bodv, and to the various causes tending at this age
to derange its circulation, is readily kindled into
an inflammatory state of its substance or mem-
branes, giving rise to active congestions, eff'usions
of fluid in the cavities and between the membranes,
and to various other organic changes particularised
in their appropriate articles.

8. b. With the susceptibility to be impressed by
the causes of disease, evinced chiefly in the ner-
vous centres and mucous surfaces, and producing
their effects, not only on them but also on the
serous cavities, there Is intimately connected a
marked disposition to be affected by medicines,
which exert their influence in an especial manner
upon the nervous system. Of these the most re-
markable are narcotiGS and irritating stimulants.
The susceptibility to the influence of the former,
particularly the preparations of opium, and their
effects, pnmarily in increasing vascular action
in the brain, and secondarily m favouring con-
gestion in the same organ, according to the dose,
have appeared to me so important, that, during
an extensive public practice amongst this class
of subjects, I have scarcely ever ventured, during
this epoch, on the exhibition of these medicines,
excepting under peculiar circumstances, which
will receive a more particular notice in other
places. A similar caution is also ncccMary in
the use of stimulating and irritating substance^.
The aperient medicines which are so often re-

D 4

40

AGE — Infancy.

quired at this age should be ehiefly of a mild and
unirritatiog quality ; and, whilst cold and moisture
must be avoided, too warm clothing, particu-
larly of the head, ought to be equally shunned,
Exposure to a mild, healthy air, frequent ablu-
tions of the surface with cold water during the
latter part of this epoch, — commencing first
with warm water, and passing on to the use of
tepid, and afterwards of cold water, as the infant
increases in strength, -—followed by frictions,
and careful attention to the state of its evacu-
ations, are means which should not be omitted in
the management of this period of life. Although
cold bathing is generally beneficial after the first
months of infancy have elapsed, care should be
taken not to subject the infant to the influence of
cold beyond a mmute or two, or loneer than may
be requisite to the perfect ablution of the surface ;
for, at this epoch especially, the impression of
cold continued for any considerable time de-
preises the vital energies, and prevents the de-
velopement of that state of healthy secretion on
the surface, which usually follows the momentary
or brief action of cold, particularly when followed
by dry frictions.

9. B, The teeond epoch of this period, extend-
iog from the commencement of the first dentition
to its completion, embraces also the important
period of weaning. The natural changes pro-
ceeding in the different structures and functions
during the Jirtt epoch also continue through this.
As this period advances, the functions of external
relation, particularly speech and voluntary loco-
motion, commence, the phenomena of perception
are more perfect, and the manifestations of mind
begin to appear. The instinctive desires and emo-
tions become more and more evident and active,
and fuinish, with the other functions, important
indications of disease, and of the means of re-
moving it. The susceptibility of the nervous
system, and of the mucous surfaces, to be im-
pressed by the usual exciting causes of disease,

— particularly by cold, moisture, atmospherical
constitutions, and vicissitudes, contagious or in-
fectious miasms, and errors of diet and regimen,

— is unimpaired.

10. a. Tuthingt which terminates the preced-
ing epoch, and ushers in this, is commonly con-
nected with more or less disorder of the system.
In infants of a healthy constitution, and in whom
the powers of life are energetic, disorder is
scarcely perceptible unless from the operation of
very efficient causes; but in those who are de-
bilitated, whose conformation has been originally
feeble, or imbued with any hereditary taint or
morbid diathesis, or who have been weakened by
unwholesome food and impure air, this process
is often attended with great disturbance in the
frame, and, owing to the morbid sensibility and
irritability it excite?, frequently kindles up most
dangerous disease. During the process of teeth-
ings particularly at its early stages, the itching
and irritation of the gums are a constant source
of excitement, or focus, whence irritation extends
to the salivary apparatus, as proved by the in-
creased flow of viscid saliva. 1 he continued de-
sire evinced by the little patient to allay the
itching of the gums, by pressing between them
whatever it can lay hold of, and the evident dis*
tress expres.«ed by it if this sensation, which is
known to be more insupportable than pain, can-

not be allayed, are indications which ought not
to be overlooked. If this distressing seosadon l>e
not allayed by judicious means, the nervoui sys«
tem becomes inordinately excited, febrile com-
motion is induced, the functions of digestion are
disordered ; and we are, consequently, not infre*
quently called upon to remove inflammation of
tne membranes or substance of the brain, vanons
convulsive afi*ections, and inflammatory dieorder
of the digestive mucous surface, owing to the
extension of irritation along the alimentaiy canal,
as well as to the acidities formed in the stomach
and bowels, from the imperfect digestion of the
food. During dentition also, a narked disposition
seems to exist in the pancreas to become excited,
owing to its close sympathy with the salivary ap-
paratus ; and I am persuaded that several states
of diarrhoea observed at this epoch originate in,
or are perpetuated by, an increased secretioa of
pancreatic fluid.

11. Owing, moreover, to the excitement and
irritation existing in the gums, afiections of the
respiratory and digestive mucous surfaces are
more frequently associated with one another, and
with increased vascular action in the nervous
centres and their envelopes. It would seem that
the irritation existing in the moutH disposes, from
its influence on the nervous system} the mucous
membranes not only to be invaded by the exciting
causes of disease, but also to undergo the raorUid
action throughout. How frequently has the ex«
perienced practitioner observed inflammatory irri-
tation of the digestive and of the respiratory
mucous surfaces associated in the same case ;
and how often has he had cause to suspect the
rapid supervention of irritation of the membranes
of the brain, or of the brain itself, either with or
without efifusion, upon inflammation of the di-
gestive mucous surface !

12. b. Weaning, — During this epoch icfati-
ing must take place. This should not be earlier
than the eighth or ninth month, or later than the
fifteenth ; and the infant ought to have, at least,
four teeth quite through the gums before it be
commenced. The milk of the mother is the in-
fant's only food during the greater part of the
preceding epoch, or, at least, until the foarlh or
fifth month, unless the mother and child be in a
weakly state. From this age upwards it requires
food m addition to the nourishment afforded hy
the mother ; but this must be eiven at first in
small quantities, and not of^ener Uian twice dailj.
As this period of weaning approaches, food in
larger proportion, and increased frequency, is
necessary ; and as soon as it shall have got teeth
to masticate animal food, this may be given it in
small quantity, and at first only twice in the
week. Animal diet is seldom required before the
completion of the first year, or previous to wean*
ing; afterwards it may be given in gradually
increased freoueucy, as the termination of the
epoch approaenes.

13. Whilst (he infant is liable to most of the
maladies which affect it during the first months,
it is now also exposed to the invasion of many
more; owing to the excitement occasioned by
teething, the state of the milk, particularly during
the last months of lactation, and the errors in
respect of both the quantity and quality of the
food. At the same time, however, its vital ener-
gies are more developed, and its functions more

AGE — Boyhood.

41

perfect ; tnd thus increarcd resbtanee is opposed
to the extension of disease, and to its disorganis*
bcf eflects. All iofectious and exanthematous
disorders are very prevalent at this age ; and, in
additioo to the maladies of the roncous surfaces
slrcsdy allnded to, the lymphatic glands, particu-
Urly those of the abdomen and thorax, are fre-
({IKacIj the seat of disease; and worms often
Krgin to form, particularly after the period of
iartatioo. At this age, also, owing to the
r^ang«s in the in^t*s food, as well as to the
irritaiioa occasioned by dentition, the disorders
vhtch origioate in depraved or imperfect digestion
tad assmilation are especially prevalent, parti*
eolsvfy aphthc, rickets, tubercnles, marasmus, and
tabes BMseDlericra, remittent fever, scrofula, and
aamerous cutaneoos eruptions.

14. €. The iherapeutieal indications at thb
epoch dne^ relate to the care which is required
to preaerve the head cool, and ward off the vascu-
lar exdteflBcot to which it is liable. Anodynes are
lea injnrioas at this period than in that precedmg
U, and are often required, paiticularly in soothing
tae irritability of the nervous system arising
cither from difficult dentition, from the exhaustion
ocrjwi<med by previous treatment, or by disease,
sad partieularly in the advanced stages of
wturapio^-coagh and croup. The state of the
peas requires particular attention ; and where
there is evidence of itching, this sensation requires
to be alhcyed, first, in the way that nature points
oit, by piesBug hard and smooth substances be-
twcra the gnins, as a coral, ivory ring, and what
K best, % gold ring, when this may be directed.
If the least appearance of local affection, as
reeefiMrtion, redness, &c., or even merely con-
^tatatJoBal disturbance, manifest themselves, the
?iims rikould be freely and deeply 8caii6ed. Ape-
nenta, of a mild and cooling nature, are often
required during tbis epoch ; and in it, as well as
ia the preoedine, blisters, even for a few hours
oslv, porticnlariy when the respiratory mucous
lui^ce ia obfitmeted and its functions interrupted,
or when the energies are exhausted and the vital
rt^iatanoe consequently reduced, must be employed
with extreme caution, and give place to the use of
thoie limments which 1 shall have occasion to re-
commced as aobatitutes for them under such cir-
cumstances.

15. ii. PcKioD, or that of Childhood (Pue-
riiia), extends from about the second to the
!«:vmth or eigh,th year, when the second dentition
b comf^eted. During this period the develope-
Kent of the different textures and organs pro-
ceeds rapidly, and their functions are more and
mere perfect. The mental manifestations, par-
lirulariy those which are intellectual, are de-
%ttlopca, and the various moral emotions gain
ttrengtb. The distinctions which exist between
f^xes throughout the whole physical and mental
coastitatioB at more advanced ages have not yet
appeared. All the soft solids of the body evince
iocreaaiog firroneas, vital cohesion, and elasticity,
and are protected by a 6rm covering of adipose
matter below the integuments, and in the interstices
between the muscles.

16. s. If the constitution be not vitiated by
hexeiijtary or acquired taint, defective nouriah-
ment, or previous ailment, or if tlic causes bo not
of a depressing nature, disease at this period
aoumei the atMoic character. Febrile diseases

are generally acute ; and, unless proceeding from
sources of infection, usually the result of local
inflammatory action, which evinces a marked
disposition to terminate in the formative process,
or effusion of coagulable lymph, particularly
when the serous surfaces are implicated. The
susceptibility to infectious diseases, particu-
larly those with exanthematous symptoms^ is
vc^ great; as well as to inflammations of the
different textures and organs — to pneumoftia,
bronchitis, cerebritis, meningitis, gastritis, ente-
ritis, &Lc.i bMides these, glandular obstructions,
chorea, verminous diseases, epilepsy, and the
various forms of angina, are very prevalent at
this age, particukrly in those whose digestive
organs have been neglected, and when morbid
matters have been allowed to accumulate in the
prima via.

17. 6. The therapeutical indications applicable
to this age present few peculiarities, besides the
necessity of resorting to active depletions, with a
cooling regimen and alvine evacuations in the
majority of its diseases ; and the keeping in recol-
lection the tendency of mucous sordes and se-
cretions to form and accumulate on the digestive
mucous surface. Such accumulations furnish a
nidus for the generation of worms, and sources of
irritation to this surface itself, and to the nerves
proceeding from it ; and originate many of the
affections which appear at this, and a subsequent
period of existence. The necessity of enjoying,
and the injurious consequences of the privation,
of wholesome nourishment and active exercise
in a pure atmosphere, and the advantages of
sleeping alone in a large well-ventilated apart-
ment, should not be overlooked, in their relation
both to the production and to the removal of
disorder. The employment of the faculties of
the mind during tliis early stage of their de-
velopement should be left, until the last year or
two of this period, more as a matter of amusement
than of exertion j and, even then, greater attention
should be paid to the developeroent of the physi-
cal powers, — the organisation upon which sound
mental manifestations very intimately depend, —
than to the precocious and even hurtful excite-
ment of -faculties which are merely budding into
existence. The emotions of mind, however, par-
ticularly those which are connected with temper
and disposition, ought first to receive attention ;
strict control cannot be prematurely applied in
this direction. In tbis and the preceding epochs
of life, it is indispensably requisite not to allow
the child to sleep with persons in bad health, or
who are far advanced in life.

18. iii. Period, or Boyhood — Girlhood.
— From the seventh or eighth year to the epoch of
commencing puberty, is chiefly characterised by
the continued growth of all the structures, and
the developement of the manifestations of mind.
Towards the middle and end of this period, the
physical and mental distinctions of sex become
more and more apparent. — a. The frame, when
free from disease or hereditary taint, evinces a
sthenic diathesis, a predominance of the sanguine,
or sanguioeo-nervous temperament, and a liability
to nearly the same diseases, particularly those
proceeding from infection and inflammation* that
prevail during childhood. There is a greater
liability to be affected with idiopathic continued
fever, with scrofulous enlargements and inflam-

42

AGE •*- Al>0I.B8CBNCE.

mstioni, particalarly of the lymphatic glands ;
mith various nervoas affections, as epilepsy, oon«
vulsions, chorea, &c. ; with cutaneous eruptions ;
with inflammations of the throat and air-passages ;
with tubercles, especially in the lungs and ali-
mentary canal ; with flexures of the spinal column,
and with verminous diseases. The nervous system
possesses great susceptibility of impressions, moral
and physical ; and inflammatory action has a
marked disposition to give rise to new formations,
unless when appearine in the advanced stages, or
as a sequela, or eruptive or infectious feveiB, when
it generally occasbns serous or sero-albuminous
effusions.

19. 6. These diseases of this period generally
require antiphlogistic remedies and evacuations,
especially purgatives, either alone or in suitable
combination, unless proceeding from depressing
causes, particularly those of a speciflc kind ; and
even tiiere the necessity of resorting to alvine
evacuations, by means of laxatives, or purgatives
combined with tonics, is imperative. The vital
resistance is usually well marked, excepting in
those who have been deprived of wholesome
nourishment and pure air, or whose constitutions
are radically in fault ; and in these, whilst tonics
and other means of restoration are required, the
due evacuations of morbid secretions and accu-
mulations is equally necessary. Care also
should be taken during this, as well as in the
preceding period, not to allow the young to
sleep in the same bed with the old, nor even with
those advanced in age or debilitated, nor with
too many — not more than three — in the same
sleeping apartment, which ought to be lai^ge and
well aired. Want of attention to this, is one of
the chief causes of disease in early life in Lon-
don, and other large towns. Academies and
boarding schools for both sexes are continually
furnishing numerous proofs of this too generally
overlookol cause of oisease, not only at this, but
also at a later stage of life. Attention is also
necessary to the exercises of both the mind and
the body. Active amusements in the open air
are now particularly required. As this period
advances, the mental powers acquire such a de-
gree of developement as to admit of their further
improvement and active exertion,— not only with-
out risk to the organisation with which they are
related, but with the certain pitMpect of advanc-
ing them nearer to the perfection to which our
natures may attain.

20. During this and the earlier terms of life
frequent changes of locality and of air, particu-
larly from one healthy and open situation to
another, and especially to one which is more
salubrious, where this can be attained, are ex-
tremely beneficial, both in promoting the de-
velopement of the frame and in removing diseases,
particularly those of a chronic kind, or which
affect the digestive and assimilating organs. In
many of these diseases more advantage has been
derived from change of air than from the use of
medicine. But, during advanced convalescence
from these and febrile diseases, the benefit ob-
tained from change of locality is most remark-
able.

21. iv. Period, or Adolbscknce, commences
with the first appearance of puberty, and extends
to the twentieth year of females, and the twenty- 1
fourth of males* Puberty appears at various!

ages, according to the climate, the drcumstancefl
connected with education, and the coostitutioa
of the individual. The usual period in this
country, is Irom the twelfth to the fourteenth
year for females ; and from the fourteenth to the
sixteenth for males. In the northern parts of
the island, it is often a year or two later in both
sexes. It is often observed earlier in boarding-
schools, both in respect of males and females.
In the latter (in London or its vicinity), I have
not infrequently met with instances of ineiistru«>
ation at ten and eleven years ; especially in san-
guine and plethoric constitutions ; and where the
apartments, particularly those for sleepingp have
been crowded and close.

22. a. This is one of the most important epochs
of human existence: for during it the natural
developement of the sexual organs iroparta a
healthy and tonic excitement throughout the
economy ; bringing to their state of full perfection
all the organs of the body and all the mani-
festations of mind, excepting those that are de-
rived from experience. The organs of respiration
and voice have acquired their full growth and
tone, the muscles their due proportion, and the
cerebro-spinal nervous ^^stem its beautiful or-
ganisation; placing man, by the exercise of its
admirable functions, at the head of all animated
creation, — the dread of all other animals, the
wonder of himself. It is chiefly during this
period of life that the mind becomea stored with
ideas, derived both from the learning of the
ancienu, the science of the modems, and the arts
and accomplishments of highly civilised life ; and
is more particularly and more ardently engaged
in decomposing the information thus acquired,
and recombining it in new and useful and at-
tractive forms.

23. As the functions and destinies of this
period are important, so they require the super-
vision of the experienced and the good. For,
with this developement and activity of both the
physical and mental powers, the instinctive feel-
mgs and emotions of our nature have also reached
the utmost limits of their activity ; and many of
them, particularly those which are related to' the
perfect condition of the reproductive or|;ans, ac-
quire an ascendancy, that both the dictates of
reason and moral restraint are required to con-
trol. Hence the propriety, both at this and the
preceding period of life, of improving the moral
affections of the mind ; of inculcating sound prin-
ciples of action and conduct, founcfed on moral
and religious obligations ; and of placing them in
such relations to the feelings, the intellectual
manifestations, and, moreover, to the accomplish-
ments, the elegancies, and the endearments of
life, as to render them attractive to a state of
mind and constitution which is more easily alliued
by example than taught by precept.

24. The evil practices which both sexes are
tiable to acquire at this period of life, and to
which they more commonly become addicted,
when they associate in numbers at seminaries
and academies, demand the strictest prevention.
They have been too generally overlooked, both
morally and medically, from the circumstance of
their consequences having been imperfectly ap-
preciated. There is no practitioner of observ-
ation and experience, — none even of limited
knowledge,— who is altogether tmaequaiated

AGE — Mature Acs.

43

with tht phynca] exTianstioii, the mental torpor,
aad all but annihilation of existence, which is the
nldnate result of indalging them. Prom this
•oorce freqoentlj spring, impotency hereafter;
tite cztinctioa of families and hereditary honours
— hooours which such persons are incapable of
arhieriiig ; the infliction, during after-life, of
maoy of the diseases which proceed from de-
bility, and the exhaustion of the nourishment and
tital eacigy of the various structures and organs ;
irameroua nervous and convulsive maladies, as
bjsteria, eptepvv, neuralgia, chorea, melancholia,
mania, idiotcy. Ace. ; the dangerous or fatal visit-
ation of levers, diseases of the heart, disorders of
the digestive organs, premature baldness and old
agY, the formation of tubercles, and the pro-
duction of pulmonary consumption ; and, lastly,
the transmisaioQ of weak and decrepit bodies and
minds to the offspring, of scrofula, rickets, verm-
iooos complaints, maxasmus, hydrocephalus, con-
mlsoos, tubercles, chorea, &c.: tne curse is
r«ited on the children to the third and fourth
apogratioB, until the perpetuated punishment ex-
tininnshes the very name of the aggressor.

25. fr. The pathological conditions of this
tee are especially characterised by exalted
tcdon. At the approach and commencement of
paberty, the glandular system is extremely prone
to congestive inflammations, particnlany the
Wsfhitic glands of the neck and arm-pits.
Tabereies are rapidly developed in the lungs;
ud thae organs are much disposed to acute and
cbnnic iaflanaroatioos of both their substance and
BBCoas surfaces. Pulmonary haemorrhages usurp
l^ place of the epistaxis of earlier epochs ; ana,
ia females, dysmcnorrhoKa, protracted or retained
»«09tniation, chlorosis, hysteria, and occasion-
allv meoorrhagia or leucorrhoea, occur. The
languineous diathesis and plethoric habit, in those
of a sound constitution, and the sanguine, irri-
table, and nervous temperaments, or the one
associated with the other, most commonly prevail
St this period of life.

26. The progriu of disease is generally rapid,
and its character acute. Inflammations are more
prone to give rise to the formative processes ; and
febrile affections, when they terminate by crises,
evince a preference to haemorrhages and sweats.
Idk>pathic fevers, inflammations of the respira-
tory organs, and of the brain or its membranes,
are the most common diseases of this age.

27. r. The therapeutical indications require
\n.t litde remark ; for the system has now nearly,
cr altogether, reached iu full growth; and the
feneral inferences which guide the practitioner
ia the employment of remedial means have now
reference, especially, to states of habit, coosti-
tutiooal powers, temperament, and diathesis, —
physical manifestations, which are now, in a
great measure, developed, but which acquire
thdr most predominant characters in adult a^e.
As the maladies of this period are generally in-
flammatory, and evince a strong tendencv to the
formative process, and as the powers of life are
now most energetic, vascular depletions, with the
antipbtogistic regimen, are generally required,
and are well borne; excepting in those whose
constitutions have been ori^nally in fault, or
who have greatly inpred it by the injurious
practice of masturbation, from which so many
saflcr, both at this and subsequent epochs of life.

28. V. Period. — Adult Aob may be divided
into the epochs, 1st, of early adult age ; and, 2d,
of mature age, or eot^rmed virility. Of each of
these I shall take a brief notice.

A. Early adult age may be dated from twenty
to thirty in the female, and from twenty-four to
thirty-five in the male. During this epoch, if
the constitutional powers have not been injured
previously, the whole frame and its individual
organs continue to acquire strength; and, al-
though the body has ceased to grow in height,
it increases in bulk, particularly the muscles of
voluntary motion and the parietes of the large
cavities. It is also more capable of enduring
continued exertion and privations; its vital en-
durance and resistance being greater than during
the period of adolescence. The features and ex-
pression of the face; the character, disposition,
temperament, and diathesis, are more unfolded,
and towards the termination of this period fully
display their manifestations.

29. B. Mature age, or confirmed virility, may
be considered as being from thirty to forty, or
forty-five, in the female, and from thirty-four
to forty-eight in the male. During this time of
life, the features of the countenance fully assume
those modifications of character arising from the
influence of the passions and emotions of the
mind ; and the appetites, habits, and occupa-
tions of life impnnt upon the frame generally
certain appearances, arising from their continued
influence on the constitution. The muscular
organs, particularly the muscles of the extremities,
are prominently marked ; the chest fully de-
veloped ; the body spare and active ; the adipose
structure extremely scanty, and the abdomen
small, in those habitually devoted to laborious
employments, not of a sedentary nature, and to
active exercise, either on foot or horseback. The
sedentary, those addicted to the indulgence of
the appetites, and particularly those given to
the gratifications of the table, have large abdo-
mens, small extremities, and large depositions of
adipose matter beneath the integuments, between
the muscles, in the omentum and surrounding the
viscera, with a weak and defective^developement
of the muscular parts. The studious present
the chief marks of their occupations on tne fea-
tures of the countenance and character of the
head ; the appearance of the rest of the frame
vaiying with the habits and indulgences with
which study or the prosecution of science may
be conjoined. At tnis period of life also the
feelings', the anxieties, the disappointments, the
losses, and the various moral emotions of life,
begin to manifest those effects upon the frame,
which become still more fully expressed during
the following epoch.

30. This and the preceding period of adult
age are, upon the whole, the most exempt of all
others from disease ; but about the age of forty,
and still more so as the age of fifty is approached,
the sanguineous circulation becomes more and
more languid, particularly in the veins: hence
the frequency of venous congestions and visceral
obstructions, with the various diseases depending
thereupon, particularly hsmorrhoids ; bilious de-
rangements ; bilious and gastric fevers ; inflam-
mations ; affections of the heart ; apoplexy and
paralysis; derangements of the stomach and liver ;
haematemesiB ; affections of the joints, as gout aiid

44

AGE — In its specific Aocbftatiox.

rheumatism ; diseases of the urinary organs ; hys-
teria and uterine disorders ; hypochondriasis, and
affections of the mind. At this period, therapeu-
tical means require to be strictly regulated ac-
cording to the sex, consutution, temperament,
habits, and occupations of the affected.

31. II. Age, in its specific ^icceptation,
may be divided into two periods, and these into

four epochs: viz. 1st, Declining age; 2d, Advanced
age: 3d, Old age; 4th, Decrepitude, or second
infancy. Before I proceed to consider these in-
dividually, I will take a view of the changes
which supervene with age in the structures and
functions of the body.

Age, in the specific acceptation of ike word,
may be considered as commencing when the
vital energies of the different organs begin to de-
cline,— when the. maturity of life glides into
decay. The period at which this change su-
pervenes varies very much in different persons,
according to their constitutions, employments,
and habits during the earlier epochs of existence.
In many it is so gradual as to be imperceptible ;
in others it is more obvious ; and in some it is
induced rapidly and remarkably, by mental an-
xieties and bodily disease. The usual period of
its advent, in both sexes, and the different epochs
in which age may be divided, will be stated in
the sequel.

32. As age steals on, all the functions are per-
formed more languidly than in earlier life. The
energies of the ganglial system decline, as
evinced by the digestive, circulating, and secret-
ing functions, which it actuates. The sensibility
of the cerebro-spinal system, and of its dependent
organs ; the acuteness of our intellectual powers,
our moral emotions and affections, and the ac-
tivity and strength of the locomotive organs, — all
experience diminution, great in proportion to the
advances of age.

In noticing the pathological and therapeutical
relations of age, those changes of structure and of
function which supervene with it will first re-
ceive attention; nejt, the different terms into
which it may be divided, with those modifications
which diseas^ actions generally assume in each
term respectively, and those indications which
should guide our practice in the diseases to which
each is most obnoxious, will be briefly considered.

33. A, The modifications of structure produced
by age are occasionally slight ; but most com-
monly they are very remarkable, particultrrly in
ccrtam organs. In some parts they are scarcely
perceptible, in others more obvious, consisting
chieHy of increase of density ; and in many they
amount to actual change of texture.

The integuments, particularly those of the face,
and the hair, are amongst the earliest parts to
exhibit the advance of age ; and they most ob-
viously indicate the different stages of its pro-
gress. 1'he integuments of the face seem more
developed than in early or mature age. They
arc denser and thicker, especially the cutis vera
and rete mucosum ; which latter assumes also a
somewhat darker tint. The skin appears more
loosely attached to the parts underneath it, chiefly
owing to the diminution of the subjacent fat, and
shrinking of the other soft solids. Hence it ap-

Sears, particularly in the face, neck, and hanas,
accid and wrinkled.
i 4. The hairs of the b^ad are, perhaps, tiie first

to evince the commencement of age ; and they
present the most common indications of the pro-
gress of decay, either by a more or less complete
change of colour, or a partial and general loss of
them. The change of colour at first consists or
a few white or grey hairs, scattered amongst
those of a natural hue ', but these gradually be-
come more numerous, particularly on the tem-
ples, until the whole hair is altogether grey, and
ultimately white and transparent. As this change
proceeds, the h&ir also falls out, especially on the
crown and forehead. There are, however, many
circumstances which accelerate these phenomena,
independently of age. Thus fevers, severe courses
of mercury, masturbation, &c. will occasion
the loss of the hair. But when it ^lls out from
disease, the bulbous roots not being obliterated,
its reproduction generally follows; wherea«,
when It is lost from old age or from masturba-
tion, it is never reproduced. There are also
various causes whicn occasion a change of iis
colour, particularly the depressing passions, in-
tense application to study, anxieties of mind,
venereal indulgences, £cc., and which at the
same time accelerate the loss of it. The change
of colour, and subsequent loss of hair, seem to
arise from deficient nutrition, and consequent
atrophy, or destruction of the bulb, together with
some change in the skin itself. In some case^ it
seems to arise from chronic disease of the rcte
mucosum and cuticle, as stated in the pathology
of certain cutaneous affections.

35. The adipose and cellular tissues experi-
ence considerable change. The fatty deposit
diminishes with the progress of a^e, and it some-
times becomes more fluid and watery, as well as
of a deeper tint. The cellular tissue is somewhat
denser, more fragile, and less elastic than in early
life. In some situations it assumes a fibrous
character, particularly that portion of it which
invests the muscular fibres. The serous mm"
branes are also more dense, more subject to ossi£c
deposits, and their free surface drier than in early
life. The mucous surfaces exhibit but little
change, excepting as respects their greater pale-
ness, and tendency to certain states of disease.
The fibrous structures become more rigid, and in
various parts the seat of ossific deposits. They
also assume a deeper colour, and finner aod
tougher consistence, whilst their physical cohe-
sion is much increased as age advances.

36. The muscles of voluntary motion expe-
rience a very marked change, particularly at
the advanced epochs of age. They are much_
diminished in bulk. Their fibres are more rigid,
less readily influenced by stimuli, and less coQ'
tractile than in early life. They are also less
under the control of volition, much less energetic
in their actions, more flaccid, and endowed with
less vital tenacity. Their structure is also some*
what modified. They are paler, sometimes of a
light yellow colour, and their fibres leas distinct
than in youth. The tendons and aponeurotic
expansions of muscles, as well as the cellular
tissue intervening, are often partially ossified.
Portion3 of muscles, near their tendons, are some-
times converted into a tendinous structure ; and
the secretions poured into the sheaths of the ten-
dons are remarkably diminished. From all these
changes result the vacillating, embartaased, an<l
weak movements of the aged.

46

AGE-— In IT9 SPECIFIC Aoceptatiok.

the secretion and retention of this fluid, or after its
discharge.

45. Not only are the mechanical conditions of
the diflPerent parts of the body modiBed by age, as
now stated, but their chemical properties are also
similarly affected. The gelatin disappears, or be-
comes changed to albumen ; the fibrin is in-
creased, and assumes a deeper hue, and is less
easily affected by maceration or exposure to the
air. The phosphate of lime is augmented, and
often accumulates to a very hurtful extent, to-
gether with the other earthly salts and urea.

46. B, Of the amditiont nf function charac-
terising the advance of age, — a. Although the
changes, which have been now described as
supervening in the different structures with age,
may have originated in those imperceptible and
slow modifications which the various organic
functions experience from peculiarities of consti-
tution, of food and employment, or from ac-
quired habits and indulgences ; yet there can be
no doubt that, when once induced, they modify
still further these functions, and thus draw 6n
other lesions, and ultimately still greater alter-
ations of both function and structure, or even
speedily fatal disease. But we are not altogether
justified in considering these contingencies as the
primary causes of the changes now described.

^ We are rather to view them as more or less re-
mote effects of the failure of the vital endowment
of the frame, manifesting itself first in a lea per-
fect performance of the different functions, and
subsequently in modifications of structure, and
ultimately in very obvious lesions of both function
and structure.

47. 6. It was supposed by Brown and others,
that the embryo at its earliest formation is endowed
with a certain sum or allotment of vitality, which,
in the earlier epochs of life, is engaged in the form-
ation of, and in bringing to perfection, the differ-
ent structures and organs of the frame ; that it is
gradually exhausting itself ever after, until it at
last expires ; and that the greater the excitement
of its different manifestations and functions during
the subseauent stages of existence, the more
rapidly will its termination be reached ; that the
oil with which the lamp of human, and indeed all
animal, existence bums, is filled at its commence-
ment, and is never afterwardssupplied ; and that the
more brilliant the flame, the snorter will be its
duration. This captivatine hypothesis, however,
appears, on an intimate view, irreconcilable with
many of the phenomena of health and disease.
It cannot readdy be conceded that the allotment
of vitality betowed upon the germ or germs can
exceed that possessed by the parents, — for the
hypothesis is, that the sum of vitality is greater
the younger the animal ; and that it diminishes
with the advance of days and years, from the
period of its endowing the embryo. But it is ob-
vious, that the greater vital endowment cannot
issue from the smaller; that the parents cannot
possibly impart to the embryo more than they
possess, they still retaining a portion afterwards :
more particularly when we consider that the
greater endowment is imparted not to one embryo
only, but to several, as is the case in the lower
animals, and often in the human species also.

48. The phenomens, moreover, of disease fur-
nish us with proob that this sum of vital endowment
is neitfaer thus early and at onoe bestowed, nor \

thus uniformly diminished, aooordmg to the waste
it experiences, without occasional reinforcement.
We frequently perceive all the manifestations of
life reduced, at different epochs of existence,
nearly to total extinction, particularly in several
kinds of fever, when, having received the requi-
site aid from external stimuli, they have been
gradually restored to their former activity. In-
deed, the various circumstances in which the body
is placed, and the different states it presents at
different periods of hfe, and from numerous causes
which affect it, seem rather to favour the idea that
the sum of vitality, and its manifestations in the
different or^s, fluctuate more or less during the
allotted penod of existence; that a certain emao-
ation of vitality proceeds from the parents, great
in proportion to their constitutional powers ; but
that this endovrment is constantly experiencing ao
accession, first from the mother, and subsecjuently
from the common sources of air and aliment;
that this reinforcement is thus constantly supply-
ing the waste arising from the exercise of the
various functions, and adding to the bulk of the
structures, until manhood is reached ; and thst at
this period the sum of vitality has reached its
greatest amount, from which it ^adually decUnei,
owing rather to the waste, particularly that occa-
sioned by the exercise of the generative fonctioos,
exceeding the supply, ihan from the continued
expenditure of what is at first bestowed and never
afterwards reinforced.

49. Having been induced by the foregoing, aitii
other considerations, to relinquish the former for
the latter hypothesis, I infer that the gradual di-
minution of the vital energies that accompanies
the progress of age is more or less manifested
throughout all the frame ; that the fuoctioos
first evince this decline, and that the organs them*
selves are at last modified in organisation, fraoi
the slightest and almost inappreciable shades to
the most marked alterations^ The changes of
structure, once induced, tend most essentiallv to
heighten and to perpetuate the previously slight
disorders of function, until both the one and the
oiher undergo, by reciprocity of influence, most
important alterations, terminating at last in deatii,
and the dissolution of the frame. — I now pn>«
ceed briefly to notice those changes of function,
which, frequently related to the alterations of
structure described above, mark the existence of

Ag«.

50. c, I have, in another place, stated that, of
all the different tissues of the frame, the ganglitl
system is the most intimately related, in every way,
to the vital influence which endows the body.
And it is precisely those organs which are most
immediately connected with this system that first
furnish proofs of incipient decline in the languor
or imperfections of their functions. Amongst those
functions are comprised those of digestion, secre-
tion, circulation, assimilation, the preiervation of
the animal temperature, and generatioo. The
functions of animal relation are not so soon af-
fected ; and at first the change in them is rsther
secondary, and owing to the pre-existiDg chsngs
of the functions of organic life, --of those func-
tions which are excit^ or actuated through the
medium of the ganglia! system.

51 . As ver^ intimately dependent upon the stste
of the ganglial system, the eterttima oasnifest,
with the advance of age, the most ninarkabl«

48

AGE — Old Aoe.

impaired, excepting in as far as respect early-
formed associations and affections, which are;
often recalled with acute and even overwhelming
emotion.

58. As age advances sleep is mach lessened ;
and not only is the duration of repose abridged,
but also its soundness ; the rest of the aged being
imperfect, and disturbed by dreams. It is difficult
to explain this — indeed no satisfactory explan-
ation of it has yet been offered ; but it is gene-
rally observed, particularly in very advanced
age.

59. Such are the changes induced by age in
the various structures and functions of the body,
.as evidently caused by the gradual decline of the
vital energy, from the period of full manhood to
its ultimate extinction. I have described them
as much divested as possible of the effects of dis-
ease. As now noticed, those changes gradually
lapse into death, — the lamp of life havmg burnt
out, its oil having been exhausted, after a gradual
diminution of the supply, without any single
organ evincing that state of disease to which the
cessation of life can be ascribed. This is, how-
ever, not a common occurrence ; for, during the
gradual decay that marks the progress of age,
some oi^n or other, owing to the deleterious influ-
ence of surrounding agents, or of mental emotions,
and the weak resistance of the vital influence,
experiences a more or less marked derangement,
which increases to actual disease, and either
abridges the remaining short period of existence,
or renders it less supportable.

I now proceed to notice^ the different epochs of
advanced age, with reference chiefly to the dis-
eases incidental to each, and to the therapeutical
considerations which should influence the treat-
ment of them. (See Climacteric Disease.)

60. vi. Period, or Declinivo Age. — 1st
Epoch, or deelininfi; age, extends from 42 or
45 to 55 in the female, and from 48 to 60
in the male. -—a. During this period the ap-
petites, occupations, and habits express them-
selves still more. strongly upon the outward ap-
pearance of the frame than in that immediately
preceding it ; and the feelings, emotions, dis-
appointments, and anxieties of life manifest more
fully their effects upon the internal organs, as
well as upon the external aspect. Venous con-
gestions, visceral obstructions and engorgements,
with all the specific forms of disease already
enumerated (§ 30.), are more frequent than during
earlier epochs, particularly apoplexy and poralysis,
hxmorruoids, hepatic disorder, dropsies, structural
change in the kidneys and bladder, hypochon-
driasis, h^emalemevis, gout, and chronic aflTections
of the respiratory organs.

61. b. In this period, the second great change
to which the constitution of the female is liable
generally occurs, terminating that epoch in which
her sexual constitution is especially marked ; and
with this change frequently commence, or are
matured, several diseases of the female organs.
Morbid changes of the uterus and its oppendageF,
as well as of tiie breast, are now very frequent ;
and sometimes they assume a malignant character.
Various maladies, to which the female was less
exposed than the male, are now ofteoer met with ;
and her constitution, with its disposition to disease,
approaches more nearly to tliat of the male than
during the time of marked uterine activity.

62. 2d Epoch, or advanced age, may be reck-
oned to commence about 55. and to extend to
63 or 68 for the female ; and to begin about 60,
and extend to 65 or 70, in the male. During
this epoch the nervous, circulating, and muscular
energies begin to languish, with the vital actions
of the diflerent internal organs. The functions
of the sexual organs gradually disappear. The
female no longer conceives ; and sexual plethora
has ceased to supervene and to relieve itself by a
periodical dischar^. The ovaria begin now to
be gradually diminished in bulk, and to assume
a firmer structure; the appetite for procreation
slowly disappearing ($ 43.54.). — The male organs
also either becon)^ less disposed to their proper
functions, or nearly altogether lose the faculty
of performing them, particularly when the ener-
gies of the constitution have been exhausted by

{>revioa8 indulgences carried to an excessive
ength, or by mental exertions. The teeth decay,
and the digestive functions suffer from the imper-
fect mastication of the food ($ 41.).

63. vii. P«RioT>, or Old Age. — 1st Epoch, or
ripe old age, dates from the preceding, ana extends
to 75 or 80 in both sexes. During this term the
sensiferous and sanguiferous systems languis^h
more and more, and all the vital organs experience
a rapid decline of activity. The teeth rail out,
the gums are partially absorbed, and the digestive
functions are greatly impaired. The sexual organs
are nearly or altogether deprived of their func-
tions ; the digestive and assimilating viscera ex-
perience a marked diminution of power; and
senile marasmus, or the leanness of old age, ad-
vances ($53.).

64. a. The diseases of this and the preceding
epochs are chiefly weak or imperfect digestion
and assimilation ; chronic inflammations ; genenil
asthenia and cachexia ; apoplexies ; paralysis ; loss
of the senses of ^ht and hearing; senile gan-
grene ; comatose afl^ctions ; dyspnoea ; diseases of
the heart and liver ; dropsies ; organic changes
in the urinary and sexual organs of both sexct ;
passive hemorrhages, from the stomach, bowel?,
and urinary organs ; mental disorder; and gradual
extinction of the vital functions and energiec.
Febrile and inflammatory diseases have a much
more marked disposition to terminate in organic
change, owing to tne diminution of vital resistance,
than during the preceding epochs of life.

65. fr. The tftfrapeuttca/ indications of this period
are in some respects important, but chiefly with
reference to the necessity of supporting the powers
of life during the diseases to which it is liable.
When inflammatory or febrile disorder is present,
and depletions or evacuations are necessary, we
should, particularly if we employ them actively,
watch their effects, and resort to the use of meani
calculated to support the frame as soon as indi-
cations of exhaustion are manifested. Purgatives
at this period should, if frequently repeated, al-
ways be combined with warm, tonic, or support-
ing medicines, or with a restorative regimen ; and
a strict reference ought to be made to the habits,
constitutional powers, and feelings of the patient,
in all the remedies we prescribe. Old habits
must not be suddenly relinquished or opposed,
and the powers of life should be carefully
watched ; for, if unheedingly reduced, they will,
particularly in large cities, often sink most ra-
pidly, without the power of nllyiog. When we

AG£— DSCBSPXTVDE.

49

eoaoder t]iat» is pexvona tdvanced to tluB age, a
MQfidenble portioD of the arterial sjBtem is often
Iq ■ state of aiow ofganie disease ; that the venous
ifdeni ia prooe to cooeestion, is sometimes relaxed
sAd almost varicoae, alwars deficient in vital con-
tneiilityp and acaicely able to perfonn its func-
iiottt ; aod that both the one and the other cannot
ii»ebj so TVfldily accommodate themselves to
sodden or copious losaes of blood as in early life
tad wbea they are perfectly free from disease,
^ canooi be surprised at the sudden depression
oera«wDed by vascular depletion, or other means
vhich produce a rapid discharge by the emnnc-
tflfies ot the watery parts of the blood, or a sudden
^pienoB of the nervous energy, even although
symptoms aeemed unequivocally to demand their
uBployment.

66. The lej< tpoeh, or that of DtcrepUudt, or
ncgs^ imfanc^f, commences at from 75 to 80, and
tctmioates the life of those whose span of existence
n thus far prolonged. A greater number of
fdoales thau of mines reach this extreme age, es-
pei-ially the utmost extreme. During this period,
iJi the phyncal and mental powers rapidly deciine.
The body emaciates, the muscles waste, and the
idipose structure is absorbed; the integuments
kcomiog lax, wrinkled, dry, and disposed to re-
tiioa accumulations of sordes. The knees totter and
lead under the weight of the body ; the trunk
<u>ops, and is incapable of any considerable mo-
tbo, excepting forwards; and the features are
wm, devoid of colour, wrinkled, and emaciated,
•ad apparently consisting chiefly of iotegumental
covenog ($ 33.).

67. 0. Coagesdons, enlargeDents, obstructions,
aaJ even atrophy of the internal viscera; effu-
pom of fluid into the shut cavities; irregularity
of ibe heart's action from loss of its vital activity,
cr structural change of its valves, its arteries, or
mcaeular texture, or from disproportion between
the capaciyes of its compartments ; lesions of the
^2>calar system generally, in which either those
cf the arteries or of the veins predomioate. Pas-
she hemorrhages from the mucous surfaces, par-
ticalariy those of the alimentary canal and
criaary apparatus ; general asthenu, or cachexia ;
aari «low extinction ol the vital and natural functions
of the frame, — the ganghal, the cerebro-spinal,
aod the circulating systems ; and the digestive, the
Tvtputxorj, the secreting, and excreting organs,
rt lacing uidividualW, or either of them coniomtly
«kh others, more orless disease,— are the principal
f Au«ei of death : and thus man, whose mental
and physical constitution and organisation were
ejects of profound study and admiration to him-
ttjf, pasecs away ; the vital essence, that actuated
ti^ wisely de%ued frame with which it was so
R:rpTi«ingIy associated, returning to the Divine
xsrce wheooe it emanated ; and the gross mate-
lols, which it combined and preserved in won-
itrfal states of association, assuming novel modes
«t existence, and serving to form new beings
aiBch lower in the scale of organised creation.

68. h. The rapidity with which acute disease ge-
cerally runs its course at this period, and the ce-
Iffity with which organic change will frequently
ittpenreoe and extinguish the dimly burning taper
«^ ii/e. require mat decision and circumspection
«« the part of the physician. The resistance
vbicH the energies oflife usually oppose, both to
tU extcosioo ofdisease to other viscera from that

Vou h

first attacked, and to its disorganising efTeets in
its primary seat, is now so excessively weakened,
that remedies, directed with a due regard to the
previous habits of the patient, in support of those
energies, are particularly necessary. On the choice
of cordial remedies, and on their appropriate ap-
plication to the circumstances of individual cases,
will depend their success, and the reputation of
the physician. At this period, depletions and
all evacuations, excepting such as are requisite to
carry off accumulations of morbid matters from
the prtmiB vitr, and which impart, along with
their evacuating operation, a restorative and cor-
dial influence, must be abstained from ; and care
should be taken that fainting, or even nervous de>-
pression, may not supervene from their action.
Warmth, at this and the preceding terms of
advanced age, is indispensably required, both in
the clothing and apartments; but it should be
equable, and not too high. The lungs of very
a|ed persons should be guarded from the ingress
of very cold air, as the impression of cold in this
organ paralyses its fonctions, arrests those changes
which the blood undergoes during respiration, and
induces apoplectic or comatose seizures, and
idiopathic syncope or inaction of the heart. For
these reasons, also, atmospherical vicissitudes
should be assiduously avoided, as far as the means
of tloing so are placed within our reach. There
is scarcely any measure more influential in sup-
porting the sinking vital energies of age than the
communication of animal warmth, particularly
from the young of our own species. This was
well known to the ancients, and is one of the
oldest restorative means of treatment practised,
having been adopted bv David. The aged oupht
also to avoid the use of very cold fluids, as bemg
apt to depress the energy of the stomach below
the power of healthy re-action. Medicines, also,
particularly purgatives of a cold nature, as the
neutral salts, if exhibited at all, require to be
combined with warm aromatics or stimulants, in
order to counteract their depressing influence
upon the alimentary canal, and on the nerves of
organic life.

BiBLioaBAPBV.— G. E. StaU, De Moitorum iEtatum
FundBinentU Fathologico Therapeuticb. Hake, 1696, 4to.

— F. Hqff^nmmt De I£UX\» MuUtione Mortmrum Caasd
et Remedio. UalL 17S0, 4to. — Lmiunu. DiMor. Meta.
morpbosis Humana in Amoen. Acad. vol. rii. p. 143. —
fVeltted, De .£ute Vergente, Svo. Lond. 1724. — Plm, De
Brevioric et Infinnlorif Vita Cauaia. Lips. 1788. -» C. A.
PkUifes, De Decremento Homin., JEUtu Periodo, et Ha-
rasno Senill In itoecie. HaUe, 1808. — J. H. F. Autenrietk,
De Ortu quorund. Morbor. Provectlor. Atatia, Ac Tutx.
1805 — J. Schneider, Handti. Uber die Krankh., des Mann,
baren Alters. 2 aUh. 1808-12. — Pinei.ln Archives Ote.
Medccine, t. xi. p. 7. — Foucari, in IbidL, t v. p. 396. ;
t. vi. p. 87. — P. Jt ^. Espamn, Eual sur Ics Aget de
l'Homin& Paris, Ann. tL Svo. — F. E. Jolhf, Aper^u
PhvuioL et HMical »ur lea Premien Agei de la Vie Hu-
malnc, 4to. Paria, 18t& — > J. A. Oetmer, De MutationilMia
quaa tubit Infant Btatim post Paitam. Erlang. 1796. —
a. X. Boer, Vcrsuch einer uaratellungdet Kindlichen Or-
ganiraiuft in Phyiiogolif ch.patholog. und Therapeut Hln-
•icht Wien. 1815. — A O. Setter, Vrogr. de Morbii 8e-
Duro. Vitetk. 1807. — A. Carlitle, JEfuay on the DiwTden of
Old Age. Lond. 1817. — L. H. ^edlaender, Funda-
menta Doctrina» Pathologies, &r, Llpi. 18S8. 8va —
Eullier, art Age. Dictionnaire de MMecine, en 18 voL,
t prem. Paria, 1831. — L, J. Begin, art. Age, Dictionnaire
de Medecine et de Chirurgle Pratique*, t L Parii, 18S9.

— B.C. Fmut, Die Perioden det Lebena. Berlin, 1794,
8vo. — a IV. Hitfeland, und R. A. Rudolfki, £ncvdopa-
di»chei Worterbuch dcr 5fcdiciniachcn wiMcntcnaflen.
Zwictcr Band. Berlin, 1888. -^J. JoAnmn, The Economy
of Health, or the Stream iif Human life from the Cradle
to the Orare. I^nd. Svo^ 1687. —/*. M. Bogei^ Cyc
Pract. Med. vol I. p. S*>

E.

60

AMAUROSIS — Patboloot or.

AGRYPNIA. See SLEBPLsaBHsss.
AGUE. See Fsvsr — Intermittbmt Fbvbrs.
AlK. See Disease, itt Cautation, lUmoval, ifc,
ALOPECIA. See Haib, the Los* of.
AMAUROSIS, from ifAmufif, obscure. Syn.
Gutta Serena, Suffutio Nigra, Celsus, Lucretius,
Pliny. ObiCiiritat, HeUtudo, Paulus ^gin.
Paropiit Amaurveii, Good. Cataraeta Nigra,
Auct. Germ, quibusd. L'Amauroee, Fr.
Dm Schtoarte Staar, Germ. Gotta Serena, Ital.
Stekelindkeit, HoL Suffiuion, Dtop Serene,
MiltoD. Dimness of Stgnt, Blindness.

Clabsif. 4. Class, Local Diseauses; 1. Order,
Impaired Sensations (CuUen). 4. CUus,
Diseases of the Nervous Function ; 2.
Order, Affecting the Sensations (Good),
Functional Amaurosis, I. Class, iV. Or-
der. Organic Amaurosis, IV. Class, III.
Order {Author, see the Preface).

1. Depin. Partial or total blindness, from affec'
tion of the retina, or of the nerves, or of that
part of the brain related to the organ oj sight,
whether arising primarily from functional disorder,
congestion, in/iammation, or any other change of
these parts ; or occurring from sympathy with other
organs. Or, in other words. Partial or total lou
of sight, from other causes than those whidt obstruct
the passage of the rays of Hght to the bottom of the
eye.

2. Amaurosis is met with at all ages ; but most
frequently in the more advanced terms of life. It
is sometimes congenital ; and in these cases it is
often difficult to ascertain the nature and seat of
the affection. When it occurs at advanced periods
of life, an attentive enquiry into the history of the
disease, of the previous habits and ailments of the
patient, and of the various resulting and related
morbid phenomena, will generally throw light
upon its pathology.

3. I. Seat of Amaurosis. — 1st, In the retims,
-^Viewing the delicate structure of the redna ; its
relation to the optic nerve, of which it is an expan-
sion of great tenuity; its connection with the
choroid and hyaloid membrane, and its nervous
and vascular communications; and considering
the various morbid states it is liable to undergo,
in consequence of its relations with these and
other parts ; a partial, and even total, abolition of
its functions is to be looked for on some occasions.
It is, like ail other parts of the frame, liable to
congestion and inflammation, with their usual re-
sults; and, like other nervous parts, its functions
are subject to a partial or complete extinction
without itself evincing any change of structure,
its sensibility alone being impaired or abolished ;
owing either to some unappredable change, or to
some one or more of those alterations in iu adjoin-
ing or related parts about to be noticed.

4. 2d, In the optic nerves, — These nerves maybe
more or less changed in some part of their course,
from the anterior pair of the corpora quadrigemina,
along the thalami, the tubera cinerea, and their
partial decussation, until they terminate in the
formation of the retinse. In appreciating, however,
lesions in the course of the optic nerves, the results
of experiments on them should be taken into con-
sideration : — if an optic nerve be divided previous
to this decussation, sight is altogether lost on the
opposite side ; but if the division be made between
the decussation and the eye, vision is lost on the
■ame side.

5. 3d, In ihMgangUalnfrvet, Then it eveiy rea-
son to suppose that the retina is in intimate commu-
nication with other nerves, and that it mutually
influences and is influenced by them. Branches
of the great sympathetic may be traced upwards,
from the first cervical ganglion, to the gmglioo
lodged in the cavernous sinus ; whence branches
proceed and communicate with the third, the firrt
division of the fifth, and sixth pain of nerves.
Branches also pass firom the cavernous gaoglioa
directly to the lenticular ganglion. As the internal
carotid artery passes into the cranium, it is sur-
rounded by the sympathetic nerves, which accom-
pany all its ramifications. The ophthalmic artery
IS invested with these nerves ; its branches to tlie
choroid, iris, and retina being similarly provided.
Branches of nerves, moreover, proceed from Uie
lenticular ganglion, as M. Kibes, (M^. deUSoc.
hUd. d* Emulation, t vii. p. 99.), and others ha?e
demonstrated, to the iris, giving more miovie
branches in their course to the retina. This coo-
nection being established, morbid stales of Uiese
nerves and ganglia, or changes of structure in
their vicinity affecting their functions, must nects-
sarily impair the sense of sight.

6. 4th, Other nerves, as Uie fifth and third pair
are, in some cases, also theseatofamaurons. It
has been shown by Maorndis and Desmocums
that the integrity of the fifth pair is necessary to
the perfect function of the retina ; and Mr. Miro
has furnished evidence that the third pair is re-
quisite to the motions of the pupil. If the great
sympathetic be divided in the upper part of the
neck, the pupil becomes contracted and immove-
able, and the eye wastes.

7. 5th, Parts of the emeephaUm connected with
the optic nerves in their course are occasioDtllj
the seat of amaurosis, as pathological research and
experiment have shown. MM. Maoewdu and
Serres have proved that, when these parts are
wounded, the aight of the opposile eye becomes
either weak or extinct.

8. 6th, The pineal and pituitary glands are
frequently the only parts in which any aiteratioa
can be detected in the examination of amaurotic
subjects. I'he connection of these glands with
the ganglial system is stated at another place.
Besides these, other parts of the brain, wlten the
seat of organic disease, are not infrequently
the principal source of amaurosis, as shown
hereafter.

9. II. Causes. — 1st, The prediepoeing eaum
of amaurosis are very diversified. Amongst these,
the influence of hereditary disposition is well csta-
bltshed . B err traced it in several fiunilies ; is ooe
of them through three successive generations, and
particularly in the femalea of tliat family who had
not borne children, it having appeared in them at
the ceasation of the mensea. Beer also states, that
dark eyes are much more liable to it than the light ;
the proportion being upwards of twentjr to one.

1 0. VV hatever tends to favour sanguineous con-
gestion of, or serous effusion in, the enoephalon.
particularly insolation ; forced exertions of the
mind or body; excesses of passion ; the pregnaot
and puerperal states ; occupations requiring fre-
quent stooping ; errors of diet, and neglected ail-
ments affecting the stomach and liver ; the abuse
of wine or spirituous liquors; suppresaed dis--
charges, parucularly those from tbie nose and

inieiruption or entiiis cevation, of Uis

• a

AMAUROSIS— PiiT90L0OY of.

€1

oeoaes; the goutj, rfaenmaticy and strumous
diithein; the netrocession or suppressioii of
eruptife diseues; aud habitual oonstipatioD ; —
whatever exhausts the vital energy of the brain,
uMi oerves supplying the organ, as chronic diar>
rticea, typhoid fevers, the exceasive use of snuff,
Icag-continued grief, prolonged suckling, neg-
kded Boor albus, excessive venery, and manus-
tnpation j— and lastly, whatever exhausts slowly
(iie sensibiiity of the organs of sight themselves ;
a» the incautious use of the eyes in a glaring
..^iil or on minute objects, and the existence of
•triiooiB ophthalmia in chndhood, generally prc-
i:upm to amaurosia.

U. 2d, The exciting causes are very numerous ;
isdftd, any of the causes enumerated as merely
predispoiiag to the affection may excite it, when
ximg long or intensely, although the successive
or combined action of various causes are gene-
rally required. Amongst the most common ex-
ciong causes, are over-exertion of the sight;
cipo&ure to very bright light ; its occupation on
siJDute objects, or employment in c^Ludle or lamp
liiht, and during the hours usually devoted to
il«cp. The sensibility of the retina may be de-
^jed, even by a aiDgle exposure to these causes.
Ugbtnmg is another cause, which seems to act
bj extinguishing the sensibility of this very deli-
cate part In general, however, it is the long-
c&atiaued over-excitement of the organs of sight
thit occasions the g^radual abolition of their func-
Ua% Injuries on the eye, and in its vicinity, are
^ frequent causes of the disease.

12. Poisonous substances occasionally pro-
duct an attack of amaurosis; sometimes sud-
<^&iy, a other times slowly. Belladonna, stra-
BQtuam, solanum dulcamara, &c., fish-poison,
^vious fungi, and animal poisons, occasionally
^ve the former effect; but it is most frequently
^1)' of temporary duration; whilst other nar-
cctus taken habitually, as opium and tobacco,
pnxlttce the latter effect, and in a more perma-
0€&t manner. The poison of lead, blows on the
k^, child-labour, and puerperal convulsion,
fibqoeot attacks of epileptic or other convulsions,
c&tbral apoplexies and paralysis, injuries of
ti« branches of the fifth pair of nerves (three
^3ses of which have come before me), and even
imution of these nerves, will produce this affec-
^bQ i it has also been observed to supervene to
gastiic and intestinal irritation, particularly when
<>OLaaoocd by worms ; to hypochondriasis, and
accumulations of bile in the livw, &c.; to frights,
^ to the irritation proceeding from carious teeth.
Ihe sudden suppression of epistaxis, of hasmor-
rboids of the lochia, of the milk in nurses, of the
laeoKs, or of the perspiration ; the repulsion of
miptioos on the bead and behind the ears, and
^'^ drying up of old ulcers, have, aeverally, occa-
ii.cid the disease. But most frequently it is the
ruult of two or more of these causes, acting
if'ikr drcumttanoes of predisposition. Females
«ub daii eyta are extremely liable to the disease,
&pon the cessation of the menses ; and, like deaf-
^^1 it is apt to appear after severe attacka of
tjpboid and scariet fevers. Amon^ the more
nt« cidtiog eausea of this affection, are the
fMity and rheumatic diathesis, or misplaced and
ittiocadent gout and rheumatiflm ; the constitu-
tttoal elTccu of syphilis, and hurtful influence of
■ttTcuiial eowMi ;— all which have been aasigned

as causes of the disease by some authors, and de-
nied by others ; but, undoubtedly, producing it
on some occasions, although not so frequently as
the former believe.

13. 3d, The proximate or efficient causes of this
affection are various. It has been disputed whe-
ther or not it can arise from altered function only,
and without change of structure. Mr. Xbavebs
believes that it does, but Mr. Mackenzib denies
it can depend upon morbid function merely ; and
other writers take opposite sides of the question.
There can, however, be no doubt, if we atten-
tively consider the disease in relation to the ex-
citing causes and the effects which are observed
to result from them, that, although most com-
monly the consequence of some appreciable
change in some one or more of those parts in-
stanc^ed as its seat (§ 3-^.), it is occasionally
unattended with such change, --^ at least to such
an extent as our observation of the effects pro-
ceeding from similar alterations would lead us to
expect. It should not be overlooked that the
operation of many of the causes which have been
adduced above is entirely vital — upon the func-
tions of life, as manifested in the organ, or in
remote parts of the frame ; — that their effects are
sometimes almost instant, and before organic
change could have been produced ; and that the
disappearance of thdr effects has been sometimes
as sudden, and oflen before the restoration of
morbid structure, providing that it existed, could
have been brought about. I believe, after a care**
ful perusal of the works which have been fur-
nished by surgeons on this disease, that a too
marked disposition has been evinced to consider it
as a result of organic change in the organ and
the nerves, and vessels connected with it, and
without relation to qonstitutional and vital causes.

14. When describing the seat of amaurosis,
the influence of organic changes has been briefly
noticed ; and a fuller reference to them will be
made in the sequel. Amongst the numerous
lesions of structure that occur in the brain and
its membranes, there are many that affect the
nerves of sight, more particularly the optic nerves,
or which implicate them organically in some pait
of their course in a very remarkable manner.
Alterations in the bones of the cranium, as well
in the membranes, obstructing the functions either
of these nerves or of the other nerves subservient
to the perfect exercise of this important sense, are
also not uncommon.

15. The xFPiaENT causes of this affection,
therefore, are, 1st, vital or functional, depending
upon imperfect or abolished sensibility of the
retina, or of the optic and other nerves subservient
to vision, owing either to causes which, from their
direct and local action, depress or exhaust this
property, or to those which, from their primary
influence upon the frame, have an indirect de-
pressing effect, which is not limited to this organ,
although manifested in it in a more marked degree,
owing to various concurrent circumstances. This
constitutes the Junctional form of amaurosis ad-
mitted by Beeh, Wabdrop, Travebs, Sahsok,
and others, and which Beer divides into two
subordinate kinds : fint, that which proceeds
from direct depression of the vital senaibility of
the eye ; and, second, that which is owing to in-
ordinate excitement, and consequent exhaustioB
of this property.

£ 3

62

AMAUKOSIS — Symptoms.

16. 2d, A eongettive or inJlammaUny ttatt of
ikt vessels of the retina, or parts immediately
adjoining, or the ustial effects of these states. —
Portal, pLOucQutr, Prochassa, Rousseau,
Sanson, Maoenois, and other pathologists, have
observed varicose states of these vessels ; unusual
injection of the minute arteries of the adjoining
coats, a§d of the retina itself; a complete reti-
nitis; exudations of lymph under the choroid,
near the ciliary circle ; inflammation of the ex-
ternal surface of the sclerotic ; vascular injection,
and firm adhesion of the retina to the choroid ;
partial detachment of the retina from thb coat ;
and thickening, morbid density, and change of
colour of the retina. Ossification ; fibrous de-
generation, with partial thickening ; wasting, and
malignant disease of the retina, and even the
developement of transparent vesicles in it, have
all been noticed by Haller, Morgagni, Heis-
TER, Sanson, and other authors.

17. 3d, Lesions affecting the optic nerves,—'
These consist chiefly of tumours of various kinds
— osseous, fibrous, encysted, steatomatous, puri-
form, aneurismal, &c. — formed in their vicinity,
either in the brain, the membranes, or in the bones
of the cranium, and involving, or compressing
them, in any part of their course. They are like-
wise, occasionally, the seat of some one, or even
more, of those organic changes of their proper
structure and sheaths, to which nervous parts are
liable. Their vessels may be varicose; their
fibres may be infiltrated with serum ; they may be
injured by external violence, and they may be
wasted ; which last is very frequently observed.
Adventitious deposits, as osseous and earthy mat-
ter, malignant formations, cysts and hydatids,
may even form in their sheaths, although more
rarely than the foregoing lesions. The writings
of pathologists abound with instances of these
changes. Wheu only one eye has been amau-
rotic, the optic nerve of that side has been found
wasted anterior to its partial decussation ; and on
the opposite side, posterior to this union. But
this is by no means an uniform circumstance, and,
when observed, the atrophy is not distinctly con-
tinuous. Indeed, the wasting has been detected
on the same side, after the union of these nerves,
as well as before. But if the opinion of Trevi-
RANus and Wollaston be correct, —that decus-
sation of these nerves at their union is only partial,
and that it takes place chiefly between ,the parts
which are nearest each other, — wasting of one of
them may be in one case more remarkable on the
same side, and in another case more observable
on the opposite side. When the amaurosis is
accompanied with wasting of the optic nerve,
from causes not primarily consisting of inflam-
mation or its consequences in the retina or ad>
joining coats, this nervous expansion is also
generally wasted, transparent, or changed in
colour. When the cause exists in the pineal or
pituitary glands, the wastin? is often chiefly ob-
servable at the union of the optic nerves. In
these cases, both eyes are affected. Facts illus-
trative of this have been recorded by Vieussens,
Ds Haen, RuLLiER, Rayer, Ward, and San-
son.

18. 4th, Lesions seated in the encephalon, — The
Kope of this article will not admit of further
reference to the numerous changes which occa-
sionally produce amaurosb, from their afiecting

the optic nerves in their different oonaeclions with
various partt of the encephalon. All the alter-
ations which are describea in the articles on moT'
bid structures of the brain and rrs msmbranf^,
will produce the disease, when they impede the
functions of the optic nerves, although the struc-
ture of these nerves may be uninjured. The most
frequent and remarkable of these are, organic
lesions of the pineal and pituitary glands (§B.),
sanguineous and serous effusions, various kinds of
tumours, abscesses, softening of the brain, &c«

19. 5th, Lesions of nerves subsidiary to the
integrity of the organ and of its functions,— la-
juries, compression, and even irritation of the fifth
pair of nerves, particularly its ophthalmic branch,
of the third and sixth pairs, and of the ganglia or
their ramifications, by organic change in the brain,
its membranes, bones of the cranium, or parts in
the course of thdr branches, have been shown, in
numerous instances, to have been the chief effi-
cient causes of amaurosis.

20. III. Symptoms. — The symptoms of amau-
rosis are, 1st, those which the patient himself
experiences ; and, 2d, those which the physician
detects in the eyes, or in the various organic and
animal functions. Each of these classes of symp*
toms are to be enquired into separately, com-
mencing with either of them. Each eye should
be carefully and separately examined ; and it
will be better that the other is excluded from the
light, whilst the examination is being made.

21. 1st, The patient complains of impaired
vision, which may be of gradual accession, or re-
markably sudden, and amounting to almost total
deprivation of sight. Hence the disease has been
distinguished by the epithets slow and gudden, tm-
complete and complete, or imperfect and perfect,

22. At the commencement, the failure of vision
is sometimes only occasional, for a short time, and
after longer or shorter intervals {amaurosis vaga).
In some cases it assumes the form of day-hlind'
nesSf in others of night-blindness : and it not in-
frequently recurs for a time after great exertion of
the eyes, either with minute or bright objects.
Transient and sudden attacks of the disease^ are
often the consequence of disorder of the digestive
organs, or rather the result of a state of the vital
manifestations which occasions equally loss of
sieht as well as loss of the digestive functions.
The failure of sight is often at first only partial >—
extending only to a part of the field of vision. lo
some cases, intervening portions of the field are
obscured {visus intemtptus). In other cam,
one half of it is hid firom view (hemiopia). Oc-
casionally objects are only seen in a particular di-
rection (yisus obliqutu) ; and some patients discern
objects in a distorted form-^crooiLed, routilaled,
shortened, lengthened, or inverted (visus defigura-
tus). Beer states that the flame of a candle will
often appear elongated, and as if. separated into
several portions, to such patients,— >s symptom
indicating disease within the head.

23. In some instances the failure of sight as-
sumes a myopic or a presbyopic form : but this is
not so frequent as the occurrence of false impres-
sions, in the form either of flashes of light, shining
stars, globes of light, and various other lucid spec-
tra (photopsia), or of muscae volitantes. raise
impressions of colour (chrupsia) are also frequent
attendants on the early stages of amaurosis. Lumi-

I nous spectre are commonly met with is plethoric

AMAUROSIS — Symptoms.

63

perMu, and wlien the amaurosis depends upon
locmatA vascularity, or inflammation of the re-
tina ; motes» black specks, muscae volitantes, and
thick mists or clou<u, when the afTeciion is de-
pendent upon exhaustion of the sennbility and
%ital energy of the organ, and when it occurs in
djfpeptio subjects from exhausting causes. Double
▼>iott is also a common symptom, particularly
«hea the cause exists within the head.

24. As the disease advances, the field of vision
appear! as if olM>cured by a cloud, or net-work ;
the latter a.ppearing gre^ or black in a good light,
Imt oocasioaally beconuoe white, silvery, yellow-
i>li red, and luminous in the dark. In addition to
these, the patient sometimes complains, particu-
Isriy eariy in the disease, of some intolerance of
H?bt, or of pain in the eyes on being exposed to
II. But, in other cases, from the very beginning,
<fim2nished sensibility of the retina, and a constant
desire for a stronger light — a thirst of light — are
present.

25. Pun in the eyes, and commonly also in the
bead, n one of the most important symptoms of
amauroais. It should, therefore, be carefully in-
vestigated. We ought to ascertain its precise seat
aod extent ; its character — whether it be acute,
^vative, throbbing, occasional, or permanent.
The circomstances which relieve or exasperate it
ihould also be noted ; as the horizontal posture,
temperature, exercise, diet, the use of stimuli, &c.
We should also notice whether it be accompanied
«ith vertigo, tinnitus aurium, watchfulness, or
^idpor, coma, forgetfulness, inability of exertion,
or hilnre of other mental manifestations ; as, from
the nature and grouping of these symptoms, we
iofer the nature of the efficient cause of the
di«ease, particularly as they suggest its existence
within the craniom.

26. Unusual drynesas of the eyes and nostrils
MXBctimes is observed in amaurosis ; and in these
ra*s benefit is often derived from a restoration of
the secretions of the lachrymal gland, conjunctiva,
and Schneiderian membrane. (Mackenzie.)

27. The general health, and previous ailments
af the patient, require a particular investigation.
The eoo^titution and diathesis — whether he be
tinnnous or gouty ; whether he has had syphilis,
or undergone long courses.of mercury ; whether
ite has had typhoid fevers, or inflammations of the
brain, or apoplexy, paralysis, epilepsy, or injuries
60 the head ; whetlier he has been subject to
complaints of the digestive organs, or has been,
or is, affected with worms : if a female, whether
'be has been frequently attacked with paroxysms
cf hysteria, or any of its- anomalous forms, or with
<^»Tnlsions in the puerperal state, and particu-
liriy whether or no there exist any sign of disorder
ii the oterine organs — are all particulars most
rc<)niute to be known.

28. 2d, The form, colour, vascularity, and mobi-
Uir of the different parts of the eye, and habit and
appearance of the patient, next require investiga-
*Joo. The amaurotic patient walks with a gait
(>f asoertainty, and a staring and unmeanioe look.
In «oDie case* this want of convergency of the eyes
|o«ards an obiect may amount to slight squint-
•n^, occasionally with oscillation, and sometimes
»ith unusual fixity of the eyes. In some instances,
(he motions of the eyelids, aod of the eyes them-
*»Wes, are more or less impeded, or even palsied,'
— the evator palpebrs superioris, and Uie orbicu-|

laris palpebrarum being often affected. These
phenomena are chiefly remarked in cases where
the motor oculi, or the facial nerve, is injured.

29. One or both eyes are often unusually pro-
minent. The colour of the sclerotica is frequently
somewhat changed — beiogeitheryellowish, bluish,
or ash -coloured. This coat is often covered with
small varicose veins. The consistenc^Palso, of
amaurotic eyes is occasionally altered ; in some
cases the eyeball is firmer to the touch, in others
softer, than natural. In rarer instances, it is
flattened on one or more of its sides.

30. The pupil is generally slug^sh and limited
in its motions, or altogether depnved of motion,
and dilated. More rarely it is contracted. In
many cases it is neither dilated nor contracted.
A widely dilated pupil, although generally at-
tendant on pressure on the brain, also occasionally
depends on other causes. Early or incomplete
amaurosis is rarely attended with dilated pupil ; but
after all vision is extinct, the pupil is generally more
or less expanded and motionless. It should not
be overlooked, that where only one eye is amau-
rotic, the motions of the pupil oi the affected organ
will often follow those of the sound one, when
protected from, or exposed to light; and even, as
observed by Janin, both eyes may be completely
amaurotic, and yet both pupils will vary in diameter
with the intensity of light to which they are ex-
posed. This phenomenon can only be explained
by referring to the nerves supplying the different
parts of the orgao. The iris, being chiefly sup-

f>Iied with ganglial nerves, will often retain its
iaculty of motion, when the eflicient cause of the
disease affects the optic nerves at any place between
their origin and their communication with the
third pair; or when the affection of the optic
nerves within the cranium does not leave the retina
altogether deprived of sensibility, although the
impression cannot be conveyed to the bram, the
subsidiary nerves, particularly the third and fifth

flairs, and the branches from the cavernous and
enlicular ganglions, still bestowing suflicient sensi
bility and mobility on the iris to admit of motion
on beine stimulated.

31. Sesides the size of the pupil, it is necessary
to attend to the characters or the motions of the
iris. This part may contract on one side, or in
one part, drawing the pupil to one side, or giving
it an irregular appearance. It may also seem as
protruded towards the cornea, or it may appear
sunk inwards, and have a funnel-like shape.
-(Macxenzie.)

32. The appearance of the humours of the eye
is also important. In hydrocephalus, or when
occurring in young subjects, the pupil has the
natural black hue. But in elderly subjects some
degree of glaucoma accompanies amaurosis. This
appearance is in general unfavourable.

33. The presence of the marks of injuries about
the face and head is important, as marking pro-
bable injury of parts within the cranium, or of
some nerves subservient to the perfect condition
of the organ. The character of the countenance,
the shape of the head, the state of* the vessels of
the head and eyes, and the general habit of body,
require to be noticed. The inference which ought
to be drawn as to the exact nature of the disease
will be very different when it is met with in the
plethoric, the highly fed, and the indolent, from
that which will be deduced from its occurrence in

£ 9

64

AMAUEOSIS— Specim o?.

the emaciated, or exhausted subject. The pro-
bable predisposing and exciting causes' should also
be investigated, as they have an obvious relation
to their emcts. Attention should be directed to
the previoiis habits, indulgences, ailments, occu-
pations, and modes of life of the patient, &c., with
the vievuf throwing light upon the causes and
patholonSd relations of the malady.

34. The duration of the disease is extremely
various. It may, in slighter cases, be only of a
few hours' or days' contmuance ; may altogether
disappear, either spontaneously or from treatment,
and never afterwards recur ; or it may return afler
an indefinite period, from errors in diet, disorders
of the digestive organs, or from the operation of
the causes usually producing the disease. It very
frequently continues all the life of the patient.

35. IV. Stages, Grades, and Forms. — The
stages of amaurosis are incipient and confirmed. In
the former the sight is generally not altogether lost,
although more or less impaired. Treatment will
often retard or check the progress of the disease,
and sometimes even bring about a perfect cure. But
the blindness may be complete from the first : in this
case, medicines are generally without effect. In the
confirmed stage, the disease is usually stationary ;
but the sight is not always altop^ether lost : the
patient often retaining a perception of light and
shadow, or even of objects, when illuminated or
strongly contrasted. When this power of distin-
guishme any object or colour is sml retained, even
m the slightest degree, the amaurosis is said to be
incomplete. When the patient is insensible even
to the presence of light, the disease is complete.
It may be limited to one eye, in the incipient or
incomplete states ; or it may affect both equally,
either in an incomplete or complete form. It may
also be incipient in one eye, and confirmed in the
other ; and it may be more or less complete in
either. It may likewise, in one or other of these
states or forms, assume a recurrent or remittent
type ; but such cases are comparatively rare.

36. But, besides these stages and grades of the
disease, other forms occasionally present them-
selves, which will be more fully noticed in the
sequel. It may be Idiopathic, depending upon
changes, either functional or organic , taking place
primarily in the nervous apparatus of the eye, and
existing timply, and without any other associated
lesion: or it may be complicate with lesions of
adjoining parts, or with other diseases of the eye,
particularly of its humours, more especially with
glaucoma and cataract. It may also be conucu-
tive of other diseases ; most frequently of organic
changes within the head, or in the vicinity of the
orbit, as in apoplexy, paralysis, &c. And, lastly,
it may be tymptomatic of, or supervening to, pre-
existent disease of distant parts, particularly of the
abdominal viscera ; or it may oe occasioned by
pregnancy, and more rarely by diseases of the
puerperal state. It is not infrequentlv thus symp-
tomatic of colic from lead, accumulations of fecal
matters in the large bowels, hypochondriasis, &c.

37. According to these states of the disease, its
different species will next be considered, and the
treatment which is appropriate to each of them
will subsequently be pointed out : for it is obvious,
that the success of remedies will, in this very diffi*
cult and variously complicated disease, mainly
depend upon the strict appropriation of remedies
to its different varieties aiKl states.

38. Spec, 1st, Functional ilmatinwit.— This
form of the dianse generally arises, — 1st, from
suspension or exhaustion of nervous and sensorial
power ; from various local and constitutiooal causes
(§ 13.) ; from inordinate excitement or exertion of
the visual organs ; from mental exertion, watchful-
ness, and sedenuuy habits ; from the deleterious
action of mineral, vegetable, and animal poisons, as
lead, mercury, narcotics, &c. : 2d, from venereal
indulgences; excessive secretions and evacuations ;
depression of the vital energies from diseases of
deoility and exhaustion : and, 3d, from temporary
diminution of the local circulation ; from simple
congestion, or occasional determination of blood
in the veins or arteries ; and from the irritation or
disturbance of the digestive organs, or of some
other of the abdominal viscera.

39. The symptoms of this species are, chicfiy,
more or less obscuration of vision, occurring slowly
or suddenly, the visus nebulosus, and muses vo-
litantes ; a somewhat contracted pupil, and clear
state of the humours ; equal imperfection of si^^ht
in both eyes ; pale, languid countenance, and de-
pression of the eyes in the orbits ; a languid, small,
or weak pulse ; increased dimness, or sudden abo>
lition of sight upon quickly assuming the erect,
from the horizontal posture. An improved stale
of the sight after a light meal, or p^rateful stimulus ;
nervous headachs ; weak digestion, sluggish state
of the bowels, flatulency, foul or loaded tongue »
and indisposition for, as well as incapability of,
physical or mental exertion or occupation *, weak-
ness in the joints ; occasionally nocturnal emissions,
&c. in the male, and leucorrhcea in the female.

40. This species of amaurosis may be, Ut,
Primary, ana uncompUcated. — In this case it
usually proceeds from causes which depress or
exhaust the sensibility of the retina ana its re-
lated nerves. 2d, It may likewise be coruecuiii^ ;
particularly of excessive secretions and discharj^t'<
from the uterus, mammae, kidneys, testes, anJ
prostate; or from exhausting and debilitating
diseases, as adynamic diseases, hemorrhages, kc.
3(1, Symptomatic of, or complicated with, hysteria,
hypochondriasis, colica pictorium, diminished
vital energy of the digestive organs, and all the
various forms of indigestion; the presence of
worms in the bowels ; pregnancy ; obstruction and
accumulation of bile in the bile-ducts or bladder,
&c. : and, 4th, Metastatic, or supervening upon
impeded or checked secretions ana discharges ; id
which cases it is generally accompanied with con-
gestion, or determination* of blood to the head, in
which the eyes may partake, but not to an extent
constituting inflammatory action or organic change ;
and it assumes a state nearly approaching to thit
characterisiog the next species.

41. Spec, 2d, Amaurosis from active conges-
tion.— The existence of this species of the disea>e
is more a matter of inference, than almost any
other of those in which I have divided the disease.
Yet it seems undoubtedly to exist ; cspeclallr
when amaurosis is consequent upon obstruciiHl
secretions and discharges, or the drying up of
eruptions ; upon frequent stooping, or wearing a
tight neckcloth ; upon fits of pasnon, when it
occurs in plethoric persons; and after narcotic
poisons.

42. The symptoms indicating it, are throbbing
in the eyes, tinnitus aurium, turgcscence of the
vessels of the sclerotica and conjunctiva, a some*

AMAUKOSIS — Specibs or.

6$

vhat ooDtncted pupil, and clear state of the
humoan ; twgesceace of the features, or lividity
or bloatednesB of the face ; fulness of the ju^lar
Tciiis, pfocnioence of the eyes, and impeded circu-
lation throuc^h the lungs or cavities or the heart.

43. ThW form of the disease is seldom primary
aad ^neomplieaUd, It is commonly eomecutive,
or S9»ptamatie, generally of obstructed discharges,
&c ($ 12.), of disease within tlie head, particu-
iirly of sanguineous congestions, or effusions, and
iitwisaes of the lungs and heart. It not infre-
quently occurs transitorily from pregnancy, epi-
ie;wy, and hysteria ; and more rarely from gout
and rheumatiam.

44. Spec» 3d, Amaurotis from inflammation of
t\e rtlxma, and internal parti of tho eye. — In stating
amaurons to be often a symptom merely of reti-
nitis, I am supported by the opinions of many of
tSe best British and Continental writers on the
<!^««ase. But I believe it very seldom occurs,
that the mflammation is limited to this membrane,
but that the choroid and iris generally participate
with it in the morbid action; and that, when
they, on the other hand, are thus affected, the
reona is also inflamed. Amaurosis is therefore a
e(M)seqaence of inflammation of the internal struc-
Uirea of the eye : but does inflammation of these
farts uniformly produce amaurosis? It is not
always consecutive of iritis ; and I believe that
thp retina may be inflamed, and yet but very
«l;frht amaurotic symptoms may be occasioned
thfreby, particularly during the early stages of
the retinitis. It is chiefly when the inflammatory
totioQ has produced some degree of organic
legion of the affected parts, that amaurosis is
manifested.

45. This form of amaurons generally proceeds
from nearly the same causes as the foregoing
( i 10— 12.). It may be produced by syphilis, mer-
cury, eruptive and continued fevers, cold in any
form actmg upon the eyes or face; suppressed
4£ischar|^, or eruptions on the head or bemnd the
ears; injuries of the eye and adjoining parts;
roQCttSMons, and the usual causes of inflamma-
tion in other parts.

46. The symptonu wy with the extent and
ioteasity of the inflammation. In its slighter
ftUles, the progress of the disease, and of the
cymptoms, is insidious and slow. In these cases,
liiUe or no pain is complained of, either in the eye
or in the head. The pupil is more commonly
contracted than (filatea, and the spectra are
Qsually luminous, but sometimes not very sensi-
bly so. With this slight and often chronic state
of inflammatory action, the amaurosis may be
tocreaong fast, and the observation of vision very
i;reat, and yet the symptoms may not be dis-
tinctive ; if we except the appearances furnished
bv the sclerotic, which, in retinitis, as well as in
inns, abouuds in red vessels, converging in distinct
iinei, and forming, by their delicate reticulations, a
i«i zone round the cornea, and which thus furnishes
tbs only <tymptom, that can be depended upon, of
^ligit or incipient retinitis.

47. In the more intense states of inflammation
of the internal parts of the eye, the amaurosis is
attended with painful vision ; intolerance of light ;
marks of fire, or drops of a T«d colour falling from
the eyes; flashes of light ; pain darting through
the head, ettber from, or to the bottom of the eye-
balls; the pupili are dilated, and the humours

thick or muddy ; and there are more or les*
acceleration of pulse and constitutional dis-
turbance.

48. This species of amaurosis is often primary
or idiopathic; it may also be nmpie or complin
oated^ When it occurs in a complicated form, it
is, most frequently, associated with iritis, with
meningitis, with eruptive or continued fevers,
and with rheumatism, gout, or syphilis. It may
also occur eonteeutively, and from metagtatis,
particularly after the disappearance of exanthe-
matous eruptions, as in the measles, small-pox,
erysipelas ; of chronic eruptions ; and after the
suppression of habitual or periodical discharges,
secretions, and evacuations (§ 12.).

49. Spec. 4th, Amauro$it from advanced diS'
or^anixation of the retina and adjoining ports.-—
Disorganixation of these parts is usually a result
of inflammation. But it is difficult to determine
at what stage of the inflammation organic change
commences. I am to consider it here as mr
advanced ; ^et, the inflammation that occasioned
it may be still present. The eautet of this species
are the same as those of the foregoing ; but the
tymptomi are somewhat different. The vision is
more obscured. A film seems interposed between
the e^e and field of vision. The pupil is sluggish,
and It is often scarcely dilated ; it is frequently
irregular. The margin of the iris sometimes
partly adheres to the capsule of the lens. The
sclerotic is often very vascular, and even livid,
from the enlarged and loaded state of its veins,
which are very numerous and tortuous. The
shape of the eye is sometimes changed, particu-
larly in the most advanced cases ; it is prominent
in some parts, and depressed in others. The
eyeball is occasionally, also, soffer or firmer than
natural.

50. This form of amaurosis is always emsecu'
tive of the second and third species, more particu-
larly of the latter; and hence, participates in
many of their characters ($ 41 — 48.). ana occurs
under many of the same circumstances as they.
It is occasionally complicated with cataract, with
opacities of the cornea, or with disorganization of
parts within the head.

51. Spec. 5th, Amaurosii from external injurieg
of the eyes. — A blow on the eyeball will not
infrequently occasion blindness, without produc-
ing any apparent injury of its visible parts. It is
difficult, or altogether impossible, to ascertain the
nature of the mischief that has been inflicted.
The concussion of the organ, and the lesion of
the sensibility of the retina and optic nerve, may,
in some of the cases, particularly when the con-
sequent amaurosis is merely temporary, constitute
the principal or only change. In more perma-
nent and severe instances, it is very probable that
the delicate connections of the rotma with the
adjoining parts are injured. Ecchymosis may
also be occa«oned, or inflammation may super-
vene. ' In these cases the pupil is either dilated,
or of an irregular form ; ana according to the ex-
tent of injury will the phenomena partake of the
characters which have been assigned to the third
znd fourth species of the disease.

52. Spec. 6th, Amaurosis from disease toithin
the head affecting the functions of the optic nerve,
or other nerves subservient to the sense of sight. — It
is obvious that disease within the cranium, either
of the substance of the brain, or of its membranes^

£ 4

66

AMAUROSIS — SPBctsft op.

producing prMsare of, or interrapted circulation
in, the ports with which the optic nenre is con-
nected at its origin, or during its course, or acting
In a similar manner on the nenre itself, will pro*
duce amaurosis. In these cases it is a conteeutiv$
affection — a symptom merely of disease, often
existing for a lone time previously. I have al-
ready alluded to the nature of these lesions, and
to tlieir extreme diversity ($ 17, 18.)* Perhaps the
most common and the most iot^esting of them
are organic changes of the pituitary and pineal
glands, hemorrhage, sanguineous congestion,
aneurismal and other tumours, &c. In these
cases it is very common to find cerebral symptoms
complained of long before the sight is affected ;
and to observe the gradual accession of the dis-
ease either in one or both eyes ; or first in one and
afterwards in another, with complete loss of vision,
followed at last by changes of tne structure of the

53. When organic lesion of the pituitary
and pineal glan<u has occasioned the disease,
judging from the cases recorded by De Haek,
Wensxl, ViEussBNS, Levzqus, Ward, Rullisb,
and Rayeb, both eyes are generally gradually
and equally affected, after the existence of ce-
rebral symptoms, chiefly consisting of pain and
weight referred to the more anterior parts of the
head ; of a repugnance to exertion, apathy, loss
o memory, and weakness of the mental energies.
In cases of sanguineous congestion, or haemorrhages
in the situations referred to, the attack is sadden,
and the blindness is often not the most remarkable
symptom.

54. In some eases resulting from organic dis-
ease within the head, cerebral symptoms, particu-
larly those of an acute kind, are not complained
of until the amaurosis is far advanced. In its
progress, objects frequently seem to the patient
disfigured or perverted. In many eases of amau-
rosis from oiiganic change of the skull, mem-
branes, or brsio, the affection commences with
intolerance of light, strabismus, giddiness, lumin-
ous spectra, convulsive motions of the eyes and
eyelids, contracted pupil, and turgescence of the
blood-vessels of the eyes, loss of bearing, smell or
taste, or both, violent headach, rapidly followed
by complete amaurosis, protrunon of the eyeball,
and abolition of the external senses and of the
powers of mind.

55. This species of amaurosis is often compli-
cated with, or preceded by, epilepsy, paralysis,
apoplexy, ottorrhea, or disease of the ears, hysteria,
and various nervous affections. It is chiefly by
attending to these antecedent disorders, or other
slighter cerebral symptoms, that we can form any
idea of the nature of the amaurosis. The appear-
ance of the eye, and particularly of the pupil, is
not to be depended upon ; for, although tne pupil
is usually dilated and immoveable, the exceptions
are too numerous to admit of considering it as an
uniform occurrence.

56. Spee» 7th, Amaurotit from d'ueate of the
optie nerves, or of thxir iheatht.—ThJB species of
amaurosis always advances slowly, generally com-
mencing in one eye, with a black cloud, which
grows more and more dense, great' disfigurement
and perversion of objects, without pain of the head
or eye. There is, however, a sensation of pres-
sure at the bottom of the eve, as if forcing the
eyeball from its socket, The pupil is generally,

from the commencement, much dilated, and an*
golar, from irregular action of the iris. B v de*
grees, according to Beeb, glaucomatona change
of the vitreous humour supervenes, and al^terwaids
of the lens itself, but without any varicose affection
of the vessels of the eye. At fast the eyeball be-
comes somewhat smaller than natural, but com-
plete atrophy does not ensue.

57. Spec, 8th, AmaurotU from Isewne of
branches of the fifth nerve, 6;e. — The experiments
of Bell and Maoendie first threw light upon this
cause or form of amaurosis. I believe that it is
by no means infrequent. Four cases of it have
come before me in private practice ; in three of
which the principal trunk or branches of the
ophthalmic nerve were implicated. In one of
these the amaurosis was very slight ; in tbe othr
two it was very considerable, although not com-
plete, and was a consecutive phenomenon of
very extensive disease. I saw two of them, in
consultation with respectable practitiooers in my
vicinity. The fourth case very recently occurred
in a member of my own family. In it the frontal
branch on the right side was pressed upon by a
common boil ; the sight of the eye was nearly
altogether lost, but was soon restored when tbe
boil broke.

58. Numerous cases are on record, in which
partial amaurosis is said to have occurred after
mjuries and wounds of the eyebrows, cheeks, and
forehead ; or from the irritation and extraction of
diseased teeth. The appearance of the disease
from these causes was noticed by Mobgagni,
PiNEL, Beeb, Wardrop, Travebs, Pevada.
Rises, &c., before the functions of this nerve
were so well known as they are now. Its occur-
rence from wounds of the eyebrows is mentioned
even in the writings of Hippocrates.

59. Amaurosis from these causes is, in some
rare instances, complicated with facial neuralgia,
toothach, rheumatism of the face, and tumours
or abscesses developed in tbe vicinity of the eye,
and within the cranium in the course of the fifth
nerve. I met with it in a case of ottorrfasBa, ter-
minating in caries of the bones, and extensive
disease of the internal parts in the vicinity. It is
also, in some cases, accompanied with paralysis
of the upper lid, and in others with paralysis of
different muscles of the eye. In these cases, the
third or sixth nerves have, most probably, been
chiefly affected. When the ophthalmic nerve is
afifected within the cranium, it is diflicult, if not
impossible, to determine the particular seat of
lesion from tbe amaurotic symptoms. Facts have
not been observed in sufficient number, and with
requisite precision, to admit of any statement being
maide respecting the pupil and motions of (he iris
in this species of the disease. I believe, however,
that serious organic, as well as functional, lesions
of the organ may supervene to it.

60. There are other varieties of amaurosis par-
ticularised by Beer, Weller, Sanson, and other
German and French writers, some of them of
rare or doubtful existence, or at least referrible
to the species into which I have here divided the
disease. From amongst these I may eonme-
rate the following: — Gouty amaurosis 9 rheu-
matic amaurosis 3 amaurosis from the sudden re-
pulsion, or cure of cutaneous eruptions, or oM
ulcers; amaurosis from suppressed secretions and
evacuatioD$; puerperal aina^irosis, ficc, U i*

AMAUROSIS «^ Ducyosn — Pboovosts.

67

criiknt ihtt these ere only oceanoiia], and bv no
BMos frequent, causes of the disease, which
ffDght to be kept in recollection by 4be practi-
uoDcr, hot vrhich can act only by indacing some
•ae or other of the forms into which it has been
ih\ided ; more particularly the iecond, third,
jMirtk, and tixtk, la as far as they may require
a nxKlified plan of treatment, they will receive
aiteotioa io the sequel.

61. In addition to these, I may notice the cat**-
es€ anurnmit of Bexr, which is only met with in
die old, debilitated, thin, and emaciated; parti-
colarly those who are grey, or white* headed. At
ibe cofflmencement of this amaurosisy the iris
retains its mobility ; but it afterwards is slow and
tie pupil dilated. Deep in the bottom of the eye,
> coocave pale grey, or yellowish green> or reddish,
variegated opacity is observed. The further the
disease advances, the paler the bottom of t|^e eye
becomes, the paleness extending to the iris, until
•t last a slender vascular plexus — the ordinary
ramification of the central artery and vein — may
be dJKeroed. With this state of the eye, decline
or total abolition of vision is the consequence.
This lars form of amaurosis seems to consist of a
(Idideafy of the pigmentnm nigrum, and of the
apetDm of the uvea. It appears closely allied to
£ir advanced glaucoma. This form of the disease
is seldom or ever benefited by medical treatment.

62. V. Diagnosis. — Amaurosis is liable to
be mistaken for incipient cataract, and for glau-
CM. When cataract is fully developed, the two
<^seaies can scarcely be confounded. That a
c nr diagnosis should be made between incipient
ntarict and amataroeis is of the greatest import-
lace in practice.-— il. As to the impaired vision
ia iMJth diseaaes at their commencement, it ma^^ be
remarked that in eataraet, the difficult of sight
"'■iiUBB very slowly, and is compared to a dif-
fosed mirt, thin cloud, or gauze intervening
beiveen the eye and the object; whereas in
Oiarvsit, the dimness or loss of sight is either
nddea or partial, resembling a fly, spots, or motes
^verifig parts of an objecL However, a mist, or
^ doad, often is complained of in incipient
unaarods, and, increasing in denaty, at last de-
piives the patient of right; but a complete depri-
TidoQ of sight never occurs in cataract. As inci-
pient cataract depends upon commencing opacity,
gt'oerally at the centre of the lens, the appearance
of a mist, &c., is generally roost perceived when
t^e patient looks straight forwara; vision being
more distiDct when he looks sideways. This com-
tr-ooly does not obtain in amaurosis, although it
'tmetiffiei docs.

. ^- B, The degree of light which the pa-
Uat desires is also important. When amaurosis
(I^peiids upon insensibility of the retina, there is
& great desire of strong light, and he sees the best
at DooDday, or when objects are brilliantly illu-
uTjiated. The opposite of this obtains in cataract ;
for a strong light, causing the pupil to contract,
Ike nv% of light reflected from the object must
^ chiefly through the central and more opaque
l<an of the lens. In addition to this we should
iiUeiMi to the antecedent and attendant symptoms
^^ tmaoross; especially verti|[o, headach, dis-
order of the digestive organs, without which cata-
'»« usually commences.

^. C. Upon examining the pupil, incipient
«n*wosTs presents either the pet-tUc|t coloyr of

healthy— excepting in the^ oatVeye amaurosis of
Bxsa, which is of rare occurrence, and presented
to us under circumstances not to ^e mistaken, — or
a paleness or greenness, visible only when the eye
is examined in particular directions, constituting
amaurosis with glaucoma. This appearance evi-
dently arises from deficiency of the pigmentum
nigrum, and incipient dissolution of the hyaloid
membrane ; and when it amounts to a high de-
gree, constitutes the cat's-eye amaurosis of Beer.

65. Mr. Mackenzie remarks on this subject,
that attention to the following circumstances will
generally enable the observer to distinguish glau-
comatous amaurosis and cataract : — 1st, The
opacity in glaucoma is always greenish, whereas
in incipient cataract it is always greyish. 2d, The
opacity in glaucoma appears seated at a consider-
able distance behind the pupil, or deep in the
vitreous humour ; whereas in lenticular cataract,
the opacity is close behind the pupil. In posterior
capsular cataract, the opacity is deep in the eye,
but is always streaked ; whereas the glaucomatous
reflection is always uniform, never spotted, nor
radiated. Sd, Upon close examination of the
surface of lenticular opacity by means of a double
convex lens, it is seen slightly rough, somewhat
dull, never smooth or polished — forming, in these
respects, a striking contrast to the appearances
presented by glaucomatous opacity. 4th, The
eyeball, io glaucomatous amaurosis, always feels
firmer than natural ; while in cataract it presents
the usual degree of firmness. 5th, Glaucoma
proceeds very slowly in its course, scarcely in-
creasing for years ; whereas the vision, in cataract,
much more rapidly declines, and keeps pace vrith
the growing opacity.

66. D. The mobility of the iris is a principal
source of diagnosis. For, in incipient cataract,
the contractions of the pupil are as extensive and
as vivid as in health ; but, in incipient amaurosis
the pupil is either dilated and fixed, or its motions
limited and slow. Also, in the latter 'disease, the
movements of the eyeballs and eyelids are often
imperfect, or diflicult ; whereas no impediment of
this description exists in cataract. In many cases
of amaurosis, we observe a want of direction in the
eyes, or a slight degree of strabismus, not infre-
quently with a want of power over the motions
of the upper lid, — symptoms that never occur in
cataract.

67. VI. Prognosis. — This is unfavourable.
When the cause of the disease is evident, and it
is merely functional, or simply congestive or in-
flammatory, and the patient young, or in the prime
of life, but under middle age, a complete cure is
not infrequent. This may be obtained although
much more rarely, even when the loss of sight is
total. But in every case the predisposing and
exciting causes, and the eflTects of remedies, must
be taken into account io forming our prognosis.
Much more commonly only partial amendment is
produced. Amaurosis is generally less unfavour-
able when suddenly, thou when slowly induced.
When the pupil is only slightly dilated, still
moveable, of its natural form, the eyeball neither
firmer nor softer than in health, and no glaucoma
present, the prognosis is obviously more favourable
than when the pupil is fixed in the states either of
expansion or contraction, or when the eyeball is
either boggy or preternaturally hard, or when the

I bottom of the eye presents a greenbh opacity.

58

AMAUROSIS —Trsathxvt.

68. If the attack has been sudden, and nearly
complete, or if objects are seen in a perverted or
distorted form, or double ; if the amaurosis be at-
tended with want of power in the muscles of the
eyeball or eyelids, we should suspect that the
cause consists of general or partial pressure, or
q^her organic disease, within tiie cranium, which,
although indicating both danger and the permanent
loss of sight, will sometimes be removed by ener-
getic treatment. If one amaurotic and paralytic
symptom slowly supervene on another, we should
cbead the mduaJ developement of tumours,
cysts, exostosis, &c. within the head, the situation
and nature of which can be suspected only, and
chiefly from the nature of the attendant or pre-
ceding symptoms. But in all these the prognosis
is necessarily very unfavourable.

69. VII. Trbatmknt. — In order to employ
remedies in this affection with any degree of
benefit, it will be necessary to direct them with a
very particular reference to the pathological con-
ditioDS of the eyes, the brain, and system generally,
as now pointed out. Having separated the dis-
ease into the foregoing species or varieties, in
order that the treatment may be pointed out
with greater precision, I proceed to detail the
measures which I consider appropriate to each,
conformably to the most experienced authors,
and to my own observation.

70. A, Of the fint ipecies. — The treatment
of this, the most strictly functional form of the
disease, should have strict reference to the causes
which induced it, — whether those acting directly
on the organ, or those which act indirectly, and
in consequence of inducing disorder of other parts.
When amaurosis proceeds from direct causes,
either of a depressing or an exhausting nature,
the appearance of the eye, as well as the charac-
ter of the symptoms, require an attentive examin-
ation, chiefly with a view to ascertain the existence
of inflammatory action, or even active congestion
of the internal parts. A complete removal of
the causes must be insisted on ; and, if no symp-
toms indicative of inflammation (§ 46.) exist, but,
on the contrary, debility, a languid circulation,
musc€R voUtantet, or dark spectra, &c. (§ 39.),
tonics and stimulants, both mternally and exter-
nally, are required. A light, nutritious, and
invigorating diet, with change of air, repose of
the organs, moderate exercise, vegetable, and af-
terwards mineral tonics, and the usual means of
improving the digestive organs, and promoting
the functions of the bowels and secreting viscera,
are in these cases chiefly to be depended on.
Small doses of strj/chnitu, or of the extract of nux
vomica, may also be given (Form. 541. 565.).
When, however, we find evidence of congestioo
or increased vascular action of the internal parts
of the eye to have been induced, the means to be
employed in the next species roust be resorted to.

71. When this species of amaurosis proceeds
from interruption or disorder of the digestive func-
tions, as indicated by the symptoms of such dis-
order, by a foul tongue, acidity and flatulence of
stomach, and torpid bowels (i 39.), emetics, as
recommended by Kichter, Otto, Schmuckkr,
pLCMaiiNG, Scarpa, and Mackekzif, may be ex-
hibited ; but, unless the symptoms of interrupted
digestion, or of indigestible and injurious sub-
stances remaining upon the stomach, or of biliary
obstruction, be unequivocally present, little ad-

vantage will be derived from them : in plethoric
persons, or where these causes of disorder do not
exist, they 'may be even injurious. Amaurosis
from disorder of the digestive organ is generally
imperfect, and sometimes slight ; and its progress
slow. In this form, Scarpa recommends full
vomiting to be produced by the patient taking
a spoonful, eveiy half hour, of a solution of
three grains of tartar emetic in four ounces of
water; and, on the following day, opening pow-
ders to be commenced with, consisting of an
ounce of bitartrate of potash and one erain of
potassio-tartrate of antimony, divided into six equal
parts. The patient is to tske one of these parts
in the morning, another four hours afterwards,
and a third in the evening, for eight or ten suc-
cessive days. The eflPects of these are, nausea,
and increased evacuations from the bowels ; and,
in the^ourse of a few days, vomiting. If, daring
their use, the patient should complain of a bitter
taste in the mouth, vain efforts at vomiting, and
no improvement of sight, the emetic, as at first
directed, is to be again taken ; and this is to be
repeated a third or fourth time, if the bitter taste,
acid eructations, nausea, &c. continue. The re-
petition will often at last succeed in procuring the
discharge of a yellowish or greenish matter from
the stomach, to the relief of the head and eyes.

72. The stomach, and through it the liver,
having been thus acted upon, the following re-
solvent pills of ScH mucker are to be taken, to the
extent of fifteen grains, night and morning.

No. IL R Gum. Sagapen.. Oum. GalbAni,*SApon.VeDct,
aa 3J. : RheiSiii. ; Antimonti Pot.-Tartratii gr. xt. :
Ext Gtycyrrh. 3 J. Divide in Pllul. gr, lU.

These pills are to be continued for four or nx

weeks. Instead of these, the pills reoommoided

by Richteh may be prescribed.

Vo. 11. B Oum. Ammonlad, Gma. AaiatatM., Stop.
Venet, Had. Valertaa, Sumnit Amla». tf 5U. ; Anci-
monil BoUMio-Tartratii gr. zviU- i Syxuiv q. e, U.H
divide In Pilulaigr.UJ. •*• . / i* ^

From twenty to thirty grains are to be taien
three times a day for some weeks.

73. If these succeed in improving the state of
the stomach and nght, Scarpa directs means cal-
culated to strengthen the digestive organs, sad
nervous system: such as the daily exhibition of
bark and valerian, more particularly in periodic
amaurosis ; a light, digestible animal diet, with s
moderate quantity of wine, and wholesome air
and exercise. He further prescribes, as advised
by Thilsnius and Moriogia, the vap<mr of liquor
ammonite directed to the eye, with the view of ex-
citing the nerves of the organ; and employed,
three or four times a day, so as to occaaon each
time a copious secretion of tears. In conjunction
with the use of this vapour, other external stimu-
lants, as blisters to the nape of the neck, behind
the ears, or to the temples ; irritation of the nerves
of the nostrils by sternutative powders ; and, lastly,
sparks of electricity may be resorted to. Various
volatile substances, spirituous, saline, and olei-
ginous, have been recommended to be applied to
the eyes, either in a state of vapour, or of solution,
and dropped into them, by Warnsr, Sagas,
Man A ROUS, Dunxkler, Cmomel, St. Yves, and
SciiMvcKER ; but these require to be cautiously
resorted to. Substances of a like description
have also been prescribed in the form of coUjfrio,
in this species or amaurosis. Plenck recommends
for this purpose a drachm of the erocut meiat-

60 AMAXjroSIS — Triatmekt.

eztrtet of nux vomica, may be prescnbed both
ioteraally and topically. (Form. 542. 565.)
The coDDectioQ of the disease with hysteria, hypo-

and, in some cases, with ammonia or camphor,
may be exhibited, or aconitum combined with anti-
monials, and purified sulphur ; and rubefacients

chondriasis, obittructions of any of the abdominal I applied behina the ears, or to the temples. When
secretions, chiefly requires the combination of ; it appears after the suppression of eruptions, and
antispasmodics with aperients ; chlorine, iodine, ' healing of old ulcers, the use of the tartar emetic
or sulphureous baths; the occasional exhibition ! ointment, setons, and perpetual blisters behind
of a brisk purgative ; and, afterwards, the warm ' the ears, are particularly indicatetl. If it follows
nth-water bath, tonics with &tiraulants, and strict ; a suppressed cold, Weller recommends weak
attention to the secretions and functions of the ' sternutatories, with calomel or helIel)ore.
digestive organs, and to diet, air, and exercise, i 82. Mr. Traveks has very justly remarked,
A Iter all obstruction is removed, cold bathing, or ' that a loss of balance of the circulation, produ-
chalybcate or salt-water baths, followed by fric- \ cing undue determination of blood to the head,
tions of the cutaneous surface, may be used. i often exists independently of general plethora,

80. B. 0/ the second species, — When amau- ■ and is aggravated by sanguineous depletion. It
rosis is attended with those symptoms which I . is sometimes even met with in corpulent persons ;
have described as marking active congestion of ' and is not infrequent after over-excitement and
the internal parts of the eye, or of the head or ' chronic inflammation. Instead of requiring losa
thoracic viscera ($ 41. )t a very different treat- I of blood for its removal, this state of the disease
ment to that cnjoiDcd above is requisite. In the demands an equalisation of the circulation, by
first species of amaurosis, Mood- /«(fin^ is generally ' promoting the various secretions, and the deriv*
prejudicial — it ha<i even caused the disease; but, | ation of the excessive supply to other parts by
in the congestive species, blood-letting, either ge- the means now stated, assisted by an abttemious
neral or local, or both, according to the circum- and regular diet, gentle exercise in the open air,
stances of the case, is indispensable. In every | the promotion of the functions of the liver and
form of the disease the means of cure must be bowels, and the means usually employed to be-
regulated b^' the apparent vascularity of the eye, , nefit the general health. Even in some of these
the plethoric state of the countenance and body, ', cases, the local means noticed above, as the va-
and by the state of the arterial pulse, examined, ' pours of ammonia, 6tc. (^ 73.), may be service,
not only at the wrists, but also in the carotids and i able in restoring the tone of the vessels of tlie eyes,
temples. | 83. C. Of the third s;)«ci«<.— -Inflammation

After depletion, to an extent which the well- of the internal parts of the eye, particularly of
informed practitioner will be led to adopt accord- the retina, requires decision, in the more intenae
iog to the particular character.^ of the cose, the , cases, and a vigorous but judicious application
promotion of the alvine discharges, and of the , of the usual antiphlogistic remedies. In the
cutaneous and alvine secretions, will next require slighter cases, the exact nature of the disease may
his attention, as salutary modes of derivation and j be mistaken for either of the forgoing speciea.
evacuation ; and afterwards the application of , Slieht or slow inflammatory action may exist

blisters, setons, issues, and other counter-irritants,
behind the ears, or to the nape of the neck, will
generally be necessary to complete, or to render
permanent, the cure. The ointment of the potas

without any material aflection of the pulse, or
pain of the organ ; but the appearance of the
blood-vessels of the sclerotic, and the state of the
iris, will often indicate its presence when other

sio-tartrate of antimony, moxas, the mezereon j signs arc wanting. When the attack is acute,
issue, the actual cauter}' to the nape of the neck, j both general and local depletions are required,
or to the occiput, and errhine.«, nave severally | In these ca<cs Plenck has advised the perform*
been recommended by eminent continental writers ' ance of orteriotomy ; Spioelius and Hoffmann
in this state of the dir^casc. ! of blood-letting from the frontal vein ; and Sau-

81. The ihoirtr-hath, sponging the head with ' vacss from the iugulars. But vascular depletion
cold water night and morninor, the cold douche^ or I is not to be relied upon nlonc. Active cvacu-
thc efl^'usion of a stream of coM water on the head, I aliens from the bowels, determination to the skin
arc means which ought not to be neglected in j by small and repeated doses of antimonials, and
those cases in which the congestion is of an , the use of the tartar emetic blister or plaster be-
activc character, or approaches to the inflamma- , hind the ears, or to the nape of the neck, are to be
tory state. When this form of the disease is con- also adopted.

secutive of interrupted or suppressed discharges I 84. If these means fail of producing a veiy
or evacuations, the restoration of these must be , decided impruvement in a very short time, we
attempted. If the menses be suppressed, leeches must endeavour to afl*ect the mouth slightly with
to the pudenda, or the insides of the tops of the mercury, without producing salivation. In order
thighs ; or bleeding from the feet ; the prepar- that this may be done with rapidity, and with as
ations of iodine, aloetic purgatives, and other em- liitle mercury as pos.sible, the pieparations of this
menagogucs ; stimulating pediluvia, and the Ai/i- ' mineral to be employed will be advantageously
hathf with the other means usually resorted to in combined with James's powder, or compound pow-
cases of amcnorrhcca, arc to be employed. If it ' der of antimony, and small doses of camphor. The
proceed from suppressed haemorrhoids, leeches ' treatment is, in such cases, similar to that usually
may be applied to the vicinity of the anus, and resorted to in iritis. Much of the advantages to
purgatives, with calomel, colocvnth, and aloes, ■ be procured from the use of mercury in this form
prescribed. If it supervene on the disappearance of amaurosis, as well us in iritis, depends upon
of gout or rheumatism, sinapisms and irritating the promptitude with which it is employed. In
cataplasms may be directed to the extremities, , this Traveks, Law rinck, Macrenzii,, and othen
and free alvine evacuations procured; after which : agree. Indeed, the use of calomel, and other
colchicum, combined with alkalies or magnesia, i preparations of mercury, either alon^, or cant^

AMAUROSIS — Tbeatment.

61

biocd with other gubstanctt, has been adopted in
tite isflammatory states of amaurosis, from the
tune of Hexstkb and Boebhaavb. Banc, Hdd-
jMASir, JScHMucixa, ZuxcKSR, and Breitino,
igree in lecommendiog them. Boettcher ad-
mes the combination of calomel with belladonna )
ud Hsy, calomel with camphor : both being
jndidoos modes of combining this medicine.
MiAD, Stahl, HorncANN, and Isenflauii, ad-
s'se the production of salivation ; but I agree
vitb Tea VERS in considering the affection of the
niouth as sofficient. The use of mercury is much
pr&i$cd by Beer in such cases, as well as in those
0/ a cyphiliiic origin, or which are complicated
vith engorgement of any of the abdominal vis-
cera. Care should be had not to employ mercury
ic debilitated or scorbutic persons, and when the
m b soft or boggy. Many of the continental
vriten, and Mr. Ware, prefer the bichloride to
ocher preparations. It is best exhibited, as recom-
mended by Van Swieten, dissolved in brandy,
azkd taken in a basin of sago or gruel. It may
be continued for six weeks, or even loiifi^er.

85. The success which has resulted from the
eiUbition of the aiwm ttrebiathindi in iritis in-
doced me to prescribe it, after depletions, in two
tsses of this form of amaurosis ; and with satis-
fwtoiy lesults in both. In persons far advanced
ui life, in scrofulous subjects, and in debilitated
iKTWQs, this oil is certainly a less hazardous me-
drnne than the mercury exhibited so as to aiiect
tike system.

86. In the slighter or more chronic inflamma-
tory fonns of amaurosis, particularly when met
with io the description of subjects just now al-
luded to, much circumspection is necessary in the
»e of djepletions : general blood-letting is here
ludnuBble, particularly when this class of pa-
tients are ni ted, and live in close and ill ven-
tisied streets and apartments in large towns, and
local depletions only are indicated. In cases of
tkK description, and under these circumstances,
tbe oleum terebinthinas will prove a valuable me-
dicioe; and even, although we may deplete thus
locally, tbe internal exhibition of tonics, with a
Qutritkous diet, attention to the alvine secretions
&ad evacaations, and a wholesome air, will prove
tbe most beneficial remedies.

87. This form of amaurosis, as well as the
pf^cediag, will occasionally supenrene from sup-
ftsstd evacuations and eruptions, and, more
rtrely, from misplaced gout and rheumatism.
(^48.) In such cases, the treatment already
recommended, as appropriate to each of these
f$8l.), will be equally applicable here.

87. Besides the above means, it has been re-
commended by BaoMriELO, to insert an issue in
(be aealp ; by Hoffmann, to apply leeches to the
uttides of the nostrils ; by numerous authors, to
nnploj errhines and ttemutativcs, with the view
^ provoUne a copious secretion from the Schnei*
^ertih membrane ; and by as many others, to use
tbe ictual or potential cautery, setons, moxas,
&c. to the nape of the neck, or to tlie occiput.
Ueches and counter-iirilants are safe, and
'c^nietimes useful, remedies in this and the pre-
ceding spedes ; but enhines and stemutatives may
he hattfttl, unless the affection has arisen from
sBppretMd discharges from the nostrils. They
vc most serviceable in the functional state of the
Tbe Mfest that can be employed in this

species of amaurosis is the one recommended by
the late Mr. Ware. It consists of ten grains of
the hydrargyrus sulphuratus, well mixed with a
drachm of common sugar : a small pinch of it
generally produces a copious discharge of mucus
from the nose.

89. D. Of the fourth, and remaining species,—
When we have reason to suspect that the amau-
rosis depends upon advanced organic lesion of
the internal parts of the organ, consequent upon
inflammation, we should still bear in mind tnat,
with the supervention of such lesion, whatever it
may be, the inflammatory action seldom alto-
gether subsides, but continues, more or leai, in a
chronic, atonic, or disorganizing form. There-
fore the propriety of still having recourse to local
depletions, particularly if these have been ne-
glected early in the disease, to purgatives, deriva-
tives, or revulsants ; the cold douche to the head ;
and, afterwards, to the use of stimulating vapours,
when we have reason to suspect tliat the cnange
continues rather in consequence of lost tone of
the vessels, and inaction of the absorbents, than
from increased action. Under such circum-
stances, the vapour of camphor and acetic acid,
or of the liquor ammonis, may be tried.

90. a, Ir the amaurosis have arisen from extern
nal injury of the ball of the eye, or concussion of
the organ (| 51.), the chief indication is to pre-
vent, or to repress, increased vascular action, by
the means already recommended ; to attend to
diet and regimen, and to keep the organ in a
ouiet inactive state for some time ; after which, if
tlie affection still continue, the treatment must
be directed according to tbe particular lesion,
functional or organic, that may have been pri-
marily or consecutively produced.

91. b. When the history of the case leads us
to suspect the dependence of this affection upon
disease within the htad ($ 52.), or tumours
pressing upon the o/ptic nerve, &c. (§ 56.),
the treatment must necessarily be directed, ac-
cording as the symptoms referable chiefly to the
head may lead us to infer the nature of the pri-
mary lesion. If such symptoms, particularly the
temperature of the head, and the action of the
carotids, indicate the existence of congestion,
interrupted circulation, or increased action, the
treatment must be accordingly. But, under almost

I every circumstance, counter-irritation, and exter-
nal as well as internal revulsant!$, will prove
safe, and sometimes serviceable, means of cure.

92. If we have reason to suspect the formation
of tumours -, thickening, or other change, of the
membranes or of the bones, particularly as a
consequence of syphilb; and extravasations of
blood, or of serum, within the cranium, or in the
course of the. optic nerves, &c. (§52.)» the
internal use of the preparations of iodine, and
particularly of the iodide of mercury or of po*
tassium(jaee Form. 323, 324.), should not be over-
looked. I have employed these preparations
with much benefit in three cases of amaurosis
connected with paralysis ; two of them conse-
quent upon apoplectic seizures. In the intervals
between the courses of iodine, deobstruents, and
alterative doses of blue pill, with the extracts of
sarsaparilla and taraxacum, or with the decoction
or other preparations of sarsaparilla, should be
prescribed.

93. c. When the affection seems connected with

62

ANGINA PECTORIS — Symptoms.

letion of the other nervet tubtervient to vision ($ 57.),
the treatment must necessarily depend upon the
seat and nature of this lesion, and, in some rarer
cases, upon the state of the associated derange-
ment. If it be connected with neuralgia of the
nerves of the face, disorder or irritation of these
nerves may exist at their origin, or in their
course through the membranes and bon^ of the
cranium. The cause may also be external — in a
diseased tooth or stump, or a partially separated
external branch of the oplbalmic trunk of the
fifth nerve. In all such cases, as well as in the
other forms, states, and associations, of the fifth,
sixth, seventh, and eighth species, which have
been enumerated, the treatment must vary in
each, and be directed according to the very nu-
merous pathological conditions, which the welK
informed pathologist will detect, either as their
efficient causes, or as their related effects.

94. Throughout the treatment of this disease,
the practitioner should keep the following facts in
recollection : — 1st, An appropriate, and hence
successful, method of cure should have an inti-
mate relation to both the remote and proximate
causes of the disease, and the natural or morbid
diathesis of the patient : 2d, It must be directed
after a minute inspection of the eyes, and exa-
mination into symptoms connected with the head
and the digestive viscera : 3d, It must be modified
according to the nature of its related, associated,
and symptomatic disorders : and, 4th, That much
of the success will often 'depend upon the strict
regulation of the patient's digestive and organic
functions j upon diet and regimen ; and upon a
regulated exercise both of the organ of sight and
of the body, with a pure and temperate air.
Keeping these indications in recollection, the
practitioner will modify and adapt the treatment
to the presumed nature, seat, complication, and
relations of the disease.

BiBLiocRAmY. — Cradokf GeneralU circai Suffiuionero,
Guttjun Screnam, et Indam. Ac. Leid. \QSS. -^ HeisteTt
Apologia et Uber. lUurtratlo SyttematU lui de CaUr.,
(*laucoin., et AmauroaL Alt. 1717, ISmo. — CEheme, De
Araaurofei. Leip. 1748, ^lo. — }Vamer^ Detciipt of the
Human Eye and itf Ditcaceg. Lond. 17/H. — Sproegel, in

WahrnehmuDgen. Ber. 1774. —et Vennische Chirurg.
Schrif. 17m.^JiicAUr, Anfansgriinde der WunderineiE.
Goet. n^. —Scarpa^ Ouerva«ioni sutic Malattic degli
C)cchi. Venet ISO'i. ; 2d ed. 1816. — Ftqjani, CoUezione
d'OMervaiionL Rom. 180a — WemuBlj Manuel de TOcu-
lltte, &c. Parii, 18U& — Kieuer, Ueber die Natur, Una.
Chen, Kennseichen, and Hcilung dea Schwarie Staars.
Goct. 1811.— Jirrr, Lehrevon den Augenkrankbciten. Ac.
Wicn. 1817.— tVardropt On the Morbid Anatomy of the
Human Eye, S vols. 8va Lond. 1818.— 7VatF£r«,Sjrnop«i«
of the Disease of the Eye. Ac. Lond. 18W, Svo.—Ste-
pctuon, On the Nature, Ac of the dilfkrent Species of
Amauroiis, Lond. lS2i. '- Demtmn, Pr6cts Th^orique et

Pratique sur Ics Maladies des Yeux. Paris, 1821 fVetier,

Manual of the Diseases of the Human Eye; by Mon.
tealh. Olasg. 1821, 2 vols. 8vo — Bayer, Archives Q^n^r.
dc M^decine, t vi. Paris, 1823. — ilartoUn, art. Ammh
ro$e. Diet de M«Jd., i. il. Paris, 1822.— San»oH, art
Amaurote, in Diet de MM et Chirurg. Pratiques, t iL
Paris, 1889. — Lawrence, Lectures on Diseases of the
Eye i Lancet, vol. x., 18SU. — Benedict, art Amaurotu, in
Kiicyclopadisches WOrterb. der Mediciniscben Wisscn.
chaften. b. ii. Bert. I8Sa — Mackenzie, PracUcal Treatise
on the Diseases of the JSye. Lond. 18^0, 8vo.— i7. Mid-
d/emore. On Diseases of the Eye. Lond. 1836, 8va roL U.
p. 252. — (Sec also Bibiiog. and Be/er. to art Eve.)

AMENORRHGEA. See Menstruation.
AMNIOS. See Dropsy of the Amnion.
ANvEMIA. See Btooo, Dejideney of.
A^ii:STU£SIA. See Sensations, UwWl
Utates of'.

ANASARCA. See Dropst or tsb CstLuiaft

Membrane.
ANEURISM. See Aorta, Aneurism of; and

Arteries, Morbid Structuree of»
ANGINA. See Croup. Larynx, InftantMa*
tioMof, FBAnYiiX,InJiammatian§af, Throat,
Jnflammationt of.
ANGINA PECTORIS. Syn. Cardi4>gmus
Cordis Sinistri, Sauvagei. Angina Pectoris,
Heberden. Asthma Jrtftrittcum, Schmidt.
Diaphragmatic Gout, Barton. Asthma DoUy-
rifieum, Darwin. Syncope Anzinosa, Parry.
Angor Pectoris, J. Frank. Attamu Convulti*
vum, Eisner. Pnigophobia, Swediaur. Ster'>
nodynia Syncopalis, Sluis. Asthenia Peetoraiis,
Young. Stenocardia, Brera. Asthma Spattia>'
Arthriticum, Steelier. Stemalgia, Baumes and
Good. VAngine de Poitrine, Fr. Brustbraune,
HerskUmme, Brustklemme, Ger, Angina di
Petto, Ital. Suffocative Breastpang, £ng.
Classif. 2. CUlss, Diseases of the fUnpira-
tory Function; 2. Order, Affecting tbe
Lungs, their Membranes, or motive Power
{Good), II. Class, I. Order {Author,
see Preface),
h Defin. Acute censtrietory pain at the lower
part of the sternum, inclining to the Ufi side, and
extending to the arm, accompanied tnth great
anxiety, difficulty of breathing, tendency tosyncope,
and feeling of approaching diseolutionm

2. This affection was not recognised as a distinct
disease by medical authors, until Dr. Heberden
described it as such in the Medical Transactions of
the London CoUeseof Physicians ( voU. ii. and iii.) ;
but the works of Morgagni and Hoffmann show
that they were not unacquainted with it in practice.
It was also noticed by Poter (^Opera, No. 2*2.
p. 302.), under the head *' Respirandi difficultas,
que per intervalla deambulantibus incidit ; " and be
remarks respecting it, that the attacks were some-
times 60 severe that persons had been suddenly
carried off by them. Obscure notices of affectioot,
which probably were of this nature in some in-
stances, may also be detected in authors from
Hippocrates downwards. From amongst these,
the reader may refer to Aretavs {Opera, p. 7.
Oxon. 1723), Cslius Aursuanus (lib. ii. c. i.
p. 348.), Barteletti (Methcdus in Dyspnaam,
Bon. 1632), and others, adduced by Zbcbinelu
(Sulla Angina di Petto, Pad. 1813), who sup-
poses that the case of Seneca ( Opera, t, ii. p. 236.),
which he has himself described by tne term
tuspirium, was actually this malady. Dt, Cvllsm
has passed Angina Pectoris over in his work -, but
it has been well described by Drs. FoniERoiLi.,
Wall, Duncan, Buttbri Perczval, Darwin,
Macbrioe, Hamilton, Macqueen, Johnstons,
Haygarth, Parry, NicuoLL,aiid Good, in this
country; and by J urine, Brera, Lbntin, Dks-
portes, Kreysic, Hitter, Zecbinelu, and
Stobller, on the Continent ', and by Dr. Cbap-
UAN, in America.

3. Pathology. — I. Symptoms. — Anattsckof
this disease is often preceded by oonsideiBble de-
rangement of the digestive organs, especially by
flatulence, acid or acrid eructations, or other
symptoms of indigestion, with torpid bowels* pains
in the limbs, and occasional spasms about the
chest ; but it frequently abo attacks a patient, parti-
cularly when walking or ascending an emineooe,
without any, or with but alight, premooitioD*

ANGINA PECTORIS— Causm.

63

4. A. In its aeute/orm, the patient is seized with
A seme of puoful constriction of the chest, par-
tic uJarly at the cardiac region, about the lower
l»it of the sternam, inclining to the left, and ex-
tcading to the left, occasionally also to the right,
ann — at fint no further than the insertion of the
deltoid muscle ; hut the pain often successively
reaches to the elbows, wrists, and sometimes even
tu the fingeia. This is the mildest form of the
di>ease, and soon subsides with the disappearance
of its exciting cause.

5. In the more violent form of the attack, the
pain and sense of constriction in the chest, and
fiaio ia the left ann, which also frequently ex-
tends u> the right, amount to excruciating agony ;
beio^ likened, by Lasnnec, to the piercing of
nails or the laceration by the claws of animals.
Tbis feelii^ is accompanied by a sense of syncope
or sttflbcation, sometimes with suffocative orthop-
n<£a, convulsive dyspnoea, and palpitations;
always with extreme anxiety, and a sense of ap-
proaching dissolution. The suffocative sensation
IS chitfacterised by concomitant tightness and
folneaa of the chest, and flatulent distension of
tbe aUHnach, and irritative feeling in this organ,
which is relieved by eructations. During this
period the poise is variously affected, sometimes
httle changed, at other tiroes extremely weak,
JmgalMT, or intermiuent -, and occasionally it is
fall, active, and bounding. If the attack has been
Bid need by walking or exercise, the patient sud-
denly stands slill, from a feeling that perseverance
in euher would produce a total suspension of
living power. In the slighter attacks, or early in
the dtteaae, rest merely will often immediately
remove ii ; but this is seldom the case in the pro-
tncted and severe forms in which it frequently

6. The paroxysm continues from a few minutes
to one or more hours, according to the severity
and the dnratioa of the disease. When the mal-
ady has assumed a chronic form, and its attacks
occur during the night, or when the patient is at
rest, the paroxysm is less violent, but generally of
much longer duration ; whereas, when it is in-
doeed by exertion, &c., it is of extreme violence,
bst of short continuance: the average duration
of the fit may be about half an hour. Upon its
oeaslion the patient merely retains a slight feeling
of the vat ions symptoms, with numbness of the
arms, particularly the left. When the disease
IS of short standing, the paroxysms occur at long
iattrvals, which are gradually shortened, until
there ia but httle exemption from them, and the
affection assumes a less acute character.

7. B. The chronic form of the disease is charac-
lefisad by the circumstance of its being frequently
a consequence of the acute -, by the occurrence
of the lit from the slightest causes, and after short
or iaperiect intervals of exemption ; by its recur-
rence when the patient is at rest or asleep ; and
by its much longer duration, but less extreme
violence. Even S this form be induced bjr exer-
cite, rest has little influence in shortening its
duration, is in the preceding ; and the paroxysm
Us been protracted, not only Cor some hourv, but
even for several days. Palpitation of the heart,
irregular and intermitting pulse, are more fre-
quently coDComitaots of tbis state of the disease
than of the other. In the case of a very eminent
and learAed member of the profession, whom I

long attended in this form of the disease, the
attack has often continued as now described, with
little remission, for several weeks. Sometimes the
irregularity of the pulse is observed only during
the paroxysm ; but in some cases it is continued,
as l5r. FoTHxaciLL has correctly remarked, during
the intervals, particularly when they are marked
by imperfect relief.

8. This form of the disease may also occur
primarily. It has twice presented itself to me in
this manner. During the severity of the attack,
leipothymia, a feeling of dissolution from the in-
tense B^ony, and these followed by palpitations,
and an irregular state of the pulse, generally occur.
In some cases the agonizmg pain extends, not
only to the arm or arms, but ascends aUo up the
throat and lower jaw, accompanied with a severe
sensation of spastic constriction. In the majority
of cases the above sensations are only present
when excited by motion, by assuming suddenly
the erect posture, or even by attempting to read ;
a neuralgic kind of pain generally, however, being
felt under the sternum, and extending to the arms :
but in some coses, and in two which occurred to
me, the exacerbations were often referable to no
very evident cause, they sometimes occurring
during the night, although the above causes
geneially induced them.

9. ^notwithstanding the remarkable distress
characterising the paroxysm, this disease, par-
ticularly in us acute slate, sometimes does not
early affect the constitution, or entail any per-
manent lesion ; the patient often enjoying toler-
able health in the intermissions, and performing
all his functions naturally, and without embar-
rassment, ^^til shortly before an attack. After
its protracted continuance, however, the vital
energies of the frame, particularly as they are
manifested in the digestive and circulating organs,
give way. Marked disorder of the chylopoietic
viscera, attended with various dyspeptic symptoms,
occasionally with great irritability of the stomach
and bowels, impeded respiration, anxious and
pale countenance, flubby state of the integu-
ments and muscles, marked deiangement of the
circulation, oedema, dropsy, &c., at last super-
vene. But it more generally happens that the
patient is carried suddenly off by a paroxysm
before this state of the system is occasioned ; or
he sinks under the complicated derangement
proceeding from an attack, and from some one of
the organic changes which the continuance and
repeated fits of the disease had induced.

10. II. Causes. — 1. Predisposing, — This disease
usually attacks the middle aged, and those beyond
it; and n.en much more frequently than women.
Of nearly one hundred cases, about seventy were
upwards of fifty years of age ; and seventy-nine
out of the number were males ; nearly one half
terminated fatally, and almost the whole of them
suddenly. It has been said also to occur more
commonly in robust and corpulent persons with
short necks. But JvaiNEand Chapman dispute
this. My own experience agrees with theirs in
respect of its being equally common in persons
of a spare as of a full habit. It is most prevalent
in those of gouty and rheumatic diathesis, and
who lead an indolent, or studious and sedentary
life, or who have been subjected to much and
continued anxiety and distress of mind, or in-
dulged in much food, and spirituous or other

64

ANGINA PECTORIS — Duokosis — Pbogkosxi.

llquon. JuRiN'E and Pare itate that they have
scarcely met with it under fifty yean of age. The
most violent and distinctly marked case of it
which ever came before me occurred in a gentle-
man at the age of thirty-four. During 1821, I
attended an uumurricd lady, a^d twenty-six, who
laboured under it in a slighter form ; and re-
cently, in 1830, another single female, at the age
of iwcnty-fivc, came under my cnrc, with the dis-
ease in its most violent grade. In both the<%
females it seemed perfectly uncoonected with
uterine disturbance, menstruation being regular,
and no tendency to hysteria having at any time
evinced itself, or could be detected, my attention
having been directed to this point. They both
ultimately recovereil, after a lung tieatment, and
the employment of very decided measures. Nearly
all the cases which have come under my observ-
ation weie move or less referable to mental
causes, particularly to disappointment, anxiety,
and other depressing passions. Dr. Hamii.i-un
conceives that there is an hereditary disposition to
the aflfection. If we consider it to l>e of gouty
ori>;in, as contended for by DurrKR, Macqi'ekn,
KiriEit, SioELLKR, TiiiKKNius, Elsner, aiid
CiiAi'M.w, an hereditar}' disposition maybe also
conceded. l)ut, although very satisfactory proofs
have been adduced by these authors, and par-
ticularly by Dr. Chapman, in an able paper he
has recently published on this disease (American
Journ, of Med, ScieiiceSt No. xiii. p. 67.), yet it
does not seem always to depend upon gout. Of
the four cases which occurred to Dr. Black, of
Newry, one only was subject to gout {Med, Chir,
Trans, vol. vii.). ^

11. 2d, The disease is usually netted by walk-
ing, especially walking against the wind, or up
hili ; by ascending a flight of stairs, or any ac-
clivity, particularly when the stomach is full or
disteDiIed by flatus. It is also readily induced by
either the exciting or the depressing passions, and
by whatever perturbates the mind or occasions
emotion. It may al<>o be induced by the most
trifling cau«es, in some susceptible and irritable
habits, a-; by gentle walking, coughing, speaking,
or reading aloud ; by su<Jdeiily iLssuming the
erect posture ; by straining at stool ; or even by u
meal, however iitoJuratv, &c. It may also occur
in a state of abrolut*.- repose, particularly when
liie disease has become chronic ; and the patient
may be routed from sleep by an attack.

12. 1 have seen it occasioned by nipid changes
of temperature, particularly by a rapid change to
great cold ; but different persons seem differently
uflectcd by extreme states of atmospheric tempe-
rature. In some slight cases the fit has been
shoitened, by the patient struggling to overcome
it, by frequently attempting to make a full in-
spiration; but this has also failed. The patient
Is incap'jble of making this attempt in the more
severe paroxviims.

13. III. DrAONosis. — Angina pectoris is more
liable to be confounded with asthma than with
any other di.^a!$c. I^ut a close attention to the
phenomena attending upon both uH'ections, will
readily disclose a very great difference between
them. The paroxy>:ms of asthma always come
on during the nij»ht, or at the close of the day :
thciy are characterised by a heavy dyspncca,
wheezing, and cough, are relieved by expector-
ation and exposure to fresh air, and subsiuo gra«

dually towards morning. I1iey are not excited
in the same way, nor by similar causes, nor
marked by the acute and peculiar pain in the
sternum and lefi nrm, which is distinctive of
angina pectoris. The stethoscope and percussion
fiirnish us with no signs peculiar to tne disease
under consideration, unless it be complicated, as
is sometimes the case, with organic le>ion of the
heart and lungs, or with effubion of fluid within
the cavity of the pleura or peiicardium, when they
materially a«^sist us in ascertaining the nature of
the complication ; and they also serve, by enabling
us to ascertain other affections of the heart, to dis-
tinguish between it and them.

14. IV. Prognosis. — In recent cases, of no
very violent character, recovery will frequently
take place under judicious management. Rut when
the disease has become inveterate from neglect,
or from being associated with, or from having given
rise to, organic lesion, and when it has appeared
in a decayed constitution, or has been preceded
by other diseases of the heart or lungs, an un-
favourable result should be apprehended sooner
or later to take place : but the peiiod of its oc-
currence is uncertain ; and the event is generally
sudden —^sometimes like an electric shock ; the
movements of the heart being instantly arrested.
This i>sue is often occasioned by a full meal, or
by exercise or mental emotions ; but it also occurs
in old or chronic cases, when the patient is at
rest, and apjiarently uninfluence<l by any circum-
stance or occurrence. When it is followed by
symptoms of effusion of fluid within the thorax, or
cedema of the extremities, a fatal tennination if
seldom far distant.

15. V. Proxisiatb Cause,&c. — Notwithstand-
ing the number of examinations which have been
made after death from this disease, but little light
has been thrown upon it. This is not so much
owing to the absence of morbid apjiearances at
to the extreme diver«tity of those which have lieen
observed. Like epilepsy or dyspna*a, it hai
presented alnicst every lesion to which the or^ns
which it affects nro lioble. ^lany of these may
be viewed ns acci(lt:ntal concomitants, or as con-
current causes ; and not infrequently as results
of the repeated functional disturbance occurring
during repeated attacks. In several instances, not
the slightest morbid appearance could be detected :
but nmrc frequently the heart and the large
vessels in its vicinity have presented marks of
disease, generally varied in its nature, and oppo-
site as to its characters. The most common of
these are ossification of the coronary arteries;
ossification of the valves of the heart or of the
arterial trunks ; enlargement of some of the cavitioi
of the heart, cither witii diminished or increased
thickness of their parietes; but most frequently
with softening, paleness, and tenuity of the muscular
stRicturc of the organ ; varicose dilatation of the
coronary veins (Uulra) ; de{)ositions of adipose
matter, to the extent of impeding its functions;
effusions of serum, blood, 6cc. into the pericardium
or cavity of the pleuia, etc. (FoxiitRGiLr., Black,
&c.) It has justly been remaiked, by my friend
Dr. UwiNs, •• that theie is scarcely any malform-
ation of the heart or its blood-vessels, that hai
not been occasionally found after death, from
what would be considered angina pectoris : while,
on the other hand, individuals have fallen victims
to the aflfection, fully marked, and the most oceo-

ANGINA PECTORIS — Pathological Relations.

65

nt« pest mortem examination has not been able
u> dtrtcct the slightest iodication of structural de-
r^Qgfraeot.'' — (^Compend, of Tfuoret. and Pract.
Mm.) — Id some cases the only morbid appear-
aicts obsenred have been in other, and distant
oTpja, from that which seems to be, if not the
chsef teat of the disease, at least the organ chiefly
lieded in its functions by it -^ the neart and
bive veatek having been altogether exempt from
lc!iu«. These appearances were adhesions of the
stfotts sor^ce of the Inogs to adjoining parts;
vrotts effiiiionB into the pleura ; thickening of the
rRpvraiory mucous surface; dilatation of the
LroDchi; oedema of the intervesicular cellular
c^ue of the lungs ; abscess and tumours in
I'le mediastiaum ; ossification of the cartilages
oi the ribs (Wicumakn, Jahn) ; tubercles, en-
largement, scirrhooity, &c. of the liver (PanciVAL,
Utvam, Breea, and Walker) ; scirrhus of the
jFTlonjs, &c.

16. These lesions serve less to throw light on
tU precise mture of the disease than an attentive
etunination of the morbid phenomena during the
'lie of the patienty and a calm appreciation of their
reiitioos, particularly with respect to the agents
'fodiag to diminish, remove, or to exasperate
i::ria. This aflection has been eonndered by
Luj authors as spasmodic, " although the part
cis^diately eoncemed seems not to have been
<}tiigtated or understood." Dr. Chapman le-
caits, that this hypothesis is rendered probable,
^5 tbe general complexion of the disease— its
^zi«%, symptoms, and cuia-^and by its analogy
to other aisoffders confessedly of this character.

n. Dr. FoTHBRGiLL supposed it to be occa-
<>M«1 by obesity, and particularly b^ a collection
vf fa ibont the heart ; be also considered that it
*ts lonctinies symptomatic of water in the peri-
^idiom or cavity ot the thorax. Parry, Jevnek,
l''i-iNi, Krevsio, J3osTOcs,and some others, have
« «nrd this affectian as a species of syncope oc-
fisioatd by the accumulation of blood m the
>^. from an oeafi cation of the coronary arteries.
l^K. HotACE and Torres conceive that it most
'*'^{UeDtly arises fiom a plethoric atate of the
< '>«d vessels, more especially from a dispropor-
' "Ate accumulation of blood in the heart and
'^i^^e vessels. To the first and second of these
' pinions it may be objected, that there is no ob-
v.Qii« connection between the eflTect and the
''*'i^ ; lor, as the cause is permanent, the effect
'^o>j!d be continued, or at least present but
L'tle abatement, whereas the intermissions be-
'^eeo the paroxysms are often characterised bv a
Mam of the healthy functions. It may be further
'•^'•rtl, in opposition to this hypothesis, that many
-'•il cases have occurred in which this par-
» *j)v lenon was not found on disaectioD. La-
*^^fc states that he has examined several sub-
.•'c*j who bad laboured under thia disease, and in
^oe of them did he find the coronary arteries
(*^M. Besides, cases are recorded by Mor-
'^cti, SivAc, Watsok, CoRVxsAaT, Andral,
^nii others, in which ossification of these vessels
*i7e not productive, during life, of the sufieiiogs
^^ctensiog this disease. Indeed tbe core-
'^ iiteries are often found oasified in old per-
*i^*\ y\xo had not complained during life of any
•tittuoa of the heart, and who certainly never
*(^e Attacked by this malady. As to the last of
^^ tbove opittofiSi vis. that adopted by Dr.

Hosack, Dr. Chapman has very justly observed'
" that even allowing the fulness and irregularity
of the circulation contended for, which f am by
no means disposed to do, as uniform concomitants,
these I should take to be rather the effects of pre-
vious irritation or excitement, than the cause of
the disease. Do we not also know, that such a
condition of the vessels can exist without inducing
angina pectoris? Were fulness and irregularity
in the circulation only required for the production
of the disease, instead of a rare, would we not
have it as a dail^f occurrence? The fact, more-
over, is, that angina pectoris, though oftener, per-
haps, attacking the plethoric, is to be met with,
asl have before said, in the feeble and attenuated."
I may add to this, that the severest case of the
disease which has ever occurred to me was that of
a gentleman who had suffered severely from re-
peated and profuse haemoptysu, and other symp-
toms of disease of the lungs. All these disap-
peared, but were followed, after some time, by
angina pectoris. He was feeble and attenuated ;
but it was considered advisable to try the cfl^ect of
bloodletting to a moderate extent : this gave no
relief; it was repeated, but the symptoms were
evidently aggravated by tbe measure.

18. Dr. J URINE considers the disease as a ner-
vous affection ; and he. supports this opinion by
referring to the sudden and unexpected manner
of its attack — to its sudden termination in death,
or restoration to health — the nature of the ex-
citing causes of the paroxysm — the equality and
reguUrity of the pulse, in the majority of cases,
during the paroxysm-^ to the state of the respir-
ation—-to the painful sensation extending to the
upper extremitieB— and lastly, to the circumstance
of antispasmodics being beneficial in its treatment.
The proximate cause, he adds, consists of an
affection of tlie pulmonary nerves, disturbing the
functions of the lungs, impairing the decarboni-
sation of the blood, and producing the pain in the
sternum. This affection of the pulmonary nerves
is communicated to the cardiac plexus, and de-
ranges, secondarily, the heart and large vessels.
The imperfect decarbonisation of the blood di-
minishes its stimulating influence on the heart and
lungs, giving rise to repeated attacks, until it
occasions the death of those organs, and then of
the brain.

19. MM. Desportxs and Labknxc have
adopted a nearly similar view of the disease, with
this difference, that they consider its particular
seat may vary according to circumstances. Thus,
M.Laennec states, that when there exists, simul-
taneously, pain in the heart and luncs, we may
presume that the affection is seated chiefly in the
pneumo-gastric nerves ; but where there is simply
stricture of the heart, without pulmonary pain or
difficulty of breathing, its site is in the nerves
which the heart receives from the great sympa-
thetic. But he supposes that other nerves may
also be implTcated at the same time, either by
direct anastomosis or by sympathy ; and that tbe
branches of the bronchial plexus, particularly the
cubital, are nearly always so affected. "The
anterior thoracic originating in the superficial
cervical plexus are, moreover, frequently impli-
cated ; and this is sometimes further the case with
the branches derived from the lumbar and sacral
plexuses, when the tbi^h and leg participate in
the attack, which occasionally hapiHsu/'

F

66

ANGINA PECTORIS— Tbxatmeht.

20. Brera, Zbchinrlli, Avbrardi, and some
others consider the disease to be occasioned by
pressure of enlarged abdominal viscera on the
Leart, particularly of enlarged liver. Josbph
Frank conceives it to prooeed from congestion
of the cavities of the heart, occasioned by defec-
tive nourishment of its muscular structure ; this
defective nutrition itself resulting from previous
inflammation, or from metastasis of gout or rheu*
matism, or from disease of the coronary arteries.
{Prax. Med. Univ* Prxcep., t ii. p. 2^.) Re-
specting these, it may only be added, that the
symptoms of aneina pectoris aro very seldom as-
sociated with enlargement of the abdominal via-
cera; and that, although they are much more
frequently connected with the lesions alluded to by
Frank, this connection is by no means uniform,
and is obviously not one of cause and effect;
these lesions- bein^ rather coincident and partial
results of the morbid state of the nerves, the altered
sensibility of which constitutes one of the chief
characteristics of the disease. It may be further
stated, that Dr. Darwin views it as a particular
species of asthma, producing cramp of a peculiar
kmd in the diaphragm, or the other muscles of
respiration ; and Dr. Butter, while he conceives
it to be of gouty origin, also refers it to the respir-
atory organs, particularly to the diaphragm. On
these opinions it is unnecessary to comment.

21. Dr. Chapuak, to whose valuable paper I
have already referred, states, "That the disease is
a species of neuralgia, I am entirely persuaded,
commencing for the most part in the} pneu mo-gas-
tric nerve, and spreading in different directions,
as other nerves may become involved. The de-
rangement of the heart and other structures, with
which it is sometimes associated, I hold to be
coincidences or effects, and not the cause ; since,
among many reasons which might be adduced in
corroboration of it, the disease has undoubtedly
prevailed independently of such organic lesions,
and, conversely, these have existed without occa-
sioning it. But what is the immediate cause of
the irntation of the nerves, inducing this neuralgic
condition, giving rise to the subsequent pheno-
mena of the disease ? This is a question, which
hitherto has not been clearly answered. My con-
viction is, that it is derived from irregular gout,
which misplaced, thus operates as an irritant of
the nerves, and probably first of those of the
stomach."

22. It will be remarked from the foregoing,
that J URINE, DsspoRTEs, Labnnec, and Ciup-
siAN agree so far as to impute the disease to a
species ol neuralgia of the pulmonary and cardiac
nerves, affecting the functions of the heart and
respiratory organs, and extending by nervous con-
nection to other parts ; the organic lc»ions found
in fatal cases being either coincidences, or effects
of the disease ; and after an attentive examination
of the phenomena attendant on several cases of
the affection which have come before me, I see
no reason for differing materially from this opinion.
With regsrd to the origin of this affection of the
nerves in misplaced gout, I cannot so implicitly
agree with Dr. Chapman. The connection had
been previously remurked by several physicians, as
I have already stated, particularly by those whose
aames have been adduced, as well as by Schmidt
nnd Burton,-— a circumstance favourable to the
idea that it is founded in truth ; and evidence of

it may even be found in Dr. Muso rave's very
excellent, but now scaroely ever noticed work, oa
Anomalous Gout. Wicumann, however, has dis-
puted this connection, and apparently with much
reason. The notice^ which had been taken of this
morbid relation is very candidly referred to by
Dr. Chapman, who has adduced the particulars
of six cases in which this affection was evidently
connected with gout, and in which recovery
took place, after means had been successfally
employed to invite this disease to the extremities.
In the majority of those cases the patients had
never previously suffered a gouty attack, and yet
the means employed were successful in causing
it to appear in the lower extremities.

23. But whether this disease is merely a form
of misplaced gout, or an affection tui generis,
which, when occurring in persons of a gouty dia-
thesis, the induction of the regular| gouty parox-
ysm in the extremities generally removes, my
experience does not enable me to decide. In two
persons whom I was lately called to treat, and
with whom I have been long acquainted, I have
no reason to suspect a gouty tendency ; but the
connection so satisfactorily established by JDr.
Chapman is evidently by no means infrequent,
and is one which ought never to be overlooked
during treatment, fori have remarked it in three
or four instances. I believe that, in addition to
the nervous character of the malady, the sub-
stance of the heart is often weak, thin, pale, and
attenuated, or even softened, as if its substance
were imperfectly and unhealthilv nourished ; and
that its cavities, consequently, become oceasioo-
ally dilated and congest^. This view is accord-
ant with the treatment generally found most
successful in removing the disease. In a grtrat
proportion of the cases before referred to ($ 10.),
of which I had made notes, chiefly collected from
authors, dissection had been made in about fifty
of those which were fatal ; and out of this num-
ber nearly forty presented some degree of disease
of the heart or large vessels ; — most frequendy
ossification of the valves, coronary arteries, and
aorta ; and softening and emaciation of the heart.
But whether these lesbns were rather the coo-
sequence than the cause of the disease may be
disputed.

24. VI. The Treatment of this disease neces-
sarily respects, lat, the measures which may be
adopted during the paroxysm ; and, 2d, thoce
which should be resorted to in the intervals, wiUi
tlie view of effecting a perfect cure.

25. 1st, In retpect of the meane which may be
emptoyed during the Jit, with the view cf diminith"
ing its duration and violence, no very precise or
dogmatic direction ought to be given. Much will
depend upon the peculiar characters of the case.
The patient should always be placed in a stale of
tranquillity ; and, particularly, if the countenance
be pale, and the carotids pulsating feebly, in the
supine or reclining position. The propriety of
bluing in the fit has been discussed by several
physicians, and depends entirely upon the parti-
cular features of the attack. Where the symp*
toros are urgent, the patient plethoric or vigorous,
or the pulse full and possessed of tone, there can
be no doubt as to the propriety of the measure.
Dr. Read (Dub.MeiL Trans., vol.i. p. 105.) has
recorded a case which well illustrates the good
effects of this treatment daring the paroxysm* I n

68

ANGINA PECTORIS — Thkatment.

commended by Perkihs (Mem, of Med. Soc. of |
Lottd,f V. iii.), in doses of a grain, with a quarter |
of a grain of opium, given twice a day, has a
similar action; but it generally vn necessary to
give it more frequently, and to mcrea»e the doses.
With the same view I have given the hydrocyanic
aeidf either simply, or combined with the oxide of
zinc, forming a ^anide of %inc, and in one case
particularly, with greater advantage than from
any other means. I have reason to believe that
ihe cyanide of iron vfiW prove equally beneficial ;
but my experience of its effects is too imperfect as
yet to allow me to speak decidedly as to its merits
in this disease.

32. In a case which occurred to me a year
since, I employed the preparations of tron, parti-
cularly the sesquioxide, being led to adopt them by
the neuralgic cnaracters of the case, ana certainly
with apparent advantage ; but I should add that
local means were also in operation at the same
time. Wherever we have reason to suppose that
the heart is debilitated, imperfectly nourished, or
attenuated, the employment of tonics, particularly
bark, and the preparations of iron, either alone or
with antispasmodics, is particularly indicated, with
strict attention to diet and regimen. Auscultation
will be found of service, by intimating to us the
particular state of the heart, which must in a great
measure regulate our practice.

33. In a case of the disease which came under
my care in 1824, 1 prescribed the nitrate of silver
triturated with a vegetable extract, as recommended
by Sementini. Thl« substance was continued in
increased doses, until it occasioned an eruption,
resembling nettle-rash, on the skin, — an effect
noticed by this physician. The relief afforded by
it, after this eruption began to appear, was decided.
The patient is, at the present time in the enjoy-
ment of tolerable health. At the period of my
prescribing this substance, I conceived that its ex-
nibition in this disease had originated with myself;
but I subsequently found that it had been given
in two cases of angina pectoris, with advantage,
so long ago as thirty years, by Dr. Cappe {Dun-
can*s Annals of Med,, vol. iii.).

34. Arsenic, in the form of Fowler's solution,
had been recommended in this disease by Dr.
Alexandeb (Med, Comment., vol. xv. p. 373.),
at a period antecedent to the introduction of the
nitrate of silver into practice, as an internal me-
dicine; and subsequently by Sir G. Blane, who
gave it with advantage, combined with digitalis
and mercury (Med. Chir, Travu., vol. iv. p. 136.).

35. Besides these, preparations of Intrk and
other vegetable tonics have been recommended,
either alone, or in combination with antispasmodics
and anodynes. The hydrosulphuret of ammonia,
in gradually increased doses (from eight drops to
thirty) twice or thrice daily. The different prepa-
rations of vaUrian, the ammonio-sulphate of copper
and sulphate of quinine, have likewise been em-
ployed, and occasionally with decided advantage :
from the last of these, combined with an anodyne,
particularly with opium and camphor, I have
observed much benefit to be derived. The follow-
ing formulas may be employed.

No. 18. B InAisi Romp Co. 3xJ. ; Quinina Sulpb.

Sr.j.— 41; Acldi Sulph. Arom. Tt) x. : Spirit. JEXher.
ulph. Comp. 3 J. ; llnct Opii. T1\xiJ. M. Fiat Hauctut
bit In die cairfendut. Or,
No. m IV Extracti Anthcmid. d^; Quinine Suiph.

fr. xij. ; MatMe PiluL GaltMn. Comp. dJ. ; Camphors
ubactr/gr. xr. ; Syrup. Papaverii, q. i. mvx tend et

divide In Pilulaj xxiv., quarum capiat unam ad Unai ve i
tre* bis terve quotidid.

Having derived much advanta^ from the inter-
nal use of the bi^borate of soda m dyspeptic irri-
tability of the alimentary canal, I was induced to
employ it in a case of this disease which occurred
to me a few years since, in doses of from twenty
to thirty grains, given in the decoctum of althsae.
It produced some relief; but the case was of the
greatest severity, and little benefit, at least of a
permanent description, was derived from any
means which were adopted, excepting from the
prussic acid.

36. Mercurials have received the sanctioa of
Brer A. I have employed them in three cases, at
first as an alterative ; five grains of blue pill hav-
ing been directed occasionally at bed«time, and
subsequently so as to afl'ect the mouth. In one
of these the alterative dose had a beneficial effect
upon the state of the stomach and bowels ; but
this was of short duration. When, however,
pushed further, so as to affect the gums, great
irritability of the system, fever, restlessness, and
increased pain, anxiety, and sinking, were occa-
sioned by It. In the other case, evidently con-
nected with hepatic disorder, the blue pill was
also at first given as an alterative on alternate
nights. It affected the gums after a few dose<s.
and afforded relief. It was now pushed with the
intention of inducing salivation ; and a somewhat
violent effect was produced on the mouth, which
was relieved upon exciting the salivarr glaD<U.
Decided advantage was now procured ; the bowels
were kept open by means of a stomachic aperient,
an issue inserted in one of the thighs* and change of
air recommended. This patient perfectly recovered .

37. Where plethora exists, blood-letting in the
intervals will be serviceable, with a light abste-
mious diet. When the paroxysms are apt to oc-
cur during the night, 1 have found an opiate
given at bed-time, as recommended by Dr. IIe-
BERDEN, of great service. In one case of this
description I gave the acetate of morphine, in the
dose of an eighth of a grain, but it occasioned
such distressing feelings of sinking, and general
depression of the powers of life, that stimulant*
were required ; yet the same patient had expe-
rienced relief from opium combined with camphor.
On one occasion I tried the effects of iodine in
the form of the tincture ; but although its use wa&
adopted with great caution, seven drops only hav-
ing been given three times a day, it occasioned an
increase of all the symptoms, apparently owing to
its irritating effects on the digestive mucous sur-
face, and the idiosyncrasy of the patient. I may
here notice the practice recommended by Sciii^.
SINGER (Hufeland^s Joum,, vol. i. p. 57.), coq.
sisting in the exhibition, every two hours, of the
extract of the lactuea virosa, in doses of two
grains, with half a grain of digitalis. What efiTect
may we expect from the use of colchicum ? \\ here
the disease seems to originate in gout, the colchi-
cum might be tried; but its use would require
great circumspection. In my opinion, it sliould
only be given in combination with stimulants, or
antispasmodics and tonics, the tinctnra colchici
composita being the most promising preparation of
it in such a case.

38. Although the patient labouring under thi*
disease is generally incapable of any, excepting
the most gentle, exercise > yet this should bo

70

AORTA «- Nervous Pulsation of.

Fftrti. ISIS— £«MiMr, Traits del* AuMulUtion Mediate.
Paris, 1^6. — da/nwan, American Journal of Medical
Sclencoi, vc»l. viL Phil. lail. — Jatlyt in DicUonnaire do
Medicine et Chinirg. Pratique*, »c., torn. ii. Pari*, ISi*!'.
—J. llifpe^ On I>i«ca«ei of the Heart Lund. 8vo. X^iiL
p. Vl\.~~ Bouitland^ Tniit6 Clinique dei Maladies du
Canir. ParU, Kva 1S35. torn. ii. p. 491.

ANIMATION. SlISPENDKD. See Asphyxy .

ANTIPATHY. Syn. *Amra9if, Gr. Antipathia,

Lat. Der WidencUlef die Antipathie, (Jer.

Antipathie, Fr. Antipatia, Avversione, Ital.

Antipathia Setisilis, et A. Inxensilis, (iood.

Clasaif. — 4. Class; 4. Order ((iood).

I. Class; IV. ORnr.ii (^Author),

1. Defiv. IntiTnal hnrrnr and distress on the
. perception of pttrticular objects, mth great restless-
ness, or withfaintinf:,

2. This singular aflcction has merely been men-
tioned by CvLLEN : it has, however, received
more attention from Sauvaoes, LiNN.f:r.s, Vocki.,
Ploucquet, Pabsamevt, and (Joon. The last
named writer has needlessly divi<led it into two
species — sensile and insensile antinatliy ; the
former arising from objects or subject* which
strike some one of the senses ; the latter from the
presence of an object, as soon ns it comes within
the sphere of some unknown influence, although
unoerceived by any of the sen-jcs.

*. There are numerous in-stanccs of singular
antipathy on record ; and most {tersons of observ-
ation have met with others in the course of their
experience. The vulgar explain them generally
by considering that the mother had experienced a
fr^ht from tlie objects of antipathy during the
early months of pregnancy — and there aie, no
doubt, some frtcts which countenance the sup-
position. Thus, Jamks the First could not endure
the sight of a drawn sword : Kizio was killed at
the feet of Queen Mahv when pregnant with him ;
and many other instances ore mentioned by writers :
but more frequently the pltmous themselves, who
are thus affected, have experience*! frights during
the early months of infancy, or have ha<l their
minds early and indelibly impressed by certain sub-
ject*. Peteh the Great had a fall from a bridge
into the water, when an infant, and he could not
afterwards endure to hear the rattling of a car-
riage passing over a bridge. Persons often retain
the antipathy to the sight of crj1)s. lobsters, bic,
which had been occasioned by fright from them
in infancy or childhood. A man-servant iu the
author's family, advanced in life, had so great an
antipathy to the sight of a mouse, tliat he would
fly as fast as he was able from the place where one
was seen ; and become (juite frantic at the sight.
He stated that his mother, who likewise had an
antipathy to mice, had been distressed by one
thrown upon her when pregnant of him. Some
persons cannot endure certain odours, from the
faintness, or sickness, or sense of anxiety and dis-
tress they occasion. This appears to piocced from
peculiar idiosyncrasy. 1 have likewise seen per-
sons who could not touch cerbiin smooth objects
without feeling a peculiar shudder or horror, fol-
lowed by faintness in some. This appears to arise
from associations excited in susceptible or sensitive
minds.

4. The most singular instances of antipathy

are those which occur at the presence of objects

unperceived by any of the senses, forming the

iiuensile antipathy of Dr. Goon. Thus, a cat

Cpacealetl to a room has been known to produce

^ most iadcscribable distress or horror in a person

who has not perceived it by any one sense* and
has been, in no other way, informed of its pre-
sence. Some singular idiosyncrasy, doubt [ess,
exists in such cases. Sauvaoes conceives that an
etfluvium proceeds from the animal, which, com-
bining with that emanating from the person thus
affected, occasions tiie unpleasant sensations upon
his peculiar organisation or idiosyncrasy. This
is, perhaps, the only opinion that can be formed
on the subject.

5. The TiiKATMENT to be adopted for the re-
moval of antipatiiies consists chiefly of resolute
endeavours to overcome the morbid impression,
by gradually accustomintr the mind to its influ-
ence. Indeed, this is the only remedy that can
be resorted to. Its adoption, successfully or
otherwise, will enthrly de]>end upon the mental
energy of the patient. Dut there cannot be a
doubt, that all impressions, however unpleasant
or distressing, may be ultinuitely overcome by
repetition, and a Arm resolution either to endure,
or not to be aflccto<l by them. The following
works will furnish some curious information on
this subject, with much trifling, silly hypothesis,

and irrelevant matter : —

BiBLiooRAPiiT. I.iutfySf Dixi. Antiwathia* Singularci,
&C. Jen. loT-S. — S. kattraif^ Aditus Novui .id Occulta
S\-mp.ithia> I't Antiiiathui:' Causae. (ila.<ig. IG^N.— AM>//(£«r,
Tlicatr. Synipnthet., p. 1.3S. — Hmhtlph, l)e AntiiMthu
Humana. Banil, Ylim).— Sckurig. (.'hyloloeia, p. 96. et
Vl't, etfeu.— McHfz, Oivier. Anti)kitliia> Pny<. Phomoiu.
ad 8U.-M Caiifa^ Rovocata. 1a\h. I7<»< — Du f'tn'sim, De
Antipathia Ihimana. Uafiil, ITol — Zwfnger, De Ant\m
pathia Humana, Fabric DitKcrt. Select., n I. — ScAiriM-
wc*r, l)c Antiii.'ithia. Jvna*, Itl'iU. — llernutaedt, Wuiu
dorlMire Kralle der Natiir durrh die Symp. und Anil,
pathie. Koteiib. 1776, Kvo. — Passament, KimI sur let
Anti|iathic», Paris 1811. ~- M. Uvutt, i>tudy of Med. by
CiAv/nT, vol ill. p. .jdG.
ANUS. See lU.r ri'M.
AOllTA. Syn. Anerin Maf^na. Aorte, Fr.

Aorta^ die f^rpsse S<'hla>;adn', Ihuptstamm alltr

KurpcquilHirderiif G'er. lis Diseases.

1. I'his moot important vessel is liable to all the
lesions which have been noticed under the article
AKrEHiFs. Some of them, however, when seated
in this artery, are so important, particularly as
lespects their eflects upon adjoining viscera, and
their extremely dangerous conseiiuences generally,
that I propose to give a succinct account of them
in this place. In doing this, I shall so far depart
from the alphabetical arrangement, in respect of
the subordinate heads of the subject, as may be
requisite to the considfrntion of it in strict patho-
logical onler. Functional disorder, therefore, of
tlii.-> vessel will bo frst considered ; veit, inflam-
mation ; and, /a.sf/y, those lesions which usually
result from inflammation, &:c., ns aneurism, con-
<!trirtion, obliteration of the vessel. &c.

2. I. NeUVOIS PlLSATION OFTHEAHnOMI?rAL

Aorta. — Ci.as-ij'. II. Class; I. On der. —
Tiiis is not an infrequent aflection in wcok, ema-
ciated, and delicite per>ons, and particularly
hy>terical ffinnles. It is often associated whh
collections of air in the colon or stomach; and
with accumubtion^ of ficcal matters or morbid
sccn;tions in the ca.*cum. It is also not infre-
quently consefitient upon neglected dyspepsia.

3. i. The Siimpioms are generally very character-
istic of the nature of the complaint, and sufficiently
serve to di«*tlnguisli it from organic lesion of the
vessel. The morbid pulsation is generally asso-
ciated with nervous or hysterical symptoms, and
is of a variable character. It h mcreased and
diminished, sometimes without any evident cause,

AORTA -^Intlahhatiok ov.

bat moM frtqwtitly by mental or moral affection
ami emocioos, or by constxtntional causes. Dis-
orders of the atomacfa, ami irregnlarity of the
Bterine fimetiooa, also sometimes occasion or re-
produce it ; and I have observed it to follow upon
the paroxysms of anking or leipotbymiay to which
very delioue females an occasionally liable.

4. Upon preming^ the stethoscope firmly over
the aotta, the puiMtion will be generally felt
limited in extent, in its transverse or lateral direo-
tioB, but it wiH be very perceptible in the course
of the reseel from the bifurcation to the epigastrium.
Instead of the gradnal, steady, and strong motion
or impulse attending aneurisro, there is felt a vi-
fwous and smart jerk ; and the sound is either
owf^ • slight whiszing, or is scarcely to be beard.

5. n. The TrMtment of nervous pulsation of the
aorta will entirely depend upon the peculiar cir-
punRrta&cea of the case in which it occurs. If the
parox^rsm is severe, the preparations of asther, as-
ssfioetida, valerian, and ammonia, should be exhi-
bited. I have seen much benefit afforded by strong
coffee and g^reen tea in these cases. The dependence
of the affKtion on mental emotions indicates the
propriety of advising a tranquil state of mind and a
mild diet, with attention to the regular functions of
the bow^s. In eases evincing much irritability,
oiental or corporeal, hyoscyamus, conium, or the
icetate or salphate of morphine, in very small
do«e6, particularly hyoscyamus combined with
eiraphor, will be found useful. The preparations
of morphine* however, should be cautiously admi-
nifterad in tlids afifection. In a case which occurred
to me some time ago, the sixteenth part of a grain
only of the acetate of morphine was followed by
unpleasant depression. Upon the whole, more
sdvsntage will accrue from the antispasmodics
tbaa from the sedatives just named ; but in cases
fharacterised by attendant irritabilitv, the combi-
BitieQ of substances belonging to both these classes
of lemedies will be of great service.

6. In all cases of this affection occurring in fe-
males, ^-tnd the great majority of them do occur
in this sex,— the state of the menstrual discharge
ihoald receive the utmost attention. When the
Bioie distiMMUg state of the affection subsides, a
■lore looie regimen and plan of cure may be
adopted. The bitter infusions and decocdons, par-
tiruUrly those of calumba, cinchona, eascanlla,
tad chamomile, with the alkaline preparations,
&C., and sobsequently the preparations of iron,
the shower bath, cold salt water bathing, chalv-
bestes, regular exerdae in the open air, and light
astritioDS diet, are the means chiefly to be de-
pended on. When auoeiaud with other ailments,
it is geoerally symptomatic of them, and therefore
iatadi eases the treatment must be directed to the
primary complaint. »

T.n.IifFLjiiiiiATiojv Of THE Aorta. — Srv.Aor-
tUit,A9rtite,yr, Dii A^frten&ntiundung^Ger, Clas-
irr. n. Class ; II. Ordbk. — Inflammation of the
i9rta ooeasiooally trites place, but more frequently
ia a chranic than an acnte form, and commonly
cooaeeatively of inflammation of the internal sur-
&ee of the heart, and during the course of certain
4iles of fever. The internal membrane of the
venel is sometimes alone inflamed, particularly
when the disease takes place during fevers, or
citeods to it from the internal surface of the heart's
cavities ; but, in several cases, the subjacent cel-
lular tivM, or both it and the internal membrane,

are chiefly affected. Aortitis seldom originates in
the exterior coats of the vessel.

8. i. The Causes of aortitis are, — 1st, External
injuries, as blows, contusions, falls, &c.; 2d, Vio-
lent, or too long-continued exeruon ; 3d, The use
of hot, stimulating and acrid ingesta, spirituous
liauors, and the 'introduction, by absorption or
otherwise, of irritating poisons and morbid secre-
tions,' &C. into the circulation ; 4th, The extension
of inflammation from the heart, lungs, pleura, and
pericardium, and the Oppression of the eruption
m eruptive fevers; — M. Portal states (Attat,
Med,, t. iii. p. 127.) that he has met with it in
cases of this description; — and, 5th, The causes
which are productive of diseases of the heart.

9. ii. The Stm ftoms can scarcely be stated with
any hopes of enabling the practitioner to distin-
guish this disease, which is generally met with in
conjunction with other maladies; particularly
fevers, and inflammations of the heart, lungs, pert-
cardium, and pleura, and disclosed to us only by
post morUm examination.-— a. When inflammation
more or less acute extends along the descending
aorta, the patient generally complains of a smarting
and painful sensation in the direction of the spine,
with a violent feeling of pulsation of the aorta ;
extending to the iliacs, without any appearance of
enlargement or tumour ; and unaccompanied by
smallnesB of pulse in the remoter arteries, particu-
larly those of the superior parts and extremities of
the body. In the more acute cases, a sensation of
heat is felt in the region of the vessel, sometimes
with oppressive anxiety, leipothymia, or tendency
to fainting, and always increased force and vivacity
of the pulsations of the vessel.

10. b. The chronic states of this disease admit not
of recognition until they have produced some one
of those organic lesions, which occasioned marked
obstruction of the circulation, or aneurismal dila*
tations. Dyspnoea upon slight exertion, emaciation,
a pale yellowish tint of countenance, palpitations,
hypertrophy and dilatation of the heart's cavities,
oedema of the extremities, &c. are then the usual
symptoms ; and, although they furnish no certain
evidence of the existence of this disease, yet when
they are present, without the signs of narrowing
of, or obstruction in, the orifices of the heart's ca-
vities, and of the origin of the aorta, chronic dis-
ease of the aorta may be presumed to exist.

11. c. Aortitis, particularly in its chronic states,
is occasionally complicated with hypertrophy of the
left ventricle ; the hypertrophy either causing the
inflammation of the aorta, or the latter occasiooing
the former, particularly when the canal of the ves-
sel is narrowed or obstructed by the effects of the
inflammation. The other complications have been
already noticed (§ 7^9.). It is chiefly owing to
the more frequent occurrence of the disease in a
complicated, than in a simple form, that it is so
commonly overlooked, and so diflicult to be as-
certained, even when its existence is suspected.

12. iii. The Proonobis of this disease, when its
existence is presumed, is always unfiivourable ; on
account l>otn of our ignorance of much that is im •
portant respecting its symptoms, complications, and
consequences, and of the fatal nature, sooner or later,
of a great part of the effects to which it gives rise.

13. iv. The Lesions produced by inflammation
of the aorta are nearly the same as those I have
enumerated in the article on the lesions of arteries.
But as these changes, when affecting this important

F 4

AORTA — Am£vri8m of.

73

quently hu « neck of lees diameter than the body
of the sac. It ieems to arise from a loss of elasti-
city aad vital resjafanoe of the portion of the
tcskI thus afiected» io consequence of chronic
ioflammaticm and its effects. Owing to this cause
tiie dilated portion of the vessel often presents
many of the lesiooa described as consecutive of
liie inflanunatory state, particularly reddened
rpo^ minute figures, atheromatous, cartilagin-
ous, or oBsific depoeita, &c. This variety most
coouaonly affects the ascending portion and arch
0! the aorta, and shoots out from its anterior or
Iitoal parlA. It often attains a considerable bise,
beifl^ sometimes as Utfge or larger than the fcetal
heart, siid generally inclines toward the right side
of the cbc^. The dilated coats of the veesel
vt generally thicker, and but very rarely thinner
\hka natural, unless in parts of the aneurismal
pottch. When it arises from the root of the aorta,
tad the inner and middle coats burst* fatal extra-
rasation takes place within the pericardium ; no
filse aneurism taking place in this situation, owing
to this pan of the vessel being destitute of the
celiulsr coat. Coagula do not frequently form in
true sneuiism as long as the current of blood in
the sac continues to be not much obstructed ; but
when, owing to the nairowness of its mouth, or
to retardation of the current of circulation in it,
a partial stagnation takes nlace, coagula then
form, frequently in an irregular or confused state,
ImI sometimes m tegular layers.

21, C. Aneurism with ulceiation of the in-
tenml roots, or Jaltt aneurism. This variety
viaes, 1st, from mpturs or j^Murcs of the internal
coats, owing to a loss of their vital cohesion, and
to friabilisy consei^uent upon chronic inflamma-
tion, ssfoctated with fungous, calcareous, and
steatomatous deposits ; and is often occasioned
U accideats, or violent or sudden extension of
the vessel ; 2d, from ulceration following scro-
fulous and chronic inflammations, and the de-
tacbmcnt of various depositions formed in the
mtemal membrane. Cases have been recorded
by Laennsc aod Guthrie, wherein fissures of
the internal coats of the vessel, instead of pro-
ducing aoeurbmal dilatation of the external coat,
Ud dissected it from the fibrous tunic along the
greater part of the length of the vessel ; but such
occurrences are very rare. This variety of aoeu-
tirm cannot be formed at the commencement of
the aorta : it is most frequently met with in the
(icacendiog aorta, and the part opposite to the
turKHir or sac is generally not in the least dilated.
Xumeioos instances of this variety of aneurism
vt recorded by modern authors.

22. D. Mixed or compound arkuriam. After
all the coats of the vessel have been dilated to
i certain extent, forming either simple expansion
ur tnie aneurism, but, owing to the less extensi-
ble properties of the internal coats, conjoined with
tbe efiects of previous or existing inflammatory
action, rupture or ulceration of them takes place,
the impulse of the current of the circulation di-
UttA itill further the yielding cellular coat of the
^tasel, and a sac or cyst is thus not infrequently
ibrmed of this coat surmounting the primary
aaearism. In this case the perforated internal
omu form tbe neck of the cyst, which is always
Qirrower than the cyst itself. VVben the ruptured
pm of the internal coats is considerable, so that
ilse impuUe from th« cturej^t of blood prevents its

ooaguUition in this cyst ; or, when in this, as in
the other varieties of aneurism, coagulable lymph
is not formed, so as to give rise to layers of fibrin-
ous coegula within the sac calculated to support
it, rupture of the sac will sometimes occur, aod a
diffused form of aneurism be the result.

23. £. Of certain changes connected v>ith
aneurism of the aorta. In some rare instances
an aneurism of this vessel has been observed by
Haller, Dubois, Dupuytrbn, and Laennec,
consisting of hernia of the inner coat through the
ruptured fibrous coat. But it is obvious that
aneurism, or tumours of this description, can sel-
dom reach any considerable sixe without being
either ruptured, owing to the more friable nature
of tbe internal membrane, or confined by granu-
lations and adhesions on its external surface, as
shown by the experiments of Hunter, Scarpa,
and Home. Solid small tumours, of the size of
nuts, and closely attached to the aorta, have been
described byCoRviSART aod Hodgson ; the latter
of whom supposes, with Labnnec and Bxktin,
that they are the remains of spontaneously cored
aneurisms, their sacs having been filled with co-
agula, and their size afterwards diminished by
absorption. The deficiency of the coats of the
vessel, at their points of union with it, seems to
confirm this opinion.

24. a. One of tbe most important changes
connected with this disease is the deposition of
fi brine and the formation of coagula on the inter-
nal surface of the sac. This process generally
appears to proceed by progressive steps : and tbe
deposition thus presents successive layers. Tbe
most central of these generally consist of blood
only, more or less firmly coagulated ; and each
layer becomes firmer, drier, and paler, and more
and more fibrinous, until the parietes of the sac is
reached. In many cases, the most external layers
chiefly consist of a whitish or greyish yellow
fi brine, more or less opaque and friable. Some-
times they nearly resemble dried paste. The
more recently formed coagula are soft, loose, and
often only partially adherent to the layer next it.
In some cases, blood seems infiltrated between
the layers. Those next the vessel are geocrally
united to it by a fine cellular-like tissue, furnish-
ing appearances of a partial organisation. These
depositions evidently proceed from the effusion of
coagulable lymph from the internal surface of the
aneurismal sac, and the partial stagnation or
retardation of the blood, favoured by the narrow-
ness of the neck of the sac, and the inflamed, un-
even, or rugged state of its internal surface. When
neither of these states exists, as is often the case
in respect of the first two varieties of the disease, and
particularly when the neck of the poucli is wide,
neither coagula nor layers of fibrinous deposits
are formed. When, however, inflammation of
the internal suiface of the dilated vessel or of the
sac exists, aod when a morbid secretion takes
place from it, this will originate coagulation of
a portion of the blood wliich comes in contact
with it, and form, at the same time, a bond of
union between the coagulum and the internal sur-
face of the dilated coats of the vessel. I'he
thickness and compactness of the coagula in
aortic aneurisms are often remarkably great, and
are chiefly to be imputed to this mode of origin.
(See art. Blood.)

25. fr. As the aneurismal tumour enlarges, it

74

AORTA — AvsTmisx or;

f

generally occarions important changes both in
Itself and in adjoining parts. Those which re-
spect the sac itself are chicHy thickening of the
dilated coats, or thinning of them ; aud, m some
instances, of both thew changes in the same case.
When the extension of the sac is considerable, or
when moderate, if oppoiierl by n tinn substance, ns
cartilage or bone, ulceration or abmrption of the
parietei of the sac, inflammation of its more ex-
terior parts and adhesion to adjoining structures ;
and, ultimately, as the tumour increases, perfo-
ration or rupture of the more prominent part, fol-
lowed by fatal hsmorrliagc, take place. I'hc
mode in which the aneurism bursts is difTerent,
according to its situation and the Btructure which
it compresses and destroys; tlius it not infre-
quently breaks by ulceration and ^Mrforation of n
limited part of the sac. In some rases, particu-
larly when it opens into a serous cavity, distinct
laceration of the more exterior covering occura;
when it reaches u mucous surface or the skin, a
slough is formed on its most nrominent part, which
is soon detached, and fatal hemorrhage is the
result. In the majority of such cases, the proper
coats of the vessel may have been long previously
destroyed at one part or other of the sac. Hut,
if the aneurism form at the root of the aorta, rup-
ture or ulceration of tlie proper coats of the vessel
is followed by instant effusion of blood into the
pericardium. Rupture of the ancurismal tumour,
ns respects the coats of the vessel, whether burst-
ing into a hollow cavity or upiMi a surface, or
forming a diffused aneurism, is generally trans-
verse ; but it is, in some cases, longitudinal, when
it implicates all the coats of the vessel ; or the rup-
ture of the internal coats is traasverse, and that of the
external coat longitudinal ; the former being almost
universally transverse. The effects of aneurism
upon adjoming parts retiuire particular notice.

26. /". Of the effects of aortal aneurisnu vn
adjoining parts^ and the situations in which theu
break. The effects of aneurisms on adjoining
parts necessarily depend upon their volume, firm-
ness, and position. I'lie heart, lungs, trachea,
large bronchi, op-sophagus, pulmonary artery, large
veins, thoracic duct, and various organs con-
tained in the abdomimil cnvity, may be displacctl,
atrophied, or partially destroyed, by the compres-
sion occosioued by 1 hem .

27. o. 'i'he vena cava is not infrequently more or
less obstructed by the pressure of aortal aneurisms.
JVI. Reyn.aud {.fount. //«hr^)m. t.ii. p. 109.) met
with a case in which this ves<el was very nearly
obliterated by nn aortal aneurism, and M. Ik>i'iL-
LAUD mentions a case in which the superior vena
cava was so much compressed by an aneurism at
the arch of the aorta, that apoplexy was caused by
it {Diet, de Med.^et Chii: Frut.,t. ili.p. 403.) ; and
CoRvisAiiT {Journ. de Mtd.par MM, Corvitartt
&c., t.iii. p. 85.) and Hektiv, relate similar in-
stances. The thoracic duct has also been de-
stroyed by it, as was obser\'ed by M . Laevnfc.
Mr. lloiKisoN and Sir A. Cooper met with cases

in which the common carotid, and subclavian
arteries were completely obliterated by the pres-
sure of aortal aneurism.

28. b, U'hen the pressure of an aortal aneur-
i9m fJcstrofH an adjoining viscus or structure, the

ulcerative inffammadoa is often extende«l from the
^«w/es of the sac to them, followed by the ad- i
fiegma and absorption or u/ceraUon of the parts 1

moat compressed, until the tamonr bursts, in one
of the moues now stated ($ 25.), into one or other
of the following situations : — - Aneurism of the
ascending or pericardial aorta generally opens
into the pericaitlium : in three cases it bursts into
the pulmonary artery, recorded by Dr. Wef.ls
( Trant. of Society for Impr, of Med, and Chirurg,
Knowledge, vol. in. p. 85.), M. Sue (Joum, de
Mtd, Contin», t. xxiv. p. 124.), and MM. Paye.v
and Zeink (BnLde Fac.de Mtd., No. 3. 1819.).
Aneurism of the arch of the aorta may break into
the trachea, oesophagus, pleural cavity, or into
the pericardium. That of the descending aorta
generally bursts into tlie pleura, oesophagus, pos-
terior mediastinum, or into the lungs. Aneunsms
of the pectoral aorta most frequently burst into
the left pleura ', they have, however, been known,
but in two instances only, — recorded by M. La-
EVNEc and Mr. Chandler, — to open into the
spinal canal, having destroyed the bodies of the
vertebrs, which are generally more or less in-
jured in cases of aortal aneunsm of considerable
size. When seate<l in the ascending aorta, they
often destroy the sternum ; in both cases causing
interstitial absorption of the bone, and often of
the parieles of the sac and fibrinous layers of
coagula in contact with it, so that the blool
washes the bone itself. The cartilages usually
resist the ^iressure of aneurisms, either altogether,
or much longer than the bones ; and when the
periosteum is inflamed by the pressure of the
aneurism, an ossific deposit is not infrequently
fonned around the tumour.

29. r. Aneurism of the aorta may, however,
destroy life, even without breaking in any of the
above directions ; either by impeding the action
of tiie heart and displacing it, or by compressiiig
the organs of respiration, or by occasionmg con* .
gestion, infiltration, and hepatization of the lungs;
or by compressing the oesophagus, or injuring
some of the thoracic ^^nglia ; or it may destroy
or compress the thoracic duct and large veina, as
stated above {§ 27.), to a fatal extent.

30. d. The bursting of an aneurism of the
aorta is not necessarily followed by instant death,
as has been shown by MM. Laennec and
Marjolin, and very recently by Mr. S. Cooper.
In a case read by this very able surgeon, at
the Medico- Chirurgical Society, where the aortal
aneurism had pointed under the left shoulder-
blade, but subsequently broke into the oesophagus,
several pounds of blood were dischsrged by vo-
miting and stool, yet the patient lived for many
months afterwards, and pursued a laborious occu-
pation ; a second hsmorrhage at last, proving
fatal. When the sac of an aortal aneurism bursts,
and the blood flows into a cavity or viscus, from
which it is readily discharged, death usually is
soon produced. Hut when the opening in the
sac is so situated that the bloofl is effused into
the cellular structure, and what was before a
true or enc}'sted al>scess becomes a diffused one,
life may be prolonged for some days or weeks,
or even longer. This, however, will depend upon
the situation in which the rupture takes place,
and the nature of the parts into or upon which
the blood is efl^used. When the sac of an aneu-
rism is ruptured, the laceration is generally in the
same axis, or nearly so, with the opening into the
sac, owing \A Ihe impulse l>eing greatest in this
direc^OQ, >in\esa a dviet^iice \a QecasuotMA bf

76 AORTA -

of the verlebne, under the left shoulder-blade,
and pushes out this part. The strong pulsations
always present in the tumour indicate its nature.
Notwithstanding, it may subside, or altogether
disappear for a time under an appropriate treat-
ment. Previous to the apptmnince of the tumour,
the symptoms arc, as already shown, extremely
fallacious.

37. In the advanced stages of aneurism of the
thoracic aorta there are generally coughs with
mucous or bloody cxnectoralion, dy«pnoba, and
even orlhopnoca, dysphagia, attacks of spasmodic
suffocation, pain in tlic left shoulder, axilla, inner
side of the arm, and ascending up the left side of
the neck, with pricking pains in the tumour, and
sometimes with a sense of whizzing or rushing at
the top of, or under the sternum, and occasionally
sensible to the iiand. A diagging downwards of
the larynx is sometimes complained of. All fe-
brile symptoms are ;;cncrally absent Although
these are the rational symptoms which arc most
to be depended upon, they must be viewed with
those reservations which I have particularised in
the preceding paragraphs.

3B. 2d, When the aneurism is seitcd in tlie
abdominal ai>f'ta, acute pain is complained of in
the lumbar region, occasionally shooting into
cither hypochondria, and downwards into the
thighs and scrotum. It is generally constant,
but is also souietimcs intcTmittent. It is often
exacerbated into violent paroxysms, being dull
and fixed in the intervals, it is aggravated by
constipation, ch:in<;:: of position, or pressure on
the loias, and is unattomled by any sense of heat
in the part. In some ca>es there is also numb-
ness of the lower limbs, as in that recorded bv
Mr, Mayo {Med. (hz., April, 1829), where
the aneurism was situated uetween the crura
of the diaphragm and the dorsal pains were ex-
cruciating. The patient often complains of severe
fits of colic, accompanied with spasm of the
abdominal mu-»<:les, and occasionally there are
nausea and irritation of llie stumacli, but with
little loss of ap|)etite. Constipation is always
present. Decubitus on the left side or back often
produces great distress, and occoi-ions palpitation,
which genenilly s'lb-^ides upon turning on the
face or right side. Coldness, formication, prick-
ing, and numbness of tlic lower extremities, arc
not inirei[uent ; and in some cases paraplegia has
occurred, with involuntarv cvacuaWons of the
urine und fa.'ces.

39. The tumour may not become perceptible
externnlly., but as it increases it will press in-
juriously upon, and sometimes displace, one or
other of the abdominal viscera, particularly the
stomacii, liver, and even the heart. When the
tumour can be detected external Iv, it has ge-
nerally been on tlic left side, nearly on a level
with the hist dorsal vertebra. When large, it
often impeilcs the action of the diaphm.^Mn, and
thus deranges the respiration, in some cases it
has pressed upon the pericardium, and tlius had
the double pulsation of the heart communicated
to it. (See Cases by .l)rs. Ghavis and .Sio-«js,
Ihih, I]o»p. Hcjuirht vol. v. y. 24.)

40. /'. >>igiii Jurniilied bu auictilUition, — Diil-
ncss of sound upon jH'irtiy^i'yn u( the upper sternal
portion of the chest and caiiilni^e> of liic ri^ht
ribs, although present in uneurisni of the jiecturul

eortUf also occurs in other lesions of the thoracic

■ Aneuaxsm or.

viscera. Dr. £luot£On states, that a thrilling
sensation eiven to the hand only, or chiefly,
when applied afwiet or to the right of the cardiac
region, and a bellows-sound heard in the same
situation, may justly give a stiong suspicion of
the disease. But that neither the Ixdlows-sound
nor the thrill, always occurs. In four cases out
of seven he found both wanting. Laennkc never
observed the thiill l>efore the tumour became
visible externally. lie considers that the chief
diagnostic of aortal aneurbim is a strong and
single pulsation, discernible by the ear in the
situation of the aneurism, synchronous with the
pulse at the wrist, stronger and louder than the
action of the ventricles, and unaccompanied by
the sound of the auricles. When, however, the
aneurism comes in contact with the pericardium,
a double instead of a single pulsation of the
heait is communicated to the tumour. This wis
remarked in the cases recorded by M. Cruveil-
II Kin, and i^rs. Cikavls and Stoki^s.

41. Dr. lloPF observe**, that it is unimportant
whether the pulsations be single or double; for,
though the latter, may be distinguished from
the 1 eating of titc heart by unequivocal cri«
teiia, viz.: — " 1st. The ^first ancurismal sound
coinciding with the pulse, is invariably loader
than the hcaltliy \entricular sound, and, ge-
nerally, than the most considerable bellows-
murmurs of the ventricles. — 2d. On exploit
ing the aneurismal sound from its source to-
wards the Kgion of the heart, it is found to
decrease pro(!rc»sively, until it cither becomes
totally inaudible, or is lost in the predominance
of the ventricular sound. Now, if the sound
emanated from the heart alone, instead of de-
creasing it would increase on approximating
towaids the pra.'cordial region. — 3d. The itcoad
sound actually does sustain this progressive aug-
mentation on advancing towards tlie heart; and
as its nature and rhythm aie found to l)e precisely
similar to those of tiie ventricul.tr diastole neard ia
the pia:cordial r(;^ion, it is distinctly identified as
the dia^itolic sound.* The second sound, there-
fore, corroborates rather than in\ alidates the evi-
dence of aneuii>m affonled by the first; for, if
both suund> proceeded from the heart, both would,
on approximating touanls it, or receding from,
sustam the s>ime progressive changes of ioten-
sity." (Diieases of the Uairt and Great Veaelt^
p. 425.) ik'sides these views, with which Icon-
cur, the .sound of the aneurismal pulsation is deep,
hoarse, and of short duration, commencing and
terminating abruptly, louder than the loudot
bellows-inumiui^ ol the heart, and of a ra^g
or grating cliaracter.

42. 1 lie sound of aortal aneurisms i^ gcocnUj
audible in the back; and, when the desceodiiw
aorta is the seat, it i- louder in this sii nation ihaa
on the breast. If it pre>cnt>i the abrupt, Taspkf
cliaiaeter, when heard on the back, the evidence
of aneurism is complete; for, as Dr. Ilupiob-
Kivcs, the loudest sounds of the heart, vfaca
heard in this situation, are so softened and nb-
dued by the distance as totally to lose their banki
ness. 'J'liis Ls in accordance with the opioioaof
AI. IJi.nTiN, who very <or:ictly observes, tkt .
when l!.e sietlioscope is applied upon the sttennua
in aneuri.sm of the sub.->ternal aorta, and oa tki

* See art. Acsci ltai jns and IlEAar, as to the

uf this ofKnu.

78

AORTA— CovBTBicTXON AKD Obutiration of.

beneficial, exercise on foot, or on honeUack,
enpecially the latter, must be avoided, and the
utmost attention should be always directed to the
digestive, secreting, and excreting functions.

49. When, in consc<iucnce of the energetic
action of the heart, or the plethoric state of the
circulation, or excesbivc action of the tumour, we
determine on depiction, it ought to be perfonued
in the recumbent posture ; and the quantity as
well as the manner of abstracting it should be
such as to prevent any risk from too great depres-
sion, and itb consequent reaction, whether of the
heart or of the urturies. When the disease u
attended with paroxysms of palpitation, depletion
will be seldom of any use, and should therefore
be cautiously employed in such cases. Local </e-
pletioHs may be resorted to when local pains are
complained of; but, if the tumour has nearly
reached any of the surfucc!^, they arc seldom pro-
ductive of benefit.

50. Di^itatii hns been gcuonilly recommended ;
it may be of !»ome service when exhibited cau-
tiously, and in moderate doses, but its full effects
must be guarded against. The same rcmarkti
apply to fiolckicum. The guperacetate of lead^
combinefl with the acetic acid, and small doses
of opium, is preferable to digitalis; and any
hurttui effect that would arise from it will be
prevented by an occasional dose of castor oil. In
cases attended with palpitation of the heart, or
inordinate pulsation uf the tumour, I have pre-
scribed the sulphate of tine, and the sulphate of
alumina, generally combined with small doses of
camphor and hyoKyamut, with considei-able bene-
fit as palliatives. The acetate of lead may also
be exhibited in a similar state of combination.

51. The applicatioD of ice to the tumour has
been advi<ed by Continental physicians ; but it
is often productive of much distress. A lotion,
or repeated sponging, and occasionally the con-
t'.nued application of epithems may l>e employed ;
morally and physically, with careful prevention
of plethora arid sur-aetion of the heart, is iadis-
peiisible; other means will be useful, chiefly in
and cither of tl>o<:o recom mended in F. 157. 332.
33(i. may be adopted, l^erftct repose, however,
as far aa they eouduee to these stales. I(y en-
deavouiing in t)ii!» manner to bring about the
spontaneuus cure oi aortal ancurLsin, it may be
suppofied that we risk inducing the oblilenition of
the vessel : but I believe that this is not so likely
to occur in the aorta as in smaller arteries; and
even were it to occur, the result does not appear
so hazardous as ihc continued increase of the
aneurLsmal tumours ; as sufHeient evidence is on
rcconl of the po'isibility of a collateral circulation
being established.

ti2» IV. Ki'riruE or all the coats of ttie
AoiiTA, wiibuul aneuii'<inal dilatation of the ves-
sel, is a very rare occurrence, and has been met
with only alter violent external injuries, such as
falls, or leaping from a great height, and from
mental excite luent, when the ve.>sel has been
previously disi-a^d. in llie Kphemerides Piiy-
fuco-Mediru: Natura' Curiosorum (^Dec, iii.
Ann. ii. Oh*, 10.), a case is recorded, in which it
was rupturtnl by a blow on the h){)ocliOudriuni.
Air. Jam Ka has recordeil an in»lance of rupture
and instant death in an active seaman, previ-
ously in good health, from jumping out of his ham-
BBOck {^Lond Med, aiui Vhjft, Joum,, vol. xviiL) j

and Mr. Arxott has given a similir case, pro-
duced by a violent concussion of the body, from
falling from a scaffold ( Ibid,, vol. Iviii. p. 19.).
The most instructive case, however, of ru|»ture of
the aorta without aneurism has been minutely
detailed by Mr. Uose i^Lond, Med. and Phiftm
Journ., vol. Iviii. 4to. p. 15.). In this case, as in
the others, tlie coats of the aorta were all rup-
tured. They were more readily lacerated thaa
usual, and the inner coat had a thickened
stertomatouB appearance. A case is girea
by Dr. Hume [Clasgouo Med. Journ., vol. iv«
p. 148.), in which rupture of the aorta took place
in a strong man upon getting into bed, followed
by death m a few hours. An aperture, the site
of a quill, was found in the vessel about two
inches above its bifurcation. No account is
given of the state of its coats.

53. V. Const KicrxoN and OnLirEnAxioN or
THE AoaxA liave l>een observed by several pa-
thologists. Stoi.rck {Annales Med, ii. p. 262.),
Meckel {Mt moires de Jierlin, 1756), Sandifort
{^Observat, Anaiom, Path. it'. Xo. 10.), and Dr.
Graham {^Ti-ans, Meti. Chir.Soc., vol. v. p. 287.),
with other recent authors, have recordel cases of
extreme constriction of the aorta ; whilst M.
DiA&uLT {Journ, de Chirurg. 1792), jSI. Bras-
dor {Recueil Veriodique de la •Soc de M£d, a
Parte, t, iii. No. 18.), Dr. A. Monro (Or
Aneurvims of the Abd, Aorta, p. 5.), Dr. Good-
isoy (Dub, Hasp, Hep., vol. ii. p. 193.), M.
Velpeav, (Revue Med., t. iii. 1825., p. 326.),
and M. Reynaud (Journ, IleMom. de M£d,, Ui.
p. 161.), have adduced cases wherein this vessel
was entirely obliterated, the circulation having
been preserved by the anastomosis and enlai)^-
mcnt of the arteries sent off above and below tlie
seat of obliteration.

54. With respect to the origin of this lesion, it
may be referred primarily to inflammation of the
vessel. But various intermediate changes will
necessarily have taken plai%, from the more im-
mediate effects of inflammation to the complete
obliteration of the vessel. It ii probable that, in
some rare instances, as in large arterial trunks,
the transverse rupture of the internul membrane
uf the vessel, with the consequent effusion of
lymph, and formation of fibrinous coagula, may
so obstruct its canal as to give rise to its partial
or total obliteration, without any aneurismal
tumour having formed ; and it is not improbable
that obliteration ur constiiction of the canal may
have proceeded in other cases, from the adianced
stages of the s{H)ntaneuus cure of aneurism ; the
deposition of fibrinous coagula, and the sulise-
<juent changes whicii had taken place in tliem,
and the diseasi-d coats of the vessel, having ended
in oblitoralion, and the establishment of a col-
lateral circulation.

niBUix,HKPH\:~.i/oi'f,afrvi\ Do Set], et Cau4. Morfx
)iit xvii. i>t xviii. — .V«Ar^/, rhiln<t. Trant.

Ilodgtom^

On DiM-urt «if .\rtiTied, Ac. y, I'JT. — Cwrrfsart, Sur ici
Malailii-9 till I'liriir, Ar. \t. :M:i.^.Sfarpa, KilletMonl c«l

(>i>«crvazi(i:ii null' AiK-iir:«:iia. I'aMa, 1S04 A'ryynjf,

l>iG Kraiikhcitcii di-s Mit/oiu. lU-ri. 1N14-1<1 Tctta,

Dclle MaUltic ilcl i'uuTC,\i\ Nap. IHi^S — l'niu(foot.

le Diaguottique dei Aneurynncs ciu rAorte. Fsria, 1813.

APOPLEXY — Af FKo^cu

«d Tn /'Jwcvk^f. In hit Medl

APHONIA. Se« \'oicb. Mi^rUd StaM d/.
Ai'IlTH.f. SccTbiuih.
APOPLEXY. Deriv. and Svnon. Apopluw
fmrn iwrr\iffm, peiculio. Ajdmnio, IHi-

.VnroniB JtMofutin

Cell. MiT^i Am

Lommiui. Sidtralio, Prmuio, IMoliaar.

^tciflua, Ger. Jp^'^J''. *"'■ -l«id"i".

lW», Ctttiota, lul. d/idplEi^, Pol.

Cuuir.— 2. CJou.NervoiuDlKase^til. Or.

<lcr,Cixii&to>eAffectioD9(Cul(tn}. 4.CiaH,

Nerroiu UaladLcj ; 4. Ord<r, AffeLUn,;

lbeSeii»oriBlPow«n(Cwd>. IV.Cl^.s,

111. Ordkh (JuW, KflPn/a<0.

lUM. A latol cDRKiournfii,
n olfctr icDr-cft,

1. \a«

nufmanor' iA«/unclig>u d/ ue itbiii, m/iira-
Im uJ cnciiJa(i«n itingnwrf or loi ihilurbtd.

till JwiMrrAa^r, or damngmfni df |A( uuKular
ijilat tf lit bruin, and tittir cDnvjumcM.

'2. I>iin>criOM!. Tbere aie fewdiseasea wbich
pnmt t. gieiter vuiety of modes af stuck, or
'^b depend upoa a greater number of Ichodi
of tb« organ iSeclcd, Uian thai now under
4,^ilcntioD. Ita sourcefl, modes of manifeslalJOD,
iihI morbid relatioaa aie numerooi, and many of
ili«iD difficult of invealigstion. Tbeae circum-
lUiKfi have given liie lo various allempie al
unnjing tbe pbcnomena of the diseaie in Bucb
1 wijr ai to iodicale tbe relatioas which sutuUl
Ixlaeeii tbe chajiget nilhin the bead, on whiuh il
ilcpeub, and ih« mode and progress of attack,
Auipluj ha* long been described aa cooustiaij
if ceitajn fDrm*, which have beea distinguiahed
liv ume authon aa tbe lan^ina and sernu, wi '
itltreace (o tbe dMdig of ihe effusion ; b; olhei-,
3i iht wrc«u and hitivut, according to tbeir idea
^ ih* more immediate causes. By aeveral wrilerr
it baa been, witb more justice, divided into ncliii
oruAnic, and paiii» oruM'itntc; or (n(a>iic ant
*mu, according lo the slate of the constiluliona
M vital poiter* and respiration, and ihe degrei
of vuruiar action accompanying it. All tbca<
uran^enienti are, however, only partially toundcc
u truth: in msny reapECta they are entirely er
i«wo(u. Wherein ihey are either Ihe one or tli<
vtber Kill appeal in tbe sequel. M. Ci
use of ihe most lecent and best wri
ilL-eue, confiae* the lerm Apoplexy lo
leace a( sponUneous hemorrhage in the brain,
ud divide* it into two ipeciea : — lat, That cod'
'<-tiag of a collection of blood in a torn part of

Oa IBEUaviTOBy SlONI OF. 79

impos»ble to ascertain, during life, whether ex-
tiavualion of blood ha* actually Uken place, or
merely great congeation of the veaaels, with ot
without serous efTuaion ; and many cateaof true
apopleiy occur ocoaaioiilng death, as well a*
where complete recovery takes place, without
either of the leuoos 10 which he impules the
lease, having exiated.

3. In the account which I will endeavour to
give of the disease, its common form of approach
and attack will be described ; next, the difTerent
inodea in wiiieb tbe attack is made, dialinguiabing
the principal forms it assumes ; and aflerwanla
will be noticed several important states of llie
malady, arising from peculiar causes and ante-
cedent aSections. When detailing Ihe different
ties and stales of Ihe disease, it will be made
/est that the distinctions heretofore offered,
lugh occasionally obtuning, have no uaiform
ven general relation lo the lesion* existing
in Ihe head; that apoplexy, witb the symp-
desciibed a* charactentlic of ureut effusion,
been frequently found lo proceed from
uineouB extravasation ; and tlial the uii-
nmi has aumelimea only presented alight
la effusion : a similar objecdon being also
applicable to all Ihe other distiuction* above enu-

1. DiacnipnoN. — i. Or tiie Afphojicii,

tance of recognising the approach of tliia
le must be evident lo the piaclical reader;
for judicioua measures, employed at thia period,
will often succeed in preveoting an allack,or will
■ndcril less severe, even when they fail of avert-
ig it altogether. The most common precursory
tymplomaare, ateodency to sleep aiuoaccualomed
periods ; a heavier sleep than uaual, particularly
■' accompanied with profound, laborious, or ster.
roua breathing, stridor of tbe teeth ; nightmare ;
succussiuna of Ihe frame, or cramps i a lethargic
feeling and diowsineis even during the waking
hours; more rarely, unusual wakefijlnesd ; pain*
in different parts of the head, or general head-
ache or Diegiim ; a sense of weight or fulnese in
the head, or of pulsalion of the arleries ; inco.
herent talking, resembling intoiieatioQ ; a turgid
appearance of the veins of the head, particularly

lefor.

idilyorr,

I aurfao

x\; and, Id, That with sanguineous infiltiation
ioLD ibe iotteaed structure — or capillary eiud-
1 luQ into, and cambiusd witb, its substance,
'liie dtlerts of this arrangement, a* well a* of
tl^ii puhology, particulariy in regard to practical
purpoM*. mu« be apparenli Ibr it will often b«

toEs of recollection ; irritability of temper, or
unusual serenity or apathy of mind ; a disposition
lo shed tears ; suffusion of the conjunctiva ; col-
lapscdappearanreof ihealsnasi; moals floating
before tbe eyes, or dimness of vision (amaurosis) ;
scintillaiioLS, or bright or shiniog coruicnlions
before the eyea during darkness ; inability to
follow the line in reading ; double vision, or a
sbaipei sight than usual ; difficulty in shutting or
opening the eye* ; noises in the eais ; dulnes* of
hearing; a sensation of an unusual fcclor; ilry-
neaa of the nostrils ; continued sneezing ; frequent
yawning ; singultus ; stammering, or indialiiii;!

another, or forgetfulneas of words and names ;
diflicoily of swallowing, or fits of coughing upon
deglutition ; leipothymia, vertigo, or a aensution
approaching to faintnese; diSiculiy of writing, or
inability to apell the words, or to follow a slralglit
line i lorpor, or numbness, or pricking of the ex-
uemiliei; ilcbiog, or fonnicalion of ihemrbcej

80

APOPLEXY— Simple axd Primary.

paiQ9 of the joints or limbs ; a feeliog of fatigue
upon slight exercise ; partial or slight paralytic
affections, chiefly of the muscles of the face, or
confined to a limb or part of a limb, occasioning
drooping of the eyelids, imperfect utterance, slight
distortion of the mouth ; an unsteady or tremulous
gait; tripping upon ascending or descending a
stair, or in walking; difficulty in voiding the
urine, &c.

5. ii. TliEClIARArTERISTIcSVMPTOMS, ORTIIOSF.

coN'STiTVTiNO riiE Attack. Aftcr one or more
of the foregoing signs, or after the succession of
two or more of them, and their continuance for a
short or long period, the phenomena which con-
stitute the disease sui)ervenc. Sometimes the
premonitory signs are so slight, and of so short
duration, as to escape notice, the attack being
severe and sudden : at other times they are very
remarkable, and several of them are grouped to-
gether, the attack advancing either gradually and
severely, or suddenly, and disappearing rapidly;
yet recurring after an indefinite time. The mode
of approach and attack sometimes has a close
relation to the state of internal lesion ; but, occa-
Monally no such relation can be traced, as will
be shown and explained hereafter. The premo-
nitory signs, as well as the early part of the
attack, generally present more or less either of
augmented or dimiimhed vascular action, parti-
cularly about tiic head, according to the state of
the vital powers. The character of the symp-
toms, therefore, in respect of degree of vascular
action and constitutional power, should receive
the utmost attention, as bemg our be>t guide to a
successful treatment.

6. A. In the most severe and sudden forms of
ottack, -** the apopleria fnlminaus of the older
authors, and some of the Continental writers of
the present day ; thefortissima of Dr. Cookk and
others ; ihc apopleiiejondroyanle of the French, —
the patient is struck down instantly, sometimes
froths at the mouth, lius a livid countenance,
complete relaxation and immobility of the volun-
tary muflcles and limbs, and inconscious evacu*
ation of the urine und fu^ce.^ ; and dic^ very shortly
afterwards, either with or without stertor, or rattle
of the respiration, with cold, livid extremities;
cold perspirntioD, and sometimes a cadaverous
cast of countenance.

7. B, In the more active or sthenic forms of
attack, — the Jpnplex in fnrti» ; the entonic apoplexy
of Dr. GiK)!) ; A. e\quisita of various authors, —
the iMitient is more or loss suddenly seized with
profound stupor, the eyes being ciihur open or
closed ; the breathing deep, blow, sonorous, or
stertorous ; and the pulse slow, full, hard, or
strong : sometimes irregular or unc()ual. In this
state of the disease, the above are often the chief
symptoms, no signs of paralysis being observed.
iiut freriuently the mouth is drawn to one side,
the eyes are distorted, and one eyelid immove-
able, with relaxation, loss of sensation and of
motion of a limb, or of one side of the body ; the
nrm of the non-paralysed side being often closely
applied either to the che<it or to the genital organs.
In this lutlcr state of the disease, there is some-
times also some degree of paralvsis of the urinary
bladder, or of its sphincter, givmg rise to ischu-
lia, or eneunsis, or a combination of both. The

'iMtient generally lies on t/ie paralysed side, which
i^axed, wcajjablc of motion, ond inseusible to

the application of irritants ; whilst the limbs of
the opposite side are sometimes subject to spastic
contractions.

8. C. In the more gradual seizures, or those
of a less complete character, — the atonic apo-
plexy of Dr. Good ; the Aptyplexia imperfecta, the
parapoplexia of various writers, — the patient, after
experiencing some of the premonitory symptoms,
is seized with alarming vertigo, leipothymia, or
feeling of faintness ; sickness at stomach and
vomiting ; disturbance of tlie senses, particularly
of the sense of sight ; loss of memory ; partial
loss of sense, consciousness, speech, and volun-
tary motion ; weak, irregular, and sometimes
quick pulse, with more or less of sopor.

9. msides the foregoing forms of apoplexy, —
which differ merely in respect of the state of the
constitutional powers, the severity of attack, and
the grouping of the symptoms, and not as to the
organic lesions which occasion them, — other dis-
tinctions offer themselves, which are siill more
dcsen'ing of attention, as generally having a more
intimate relation to the changes which are going
on within the head, than the degrees of severity
of seizure merely. Viewing, therefore, the pre-
monitory symptoms as common to all its varie-
ties, I shall divide the disease according to the
form, manner, and complication of the attack,
and consider, briefly, — Ut, The sudden form of
apoplectic seizure, in its simple state, and uuat-
sociated with paralysis ; 2d, The gradually in-
creasing, or ingravescent attack ; 3(1, These states
of seizure complicated with paralysis ; and 4th, that
form which commences with paralysis, and afler
an indefinite period passes into complete apoplexy.

10. iii. SniPLE and Phimary Apoplexy. A,
Description, In this variety of the disease the
patient falls down deprived of sense, conscious-
ness and voluntary motion, is like a person in a
very deep sleep, with his face much flushed,
tumid, and occasionally livid ; his breathing slow,
deep, and stertorous; his pulse full, natural in
fre((ucncy, or slower than usual. Sometimes
slight convulsions of the limb?:, or contractions of
the muscles occur, or contractions of the mus-
cles of one side, and relaxation of those of
the other. The attack, in rarer instances, is
either usheretl in or accompanied with general
convuls^ions, passing into complete apoplexy, or
profound comn. The patient may continue in this
state of profound stupor for sevenil days ; or he may
recover after some nours, or even minutes, when
judicious assistance has l>een instantly procured.

11.^. This form of the disease terminates, 1st,
in perfect recovery, — often in the course of a
few hours, — but rarely when the attack has con*
tinned longer than one or two days. I have,
however, seen cases of perfect recovery in com-
paratively young or robust subjects, after the
apoplectic state had been of scvend days' dura.
tion. 2d, In death, which may take place in the
course of a very few hours, or after some days, but
most commonly from the first to the fourth day.

12. ('. The appearances \v\iic\i this class of cafes
present on dissection mny l>c arranged into-^ Ist,
Those which are insufhcicnt to account fur the
symptoms, or their termination in death ; Sd,
Those which proceed from intense injection and con-
gestion of the membranes of the brain, and of the
cerebral structures; Ikl, Those which are accom-
panied V\i\\ an elTusloaof serum, or engorgement

98 APOPLKX Y — ThiATMrxT or.

tinaes, Uie cttpillarics are soon afterwanls injected
and dilated ; and, in proportion as ttiey cnlurgo
from the distending power to which they are more
immediately subject, the veins are coinprcKSc:!,
owing to tlic physical conditicih of the bniin, more
or less emptied, and admit of the grentur dilatation
of the capillaries, some one or more of wiiicli may
be even ruptured from the increased action and
distension.

118. k. Incases accompanied with hgnmrrhafret
and consequent Inccrntion of the cortbrnl struc-
ture, the deprivation of function may be i\n much

an effect of suppression of the vital influence of i cure, but also as regnrd.* the most energetic mea«
the organ, owing to the shock prmluced by the I surcs and the intentions with which they should
injury, as of pressure upon the veins, and con- ' In; employed. This is evidently owing to the
sequent injection of the arterial capillaries. In . difference which has been long acknowledged to
cases of this description, the state described al>ovc I exist in the pathological states conittituting the
"'■'""" ' ' r ., 1 , I disease, but which has rccemly l»een questioned.

suppressing the functions of the organ ; and thiit,
as apoplexy docs not uniformly depi'nd upon the
same pathological state of the nervous influence
and circulation of the brain, particularly in respect
of the kind or degree of vital depression and vaa-
cular reaction, a due regaril ought therefore to be
had to the nature of the change in each case, u
far as it may be ascertuinrd, and a treatment
strictly appropriated to it adopted.

1 23. >■ I . T R F AT M r NT. — Ihc treatment of apo-
plexy has long furnished subjects for discussion, not
only as respf:ct8 the more subordinate means of

($ 1 12. d.) may exist, and be followed by haj-
morrhage and laceration of the part in which it
occurs, proilucing tlie abolition of the cerebral
function, .great vital depression, sickne*?, and
other signs of dangerous injury sustained by a
vital organ. The pressure o(!casioned by the
haemorrhage will l>e followed by obslructe<l cir-
culation, and, under favourable circum-stanccs,
by increased action of the arteries and heart to
overcome it.

^Vithout recurring to the changes so fully de-
scribtM] above, I may remark, that a person is
seized with apoplexy, and, instead of bdoj;
blooded, is trented with stimulants and restom«
tives, and yet he recovers without paralysis having
supervened. Another {xirson is blooded lar^gely,
and he recovers. A third is treated in a nmilar
manner, and he becomes hemiplegic in the course
of the attack ; and a fourth is also b1oo<led, and

119. /. In apoplexy predicating on dissection f lie dies. Now thew are very common occur-
eongni'wn and serous effusion, these states may be ' rences, and ]>oint to very important considemiionfy
oflen considered rather in the light of jKUt mortem \ which I will pursue a little further. A thin,
changes than the pathological states which had . spare, and debilitated man staggers as he walks,
existed previously to death; it may even be pre- ' and falls down in the street, with palccountenancet
sumed that the distension and concestion of the | feeble pulse, and laborious or slightly stertorous
capillaries, chiefly the arterial capillaries of the ; breathing. He is blooded by the nearest medieal
or^an, had ovcrpowcR'd ito functions; and that, i man almost immedintely, and recovers. A lai^
as in other parts, when the injection of the b1oo<j ' man, of a fnll habit and lax fibre, suddenly m-
into them no longer is continued, and the di^-tcrul- | comes npoplectic, and is instantly treated with
ing cause has ceased to exist, they have gradual ly j stimnlanL», and volatile substances held to the
discharged their contents into the veins, which > nostrils, and hi«i consciousness and Tolontary mo*
now had space given them for «lilalation, owing \ tion are restored in a few minutes. One practi-
to the emptying of the capillaries ; ami thus the i tioner of large experience stales, that he nerer
blood has passed into the veins soon af^er death, i draws blood from a patient in apoplexy, excepting

120. TO. Ilajmorrhnge in the brain may result ■ under |K'culiar circum'*tances, and avers that he
from the following states: — «. Exhausted vital ! is more successful in his treatment than thosa
energy of the ganjjlial organic nerves supplying . who do. Another considers that when one fall
the vessels and organ favouring their distension 1 blood-letting fails of giving relief, no benefit will
and rupture : Q. J)isea<ed statu of the (^oaLs of the \ be derived from pushing it further, but much risk of
vessKls themselves : y. Organic change of the cere- | giving rise to paralysis. A third physician equally
bral structure, extending to, or influencinir the state i eminent and exjxiri«*nct*d, confides in blood-lettiog
of, the vessels ramified in it : >. lncrcJiM?d impetus ' almost solely, and carries it often to a great
of blood from augmmled action of the heart and | amount; anil a fourth whilst he discards depletion,
larger arteries, combined with cither of the other ' trusts to stimulints chiefly.

stales: i. Imptuled return of the blowl from the ! 124. But if we examine into their success, we
head, similarly associated. | shall find, iwrha|)s, that some difTerence as to

121. n. The vital energy of the organ, resulting degree may exist; and that, whilst many patients
chiefly from the mutual influence of the gnncrlial seem benefited, others expjriencc no relief, if they
and vascular sy«*tems, may be so far affccttnl as bo not even actually injured, by the kind of prac*
to occasion the attack with all the orgsmic chanires ti(» thus exclusively adopted. There is, however,
observed in fatid cases ; and sometimes in such a . one part of the treatment which is more or less
manner as to constitute the disease, even without adopted by all: this is the use of purgatives;
these changes having taken place ; although they ; which, when judiciously admini^ered, are the
are most frequpntly produced, thereby heightening most generally applicable and beneficial of all
the primary lesion. i the menn<i usually advised. Were it possible to

122. «». As corollaries from the foregoing, I infer ^ ascertain duriiifr life the exact pathological con-
thnt apoplexy of^cn orij.Mnates in exhausted or dition obtaining in the various cases of apoplexy,
suppressed influence of the gantjlial apparatus of and to convey a correct description of the signs
the encephalon, with a ro'ngcsicd state of its by whi( h each may be known, then the Iwsis for
arterial capillaries, or impainnl condition of their a' rational method of cure could be firmly laid:
circulating functions, and still more fpcqufntly in but iIm* skilful practitioner is ^t\td in the treat-
extra va.^at ion of bloo<l, eithi^r or all of which mont he aifopts by considerations, circumstances,
changes iwist necessarily exist lo tlic exlcut of and appearances,* which scarcely admit of de-

98 APOPLKXY — ThrATMEST or.

tinues, the capillaries arc soon aftcrwardd injecteil suppreming the functions* of the organ ; and that,
and dilated ; and, in proportion ns they enlurgc a.s apoplexy does not uniformly depend npon the
from the distending power to which they are more ' same pathological state of the nervous influence
immediately subject, the veins arc coiiipri'sscd, and circulation of the brain, particularly in re«pcct
owine: to the physical conditio^ of the bniin, more of the kind or degree of vital depression and vas-
cular reaction, n due regarvl ougfit therefore to be

owing to the physical

or less emptied, and admit of the greater dilatation

of the capdlaricA, some one or mure of which may

had to the nature of the change in each case,

be even ruptured from the incrunscd action and fur as it may 1>e ascertained, and a treatment

distension.

118. fc. In cases accompanied with hemorrhage ^
and consequent laceration of t!ie certbrnl slruc

strictly appropriated to it adopted.

123. A'l. Trf.aimf.nt. — The treatment of apo-
plexy has long furni^ihed subjects for discussion, not

lure, the deprivation of function may bo ns much j only as re^^ixicts the more subordinate means of
an effiect or suppression of the vital influence of \ cure, but also as regards the most energetic mea-
the organ, owing to the shock produced by the sure? and the intentions with which they should
injury, as of pressure upon the veins, and con- bo employed. This is evidently owing to the
sequent injection of the arterial capillaries. In j diflt^rence which has been long acknowledged to
cases of this description, the state described above ! exist in the pathological states constituting the

($ 112. d.) may exist, and be followed by htr
morriiage and laceration of the part in whirh it
occurs, proilucing the abolition of the cerebnd
function, .great vital depression, sickness, and
other signs of dangerous injury sustained by a
vital organ. The pressure occasioned by the
hiemorrhnge will be followed by obstructe<l cir-
culation, and, under favourable cin'um<tancc«»,
by increased action of the arteries and heart to
overcome it.

119. /. In apoplexy presenting on dissection

disease, but which has recently been questionea.
Without recurring to the changes so fully de-
scribed abnvc, 1 may remark, that a person is
seized with apoplexy i and, instead of beioj;
blooded, is treated with stimulants and resiora*
tives, und yet he recovers without poralyms havii^
supervened. Another person is blooded largely,
and he recovers. A third is treated in a similar
manner, and he becomes liemiplf gic in the course
of the attack ; and a fourth is also blooded, and
he dies, Now these are very common occur-

eongalhn and serous effusion, these states may Ik3 ■ rence^, and jtoint to very important conaderationi,
often considereil rather in the light of jMst nwrtem ■ which I will pursue a little funlicr. A thin,
changes than the pathological states which had | spare, and debilitated man stiis^gers as he walks,
existed previously to death; it may even be pre- J and falls down in the street, with pale countenance,
sumed that the distension and congestion of (he ! feeble pulse, and Inborions or slightly sCertorons
capillaries, chiefly the arterial capillaries of the i breathing. He is blooded by the nearest medical
organ, hod overpowered its functions; and that, | man almont immediately, and recovers. A Iar]ge
as in other parts when the injection of the blood i man, of a full habit and lax fibre, suddenly be*
into them no longer is continued, and the distend- I comes apoplectic, and is instantly treated with
ing cause has ceas(r<l to exist, they have gradunllv ' stimulants, and volatile substances held to the
discharged their contents into the veins, which | na<«trils, und his con<iciousness and voluntary mo-
now hud space given them for dilatation, owing . tion are restored in a few minutes. One practi-
to the emptying of the capillaries ; and thus the < tinner of large experience states, that he nerer
blood has passed into the veins soon aflter death, j draws blood from a patient in apoplexy, excepting

120. m. Hiemorrhagc in the brain may result , under peculiar rircum stances, and avers that be
from the following states: — a. Kxhausted vital ; is more successful in his treatment than those
energy of the ganjilinl organic nerves supplying ! who ilo. Another consi«lers that wlien one full
the vessels and organ favouring their distension | blood-letting fails of giving relief, no benefit will
and rupture : 0, Diseased slate of the coats of the | be derived from pushing it further, but much risk of
vessels themselves : y. Organic change of the cere- i giving rise to paralysis. A third physiciun equally
bralstructuie, extending to, or influencing the state ' eminent and exj)enence«l, con fide^ in blood-letting
of, the vessels ramified in it: i. IncreoKMl impetus | almo«»t solely, and carries it of>cn to a great
of blood from auf^mented action of the heart and , amount ; anil a fourth whilst he discards depletion,
larger arteries, combined with either of the other i trusts to stimuhints chiefly.

states: i. Imp<;ded return of the blood from the | 124. Hut if we exarnmc into their success, we
head, similarly associated. i jthall find, perha|)s, that some ilifTercnce as to

121. fi. The vital energy of thcorgnn, resulting ' degree may exist; ami that, whilst many patients
chiefly from the mutual influence of the (rangliol seem benefited, others expcricnee no relief, if tbey
and vascular systems, may be so far nflTected as ' be not even actually injured, by the kind ofprac-
to occasion the attack with all the organic changes ' tice thus exclusively adopted. There is, however,
observed in fatid cases ; and sometimes in such a one part of the treatment which is more or less
manner as to constitute the disease, even without | adopted by all: this is the use of purgatives;
these changes having taken place ; although they \ which, when judiciously administered, are the
are most frequently produci^d, thereby heightening , most generally applicable and beneficial of all
the primary lesion. ' the means uiMially advised. Were it possible to

122. (I. As corollaries from the foregoing, I infer ascertain during life the exact pathological cod-
that apoplexy of\en ori^iinates in exliau«ited or «lition obtaining in the various cases of apoplexy,
suppressed influence of the ganulini apparatus of and to convey a correct description of tnc signs
the encephnlon, with a congested state of its by whirh each may l>e known, then the basis for
arterial capillaries or impaired comlition of their a* rational method of cure could lie firmly laid:
rirculiiting function^, and still more frequently in but the skilful practitioner is guided in the treat-
extravasation of blood, eithf^r or all of whirh ment he a<lopts by cou'^iflcrations, circumstances,
chaaffcf* nvisX. neces^irily exist to the extent of : anfl apjicarances,' which scarcely admit of de-

ARTERIES — Morbid Stsucturb of.

119

beiDv kept up by the enlargement of coUatenii
bnitcbes, the obstructed part is deprived of its
fuQctioQS, and ■ubsequently undeiigoes those
changes which all vascular or other canals expe-
rience when they no longer are pervious to the
fluids which usually circulate through them, — -
they have the fibrinous coagula, which have been
formed in tbeir cavities, and the lymph effused
between tbeir coats, absorbed, and their coats be-
come condensed into ligamentous chords.

56. e. The third species has been met with in
(be aorta by Dr. Goodison (Dub, Hotp. Rep.
vol. ii. p. 193.), and M. Velpeau {Riv. Mid,
1825, t.iii. D. 326.) In Dr. Goodison's case,
aa oaseous aeposit surrounded the canal of tlie
vessel, which was completely filled at this part
with a dense fleshy and nbrinoui mass, resembling
the structure of the heart. A similar obliteration
also existed in the iliac arteries. In M. Vel-
peau's caae, the obliteration was owing to the
fiKmation of a scirrhous or carcinomatous tumour
n the vessel, resembling similar tumours deve-
bped in different parts of the body. Obliteration
by polypous or other growths, by fibrinous
coagula and coagulable lymph, by oasific deposits,
kc are also found in lai^ arterial branches,
eipecially in those supplying the lower extremities.
The obhteration of tne arteries by ossification is
one of the principal causes of the gangrene of
^ed penona. When a eonsiderable artery, or
even the aorta, becomes either much obstructed,
or entirelv obliterated, in any of the above ways,
the drentttion is generally carried on by enlarged
collateral vessels.

57. d. The fourth species has been observed
ia several large arterial trunks. Dr. Monro's case
of obliteration of the aorta may be partly ascribed
to this cause; the coats of the vessel, although
entire, being dilated below the constricted part.

58. D, At^BOlflKOUS IND PURULENT MaTTER.

— M. Gendrim {Hiit. Anat, det Inflam, t. ii.
p. 9.) has clearly proved, by his experiments,
tliat, when an artery is artificially irritated, its
pirietes soon become injected, swollen, softened,
ind infiltrated by a serous fluid ; its internal sur-
fsee is coated by an atltuminout exudation, and
etUeetims t^ put form, either in the interior of the
vessel, or between its coats. He has, moreover,
demonstiated that, if the artery continues full of
Uood during the* experiment, this fluid is coagu-
Uted, and altered in a variety of ways by the mor-
bid secretion poured into it from the internal surface
of the inflamed vessel. Similar appearances have
been observed from disease, particularly in the
softa and large arterial trunks, where they are
most obvious. Mr. Hodson and M. Bouillaud
foQod the internal surface of the aorta lined with
a perfect /a(j» memhrane ; and when this was re-
moved, the surface of the vessel was of a bright
red coloor. M. Andral has observed the inter-
nal menbrane of the artery raised by small abt-
Mws, aometimes as large as the ate of a nut,
ntaated between the internal and middle coats.
It is probably to the bursting of those into the
vessel that ulceration of the internal tunics is
owing. Pus is also sometimes found in the in-
terior of arteries, either unmixed with the blood,
or mixed with it and altering its appearance.

59. K. Atbbrov atous matter is frequently
foiiikl between the inner and middle coats of ar-
tssias. It was first noticed in this situation by

Monro and Haller. It is generally of the
consistence of suet, of a cheesy opaque appear^
ance, is greasy to the touch, with minute gritty
particles thinly scattered through it. In some
cases it resembles more nearly a semi-concrete
pus, and seems to result from the changes which
pus may have undergone subsequently to ita
secretion. In other cases the atheromatous mat*
ter abounds in gritty particles, which occasion-
ally even exceed the suety part ; and the depo-
sition thus passes into the form of a calcareous
concretion. It is extremely probable that these
varieties of morbid formation are connected
with chronic inflammatory action of the coats of
the vessel.

60. A variety of the atheromatous matter has
been described by Morgagni, Scarpa, Stenizel,
and Craioie, under the denomination of tteato*
matotis deposition. The name, however, as Dr.
Craioie has remarked, is not well cboeeo, inas-
much as this formation is not adipose, but a firm
cheesy or waxy matter, of a yellowish or fawn
colour. It seems merely a more concrete variety
of the foregoing, and differing from it chiefly in
the absence of gritty particles. It is more fre-
quently found at the bifurcations of arteries, but
it is not limited to those situations $ and is gene-
rally deposited between the inner and middle
coats. When the quantity of this matter is con-
siderable, it encroaches on the calibre of the ves-
sel. This substance is met with either alone, or
with patches of calcareous deposit. It probably
derives its origin from a similar source to the
atheromatous matter ; and, according to Scarpa,
always terminates in ulceration; but this is not
invariably the case, as it has been observed, par-
ticularly when unattended with calcareous form-
ations, distending the coats of the vessel to a great
extent without any ulceration. This change,
however, takes place very generally, either when
the deposition of this matter is considerable, or
when associated with calcareous formations.
When ulceration takes place, the coats of the ves-
sel are soon destroyed to a greater or less extent,
and rupture follows ; taking place, as shown by
JVfr. HonosoNf in a transverse direction to the axis
of the vessel, and givins rise to extensive or fatal
hemorrhage, or to circumscribed or diffused
aneurism, according to the situation of the aper-
ture in the vessel.

61. F, Calcareous or otteout eoneretions are
the most frequent morbid appearances presented by
artftries. These concretions, however, differ from
healthy bone chiefly in wanting the fibrtkus struc-
ture, in not being necessarily deposited in a car-
tilaginous matrix, in consbting of a larger pro-
portion of phosphate of lime, and less animal
matter, and in presenting an irregular, homo-
geneous, and unoi^^ised appearance. Bichat
and Baillie considered that the larger proportion
of persons above nxty years of age have some
part of the arterial system affected by Uiese form-
ations. This change is very seldom observed in
early life. You no found it, however, in an infant ;
Wilson in a young child; and Andral in the
aorta of a child of eight years of age. M . An d r a l
has met with osnfic lamine in the aorta, in five
or six persons of from eighteen to twenty-four
years ot age : and an extensive ossification of the
superior mesenteric artery of a person not quite
thirty. This species of formation always is seated

14

126

ARTS AND EMPLOYMENTS— A8 Causes or Diseasi,

occurred to him. LsmoM reoommended sul-
phur ; and I believe that its good effects are yery
considerable. In a case which lately came be-
fore me, of violent cephalalgia, with muscular
tremors, &c., after a severe mercurial course,
large doses of sulphur merely, given every night
in treacle, produced a cure in a few days. Mr.
Pearson chiefly relied upon exposure to a dry
and open air. Sementimi stauss, that he obtained
uniform advantage from the internal use of the
nitrate of silver, beginning with an eighth of a
grain, and gradually increasing the dose 'to three
grains in the day. I have lately employed the
tincture of iodine in two cases of this affection
with success; and in one instance I prescribed
strychnine, but lost sight of the patient before its
effects were apparent. Mr. Eable {Ltmd, Med,
Gat. vol. xi. p. 31.) gave five grains of the extract
of conium, three times a day, with benefit.

26. c. It is obvious that it is of importance to be
in the possession of plans to prevent the injurious
effects of mercury on those employed in the arts
in whicK it is used. These are sufficiently sim-
ple, and consist chiefly of common attention
to cleanlineas, and avoiding the fumes of the
mineral during the various parts of the processes
of gilding. Workmen should avoid touching the
amalgams that are used with the naked hand ;
and ought to make frequent ablutions, particu-
larly before taking a meal. During the process
of volatilising the mercury by heat, the utmost
caution should be exercised in performing the
operation with a stove in which the current of air
is very brisk, so that the fumes may be carried fully
up the flue. In roost of the manufactories in this
country, the stoves are now sufficiently well con-
structed for this purpose, the carelessness of th«
artisan being the chief cause of danger from his
occupation. M. Jussieu states, that the free
workmen in the large quicksilver mines at Alma-
den, who took care to change their whole dress,
and attended to cleanliness, were but little af-
fected by their occupation ; but that the slaves,
who could not afford a change of raiment, took
their meals in the mines generally without ablu-
lionSy were subject to swellings of the parotids,
aphthous sore throat, salivation, eruptions, and
tremors. (M^m. de VAcad, des Sciences, 1719,
p. 474.)

27. B, Lead.'^a, Injurious effects from lead,
in the various slates in which it is used, are very
frequent and often fatal. Its oxides may be car-
ried off in ia state of vapour, dissolved in volatile
substances, as by turpentme in painting, and thus be
inhaled into the lung;*, and act most injuriously on
the frame. It may also pass into the alimentary
canal in various ways, or it may be absorbed from
the skin, particularly of the hands, where it will
both act locally, and be carried into the iiystem,
and produce its effects as when introduced by the
two former channels. These effects are chiefly
lead colic and paralysis. The workmen employed
in lead mines, those who are engaged in procur-
ing it from its ores, who cast it or manufacture its
various preparations, and who use tliem in the
different arts, as plumbers, glaziers, painters in
oils or water-colours, oolour>grinders, type- foun-
ders, printers, are the most liable to be effected
by lead ; but all classes, under certain circum-
stances, may also experience injurious effects from
it. The deleterious nature of this mineFal h cer-

tainly very great ; but the fitCal reaulls are tarely
not one in three annually, as stated by Sir John
Sinclair.

28. 6. M. Merat has. furnished some very in-
teresting information reipecdng the frequency of
coliea pietonum m the various classes of aitisans
who come in contact with any of the different
preparations of lead. It is derived from the Ibt,
kept at the hospital La Charity, in Paris, in the
years 1776 and 181 1. The toul number in both
years were ^79. Of these 241 were artisaas,
whose trades exposed them to the poison of lead,
viz. 148 painters, 28 plumbers, 16 potters, IS
porcelain makers, 12 lapidaries, 9 eolour-grindera,
3 glass-blowers, 2 glaziers, 2 toymen, 2 shoe-
makers, 1 printer, 1 lead miner, 1 shot manufac-
turer. Of the remainder, 17 belonged to trades
exposed to copper. Of the 279 cases, 24 were
under twenty years of age, these being chiefly
painter boys, not above fifteen ; 1 13 were betweea
nineteen and thirty ; 66 between twenty •nine
and forty ; 38 between thirty-nine and fifty ; 28
between forty-nine and sixty ; and 10 older than
sixty. Among the 279 cases, 15 died, or 5'4 per
cent. (See the article Colic, from Lead.)

29. e. The tneaturet of prevention from the action
of the preparations of lead differ in no respeot from
those which have been stated in relation to mer-
cury ($ 26.) They chiefly consist of strict atten-
tion to personal cleanliness. The instructions
given by M. Merat are very complete, but are
too particular to be followed by workmen. He
recommends that the working clothes should be
made of strong oompact linen, be changed and
washed once or twice a week, and be worn as
little as possible out of the workshop ; a light
impervious cap ought always to be worn on the
head. The artisan should never take his meals
in the workshop, or without strict ablution of the
hands, mouth, and face ; and he ought to break-
fast before leaving his home.

30. Derangements of the digestive organs ought
to be watched with care. If colicky symptoms
occur, he should leave off work, and tale an
aperient. He ought always to guard against
constipation. The diet of those exposed to be
affected by the preparations of lead is of conse-
quence. It should be light and digestible ; and
poor acid drinks ought to be avoided, particularly
cider, as themselves often containing lead. Va-
rious articles of diet have been recommended as
calculated to impede the hurtful action of lead
on the frame. Hoffmann mentions brandy — a
somewhat dangerous recommendation. Fat food
has been accounted preservative. Db Ha ex
states, that the woikers in a lead mine in Styria
were much affected by a colic and palsy, but, by
being told by a quack doctor to eat a good deal
of fat, particularly at breakfast, they were exempt
from toese direases for three years (Ref. MmI.
p. i. ch. ix.) Similar facts lespectiog the good
effects of fat meat, as a preventative of the effects
of lead, are recorded by Sir George Baser
(^Trant, of Land, CoU, of Phyt, vol. ii. p. 457.)
and Mr. Wilson (Edin. PAjft. and Ltl. EttayM,
I. p. 521.) Those who work at furnaces in which
lead is sntelted, fused, or oxydised, should be

Erotected by a strong draught through them. Mr.
•RAID, of the extensive mines at Leadhills, in*
formed Profesmr Ciiristison (tee hit mmi tmlu^
able work on Poiamu, ^c. p. 506.), that wherever

140

ASTHMA — SpAfiMODic.

tion suggests itself, viz. can this augmented
action of the lungs be owin^ solely to the state
of this organ, or is it associated with, or partly
depending upon, increased activity of the respir-
atory muscles, particularly the diaphragm ? M.
Laennec states that it cannot be produced at
will by a full inspiration; and, therefore, infers
that this state of tne lungs is a primary condition
of them, and not dependmg on increased inspir-
atory efforts.

32. From this consideration I am led to infer
that, although the vital expansile action of the
lungs may be increased in this variety of asthma,
it is accomplished with, and much assisted by,
augmented activity of the diaphraero, which per-
forms its office more promptly and completely in
this variety of asthma than in any other; that
instead of the disease being characterised by
spasm of the smaller ramifications of the bronchi
and air-cells, as in the second variety of asthma,
the air penetrates more fully into them than
usual ; and that, if any spasm exists, it is limited
to the trachea and large bronchial tubes ; the
exalted state of expansion of the lungs, and of
function of the diaphragm, being an effort to
counteract this morbid condition of the large
tubes, and to supply the wants of the system by
a more forcible inspiration ; the increased rapidity
with which the air is thereby made to pass
through the stnctured canals making more than
amends for the diminished calibre of the passage.
This form of the disease is frequently tymptomatie
of nervous affections, particularly of hysteria,
when the globus hystericus affects the state of
the trachea, and of various diseases, in which the
blood is imperfectly changed in its circulation
through the lungs. But when thus symptomatic,
it n often slight and evanescent.

33. 2d, SpatJMdic Aithma, Syn. Periodic
Asthma. Convulsive Asthma, Wiliit, BagUvi,
Boerhaave. Asthma Siccum, Musgrave. Occult
dry Asthma, EtmuUer, Spasmodic Asthma, La-
ennee. Dry Asthma, Good, — Char. Parox-
ysmt sudden, violent, and of short duration, at'
tended with hard spasmodic constriction in the
chest ; sHght, dry, and difficult cough, and with a
scanty expectoration, occurring only towards their
close.

34. I stated that the vital expansive action of
the lungs was increased in the fore|;oing variety.
In this the ramifications of the air-tubes, and
perhaps the air^celb themselves, seem to be unna-
turally constricied. The respiration, when ex-
amined by the stethoscope, or by the ear merely,
is heard either very imperfectly even on the moat
forcible respiration, or to a small extent only, or
its sound may be but little impaired. The chest,
during the paroxysm, sounds ill on percussion.
These phenomena indicate that there is an im-
perfect entrance of the air into the air-cells. M.
Laennec states, that if the patient after holding
his breath nearly as long as he can, breathes
quietly, the spasm will often be overcome as it
were by surprise, and the entry of the air into the
cells will be heard in a clear or even puerile
sound. This, and various other circumstances,
independently of the proof furnished by the struc-
ture of the air-tubes, indicate that the obstruction
to the entrance of air into the cells is owing to
spasm of the muscular fibres.

35. Dr. Williams believes that spasmodic

asthma may be partial, affecting one lung only^
or one more than the other ; but this is very seU
dom the case, unless when it is occasioned by,
or complicated with, dry catarrh, which is some-
times partial ; or when the spasmodic constriction
is excited by a collection of a pituitous fluid in
some of the bronchi, — a complication of not in-
frequent occurrence, but falling more strictly
under the next form of the disease. Although
the paroxysms of the primarily spasmodic aathma
are sudden, and generally of short duration, yet
the disease is often of long continuance, and may,
to a certain extent, become balntual, as sbowa
by Dr. Brsb and others.

36. During the spasm, the langs seem, from
an attentive examination of the thorax, somewhat
drawn together, owing to the constrictioD of the
air-tubes ; and the parietes of the chest, being
necessarily pressed inwards at the same time,
generally yield a less clear sound on percuasion.
The scrobiculis cordis is also drawn inwards and
upwards, indicating the manner in which the
diaphragm is afifectM during the paroxysm. This

ghenomenon, which was fint pointed out by
cuBiDMANTEL (FriinkUchc B^rUge, No. 5.),
arises either tirom the diaphragm being prevented
from contracting to its full extent by the spastic
constriction of the air-vessels, or from a temporary
paralysis of this muscle. That the latter state
should take place, and be followed in a short
space of time by a perfect restoration of aetioD,
and that repeated seizures of this description
should be always succeeded by a similarly rapid
return to the healthy state, cannot be admitted
by any person who takes an intimate and com-
prehensive view of the operation of the animal
economy in health and disease. That retraction
of the epigastrium, and even of the hypochondria ,
is owing to imperfect descent of the diaphragm
from constriction of the air-cells, seems |>roved by
the circumstanoe, that the pleural cavity is per-
fectly closed, and forms nearlv a vacuum, and
consequently the capacity of the thorax cannot
be enlarged by the action either of the diapbragm
or of the other respiratory muscles, without the
expansion of the lungs. But this organ is only
imperfectly expanded, owing to the spasm of its
air-vessels; consequentlv the diaphragm cither
cannot assume its u«ual place, or does so im-
perfectly, notwithstanding its efforts to accomplish
this end ; and the parietes of the thorax an every
where pressed inwards, following the retracted
state of the lunes themselves, and are only
partially dilated after the most energetic adioii ot
the respiratory muscles, which at last overcomes
the spasm of the air-tubes, as the want of respir-
ation throws the former into spasmodie action,
and tends to relax the spastic state of the
latter.

37. This condition of the air-vesseb, nod the
antagonising action of the respiratory mnsries
during the paroxysm, have a neoessary teodeney
to form a vacuum in the thoracic cavity ; but this
can take place to a very small extent only, as the
action of the respiratory muscles is insumoieiit to
overcome both tne pressure of the atmosphere
surrounding the chest, and the spastic stnctare
of the air-tubes, as long as this stricture eontiniaes
in full force. The conseauence, however, of this
antagonising action and tendency to fiDtm n
vacuum jb, that a larger quantity of blood is

14a

ASTHMA ^ DuGKOits.

from which it is imperiecUy eipellcd. From
this drcanutuiee the HkBgs aie often kept in a
ftate of inordinate dilatation, and the respiratory
mnscles excited to conmlsiYe actions, occaaoning
dilatation or rupture of the air-calls, and conse-
quent emphysema of the lungs. In the more
advanced stages of the disease, in old and debili-
tated subjects, thb struggle to dilate the thorax
still further, proceeding from the wants of the
system for* respiration, and to expel the air from
the lungs through the obstacles placed in its
way, g^ierally terminates unlaTOurably to the
latter part of the respiratory actions ; conse-
quently expectoTBiion is impeded or suppressed,
and life is terminated, with the air-tubes and cells,
and even the substance of the lungs> loaded
and infiltrated with mucus, air, and serum. It is
in this state that active stimulants and emetics, by
rousing the enenies of the frame, and by exciting
the expiratory erorts during the procem of vomit-
ing, prove so frequently beneficial.

44. lliis form of asthma may be partial, af-
fecting one lung only, or one more than another ;
but it is more commonly general; and in some
constitutions, particularly in aged persons, aud
when it has supervened to repeated attadu of
catarrh, the quantity of viscid mucus expectorated
is very great.

46. Its anaUmueal ckaraettri are, slight swell-
iog, or thickening, and softening of, the mucous
membrane, with a slight appearance of redness in
parts, and with marked congestion, and purplish
tint of portions of this surface in the more severe
or protracted cases. Sometimes these lesions are
accompanied with slight oedema of the membrane,
and the development of miliary tubarcks in the
lungs.

46. As the majority of cases of this disease is
characterised from the commencement by copious
expectoration, it becomes a question how far it
deserves to be considered as a variety of asthma ;
but taking all its phenomena into consideration,
particularly the spasm of the air»passages, and
convulsive action of the respiratory muscles, as
well as the circumstance of it having been usually
considered as a species of asthma, and the dif-
ficulty of arranging it otherwise, 1 was unwilling
either to assign it a different place, or to make
it a distinct (Usease, to which it scarcely can lay
claim. M. Laennbc has placed it amongst ca-
tarrhal inflammatory afTections of the bronchi:
but I conceive that it is seldom inflammatory
either in its origin or progress ; and that, although
occasionally commencing in, and always aggra-
vated by, catarrh, it is not necessarily a catarrhal
disease. Besides, inflammations of the bronchi
and catarrhs are not identical afiections, although
the latter frequently pass into the former.

47. Hut, besides these considerations, many of
the phenomena essentially characteristic of asthma
always attend it to a greater or less extent. Upon
an attentive examination, however, of the chest
of a person afflicted with this affection, by auscul-
tation and percuHion, these phenomena are found
to vary, in diflfierent cases, or even in the same
case, at different periods of the attack ; yet they
are essentially the same as those which mark (he
preceding varieties, although not so evident to the
senses as in them, inasmuch as they are obscured
by a more prominent symptom —the copious mu-
cous secretion and expectoration. Sometimes it

I i« manifest that certain parts of the atMubes are
'differently, or even oppositely, affected at different
' periods of the attack. M'hen the viscid raucous
secretion proceeds from, and is still present in,
the smaller ramifications of the air-vessels, this
condition, together with some degree of spastic
constriction of their circular fibres, either in a
part only, or more or less throughout the organ,
occmiotts many of the symptoms which chvac-
tefise the teemd or spasmodic Taiiety of the
disease. But in proportion as the secretion rises
to the larger air-tubes, and leaves the smaller
ramifications clear ; or when the mucous secre-
tion proceeds chiefly from the former parts, and
excites, or is accompanied with, spasms of these
canals, but not to the extent of preventii^ the
passage of air into the parts of the lungs which
they supply ; these parts generally expand freely,
owing to t^ vital activity of the omn, the vraots
of the system for the changes effected on the
blood by respiration, and the active contraction
of the inspiratory muscles during the convulsive
efforts of tlie paroxysm. Hence the part of the
lungs thus affeeted generally fnraish the puer^e
respiration, and a clear sound on pereuasion, with
a full and prompt performance of the inspiratory
actions, — phenomena characteristic of me^Eni
or nervous form of asthma.

48. III. Diagnosis. — From the foregobg ac-
count of the symptoms and forms of asthma, it will
appear obvious that the distinction of it from
every other disease cannot be difficult, particularly
if we carefully bring auscultation and percus-
sion to our assistance. The sudden attack of
the paroxysms, the short period of their duration,
the violence of their symptoms, their returning
after intervals of ease and of tolerable health,
are sufficient to characterise the disease. It b
only when asthma is complicated with, or has
induced, other diseases — as chronic or acute
bronchitis, pneumonia, tubercular phihiss, or-
ganic changes of the heart and large vessels, or
efTusiotts of fluid within the thorax •^- that diffi-
culty can arise in determining the exact state of
parts ; and here we have it in our power to resort
to auscultation and percussion, which, if this
disease be simple and uncomplicated, will furnish
us with no veiy unnatural sound, at least with
none which will exist with any permanency in
any particular part of the chest ; and if it be
complicated, the nature and the extent of the
organic changes will be ascertained by these
means, as pointed out under their respective
heads.

49. A, Spatmodie affeetiimM ef tJu Utm^s may
be mistaken for asthma ; but they may readilT be
distinguished from it by the sound occasioned by
the passage of air through the narrowed passage,
which is very different from the wheezing sound
of the asthmatic respiration. Besides, in all the
affections of the glottis, the jx^tient readily points
to it as the seat of his sufTerines. The patient
also betrays much more alarm of impending suf-
focation ; whereas in asthma he is seldom appre-
hensive of the result, however severe tha attack
may be.

50. B. Severe cases of acute hnmckitk, owing to
the viscid and copious expectoration accumulated
in the bronchi and traeb€«, and to the spasm ex-
cited in these parts and in the glottis during its
expulsion, are oflen aecompanwd with ^ of

160

AUSCULTATION — or toe Heart.

24. c. Pectoriloquy, — The existence, in disease,
of vocal resonance in any part of the clieat, to
the extent of laryngophony, has been termed
pectaritoquy by Laennec. It may be either tin-
perfect or perfect. It is the result of a morbid
cavity, formed in the substance of the lungs, and
communicating with the bronchi ; to which cavity
the sound of the voice, or vibrations of the air in
the tubes, is propagated. When the stethoscope
is applied to a part of the chest, under which one
of these cavities is situated, the words which the
patient utters seem to proceed from that spot;
and hence the term pectoriloquy, " The distinction
between perfect and imperfect pectoriloquy is, as
in the case of natural resonance, whether the
voice seems to traverse the tube, or remain at the
end; and the physical difference producing the
two modifications consists in the size and situa-
tion of the cavity. The most perfect pectoriloquy
is produced in cavities of moderate size, which arc
situated near the surface of the lung, and freely
communicate with a large bronchial tube. If the
cavity be deep-seated, or if its communication with
the bronchi be imperfect, the resonance of the voice
will not amount to perfect pectoriloquy. True pec-
toriloquy produced by a cavity, is generally abruptly
drcumncnbed, so that its limits can be dwtinctly
traced." — (WiLLiAMs'i Rational Expotilion, Sre,
p. 43.). Andral appears to be correct in con-
sidering perfect pectoriloquy as not common, and
that the imperfect state of this sound, or broncho-
phony, is very frequently mistaken for it. When
present in any part of the chest where there is
naturally no bronchial resonance, it may be con-
sidered as a certain indication of the existence of
% morbid cavity, generally tubercular; and when
heard in situations of natural bronchial resonance,
although more doubtful, yet if it be perfect, dis-
tinctly circumscribed, and heard on one side
only, the same conclusion must be come to. It
may be further added, that an empty state of the
cavity, its rounded and regular shape, and natural
sharpness of the voice, particularly in women and
children, tend to render pectoriloquy perfect.

26. III. Auscultation op the Heart. — A,
In itt healthy state, I have always viewed Lakn-
KEc's explanation of the sounds proceeding from
the heart*s contractions as the most defective
£art of the exposition of his system ; and a similar
opinion seems to have been entertained by Mr.
Turner, Dr. Williams, and several others. The
observations of Mr. Turner, and of Drs. Stokes
and CoRHiG AN, first shook the stability of the views
of Laennec on this subject; and the recently
published researches of Dr. Hope have almost
altogether overthrown them. As I cooMder the
exposition of the actions and sounds of the heart,
given in Dr. Hope's work, to be the most accu-
rate, I shall follow it on this occasion.

26. 1st. Of the Contractiotii of the Heart in the
order of their occurrence, 6(c. — The first motion
of the heart following the interval of repose, is
the systole of the auncle. It is a very brief and
slight contractile movement, most considerable in
the auricular appendix, and propagated toward
the ventricle, in the systole of which it termin-
ates, by a nearly continuous action. The sys-
tole of the ventncle commences suddenly, and
diminishes considerably the volume of the organ.
" Sj^nchronous with the systole are the first sound,
the impulse of the apex against the ribs, and the

pulse of the vessels near the heart ;" the pulae at
the radial arteries following at a barely appre-
ciable interval. The diastole of the veotncles
follows their systole; and these compartments
return, by an instantaneous expansive movement,
to the same state as during the previous interval
of repose. I'he diastole is accompanied with the
second sound, with a rush of blood from the au-
ricle, by a contractile motion of this cavity most
observable at its sinus, and by a retrocessioo of
the apex of the heart from the ribs. ** Next
succeeds the interval of repose, during which the
ventricles remain at rest in a state of fulness,
though not of distension, through the whole
period intervening between the second and the
first sounds; but the auricle remains at rest
during the firbt portion only of that period, the
remainder being occupied by its next contraction,
with which recommences the series of actions
described.^ — (Hope on the Dis, of the Heart,
Sfe,p,AO,)

27. The rhythm of the heart, or the duration
of the several parts of this Ncriea of actions, con-
stituting what may be called a beat, is the same
as described bv Laennec : — 1st, The ventricular
systole occupies half the time of a whole beat ;
2d, I1ie ventricular dia«tole occupies a fourth, or
at most a third ; 3d, The interval of ventricular
repose occupies a fourth, or rather leas, during
the latter half of which the auricular systole
takes place.

28. 2d. Causet and mechanitm of thetnotion, —
The auricles, being always in a state of fulness,
arrive, during the first half of the period of repose
of the ventricles, at a state of distension, on
which they react and propel a small additional
quantity of blood into the full but not yet dis-
tended ventricles, in order to bring them to thia
state, and to cause them to react, and thus expel
a greater or less portion of their contents. Dunng
the expulsion of the contents of the ventricles,
Dr. Hope considers that the apex of the heart
is tilted upwards and forwards, and occasions the
impulse against the ribs, in consequence of the
retraction of the ventricles upon their base, and
on the auricles, which, being in a state of ex-
treme distension, serve as a fulcrum beneath
them. The diattole of the ventricles appears to
be occasioned, l&t, by the relaxation of the prin-
cipal part of their muscular structure, assisted by
an elastic property ; 2d, by the distension of the
auricles, which has arrived at its height, and
brings into action certain layers of ventricular
fibres having a powerful influence in distending
these cavities ; 3d, by the width of the auriculo-
ventricular opening, which allows the blood to
rush instantaneously, and with facility, from the
auricles into the ventricles. The blood expelled
from the former cavities into the latter being in-
stantly replaced from the ven« cavs, distensioa
of the auricles immediately recurs, and the same
series of actions is continued.

29. 3d. Causet cf the sound*, — There can be
no doubt that Uie sounds of the heart's actions
are not produced by the mere contraction of its
muscular structure. To what other cause can
we impute them 1 I conceive that they can only
be referred to the action of the parietes of the
cavities on the fluid circulating through them,
and to the motions of this fluid. According to
this view, which has been very diligently investi-

BLOOD — Excess or — PtETnoRA.

169

13. DEThr. Greater fulneu of the vascular
9^stem than m eompatibU with the continuance of
hmlth ; or repletion of thii vyttem.

14. The unportaace of attending to the vary>
iog states of the circulating system, in respect of
boch cm&enifice and deficvenof of the fluid coo-
tained in it, has been acknowledged since the
^e of Galen. After the doctrine of nervous
iofloence had superseded the humoral pathology,
the state of the blood in disease experienced a
noie eenerml neglect, than the part actually per-
ibnned by this fluid in the causation and perpe-
tuation of morbid actions ought to have procured
for it« Yet have there always been a succession
of able observers and writers, who have never lost
s%bt of tbc influence of the quantity as well as
^uaHtif of the blood in producing, as well as in
iiodifyiog, disease ; and more recently the subject
has deservedly received an increased and an in-
cmsiog attention. Plethora is the opposite of
anemia : both may be, to a certain extent, com-
pstihle with health ; but both predispose more or
ie« to disorder, and, beyond certain limits, con-
ftitote distinct and opposite states of disease.

15. i. General Plethora. — A, States of , —
Galen, Baillou, Fxrkel, Riviere, and others,
conadensd plethora to be of two kinds ; to which
Mbteqaent writers added two more. As these
t&boctions are still, in several respects, founded
ia trath, notwithstanding the neglect into which
they had bog fallen, I will here briefly notice
thsm. 1st, True or absolute plethora — plethora
ed vnm ; 2d, Apparent, or false plethora — pie-
tkera ad tolumen ; 3d, Plethora relative to space
^pktkera ad spatium ; 4th, Plethora in relation
to vital power — plethora ad vires. It will be ob-
serred that the fint and second of these, the spe-
cies recognised by the earliest writers, are still
npon the whole the most important. In the first,
the blood is permanently increased bevond the
wants of the system. In the second, plethora is
merely a paasine occurrence, arising from tempo-
nry caQ«s, as the general turgescence occasioned
by sodden or high ranges of temperature, &c. In
the third, the blood may not be increased, but its
relative quantity may be too great, as is observed
•fter amputationa of one or two limbs. In the

fourth, tne quantity may not be too great, if this
fluid were actuated by a healthy state of the vital
energy : but it may be excessive in respect of the
influence by which it is circulated in all parts of
the body. Now, those distinctions are actually
ioQoded in nature ; and although they may all be
resolved into one pathological proposition, viz.
greater repletion of the vascular system than the
vant) and conditions of the economy xequtre, still
they must have become matteia of experience to
every one whose range of ob<iiervation has been
tuch as entitle his opinions to respect. I shall
merely remark upon such of them as admit of
dispute.

16. False plethora is very generally observed
to occur in persons suddenly exposed to elevations
of temperature, and depends more upon the eflect
of heat in exciting the vital turgescence of the
eapillary vessels, whereby a craving for fluid is
created, and a larger quantity is abeorbed, than
upon the expansion of the fluids themselves,
owiflg to the increase of temperature. A state of
f»lse plethora is very frequently occasioned , — and
is Kmta produotive of more serious consequences

than have generally been imputed to it, — by in<*
gurgitation and increased temperature conjoined ;
and it should not be overlooked, that these com*
bined influences not infrequently affect those who
are already permanently plethoric. This will be
more forcibly and truly shown by what must
have fallen under the observation of many. A
red faced, full veined, and robust looking person,
of from forty to sixty, sits down to dinner with a
good appetite. He eats three times as much as
his body reouires, and he excites the stomach to*
digest it by arinking stimulating fluids to six tiroes
the quantity that is necessary. All this, moreover,
is done in a close and overheated apartment. The
vital turgescence and expansibility of the capil-
laries and veins are excited to the utmost; the
whole surface is full and plump, and the ex*
tremities even swollen. Now, a person thus
circumstanced, particularly from four to eight or
more hours after such ingurgitation, actually has
the quantity of his circulating fluids increased
from one sixth to one third, at a moderate calcu-
lation: but the increase is generally soon di-
minished by the pulmonary exhalation ; the
urinary, the perspiratory, and intestinal secretions ;
which are all greatly augmented, and are thus
the safety valves of the circulation. But how
often, notwithstanding, do we observe the vessels
at last yield before Uie mass which distends or
overloads them, and apoplexy, and various other
hsroorrhages and congestions, i-esult ; particularly
when any one of these safety valves are obstruct-
ed or tardy in their action — when the nervous
or vital influence is either depressed or much
exhausted \m the previous excitement, and the
vessels are irritated, or their actions otherwise
changed by the state of their contents.

17. That plethora is a not infreouent result
of amputations cannot be disputed, although the
privation of suflicient exercira, which is thereby
occasioned, will partly account for the occur*
rence ; at the same time we generally observe
that the same quantity of food is taken, and the
same quantity of blood is prepared for the body,
when deprivMl of one fourtn part of the structures
reqjutnng support, as was provided for its nourish-
ment when It was in a state of inte|;rity.

18. That plethora may exist m conjunction
with deficient vital or nervous power, and that,
although the quantify of blood in the system may
not exceed that of health, and yet be too great
for this power to control, cannot be doubted.
We are constantly observing such pathological
conditions, both at the commencement and in the
progress of disease ; and frequently remark their
mfluence in its advanced states and terminations.
(See article Congestion.)

1 9. B. The causes of plethora are so manifest as
scarcely to require enumeration. They may ope-
rate either singly or in conjunction. They con-
sist, 1st, Of the introduction into the vascular
system of a greater quantity of the nutritious
elements than is necessary to the support of the
organisation ; and, 2d, Of the retention in the
blood of those parts which are usually removed
by the secreting and excreting organs. It must
be evident that the former is owing to excess of
nourishment and stimulating fluids; whilst the
latter proceeds most commonly from insufiicient
exercise, suppressed natural secretions and ex-
cretions, or accustomed morbid di^harges. How

MLOOD^ Effects of LAncm Loss or. 177

pa^ec:: npully into a state of letharey and coma, ' borne, although seemingly indicated, and although

mhifh on ouin^rou^ occasions I have seen mis- the ciuantit^' of blood in the frame be not lessened.

tik: u ioT <.'ffu«ion of serum within the cranium. In illustration of the former of these, 1 may state
o: '

CLi '

i« fodsJ. or the ctfu«iun in to an extent insulfi- who had complained of an acute and painful

ii-.s; to Lccouut I'ur the romatow symptoms. disease, obviously functional, for which he had

r»* rndt-r more favourable circumstancos the been blooded only twice on successive days, and

r,ci '.-.m i« £:r.)duaily followed by returning health, on neither occasion to above thirty ounces ; and

•r ii-^jMti into a state of chronic exhaustion or as- yet the symptoms of excessive loss of blood ap-

'.jf-nii. which Is variou«ily characterised. In some peared, from which he died in twenty-four hours

•ja.x3 :t i^ attended by somnolency, alternating after the second depletion. The most careful

•' I . 1 I" * c • .i_ 1 /•* rj •• III.. ••

1&: u i«>r onu^ion oi serum wittnn the cranium, in illustration of the former of these, 1 may state

^>: !.yir\icepbalu^, particularly when it has been that many years ago I had an opportunity of re-

pf'<»iitd by convuUionr>, as in often the case in marking minutely the ap}>enrances on dissection

cL;'.irci. In many ^uch ca-<es, either no effusion of a man of middle age, and somewhat fat.

tbr ai^lc'inen : in several, by pule, emaciated, vascular than usual. That in various diseases,

ur 'ii-icolourtrd countenance and skin ; amaurosis, unattended by diminution of the circulating

rtrrouf tremors, or jactitation ; delirium, or fluid, depletion will produce marked symptoms of

ciaia : and in puerperal females by a form of depression and sinking, owing to the state of the

aaaia which iiequircs to be carefully distinguished, vital power being insufficient to accommodate the

c&d which i» particularly noticed under the vessels, by their tonic or vital contraction, to the

arthrle on Puerperal Mania. In addition to these reduced bulk of the blood, is well known,

fusct:onal dii«rders following reaction aflter large and has been fully discussed in the articles on

Ic-9'>4»5 of blood, organic changes may supervene ; Adynamic Fevers, Erysipelas^ and Puerperal

"^ith a«: eifu<^iun of serum and extravasation of Fevers ; in which, as well as in puerperal mania,

l>;ood upon the brain, effusion into the bronchi and various other acute diseases, large vascular

itA air-celU. dropsical eflf^iisions in various part:*, depletion is often most injurious.

iL-.!! ^ulent dkitA'nsioo of the stomach and bowels. 63. A, Of excessive ioM of blood in diseases of

\\ U:& recovery takes place, the puUe always con- eicilement. — The morbid effects of lai^ deple-

Utiles sm«Lll and frequent for a long time, owing tions will necessarily vary with the nature of the

lo the RBtrkable diminution of the fluid in the disease in which they are employed. When

vt««k carried too far, in cases of excitement, where the

61. C. Of the itisiditms effects produced by nervous or vital power is not depressed, and the

tiKtii tut fjten repeated losses of blood, — Loss of blood itself rich or healthy, reaction genertUy

lilood occurring in this manner produces effects : follows each large depiction, and thus often ez«

«h&ercat from thoj^e now described. They gene- | acerbates or brings back the disease for which it

nliy a« may be expected, advance slowly, and : was employed, and which had been relieved by

often ext^t cither altogether, or a long time, with- • the primary effects of the evacuation. This is

•'•at (kti'Ction. They are extremely various, ac- ' more remarkably the case in acute inflammations

c9rJiag to the age and constitution of the person, of internal viscera, particularly of the brain or its

Titey mo^t frequently o<x»asion a pale, leuco- membranes. Thus, every observing practitioner

ptiir'imalic.ai.d lax ap{iearanceoftliecountenanre must often have noticefl, that a lari;e depletion,

ioil surface ; a very c^uick, weak, and irritable when carried to deliquium, will have entirely re-

pa!<i< ; hurTic-<l, and' oppressed respiration ; fre- moved the symptoms of acute inflammation when

i\>nx palpitations, ana sense of sinking ; borbo- the patient has recovered consciousness ; and that

;)::aii, zind hysterical symptoms; flatulent dis- he expresses the utmost nlief. Hut it generally

liifeion of the colon, and colicky pains ; swellings happens that the inordinate depression — the

ri the ankles, and dropsical effusions in other ! very full syncope that is thought essential to the

part*: in female^, difficult and scanty menstru- securing of advantage from the depletion -^ is fol-

vion. chhiro-ls, deviations of the .spinal column, lowed by an equally excessive de«jree of vascular

eprlrpiic convul-iuns, pains in the loins, and reaction, with which all the symptoms of inflam-

XiTioii anomalous affections of a painful or mation return; and the general reaction is ascribed

spwrioJic kind ; tremors and irregular action of entirely, but erroneously, to the return of the in-

B.ircle*; chorea; paralysis; dysjieptic di<«orders, flammation, instead of the latter being imputetl to

*a!i irR';rularity of the btiwels; a dispo->ition to the former, which has rekindlc<l or exasperated

*}t:ro>.; an:auri>is; and all the symptoms of it, when beginning to subside. The consecjuenco

«!karniu, which indtred is the primary or real state is, that another very large depletion is again pre-

ot diMAM: proflured, and constitutes the chief scribed for its removal -. and the patient, recollect-

i'ninge detected ujM)n examination after death ; ing the relief it temporarily afforded him, readily

tfi^»iher with serous effusion in some situations, consents. Blood is taken to full syncope — again

-tjiiipile bloodless stite of the viscera, and of relief is felt — again reaction returns — and again

tlie iieart i!<elf. the local symptoms are reproduced : and thus,

62. ii. Of kxce5*ive I.o»s of Dlooo in the large depletion, full syncope, reaction, and the

foLR-t or VARIOUS uiSEAsi*. — Tlierc are two | supervention on the original malady of some or all

iaportaiu ranstderations which should not be over- of the phenomena described alwve as the conse-

iOukt*! in piactice ; vlx. that in many diseases, quence of excessive loss of blood, are brought

tppartDtly attended with excitement, we shall , before the practitioner, and he is astonished at

O'-ei Hith cajses in which the actual quantity of ■ the obstinacy, cour«e, and termination of the

UochI It the body is much less than usual ; and I di-^ease; which, under such circumstances, gen#»

iQ %ariou5 otheis, blood-leiting will often not be • rally ends in dropsical efl'u&ion in the cavity I

V'-.L. I, N

BLOOD— 'iTi MoBBio Relations.

187

^h, The passage into the blood of morbid matten
fanned in the Mine body that is the seat of disease.

111. A, Of viiiatioa of iht btood by the fiuidi
vktck form tl.— -The nuids which supply the
waste of the blood are not infrequently vitiated,
aod thereby change the state of the circulatiog
mass. The chief sources of this vitiation are
bBrtlol or unwholesome inoesta. Many articles,
even of food, will be hurtnil when too long con-
tioiied. The injurious effects of salt provisions on
the blood, when exclusively employed, and par-
ticiilariy if depressing causes cooperate with this
diet, are evident, and are fully illustrated in the
article oo Scurvy. The influence of diseased
r)e, in first changing the condition of the blood,
ud ioduciog a state of chronic arteritis, terrain-
tUttg in gangrene of the extremities, is also well
known ; and the effects of^ diseased or putrid flesh
upon the system have been often noticed, aU
tfaoagfa not always correctly traced to the quarters
wbefe the principal changes are produced. M.
Bestin states that a number of negroes in Gua-
ddoype, having eaten the flesh of some animals
dead of an epizooty, were seixed with fever, and
nolent ileus, of which the greater number died :
tod Domerous cases are on record, where persons
AxA up in besieged towns, having partaken of
putiid animal matter, or of the flesh of animals
ttttt have died, have been seized with malignant
•tttcs of disease ; and the blood has been found
iiwl, dbsolved, blackish, grumous, ^c. upon ez-
snioilisa after death. In these, and numerous
floilir instances which, might be adduced, al-
ihoa^h the state of the blood has been alluded to
ia general terms, the information has been de-
ficient in precision, and has been furnished inci-
dcDtaliy^ the attention of the observer having been'
duccted toother quarters.

112. H. Mag EN DIE adduces in his Journal,
tbe instioee of a man, who, after a long use of
Tcgciables in which the oxalates abounded, un-
derwent the operation of lithotomy, and a large
oxalate of lime calculus was removed from him.
^Ve knoir that a large proportion of both 6ur mi-
neral and vegetable medicines operate by being
absorbed into the circulation (see art. Absorption,
&c.) ; and there is every reason to suppose that
various morbid or foreign matters may pass with
t|K chyle into the blood, and modify its condi-
tioQ. The excessive or long-continued use of
^^alies, or of alkaline salts with excess of base,
has the effeet of diminishing the cohesion and
tbe viKosity of tlie blood, and of preventing it
from coaeulating after it has been removed from
tbe vesscL ; and while these substances thus, as
it were, dissolve, or attenuate this fluid, they -also
diminish the vital cohefrion and tonic contractility
^ the extreme vessels, and of the tissues, and cre-
ate a dtsposiiion to extravasation of blood in tlie
parenchyma of the organs, and to exudation of it
from the mucous surfaces. On the other hand,
the acids — particularly the mineral acids — tur-
pentine, the acetate of lead, and all the salts,
— especially those with excess of acid ^ have
the effect of increasing the healthy erasis of the
blood, and of prodocmg an opposite change to
th^t now stated. When used in excess, however,
or iojacted into the veins, they have been con-
^'Ittxively shown to give rise to fibrinous concre-

it grumous, and unfitted for circulation through
the minute capillary vessels, particularly those of
the lungs. The influence ot salted provisions,
long and exclusively employed, in which the
soda is generally in excess, in attenuating the
blood, in preventing its coagulation when removed
from the vessels, and in relaxing the soft solids ;
and the effect of acids in removing these morbid
states, are well illustrated by the nature, progress,
treatment, and prophylaxis of scurvy.

113. That the nature of the food materially
affects the state of the blood is further shown by
the general character of the diseases most pre*
valent in various communities, living chiefly on
certain kinds of aliment. The inhabitants of se-
veral places in the north of Europe, who live
principally on Juh, a large proportion of which is
usually kept until it has become remarkably stale,
or even amrooniacal, from incipient decomposition,
who seldom partake of flesh meat unless in a simi-
lar state of change, and who dry or smoke both
these kinds of food, instead of siting them, are
generally subject to diseases which arise from^ or
are connected with, an impure state, or weak
cohesion, of the circulating fluid. It should not,
however, be overlooked, that the more complete
changes which respiration effects on the blood in
cold cliipates, and the active exercise of the func-
tions of depuration, under the influence of the
vital energies, serve to counteract the morbid al-
terations which this cause would induce. Yet
still the prevalence of disorder in these eliminating
organs, particularly the mucous and cutaneous
surfaces, which preserve the purity of the blood ;
and the marked disposition, which all febrile dis-
eases evince, in persons thus circumstanced, to-
wards vitiation of the circulating fluid ; and the
consequently low or adynamic symptoms which
characterise .their progress and termination ; are
sufficient indications of a change in tlie consti-
tution of this fluid. It is worthy of notice,' that
communities which live in the manner now al-
luded to, generally employ remarkably acid be-
verages, usually consisting of the fermented whey
of butter-milk, and a fermented farinaceous in-
fusion. I believe that nothing could be used aa
common drink better calculated than these to coun-
teract the ill effects of their diet on the blood. Be-
sides the acid existing in these beverages, they also
contain much carbonic acid sas,which likewise con-
tributes to their wholesome influence on the blood.

114. The effects of living upon much fresh
animal food, in increasing the quantity of fibrine,
in rendering the blood rich and abundant, and in
disposing to inflammatory diseases, are too well
known in all their relations to require illustration.
But when we consider the influence of various
kinds of aliments in roodifyioe the state of the
blood, we ought never to overlook that, as its or-
ganisation and vital manifestations commence
with the chyle, and depend upon the vital con-
dition of the vessels and tissues, and upon the
perfect discbarge of all the functions which con-
tribute to its formation and purification, the extent
of mischief produced by unwholesome food will
be commensurate with the deficiency of vital en-
ergy, and the imperfection of the various or-
ganic functions. A person of a robust consti-
tution, breathing a pure air, and assisting the

liuQs in'the vessels, to coagulate the albumen of < eliminating functions by regular exercise, will
the blood, to darken its colour, and thus to render | suffer much less, than the detnlitated, the indolent.

BLUE DISEASE — Pathology of.

199

tioD. At the same time many of the substances
mentioned above may be employed as beverages,
coodimenti, or preventives ; more particularly the
nedicinefl formerly denominated antiscorbutics,
the citric acid, lemons, lemon-juice with sugar ;
vio^r in which the warm spices, as capsicums,
b«?e been iofosed ; the chlondes, campnor, qui-
DJoe, &c. As it has been satisfactorily shown
that great excitement and acceleration of the
cimilation, bendes exhausting nervous and vital
power, have also the effect of changing, and even
of corruptiog, the state of the blood, such excite-
ment should be prevented, and allayed when
present, bj appropriate evacuations, and by refri-
gerant salme medicines and beverages.

BiBUoa AKD Rbfbe.— J4»cra/K«, De Sanguine ex.
Veni Mitto Judicium. 4to. Prag. 16ia— Al HqfiHonn, De

SaDgume,et cgiu Ot»ervatione 4Ca Altd. 1660 A Baule,

Aoatom. OtMenr. on Milk found in Veins inctead of

Hood, PtiU. Tram. 1655, pa 100. 139. ; and Natural Hit.

tonroT the Human Blood, 8va Lond. 1684. ~ Oncrfen,

EsperimeoU on the Blood,, by injecting various Sub.

(tanccf into tiie Veint, Pbiloc Trans, vol xxvii. p. 485.

>*kmmiimg mt important faeU.)^ AMmust De PraviUte

Saagttinliw 4ta Franc. 168a — De Sandris, De Natural!

tt Pnetematurali Sanguinis Statu, 4ta Bon. 1696.—

ituiMw, De Sanguinis Pravitatc. 4ta UltraJ. 17QS. —

SftacftiRk De Mortns ex Cnwi Sanguinis Alterato oriundis.

Uai^ 1706. ~^. HqffmanHf De Judicio ex Sanguine

per VcDcsectiooem emis«o. Halap, 1727. — Piiend,

EmtDenalogia, Opera Omnia, p. \30. fol. Lond. 1733.

[Cmtaiuu mmmber <^ important fJtpertmentt.) — Schuri'

fiai, Hcfliatologia Historico.Mcdica.4to. Dresd. 1741.—

Sekmneke, H»matologia, sive Sang. Hist 4to. HagsJ743.

-Niootai, De Spissitudine Sanguinis. 4to. Hale, 1749. —

Smkmr, Dc uimia Sanguinis Fluidiute, et Morb. inde

onoadiilta. Halsr. 1749. — Meyer, De Signis ex Sang.

KrTawot. petend. Hals, lISS.^HaUer, ElemenU
jaoksim^ 4ta voL ii. p. 17. et »tq. {A eoUetion of tau
m/nm facta, with important new observations.) — Hctn.
M^ Exptoixnent. loquirv into the Properties of toe Blood.
^ Load. ini. : and Philos. Trans. 1773, p. 503. — Bor-
^ Aoalne Med. du Sang. Paris, IT15. — MUman, in
1>ut. of Lond. Col. of Phys. vol. it p. 47a — Lindt On
Ji&ems of Hot OtmatesL 3d ed. 8vo. Lond. 1777. —
f^ri^. On Dtaeaaes of the Army, Ac 8vo. Lond. 1775 ~
Ay, Otaerrations on the Blood. Lond. 1719. ^Ferris,
I>e 8uiguinis per Corpus vivum CircuL Putredine. 8vo.
£dtiL ITMl — Gruner, De Pathologia Sangulnix Jen. 1791.
•^Dtfeiu, ct Parmentter, Memmre sur les Alterations du
Stng. Ma Paris, 1797 — Lentin, Beytriige, &c. b. iv.
P 1KL-S25.— Werlkiiff: Opern. p. 748. — J. Huniery On
thv Blood, Inflammation, &c. 4to. Lond. 1195.— Weits, On
(tie Coloar of the Blood, Pha Trans. 1797, p^ 41& —
^akt or the Diseases arising fh>m vicious Blood. Loud.
I^JU— Au/odt. Medico.Cbirurg. Trans, t. i. p. 47.—
Tkactrak^ On the Properties of the Blood, &c. 8va Lond.
ISlft . Wilson. Lectures on the Blood and Vascular Sys>
tno,8vo. Lond. 1819, pp. S4 50. —Autenreith, Physiologic
USSD.gfiS. 1054.— Ho(^ in Hitfeiand's Joum. der Pr.
HeUlL ix. b. 4bt. pL ^.^MichaeUs^ in Ibid. xir. In S st
h ^•^.Coplandt to Appendix, to M. liickerand't Elements
<^ I*hykiolog7, Sd edit. p. 636.— ArMowmur, Observations
*ur )e Sang. Paris, 18SS. 4to. — ^om^, in Philo& Trans,
for isas, p. 189. '-' Gendriny Recherches sur les Fi^vres,
Ice t ii PL ]45w ; et Traiie Anat des Inflam. t ii. p. 565,
t^^.~BeUimMeri. in Annali Universali di Med. Ap. I8S7.
—^ialCs, in Meeker* Archiv far Anat und Physiol,
IflSS, Na IT. p. 4IS7.'^ Trousseaux, in Archives G6n. de
MR t xiv. p. 328, — Leuret, Archives, &c: t. xi. p. 383.
-&fgahu,in Ibid, t xiL p. 103l — Ditpvy, in Ibid, t xiv.
p S%L .>. Aiyrr, Ibid, t XT. pi 13& — Gaspard, in Mafen-
dif't Joum. de Physiol. £xp«Mr. t. ii. p. 1., et t iv. p. I. —
Mefendie, in Ibid. L \\l — Jioekotix,m Nouv. Biblioth. de
Hed. Sep. et Not. 1823. — Diet, de M6d. t. xvi. p. S06. ; et
Joom. Hebdom. de Med. t. ii. p. SSO. — Bofsseau, Nosogra^
phie Orgaoique, t iiL p. 17a. — Velpeau. Recherches sur les
Alterations du Sang. 8vo. Paris, 18S6. — Christison, in
Eiitn. Med. and Surg. Joum. No. ciii. p. ?74. — SabtngtoHt
in Traoa. Med. Cbir. Soc. t xvi. — .&6ef. Anatomie Pa.
Uiologique &a t.L p. 308 — Amdral, Pathological Ana-
tomy, by T\nmsend and West, toL L p. 63S. — Piorry,
ProcM^ Op^ratoire, ttc, et Collection de M6rooirea sur
^boiofie, &c Paris 1(131. i sur U Circulation, p. 908.
J. Dasjft in Edin. Med. and Surg. Joum. toI. xxx. p. S49.

BLUE DISEASE. Svn. Cyanosit, (xv-wf,
Mae, and vas-^c, disease,) Beaumes. JVIoi-^s
CtTuie^i, Cyanapathia, Marc. Exangia Cy-

ania. Good. Cyanote, Fr. Die Blauiueht, Ger.

Biue Skin, Blue Jaundice,

Classxf. 3. Ctats, Sanguineous Function ;
4. Order, Cachexies {Good). IV. Class,
II. OuDEB (Author, see Preface),

1« Defxn. a blue violet, or jmrjUe colour of the
integumentSf particularly of parts mually pre*
tenting a rose or fieth tint, as the cheeh, lips, mu-
cous surfaces, Sfc.

2. A blue or purple colour of the integuments
of parts, or nearly the whole of the body, may
occur as a symptom in the last stage of various
acute diseases. But it is present from the begin*
ning of this affection, is frequently connected with
comparatively little disturbance until some sudden
change takes place, and generally results from
chronic organic lesion. In other maladies this
colour is an accidental, occasional, and not the
most important symptom ; in this affection it ap-
pears as the only, or the most remarkable, change
observed during life.

3. 1. Its Patiiology. — According to M. Giit»
TRAC, who has directed much attention to this
affection, it always proceeds from organic change
of the heart or laiige vessels ; the admixture of
venous with arterial blood, and the distribution of
it to the surfaces of the body, being the immediate
or essential cause of the alteration of colour. This
pathology agrees with the opinion of Senac and
MoRGAONi: it has, however, been disputed,
M. CoRvisART first threw out doubts of the con-
stant origin of cyanosis in this source ', and more
recently MM. Ferrub, Bresch£t,Marc, Louis,
FouQuxER, and Cramfton, have adduced facts
which seem to militate against it, while it has re-
ceived the able support of M. Bouillaud.

4. M. Ferrus contends, 1st, That cyanoais
sometimes has existed to an intense degree, and yet
upon post mortem examination no lesion could
be detected admitting of the admixture of venous
blood; nor any organic change of the heart or
respiratory organs : 2d, That the opening of
Botal may continue unclosed for many years
without blueness of the surface being occasioned:
and, 3di That the admixture and circulation
of venous with arterial blood have been demon*
strated to occur in some cases, without giving
rise to this peculiar appearance. That the second
and third objections are well founded seems al-
most incontrovertible. Numerous instances have
been recorded by Louis, and others, which fully
prove these facts«. I have met with cases in
children, where the communication between both
udes of the heart seemed very free, and yet no
alteration of the natural colour existed ; and others,
in which the change was evident during the pa-
roxysms of suffocation only. But I must agree
withCoRvisART, Richxrano,Clo«uet,Gintrac,
and BouiLLAVD, that the existence of this opening
is no certain proof of admixture of the venous and
arterial blood ; for if the contractile powers of
both ventricles are nearly equal, in relation to
the resistance to be overcome, and if the natural
0|>enings of the cavities be not obstructed, no ad-
mixture of the blood in both sides of the heart
could take place.

5. The principal force 5^f the objections, there*
fore, urged by M. FERiius, evidently rests upon
the fact of the non-existence of oi^nic disease of
the heart, large vessels, or lungs, in some cases
of the disease, — a fact which is still not satis*

04

942

BRAIN •— SorrsKiNO or trs •- Trxatvbmt.

delirium ; in the ncn-if^mmatory form of uft$n-
ing, the intellectual faculties are enfeebled, or
much weakened; the countenance is generally
pale,colourle«,or Bometimes even sunk ; whereas
m inflammatory goftening it is red, or more or less
injected, or even tumid.

220. B, Indirect tympUnnt,^^a, In this second
stage of the disease, the organic functions are
more or less affected : there is no appetite ; the
teeth and gums are dry, tiie tongue rough, brown,
blackish, chopped or traversed by small fissures ;
deglutition is difficult: sometimes there is vo-
miting, first of the ingesta, and afterwards of bile :
all the excretions are involuntary; frequently
there is constipation : respiration is laboured, and
at last stertorous; the pulse feeble, frequently
irregular or unequal, or even intermittent, and
the skin is cold. — 6. In inflammatory $(ftening
there is great thirst, redness of the tongue, sensi-
bility of the epigastrium and abdomen, hot skin,
a strong and frequent pulse, &c. (See § 170.)

221. The second period may be of longer or
shorter duration. The morbid phenomena often
continue stationary for a considerable period, and
then make rapid progress; at other times the
progress is slignt, but constant ; in some cases it
u constant and remarkable. This disease very
rarely retrogrades or evinces much amelioration ;
its progress is essentially continued and increas-
ing. The anatomicaL characters of softeninz have
been already fully described ($ 70, etseq.). It may
be stated in general, that when it is the result of
inflammatory action, as it most frequently is, Ist,
The colour of the softened part is, more or less,
deeper than natural, or of a rose tint ; 2d, It
contains a certain quantity of pus, sometimes
infiltrated through the softened tissue; and, 3d,
Febrile symptoms have existed previously to the
death of the patient.

222. ii. Trsatmxnt.— It is unnecessary to add
any thing to what has been already advanced
respecting the treatment of the inflammatory states
of softening, which are essentially the consequence
of partial cerebritis (see $ 191, «t geq,). When,
however, the disease does not present an inflam-
matory character, it becomes necessary not only
to enjoin abstinence from all debilitating means,
but from the commencement to appl;jr rubefa-
ments, to throw irritants into the great intestines
(see £nem. F. 141. 150.), and to have recourse
to tonics, aromatics, &c., of which the sulphates
of line, iron, or quinine, in small doses, with sul-
phuric acid, or the less heating astringent tonics
belonging to the vegetable kingdom, are the most
eligible ; preserving, at the same time a regular
slate of the alvine secretioos and evacuations,
and of the other digestive functions.

223. Regimen. — The gently tonic, chalybeate,
and aperient mineral waters are of service in the
Bon-inflanmiatoiy form of the disease ; whilst
those only which are aperient and deobstruent
sboaid be ventured upon in its inflammatory
states, when they may be tried and varied ; local
evacuations, revulsives, particularlv setons, issues,
he, being kept discharging at tne same time.
In both forms of the disease, gentle travelling,
abd change of air, and agreeable and quiet amuse-
ment, without undue mental excitement of any
kind* will be of much service. M. Rostan's in-
iunotions under this head may be summed up as
folfows:*-- Those alimentary and medicinal sub*

stances which exert a strong and speedy actios
on the encephalon, should oe strictly sbanofid.
Wine, spirits, coffee, and spices, are of this nuiS'
ber. Excess at the table is dangerous. The diet
should be mild and moderate, and the fiood easy
of digestion, but not too nutritious. The impres-
sion of cold air on the head may be ^vourable :
sudden passage into a heated place must be
avoided : the patient should inhabit a cool ntu-
ation. Whatever, by compressing the lioibs or
the organs contained in cavities, may fa%o«r
cerebral cougestion, roust be rigidly prosciibed.
Warm, as well as cold bathing sboula be inier-
dieted: tepid bathing alone mny be permitted,
although with much caution. Cold lotions to \it
head are advantageous in the inflammatory fsnn
of the disease, provided we do not permit resction
to be established ; at the same time pediluvia
containing mustard may be prescribed. The
ordinary excretions should be kept up ; but sexQ»l
indulgence, too violent exercise^ strong emotioDS,
lon^ study, and watching, should be carefailj
avoided. The age, strength, constitution, habits,
and state of the patient, and the character of the
symptoms, must modify these precepts.

BiBLioo. AND RBraB.*-t OisKASBs om VSMIiimtt

OP TBB BbaIN, &CL— L ALTXaATIONS OT THB Oua* MaTSA

— llaUftt Opera Minora, voL UL n. 863L — JbrdSac*. B«i.
trSge, Ix L pi 87. — OmerU in Edin. UwA. and Sarf.
Joum. No. 95. {Dwn mater mbaorbed mtd omML' —
(Hto, AiuU. Pathol, ftc. ; uid Bomthu, flcpukhitt
Anatom. voL I. p. 4L {Dwra mater tkiekemed to keif at
imek,) — Lieutand, Hitt Anatom. Med. voL ill hi.
oba. & 16. 7S. 16ft. { et Treamrt, Joum. de M6L t n
p. 189. ; and B. Brown^ Lond. Med. B«pot. edic by (>p*
/ofu/, vol. xvii. p. 108. [Dura mater dry, $kriarUei, ^r.'
"GendrtH, Hlttoire Anat dea Inflam. 8vo. Parte. IVA
iMetanoid deposit fVi dura mater.) — Lmdudg, Advtfnra
Med. Pract vol it p. 45Q. ; ct J. P. Frank, De CaraiuL
Horn. Moth. I Ti. p. 101. ; et Vorgtet, Handbuch, Ac.
Ix it pL a ( iVater between the boaee ami dmra mam m
hydropic children.) — Biermayer^ MuMum Anatoia. Pa.
tfiolM. Na 94.: et KtHan, Anat. Uotenochuns; &c
pL ISTT; and LoMein, CompCe rcnda tur lea lYavaux
Anatom. t L p. 66. {Layer* ofdara auUer anaratei kf
blood, eoagtUa, and put^ <— Stamley, Med. Oiinirg. ia^
ciety'* Trans. toL iii. p. si. {l>mra mater bmrU dermg
coughing tevem months after trepanning.) — Bodhofr, I>g
Oaiflcaiione Dure MaUia^itc. 4Ca Hala^ 176«^*r««n,
Catuf aliquot OMtflcat fa Membr. Ceretiri inveat Btm.
1825. — Loder, ObscrvaL Anatom. Tumot^ Srirrbon ia
Bail Cranii, Ac 4Ca Jena, 1779. >- l^mnger, De Fonfs
Dura Matria, Ac. Erf. lS01.->^. JL Oertei, Anat PttJioi.
de Ceret>ri et Heniogum TumorilNUt. Sia Bcr. I&^~
Otto.SeM. Beobachtungen, t ii. p. 861 Na a6.^Ia«A,Sbr
lei Tumeura Fongeuasi de la Dure Mdiv, la Mf m. (i*
r Acad, de Chirurg. t. r. p. 1. Paria, ITIk^Medbtt^ Hairf.
buch der Path. Anat bi IL S. p. 394. -^PatteUa, £&crcitAt.
Patholog. vol. I. pi 93—104.

ii. Altbrations or thb AaaciiNom aud Pia MiTn.

— Piorry, De I'lrritaUon £nc«pbalique dca Eoikn, Ac.
Paria, 182a. — Senn, Sur la Mtolngite Aigue dca EdAbi^
Ac. Paris. 1825. ^ Parent'DuehateM et MarHnrt, Sut
1 'Inflammation de 1' Ancbnold C6r6brale et Spiiiale, tte.
Paris, 1821. — Afylf. Sur Mcningitfa Chrooica, In Kkw.
MM, Fev. 1825.; Meningitis Acuta, Ibid 19ft. ^Gtm-
tirin. Hist Anat. dea Inflammat 8 1. Fkris, IStt. — To*
ehenm, Reeherches Anat PatboL aur U MM. Pnt t iiL
pi 4—36. — Barkhameen, Bcobacbtuogea Qbcr den SaiiAr*
wahnsiun, Oder das |DeUrium TretneniL Bmbb. US0.~
Portaif Coon d*Anat MMicale, t iv. & TIX — J^ifTMsa,
Anoo Clinico-Medioa Pama, 1823^ IKk «» Sd. Tkemp'
sout in Lood. Med. Repository, edit by Ondmad, Ncr.
1821— BSniMir, Engravtogt, Ac. fuc x.— Irnisf/, IV-
Penitiori Structun Cereliri, eaa L— ^if, la Tnm. of
ColL of PhjK voL ▼._& S34. (Sartk^ eontr^imt m p*
mater.) ^ Otto, Selt Beobachtungen. Ac, ct Vcnrirb.
niu, Ac paedm. -^Etanirol, in Diet dM Seicoces Ht^.
t viiL art Dhnenee. {Cyett contatntng Mmeinpta makr )

^^Aeprey, in Lond. Med. and Pbfs. Joum. {Bomnm^
cretiont on each tide.) — Sasse, Zdtacbrift f. AnUM|Mv
logic, 18^3. pi 11. 4lt^ Bmdach, Bcitragt, Ac. b. N.
TK lOT. 287. (ftpdatidt, ^)^£arle, in Med. Chirarr.
Transw vol. xiii. So. I& — Hmbtt. Morbid Aaat sf tlit
Human Brain. 4to. London, 1828w — Abercrombirt On tba
Brain, Ac Kalh. I8fi& — Mimro, Morbid Aaatoayef (»f
Brtin in Hjdncephsltts» Ac fidin. iSMf^-Mr^gbt, Mc*>

BRONCHI— • Inflammation of tbs — Biaonosis*

265

small mi6t ; in othen, an opposite disposition is
remarked. OecasioDally the redness only exists
iaiotervals, in the form of bands or of isolated
spots, fonning, as it were, as many circumscribed
pblegmaaic, between which the mucons coat is
viiite and healthy.

56. fi. When the inflammation is chronic, the
mucons membrane generally loses its lively red-
ness : it presents & livid, violet-coloured, or brown<
ishtioL Finally, and what is very remarkable,
in individuals offeriog all the symptoms of inve-
teste chronic bronchitis, with puriform expec-
tofitioD, the mucous membrane of the lungs has
beea found scarcelj^ rose-coloured, and even per-
&ctly pale through its whole extent, Bayle and
AsMAL have particularly noticed this fact. I
vouU not wisb to conclude that there is not, and
kait of all, that there has not been, inflammation
in these cases ; but I think a very copious secre-
tioa will often take place from mucous surfaces,
sad usnme even a purulent appearance during its
KtotioQ in the bronchi, from lost tone of the
citreae capillary vessels, with, perhaps, an in-
crmed flOx or determination of the circulating
fldid in Older to supply the discharge, all vascu-
^nty disappearing with the cessation of circula-
^ The other changes observed on post mor-
tem iflspeetioD, jparticularly in the more chronic
Astes of bronchitis, consist chiefly of thickening,
><^iB|, ulceration, &c. of tlie mucous mem-
bnae, dilatation of the bronchi, &c. (See $ 7,

«>7. v.DiAOvosie^-^The characters of the cmigk,
ittl of the tputa, and the physical signs, are our
ekief guides in the diagnosis of bronchitis. The
^u>taiy I have given of the disease will be gene-
nliy suKcieat to enable even the inexperienced
to recognise it : but it will often be necessary to
vrive at more precise and certain information as
to the extent of lesion, and its existence either in
tnaple or in a complicated form.

6S. A, Of the acute, — a. Bjf auicultatwn, —In
iW fint iuge of the disease, the inflammation
uoiei tumefaction of the mucous bronchial sur-
^ce, and consequent diminution of the calibre of
titt tabes. This aitate occasions a modification of
^ respiratory sound in them : and, hence, either
m'tk the unaided ear, or with tlie stethoscope, we
l|or at first the " dry hnmchial rhonchu* ;" con-
iMing chiefly of a sibilous or whistling sound ;
KcasiooaUy with a deeper tone, resembling the
iMtt of % violoncello, or the cooine of a pigeon,
pftfticalarly when the large bronchi are affected.
I'beie sounds (see Auscultation, $ 14.), deoo*
Biaaied the sifriloiis and mnotpus rhmichi, are pre-
heat chiefly in the early stage, and beforo exjpec-
tontioB takes place ; and prove the accuracy or the
ntional inCereaceof Dr.BADHAM,thatthedifiioult
^""t^thiag of this period is owing to the state of
^ Bacons membrane ; and I would add, of its
NbHBQcoua cellular tissue also. To these sounds
* sddtd the muc9u» vhonchtu ; and in propor-
^ w the bronchial secrolioo, to which it is
owuig, aagaents, this sound becomes predomi-
**^ When the inflammation is seated in the
J^^Sa tabes, the bubbles of mucous rhonchus are
Isige snd aseveu; and the respiration may be
<|iU heard over the chest. But when the mucous

I • !lll*j* ^» ■°*^ "• **•■"* constantly, it may
iJfJ^Bned that the small bronchi aro invaded,
when this is the casein a aevcie degree, there is

also slightly diminished resonance of the chiefly
affected part upon percussion. As the disease
proceeds, and the secretion passes into an opaque
and thickened state, the mucous rhonchus becomes
interrupted, sometimes with obstruction of the
respiratory sound in a portion of the lungs, and
passes into a sibilant or clicking sound. These
changes arise from the entire or partial obstruc-
tion of one or more tubes by the thickened mucus,
and are generally of temporary continuance :
occurring now in one part of the chest, and dis-
appearing; and now in another. This state of
the bronchi fully explains the dyspnoea of this
stage.

59. 6. Rational diagnosis. — a. The cough in
branchitis is loose, diffused, and deep ; in pa-
roxysms, and attended with fever, often with
wheezing. In pertussis, it is in severe paroxysms,
unattended by fever or wheezmg ; is accompanied
with a distinct whoop ; and terminates in vomiting.
In croup it is sonorous, clanging, and harsh. In
laryngitis, it is suffocating, shrill, or grunting ;
and, on inspiration, attended with a drawing down
of the pomum Adami to the sternum, and retrac-
tion of the epigastrium and hypochondria. In
pneumonia, it is deep in the chest ; frequent and
short, often hard ; and gives a metallic sort of
noise. And, in pleuritis, it is short, dry, hard ;
sometimes slight, but always suppressed and pain-
ful.— B, The expectoration in bronchitis is abundant
after the second or third day, or even from the
first : in pertussis, it only follows the vomiting :
in pneumonia, it is mora rounded, distinct, thick-
ened, purulent, rusty, and intimately streaked
with blood : in pleuritis, croup, and laryngitis, it
is scanty, thin, frothy in the latter; sometimes
with shreds or pieces of lymph, and entirely dif-
ferent in appearance from that of bronchitis. —
y. Pain in bronchitis is scarcely complained of j
and consists merely of a sense of soreness, heat,
and tightness in the chest, particularly beneath
the sternum, and is not increased on full inspir-
ation : in pneumonia, it is more marked, especially
in certain parts of the chest, generally nearer the
lateral regions, and is increased on inspiration
or prolonged expiration: in pleuritis, it is very
acute, and a full inspiration is impossible : in
croup and laryngitis, the pain is increased upon
pressing the trachea and larynx. — ^. llie coun--
tenance in bronchitis is more frequently pallid or
bloated ; in pneumonia, it is generally flushed ; and
dyspnoea is greater in the former than in the latter.
The breathing is wheexing and hurried in acute
bronchitis ; in pneumonia it is less so, and gene-
rally without tne bronchial wheeze. The pulse,
in the former, is frequent, full, free, developed,
and soflj in the latter, full, hard, bounding or
vibrating, and sometimes oppressed and undeve-
loped. The general febrile symptoms are more
continued in pneumonia than in bronchitis ; morn-
ing remissions, with free perspiration, being more
frequent in the latter than in the former. Tho
physical sigtfs in pneumonia, pleuritis, &c.,are the
surest means of their diagnosis. (See art. Lungs
— Injiammation of.)

60. Some cases of asthenic bronchitis may be
mistaken for humoral asthma ; and occasionally
no very distinct line of demarcation can be drawn,
both affections either insensibly passing into each
other, or being complicated with one another.

' But, generally, the slow accession of the former.

362

BRONCHI —Cjikovic Ihflammattow op the -—Treatment.

inspiratory whoopi and vomitingi, not appearing
fur mme days subset |uently. In other cases — and
those, perhaps liie most numerous, — the infiani-
matury afTcction ha<^ not appeared until after thu
invasion of {lertuiisis. When tlius associated,
bronchitis may be cither sthenic or asthenic ; the
one or the other being more generally prevulent
in some seasons than in others. During the
years sjiecitiud iibovc (§ 83.), the asthenic

collecting, however, that the accumulative tnd
sinking effects of either digitalis or colcbicum
sometimes appear very rapidly, and in an alarming
degree, when they sre given either at the same
time or after the exhihilion of the potassio- tartrate
of antimony. Disease of the brain or its meml)ranes
su{)ervening in the course of bronchitis has been
considereil m the article Bhain (^ 166.).
90. Thesi'B-AcrTEFonM of bronchitis requires in

state was most common ; and I have feen several ' all respects the same treatment as the acute uncom-
cases in which sanguineous depletion had been ! plicated disease, but not carried so far; the activity
injudiciously practised, particularly as respects of the means should have due relation to the acute-
nuantity. Cerebral symptoms are apt to occur ! ne^s of the attack, and the effects they produce,
during this complication, and also infiltration or 91. 2d. OfChronicHbonchitis. — M.Broos-
hepatisation of a |>art of the substance of the sais hos very justly stated the indications of cure
lungs. These unfavourable terminations should | in chronic bronchitis to be, Ist, to diminish the
be anticipated and prevented by smRll local de- > general excitability, and to keep the circulation
pletions,— -by leechen applied behind the ears;
by the exhibition of camphor combined with ipe-
cacuanha or antimoni2il.<», and oarcoticn, particu-

quiet ; 2d. to solicit the excitement and the flaidi

to other organs, particularly towards the Am ;

and, to these I would add a 3d, namely, to re-

larly conium or hyo»cyaraus ; by diaplioretics store the healthy tone and functions of the bron-

with diuretics ; and more especially by tlie use of
the liniments and rcvulsnnts already recommended
(§ 79.). (See IIoopinx Corcn.)

87. /. The simultaneous occurrence of inflam-
matory action in both the digestive and respiratory
mucous surfaces is not infrequent, particularly in
children ; and means calculated to benefit the
one. genemlly aggravates the other, or risks the

chial surface, by means which seem to have this
effect either directly or indirectly. It is obvioiu,
however, that the accomplishment of the ffnt and
second intentions have an indirect influence in
bringing about the third.

92. a. General hUwtl -letting is inadmissible in
this state of the disease ; and even local bleedings

.^ ^ „^ _ ,_ _ should in many cases be employed with caution.

accession of ccrelind di!«ca(«. 1 have found \ (dipping, however, to a moderate extent, is very
small local depletions, followed by the pulv. ipc- \ frequently requiicd ; and it is evidently more ad*
cacuaidite comp., combined with small doses of j vnniap^us to reptHit the operation to a small
calomel, or liydrarL'. cum creta and raniplior ; j extent, than to abstract a large nuanrity at once,
the warm balh and jfrictions, with the stimulating j \Vhen the disease has existed long, and is at-
linimimts already specified (^79.); the npplieu- j tended with a copious discharge, much ^iieral
tiun of bliitei-s lor u f(;w hour.4 only, and otlv.u re- , debility, and absence of puin upon full inspiration,
peated ; the lii|. ammoni.13 ncet., with spirit, a^her. . even local depletion cannot be %'enturcd on. Next
nit., camphor mixture, diui-etics, &c., constitute in importance to depiction is nninter-irrifaftioii;

and for this purpose several means are presented
' to us. When tliere is a tendency to acute action,

the princijial means of cure.

88. ff. 'J'he n^vsociation of hfpntic disorder with
bronchitis is not rare. But the affection of the
biliary organs does not always precede the bron-
chial dinurase : it often oecui^ in its progress; an
increased, as well as a morbid, secretion of bile
supervening, probably in consequence of the vica-
rious inciciise of function of the liver, and its
irritation by, and elimination of, the morbid ele-
ments iiceumulateiJ in the blood owing to the
impelled function of the lungs. 'I'his complica-
tion requires the use of mercurial purges com-
bined %vith camphor and antimony, particularly
James's or kermes powder (F. fi37.); external
irritants and revulsnnt!;!, cathartic enemata ( F.
lol.), &c. A similar treatment is indicated when
the di:<ease is connected with the translation of
eiysipelus, «;out, or rheumatism.

H9. h. If the indamniation extend to the xuft-

or when the cough is at all painful, and the spu-
tum puriform, either the tartarised antimonial
ointment, or a large issue or seion in the side, if
preferable : bui when there is very marked relax-
ation of the bronchial mucous surfaces, blisters,
and rubefacients, or a succession of them, seem
more appropriate. I have, however, found, in a
number of case?*, tlic ihiimeutSf No. 296, 297.
311. in the Appendix, productive of much greater
advanta<;e, and more generally applicable, than
either blisters or the ointments. They may be
employed once or twice daily. The vapour arising
from tliem, and diff'using itself around, has also a
direct and l)enefieial effect, by being inhaled, upon
the diseased mucous membrane. M. Broussais it
very favourable to the use of tftous and Issues ; and
1 have seen ricveral instances of marked benefit

stance of the lungs or jtlfura, the antiphlogistic . from them, particularly in the obstinate state of
treatment should bo rigorously enforced : the so- ; the difsease which simulate^ tubercular phthisif.
lutionof the pota.s>io-tartrate of antimony ought to ' He also recommends warm cataplasms to the
be given in frt^^uentdoses, and carried as far as cir- 1 chest, made rubefacient by the addition of mus-
cunista nces will permit; internal and external revul- j tnrd. I have seen advantage produced by warm
santsresfOilciltoat the same lime; and diaphoretics \ bread and water poultices applied over blistered
and diuretics suited to individual rases prescribed. I surfaces, and the seals of i^^sues formed by the
In some instances, either colchicum or digitalis, or mezereon bark, and by the same kind of poufiices,
both, may bo substituted for the antimony; but ' to each of which one or two table-spoonsful of the
they answer belter, particularly the digimli'*. after I nitro-hydrochloric lotion (F. 834.) had licen
this medicine has previously been u.-ed. If we have i added. But it is chiefly early in the chronic disease,
reason to suppose that effmimt of serum has taken ! or when it has recently passed into this state from
place in the thoracic cavities, diuretics, and, j the acute, that issues and setons prove bucccmIuI.
vaongift otben, digitaUs, should be employed ; re- 1 They exhaust the energies of the lystem too

266 BRONCHI ^Dilatation of thb — Treatment.

the chlorate of potash, are required. If the child I the red Bourdeaui wines, or tlie wines of Bur«
be not very young, either of these latter may be gundy — the former generally reduoed by ooo
combined witii belladonna, or with conium, and | third or one half water ; or beer or ale, aln
given in lioueyor .syrup of s^juiiU; or with simple reduced, to which a little of the liquor potassa,
syrup, su>rar, powdered liquurice-rooi, or with the or of Brdndish's alkaline solution, has been added,
compound tra>j;acantli powder. ^Vhen the disease may also be tried nt meals ; and either of tbeie,
i!) associated with chronic irritation of the mucous ' or of the more cooling beverages, adopted, that
surface of tiie bowels, the chlorate of lime will be < may be found to agree best with the patient. If

of much service, and will .soon retitrain the latter
affection ; the use of the liniinents already recom-
mended (F. "296, 311.), in addition, generally con-
tributing to cure the bronchial disease. £itherof
these liniments has often been sufficient of itself
to remove all disorder, both in the consecutive
states, and in the different complications noticed
at this place ; and, when bronchitis seems to have
a tendency to terminate, or has actually termi-
nated, in cfTiision, they have powerfully assisted
the treatment. When, however, dropsies super-
vene, in addition to them, colchicum or dijritalis,
with astringent tonics ; siiuilU, with blue pill, ta-
raxacum, or extract of sar.?npni ilia; the prcpar-
atinos of iiHiine, alone or with narcotics ; bi-tar-
tnite of potash, with the bi-lH>rate of soda, parti-
cularly this last ; and various other diuretic and
deobsirucnt medicines in diflercnt forms of com-
bination — of which numerous examples arc given
in the Appendix — and the |;eucral plan of treat-
ment recommended in the article Dnorsv ; should
be employed.

103. C. The re<;hnentil fi-Aifmfnf of bronchitis
requires strict attention. — a. In the sthenic acute
disease it should be strictly antiphlogistic ; and, at
the conimencement of convalescence, a farina-

the disease evince a disposition to terminate la
dropsy, the imperial drink, with the addition of a
little l)t-borate of soda, or F. 590. 591., will be
most serviceable. In the advanced period of
chronic, or during convalescence from acute, brai-
chitis, the sulphureous mineral waters will oftea
be beneficial. Those of Harrowgate, Leamingtmi,
or Moffat, may be tried ; or of Knghein, BonoM,
Bareges, or Cautercts (Roche); ortheartifical
waters of Kras or Carlsbad.

105. e. Few diseases are more benefited thu
chronic bronchitis by change tf air, A ica-
dence on the southern coast, particularly at Toi^
quay, and in various other parts of Devonshiref
during the winter and spring montlis, ruardiiig
against vicissitudes of climate, — whicn, how>
ever, is mil Jer and lees variable in this part of
the island than any where else ; wearing nannd
next the skin, especially during winter andipriu;
gentle exercise on honieback, or the use of ua
swing ; and constant attention to the state of thi
bowcU ; are severally of great importance. Dnriag
the progress of convalescence, as well as in the
earlier stages of disease, particularly if the secre-
tion from the bronchi continue, it will be neea-
sary to resort occasionally to an emetic ; and ia

ceous diet adopted, until out-of-duor exercise may a day or two subsequently, notwithstanding tha

Ik) taken, orsliorlly betore. In the mlhenic utatcs
of acute bronchitis, ihi' regimen i<« cliiefly nppli-

bowels may be freely open, to an active cathartic.
In these cuse<(, the addition of a vegetable bitter

cable to the ooniinencemont of the disease: s^uh- or tonic to a purgative medicine, — as the sul-
sc'qiurntly, nouri-thnient in <inall (|iiautitie.<, suited, I phate of quinine to aloes, or the infusion or ex«
in kin'l :in(l fr((iin"ticy «»f paitakiri^ of it, to tin.' | trari of gentian to senna, — will have a decidedly
state of thu syni])tom(>, the powc.s of the digt^stivc I cathartic o})eration, witiiout lowering the eneif^
organs, and feelings of the patient, $:hould be ufthc frame. There are few diseases more bena-
peimitied ; and even animal food of a digestible fited, either in their progress or decline, than UuMa
nature, in moderate quantity, may in some cases, | now discussed, by active purging ; but it will
particularly in the aged, be permitted oneea day. | oflen be requisite to combine the purgatives widi
The decoction of Iceland mos<, jellies, mucilagi- ' ^ti!nuIuats or tonic.^, in order that an active or
nous and emollient soups; shell-fi.sh ; the different ! continued operation on the bowels may not ex*
kinds of white fish, diessed either with sweet oil I haust the patient. During convalescence, tha
or the oil obtained by boiling their fresh livers; j free use of purgatives requires a liberal andii^
the lighter kimis of animal food : and, in the ca :e j vigorating diet.

of infants, attention to the milk of the mother, or ; 106. V. Dii.atatiov of the BnoNCHl.^-
a healthy wet-nurse ; an* all occasionally of ser- 1 i. 'I'hc anatomical characters and physical lignt of
vice durin<; early convalescence from the acute this change of the bronchi have been already
forms of bronchitis, anil in tlie progress of the more ■ descrilied (5 If).). It is almost entirely a con-
febrile states of tiio chrnnic disease. In the more . sequence of, or an attendant upon, the more
asthenic cases of this latter, or when the exi)ec- | chronic cases of bronchitis, or of hooping-cough

done, and in looderatf' (|uantity ; new-laid raw out which, M. Louis, and other pathologisla, who
eggs; or a due piopoition of di>;e.stible and sti- have devoted much attention to pulmonary dit-
mulating food; will be found most serviceable. ' eases, have sometimes failed of aistinguishiog it
In nearly all the chronic stat(!s of the disease, from phthisis.

particularly in their advanced sUiges, a light nu- ' 107. ii. The Treatment of this alteration is nearly

tritious diet is necrs^ary. I the same as that which has been recommended in

104. /». The jraticnt's hcrcraf^e should receive . the more chronic states of bronchitis. The meim

particulai attention. Lemonade, imperial, barley- which are especially indicated consist of the inibala-

water, and the cooliiiir and aperieut drinks pre- j fiVm of balsamic and terebinthinate fumes ; of tho«

scribeil in the Appendix ( F. 588 — 5\).'>. 91(5.). j of crcn*ote, chlorine, iodine.&c. (^99. 100,); tha

i/hould ha vmphyvd in the sthenic form of the , internal use of balsams, tonics, and bitten, partiev-

Mcute disoaiQ, la the asthenic and cbrouic states, I \ar\y lU« «Ml^hates of quinine, or of liac, or ina ;

BRONCHIAL ftVX — DiAONons.

967

umI other praparalioQa of dnchoia or tteel ; with
the QM of the lioimenti alreody noticed (i 102.) ;
ot the ■itro-hjdrochloric acid lotion on tne chest.
The chlorate of polish, or of Hone, seems indicated
m this form of the diseise. An open state of the
towels, to occasional cathartic, nutritions diet,
aui chaage of air, are ako evidently required. In
uber respects, the treatment already detailed (i
M, ittiq.) may be followed ; or modified accora-
i^ to the peoDuarities of the case.

108. VI. UlCBBATtOK OF THB BaOMCRI

(4ee H 7, 8.) is another alteration which is pro-
dued by, or is attendant on the advanced stages
«f. chronic bronebitis ; roost frequently, however,
•Wd complicated with tubercular phthisis. It
B oot infitequently met with, particularly after
bmaehitis occasioned by the mecnanical irritation
of aioersl, vegetable, or animal molecules. The
eiisttnce of olceration, when seated in the bronchi,
i> Bfit indicated by any sign in addition to those
v'lieh Bceompany the most chronic states of bron-
I'lHis, or tubercular disease, when it arises from,
or is complicated with, this change. When affeet-
isg the Laeynx or Trachea (see these articles),
u niy frequently b« suspected, or occasionally
prr>9Qoflticated. In a case which occurred in the
t^lea, B prognoais to this eflbot was given by me
loQgb^ death.

^09. The TaEArmitT of this lesion, even

cMUineiistence be ascertained during life, can-

Qotbedifeent f^om that required in some other

tUttt of chronic bronchitis. That ulceration

Bij tike place in the bronchi, and heal, as

ntoced 1^ the appeavance of cicatrices, has been

i^^oftuosd by M.Laennec, and other patbolo-

^ Is tdditioo to the means of cure already

(ittcnbed, the establishment of local drains of

tW moit active kind is obviously required.

Blisters ud imies a,pplied to a distant part have

Bdt been found of use by M. Lasnkxc. He pre*

^<B the repeated application of small moxas as

i^ev the seat of diseaae as possible, and the pre-

Mrvitioa of absolute rest and silence. The in-

Ulation of emollient, anodyne and balsamic

vapours and fumes ma^ likewise be tried ; and,

if the dtseese be devoid of marked febrile ex*

riteme&t, the expectoration abundant, and the

po^rsof life oonsequentlv reduced, the treatment

ulvised for dilaUtion of the bronchi ($ 19.) may

\t employed in all its parts. (For the treatment

i>f other organic changes of the air*pa8sages, see

•rti. CaouF, Larynx, Jjwq* -^ H^tmorrkage

from, and TaACBXA.)

Vll. BaoKCBiAL Flux. — Bronckorrhaea (from

Bf»7^»f and /t«.) — 8yw. Broneharrkie

(Rocke); Catarrh» PUuiteus (Laennec) ;

MttCMM Flux.

Claisiv. 1. Class, III. Oaosn (Author).

110. Dam;. Ajius of watery mueu$, or^hUgm,
Jrm tktekai, wUh mart or lo$$ cough, but without
Jtttr ; frtfuintly oceatwning eihauttion*

111. This affection varies considerably. It is
^^ a variety of chronic bronchitis ; bemg con-
itcntive of it m persons advanced in life, or those
*^ s rsUued and phlegmatic or pituitous habit of
^y> In other eases it appears from the com*
aeocement, or conaecatively of slight catarrh, as
Intermediate between chronic bronohitis and
Umoral sAhma. This appellation may, upon
\\ut whole, therefore, be viewed as apphcable to
(^ esses whieh ait attended with a more

abundant, fluid, and transparent expectoration,
than is observed in chronic bronchitis, and are
devoid of fever and all other signs of inflamma-
tory action ; whilst they are equally without the
severe dyspncea, the paroxysms of suffocation
and cough, and the intermissions, characterising
humid asthma.

112. L Bronehorrhoea proceeds generally from
similar eauifs to those wnich produce common
catarrh, or bronchitis, even although it be not
eonsecutive of some one of the forms of bronchial
inflammation. It is very frequently, either at its
commencement, or recurrence, connected with
cold and moist states of the atmosphere, or occa-
sioned by exposure to cold in some one or other
of its forms. When it occurs as a sequela of
bronchitis, it may be viewed as arising from lost
tone of the vessels and of the bronchial surface,
the flux or determination to this part still con-
tinuing, from peculiarity of habit or some other
cause, after aft inflammatory and febrile symp-
toms have been removed. Thus, it is very fre-
quent in aged persons of relaxed fibres, who
hsve experienced repeated attacks of pulmonary
catarrh.

113. ii. Diagnoitie 5ymptofni. — Bronehorrhoea
may be distinguished from chronic bronchitis,
tubercular phthisis, and humoral asthma, by the
following cnaracters : — The quantity of fluid
expectorated is very great ; being in some cases,
as much as four or five pounds in the twenty-
four hours. The sputum is colourless, ropy,
transparent, slightly frothy on the surface, and
resembling the white of egg mixed with water.
It is without the thickened sputa generally ac-
companyior chronic bronchitis. There is con-
siderable dyspnoea, but the chest sounds well
thoughout upon percussion; and the cough is
slight comparatively to the quantity of the ex-
pectoration, being evidently no more than is
occasioned by the discharge of the secreted fluid.
The pulse and temperature of the skin are na-
tural, and there are no night sweats. The appe-
tite is generally unimpaired ; and emaciation is
not remarkable, or not at all observed, unless
the quantity of the sputum be extremely great.
M. Nauchb states, tnat the expectoration in
this state of disease is always more or less acid,
and reddens litmus paper, whilst that proceeding
from inflammatory action restores the blue tint to
this paper after being reddened by acids. On aus-
cultation, the respiratory murmur is commonly
weak, but is very rarely suspended. The sibilous
rhonchus is heard moie or less distinctly, and
often mixed with the sonorous, and occasionally
with the mucous rhonchus, the babbles of whicn
seem to burst upon the surface of a fluid of less
consistence than in bronchitis.

114. Bronehorrhoea usually commences with
catarrhal symptoms, and frequently without fever.
In other cases, after bronchitis has continued
chronic for a longer or shorter period, the ex-
pectoration becomes less consistent and less
opaque, more abundant, and similar to that de-
scribed ; and the affection becomes established,
—aggravated at times by disorder of the stomach
or bowels, or by changes of the air, especially by
cold and moisture, or by arrest of the cutaneous
transpiration fVom any cause, — and ameliorated
at otner times by a warm dry air, an open state
of the bowels, and light noonshiog diet, taken in

268

BRONCHIAL FLUX— Treatment.

moderate quantity. VacillatiDg in this manner,
the disease may continue for yean if it be not
severe, without materially affecting the strength.
But more frequently the discharge increases,
after irregularly prolonged, and more or less
slight intervals ; tne patient loses his flesh, and
becomes paler; his strength is impaired; dys-
pncea increases ; and, in some cases, the affection
either runs into humoral asthma, or the quantity
of expectoration is augmented so as to exhaust
his energies, and to occasion suffocating parox-
ysms of cough. In rarer cases, the quantity of
the bronchial discharge has been so great as to
occasion the exhaustion and death of the patient.
M. Andral has detailed two cases of tnis de-
scription, wherein, upon dissection, no evidence
of inflammation or congestion could be found in
the air-tubes. M. Roche, has described, what
he has designated an acute form of this affection,
which other French pathologists have named
catarrhe suffocant; but it diflera in no respects
from the more humoral states of asthma, described
in its more appropriate place, and presenting all
the symptoms of spasm of the air-passages, with
a copious viscid expectoration; the spasm and
other symptoms subsiding after the bronchi and
trachea are unloaded of the secretion accumu-
lated in them. Bronchorrhoea has, in rare in-
stances, been the means of removing other diseases.
M. Andral states that he has seen hydrothorax
disappear afler the establishment of a copious
bronchial flux.

115. iii. Treatment. — After the full exposition
that has been given of the means of cure in the
different states of chronic bronchitis, to some of
which bronchorrhosa is closely allied, it will be
suflicient to enumerate succinctly the various
means which are applicable to this affection. As
the disease essentially consists of an increased
secretion and exhalation from the respiratory
mucous membrane, with a determination of the
circulation to that quarter, and deficient tone of
the vessels distributed to it, the obvious indico'
tions are, to increase the secretions from other
surfaces and organs, thereby to derive from the
lungs, and to restore the lost tone of this mem-
brane and its vessels. In some cases, accord-
ingly, it will be advantageous to commence with
an ipecacuanha or sulphate of zinc emetic^ and
afterwards to act freely upon the secretions
and alvine excretions by purgatives. I have
never seen a case of the disease which has not
been much relieved by purgatives ; taking care,
however, that they should not lower the energies
of the constitution, by combining them with
tonics, bitters, or stimulants, and afiowing suffi-
cient light nourishment to admit of this mode of
derivation being satisfactorily employed. In the
intervals between the exhibition of purgatives,
diuretics and diaphoretics may be exhibited, and
the cutaneous functions promoted by wearing ,
flannel next the skin during the winter and spring
months.

116. Expectorants are very much employed in
this affection ; but some of this class of medicines
are seldom of benefit in it, unless combined
with opium. The balsams and terebinthinates
(F. 484—487. 489.) ; the sulphate of zinc, with
myrrh, or the compound galbanum pill ; and
either of these, with camphor and opium ; are
often of service. In addition to these, tnhalationt,

as recommended in another part ($ 99, 100.), may
be employed. Although astnngents and iQ>
halations are often required, yet we should be
cautious in using them when the disease has beea
of very long continuance, particularly in penoQ»
advanced in age, or when there is any irregulamv
of the action of the heart, or physical sign pf
organic change about this organ, complicated
with it ; inasmuch as the arrest of an habitail
discharge will, in such circumstances, risk lut
supervention of effusion in the cavities of tit
thorax. It will be more judicious, in these ca.<ieit,
to confide in purgatives combined with bttter
tonics ; in diuretics, and in diaphoretics, so 8.*> to
moderate the discharge, and prevent its increase,
or its exhausting efi^cts upon the system. Al
the same time the vital energies should be pro-
moted by a light nutritious diet, moderate exercise,
and change of air, with the sulphureous or frently
tonic mineral waters. In other cases, where tbe
age of the patient, the regular or healthy state of
the heart's action, the absence of leucopblegmacta,
and the circumstances of the case altogether, an
such as to preclude dread of the consequence^c of
suppressing this discharge, cold sponging the ^jt-
face of the body by the nitro-hydrochlonc lotion.
&c. ($101.), and the liniments already noting!
(F. 296. 311.), with the internal use of the more
astringent tonics, particularly the sulphate of imn
or of quinine, in addition to the measures already
recommended, may also be practised.

BiBLioo. AXP Refbb. — MorAi^t Princepi Medieiuk Ua
Rest. lG65.'^Rcederer, Diaier. de Caurrho Pbthwe
Mentiente. 4to. OoeC. 1758. — Rickler, On Mucoim Cou
lumption. in Med. and Surgical ObMrvationt. Edintmnrl),
179i — Beddoes, On the Medtrinal Use ofFactitiotifl Am,
&c. Briit. 1795. —Englehart, De Catarrhe Inflammatorio,
4to. Lund. 1799. — i^ Rocke, Easai lur le Catftirb^ Put-

monaire Aigu, 8to. Paris, 180S JBertrmmd, Snr U IH*-

tinction du Catarrhe, de la Pleuriaie, et Peripacim. kc
4to. Parit, 1804 — Cabani$, Obwry. tur lea Affbct.CaUn^
8vo. Parifl, 1807.— AMiAam, On tbe TnOammatory Afffec
tioni of the Mucous Memb. of tbe BronchiiB,8TO. LooA
1810 — J. P. Prank, Inter|x Clinic, p. 110. Tub. I81f.—
J. Prank, Praxis Medica, &c. part ii. toL ri. p. 5S9.~ A-t-
riar. On the Effects of Pneumatic Medicine, Medical His.

toriet. ftc. vol. ii. p. 361. Load. 1810 Bnmssa^, Hictnre

det Phlegmasiet, ou Inflammation* Cbnmlque«,&e. t. u
p. 69. 3d edit. Paris, 18S2. — CAiiyiv, On the Pathol, of the
Larynx and Bronchia. Edinb. 1809. — > Aiari, Du Si^pr ft
de U Nature de« Maladies, 2 1 Paris* IKl^nUfrm*,
Diet, des Scien. M6d. t. xxxii. p. SOS. .- Hastmg*^ Ou h>-
flam, of the Mucous Membrane of the Lungs, ^c. 6vo
Lond. 1890.; and Midland Medical Reporter. toI. li.
a 397. — Roche et Samson, Nouveaux Qemcns de Pachol.
Medico. Chirurgicale. t. i. p.5e0.; et Diet de M4d. el Chir
Prat t. iv. p.S5S — Armttrong^On Scarlet Fever, Mc«*lcs,
and Consumption, 8d edit. Lond. 1818. ^BoaOtaad, m
Joum. Complement, de Diet, det Sciences MU. t %xx.
p. 5. — Duncan^ Observations on Pulmonanr Consainp>
tion, 9d edit. p. 162. — Larmwc, TVait^ de l'AusculUtii«
Mediate et dea Maladies dca Pouraona, Ac. iJ AS«t

Paris, 1826.; et R<v. M^d. t 1. p. 384. 1894 Amdrml,

Clinique MMicale, &c. t. li. p. 1. ; et Anatomie Pstbo.
logique, t. ii. p. 4fi5. ; ct Archives Qhnit. de Mfderiae.
t Tv. p. 314. — Royer-CoUard, Nouv. BibUoth. MM. 1. 1.

p. 196. 18S6.— Santa, Rev. Medicate, t. ii. p. 590. \Wr

MUls, Account of Morbid Appearancet fraaa Disordenof
the Lungs and Heart. 8to. Lond. 189a — Akoek, On la-
flammallon of the Mucous Memb. of the Orgaoa of Kr>
spiretinn. Medical IntelUgencer, No*, vii. and vui. p. 151.
— R. Harruom, in Medical and Phyxkal Jouro. Jul« ,
1890.-.Jwk)uoit*s Medico-Chirurf. Review, Dec. l»'

?. 341 . -^Ckontel, Diet, de M^d. t. iv. p. 4 17. (art. Cstarrkf
*i$lmonaire.) — Hildenbrand, Inititut. Practico-Ncdicv,
t ill. \t.Alii.^Pagen$tech€r, in ih^Mmmfs Joura drr
Pract. Heiik. Nov. 18S7.— OMION.ODiheTNatacoOf
several Varieties of l\iliDonarT Coiuumi4ino,andonthe
Vapour of Tar in that Disease, 8vo. Lond7l8tS -AJMr-
son, IxMid. Medical Oatette, vol. viii. in SS9. ; and UncH.
vol. xvii. p^ 467. ~ Baykt Recheccbea aor la Pbtbiur im
some eases of (Tronic oronekUisJbmnd the hronckid mr-
face pate, and without cAiMftf), dba. xltx. p. 992. Pari«*
\%iO.~»Abercrombia, in Bdln. Medical and Soigical Jau.
nal, VOL xvii. p. 59. iUletraHom ^ the hrmekL)'^^'

BRONCHOCELE-- Caubks and Morbid Rslatxoks.

269

Tmhn, Od Tn Vapour In DiieMCS of the Lungs, ftc. in
Medical and Phjsical Journ. rol. xMlL p.S81.— fPiY-
htiMu, On Che Pbjncal Sign* of DlseaM* of the Lungs,

&c. p. m. 8va LoocL 1829 F»rbe$t Original Caaes, illua.

tnnng tAe Uae of the Stethoacope and Percuuion, 8vo.
Lo«d. 1A31. — Gendrm^ Hiatoire \natom. des Inflamma-
tuos, kci.\. p. 5«6. Parii, 18%. ~ Bright, Reporta of
Mfltcal Caiea, &c. ni I«7. 4ta Lond. 1827. — Graoes, in
Arattenr't Med. and Sur^ Journ. voL vii. p. 193.

BRONXHOCELE (from BpoVx«c. throat, and
xn>«, a swelliajf). Syn. Hernia Gutturalis,
Gomum, Lufir'a^renbruch, Kropf, Ger. Goitre^
Fr. Broncocele, Gotw, Ital. Thyrophraxia,
Aiiberti CynaneheThifroidea, Comdi, Goitre,
** Dnbythire Neek:*
Classxf. 4. Clau, Local Diseases ; 6. Order,
Tnmours {CuUen). 6. Class, Exceroent
Function ; 1. Order, AfTecting the Paren-
chyma (Good). IV. Class, IV. Order
(Author, see Preface).
!• Daiv. Chranie enlargement of the thyroid
i^'id, ionutimet with change in the surrounding
}»fU, generally increating slowly, often continuing
f^ «earf, and depending upon constitutional
csves.

^. I. Causu, and Morbid Relations. — This
i>tas^ is endemieal in Derbyshire, and some other
pirtsof this country ; but most remarkably so in
Sviueriind, various adjoining districts, and in
K-Qie places in South America. It usually occurs
<iariag the early epochs of life, most frequently
about ^ period of puberty, in persons of a weak
^ iu fibre, and generally in females ; it very
^litm being observed in Great Britain in males :
l>ot (he comparative frequency of it in the latter
*tc u greater in Switzerland, and other parts
*boe it ii very prevalent, and is connected with
crrtiainii. In a considerable number of cases
vfajch have come before me in females, I have
KevcT met with any before the period of com-
itendng puberty, — not even at the Infirmary
for Children ; although the menses have often
J*«n delayed for a year or two, or even longer,
^i^ the tumour has appeared at this epoch ; and
I ittre seldom olMcrved an instance in this sex
t'atOQaected with some kind of irregularity of
^ mettAmal discharge, or disorder of the uterine
^iQctioos. In two cases, occurring in married
ft^miles, who were under my care, unhealthy or
irrejcuUr menstruation had existed during the
cQsinnitsoe of the goitre ; in one case for eight
)^f, in the other for five : upon its disappear-
^'"^, pregnancy took place in both. Suppression
<^f the menses has sometimes caused its sudden
*?peuance and rapid developement ; and it more
'Arely has originated during pregnancy and the
puerperal states. Authors have adduced conclu-
>i>e proofs of ita occurrence hereditarily, inde-
P««fcttily of endemic influence.

3- Dr. Goon has attributed the disease, in a
^^ nessnie, to poverty, and the nature of the
M : the rich being exempt from it. This is,
ottwever, very far from being the case. I have
^a Mveral eases of bronchocele in the richest of
fo» netropolis. He is also wrong in attributing
»| to the use, in Derbyshire, of oaten cakes. In
^(otlAod, where this article of diet is in general
0*. bronchocele is rare.

♦. That it chiefly depends upon certain phy»
«€al caoics is shown by its prevalence in certam
d««nctsin preference to others, and by the cir-
<^ui&itaQca of ite disappearance when persons
«ect«d by it endemically have changed their

residence. M. Alibeut mentions his having
seen it disappear after a residence in Paris. It
has been very generally imputed to the water
used by those afitected. Since the time of Pliny,
it has been attributed to the use of snow water.
But it prevails in several places where this cause
does not exist, as in Sumatra, and several parts of
South America. The Swiss who drink snow
water are free from the disease, while those who
use hard spring water are most commonly af-
fected. Captain Franklin states, that at a part
in his iourney to the Polar Sea, where bronchocele
prevails, it is confined to those who drink river
water, and that those who use melted snow escape.
Mr. Bally ascribes its frequency, in a district in
Switzerland, to the use of spring water impreg-
nated with calcareous or mineral substances ;
and he states, that those who use not this water are
free from both goitre and cretinism. Dr. Coinoet
observed that the inhabitants of Geneva, who
drink the hard pump waters, are those most liable
to bronchocele. Its prevalence in Nottingham
is ascribed by Dr. Manson to the same cause ;
which also seems to occasion it in Sussex and
Hampshire, in the valleys of which counties it is
frequently met with.

5. That this is, however, not the only cause,
may be inferred from other physical circum-
stances connected with its endemieal preva*
lence. Its great frequency in low, moist, marshy,
and warm valleys, and the exemption of the
inhabitants of dry and elevated situations, have
been shown by Larry, Foders, Saussure,
Rk£ves, Clark, Valentin, PosTiGLioys, and
J. Johnson, as respects various districts in Swit-
zerland, the Tyrol, Carintliia, the Vallais, and
the north of Italy. Similar facts have been ad-
duced by Dr. Gibson, and Humboldt, in regard
to the United States, and South America. It is
most probable, however, that the exhalations from
the soil of those localities are not the only, but
a concurrent cause, co-operating with others pos-
sessing equal influence in the production of the
disease, and particularly with the nature of the
water. But it as certainly sometimes appears
where neither of those causes can be traced, a»
in London ; disorder of some kind in the uterine
functions being the most frequent morbid re-
lation it has presented, as far as my experience
has gone. Its connection with cretinism in the
districts on the Continent above alluded to, and
the occasional appearance of the disease at very
early periods of life — it being even sometimes
congenital, in these countries, as well as being
more common there in the male sex than in
this country — are matters of some interest, and
not readily admitting of explanation; since po-
verty, close, confined, and ill-ventilated apart-
ments, are not the chief causes of lliose phe-
nomena, as shown by their absence in the
poorest classes in this metropolis. Dr. Parrf
has seen gohre follow diseases of the heart, and
epilepsy. Flajani has noticed the common oc-
currence of palpitations and affections of the
lungs from the disorder it has occasioned of the
respiratory function. When the tumour is very
lai^, or hard, or when it has increased sud-
denly, it not infrequently occasions most urgent
symptoms, by its pressure on the trachea, oeso-
phagus, and jugular veins.

6, As respects the external and internal appear-^

970

BRONCHOCELE •• DuOlroitI*-* TatAficmt.

antf of tbk tumouri I may briefly observe that
It affeots generally the whole gland ; but ii also
sometimes confined to the lateral or to the middle,
lobes : it is more rarely large on one side than
another. At first it is commonly compact,
rounded and equal ; but, as it increases, it is
either soft and flabby to the touch, or unequal,
irregular, hard, and obscurely lobulated. It is
usually free from pain, and is not dbcoloured*
When it is greatly mcreased in size, and is soft,
it appears pendulous, chiefly owing to its lower
parts being most enlarged. When the tumour is
divided, the cells of the gland are found, accord-
ing to Hunter, Baillie, and B. Bell, filled
with a more or less viscid fluid ; and are of varioua
sizes, ffenerally from that of a pea downwards,
not only in different cases, but even in the same
gland. In the older, harder, and more irregular
forms of the tumour, melicerous, steatomatous^
cartilaginous, and os^c deposita have been met
with in parts of it, by Celsus, De Habi«,Frsttao,
GiRAUD, Hedbnos, and others. The usual state
in which this disease presents itself, obviously, is
that of an increased secretion into the cells of
the gland, distending them more or less; the other
changes sometimes observed, being consequences
of obscure irritation induced in parts of it during
its continuance or growth.

7« II. Diagnosis.-- It is necessary to be aware
that other diseases of either a more acute or ma-
lignant character may afiect the thyroid gland
and its vicinity, and be mistaken for bronchooele.
Ist, The gland may be either healthy, or hot little
enlarged ; the tumour .consisting chiefly of thick-
ened surrounding cellular tissue, sometimes con-
taining cysts filled either with a serous, albumin-
ous, or purulent matter. Large encysted tumourt
may also form in the course of the trachea. But
these may be readily distinguished by their situ-
ation, form, and fluctuation. 2d, The gland itself
may be the seat of chronic or aettte inftumnuition*
In this case the swelling increases more rapidlv,
but seldom attains a large size ; and is generally
attended by redness of its surface, and mcreased
temperature. It is also painful, particularly on
pressure, and is very hard. I lately saw a case
of this description, in a married female of about
thirty, who was also seen by Mr. Llotd, where
the mflammation had proceeded to suppuration,
and had terminated in an external opening. I
believe that inflammation of the gland never
occurs but in scrofulous habits. 3d, The gland
may also be the seat of scirrhut, which may
ultimately go on to carcinomatous ulceration ;
but this IS a rare occurrence. In this case the
gland is very hard, seldom large, sometimes
scarcely increased in bulk, and is the seat of
sharp darting pains. It is only met with in
persons advanced in age. Aubbrt states, that he
nas observed a case of gottre pass into cancer ;
but I doubt the fact ; cancer having a veij
wide end indeterminate signification with this
writer. The disease can scarcely be mistaken
for aneurism of any of the thyroidal arteries, if
any share of attention be directed to the subject*
Bronchocele has been considered in the lignt of
a strumous disease — as a form of scrofula. Dr.
PosTio lions, however, contends that no connec-
tion exists between these diseases. As respects
the state of morbid action in the gland, the con-
comitant pheAomeMy and the respeotive teninn*

attons of both diseases* tliere is oeitaiiily ao inti-
mate relation between them.

8. III. TRBATMENT^-^Previons to the ase of io-
dine in the cure of bronchocele, numerous remedial
means were recommended by writers. Of these,
the most common were frictions with various
liniments ; dry rubbing ; stimulating and astrin-
gent lotions; cold bathing, and cold dovcbec;
mercurial applications ; plasters with cicuta and
ammoniacum, or with ammoniaeum and bydrarg. ;
repeated blistering; leeches applied to the tu-
mour ; electricity and galvanism ; nozas, issuer,
and setons; ligature of the arteries sapplyiDf
the gland; and extirpation of the giana haelf.
Amongst the internal remedies reeonmended, I
may notice the various preparations of mercury ;
digitalis combined with camphor ^OssiANDEa);
suTphuret of potassium ; chloride or barium (Po»-
tiolionb) } cicuta or belladonna, either aloee, or
with the chloride of barium ; the chloride of cal-
cium ; preparations of potash and soda ; various
mineral springs ; the use of sea vrater, and of ds>
tilled water ; the ammonio-chloride of iron ; burnt
sponge» given either akme, or with mercury ; and
the ashes of the/ueus virieulaeus (Rvssell).

9. Of all these, the most celebrated was barnt
sponge ; and, after the discovery of lodutr, this
substance, which, having been found by Dr.
Stravb, of Berne, to be contained in otfieioal
sponge, was recommended by him in* 1629, and
adopted by Dr. Coxndet, of Geneva : and so sac-
oessfnl has this medicine proved ,in the treatmsot
of bronchocele, that, of a hundred and tweot}
cases treated with it by Dr. Manson, of Nottiof-
ham, seventy-nine were cured, eleven gieatlr
relieved, and two only were not benefited bV
it. Of several cases of the disease which have
come before me since the introdnelioB of thi«
remedy into practice, there has not been one
which has not either been cored or renait-
ably improved by it. I believe, however, thai
although it has been found the most certainiT
beneficial of any medicine ever employed ia
bronchocele, some other praetitioners have oot
derived an equally uniform advantage from iti
use. I can account for this only by coosideiiBjr
that it has been given in too large and irritatiBK
doses, or in an improper form ; and vrithoet dae
attention having been paid to oertam mortnd sad
constitutional relations of the disease during the
treatmenL The cases of two females who were
lately completely cured by the remedy eonflrm tbi*
inference. They had both had the tumour for sere-
ral years, one for nine years ; and had, on foraer
occasions, gone through long coarMS of iodiar.
prescribed by jodicioos and eminent ^lactitioDer*,
out without advantage. When this medicine
was ordered by moi it was, therefore, with great
diiiicnlty that they were induced to have reeoone
to it again. It was ordered in very smell dosc«,
oiVen repeated, and striet attention was paid to
the state of the secietioBs, and to the uterine
functions. In the course of a fortnight aa in-
provement was manifest; and of a few week*
longer, a great decrease of the tmnoufi bad
taken place. One of these females, a married
woman, who bad been once pregmmt nine yesrs
before, upon Ube disappearance of the temour
came with child; soon after which it somewbt
suddenly reappeared, but the reaumptioB of tht»
iodine again dispentd it. TbtprepmiieMgiveo

216

C^CUM-— FaVCTtONlL DtSOftDtft OF.

in it for a ve^ lottg petiod, sometimes without
producing much disorder, at other times occasion-
ing the most violent effects. In other cases, in
addition to various morbid matters, large balls of
worms, both lumbrici and ascarides, collect in
this viscus, and occasion much local irritation, or
even inflammation of its inner surface, and con-
stitutional disturbance. Mr. Blaceadder has
detailed some interesting instances of this occur-
rence. He found, in a patient who had com-
plained of disorder of various organs, and of a
gnawing soreness in the right iliac region, ragged
ulceration of the iniier surface of the cecum,
which contuned an immense number of worms.
The rest of the alimentary canal was sound.

8. B. When the cecum is much enlarged, or
otherwise diseased, it may also be ditplaeed.
Cases are record^ by Salzmann and Annes-
LBY, in which its attachment to the internal iliac
muscle had yielded so far that it had passed over
to the left side ; and others, in which it had de-
scended very low into the middle of the pelvis,
and pressed upon the urinary bladder.

9. Not only may indigestible substances and
morbid concretions sometimes lodge in the
cecum, producing much local irritation and
general disturbance, but they may, when small,
sometimes pass into the vermiform appendage,
where they occasion, as will be shown in the
sequel, the most dangerous effects. It does not,
however, appear that the simple presence of any
of these substances in this process is always fol-
lowed by such results. Mr. Black a doer relates
a case in which he found a small concretion in
this part, and yet the patient had not complained
of any symptom referrible to the right iliac
region. I have treated, or been consulted re-
specting, four cases, in which foreign bodies and
concretions were found in the appendix after
death ; and in all, the symptoms were those of the
most violent peritonitis complicated with ileus,
and terminating in sphacelation of this process
itself. Two of these I attended with Mr. Painter,
of Crawford-Street, by whom the inspections were
made; and who ascertained that tne substance
found in the appendix, in one case, consisted
chiefly of cholesterioe.

10. ii. Symptoms. — The phenomeva usually
occasioned by fecal matters collected in the cs?-
cum, and by distension, enlargement, or irritation
of this viscus, will necessarily vary with the na-
ture of the offending substances, the extent to
which they may have accumulated, and the age,
temperament, and habit of body of the patient.
The disorders which result are, 1st, Local ; 2d,
Symptomatic, and 3d, Constitutional.— a. The
local sigm are more or less fulness, hardness, or
distension in the right iliac region : sometimes, on
examination carefully with the points of the
fingers, the abdominal muscles being relaxed, a
doughy hardness is felt. In other cases little or
no pain, even upon a minute examination, is oom-
plamed of; but occasionally, especially if the
disorder be about inducing inflammation, both
tenderness and pain either exist more or less con-
stantly, or come on in paroxysms ; and the patient
generally reposes on the nghi side. When the
bowels are constipated, and interruption of the
passage of matters through the cecum occurs,
the paroxysms of pain are very acute, and some*
tim«8 att^id^d by vomiting, and all the symp-

toms of the most severe colic, or even those of
ileus. In such cases, upon examinatioD, ogw
of obstruction either in the cecum or is its
vicinity are detected, unless general peritooita
may have come on ; and then the origm of dis-
ease is very generally referred to the cecal region,
or the tenderness and pain are moot acute in that
situation.

11. fr. The sjfmptamaiie diaerden, when this
viscus is much distended, either by fecal or
other matters, or by flatus, or by both, u is aoA
commonly the case, are, numbness of the right
thigh, oedema of the right foot and ankle ; some-
times retraction of the testicle, or frequeot calls
to empty the bladder, and sometimes hemor-
rhoids ; uneasiness or pain in the right iliac regioo,
often extending to the bypocfaondrium ; vtrioa
dyspeptic symptoms, costive or irregular state of
the bowels ; oifcasionally diarrhoea, with scsDtr,
offensive, and mucous stools; and, if iiritation
be excited in the mucous surface and follicles of
the organ, the efforts made to evacuate the boweb
are attended by severe tormina, and ereo by
retchine. I have seen seveiml cases of vsrioose
veins of the lee, or indolent ulcers, and a case of
disease of the bones of the foot, the occmreDee
of which was evidently connected with great
distension and accumulations in the emcnm ; Um
symptoms of this disorder, with more or lets
tumefaction and hardness in the iliac regioo,
having been found on examination. The jitft*
ness of this view was fully shown by tie sacccu
of the treatment, which was based upon it

12. e. As long as the states of disorder hare
not advanced to inflammation or ulceratioo, the
effects are often not very manifest upon the m-
stUutum. The countenance and skin, bowerer,
are pale and lax ; the complexion is deBdent of
clearness, and, with the surface ^penerally, oftco
covered with an oily or dirty moistore ; the per-
spiration is foetid, and the breath offensire ; the
soft solids lose their elasticity, and are slightly
emaciated ; the lips are usually pale, the toogoe
white or loaded at its centre and base, foeeiiiDa
red at its point and edges; the pulse is weak,
soft, or small, frequently slow, but easily seeder-
ated ; and, at an advanced stage, the sjmptoici
more clearly manifest that the blood is iInpe^
fectly depurated, or that it is affected by tbe
al>sorption of a portion of the excremcntiuoiH
matters retained in the cecum. In addition to
these symptoms, general debility, and disiociios*
tion to any physical or mental exertjoo, are of^eo
complained of. The above states of disonler
continue for a longer or shorter period ; wbea at
last the local irritation either produces ioereastd
action of the muscular coat of the cecum, and
ultimately the dislodgment of the offending mat-
ters, or ^ves rise to acute or chronic »tAtei «(
inflammation, and various consecutive org^oic
changes. In some instances, the accnmulatioa
in this viscus, and the spasm of the adjoiniog^
parts, amount to complete obstruction of tli«
passage through the alimentary canal, ereo itith*
out inflammation or any disorganisatioo of tfao
cecum itself having taken place ; causing violeet*
colic and ileus, as in the cases already ootict^
($10.); the most marked symptoms duriof I«^
being referrible to the superior portions oi tb<
tube, and the lesions after death bdog mou rt-
markable in those parts, paiticolariy about ibo

C JSCUM — Ikvlammation ov •«- Cattses.

277

tenninition of the ilium, and the ilio-cscal
Tiire.

13. iii. Trxatment. — The intentions in this
lUkte of disorder are very obvious ; namely, 1st,
to evacoate morbid collections ; and, 2d, to pre-
veat their le-accumulatioo, by preserving a
regular tonic action of the viscus, and by strength-
ening the digestive organs generally.—- a. The
encuation of the accumulated or retained mat-
ters is to be attempted by means appropriate to
die circumstances of the case. If there exist
irritabiiitv of stomach, or even any tendency to
it, or to iebrile action ; or if there be any pain or
soreoen in the iliac region ; full doses of calomel
should be first exhibited, the enemata about to be
saggested administered, and the liniments pre-
scribed in the Appendix (F. 296. 311.) gssidu-
oibij nibbed over the cscal region, with the
view of exciting the healthy action of the viscus.
If, OQ the other hand, the stomach and bowels
be torpid, and the former can retain purgative
or cathartic medicines, they may be given, select-
iog those which are the least irritating in their
elFecti. I have seen inattention to this caution,
the most stimulating cathartics having been ex-
bibited, productive of the worst consequences ; a
cute of disorder simply functiooal, or colic from
distension and obstruction of the cascum, being
eoo¥erted into either inflammation of the bowels
or (laanrous ileus. When, therefore, an initable
state of the stomach supervenes in our attempts to
remove obstructions of this viscus, we should
delist from the exhibition of pure;ative8, or even
of aperients by the mouth, excepting full doses of
alomel, or calomel combined with hyoscyamus
or o|Mum, and moderate doses of nitrate of potash,
or carbonate of soda, or of both, which will
generally be retained, and will allay the sickness
ud retchings. But we ought strenuously to per-
fi^t in the administration of enemata — preferring
thoiie which are oleagioous, saponaceous, and sol-
Teni — and in the use of the liniments and frictions.
The enemata should be always large, and injected
hy means of the valve-syringe now in use, so that
tiiey may reach the seat of obstruction. In ob-
stinate cases, this object will be facilitated by
placing the patient upon his knees, and elbows
daring their adminbtratioo, and elevating the
pelris as much as possible above the rest of the
^ok. The practitioner should not be discou-
nted by the ineffectual administration of several
lojectjons, but repeat them according to circum-
■^aces, employing at the same time frictions over
il^ abdomen with the liniments already advised.
If flatulent distention of the abdomen be present,
they will assist in removing it ;*but in such cases
the terebinthinate enemata ought to be preferred.
When we suspect the presence of worms, in ad-
dtfioa to other morbid matters, aloes and the
alkaline solutions, assafoetida, camphor, lime-
^ter, &c. may be used in the injections. In
the slighter and more usual cases, the aperients in
^'ommon use, particularly castor oil, the com-
poand decoction of aloes, the combination of the
compound infusions of senna and of gentian, or
the infusion of senna with decoction of cinchona,
o"" the several formuls of this description con-
tained in the Appendix (F.215. 266. 662. 575.),
aay be prescnbed, as they may appear appro-
priate to the circumstances of the case.
14. fr. Having apparently removed whatever

obstruction may have existed, — the csBcal region
being soft and natural, and the actions of the
bowels free, — the object is next to prevent the
recurrence of disorder, and to strengthen the
digestive or^;ans, by vegetable tonics and bitters
combined with aperients ; by .sulphate of quinine
with aloes ; by small doses of blue pill with the
alkaline carbonates and other deobstruents, and
given occasionally with the view of promoting
and correcting the secretions ; by the occasionid
use of the linimeifts above referred to, or by
wearing a warm stimulating plaster (see F. 109.
115. 117.) over the right inferior regions of the
abdomen. In every case; attention should be
paid to the state of the digestive, assimilating, and
secreting functions; regular evacuations of the
bowels promoted, by the occasional use of ene-
mata ; and the diet strictly attended to.

II. Inflammation op the Caecum. Classif.
III. Class, I. Order (Author).

15. Although inflammations of this viscus have
been generally overlooked or confounded with
those affecting either the colon, the small intes-
tines, or the peritoneum, there are few diseases
more defined in their character, or more distinctly
limited in the great proportion of the instances of
their occurrence, than they arc. In respect of
its seat, inflammation ma^ aflfect chiefly the mu-
cous surface, or the follicles, or all the coats of
the organ more or less : or it may attack the ver«
miform appendix only, or the cellular tissue
connecting the caecum to the internal iliac muscle.
As to the charactgr of the inflammatory action, it
may be sthenic and acute; or acute, asthenic,
and spreading, as in dysentery and fever : it may
also be more or less chronic. Cases of all these
states of disease are to be found scattered through
the works of modem medical authors, and most
of them have come before me. The first case
which attracted my attention to the importance
of attending to the state of this viscus in various
abdominal diseases, occurred in 1816, in a hot
climate. The patient had the usual symptoms of
inflammatory dysentery, with violent pain, and
subsequently tumefaction in the cecal region.
The disease had been neglected in its early
stages ; and it was only shortly before the sudden
subsidence of this tumour that I observed it.
Upon strainine at stool, a sensation of something
having burst internally was felt; and very soon
afterwards above a pint of purulent matter, mixed
with a little blood, was discharged. Upon exa-
mination six hours after death, the ciecum was
found ulcerated, discoloured, and nearly sphace-
lated, with an opening through the part attached
to the abdominal parietes leading to the nearly
empty sac of an abscess which had formed in the
cellular tissue connecting this viscus to the side ;
the mucous membrane of the colon was inflamed
in parts, and excoriated.

16. i. The Causes of inflammations of the cae-
cum are chiefly the functional disorders already
described. A morbid state of the abdominal secre-
tions, and particularly an increased secretion of
vitiated acnd bile ; the irritation of foreign bodies,
indigestible substances, and of worms ; a strangu-
lated hemiir, or the pressure of an ill- constructed
truss; the suppression of the haemorrhoidal and
menstrual discharges ; and the presence of biliary
or intestinal concretions, hardened fteces, or the
stones of hruits, or their escape into the vermiform

T3

396

CATARRH — CoifPLXcATxoNB of.

of cfttarrh either diaftppears, as in the slighter
states of the disorder, with a dimiDtshed and
thickened secretion, less frequent and less severe
fits of coughing, and subsidence of fever, in from
four, to seven or nine days; or it affects, in a
much shorter period, — sofhetimes almost from
its commencement, — the pharynx, trachea, and
large bronchi, producing slight or severe bron-
chitis ; or it terminates in this disease, or in pneu-
monia, or even in pleuritis. But most commoniy,
under proper management, it is attended merely
by a moderate catarrhal affection of the trachea
and bronchi ; with fits of coughing, increased
mucous expectoration, &c., constituting catarrhal
bronchitis. It also sometimes extends down the
oesophagus, and affects slightly the stomach, in-
ducmg numerous dyspeptic symptoms ; and, in
persons with an irritable state of the digestive
tube, occasionally passing off at last with mucous
or serous diarrhoea.

11. III. Prognosis. — In general, catarrh is a
▼ery slight ailment, and attended with no danger
as respects itself. But, in aged persons, in those
disposed to pectoral diseases, particularly those
who may have tubercles already formed in the
lungs, who have had haemoptysis, or who are
asthmatic, or have experienced attacks of bron-
chitis, pneumonia, or pleuritis, cafaThal affec-
tions require strict attention, as they very often
quickly produce, or terminate in, these maladies.
In many persons, also, they are very prone to
become chronic, either in the form of a chronic
eoryia, with continued irritation, and slight red-
ness of the posterior nares and fauces, and an
abundant muco-puriform discharge ; or in some
one of the states of chronic bronchitis. In the
aged, and in those of a phlegmatic temperament,
or lax habit of body, catarrh often passes into a
chronic bronchial flux, when it has been neglected,
or renewed by incautious exposures during the
treatment Cnildren of a lymphatic and flaccid
habit of body are very liable to catarrh in the
form of curyta ; and in them it very frequently
assumes a chronic form ; the thick muoo*purulent
secretion filling up the nares, and, in infants, pre-
venting them from taking the breast, and render-
ing them irritable, each attempt at sucking
disordering the pulmonary and cerebral circula-
tion in such a manner as even to occasion
convulsions. In children also, the coryxa, when
allowed to become chronic, sometimes degenerates
into oza:na, with ulceration.

12, IV. Complications.— -Catarrh very com-
monly ushers in the febrile exanthemata, particu-
larly measles ; and even accompanies them through
their course, especially in the form of bronchitis.
It is also very liable to appear during convales-
cence from them. Its connection with rheum-
atism has already been noticed ($3.), both dis-
orders evidently springing from the same causes.
Continued fevers, as well as some epidemic visit-
ations of fever, are not infrequently complicated
with catarrhal affections. The association of
catarrh with biliary and gastric derangements is
very common, sometimes in consequence of the
disposition to bo affected by its causes during
biliary disturbance, and occasionally owins; to
the circumstance of simultaneous disorder of the
digestive, cephalic, and respiratory mucous sur-
faces, having arisen from toe impression of the
same exciting causes. These complications have

especially characterised the various occarrenees
of epidemic catarrh, which have been observed.
(See art. Influenza.)

13. V. The Nature of Catarrb is deserving
of some notice. Many pathologists, particularly
those o' the modern Parisian school, — the fol-
low, s of Laennec and Broussais, — consider it
r^ ordinary inflammation of the cephalic mucous
membranes, or parts of this tissue which it usually
affects. Other pathologists, more especially
RicHTER and Hildenbrand, view it, with stricter
propriety, as an inflammation of a specific kind.
I believe, although it very often terminates in
true inflammation when it extends to the broocbtal
tubes, that it chiefly consists of a specific irritatioa
of that portion of the mucous surface primarily
affected by it, nearly allied to inflammation, and
soon followed by, or accompanied with, great in-
crease of the secreting functions of the part ; or,
in other words, that is is not pure inflammation,
but an irritation of a specific or peculiar kind,
attended by slightly increased vascnlaiity, afflux
of the circulating fluids, and augmented secrelioo.
Since the time that Van Helmont ridiculed, in
his Catarrhi Deiiramenta, the opinions then en>
tertained respecting catanh, enquiries into iti
natu/e have been more rational, although, up to
the present time, ideas have still continued very
vague as to the extent of surface affected by it,
many even of modem writers compiisiog under
catarrh, not only bronchitis, but even all aficc-
tion of mucous surfaces, attended with a copious
serous or sero-mucous discharge.

14. One of the most interesting questions con-
nected with this subject, and one which has been
agitated by J. P. Kraxk and others, is, whether
the defluxion is a consequence of the suppreefioa
of the cutaneous perspiration, arising out of the
irritation which the secretion retained in the cir-
culation produces upon thexephalic and pulmoniR
mucous surfaces ; or of the specific irritatioQ and
morbid impression of those parts by Uie exciting
causes of the disease. The former opinion was
very generally received by the followers of the
humoral pathology ; and the latter by Homins,
and subsequently by Cullcn, Pinel, and other
disciples of his school. Pinel consideied the
febrile phenomena merely as symptomatic of the
inflamed mucourmembraoe, discarding the plan»*
ibie opinion advanced by Botai., that wutever
of inflammation exists is caused by the acrimony
of the catarrhal discharge, and that the local
ailment is consecutive of the constitutional dis»
turbaoce, — a doctrine which is in strict acconl-
ance with the description of the disease given by
RiciiTED, and with the more usual succcsaioB of
its phenomena. In some cases, however, it is
very difficult to determine the priority of the
general disturbance, the local ailment briogf
equally early. Upon the whole, I believe it i»
not proved that the constitutional affection is the
consequence of the local, although the former is
generally increased in proportion to the sevcriiy
of the latter ; nor does it appear that the dr>
fluxion is caused by the suppression of the cvts-
neous perspiration, even granting that suppresMOO
is actually produced,— a position by no means
established. I would thence infer that the causes
of catarrh affect primarily the organic wrrt*
supplying the surface principally dinoidcred, and,
through them, the system generaliy; and that.

CELLULAR TISSUE *Isn.AMHAnoN ot^Tcrminatiokb.

301

dtTS, the {Atient complains of rigors, remarkable
debility, and frequency of pulse, with sickness at
stomach, retcbiogs, 6cc. A pustule appears in
the part, but not always; and generally no con-
nection can be traced between it, even when it is
formed, and the diffusive inflammation which
takes place during the progress of the constilu-
tiooal affection. In some cases, a few red lines
may be traced, or swelling of the surrounding
part is observed ; but neither advances any dis-
taaee, the parts above being perfectly sound. In
the coune. of the violent fever induced by Uie in-
oculation in the hand, the consecutive inflamma-
tion usually appears in the axilla, and extends
towards the sternum, along the neck, down to the
loins or haunch, or even to the thigh of the same
side. In some instances, it terminates at the
mesial line ; in others, it passes continuously to
tbe other side. It occasionally is translated from
one side or part to the other, by a kind of metas-
tasis, as in gout or erysipelas.

l& The inflammation of the cellular tissue of
the trunk, whether arising from a continuous ex-
tension of the disease from the arm, or part ori-
gioally affected, as in certain states of the disease
(^ 13, 13.), or in the course of the constitutional
eommotion ^$ 14.) excited by the inoculation of
t morbid vims, always possesses peculiar cha-
raetoistics : it is diffuse or extensive, without the
M&sllcst tendency to point ; being flatly elevated
ibove the sound parts, usually by a raised or
defined margin. It is smooth and equal, without
central hardness, and with all the characters
already noticed ($ 12.). In general, no chords,
which can be supposed to be diseased lymphatics,
veios, or arteries, can be traced under tbe surface,
ind the glands are either very slightly or not at all
enlarged. Tbe diffused swelling commonly fur-
nishes an obscure sense of fluctuation ; but, fre-
quently, when punctures have been made into it,
little or no discoarge has been procured.

17. The pain of tbe swollen part is most acute
in every instance, whether the swelling be in an
eitremity, or extend along it to the trunk, or com-
mence in tbe trunk itself; and it is quite inde-
peident of whatever affection of the skin may
accompany the malady. In some cases, the in-
teguntents present not the least redness, although
the oelluhir tissue has extensively suppurated, or
CTCD sphacehUed ; but the skin is commonly more
or less affected, although in a secondary manner,
ia consequence of the extension of disease from
the cellular tisane to it, and generally subse-
quently to the manifestation of acute pain. In
the advanced stages, the skin has often a reddish
or pink coloured blush, and occasionally a mot-
tled or livid hue. In some cases, at a still further
advanced period, solitary vesicles form over the
diseased cellular tissue, and contain a serous, or
sero-sanguioeous, or ichorous fluid. The tem-
peiatare of the part is sometimes much below
natural.

18. B. Tlie fthrilt commotion, whether appear-
ing coQsecuttvely of the diffuse in6ammation,
directly produced in the pert primarily injured,
or previously to the affection of the trunk » is of a
^phoid or adynamic l3rpe> and is accompanied with
the most marked disorder of the nervous system,
with anxious collapsed countenance, and fre-
quency of pulse ; more particularly when excited
hy m inocolatioQ of » morbid matter, as by

wounds from dissecting recent subjects, and when
preceding the disease of the cellular tissue of the
trunk. The fever sometimes commences insidi-
ously, but more frequently in a very evident ot
tumultuous manner. The pulse soon becomes
very quick, sharp, broad, soft, or compres-
sible. The patient lies in the supine posture,
with depressed shoulders, and without turning to
either side. Delirium is common, but it is gene*
rally intermittent; and profound coma is rare.
The respiration always is quick, laborious, and
painful, partly owing to the inflammation of the
cellular tissue of the side of the thorax, and its
extension to the costal pleura. As the disease
advances, the peculiar cadaverous foetor emitted
by the patient, the yellowish or lurid hue of tiie
surface, the offensive and sometimes coloured
sweat, which, in rare instances, proves critical,
and the tendency to ulceration in the parts pressed
by the weight of the body, show that the blood,
the secretions, and the soft solids, are more or less
contaminated. Towards a fatal close, the raving
delirium is often accompanied with muttering,
and starting of the tendons ; and alternated with
stupor ; the breathing becombg panting, labori-
ous, or interrupted.

19. The Terminatioks of the disease vary
with the exciting cause, the state of the patient s
constitution, and the part primarily affected.
When it arises from mechanical causes, as after
venesection, simple puncture, ficc, it may termi-
nate with spreading tuppuration, which mav or
may not be attended by ibughing of the cellular
structure : and this result may occur both in cases
which end fatally and in those that recover ; a
partial regeneration of this tissue taking place in
some of we latter. In the milder cases, the in-
flammatory action changes its character, and
shows a tendency to stop ; the disease terminating
in phlegmonic suppuration and granulation. If
the cellular substance adjoining a serous mem-
brane become affected, this latter participates,
and the inflammation spreads rapidly over it,
generally producing an effusion of sanguineous
serum ; but sometimes, also, adhesion of the
opposite surfaces. Occasionally the adjoining
periosteum becomes diseased, and even the car-
tilages and bones denuded. A fatal termination
occurs either rapidly from the intensity of the
disease, or more slowly from some one of its
sequelfB : and usually takes place, in the first
instance, in from four to fourteen days; in the
second, not till after two or more weeks, or even
longer ; but the common period is from the sixth
to the tenth day.

20. III. ApPEARJiNCES CM DiSSECTION. Df.

Duncan has given a very minute and accurate
account of the successive changes that take place
in the diseased structure. As the malady often
atUcks progressively various parts, it is some-
times found after death, in all its stages, in the
same subject. In the part last affected, which
is frequently the space between the last ribs and
the OS ilium, the cellular substance is merely
oedematouB, with increased vascularity ; the infil-
trated fluid being either limpid or tinged with
red, and readily flowing from the divided tissue.
In a more advanced stage, the effused matter is
less fluid, often higher coloured, but not yet puri-
form. The diseased structure is next found gorged
with a white semifluid matter, which greatly aug-

320 CHOLERA — Duration and Pbogkosis.

spasmodic contractions of the Alimentary canal, its own cure in the conne of some honn ; or it

A* i^z J • »^_j M.^ _f .!__ *: r A : :iJ .i^^^. Ci^ ^~^.

to vomiting and purging, 'and to spasms of the
voluntary musclef, &c. , tlie bile accumulated in
the gall-bladder and hepatic ducts being let lua^c
and thrown into the intestines only subscqueully

continues for one, two, or in milder cases for even
three days, and ceases by degrees; the morbid
secretions which excited the attack having been
evacuated, and the irritation they occasioned

to the seizure, and owing to the vomitings and ■ having subsided. Although nature may accom*
purgings which usher it in. In some cases, in- plish this without aid, yet the assistance of art is
deed, this irruption of bile is prevented from • generally required to ensure its attainment. The
taking place, until an advanced stage, by spasm ^brilc symptoms attending the early stage of the
of the common duct, extended to it from the ' disease, unless in some instances of its epidemic
duotlenum, as more commonly occurs in the third I prevalence, are merely the consequence of the
variety of the disonlur. When the various causa I pain, spasms, vomitings, and general commotion
now referred to combine to produce the disease, | of the ner\-ous system, and usually subside im-
particularly in persons of a nervous and irritable j mediately these disorders are allayed,
temperament, and who have neglected, for a con- | ii. Ciioleiia Flaiulenta, FtatuUnt Cholera ;
siderable time before, the state of the bowels, and | X'^^f* f^P^* ^^- i ^^* Sicca, Lat.
secretions poured into tliem, it cannot be a matter I 12. Defin. Vomiting and verging ran, sone-
of surprise, tliat its symptoms assume the severe { times retchings; gripings and spasms of the ab'
form described by Sydenham. j dominal muscles, with great atuL oppreuiveflatu-

10. Symptoms, — DiliouR cholera, in whatever ■ /«itc«, temporallif relieved hy eructations, and
state it occurs, differs chietly in its degree of se- dejections ofjiatus,

verity. It is chiefly characterised by anxiety, | 13. I'liis variety was formed by Hippocrates,
and by painful and violent gripings, evidently ! continued by Sydenham, and, aRer having been
proceeding from spasmodic contractions of the ! di^ontinued by the majority of modem writers^

alimentarv canal, taking tlie duodenum for their
point of cieparture, and occasioning the continued

who, if they at all remarked it, considered it
rather as a form of colic than of cholera, wat

or frequently repeated rejection of their contents ; again distinguished as a species of this latter dis.
by vomiting and purging. Owing to the ana- : eaa^c by Dr. Good. It is veiy rarely met with in
tomical connection of the great sympathetic or practice ; and generally holds an intermediate
gangtial system with the voluntary nerves and ' rank between flatulent colic and cholera, some-
other parts of the frame, the spasms extend to I times approaching more nearly to the former.

the abdominal muscles, and muscles of the lower
extremities, — the testes being forcibly retracted to
the abdominal ring, — and are accompanied with

In none of the very few cases of this descripdoi
which have come before me (not exceeding two
or three), have I observed a natural secretion of

p;rcat pain. The tongue is dry or clammy ; thirst j bile ; but, on the contrary, the liver has evinced
IS very urgent, and the urine scanty and high | signs of great torpor, and the whole digestive
coloured. The pulse is at Hrst full and frequent ; j organs have been manifestly enfeebled, long pro-
but, as the disease continues, it becomes smaller, tracted dyspepsia and hypochondriasis having
weaker, and more rapid. At more advanced existed previous to the attack,
periods, the spasms sometimes extend to the arms 1 4. This form of tlie disca«e is chiefly cht-
and hands. The symptoms often continue with ractcrised by spasms of the alimentary * canal,
little variation for some hours ; but, when the ' apparently excited by acrid, rancid, and indi-
attark m severe, seldom without the patient's ' gestible substances ; and by an irritating gas,
strength being p^reatly reduced ; the countenance i either secreted from the digc&tivc mucous surface,
at last becoming anxious and collopscd ; the r or generated from the decomposition of the im-
breathing frequent, interrupted, and laborious, pcrfoctly digested food. ( See articles Colic and
and sometimes with singultus; the pulse feeble. Flatvi.kncy.) 1' he painful and flatulent griptng
irregular, and intermittent ; and the extremities is accompanied with severe spasm of the abdo-
cold or clammy, with leipothymia or fainting. minal muscles, anxiety, occai>ional retchings,

11. Duration and Frogna»is. — The cholera of flatulent irritations, and calls to stool, with slight
temperate climates is seldom fatal, unless when it tenesmus, and very scanty, oficnsive, pale co-
is more than usually prevalent, after very rainy \ loured, and watery evacuations, with flatus. Con-
and hot seasons. IWt, when neglected or im- < siderable depression of the powers of life, acceler'
properly treated, especially at such times, a fatal j ation of pulse, pale, anxious countenance, cold-
iri(:ue may occur, but very rarely in loss time . ness of trie extremities, and sometimes alarming
than twenty-four hours. In milder cases, it may sinking, suiiervcne, when the disease has been
extend to two or three days, and then terminate > neglected.

either favourably or unfavourably, most com- | 15. Causes, — This rare form of cholera chiefly
monly the former ; the vomitin«r, pur>;ing, and ' appears in the debilitated, and those of a melan-
apasms subsiding, and entirely ceasmg, the pulse ! cliolic temperament ; and is generally excited bya
becoming slower and fuller, and the countenance ' surfeit, by cold drinks when the iMxly is overheated,
resuming its former expression. An unfavour- | by the use of cold or unri|)c fruits, particularly
able it>sue is indicated by a continuance of the ,' melons, water-melons, cucumbers, unripe plums,
purging and vomiting, particularly after sub- I mushrooms, and animal poisons, especially the
stances arc taken into the stomnch, a hurried, j rank parts of bacon, or ton{;ues, sausages, &c.
gasping respiration ; great frequency, feeblcnes*, ; when kept too lonfr, or insufl^ciently cured j also
irregularity, and intermissions of the pul^ ; col- by unliealthy or atalc flsh. and by cold or mois-
]ap<« and paleness of the countenance ; coIdne!^s ture after having been exposed for some time
and pulselessness of the extremities, with anxiety, ■ previously to a high range of temperature. The
and frequent faintings, 6cc. In general, how- author was very recently the subject of on attack
rgr, even whw k(t to itself| the dueaM operate! ! as described above, from having parttken ni

336

CHOLERIC FEVER OF INFANTS— Treatment.

the mesenteric glandf are often enlari^ed ; the I every fifteen minutes. Of this treatment I have
liver is sometimes darker, and generally much I hail no experience. In cases where the more
larger, than natural ; the gall-bladder is occaMon- bulky medicines are not retained, the plan of
ally filled with bile ; and the spleen is manifestly giving uiinute doses of calomel, adopted by Dr.
conge*<ted. In a few instance)*, the intestines have Df.uKFJS niay be followed. lie directs a quarter
been found more remarkably inflamed, and ad- 1 of u grain of calomel, intimately mixed with half
herent by means of exudations of lymph on their | a grain or a grain of sugar, to be placed dry,
peritoneal surfaces. In the more protracted ca^rs, ! every hour, upon the child*6 tongue, until the
effusions of serum are found within ttie cranium ; stools become more copious, less frequent, and of
but, in recent cases, the brain pn.«euts little or ! a dark ?reen colour. When this change is ef-
no morbid appearances beyond Kiight congestion. fccted, the potvderft arc to be gi

7. E, In Nature, — The symptoms, and the
appearances after death, clearly Bhow that this

given less frei[uently.
After the bowels have been well evacuated, he
prescril>es an injection in the evening, with a few

diseitM consists of inflammatory irritation, often i drops of laudanum, according to the age of the
rapidly pas<in^ into inflammation of the greater | child ; and if the disorder is not much abated,
part of the mucous surface of the stomach, and of : he recommence*^ with the calomel powders as
the small and large intestines ; frequently accom- 1 above, on the following morning, repeating the
panied with deprfs^ed vital energy of the frame, injection at ni<;ht. I have never tried this prac-
tice, having found the means recommended in
the preceding paragraph ($ 8.), with those about
to be noticed, geneniUy succes>ful.

10. In the more acute causes, especially when
fever is early developed, and much heat of the
abdomen or uf the head is complained of, the dis-
ease should be viewed as being entirely dependent
upon inflammation of the mucous surface of the
di^'estive tuU;, and nfl^eeting the brain sympa-
thetically. In these, leeches must be placed
upon the epigastrium, or behind the ears; if ap-
plied to the former situation, a succesMon of warm

congestion of the liver, and a morbid state of the
abdominal secretion^, and occa-Moning sympathe-
tic disorder cither of the functions or of the sub-
stance of the brain and its membranes.

8. II. TiiEATMENT. — At the commencement
of the di^ase, demulcents may be administered.
Dr. Rush recommends an ipecacuanha emetic ;
but Dr. Dewkes disapproves of emetics — an opi-
nion which is agreeable to my experience. I
have usually first had recourse, in the slighter
erases, either to hydrarg. cum cretn or calomel, in
fre(]uent doses, and combined with magnc«ia or
soda ; or to nitrate of potash with the carbonate
of soda, in demulcents ; and to the application
of leeches on the epigastrium, whenever ten<ler-
ncss of this region could be detected. Alter a few
of these powders have been taken, a do-sc of calo-
mel, sometimes with a grain of James's powder,
has been given at bed-lime, and castor oil the
following morning : at the same time, oleaginous
glysters have been administered, and, as the
symptoms abated, those of on emollient kind
employed. If the patient be not very young, a
few drops of tinct. opii, or a little «yrup of pop-
pies, may genenilly be added to the injection. The
warm bath, or the semicupium, should never be
omitted in the treatment of this disease, the sur-
face being well rubbeil with a coarse towel upon
coming out of the bath, and the child afterwards
placerl in warm blankets. I'hese means, if early
resorted to, will generally succeed in the less
severe cases occurring in temperate climates.
But, in the more intense atatrs of the malady,
medicines given by the mouth will not be re-

f»oulliccs should follow them, a full dose of ca-
omel, intimately mixed with a little sugar, be
exhibited, and, soon afterwards, an oleaginous
injection (olive oil or castor oil, or both, in gruel,
strained mutton broth, or any other demulcent
vehicle) thrown U^). If these measures fail of

firoduciu^ the aiivantage cx})ccted, the back,
oius, or insides of the thighs, should be rubbed,
twice or thrice daily with either of the linimenti
F. 29(j. 300. 311., parlicubirly upon coming out of
the warm-bath, or semicupium, which ought to be
employed once or twi(;c daily, and rendered more
eflicient by adding salt or mustard, or both, to it.
The application of bli>ler8 for two, three, or four
hours, and re-applicaiion of them for an erjually
short time in another place, may be subsequently
h.id lecoursc to, when the preceding measures do
not answer the purpo-^ for which they were
directetl. In the more severe cases, pailic.ularly
when the motions are blootly, a mucilaginous
diau^'ht, with cantor oil and two or three drops of
laud:inum, may be ^iven ; and, if it be not re-

tained ; and such a dose of opium as will not be j tstint-d, an enema, consisting of the same ingrc
rejectetl, may be injurious. In these, it will be : dienU, may be admiiii.stere«l, or any of the ene-

{>refemble to commence with the application of mata contained in the ApiKMulix suited to the
eechcs to the epitj^astrium ; and to endeavour to > circumstances of the case, and proportioned to

procure more healthy evacuations, and a dis-
charge of bile downwards, by re j en ted injections,
consisting of a solution of coumion salt (about

the age of the patimt.

11, In tlie ajlvancrd s-iagc of the disease, espe-
cially when it paoi-s into a dysenteric state, and

two or three tc-a-spoonfuU) in warm water. I'he • when the exhaustion is great, and the stools are
frequency of the stools ouj^ht not to prevent the | ofl^'n^ive, {.mall do-^es of the chlorate of lime, or
administration of the injeciion ; which will gene- | of potash, in an aron-.ntic water, or in mucilaginous

rally relieve the vomiting and other syniptonw as
soon UK bilious or fa?cal evacuations arc procurcii.
9. When the d si-ase app«.urs to be brought on
by impropi.T in{;c<ta, the vomiting may be pro-
moted by dilnenti. Hut the object shouhl b; to j

quiet the stomach a«« soon as pi»s^ihle. For tliis i with the chlorates, or either beloix* or after they
purjmsc Dr. • i.wrts n commends, for very voting I havr been \rm\ : —

children, as well as lor those who are older, a tea- ■ j^-„ ,^j. ^ Uydrr.ift. rum Creta Rr. j. ; Magn. Cak-ln.
l/ul of strong coffee, without sugar or milk, I gr. iij. ; Cium. Acacis et Saccti. Albi oigr. v.} llmH.

diaughts vr injections, will be very sorsiceable.
In this chronic period, when the disorder lapstra
into the form of diarrha'a. proceeding from chro-
nic iiiHanm:a!i«m of the intestinal miirous surface,
the foll«>winy: fiowders may be given alternately

332

CHOREA AND RELATED AFFECTIONS-- TaiAniiNTOf.

admitted, that tbe poisoa of the tarantula spider
is most successfully counteracted by the exciting
influence of music on the mind« and the profuse
perspirations nroduced bv continued dancing. A
MTiiter in the Nsto York Medical R*poiitory details
an instance of a convulsive disorder occasioned
by ^e bite of a spider, and cured by music. Mr.
Kinder Wood has recorded a case, which ori-
ginated in disordered menstrual function, with
cerebral symptoms and painful aflPections of the
nerves of the face, that resembled in every respect
the malady to which the German physicians gave
the name of chorea.

20. The disorder, also, which has usually been
called the ** Leaping Ague " in Scotland, seems to
be very closely allnd to the original chorea. It
is described very nearly as follows by a writer in
the Edinburgh idediealand Surgical Jifumal : —
Those affected first compUin of a pain in the
head or lower part of the back, to which suc-
ceed convulsive fits, or fits of dandng, at certain
periods. During the paroxysm tbey distort their
bodies in various ways, and leap about in a sur-
prising manner. Sometimes they run with great
velocity even in dangerous places, and when
oonfinoi, climb or leap from the floors of the cot-
tages to the rafters, or swing by, or whirl around,
one of them. They often dance or leap about
with greater agility, vigour, and exactness, than
they are capable of exerting at other periods;
the affection apparently consisting chiefly of a
morbid and irresistible propensity to dance, tumble,
and run about in a fisntastic manner. Cases of this
form of disorder have been detailed by Tulpius,
Penaoa, Rbil, BrOckmann, Westpual,C rich-
ton, PiEDAONEL, Laurent, and others. In M.
Piedaonel's case there was a propensity to run
forwards, until the patient, a man, dropped down
exhausted. On examining the brain afUr death, tu-
bercles were foiind pressing on the anterior part of
the hemisphere* A similar instance occurred in
the father of a medical friend, and terminated in
paralysis. The subject of M. L a u rent's case was
propelled backwards with considerable velocity.

21. Dr. Watt has given the history of a dis-
order, which he has called chorea, or periodical)jac-
titadon, in a girl of ten years, that was preceded
by excruciating headach and vomiting. To this
affection of the head succeeded the propensity to
turn around in one direction on her feet with
great velocity like a spinning top. This propen-
sity subsided after having continued aoove a
month, but was followed by an exasperated re-
turn of the headach, and loss of power over the
muscles of the neck. She was afterwards aeized
by a different kind of motion, occurring in fits,
which lasted daily, from two or three, to six or
seven hours; this consisted in placing herself
across the bed, and rolling rapidly round on her
sides from one end of it to the other. When laid
in the shallow part of a river she rolled around,
although at the point of being drowned. The
affusion of cold water did not stop the rotations,
which were about sixty in a minute. In a little
more ,than a month these movements were re-
placed by others of a different kind. She now
laid herself on her back, and, drawing her head
and heels towards each other, raised her trunk,
afterwards falling with some force on her back by
straightening her body. These motions were re-
peateid ten or twelve times in a minute, were con*

tinned for about five weeks, and were then fol«
lowed by the propensity of standing upoo kcr
head. Having raised her feet perpenoiciilvly
upwards, she fell down as if deaa, but iaftudv
placed herself on her head as before, agaia ftlf,
and continued to repeat these movements for fif-
teen hours a day, and as rapidly as twelve or 6^
teen times a minute. The affection had resiited
emetics, cathartics, local depletion, blisteriDg,
setons, &a, but disappeared after a spontaneous
diarrhoea. Dr. Watt refers to two similar caso
which had come to his knowledge ; and anotbct
instance has been adduced by the writer, under
the designation of ** Inquirer, of an instmciive
article on tbe subject, in the third volnme of xha
EdirUmrgh Mediail JoumaL Mr. |HuNTti Las
also given the particulars of an instance of rotstorf
affection resembling chorea, in the twenty-Uuni
volume of the same work.

22. Dr. Robertson has described a peculiar
form of convulsion, in many respects like chorea,
which spread at one time (1800) as an epideinic
amongst a sect of rel^ous enthusiasts in the fitiies
of Tennessee and iGntucky, evidently from ibe
influence of imagination and irritation on morbidly
excited minds. The seizure was violent, and dt»-
tinctly convulsive at the commeooement, but it
usually passed from this state into one more
chronic, and more nearly approaching chorea.
Persons thus affected are descrioed by Dr.RoscBT-
SON as being continually interrupted in their cod-
versation by the irregular contractions of ibe
muscles, and as having no command oter tbe«
contractions by any effort of volition ; lying dowa
in bed does not prevent them, but they almvs
cease during sleep. Hemissions and exacerbatioos
are common, but occur without regularity. Dano^
the remission, a paroxysm is often excited by the
sight of an affected person, but more frec^uentlj
by shaking hands with him. The sensanoos of
the patient during the fit are said to be agreeable,
and are expressed by the enthusiastic by Uughiog,
shouting, dancing, &c., followed by fatigue, sad
a sense of ^enenu soreness. Tbe affection at la«t
becomes slighter by degrees, and finally disap-
pears. Cases of similar nervous disorders, aad
apparently intermediate between chorea and con-
vulsions, and often partaking of many of ibc
features of hysteria, as well as the affection called
MalleatiOf have been detailed by Tvlpios, Hom-

TIUS, MOROAGNI, WiCHMANN, MaJSKOIE, Sttd

Others above referred to ($ 20.). - It k difficult to
believe, however, upon perusing tbe particvlars of
the foregoing cases, that tbey are ailogeUier ibe
actual phenomena of disease. It is very probable
that tlie morbid affection of mind,— the disorder
state of the desires, orjof the mental impressioos.^-
exalts the derangement of the nervous system to
that singular pitch, of which thew cases sre rare
examples. (See arts. Convulsions, and Hts-

TERXA.)

23. VI. Treatment. — A. Conspttiui pf tki
treatment, — Purgativet have been rBCODoeoded
in chorea by Sydenham, Wrytt, Hamilton,
Cheyne, and others. Sydenbam, however, dui
not confide the cure of this affection to them en*
tirely, for be also directed occasional depletion*
with tonics in the days intervening betwcea the
exhibition of the purgatives, and narcotics at bed*
time. Emmenagoguet, particularly aloes, myrrh,
aseafoetida, hellebore, savine, castor, the nilir'

836 ' CLIMACTERIC DECAY — Symptoms.

in which 0io suppression of the rheum&tic affection
of the joiDts by the use of embrocations and lini-
ments was rapidly succeeded by the appearance
of internal disease, the application of such riMnc-
dies to the external scat of the rheumatic disorder
should not be resorted to.

36. In the irregular forms of chorea, particu-
larly those which present more or less of an hy-
steric characlcr» the functions of the uterus, and
the circulation of the brain or spinal chord, or
both, are often diMordercd. In these it will be
requisite not only to evacuate the liowcls freely,
but also to allay uterine irritation, where it seems
to exist, by leeches applied to the tops of the tUghs,
or cuppin<; over the sacrum, and to promote the
monthly evacuation, when scanty or retained, by
purgatives and emmenagogue**. In many cases
of this description, the application of a number of
leeches to the occiput, neck, and behind the cars,
the cold affusion on the head, or the shower bath,
with warm clothing on the lower part of the body,
and due regulation of the moral cmotioa^, will
materially aid the treatment. The more
attack assumes the characters of tonic convulsion,
the more requisite will it in general be to have
recourse to local depletions, cspcciitlly if the afTcc-
tion occur after puberty, and be connected with
interrupted menstruation.

37. During convalescence, and even in the ad-
vanced course of treatment, change of air, agree-
able amusement, exercise in the open air, (the use
of chalybeate or aperient minenil waters, and a
light nutritious diet, commencing with warm salt
water bathing during iho treatment, and conclud-
ing with cold salt water bathing in advanced con-
valescence, followed by smart frictions of the
surface of the body upon coming out of the bath,
will materially promote and contirm recovery, as
well as prevent a return of the disease.

ChinifK. Soc. vol. ir/p. iS.^Kimltr Wooi, In Ibid
t. vii. p. 237. — n'att, in IbUI. vol. v. p. 1.— Salter, Iq

Ibid. vol. X. p. 218. — Gre/fory, Ibid. vol. xl. p. SXI mu

Ian, Reporu iin the Di«ca»cs o( lA»ndon, p. 245. ; and Med.
.ind l*hy«. Juurn. vol. vii. —Coxr, ftlcd. and Phy«. Journ.
vol. xiti. p. m'u, and vol. xviit. ik 221 . — Paterton^ in Ibid,
vol. xiii. p. 119.. vol. xv. p. 127., and vol. xviii. p. iB(.^
Peltz^ Ibid. vol. lix. p. •I.54 — J&r«/,DeZincoeJuMueUfa
praecipuc in Chorea. Jen. 1S12. — Mattm, in Lend. Ued.
Keiioa. vol. V. p. 14S. ^ BediiigJtfM, CompeiKl. oT Med.
Practice, Lond. IN in. p. 52 — Copland, in Lond. Medical
KcixMitory, &c. vol.xv. p. 23 — Prickard^ in Ibid. vol.xxL
n. l.—.Itoesfr^ in Hufcland'^ Journ. dcr Pract. Heilk.
Nov. 1824L ^SerrrSf Ijancet, vol. xiii. p. 1^3. — AlfpramdL
in Gioniale Analit. di Med. Milano, GuiKnn,18'J8. ^Ptr,
rari, in Ibid. Novcinb. 1828. — Gf^mry, Med. GaicCte,
vol. i. p. u\. -^Armstnmf, hix Lecture* on Medicine, Lan-
cct. vol. viiL p. 7U. — Clutterhuck^ I^scturc* on Med. lUd.
vol. xii. p. A'J^. — Pitdagnfl, in Mi^Jtndie'* PhyriolMy.

Phy». of Dublin, voL iv. n. III. — iiriffith, Philad. Mc7

Mus. 18(iti — /Urivst in Kdin. Med. and Surfr. Journ.

vol. viii. p. :IH. "Hunttr, in Ibid. vol. xxiii. p. *Jil. —Jtf,

/n\Vg, Ibid. p. TiZ.'^Stuari, in Ibid. vol. xxviiL p. 971...

L'wiHSf in Ilnd. \ol. viii. p. 408. — 5 ican. in Ibid. vol. xxii.

p. f»| — Crichton, in Ibid. vol. xxxi. p. SCO. — A/naaoii, Re.

, Will i.cnrchcj on the ElfccU of Iodine, &c. p. TSi}. — Kllkisom,

e the ' '^'^'^^*- "^ ^('^l- ^"^1 Chirurfc Soc. vol. xiii. p. 252. ; and

Med. Gazt'tte, vol. vii. n.&V> — Chiskolm, On DifeaiciaC

oMfi^, in tnc American Journ. of
Milt. .Seicnci'5, vol. ix. p. did. — JTroiMi, Medico-Chlruni.
cal Review, &c. vol. xv. p. :i26.>-JoAiMO», in Ibid, vol.xr.
p. 181. — &riv*. Revue MMicale, 18t7, t. iii. p. 518.

CLIMACTERIC DECAY. — C/imorteric Dif.

eme.

Cr.ASHf. 3. Class, 4. Order (Good). I,
Class. V. Order (Author^,

1. Dr.Fi.N*. — (ienerat decline of the vital pcwen^
at the ttf*e of senescence, without any evident eaute,

2. The ancients believed tliat very important
changes took place in the economy at certtia
period.^; the hrst being the seventh year, and
the subs(;(|uent ej>oclm answering to the numben
resuliinjT from the multiplication of three, seven,

p.-irti.]). 14'J., |>art Iii. caj». vi. p.t'il.— /yi/;-««v.'M.', In.stitut.

vol. iii. p. i-MC. — Pt'itattti, Saggio d'()t-<>i>rva2ir>ni, n. f»

Mt'rk, Mwacuni dcr Heilliundc, b. iv. p. 1«W. — .S7t>//, Hat.
M;tl. iwrs iii. p. 4(J.'»., ct par> iv. \\ 4«»'». — JW'ntit, N'.ndir ichl
von dcra Krankenin»titut zu Krianjr. ITS.^. — //<i///in^iT,
N. M;«j». b. ix. p. IS*;.-- A'r^-rr, in l'hu't'% Xuso>r. I'liilos.
t. il. p 14. — (ifa»h, I'liil. Tranj.. vol. Iiti. I7im. — Dc Ham,
Rat. M«l. p.nr. iii. p. iltii!. — .SV</;r;i. I);sniTt. Mori*. C.vus,
.Sp. &.C. I'lMwiI. 17S.'». — Saliiifnt, I)e Morh. V.1U01. INKtli.
Vion. llf^'X^Piouc'iHit, ObsiT. Mo»l. 'J'lihinp. 17S7. —
n'/iUt\ lltlin. M«l. ('timiiifiil. vol. iv. p. r,XK—Harf, in
H»id. vol.i. p.76.— '^//I'r, in Rml. vol. iii. p. Ifsl.— /IVi/Avf,
in Ibid, vol, x. p.^^H. —Ar/mtrnne, in ll»!«l. vol. ix. p. .•;i7.

Phj

Sti. Viti, Hvo. PhiLvl. \i<)'K—llanwt:n, On Purp.itivo Mc.
dicint's ch, s'x.—PL'nk, I)c .Morbis Infantum. Vkmi. 1^)7.

>lk'Tho

n.As, who derived it from the Egyptians; and,
althouj^jh its truth has lieen denied'by many emi-
nent physicians, it has been belitsved in by othen.
J'he changes which take place at these epocb
arc of two op]iosite kinds; that of renovation,
and that of decay. It is the latter of these wliich
will be hen.» considered.

;i. I. Symptoms. — This disease has been very
minutely described by Sir J I. Uamohd. It
usually comes on insensibly. The patieut first

rKltmtl'ltn-.! r\t f.tli^'.im ..nv^n nK..!.* ^....-aI L*

; ()i«. do l>b. M-ct. ii. *, x.^Strah.ston, Thotijilus, complain-. 01 laliguc upon slight exertion ; hia
v=«. anti I'racl «rc. Yoric, 17I«.— ^.»A*r/»»w, On ("horea nj»})etite bec

becomes impaiicd ; his nights are dis«
turbed or sleepless, and his mornings unrcfreshcd.
The tongne is somewhat white ; the pulse a littlo

ionally
the

tfr/f*. in iiornsi Arcniv, &r. i». in. yr^ti. — urucKtu.inn, i "" *". "•»> "•■^|*"rv« «» nn«rii. j^hv uiiiiv q

n Ibi<L Jan. Hll.p. 'i.ctlKl?, p. l»w. ; vt Journ. do MlhI. I not deficient, but the bowels are sluggish, and

;„[''r*i: A'r'-jr::.'t*//,«"s;:;.. m™«k t^^. • ir-'"'- r}\ 'r^^- ".~ <><=.™'i'»'='"y feu shooting

In
t

vol.

INnit. t. xviii. p. ijJJj. — /-'mimA. .Ada ln^tlf. I'lin. Vil.
iicns. t. iii. p. .'il. — Tht'uisink, Mfobaclit. der K. K.
Jfwephr- Academic, li. i. n. :i.—Ki'ticr/infi, De Chorea Sti.
Viti. Erf. IfAKh — SclMt'jTi'r, Kinderkrankh. p. -J^x— /W/,
FieberichTc, b. iv. p. OM, — Martin, Ttaai, of Med. and

loses nil its powers; the emaciation is greater*
the lower limbs are num.' (edematous ; restlessnesf
through the day and sleeplessness through the
night, increase, and all the vital maidf«ftatkui^

360

COLIC — Its Pathology.

the organ aflTected, can be attended with no dan-
ger, panicularly when the inflammation is acute,
and chiefly attacks serons surfaces ; and it may be
in some instances productive of benefit ; but we
are still in want of faithfully observed facts to
illustrate the effects of this treatment in a satis-
factory manner. In hemorrhagic aflPectioos, a
judicious use of cold is oflen of great service — as
the cold affusion or aspersion, the shower-bath,
and cold sponging, in epistaxis and haemoptysis;
iced fluids taken into the stomach in hasmate-
mesis; enemata, and injections per vaginam, of
cold liquids, in haemorrhage from the bowels,
meoorrhagia, and flooding after delivery. Dr.
Drake, of New York, has recently recommended
very cold air to be respired in inflammations of
the respiratory organs; but, from the admitted
influence of cold air in increasing the activity of
the respiratory functions, and, consequently, the
phlogistic disposition of the circulation, it appears
to me a practice of doubtful efficacy.

BiDUoo. AMD Rhvbe.— .i. Pathohgieot Operation qf
Coldf ^c. — Q. Curthu, De GcatU Alexand. Mng. 1. vil.

cap. 5 — Boute, Hiitory of Cold, 4to. Ixmd. 1683 Weiicl,

Dc FriRore Morbirero. Jen», IG96.— J^Awdc/k}^, Dc Fri-
gidU Nervorum Systematts inlmicU. Lugd. Bat. 1736.—
QuclnuUxt Prog, quo Frigorit AcriorU in Corimre effectu*
cxpcdit, &c., in lidtleri Dup. Med. vol. vi. 1758.— Ca/Tw/,
CH»erv. Anat dec. L p. S. — GmetH, Voy. en SiMrief t. i.

f. 381. —GUu/back, De Mortrisa Vcstitu inaufflcienULftc.
'raoc. 176S. — Rosen, Anat. p. 148. — LroaAanf, De Frig.
Atmoqih. EfRKst. in Cornui Humanum. Lips. 1771.—
SaOer, Pbydol. l.xii. ^ ISL— Ckf//CTi,DeFrigoreetejuique
Viet£fi^tibu«in Corpus Humanum. Edin. 178a— Oirr/f,
in Edin. Med. Comment, vol. xviit. n. 37. p. 257. — A>
berden. In Philos. lYans. 17a') and 179& — /*mo, De Med.
Brasil. I. L — Farat et Martm. Actes de la Soc. de Sant6
de Lyon, t. i. p. 300. — J2i»A, Med. Inouirles, No. a— I'.
HumboUti^ Vcrsuche iibcr die Ocrciztc Ncrvcn-und Mus.
kelfaser, b. ii. p. 221. ct 238^ — GiVrnmni, in Hartes N.
Journ. dcr Med. Literatur. b. x. st. 1. p. 5k«-Aozier(*, Sur
la v6ritablc Mode d' Action du Froid, Xc. Journ. G^n. de
MM. t. XX. p. 435. — Art. Froitt, in Diet, de Scicn. M6d.
t xvii. p. M. — M. BeoMffN^ Dcs EflTets du Froid, avcc
un Aiicr^u sur la Campagne de Rursie. Sva Paris, 1817.
Translated, with adilitions, by J. CicndiHning, 6vo. Loud.
1826.— ir.-//iVr, On I>e«th from Cold, 'JVan*. of Medico.
Chirurg. Society of Edinbi voL L p. 84 — Oendinnmg^ On
Cold as a Cause of Disease, Ac, Lond. Med. and Physical
Journ. for June, July, and Sept. 1832.

ii. Therapeuiicai ActioM fff Cold. ^SttrtJMmut, De Uiu
Nivis Medico, cap. 1.5. iSl.^De Parrot, Animadver-
•tones de Nivis in Potu Usu, 8vo. \(Sl.^ yaltisneri, Del*
Uso e dell* Abuso delle Bevande e Bagnature Calde o
Frcdde, 4ta Modena, 1725. — F. Hqffmann, De Potus
frigid! Salubritatc. Hala*, 1729. — AicAA-r, De Salutari
Frigoris in Mcdicina Usu. Goet. 1740. — BhiAtne, Mortw-
rum Curationos ikjt Frigtis. Goct. 177a — Limnnu, in
AmoenitAt. Acad. vol. vii. Na 13rt.— Fran*, Interpi Clinic
▼ot. i. p. 437. et seg. — K/ett, Dc Epilhematura frigidorura
Vi atque Usu,&c. Erl. 1794. — Bom, De Cal. et Frig. Usu
Med. Ro«t. 1801. — Hn/eiamt, Bibliothek der Pract.
Heilk. xU. b. iil. st p. & — tVeber, Horn's Archiv. ftir
PnicL Med. b.vl. p. 237.— J. Cmrrie, Med. Reports on the
Eftiecta of Water, Cold and Warm, as a Remedy in Fctct.
Svo. Liverp. 1191.— Drake, On the Keq>lration' of Cold
Air in Pulmonary Diseases, Amer. Journ. of Med. Science*,
vol. IL p. 22a ^ J. CofiUauLOn the Aintsion of Cokl
Water in the Treatment of Diseasce, and of its Mode of
Operation, in Lond. Medical Gasefcte, vol. x. p. 59. and 78.

COLIC. — Der. and Syn. from ««Xo», CoUm.

KwXixev aXynfAa, Gr. Colicay Passio Colica,

Dolor Cotieus, Enteralgia, Colicodifnia, Tor-

mim, Auct. Var. Colique, Fr. Das Bauchgrim-

men, die Kolik. Germ. Dolor i Colici, ItaJ.

Belly- Ach, £ng.

Classif. 1. Clau, Nervous Diseases;

3. Order, Spasmodic Affections (Cullen).

1. Class, Diseases of Digestion ; 1. Order,

Affecting the Alimentary Canal (Goitd),

I. Class, I. Order (Author, in Preface),

1. DEnN. Severe griphg paint in the bowels,
with costiveness, and often trith vomiting,

2. Colic was formerly considered as seated

chiefly, if not entifely, in the colon ; but maay
writers of the last three centoriea have applied the
term to acute pains of the bowels, aibeoded by
costiveness, and unaccompanied by fever, arinDg
either from a primary affection of them, or from
disease of some other viscus in their immediate
vicinity, with which they are connected, and
often sympathetically affected, through the me«
dium of the ganglial nerves.

3. The first mention made of the disease, by the
denomination Colieus Dolor, is to be foood in
Celsus and Pliny ; and, according to Scnuebt
and Tronchin, the same name was used by
Them ISDN and Fiiilon, physicians of the Au-
gustine age, when, as Sprenoel justly suppose,
colic must, from the manners of that peiioa, iiare
been a common complainL But, although the
term ^olic appears aot to have been ia oie, it
cannot be supposed that such affections were
before unknown. It is more probable that they
were included under the general appellation
of abdominal pains, in use from the time of
Hippocnite.s. The greater number of modem
writers have divided the disease into ccrtaia
species of varieties, according to the presumed
nature of its exciting causes and patnological
states. Sauvaoes presents us, accordingly, with
no less than 22 varieties. Dr. Cvllen arranges
the idiopathic states of the colic into, 1st, 11k
Spasmodic, either with stercoraceous vomiting, or
with inflammation superadded ; 2d, The CoSe «/
Poiion ; 3d, Colic from continued oonslipadoQ ;
4th, From acrid matters in the bowels ; 5ih, From
retention of the meconium ; 6th, From stricture of
the bowels ; and, 7th, From the obstruction occa-
sioned by calculous formations. Dr. Gnoa
adopts a nearly similar divi>ion to the foregoioc*
preserving the ist, 2d, 3d, and 6th varielifs; ani
substituting for the others. Colic from Sorfeit, lod
Colic from the generation of Flatulence — C it'
6ar/a and C. Flatnlenta. M. Par iset gives ibe fol-
lowing varieties :— the flatulent ; thesterconceou^;
the bilious ; the inflammatory ; the hacroorrhoidRl ;
the menstrual ; the spasmodic ; the metasutic ;
from calculous and other hard bodies *, the vcr*
mioous; from organic changes in the bowcb;
and from lead. M. Chomel divides the di^esM
into nearly the same varieties, and adds to them
that arising from acerb or acid fruits, and Tit-
mented liquors, or Coligve VegetaU, The oaly
additional arrangement of the fonns of colic,
which deserves l^ing noticed, has been givca by
SciiMiDTMANN, 88 follows: — .4. InflamtDator)
colic ; B. Sanguineous or plethoric colic ; ^'>
From substances passing through or lodged io
the bowels; D, From the metastasis or repre^
sion of other diseases ; £. Flatulent colic ; tad
F. Nervous colic. Each of these eonpmo
several varieties, according to die cicitiog aod
proximate causes.

4. Colic, according to the extended aoocpt-
ation of the word, arises from so many causes
and presents so many morbid relations, that •
satisfactory arrangement of its different states »
by no means an easy matter. 1 shall, bowercr.
attempt to group into distinct species those foniM
of the disease which resemble each other wo^^
nearly, or which aiif^e from intimately rel»t«J
causes, noticing the peculiarities or moiRctw^

f>resented by the principal varieties. Tho«
brms of colic which chiefly, or more im"^
diately, depend upon a morbid state of tbv

372

COLIC— Treatment op Bilious, &c.

it will other be independent of any marked dis-
tennon of the abdomen, or it ^'ill be attended
with tension and fulness, anxiety, a dark or dusky
appearance about the eyes and moutli, and with
thirst. Under these circumstances especially,
and in the more severe attacks, particularly in
the spasmodic, occurring in persons previously in
healtn, blood-letting should not be omitted ; and
even in doubtful cases, blood may be taken
either from the arm, or from the abdomen by
cupping or leeches, followed by fomentations
and poultices, — if there be tumefaction, by the
warm turpentine fomentation and injeciioo.
Heating carminatives and antispasmodics will be
injurious in all such cases, whether vomiting be
present or not ; and too active endeavours to
procure alvine evacuations by means of purga-
tives given by the mouth may increase the dis-
order. I have derived more advantage in these
cases from small and repeated doses of the car-
bonate of soda, or the biborate of soda, with nitre,
in camphor mixture or some aromatic water —
from the use of enemata and gentle frictions of
the surface of the abdomen with a rubefacient
liniment (F. 311. 313.) — than from purgatives.
In a few cases I have given the hydrocyanic acid,
either in full doses of the oleum ricini, or in the
oleum amygdal. dulcis. When judiciously pre-
scribed, this powerful sedative has a roost benefi-
cial effect in restoring the digestive functions after
the attack is removed. The hydrargyrum cum
creta, or the blue pill, with taraxacum, hyoscya-
mus, or extract of hop, may also be given after
the action of the bowels is restored.

55. B. Treatment of co/tc from injurioui in-
getta, S^-c, {§ 10.) — o. The state of disorder
proceeding from cold acid beverages will gene-
rally be soon removed by antacids, combined
witn narcotics, as ammonia, soda, magnesia, &c.

S'ven with opium, or hyoscyamus, and with cor-
als or carmmatives (F. 179.347, 348.); enemata
and frictions of the abdomen, as already recom-
mended (§ 51 .) may be also employed, according
to the circumstances of the case. — b. When the
affection is occasioned by cold, acerb, or indiges-
tible fruit or food, it will generally be necessary
to commence the treatment by an active warm
emetic ; and afterwards cordials, cardiacs, and
enemata (i 51, 52.), may be prescribed. — c. If
the complaint be produced by fish, Cayenne
pepper is an almost unfailing antidote. — d. If it
be occasioned by smoked or tainted meat, or
other esculents that have disagreed with the di-
gestive organs, emetics, and afterwards cordials,
warm aromatics, and stimulating clysters, with
frictions of the abdomen, are among the most
successful means. — e. Colic sometimes is a conse-

auence of indigestion, and of acidity or sordesin the
igestive tube, often occasioned by too much or
indigestible food ; it then requires a combination
of antacids with aperients or purgatives, as the
compound decoction of aloes, or the compound
infusions of gentian and senna, with soda and am-
monia. After the urgent symptoms are removed,
the digestive functions should be strengthened and
promoted by gentle tonics and deobstruent laxa-
tives (F. 214. 218. 362. 872.). Riciiter recOm-
mends for this purpose equal parts of assafcetida
and ihefel tauri ini;)?cfa/uni, especially in the form
of the complaint proceeding from acidity.

56, The colic of' infantt has been stated to

proceed chie6y from acidity of the frima w oc-
casioned by the quality or quantity of the ingesta
(§ 15.). The carbonates of the alkalies, mag-
nesia, and the preparations of chalk or lime, •iih
carminatives and cordiaU, are therefore raqoircd.
(See t . 616 633.). A combination of magoent
with the oxide of zinc is prescribed by Hicbtxs.
Magnesia, soda, or ammonia, in the aqua faoi*
culi dulcis or aq. anisi, and afterwards a dose of
fresh castor oil ; the semicupium, and, if it be n-
quisite, an emollient or oleaginous enema, to wbich
a little extractum rule, oleum aiusi,or tiocuita §»-
safcetide, has been added, will generally remou'
all disorder. If, however, these do not sood give
relief, the enema should be repealed, aod the
abdomen rubbed with an antispasmodic lini-
ment ($51, K 135.). If the complaiot occqi
about the period of dentition, the gumi ou^^ht
to be examined, and scarified, if any fuioes
or redness be remarked in them. If tiwse
means fail, those recommended in the section
on volvulut ($ 77. et teq,) must be pat u
practice.

57. C. Treatment of colic from morbid leerttim,
&fc, — a. The colic occurring in nem-binii vijtntt,
from retention of the meconium, is generally won
removed by a doae of castor oil ; aod. if it f«il.
by an oleagmous clyster, or by one cootalDiog i
tea-spoonful of honey and another of comouiD
salt, agisted by the semicupiuro, and the oeaos
staled above ($ 56.). — 6. Colic from MmaiK^-
tion offacal matter* (§ 19.), or from cooslipatioo
of the bowels, obviously requires par^ve
and oleaginous or saponaceous injections. Stoh
prescribed emetics in this form of the compUiot.
and was followed in the practice by Suu vmI
HosACK ; RivEiiius gave rhubarb and the tur-
pentines ; and Daglivi and Sydenham advised
cathartics and anodynes in oleaginous emuli^oof.
The preparations of sulphur, in doses sofficieot
to act on the bowels, have been praised bj
AcnicoLA and Rave ; and frictions and banda^
of the abdomen have been recommendtd b<
many eminent writera. In this form of ^
disease, more advantages will be obta'ned fiu:a
the repeated exhibition of medicines of a simp')
relaxing operation (see F. 82. 96. 430.). aMt>ti;l
by large oleaginous and saponaceous iojectioib
in the manner recommended by Dr. Ma&w»li.
^see § 77.), than by cathartics, which oiay im-
tate or inflame the upper parts of the digouve
canal, before they can reach or affect the ps-t*
where obstruction exists. Spirits of torpeotioe.
with olive or castor oil, when perfectly dilfosed
and suspended in a suitable vehicle, are «•
tremely efficacious in this state of disorder. Ab
ounce of the spirits, with two or three of e>d>«r
of these oils, m about nxteen or twen(vf«>u'
ounces of a mucilaginous decoction, should \*
slowly but steadily thrown up by means of ^^
enema apparatus, the pipe of which may be pro-
vided with a guard, to prevent the regurgiUMs
of the fiuid. In order to facilitate the passsfe
of this enema along the colon, the patient luiy
be placed in bed, with the pelvis constdersblT
elevated, and friction ef the abdomen may ^
employed during and after the injection of '^
If there be no nausea, the following way j*
taken, and repeated in six or eight boan, if >t ^
requisite : —

No. 18$. 3 Pocassc Bitart Inpuiv. }i«s^-3U-^ ^^

378

COLIC AND ILEUS— TaxATMorr Of.

marks, it should bd frequently repetted, and its
effects carefully watched. Although the infu-
sion of tobacco has been chosen for injection by
ViCAT, Fowler, Campbt, Comraoi, Hupblaud,
and Abbrcrombib, yet I agree with Sydbwham,
De Habn, Saoar, Quarin, and many others, in
considering the smoke superior to the infusion ;
the former being adopted by some merely on ac*
count of the greater facility of conveying it into
the bowels, and without reference to me very
different operation of these two modes of employ-
ing this powerful medicine. But in oases where
inflation by air or tobacco smoke is adopted, pur;^-
ative injections should speedily follow, as di-
rected by Hippocrates, if « vac nations have not
taken place ; for the smoke may even pass out by
the mouth, and yet copious motions may not
otherwise be procured. Besides these means,
yeoit has been administered as an injection in
warm small beer, with the intention of evolving
its fixed air in the bowels, and thereby extricat-
ing anv unnatural convolution or slight invagin-
ation that may have been formed. Sulpkurie
mther has likewise been thrown into the larse
bowels, with the expectation that its fumes would
operate in a similar manner. Antimonial mne,
and the powdtr or infution of ipecacuanha have
been prescribed in enemata, with the view of re-
laxing spasm, in cases where it is presumed to be
the chief cause of obstruction ; whibt the infusion
of poppies and of chamomile flowers, various ano-
dyne, saponaceous, laxative, and oleaginous in-
jections ($57. 66.), have also been directed with
the views already stated.

78. /. Bathtt ^e. — Tepid or warm batht are
sometimes useful adjuvants in the early stages of
the disease, and are generally recommended.
Cold Jiuidt taken into me stomach, and thrown
into the large bowels, in considerable quantities,
and cold epitliemt constantly applied on the abdo-
men, have been prescribed by Bureau *, Maret,
Ranob, Stcidele, Darwin, Conradi, Bald*
moBR, Smith, and Abbrcrombib. The dashing
of cold water over the lower extremities and ab-
domen of the patient, whilst he is kept in a stand-
ing posture, has likewise been directed by several
physicians ; but this practice, although occasion-
ally of service, seems leas successful than the
judicious application of cold to the surface of the
abdomen itself. When this cavitv is distended,
tense, painful on pressure, particularly in a cir-
oumscnbed portion, with increased temperature
of its surface, the cold douche, or the applica-
tion of cloths moistened with vinegar and water,
will often prove of advantage. Dr. Brandis, of
Copenhagen, states that he has employed iced
drinks, and cloths wetted with iced water to the
abdomen, in ten cases with success ; and that in
some instances the practice requires to be perse-
vered in for a long time, and assisted by anti-
spasmodic and laxative enemata, and by opiates
with stimulants and tonics taken internally.

79. g» When signs of depression of the vital
energy manifest themselves in the advanced stage
of the disease, ttimulanU are required, and, if judi-
ciously selected and oombinea, their exhibition

* Mr. BosBAU retiommcnids the um, and gfv«t a plata
datcriptire, of atlmple hydraulic apparatus for lnJoetloD»,
the Mme In all reipecU at one lately Introduced Into this
country from France, under the name of dyimaduct, but
^Mch U tutted only to the tnjeetlflo of water.

will sometimes be rapidly followed bTaneDdmeot.
Wherever the lowering measures siready noticed
are followed by increase of the symptoms, pirticQ-
larly vomiting and restlessness, or by sinking of tbe
nervous power or of animal heat on the sarfsce of
tbetrunkf antispasmodic stimulants and toma
should be conjoined, according to circumstaiice»,
with certain of the measures described aboie.
Purgative tinctures are sometimes of service in
this state, particularly the tinctures of aloes, with
liquor potassss, and tinct. hyoseyami ; and tbe
compound tincture of senna, with tinct. ammoii.
comp. and spirit anisi, in large or often repMted
doses. Notwithstanding constant or even fceulcot
vomiting in this stage, advantage will sometnna
be derived from a full dose of unrectified oil $f
turpentine (from 3 iv. — ^x.), taken on the sur&ce
of aqua pimentse, to which either spirit, aois,
tinct. cardamom, co., or tinct. capwci, has bees
added. I have seen the vomiting cease, and ihe
distension of the abdomen rapidlv subside, tin*
mediately after this draught, which should be
repeated if the former has been thrown off. A
full dose of common oil of turpentine, tskea bjr
the mouth, has a singular effect in constrictiof,
and, as it were, drawing the small iatestioee cIom
to the root of the mesentery ; so that, in eaie*
where I have given it, and in which hernia bad
chanced to exist, tbe hernial sac has becoiDe
quite empty soon after its exhibition. May not
tne advantage obtained by it occasionally iriie
from the disentanglement of a constricted or ub'
prisoned portion of intestine by this mode of
operation, as well as from its influence in restor-
ing the action of the paralysed and dilated ooai*
of the bowel in other cases ? In many stsles of
inflammatory action, particularly those atteoded
with exhausted tone of the capillaries and de>
pressed vital power, it is one or the most sctive
means we possess of preventing gangreoe or
effusion, and of restoring the natural actioa oi
the vessels.

80. h» In some cases; after depletioos bsve
been carried far, or in nervous and iniisbie
habits, tbe inverted action of the stomach tod
upper part of the alimentary canal appeals to
continue in consequence of tbe vital exbsuftioa
and irritability of parts ; but if these ststee wen
put a stop to for a while, and the powers of life
supportea, the natural action of tbe bowels— re-
specting the immediate restoration of which tbe
patient is often injuriously harassed — would ge-
nerally at last return. Under such circumstsooes,
pills consisting of the irimitrate rfbitmnA^mpk^.
and opium, frequently repeated ; or of the first of
these, and extract of hop, or of henbane, or tbe
hydrocyanic acid, in the recent oleun any^^l*
dulcis, or oleum olive, in moderate but ratber
frequent doses, and occasionally with so aro>
matic spirit or distilled water ; will often pn>»e
of service, particularly when aided by theexteroa]
means about to be recommended. When ibo
exhibited, the hydrocyanic acid hasareHortiite
effect ; and it is still further beneficial wfaa
associated with suitable sUmulants, as camphor,
aether, &c. Jn a few instances X haveiofentd
from the situation of the pain, and other synp*
toms, that the disorder originated in the dttodeasn
or jejunum ; and in these especially, tbe triMiias*^
of bismuth and the hydrooyanic acid bate bei& ^
oonaiderable benefit. The oompound lMc<ar« ^

COLIC -^ Treatmekt of itb Stupatbetyc States.

381

lation through the |M>rtal vessels, and the coDse*
quent fits of colic, being both relieved by the
coosecutive hsmorrhage from the haemorrhoiUal
TetDs and mucous surface of the rectum. In
almost all soch cases, in addition to the conges-
tioQ aod associated disorder of the assistant
chylopoietic viscera, there are more or less
vascular plethora, impeded secretion generally,
aad deScient energy of the organic nervous
system, — a complicated , state of disorder evi-
deotlj requiring local depletions from the region
of the liver, or, as Continental practitioners very
n^sooably prefer, from the vicinity of the anus,
with the remedies above stated, and assisted by
reg^ilw exercise, gentle tonics, aperients, and a
regulated diet and regimen. From this it will
not appear singular that very dangerous attacks
of i*olic, or even of ileus, will sometimes occur
after the operation for haemorrhoids or anal
fi^tuls, or other morbid states of the rectum,
wbea performed, as they sometimes are, without
previous medical treatment of a kind appro-
pn4te to the state of internal disease. — c. The
torn plication of coUc with either acute or chronic
jauNi/ief is evidently referrible, either to the
psnage of gall-stones ($ 86.), or to the patholo-
gical state of the liver now noticed, or to innamma-
tory action in the duodenum or biliary ducts, or,
lastly, to congestion of bile in the hepatic ducts, or
in the gall-bladder. When symptoms 0/ local
plelltora or congestion can be detected, cupping,
a&d the rest of the treatment now directed, will be
ier>-iceable. ^See Jaundice — Ti-eatmentof.)

91. F, Wnen the colic arises from atonic,
muplaoed, or erratic gout, large doses of the
carboaates of the alkalies, or magnesia, with cam-
phor or ammonia, are reauired, followed by blood-
lettiag, if the pulse, habit of body, and strength of
thepadeot admit of it; by calomel, witli cam-
phor and hyoscyamus, or opium, at bed-time ; by
active cathartics, conjoined with stimulants and
re&toratives, as long as the alvine evacuations
indicate the propriety of their exhibition ; by
pQrg^itive and antispasmodic injections, and by
rubefacients and sinapisms to the lower extre-
n^itiea. After morbid secretions and retained
f«ces are evacuated, colchicum may then be
givcQ with ammonia, or with camphor and mag-
Deiia. But arthritic colic occurs most frequently
in aged peraonii, or in those with exhausted con-
ttiiutioDS, in whom, instead of evacuations, be*
yond tlie expul^OD of morbid secretions, active
stimalaots, — as large doses of camphor and am-
monia, or of guaiacuffi and ammonia, — with
vwm spices, Cayenne pepper, and sometimes
combined with opium or aconitum, and assisted by
uoapiama, are indispensably requisite.

92. G. If colic supervene on the dlsappear-
>ace or suppression of rheumatiitn from the joints
or apoaearoses, or on the repulsion ofchnmic erup'
i^t local depletions, followed by camphorated
lioimeota and fomentations ; warm turpentine
epiih«ms applied on the abdomen ; calomel, with
aoUmonial preparations, or with ipecacuanha and
opium ; warm vapour and fumigating batlis ; the
carbonate) of the alkalies, sulphur, the compound
decoction of aarsaparilla, or the decoction of dul-
camara ; blisters, plasters, or ointments, with the
potasaic^artrate of antimony, saponaceous and
oltsiriooQi eneroata ; and sinapisms to the extre-
i&uieft or parts primarily aJBTected ; constitute the

ohief means of cure. The frequency, and, in two
of the forms of the disease especially, the danger,
of the complaint now discussed, have induced me
to be more circumstantial in the account of its patho-
logy and treatment than may appear requisite to
many : but I am convinced that the experienced
practitioner will not be of the number ; but will find
cause to regret, with myself, upon reviewing his
knowledge, that his information on the subject is
not greater than his means of observation have yet
afforded him, or my labours can possibly assist
him in obtaining.

BiBLioo. AND Rspfca i<. Common Forms op Colic. —

Pting, Hist. Nat. L xxtL cap. i. ^ (kUus, De Medi-
clna, 1. iv. lect. 13, 14. — Alexander Tralit'anus, 1. lii.
ch. 44. — Baillou, Contult. vol. i. p. 5. — Sckenck, 1. lil.
pp. 173. 179. and 874. — WiUis^ Opera Omnia, de Aoiin.

Brut., par. 11. cap. 16. p. 208 Bonety Sepulchretum,

&c. 1. ill. sect xir. obser. I. 6. ; et Mercurius Com-

fltalitlns, p. lis. etteq River iiu, Observ. cent. L ob.
3, 13. &9, &c.; cent. IL ob. 18. 38, &c. ; cent. Hi. ob. 88.

48 RoOnky De Dolorc CoUco. Jenor. 1660 — Alberti, De

Colica Hcmorrholdall. Hats. 1718. Hqffynann, De Intes-
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n. IC. — HuxAmn, in Fhilos. Trans. No. 422. -^Harris, De
Morb. Inf. p. 31. — Kttm^er^ Amoen. Exot. p. 588. — >
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1749. ~ yfencota. Comment, in Popfliiiffi, De Snlphure,
p. 416. 46£ — Sttuvagei, .Nosologle Methodique, &c. t. ii.

p. b\0 StoU, Ratio Med. par. 11. p.l35. 138., par. ill. p.65.

— Aoaen, De Dolor. Spaatico-flatulentia Prim. Viar. 8vo.
Lond. 1771. — Bunerii Inatitut. Med. Pract. toI. iv. ed.
Lipa. p. 358. etseq.—Banm^ In Act. Reg. Soc. Med.Havn.
vol.i. p.2S5. f<a«9.,etvol.lii. p.ll5. et 141. ftMcq.—Ranoi?t
in Ibid. p. 349., et vol. iv. p. 113 — Konfg^ De Kerned. In-
digenta. ~ Tbd^. Biblloth. 1. 3. 148.'— Totimay, Ergo Co.
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pository, Tol. v. No. ilL art 3. — Conradi^ in Hvfeland^t
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vil. b. p. 168 Fromm, De Oleo Rlcinl, ^usque in variis

Col. Spec, cffectu prttstant., 4to. 1806. — Miehaeiis, In Lo'
der*» Journ. fUr die Chirurg. ill. b. p.633b — Tkomatm, An-

nalenad 1800, n. 871 OdJert in Journ. de Med. t. xlix.

p. 337. —Hotackt In Lond. Med.RepoBitory,vol.xTili.p.77.
— Ch&mel, Diet, de M^decine, vol. ▼. p. 448 — Schmtdt'
mann. Summa Observat. Medicar. vol. iv. p. 373. et teq,

B. West Indian and Madrid Colic. — //rrnandez,
Trattato del Dolor Collco, 4to. Madrlti, 1790. — Hunier^
On Diseases of Jamaica, &a — Lind, On tbe Diseases of
Hot Climates, p. 254. — Luzuriaga, Dlssertacion Medica
sobre el Colicode Madrid. Mad. 1796.— CAuAoAn, On the
Diseases of Hot Climates, &c. 8vo. Lond. 1822. p. 98. —
Larrey, Mem. de Chirurg. Milit t.iii. — Atdagnier^ Re-
cherches sur la Collque de Madrid. Paris, 1811 — Librou,
in Collect. desThdses louten. i I'Ecolede MM. de Paris.

1809. No. 82 Jacob, Ibid, 1815, No. 86.— 7AoffMO»,:Edin.

Med. and Surg. Journ. Nov. 1818, p. 614.— Afaugravr, in
Lond. Med. Repoaitory, bv Copland^ Nov. 1825. — Pascal
in Journ. dea Progrda dea Sclen. Med. 1. 11. p. 240— lfar>
quand, in Journ. Complement dcs Sclcn. Mt^d. t. xxiU.

B. 97. — Qw'er, Account of the Bllioua CoUc, or Dry
elly-ache, 8vo. London, 1778. {extremely valuable).

C. Lear Couc. -^ Reidlin, Lin. Med. 1695, p. 168.—
Calmetie Riverlua Renovatua, vol. i. Lyon. .1704. .— Van
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Pictonum. Amftt. 1 755 De linen, De Colica Pictonum

Hagae, 1745. —^f'airen. In Med. Tranaac. of Col. of Phys.

of Lond. vol. il. No. 7 Eyerel, Sylloge, obs. iv — Astrue,

in HaUer.CoWeci. Diss. Pract. vol. ill. No. 84 — Stott, Rat.
M^d. 11. p. 870., iv. p. 76., vi. p. 333., vii. p. 307. et sea. —
G. Baker, Medical Tracts republished by his Son, 6vo.
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Progr^s des Scienc. MM. 1. 11. p.842. -^Woiff', in Formay,
Ephemer. von Berlin, i. b. 2 at. p. 83 — Qiuit'm,Auimad.
veralonea. p. 187. — Z.t>s<l<, De Altimlnls Virtute Medica.
GSt. 1784. — Hardy, of the CoUc of Poltou and Devon.

shire, 8vo. Lond. 1779 Gamett, in Mem. of Med. Soc. of

Lond. vol. v. p. 123 PercivaL in Edln. Med. Comment.

vol.iI. p.239.— ilfcoc*, The Endemic Colic of Devonshire,
not caused by a Solution of Lead in the Cyder ; with Ro-
marki on Dr. Baker's Essay. Plymouth, 1709..i^i<cAar,

LUDMn Ub«rLondQn,ftc p.m.— Aw-ffr, In Hom*s.
[liv. li. b. p. Mt — GendroHy In R^uell PerlodlqUe

382

B«merki
N. Archiv,

de la Soc. de Santid Paris. No. 6., ct t.iL.p. 9SI^.^Cheyne,
in Bdln. Med. and Surg. Joum. vol. It. p. ZlA.-^Sommer,
in Hufelaiuti Joum. oiBr Pract. Artneyk. tH. b. p. 83. —
MtchaHUt, in Ibid. xU. 4 tt. p. 31. — Gebcl, in HttfelanirM
Joum. der Heilk. 1. b. p. 196., et xvll. b. 3st. p. 101 —
JBatemau^ Art. CoUc. in Xen'i Cydopadia;— AoAer<«, in
TranMC. of Lond. Coll. oT Phjt. vol. v. p. 45. — Pern-
berton. On the Abdom. Viscera, *c. p. ISO. — Andral^
CUnlque MMical«,t. Ir. Paris, 1817. — i>aW«er, in Diet,
des Sciences Med. t. vl. p. ^—Oifila, ToxicolMrie G^n€-
rale, i. p. G37.^Frieset m Archiv. der Pract. Heilk. fiir
Sehleslen, Ir. b. 1st. n. 6. —Andral, in R^Tue M6d. t. ii.
1894, p. 203. — Kaptlery Archives G6a6r. de MMecine,
t. XTiil. p.370 — Graves, Dublin Hospital Reporu, vol. iv.

p. 45 Gregory, Practice of Phys. 3d edit. p. 524 Ckri't'

tfMon, On Poisons, p. 493.— J.CoplaiMf, in Lond. Med. and
Surg. Joum. voL i. p. 147. ; and In Lond. Med. Repository,
vol. xvili. p. 322. — Fimmier, in Joum. Hebdomad, ae
Bl^d. t. vlL Paris, 1830. » Gendrin, Transact Medlcales,
Jan. 183lt.— {/icr/iu, Med. and Phys. Joum., v. xxxi'p. 441.
D* ILBUS AND Volvulus — Hippoeratn, Ilifi »t«r«», iii.,
Opera, p. 491. : Ilifi rmdtti. Op. p. b%.—ScrilHmhu Largutt
De Compos. Med. ch. S8 — iffrCcna.Curat.Acut.l.U.c.K.—
Pauhu ^fi^Aiela,l.lil.c.44.— AtfrlAo/mw, Bpist.lit.p.984. ;
Hlstoria. Anatom. cent. v. hist. S3. ; et De Utu Nivis Me-
dico, p. 145.— ^tfmAatn, Opera, p. 2G7.— Zocu/im Lust'
tonus, Pract. Admlrab. 1. if. olMer. 29 — Bonet, SepuU
chretum, 1. Hi. sect. 14. obs. 7. 84.,etl.iv. sect, l.ob.u.—
Morgagni, Eplst. xxxiv. Ma 11, 12. 18.— Ficai, Delect
Observat. Pract. App. p. 31 — Uqffhuiim, De Passtone
Iliaca, Opera, Sapp. ii. n. i. — Sagar, Systcma Mor-
borum, &c. p. 391. Vlon. 1757. — Quarin, De Cur. Feb.
et Inflam. p. 384. Vien. 1781. — Monro, primus, Obserr.
en lotus-susceptio, in Bdln. Med. and Phys. Essays,
vol. ii. art. 97. : Ibid. vol. ill. p. 887. — Simsom, in
Ibid. vol. V. par. it. p. 664. ~ De Haen, Rat. M^d. par. 1.
p. 113., par. viU.c.5.,par. Ix.c. 6.,andpar. xi.c. 3.~Jtf(mro,
f«rr/«w. Morbid Anat. of the Gullet,* stomach, and Intes-
tines. 8vo. 2d. edit. p. 00— ffAai«i^, in PhUos. Transac.
vol. Ixxvl. — Fowler, Med. Reports of Tobacco, Lond.
\'J9Xt.'~Banhez, Obtorvat sur les Collques Illaques essen-
tiellement Nerveuses, in Mem.deU Societe Mvd. d'Emu-
lation, t. Hi. p. ^X.^Darwht, Zoonomia, vol. li. p. 033.—.
Ludtcig, De Causli Obstruct. Alvlnc, p. 32. — Howship, in
Med. and Surg. Juurn.vol.viU.p.lk9 — Hufeland, in Journ.
der Pract. Arsneyk. ii. b. p. 309. ; et in Joum. der Pract.
Heilk. Nov. 1809, p. im.^Scks^, in Ibid. Dec. 1810.
p. 80 — Conradi, in HttfelaiuTs Journ. der Pract. Ars-
nevk. vl. b. p. 49^.— Forbes, In Edin. Med. Comment,
vol. ix. p. 266 — Scoit, in Ibid. vol. v. p. 188.— N^inson,
On Crude Mercury In Obstructions of the Bowels, Lond.
1788. — BaiUie, Series of Engravings, fasc. Iv. tab. i. —
SimSf Observations on Epidemic Disorders, Ac. p. 27. —
Gadoiia, De Vomlta Intestiuor. sive Volvulo. Vien. 1771.

— Hartmann, De Ileo Cognoscendo et Curand. 17H0. —
Gatleskjf, Vom Miserere, etc. p. 70 — Salgues, In Journ. de
Medecine, t. xxxvL p. 515.— fFo{^, in HttfelamTs Joum.
der Pract. Heilk. xvll. b. p. 189 — Bureau, in Mem. of
Med. Soc. of Lond. vol.il. p. 927. — Baidinger, N. Magasin,
viil. b. p. 77. — Vogel, Methodo den Ileus, Ac. Unier^s
Journ. riir Chlrurg. i. b. p. 541. — Mottfakon, In Diet, des
Sciences Med. t. xxiil. p. SAL-^Ratge h^lorme. in Diet de

Mfdecine, vol. xxl. p. 409 Rickter, Die Specielle The.

raple, iv. b. p. 171 — HK.-^- Bauer, Archives G£n£r. de
M^d. t V. p. 68. — Lebidois, Ibid. t. xIH. p. 230. — I.ouis^
Ibid. t. xiv. p. 185. — BegnouU, Joum. Univers. des Scien.
M6d. t. Iv. — Mortier, Journ. Complement des Scienc.
M£d. t Wl-^Faget, Joum..G^n^r.de M^d. t. xL—Dance,
Sur les Invaginations des Intestlns. in R6pert G^n£r.

d'Anatom. et Patholog &c. 1. 1. p. 441 Smhh, in Edin.

Med. and Surg. Joum. vol. Ix. p. 287 Maxwell, in Ibid.

vol. xxl. p. 7i.^BoUand, Archives O^n^r. de MMecine,
t. V. n. fiO. — Fuschtus, in Ibid. t. ix. p. 1 16.— Jt/. Buet,
In Ibid. p. 230. — Belluci, in Ibid. t. xviU. p. ^m. — Bli-
zard, in Trans, of Med.-Chirurg. Soc. vol.1. No. 14.—

— Baud,in Joum. Gen. de Mdd. t.xxiv. p. 20 Brandis,

inNouv. Joura.de MM.t.v.p.89 mUan, Miscellaneous

Worku, by Smith, Lond. 1820, p. 385. — ^5rrcrom6tV. On
Diseases of the Abdominal Viscera, &c. Edin. 1 828, p. 104.

— Beilby, Alison, ^e., in Ed. Med. and Surg. Journ.
vol.xUv. p. 980. et seq — Wood, in Bost. Med. and Surg.
Journ. 1H35,

Those who wish to be acquainted more fully with the
opinions of the writers of the fiaeenth, sixteenth, and
seventeenth centuries, as to Jleus and Colic, will find them
detailed at ronslderable length in Bonet's Polyatthes, *c.
fol.vol. L p. 500. et seq. ; In his Mereurrus, M. p. 1 16. ; and
in Manoxt's BibUolheca Medico Praetica, fol. vol. I.p.575.
Although I have not availed myself of these collections
in any way. owing to mv circumscribed limits, and desire
to give more precise information of a later date, and more
in accordance with ray experience, than that which they
Airnlsh. yet will they be round to conUIn much of what
has been considered of much more modem date, and.
«ben sifted frOB the reftiae, of no mean valuo*

COLON— ToKPxft Statu of, &e.

The BMiogmuky of tbeM diiwict ta Pi.ooc«nr'i
Med. Digesta, is brought down to the commenccineat of
this century ; but many of the references are taaccorat*:
that by YooNo is very scanty, and not salect. Ths list
appended to the art. /2nw, in the great French Dictkmar;,
is entirely a catalogue of Theses on the subfect of do
viriue { Instead of coniisdng, as it ou^t, of references to
the experience of the best practical writers.

COLON.— Syn. k«Xsv. Der Grimwndarm, Ger.

Th» Large Bowei.

1 . The colon is very often the sett of disease,
the rest of the alimentary canal being bat light);
affected. In some complaints, as cmutipctioR,
eolie, and dysenttry, it is the part priacipally
disordered ; and in others, as indiguHmt dm»
rhaa, Ueuif peritonitis, &c., it participatei io the
disease with the rest of the dif^tive organs. The
investipration, therefore, of these maladies neoes*
sarily includes the consideration of the chief oor.
hid states of this viicus. But there are other
derangements which require a brief notice at tbi
place, and which do not belong to these disettes,
or to those changes of structure that are ooomoa
to it and the rest of the alimentary canal, and ve
considered in the article on the Pathoiogy of tks
Digestive Canal.

1. Torpor or Atohy op tbk Coi^h, and m

CONBEQOBNCES. ClASBIP. I. ClaIS, I.

Order (Author),

2. Defin. General delnHttf, mth imdigeitaa;
slow or irregular state <j' the bowels; distenuon,
horbonigtnif or striduUms noisee, in the caurutf
the colon ; frequentlit pain or w/ieaiinetf, sMRelisin
with tumours in some part of this rismf.

3. i. Its Pathology.— -Atony end disteitfioo
of the colon may be variously associatni wuh
other disorders. They obtain more or less in all
cases of constipation and colic which depend oot
upon inflammation, or upon diminution or coa>
striction of the canal of the intestines ; and thry
are als>o often complicated with torpor of the liver,
and deficient secretion from the internal »urf>ce
of the colon. Distension is usually oocisioDed
by flatus or fecal matters : and it may prodoce
little or no inconvenience, beyond constipatioD,
until it reaches a great extent ; but it frequently
gives rise to flatulent and ttereoraeeouM eolie, sod
even to ileus. The gases found in the ooloo are
azote, carbonic acid gas, and carbo retted hydro*
gen, in varying proportions ; and when they s^;
cumulate largely, they always produce borbo^rri
or an unpleasant or painful sense of disteosjoo,
and constipation or colic. A, Flatulent ditten-
rion of the colon (see Flatulewce) is commorly
dependent upon want of vital tone of the di^o
tive organs generally, and of this viscus pamco*
larly. In irritation or inflammation of the btm*-)?.
flatus is also generated in great quantity *, but n m
usually expelled quickly, especially wiieo tM
are unobstructed, owing to reaction of thdr mu-i-
cular coats. Much doubt exists as to the mnnt
whence this flatus proceeds. The circomiitame
of its rapid reproaoction after its evacnstioo.
when the bowels contain no substances whrh
could give rise to it, and various physiological
considerations, lead me to infer that it n in rrcai
measure exhaled from the digestive mucou*^ Mir*
face ; the gases consisting chiefly of those wfasrh
pass into, or are formed by, the blood ; and wh><*h,
m health, are afterwards given out from it, od (be
mucous surface of the lungs. Peraons who o'te i
expel the flatus from the lower bowels, wherv it
evidently ia destined to perform uaefol pntjetf

COLON— ToAMA Of.

383

ia the economy, ore moit subject to an atonic
sttte of the colon, and to a continued as well as
IB increased generation of the intestinal gases :
lod, when cireamsUnces prevent the accustomed
freqoeocy of their discbarse, are most liable to
experience the effects of their accumulation.
Atoatc distension of the colon by flatus is also
a common attendant upon congestion of some one
or more of the abdominal visoera» and even upon
gsneial vascular plethora« particularly when it
oppresses the circulating energies. It also often
aceompauies hysteria : and, owing to the increased
seosibiiity of the organic nerves, as well as to the
morbid irritability and irregular action of the mus-
cslir fibres of the bowels, gives rise to various
psinfiil sensations in their course, and to anoma-
loDf states of disorder.

4. B. When an atanie and flatulent state of the
eoloQ is associated tpith morbid irritability of the
mucttlar coat, painful sensations in some part of the
cooiae of this viscus are frequently complained of,
panicttlarly by females ; are by them often referred
to its left arch and descending portion ; and are
atteoded by loud croaking or stridulous noises,
efpeeially upon full respiration and mental emo-
tioQ. The bovrels are usually constipated, and
attempts at evacuation are accompanied with
»)<?bt tenesmus, the stools being discoloured, hard,
dim J, or in lumps. The abdomen is tumid;
tad tenderness, often shifting its place, and varying
in drgree or duration, is sometimes felt. The
whole digestive organs necessarily participate in
this state of disorder, and perform their functions
inperfeetly. The nervous system of organic life
acquires ioereaaed sensibility ; the cerebro-spinal
oyatem becomes morbidly susceptible of im-
pRssions, particularly in females; the counte-
fiance is pate, slightly discoloured, and often
eovercd by an oily moisture ; the tongue is loaded,
flabby, sometimes large, presenting fissures on its
mrraee, and the impressions of the teeth on its
edges ; the pulse is weak and soft ; and a sense
of distension and oppression follows a full meal.
yh» state of disorder is very frequent in young
females, who take not sufficient exercise; and,
when oefflecied, is often the forerunner of more
•erimia ailments, both of the bowels and of the
gei^entive organs.

5. C. Deficient vital energy of the colon also
gives rise to relaxation or irregutar action of its
costs, to constipation, and to collections of fecal
matters, generally with more or less flatulence.
Fetat aceumulatiom to a great amount is most
fonmonly met with in aged females, or persons
far advanced in life, who have injured the tone
of the bowel by the frequent use of cathartics,
and have passed a sedentary and luxurious exist-
ence. They also occur, but to a much less ex-
tent, in children and young persons, especially
females from the ninth to the eighteenth year of
s^, and even upwards. Sometimes they occa-
>ioQ Itrge tumours, particularly in the cscum
and sigmoid flexure, but occasionally also in the
traofverse arch and other parts of the colon.
Wbea distension proceeds from retained fscal
niattef8, in additions to the local signs observed on
careful examination and percussion of the abdo-
men in the course of this bowel, numerous symp-
tomatic ailments are complained of. These vary
Irat Httle from those described above (§ 4.^, and
ia the article treating of aceumuUtiona in the

Cjboum ($11*)* 1^* countenance and skin are
^nerally foul, unhealthy, and devoid of aoima*
tion ; tlie perspiration is' thick, clammy, foetid,
and oleaginous ; the breath very offensive ; the
tongue loaded or furred ; the lips and gums are
pale ; muscular energy is much diminished ; the
appetite imperfect or capricious; digestion diffi<*
cult ; headach or vertigo is often present ; the
abdomen is tumid, doughy, and inelastic ; the
urine is loaded ; the bowels are either constipated
or irregular, or, if daily evacuations take place,
the motions are slimy, very dark, or otherwise dis*
coloured, scanty, and offensive ; and the pulse
softy weak, often slow, but afterwards accelerated.
In many cases, pains in the loins, abdomen, and
limbs are complained of, with mental inactivity,
general lassitude, cedema of the lower extremities,
flabby inelastic state of the soft solids, leipo-
thyrow, or fainting, upon quickly assuming the
erect posture, and occasional fits of sinking, espe-
cially in females*

6. Although torpor of the colon is most fre-
quently followed by faecal accumulations and
distension, yet these are neither constant nor ne-
cessary results of this state, at least to any very
manifest extent ; for sordes and faecal collections
may be very injurious to the miicous surface,
without proving so from their bulk or mechanical
effects only. Indeed they are often noxious from
their acrimony, without occasioning remarkable
distension, or any degree of obstruction, par-
ticularly when the vital energies are depressed*
Their presence, therefore, should be inferred
rather from various remote symptoms than from
those which are referrible to the colon itself*
But whenever disorder of remote organs Irads us
to suspect torpor of this bowel, the practitioner
should make an accurate examination of all the
abdominal regions, commencing with that of the
caecum, following the course of the colon be-
tween the ilium and right ribs, below the epi-
gastrium and under l>oth hypochondria, to the
left side and iliac fossai and to the hypogastrium.
If a sensation of doughy fulness be felt by the
examiner, in any part of its course, the internal
surface of the bowel is probably lined with sordes
and accumulated secretions which its vital energy
has not been sufficient to throw off. If hardness
be felt, with more or less tumour, faecal col-
lections are most likely formed. But the evi-
dence furnished by this examination should not
satisfy us : we should inquire after the symptoms
stated above, particularly the foul or clammy
tongue, foetor of the breath, unnatural state of the
countenance, and cutaneous surface, and the of-
fensive and morbid evacuations usually attendant
upon this ailment. A belief is too generally
entertained, that faecal matters and sordes will
not accumulate in the colon, unless the patient
has been constipated. But they may collect in
its cells, the more central part of the canal allow-
ing daily evacuations ; and they may even remain
there for a considerable period, producing much
irritation, and even a relaxed state of the bowels ;
thereby misleading the judgment of the prac-
titioner as to the pathological state constituting
the disorder. How, therefore, is he to form an
accurate opinion ? By a careful examination of
the abdomen in the course of the colon, of the
urine, of the stools, and of all the organic and
, animal functions, and by ascertaining the presence

COLON— Torpor or«^TREATicliKT.

385

geatioos ukl «£r«isioiii of lerani on the brain
ind its membitna*, sapervene as the more remote
tSecU. — e. Fscal or flatulent accumnlatiooB in
the colon affect, in a very evident manner, the
fuoctioiis of the imall intestines and stomach, or
iocrease diM>rder in these viscera, when it pre-
viouly eiists,— a droamstance of freqaent oc-
curreoce, the fanetion of digestion beiog equally
inpeded with that of defscation, and owing to
the man primaiy pathological state, oamelv,
ifflperfcct manifestation of vital power through*
out the organic nervous system. Hence the in-
digestion, the acrid and flatulent eructations, and
ibe tDperfeet chylifaction and nutrition, so fre-
quentiv attociated with torpid function of the
Urge bowels.— ><i. In children' and young per-
sons, the mnootts sordes, morbid aecretioDs, and^^
excremeotitious matters, that collect as a conse-
quence of this state, become not only a nidus for
HOrms — remarkably favouring their generation ;
but slfo a cause of irritation to the mucous sur-
face, to the absorbing vessels, and to the mesen-
i«nc glands, owing to their partial absorption,
either alone, or with whatever chvle may be formed.
That diseues of the intestinal mucous surface,
^ that obstruction and enlargement of these
gbuKb, with the consequent maroimui, &c., often
vise from the morbid impression and irritation
catiied by these retained eicretions, an extensive
experience in the diseases of children has fully
coQvinced me; and that dysentery and diarrhoea,
imo&g this class of patients, as well as in adults,
frequently proceed from this cause, more espe-
<^uJly in warm and unhealthy climates, will be
^Dowledged by every experienced practitioner,
—e. Even many of the diseases that affect the
tkio, and chronic ulcers of the lower extremities,
an«e from the absorption from the large bowels
of excrementitions matters, that irritate and in-
^ame, in the course of their elimination from the
blood by the cotaoeous function, the delicate
nicalar tissue subjacent to the cuticle. Thb is
p^ticnlarly the case in warm countries and sea-
MDs, in which the quantity of these matters
iiwiys passing out of the circulation by the skin is
mach greater than is usually supposed. What-
ever OMoioo may be formed as to the origin of
iuch anectioos, there can be no doubt that the
t.-c«tment based upon this doctrine is the most
iBccessfttl in removmg them. — /. Among other
cDriseqnences of fscal accumulations in the colon,
elongations and displacements of this bowel may
be ranked ; and when these changes take place,
tbeT increase the disorder which occasioned them.
It has often been remarked, particularly by Es-
^^iBor, HiNzx, and otbera, that displacement of
I'le colon is one of the most common morbid ap-
peirances found in the bodies of hypochondriacal
umI melancholic persons. Torpor or atony of this
^^u favouring fascal accumulations in it, is an
important characteristic of these affections, and is
maoifeslly connected with the causation of dis-
placement of the large bowel. (See art. Hypo-
cuovnaiAsis, &c.)

, 11. ii. TatATMiNT. — The indications of cure
iQ cases of torpid function of the colon, consist —
l^t, of e?acttating whatever fecal or acrimonious
matters may have collected in it ; and, 2d, of
ifsionng the energy of the digestive organs, and
dtrectio* such regimen as may prevent a return of
iho Uifonier.— il. Many practitioners, deceived
Vou I.

by the reports of the patient, or misled by the
appearances of the stools procured by the first
purgatives prescribed, stop far short of the point
to which these medicines should be carried. It
is not sufficient to order two or three doses of
purgatives, or even of active cathartics ; but they
ought to be repeated, or continued so as to
secure their full effect, and be combined with
such other medicines as will promote their opera-
tion without weakening the parts which they
stimulate, and will prevent the patient from being
debilitated by them. In all affections of the
colon, purgatives that procure full, bulky, and
not frequent or watery evacuations, should be
selected. The preparations of aloes (F. 181.
454.), those of senna combined with gentian
(F. 266. 430.), castor oil, rhubarb and mag-
nesia, precipitated sulphur (F. 45. 82. 96.), the
compound jalap powder, 6cc. (F. 635, 636. 652.),
operate in this manner ; and, particularly when
we wish to promote the secretions from the in-
testinal surface, may be exhibited after a dose of
calomel or blue pill taken at bed-time ; or the
compound extract of colocynth, or the aloes and
mvrrh pill, or jalap, may be combined with one
of*^ these mercurial preparations, and the extract
of hyoscyamus, (see F. 462. 471. 881.). When
it is necessary to continue the exhibition of
pui*gatives, they should be dther alternated with
tonics, or combined with vegetable bitten, which
will both promote their action, and increase
the strength of the patient, (see F. 562. 572.).
When the motions are morbid, great advantage
will be derived from resorting to the use of clys*
mata, as recommended in the article Colic
($ 57. 66. 77.). If fecal collections to a great
extent have formed, they are indispensable
remedies ; and if symptoms of obstruction, or of
irritation, or chronic inflammation, are manifest,
they should be assisted by the external means
there advised ($ 66. 83.). Under every circum-
stance, the exhibition .of purgatives by the mouth,
and of enemata, should be persisted in until the
stools assume a natural appearance. (See also
the Treattnent of diseases of the Cjecum, and of
Constipation).

12. In cases where retained matters in the
colon have occasioned irritation, such clysters as
will promote the full evacuation of its contents,
and at the same time allay irritation, ought to be
resorted to from time to time. These will relax
irregular constrictions of the bowel, promote the
operation of purgatives given by the mouth, dis-
solve hardened feces, and loosen the adhesion of
tenacious secretions lodged in its cells. In cases
of this description, the soap injection, with, or
without, the addition of castor or olive oil, the
compound decoction of barley with common salt,
or the potassio-tartrate of soda; the infusion of
linseed, with the biborate, or the carbonate of soda
and assafcetida ; the decoction of marsh-mallows^
with the infusion of camomile-flowers and linseed
oil ; and the turpentines, triturated with white of
egg or mucilage ; will have a most beneficial
effect, particularly when assistetl by appropriate
laxatives taken by the mouth. When the irri-
tation of the bowel appears to be accompanied
by spasmodic constriction, the aperients should
be combined with either camphor, ammonia, ipe-
cacuanha, hyoscyamus, the compound galbanum
pill, ice, (F. 463. 890.). according to existing cir-

C c

386

COLON— UvKATirmiL Poflinoirs or.

eamiUii6es. In caiM of thif kind, much delnlitr
is often preKnt, ud the fuactions of the Btomach
reqaire the aid of li^ht nutritiouB food and gentle
tonicfl) the purgatiTet being exhibited either at
bed-time» or early in the morning, so as not to
disorder the functions of the stomach. Such
eccoprotic or alteratiTO laxatiTes as are slow in
their operation (F. 503. 893.) should be taken at
night, and purgatives or cathartics that are quick
in their action early in the morning, so that they
may not interfere either with necessary food or
with requisite avocations.

13. When the fascal* accumulations cannot be
removed by the above means, others of a more
powerful nature, as the elaterium or croton oil,
assisted by oolocynth or terebinthinate injections ;
and the purgatives advised in the more obstmate
cases of colie and etmstipation, assisted by shocks
of electricity and salvanism passed through the
abdomen; should he resorted to. When the
boweb are acted upon with great difficulty, the
stools being very black and offensive, we may
generally infer that not only is the colon torpid, but
the follicles are loaded or obstructed, and their
secretion morbid. In these cases, galvanism, as
shown in an instructive case by Mr. Clarkbon,
promises to be of much service. In several in-
stances, when the pulse has been weak, and the skin
cool, I have added the exttact of nuz vomica to the
purgative, with much advantage, and combined a
portion of this active substance with the liniment
(F. 306.) which has been rubbed on the abdomen.

14. B. lu order to prevent the re-accumula-
lion of morbid matters in the colon, and give tone
to the digestive organs generally, the patient
should daily attend to the first intimations of eva-
cuation, and promote the functions of digestion
and defecation, by resorting, whenever they
flag, to aperients or laxatives, combined with
tonics. Blue pill, with the aloes or myrrh pill,
or F. 470., may be occasionally taken at night,
and the tonic and aperient medicine (F. 266.)
the following momiog. The diet and regimen
should be carefully regulated, and exercise be
taken in the open air, either on foot or horseback.
After health has been in a great measure re-
stored, chalybeate mineral waters, and the arti-
ficial waters of Ems and Pyrmont, will be pro-
ductive of much benefit; but frequently it will
be more advantageous to commence with the
Harrogate or Leamington waters, or with the ar-
tificial waters of Seidschutx, Eger, or Carlsbad,
and have recourse subsequently to the chalybeates
of Cheltenham or Tuobridge. In many cases,
the warm or tepid salt water douche over the
abdomen, sea-baihing, frictions of the surface of
the body, and of the belly especially, night and
morning, with either a hard towel or brush, will
prove of much service.

15. II. Unnatural Positions optbz Colon,
&c.-— This viscus is not infrequently found mis-
placed, and forming singular flexures, in those
who have suffered from constipation, fecal re-
tention, dysentery, hypochondnasis, or melan-
cholia. But there are no constant symptoms by
which such changes can be infeired with much
certainty during the life of the patient. M. Ea-
QOtROL found, out of 168 dissections of melancho-
lic patients, the colon displaced in 33. This
change had previously been remarked by Mor-
OAQNt (D$ iied. ft Catii. Marb, epist. iv. art. 16.

«f ieq,), Haller (Elsm. PkyM, 1. xnv. nc. 13.
et iiq.), SoBMif XRRivo (Dm Corp. Hiiai. Fahrka,
t. iv. p. 313.), and Wills, but unconnected
with mental disorder. In many cases, the bowel
is not only displaced, but is also elongated, with-
out being diviaed, as in its natural state, into celb
by partial partitions, and the tonio action of iis
longitudinal bands. These changes seem to be
favoured by relaxation of the roesoooloo, and by
complete atony of those bands. An elongated
and displaced state of the colon is common m
cases of old hernia ; and in these is often cod-
nected with a stretched appearance of tbo mese&'
tery, but without any organic change of the
coats of the bowel : but sometimes the unnatural
flexure or duplicatnre is adherent at its opposite
^des, forming a large loop ; partiealarly wImo it
has been consecutive of acute or inflammatorr
dysentery. Displacement may take plaee in sst
part of the bowel, but it is most common in Um
transverse arch and sigmoid flexure ; the former
part hanging down towards the pubis, general ?j
m an UMdhering, but occasionally in an adher-
ing, loop; and the latter part crossing over to
the right side of the abdomen, or passing bebifrl i
the pubis. Duplicatures of the ^H>lon may also
form at the right or left parts of its arch ; the op-
posite peritoneal surfaces being more fireqoeotlT,
m sucn cases, adherent to a considerable exieot
by coagulable lymph. Several plates are gives
by Mr. Annesley, illustrative of this chaope :
which is not infrequentlv observed in fatal ca$e«of
chronic dysentery, particularly in warm climate*.
That these unnatural flexures are also often caowd
by fecal collections, and by obstructions to the
fecal discharges situated either in the rectum or
in the sigmoid flexure of the colon, appean ^err
probable ; but they may also arise from a na-
turally elongated formation of the bowel. That,
when once produced, they favour such coUectians,
with their consequences, particularly severe dj«-
peptic and hypochondriacal ailments, dysenten-.
severe colic, or even ileus, and great distension cr
inflammation of the colon or small intestines, cao-
not be doubted ; but that they will occasion is-
sanity or melancholy, as EsQUinoL and Hn«zt
suppose, seems not to be made out. Dr. Ykli^ily
states, that Mr. Lawrence and Mr. Dalrtmfii,
who have examined many bodies of insane per-
sons, have very seldom observed in them any oe\i-
ation from the natural course of the colon.

16. As we have no certain or even probable
means of asoertaininff the existence of tht*e
changes during life, it is unnecessarv to offer any
remarks on their treatment. Hut this is a mstitv
of but little importance, as the disorders which
they produce are in all respects the same as thi«e
already noticed ; and even if their nature were
recognised, they can be remedied or alleviated
only by the means described above, particularly
by laxative and solvent enemata ; and by what<>
ever will, whether taken by the mouth, ormjecte<i
per anum, preserve a fluid state of the stooL*. or
reduce them to a softened condition, and promote
the healthy secretions and regular fuoctitms ot
the large bowels, and of the digestive or^am in
general. (See F.82.98. 144.)— See art, UmisT-
iv£ Canal, for the organic lesions of the coIod .
and arts. DtARRHaA, DrtcvrxRY, and Kri^^
1INES, for its other diseases.)
BULioo. ANO Bsfaa. — iirwrMai, 0« Bceond. Atit-

GOHA AND LETHARGY —Tbeatvint or.

aoi

cathtitic dyiCen« donjotned with dmilar sub-
stances ; the use of coffee and green tea, particu-
brly vlwa this state of disease has followed the
ingestion of sedative or narcotic poisons, and
after the stomach has been evacuated by emetics
and the stomach pump, and washed out by the
injection of warm water ; are severally of use in
tbitt state of coma, and may be resorted to in
rarious combinations, aooording to the circum-
stances and severity of the case. All these mea-
sures are, however, not equally applicable to
every ease where this pathological state may be
presomed to exist ; but the judgment and ezpe-
rienoe of the practitioner can alone enable him to
employ them in an appropriate manner; the
ihaides of dtfferanoe in particular cases requiring
certain means, or peculiar combinations of them,
scarcely admitting of descriptioD, at least within
the limits to which I am necessarily confined.

17.£.ThewcoN<f pathological state ($ 13, 14.6.)»
when closely verging, as it occasionally does, upon
the first, will require several of the means enu-
merated with respect to it; whilst, when fully
iomed, and apprMching that of active determin-
atioQ or congestion, but few of them are appli-
cable. Much, however, will manifestly depend
upon the habits, and the constitution of the pa-
tient ; upon the nature and duration of the disease
of which ooma is an advanced phenomenon ; and
<ipoo the state of the pulse, tne temperature of
tbe bead, and the character of the countenance.
Tbe^rst state is injured by blood-letting in any
form, it being even not an infrequent consequence
of inanitioD, or even of anaemia of the brain ; but
tbis second state will generally be benefited by
depletion, and in. proportion to its approxima-
tioo to the third uod fourth states described
•^ve {§ 13, 14. «.). The question chiefly is
^ to what extent it may be carried, and the
aaiiQer in which it may be performed. In the
majority of cases, local depletions by cupping
between the shoulders and nape of the neck, or
by leeches applied behind the ears or on the neck
umI occiput ; by simple scarifications by a lancet
in the last-named situation, in some cases; in
otben, bleeding from the feet i whilst they are
placed in warm water, and cold or tepid water
u being poured in a stream upon the head ; and
iQ certain instances the application of a number
of leeches on the inside of the tops of the thighs,
w about the anus ; are the preferable modes of
baving reoonxie to depletion in this state of disease :
but the extent to which the evacuation should be
earried must entirely depend upon the symptoms
tad circumstancee of the case, and the effects
produced by it. In addition to this important
■^oa, pa]^g;atives ought to be given oy the
noQth, and their action increased by cathartic
elyiten, in which either assafcetida, valerian,
^*iBpboT, the terebinthinates, or other antispas-
modics and stimulants, may be also exhibited.
Cottttter.irritants and derivatives should be ap-
plied, bat at a distance from the head; and,
*hile a frequent operation of the bowels is pro-
<|^. the functions of the skin and kidneys
wonM be pvomoted by diaphoretics and diuretics,
foe eztiemities being kept warm, the head cool,
>U hair ent off, and the shoulders highly ele-
vat«l. In many instances of this state, even
lonl depletieo riiould be cautiously employed ;
^ u tfaew, as well at in othen, much advantage

will often accrue from having recourse to resto-
rative means. It is in this pathological condition
of coma, and in those about to be noticed, that
oil of turpentine, in large doses, so as to act freely
on the bowels, has proved so beneficial in my
practice. This state very generally obtains in
coma from narcotics and spirituous liquors ; and
is then, especially, very remarkably benefited by
the cold affusion on the head, and the prepara-
tions of ammonia.

18. C. The third znd fourth states ($ 13, 14, c.)
require nearly the same treatment as the second,
but carried much further ; general and local de-
pletion, cold affusion on the head, or the applica-
tion of ice, or evaporating lotions; the most
active cathartics, clysters, and derivants or coun-
ter-irritants, and the other measures, as fully
pointed out in the article on Ir^fiammation of the
DRAiv ($ 174.). When these states have gone
on to effusion either of blood or of serum, — the
sijth pathological condition adduced, — the
treatment recommended in Apoplexy and in
Dropsy or tub £ncspbau>n (see these articles)
should be employed.

19. D, The Jifth pathological state obviously
requires stimulants, tonics, and antiseptics, par-
ticularly camphor, in considerable doses; the
chlorides of sodium, potassium, &c.; wine, with
cordials, spices, &c. ; oark, with camphor; purga-
tives conjoined with stimulants, so as to excite
the eliminating or depuratory functions ; cathar-
tic, tonic, and antiseptic clysters; calomel,
combined with camphor and ammonia, or musk ;
the turpentines given by the mouth, and in one-
mata, with capsicum and aromatics; external
derivation and counter»irritation ; the various
balsams, with the chlorides, &c. ; quinine, with
the aromatic sulphuric acid ; the preparations of
cinchona or cascarilla with soda, or with the hy-
drochloric acid, or hydrochloric aether ; Cayenne
pepper internally, as well as externally in
camphorated embrocations, &c. When coma
is consequent upon the retrocession of gout ,
rheumatism, erysipelas, or cutaneous eruptions,
the propriety of having recourse to sinapisms,
rubefacient pediluvia, and other derivatives, in
addition to such other means as the s^ptoms of
the case may suggest, must be obvious. If it
follow suppressed discharges, we should endea-
vour to restore these, or produce one supplemental
of them. (See the treatment of the diseases of
which coma is most frequently an important
symptom.)

BiBLiOG. AKD Rbfes. — B^Hfcroies, IIi^} y«i>#wy, ili.
OppL p. 488. — (kriau Lib. de Comate, cup. ii. t vU. p, 195.
-^ CetnUyX. Ui. caa »).— ilretetu, Cur. Acut 1. i..*c. 9. —
Paului JEgmrta, i. iii. cap. 9. et 10. — Or&Mthu^ Synop.
1. viii. e. i. — >il9fomfM, Canon. L iiL fen. i. tract iii. c. 7.
&c — ZacM^M LutUamUt Pr. Hiit. L vii. obi. i. {The
actual cautery behind the ears.) — AAm/im, 1. i. obs. 36,
{The cautery to the neck.) -~ SeverHnu, De Efficac. Med.
p. ilS.^BalUmku, ContuH. L i. 4S., 1. iii. 32. _ WiUit^
De Anim. Brut Path. cap. 3. 4, ft — Bt^ernu, Praz. Med.
t. L cap. l ^ Sydenham, Opera, p. S81. — Bonet, Sepul.
chretura, L i. sect iii. obs. 5. 15. 18. — fum, De Comate
Somnalenta BafttL IffJ^.—Heinz, De Aiftctibtu Soporotla.
Argent Iffn^-^Moreagni, £pi*t. ▼. art. 13. S3. 99—36. -.-
BeUtni, De Horbii Capitis, p. 455. — Hqffinann, De Af.
fed. SopordsiB, obi. 5. Oppi liL p. fild — Boerhaave, De
MorUs Nenrorum, p.640.->Ci>r/A«ttcer, De Typbomania.
Francf. 1750. — KrUger^ De Somno, Morborum Matre et
Filia Helnu. VJ5^.^HaUer, Ob«ervat Med. Pract. Goet
nSd, — Sauvagei, v. iii. claM. vi.~xzlx. l.—Bang, in
Acta Reg. Soc. Med. Hafb. vol. iii. p. 1S7. — /lo^r/, Beo-
bachtungen. No. 9. — Hinxe, in Stark*t Archiv. b. vi.
p. 178. -. BekreiulMt in thifelttntTi Journ. der Pr. Heilk.
U xL Sit p. 1. } /M. b. XX. 4Ui St p. 5. {.QatHOdm rs-

C c 4

CONGESTION OF BLOOD— Its Natu»2. &c.

401

wilt asflume dtber t concrete or fluid form,
owing to modifications of its state as originally
secreted, or to the action of other matters upon
il during its retention in the bowels or urinary
bladder.

24. A singnlar case has been recorded by Dr.
KsxNSDY (MedicO'Chirurgical Journal for Sept*
1817.), of an intestinal concretion, which was
fouod, upon its analysis by Dr. U re, to be similar
io its composition to amborgrise.

25. C. lutestinal concretions have been found to
consist eotirely of those matters which have been
fwtllowed from either a depraved appetite, or
bid habit ; thus, concretions causing violent
•ymptoms, have been produced by the habit
of cbewiog the ends or threads used in sew-
isf, and which have formed a firm felt with the
BQciis of the intestioes and some fscal matters.
1 wu lately consulted in the case of a young
Udy who had been long under treatment for
ofaicure abdominal disease, respecting the na-
ture of which no two of the sevenu eminent
pneniiooers who had been in attendance agreed.
Tiie existence of accumulated matters in the
cxcam and colon seemed evident to me, upon
ouninatioo, and from the character of the consti-
ttttiooal and other symptoms. Purgatives and
iojections weie long persisted in; at last several
coDcredoos — (about twelve)— from the size of
t filbert, to that of a walnut, were evacuated.
I'poa examination, tlaey presented a substance
resefflbling pasteboard, with a faecal smell, of
a brown colour, and containing earthy parti-
cles. On being broken down and macerated,
^cy were foaml to consist chiefly of coarse
ptper reduced to a pulpy state, but containing
fr^eats not matexially altered. The portions
of pulpy paper were agglutinated with mucus,
portions of raeces, and a little phosphate of lime.
After aome time, the patient confessed that she
^ occaaiooallv been in the habit, about the age
of thirteen and fourteen, of chewing, and some-
times swallowing, portions of the grey paper, with
illicit she curled her hair. After the evacuation
of these concretions, all the symptoms disap-
peared, and she rapidly recovered. A few years
H^f I attended, with Mr.ANNSSLSY, a similar
(^ to the foregoing, but in a younger lady. She
'^▼ered perfectly by the use of purgatives and
clyaew.

Biiuoo. AMD BeFBE. — A. 9. HoIItr, Elementa' Phv-
f oi<ti» Corporia Hani«nl» t vU. p. 176. — Waltker, De
(<WfciaentiB termtrlbua in variit Putibua Corporii
Kumani repertu, fol. 1775.— SL FftxgeraJd, in Ediu. Med.
j^oBuaeot vol vikL p. 989. ~ Sir E. Homcy in Philot.
Tnns. 1813, srt. SL^Mereet, On tb« Chemical Hia-
tor? and Medical Trcatoieot of Calculoua Diaordera, 1817.
—M. Laiukrt M^moire aur lea Concr^tiona qui ae fonnent
03AI \t CoqM de I'Homme Paria, 1825. — J. Porta et
J^dit-fMHeBeUe, in ArehiTcs O^n. de MMecine. t xii.
f. it}.. p. Dmit. in Ibid. t. xviL p. IIL — Tarbet and
iinean, in Edin. Med. and Surg. Joum. vol. xxlv. p. 84.
»d9a~0. ^i^«/, Anatomie Pathologique, fte. til.
r^«, 185a — i<. Momro, ^c.. The Bforbid Anatomy
« ibc GiiDeL Stomach, and Inteatinee, 8d edit Edin.
i>M. (ContahM the moat complete account of Intestinal
CakuU with whieh lam acquainted.)

CONGESTION OF BLOOD. Classip. Ge-

MRAL Patbolooy : and I. Class, IV. Or-

Dia (i!ui*or,in Preface),

I. Dtnx. DeJicitHt vital tone or power, chiefly

V '«« eepiilory vestelt and veiuif oecationing aceu'

nutation of Ibod in them, and a languid or more

<w 'ea retarded circulation, the funclion$ of the
>ouI,

organ or part being thereby proportionately difor-
dered,

2. I. Nature and Relations op Concrstion.
— It has been stated in other places ^see arts.
Blood, Disease,) that morbid states of the vas-
cular system, and of the fluid circulating through
it, must be imputed, in a large proportion of cases,
to changes induced primarily in the organic
nervous system, which is, anatomically, most
intimately connected, not only with the circulating
system, but also with the organs essentially vital ;
this connection subsisting by ramifications pro-
ceeding to them both directly and obviously eitlier
from the great central ganglion, or from appro-
priate subordinate ganglia, as well as indirectly
and less apparently through the medium of the
blood* vessels, on which the organic nervous
system is everywhere profusely distributed, the
one accompanying the other throughout the
frame. Thus mtimately interwoven, Uiey expe-
rience reciprocative changes, and generate a com-
mon influence. The vital organs, as well as
their subordinate parts, in the more perfect ani-
mals, being supplied by both these systems, —
the most rudimental type and essential requisites
of organisation, — and actuated by their common
influence, are thereby enabled to perform their
destined functions; the superadded or peculiar
organisation of each organ oeing the instrument,
which, thus actuated, performs specific oflices in
the economy*

3. It results from this, — 1st, That we are not
justified in considering changes in the states of
vascular action, or in the relation subsisting be-
tween the vessels and the quantity or quality of
the fluids circulating in them, apart from the
condition of the organic nervous system, which
is thus intimately connected, by structure and
function, both with them and with all vital
organs ; 2d, That chanees in the vascular system
are very often induced by impressions made
primarily upon the organic nervous system ;
whilst, on the other hand, a morbid state of the
former, particularly in respect of its circulating
contents, will most seriously aflPect the latter;
and 3d» That upon tracin|[ the procession of mor-
bid phenomena, the firet impression made by the
exciting cause, and earliest change from the
healtliy state, will be found in the functions of
this system of nerves, in perhapa the larger pro-
portion of cases ; vascular action, &c., and the
secreting and asrimilaUng functions being very
soon afterwards disordered* The truth of these
propositions will become more manifest after
navmg surveyed the causes which induce con-
gestion, the phenomena which accompany it
either as coincidences or consequences, ana the
results to which it leads ; and we shall be more
fully convinced of the propriety of viewing it as
very much more frequently a link merely in the
chain of morbid action, than as a primary or even
an early change.

4. Congestion has been divided by many mo-
dem pathologists into active and pauive, they un-
derstanding by the former that state of vascular
action which coincides with active determination
of blood, according to the meaning I have attached
to itin another article. (See Blood, $ 25.) It
may be defined to be a vital excitement with
somewhat of expansion of the vessels, and the cir-
culation of a larger quanti^ of blood through

D d

CONGESTtOK OV BLOOD— In Cavsu, &e.

402

them, Without any obvious tendency to form new
productions, or to occasion disorganisation, unless
mflummation, or some other morbid condition,
supervene, which is very often the case. From this
state — activ$ emgeitian (see Blood, § 26.) —
in which the vital action of the vessels is above
their healthy standard, there is every intermediate
gprade, lapsing insensibly into extreme pattive
conention, in which there is deficient or depressed
vital power, the current of the circulation through
the weakened vessels being remarkably languid
and retarded. In this state, the venous and arte-
rial capillaries, having lost the principal part of
their tone or vital tension, re-act imperfectly upon
the mass of blood injected into them by the^.heart's
action , and become distended and congested. This
state, then, existing in any degree, down to that
which is barely compatible with the continuance of
the life of the part, constitutes congestion ; it being
thus considered as a state of sub-action, and not of
super-acUoo, as determination of blood undoubt-
edly is.

5. i. In respect of the modei of aeeetsim by
which congestion presents itself, much diversity
exists. It may occur suddenly, after intense
causes; slowly, after slight influences or other
disease ; and almost insensibly, after active deter-
minations of blood and inflammatory action. It
may be almost the primary lesion, the impression
made by the exciting cause upon the organic
nerves being the only previous change; or it
may be one of the most remote, and only ante-
cedent of, or immediately consequent upon, dis-
solution. It is generally the result of directly or
indirectly depressing causes ; and assumes every
grade according to the intensity of their operation
relatively to the organic nervous or vital energies
of the frame on which they act.

6. ii. The teituree mott liable to undergo eon-
gettion are such as, owing to their conformation,
particularly the laxity of their vital and physical
cohesion, admit of the distension of their vessels.
Cellular parts, and organs in which the cellular
structure predominates, as the parenchyma of
various internal orpins, particularly the brain, the
lungs, the liver, spleen, and kidneys ; the mucous
membranes, especially those of the bronchi and
digestive canal, and the uterus and ovaria ; are
most liable to experience this state of their blood-
vessels. Besides these, however, other and less
yielding structures, as the serous and fibrous
membranes, the skin, the muscles, &c., may be
congested to a certain extent, particularly after
exhaustion of the vital energies of the frame, and
diminution of the vital cohesion of these structures,
either by causes which depress the organic ner-
vous power, or by noxious agents contaminating
the blood, or by over excitement of the vascular
system of the congested part, or of the whole
frame. In one or other oi these three ways, con-
gestion supervenes when it is observed at the
commencement in the course, or towards the close
of febrile and constitutional maladies ; the same
causes, and operating in a similar manner, also
occasioning congestion of those viscera which are
most liable to it by conformation.

7. iii. The eautet of congution are, therefore,
l»t. Those which act by primarily depressing the
organic nervous influence ; such as advanced age ;
the continued or prolonged impreasioo of cold,
mental anxiety, and all the depressing pa«ioDs

and moral emotions ; prolonged sl6tp,Be&tiliad
phjTsical inactivity; miasmal, eontsgiost, cr
infectious emanations ; various vegetable, snbsl,
and gaseous poisons; and the rapid leai of tbe
natural electrical tension of the frame: Sd.TlwM
which mechanically impede the idnn or orb-
lation of the blood itself, or which chiBgc its
quantity and quality, either locally or gc&enO)^;
as excessive neat; general plethora, praliu»i
either by too full living, or by the supuiwioB of
the natural or accustomed discharges, iDtempted
circulation through the heart, the langi, Imfi
&c.; a long retained posture by debilitated per-
sons ; the use of unneeesniy ligatures and tigi^i
lacing ; improper and nnwfaioleKNne food; cob*
tamination of the blood by the abiorptioD or in-
troduction into it of noxious minenU, vegotabk.
and animal substances, or gaseous fluids; lod
changes taking place in its oonstitutioQ, fron ike
interrupted secretion and elimination of boitfti
matters from it (see Btoon, $ 1 15. s(Mo.)--ibe»
latter causes affecting the vital mamfesUtioa of
the vessels and nervous systems ; 3d, Those gssks
which exhaust the irritability or vital lorn of tbe
vessels, by previously exciting then abon thcr
natural state of action ; as local detemintioBs of
blood, general vascular exciteraent ; fadgiN fraa
violent or continued exertion ; pre-exiitiBg fere.
inflammation, or other dieeases. Thus it will be
seen that congestion arises from chtoges iadoctil
(a) in the state of organic nervous pover, loJ
externally to the vessels ; (6) in the blood ittelf.
and acting internally on the vessels sod ltn^
tures ; (e) in the coats of the vosrU iIkb-
selves ; and (d) in two or more of th«e wa:^
taneously.

8. iv. The nfmpUmu indicmtiag the existsMS o^
congestion are sometimes very apparsot, st otber
times yery obscure. When it is preseut is •
marked degree and in vital organs, the distiirb>
ance of function is usually so mat as to iod^
cate its existence; but even then the kind ot
disturbance may be very nearly the sams ss pro-
ceeds from morbid states, which we sfasll brff-
after find congestion not infrequently occwocs
viz. sanguineous or serous emision; ss in the
cases of intense congestion of the eaoeplttloD.
Upon the whole, however, it gives rite (o psrt»l
loss, or entire abolition, of the fnnetioiis of ^
affected part Thus, congestion of tbt bmc
when moderate, will occasion a slight stale ^
lethargy, or vertigo, &c.; where more ff*^^-
epilepsy, coma, or apoplexy. CongestioD of ^
hver is attended by more or leas complete 9f^
of the biliary secretion, with tumefaoboo of tbr
organ, &c. ; and congestion of the brDOckislfs^
face and lungs, with dyspnoM. asthma, &c. /<*
brile phenomena seldom accompany ceagsitios.
unless it arise in the course, or towards the eleit>
of febrile diseases, or be excited by infection oi
miasmal emanations, or is about to pass into n
inflammatory or hemorrhagic stale. ^^*'^
occurs in large 6ecretin|^ viscera or suHseei* v«
function of secretion is either impeded, vicatf*!. cj
altogether suspended ; a return or incresse «
the secreting action either restoring the heM)
state of circulaUoo, or converting it into •ctl*'?
determination, or even into ioflammatiOQ. ^^ ^
congestion affects several parts, or two or w^
important viscera, as on the iovasioo or lo«»w»
the dose of malignant fevert, or when the orcv

404

CONGESTION OP BLOOD— TaEATMtKt.

but shortly before, or at the time of death, and
yet be very evident upon inspection afterwards.
This is not infrequently observed in respect of
parenchymatous organs and mucous and villous
surfaces. When congestion, however, occurs in
the large viscera, as ttie brain, lungs, liver, and
spleen, and continues up to the time of dissolu-
tion, it is generally very manifest in them upon
dissection. In many diseases, particularly those
in which the blood becomes affected previously
to, or continues fluid afUr, death, and in those
which terminate by asphyxy, congestion of de-
pending parts is a very common poii mortem
occurrence, and one which should be carefully
distinguished from the congestion that has existed
during life.

12. II.Opthb Treatmsnt of Conoestions.—
i. It is necessary always to keep in view the fact,
that congestion is a consecutive lesion, arising
generally from causes which depress the vital
manifestation of the organic system of nerves
supplying the blood-vessels ; and that, although
it IS very frequently associated with general ple-
thora, and necessarily implies the existence of
local plethora (see Blood, § 23.), yet, on ac-
count of this depression of nervous power, general
depUtian, unless to a small amount, is seldom of
much service in the treatment of congestion, un^-
less it be conjoined with the use of stimulants,
derivatives, and excitants of the secreting func-
tions.— a. But local depletions, particularly when
directed in such a manner as to operate some
degree of revulsion from the congested part,
sometimes carried to a considerable extent, or
repeated as circumstances require, are among the
most reauisite means of cure. — 6. When the
powers of life are much reduced, even loqal de*
pletions should be employed with caution, and
never without having recourse, at the same time,
or previously, to suitable excHantt and external
derivatives. Of these classes of remedies, the
most preferable are such as tend to equalise the
circulation throughout the viscera, and determine
it to the periphery of the frame. Diaphoretics ;
the warm or vapour bath; warm poultices and
fomentations ; rubefacient tmbrocations, epithems or
poultices, especially those with Cayenne pepper,
mustard, horseradish, &c. ; blisters, and warm and
rubefacient pecfi/uvia ; are calculated to accom-
plish these purposes.—- c. Much advantage will
also accrue from attempting to restore by emetics,
purgatives, or other remedies, the secretions
of the mucous surfaces, and the functions of
the congested organ; as the restoration of these
functions, which are generally impeded or alto-

gither arrested, will unload the vessels, and acce-
rate the retarded circulation in them. But it
•hould be kept in mind, that the medicioes thair
operate in this manner are generally local and
specific excitanta ; and henoe that they, as well as
me stimulants usually given internally, should be
exhibited with caution, and preferably at the
same time that local depletion, with derivation to
the surface of the body and lower extremities, are
being employed. Without attention to these pre-
cautions, we may convert, particularly in pledioric
persons, simple congestion into active determin-
ation of blooa, or into inflammation. — d. The dif-
fusible stimulants that are generally roost service-
able in removing conpeations are, camphor, the
prepaFationi of ammomai the Ktbers, weak infu*

sions of arnica or serpentaria, warm dilnc&ts with
saline medicines or the nitro-hydrochlotic acids,
the liquor ammonis acetatis, small doses of ipe-
cacuanha, with camphor and opium, &c., and
several of the gum- resins and essential cik.-^i.
In many cases of congestion of vital orgsu, it
will be requisite, in addition to the foregoiDg
measures, to direct internal revulsant agsnU to
remote viscera. Thus, in congestion of the hcsd
or lungs, we shall derive advantage from ezcitia;
the action of the lower bowels by irriieting ca-
thartics and injections ; and, having pmciibed
depletions and external derivation, from a jodidoes
employment of active diuretics, — f. In all ctses,
it will be necessary to promote the natural Mcre-
tions and excretions ; inasmuch as we thereby
keep up a re^lar distribution of the dreuliting
fluids, and eliminate from them such hurtful fful>>
stances as mi^ht irritate the vesseb and iodaoe
consecutive disease, if they were allowed to seen-
mulatcw— ^. In many instances, benefit willaccrat
from the affusion or asperuon of cM or itfd
vMter over the part enclosing the congested or-
gan, especially when the state of the poke, tul
the seat of congestion, lead us to dread the npcr-
vention of hsemorrhage, as in congestion of tiie
brain or of the lungs. — h. Besides the ezterotl
means already alluded to, various others nay be
employed near the seat of congestion ; as mass,
the actual cautery, dry cupping, stimulation or
rubefacient liniments, dry fnction, the warn sod
tepid affusion or douche, the nitro-hydrockloric acid
lotion, chlorine or fumigating bnihs, eiectiicitj
or galvanism ; but these are most appropriste to
the more chronic states of congestion. There an
other remedies besides the few now addoced,«hicb
are suitable to particular states and seals of coo-
gestion, and which fall under different heads.

13. ii. Having removed the congestion, it will
be necessary to employ means to prevent itsrecor-
rence, for the part once thus affected long retain a
morbid dbposition. This object can be ohtaioed
onlv by a careful avoidance of the exciting caoto
— by preserving a free state of the secretions and
excretions — by promoting the digestive (unctioo^,
and invigorating the system by moderate exercee
in the open air, either on foot or horseback ^btr
the use of mineral watera, particularly those which
combine a tonic with an aperient and deobscruesi
operation, as the waters of Cheltenham, Harrogsle.
Scarborough, Leamington, Seidschntx, Cari^.
Bath» Marienbad, Vichy, and £ger — by warsi
clothioff, and by guarding against general vaieo-
lar plethore.

BiBLioo. AND Rxraa.— SloA/, De Moca TDnico ykti-,
indeque pendente Motu Sancuinb pvticulari, Ac. JeM«
1698. ~~ Bagtivfj Opp. |X SSa— Juadbr. Duwit. dc Oon.

Citionkbuc Hate, 1748.— /<n^w«N,l3«Coiveittonai
edianismo. £rL 174a ^A.E. BUdhser, Oe CvfffW
NaturA, Cauiic, et Effectibua. Hale, 1749 — \koht, IV
Congettionibua. Jtnae 1761. — Wetttor, De CAUfctths >-
but. LuRd. Bat 1779.— 'Crawl, De Sanfulato Conpnt
Helm. 1796. — Ooldkamen, De Tbeoria Caimett, MMfetaM
Praxl inacrvit lUhe, 17M. — Marem^Tyon BUcfa.
B. 397. . ttniin, Bcymge, ftc p. 829 r< «rf . ~ Bhei,
Medicin. Bemerkungen, p. 6S.— > Anandte* Vcnadi obcr
die Lebentkraft,p. 192, -^ Sortkes. in Mtai. delaSob
MM. d'Emulation, t. Ii. p. l.^Hof^^n^rintr, Vtbrr dk
OehlmwaMertucht. p, 191.-' Horn, BeUiiife cur UM.
Klintk. b. U. p. 88. 91 — AmtenrirtM, JfhysMet^ S >I
Sm.^ReU, Ueber die Lebenakraft, v. Arch. v. Air n>r-
•iolocie, b. L sL 1. pi ISft— QvitMc/, in U^fctom^* Joum
der Pnct. Heilkuude. bi zllL at. 4.1^ 19S.— Soit^rpr,
Med. Chir. Zcitunff, 1801, b. iv. p. 857.— .iMcr. to iKm
and Phya. Joum. voL xxi. p, 9^ — Prttg, PHaopha «r
Pathology. Lond. 188S, n. 44& — £« SarTm, la Cfclnf.
ofrrsct.Jied.toLl.p.4fil

CONSTIPATION — TllEATMBNT.

411

bougie, which ought to be passed ss Htx as pos-
sible up the reotum.

24. d. If alyine obstrttction be apparenily
owing to organic, malignant, or other diseases
about the uterus, its appendiiges, the vagina, or
rectnm (^10.); or to sposm(^c constriction of
the sphincter ani eicited oy inflammatory irritation
io iu vicinity, or by hemorrhoids, the warm bath,
semienpiam, or the hip>bath ; the vapour of hot
water and narcotic decoctions directed to the
aous; anodyne and rslaiing injections; and the
extract of conium or hyoscyarous, made into
eith«r a suppository or an ointment, with the
addition of a little of the eitraet of belladonna;
tea; bs prescribed, along with such other mea*
surea as the circumstances of the ease may
require.

25. «. When constipation is dependent upon,
or Biiociated with, disease of the spine, or in-
flammatory irritation of the membranes and en-
velopes of the chord, leeches should be applied
near the place where pain is complained or; or
the patient may be cupped in the vicinity, kept
quiet, sod in the honzontal position ; and the
icuoQ of the bowels promoted by the means
stated above (^ 16, 17.), and by terebinthioato
iojectioos. If inflation of the bowels exist, the
carminstive liniment may be employed; and if
i«DdenesB, tonsioo, or pain of the abdomen be
complaioed of, leeches, foUowed by fomentations,
&c. u already advised ($ 22.), should be re-
sorted to.

26. C. Besides the above, other means have
been recommended by authors in various states
o( the disease, and found of much service when
•ppropriately prescribed. Jobudens advises the
frHjueat sdaaiaistration of a$taf<ttida in enemata,
tod, in cases of deficient secretion and healthy
iction of the colon, it is certainly of essential
ue, either alone or in conjunction with purg-
ative medicines. Starsx recommends the in-
tpiMted ox-gtU, both in the form of pills and in
clTsten. In Um latter form, it is calculated to
{trove an eacellent adjuvant of other means ; and
vbea combined with aloes, taraxacum, soap, ex-
t/tct of centian, ice. (F. 659. 562.), it is very
cervieeable in restoring the healthy functions of
tiie bowels, and digestive organs generally.
WzKUT directs repeated clysters of the decootion
of^M^ to be thrown up. Numerous writers
inve advocated the application of cold, in cases
of obadnate constipation. Scaanx, A. Fomsbca,
BuMARo, and Laisoh advise the patient to
walk or stand upon a marble pavement or slab ;
&ul Brassavolus states that Savanarola cured
the Duke cf Ferrera, by making him walk bare-
footed over a cold wet marble floor. Stxvim-
^^, Falconir, Pbrcival, and Spxhcr direct
the sflfoaum of cold water over the lower and
Qpper eitremities, and adduce oases wherein the
practice had been successful after other measures
oad failed. Kite, BARTRAai, Samcassini, and
^uMtoniAifM recommend cold epithems, and
the affoaion or aspersioQ of cold water, over the
abdomen; end Kaiulbr, Korb, and Bbandis
advocate the administration of cold dysmata, in
addition to the employment of cold externally.
Tbeeoldaod tepid iMwsr bath, the cold plunge
^th, and warm and tepid bathing, have severally
^a resorted to in sId of other measnres, and
^ frequently of use,— the fefmer particttlarly

in habitual constipation, the latter in cases at-
tended by difiicult and imperfect evacuation, and
seemingly dependent upon rigidity of the longi-
tudinal bands of the colon. Eleetrieity and
fabjanism have been employed successfully by
[rrs, SioAVD la Fond, Grapknoixsser, and
Clarxson ; and the injection of tobaeeo gmekt,
and of a weak infusion of the leaves of tobaeeo,
has been advised by Von Mxrtxvs, Vooel, and
other authors referred to, when discussing the
troaiment of Colic and Ilevs (which see). The
decoction of barberry ; powdered charcoal (Mit-
chell and Daniel), in the dose of one, two, or
three teble-spoonsful given every hour in milk
or lime water ; frictions of the abdomen (Quxl-
MALz); inunction of it with linseed or oliv^ oil
(Riedlin,&c.) ; fomenUtlons coonsting of senna
leaves made hot and moiat by boiling water, and
placed over the abdomen ^Pxrrr) ; purgative ex*
tracte; tinctures, and infusions, applied to this
situation, either in the form of ointment or foment-
ation (ScHENCK, Alibbrt, &c.) ; ^od enematR
conUinine the potoasio-tartrate of antifrnm;^ ( Elia s),
have also been employed. The exhibition ofemetits
was advised by Hippocrates, Praxagoru^,
Cjelius Aurelianus, and Alexander Tralles ;
and ofipecacuanha or andmonial emetics by Stoll,
Sims, Sumeire, Deplace, and Hosacx. I have
seen benefit derived from inunction of the abdomen
with an admixture of castor and linseed oils, to
which three or four drops of croton oil had been
added. In a great proportion of the cases of con-
stipation which have occurred to me since 1817,
when I first adopted the prnctice, very certain and
immediate advantage has been derived from a full
dose of calomel (either with or without opium or
hyoscyamus), followed in a few hours by half an
ounce of oil of turpentine, and an equal or some-
what larger ouantity of castor oil, taien either in
a cup of mUk, or in a glass of some aromatic
water. The action of these has usually been
promoted by an injection containing castor, olive,
or almond oil; and, if the operation has not
been sufiiciently copious, another dose of castor
oil has been given, and the enema repeated.*

• The foUowing mmopsia axhibita a auooinct Ti«w of the
treatment .—1. Irthe pulaebe bard or conitrlctod, and If
there be patn, InereiMd on preaaure, bleed genemlly or
locally, or both — apply bliaten or hot fbnenutiona, or
the cold efflttion, or cold eplthema, &&, on the abdomen |
afterwarda exhibit purgative*, enemata, Ac %. If con-
stipation aaenuto ari«e from diminlihcd accretion and
exbalaUon, give catoroel or blue pill, carbonatei of the
alkalica. Jalap, the purgaUve oil*, aaona, camboge, cla-
terium, croton oil, Ac. aoeording to circumitancea. a If
It depend upon a rigid fibre and habit of body, combine
purgatifoa with reURanta and nauaeants— with Ipeca.
cuanha, antimony, colchicum, aoda, hyoecyamut, Ac. ;
prficribe emollient and relaxant medieinet In preference
to thoae that are acrid ) and give them with antimaamo-
dioa and sedatives. 4^ When it arises ttma torpid perl,
sultic action and lessened secretion, conjoin tonics, gum
resins, and bitters, with purgaUvesaad aperienU ; myrrh,
aataftetida, galbanum, &c.,with aloea ; sulphate of quinine,
or ext. of gentian with aloes: the alkaline solutions,
with tonic inftisions -, use friction with stimulaUng UnU
ments to the abdomen, or along the spine; resort to tJie
cold salt-water bath or shower bath, and the tonic and
aperient mineral waters of Cheltenham, Leamington,
Vichy, and Carlsbad. & When It is attended by ac
cumulatione of hardened faces m the colon, have recourse
to coptoua soapy or oily clyater»*-to the introduction of a
marrow-spoon to break down the feces— to the injec-
tions of cold water, &a, by the ralve-apparatus, with a
long bougie attached to the pipe .-to the aspersion of
cold water on the abdomen, or the application of cold to
the lower extremities, Ac. C. If it proceedfrom ornnlc
change of the large bowels, or of parte afteting them.
aoUi^evaoMtton by emoUteot and rdaxaat enemsia, and

414

CONVULSIONS —I^ocAt-

vaiy as greatly in daration, modes of acceanon,
and recarreoce, ai well as in the namber of parU
aflTected by them. Hence, they may be aeut§ or
cArofite— moat frequently the former; partial or
genfral ; continued, rtcurrtnt, or intermittent ;
uncertain, in their accession, or periodic; and
they may, moreover, attack a namber of parts
in succession. The circumstances and causes
which originate them will also impart to them
certain characters, which, although frequently
difficult of detection, should not be overlooked.
Thus, they are either idiopathie or symptomatic,
most frequently the latter, even when the primary
lesion illudes observation. But these diversities
of form, although most deserving of attention,
can only partially serve as a basis for the prac-
tical consideration of convulsions. I shall tnere-
fore view them— Ut, In respect of their partial
or local occurrence ; 2d, As to their general mani-
festations y 3d, As they ajflfeot infants and children ;
and, 4th, As we observe them in connection with
the puerperal states : 1 shall also notice them as
associated with, or consequent upon, other acute
diseases.

7. i. Pahtxal on Local Convulsioks : —
Many of the disorders which have been imputed
to convulsion of individual parts, fall more appro*
priately under the denomination of spasm. I
shall therefore briefly notice only such as, from
the alternation of relaxation and contraction,
appear to approximate to the convulsive state.
A, Involuntary contractile parts are more sub-
ject to spasmodic action, than to that which
may be said to be really oonvuluve. Whether
or not certain of the pnenomena presented in
various diseases of the alimentary canal, as gas-
trodynia, pyrosu, rumination, retchings, colio,
borborygmi, ileus, the tormina of dysentery, &c.,
are more properly convulsive or spasmodic,
must be entirely a matter of opinion, to which
but little practical importance should be attached,
as they are both modifications merely of the same
proximate condition. This remark applies equally
to the abnormal actions sometimes presented by
the urinaiy bladder and uterus ; and it is proba-
ble that palpitations of the heart, and angina
pectoris, are chiefly manifestations of convulsive
contractions of this viscus. (See Anotna Pbcto-
Kis, and Hb4Rt — Palpitationtof,) That hiccup
is altogether owing to convulsive actions of the
diaphragm, cannotM doubted. (See Hiccdp.)

8. B. Voluntary muicUt and parte present the
most unequivocal appeannee of partial or local
convulsions ; although several local affections, de-
nominated convulsive by some writers, are, more
strictly speaking, spasm or cremp of particular
muscles. — a. The muncles of the eyo'ltde, owing
either to the contraction of an ill habit, or to
irritation of the ophthalmic branch of the fifth
pair of nerves, are sometimes clonically con-
vulsed — fonning the nietitaiio of aothon.-^fr.
The muscles of the eye'balU are also not infre-
quently similarly affected, particularly in infants
and children — occasioning, particularly during
sleep, rolling of the eyes. This state of local
convulsion is common during dentition, and dis-
orders of the stomach and bowels. Either a mora
severe state of convulsion of these muscles, ap-
proschiog to spasmodic contraction of one or
more of tbem, or a paralysis of their antagonists,
will occasion distortion of the eyea» or stmbismas^

with or without irregular OicUlatioM of the iiii,
dilated pupil, &c. ; as in inflammatory and ornuc
affecbons within the crauium, and ia vcmmogi
disorders.— c. Twitching convulsions of the «i<i*
cles of the face, or those inserted Into the iip>,
retraction of the angles of the month, giriog tat
to what has been called the rime eardmev; ut
often observed, but generally as a synptoo U
the invasion or actual existence of most ds&zer-
ous diseastt ; as inflammation of the eacephsidc,
or of the diaphragm, and various oiganic cUeta
afleoting the substance of the brain. Twitchio^
of the muscles of the face, however, soflMbna
occur in persons of a nervona and irritsble in*
perameat, or with an excited brain, withootu?
uiparent disease. — d. Convulsive movenesti cil
the tongue are seldom obsen-ed unconnected w\%
irregular movements of other parts, unlai io (Ik
diseases now named and in apoplesy<— «. Sli^it
convulsive actions of the mtMoisf of tm leisirjti .
giving rise to grinding of the teeth ia slcq), m
very common occurrences in persons with «or«i.
or other diseases of the alimentary caosl ; or a>
cited circulation of the encephalon. I have kcq t
case of clonic convulsion of the muscles of the hw
jaw, this part being in a state of eonslaol nwtwo.
alternately to either side, owing to theeoatftetioei
of one side taking place when relaxation oecsnd
in the other.—/. Trtumis, or spasoiodic ex-
traction of these muscles in infants, arises ftm
disorden of the prima via, the imprenon ^.
cold, or irritation of the umbilicos, bat doo
not strictly fall under the head of coowUiu}.
— g. A clonically convalsed stats of ths
mujc^ft of the neck are sometimes, bat nith.
observed, producing convulsive tremor, or ihtl-
ing palsy of the head, which is aggrsvsted oa
certain occasions of mental pertnrbatios, lad
nervous or vascular excitement. (See Paut.
Shaxiko, and Tremob. — A. The aboonst'
actions which approximate more closely u
the permanent or spastic cootrsctioot. asi
aflPect one or more of the cervical and ndjdaa:
muscles, are mUch more commoa, and it
often induced by a current of oold sir, hj
over-streining, or by inflammatoiy vniMum
about the bodies, or intervertebral snbstsoee ci
the upper cervical vertebra ; or frooi d)«e$i
about the medulla oblonnta or base of i^>r
brain ', or from irritation of remote paits~4s tf
the genital organs of the uterus or ovsris: ^
from strangulated hernia, — an instance of ^^^^
last has been observed by myself. lBslliO(!i
cases, the head is drawn more or less to ooe uii^>
or backwards, or forwards ; but sinilar flexnn<
of the neck often are occasioned by the psnlTV*
of muscles on the side from which the bad •»
bent, the tonic or natural action of the vasffMt*^
muscles drawing the head from the psrsl))*^
side. In the one ease, however, the musclaarc
rigid and strung like a cord on the cooinctnl
side, and more or leas pain is complsioed oi
either in them or in the vicinity, paiticalvl/ i'l
attempts to bend or turn the head or neck lo '"
opponte direction ; whilst, in the other case, thex
symptoms are wantiog. These are don |S«*
perly cases of spasm than of local cobviiImb.
as the contraction seldom alteraatsa with rrin*
ation, but is commonly mora or less pcrvsaeni.
However, cases sometimes oeear, which en
intermediate between permaneat span sodooo-

CONVULSIONS -Osynut*

416

tqUod, MMcndljf as a qrmptom of the diseMet
Ittt rafcrred to. — i. Convalnve movemenU ia the
pharynx ind caof^gutt impediog or preventing
deglQlitkm, lie frequent in bycteria, and in the
list stage of le vend fatal dueatei. — k. They also
aifect the muscles of the iaryiur, the diaphragm^
aod other respiratory muicles, either separately,
in rapid socoession, or nearly simultaneously.
Sons of these affections are transient, and the
Riiilt of slight causes ; as in sneezing, coughing,
sighiog, sobbing, &c. : others are extremelv dan-
geroos, owing to the nature of the parts affected,
the severity and continuance of the convulsive
movemenis, and the dreurostances in which they
supervene ; as in spasm of the glottis, spasmodic
croop, certain states of asthma, with severe fits
of coeshing, singvltus, he, — /. Convulsive ao-
tioof tLo occur in the muadet pf lAs ahdomm ;
u in hysteria, eommon and lead colic, and in
eoQsequence of totestinal worms. The most re-
markable iontaooes of true convulsions of the
tbdomioal muscles merely, that I have observed,
have occurred in adult parsons infested by the |
lai^ round worn. — m. The mtacki ^ tK$ spins
MMoetines experience convulsive actions, but
more frequently spastic contractions, occasioned
by bystena, disaaaa of the bodies of the vertebne
or nembraaos of the spinal chord, injuries of ad-
jwuQg parts, strangulated hernia, acute rheu-
matiia, the passa^^ of biliary or renal calculi
tloog the ducts, and inflammatory irritation of
tbe Qterus or ovafia.— n. Either one or both of
tbe upper cxrrtml<i«i are occasionally affected
by eoQvttlsions, more commonly both. The
Sngen are generally clenched around the thumb,
fthich is drawn upon the palm ; the arm being
cither ezlended forcibly, and the hand turned as
is pronation, or tbe fore-arm bent upon the arm,
or both thaw occurring in rapid alternatioa.
Soeh are the mors tonic convulsions of the upper
extreoities; but their muscles also experience
tiigbt and extremely clonic contractions ; as the
nkuUut Undimtm often observed towards the
close of fevers and diseases of the brain; the
nore toaic or spastic convulsions, particularly
when effecting one arm only, also arising from
ieaons of some pnrt of the encephalon, or of the
spper portion of the spinarchord.~*o. Convnl-
aeos of the Uno^r Mxtrtmitin are characterised
by analogous movements, and chiefly affect the
flcior and extensor muscles. The toes are bent
downwards, and the legs and thighs either drawn
upwards or extended, or both the one and tbe
ether alternately.

9. Convoloioos of voluntary muscles ma^ occur
u Mw described, or in two or more situations, or
even in different or opposite parts, either simul*
taoeottsly or in suocession. Tney may affect one
■ids of tbe body only, the other being in its natural
■tale, or paralysed, lliey much less frequently
ittaek either half transversely.

10. ii. GtNxnAL Cowtuisions. — Genera!
con V visions observe no certain mode of accession.
Oo tome occasions they attack suddenly; but
tbey are much more frequently preceded bv pre-
monitory signs, especisllT in ehildren and chronic
cases, — a knowledge of, and attention to, which
msy be made available in preventing their oc-
cnneoce. Thev ere also sometimes recurrent, or
laccsed each otW, with more or less rapidity.
U. A, Th§ fTtmanittty tigui are Yertigo and

dininess, irritability of temper ; flushingB, or alter-
nate flushing and paleness of the face ; luminous
or other spectra floating before the eyes ; various
noises in the ears ; partial loss of sight or hearing ;
restless or unsound sleep, or uncommon weight
or drowsiness ; fulness or prominence, and roll*
ing of the eyes ; clenching, or grinding of the
teeth, clenching of the haiSs, &c. during sleep ;
a tumid appearance of the countenance and
hands ; coldness or cramps of tbe extremities ;
slight tremors, shivering, horripilation, shudder-
ing or horrors ; nausea, retching or vomiting ; or
pam and distension of stomach and left hypo-
chondrium ; unusual flatulence of the stomach
and bowels, or other dyspeptic symptoms ; pains
in the loins or back ; frequent signing or sobbing ;
numbness of various parts ; stammering or im-
peded utterance, loss of memory, and absence
of mind ; palpitations, or slowness and inegu-
larity of pulse ; slow, laborious, or irregular respi-
ration ; and sometimes, a copious discharge of limpid
urine. In some instances, leipothymia, or threatened
syncope, precedes the general convulsions.

12. JB. a. TK$mor§ toiite istfurs.— The con*
vulsive movements constituting the paroxysm
generally follow rapidly upon one or more of^the
above signs, and var^ remarkably as to violence
and duration. During their continuance, the
oountenance is vervmueh distorted ; the eye-balls
are prominent, full, wild, staring, and rolled in
all airectbns ; the eyelids are either open, or ra-
pidly shut and opened; the patient grinds and
gnashes his teeth, and sometimes foams at the
liiouth, or protrudes the tongue. The alternate
contractions and relaxations of the whole volun-
tary muscles, and contractions and extensions of
all the limbs, are performed with the utmost irre-
gularit^r, rapidity, and vrith so great force, as often
to require the united strength of several persons
to preserve the patient from injuring himself. In
these struggles, tbe teeth, or even the bones of
the extremities, have been, in some instances,
broken. The respiration is laborious, interrupted,
and sometimes accompanied by a hissing noise.
The countenance, and indeed the whole scalp,
are sometimes tumid, bloated, or red, and often
leaden or livid towards the close of the fit, parti-
cularly in plethoric persons, when the respiratory
actions are much impeded, and the afTection ori-
ginates in cerebral disease. In other cases, the
face is pale, and the pulse weak, or small and
constricted. The urine and faeces are occasionally
voided with violence during the paroxysm : occa-
sionally large quantities of limpid urine are passed.
In these, the pulse is generally full, strong, and
commonly slow or irregular. In many instances,
the general sensibility and consciousness are but
very slightly impaired, particularly in the more
simple cases, and when the proximate cause is
not seated in the encephalon ; but in proportion as
this part is affected, primarily or consecutively,
and the neck and face tumid and livid, the cere-
bral functions are obscured, and the convulsions
attended by stupor, delirium, &c., or rapidly pass
into, or are followed by, these states.

13. b. The more eUmie convu/«ums.->Such are
the common manifestations, of convulsions, when
they are not occasioned by inanition; the pa-
roxysms, however, varyinr greatly in violence,
duration, and freauency of recurrence, according
to the degree of vital energy, and numerotis other

414

CONVULSIONS — UoAU

vary ag greatly in daratiott, modes of accoMioiif
and recurrence, aa well aa in the number of parts
affected by them. Hence, they may be acutt or
chronic— most frequently the former; partial or
general ; cmtinuei, recurrent, or intermittent ;
uncertain, in their accession, or periodic; and
they may, moreover, attack a number of parts
in succession. The circumstances and causes
which ongioate them will also impart to them
certain characters, which, although frequently
difficult of detection, should not be overlooked.
Thus, they are either idiopathic or tymptomatie,
most frequently the latter, even when the primary
lesion illudes observation. But these diversities
of form, although most deserving of attention,
can only partially serve as a basis for the prac-
tical consideration of convulsions. I shall tnere*
fore view thero-<-lst. In respect of their partial
or 1o<ml1 occurrence ; 2d, As to their general mani-
festations ', 3d, As they affect infants and children ;
and, 4th, As we observe them in connection with
the puerperal states : I shall also notice them as
associated with, or consequent upon, other acute
diseases.

7. i. Pabtxal on Local Convulsions: —
Many of the disorders which have been imputed
to convulsion of individual parts, fall more appro*
priately under the denomination of spasm. I
shall therefore briefly notice only such as, from
the alternation of relaxation and contraction,
appear to approximate to the convulsive state.
A. Involuntarjf contractile parte are more sub-
ject to spasmodic action, than to that which
may be said to be really convulsive. Whether
or not certain of the phenomena presented in
various diseases of the alimentary canal, as gas-
trodynia, pyrosis, rumination, retchings, colic,
borborygmi, ileus, the tormina of dysentery, &c.,
are more properly convulsive or spasmodic,
must be entirely a matter of opinion, to which
but little practical iraportaoee should be attached,
as they are both modifications merely of the same
proximate condition. This remark applies equally
to the abnormal actions sometimes presented by
the urinary bladder and uterus ; and it is proba-
ble that palpitations of the heart, and angioa
pectoris, are chiefly manifestations of convulsive
contractions of this viscus. (See Anoina Pkcto-
KI6, and Heart — Palpitationiof.) That hiccup
is altogether owing to convuluve actions of the
diaphragm, cannot be doubted. (See Hiccup.)

8. B. Voluntary mueeUt and parte present the
most unequivocal appearance of partial or local
convulsions ; although several local affections, de-
nominated convulsive by some writers, are, more
strictly speaking, spasm or cramp of particular
muscles. — a. The muscles of the eyC'lide, owing
either to the contraction of an ill habit, or to
irritation of the ophthalmic branch of the fifth
pair of nerves, are sometimes clonically con-
vulsed—-forming the nictitatio of authors. — 'b.
The muscles of the eyC'talle are also not infre-
quently similarly affected, particularly in infants
and children — occasioning, particularly during
sleep, rolling of the eyes. This state of local
convulsion is common during dentition, and dis-
orders of the stomach and bowels. Either a more
severe slate of convulsion of these muscles, ap-
proaching to spasmodic contraction of one or
more of them, or a paralysis of their antagonists,
will occasion distoilkm of the eyee, or atmbismus.

with or without irregular otcillatioM of tke irj,
dilated pupil, &c. ; as in inflammatory and ornsie
affections within the cranium, and in ywamm
disorders.— c. Twitching coovulsioos ef the isiii-
clee of the face, or those inserted ioto the lip»;
retraction of the angles of the month, givio| Yve
to what has been called the ritue tardeniaa; are
often observed, but generally as a synpioa o(
the invasion or actual existence of most dsaj;«r>
ous diseases ; as inflammation of the eocepbU.
or of the diaphragm, and various organic dissga
aflTeoting the substance of the brain. Twitckogi
of the muscles of the face, however, MaMtisia
occur in persons pf a nervous and iriiiabit m>
perament, or with an excited brain, withoat nj
apparent disease. — d. Convulsive movencnn fi
the tongue are seldom observed unoonnectsd «i:b
irregular movements of other parts, nakM ia tbt
diseases now named and in apoplezy<— «. Sl^j
convulsive actions of the mutelee ef tM leuerjti ,
giving rise to grinding of the teeth in sleep, ire
very common occurrences in persons with womf,
or other diseases of the alimentary canal ; or o-
cited circulation of the encephalon. I hsve em i
case of clonic convulsion of the muscles of lbs lovt;
jaw, this part being in a state of constant loobao,
alternately to either aide, owing to theeootndioBi
of one side taking place when relaxatioD oecemi
in the other. «-/• Triemue, or apasDodio ess-
traction of these muscles in infants, arises frois
disorders of the prima via, the impresnon uf
cold, or irritation of the umbslicus, but does
not strictly fall under the head of ooavulaoM
— g- A clonically convulsed slate of the
mutcUi of the nscM are sometimes, but riitW.
observed, producing convulsive tremor, or eksi-
ing palsy of the head, which is aggravated oo
certam oocanons of mental pertarbalion, ttd.
nervous or vascular excitement. (See Faut.
Shaxiko, and Tremob. — h. The abosfnt!
actions which approximate more closely to
the permanent or spastic eoatraetioni, »ui
affect one or more of the cervical and idjoisic;
muscles, are mUch more common, sod ut
often induced by a current of cold sir» H
over-straining, or by inflammatoiy irriutes
about the bodies, or intervertebrsl sobrta&ct of
the upper cervical vertebrss ; or from 6mm
about the medulla oblongata or base of tk
brain ; or from irritation of remote parts— ei «>
the genital organs of the uterus or ovsris; er
from strangulated hernia,— an instance of m^^
last has bten observed by myaelf. Iasll««c^
cases, the head is drawn more or less to oat uU.
or backwards, or forwards; but simibr flcnm
of the neck often are occasioned by the psrsly««
of muscles on the side from which the bcsd s
bent, the tonic or natural action of the nnilicctnt
muscles drawing the head Iron the paralyted
side. In the one ease, however, the mttselcfsri
rigid and strung like a ooid on the eoDincfl
side, and more or less pain is comptstaed o^
either in them or in the vicinity, partieolsrly tt
attempts to bend or turn the head or neck ts u
opposite direetbn ; whilst, in the other ease, t^
symptoms are wanting. These are more |S9-
perly cases of spasm than of bcal coavalflHii
as the contraction seldom alteniates wiik itUi»
ation, but ia oommooly mora or leas ptrnaaeBt.
However, cases sometimes oeear, which en
tAtermediate between permanent sfean and coa*

CONVULSIONS — CmmAU

416

▼olfloo, eipecttlly m a symptom of the diseaaet dizziness, irritability of temper ; flushings, or alter-

list lefenva to. — i. ConTolsive movements in the
phiuynx and ^ttafiiagut, imptMliDg or preventing
deglutition, are frequent in hysteria, and in the
list stase of several faul diseases.— Ic. They also
affect the muscles of the iarynx, the diaphragm,
sod other respiratory muscles, either separately,
io rapid succession, or nearly simultaneously.
Some of these affections are transient, and the
result of slight causes ; as in sneeang, coughiog,
sgkiog, sobbing, &c.: others are extremely dan-
gerous, owing to the nature of the parts affected,
the severity and continuance of the convulsive
sMvements, and the circumstances in which they
iupervene j as in spasm of the glottis, spasmodic
croupp certain states of asthma, with severe fits
of ooBshing, singultus, &c. — /. Convulsive ac-
lioos UM occur in the muieln rf th» abdomtn;
H in hysteria, common and lead colic, and in
ooniequence of intestinal worms. The most re-
markable instances of true convulsions of the
abdominal musclea merely, that I have observed,
bre occurred in adult panons infested by the
large round worm. — m. The muteUt of th* tpim
fomettoies eiperience convulsive actions, but
more frH|neatly epasdc contractions, occarioned
bj hystena, discaen of the bodies of the vertebras
or membranes of the spinal chord, injuries of ad-
joining perts, strangulated hernia, acute rheu-
Dstjin, the passage of biliary or renal calculi
along the ducts, and inflammatory irritation of
Uw ttlems or ovsma.-*n. Either ope or both of
lbs upptr axtrsmitisi are occanonally affected
by eonvulrions, more commonly both. The
in^n are generally clenched around the thumb,
ahich is drawn npon the palm ; the arm being
cither extended forcibly, and the hand turned as
in pronation, or the fore-arm bent upon the arm,
or both thaw occurring in rapid alternation.
Such are the mora tonic convulsions of the upper
extmities; but their muscles also experience
•ligbt and extremely clonic contractions; as the
nAtuUut undimtm often observed towards the
close of fevers and diseases of the brain; the
aoce tonic or spastie convulsions, particularly
vbsn affecting one arm only, also arising from
lesions of some part of the encephalon, or of the
■pper portion of the spinarchord. — o. Convul-
noos of the (owar axtramitia are characterised
by analogoua movements, and chiefly affect the
ileior and extensor muscles. The toes are bent
downwards, and the legs and thighs either drawn
upwvdt or extended, or both the one and the
otber alternately.
9. Convniiions of voluntary muscles may occur

u aow described, or m two or more situations, or
even in different or opposite parts, either simul-
uaeoualy or in sneccssion. They may affect one
ode of the body only, the other b^ng in its natural
■tat«, or paralysed. They much leas frequently
auark either half transversely.

10. ii. GxNcaAL Cowvuisiows. — • General
cottTulsions observe no certain mode of accessioo.
On some occasions they attack suddenly; but
tbey are much more frequently preceded by pre-
monitory signs, especially in children and chronic
cases, — m knowledge or, and attention to, which
may be made available in preventing their oc-
currence. They are also sometimes recurrent, or
laeceed each other, with more or less rapidity.

U. A, Tk4 jnvaaonifsry j^giM are vertigo and

nate flushing and paleness of the face ; luminous
or other spectra floating before the eyes ; various
noises in tne ears ; partial loss of sight or hearing ;
restless or unsound sleep, or uncommon weight
or drowsmess ; fulness or prominence, and roll-
ing of the eyes ; clenching, or grinding of the
teeth, cleoohing of the hands, &c. during sleep ;
a tumid appearance of the countenance and
hands ; coldness or cramps of the extremities ;
slight tremors, shivering, norripilation, shudder-
ing or horrors ; nausea, retching or vomiting ; or
pam and distension of stomach and left hypo-
chondrium ; unusual flatulence of the stomach
and bowels, or other dyspeptic symptoms ; peine
in the loins or back ; frequent sighing or sobbing ;
numbness of various parts ; stammering or im-
peded utterance, loss of memory, and absence
of mind ; palpitations, or slowness and irregu-
larity of pulse ; slow, laborious, or irregular respi-
ration ; and sometimes, a copious discharge of limpid
urine. In some instances, leipothymia, or threatened
syncope, precedes the general convulsions.

12. jB. a. Thamora tonic leisurs.^ The con-
vulsive movements constituting the paroxysm
generally follow rapidly upon one or more of^the
above signs, and vary remarkably as to violence
and duration. During their continuance, the
countenance is very much distorted ; the eye-balls
are prominent, full, wild, staring, and rolled in
all oirections ; the eyelids are either open, or ra-
pidly shut and opened; the patient grinds and
gnashes his teeth, and sometimes foams at the
mouth, or protrudes the tongue. The alternate
contractions and relaxations of the whole volun-
tary muscles, and contractions and extensions of
all the limbs, are performed with the utmost irre-
gularity, nnidity, and with so great foree, as often
to require toe united strength of several persons
to preserve the patient from injuring himself. In
these struggles, the teeth, or even the bones of
the extremities, have been, in some instances,
broken. The respintion is laborious, interrupted,
and sometimes accompanied by a hissing noise.
The countenance, and indeed the whole scalp,
are sometimes tumid, bloated, or red, and often
leaden or livid towards the close of the fit, parti-
cularly in plethoric persons, when the respiratory
actions are much impeded, and the affection ori-
ginates in cerebral disease. In other cases, the
face is pale, and the pulse weak, or small and
constricted. The urine and fasces are occasionally
voided with violence during the paroxysm : occa-
sionally laree quantities of limpid urine are passed.
In these, the pulse is generally full, strong, and'
commonly slow or irregular. In many instances,
the general sensibility and consciousness are but
very slightly impaired, particularly in the more
simple cases, and when the proximate cause is
not seated in the encephalon ; but in proportion as
this nart ia affected, primarily or consecutively,
and tne neck and face tumid and livid, the cere-
bral functions are obscured, and the convulsions
attended by stupor, delirium, &c., or rapidly pass
into, or are followed by, these states.

13. b, Tho more elonie convuitions,^-' Hnch BTe
the common manifestations, of convulsions, when
they are not occasioned by inanition; the pa-
roxysms, however, varyinv greatly in violence,
duration, and freauency of recurrence, accordbg
to the degree of vital enei<gy, and numerous other

CONVULSIONS, INFANTILE — Symptoms and History op.

417

vuldoos were most violent, giddiness, with loss of
bearing and recollection. During convalescence,
the least fright, or sudden alarm, brousht on a
slight paroxysm. (See Chouea and Related
ArrEcnoNs, &c.)

19. iii. Infantilx Contdlsions. — Convul-
sions ofWn attack infants of a delicate and irri-
table frame, and those who are seized by severe
ioteroal or constitutional disease, or are suffering
some concealed visceral irritation. They occur
most frequently in children under four or five
years of age, and particularly during dentition.
They decline in frequency from this epoch to the
(ommencement of the second dentition, or about
the seventh year, when they again are often met
with. Mr. North doubts that any increase takes
place at the seventh year. The above is the re-
sult of my experiencei which in great measure
agrees with that of Beauues, Tissot, and others.
Ai iafiuktile convulsions present various peculiar-
ities in their causes, phenomena, complications, and
consequences, and are besides among the most im-
portant morbid conditions which come before the
pnctitiooer, I shall consider them apart.

20. A, Premonitory ngnt often usher in the
attack, but occasionally no such symptoms are
observed. I suspect, however, that they are
more commonly altogether overlooked, than en-
tirely absent. They consist chiefly of manifest-
ations of generally increased irritability. This
i) shown by the temper, if the child be a few
months old or upwards ; by want of sleep at night,
and heaviness in the day, or by perfect insomnia ;
by a lighter and shorter sleep than usual, the
child starting up on the slightest noises, or as
rrom a frigiitfial dream, with fits of screaming
without evident or sufficient cause ; by alternately
Rushed and pale countenance or unwonted ani-
natioQ of the face and eyes, followed by languor
and heaviness ; by a half closed or open state of
the eyelids during slumber, with starlings and
twitclungs; by fixed, vacant, staring eyes, the
pupils Ixang either contracted or dilated, or fre-

Suent oscillations of the iris, without being in-
uenced by the admission of light, or contraction
of one pupil while the other is dilated ; by stretch-
JQg^ or ri^ extensions of the limbs ; by hiccup, or
irregularity of breathing, or short gasps, followed
hy long laborious inspirations ; by twitchings of
the fingers, or clenching of the hands, or pressure
of the thumb upon the palm, the fingers being
extended aod separated from each other, or fre-
fluently moved about; by the sudden relinquishing
(>f the breast soon af^er having sought it eagerly,
aod the throwing back the head, with an exjpres-
Mon of anxiety, and an appearance of dimcult
deglutition ; and by fulness of the upper lip, with
a puched nose and countenance, and slight blue-
cf«« below the eyes and about the mouth. Many
of the^ symptoms, deagnated by the vulgar,
" invard Jiu, may with justice be attributed to
inflammatorv irritation of the arachnoid, as indeed
contended for by PAntxT, Martinet, Lalle-
^>^M>, ice, and, in my opinion, especially of the
arachnoid of the base and internal surfaces of the
brain. Bkachet and NortA have enumerated
them as premonitory of convulsions, which they
doubtless most freauently precede ; but in a great
many cases convulsions bold the same relation to
inflammatory and febrile attacks in infants, as
r^gon do to the same diseases occurring in adults^
Vol, I.

and hence these signs must often be common to
both, and also to some other infantile diseases.
This is shown by their frequency in remittent fever,
and other inflammatory irritations of the gastro-
intestinal mucous surface of children.

21. B. The paroxysm of convulsions in children
is similar to that occurring in adults. In th'e
most severe cases, there is a violent, involuntary,
and alternating or convulsive action of all the
voluntary muscles extending to some internal or
involuntary parts ; in which, indeed, the affection
often seems to originate, or which appear to be
those first affected. In plethoric infants the face
and scalp are tumid, readened, and subsequently
livid ; the eyes are distorted and staring, or turned
up beneath the upper eyelid, leaving only the
schlerotic visible ; the respiration is impeded and
laborious, but very rarely attended by foaming
at the mouth and protrusion of the tongue, unless
the paroxysm be epileptic. The whole surface
often becomes slightly violet-coloured towards
the close of the fit, and the hands tumid. In
many instances, particularly in weak or exhausted
children, the seizure is much less violent, the
countenance being pale and collapsed, and the
convulsions more clonic. There are sometimes
only twitchings of the muscles of the face, and
alternate contractions and relaxations, or rapid
shocks, of a few parts, or of only one half of the
body, or of various parts in succession, with slight
blueness about the eyes and mouth ; but more
frequently the whole body is convulsed, and the
countenance distorted and haggard. In some
cases, the thumbs are drawn into the palmsi and
the great toes towards the soles. The mental
faculties, and general sensibilitv, in the slight or
clonic convulsions, are generally not interrupted.
They are also, however, frequently obscured, but
only during the height of the paroxysm ; and
some^mes even entirely abolished in the severe
recurrent convulsions attending cerebral disea«;e
— the eclampsia of some authors ($24.).

22. C. The utmost diversity exists as to the
duration and recurrence of the fit. In some cases
it is only momentary or of a very few minutes'
duration. In other instances it continues for se-
veral hours, with frequent remissions. It may
likewise cease, and shortly afterwards return, and
thus subside and recur at short but irregular in-
tervals for several times, and at last cease alto*
gether, or terminate life. Or the first seizure may
be so severe as to be fatal. These recurring fits
are often at last attended by insensibility, which is
not altogether, or even not at all, recovered from
in the intervals. This form of the malady is
more common in children than in adults, except-
ing as it occurs in the puerperal states, or towards
the termination of tumours and abscesses in the
brain. As the convulsive movements constituting
the fit become less and less violent and constant,
and respiration fuller and freer, the natural ap-
pearance of the surface returns, and the child Ls
enabled to cry ; it afterwards falls either into a
refreshing sleep, or, if the convulsions have* a
cerebral origin, into a stupid or lethargic state of
various duration.

23. D. There is a species of spastic or tonic
convulsion, which is but rarely met with, afl^ect-
ing chiefly the extremities. It seems more nearly
allied to spasm than convulsion» into which,
howevefi it sometimes passes ; and occurs, chiefly,

£e

CONVULSIONS— Termwatioks — Prognosis.

421

peni eoDTiiIaoiis, in which both an lost; by
the geoeral absence of the consecutive sleep or
sopor of epilepsy ; by the irregular and frequently
recurring form of the seizure ; by what is known
of its origin and connection with obvious causes,
and by the mode of its attack and of recovery from
it. I'here are also various symptoms which,
although common to eclampsia, puerperal con-
vuIsioDS, and epiUpty, are yet peculiarly cha-
racteristie of this last ; and we find, in addition,
other phenomena which simple convulsions sel-
dom present, particularly the frightful scream
00 the accession of the epileptic fit, the ante-
c^eot aura or peculiar premonitory signs, the
veiy sudden and unexpected seizure when the
aura is wanting, the expulsion of the seminal
and prostatic secretions, as well as of the alvine
excretions; the more frequent occurrence of
foaming at the mouth, and severer affection of
the respiratory muscles; the more leaden appear-
aaee of the countenance, and the more common
recurrence of the paroxysm at a stated time, than
io convulsions, particularly after the first sleep,
or when the patient awakens or is rising in the
morning. (See Epilepsy — Diagnosis.) — 8, Con-
volfions are readily distinguished from hyiieria,
by the antecedent copious discharge of pale
urine, the globus hystericus, and the borborygmi ;
and by the alternate crying and laughing attend-
ing the seizure of the latter. Some instances of
simple convulsion, arising from irritation of the
l^soale organs, will, however, very nearly ap-
proach, if not altogether run into, the hysterical
character; as we also see many cases of puer-
peral convulsion difiPering but little from epi-
lepsy, excepting in the frequent recurrence of
tlie paroxysm in the former before the patient
has recovered from the sopor consequent upon
the antecedent fit, and in one or two of the
diagnostic signs noticed above. — y. The continued
or permanent nature of the spasms in all the
forms of tetanui, and the absence of any tendency
to obscuration of the general sensibility and men-
tal facnlties, during the whole unremitting dura-
tion of this dreadful disease, are sufficient diag-
Bostics between it and convubions. — ^. Rabidity
cannot be mbtaken for this aifection, if the
history of the ca«e, the uncommonly increased
•^osilMlity of the 'whole frame, the dread of fluids,
iod unimpaired cerebral functions, characterising
rabies, be attended to ; for, although convulsive
seizures occur frequently in it, they are produced
hy 80 slight external or mental causes — by every
attempt at swallowing liquids — that their nature
utd origin cannot be for a moment doubted.
(See Rabidity.)

36. III. Tan Ml NATIONS OR Consxqttences, and
pRocKosis. — A. Convulsions, in any of the
forms now placed before the reader, may termi'
ftffte, (d) in health ; (6) in some other disease ;
1^1 (c) in immediate dissolution, a. Their (er-
viination in health may be marked by no peculiar
phenomenon, beyond the non-recurrence of the
'eizare. In other cases they are followed by
critieal evacuations, particularly haemorrhage
from the nose, mouth, or ears, after which they
way never recur, or which may produce an
immunity from them for a time. Vomiting and
diarrbcea, or the accession of the catamenia, may
likewise prove critical.

37. 6..They often tuefolUnoed hy ethir dtHosei;

or rather the original disorder or change of struc-
ture, of which convulsions are merely a part of
the sensible and outward signs, may, from its
increase, or extension to adjoining parts, occasion
other or additional phenomena more or less inti-
mately allied to convulsion, as palsy, apoplexy,
coma, loss of speech, or of sight, or hearing,
chorea, or mania, delirium, idiotcy, SiC, each of
which may pass into the other, or be variously
associated with one another. Thus, loss of sight,
hearing, speech, and idiotcy, may be the con-
sequences in the same case. Also, either of these
consecutive phenomena may arise from the cere-
bral congestion, and its effects, produced by the
frequent recurrence or by the severity of the fit,
particularly when the respiratory functions are
much impeded in it, and tne system is plethoric
and relaxed. Mv limits will not admit of ill us-
trations of these facts, either from my own ex-
perience, or from the other sources which are
referred to at the end of the article; but they
are of common occurrence, and may, after con«
tinning for a longer or shorter time — in some
cases for many years ^- in others for a very short
period — either be recovered from, or terminate
existence. In some cases, convulsions are fol-
lowed by a state of leipothymia, trance, or
complete syncope, which, when profound and
continued, may be mistaken for dissolution, and
endanger premature interment. There is reason
to suppose that, in some countries where inter-
ment usually follows death at a much shorter
period than in Great Britain, this dreadful fate
has overtaken the patient. In other instances,
lethargy, or torpor, terminates the paroxysm,
which, in rare instances, has been of long dura-
tion, and also may be mistaken for death. Whilst
the convulsions of childhood more commonly
give rise to, or terminate in, loss of one or more
of the functions of sense, in chorea, in idiotcy,
or in hydrocephalus ; those attacking adults are
more disposed to pass into either apoplexy, coma,
palsy, or mania: and whilst the convulsions of
the former class of subjects are more freauently
the consequence of irritations affecting the ab-
dominal viscera, those of the latter, excepting in
females, are more generally the result of disease
within the cranium or spinal column, often at a
certain stage of its progress.

38. c. Their termination in death takes place
either through the intervention of one or more of
the diseases noticed above as their consequences,
or, more directly, from the extension of convulsion
or spasm to the respiratory muscles, inducing
asphyxy, or from an overwhelming congestion or
effusion of blood in the brain. This sudden un-
favourable change more commonly occurs in
puerperal convulsions than in other forms, ex-
cepting when they proceed from abscesses or tu-
mours within the cranium. Death may also occur
from accidental suffocation during the paroxysm.

39. B, The Prognosis of convulsions depends
chiefly on what is known of their cansei, on the
antecedent and consecutive phenomena, on the
history of the case, and the degree in which
the functions of the brain and nervous system
are affected during and after the fit. a. If the
convulsions occur in children, without fever or
any primary or cerebral disturbance, and ap-
parently from worms, disorder of the prima via,
See, A favourable opinion may be entertained.

£e 3

43*2

CONVULSIONS —CAvtM or.

Bat when they ere preceded by head-affection,
by fever, followed by stnbismus, stapor, or lo«
of one or more of the functions of seme ; when
they are prolonged or recurrent ; or are followed
by signB of any of the unfavourable terminations
noticed above, much danger should be appre-
hended. Indeed, all cases depending upon cere-
bral disease are attended by more or less danger,
which, in some instances, become most imminent,
particularly when the symptoms of hydrocephalus
are present. — 6. In adult pencnt the prognosis
is equally unfavourable, when the affection is
evidently the result of cerebral disease, or of
organic changes — and when the fits become
more and more frequent, or severe, with more
marked cerebral disturbance, either attending
upon, or following them. On the other hand,
when they are symptomatic of disorders of the
prima via, or of the generative organs, a favour-
able opinion may be entertained. — e. Puerperal
convultitms, however, should never be considered
devoid of danger, more especially when they oc-
cur after delivery ; or in consequence of great
exhaustion of vital power, or of uterine hie-
morrhage. When they are slight, are unattended
by stertorous breathing, or by paralytic or apo-
plectic symptoms, and when parturition b so far
advanced as to readily ^dmit of its completion by
art, less danger may be feared. But the prog-
nosis of convulsions generally must be inferr^
from a careful review of the diveraified circum-
stances of individual cases, especially in respect
of their remote and efficient causes, and of their
disposition to terminate in either of the ways
pomted out.

40. IV. Appearances on Dissection op
FATAL Cases. (See Brain, § 4 — 133.), Epilepsy,
and Spinal Chord.

41. V. Remote and efpicient Causes. —
i« The remote cautes of convuUiens are numerous ;
but they often require a certain original or ac-
quired predispotition of system to insure their
operation ; and various influences which may
only predispose to them in some persons, may
even excite them in others. A, Predispomg.
There is every reason to suppose that the off-
spring may derive constitutional predisposition to
convulsions from the parents. Persons of a ner-
vous and irritable temperament, — of a delicate
frame, and largely developed bead ^Desessartz),
— of a relaxed and soft fiore, and plethoric vascu-
lar system, — children whose fontanelles are very
late in closing, — those who are naturally of a
quick, sensitive, and unstable disposition, and
whose physical and moral constitutions are
readily impressed, — are predisposed by original
conformation. Those infants who have experienced
injury of the cranium during parturition (Sm el-
lie); persons who have early, prematurely, or
inordinately indulged in venereal pleasures —
who have placed no restraint on their passions,
particularly anger, — who have become debi-
litated by any cause (Avtenrietii), — who have
had their cerebral organs unduly and too early
excited, and before the process of developement
was sufficiently far advanced; the present state
of civilisation and precocious mental improve-
ment ; the greater irritability of the system ac-
companying the epochs of dentition ; the irritable
and plethoric states attendant upon pregnancy ;
habitual determination of blood to the head ;

previous attacka of eoBwkion, cither befoie or
after puberty, or in a former pregnaney; n-
tempti to oonceal pregnancy, and the aieotsl
distress and shame attending it in nnmsined
women ; exhaustion of nervous or vitU power \n
increased discharges, long continued piio, or
want of sleep; all luxurious indulgenoes; too
much sleep ; inanition and want ; prolonged Ue-
tation ; fluor albui, &o. ; and cdtain eketiicil
states of the air, by which the nervous lysiciB a
influenced, and rendered mora suseepfible of im*
pressions and excitement ; are the chief cantf
which generate a predispontion in the frame. It
haa been remarked by Dr. Ramsbottom, and
other writers, that pneiperal convuliioDs were
most frequently produeea during wann electrical
states of the atmosphere.

42. fi. The exciting eausrn of the various fono*
of convulsion are very numerous ; and they set
in diflferent ways in producing their effects. Ibsra
alrndy stated, that irritation of a part of the o^
ganie or ganglial nervous syaiem will be ntia-
mitted by tw communicating bunches to the
spmal nerves, and produce convulsive actioDs of
the muscles they supply, without the braia expe-
riencing any evident lesion ; whilst, in other osm*,
the irritation maybe conveyed to the brain, either
directly by the organic nerves, or through the
medium of the spinal chord, the cerebrsl fosr-
tions suflTering accordingly. But irritatiott or
oijgfanic change of any of the parts ooDtaiocd
within the cranium will also occasion cottval«ioD<,
the general sensibility and mental raanifcstttioes
being then more or leas obscured or perverted
during the paroxysm or subaequeotly. Hmk
facts, which might be illustrated by aumenras
cases, the history and results of which 1 b««e
attentively oboerved, naturally point to a diriiioD
of the causes, first, into those which act vpon
some portion of the omnic nerroos circle, or ^t
viscera which it supplies; and, teeondlf, ap»
the cerebro-spinal system itself. But, although
it is useful to make this distinction, particolarly
for practical purposes, yet it should sol be over-
looked, that irritations affecting the fomer voiM
rarely be followed by convulsions, unteai tbe
latter posMSsed a maAed di^Msition to diMS$r,
ss fsr as regards increased sosceptibilitj tod
proneness to experience alterations from tbe
nealthy condition of its dreulatioD.

43. a. The exciting causes which set niore
immedistely upon the organic ntrvout jytfni, tsd
through it upon the spmal nerves or brain, or
both, are the following ;~^ a. In it^anU sot!
children, the retention m the meconinm ; a met'
bid state of the umbilical chord ; uawboleiffM
milk, or improper feeding : acid or acrid tatd»,
and various diseases of the alimeotaiy eaasl ; «d
overloaded stomach ; suppression or leteatioa of
the urine ; accumulated flatus, or morbid ttett-
tions, and (he presence of worms, oocsMsiog
irritation of the bowels ; the ingestion of smd
substances — as very irritating purgatives (Gost
and Lentilios), or emetics (Rtx]>iJN)><—x^
enomata ; noxious or indigestible sabstsnce* Isken
al food ; acidity of tbe prima via ; deniilioQ oi
either of its epochs, particularly cstbog the rjt
and molar teeth ; the irritation of pained or caiiotti
teeth ; and calculi in tbe urinary orgasm &«•
B. In persons about, or tuhtejmntif te, p^tben^ .
and occasionally in chiklrM, orgaaie dinsHS of

CONVULSIONS — Tbeatmwt.

425

find pretHdy tbtt state wUch is described in the
trticfe Blood ($ 53 — O0.)> And that, instead of
congestion, there is general ansmia, with cerebral
imtatioo, combining with the phyncal condition
o( the brain, to determine to it the greater part
of the blood in the system. In other cases, there
ii apparently anasmia of the brain, at least at the
comnBencement of the fit, and either conscious-
Msi is retained, or it is lost from the state of the
cerebral circulation. These forms of seizure may
be called an^mial ; inasmuch as they arise either
from a general deficiency of blood, or from
sDiemia of the brain, although the vessels of this
organ soon become partially congested from the
impeded respiration, and interrupted circulation
through the lungs and heart, at the commence,
meat of the paroxysm. In these, a very opposite
treatment to depletion is required. 1'he ob-
fiervatioBs of Lath a v, Hall, Gooch* North,
and the author, on this important practical to{Hc,
have, however, induced the practitioners of the
present day to resort to blood-letting in convul-
lions in a much more discriminating manner than
ibrmerly.

50. d. Next in importance is the judicious
employment of cold and hiat — of cold in the
form of cold affuaon on the head and spine, and
of heat in that of warm bath or semicupium.
Aq appropriate use of these is more generally
^rviceable, and often less dangerous, than deple-
tions. The cold affution to the bead, and, in
cases where there seems to be irritation of the
spinal envelopes, along the vertebrs ; and cold,
in the form of epithcms, evaporating lotions,
pounded ice to the head, when convulsions are
produced by inflammatory action in the brain or
^nal chord ; are among the chief forms in which
Uiis agent is admissible. The cold bath, although
adviseid by Currib, Loeffler, Beavmfs, Bay*
NARo, and others, is, in my opinion, a hazardous
eiperiment during the paroxysm, and sometimes
even in the interval. The tcarm bath, or $emi'
cupiumf is frequently of much service, and par-
ticularly when there is either high nervous irri-
tation ; a dry harsh skin, or cold surface or ex-
tremities; and my experience accords with that of

HtlLSaOMN, liZMRISCHBN, DoERNER, SUd StUTZ,

respecting the propriety of adding a quantity of
the [fixed alkalies, or their carbonates, to the
Water. When the head is much affected, either
by inflammatory irritation of the membranes or
iciive congestion, cold afi'osion, or cold epithems
or lotions, may be employed whilst the patient is
ia the warm bath, or is using the semicupium
or pedilnvium. In slight cases of convulsion,
the aspersion merely of cold water over the
face, head, or neek, is often of service. Large
draughts of cold water were recommended by
lIorniAMf ; and they, as well as water ices, and
Cold clysters, have been several times employed
by myself with much benefit. Cold injections are
praised by Lamghans and Marx. Cold aflusion,
ccid aspersion, and cold epithems, have been
}nne&cribed by Curb is, Dupont, D gem ling, and
others; but the two former were usually directed
by them to the surface generally, instead of to the
bead, —a circumstance which accounts for the
disuse into which it had fallen, when the practice
was revived some years since by the author.

51. f. If the patient can swallow, and the
nvsclesof thejaw are not much iff^cted, cathartic

medicines should be ^ven by the mouth ; but in
most instances it will be preferable to delay
them until after the seizure. But I have under
no circumstances been prevented from directing
a cathartic and antispastnodic enema to be thrown
up. Either of F. 131 — 136. may be employed
and repeated, if it be not retained, as is frequently
the case. When purgatives can be taken, a full
dose of calomel, either alone or with jalap, fol-
lowed soon afterwards by an active cathartic
draught or mixture, consisting of senna, tincture of
jalap, carminatives, and antispasmodics, particu-
larly the preparations of ammonia and camphor,
is, upon the whole, the most appropriate. But
under every circumstance the operation of these
should be promoted by enemata. When we
wish to produce an active derivation from the
head and spine, as well as alvine evacuations,
the croton oil, elaterium, ol. terebinthinaB, Ace,
may be employed. But, where the object is
chiefly to bring away offending secretions, and
other causes of irritation, and at the same time to
allay disordered action in the prima via, calomel,
jalap, rhubarb, and senna, are, perhaps, the best
purgatives we can employ. Iheir action will,
in all instances, be mucn increased, and a marked
change be often produced in the disease, by an
occasional dose of the ol. terebinth, and ol.
ricini, assisted by the enemata already recom-
mended. If convulsions arise from worms in tiie
intestines, anthehnintie purgatives, during both
the paroxysms and interval, should not be omitted.
Calomel may generally, with due address, be
exhibited during the fit, and subsequently other
anthelmintics may be given. Bergivs and
Barton prefer the Spigelia Marylandica in such
cases ; but the other means adopted in verminous
disorders may be employed according to cir-
cumstances. Emetics are sometimes of service,
when exhibited upon the first intimation of the
seizure, particularly if there be indications of
gastric irritation from offending or noxious ingesta,
and acid sordes, or if the paroxysms assume a
periodic form. Schenck, Schjeffer, Rig el,
CoNRADi, Hufeland, Rud Sbhtii, advise them
chiefly in such cases. Thom recommends them
to be exhibited to the nurse, when convulsions
attack infants.

52. /'. Antispasmodics are soQietimes produc-
tive of instant relief, when employed in large
doses, early in or upon the first intimation of the
fit, particularly when it arises from debility, or
irritation in the prima via, or morbid nervous
susceptibility; but they seldom can be taken
in the paroxysm, unless it be slight, or arise
from exhaustiog causes, and then they are
often of great service, especially if they be com-
bined with restoratives and opium, conium, or
hyoscyamus. The aethers, camphor, musk, assa-
fcetida, valerian, the preparations of ammonia,
bismuth, zinc, &c., are amongst the most effica-
cious in these cases. When inflammatory irri-^
tation seems to exist in the membranes of the
brain, they are obviously contra-indicated ; but
congestion of a passive nature, especially when
the pulsations of the carotids are not strong or
hard, and the temperature of the head is not
increased, should be no reason for omitting them.
An extensive experience, however, of the effects
of the spirit of turpentine in convulsive diseases,
has convinced me that it is the roost efiicacious

CONVULSIONS —TRaAncsMt.

427

epiUiems, and ioternal and external reTulaacts, if
It exhibit appeannces of congestion or inflamma-
tory irritaiion ; and warm diaphoretics, gentle
toDics, and antispasmodics, and other means of
tapportiog the manifestations of vital power in the
oervotti systems, and of promoting tne secreting
and eicreting functions.

56. k. When convulsions are produced by
nartotic or acrv-nareoHe peitom, the immediate
encQStion of the noxious substance by the
stomach pump, or by emetics, the cold afifusion
oo the head, followed by stimulants and antt-
spasmodic), green tea, or coffee, stimulating
(iKmata, and frictions of the surface, are chiefly
to be depended upon. If they proceed from the
fuma «f lead or m«rritry, antispasmodics, tonics,
sbmalaots, strychnine, or nux vomica, with
pur^bves, are most serviceable, particularly when
mated by the warm bath, and bv frictions
of the surface afterwards with stimulating lini-
meats. Serpentaria, the arnica montana, and
camphor, are often beneficial remedies in those
casM.

67. /. Cottvulsioiis either of a partial, a general,
or irregular and anomalons form, arising from
initatim cf the Jemale organt, require local
<i<p)etio&s, cooling aperients, and antispasmodics ;
th« ioternal use of soda and nitre ; cold clysters ;
the cold affusion or aspenion ; the tepid bath ; or
the »hower bath, while standing in warm water ;
and dnogbts of cold water. In a case of general
c3Dvttlsiord aristn? from inflammatory irritation
aboqtihe neck of the uterus, with leucorrhcea, I
directed the patient to take a lemon ice, or to
driok as mnch as sb« could of cold spring watfir
apon the intimation of the seizure ; and she has
lutberto done so with uniform benefit. Having
seeo her during the paroxysm, and perceiving
(Ha »he Tetttn«l ber consciousness, cold water
«u given, and swallowed with some difiiculty.
The benefit was almost instantaneous. If the
coDvubions be connected with difficult, or sup-
pre!se<l menstruation, general or local depletions,
tod afterwards the warm general or hip bath,
full doses of the preparations of assafoetida and
UBtBODia, particularly the tinct. ammon. comp.,
(hegpir. ammon. fcetid., or the tinct guaiaci com*
po*ita, alto camphor, and the boracic acid, or the
btborate of soda, have proved the most effectual
remedies in my practiee. But the means already
«d*ised to prevent congestion or irritation within
tbe craDiam, should be resorted to upon the
fint intimation of the fit. Bleeding by leeches
from the inside tops of the thighs are indicated in
f^c« eases ; but it can be practised only in the
iotenral.

58. B. Tktprtvention of the panay tins is to be
attempted, with due attention to the remote and
proximate causes, the former of which should be'
removed as completely as possible, and the latter
^»<^tical]y but cautiously combated ; feeoi-
lectiog always that convulsions are the outward
roaoifeitations of certain lesions of the nervous,
ftcting on the muscular, functions ; and that our
^nowIfdg:e of such lesions extends not beyond
^he inference that they consist of depresnon or
'ihtostioo of vital power, or of irritation, or of
congtrtion, and occasionally, of two or all these
«iatei conjoined, some one of them predominating
f^ver the others, and being associated with addi-
tional and evM opposite changes. Many of the

means already noticed are requisite in the intervals,
as well as in the paroxysm, especially when
judiciously modified to the circumstances of the
case. a. Vateular depletion is often required,
and in similar states of disease to those already
pointed out ; but it should be directed with great
circumspection, and to a moderate extent, unless
the signs of active cerebral congestion, or of
inflammatory irritation, or of general plethora, be
unequivocal. If, however, opposite states obtain,
viz. exhaustion, and deficiency of blood, very
different means must be employed. In roost
instances of convulsions, the quantity of the
circulating fluid is not so frequently either much
above or much below the usual proportion, as
the influence, — vital or nervons,or by whatever
name it may be called, — by which the distri-
bution of blood throughout the frame is regu-
lated, is disturbed so as to determine or attract
a larger proportion to one pert than to an-
other. In no peculiarity of constitution is
the old doctrine, " uhi irritatM, ibi flurus,"
more frequently illustrated than in that in
which convulsive complaints are most commonly
observed ; and, in these disei^es, we are
continually finding fluxion one of the earliest
consequences of irritation. I have long thought,
and on several occasions contended, that, in the
common routine of practice, blood-letting is too
indiscriminately employed to remove such
determinations or irregular distribution of the
circulating mass; and that, although it sometimes
succeeds, owing to its being associated with other
and more appropriate means, it often fails, or
even augments the mischief, by increasing the
debility and susceptibility of impressions from
exciting or irritating causes, that generally cha-
racterises the nervous system of persons subject
to convulsive seizures. Therefore, when the
abstraction of blood is really necessary, it should
be performed in such a manner, and be ac-
companied with, or followed by, such medicines
as are most likely to equalise the circulation ;
and it is chiefly in this way that many of those
about to be noticed are productive of any ser-
vice in the disease. Local depletions, in mo-
derate quantity, repeated according to circum-
stances,— from the nape of the neck or occiput,
when the head is affected, and along the spine, if
irritation of the membranes of the chord is
suspected, — and assisted by such other means as the
case may require, are more generally applicable
in the intervals than large ventesections.

59. b. There are few remedies more beneficial
in convulsions than mild purgatives, or ape-
rients, taken daily, and conjoined with tonics
and antispasmodics. Active purgation, if long
persisted in, will lower the vital energy, and
thereby favour the return of the fits ; but the
more deobstment and eccoprotic medicines of
this class, particularly when thus combined, may
be given, so as to procure two or three feculent
evacuations daily. Thus prescribed, purgatives
will increase the patient's strength, and often
procure a prolonged immunity from the seizures.
Aloes, witn quinine or iron, and camphor; or
with myrrh, assafoetida, the tonic eztract.4, &c.,
and occasionally with blue pill, or with extract
of hop, hyoscyamus, or conium (F. 460 — 471.) ;
senna, with sentian or bark, the preparations of
ammonia, asUier, &c. (F. 26i6. 872.) ^ and either

CONVULSIONS — TnxATumr.

429

upon the iniide of the thighs, or on the epigastrium,
or along the spine. Several writers have directed
blisters to the head ; but the pathological states
atltnittiog of their application in this situation are
cuoiparaiively rare, and require the most intimate
knowledge of disease, and appreciation of symp-
toms for their recognition. It is only when the
v.idl eoergy of the brain is profoundly sunk or
exhausted, and not suppressed by congestion, or
active determination ot blood, or the pressure of
effused fluids, or adventitious formations, that a
l/lkcr on the scalp can be of any service. When
applied to the nane of the neck, or behind the
ears, or between tne shoulders, they aie seldom
of much use, unless kept open for some time.
Ibe pea or mezereon issue in the insides of the
tMghs, and antispasmodic liniments or plasters
aloDg the spine, or over the epigastrium, are
iometimes useful auxiliaries.

64. g. Eleetrieity and galvaniim have been
proposed in convulsions ; but I agree with Gba-
f i.vGiEssER in thinking them hazardous, h. Cold
batkifig has been very commonly recommended ;
bot it requires discrimination. It will benefit
chiefiy those cases which are unconnected with
organic lesion, and which depend upon general
debility and susceptibility of toe nervous system.
la these the salt water bath should be preferred,
aod its use commenced in the tepid state, the
teoiperature of successive baths being gradually
r»Iaoed. The cold ihower both is more generally
applicable, particularly upon getting out of bed ;
aod «lieo it cannot be resorted to, the patient
ought to sponge or bathe the whole head with
lold water every morning. The strictest atten-
lioQ should, at the same lime, Ijc paid to the state
"f the digestive functions, and of the alvine eva-
cuations. Cutaneous excretion also ought to be
promoted ; for, not only are all the other func-
^Qs thereby improved, but contingent disturb-
^Qce of any of them, and the irregular distribution
of blood, in which convulsions often originate,
!>'t less likely to take place whilst the circulation
ia the surfaces is uninterrupted. It is probably
from this mode of operation, as much as from
^bcir antispasmodic action, that service has been
obtained from several diaphoretics, particularly
ilit kerme* mineral, and other antimomals, recom-
ni«>nded by Uvzaa, Gulbrand, Struvx, and
Hari>er. t. Warm bath$, kip baths, stmicupium,
^c, when any advantage is derived from them in
^le intervals, act chiedy in this manner. But I
^l'.e\'e that they will seldom be productive of
ii^uch benefit, unless in cases connected with sup-
prcsiHid eruptions, or the exanthemata, or with
'^r^lar or difficult menstruation, and with dis-
orders of the digestive canal in children ; and in
^^^•4 the effects of warm baths will be much
^QhsQced by stimulating or irritating frictions of
^(ie surface immediately upon coming out of
ibem.

6o. k. The almost epidemic prevalence of con-
^iiUioos during slates of religious enthusiasm and
'Cental excitement, as shown by the occurrences
^Irettly referred to ($ 16 — ld.)>&nd by the seizures
^Mat afiected many of the Jansenists who made
pilgrimages to the grave of Deacon Paris, during
^'le penecution of this sect in 1724, as well as by
^he coDvulsioos at one time so uncommonly fre-
'l^«nt in the Methodist meetings in various parts
^i Cornwall, as described by Mr, Cornish,

should lead the physician to recommend such
moral regimen as the ciroumstances of particular
cases may seem to require. The above facts, as
well as the circumstances recorded by Boer-
HikAvx, of almost all the girls and boys in the
hospital of Haerlem being seized by convulsions
from their seeing a girl who had been frightened
into them, will alone show the importance of
separating the affected from females or other
susceptible persons. There can be no doubt
that simple hysterical or epileptic convulsions
occurring in one among a crowd of females will
' often occasion convulsive seizures in others, par-
ticularly in those of a delicate frame and nervous
temperament, although they may have never
previously been similarly disordered. I have
met with such an occurrence more than once.
Indeed, the number of these attacks on the public
occasions referred to, is a sufficient proof both of
the influence of the mind in producing them, and
of the propriety of the immediate separation of a
person thus seized, as was judiciously and suc-
cessfully practised by Dr. Uaygartii. The
propensity to become affected by convulsions
from seeing one in a fit appears to have been well
known to the Romans, and from its frequency
on occasions of public assembly, as much as from
other considerations, they obtained the name of
Morbut Comitialit, which has been understood
as applying only to epilep»y, but which I be-
lieve nad a much wider signification, and com-
prised all convulsive seizures. That fear or
terror will not only occasion convulsions, but
also remove them, or at least often prevent their
accession, might be inferred a priori, even if it
were not proved by experience. The actual
cautery employed by Bosruaavb soon put a
stop to them in the hospital at Haerlem : and
their prevalence in certain of the Zetland Isles
was said to have been arrested by the uncere-
monious ducking inflicted upon two or three of
those affected; the fear of being treated in the
same way having effectually prevented others
from being attacked.

66. L JUgimttt, — The circumstance of those
convulsions which arise in crowded assemblies
from mental excitement and religious impressions
being often ushered in by faintings, and signs of
congestion of the cavities of the heart, of the large
vessels, of the lungs, &c., should suggest the
avoidance, by susceptible persons, of warm and
crowded assemblies, where the foul and moist air
conspires with moral emotions in depressing the
nervous power, and in favouring congestions of
the heart's cavities and large vessels; as well
as the propriety of removal to the open air, and
of having recourse to antispasmodic stimulants
upon the approach of the siokin^^ and oppression
at the epigastrium and prscordia, which often
usher in the fit. The importance of administer-
ing to the mental affections and emotions — of
relieving as much as possible anxiety or de-
spondency— ought to be pointed out to those
concerned, and the patient encouraged strenu-
ously to resist the invasion of the paroxysm.
Persons subject to convulsions should never
receive indulgence on account of them, but be
made to know that they may be warded off, by
not yielding to the feelings which often favour or
produce them. Regular hours of rest, of recre-
ation, and of eating, should be adopt^ ; seden-

430

CONVULSIONS OP CHILD HEK—TRiiTMENt.

taiy habttt avoided ; exercise in the open air
taken daily, and both the mind and body duly
occupied without fatiguing either the one or the
other. In some eases, depending upon disease
of the brain or its membranes, the appetite is
morbidly increased, and much more food is
taken than is requisite to the wants of the frame.
Others are connected with indulgence in spirit-
uous liquors. It is almost unnecessary to add,
that unless these excesses be guarded against,
and the diet and regimen dul^ regulated, medical
treatment will not be efficacious.

67. ii. Treatmbntof Convulsions in iNyANTs
AND Children. — il. Many of the measures al-
ready recommended in the parwcytm may be also
employed in this class of patients ; but in asuitable
form and with strict reference to existing patho-
logical states. Where we observe the indica-
tions of cerebral irritation and congestion ($21.24.),
eupplne on the nape of the neck, behind the ears
or occiput ; the warm bath or semicupium, with
cold affusion ; cold epithems, &c., on the head,
the hair having been removed or cut close; a
dose of calomel, or of calomel and scammony if
the child can swallow, and a cathartic and anti-
spasmodic injection ; are suitable remedies, The
jugular vein may be opened in robust or well-
grown children ; but care should be taken not to
bleed them to syncope, as a return of the con-
vulsions may be thereby occasioned. Children
ought to be blooded with great caution during a
fit ; for, although I cannot go to far as to say,
with Harris, that it is dangerous to bleed in
the paroxysm, yet I believe that the convulsions
will occasion a hurtful quantity of blood to flow
without any immediate effect, if the evacuation
be pusheJ with the view either of subduing them,
or inducing syncope. It is as improper as it is
futile to lay down any rules as to the extent to
which depletion may be carried. It is obvious,
that when the child is plethoric, the head large
and hot, the eyes suffused and prominent, the
carotids throbbing, &c., it may be practised
freely, even in the fit, without risk.

68. a. Convulsions sometimes proceed from
the nature of the ingesta. If this be the case,
and if the abdomen be distended, an emetic
should be exhibited without delay. Seizures not
infrequently arise during the penod of dentition
from indigestible or irritating substances in the
prima via, and in such cases often commence in
simple flatulent colic. After an emetic has been
exhibited, or even independently of it, a purga-
tive, \t it can be taken, should be prescribed,
along with carminatives or antispasmodics, and a
clyster thrown up. In cases of this description, I
have found a dose of calomel, with soda or potash,
or the hydrarg. cum creta, followed by either
of the following mixtures, a carminative enema,
and friction with an antispasmodic liniment on the
abdomen or spine, the most successful means.

No. 15S R Magneifae Calcinatoe 3 88.:Sacchari AlbiSj.;
Olei Anisi ittV. ; tere bene siinul, et adde Aqus Foenicull
Dul. 3 jsi* ; Spirit. Amnion. Foetid. V\ xv. ; Pulv. Rbal
gr. xvj. ; Syrup. Papaveria 3 >J. Fiat Mist., rujiu|capUt
cooh. unum, yel duo minima, tcrttis vel quartis horis.

No. Id9. H Olei RicinI 3 iij.— 3 m. ; Olei Terebinth.
3 j. — 3y. ; tere cum Vitel. Ovi, et adde Aq. Fonilculi
3 M.~3 j. ; Svrup. Papaverislct byrup. Rous ia 3 ij. M.
Fiat Mist., cujus tumat partem quartamvel tertiam, ter-
tils vel quartii horis.

69. h, Clysteri, containing valerian, assafoetida,
or a terebinihinate substance, triturated with 0^

yolk of egg, and any of the canninative ivtten,
to which oleum ricini or ol. olive may be umnb-
times added, are the most appropriate lo tboy
cases. Much discriminatioa is required as to
the choice and continuance of cold applicttioM to
the head, particularly if the warm bath or semi*
cupium be simultaneously resorted to. IW
combined means should never be left to the div
cretion of a nurra, at least without the penosd
superintendence of the practitioner in the fint
instance. In general, as soon as the tempentarc
is reduced, and the features become pale aod
shrunk, or the fontanelle (if unclosed) level, or it
all depressed, whether the convulsions, or sopor.
when present, disappear or not, the appliesUoo d
cold to the head, in any form, should be left oB,
to be again resumed when the symptoms reqoimi^
it recur.

70. c. During dentition, or even before ^
teeth approach the margin of the gum*, im
scarifications ought to be practised, and repeiW
as soon as the scarified parts cicatriM, otben(>e
the obstacle to the passage of the teeth will t«
thereby increased. If general or cerebral ple-
thora be not present, or has been removed, aoi!
the bowels have been fully evacuated, a&y of lix
alkaline or earthy carbonates, with aqns fct^i-
culi, or aq. piment«, ether, camphor, 6.r^
with the extract of conium or hyoscyamos, or i^i*
syrup of poppies, or small doses of laudaDuc.
may be prescribed with the view of toothing
the susceptibility and irritability of the fnate ■.'
this period. Form. 347. 442. 865. have txf^
ordered by me very generally io such csm. i'
the Infirmary for Children. In very yoon? '^
fants, convuuions may be occasioned solely bj tV
retention and accumulation of acid anl acr.(l
sordes in the prima via. These are readily r*
moved by a dose of calomel, followed by oUy
ginous or other purgatives, the semico pinto, t^
clysters. Tissor and Sharp state that they ht^c
been produced by the retention of the meco&raT.
owing to spasmodic stricture of thespbiaciern.
This IS, however, a rare occurreooe. Emolllfct'.
oleaginous laxatives, the semicupium, tlystf^.
and anodyne liniments, are appropriate lo sec*
cases. It has been repeatedly contended for rj
most of the older, although denied by maov ^^
dern writers, that the anxieties, the'roore Tiolf^
passions, and the irregularities of the nurw, c 15
change her milk so as to disorder the <ligt«i(
organs, and thereby give rise to oonvalsioc^ 't
delicate infants. This fact is establisbed by r^
peated observation. I perfectly agree with Mr-
North, who has taken a very judidous rie* tf
this subject, that it should never be oreriool'^.
The obvious remedy in such cases is to cbtir^
the nurse ; and, if this cannot be done, to ntia^'
as far as may be the cause of disorder; to proo^
her digestive and excreting fuoctioos; to tnt-
quillise or subdue any mental distorbaocv (r
febrile action that may affect the state of t>-
milk, and to prescribe for the infant tprnri'j
with soda or ammonia, or other antseiJi w*
antispasmodics. I have often employed tbeo^:-'
of tine or trisnitrate of bismuth with soda, or tf>f
pulvis Crete compos., and either the pol^ 'P^^
cacnanhs comp., or small doses of coeian f*
hyoscyamus, with much advantage in these f*** •
or simply the bi*boRte of teda in camphor niKsir,
or aq. foenicttli.

C0NVULSI0K8 Of CHILD HEN— Thiatmek*.

431

11, d. The eoid bath is a Terr doubtful re-
medy ia the eeiiare: it it much less efficacious
tbao the oold aiTudon on the head ; and when
th« child retains its consciousness, it even some-
tines aggravates the mischief. Of the recom-
meDdstioD of Dr. Brokn, to employ gradually
iocres^ prcsmrs on the epigastrium during the
fit, I have had no experience : it, however, de-
serves a trial.

72. e. Of the use of hUtUn in convulsions, as
well as of alkaline nibeftusientB, as the liquor am-
moais, no favourable idea should be entertained,
as tbey require the utmost discrimination, and
are fu from beinff unattended by risk : for, al-
tboogh they will often cut short thie paroxysm, yet
they will also occasionally produce so violent irri-
utioD and inflammation as to be rapidly followed
by sphacelation of the integ^uments. This is liable
to happen particularly in ill or insufficiently fed,
in delicate and irritable children ; in those of a
grM or fat habit of body, who have been al-
lowed to feed upon the richer sorts of animal
food u» exclusively ; in the state of vital ex-
litoitioa observed in the latter stages of dis-
etse, as well as in the early periods when the
poise is veiy quick, irritable, or sharp, the skin
jryaDd burning, and the cerebral organs much
excited or oppre^ed ; — under such circumstances,
I have usually directed a liniment composed of
equal quantities of the liniment, saponis et opii
{id. Pkar.), and of the liniment, terebinthinae,
or either of F. 308. 311. to be rubbed on the
epigutrinm and abdomen, or along the spine.
Thuhbebo advises the cajuput oil to be applied
^ the epigastric region during the fit; Hbrz
directs the animal »il of dippel to the same region,
sod Abbauamson the oil ot rue. Either of these
will frequently cut short the paroxysm, but I can
a^rt, from a very extensive experience, that the
limmeata I have recommended are the safest and
most eflScacious.

73. /. When convulsions occur in the invasion
of iDy of the exanih0matou$ fevers, or upon the
retrocessioQ of the eruption, the treatment must
*^^P«id, in a great measure, on the habit and
■treogth of body, and the extent to which the
l»ruQ is affected. If cerebral congestion or irri-
tatioD, with general beat of surface exist, local
<i«pletioos, the cold affonon on the head, whilst
the patient is plunged in a warm bath, to which
*ooe vegetable or mineral alkali has been added,
cooHog aperients, cathartic imections, the tartar-
emetic ointment and solution F.749. rubbed on the
spine, and diaphoretics, are generally roost service-
^hle. After the bowels have been freely evacuated,
fhe carbonate of soda and nitrate of potash, given
in mticilaginous vehicles ; the spirit, stheris mtrici,
^ith the liquor ammonis acetatis in camphor
jtilep, &c.; may be prescribed. If the skin be
cool, and the pulse weak, or if the fit Jiave oc<nirred
tfter the disappearance of the eruption, salt and
nustard may be put in the bath ; and if the coun-
tenance be pale and collapsed, and the cerebral
functions not materially disturbed, warm and
cordul diaphoretics, as the preparations of ammonia,
<^inphor, serpentaria, &c., exhibited from time to
time. Frictions of the surface, immediately after
the patient is Uken out of the bath, will generally
promote its good efifects.

74. g. If convulsions occur in the course of fcoop-
»»g cmtgk or ereup, we may conclude that congeso

tion, or inflammatory irritation of the membranes
of the brain, has supervened, and should direct
local depletions, the cold aflTusion on the head,
semicupium, and the carbonates of the fixed al-
kalies, with opium, hyoscyamus, or belladonna,
in minute doses, unless the patient is already
much reduced by repeated or large evacuations,
when we may infer that the convulsive seizures
are connected with anasmia, and should prescribe
the treatment already described in relation to this
state ($ 55.).

75. h. The convulsions which occur so fre-
quently as a consequence of chronic or sei'^re
bowel compUtinU, and of exhaustion from other
diseases, and which have been too frequently
imputed to dropsical effusion in the ventricles,
require cordial antispasmodics, tonics, and light
nutridous diet. Although sometimes attended
by more or less effusion, arieing from the phy-
sical condition of the cranium and its contents,
and serving to prevent any vacuum from being
occasioned by the de%!iency of blood in the
cerebral vessels, yet the convulsions should not be
viewed as procecKling from the effused fluid, but
rather from the irregular and imperfect supply of
blood to the cerebral structure.

76. t.The seizures that follow great losses of
blood in children are generally characterised by too
active determination of this fluid to the cerebral
structure ; and require the head to be kept cool
and elevated, the bowels to be acted upon, and re-
storatives, antispasmodics, cordials, and tonics to
be administered with the extract of poppies, conium,
or hyoscyamus, according to the peculiarities of the
case.

77. h. If convulnons follow the disappearance
or rejyuUion of chronic eruptions, we should
dread the existence of inflammatory irritation of
the membranes of the brain or medulla oblongata
or spinalis, with a tendency to serous effusion.
Local depletions, the warm bath ; frictions of the
surface, particularly of the part whence the
eruption nad disappeared, with irritating lini-
ments; the use of sinapisms, and deobslruent
purgatives, as calomel, &c. ; are chiefly to be con-
fided in.

78. /. When the seizures have recurred several
times, particularly in infants, and are attended by
dilated pupil, squinting, slow pulse, &c., their
connection with hydrocephalus may be inferred.
In such cases, even local depletions should be
employed with caution : but in many instances
they may still be resorted to, in small quantity ;
ana followed by alterative doses of calomel or
hyd. cum creta, diuretics, small doses of digitalis
with spirit, sether. nit. and the use of the liniment
(F. 311.) to the head and loins both in the fit and
in the interval.

79. JB. The preventive treatment,'^— a, in pie-
thoric, fat, and gross-living children, should chiefly
consist of a proper regulation of diet, as advised
by Beaumes. Farinaceous food ought to be
adopted, with only an occasional indulgence of
the less stimulating meats. No rational plan of
treatment, however, can be attempted with the
view of prevention, without strict reference to the
remote and proximate causes of the affection ;
the former of which should be carefully avoided,
and the latter removed by suitable treatment.
When we detect cerebral irritation, or determin-
ation of blood to the bndn, or active congestion.

432

CONVULSIONS, PUERPERAL— TRKATMEHt.

cupping, as already directed ; the daily affusion [
of cold water oo, and a constantly cool state of,
the head ; a moderate, but continued, action on
all the secreting and excreting organs ; tranquil-
Uty, and the abstraction of aU excitement of the
mind and senses ; a bland and low diet ; the use of
revulsants, and wann clothing on the lower extre-
mities ; are the most appropriate remedies.

80. b. In very delicate children, where no
evident inflammatory irritation within the head
exists, a tonic treatment is obviously requisite.
The sesquioxide or ammonio-tartrite of iron may
be given, either alone, or with other antispas-
modics, or any of the other preparations of this
metal. The sulphate of quimoe, or the prepara-
tions of cinchona, with liq. ammonis acetatis, and
a little of any of the compound spirits of am-
monia ; suitable diet, attention to the state of the
bowels, and change of air, will also be of senrice.
Calomel, in frequently repeated doses, either alone
or with purgatives or anodynes, has been most
injuriously resorted to by^actitioners* upon the
mistaken notion that donvulsions are always
connected with irritation within the cranium,
and that this medicine alone can remove this
state ; whereas, if calomel be prescribed in small
and frequently repeated doses, it will actually
increase the susceptibility and irritability of the
body generally. When, however, it is given in
full doses at distant intervals, or only occasion-
ally, and either combined with jalap or some
more active purgative, or followed by cathartics
and enemata, it is a valuable remedy. Where
the bowels are thus judiciously acted upon from
time to time, and particularly if this be accom-
plished by a terebinthinated draught, tonics, com-
bined with antispasmodics and anodynes, will be
of the greatest benefit, especially if there be no
disorder of the cerebral functions to forbid their
exhibition. The sulphate or oxide of zinc, or the
sulphate of quinine, or the oil or other preparations
of valerian, or assafoetida, musk, &c., with either
conium, hyoscyamus, or the extract of poppy ; the
tonic decoctions and infusions,with the alkalies ; and
various other remedies already recommended in the
intervals ($61. 75.), may be severally employed,
according to circumstances, after purgatives have
been duly prescribed, and the stools have become
natural.

81. r. When we have, reason to infer that
the convulsions proceed from intestinal toomu,
calomel with camphor, and the other cathartics
noticed above; the occasional exhibition of an
active terebinthinate draught, followed by ene-
mata, containing aloes, assafoetida, camphor,
&c., and subsequently, by the preparations of
iron, as well as any other of the remedies and
modes of combining (hem described in the
article Worms, may be directed. It is generally
remarked by the German writers, that worms
never form in the alimentary canal previously to
weaning, if the milk be healthy ; and the observa-
tion is confirmed by my experience. It is there-
fore, after this period, that convulsions can be
referred to this cause.

82. d. The marked hereditary and emutitu-
tional tendency to convulsions in the same family
of children, and the very frequent connection of
this affection with cerebral irritaUon, or with
dropsical effusion in the ventricles, or between
tlie membranes, in such cases, have presented

difficulties to every practitioner. I beliert tkit
the disease, when oocorriog in this manner, hti
been too frequently ascribed to iaflsmiDslorF
action, and a too lowering treatment adopted.
Mr. Hill recommends the aisenieal nlotiDfl,
with musk, in these cases ; and I doubt dm ther
utility, if carefully employed ; but other tockf
and antispasmodics, particularly the weaker pre>
parations of bark or calumba, with the bqov
potaasa?, and small doses of conium, or s}Tap.
papav., or opium, if the child be not too yont,
and if the watchfulness or erethysm of the br4ia
be present, will be found still more servicetbk,
especially if the head be kept cool, the tecmiota
and excretions carefully promoted, and the bdon*
occasionally excited by the addition of dinrcw
to the tonics, as the spir. aether, nit., digitiiiN
syrup, scillae, &c., or by the a]^licatioo of i
suitable liniment (F. 31 1.) to the loins. Imercn)
cases of this description, I have directed, after
other means had failed, and while tonkx, ai so*
prescribed, were given, the hair to be cat off.
and the liniment to be rubbed upon the beaii
immediately after the cold affusion. Is case
connected with inflammatory irritation of tk
membranes, local depletions, the cold affusoo.
&c. ($ 67.) should precede the above trcit-
ment.

83. e. The diet and reginun of children tkt
have once experienced a seixure of coavidaoiSf
ought to be carefully attended to. The stooait^
ought never to be overloaded, either bj ttx
mother's milk, or by its ordinary food, wlurit
should be always recently prepared, and easj «•
digestion. As crying often brings back \U
seizures in infants and young children, it ikooii
be prevented as much as poaable. Wbeo
the bowels have been sufficiently encaated
by the medicines suggested, from one to tbnf
grains of the hydrargymm cum creia^ eitW
alone, or with the carbonates of the fixed slbLn
may be given at first every night and monitc.
and afterwards every night, or every otber ca-
tbird night. The head should be always elr-
vated ; and whilst in bed or indoors, it ought u
have no other covering upon it than that «>>^
which Nature has providea it. On no occa>>or
should the warm fur or beaver hat^, which j^
very impropcily worn by children, be used; aof
ought the mental powers to be preinatardj <^^
inordinately excited. In a word, tne head sboci^i
be kept always cool, the mind tranquil, the \9*^
limbs warm, and the bowels open. A fnx,WB-
perate, and healthy atmosphere, with occasaoaj
chaoge of air is also as necessary as nedi^
treatment.

84. iii. Taeatmsnt of Puerpcbal Co^tti*
810N8. — The more frequent occurrence of coa*a'j
sions in a first pregnancy, during a protiactN
labour in those who have experienced them pi|^
viously ; the period of the puerperal sttte» 'i^
the progress of the labour and state of the o» at^"
when they do occur ; the characters they asttine-^
whether tliose of eclampsia, of epilepsyt ^ ^^^
teria, or of simple clonic convulsion; thee****
which induce tbem, the circumstances coooeiioJ
with them, and the fact that they, more thas '«<
of the other forms of convulsion, are the roult «
active determination of the blood to the be**'''
which, however, is merely the effect of tmitst^
primarily seated in the ebdooiflal viicc*i ^*

CONVULSIONS, PUERPERAL— TBBATMKKt.

433'

vll to be taken into consideration in* the treatment
of them. The intenliont of cure are the same in
this as in the foregoing^ states of convulsion ; and
ihey should be prompUy fulfilled.

83. A. In order to cut short the seizure,-— a.
Afier having resorted to suitable means to protect
the tongue, as the introduction of a cork between
the teeth, &c., blood-letting from the arm, but
preferably from the jugular vein, when it can be
easily performed, should be employed, and carried
a ooce to a decided extent relatively to the
vigour and habit of body of the patient ; and
it should be repeated after a short interval, if the
coDvuIsioQS recur, and there be no circumstances
to forbid it. Simultaneously with tlie flow of
Uood, or immediately after it, the affusion of cold
Kettr or the application of a bladder of pounded
ice 00 the head, and the exhibition of ten grains
of calomel, and from five to ten grains of camphor,
pevioittly reduced to a powder by a few drops of
spirit, with or without an equal quantity of musk,
and shortly afterwards of two or three drops of cro-
(m oil, should never be omitted. These medicines
may readily be administered, by mixing them in
sweet butter, and introducing a portion from time
to time over the root of the tongue, upon the end
of an ivory letter folder, or upon the nandle of a
spoon. A cathartic and antispasnwdie enema
(F. 141. 149.) should also be thrown up without
^lay; and immediately repeated, if it be re-
turned. The combined effects of these will sel-
dom fail of producing a solution of the paroxysm.
My experience of the excellent effects of cam-
phor is fully confirmed by Dr. Hahiltok, al-
though Cbadssier expresses an unfavourable
opinion of it, and of all heating antispasmodics ;
Aod the recently published observations of Mr.
MicaxLL are strongly in favour of musk, which
he gives in doses of from one to ' two scruples,
depletion may be carried further in those states
of the disease which assume the characters of
Miampsia, or which are attended by great fulness
^ix>ut the head, or stertorous breathing, than in
almost any other malady. Ciiaussier advises,
after general depletion has been practised, local
bleeding from the nape of the neck and occiput,
or from the epigastiic region.

86. 0. As to the propriety of prescribing opium
ia puerperal convulsions, very opposite opinions
^avc been given. Pjstit, Hamilton, Merriuan,
&Qd Dewees consider it most injurious ; Manning
iod Bla.'vd recommend it, and Leake and Burns,
^ith a judicious discrimination, state, that when
the disease is not accompanied with fulness of the
vessels of the head, it may be exhibited with ad-
vantage after blood-letting. In this decision I con-
cur, and add, that.it should always be given either
>^ith camphor, as directed by Stoerck, or with
^ carbonates of the alkalies, as advised by
^Tvn and Brcninouauskn, or with both ; more
particularly when the convulsions occur from
Excessive irritability, or previously to the period
of full gestation, or after delivery^ or when they
^ume chiefly the characters of hysteria. Rinck
Applies it to the abdomen, and Hufeland to the
^les of the feet,

87. y. Some difference of opinion exists as to
the propriety of exhibiting emetics in this disease.
I)enman is in favour of them, but Mauriceau,
CuAi'ssncR, and Hamilton condemn them, unless
>fter blood-iettiogi and whea the seizure has

Vol. L

been excited by improper ingesta,-* the onlycir**
cumstances under which, in my opinion, they
should be given, and in which Dr. Blundell
also recommends them. Of the good effects of
active cathartics there cannot be the least doubt.
I have always observed, as Dr. Merriman has
stated, that the stools procured by them are morbid
and offensive.

80. ^. The next practical point of importance
is, whether or not the patient should be imme-
diately delivered ; and on this the sentiments of
the most eminent accoucheurs are at apparent,
rather than actual variance. No person will
deny that the state of the uterus is connected
with the cause of the seizure; therefore it
would obviously seem requisite to remove that
state. But the' objectors reply, that convulsions
also occur after delivery, when this state of uterus
no longer exists: I have, however, never met
with any, of several cases of convulsions after
delivery for which I have prescribed, that did
not arise from analogcyis causes of irritation, viz.
an over-distended urinary bladder, the retention
of the placenta or of coagula in the uterus, or
the accumulation of faecal or irritating matters in
the bowels. I therefore would adhere to the
opinion I have often given, namely, if the above
means have failed, and if the labour be so fur
advanced as to enable the accoucheur to deliver
immediately without force or injurious interfer-
ence, then let it be done. If the labour be not
so far advanced, but yet the os uteri is consider-
ably dilated, then the membranes may be rup-
tured, particularly if they be very tumid, — if,
indeed, they have not been already ruptured,
which is often the case, — and either full doses of
the bibarate of soda (3j. to 3ss.) given, or the
ergot of rye. If the os uteri be rigid or undiluted,
the former of these will be preferable. If, how-
ever, the labour has not proceeded far, then
any interference, excepting by the exhibition of
medicinal substances, may be more injurious
than beneficial. La Motte, Osborne, Leake,
Hamilton, Dubois, Ashwell, Nauche, Mi-
guel, Burns, Osianders father and son.
Duces, and Ramsbotham, are favourable to as
early delivery as possible without violence;
whilst Bland, Gartbshorb, Baudelocque,
Hull, Gardien, Denuan, and Blundell, are
against forcible dilatation of the os uteri, and
attempts at delivery in the early stage of labour.
After all, the difference is more in words than in
intention; for the general object is to hasten
delivery, without injurious interference, if the
labour be so far advanced as to render the attempt
prudent; and those who have espoused either
side have stated their opinions with such excep-
tions and limitations, and with so little precision,
as to leave the subject nearly where they found
it, and to render it no easy matter to ascertain
under what circumstances they would either have
recourse to art, or trust to nature. When the
treatment already recommended fails, or is fol-
lowed by an exasperation of the convulsions, —
which will very seldom occur if it have been
judiciously directed, — then I conceive that the
active interference of art should be called to our
aid. There is, perhaps, no subject on which
opinions are stated to be so much at variance as
on this, — each succeeding writer placing those of
bis predecessors in opposition, even where no real

434

CONVULSIONS, PUERPERAL— TBBATMftNt.

'difference exists, and thereby bewildering the in-
experienced, in order that he may have the credit
of giving a decision respecting it.

89. 1. Chaussibr recommends, in rigidity of the
uterine orifice, the application of a pomade con-
taining belladonna, with a view of relaxing the
spastic contraction, which, he states, is not limited
to this part, but extends to the whole of the organ.
I believe, however, that the body of the womb is
generally free from spasmodic contraction. This
preparation consists of two drachms of the extract
of this narcotic, softened with an equal quantity
of water, and triturated with about an ounce ol
prepared lard. A piece, the size of a small nut,
IS to be introduced into a female syringe, open at
the extremity, and conveyed to the os uteri, where
it is to be applied by pu«hing onwards the piston.
In about half an hour the rigidity subsides, and
the labour proceeds. Of. this practice L have no
experience. M. Ciiaussier discourages any other
attempt at dilatation of the os uteri, as irritating
the parts, and inducing a recurrence of the con-
vuKoions.

90. (. I have never omitted, in any case
treated by me since 1819, to employ the effusion
of a stream of cold water on the head, and the
injection of turpentine clysters, sometimes with
camphor, assafcetida, or valerian, and the results
have been most satisfactory, — a much less quantity
of blood having been detracted than is usually
required in such cases. 1 am not aware that
eithe^ of these two remedies had ever been em-
ployed in puerperal convulsions, until long after
I had given publicity to the practice, — a prac-
tice which 1 know to have been recommended
very recently by those, who, at that time, ridi-
culed it. In the more rare states of the disease,
which are attended by a weak quick pulse, pale
features, and hysterical symptoms, eoemata con-
taining valerian, assafcetida, or camph tr, are very
serviceable. In thone which assume the comatose
or apoplectic characters, htisiett applied to the
nape of the neck, and unnpitms to the ankles and
calves of the legs, are useful adjuvants of the
measures already recommended.

91. q. In all casei occurring previously to,
during, or after parturition, the state of the blad-
der, and of the bowels, ou^ht to be carefully
enquired into. Early in 1823, I was called to
the Queen's Lying-in Hospital, by the house
pupil, to a patient who had been seized with
puerperal fever on the second day after delivery,
but wan convalescent from it, when she was at-
tacked bv convulsions, brought on by a dist^pded
urinary bladder. I found that the urine had
been drawn off, and that she had been bloode<l
once largely. The case was one of extreme
severity and danger ; the convulsions were unre-
mitting, and attended by profound coma and
asphyxy. The vein was re-opened, and, while
the blood flowed, a stream of cold water was kept
playing upon the vertex, and, at the same time, <
a clyster with turpentine and camphor was
thrown up. Thus, the three most powerful— the
almost only, remedies to be confided in, were
simultaneously in operation. The patient rapidly
recovered. Purgatives were given by the mouth,
upon the solution of the convulsions ; deglutition
having been entirely abolished during the whole
seizure. This was one of the earliest cases in
which I had ventured upon the iimultan»oui j

employment of tbeae powerful agents, the oe of
them in tucceasion having been genarally adopud
by roe previously. I allude mora paiticalarly to
this case, because of its uncommon seventy ; of
its occurrence soon after a naoot daagtroos ta
ease, as late as nine dayt after delivery, m apsb*
lie institution, and at i time when mj poblic
reco-nmendation of th« practice apparatly n-
oeived but little attendon ; altboogb it «fll not
now be looked on with scepticism.

92. d. Of other remediet but little may be nid,
as they should be viewed as auxiliaries merelT.
I have already expressed myself favoaraW; o(
camphor (^ 85. ) . Bunita condemoa it ; bat, wbca
exhibited after depletion, and at the same tm
with the cold affuaion on th« head, and ostbuic
and antispasmodic clyatera, it is a valaable ac-
dicine. Under the same oircurastanoes, mti,
n«afGetida, and the other antispasnodics, «i)i
also be of use ; for all risk of their injorioas sriwi
on the brain is prevented by the cold affoMB,
whilst they co-operate with the terebiatbiasteio*
jections to excite the contractiona of the body of
the uterus, and remove spastic oonstriciioflofit)
neck. Of the ergot of rjft, my experieact i»
limited. I have given it only in one esse of titu
disease, and then it was combined with biboiate of
soda, •«- a medicine undeservedly falleo into di»-
repute — but which I have prescribed formtsy
years. The labour in that cMe proceeded rsfidlf ,
and the patient recovered. Much difecoce of
opinion exists as to the effects of, and propriHT of
giving, the ergot in convulsions. If the os alui be
diiatMi, and the external parts free froo rigidity,
blood-letting, the cold affusion, and catbirti;
injections, having been actively but tasactssf-
fully employed, there can be no doobt of tbe pro>
priety of exhibiting it. Opinions will always bi
at variance as to the benefits derived fron vth-
stances recently introduced into pmctice; (or,v
all medicines are remedies only from tbeii ap|m-
priate use, experience of their operation is r^qoirad
to ascei tain the circumstances in which they m
truly of service. In a case of puerperal cosfsl-
sions— I believe the fin»t in which the cn^otwu
exhibited —Dr. Brincxlx gave it after the meta
usually adopted had failed. Twenty otfiui«*
after the first dose had been taken, uterine tttiofl
came on, and the patient recovered. It is ftroof?))
recommended by Dr. WATEnBousa, of Pbiladd-
phia, and by Mr. MrcBKLL.

93. I. In cases of unyielding rigidity or eillo*
sity of the os uteri, Van Swibtem advised u «-
ci$wn to be made through its maigin. Drsotf.
and, subsequently, Lavvbrjat, Bowir, and Cor-
TOULY, who considered it perfectly justifiible sAer
blood-letting, the warm hath, and other biOSU
usually employed, had failed, have had i*^*^
to this operation. M. Cooto©lt has recordts
four cases (two of which are quoted by .M' V'*
quel) in which it was resorted to ; three of tb»^
recovered. The death of the fourth he tm|rateil to
the circumstance of it having been toe loof ^
layed . M . N a vcn b also fiivours this opertlios a
the above circomstsnces, espeetally if tmolhni
and narcotic injections into the vagina have faucd
to relax the rigidity.

94. a. The warm hath, and enollicot /'w'"^'
ationt, followed by the use of an 'o*^y"f**J^
on the abdomen, have been reeommfidsd by
Dbmmak and Havcum $ aad the tifU ^^ ^

436

COUGH — Causes at.

JFrom abseeti qf ihe ear) ; et Hbm'i Archir. b. I. p. 329.
— Conradi't in Httfifland'* Journ. der Pract Hetlk. b. vii.
it 2. p. 6.~'Hargens, in Ibid. b. vii. it. 1. p. 1 H,—Doer'
ner, in Ibid. b. xv. it 4. p. 94. — Henruehen, in Ibid,
b. XV. %i. 4. p. 79. — Michaelis, in Ibid. b. iil. p. 3*4. —
Witdtmann, in Ibid. b. vi. pi 418. — Siruve, in Ibid,
b. xxiiL bt 4. p. %.-~SchnuUxt in Ibid. b. xi. st 4. pi 169.
•" Heilhroun^ in Hitfetand und HarU» N. Journ. der
Ausl. Med. Chlr. Lit. b. li. »t. 1. p. 187.— P<mr/, in 'VtaxiK
of College of Phvi. of Lond. vol iv. art. 8. •» Latkamt in
Ibid, vol vi. p. m — Comuh, in Lond. Med. and Phvri-
cal Journ. vol. xxxl. p. 373. — T^JHer, in Richter** Chir.
Biblioth. bi viii. p. 732.— JCiyAj, Mcdicin. Beobachtun-
gcn, b. ii. heft 2d. — Sumeire, in Journ. de MM. t xxL

p. 2^4 Duptmi, in Ibid. t. xxxlL p. ISa —Parry, Mem.

of Med. Soc or Lond. vo). lii. art 8. {Comprasiom qf the
carolids.) — BiandU, in Brera** Comment Medici, dec i.
t ii. art i.-^Grapengkssfr, Ver«uche. p. 9^ — Picnt, in
Abhandl. derUoieph.Acad. b. i. p. 3ia (Ipecacvanha.) — .
Thunbfrg, De Oleo Cajeputi. Um. 1797. — //rrz, Briefc,
St. I. art \. — Abrahamton^ In^MetAeF* N. Archiv. bi i.
at 3. art iX.-^Hnf eland. Bemerkung. ilber Blattern, &c

Naumann, in Encydopad. Worterbuch der Med. Wi«-
lensdh. b. viii. p. SAU — Thackerap, in Med. and Phv«.
Journ. vol. x. p. 410.. and vol. xii. p. 508— AirloM, in Ibid,
vol. viii. p. 428. ; EiliiL Med. and Surg. Journ. vol Iil p. 441.
—Clarke, in Ibid, vol v. p. SGS.—Hill, in Ibid, vol v. p. 318.
— Thomson, in Ibid. vol. xiv. p. 614. {Diueetiona in.) —
haygarth. Of Imagination aa a Cause or Curo of Di«-
ord^ra. Bath, WOO.— Portal, Anatomle MMicale, t. iv.
u. 69. et tea. {Results qf Dissectknu i^.) — Dessesartz, in
Journ. do Med. t, xlvii. p. 114.— ^inc*, in Stark*t Archiv.

b.v. p.3S9 Korimm, m Httfeland't Journ. der Pract

Arineyk, b. iv. p. 3Al.—Ca»alM, in Journ. Gen6r. de Med.
Dec 1810, p. 371. {Bismuth.) — Sckarffirr, in Hu/eland'*
Journ. der Pract Heilk. Feb. 1810, p. li&.—Gebel, in Ibid,
b. xvil 81.3. p. 108. {Musk in large do»es.)-'Berge,in Med.
Chir. Ucv. vol. XXV. p. SOI.— Denny, in Ibid. vol. xxvil
p. 485. —Lee, in Lond. Med. Gas. vol. xxi. p. 11.

ii. CoN\i'L8ioN8 OF Childxbm. — Aflrriff, De Mocbis
Infantum, p. 102. — Rosen, Trait6 de Malad. des Enfani,
8vo. — Beaumes, Traits de« Convulsions dans TEnfance,
8vo. Paris, \m^—Capuron, Des Maladies des Enfans, Sva
Paris, 1813. p.407.— (jar</t«M,Trait(dc Malad. des Enfkns,
t iv. ; D'Accouchcmens, 3d ed. p. S39 — J, Clarke,
Commentaries on the Diseases of Children, 8vo. p. 80.
( 'Poo exclusively referred to cerebral irritation.)— Jacques,
in Journ. Gen^r. de Med. t. xxix. ii. 280. — ^onn. in
Ibid, t xxxi. p.457. — Pwryy. De rinitation En§cphal.
des Enfans. Faris, 1823. — underwood. On Diseases of
Children, by Merriman. Lond. 1827, p. 233. — Bracket,
Sur Ic« Convulsions des.Enfans, 8va Paris, 1824. {A good
book, with too partial a leaning to cerebral irritation.) ^
J. North, Practical Observat on the Convulsions of In.
fants, Hvo. Lond. 1826. {An able and Judicious work.)

iil PtrxnPBRAL CoKYVLSioNiL — J. Ijcoke, On the Acute
Diseases of Females, &c. 6tb edit pi 338. {Conpul.from
ktemorrh. and inanition welt treated qf.) — Manning,
On Female Diseases. Lond. 1775, p. 357. — Dmman, In.
trod to Practice of Midwifery, 5t)i ed. p. 969.— Hamilton,
£din. Ann. of Med. vol. v. p. 318. — Coutouly, in Journ.
06n6r. de M^d. t. xxxil pi 157. — Fritx, De Convuls.
(Jravid. et Parturient turn. Wirceb. IHIO. — Michaelis, in
Siebold*» Lucina, b. vi. p. 37. — BrUrkmann, in Horn**
Archiv. Jan. 1811, p. 10. — Oflic, Mfemolres sur divers
I'oinU d* Accouchcmcns. Paris, 18 10. — Gardien, Trait£
Complet d'Accouchem. t iL p. 418. — Stuix, Michaelis,
Wiedemann^ and Bruninghausen, in Hnfcland*% Journ.
ftc. b. X. Nu 4. ; and in Lond. Med. and Phys. Journ.
vol V. p. 473. and 557. —J. P. Osiander, Deutsche Zcit.
echrifl f. Gcburtskunde, b. il at. 3. p. 538. — J. L, Boer,
Abhandl und. Versuchc Gcburtshuf. InhalU, Ac. &c. 1791,
b. iil. p. 192. — Hu/rland, Journ. der Pract Heilk. Dec.
1^16. — Wagner, De Eclampsia Exquinifa in Partu.
Morb. 1817. —J. Clarke, in Trans, of Irish College of
Phy«. t i. p.381.— ACrrriffian, On DifT.cult Parturition,
with Rcm.trks on the Manftgem. of Labours, 8vo. Lond.
1820, p. 135. — Dewees, in Amer. Meil Record, No. iii.;
and in Johnson's Med..Chirurg. lie v. June, IS^O, p. 128.

— Brinckle, Philadelphia Med. Journ. vol vi. j^ 186. —
Goupil, in JouTti. des Progr^ des Scien. MM. t iii. p. 161.

— Duges, in H^v. M^'d. t. i. 1826, p. 378. ; ct Manuel Ob.
st6t Pans, 1S30, p. 275. ; et Diet, de Med. Prat, t vi. p. 537.

— Chaussier, Sur les Convulsions oui attaq. les Femmes
Enceintes. Paris, 1^24^ — Miguel^ De Convulsions chei
les Femmes Enceintes, en Travail, &e. 8vo. Paris, 1824i
—Blundell, Lectures, in Lancet, vol. xiv. p. 484. ct 513.-o
Bums, Principle* of Midwifery, Gth ed. p. 484. — Ryan,
Manual of Midwifery, 2d ed. p. 285 — MicheU, On Dif-
ficult Parturition, and the Use of Ergot of Rye, Ac. 8va
\h£A.—Nauehe, Des Maladies prop, aux Femmes, Ac. 8ro.
Paris, 1829. p. 449.

COKPULENCY. Sec Obesity.

COUGH.^Syn. Bq^ Gr. TtiJiif . Lit. fitr,
Good. Pfieimj TuuU, Young. Dtr H%iUn,
Germ. TouXf Fr. Toua, Ital.

Classip. — 2. Clatt, Diseases of the Respi-
ratory FuQCtioa; 2. Order, Affecting the
Lungs (Good), IL Class, III. Orou
(Autlior).

1. Defin. Violent and tonoroui eijntlsim (j
air from the lungs, preceded, rapidlif folUved h,
or aUemating with, quick inspiration,

2. L Pathology. — Dr. Cullen and severJ
other nosologists have considered couefa as chiefly
a symptom, which undoubtedly it is m»t frt>
quently ; but I agree with Dr. Youxc and Dr.
M. Good in believinfl^ that it is entitled to be
viewed on some occasions, as an idiopathic affec-
tion. Dr. Good, however, has ranked it a« a
genus, and comprised under it Tanous affectiocs
which are either merely slight forms of BaoNcni-
Tis, or the results of organic changes in tW
Lungs, and which I have treated of io tkt**
articles, and in those on BBONCHOBaiioa, Ci-
TARnn, and Influenza. He has, moreover, sub-
divided it into more varieties than can easilj be
recognised in practice, and has viewed Hoorisc-
couou as a species of the genus, instmd of «
distinct disease.

3. Causes. -^ Cou^h, in either of the fonu
about to be particularised, commonly atteinb dis-
orders of the air-passages, and of parts in ibeir
vicinity, particularly of the larynx ; also those of
the lungs, and their membranous coverings ; ssd
sometimes diseases of other organs by which the
respiratory functions are affected Bympathelicilly
— or rather, from continuity of tissue or nerraut
communication. It is thus occasioned by tSrc-
tioDS about the fauces, tonsils, pharynx, and aev'k :
by the irritation of dentition ; by diseases of tb^
oesophagus, particularly when infiammatioa at^
ulceration of this part extends to, or peoet/ites |
the membranous part of the trachea (KArni* i
HouT, Mr. Byam. and myself); diseases of lit
spine and its contents (Wicbmann); by cryu-
ceous or calcareous formations in the ramifaA'
tions of the bronchi (Moroagni. Bonet, C miui.
Portal, and myself in several cases, two J
which occurred in gouty subjects); by all (or-
ganic changes of the thoracic viscera; by t^^
accidental passage of foreign substances, soIhI vt
fluid, into the air-passages; by the lodgment of
the eggs or larva* of insects in the same sitojitioo
( VocEL and Percival, &c) ; by the irritabili:?
of parts attendant upon the nervous tempenoii^^
ana debility; by the influence of initatioD toJ
imagination, — a cause which did not escspe tU
observation of the acute MoNTAiGNB;incgula:^
misplaced gout ; the irriubility of the ptrU coa-
tinning some time af^r measles, or inflainiDauo<'^
of the air-passages or lungs ; disorders uf tbc di-
gestive organs, particularly the stomach aoU liKf.
&c. (WiNTHER, Stein, Pbbcxval, &c.); by ■*••
cumulations of bile in its receptacle ; by ibe an-
tation of worms ; by the repulsion of cutaoeoo*
eruptions, and the healing of old sores, ami s«p-
prcssion of chronic or accustomed 6kcUu^
From this enumeration it is evident that cous:b ^
chiefly a symptom of numerous patholo^cal »i»w.
which will be found very fully detcnbed w^^
different heads, as indicated above. The sfi^t*^
cough noticed by some writers falls aader tj»«
article Influemzs, Io the act of c^i^* ^

442

CRETINISM— DiscftiPTzoK or.

M. De Saussvue, Ackbrmann, Fooini, Iphop,
Eruard, the Wenzels, and Knolz, have given
us the best de^ription of this state of mental
and bodily deformity, in respect both of its na-
ture and causes. The brief account of it by Dr.
Good is both imperfect and erroneous, and must
have been written in perfect ignorance of the de-
scriptions of the above eminent observers, as well
as of others deserving of perusal. He very inaccu-
rately associates it with broochocele on the one
hand, and with rachitis on the other, with the
former of which it is not necessarily, although very
frequently, connected, and from the latter it is
totally distinct.

3. I. Description. — Cretinism presents va-
rious modifications in kind, and every inter-
mediate grade between that extreme dep^ree of
physical and meotal debasement which is cha-
racterised by the utmost deformity and entire
absence of mental manifestation, the organic or
vegetative functions only being performed, and
that condition which may be considered as very
nearly approaching the healthy constitution of
man. There are certain circumstances which
distinguish cretins from other idiots, viz. o. They
present certain bodily deformities, which are sel-
dom or never observed in other idiots ; and, b.
Their physical and mental infirmities are always
the result of endemic causes.

4. In general, some degree of gottre is attend-
ant on cretinism, but not invariably. Professor
Knolz states, that it is sometimes absent, and
occasionally slight, the thyroid gland being en-
larged in no greater proportion than several other
glands are in the same subject. The stature is
seldom above four feet and a half, often much
less ; the cranium is deformed and has a conical
shape — the forehead being thrown backwards,
narrowed, and flattened, and the occiput beine
nearly on a line with the neck ; the flesh is soft
and flaccid -, the skin wrinkled, yellowish, or
pale and cadaverous, dirty, and covered by
chronic eruptions ; the tongue is thick, and hang-
ing out of the mouth, which is open, large,
and slavering; the lower jaw is elongated and
prominent; the eyelids are thick, the eyes red,
small, but promment, watery, and frequently
squinting ; the nose is flat ; and the whole coun-
tenance is idiotic or expressive only of lascivious-
ness. The belly is large and pendulous; the
neck either short and thidc, or long and thin ; the
limbs crooked, short, distorted, &c. ; and the gait
imperfect and waddling. Tlie senses are more
or less defective, or altogether abolished ; the
cretin being often deaf and dumb, and those who
possess the faculty of speech expressing them-
selves imperfectly and with difficulty. The in-
tellectual functions are either entirely absent or
imperfectly developed, whilst the or^nic or
vegetative functions are in a state of increased
activity : cretins being voracious, lascivious, and
addicted to masturbation. They appear to have
no other enjo^ent than eating and sleeping ; and
their insensibility is often so great that they obey
not the calls of nature. In some instances, the
bodily deformity is not so remarkable as that now
described ; imbecility, flaccidity of the soft solids,
with bronchocele, constituting the extent of in-
firmity.*

• The followinff account of th« ** Fkug," or oratiM of
SslstKmrg, is abridged firom that given bj Profasor ' Jarhmcker

5. The cretin, like most idiola, seldon sttint
an advanced age ; indeed, few of them reich vp.
wards of thirty yean. Clayton reautkt, tbst
although they die earlv, they soon preteot tb
appearance of age. They are usually oftbe
lymphatic temperament, with light hair and grvf
eyes ; the female cretin bavtae enoraNNuij lif|e
and pendulous breasts. The leas debased siooo^
them marry, rarely with one another^ bet do am
propagate cretinism, the jpredispositioo ool; to it
oeing derived by the oftpriog from the pv«at^.
MalAcarnb (^Mim, de I Acad, de T«rtK)t!tr>
butes the mental debasement to the coatncno&
of the bones of the cranium, which preveou tb
cerebral organs from acquiring their oatini
dimensions and functions ; and Acttiii^^
espouses a nearly similar opinion. The eoc*
formation of the body is generally slated sot lo
be congenita], althoagh, at birth, the cretin ntti
appear weak, puny, or sickly. It usually cent*
on gradually from birth ; and M. De SAierri
states, that children who, living in the locilitin
where it is endemic, and are not affected st cif^t
or ten years, generally escape it ; and that iofuti
who are brought into these districts at s ren
early age, are equally subject to K with tbse
who are born in them.

Knolz : —The whole twdf !• stanted, iu bcifbC ool a-
ceeding four feet There i» a total want of due wmwniM
between its diflferent parts : the height of the heMi, toi
reference to the rest of the body, being Kith or iJOt, it.
•tead of 1.8tb, the natural praportioo. The neck it «m|.
and bent downwards. The maming are very volumuwa
and pendent; the upper limbi reach below the kNB.
the arm ii ihorter than the fore-arm ; the cheit ean^ .
the al)domen hemi#pherical, and of a length not aent
ing the height of the head ; the pcols and tcrocun cua*
down to the lineea ; the thlghi are, with thebauodwi, d i
greater width than the shoulders, and are ihortcr lk«a ^*
leg*, the eal vet l>eing almost waatiog ; the foot b email, arc
the loei partly distorted ; the lower extrcmitic* are dwrtr
than the upper half of the body. In the bead, the ■»-
ticating organs, the lower jaw, nd the uoae, pieimwkfKt
oonsiderably over the organs of aenae and intcttifrw
The skull is depressed, and forms a lengthened aod jrp
lar elliiwU ; the receding forehead presents, iBtrrssI '.
large flrontal sinuses, to which thelMwn hasTiddcdsp^^
of its place ; the top of the head la not vauUid. twi tau-
tened i the occiput projects but slightly, and nou alv^
even with the nape of the neck, m In nnalnstiof ••»
mals. The (ace Is neither oval nor round, but •yrBsi ivi
In width ; the parts of which it is composed btiaf »(
and short, ana the maxillary bones nriifectinr !'•<'*■
The forehead is narrow, gattened, and low ; ttie tya ■*
unusually for apart, diverge slightly, and are hmU, Mi
seated deep in the orbit ; the pupil is contracted, snd v,
verv sensitive to light ; their eaienial anelcs are ataiti*
higher than the internal ; the eyeMs, unless wbca di«f>
slcally swollen, are flaccid and pendent -, the l«A » •
fixed stare without expression, and turns with iadtmr-
ence ftom all that Is not eaUble. The root af the mve'
widened and depressed, the bones of the nose squsfv , t»«
sygoniatic bones are wide, and extronehr i«it(««tH
the external ear Is large, stands out from the bc*t. <*•
bearing is very defective. The elongated kem ef u*f
lower jaw of the cretins, and their thick and paddsd b^
make them resemble ruminating creatures men ttu ^
than man. The tongue is thick, and rethcr cjUbAt^v
than flat; the saliva is continiially running Uvm M
angles of the mouth. Enlargement or the thyroid |i»sd
is recognised as one of the signs of aetanisaa j but «* i*A
is no sure guide to the extent of the existing Ibtmtt
The throat presents, also, other obstmotcd ghodiw TV
thorax to generally narrow and fl4t ; the aMw*^ ■*
usually distended with gases, and largely dcvvlm u.
wards the chest; the flesh of the extrenitica isiitt^.
the knee of an Irregular shape, and nsuaily bsid . u*
Angers are very long and lank, and the nails vcrr na^
The upper part of the vertebral column being »[^-
more or less forward, and the lower part, with tbeww"
being puahed backward, tbe aaenim aasuinm a
risontal, and the other pelvic hones a weti
position, than In the healthy fomallon
masticating and digestive organa, those of gcocrstto «»

ttn «

ikr

also stroogly developed, espeoiaUv to the meiciMrenj
A» *. r*i7m-. Sl*ay«, biL St L mr *"

CRISIS.

443

6. II. Causes.— The principal, if not the
8Dly, cause of cretiirism is dwelliDg, during in-
fancy and childhood, in deep, narrow, moist, and
mslarious valleys, sitnated at a lower level than
3000 feet above the ocean, where the air is
itaipiant, and the solar beams intercepted by the
moontains. MM. Ferrus, Georoet, and the
inthors already referred to, state, that cretins
become numerous in proportion as the valleys
imk below this elevation. In addition to those
canscf, may be added the poverty, ill-feeding,
ironkeoness, indolence, dirtiness, sensuality, and
low debauchery of the parents, — circumstances
tending to the production of an infirm and de-
formed offspring ; the inactivity and filth into
which chil<»'en who begin to evince signs of
CTctioism are allowed to sink, and the influence
of water holding calcareous and other mineral
substances in solution. MM. De Saussvrb
and FoDERE, however, deny that the water is
concerned in the production of this infirmity ; but
MM. Ballt ana Rambuteau show that much
is owing to it in the causation of cretinism, as well
as Broschocele (see that article). The last
named authority states that the offiipring of the
Mtives of Valais, who intermarry with persons
from the Italian side of the Alps, are more subject
to cretinism than those born of native parents;
that females who have husbands from the higher
Alps seldom have children affected by this in-
timity ; that wherever cretins are seen, gohre is
ilso prevalent ; but that the latter is found in
places where the former does not exist; and,
consequently, that the same causes that occasion
goitre, when present in an intense degree, also
prodace cretinism.

7. III. The Treatment of this infirmity is
necesGarily preventive rather than curative, and
consists of tne amelioration of the physical and
Koral condition of the parents ; of the removal
of infants, as soon as signs of the malady manifest
themselves, to more elevated and open localities,
and to mountainous districts, to enjoy a purer air
acd stronger light; of obliging them to exert
themselves in some useful and suitable emplo^^-
nent, and to pay attention to personal cleanli-
wsi; of frequent ablutions, followed by active
tod stimulating frictions of the whole surface
of the body; of the use of stimulating tonics
(Erbakd); and of allowing them a stimulating
iod strengthening diet, wim a large proportion
of animal food. Jobias Sibilbr, who wrote in
1574, states that the malformation, constituting
the physical infirmity, is sometimes congenital ;
and probably it is so occasionally. In such cases,
il u not likely that much advantage will accrue
from any mean)). M. Rambuteau, however,
states that it is scarcely ever congenital ; but it is
sot nnlikely that experienced observers may pre-
dicate, from the appearance of the newly born in-
^Dt, whether or not it is likely to become the
subject of this dreadful infirmity — may observe
|hatsute of developement and formation, which,
if not actually the incipient malady, is predis-
ponent to its occurrence.

BiBLioQ. AMD Rsrta Slorr, Alpeurelse VorboreU

lunj par. Iv. — Be Satusure^ voyage dans lei Alpefc
^en*». 1786.— Off^on, in Mem. of the Lit. and Phllos.
«. of Mancbotcr, 1790, vol viLL art. IS. — AckermanHy

Ivkof, De CrtlenisBo. Vlteb. 180«. — Uickailis, in 22Shi-
membach'* Biblioth. b. ill. p. 640 — Vire^i in Diet. Scienc.
Med. t. ylL p. 343. — Geonei, Diet de M^decine, t vii.

des Scien. Med. txxi. 1830, p. 390.— J. Johnton, Change
of Air. or the Partuit of Health ; being an Excursion
through France, SwiUerlaod, and Italy, &c Svo. lond.
1831, p. 56.

CRISIS. — SvN. KpiV»c,a judgment or decision
(from xp/y«, I judge or determine). J%uiicium,
Judtcatio, Lat. Entscheidung der Krankheit,
Ger. Crise, Fr. Criii, Ital.

Classif. — Pkocnosis.
1. Crisis may be defined a sudden change dur*
ing the height of a disease^ tending either to re'
covery or to death. Critical changes have been
much regarded in the prognosis and treatment of
diseases, from the time of Hippocbates, who first
mentioned them, and the days on which they
occur, down to the present period. Asclepzades,
and the methodists, however, denied their in-
fluence, and disputed the existence of critical
days. Galen and his followers attached great
importance to them. It is recorded, that, having
been called to a patient — a young man — with two
disciples of Themison, Galen prognosticated a
favourable change by a critical hsmorrha|;e. The
opinion was ridiculed by the two methodists, who
advised blood-letting; but it was soon verified,
for the patient had a copious epistaxis, after which
he recovered. It is unnecessary to allude to the
writers who have contended for the importance of
this subject : they comprise most of the eminent
names in medicine, from Hippocrates to Cvllen,
PiNEL, Frank, Hildsnbrand, and Kreyssig*
The titles of many hundred volumes that have
been written upon it might be adduced in proof of
the consideration attached to it: and although
much more has been imputed to critical evacu*
ations, and days, particularly by the humoral
pathologists, than legitimately belongs to them,
and granting that too devoted an attention to
them has induced many to adopt injudicious in-
dications, and weak measures of cure, yet some
reputation will be acquired from the prognosis
which an acquaintance with them will enable the
physician to five ; and much benefit will result to
the patient from the treatment which this know-
ledge will sui^gest.

2. Since the overturn of the humoral pathology,
the doctrine of critical evacuations has undeserv-
edly fallen into disrepute, although the eminent
writers who contributed most to the overthrow
are amongst its most rational and warm espousers.
In our own country, at the present time, too little
attention is paid to these evacuations, and still
less to the periods at which they occur. There
can be no doubt that the former is the most im-
porunt ; but the latter part of the subject should
not be disregarded. After all that has been urged
in favour of, or in opposition to, the doctrine, I may
conclude that, in temperate climates, a number
of di^eases, particularly fevers, run on for certain
periods with regularity, and, af\er an exasperation
«f the symptoms, or some violent perturbation of
the economy, terminate by evacuations of diflPerent
kinds, which tend to remove the train of morbid
actions, and to restore the healthy functions. In
other cases, the exasperation of disorder is fol-
lowed by imperfect evacuations, occurring in an
irregular manner ; whilst in some it gives rise to

444

CRISES— Description of.

additional phenomena of a dangerous or fatal cha-
racter: hence crises have been denominated ta-
lutar}t and complete, imperfect Bud fatal. It was
considered by the older writers requisite to a sa-
lutary crisis, that the evacuations constituting it
should be attended by favourable symptoms, and
be copious and manifest ; and not only appropriate
to the disease, but also consistent with tne state of
the patient. An imperfect crisis was considered
better or worse: the better state alleviating the
malady; the worse rendering it more severe and
dangerous, from the supervention of metastases
and complications. Having described the phe-
nomena which are critical, I shall next notice the
periods of disease at which they are most frequently
observed.

3. 1. Crises manifest themselves, — 1st. On the
SKIN : A. by sweats ; B, by acute or chronic erup-
tions. 2d. In the cellular tissue: A, by
swellings in various parts ; A, hv boils and car-
buncles ; C. by gangrene; and D. by purulent col-
lections. 3d. In the glands : B. by buboes ; B,
by swelling of the parotids ; C. by salivation ; D.
by a flux of urine. 4th. On the mucous sur-
faces : A. by increased excretion — a. from the
nose ; b. from the bronchi, &c. ; c, from the sto-
mach (vomiting) ; d. from the bowels (diarrhoea) ;
B. by sanguineous exhalation— a. by flux — a. the
hiemorrhoidal ; $. the menstrual ; b, by haemor-
rhagy ; a. from the nose (epistaxis) ; 0. from the
bronchi (hemoptysis) ; y, from the stomach
(hsmalemesis) ; K from the intestines; i. from
the uterus (monorrhagia); (. from the urinary
organs (htcmaturia).

4. 1st. A. Sweats are salutary crises in continued
and bilious fevers, in inflammations of the luo^
and liver, in bronchitis, and less frequently m
rheumatism. Fracastori describes an epidemic
putrid fever which generally terminated favourably
m this manner. Acute dropsy, particularly ana-
sarca, when caused by interrupted perspiration,
sometimes disappears after copious sweats. This
evacuation is usually preceded and indicated by a
sofl, full, open puUe ; by a diminution of the al-
vine evacuations; by softness, and occasionally
slight itching, of the skin ; and by increased colour
of the cheeks. A salutary sweat should be dis-
tinguished from such as are limited to the fore-
head or face, and the neck or breast, whilst the
rest of the body is dry ; or those which cover only
the lower extremities : these constitute merely
partial or incomplete crises, and merely diminish
the violence of disease.

5. B. Eruptions. — Miliary and vesicular erup-
tions only are critical: the others are mereiy
symptomatic, or even from a part of the disease ;
as erysipelas, purpura, petechia?, &c. A miliary
eruption is favourable, if the symptoms subside,
if the patient feels an itching or pricking, if they
be general, and do not appear before the seventh
day : if they be unattended by fulness of the sur-
face ; and if their subsidence be followed by vomit-
ings, hiccup, or convulsions, they indicate a fatal
termination (Landrk-Beauvais). Sometimes a
miliary eruption comes out at different periods,
and prolongs the disease, when partial relief fol-
lows it, each appearance being an incomplete
crisis. Many chronic eruptions may not only be
complicatioiis of visceral disease, but occasionally
imperfect crises, — they alleviating the internal ma-
lady. They are more rarely completely salutary.

6. 2d. A, SwelUngi of various parts, as of t\i(»
face or neck, the han((s, the lower extremities
&c., have been considered as partial crisei in atixii
and gastric feveia, and in exanthematousdiaeaae^.—
B. Boils are critical in some complaim», par*
ticularly towards the termination of acute disease,
especially small-pox.— C. Gangrenont pnsta!ei( r
anthrax occur in malignant or pestilential fe\tr* ;
gangrenous escars also are met with in ntuir
cases, as well as in typhoid or adynamic fercr^ ;
particularly about the sacrum, and in pli^n
which have been blistered, or pressed upon. I,
in such cases, the febrile symptoms subside npct
the sphacelation, and if the gangrenous cbv:-
be rapidly and distinctly circumscribed, it rai) U
favourably critical ; but if the symptoms cnatinui,
and the pulse becomes more frequent, wci,
small, ana soft, the local mischief b entirely s>c j-
tomatic, and indicative of an uii favourable ur-
mtnation.-— D. Purulent collections are indica'ii
by the continuance of the disease wit boat anj
considerable evacuation, or exhaustion; bya«c:04
of chill, horripilation or rigor, occurring at intt'-
vals, without any manifest cause; by the u^
charge of much clear urine ; by partial sv(at« :
by a softness of the pulse ; by a remittent or Iki--
tic fever, and by flabbiness of the soft solids, lit
favourable changes of this nature occur in tU
extremities, and suppurate easily and npiHlt.
Those that are unfavourable take place in ^st
internal viscus.

7. 3d. A. Buboes chiefly belong to pestilestiil
fevers ; but they are occasionally o)i8erTed in l^'
adynamic fevers of temperate climates. Thry v-
dicate a favourable or fatal crisis in the msar^r
stated with respect to gangrenous escan. — T.
Swellings tf the parotids occur in lowormaHs[i»*'<
fevers; and appear either alone, or with <fl^<'i
critical changes. They are commonly prtetau
by a slight rigor; by severe headach, ^npof.
noises in the ears, and deafness, with paleot^.
swelling, and sometimes redness of the coqi>«
tenance. This occurrence is rarely critical, a«»^.
of itself, furnishes no sure indication of the i«8'
if accompanied with favourable changes, it !<*
comes an additional sign of returning health ; tit
if the swelling is slow, or disappears in a ur)
short time, the other symptoms still continoio ,
it is a dangerous circumstance. — C. &(iiJ^l
was noticed by Syoenham as a principal rrmr-'i
evacuation in the fevers of 1667 and 1668 i «fi^
it occurred in the epidemic that prevaiW ii
Breslaw in 1700. It occasionally mpenrenes «
some forms of cynanche,and in bilious and gt^*^
fevers. — D. The urine is sometimes discharp^
copiously at the height of febrile and inflainiDat*^'
diseases; and is to be viewed as a fatimrabje
occurrence. It is usually clear when re«of-y
evacuated, but deposits soon afterwards a ^biirt
or rose-coloured sediment. The «ymp<*w «« ••
eating this discharge are very ohscnve,^ S^
authors have noticed the " pulsus myurusy^hirh
consists of every three or four succeaiivc UP**
ations being proereasively diminished. A »Q« <•'
weight below the hypochondria; of en^a^'J
tension in the hypogastrium, and of heat lo U"
urinary organs, 1*^ stated by M. Landbe-Biuvji^

to precede this evacuation.

8. 4lh. A. a. Cw^^.orsero-mocoofeicrujnn

from the nose, is sometimes critical in c*ftt>9««''
fevers; but little importance is to be ««»«*•«» "

CRISES— Dbscbxptxos of.

445

it. — b* Mucous aereiion from the bronchi is fre-
quently a partial crisis in several fevers, and io
iDflammatioos of the thoracic viscera (see Bbonchi
aod Lungs). — c. Vomitings are rarely indications
of a perfect crisis*, they occasionally, however,
favour the devclopement of those changes which
precede a favourable termination of disease. They
are sometimes ushered in by a bitter taste in the
mouth, yellowish fur on the tongue, suborbitar
pciio, and headach, nausea, salivation, coldness
of tbc extremities ; and frequency, and occaaon-
aliy iotermL^ions, of the pulse. — dt. Diarrhcta and
copious alvine evacuations are favourable crises in
oearly all acute, and even in some chronic dis*
ea^es. But it is necessary that they should be fs«
culeot or bilious, and homogeneous — not watery
or flocculent: if they approach to a natural, or
have a yellowish brown colour, and are followed
by a!>ateinent of fever, ficc, a favourable crisis
&ay be confidently looked for. The chronic dis-
ea<7t, in which they indicate a change tending to
health, are congestions and inflammations of the
liver and spleen, hypochondriasis and melancholy,
»li^ht or incipient dropsies, rheumatism, and gout.
1 bey are usually preceded by borborygmi, with
*iight 6atulent distension of the abdomen ; flatu-
lence and eructation ; a sense of tennon and
QBeasiness in the lumbar region ; flying pains in
t\\t extremities; and a developed but unequal
pulse, occasionally with irregular intermissions.

d. B, Sanguineous exhatations are often critical in
the more inflammatory states of fever, and in the
phWgmasiac. According to Hoffmann and Lan-
ark-Be iuvAis, discharges of blood from the nose,
Oic hxiDorrfaoidal vessels, or the uterus, are equally
Kilotary in ardent fevers. In general, these
hemorrhages are preceded by depression of the
morbid temperature, and erethism of the skin ;
by slight horripilations of the limbs ; by a more
open and rebounding pulse ; and a sense of heat,
pruritus, and tickling, in the part whence the
evacuation is about to proceed. — a. The memtrual
,fiui is sometimes a rapid crisis in fevers and
phiegmasic. It is indicated by dull heavy pains
^ the loios, gro'ms, and tops of the thighs ; by
ieQ.«ion in the hypogastrium ; heat and pruritus
of the genitals ; pallor of the face, and a dark
nrcle round the eyes ; swelling of the breasts ;
pile, scanty urine ; horripilation, and erithism of
(he »kin ; and by a quick, sharp, and unequal
pu)i>e. Very frequently the menses appear at
tite regular period, or a little earlier, or later, in
fevers and inflammations, without aflbrding any,
»r but imperfect relief. In these cases, they
>^iouId not paralyse the activity of the treatment.
When they occur at or before the usual time, are
ftbundant, and are attended by evident benefit,
tiiey should be considered as critical : but if they
arc delayed, or are diflicult or scanty, they are
imperfect cmes, and should not interfere with
the measures which the circumstances of the case
roay require.— 6. The htsnwrrhoidal flux is often
<'ntical in inflammatory fever, pneumonia, hena-
t>UA, ao'i other phlegmasiae. Staiil states tnat
a return of this discharge is sometimes favourable
in lofiainmations of the brain, and particularly in
i^^patiiis, nephritis, melancholia, hypochondriasis,
and mania. The dil)servatton is certainly correct.
Ihw evacuation is indicated by pains in the loins
and the groins ; by a sense of uneasiness and
pressors towards the aatis and perineum j by fre-

auent desire to pass the urine and go to stool ; by
atulence and borborygmi, slight pallor of the
face, and fulness of the hypochondria ; and
by fulness and inequality of the pulse as to
strength. — c. Critical epistaxis was considered of
^reat importance by the older physicians, who
paid much attention to the symptoms indicating
Its acceuion : these are, redness, with slight tume-
faction of the face and eyes ; reddish or brilliant
objects floating before the eyes ; the involuntary
shedding of tears ; weight of the temples, and
beating of their arteries ; deafness, or noises in
the ears; slight delirium, or vertigo; a sense of
tension in the neck, with distfpsion of its veins;
a dull pain in the forehead, and at the root of the
nose, or an itching and tickling in the nostrils ;
a quick, hard, full, and an unequal pulse ; fre-
quent and slightly laborious respiration ; some-
times with tension or oppression, without pain,
at the praecordia. Occasionally, pallor, and con-
striction of the whole surface, coldness of the
lower extremities, and horripilations, also precede
a critical epistaxis. This crisis is most common
in young persons, and adults whose vital energies
have been previously unimpaired, and who have
been subject to this evacuation. It occurs most
frequently in summer and autumn ; in the more
inflammatory states of fever ; in the acute phleg-
masiae affecting the super-diaphragmatic organs ;
and rarely in hepatitis. If the discharge consists
of a few drops only, it is an alarming symptom ;
and although it be copious, if not soon followed
by amendment* it is unfavourable. When ex-
cessive, and attended by syncope, convulsions,
loss of power, partial or cold sweats, and cold ex-
tremities, it is a fatol sign. A syncope, however,
which terminates the epistaxis, is often followed
by recovery (Landr£*Beauvais).

10. d. Hemoptysis, hamutemesis, hmmaturia,
and intestinal htemorrhagy, are always false or un-
favourable crises. They are generally preceded
by tension and tenderness of the hypochondria ;
and supervene roost frequently in adynamic, malig-
nant, and pestilential fevers ; in confluent small-
pox, scarletina maligna, and in scurvy : they oc-
cur less frequently in females than in males.

11. il. 1'he above are the phenomena which
have usually been considered critical by the older,
and which are admitted by the best modern,
medical writers ; as well as the symptoms which
indicate their accession. There arc, however,
still some circumstanaes connected with them de-
serving of notice. — a. The /itfrnorrAa^/c evacu-
ations occur most frequently in the spring, or in
dry summers, in persons from 15 to 35 years of
age, of a sanguine or irritable temperament, and
in acute complaints. — 6. The cjitaneous evacu-
ation is most common in summer and autumn,
in robust and fat persons upwards of 30 years of
age, and in continued, remittent, and intermittent
fevers.— c. A critical diarrhea is most frequent
in autumn, in persons of a bilious temperament,
and in remittent and intermittent fevers. — d. Dis-
charges of urine are observed in all ages, in all
seasons, particularly winter and spring, and in all
acute diseases.

12. B, Critical evacuations are — a. rare, in
persons enfeebled by age, or by some other ante-
cedent disease ; in very moist and verv cold, or
very hot climates ; during remarkably sudden
and great vicisntudes of weather; and especially

446

CRISES— CAvifts.

when the vital energies are much lednoed by a
loweriog and an evacuating treatmenL — b. They
are not always atmilar in the same diseases ; and
they vary in respect of the natare of the discharges,
and of the periods at which thej take place, as
well as of the orgins by which they are prodaced.
A favourable change in gastric, bilious, and ady-
namic fevers, is often attended by alvioe dis-
charges of a homogeneous, fluid, yellowish, yel-
lowish brown, or brownish black appearance, —
in ioflammatory fevers, in young men, by ep-
staiis, often occurring on the seventh day, — in
these diseases, in young women, by a copious
flow of the catan^ia taking place on the same
day, — and in men of middle age, by sweats, or by
some other discharges coming on the fourteenth,
or at a subsequent period. Catarrhal and bron-
chial complaints terminate with eipectoration, or
with sweats, or a copious flow of urine, &c.

13. C. The duraiioH of critical evacuations is
very uncertain. The hemorrhagic, the alvine,
and the urinary, seldom continue longer than
twelve or twenty*foor hours, sometimes even much
leas. Sweats and expectoration are occasionally
of no longer duration ; but, in the majority of in-
stances, these two evacuations are prolonged se-
veral days before the disease is entirely subdued.
Purulent collections and gangrene may take place
in a few hours, but they generally require a much
longer period.

14. b. Critical discharges cannot be changed
or determined in their route or period of eruption,
by art ; and when they supervene, they cannot
be safely interfered with, unless they threaten
life by their excess. If they be interrupted by
accident, or by an injudicious nnd meddling
practice, they are followed by unfavourable me-
tastases and complications, or sequeic, some-
times terminating in organic change, and death.
Thus, when the perspirations which occur upon
the change in fevers, and some of the exanthe-
mata, are interrupted, efl'usion often takes place
from serous surfaces, or into the cellular tissue.
The roost active vascular depletions can never
compensate for the suppression of an abundant
menstrual or haemorrhoiUal flux, occurring at the
acm6 of acute diseases ; — the effects of an are
here unequal to those produced by nature. Hence
the advantage of recognising critical evacuations,
even although we may not otherwise confide in
them. Although it is thus important to attend to
them in our prognosis, and especially in the treat-
ment, when signs of their accession appear, or
when they are actually present, yet the ex-
pectation of their occurrence ought never to
interfere with or prevent the adoption of judicious
intentions and means of cure. £ven granting,
with Hahnemann, that they are not to be imitate!
by art, still they furnish several useful indica-
tions. *' Quo natura vergit, eo ducendum est**
may occasionally be adopted, after a careful con-
sideration of the changes of which they are the
effects, but not the causes. Much mischief has
accrued from considering critical evacuations as
the causes, and not as the consequences, of
changes that take place in the economy at the
acm^ of acute diseases. Reil has touched upon
this fallacy, but has not considered the nature of
the changes of which critical evacuations are the
effects, or attempted to explain the manner of
their acoesnon.

IS.II.CausiSfAec. — if.WehavaneQthslcnKi
take place chiefly from eliminating or eicreu:
snr&ces and organs; and that they coasot ot i
eoptons irniptioa of either previoody sapiiftaed
secretions and excretions, or an aocosiomcd ua-
guineona evacuation ; but the causes wKick oc*
casioo, and the changes which precede them, tn
not 80 readily reoogmsed. Wlhen we consider ct
what they consist, especially in relatioa to ti^
(act of their occurrence only in maladie* e)nnc>
teri<ed in their earlier stages by iaierraptcd <«•
cretion and excretion, and by morbid exateoxai
of the vascular sptem— the vascular exotesMs:
bein^ perpetuated and variously modified bj <Mt«-
pension of the visceral functions now rocottosf^,
or by local irritation, or by both — we ihaH ijr,i«
at a tolerably accurate mferenca respcctia^ *>
causes of crises, and the impoitance that os^bt : •
be attached to them. There are few facts ia pa-
thology better established than that va$euhf ei*
citemeot, when it reaches a certain height, a
assumes an inflammatory form, impedes, iBte>
rupts, or even arrests, the natural ftioctioosc^
secreting or glandular organs ; whilst a lovr
grade of excitement, unattended by inflaffinat»o\
generally increases the functions of the orsa^
thus affected. Therefore, when exciteneot cq>
tinues to be expressed chiefly in the vasciibr nv
tem generally, secretion and excretion cmiiznt
impeded or entirely suspended ; and the eSi:t
materials, which, under other cireunstaoees, l'?
continually being removed from the circalati»x
accumulate in it, perpetuating and modrffto^ ti:
vascular excitement until it beoomes eihss^Ai,
and until the accumulated noxious material £
the blood irritate the viscera destined to r«n^
them, and thus incline the balance of escfteiB«£t
from the general vascular system to ehmioat^t:
organs. Hence the occurrence of criticsl cvats-
ations at the acro^ of acute diseases ; aod hmct
their importance as indications of change is tbe
states, — 1st, of vital power; 2d, of vwsc^iK
action ; 3d, of the cireolating fluid ; and. 4tti.t:
the functions of secreting and excreting viacen. Aj
crises have been neglected or ooniided in ac«ord>
ing as they agreed vrith the doctrines of thcdaj.
and have, in modem times, shared tbe fate of tb«
patholoey on which they had been so looe r*''*
ed, I shall attempt to illustrate this view \n i
reference to one of the very oommoa cireaff'
stances in which they are observed. A pewt
exposed to the causes of autumnal h\tt d '
bilious and remittent form, erperieores 6vm:
the earlier stages tbe usual symptoms of in[ip«<^'^
or interrupted secretion and general vaseaisf ei-
citement, with evening exacerbatioDs. In aa*
^quence of interrupted action of the trntocwrt*.
the blood contains an increasing proportioo ii
eflTcte materials, particularly of the eleoeet* flit
of which bile is formed. These for a mbtlf >3*
crease and modify the vascular exeitemeat. c,
when excessive in quantity, or especially cot ^f
in quality, even tend to exhaust or depre«» >' •
but they, at the same time, being apprcpn-ttf
stimuli to the biliary and depumtory viscefs, *er»'
to restore their impeded functioos, to tsra ik'
balance of excitement in favour of then, — ihere^'
to reduce the morbid vascular action, to drafi^
the cireula'ing fluid from its impurities, sod i>'
chan^ in other respects its condition ; sad liu*
the dneasa terouDatat'with an appami 9o\Ufef,

450

CROUP— HisTOBT or m Psoohbbs.

fonn of the difMse ; 2d, Nervout or Spoitnodie 1
croup, or a sUghter state of the ioBammationi'{
occurring ia nervous and irritable temperaments,
which influence the form and issue of the dis-
ease, giving rise to a spasmodic form of it ; and
3d, Inflammatory croup, or that in which the
inflammatioQ of the air-passages is carried to
a greater height, and is always attended by the
production of a membranous exudation. The
opinion that croup consists of an acute inflam-
mation, occasioning the production, in a number
of cases, of a false membrane ; in others, of an
albuminous concretion of various degrees of den-
sity ; in some, of a viscid mucous secretion, and
of the inflammatory lesions of the mucous mem-
brane itself, already described (see Bronchi, &c.
$ 3, 65.) ; has been attacked by MM. Guer-
SBI4T and Britonxeav, who consider that the
formation of a false membrane is the distinctive
character of croup ; and that those cases in which
it is not formed, are merely what they term faiu
croup. I agree with M. Bricheteau in oon-
sidermg that the distinction here contended for is
calculated more to puzzle the inexperienced, than
to advance our knowledge* The experiments of
ScHwiLcvs, J URINE, Albers, Schmidt, and
Chaussibr, as well as pathological observation,
prove that the form of disease called false
croup by the above authors proceeds from a simi-
lar state of morbid action as that denominated
the pure disease, and is merely a modification
resulting from less intensity of the inflammation,
peculianty of the temperament and habit of
Dody, the causes occasioning it, and the greater
predominance of the spasmcdic or nervous states.
The experiments of the authors now referred to
demonstrate, that the injection of irritating mat-
ters into the air-pawages sometimes produces
simple inflammatory irritation ; in others, a thick,
viscid, mucous exudation ; and in many, parti-
cularly in voung animals, a complete false mem-
orane. These diflTerenoes of opinion, which are
not confined to the writers now mentioned, but
extend to many of those quoted in the course of
the article, will appear, from what is about to be
advanced, as more apparent than real. I'hat the
disease should present numerous modifications,
approaching acute bronchitis on the one hand,
and identical with laryngitis on the other, and
varying characters according to the portion of
the air-passages chiefly aflected, the temperament,
habit of body, seventy of inflammatory action,
and association with other diseases, is an in-
ference to which a priori reasoning may lead
every practitioner. Without adopting the con-
fined views of some writers, or the hypothetical
doctrines of others, I shall be guided chiefly by
an extensive experience in the disease, and con-
aider it under the following heads : — > 1st, The
symptoms and progress of true croup ; 2d, The
varieties or modifications of the disease most fre-
quently observed ; and 3d, l*he complicated and
consecutive forms.

5, i. The usual Form and Progress or
true Croup. — The timpU and usual form of
eroup generally commences with mora or less of
precursory symptoms, and runs its course in a fe%v
days. It has neen divided by authors into dif-
ferent sUges or periods, more, 1 believe, with the
view of giving precision to their description, and
to the treatment recommended^ than from any

marked change in the character of the flpaptoou.
M. GoBus has divided it into four stages, viz.
1st, the invading or catarrhal stage ; 3d, the m*
flammatory period; 3d, the aiage of the slbo-
minous exudation ; and 4th, the period ef inni'
nent suflbcation. A nearly similar divifioo hat
also been adopted by Dr. Chbtvb. The difi*
culty of determining these various stages most be
evident $ and yet the advantages ariaa| fron i
division of the disease into distinct penodi mo^t
be evident, •— not so much, however, for tin pur-
pose of description, u for the more itncl ippiv-
priation of the means of cure. Premiuig, tkav-
fore, that croup, particularly this form oif it, ;>
strictly progressive, with no great change ia n>
features, until towards its close ; and that. thfft>
fore, all divisions of its course are merdjarb>
trery, and without any positive grounds ia aatart ;
I shall notice, 1st, its prteunory signs ; 2d. itr
d$v9hp€d and confirmed state ; and 3d, the itstt bf
eoliapu and imminent suflbcation,

6. A. The precurtory pericd, period of in-
vasi&n (Guersent), of irrUaUon (RoYEa^Ciiu
lard), caiarrhal stage (Goelis), ftbriit psn(^i
(DuoEs). These precursory si^ns are loibe-
times well marked, and of a distinctly ostanbtl
nature, as observed by Goslis; oecasiooallr
thev are slight, chiefly of a febrile descriptioB;
and either from this droumstance, or from (Jk
shortness of their duration, attract but bu<t
notice. The febrile symptoms, when mesi.
consist chiefly of alternatiuff chilliness and best, cr,
in the more acute cases, of slight chills, folio* li
by heat of skin, frequency and baidnete of ^hr,
slightly flushed countenance, want of appfti'C
headach, excited or variable spirits, altenutia;
with sadness, lassitude, &c. OAen, ia pU<t
of these, or in addition to them, there an i
short cough, hoarseness, sneexing, ooryia, wcv-
times moroseness, and all the signs of commor.
catarrh. Upon examining the pharynx a»i
mouth, no trece of inflammataon can be dt>
tected in this form of the di^eaae ; but the toes: ^
is geoerelly white, and loaded at its base. 1 -'
eyes are watery, red -, and the eyelids darker tb'i
usual. These symptoois are aomeUmes only o( ^
few houre' dumtion, or they may be prenot t>
two or even three days. In very young chiMrto.
they may be so slight aa to escape detero^=<
whiUt a somewhat diflerent train of phenoneLt.
such u heat of skin, chillineas altereatipf «>>
heat, frequent short fits of coughing durisg i'>
night, want of sleep, restlessness, iod)eslion» y
uneasiness about the throat, furnished by the ^*
quent application of the child's band to tbi» ps-"
&c. manifest themselves. The impeiiaace '^
ascertaining the invaaion of tlie diseaae bavt U i
several writers to pay much attantioa to tt>p'V
cursory symptoms. Visussxvx has altttbt 1
much importance to the catarrhal signs, at.
change in the voice. But theee are aeiby a-/
means constant ; and, even when preaeat, vsj (<
merely the commencement of a slight cataffh;
indeed, there is no symptom which eaa bs (tU '
upon, as indicating its approach, until the dw«><
is nearly fully formed.

7. B. The dmmhptd $taU rf tht dim* c
Inflammatory, of Cbryvx and Hqbacx).^ A*' '
the above symptoms have existed for a Ipn.^' *'
shorter time, or in a more or Um maiisd nM"' >
hoarseness, if it have Aot previoiisly tsi«icl

456

CROUP — DiACNosu.

nenrotts frames, but geneinlly in a more spasmodic
form.— c. Besides producing these, it may occa-
sion, although very rarely, abscess in the vicinity
of the larynx or trachea. I believe that dilata-
lion of the bronchi is a much more frequent re-
sult.— d. Of the more indirect terminations and
consequences of this disease, congestions of the
encephalon, giving rise to eonvultions and effusion
of serum in the ventricles, or between the mem-
branes, are the most important. In many cases,
particularly in delicate and nervous children, the
convulsive movements seem to commence with
the spasmodic actions of the laryngeal muscles,
and the strangulation thereby occasioned ; the
head and neck beio|f thrown back, and all the
limbs convulsed. Life is in some cases thus ter-
minated by asphyxy. Jurine, Vieussxvx, and
myself, have met with cases of hydrocephalus
following the disease ; but they are not common.

22. C. Danger is to be dreaded, when fever is
Tcry high early in the disease, and when respir-
ation is permanenily audible, cooing, and laoo-
rious, or as described above ($ 7.). When the
disease goes on to the third stage, notwithstand-
ing the treatment ; when it presents any of the
complications ($16.) and consecutive affections
($21.) already noticed ; when the discharge of
the characteristic exudation does not take place,
or when the expectoration of fragments of it is
not followed by any relief; when the counte-
nance becomes livid or leaden, the eyes sunk,
the lips and tongue dark, and the pulse very fre-
quent, small, weak, and irregular ; and the other
symptoms of vital exhaustion appear ; great danger
exists. A fatal itsue is to oe expected when
the patient presents the appearances described as
characterising the third stage, particularly those
noticed as marking its close ($ B.).

23. III. Diagnosis. — The hoarseness, and the
loud, sonorous, and ringing cough ; the forcible
and difficult inspirations ; flushed face ; injected
and wateiy eyes ; the frequent and hard pulse,
with thirst and inflammatory fever, the heaving
of the thorax and motion of the trachea, in the
developed stage ; and the husky choking cough,
the whispering voice, and wheezing respiration,
&c. of the thinl stage ; suffideotly distinguish this
disease from any other. W hen it is uncomplicated,
nothing beyond a slight redness is ever observed
in the throat -, and there is little or no pain upon
deglutition, unless the larynx be much affected.
•—a. Croup can scarcely ever be mistaken for
Cynanche fnaligna, or C. Pharyngeal or any other
form of sore throat, as long as these affections do
not extend to the larvnx ; as the great difficulty
of deglutition, and the but little disturbed state
of respiration, independently of the obvious af-
fection of the throat, &c, are sufficient to distin-
guish between them. Wheui however, portiona
of the concreted exudations in these affections
irritate the glottis, they occasion a short, tickling,
dry cough ; and even excite, in some cases, stran-
gulating spasms of the larynx, nearly resembling
croup, particularly when it is complicated with
these maladies. If, however, it be thus associated,
the croupal characters, in addition to the appear-
ances in the throat and pharynx, will be too evi-
dent to be misunderstood ; the descriptions already
given of these complications being sufficient to
point them out, ~fr. During the eruptive fever of
mtds/tfi, the tracheal affection is often so great as

to simulate croup ; and in many casta it erea
amounts, as already stated, to a slighter form of
the complaint, which usually disappears is iht
eruption oecomes matured ; but attention to tix
symptoms will readily show the natare of ik
disorder, and how far the affection of the Isijox
and trachea should be viewed as asymptoBi,«r
as an important complication of the exaatbssM*
tons disease. — e. Croup may readily be diftia-
guished from hnmchitUt by its sudden and lerais
attack ) its occurrence in the evening sod ai
night ; its remissions \ the hoarseness, sod the
ringing, dry, and frequent cou^b; the difficslt
inspirations, and impeded respiration ; the altered
voice and speech ; the sensations anid symptoaa
referrible to the trachea in the former, and to the
sternum and chest in the latter ; and by the
absence of expectoration until late in the diseue,
when it is membranous or tubular, and sol
mucous and muco-puriform, as in bronchitis, ustil
after the discharge of the membranous ezudstiou.
These characters will also serve to indioite
the supervention of croup on bronchitis,— ts
occurrence which is sometimes observed, although
much more rarely than that of bronchitis on
croup. — d. Laryngitis is with greater difficsltv
distinguished from croup than the foregoing, sod
in many respects there is little or no diffeiencc.
The practical importance of the diagnosis may
not appear great, but it is sufficiently so to war-
rant an accurate distinction. 1st. True Isiyogitis
occurs in adults ; seldom, in children, in any other
form than associated with either the simple or
complicated states of croup. 2d. It is a purei;
inflammatory disease* attenaed by a fixed bursiai
pain in the larynx, increased on preasare aad
examination ; and, when attacking adults, never
gives rise to a false membrane, nnlees it be
superinduced in the specific and epidemic tarns of
cynanche, and then it assumes modified cbtnc-
ters. 3d. It more frequently terminates ia the
manner characterising acute inflammatiooa, to-
ulceration and suppuration, than when the larjrax
vs affected in croup. 4th. It ia mora scstel;
and constantly inflammatory, the symptosB* in
more continued, and it is more benenled hj s
purely antiphlogistic treatment, than etw^f*
5th. It much ofkener passes into the chnue
form, than the latter disease. (See Laavstx—
Inflammations oJ\) — «. Chronic Uryngeel sad
tracheal inflammatiun — the laryngeal sod tra*
cheal consumption of some writers — reitabk
croup, in the hoarse voice, harah dry cough, asd
the difficulty of respiration ; but their progrew •
much slower, and less acute than croup; ^
do not present the violent paroxysms towa:6
night ; they seldom or never are observed is
children ; and ulceration of these parts of the air-
passages is always found in fatal cases.-;/
Croup may also be confounded with the di/Toa'c
inflammation which sometimes attacks, ether
primarily or consecutively, the cellular tissaeaboot
the throat, or with abscesses in the same ntasnoa ;
either of which may involve the laiynx aadneia-
branous part of the trachea, or so affect then ai
to give rise to croupal sjmptoms ; but the ea-
ternal appearances, the lUfficult degioiitioa, the
state of the throat, and the history of the csm,
will at once show the differences eaisliaff betwera
them. — g*. Pertussis and croup can hardlj bs
mistaken for each other; the lavaaba, chsfi>

CROUP — Ciirsss or.

457

ten, and jfngrtm of both diseues being so very
different. The prolonged whoop, the unchanged
voice, and the occurrence of the cough in con-
vnlaive peiosjsms after a neal, termioattDg in
Tonitiog and a copious discharge of a clear and
gJaiiy 6uid ; the complete intermissions, respira-
tion, voice and speech remaining unaffected ; the
almost entire absence of fever, and the much
more slight and chronic form of the latter disease
in its uncomplicated state ; are sufficient distinc-
tioQs. Croup may, however, occur in the course
of hooping cough ; but then its characteristic
symptoms will make it apparent to tlie attentive
observer, and point out the nature of the resulting
aaocktion. — h. The effects following su6ttaii«es
(W hace Mteaped into tk§ Irackea often resemble
croup ; but may be distinguished from it by the
sudden occurrence of pain and suffocation ; by the
frequent change of the exact seat of uneasiness
with the change of the situation of the foreign
bodv ; the dryness of the cough, and the violence
of the strangulation; and by the irregularity, the
ccmpleteness, and sometimes the lon^ continuance
of the intermissions. When a foreign substance
psMes into the glottis, and is retained there, suffo-
cation is generally occasioned either from the size
of the substance, or from the spasmodic constrict
tion of the muscles of the larynx occasioned by
ii—i. HytUria may also simulate croup; but
the age of the patient, the history of the case, and
the local and general symptoms, if attentively ob-
>erved, will ioSicate the nature of the affection. —
fc. The spasmodic states of croup closely approach
to emvultivt tpaun of' the larynx ; but the absence of
coQf^h and fever, the brief fits of strangulation, the
complete intermissions, the spasm of the thumbs and
toes, the purplish countenance, and the general con-
vuWoDs,will distinguish that affection from any form
of croup. (See Lab VNX—Conru/fivs Spatmof,)

24. IV. Causes. — A. a. Croup is more fre-
quent in cold and moist climates than in those
which are warm. Rapid and frequent vicissitudes
of season, weather, and temperature, have consi-
derable influence in producing it. Hence its
prevalence in the valleys of Switzerland and Savoy,
IB this country, particularly on its eastern side ;
ia the other north-west countries of Europe ;
and in North America. But the middle, and even
the south of Europe, are not exempt from it. M.
Valekhn has- shown its frequency in the middle
aod southern provinces of France, Goelis in Vi-
enoa, and G aisi in the north of Italy. Sir James
M'Gaicoa notices its prevalence — probably in a
complicated form, from its occurrence also in
adolis (§ 25.) — at Bombay, in 1800. According
to the iofcMination given by J urine, Lentin,
Chlyjii, and others, we might be led to infer that
it has been more common in very modern times
than formerly : the difference may, however, be
owib^ to its having been mistaken for some other
affection. I believe that it has not been so fre-
quently met with during the preceding five years,
as it was about twenty or thirty years ago. M.
Ji'RiKB remarks, that, although the table he has
giveoofthenumber of cases from 1760 to 1807,
•hows a nearly progressive increase, yet he has
observed, at Geneva, no increase during the
last eighteen years preceding the date of his
work. The following evidence, nevertheless,
would render it evident, that, in some countries

at ktft, croup is more prevalent now than for-

merly. According to the information given by
Dr. CooxsoN, a practitioner of forty years' expe-
rience in Lancaster had never seen it until 1760.
Dr. Faiedlander (Joum. de Montpellier, No.
IX. p. 276.), states, that it has become yearly
more prevalent in Vienna; and that the physician
to the Hospital for Children, who had treated,
from 1774 to 1817, nearly 60,000 children, did
not meet with a single case in the three first years
of his practice, saw it but rarely durin? the next
six years, and yet treated 1665 cases of it in the
last five years of this period. Similar facts are
also furnished by Dr. Gosus. Although croup
occurs at all seasons of the year, it is most preva-
lent in those which are cold and moist, or when
the alternations of temperature are sudden and re-
markable. I have observed it more frequently in
the months of January, February, Mareh, April,
November, and December, especially if east or
north-east winds prevail after heavy or continued
falls of rain. I believe that the above results are
nearly in accordance with those furnished by
JuRiKx, Crawforo, Mxchaxlis, Double, and
Brichbteau.

25. b. The great susceptibility of early age, aod
the narrowness of the larynx previously to
puberty, have generally been supposed to favour
the occurrence of croup. M. Blavd, however,
denies that this latter circumstance has any in-
fluence in causing it. This is doubtless the case
in respect of the production of the disease, but
not as regards its uverity and danger, both of
which it evidently increases. It is rare to meet
with croup until after the child has been weaned :
I have, however, seen it in children at the breast,
as early as three, four, five, and six months of
age ; but much mora frequently at this age in
those who have been brought up by hand ; and
in a still greater number of instances, at from
seven months to upwards of a twelvemonth, in
those which have been recently weaned. M.
DuoEs states, that he met with an instance of it
in an infant of a few days old. The age at which
the disease is most common is, according to my
exjperience, from one year to nine. But it not
iofrequently occurs at both an earlier and a
later period. Van Bcroen states, tliat it is often
observed from the age of two to five years inclu-
sive : Home assigns from fifteen months to twelve
years: Crawford mentions some cases from
fifteen months to two years, but gives the age of
from two to eight as the roost common : Cueyne,
from sixteen months to twelve years ; Salomon,
from two to five years inclusive ; Miciiajelis, from
fifteen months to ten years ; Zobel, from the latter
months of suckling to nine years; Vieusseux,
from seven months to ten years: Bernard, from
one to six vears ; Barthez, from two to ten ;
RuMSEY, till fourteen; and Caillau, from
eighteen months to eleven years. The foregoing
applies only to the simj^le and uncomplicated dis-
ease. When it occurs m a complicated form, or
consecutively upon anginous affections, particu-
larly upon inflammation of the pharynx, tonsils,
or fauces, or on the exaothematous diseases, ii
may, and, indeed, occasionally does, occur in adult
subjects, and in infants of a more tender age.
The cases published by M. Louis, and denomi-
nated by him croup in the adult, were instances
of the anginous complication. Although the oc-
currence of uncomplicated croup in adults is very

CROUP — Fatboloot of.

461

39. Tfaeie k one importtnt point not mifficiently
adverted to bj authors, vix. tne very early period
at which the tracheal exudation is often poured
out, in the inflammatory atates of the diseas^ ; the
symptoms marking the first or premonitory period
beio^ those indicatiDg the local developement of
the mahidy. Thus, a healthy child has evinced
Qo disorder for several days, or the disorder has
been so slight as to escape observation — it may
eves be more than usually lively and alert on the
day preceding the night on vrhich it is most se-
Tenly attacked ; and yet, if an emetic be that
iiKtaot exhibited, a large quantity of thick, glairy,
aognioeoos, and gelatinous matter will be brought
away from the air-passages; showing that, in
maoy instances, the early advances of the inflam-
matory action is slow and insidious ; that the cha-
ractemtic seizure often does not occur until the
exttdstion has accumulated to a considerable ex-
teDt io the trachea, or the inflammation has ex-
tended to the larynx ; and that it is partly owing
to the retention of thia matter,^- whicn is evidently
thrown out in a fluid form,-~that it concretes into
a fahe membrane, each successive discharge some-
times forming a distinct layer. MM. Gbndrin,
AvoBAL, and other pathologists, have remarked,
Ibat the inflammatory action which gives rise to
the albuminous exudation on the surface of mucous
membranes is of a sub-acute, rather than of an
fcute kind. I believe that this is the case in
respect of the inflammation of the trachea and
hiynx, m croup ; and that the formation of a false
membrane is the result not so much of the sthenic
or acute character of the local action, as of the
abnodanoe of albunaen and fibrine in the blood,
—a circumstance which partly accounts for the
frequency of relapses in some children ($41. o.),
and jus^fies Hauixb, Heckeb, and others, in
coDsideriDg the diseaue to consist of a peculiar
form of inflammatioo. Some writers, however,
suppose that the very acute symptoms, and rapid
termioation of many cases, militate against these
opinioDs; but it should be recollected that, even
tQ the most severe cases, the inflammatory action,
wbeo it commences in the trachea, often exists for
feTenI days, in the manner already noticed, until
it has either extended to the larynx, or produced
»ucb a quantity of albuminous exudation as will
oUimct respiratioD, or induce, by its irritation,

r^m of the air-passages, — these effects being
chief causes of the severity and rapid ter-
nunttion of the disease. This vrill become more
^ndent, when we consider the consequences of
iotemipted respiration upon the frame — whether
^ iuterraption proceed from the mechanical ob-
struction occasioned by the exudation and false
membrane, or the frequent recurrence or con-
tianaoce of spasm of the larynx and trachea ; or
from inflammatory action, and its consecutive
exudation extending dovm the bronchi ; Or from
two or all of these combined. These conse-
qoeoces are, in lact, the third stage of the disease ;
the symptoms of which are the usual phenomena
reiQltini; fimn obstructed respiration, intermpted
circulataon,aod congestion of the longs ; imperfect
■ftion of the air upon the blood, and the circu-
laiioo of this fluid in a nearly venous state, with
f ooj^estion of the cavities of the heart, and impeded
return of blood from the head. The circulation,
HMttovcr, of imperfectly aiterialised blood to the
nervous systems occasions lethargy, with sinking
of the rital poweiB, and increasct the disposition

to spasmodic action of involuntary parts, and to
convulsive movements of voluntary organs ; all
which (the former especially) become so promi-
nent a character of toe malady in its advanced
stages, and often terminate existence. Thus it will
appear manifest, -— and the fact is of great prac-
tical importance, — that the severity, rapidity, and
danger of croup, are not the immediate conse-
quences of the activity or acoteneas of the inflam-
matory action ; but of the exudation to which it
gives rise, and of the conformation and functions
of the parts which it afiects.

40. Duval, Jurine, Albers, and Schmidt,
have considered it worth ascertaining, in how far
the disease could heartifieiaUy pr^uced in the
lower animals ; and whether or not, when thus
produced, inflammation exists to the extent of
accounting for the phenomena, or gives rise to a
false membrane. They injected into the trachea
of fowls, dogs, cats, sheep, wolves, £(c., various
irritating sulMtances, as the bichloride or peroxide
of mercury (ScHaiiDT) dissolved in spirits of tur-
pentine, and solutions of iodine, and nitrate of
silver ; they moreover made these animals inhale
the fumes of sulphuric and hydrochloric acids;
and the results were just what might have been
anticipated, viz. that in some cases, inflammation
without any exudation was produced ; in others, a
fluid, or more or less concrete exudation was found
in various quantity ; and in all, the matter in the
air-passages was not sufficient entirely to obstruct
the access of air to the lungs ; thus confirming the
opinion jtistly contended for by Cullen and others,
that a great part of the phenomena and conse-
quences of the disease is to be attributed to spasm
of.the larynx and trachea. Schmidt succeeded
in producing a false membrane only in young ani-
mals, — a fact in accordance with the spontaneous
occurrence of the disease previously to puberty, and
to be referred to the more albuminous state of the
blood often observed at this period. It may be of
importance to know that croup — identical in its
phenomena and organic changes with the disease
in the human subject — occurs also in several of
the lower animals, especially before they are fully
grown. Its occurrence in chickens is well known
by the name of " Pip" Dupuy, Rush, Valentin,
X ouATT, and others, have observed it in horses
and dogs ; Double, in lambs and cats ; and
Gnisi and Gohier, in cows. In some of these
animals it has even occurred as an epidemic.

41. Pathological Conclutioni, — Another point,
of greater importance than it may at first seem, is
whether or not the matter concreted and moulded
on the inflamed mucous surface be exuded by this
tissue itself, or secreted by the follicular glands
with which it is so abundantly supplied. M.
G rim AUD has adopted the latter alternative. From
particular attention I have paid to this subject,
some of the results of which have been stated in
the article Bronchi ($ U, 12.), I would draw the
following inferences relative to it, and to the
pathology of croup generally: — (a) That the
mucous membrane itself is the seat of the inflam-
mation of croup ; and that its vessels exude the
albuminous or characteristic discharge, which,
from its plasticity and the eflPects of temperature
and the continued passage of air over it, becomes
concreted into a false membrane ; — (ft) That the
oceasional appearance of blood-vessels in it arises

I from the presence of red globules in the fluid when
I fim exuded from the inflamed vessels, as may be

CROUP — Trbatuint of its cohmok Foftits.

463

4d. A, TnatmiiU of the common and inflame
matortf Croup, ^ a. If the pnctitioner see the
patient io the ^rtt itago (§ 6,), particularly if
koarseoett, or a rough cough, with other catarrhal
eymptomi, be present, it will be proper to give an
actiYe aoUmoual emetie,with toe view of ful-
filUog thtfint of the above intentiooa. This will
often bring away a considerable quantity of a
thick, glsiiy, and sometimes slightly sanguineous
matter from the tnchea, and will give immediate,
aitbough generally only temporary, relief. If the
matter discharged firom the air-passages present
the shove appearances ; if the child be plethoric,
the pulse at all excited, and the countenance
flushed ; we should not be deceived by the calm
followiog the full operation of the emetic, but
filumld have reooune to blood-letting. In the
majority of instances, cupping between the shoul-
dera or on the nape of the neck, or the application
of leeches on the sternum, to an extent wnich the
age, habit of body, and strength of the patient may
warrant, will be preferable to venesection. Under
these circumstances, particularly when the nausea
occasioned by the emetic has hardly subsided,
the abstraction of little more than an ounce, or
BQ ounce and a half, of blood, for every year
that the child may have completed, will be borne,
lo town practice, the local is preferable to general
Uood-ktting ; bnt the latter will be adopted, with
advantage in the country, amongst plethoric and
robuat children. The advantages of depletion
and aatimonials are attributable to their influence
in arresting the inflammatory action, and , from the
coQiecntively accelerated absorption of fluids into
the circulation, to the relative diminution of the
albuminous constituents of the blood. I have in
several cases directed, after a moderate depletion,
aod after the operation of an emetic, a piece of folded
flannel to be wrung out of hot water, and freely
iprinkled with oil of turpentine, or vrith either of the
tininnts(J 296. 3 1 1 .), and applied around the neck
and throat This application has given instant relief.

44. Immediately after depletion, and an emetic,
the best rotemal medicine undoubtedly is calomel
>Qd Jamci'f paudor — from three to five grains of
the former, and two or three of the latter being
given. This powder may be repeated every
*<^nd, third, or fourth hour, until two or three
dcees have been taken. After the first dose, the
child should be put in a tepid bath , and be allowed
>^ much te^ dduentt as the stomach will bear, in
«hich carbonate of soda may be dissolved, and
^hicb may be rendered agreeable with syrup. If
the powdeit, siven to the extent now mentioned,
have not acted upon the bowels, castor oil, or some
^^ purgative, aBsisted by an emetic, should be
administeTed. These means, aided by the turpen-
tine epithem applied around the neck, will seldom
tail of cutting short the disease. If, however, it
■till proceed, the means to be employed in the next
^^ ahonld be adopted according to the circum-
ttanesofthecase.

45. b. The jecond or developed itage is that
ID ^hich medical aid is most frequently resorted to ;
*nd at this period, conformably with what has
o«en stated ( ^ 39.}, the disease is actually further
UTsaccd than the symptoms indicate. At its
commencement, however, the Jirst intention rf
^rt should be attempted ; but the most decided
roeana will be now requisite to attam its fulfil-
»ent. These should be put in practice, even
uthoagh the tmtme&t already recommended

may have been employed in the preceding stage.
An active antimoaial emetic should be instantly
exhibited, so as to produce full vomiting; and
immediately upon the conclusion of its operation,
blood'Utting, general or local, must be resorted
to. The abstraction of a greater quantity than
that indicated above {§ 43.) will seldom be more
beneficial, nor, indeed, will it be borne without
producing syncope, which, in children, especially,
should be avoided, as favouring the supervention
of convulsions or reaction. But it may be requi-
site, particularly when the patient has not lost any
blood during the preceding stage, to repeat the
depletion. On this, or on any tuture occasion of
repeating it, local blood-letting, in the situations
and mode already mentioned ($43.), is now to
be preferred. If they have not been prescribed
previously, the calomel and James's powder should
be given every two or three hours, until three or
four doses are taken ; and the adjuvants directed
to accompany and to follow this medicine in the
first stage, should also be employed in this.

46. Having thus carried depletion as far as
seems prudent, and fully evacuated the prima via,
if a very obvious iooprovement have not taken
place, or if the suffocating seizures recur not-
withstanding, dry cupping may be resorted to, and
afterwards either a blister should be applied be-
tween the shoulders, on the nape of the neck, or
on the epigastrium, but neoer on the throatf or the
turpentine epithem ($ 43.) ought to be applied
around the neck. If symptoms of febrile excite-
ment still attend the seizures, an emetic should be
given, so as to excite vomiting again, and be re-
peated until it has this effect fully. If the urgent
symptoms and fever still continue, vomiting may
be excited a third or fourth time at intervals of
two or three hours. The tartar emetic is, upon
the whole, the best medicine for the purpose in
the early or inflammatory states of tne disease,
and may be given in doses of half a grain, in
simple solution, to a child two or three years old,
as advised by £)r. Cheynb, and repeated at about
half an hour, or sooner, if vomiting be not induced.
M. GuERSENT prefers ipecacuanha, and advises
blood-letting to precede the exhibition of emetics.
Where the inflammatory action is considerable,
this method may be adopted; but where we may
expect to bring away the exuded matter by means
of an emetic, before it has ooncreted into a mem-
brane, it will be as well to exhibit one without
delay, and to keep up a constant nausea by the
same medicines given in frequent and small doses.
But I have seen the tartar emetic not only fail in
producing vomiting, but also prove injurious by
causing dangerous vital depression.

47. If the symptoms continue notwithstanding
the judicious use of the above means, we should
infer the formation of a false membrane, unless
the exacerbation be altogether spasmodic — the
breathing and voice becoming natural, or nearly
so, in the intervals. The measures to be employed
now should have reference to the separation
and discharge of the concrete exudation, and the
removal of spasmodic symptoms — to the fulfil-
ment of the second and third intentions proposed.
Bleeding, even if the state of the patient would
admit of it, would not promote these intentions ;
and the exhibition of calomel or mercurials,
excepting with the view of promoting all the

I abdominal secretions and excretions, and thereby
I to derive from the diseased organ, would not

^64 CROUP — Triatmbnt op ira comtoN Foams*

materially aasist our views, inaamttch as it is im-
possible thereby to affect the system of children
so as to prevent the formation of coagulable
lymph. In this case, we should assist the oper-
ations of nature in detaching the false membrane.
It has been stated, that this is accomplished by
the effusion, by the excited follicles, of a fluid
matter between the concrete substance and the
mucous coat; therefore those medicines which
have usually the effect of increasing and render-
ing more fluid the mucous secretion of the air-
passages, should now be prescribed. But care
should be taken not to eihibit these or any other
expectorants, too osrlv, or until depletion has been
carried sufficiently Hir. They are most service-
able about the termination of the second, and the
commencement of the third stage. The medicines
best calculated to act as expectorants in this dis-
ease are, the preparations of tquiUs, of ammo-
niacum, of ftnega, toe carbonatet, and the sulphu'
rett of the aUtaliet, and camphor. The oxymel or
syrup of tquUU may be given, either alone, or
with some one of the sulpburets, or with senega,
and generally to the extent of keeping up a slight
nausea, unless the excerbations of * cough and
suffocation be severe, when full vomiting should
be produced by their means. I prefer the emetic
effect at this period to be obtained by squills ; as
antimony lowers too quickly the vital power, which
ought now to be supported, so as to enable the
diseased organ to tnrow off the morbid matter
formed upon its surface. A mixture, consisting of
decoction of senega, with vinum ipecacuanhas and
oxymel of squills, may also be adopted withe(]ual
advantage. VV hen the medicines fail of exciting
vomiting, the pharynx should be irritated by a
feather. I have seen very much benefit derived
from this 'simple means ; and have considered it
more beneficial than any other, in the third stage,
in promoting the discharge of matters from the
trachea. J urine ^also places mat reliance on it.
When severe exacerbations, with spasm and threat-
ened suffocation, occur, it is always most advan-
tageous to produce instant vomiting. The sulphate
of zinc has been advised by M.Guehsrnt, and the
sulphate of copper by Dr. Hoffmann, for this pur-
pose. In this sute of the disease, I have applied
the warm turpentine epithem mentioned above
(§ 43.), around the neck, with almost instant benefit.
48. During this and the preceding stages, the
inhalation of watery and medicated vapours may
be resorted to. At the commencement of the
disease, vapours of an emollient kind are most
beneficial; but when we wish to promote ex-
pectoration, camphor may be added to the sub-
stance used in this way. Hoiia, Crawford,
p£AR80N, Ros£N, PiNEL, sud GoELis, have ap-
proved of this practice. When spasmodic symp-
toms manifest themselves, inhalation, assisted by
the tepid or warm bath, is often of use ; but anti-
spasmodics should also be prescribed with the
other medicines, or in enemata. I have never
seen any permanent advantage derived from nar-
cotics given by the mouth, except from opium or
syrup of poppies, combined with antispasmodics;
probably owing to their lowering the vital ener-
gies, which are always much depressed when
nervous symptoms appear. Great care should be
always taken in exhibiting opiates in clysters to
children : in very young children the practice is
attended by much risk. Opiates are given to
greatest advantage with ipecaeaanha, •§ io

Dotxr's powder, or with eamphor, or eakeul, a
with both. I have likewise found camphor, with
James*s powder, and hyoscyamus, of much benefit
in some cases in which I have prescribed it. Tfe«
hydrotulphvret of mnmonia may likewise be tiied
in both this and the next stage of the diKSse.

49. In many cases, the jiKiicioaa use of Mood-
letting, calomel, antimony, &e. will cut short the
disease, even although the patient may not ^h
been treated until wis period has been far sd-
vanced; and in others, the active uie of t^
means may give rise to very alarmingdepresaooif
the vital energies, even when they may nan .nc-
ceeded in removing the cause of ontroctioa sad ir-
ritation in the air- passages. In these, stiBulsau,
antispBsmodics,and restoratives most be immcdistely
resorted to, but with great caution, lest the ibIIid*
matory action may be reproduced by their nesD«.'

* The following caie will iUustntc Che above tii*en.
atlon, and may prove InitructlTe to the le« expehcocnl
reader. I hare extracted it 9erbaiim from Bf note-bdoi,
with the remarki suggested at the time appended to it :-

William Hodsom, aged five yean and a lialf, wai tm*±
on the 17th of Nov. 1821. with hoawenais. fever, lad a
ringing, dry cough. The mother opened lu bowck v«l
salts, and gave it some aotimonial wine. The foUir«i:<
day, in the evening (18th), I saw it. Thar wsa mix*
fever, with flushed countenance, and a eonslaDC, hxH
and ringing cough, with a tibilous noiae on mfintiiA
Pulse frequent and hard ; skin banfa and dry : r^it

requent

restlessnesi, tossing. dyspnoM, with hoaraeness, ssms tfc?

«...
characteristic breathii^ of croup. 1 directed btoaS-lfUjac
from a vein in the arm ; and the lilood was aUove^ :•
flow in a ftiU itream till approaching syncope was .ool*
cated, seven ounces being abstracted ; and the follow w
powders were directed to be taken every ten minutes^ t£
hill vomiting was Induced ; and subeequently every tfcrar
hours : —

No. 16S. I^ Hydrarg. Submur. gr. xzx.
Pot.Tait. gr. iU.; Pulv. Ipecacuanha gr.vj.
bend, et divide In Pulv. vUj.

Early in the rooming of the 19th I again saw tbf cb'U.
The powders hadtieen given, as above, until fall vasntaf
had been produced ; and one powder had tieeatakco nfcH-
ouently. The sense of suilocation had disappeared »1tf
the vomiting. The matters ejected oontainod moeb &**
ropy mucus, with membranous sbrada of firas ceesQi^rs^
lymph floating in it. The cough andcroopy lyn^'**
had disappeared ; the voice was clear, and the rMpira: «
easy ; but now the cnild complained of dlstressiog w^-
ness, with frequent vomiting and purging: the it*-*
were first bilious, oflinuiTe, copious, and tendrot ; ^-
they had now become watery. The nulie was e&m^ **>
ftvqueot, so as scarcely to ho counted ; and so loaU i"^
thready as hardly to be felt at the wrist. The iwr*!-^
nance was pale and sunk ; the skin cool and mnijt ; an J
all the symptoms of sinking of the powers of life. *•<▼
manifest. The powders were dlscootiUMd, and the U-r-
lowing mixture directed: —

No. 163. H Aq. Clnnam. 3 lijsa. ; Spirit Awnra
Arom. 3 JM. ; Tlnct 0|>ii Tllav. ; Synipi telle 5 H- *t

Two teaspoonsAil of this were to.be taken evcrr us ^^
fifteen minutes, until a decided effect fhmi it was eix^^i
After four or five doses, the stools and sicknra **tt r«>
strained, and the child fell into an eesy and scmnd ^mt

A blister waa now applied to the stanMiB, mhkh «»
to lie removed at the end of four hours, and poaUW<d
with a bread-and-water poultice. The aeuihupinsa 1 1 b*
employed afterwards, and at tied-tlnio. Three fraiBt iV
calomel, with one of James's powder, to be tiica «i
night, and the mist, camphors, with Uq. anmoo. acH .
vinum Ipecacuanhae. and isjrrupus papavciia, ever? tiiiw
hours. Linseed tea or barley water, with amar^sMT f^
liquorice for common drink.

90th AU the symptoms of croup hnd disappeaied , ^

there was still siMne court and fever, wkh oceMfaosl p-
roxy sms of difficult lireatbtng. Tlie Imwate had bm <f«
this morning ; pulse 120, and small. AnCimoal^ «vr «»
added to the mixture ; and an inieetlon directed, with »•
safcedda, splritustereMnthlnst, oleum ridni.andcBOiibor

In Ike cm-MMv— -He had had no return of the parot j«u
since the injection, which was retained above en !••'«:'
and had procured two evacuations. Pulse 116; etA^
less frequent t skin morenahiral. The Mistwtd sorftrt
had risen In some parts, and waa tnflacmed In all-

From this time he continued to reeoter : dlapborrCk>>
demulcents, aperients, and the ennlcaphas, hetoi •«'

ployed until convalescence was ctwnplete.

Remarket — It Is by no means unuaual to find a rerwrffv*
of the Inflammatory and local aynptows after ihej tew
been apparently moatcoaaptof^ysabdnsdtij wmMumv

CROUP «• RsM imm oir various Rbmxdies emplotsd iv.

467

cceDt mast be directed according to the same
principles. In all cases of angina, attended with
Qiembranoitt exudation, whether the attendant
coostituLional disturbance present sthenic or
astheoic characten, the local treatment advised
by Mr. MiciaNziB should be adopted upon the
appesnace of the exudation on the tonsils or
fauces, and a large blister should be applied early,
&i being the most efficacious means of preventing
the eitension of this form of inflammatiun to the
pharynx, air-passages, or OBsophagus.

57. r. The treatment of the eomplieatiotu with
ii;>ktkt, or wUh any of the eruptive f evert, will
depend, as much as the foregoing, upon the state
of vital power characterising the constitutional
•^«ctioo. The appearance of croupal symptoms
10 the course of small^poz — particularly confluent
smalt-pox — will require nearly the same medicines
^' have now been recommended (f 56.) ; and the
va^hes sdvised to be applied to the mouth and
throat will be equally serviceable in the aphthout,
as io the variohut complication. When croup is
eo3ieqtient lipoo cither mnuist, or hooping cough,
v«culsr depletion is more frequently required
than in slmost any other complication, excepting
tliat with inflammation of the throat of a stoenio
i'Hd, whether attended by albuminous exudation
ur not.

58. D. The affeetierueoiuequent upon eroitip — or
t^t«itatesof disease which it excites, or into which it
pMet— sequire not only appropriate remedies, but
a)«o the spplication of them with strict reference
•0 the primary malady, and the means by which
it wai combated. When it runs on to hrotiehitit,
the latter affection commonly assumes the asthenic
form, generally terminates fatally, and requires
(*)« treatment described in the art. BRONenms
(iVO.ftwf.). Its passage into pnewnumia is attend-
^ with similar results ; and depletions, unless they
^ve been previously neglected, are not well borne.
^Vhen diarrhaa or dyMuterie symptoms are pro-
duced, in the latter stages, by the means used to
ntioove the disease, we shall generally find the
preparations of opium, and the warm bath, as
iif-ri after to be noticed, of much benefit. A con-
»derable number of cases, particularly those
complicated with sore throat, terminate in $inking
^etheutiieH of vital power, and not by suffocation.
^ hi^ circumstance snould be kept in view in the
treatment of the last stage ; and its earliest in-
dicatioDs be met with suitable stimulants and
t'tnir^ (^ S6,)» In cases presenting imminent
"ifreiion, the question of tracheotomy should be
«ntirr^ned; but at the same time, with the re-
<^>ilertioo, that either exhausted vital power, the
^st^nnon of disease to the bronchi, and the ac-
cumulation of viscid or concrete exudations in
them, or inflammatory action, or emphysema of
the longs themselves, may tend, individually or in
combination, to prevent the success of the operation,
:i>^l^pendently of the immediate contingencies to
»»W it i» liable. (See$74.)»

* t ma? bere adduce a lainmBrj of the practice adopted
t'f tU most experienced physician in France in this dis-
«>2a>— the senior physician to the Hospital for Children
in Paris. It will be seen how closely it agrees with nty
bVD, in a similar institutkm in London : «»

M. Jauulot considers croup as a kind of angina of the
•iir-iaiiag« ; presenting inore*Ttolcnt symptoms, and
hi^iof! true paroxysms, separated by well-marked inter-
Litfkloos of a speeiai character. He admits different
direct of the disease, without changing Its nature.
Bl«cdlQg by leeches, and emetics, sre the agents he most

59. RSMABKS ON VAniOUS RXMSDI^S ADVISEDj
AND ON THK OPINIONS OP AUTBORS RE8PSCT1NO

THXM. — a. Nauteants and emetic*. In the first
stage of the disease, and in the commencement of
the second, I have sometimes found that tartar
emetic, given so as to produce and prolong a state
of nautea, has so completely relieved the croupal
symptoms as to prevent altogether the necessity of
having recourse to blood-letting : and that in other
and more severe cases, the same medicine, exhibited
so as to produce vomiting, and to continue the •
nauseating effect for some time afterwards, and
thereby to prevent reaction supervening upon the
emetic operation, has been followed by a similar
result. £ms<ics have been much recommended
after blood-letting, and the inhalation of vapour,
and when the exudation is presumed to begin to
loosen, by Home, Lbntin, Darwin, Mjierckxr,
Portal, Smith, Hecxer, Vievssevx, Humset,
&c. When the patient has not been visited suf-
ficiently early, this plan is certainly judicious. But
when he is seen in the first stage, it will be better
to attempt to prevent the formation of the false
membrane, by exhibiting naussanis or emetict in-
stantly, as now advised, and, unless the inflammatory
symptoms are very severe, before having recourse
to blood-letting. This early exhibition of emetics is
sanctioned by Crawforo, Chsykx, Pinbl, Hosack,
Tbompsov, Hvpsland, Albsrs, Schwilquf, &c.
Dr« Gaisler prescribes, on the invasion of the
disease, tartarised antimony and oxymel of col-
chicum. Whilst vsscular excitement continues,
either this combination, or the antimony only, in
repeated doses, as suggested by Cheyne and
MicHAJiLis, is the best emetic; but when we
wish to detach the membranous exudation, the
preparations of squills, alone, or with ipecacuanha,
are preferable. In the more spasmodic form of the
disease, ipecacuanha, as Goeus remarks, is as
suitable an emetic as can be adopted : but when
it is fouivl necessary to exhibit such a medicine in
the last stage of the disease, or when it is associated
with angina maligna, or attended by symptoms
of depressed vital power, senega, squills, or the
sulphate of zinc, given with stimulants and anti-
spasmodics, or F. 402.,or the sulphate of copper ( £n-
cyc^o^.t.xxii.E.p. 10.), are to be preferred. Goblis
recommends emetics in the first stage of the least
inflammatory forms, and generally in the third

frequently employs in its treatment. Emetics alone have
often sufficed to stop the disease, especiallv in weak, pale,
or bloated subjects ; but, in opposite cases, he insists on the
application of leeches, and allows the blood to flow until
^e child becomes pal», and the pulse loses its strength.
After the bleeding, he causes vomiting, several times tn
succession, at intervals of two or three hours ; and the
practice is attended by the greatest success, relief l>eing
Terr apparent after each vomit.

when the croup has arrived at the second period, with-
out having l>een opposed, and the presence of a false
membrane is suspected, M. J. directs leeches to be ap-
plied ; but, the moment they fall off, he hastens to produce
vomiting: and it Is in tbls case that he employs, by
spoonsful, every ten minutes or ouarter of an hour, the
mixture called anticroupal *, unul full vomiting is pro-
duced. He insists, also, unoo the use of errhines, and of
derivatives applied to the skin and intestinal canal.

When the disease is very rapid, it has been a question
whether or not we should commence by bleeding, or by
an emetic. M. J.'s opinion is, that w^e snould first bleed,
if the child be robust, and if it present signs of congestion
towards the superior parts ; on the contrary, he would
commence by vomiting, when the subject is pale and ex-
hausted, ana there is little heat or fever. (RATtBa'#
Medical Guide, ife.) x

• IV Inlusi Poiygala; Senegst ^Ir. ; Syrupl Ipecacuan-
hae 3]. i Oxymel. Scillc 3 tg. ; Antlmon. PoUssio-Tart.
gr. jss. MlKe.

Hh 3

CROUP — Remarks on va&ious Remedies employed in.

469

tbroat, as reeommended by some writers ; and, in
very young and delicate children, it will be better
oot to place them over leech-bites. In the latter
periods, I prefer to blisters the use of wann poul-
tices, on the surfaces of which Cayenne pepper
aD<l scraped camphor are sprinkled in quantity
>utBcient to produce redness of the cuticle ; or the
application of warm cloths, moistened with either
of the Hutments, F. 300. 307, 308. These are
panicalarly useful upon the removal of the patient
from a warm bath, especially in the compli-
cations of the disease. The turpentine epithem
already advised applied around the neck has
proved, in my practice, more successful than any
ether remedy, constitutional or local. It may
be employed at any period of the disease, and is
highly beneficial in ail its forms. Sinapismt have
been directed by many to be applied to the ex-
tremities ; but I have seen more harm than benefit
prodaced by tbem, from the distress and crying
ihey occssioned.

63. f. Internal and external emoUienttare some-
times useful auxiliaries, particularly in the first
^tage. The decoction ahhaesB, the mist, amygdal.
dulcis, the inspissated juice of the sambucus niger,
pjurilages, with liquor ammonias acetatis, vinum
ipecacuanhs, and syrup (see F. 47. 389.)f may
be used internally ; whilst warm fomentations,
with decoction of camomile flowers and poppy-
heads, are applied about the throat, and frequently
Roewed, upon the occurrence of hoarseness,
cough, and di£5cult respiration. These have the
effect of renting the approach of the latter and
more dangeroos states of the malady, even when
they fail of rendering more efficient aid. Lsntin
advises camphor to be applied to the chest ; but it
will be more beneficial to employ it along with
the fomentations, which may extend over both
the throat and the upper part of the chest ; or it
"^y be placed upon warm poultices, as advised
^ve, particularly in the more spasmodic and
complicated states of the disease.

64. ^. Cold epiihems on the throat have been
(tnployed by some writers, and particularly by
(lELD. They appear to have been of little service
io his cases. I am unable to give any opinion
respecting them from my own experience. They
K-emnot to be equal to warm f<yAentations. Goelxs
^^tes, that they are dangerous means to resort to ;
iDd ailodes to cases where they were injurious.

^« «. Semicupium and pediluvium are useful
fioies of derivation, in the first and second stages
c'fccially. But salt, mustard, and, in some cases,
3 little of either of the fixed alkalies, or of the sul-
phurets, should be added to the water, and its
temperature gndually increased as immersion is
proluDged. Ureat care is requisite in removing
tl^e p?tient from the bath, to prevent any chill.
In many cases, it will be preferable to wring as
^ry as posnble large pieces of flannel out of warm
▼•attr prepared as above, and to wrap them round
the lower limbs of the patient, changing them fre-
'{ueptly.or prolonging the use of them, according
<«> <*iicQmstances, and preserving the bed-clothes
I'l'm moisture.

66. b. Tepid and mrm hatliing are of service —
»Iw fonner in the early stages, the latter in the ad-
vanced periods, of the disease. Goelis advises
the tepid bath of about 23° or 24° of Reaum. ;
aiHl to be rendered antbpasmodic by usine a de-
' oction of chamomile flowers and poppy-beads ;

or irritant, by adding some causdc alkali ; or both
antispasmodic and derivative, by a combination of
these substances, according to the circumstances of
the case. I have, in a few instances, used these
baths, upon the recommendation of this writer, and
certainly with marked advantage, but I have in-
creased their temperature in the latter stages of the
disease, rendering them, at the same time, more ir-
ritating by the addition of an alkali. In the early
periodis, however, the emollient and antispasmodic
form of bath seems preferable, particularly when
the patient breathes the vapour rising from it.
The duration of immersion should seldom be
shorter than twenty minutes, unless circumstances
should prevent it ; and I am convinced that it
may be prolonged to two hours with odvantage,
in some mstances. In a case despaired of, I caus^,
upon the recommendation of Goslis, the child to
be put in a bath consisting of a decoction of cham-
omile flowers and poppies, to which some caustic
alkali was added. It was kept there for twenty-
five, and on a second occasion forty, minutes. It
ultimately recovered. Care must be taken that
the temperature of the bath does not fall during
its continuance. As soon as the patient is removed,
and the skin dried, he should be placed in warm
flannel, or in a blanket ; and perspiration encour-
aged by diaphoretics suited to the nature of the case
and stage of the disease ; in the early stage by anti-
mony or ipecacuanha, so as to excite slight nausea,
or occasionally vomiting, if requisite; in the latter
periods,with liquor ammonias acetatis, given in sufli-
cient quantity to produce the same efifects, or,if sink-
ing be apprehenoed, with camphor, ammonia, &c.

67. (. Purgative* have been given with different
intentions ; »- either as mere evacuants of retained
secretions and excretions ; or as active derivatives
from the seat of disease. Home, D£SEssABTZ,and
MicHAXLis, seem to have resorted to them with
the former intention ; Hamilton, Pinel, and
AuTSNREiTii, with the latter view ; Crawford,
Thompson, and others, prescribing also enemata.
My own experience is decidedly in favour of this
class of medicines ; and of employing calomel,
jalap, scammony, &c., and extract of colocynth,
with assafcetida,* &c. in enemata (§ 61, 52.).

68. Sudorijics are of use only in the early pe-
riods of croup. James's powder, and the other
preparations of antimony, subsequently ipecacu-
anha, and liquor ammonis acetatis, or the one
combined with the other, and given to the extent
of exciting nausea, in conjunction with emollients
(§ 63.), are important auxiliaries. Goelis re-
marks, that Dover's powder is seldom productive
of any benefit ; and that sudorifics are never of
service in the last stages. Gentle r{/ap^ore«ts, early
in the disease, is undoubtedly beneficial, when the
patient drinks freely of emollients ; but he with
justice adds, that very copious sweats only in-
crease the disposition to form false membranes of
a firm and adherent kind, owing to the evacuation
of too large a proportion of the watery parts of the
blood. In these opinions, Treber, Hirscufield,
and roost of the Vienna physicians, agree.

69. X. Expectorants. — Under this head may
be ranked an important part of the remedies pre-
scribed in croup. The inhalation of vapours has
already been noticed. The experienced Goelis
places much confidence in them during the first
and third stages ; in the latter of which they often
increase the cough, but they favour the discharge

Hh3

470

CROUP -^-Remarks on variovs Rsmbmu imvloted ik.

of false membranes, by increasiDg the mucous |
secrelioD by aid of which they are thrown off.
I have mentioned (§ 47.) the expectorants in which
my experience has led me to confide. There are
▼ery few which have been more generally recom-
mended than unega, Asciier, Bareer, Valen-
tin, Rover-Collard, Lentxn, Maerceer, Car-
RON, &c. recommend it after bleeding. Dr.
Archer, who attributes the greatest virtues to this
medicine, advises it to be given at the same time
as calomel, in frequent doses, until it excites vo-
miting or purging. Goelis and Treber remark,
that, although a good remedy in the third stage, it
is by no means possessed of those specific virtues
attnbuted to it by Dr. Aroier ; and in this I
agree with them. It is a useful medicine in the
complications of the disease with malignant sore-
throat or scarlatina. Squillt are chiefly trusted to
by Hvfeland, Rumsey, and Maercker, in the
latter periods. They should not be exhibited in
the more inflammatory states of the malady, until
after depletions have been carried sufiiciently far,
and we wish to procure the expulsion of the con-
crete exudations formed in the air-nassages. They
ought to be exhibited in small doses in the re-
missions, and pushed to the extent of producing
vomiting when paroxysms of suffocation occur.
After the membranous substances are removed,
squills should be altogether laid aside. The tul'
phuret of potamnm has been recommended by
Professors Serf, Ciiaussier, Mercier, and
Hecker, in doses of about four grains, given every
three or four hours. It is sometimes of much
service after depletions. It may be combined
with camphor, or small doses of ipecacuanha.

70. ^. Antiipasmodict have been veiy generally
prescribed, and particularly by MicHAiELis, Pinel,
ScHwiLouE, ViKussEux, &c., after the decided
use of antiphlogistic remedies. Home, Chsyne,
and Goelis, consider that these medicines are of
little use in common and inflammatory croup. I
am, however, convinced, from extensive experi-
ence, that, when the inflammatory symptoms are
altogether, or even nearly, removed by antiphlo-
gistic medicines, when the disease passes into a
spasmodic state, or presents from the commence-
ment a predominance of such symptoms, and when
increased initability becomes manifest, a judicious
exhibition of antispasmodic medicines is often at-
tended with benefit. Musk, eitlier alone or with
other medicines, with calomel (Michaeus and
Wig and), with squills, sulphuret of potassium, or
other expectorants, and with camphor or ammonia,
in the last stage of the malady * ; valerian and its

* The chief danger in croup often proceed! (yom the
•pasm with which the respiratory passage is affrcted in
tne progress of the disease. The obttruction of the tulie
by tne false membrane and effused matter seldom of itself
causes sufTocation; but rather this lesion, combined with
SDHsm of the muscles of the larynx and membranous por.
tion of the trachea ; and, in many cases, exhaustion is
superadded, or even constitutes the most Important
change. Depictions alone will not overcome this dis-
posttton to spasmodic action, which is generally obcerred
to supervene at intervals ; the periods elapsing between
the paroxysms varying according to the strength and
constitution of the child and the sererity of the disease.
But In many cases the spasmodic action is more frequent
and more dangerous, and the more likelv to twcome as-
sociated with convultions, the weaker the constitution
and powers of life, and the more those powers have l>«en
reduced by copious deplcti* >os. After moderate depletion,
therefore, and in many cases even previously to any, such
medicines as possess an antispasmodic power, by first
acting as nauseants, are of great lieneflt. M . Kimbbll
««ems to have partly adopted this view of tlie disease and I
of its treatment -, but I am confident be has carried it *

preparations, attafatida, or any of the other tos^
dicines of this class roentiooed above, may bt at-
ployed, either Rlone, or with expectoranti il1
opiates, particularly when the energies of cw
system begin to be depressed, or the compUbt
assumes from the first a spasmodic chaiacttr.

71. Of those medicines which are amtitpumjct
from their sedattof operation, the most importiri
are colchicum, opium, hyoseyamos, hydro«<;aa!
acid, digitalis, and tobacco. Cotekieum msf U
given combined with calomel, in the early autf it-
flammatory states of the disease, or with amn(r.a
or camphor, at a later period ; but it on^bt. •
young eoildren especially, to be exhibited wnh et-
treme caution, — in very small doses, and cvt-
fully watched. It came into fashion in thj» ic •
other diseases of tlie air-passages a few yean 9ny
and was, for a time, much employed ; I then ».«
some cases of croup in which it had bees vet
injuriously emploveu, from having been givtfi i
too large doses for the age of the child, or lu
long continued, or oombmed with other ikp-.
ments, as antimony, &c., or exhibited afWr %en
large depletions. I can most truly emui, that '
have seen at least two cases of croup, in wL«<
death was to be imputed to this subsluioc, nxt- '■
than to the effects of the disease ; and yti a .•
sometimes of use when combined as I have to*
advised. Of digitaliM I have had no expericfi' ^
in this complaint ; if exhibited at all, it sho«)4 >
conjoined with calomel. Hydro-^yome acid ^J'
been employed in some cases which I haw sm
but the same objections I have urged agsinsi n.
chioum apply to it, when prescribed tor vo-. :
children. In older patients it is someliBK* i
benefit, combined with camphor, or osak >>'
zino, or other stimulating antispasmodics, u co«<-
bating the irritability and disposition to spa^oodf
paroxysms in the latter stages. Opma

much too far. If his success has been eqna] to «iu: •-
conceives it to have been, the case* which tie has met • *
have been unusually slight. Ttiere i* no deabt ol b^
ing. blisttfing, purging br calomel, kc kc^ h»%tei Iri
pushed m hurtfUl lengths in many cases, or tnaj' * -
prlately employed ; and the same maybe said as t« «j(t
means, which have tended more to exbanst tif i '•*
energies than to cure the disease ; and there eso U "
doubt of the dlspoeiUon to spasm l>ecoraing greatfr v
of its consequences tielog more to lie dreaded, the ^ "• '
the powers of life sink ; for, with auch sioktng, the fW^
sensibility and irriubility of the frame inerfase* P '
cannnot conclude that thoae means ooatd have faem >^ -

GusedwithlnanyoooalderaldeDuaiberoftlieease»«t *■
ve fallen under my olMenratloo, and in vtiivh I '« •
never omitted also to employ antispa*modic« of tb' i
active nature, from a conviction that the disease partlf *
pends upon spasm. Mr.K.'s obaervatloDsasttftkttm^'
ment oithe disease are to the following cflhct : — " 1 9^ '
bleed or blister a child in croup : I have ne^^er tto^^'
requisite to do so, since I have adopted the plae sJ** ^
to ; although such auxiliary practice would bt ia ov a*^
respect incompatible, than as tendina to intslUii' '
general strength. The treatment 1 allude to ow^r* -
confining the child to a uniform and rather wans f -
perature, giving an emetic of ipecacuaaha. mi, -i •■
hour after, commencing the following mixture : —

No. 1G4. H Pulv. ValeriansB 3ii.: OxrmcL Sc:'U J
Tinct. Opli gtt XX. ; Aquae DestllUt* 5J. Mto(v
I administer a teaspoonfUl every boor. If the ehiU b i*'f
two to five rears old ; if from five to eight, every a«r •i^
forty minutes, so as to maintain the aDodynr 99itt
opium, and the sub-oauseant, expectorant, antl«f««''"^^
effecU of the souUl and valerian, until the tpKptu^ tn
removed ; which commonly happens In tea or t****''
hours, and which I have never seen proiracted b^^^ 'i
eight and fortv. On their subsMencey I have, ia r*^ <J
given a tirisk dose of oalomel and ialsp."

Mr. K. likewise recommends the above trestosrs' *
hooping cough and in catarrh ; and in tiKtie (Wf^ ^
are unconnected with inflammatory aetioB, it l» b<* *v
propriata. In Che sUfht and "* ^ "

croup, It alio irlU prove very '

473

CROUP— D(Et

Ihe akiD, and of
g i llghl noufishidg

te leuoune to medicine upon Ihe

if eiposuK

the wearing of flailQel
UGckcloth in wiaUr aod
diel, with slrict atlention

appearance of c&tarrhi

moislure. When croup occurs in one chiJd of.
famitif reuding ja silualiaDS where il prevwla,
more will probably be aiucked. In such caies,
remoTal to a liealihiei air is requisite. When il
IB previUeat rather in a limple or complicaied
1 parlicutarljr when the localily also in-
le riak of seizure or relapse, Ihe occa-
ihibilion of smati dowi of calomel and
ea's powder, or of hjdrare;. cunt creta with
carbonate of soda, or the baviag recourse to
eimer of them eiery second or third night,
be tried. In thtd couolr)', care should be taken
not to eipose children lo the north-easl winds of
spring, particularly when Ihey follow heavy

76. B. The Diet and Beoiuen, in the more
acute and iuflamnialoiy forms of croup, should'
be slilclly antiphlogistic ; and all food should be
withheld ualil the stags of eihausiiou supertene,
when, if light noumhineiit can be taken, ot be
desired, il should be given. In the more spasmodic
or prolonged forms, light food may be takea in small
quantity. The best berenge of which the patient

a very weak decoction of marah.

77, C. During Conv*lescenci, change of air,
u soon as it can be safely permitted, is especially
beneficial ; and strict attention ouxht to be paid to
the prophylactic means stated above (J 75.), in
order to prevent a relapse or recurrence of ihe
malady. These precautions are required during,
and For same time after, recovery from the com-
plications and consecutive atieclions of croup, as
well as from its simple forms. In Ihe winter and
spring months especially, the convaleacenl should
be kept in apartments moderately and as equably

" — Ilippoctatat Cc ""

BiBUDO. U-

llonn, cup. III. «
HfM, Epld. Bphei

I'hjii

.toll. I

'hjiick, a

—P. BlalT

ta Infantum SpasiuQ

^ ffOetr, De Ai^rina ^^

•omla. tlpsfllK, I7ei.— ('«

nu .—Homi' Ingulrr Into till
Croup. Edln. ITSft. ■-'— -

HnInAu.lnPoniitttnlntarPraTla.

- -|K>1in.]7U.(&iM»glbKI.)

— trakO^m. In tUd. p. 181.
Aoer. Fhllsioph, Trail). loL I
oa the Auhm* and Hooipini .
CravMi, D« Anftna Strlduli

The lEconomj' of NsL tn Ac

Stall, Od the Spasm. Asthma of ClUUroii, Ac. Lond.
ino. — MrClacVi*, He Angina PolTpoH. Goet. 1778.—

Couih. Svo. Ijaad.
a. Tdln. I7TI III

nSS^y

niytf.'sl

f'lat-iJvt-r'- •

Md.vDl. iv. p. Ml Miunt. OnCrmoi.laBiap'*"

iublecliorMed. Sdcute, vol. 11. p. IS.K V. IW.*"
-Ai/Ji<ir(Llo Jfmrn. tlibrtom. t tlL p. I n—Datm*^. ■
mini. dnIWh dea Sdeq. MM. 1. 1, p. lU.-V^'''
I LawinM "ii. DM. t.H.lsa. p. irf— «-*" ^

M. In lldiL vol. uv! p. *;».'— PjTlto iW 4«. t" *-'

. \^'—J?iiwmSim. Edin. JonnLof Ai£v«-
October. IKW. — jroliBt. De Cinandw Tntirit
. Edln. 1830.— OnTfmf.laDkl.ilrHtdHla'.i '
I \.~H. U. J. DrirsrHn. Trait* Tbtwiq. M FnW
:ioup,*cSro. Parli, l»ai.— T. C»*"<.E«*'''-
tr la Croup, et tur ta Ciiooel"rf»f. « v
" "--wTiwiiB.Sorliroipliiiw"'-,"''

• tt Nod ifCrtar**'

fi—ir. W. ftf*'."

474

DEBILITY — Primary.

this conaection, consider, 1st, The primary or
direct states of debility ; 2diy, Its consecutive or
secondary conditions ; and, 3dly, Those forms,
consisting not only of depressed^ but of otherwise
morbid or vitiated, vital manifestation — or com-
plicated debility. After having discussed these
topics, with reference to general dehilitjf, the more
ipecial or partial ttatei of dthility, and iU coims-
ouencsf , will be brought into view ; and the sub-
ject pursued in its relation to general and special
psthology.

5. I. Conditions OP DEBiLmr. — i. Primary
Debility (Direct, Brown; True, Hvpeland;

from Abstraction rf Stimuli, Rush and Boissbau).
This state of debility is not so frequent as is com-
monly supposed, although by no means so rare
as Broussais and his followers contend. Many of
the cases commonly imputed to it strictly belong
to the other conditions specified above ($4.).
Primary debility may be, (a) Original, or con-
genital ; and (6) Acquired. — A. The former of
these is observed in the obildren of exhausted,
dissipated, or aged parents,-— especially the male
parent, — and is familiar to every common ob-
server. It also presents itself in the infants of
those who are of a strumous diathesis, although
generally in a slighter grade, and more frequenUy
obscured by concurrent disease of particular or-
gans. This form of debility seldom continues
long without beio^ followed by some specific
malady, which it either remarkably favours, or
even more directly produces, — causes, which are
innocuous as respects infants of originally sound
stamina, variously affecting, and ultimately blight-
ing the debilitate<l oflfspring.

6. B. Acquired debility presents itielf to our
notice in every stage of life. If it supervene in
infancy and childhood, it may be, to a certain
extent, perpetuated in the coostitutioo through
life. But, in whatever period it may occur, it is
most frequently the consequence of the abttrac'
tion ofitimuli necessary to the excitation and per-
petuation of the vital manifestations to a requisite
extent. — (a) The infant that is not iufficiently,
or is injudiciously, or unnaturally nouriihed, if it
escape any of the maladies to which it is thereby
disposed, becomes pale, languid, so(t, and en-

, feeoled, or altogether diseased : it wastes ; its
flesh is flabby ; its growth is impeded ; and it at
last is the subject of anaemia, or of tubercles, or
of worms, or of disease of the digestive canal, of
the mesenteric and other glands, or of the joints
and bones. But insufficient or inappropriate
nourishment aflfects all periods of life in nearly a
similar manner. A fish diet through life gives
rise to a weaker conformation of body than
food of a mixed kind. This was proved by Peron
in respect of the natives of Van Diemen's Land.
Similar effects follow an exclusively vegetable
diet, although not to so manifest a degree. It
should, however, be admitted that those who
are obliged to live on one kind of food alone
are more liable to experience insufficient sup-
plies of it. — (b) The abstraction of the ant-
mat warmth is another cause, occasioning a
modified, and, as it were, an acute form
of debility, followed by peculiar effects, which
are fully described in tlie article Cold. —
(e) The i>rivation of tolar light has a marked
influence on the vegetable creation ; plants
being pale, sickly, and imperfectly developed.

and their proper juices scantily and isaffi-
ciently elaborated. An analogous eflect it
produced by the same cause on the aninsl cita-
tion, and particularly on man — the body beeoib-
ing pale, sickly, and etiolated; the teoiei
remarkabl;|r acute; the general sensibilitv soj
muscular irritability much heightened ; the or«
ganic actions readily influenced by the slighttii
external agents * ; and the circulating fluids thb,
watery, and deficient in albuminous constitueote,
and red globules, and in quantity. Facti ilks-
trative of this occurrence are adduced in tlte
article on anemia, which is thereby prodoee^.
(See Blood, Deficiency of, 4 4K) ihe phy-
sical and mental debility resulting from cosfiBc-
ment in dungeons and dark cells is to be sttn-
buted to the exclusion of light, restricted diet,
want of exereise and of free air» and to monl
causes combining with these in depresring the
vital powers, and ultimately producing diseaie c(
a low and dangerous form.— (d) Intimately cod-

• The remarkable and Mithentlc bistorjr of Citm
HAUsia. by the President Von Fxi'EaBtxa, ftir9)«ha
striking iUu«tratloni of the abore. The aocoantt mhci
have been recently published of this persoa sbooM tir at-
tentively perused by every patholocwt and phikwo^hr
as I>elng most lingular and instructive. Casper Riaw
was kept, from Infancy until he was eighteen jnn •>
age, in a perfectly dark cage, wlthool leaviiif U i ai>i
where be neither saw a liTtng creature, nor hesnl the
voice of nan. He was restricted fh>m using hb lisb*
his voice, his hands, or senses ; and bis food coo^nta «*
bread and water only, wbldi he found placed by km
when wakening from sleep. When exposed in Sam-
tierg, in I8!28L he was consequently, at eighteen ynn. «•
if Just come Into the world ; and as Inci^Mdile of «^-s;.
discerning ol^ects, or conveying hia tmpressioDs, » •
newly bora infant. These faculties he« novercr, •>»
acquired ; and he was placed under an able instrutf.
who has recorded his history. Darkness had been tohir
twilight The light of day at first was losupporuni^
inflamed his eyes, and tn-ougbt on spasms. SiiostirtTt
the odour of which could not be perceived br otbr^
produced severe effects in him. The smell of a gian <'
wine, even at a distance, occasioned headach i of fm^
meat, sickness, *c. j and of flowers, palnAil «ciuat>t«>
Passing by a churchyard with Dr. DaCMia, the nnril (
the dead bodies, although altogether imp«retpDbl« t
Dr. D., aflbcted him so powerfully as to occasion fkuddt:-
Ings, followed by fevensh heat, terminating in s ^uitv
perspiration. He retained a great aversion, owtnf <*
their disagreeable taste and snett, to all Uwb of fo"^
excepting bread and water. When the north pok ^i «
small magnet was held towards Mm, he dctcribcd j
drawing sensation proceeding outwards tnm the epoj^
trium, and as if a current of air went from him. Ts^
south pole affected him less ; and he said It bleti uf^**
him. Wofessors Daumbs and Hsbbhann made cr«r-«
experiments of this kind, and calculated to deceive kw .
and, even although the munet was held at a eooMrt-
able distance from him, his (edings always toU bin vr^
correctly. These exp^rlmentt always oeouioixd pr-
spiratlon. and a feeUng of lodlipositlou. He coidd <Hn*
metals placed under oU-rloths, paper, Ac, by tbo ir:^
ations tney occasioned. He described these lensstior » it
a drawing, accompanied with a chill, which sseenJed.* -
cording to the metal, more or less up the arm; and et *
attended with other distinctive feelings, the veins «f t^'
hand exposed to the metal becoming vltltaiy twca^
The variety and multitude of ol^ecU which at eoor ess e
rushing upon his attention when he thus suddeoh c>a«
into existence — the unaccustomed Impressions o* ^J
free air, and of sense — and his anxiety to eomja^'^
them — were too much for his weak frame and «u^
senses : he became d^ected and enfeebled, sod hu wrt •
oua system morbidly elevated. He was suhieet to tfvn*
and tremors ; so that a partial esciusioii from rtuf*^
excitements became for a time requisite. After Ik ^^
learned regxilarly to cat meat, his menfai scti«itT «»
diminished : hit eyes lost their brilHancr and txpfm^
the intense application and activity ef his mind ssv« **,
to absence and IndUference ; and the qulckaeis ctm"'
hcni'ion became diminished. Whether this chaofv r -;
reeded fW>m the change of diet, or from ihe pdt*"
excess of excitement witidi preoaded H, may br 4^
tioned. My limits admit not of my adding mere. 1 *
whole account is most important — the man so » t*'-^
physiolofical facU stated In It may be riUid •■>

D£BILrrV ^or thb whoib Frame.

479

wett as other paita immedialely controlled by |
the oerebro-fpinal ty»tein, have their fiinctioos
enfeebled and impaired in proportion to the de-
bility it eiperiences. But they may also be
iadividualiy affected, and in various degrees,
without this system being materially disordered.
Such occurrences generally arise from the oper-
ation of local causes, — as over-excitement of
ibe organ, and exhaustion of its sensibility by its
peculiar stimuli ; as weakness or loss of nght
frum overoexertion, or the intense or prolonged
action of light ; and loea of hearing from great
noises, &c.

18. D. The muMeulmr tirueiuret, from their
connection with the ganglial and cerebro-spinal
systems, necessarily experience the effects ot de-
pre«ion of the energies of these systems, varyfng,
AcconJing lo its acute and chronic form, its degree,
iu simple or complicated state, and the progress it
ha made. But debility seldom originates in, or
is limited to, these structures. Its earliest and
simplest manifestations in them are diminished
tone, flaccidity, wasting, particularly of volun-
twy maseles ; lowered, or in some cases, mor-
bidij increased irritability, according as the nerv-
oiu systems experience a diminution or increase
of their susceptibility ($ 17.j ; occasioning, in
90'ne cases, irregular and tremulous motions,
avl a disposition to spasmodic or convulsive
scdoo, but more frequently defective energy of
contnctioD, or power of contiouibg and repeat-
tog it, in both the involuntary and voluntary
classes of muscles. In the more acute, or the
more advanced and complicated states of ady-
otmiai the insensible tonic contractility of mus-
cular fibres are in a great measure lost; their
vital cohesion, is also so much diminished as to
admit of their being more easily torn ; they are
incapable of performing even a portion of their
functions ; and their contractions are feeble, vi-
bratory, or oscillating, productive of the utmost
fatigue, sometimes of death; and the least ex-
ertion, even that requisite to preserve the body
recumbent upon one side, cannot be sustained
for a few minutes. These extreme states of
debility occur in the most dangerous and severe
^«e8 of disease, as in adynamic fevers, scurvy,
&e., and when the circulating and secreted fluids
have become sensibly changed from their healthy
condition.

19. £. The texual orgatii, whilst they partici-
pate in the Vital depression of the general systems,
irt often themselves chiefly affected. It is by
DO means uncommon to meet with instances,
ptrticnlarly in the male sex, of the most com-
plete debility of these organs, amounting some-
t^mvf to entire loss of function, from precocious
aid ioordinate excitement and indulgence ; there
being little or no other disorder, excepting en-
f^bled mental manifestation, in some cases. In
others, however, all the organic and cerebro-spi-
oal fanctioos have become remarkably weakened,
although not to the extent experienced by the
ofe'an* in quef tioo. (See Impotencv.)

20. iiL llig ManifeMtationi of Debility in parti'
ralar Tiuue» are less evident than in the general
n«tems and associated organs ; and they are later
'n becoming evident. It is usually not until
i^e> are extreme, long-continued, or complicated,
tiiat they are remarkable.— (a) The ceUular
fwne at first evinces deficient firmness and elas- 1

ticity, with softness, and, as debility increases,
loss of its vital cohesion : it at last presents a
tendency, to oedematous or serous infiltration, and
even to hsmorrhage, owing to weakness of the
extreme vessels terminating and originating in
it, and the insufficient support it yields them.
When it is thus changed, the spread of other dis-
eases through it is thereby remarkably promoted,
and an unfavourable termination hastened, — as
in cases of diffusive inflammation, erysipelas, punc-
tured or poisoned wounds, &c. ; ite vessels having
lost their power to limit the extension of inflamma-
tion by forming coagnlable lymph. — (b) Mueout
fMmbranei are amongst the earliest of the parti-
cular tissues to>xpenence the effects of debility,
thereby increasing and perpetuating many of its
phenomena. At first their functions merely are
impeded ; their secretions either diminished, or
imperfectly excreted, or increased from relax-
ation of their vessels, or in other respects vitiated.
As debility, whether of them especially, or of the
frame in general, advances, vital cohesion be-
comes impaired, and they yield not the requisite
support to their vessels ; whence result softening,
hsBmorrhaffe from their surface, ecchymosis,
asthenic ulceration, atrophy, &c. — ^r) The le-
roiM tiauet undergo a partial diminution of their
cohesion, and permit an aqueous or serous fluid,
in some extreme cases tinged with blood, to
escape through their exhaling pores. — (d) The
enctiU textures at first evince greater suscep-
tibility, particularly when debility has been in-
duced by inordinate excitement of the sexual
organs ; but as it increases they lose their peculiar
functions. — (e) The fibroui tissue also experi*
ences relaxation, becomes lass elastic, and more
readily yields than in health, giving rise to almost
spontaneous dislocations,-— results which have
occurred in the chronic debility caused by mas*
turbation, as remarked by Sir Astley Cooper
and Mr. Copland Hutchison, and by myself in
one case. — (/) The oseeous texture occasionally
experiences, in children, an imperfect deposition
of ossific matter, or even absorption of a great
part of that already secreted ; and, in aged per-
sons, the removal of the animal matter which
gives due cohesion to this structure: and, (f)
The conieouf tiuues are often variously changed ;
the hair either falling out, or becoming thin, weak,
oc S^^y i ^he epidermis inclined to exfoliate, and
rough or scaly ; and the nails thin, long, crooked,
or irregular.

21. III. Debility of the whole Frame. —
Debility seems, as already stated, most frequently
to originate in the ganglial and vascular systems,
which I have viewed as the chief factors of life ;
the digestive, assimilative, excretory, and cerebro-
spinal organs being subsequently afl^ected. But
it may also commence in, and conlinue for a con-
siderable time limited to, eitheiveMhese, or even,
although rarely, to one or more of the individual
tissues. When existing thus locally, it usually
springs from local and indirect causes, and is at
first of a slight grade, the functions of the part
merely being impeded : but, as it continues, the
rest of the economy becomes implicated in various
degrees, owing to the reciprocity of vital action
and function existing throughout the frame.
With this universal diffusion of asthenia, the part
primarily disordered may still continue affected
in a greater degree, exhibiting the changes offunc-

480

DEBILITY— Symptoms— DuoNO«XB.

tioo, and even of stnicture, now briefly sketched
in respect of the principal systems, organs, and
tissues, according as they may be implicated ; but
in many instances, the debility becomes !co-ordi-
uate throughout ; and in rare cases, the part
originally affected even parUally recovers its
powers upon some other organ having its vital
energies more remarkably depressed.

22. IV. Charactekistic Signs, &c. — When
asthenia is thus general and fully developed, the ex-
ternal aspect of the body,and all the vital functions,
are affected ; the extent and specific characters of
ailment furnishing important pathological as well
as therapeutical indications to the practitioner : —
The countenance is pale, thin, or collapsed, some-
times bloated and discoloured : the eyes lose their
animation, and sink in the sockets, and they are
surrounded either by a dark or bluish, or by a
tumid and cedematous, circle ; the expression of the
features is languid and depressed; the lips are
pale ; the tongue watery, moist, soft, broaa, and
sometimes tremulous,and the papillse depressed and
wasted ; the voice and speech are weak, or nearly
lost ; the voluntary muscles lose their powers,
and hence, in extreme cases, the continued supine
posture, the inability to retain a position on either
side, the sinking down in bed, and the falling of
the liead on the breast or on either shoulder. The
surface of the body has its temperature diminished,
is sometimes partially covered with a cold or
clammy perspiration, becomes soft and flabby,
occasionally of a more lurid or dirty hue, or pale
and waxy, particularly in complicated debility ;
the firmness and elasticity of the soft solids are
lost, and they either present a leucophlegmatic
appearance, or they are remarkably emaciated,—
the latter being particularly the case when the
circulation is accelerated. The functions of the
stomach and bowels are impaired, or altogether
suppressed ; and hence the want of appetite, the
constipation, and emaciation, — which last affects
first the adipose tissue, and next the cellular and
least vitalised structures. When the depression
is very great, the vital attraction requisite to the
nutrition and healthy cohesion, especially of the
more remote and superficial parts, neing necessa-
rily diminished, the function of absorption gains
the ascendancy ; and the less perfectly anim^ised
constituents, particularly the adipose substance
and the effete elements, are carried back into tlie
circulation ; and thus, in some states of disease,
the body continues to live upon itself, until the
functions are restored, or life extinguished;
the external soft solids, attached to, or covering,
the bones,^meanwhi!e becoming remarkably ex-
tenuated. In general, the pulse is fre(][uent, soft,
small, and easily compressed ; the action of the
heart is weak, and leipothymia or syncope occur
upon exertion, or on quickly assuming the erect
posture. R^||i[a)ion is frequent, imperfect, or
anxious or diflicult, and the motions of the thorax
are slight and confined. The functions of the ce-
rebro-spinal system are more or less enfeebled ;
and, wiih the changes described above ($ 17.),
present the following phenomena : — Loss of me-
mory ; inability to prosecute a lengthened chain of
discussion, or to fix the attention long on one sub-
ject ; sometimes weakness, with hebetude of all
the faculties ; an unpleasant feelin|r of languor, and
exhaustion, with a sense of anxiety referable to
the praecordia and pit of the stomach ; vertigo or

headach ; noises in the ears, either with or with-
out impaired hearing ; weakness of the bmba, tad
relaxation of the ligaments of the joiab, wiU
tremors, occasionally convulsive moveo»eot», «r
local paralysis ; and ultimately low or quiet de-
lirium.

23. V. Diagnosis. — A distinctioa has usssIIt
been made between rtal and gpvriaui dtbiUt%,
The latter term, however, implies a oootrsdictioft.
But as it is the morbid condition, and not t^
name imposed upon it, that requires notice, I ntr
briefly allude to it. The state of system, to which
this name has been applied, woofd be better ci-
pressed by denominating it oppratim ^f vtii
power; this, or nearly similar appellations (*' ^p-
preuiovirium" " debilitat ah opprematuT), ht^^i
been employed by several modern palholog^
The vital manifestations may be generally or pir*
tially oppnssed by whatever impedes their free
reaction in removing the impression produced
by injurious agents, or by whatever arrests tbc
function of an important secreting organ or viul
emunctory, whereby the vascular system becoaoei
overloaded, and consequently oppressed thros'b-
out, as well as in the organ whose functioos bin
been interrupted. The distinction will be oion
easily understood by a reference to facts, —
During pneumonia, the lungs perform their fiutf'
tions in respect of the blood imperfectly, aod tbc
various secretions and excretions are dimintshei
Hence the quantity of the circnlatioff floid i» la*
creased; the circulation through tne infisical
lung rendered difficult; the ninctioos of tU
organ impeded, and the vessels generally d»>
tended beyond their power of reaction upoa
their contents, so as to restore the SBspe&dni
functions. In such cases, the poise is sop-
pressed, and not much accelereted ; but it cote
veys the sensation of a confined limit of pai^
ation, thereby suggesting the idea of a snstaioed
state either of tonicity which the Sjystole of nt
ventricle cannot much affect, or of disteibios
upon which the elasticity of the vessel reset?
imperfectly in the intermissions between the 9^>
toles. That this state actually obtains is shows
by the effects of blood-letting in chaBging tk
character of the pulse, in removing the feelia| if
oppression, and in partly restoring the stresfi^*
Inflammations of other organs — as the Inv.
brain, &c. — also furnish instances of oppR^iA
of vital power. In all these, however, the tfsu
of the surface of the body, and other synptoo'
above noticed as characterisog true deUh^i
($ 22.), do not exist. In fevers, also, the re-
action following the impression of the exctb&f
causes is very generally attended by oppreic*^
of the powers of life, owin^, in some eases, to la
overloaded state of the circulation from iDi>^
rupted secretion, &c. ; and, in other cases, pan'y
to this circumstance, and partly lo the depiessaj
influence produced by these causes still cootioc-
iog, and,, jointly with the increase in the qoaa*
tity of the circulating fluid, favouring ceBjse>n£3
of internal secreting and vital oigans. Utxt,
in several forms of these diseases^ a complicsteii
pathological state is the result ; via. dtfram^,
followed by opprased, vital power, as soos ^
attempts at reaction begin to be made, ia onLr
to overcome the injurious impnessioos, v*i
changes occasioned *by the excitiag cav«^
This suppression of power may arise oat of tivs

DEDILITV— CoNSEQi'tKCEs and Terminations — Theatment. 481

ease itself, and a most serious part of many of
the inoAt dangerous maladies, but it also predis"
jHi^s the body to be affected by the numerous ia-

debility, may be associated with it, and terminate
in ir, in its worst and eomplicuted states.
24. The I)i-i!iiirtN uf debility is extremely

Tanoui>. It may, particularly when acquired jurious a gunts to which it is constantly exposed,
and F!i;:ht. be remarkably lung, or continue 2H. iii. The pRF.ni.si'OsinoN to be affected by

through lite, which it m:iy not even ubnJge. the exciting causes of disease, arising out uf debi-

«■■■ * II I * *i II 1 'a *il 'I '>l a1 f II

Wbeo ra(iidly and jn-imarUji produced, or <re-
neni aad intense, or complicated, it is usually
geutt dfi respects its continuance ; but when
eweciiiiie, or partial, or the result of irritation
of parliculur texturc<, it is prolonged into the

lity, will necessarily vary uilli the form and grade
it <issuii)cs, and the ciicumstances in which it has
originated. 'J'his proposition is too evident to re-
quire illustration. Jiutwhun the debility proceeds
from irritation of one or more structures abstrnct-

tkrvnic state; its dumtion dopunding greatly i ing vital power from the rest (<^0.), it may not
■poo its degree, and both being extremely vu- | increase, but may. in some cases, diroiuish,
lioa^ > prc-di<|)osttiun, particularly when it is attended

n, (u) Impeded or interrupted secretion ; (/i) | of the rif^pii atury organs even diminishes the
'Mo'iei of the circulating Huids ; {c) Various ! disposition to Ije affected by malaria, and infec-
tils of irritation or iutlummntory action, in par- tiuu^ ur epidemic n^i;ents. So much, however.

25. VI. pATimnicit u. Rklationm. — i. The
CossFgi t \ri:3 ami Tliiminaiiuns of debility

i»i

Cku
Ms

tinlar or^Mns or ti.«<ues; ((/; Generdl reaction
ef tbe vascular svstem, associated with xarious
ptdti of f itil power, from the lowest, or mont
MtbifDic, to it-t highest, or most sthenic form, with
iheir nioditicutiuns ; (f.) Chancres iii the firm nes!t,
riiaicit}', nutrition, colour, form, and vitul colic-
am of tiic irofi solids, und. in some instances,
flhiRiately in iliL* hard »oIid> al<o; (/) Kfi'usioiis
offinid^f j] aqueous, serous, siin<;iiincuus, c^c.) fjom
naeou!^ or serous surface^, or in ci.'llulur or pa-
RocbTmatuus structures; (^O The ]irodueUon of
Hnieraus forms of or.Mnic clump e ; (h) The forni-
Mmm of new or ntivt:iitiiiuuH tis>ues or proiluc-
liuBS, IS tubercles, tumours, ineluiiusi-i, cancer,
kvditids. ivorms, gangrene, &c. ; and, (i) laally,
linili, which may occur directly from the intense
■ctioa of the dopressins; cause, but more com-
■ealy through tiie medium uf one or mure of the
cfaugev now c in: me rated, the first and greater
pvt of which often taking; place consecutively.

26. ii. Afrb<M'iATi(i\s or IJi.iiii.iiv. — Asthenia
if wry frequently cor.noclod with some other

by exalted sensibility and accelerated circulation.
J lius the debility aiteiiding irritation in any part

uf what constitutes liability to diseases is owing to
the temperament, diathesis, the modes of life,
and hubit of body, as well as to general or local
debility, that the exiict !»harc of each can rarely
be ascertained, (ienoral debility, either in its
direct or primary form, or as consecutive of
over-excitenient, disposes the system to be affected
by teirestriid eniaU'itions, vicissitudes of season
and weutiier, and infectious elTluvia. The more
local or partial states of debility, particularly
when existing in secreting organs and the asso-
ciated structures, render them liable to conges-
tioui, intiainmatory iiritation, to disordered secre-
tion II rid excretion, to spasmodic or convulsive
movements, to effusions, to various states of in-
tlainniuiion, and organic change, with the other con-
sequenccs and associations ot debdity above enu-
meiaied (^ 25, 26.), upon exposure to causes
which disturb the kitaiice of vital manifestatiou
thioughout the fmme in a sudilen or violent man*
ner, or which imjiede the assimilating and depura-
turv functions, and therebv disorder the vascular

■M)d>iti ct'ndition, iniplicaliti^ eiihi-r pariii!ular I actions and the circulating fluid. (See Disease
firti, or the system jr«.nerally. Amongst tluse ; — Cmises of.)

ire the consequences now enumerated ( $ 25. ) ;
kt the mo:$t important arc, (a) Tiie as>ociaiiun
sf dtipresscd with otherwise inodiried or moibiti
taitt of the vitality of the system ; (6) with u
vitiated condition of the blo«) 1 uud ^ecieted
liids, either or both uf which constitute ilie com-
pbcaivd (lebili'y alrcajly mentioned (§ H.);

2y. VII. 'i'ui: MMENT. — In attempting to re-
move debility, oui means should be directed with
a strict reference to its form, grade, and com-
plication. 'J'liese, however, are so numerous,
that ]>recisc rulis of treatme:it cannot be laid
down; the only attempts of this kind that can be
made, fulliuir iiiorc appropriately under those

(r) with a disposition to solution of the textures . di>ea5es of which depressed vital power forms an
gntrally, or of a pait n.e:x'ly, as in mnlimmnt e^senlial part. (Stc especially the Fikst Class
fcren ; \\i\ with congcitioas, and chronic or of the author's clnnsification.) In the treatment
icute iiillarim-.ar.iims of particular orpnns or stiuc- . uf debility, i;i either its simple or associated
tins, &< ill (OiiJplic'.tted ft.rms of fever, erv.-i- i states, there i.; a particular clusn of remedi(8, viz.
peU*. diffiiT-ive intlaminalions. dysentery, \i'. ; j ionia^ which are more benehcial than any other ;
(0 with intestiiiul worms, iivihiluls, und vaiious j althi)u;>li manv articles belon'^lntr to otliir classes,
■uli^Qtand adventitious foiin:itions. I as diifusive .slimulanls and antispasmodics, may

27. K kuo\\lei]^e of the patho1o>:ic .1 rciaiious . oiten be prcSv-tilied, and with irreat advantage,
of Ih'u mast important and f-injularly overlooked Tonics, whicii li.ive tlorived their name from

WttdilioD ef vital power is necessary to the pnic-
(itioner. ina!»niuch as it enables him to enterlaiii

their iiiHueiice in auunienting the tone of con-
tractile parts, owe the principal part of their

wlwjre;! and coiinecrerl views of disease, bv the 1 good eflVcls to tlu'ir elevating, in a gradual

■d rf *hich h'» may the better compreiiend sucli
•Utes of disordered action a- cannot be readily
•'"•jfOttlto any ptirlicubir tyj e or specific form,
o»jQg lo their im;}erfecily ninrk^r I clmnictbi-*,
titea-fociated disturbance I'f diliVreiit or;.'^nw aiut
*^liires, acd the want uf jiioiiiirient «yniploi>:s
wbtrcby iney m.iv be asceiiaincd. Deliihiy not
only coDstilutet, in its moie tntetise forms, dis-
VoL. 1,

in:iiiner, (h>pres<ed vital puwrr, Imrdly up to, and
sc-Idum or never :iho\e. the healthy standard;
und to the ix-riuatjenrv of their action. \\\ their
repdiliiui betnre tlie < (Verts of the previous dose
hau' sub<iii( il, the beiieticial iiiiluenrii ultimately
ii proj>:ivr;:ti.d ihro' nhout ; and as soon as one or
more important functions are restored, the rest
participate in the chun^e, and the whole assume

Li

484

DEBILITY— Tbsatment ofCompucatedakd of Local.

necessary, to select those which are the least
heating, and to exhibit them along, or alternately,
with such raedicines as will promote the secre-
tions and excretions most requiring aid, and with
internal and external derivatives from the prin-
cipal seat of disease. In cases of this description,
particularly ia the young, and in those who
previously enjoyed a sound constitution, the
returning energies of life generally stand but
little in need of a spur; they require rather a
judicious guidance, especially in respect of the
digestive, the secreting, and excreting func-
tions.

37. iii. Complicated Debility, o: that condition
of the frame which consists not merely of a de-
pressed, but of an otherwise morbid state of vital
power, has been ascribed above — 1st, to un-
wholesome food, and to imperfect assimilation;
2dly, to an impure or altered state of the cir-
culating tiuid, occasioned by impeded or dis-
ordered secretion and excretion ; and, 3dly, to tite
absorption of morbid matters into the blood,
either from some one of the mucous surfaces, or
from parts of the body in which they have been
generated. The operation and effects of these
sources of contamination have been fully insisted
on in the articles Adsorption', and Blood
(§ 110 — 151.). The indications of removing them
may be resolved into the following: — 1st, To
cut off the supply from the sources of contami-
nation ; 2d, I'o raise the powers of life, as ex-
pressed chiefly in the ganglial and circulating
ay stems, by the means pointed out under that head
($ 31.) ; 3d. To promote the depuratory actions
of the emunctories.

38. A. The propriety , of endeavouring to ac-
complish the first of these intentions cannot be
questioned ; but, when the contaminating matters
are formed in some part of the system, as in
various malignant diseases, apparently local at
their commencement, it frecjuently cannot be put
in practice, or the period at which it might have
been attempted with any prospect of success
may have passed, and the other intentions are
our only resort. — B. The second indication is to
be fulfilled by the remedies already noticed
(^31.), and the treatment recommended in the
article Blood (§ 157.); particularly by the
alkaline chlorates; the preparations of bark, of
iodine, of iron, of arsenic, or of zinc ; by as-
tringents and antiseptics, as the acetic and citric
acids, &c. ; by the preparations of the bitter roots
and woods, or of tne aromatic and tonic barks,
with liquor potassae, or the alkaline carbonates,
in the more chronic diseases, and with the sul-
phuric, the hydrochoric,or nitric acids, in the more
acute maladies, and with warm spices, &lC. ; and
by the gum-resins, the balsams, the tcrebinthinates
and camphor, prescribed according to the cir*
cumstances of the case. — C. But whilst we are
endeavouring to elevate vital energy by those
and other means, we should also fulfil the third
intention, by associating, or alternating, them with
the more tonic and tiitomachic purgatives, or with
warm and stimulating diaphoretics, as the abdo-
minal or the cutaneous* secretions may re((uirc to
be promoted.

39. iv. Debility affecting chiejiy associated m*-
g»ni, or particular textures^ requires nearly similar
means to those already advised, according to the
grade and form it may assume. I'be treatment of

'.t

its manifestations in the" ganglial and c«ircL'
systems, and in the digestive viscera, bat betr
already noticed; and is still more paxticiilari;
discussed in the articles Blood, Colon, Imdiu-
TiON, &c. — A, Debility of the eenbro'Spmii %>■,.
gan<, must be treated according to the eauie \\a
have occasioned it, and the char^ters it prt-e^tv
The causes, whether moral or physical, sboold V
removed or counteracted as far as possible ; i:>6
if it have arisen from mental excitement, itpc-*
and agreeable amusement should be ioculcitel
(a) When it is characterised by increaspd y&-
sibility, the bitter infusions with liquor pota»i
or the carbonates of soda or potash, with coa-cu
or hyoscyamus ; the preparations of iroo ; rh ■
lybeates ; vegetable tonics and aromatict. « '
small doses of opium or the preparations of lu.-
phia ; cold or shower baths; sea-bathing, rbar;^
of air, £cc., mental tranquillity, and ign&iitt
employment, are amongst the most e£rscia'
means. (6) If it be attended by incre^sf'
irritability or mobility, the mineral acids, abu
0 r with bitter infusions ; the prepamtioos of rx-
chona; the acetic acid; Hoffmann's iDOfl)Cf,
valerian, assafoetida, musk, or vegetable tootc».«^> "
opiates or anodynes, the hydrocyaoic add, tlr
Iceland moss, ass-milk, alkaline or tepid Imh-.
&c., are suitable remedies, (c) If tbe debility U
great, and particularly if it be attended by t^»«>'
or depres^on of the sensibility, dependiog oe tb^r
upon cerebral congestion, nor upon a plct^or^
state of the vascular system, the warn or d.it.-
sible stimulants, combined with permanent toox^.
aromatics and cardiacs; iodine, strychnise, or t^c
extractor nux vomica in small doaes; a'ffe*
camphor or phosphorus in minute quaDtibt*:
warm salt water bathing ; the shower bath ; ct)>
rine fumigating baths; the use of astringent si-
camphorated washes to the head and sorCuc ot
the body; the nitro- hydrochloric acid batli. vr
sponging the surface of the trunk, or even the btit'
itself, with a tepid wash, containing these uiii-
may be tried and associated with Uie fonsciv.
or other internal remedies, according to the pt<£-
liarities of the case.

40. J3. The sexual organs are debilitated— >
from imperfect developement depending up-?
their interrupted evolution, or upon geaenl tt-
thenia ; and (6) from over-excitement. 1'he /*»
of these causes seldom occurs in the male, botb
infrequently in the tomale (see Cblososis s&-
MF.NSTnuATioN), and in such cases rcqainrs t '
constitutional treatment there described. 1 ■
second cause is common to both sexes, aitbov.'i
perhaps more so in tlie male than female. ^^ -* -
It has thus originated, and exists merely ia a &!:. t-
degree, without amounting to impotency, the ^•
gans will recover their energies soon after n>»ni. ^^ ■
if regular and abstemious habits be adopted, t'-
other circumstances, and in neverer cases, atteo* > '
should be paid to the geaerul health: the n'.i
ought to be occupied by interesting poiMtt«, t'^
patient should rise early in the morning, snti *'^'
the shower bath, or local aspersion or affiiAk>Q.<i '
live regularly. If the causes in which it oric^»«*'' •
be relinquished, the sexual function will •«'/
be restored. 'i*he tonics which are the oii>-t « '
cacious in cases of this description are, the iicaI:
of the sesqui-chloride of iron, taken in the infu* ' *
of quassia, or of chamomile flowers; the uortt'v
of iodine; coffee; and the extract of Go&ia»'.

486

DEGLUTITION, DIFFICULT.

tbe skin is entirely incapable of absorbing fluids in
which it may be immersed, has led to the neglect
of medicated batht. But it should be recollected
that, independently of any power of absorption
this structure may possess, — and which I be-
lieve it possesses unaer some circumstances, and
in respect of various agents, — it is a living, an
active, a finely sensible, and, as to the nature and
extent of its functions, an important organ ; and
that it is very susceptible of impressions by which
not only its own functions are modified or altoge-
ther changed, but the actions of other organs are
variously affected in consequence of the nervous
and vascular connections and functional relations,
which bind the different parts of the economy into
one indivisible whole. Entertaining such views,
I believe that cold, tepid, warm, or medicated
baths ; that lotions or washes, or stimulating
liniments and frictions applied to the surface, —
the former in slighter cases, the latter in the more
urgent ; are not infrequently beneficial in dis-
eases of debility, when judiciously employed,
and with due reference to antecedent or existing
visceral disorder. Sea or salt water bathing;
shower baths; camphor and chalybeate baths;
warm, tepid, or cold baths, either general or
local, of iodine, or of iodine and carbonate of
potassa; baths of jlecoctions of willow or oak
Dark, sometimes with the addition of an alkaline
carbonate ; washes with camphor water, rose
water, and vinegar, applied to the trunk ; or
sponging the surface daily with a mixture of
these, at a temperature of about 60^ ; or with a
small proportion of the nitric and hydrochloric
acids in water at a temperature of 70° to 80°;
are respectively of much service, when suitably
prescribed.

46. B, Moral treatment, or attention to such
mental impressions and emotions as are cal-
culated to promote the physical means resorted
to, is particularly beneficial in restoring the vital
powers, especially when the nervous systems
manifest a more than ordinary share of dfepres-
•ion and its attendant disorders. The manner
and bearing of the physician, when calculated to
inspire confidence, will of themselves do much in
fulfilling the intentions of his prescriptions. The
faith reposed in the remedies resorted to will often
accomplish as much as they are jphysically capa-
ble of performing, and not infrequently much
more. In order to inspire this feeling, the phy-
sician should himself evince a calm, and, in cases
of great danger and depression of the vital
energies, a cheerful confidence. Hope, in what-
ever form it may be excited, and in every degree
to which it can be elevated, is a most powerful
agent in combating diseases of debility; whilst
its opposite, despondency,— the consequence and
the cause of debility, — is one of the greatest evils
we have to guard against in these maladies.
Every practitioner whose range of observation
has comprised the malignant diseases of warm
climates, or of temperate countries, must have
remarked, that when the patient dreads, and still
more if he entertains a sentiment of, an unfavour-
able issue, or if he be apathetic and careless of
the event, the very worst sign of depressed vital
power has appeared, and the most active moral
and physical stimulants are then requited ;
whilst, on the other hand, a firm confidence in
the physictao, and ardent desire of recovery, are

the best aids by which his endeavoon eaa I-

seconded.

47. C. Travelling f — owing to the exerci», '" -

change of air, the continued succession of cow'

and exciting objects presented to the tetan. ir

agreeable occupation, without exhaustion of .'

mind which attends it, and the amusing aD>l n-

hilarating matters incidental to it, — isoo« cf <' .

most eflicacious means of restoring the deprw* '

or exhausted powers of the frame, especialh C"

enfeebled functions of the digestive orgso» v :

of the nervous system ; and nearly allied to '

are pUasant society , rational amutementt, ssJ n-

ried, interesting, but not fatiguing, bodily it

mental employments.

BiBLioo. AMD Rmtu—Celsut, I. ill cmp. 4 jlrti^-'

Curat. Acut I.il. c8. {itimutnaitdassmtUL)—Atit.i
Canon. 1. i. fen. 2. doct. 8. cap. S9. — AiberU, Dc A'
Hale, 1716 — Hqfinmm, De MorbU ex D^iUiUtf i
rum oriundifl. Lugd. Bat \7a7.—BUehmtr,D9T>f*f ' ■
Part Corp. Solid, ab Immlnutacanua Coheiioiir pro^*^ '• •
HaL 1749. ^ Lvdww, De nimia AoimI DrCtfifH.
Cauu DcbiUtatU in MorbU. Lipt. 176^ ; ei D« 1
Corporum Curationem impedJeote. Uim. I79S. — ^.
Defln. Generum Morb. Goet Sva 1764. — Smtk^ -
Nosologla Methodica, roL i. p. €89. Amat. 17^- - ( '
dani, Instltut PatholoKf», Ac. Hyo. Berl. I77<».'-^^>^'
ObBerrat. on Chronic Weakncu. York, 1777. *» > -
Lfntm, Bevtrage, p. 81. (ChalubeaiebalkB.)^^. Bnm •
ElemenU Hedicina. Edin. f7S0. jand hit Work^ t"
Sont%yo.paasim.-~Saunder», in Edin. Med. Cor '
vol. ill— Nieotai, De DebfL Vera et Sparia. J«ne. •:
Widenusnn^ Dist. Slcteni Vitia Genua HumaDum U<' -
num DebllitanUa. Jenc. 1792 — Haate^ De DeUl ^
et Spuria. Lipi. 1792. — Wedekfml, De Drtul, M
Heidelb. 1797.— DanrAi, Zoonomia, or \jKm% at Or>.
Life, 8to. 1797.— fVhite, Obaervat. and Experia,rf»»

the Willow Bark. Bath, 1798 AWta, in RidUt r . > '

rurg. Biblloth. b.rl. p.7l7. (The wil/otebarie.)-U^' "
the Use of Oxrgen, or Vital Air, in the Cure of Dut ^ >
Lond. \9ao.^Hemecken, Ideen. Ac. p. 76. {Tkt mar..

?fthe old with the young.}— PUmcquet, De Rite Fen', k
ndicatione AntasthenTca. Tub. 1799. — Mtrtcri
•chreibung Ton Pjmnoot, b. U. p. 22. ( 7%c Bwrmomt i .' ' •
recommtnded.) — Hom^ Beitrage sur Medidn. k! -
b. il. p. 2y3. ( Specifies nmrgradf*. ) — Tkorndtmn. .1' •
Wurceb. Ac. t>. i. p. 43. ( 71r proprirtp «/ 4ittintmu^'<i
the /orms^ and approprUaing ike remediet) — )/««t«
Priifung des Brown- Systemt, b. 1. 11.4. p. S7
greater the debility, the more penetraiitu ami roiM >' ■
citantt. )Schreyer, in Batdmger'tli. Mag. t.*th\ f ^
( Bath* ofdewction <tf bark. ) — Grapej»geis»ery Vrn *
Ac. p. 116. -- Beddoes, On the Med. Vte. At of Fat: • j
Airs. Bristol, 1796, S70.—Cottradi, In Hv/etaad't J - '
dcr Pract. Heilk. b. vi. p. 38-5. — Otto. De Keai«<di - :

Incitantium Abuau. Franc. 1604 HWtArr, Di>q. •

Rationis Morb. ad Statum Corp. Asthrntcum. J' «
1801. — W. Fogt, De PareMOS et MeChodt P«r<w
DigniUte. Viteb. 1 90&,—Brera, Annotaiioai, Ac n4 -
Gra^e, in Hom't Archir. Sept. ISIO. p. 149. iChat^
baths. )—Mylivs, Hufeland und Himly, Joura. drr IV.
Heilk. Nov. 1809. p. 24. {Deeoctiom€^raweq0te.\-^f«n*^.
Uetier die Natur. u. Behandlong der Krun^. • ■ '
Schwache des Mcnschlichen Organismus. ScuU. 1^ ' -
C. Sprengel, Institutionei Medicc, toI. iU. p*^- ^' '
1813 — P. a Hartmassu, Theoria Morbi, ua Ptfh^ ' -
noralis. Ac. Svo. Vind. 1814. —Harles, HamfiMct
Aorstlichen Klinik« b.l. p. 2.50. — SVarvMa, Oo I
and Treat of Chronic Debnlt^, Ac. 8ro. Ixmd. 1«34 - '
Coetsem, Mediclns Theoreticc Conspcctnt, dro- i*^'
182-1, p 81 .— L. H. Fried/ander, Fundamcnte Doortitf : ^

Ihologicae, 8vo. Lipe. 182S, p 98 Boitseau^ art. Jm - -

in Diction. Abr^e des Sciences MMIcales.-^. C fi-^
in Diet, de MM. et Chlr. Prat. U ill. p. tfSL^Br^^ ■
M6moire sur TAstbcnie, 6to. Paris, 1«£9. — H»^-^
Encyclopad. WSrterbuch der Medidn. W1m«i '
p. 453. _ Geddhun, On the Pathological Statei dn*.^
ated Asthenia, Debility, Ac. in Amer. Joan. <*t >'«
Sciences, voL Ix. p. 3l5.~< See also the Btbttogw^: -•
B^erences of the art. DisxasK, and the art.T>niL<r J
In Ploueqvet*% Medidoa Digesca, toI.I.)

DEGLUTITION, DIFFICULT. -Srx. f>v^

pfiQgia (from Kc, difficulty ^ and ^>»« ' ■

or swallow). DeglutUio difficiiis tW •«;* '

Auct. Sckweres Seklingett, Ger. ih'*^ -

Fr. Dvtphagv. Difficultv rf Sn<alUnritic.

Classip. ~l. ClaM, Duetstn of ihr !•

gestive Fanetton; 1. Order, Afirci:?«

488

DEGLUTITION, DIFFICULT — Diagnosis.

lightning (Paterson), and by severe cold (Bleu-
land). It is, however, most frequently caused
by the slow developement of tumours, or cysts,
or other structural changes about the base of the
cranium, whereby either the nerves supplying
these muscles are compressed at their origin or
in their course, or a portion of the brain or of the
upper part of the spinal chord is injured.

8. ii. Complicated Dysphagv, or difficult
deglutition from structural change affecting the
parts immediately concerned in this function,
comprises a great variety of lesions. I shall
merely enumerate them with reference to their
seat; their nature, morbid relations, and treat-
ment, being fully discussed under more appropriate
heads.

9. A, DyspUagyfrom congenital malformation, —
Extreme small ness, or enlargement of the tongue;
the termination of the pharynx, or of the oeso-
phagus, in a cul-de>sac, or obliteration of the
cesophagus; the division of this part into two
canals, and its communication with the trachea ;
are the chief malformations which interrupt de>
glutition ; and are of very rare occurrence in
otherwise well-formed infants. Cases, however,
have been recorded by Blaes, Van Cuycii, Mi-
chel, BiLLARD, Martin, A. Cooper, and An-
tral. In these, death, necessarily resulting from
inanition, took place in from three to nine days.
A slight interruption to deglutition very frequently
arises from congenital fissures of the soft and hard
palates.

10. B. From diseases of the month and throat.—^
(a) Inflammation or chronic enlargement of the
tongue; ranula; sublingual calculus (Guentiier);
and aphthse, ulceration, tumours, and excres-
cences about the base of the organ (Reidlix,
Van Swieten, Tode, and Inolis) ; are not infre-
quent causes of dysphagy. Cases of chronic en-
largement of the tongue, impeding deglutition,
unconnected with malignant disease, and con-
tinuing for many years, are recorded by several
writers. I have seen an instance of this kind,
that had existed from infancy to nearly middle
age. These and other affections, with the treat-
ment appropriate to them, are particularly no-
ticed in the article upon the Dneases of, and the
Indications furnished by, the Tongue. — (ft) The
fauces and tonsils not uncommonly occasion dys-
phagy. Inflammation, suppuration, ulceration, or
destruction of the8oftpa/ate,or of ihcuvula; great
relaxation of the latter part ; inflammation, abs-
cess, chronic enlargement, and ulceration, of the
tonsUs ; fungous and other tumours and polypi of
the maxillary sinus, or posterior nares ; various
tumours or excrescences attached to tlie palate
or tonsils (Schmidt, Thilenius, &c.); and the
severe effects of mercury, or the sudden arrest of
salivation ; are generally attended by more or
less of dysphagy. — (c) When the p^arvni' is the
seat of inflammation or of its consequences, or of
the lesions now enumerated, or of malignant
disease (Keroaradkc, and myscIOi deglutition
is commonly much more impeded than when
only the fauces are aflfected ; and in some in-
stances it is extremely difficult or nearly impos-
sible. In such cases, the epiglottis and larynx
are more or less irritated, and, by the conse-
quent disorder of the respiratory actiotis, the dys-
phaey is still further increased. Foreign, and
particularly pointed or sharp, bodies lodged in

the pharynx, are also sometimes causes of <]i>-
phagy.

11. C. Dysphagy from disease of the epigla^.^
and larynx, — (a) Inflammatioo, nlcentioa.
and entire destruction of the epiglottis, or iodur-
ation, incurvation, and the removal of it U
wounds, will occasion difiicult deglutitioQ, u la
the cases recorded by Maynwarinc, Stbuiik,
Bonet, Desgranoes, Tonanni, and Lairx).
— (6) Also inflammation and ulceration of \b*
larynxt ossification of its ligaments, and dis-
placement of the OS hyoides, are generally attended
by dysphagy. The possibility of the occorrtact
of this last cause, although observed by Val-
salva, and MoLLiNELLi, has been doubted; bu
the instance of it noticed by Sir C. Bell (>urz.
Observ, p. 160.), and the case wherein it «.«
caused by swallowing a large hard suUtaoa,
recorded by Dr. Muona {Annali Vniitn, ii
Med, Nov. 1828.), put the matter at rest. Frac-
ture of this bone by external violence has pro-
duced not only an impossibility of deglatii.^^,
but even more serious consequences, as shown a
the cases published by Dr. MARci?tsoirs&i aid
M. Lalesque (Journ, Hehdom, ^c). — (See La-
rynx — Diseases of,)

12. D, Diseases of the crsophagiu, and cerd^rc
orifice of the jtomac/i, will impede or altogether ob-
struct deglutition. Inflammations and their cos-
sequences, as softening and ulceration, induratioc,
thickening, stricture, and purulent coUecticsi
between the coats of thene parts; also pamJ
dilatations, sacs and diverticula, or even larpe
pouches, either with or without thiekening aad
stricture of the part of the oesophagus immediattly
below the dilatation (Blasius, IIalleb, Meciu,
Monro, Ludlow, C. Bell, Odxer); polypoi.!
or fungous excrescences or tumours of variuiif
kinds in some portion of this canal, or in ti»
cardiac orifice of the stomach ; or scit>falotz\
callous, cartilaginous, osseous, carcinomaloas, i.r
scirrhous degeneration of these parts ; or raerr\\
enlargement or ulceration of their mucous glanti-;
and spasm, rupture, or perforation of the €e«o>
phagus, or the lodgment of foreign bodies to it .
are severally causes of dysphagy ; and are fully
described in the articles on the ratholi^cat J.v-
tamy of the Digestive Canal; and on the />i»-
eases of the (Esophagus^ as well as in those of *h*
Stomach.

13. £. Tumours pressing upon the pSiaryns, f
upon the esophagus, '^^ broncboeele, or oil«
tumours or abscesses near the throat and ia th<
neck ; tumefaction of the lymphatic and secntin;
glands below the jaw, and at the top of i^'
sternum ; aneurism of the subclavian or carotid
arteries, or of the aorta before it passes ioto tlw
abdomen ; enlarged bronchial glands, tumours of
various kinds, and abscesses in the p(brrric<r
mediastinum ; exostoses or other diseases of th^
cervical vertcbrip, and purulent coUectioB$ h^
tween them and the oesophagus (CARHicBin.
myself, and others) ; also aWesses formed U*
tween, or involving, the trachen and oesophagfc*
(Hay and myself); dropsy of the pcrifurdua
(Bang); and enlargement of the lirer; hitc
severally been observed to occasion dysphagy.

14. iii. The Diagnosis of d^'sphagy rcquir» s
few observations merely. — (a) Jo idicpeitkir. a*
well as in the sympathetic dysphagy, the ditiicoltr
takes place suddenly, disappean as suddenly, n-

490

DELIRIUM.

If abicestet have formed between the upper part of
the OBSophaguB and cerTical vertebrsi or between
the forrmer and the trachea, or about the pharyni,
an unfavourable issue might possibly be averted
by incisions made into them. If aneuritms press
upon the gullet, the treatment recommended
when discussing Diuases of the Artbries should
be put in practice.— (e) When thickitiing of the
parietes of a portion ot the cesopha^s, with more
or less of stricture or iehrhue or this canal, or of
the eardia of the stomach, is the cause of dysphagy,
cupping, or leeches applied over the sternum;
issues and mozas in the same situation, or in each
side of the neck ; the linctuses recommended
above (§ 18. c.) ; mercurial and other alteratives,
with conium, hyoscyamus, camphor, &c*; the
iodide of mercury, or the iodiae of potassium,
internally and externally ; the carbonates of
the alkalies, or the liouor piotassB in emollients,
ficc, with various other means noticed in the
article on the CEsofkaous, may be employed. If
these fail, a careful trial may be made of the bougie ;
but the utmost attention should be paid not only
to the manner of using it, but to the effects pro-
duced by it ; for if the stricture be connected with
sacs, pouches, or diverticula, or hernia of the inner
coats through the muscular, or even with simple
ulceration, — changes which not infrequently take
place in the part immediately above the strictures
—much mischief may result from even a cautious
introduction of a bougie. The frequent and ob-
vious connection of dysphagy with scrofula shows
the propriety of prescribing the medicines found
most serviceable m that disease, particularly when
occurring in the scrofulous diathesis : and m such
cases, the chloride of calcium or of barium, conium,
liquor potassas, and especially the preparations of
iodine, should be fully tried.

19. C. The treatment advised by the best writers
on this and its related affections consists of much
that has been now stated ', in addition to which,
however, I may briefly add, that, the chloride tf
barium has been recommended by Kzrssio ; cold
and iced fluids, by Tons and Montat ; conium,

by WiCHMANN, COLLOMB, HuFELAND, and JOHN-
STON ; hyoscyamus, by Witherino ; opiates, by
Ferrein and Conradi ; the liquor potassa, by
Haller; emetics, by Ferrein; and local bleed"
ings, by France and Bano. Calomel and some
other preparations of mercury have been pre-
scribed by Sequira, Stevenson, Engelhard,
Brandis, and oiherB,<-*to the extent of producing
salivation, by Kraup, Munckley, Brisbane, and
Farquh ARSON — in the form of mercurial ointment,
either alone or with the volatile liniment, rubbed
over the sternum and throat, by Dorson, Patten,
Kerksio, and W a then— internally, with anti-
mony, by Van Geun — and with aloes and
camphor, by Haller, Patten, Bang, and
Brandis, who contend strenuously for the occa-
sional origin of dysphagy in suppressed rheuma-
tism and repelled eruptions, and also recommend

u In varioui other parts of the body), were so grcstty en-
Urged 8« to Impede deglutition and respiration. She had
been treated by lereral eminent practitioners ; but the
tumours had increased. In consultation with Mr. An.
mbslbt, who had requested me to see her, a course of
iodine was recommended ; and the iodide of potassium
was employed, chiefly internally, fbr eight or nine months,
with occasional intervals not exceeding a fortnight each.
The glandular enlargements gradually sut»ldcd, the eat-
amenla appeared, and she petTCctij recovered, m Is now
-rell, and mariled.

external derivatives and irritants, as aaapisBt,
issues, setons, blisters, repeated or kept open, &c.
The surgical measures to be resorted to in vaiiooi
circumstances of the disease are fully discujeed b
the writings of J. Hunter (rroni. of a Sx.
for the Imp, of Med, and Chirurg, KnoKUd^t,
vol. i. art. 10.), Dbsault, (Surgical Works, ite.),
Ricoter, (Chirurg, Biblioth, b. xii. p. 11.). ( .
Bell (Surg. Observ, S^c), and S. Coopfi
(Surgical Dictionary, S^c),

20. D. The diet should be chiefly farioaceow,
excepting in the nervous and spasmodic Cbrmf ct
the disease ; and it ought always to be easy of di-
gestion, and taken without any heating condimeou.
All substances which irritate or excite by t}r^
direct or indirect action, are iniurious. Tbe
stomach also should never t>e loaded ; and in evm
circumstance, the secretions and excretions ouc^.^
to be carefully regulated and promoted by gestk

and appropriate means.

BiBLioa ANO RBrxa. — Femetti, Open PatboL Lo^
Bat 16M. p. aOi.'-EUmtiUer, Opera Hedlos, vol t. ^ « .
"ReUliH, Lin. Med. 1696, p. 6f. (JAefcr^) — AcAvy.
Chylologia, p. 257. UOlcenOed eptgioUts.)-^ Morg^m, Vt
Sed. et Cam. Morn, epist. xvii. 19, 90. 2S,, xrm. •£ .
xxTiU. ia~£tetoiirf, Hist. Anatom. MU. 1. il. dm M

— MitpnwarHur, Med. Facts and Obsetrat. vol. L >
Paterson^ in Ibid, vol vlii. art 6. — Baaae, De Caia f
Diir. Deglutitionis. Goet 1781 . — Smmd^f&rt, Muiu Ai ^
torn, vol ii. Ub. 107. et seq.-^QIMktr, in Med. Wocher-
bUtt 1783. & 555. — Manget, Btbitoth. Pract L iv. p. Kb

— Van Smeten, Comment, ad S 7S8. — BaUer, Opurx
FathoL obs. 78. ^ BieuUmA, Observ. AnatomiccMcdicv

p^ 170. .-TMr, in Ibid. p. 189. — Porfff/, Coun d*.\si-
tomie M£d. t iv. p. 535.— TkUenimt, Med. nod Chirv^
Bemerkungen, Ik i. p. 47.— Sfavra«m, in Med. and )'h>i
Joum. Lond. July, 180S. — JoAmIoa, in Mem. of Ked
Soc of Lond. voL ii. art 17. — CoUomb. Hedir. O r
Werke, obs. lO.-^WicAmaim, Ideen sur DiagiMstik, b <..
p. n6.—H'itkering, Eilin. Med. Comment roL avi. p -Xd

— Farqukarson, Tn Mem. of Med. Soc. of Lond. vt>' >^
p. S67.— FFofAm, in Ibid. vol L pc tB6. — Seemhm, to Mml
Obs. and Inquir. vol. vl. p. ISS.^PalUtU, Nuow Gmr.
della piu Recent Lit Medlco-Chir. t vi. a IfiSL^ilrry. r,
in Act. Helvet. toI. vii. art 6. (iihw<rrs0.)— .^tMffvr, a
Med. Obs. and Inquir. toI. iii. p. 85.— IMeoN, in Ibid v^

v\.^Sruiane, Select Case^ p. tJ BaUinmtr^ X. Mays.

sin, b. viil. p. 175., et b. xvi. n. 162. — TktuAen, De (Ari
d^eputi. Upsal. 1797. — ^dbq^, in Hwfeitt^ cm!
Himip*s Joum. der Pract Hellk. Feb. 1810. p 1)7 -
Atoms, in Ibid. Oct. 1811, p 116. ~^ Hrimetitn, m n»^
May, 1811, p. KA^MickaHis, in Ibid. Feti ISti. p5j-
Planck, Act Inslit Clin. Vilnensia, vol.UL p.96.— /4^
/en, in Auscrl. Abbandl flir Pract. Aerate^ b. xiit n 3Pf
•- ue^rvnges, in Joum. de MM. Contin. t iv. p. iJ .—
Conraai, in Amemaim*t Magaiin. Il L p. 78l*-£/icVm^''.
in Joum. Gfo^r. de Mid. t xxii. p. ia& — Daa*«r, &
Ibid, t xxlU. p. 38a— TlMMirai, in AtU di araaa, vol u.
p. iSSL—Larre^, Relat de TExpfrlit en E^ypte. sec. n i

— Hofifengaertncrt in thtfelami^ Jotira. der Pract Xn

nefk. b. vl. p. 558 Sdimidt, in Unreimmd^ Joan ^a

Pract Heilk b. xxii. st 9l p. Gt^KetAMg, in Ibid K t^
St 4. a I9i.— HH/Wmtf. in Ibid. b. ix. rt. i p aH-^/v^.
tn Edin. Med. and Surg. Joum. vol. 1. p. 91— C Aitf, ^Bft.
Observ. p. 80.— MmJ-oT, Han. d* Anatomie, t iil. p. ST -
Carmickaet, in Trans, of Irish College or Phji- vei i'..
p. 170. — Monro, Morbid Auatomy of the Hunuo Ga<ht
he. fid ed. p. 940.- Jfay, Trans, of Med..Chir. Soc <■'
Edin. vol. L p. S4&— JTergoraAv, in Archives Cimt'^^
MM. t xii. p. l96.^Br(ki, Medical Repovta, Ac toi i'.
part ii. p. m {Hysteric?)

DELIRIUM. — Stk. Parophrasynt, Ps-a-
phronia (from ir«f«, erroneously, and ^f^**
I understand), Auct. var. Paraojpe, SwedMor.
Irvereden, Abirwitt, Germ. Dftire, Fr. I^r'
lirio, Ital.

Clasbip. — Pathology; Sympiomatolafit,
I. Delirium has been deSned : ^-Disardtret i^'
«n/e//ec(ita/ powers, with or Ufithottt derengrmt'U
of the moral stntiments. But this defioiiioo » tiw
extended and va^^ve, and emUraces tbc wbolc
circle of mental diseaiei. J. Fhahcx, and «»«

1

492

DELIRIUM— DtAovosis.

of life, and by the recoyery of the memory of
languages and of ideas acquired at a very early
age, and long forgotten. Thus old persons, when
delirious, although their minds are blanks as
respects every thing present, or which have be-
come known to them from youth or manhood,
will talk of matters which had interested them

f)reviously to such periods, and sometimes in a
aoguage which they had then spoken, but of which
objects and language they had no recollection
long before their delirium, nor retained any after
their recovery. Here, again, the remarkable si-
milarity between several manifestations of de-
lirium and dreams is strongly evinced ; the objects
and ideas about which the unconscious mind
is engaged in the states of both delirium and
dreamin? being freaueutly those which had made
a vivid impression m youth, which had become
erased by the cares and employments of life, but
which are recalled during certain conditions of
the brain. The production of these in incongruous
forms, and the giving utterance to the morbid
conceptions formed of them, constitute haliu-
cinatiom ; whilst, owing to the nearly inconscious
state of the mind, the imperfect and erroneous
impressions made by surrounding objects on the
senses of the patient, give rise to inconclusive and
unconnected conceptions, in consequence of the
morbid condition of the brain, and occasion the
illusiont characterising the delirious afteotion.

5. In addition to disorder of the mental powers,
the organs of locomotion are remarkably affected.
In the low or quiet delirium, and in the less
dangerous states, in which the brain is only
functionally deranged, the muscles are cither
somewhat agitated, or very much enfeebled, and
the voice is very weak or nearly lost. In more
severe cases, the voice and the muscular force
are greatly increased; the patient, however,
sinking into a state of profound collapse after
a few violent efforts. In the most dangerous
form of delirium, particularly when it proceeds
from organic disease of the brain or its mem-
branes, it is attended, but more frequently
followed, by general convulsions, by spastic con-
tractions of one or more of the voluntar}r muscles,
by entire loss of consciousness and sensibility, or
by paralysis.

6. C. Delirium, as M. GEonoET has remarked,
may be continued or intermitUnt, even in the
continued affections of the brain. When it is
intermittent, it usually returns with the ex-
acerbation of fever that takes place in the evening
and night. When the patient recovers his rea-
son, he is generally weak and exhausted ; his
senses are readily and painfully impressed by
their respective stimuli ; and he complains of
thirst, and pains of the head and limbs. If the
delirium has been slight, and consciousness has
not been entirely abolished, he retains more or
less recollection of what had passed during its
continuance. But when it has been intense, or
of some duration, he has no knowledge of what
has occurred. The epidemic appearance of de-
lirium mentioned by Quei.malz (De Epidem.
Mentis Alienatione» Lips. 175*2.) and Micuaems
(Med. Pract, Biblioth. b. i. St. 1.) is to be
imputed to the prevalence of those diseases in
which delirium is apt to supervene, and espe-
cially in that form on whicli it is most fre-
Quentlv an atiendaat* The duration of the

paroxysm of intirmittent delirium varia froa
one to several hours ; but the conttumd fom,
particularly when occasioned by disease %i.v.\
the head, may last several days, or even iu'.t
weeks. Sometimes, as in the more severe ce-
rebral cases, it alternates with profouod coiu.
When it terminates fatally, it generally p«»-^
into coma; but in some instances the pdt;(b!
recovers his reason for a few hours before L-
solution.

7. ii. Diagnosis. — It is of the utDacfA ic-
portance that delirium should not be mi<4a)m
for insanittf, and especially that the deliraj«
patient should not be removed to an asylum u :
the insane. On two occasions 1 have uen s^dr*:
a mistake made, and about to be acted xx\fis.
when my opinion was requested. Dut tL:^:
cases recovered perfectly: to one of them — i
professional man — the removal to an em Ian.
or the supposition even of being insane, oiifU
have been ruinous. There can be no doubt thit
delirium oflen passes into insanity, e»pcrta.;«
when it has been caused by inflammatory i'a' *
of the brain, and by fevers with determlotiiuti
to the part; or when it occurs in persons Un-
ditarily predisposed to insanity ; but until it u^
assumed the features of that form of meota! (. «-
order, it certainly in no rei^pect should be uc^-A
and treated as such.

8. The causes and circumstances oriorindt-':
delirium are often of themselves sufficicot :*
show its difference from insanity. Its ocl.;-
rence in the advanced stages of acute dtfecav^.
or of chronic maladies when the powers oi i (
have become exhausted and febrile action of ::i
acute kind has supervened, is especially cha-
racteristic of delirium. The insaue patient U^
all his senses, as well as his digestive, a^indi.
tive, and locomotive powers, but litUe or r;ct ji
all impaired. His mental faculties and icvi-
gence are also but partially deranged. 11.
Geoecet has very justly remarked that Uie mcaui
disorder of the insane is often confined to i
single faculty; and even in the mo:»t cxteoti.',
or maniacal affection^, the faculties are ndxr
perverted, or insulated, ond without the l>or.ii(.i
association, rather than extinguished. Th? n.* ^i
maniacally insane person wills and reasons, au
is not always absurd in his actions. But ia t'»
delirious, all the cerebral functions are setrn.*!}
affected. His sensations are impcifect ao'l •••
correct, his ideas unconnected, his psi^i'-
disordered, his voluntary motions irregular, fetblr.
and defective; his intelligence and reoolU*-''
nearly abolished ; and he is impassive U> «''
that surrounds him. Whilst the (/e/iri<mi pAd :
presents many of the physical higns of evhau-^'-i
vital energy, or of the gravest state of diN-i^.
the tnMfi« has all the appearances of unimpoirv'-i
health, particularly in the early stages of io$a^> )>
and before consecutive organic change h;'j> uVt >
place. lu the former, the sensations and p^r\" ;*
tioos are more or less abolished; in the Ut",
they are but little or not at all impaired,—'^''
judgment only, or conviction of the umV:-
standing respeciioe them, being erroneous It-
false conviction of the insane is too strong to >.e
removed by tlie evidence of the n-a^i : i ^'
sensations and perceptions of the delirious >.'«
always too weak, even when coosciou^e^ '^
partially present, to become the ba^is of taus-!

496 DELIRIUM — Treatment.

(De Usu Nivit Medico, cap. 25.). It may be

prescribed in the form of cold affusion, pounded the ingestion of narcotic, indigestible, irritating, or

ice, cold epithems, evaporating lotions on the
head, or simple sponging. If, however, it be con-
tinued too long, or after the morbid heat has l>ccn
subdued, and ihe features have shrunk, it will be
injurious!, by depre9.<ing tlie nervous energies too
low, and favouring the supervention of coma,
or violent u;^italiuns, terminating in fatal ex-
haustion. It is requircil chiefly in the third
form of the disease; but in thej^'i*<t and second

several ^Titers ; and when delirium proceeds from

poi:aonous substances, or is connected «iih the
accumulation of suburra3 in the upper portioai of
the digestive tube, they are then rcqc'^ite. — (/)
Antispai^modicf and i'ordials, particularly valtriaB
(Wakhukg, Med. lieolMcht. No. 16.), a:issfi£iidi
(Wantf.ks, Journ. de Mid. t. Ivi. p. 115.),
musk (KoRTUM, loc. cit.), warm negus, and
similar medicines, have been recommended ; ami
aie often of service, when the powers of lifea;e

forms, when the temperature of the head is in- ' much depressed. — (g) Bliitert have \Ktu z^
created, it should be cautiously employed, or the plied to the head much too indi?'criniiQati:l)- : I
tepid afl'usion substitutL*d for it. In these, how- ] nnvc seen thum prove most injurious in tbis
ever, 1 have preferred that the scalp should be ' situation. Dr. K. Ghchrist, one of tlie b«t
sponged with a tepid and very weak solution of j writers of his time, directs them l>oth to the U
the nitro- hydrochloric ncid. — (b) Cnmjthur has and to the insidcs of the legs. 1 btlieve thatilK-r
beun nearly as universally prescnbcd. hcciiNiR i will prove beneticinl in the former situation, onir
(l)e Piattaiitui Camphorte in Detiriii. llalx, { when the powers of life are sinking fast, and ll4
1763.), and Took (in Si*c, Med. llann. Coll. ii. delirium is attended by stupor, a cool head, and
No. 34.) especially recommended it, — the latter | sunk or collapsed features, ns in ca-tes of low or
with minernl acids. It is a most excellent remedy adynamic fevers. When thii a fTectiun i^ con-
when judiciously exhibitetl. If given at all in the sequent upon fuiirile dctcrniinatioii of blood to the
third form of the affection, it should be in small ' head, blisters on ihe inside^i of the legs ^c. ntaj
doses, with nitre and antimony, or with digitalis, be useful derivatives ; but they often occauoo to
In l\\c Jint form, it miiy be prescribed in larger ■ much pain and irritation in this sttuatiuu, kf to
quantity ; and in the second, especially if there be thereby couiitcract, particularly in the turbulett
stupor or conia, or a morbid sUite of the blood, state of delirium, any good they ini^ht utltenvii«
instill larger doses, with tonics, antiseptics, aro- produce. — (/i) Of the setiatiie* or ciMifni-sifiui*
niaticR, and cordials. — (r) Opium or hyos- lants prescribed hy writers, the preparitiou of
ctiamm is noticed by Pkrcival (Land, Med. and I antimony, paiticularly .Iame;>'s ]iowder — di-diitalo,
Phif*. Jnurn. vol. i. p. 443.), Goubieu {Journ. ' and the nitrate of potash, are the most (U-jcnr-log
de Med. t. Ixxxv. p. 244.), Duipuytkin, and of notice. Wherever the delirium is conacftiJ
koKTiM {Keytriige zur Pract, Arzneuwiss. No. with increased vascular action in, or detenuiiuitioB
9.). In some states of the ^first and second , to, the head, these medicines ure of more or Im
forms of the affection, when it is purely nervous, ^ service when judiciously combined with otlierap-
or is attended by much agitation, watchfulne^^s, proprinte lemedies. Witiilkino {On Digitalu,
&c., either of these medicines may be employed, p. 33.) and Pattfrson (Med. and Phys.Liin.
In the more doubtful cases, either of them may vol. v. p. 442.) strenuously advise the preparalioM

be safely exiiibited with camphor and .Tames's
powder. In the third form, particularly when it

ofdiiritalis ; but tliey, as well a^^ thu>e of aniircony,
rt:(|uire much cauiion, if ventured \i\yon in Ik

Resumes a maniacal or violent character, and after delirium ntlcndant on low or malignant feven.

depletions have been carried as far us may be It is chiefly in the maniacal or third furni of thii

thought prudent, and the bowels have been freely j affeclion that tiiey ate mo<t beneficial, and in it

evacuated, I have repeatedly seen a full dose of they should be exhibited iu a decided manner; bot

opium or hyoscyamus, given either alone, or with in the Jirift and second, particuhirly in the de*

antimony, or James's powder, and camphor, pro- ! lirium of typhus, they are generally injurious.—

duce the happiest effect. Any unpleasant symp- | (i) 1 he actual ctiutny on the na; e of tlie neck,

torn that may result either from too large doses of | and nwxas, have been advi.Md by M. VAi.t>Ti!t

the-e narcotics, or from their inappropriato u.se, : {Med. and Phus. Jtutrn. vol. xix. p. 432.), nod

will readily be remove<i by the cold or tepid af- several otlier (lontinental wi iters. — (h) Dr.

fujiion on the head. The acetate or hydroenlorate (juanf ((^m Ferrnt, 8vo. 1771.) recommtmls llie

of moiphiii. taken in u full dose of the spirits of [ patient to be allowed to die.«s and sit up when he

pimcnta, or in any other aromatic spirit, has; fteN anxious to rlo so; but this, ami sj\entljn-

proved equally beneficial with opium, iu my prac- dicious obf^crvations of tlii.-* writer, are nsore fully

tice. The f J (e;'»a/ employment of opium has been advertwl to in tlie article on iKVJK. Iht ol>-

found very successful in delirium, by \. Cm- scrvations made on oonvsde^conce from Ivjiaiam-

AniMU.;! {SnlC Iho V.sterno delC Opio, 8vo. llor. tionnoj' the Uuain, and from I'Kvin, are peiffclly

1797.), Ward {Land. Med. and Pht^s. Journ. applicable to the management of convaliWviM*

vol.i. p. 441.), and Percival (///«/. p. 444.), who from delirium. (See these articles.)

have used it in the form of liniment (3i. triturated , „ ,..,.„ .. ,% v.

• 1 - . f ,• V •.! ■;i"' _ -.i . HiRLiof:. ,\:.n Refer. — /*. M. De IltreifM, Th* >"■

with 5 J. of adip. pnep.), either with or without p^.n^j-,^ ,.j„,^„p j;.,i„i,^ o,,,.,. ,. ,,-, ,^ ^.Jitkr. \k

camphor. — (d) Purgatiies have been justly , l)vlirii« vx Vcntricuio. Fr. ICltf . _ //wrA/ron', lii*»i'u'-
praised by all writers on thU affection. The' J. -'^.^'^ '^^ ?'• - '^'»'"^*^' '" J'i'''^' '^^"''^
ancients prescnhed them in very large doses, and xii.— 7i;VA,//..v,T, Do nelinrti.iiuin luron- el IVdk*.
preferred the hellebores, which, with calomel and lia. 4to. Jviuc, 173J. — Hucunaix, Dc Kj»cieinua .^lei-ii*
tha-^e I have already particularised, should be ac- -^''^"^'I'i'f • ^fi\ ^'■'^L*^5i.!v J^'v-'" ", vSS
lively exhibited, according to the strength of the «r:r>ajri<iitibii». Hal. 17.'»7; et De He<uci.rmn IWim*
Dittient. When the debility is great, they must Maio ()mnic nriuiKiu. h.iI.t, iTiri. — ./. f'"*-^'""^' ]J*

be associate.] with a tonic and stimulant treat- m«i. Prnct. vol. ii. p. i'j4.-;?««w<-r. IV Dfhriclh'HN
ment. — (e) Lmeticf have been mentioned by I rico. Krf. l7U3.<-Aii/i/i,Do Dviir. llycterico. ^rt-iTi^f-

498

DELIRIUM WITH TR£MOR-«-CAiriBS— Smmiis.

by the same cause ; the one being immediately
consequent upon or accompanying intoxication,
the other commonly resulting from the abstraction
of the accustomed stimulus, after an habitual or
continued indulgence in it, or af^r a protracted
fit of ebriety. A slight form of it, or merely tre-
mors of the hands or limbs, with deficient nervous
power, and occasional illusions, will sometimes
appear after habitual tippling, without intoxication
having once been produced. The use of intoxi-
cating liquors, and the neglect of sufiScient food ;
a protracted debauch, followed by sudden pri-
vation, or by depressing causes ; large or repeated
depletions employed to remove the headachs or
stupor of drunkards, or the first species of this
delirium ; the treatment indicated by the diseaaea
with which such persons may be affected; the
debility caused by the diarrhoea or cholera some-
times consequent on intemperance; the shock
arising out of severe injuries, particularly frac-
tures ; exposure t6 cold, a course of mercury, and
the puerperal state * ; are principally concerned
in the production of this affection. That the
delirium which has been called ** D. Trau-
maticum " by British writers, and " D. Nervonim"
by DuPUYTREN, is in every respect the same as
that now being considered, is proved by the fact
of its appearance chiefly in persons of intemperate
habits, by identity of phenomena, and by the
effects of various modes of treatment upon both
being alike.

10. Although the chief cause of delirium tre-
mens is evidently the abuse of intoxicatins, espe-
cially spirituous, liquors, yet this is not the only
cause. It may also be occasioned by the
drugged beverages prepared in Eastern countries,
particularly in the East Indies, when too freely
indulged in ; and by the excessive use of opium.
But it is chiefly when sobriety has followed a
protracted debauch ; and when, during the first
days of the abstraction of the accustomed sti-
mulus, the additional causes mentioned above,
come in aid of the eflicient cause, — when the
habits and indulgences of the patient have pro-
duced that state of the nervous system which
readily passes into serious disease upon its being
influenced by depreasine agents ; that true delirium
tremens takes place. Inattention to this fact, by
neaHy all the writers on the disease, excepting
Dr. Bt.AKE, has led to serious misapprehensions.
Practitioners have too generally concluded that
the delirium of drunkards is always of the same
kind; and have overlooked diflferences very ge-
nerally subsisting between that immediately pro-
duced by intoxication — the Jirgt species of this
aflTection ; and that indirectly occasioned by it
— the second species, or true delirium tremens.
An occasional, or even a single indulgence in
intoxicating liquors to excess will sometimes give
rise to the former ; a repeated, habitual, or pro-
tracted indulgence is requisite to the appearance
of the latter. The frequency of this affection,
particularly in the lower classes, justifies the
attention recently paid to it ; and I believe that
it is more common now than formerly, owing to
the cheapness, and facilities of procuring spirituous
liquors. Between 1820 and 1832, I treated 21
cases, about two-thirds of which were in consul t-

• I have Mm three cam In IniulM, and thcte vwt
habitual drunltarda : the dUeaae aopcared in two of thtm
a few days after deWrerj. ^^

ation with Mr. Hovltok, Mr. Bitawiu, Mr.
WiKSTONE, Dr. RiDiMO, and Mr. Paiktu; tin
others in dispemary and private piaclioa. U sobs
manufaetunog ana trading towns, it it of frH|Qest
occurrence. In the United States of Ameoea.u
if, however, much more eommon. thaa ia tb
country. Dr. S. Jackson states, that be bi
treated upwards of 200 caiea; Dr. C a ant, of
Philadelphia, mentions nearly the same aaabcf ;
Dr. Wars says, that he bu seta man tbsa
100 ; and Dr. Wright, that he has leecivc^, a
the institution at Baltimore, ftom 60 to 70 nm
annually. But it is evident, from the detiib iki
have furnished, in the woi^ refemd lo u tbi
end of this article, that they have included asder
the same head delirious affections isMwdntciy
consequent upon intoxioalion ; and that, owe;
to this circumstance, has arisen mvcli of At
contrariety of opinion respecting the aatare tad
treatment of the disease, which is as renaibW
amongst physicians on the other, as oa tkii, sdi
of the Atlantic.

11. III. Symptoms.— The pheDomena of d^
lirium tremens vary remarkably, from the slifbteK
forms of nervous tremor with spedral illofiBtti.
and accelerated pulse, to the most aUminf km
of vital depression, muscular agitatioa, ud
mental alienation about to be noticed. D*.
Blakb has marked out three sls^ into m\aA
the disease may with propriety be divided. U
should, however, be recollected, that thsv are 9*
always obvious or clearlv defined; that tfcry
exist only in those cases which supsrveae o& tb
abstraction of the intozieatiiig stimulus; tbitthe
first stage is wanting in those that nere inoc^
diately follow intoxication, and cooseQueatlr a
most, if not all. the ^rtt species here described,
and that, in the species now being eonridered, it
is but seldom brought under the cogaitaaee ef
the physieian, — medical aid being seldom reqviiH
until the second period is developed. As ^
treatment may be more precisely sUdtd wben At
disease admits of a division into stages, I flx'l
adopt that suggested by Dr. Blakx, and wkkl
differs but little from that which luu bfca fo'*
lowed by Dr. Lyon, Dr. Ryak, and Dr. Bit*«

flAVSEV.

12. The Jirtt ttat$ of tme delirium treofs
frequently appears rrom two fo eight or ciar
days after a protracted debauch, or a probn^
fit of intoxication : and is cooimonly attended ^7
slight febrile action, and gastrie derasgeBirat,
often aggravated by some accidental ctutt, ei-
teroal injury, or contingent ailmeet (j 9*.
generally the immediate effect of excesKS; bet
the length of time which elapser betwtea '^
abstraction of the accustomed stimulus, ssd tk
commencement of the symptoms, is oftea aac^*
tain. The first indications of the disesse re.
according to Dr. Blaxb, a peenliar sIovbm sf
the pulse, coldness and clamminess of the btodi
and feet, general debility, and diniaaiiee of tk
animal temperature. In addition to tba«.
nausea and occasional vomiting, oartieiilariT is
the morning ; much diminnbon or appetitr. •»
aversion from animal food ; exceanve pa»)NisM
from trivial exertion; frightful dreams; vrrtfo.
and sometimes cramps of the exireuiiue^ f*
complained of. The bowels are eftea ees^
pated, but sometimes open, or even rdaxcd. tM
the tongue is tremoloiis, foned, and bmi* I*

500

DELIRIUM WITH TREMOR— PaoaNOBis—pATHOLOOY.

first species (the encephalUit tremefacient) of this
kind of delinum, by its coining on a short time
after a protracted intoxication, instead of im-
mediately upon it; by its being caused indirectly,
instead of directly, by the abuse of intoxicating
liquors ; and by the pulse being stronger and fuller,
the head hotter, the face more flushed, the surface
of the trunk warmer, the delirium mofe violent,
and the patient more irritable, the tongue drier
and redder, and the vascular excrement com-
paratively greater and more sthenic, in the firtt
species ($3.), than in the second; although oc-
casionally a few cases of the latter approach these
characters of the former. — (6) Ihe same dif-
ferences, but in greater degree, exist between
delirium tremens and pkrenitis, in which are
wanting the cold, copious, clammy, and peculiar
perspiration, the soft pulse, and the moist tre-
mulous tongue and hands. The impatience of
light, and fulness of the vessels of the eyes, which
accompany the latter, are not present in the
former. The illusions, also, of delirium tremens
are peculiar, and are accompanied with an
anxious, fearful, and constant reference to con-
cerns which had previously interested the patient
in a particular manner. He can recognise his
friends, and return a rational answer to some
questions; and he is more tractable and ma-
nageable, when not irritated or opposed, than in
phrenitis. — (c) This affection may be readily
distinguished from the delirium of fever or typhut,
by the history of the case — it being the primary
and the most prominent ailment ; delirium gene-
rally supervening late in fever. In this disease,
the patient is quick in his movements ; is agitated
and talkative ; is desirous to be up ; walks about,
when permitted, in a hurried manner ; is anxious
to follow his occupation, or to avoid, or to find
out, or to chase away, some spectral illusion that
haunts him ; and is violent when opposed : in the
delirium of fever, the patient is prostrate, his
countenance less wild, his delirium is lower and
quieter, and seldom attended by attempts to get
out of bed, &c. (See Delirium, $3. 7. 10.) In
the former, there is a marked tremor of the hands,
&c. from the beginning, and the patient in the
last stage seems to search after objects which he
thinks he sees creeping over his bed, or floating
before him : in the latter, the. peculiar tremors are
wanting ; but there are subsultus tendioum, and
picking at the bedclothes, or floccitation. — (d)
From maniacal insanity it is to be distinguished
chiefly, as stated above (6), by the great frequency
and softness of pulse ; by the copious, cold, and
peculiar perspiration ; the tremulousness ; by the
nistory of the case, — ^this being an acute, the other
a chronic malady. When, however, it occurs in
the puerperal state, in which I have seen it, the
difficulty of distinguishing it from the mania
sometimes supervening at that period may be
considerable : the tremors, the greater frequency
of pulse, and more copious and colder perspir-
ations, will point out the nature of the affection,
and will lead the physician to treat it according
as the symptoms indicate a greater or less pre-
dominance of nervous exhaustion over vascular
excitement.

17. V* PaooNOsi8.-^A first attack, an a con-
stitution not yet much injured by the cause of
the disease, generally terminates favourably. I
have seen even a third attack end so; but its

more frequent recurrence, particularly if H be
attended oy signs of vascular irritation or erelhiiB
of the encephalon ($5. 15.), or by dryness of tbe
tongue, and its complication whb some ot^r
disease, are circumstances indicating great dange.
A want of correspondence in the pupils, and \hit
supervention of subsultus teodhaara or coorr:!*
sioos, or of low and muttering delirium, the p«bi
becoming quicker and smaller, are geacrall)- fitti
signs. It IS also more dangerovs when caimd bf
opium, than when proceeding from tntoxicatia^.
On the other hand, a general mitigmtioB of ibe
symptoms, less frequency of pulse, w}$h qaiet v
sound sleep, are indications of a faTonrablc lef-
mination bieing at hand. In all cases, however,
a cautious prognosis should be given, partieolvly
in broken down constitntions ; for avcccsi may
elude our best efforts, even when moat anticipated ;
and recovery may take place in the most ap-
parently desperate circnmstanoes.

18. Vl. Patbology. — A, The appaarameti ia
dismction have fumbhed only negative informatioe
as to the nature of the disease. In the tree
delirium tremens, the membranes of the tnix
evince but little change ; the chief lesioo cos-
sistine of slight opaciw of the aracbaoid, e»-
peciaTly at the base of the brain and viciaitT.
The pia mater is somewhat injected, and a ih^
effusion of serum is occasionally observed in tbe
ventricles. These appearances are, however, aci
constant ; but they are more marked, and mm
manifestly inflammatory, in those cases wfaad)
have accompanied or directly followed ialob*
cation ($ 3.). In these, the vessels are oftea
much congested, particularly those of the velin
interpositom, the arachnoid thickened, and ibe
serum more abundant, and occasiooaUy eva
sanguineous. The stomach generally ynaast
appearances of chronic gastritis, the vilhws

brane beinff either thickened or softened, or btfts
and the villi effaced. The Uesr is — =— -

diseased, — often enlarged, granulated, of «
yellow or fawn colour, or presenting the fatti
degeneration^ The lesions, hovrevcr, of itf
stomach and liver, are coincidences only, c
changes contingent on the habits of the paiirr.
and not necessarily connected with the ytihak/^
of this disease.

19. B. The nature of this disease has bees «
subject of much discussion with modern wnler.
in coa«equence of no clear distinction having hti'.
made between that form of deliriora with tress*',
which is the result of vital, and panicaisfh
nervous, exhaustion ; and that which dcp(»:>
chiefly upon excited circulation, vascular efetl<»».
or inflammatory acMon, within the head. Althoo;^
numerous instances ^iU present ihomirlin ^
which the former as weh «s the latter pathobfirs'
state exists, the one, however, yredomioaiiag ««•'
the other ; yet the fact of eithet hmhg yitma\
almost solely, if not altogether so, pcehsps w i
still greater number of cases, should not be on-
look^, as it has been fully demonstrsled, both H
the post mortem appearances, and by the j«v«s:.3
and Isdantia during life. It is most orohsMv •)
consequence of having noted the caac^ «(•
served principally in tlw Jhvt species, or is «•<«
instances of the aeeond as approach it ihe oesit-*.
that Dr. CLurrEaaocK and Dr. Bbiost knf
viewed this latter as the eoosequsDce of iaiss-
matory action in the anohaoid sod pia aster.

603

DELIRIUM WITH TREMOR —TRfiATMRNT.

propriety of prescribing cathartics, ia order to
remove accumulated secretions. From the quan-
tity of very dark, offensive, bilious evacuations
which they have procured, — often not until after
their repeated exhibition, and even in cases
where the bowels had been opened or relaxed, —
I have coucluded that collections of vitiated bile
in the gall-bladder and hapatic ducts have fa-
voured the supervention of this peculiar affection.
Under this conviction, I have always exhibited,
OS early as circumstances would permit, an ac-
tive chologogue purgative, generally a bolus con-
sisting of about ten grains of calomel, with as
much camphor, and a grain of opium, in conserve
of roses ; and, in a few hours afterwards, a warm
stomachic and aperient draught, followed in
an hour or two by an enema ^F. 135.). The
advantages arising from conjoinmg camphor, or
large doses of ammonia* or capsicum, or other
stimulants, with purgatives in this disease, are
manifest ; for, by these or similar means, we shall
succeed either in arresting its progress, or in pre-
venting the depression which might follow copious
evacuations — fears of which have paralysed the
treatment of it. In all cases, but especially in
diseases accompanied by low or melancholic de-
lirium, accumulations of vitiated bile or other
secretions should be suspected and be removed :
nor should we infer, from having at first failed in
procuring their discharge, that uo such disorder
exists; for the most active, and even the most
judiciously selected, cathartics may long fail in
evacuating the thickened and morbid contents of
the gall-bladder and hepatic ducts, particularly
when their excitability has become exnausted by
spirituous potations.

25. b. In the second stage — if it supervene
notwithstanding the above means, or if the pa-
tient be not seen until it has appeared — the
treatment should be commenced by the ex-
hibition of the calomel, camphor, &c., as pre-
scribed above ($ 24.), if they have not been
already exhibited, or if they have not iirocured
copious, dark, and offensive stools ; ano evacu-
ations ought to be promoted by warm and sti-
mulating aperient draughts, and by purgative
enemata containing assafcetida, camphor, &c.,
or consisting of F. 130. 149. The greater number
of the cases I have seen had been treated by able
practitioners, according to the plan advised by the
best writers, but without success — although
purgatives had been given where the bowels
had not been sufficiently open. In all • these,
this treatment was immediately put in practice,
and assisted by cordial draughts containing some
one of the ammoniated spirits, and tethers, 6cc.,
and by the enemata already alluded to. As
soon as alvine evacuations were procured by these
means, oinum, either alone, or with ammonia or
camphor, or with both, was prescribed in full
doses« and repeated according to its effects ; and
although they were all severe cases, one only
terminated fatally.

26. At this^ period of the disease, the warm
batht at a temperature of about 90^, will assist
materially in tranquillizing the patient, and pro-
moting the effects of opium. Dr. Wright, of
Baltimore, strongly recommends it ; but it is not
a new practice in delirium tremens, as he sup-
poses ; and he is favourable to the use of Dover's
powder, which, howfver, is more suitable to the

preceding species. Although opium should ht
given in full or decided doses, combined as iti:«ii
above, — (in from one to three or (bur grains ^tU
smaller quantity being repeated twic« or thnr«,
the larger not oftener tnan onoe, and afur a
longer interval), — it should not be perdstcd ia.
unless sufficient time be allowed to elapse afw
each dose ; for, as Dr. Pkarson has observed, d
it does not succeed after its exhibition at fiist a t
decided manner, it increases the intelleetoal cm-
fusion and danger. Some of the American pkv
sicians have recommended enormous doses of ti*
medicine. Dr. S. Brown gives from 5 j. to ,;<^.,
or even more, of laudanum for a dose. Dr. S.
Jackson prescribes from ten to fifteen or tvea
twenty grains of solid opium every two bour<,
and states, that four ounces of good laodaour.
having been given in twelve hours, paillv tt
mistake, a sound sleep of twenty-four koa^'
duration, and perfect recovery, were the re»ul'.
I only am surprised that the sleep was not Out
of death. These are not solitair instances of tb«
extravagance, if not rashness, of some Americu
practitioners; nor, indeed, has the practice ^
giving excessive doses of laudanum in this afc -
tion been limited to them. When we find tkrtt
or forty leeches ordered to be applied to the thrott
of a child five or six years old in croup, lad
repeated ofteuer even than once, and the blev^<
ing promoted, should we wonder that deiib
ensues ? Feats of hardihood in medicine are tx
often the consequence of clerical and pracuH
ignorance; and they nmy be allowed to mct\
their own reward, as long as they are not oV
truded into the annals of our science, and tbci^tr
set forth to the inexperienced as examples u> U
followed. But when this distinction is cooferrtii
on them, it becomes the duty of those who reccri
the progress of medicine, to note also, and tc
oppcHse, its backsUdings by the severest rcpr^
hensioos.

27. I believe that lai^e and frequently re-
peated doses of opium in this disease, as Dr.
Wright, of Baltimore, has remarked, iavoar the
supervention of coma, convulsions, or paial)ii« .
and that the effects of an excessive qoantit) <i
this drug very nearly resemble the phenomeas of
the last stage of the disease, jparticularly lowud*
its fatal close. This fact should not be ortr.
looked, and should lead us to distinguish betwees
the consequences of an injudicious treatmeat,
and the worst features of the malady. It b i'-n
abuse of opium that is here argued against ; it>
truly medicmal exhibition that is conteoucd (w, —
given in a quantity which sound sense will d)c*>'^.
and after accumulated and morbid secretjoia i^"
excretions have been removed, the dischtr|* if
which might be impeded, or interfered witii, b) \i.t
immediate employment of this valuable reiMd}.
I consider opium as neocasaty to the care of t!k>»
disease, as bark and analogous medicioc«» are to
the cure of ague; but, as in their case, th«
morbid colluvies, which has at least disposed tU
system to be affected, and aggravated the rnaUi .
should be removed, in order that recovery mj
be ensured and be permanent.

28. In this stage of the disease, pa/iicaii;l>
when the delirium is attended by much agitara«
or violence, it is necessary to obtain an inloeoa
over the patient's miud by moral mcaw. A^
irritating eontentknis, however, shooM be avoided .

DELIRIUM WITH TREMOR --Tiieatmbkt.

603

and the patieiif i wislu»« when not likely to prove
ioiunouft to him, be indulged. By thus granting
wbtt is leas material, he wili more readily submit
to what is important; but he ought not to be
left a moment without an attendant. Coercive
measttres will generally be found unnecessary,
if soothing and indulgent but firm treatment be
adopted, and the warm bath be occasionally
resorted to. In a majority of instances, the above
means will be followed by a remission of the
fiymptoms, and a disposition to sleep will mani-
rest Itself, ^sometimes, however, accompanied by
nervous rigon. Opium should now be left off,
or its dose much diminished; and the patient
kept as quiet as possible. His first slumbers are
often short, broken or interrupted by atartings, or
temioated bY fright. If he awaken alarmed,
his distreas snoula be soothed, and a moderate
dose of opium with warm apiced negus or punch
may be given him ; these will generally secure a
■oond sleep, from which he will awaken in a
rational state of mind. Afterwards it will only
be neceasary to support the strength b^ light
and nutritious diet, and gradually diminish the
quantities of the restoratives that have been
preBcribcd.

29. In caae^ cbaxacterised by much vital de-
presion, very frequent pulse and cold surface
oeconing in old and habitual drunkards and
broken constitutions, a liberal use of cordials,
aod even a moderate quantity of the accustomed
ifimalas, in addition to the opium, should be ad-
nioister^ from time to time ; particularly if the
iKad be cool, the face pale, and the action of
the carotids not strong. On the other hand, in
thoie cases which were described ($ 15.) as ap-
proaching the first species of the disease, cupping,
or the application of leeches on the occiput,
or nape of the neck, or behind the ears, will be
r«]uisite early in this stage; and full doses of
calomel, and the r^st of the purgative treatment,
with cold applications, or tepid affusions on the
head, should be more actively employed, and
pKcede the eihibition of opium. In this state
of the disease, opium often amavates the symp-
toms, unless It follow a judicious use of these
remedies; and other excitants are equally in-
jurious. In these cases, James's powder, or
antimony, either previously to, or conjoined with,
camphor and opium, will also be productive of
much benefit.

30. That state of the disease which comes
on after external injuries or operations ($ 9.), I
have imputed chiefly to the previously intem-
perate habits of the patient. It requires the
same treatment as the more nervous or vitally
depressed cases now alluded to ($ 29.) ; and, as
well as these, will be remarkably benefited by
small clysters contatniog moderate doses of lau-
danum, administered after the bowels have been
Bufiiciently evacuatedt and repeated according to
circamstanoea. This treatment has been much re-
lied upon by M. Dupu ytren ; but if it remove not
the disorder, after sufficient time has been allowed
for its operation, camphor may be added to it ;
and ammonia, musk, aether, &c. be given in suit-
able vehicles; or a moderate quantity of the
patient's favourite beverage allowed him, as sue-
gertfid by Dr, Collxs. Of two cases recently
reported (3fid. Gauttt, vol. vii. p. 287.), which
confirm the view I hate taken of the origin of

traumatic delirium in that state of constitution
which intemperance induces, opium failed in
one; and hydrocyanic acidt which was tried in
the other, was equally unsuccessful.

31. c. If the third ttag$ appear notwithstanding
the above treatment, little hope of recovery can
be entertained) as most likely serous effusion has
become superadded to exhausted vital and nerv-
ous influenoe. Nevertheless, medical aid should
not be withheld, especially if the patient have
not received it in tfie earlier periods, or hnve
been treated injudiciously. The hair should be
removed from the head, and either a blister ap*
plied, or one of the liniments (F.299. 308.) nibbed
upon it. A blister, sinapism, or other rubefacient,
should also be applied over the epigastrium ; and
camphor, ammonia, musk, capsicum, &c. liber-
ally administered ; restoratives and stimulants
being also exhibited in clysters. Mercurial lini-
ments containiog camphor may likewise be rubbed
upon the inside of the thighs, and the warm bath
resorted to.

32. d. Certain modts of practice have been em-
ployed, to which a brief reference may be made.
Dr. Klapp, and some other physicians of the
United States, have recommended tartar emetic
in frequent doses, until it nauseates and purges
the patient; but this treatment is more appro-
priate in the first species, or in such cases of the
second as approach it must nearly ($15.) Dr.
Speranza, of Parma {Bullet, da Scien, M^d.
Sept. 1830.), directs leeches to the head and anus,
applies ice to the scalp, and gives calomel and
jalap, and subseouently hydrocyanic acid. This
metliod is obviously suited only to the first species,
and would be injurious in most instances of the
second. From the preference he has given to
the appellation adopted by J.Frank, — Ence^
phalis tremefaciem, — I would infer that he has
never prescribed it in the true delirium tremens.
Dr. A. L. PiERSON (N. Eng. Journ, of Med.
and Surg. vol. ix. No. 2. ^p. 1820.) states, that
he gave very large doses of digitalis (sixty drops
every three hours) after bleeding, and the pa-
tient recovered ; but this was evidently a case
of this first form of the disease. Dr. Pauli in-
forms us that he has prescribed from three to six
drachms of fresh ox-gall, in aromatic water, half a
glass of brandy each morning, and two grains of
the watery extract of opium at night, in forty-
three cases, and has lost only one (Med. Gazette,
vol. ix. p. 776.). The propriety of having re-
course to moderate quantities of the stimulus to
which the patient has habituated himself, in the
depressed periods of the disease, and especially
in those cases which present the more marked
signs of exhausted nervous and vital power, has
been insisted on by Dr. Blake, Dr. Kyan, &c.,
and admitted above, as well as by others; and
quiuine, capsicum, the preparations of bop, and
various aromatics and cordials, may be also used
as adjuvants of opium.

33. e. During the treatment, little or no nourisii-
ment is desired, or even required : arrow-root
and sago, with a little brandy or white wine, may
however, be given from time to time, particu-
larly if the patient wish it. When he becomes
convalescent, the diet should be very light, but
nutritious; and a suitable beverage, in moderate
quantity, be allowed. During recovery, the state
of the digestive functions ought to be attended

Kk 4

504

DENTITION, DIFFICULT— Pathology of.

to, and promoted by tonics, and by aperients |
whenever the bowels are torpid. I have never
known or heard of an instance wherein the state
from which the patient has escaped, or tlie re-
presentations of the medical attendant or friends,
nas effected a reformation of the habits which pro-
duced the disease. However, the physician should
dischai^ge his duty, by stating to him the conse-
quences that will accrue from persisting in them.

BiBLioG. AND Rkter. — 5. B.^Pear$(m. Obfcnr. on

Brain Fever. NewcMtte, 1801 M*Whirter, in Med.

and Phyg. Joum. vol xvill. ». 153.— T. Suthm, Tract*
on Delir. Tremens, Ac. &c. Sva Lond. I8ia — Arm-
MiroHg, On Brain Fever ftx>m Intoxication, in Edin.
Med. and Surg. Joum. vol Ix. pi 58. 146. — Sieol, in Ibid.
June. 1821. — A. L. Pierson, in N. Eng. Joum. of Med.
and Surg, vol ix. 18S0. ^ S. Broum, in Amer. Med. Re-
corder, April, 1822. — JEtenp. in Ibid. vol. L ; and Eclect
Repcrt. vol. vii. p. 252 — Smnvdett, in Ibid. vol. r.—Phw.
fair^ On Del Trem., in Transac of Med. and Phyt. Soc.
of Calcutta, vol. i. a 124, — CoAtei, in North Amer. Med.
and Surg. Joum. vol. iv. ; and in JohjumC% Med.-Cliirunr.
Rev. vol. viiL N. S. p.iSJ.^Ctuteerbvck, Lecture« in
Lance^ vol. xi. p 37&-. Barkkausen, in N. A. Med. and
Surg. Joum. vol. vii.^L^Mitt^, M6m. aur la Folic dct
Ivrognes, in M§ra. de TAcad. Roy. de M£d. torn. L 4to.
Paria, 1828. p. 181 — Xvan, in Lond. Med. and Surg.
Journ. vol iii. p. 227. — HeUs, in Archivcf G6n. de M£d.
t. XV. p. 490. — A. Blake, Fract Treat, on Delirium Tre.
mens, &c. 8vo. 1830. : and in Edin. Med. and Sure Journ.
Oct. 1823, p.SOl — T.H. WHgkt, in Amer. JouraTof Med.
Sciencei, vol. vi. p. 17. — 5. JackumAn Ibid. vol. viL p S6i.

— /. Carter. On Mania k Polu, in Ibid, vol vi. p. S2l

If «rr. On the HUtory and Treatment of Delir. Trem.
8vo. Boat. U. 8. 1831. — Brigkt, Medical Reports, vol. ii.
P*f*KP-^? ^^ ^% — HiHgerton, in Lond. Med. Gai:

^®*iH*-^;-^^*?^*^^ *" ^^"^^ P.466.-J. JoAnjoi.,
reported in Lancet for March 20. 183J.

DENTITION, DIFFICULT.— Syn. Dentitio
difficilU^ Odontio DentitionU, Good. Dys-
odoHtiasis, Ploucquet. Difficult Teething,
Classif.— 1. Cfau, 1. Order (Good).
II. Class, I. Ordfr (Author),

1. Depin. — Slow or delayed ewlution of the
fee/ A, with tipu of local irritation, and con-
Mtitutional disturbance, often with disorder nui-
nifested especially in the digestive organt and
nervous systems, occurring chi^y in weak or over-
fed children,

2. A general view of the pathological relations
of dentition was exhibited in the article Ace
($10.); and, therefore, only that morbid con-
dition of the process which is unattended by
disease of an important organ, and is rcferrible
chiefly to this process it?eU, all hough often caus-
ing disease, or being accidentally associated with
it, will be here noticed.

3. i. Dentition, in the most favourable cases, is
preceded by slight salivation, by beat and fulness
of the gums, occasional flushings, increased thirst
restlessness or fretfulnrss, and frequent endeavours
to thrust things into the mouth, evidently to allay
irntaUon or itching. These symptoms generally
appear about the third or fourth monih, and pre-
cede the appearance of the teeth somedmes by
several weeks; and occasionally subside, and re-
appear shortly before the tooth make? its way
through the surface. These signs of disiurbance
arc merely the necessary attendants on the form-
ative processes going on in the gum. But very
commonly in children of deficient vital power,
and occasionally in those which are apparently '
robust, or rather plethoric from overfcwling, den-
tition M either delayed, or is attended by more
senous disorder, particularly while the canine
teeth are being protruded. In delicate children
particularlv those living in crowded towns, and
low and ill-veotilated TocaliUes, this process is

both late and slow in taking place, and is oftia
attended by signs of incre^ed irriutioo, a» red-
ness or tumefaction of the gums; by vinot»
cutaneous eruptions ; by greater fretfulness, soiDe-
times sickness and feverishneaa towards sight,
with restlesness, fits of crying, and sudden surt-
ings from sleep. These may be the only ailmeais,
which may subside either partially or alfcogetbcr
as soon as the tooth has passed tlie siirfiioe, sad
return shortly before others come in sight; JMt
not infrequently, particularly in this dasi «f
patients, disorders of the prima via, particulsrif
chronic diarrhoea, slight dyseoteric actions cr
slow remitting forms of fever, obstructioo or eo-
largement of the mesenteric glands, ofaatinate sad
recurring coughs, tubercular degeneration ia tk
lungs or digestive tube, maraamaa. &e., soptr-
veue more or less rapidly.

4. ii. In children who are of a plethoric niher
than of a robust habit of body, and which Dr. J.
Clarke has, with much justice, ascribed to onr*
feeding, the gums are otten swoHen and paiafsl
the face flushed, the head hot and puned ; sod
all the symptoms of inflammation of the bmbi-
branes of the brain, or of ioflammatory feitf
with determination to the encepbalon, freoueaLlr
supervene. In them, the symptomatic fever a
generally hi^h, and attended by great thim.
nausea, vomitings, constipation, and occasiaaally
by drowsiness or stupor, or by great initabditT
and restlessness, or by both states of disoidcr ai-
ternateljr; sometimes by short l>rdken slombcss,
/rom which the child awakens in a state of al«nt«
or in a fit of crying ; or by convulsiQttS, dl-
mibished iecretion of urine, and other signs of
cerebral afiectioo. These are the usual cfio-
comitants and symptoms, or ooofleqoeoces, of
diflicult dentition ; but thiey do not alwayi stop
here; for tliey often run on into more serioos
disease, — such disease, however, occasiooall,«
appearing more abruptly and without these pn-
cursory ailments, at least in such degree or dtt>
ation, as to become objects of attention to the
attendants, or to lead them to resort to mt^ctl
aid. These maladies, although ofien ooeasootd
either partly or chiefly by dentition, whee or-
curring in children at that epoch ; aiMi irbeiher
aflPecting the cerebral, the thoracic, or the ab-
dominal organs, or tlie skin; are still morelre-
quently independent of this process, and therefore
cannot be further alluded to in connection «lik
it, than they have already been in another pUee
(see Aoa, $ 10.); — and/tndeed, in meet iastaooa
in which a close connection between them sad
diflficult or morbid dentition is observed, it is tbtf
of concurrent effects of coostitntional pfe*!^
position and of anterior changes in the otput
functions ; the local irritation and sympatbeur
febrile disturbance eitlier exciting morbid actioB
in such organs or tissues as, from hereditary era-
formation or vice, are disposed to it ; or a^s*
vating previously existing disorder, and rcoderaf
evident what was before latent, or aoofascntd.
In these cases, therefore, dentition is to be looit^
upon either as a principal, or as a cooc«nt«t
exciting cause of many of those diseases wkirh
occur at the period of dentition — bot a caa«
most frequently concurrent with improper firtdis;
and clothing.

process is , may

5. iii. A nataral or slightly diificalt deotit«s
ay be converted into senous disease, by ths aec

DENTITION, DIFFICULT— Tbeatment.

505

QQCommon babit of giving the infant food when-
erer it cries from the initatton attending upon the
process, and thereby overloading and nirtner dis-
oHeriog the digestive processes, which are already
disordered by the feorile disturbance generally
aooompao jing it ; whilst determination of the cir-
culatioD to the head is favoured by the practice of
coTering the head in^doors or when asleep, and by
weariflg thick felt hats during mild or warm
weather. Brandis believes that diflicult den-
titioQ is the consequence of obetniction of the
stlivation which accompanies, and is salutary in,
this process : Hbckxe, that it results from a mor-
bid state of this secretion : Myuus, that it is the
effect of disorder sympathetically induced in the
IJTer: Thom, that dentition often occasions an
acrimony of the abdominal secretions, which
react upon the original seat of disorder, and upon
the system generally ; thereby rendering it difficult
or morbid : Wioakd, that the affections attending,
<^'*7iD^f and otherwise disordering, this process,
are accidental complications merely ; and John
CuBKB, that all such disorders are commonly
(be coQsequenoea of plethora arising from over-
feeding. Now, in all these opioions, there is
much truth ; and one or other, or several of them
obtain in many instances, more, however, as con-
tiogeot and related effects of the local irritation,
than as causes of the difficulty of the process,-—
which irritation is the chief or concurrent cause of
febrile disturbance, of disordered function, and at
last of more palpable disease, according to the
eoadition of particular organs at the time, and
coDstittttional or acquired predisposition.

& iv. The trmpium of the Mtcond or permanent
teeth may also be delayed or attended by sym-
pathetic disorders, particularly in persons whose
Moxif/c are insufficiently developed, and when
the dtnttt sspinites, and the canine teeth, are ap-
pearing. In delicate, nervous, and irritable sun-
jecti, swelling of the parotid and sub-maiillaiy
glands, painful and sometimes periodic aftections
of the ear or face, slight or recurring opthalmia,
irregular convulsions, or epilepsy, ana chorea,
have, in some instances, been excited by this
caose; and have disappeared upon the eruption
of the leeth, or the removal of the local irritation.

7. V. The Tbeatment of difficult dentition
should be directed with the intention — 1st, of re-
ntoviDg the local irritation ; and, 2d, of subduing
the sympathetic disorders associated with it. — il.
The local irritation requires scarification of the
guiDf whenever they are at all swollen or red ; and
particularly in the second stage of the process,
*bea ilie tooth haa reached the surface, whether
tliere be redness and swelling, or noL The pro-
priety of this operation has been, however, called
10 questioB, particularly by Sternberg, Storch,
Thom, and basNois, on the plea of its inutility,
of it occasioning ulceration or disease of the cap-
sules of the teeth, and of the cicatrix which is
sooQ afterwards formed being absorbed with greater
(lifficiilty than the other parts. But these are by
DO means valid objections — for its utility has been
pr^ed b^ the experience of Harris, Cowper
(Anat. ef tht Hum. Bodv, ^c), Bromfield (06-
<erco(iait«,^c. vol. ii. p. 17.), Berdmore (Tre4ttise
»« the Tteth, ^e, 8vo. Lond. 1770.), Hurlgck,
HriDUN, W EnEKXND, Kennedy, M arley, myself,
and most modem writers of experience : and, as to
ibc eoatingent nlcerttionof the gums, it seldom or

never occurs when the operation is judiciously
performed ; when the lancet is clean, not carried
too deep into the gum, if lancing be performed
early in the process ; and when its edge is directed
rather outwards, as recommended by Mr. Mar-
ley. That the cicatrix may oppose the passage
of the tooth is certainly not proved ; but this, if it
did, is no objection, as a repetition of the opera-
tion, is often necessary, and generally beneficial.
M. Brouzbt {Sur FLducat, Midic, det Enjani,
t. i. p. 234.) advises the surface of the ^um to be
divided, from time to time, by the point of the
nail,— >a practice which possesses the advantage of
not alarming the childy of being easily and readily
performed, and of delaying the closing of the
divided part. But care should be taken not to
perform it until the naib have been well cleaned.

8. The propriety of allowing the infant to rob
the gums witn hard substances has been ques-
tioned by Auzebi, Mablby, and others, from an
idea that thev will hereby become more callous,
and absordea vrith greater difficulty. But the
truth of this is questionable. I believe that sub-
stances pressed frequently between the gums,
materially lessen the irritation and distressing
itching Nslt in them, and promote the flow of
saliva, — results of no mean importance in pre-
venting the superveotion of sympathetic disturb-
ance. These results will be ensured, in cases of
existing irritation, by frequently moistening what-
ever substance is thus employed with biborate of
soda mixed in a little syrup of senna.

9. Besides the above, various other means have
been recommended in order to subdue the local
irritation : the chief of these are — a preservation
of a lax state of the secretions and bowels;
leeches, particularly behind the ears TSyden-
HAM, KoRTUM, Stoll, Leroy, Jowm, at Paris,
1784.); internal emollients (Paulus ^Eoinatus,
1. i. cap. 9., and Besker, Hermet. Rediviv,
p. 705.) ; various derivatives (Hvpelano) ;
calomel (Myuvs and others); the alkalies
(Heceer) ; cold applied to the face (Wicand) ;
opium (Weoexind) ; and active purging (Van-
DERMONDE Bud PoRTAL., AsuU MidicaU, t.i.
p. 2 11.). The best means of promoting the se-
cretions and alvine evacuations are, small doses
of hydraig. cum creta, conjoined with the dried
carbonate of soda, and, if the state of the bowels
requires it, with the pulv. jalapae, given every
ni^ht. Lcieches behind the ears, and cold ap-
plied to the head, should dever be neglected
whenever the temperature of this part is in-
creased, and other signs of determination of the
circulation to it are observed. In such cases
active cathartics, calomel with James'a powder,
and the rest of the treatment recommended for
cerebral diseases, are necessary. Blisters applied
also behind the ears are the best external de-
rivatives ; but they should be removed as soon
as redness is produced. Opium is very seldom ad-
missible ; but, if much irritation exist, the tepid
bath, and syrup of poppies with small doses of the
biborate or the carbonate of soda, may be pre-
scribed. If the gums become ulcerated, biborate
of soda or sulphate of alumina, or the boracic acid,
in honey or syrup of roses, should be employed.

10. 6, The tympathetic diaorden should be sub-
dued as soon as thcjr appear^— (a) If the head
indicate vascular excitement, the means already
specified (( 6. 8.) should be directed ; and if

DIABETES — Symptoms.

507

I

Ceuus. Aaitavs gHve a tolerably eotnplete
history of it, which the mAjority of his followers
merely copied. Alexander of Tralles added
nothing to either its pathology or treatment, ez-
ceptiog the drawing of a comparison between it
and Ueotery; and Abtius, taking up the same
idea, i^tates, that the one affection differs from
the other in as far as that the undigested aliments

ajs off, in the former by the urine, in the latter

y the stools ; an opinion which was afterwards
adopted byFERNEL, Dvret, Zacutvs-Lusitakus,
aod others. BatWiLLis was the first who advanced
a rational theory of the disease. Since his time,
opioioDs as to its pathology have beeti various, and
the remedies recommendea still more diversified.

3. Even up to the present day, the term dia^
betet has been applied to various states of dis-
ease : — 1st. To that consisting chiefly of diuresi*,
or morbidly increased flow of Urine, without
reference to its quality ; 2d. To that in wliich
the uriae is voided not only more frequentlv, and
in larger quantity than natural, but also of
cbaogni quality, as respects certain of its con-
'titueots, viz. albumen and urea, either of which
nay he in excess ; and, 3d, to that in which a
saccharine matter is either superadded to the
other ingredients contained in the urine, or in
part replaces them. To the last of these morbid
i»tates I shall limit the term diabetes, conformably
with the views of Dr. Prout and M. Kenauldin.
The other morbid conditions of the urine will be
Doticed when treating of the pathology of this
McretioQ. (See Urine.) Restricting, therefore,
the term diabetes to that state of the urine cha-
racterised by the presence of saccharine matter,
I have defined it accordingly. In consequence
of the very vague ideas which have but too
generally been entertained both as to the phe-
Qomena requisite to constitute this malady, and
u to its various morbid relations, diabetes has
generally been considered with reference to the
qaaotity of the fluid secreted, without regard to
the circumstance alluded to by Dr. Parr and
otben, and judiciously insisted on by Dr. Prout,
that the disease mav exist for a lone time, and
the urine be extremely saccharine, without much,
or even any, increase of its quantity ; and, when
the urinary discharge is augmented much beyond
natural, that it is much easier to reduce it even
^ the usual quantity, than to restore it altogether
^ ii<i natural quality.

4. 1. Symptoms. *— A. The vrtns of diabetic pa-
tients is generally of a pale straw or greenish
yellow colour; of a faint and peculiar odour,
iometiaies resembling that of hay or of sweet
*hey or milk, or of violets. Its taste is always
iQore or leas saccharine ; and its specific gravity
usually varies from 1*025 to 1'052. The quantity
of urea is seldom much diminished in diabetic
urine: Dr. Provt and Dr. Henry have never
c»b^rved it altogether absent ; and Mr. Kane and
Mr. M*GazooR have found it in greater relative
proportion than in healthy urine, but masked by
the sagar or saccharine matter held in solution :
there ia little or no lithic acid. The usual saline
ingredients in healthy urine eiAst in the urine of
diabetes, but in diminished quantity, whilst their
relative proportions continue nearly the same.
Dr. Watt has found a little blood in it ; but this
i« a rare occurrence: it much more frequently
contains albominotti matter analogous to that of

chyle. Dr. Henry has given a useful table,
showing the quantity of solid extract in a wine
pint of urine of dlfiferent specific gravities from
1*020 to 1-050. The following abstract of this
table will enable the reader to ascertain the quan-
tity of solid matter diabetic urine may contain : —

«r water at (W*.

Qiuatitj of aoUd «x.
trael ttt • via* pint.

QnnUtr of MUd •■.
tract fa a vta» plat,
111

lOSO

SS^t

M. dr. tar. an.
0 6 18

1091

401-6

0 6 9 1

102S
10S3

480-8

0 7 0 0

440-0

0 7 10

1024

4598

0 7 1 19

1085

478-4

0 7 9 IB

1086

4^-6

1 0 0 17

1()S7

516-8

1 0 1 16

1028

536-0

1 0 9 16

1089

655-2

1 1 0 15

1030

574-4

1 1 1 14

1031

593-6

1 1 2 13

1032

612-8

1 8 0 18

1033

fiSiO

1 9 1 18

1034

651-8

1 8 9 11

im

670-4

1 3 0 10

1036

689-6

1^19

1037

• 708-8

13 9 8

1038

728-0

14 0 8

1039

747-8

14 17

1040

7664

14 8 6

IMl

785-6

15 0 5

1042

804-8

15 14

10«3

. 824-0

15 8 3

1041

8432

16 0 3

104&

862-4

16 18

1046

881-6

lis]

1 7 0 0

1047

900-8

1048

MOO

17 10

1049

939-8

1 7 1 19

1050

95S-4

1 7 8 18

This table enables us to ascertain with consider-
able precision the quantity of solid matter voided
by a diabetic patient in a given time. Thus,
suppose 10 pints are passed in 24 hours, of the
average specific gravity 1*040, it ia evident that

this will contain 10 x 1 ..4.. 2.. 6a 15 ..7. .2, or
upwards of a pound and a quarter of solid extract.
Diabetic urine, in a moderate temperature, be-
comes sour, smells like turned milk, and some-
times ferments. With the addition of a little yeast,
it readily undergoes the vinous fermentation,
yielding alcohol oy distillation, the quantity of
which indicates the amount of saccharine matter
in the urine.

5. Besides the taccharine condition of the urine,
the next most striking and constant symptom ia
its incTBased quantity. Sometimes the quantity
voided is enormous. P. Frank details a case in
which 52 11m. were passed in twenty-four hours ;
and instances are by no means uncommon of
from twenty-five to thirty-five pints having been
discharged in the same time tor weeks, or even
months together. In some cases the urine has
been said to have been nearly double the quantity
of the whole ingesta, — a circumstance which
has puzzled physiologists to explain, and has in-
duced some to believe that, in addition to the
coUiquation of the solids of the body, absorption
of moisture from the air actually takes place
during the disease in some cases, either through
the medium of the respiratory organs or cutaneous
surface, or both. I believe, however, that so
great a diflference between the quanti^ of the
ingesta and urine, as here stated, is extremely
rare; although a considerable excess has been
proved by I&. Baroslby : and the experiments
of modem physiologists have shown that tha

DIABETES— Organic CHANOta— 'Paogkosxs amD Diagnosis.

509

Tio(i6 health of the patient, the nature of the
excidng cause, the form of the comulication, the
diet and regimen prescribed, and tne means of
cure employed. It is always exasperated during
cold and moist weather. Fbamk states, that it is
also worse in autumn. Hecesr, Thenard, Dv-
riTYTREN, and the author, have known it to con-
lioue, with intervals of improvement, for many
years ; and Oootsrdyce states that he treated a
cs« that terminated unfavourably in a few days.
VVben the issue is fatal, it commonly runs its
coarse in a few months, and is seldom of shorter
duration than several weeks. I believe that the
(liiiease not infreauently exists, for a considerable
time at least, without any veiy sensible increase of
the quantity of the urinary discharge, and that it
'» heuce often far advanced before it comes before
the physician ; and that many cases which have
been believed or staled to have been cured, have
expeneoced merely a temporary benefit, — the
malady returning in all its severity from the
(lightest exposure to its more common exciting
causes, or the least want of attention to the
requisite diet and regimen.

11. iv. Obgamic Changes are by no means
constantly observed after diabetes, even in the
nrinary organs; and, when present in them» are
Qot sQch as may account for the disease ; but, as
Hicker has justly contended, are rather its effects
than its causes. Hutberford, Home, Dupuy-
TREN, Seoalas, and Dezeiueris, have found the
kidaeyi somewhat enlarged and vascular. Bonet,
MoacAONi, Monro, Hebtsog, Cawlev, De-
iA(JLT,aod HscxEBy have observed them only more
flaccid than natural : and Cbuicssbanes, Reil,
RtTHERroBD, Duncan, and Baillie, have re-
loarked merely a more turgid state of their blood^
vessels; which Frank and Vstter have stated to
bave been more lacerable than in the healthy
state. In rarer instances, one or even both
kidneys have been observed much smaller than
Dsoal (P. Frank, MUller). Hydatids have
been found, by Beer, filling and distending
them enormously ; and calculi have been de-
tected in their pelvis by Baillov. Royscii and
HtcKER met with cartilaginous induration of their
envelopes and cortical substance; and Brodib
found tbeir structure hard and gristly. Muller
mentioosenlargement of their nerves; and Duncan
recordi a case in which the splanchnic nerves were
all enlarged to three or four times their natural
nxe. CoMRADi observed the pelvis of the kidneys
enlarged so as to contain a small orange; and
HuYscH, Rutherford, Reil, Heckbr, and
Claikx, remarked considerable dilatation of the
ureten. Increased size of either the pelvis of the
kidneys, or of the ureters, or urinary bladder, or
even of them all, is not infrequent. In some
instances, the bladder is thickened, or contracted,
and slightly inflamed, and the prostate enlarged.
All the unnary organs, however, have been found
u frequently natural, even by the authors now
mentioned, as presentiog the above changes.

12. Next in frequency to enlai^eroent and
flaccidity of the kidneys, the metetiUrie glands
have prssented morbid appearances. Mascagni,
JtJKcut, HiMLY, Reil, Home, Cawley, and
HicxER, have found them enlarged, obstructed,
tod otliervise changed ; but they also have been
met with perfectly natural, by the same authors,
M Will as by others. RuTMBBroRD and Monbo

have observed enlargement, softening, and in-
creased vascularity of the absorbent glands gene*
rally. The thoracic duct has, in a few instances,
been found greatly enlarged and dilated. The
lungs are, perhaps, as frequently diseased as any
other organ. I have never seen a case examined
in which they were perfectly healthy. Luroth,
Seoalas, Dupuytrbn, and Horn, have severally
observed tubercles in every stage of their progress ;
ulcerations, tubercular excavations, hepatisations,
and purulent collections or disseminated vomicas,
in the lungs, as well as inflammation of the
pleura, and its consec^uences — adhesions of the
pleura, &c., of the pencardium and pleura, serous
effusion into the pleural cavity, &c. M. Lubotu
detected, in addition to hepatisation of, and ex*
cavations in, the lungs, aneurism of the pul-
monary artery, the kidneys being sound. Similar
states of the pulmonary artery, lungs, and kid*
neys, were found in a case recorded by M.
Lobstein; the lungs being extensively tuber*
culated, hepatised, and adherent to the thorax*
without any manifest thoracic symptoms during
life. The digutive organs have been next most
frequently dlieased. Dupvytrxm and Segalas
have observed a more vascular state than natural
of the digestive mucous surfiace, but without any
organic change of the stomach, or intestines,
beyond dilatation of the former, and of the
duodenum, Ruthbrford and Baillib always
found the stomach healthy. The liver is more
frequently diseased. Mbad states that it was
always altered in structure; whilst Cullbn,
Frank, and Home, generally observed it natural*
Cawlby and Heckeb have comiponly detected
organic change of this viscus. The spleen and
pancreas have seldom presenied any lesion.
MicHAJELis, Con RAM, and Hecks r, detected
chyle imperfectly mixed with the blood in the
large vessels and cavities of the heart ; and the
same .authors, and Marshall, remarked a cho-
colate appearance of the blood in all the vessels.
Dr. Rutherford states that the blood was black
and fluid in all the cases he inspected. In the
cases I have seen examined, the mucous surface
of the stomach, and of the upper parts of the
small intestines, was rugous ana vascular. The
lungs were congested or hepatised, or tuber-
culated and excavated, or their pleuras adherent.
The heart was flaccid, soft, and small ; the blood
dark and semi-fluid ; the kidneys congested with
dark blood, and somewhat large ; the super-renal
capsules somewhat indurated; and toe renal
ganglia more than usually large. But these
changes are not uniformly observed ; several of
them were wanting ; and in one or two instances,
no decidedly morbid change was detected, beyond
the absence of the usual cadaverous and peculiar
odour generally perceived upon opening the ca-
vities. Upon the whole, therefore, post nutrtem
research has thrown but little light on the nature
of diabetes, further than showing that it is the
result of a morbid condition of several, if not all,
of the digestive, assimilating, and excreting vis-
cera, and not cf any one of them.

13. II. Prognosis and Diagnosis. — A, Al-
though patients whose constitutional powers are
not greatly reduced, may sometimes live for many
years, under judicious treatment, in this disease,
yet should the prognosis be ujpon the whole very
I uuEavourable : a cure may, however, be effected

filO

DIABETES— Cavibs ind Natubv o*.

by appropriate means adopted early; but this
result IS comparatively rare, and should never be
coosidered as perfect, unless the healthy quality,
as well as quantity, of the urine be altogether
recovered, and the strength and bulk of the bod^
be restored. Partial, or even ywy great, relief is
often afforded ; but the malady after a while re-
turns, and may proceed without admitting of relief
to a fatal issue, or be again and again checked by
treatment. Much depends upon the patients
themselves, and the strictness with which the
prescribed regimen is followed ; for, as the disease
often originates in excesses, a return to them
upon partial, or tolerable, recovery, will bring
back the disease. When we find it complicated,
as it most oommonly is, with organic disease of
the lungs, liver, or lymphatic system, a favourable
issue cannot be expected. Out of from twelve
to fifteen cases I nave treated, I know of two
only at the present time that have perfectly re-
covered. One of these, a married woman, who
had previously been attended by an eminent
writer on the disease, has continued perfectly
well for six or seven yean j but although not yet
thirty-five, the catamenia, which had disappeared
before the development of diabetes, has not re*
turned. The chances may, perhaps, be estimated
at about five or six» or even higher, against the
patient ; but much will depend upon the quan-
tity and onality of the urine, the progiws of the
disease, toe age, visceral complications, constitu-
tional powers, the state and functions of the skin,
the degree of emaciation* and circumstances and
pbaracter of the patient. I believe that the prog-
nosis should be much more unfavourable where
the urine is mellitic, than when it is not so changed,
however abundant it may be.

14. B. The Diagnatis of diabetes mellitus is very
readily formed from the sensible properties of the
urine. (See theSymptatiu, $ 4. ; and art. Urine.)

15. III. Cavskb.'^^A, Prediipming, Here-
ditary predisposition to this disease has been re-
markea by several authors. Dr. Provt has
observed it in ifour instances. Iscnplamm states
that he knew of seven of the descendants of a
diabetic patient, who died of the malady. Mon-
TON, Brisbane, Rollo, Blumenbacm, Frane,
Storcr, and Clarkr, also furnish similar facts.
Diabetes is more frequently met with in the male,
than in the female sex ; and in persons who either
are past the period of puberity, or are advanced
in years. The true diabetes mellitus is rare in
children, whilst albuminous urine and enuresis
are frequent complaints in them. It is much
more common in cold and moist countries, par-
ticularly those in which the inhabitants live chiefiy
on rye, or any other vegetable food, or are imper-
fectlv nourished, than in warm or dry climates :
and IS hence oftener met with in Great Britain,
Ireland, Holland, Denmark, and Sweden, than in
France and Germany ; and in the western, than in
the eastern side of this island. J. Frank states
that he saw a greater number of cases of it in
Italy, than in any part of Germany. Dr. Christib
observed it more frequently amongst the inha-
bitants of Ceylon, than in any part^f continental
India ; and imputes it to the moist state of the
atmosphere, and their poor vegetable diet. The
scrofotoos diathesis also predisposes to it.

16. B. The Eseitimg Caum are not so pi«-
cisely aseertaiMd af the pradiipoiiBg, mmI Oieir

connection with the origin of the disaiM aet «s
obvious as could be desired ; but the folkwiiii,
acting either individually or in conjunctioB, psr-
ticularly in the latter mode, may be oooaidtred
as most oommonly productive of diabetes, when
a predisposition to it exists, either hereditarilj.fii
from visceral disease : — Continued or repested ex-
posure to cold and moisture ; drinking cold fliub
when the body is over-healed i suppression of la
habitual perspiration, by whatever means -, ickl-
ulous or fermented liquors, particularly io Bill
liquors, cyder, &c* ; the exhauilioo arising fm
exoeasive evacuations and morbid discbarge», or
from undue sexual intercouiae i great bodil; aad
mental exertions; the depressing pasnoos, ma
as anxiety, disappointment, &c. ; and wUuvtr
occasions pjeat exnaustion of the poweis of lite.
and of assimilation, is sometimes productive oi ibe
malady. Besides these, authors have addooed
othem as its occasional causes. AuTaxatini
mentions the use of acids and acidulous fluidii
BoERHAAVB, LisTSR, Stsdman, Bud Fram, tbe
abuse of diuretics and diluents; Svdenbam aod
Senac, excessive horse exerciie ; Rvyscb, Cat*
SBX.DBN, and Latham, the existenoe of rbroax
abscesses and carbunclea ; Frane, tbe carryui
of heavy weights ; BBNNBwnx (Oshjw's JsAr»>
berichi, ^c. July, 1828.) relates tbe case of a
female who was affected by tbe diseeae dariac
two succeseive pregnancies; Plovoqcki sad
others have observed it result from falls, and iB>
juries on tbe back, loins, and hips; and Baium,
Brendel, Weber, Lanzoni, and Fraks, tk
drying up of olirooic eruptions, exantheD«.
fiuor albus, &c., or tbe suppression of bcmf-
rhages. It may be suspected, however, of t^«
last named phenomena, that, instead of Ixni
causes of the disease, they are actually tbe effcrii
resulting from the internal changes ooottitutiBi
its early sta^-^diabetes, or the internal chaagts
leading to it, having commenced prcvioa«iy cs
the disappearance of the external diaorden — for
it has been often remarked that sores heal nwily
during the disease. Diabetes may, indeed. b«
frequently considered a remote effeet in tbe cksa
of morbid causation ; functional or even strm-iursJ
change of the assimilating viscera, particulsitv
the lungs and digestive orsaos, existing for Bouy
months, or even years, before the increase, or u«
saccharine state, of the urine has attracted atKatMi.
17. C. The prortmars caum of dtabcio m
still extremely obscure, although several auitwi
of deserved reputation have endeavoured is ci>
plain it. — 1st. It has been ascribed to a atorUi
condition of the kidneys. This ia the oidc4
opinion that has been entertained rsspcctioK •!■
nature. The Greek writers considered disbciM
to be owing to relaxation, debility, and iocmicd
irritability of these viscera ; the irritability beta/,
as they supposed, the cause of their mori«i
activity ; and the relaxation and debility allowia;
the more liquid parts of the blood to pass tkAm^li
the excretories without restraint or change, $ad,
consequently, in a crude state, like the food n
lientery. The supporters of this doi.*trioe adducv^
in proof of it, those morbid cbanns that bs«v
been observed in the kidneys, witbont agretisf
amongst themselves aa to the partionlar cbaoftt
which really constitute the disease, Some eso-
sider that they are essentially wtleiBBiawty»
But they overlook the ftct4» tUt dtddeJ aad

612

DIABETES — CivsEs akd Natdrs oir.

actioD. P. Frank has Tery materially moulded
this hypothesis, and into a more plausible form, by
relinquishing the untenable idea of a retrograde
action of the absorbents. He conceives that
diabetes is a disease of the lymphatic system,
conjoined with excitement of the urinary organs ;
that it proceeds from stimulation of both these
by some virus formed within, or introduced from
without, and producing a reverse effect to that oc-
casioned by the virus of the rabies canina ; so
that, while the latter produces a dread of liquids,
the former excites a constant desire for them. In
support of this doctrine, he adduces the opinion
of the ancients, that diabetes is occasioned by
the virus of a serpent called diptat, and hence
the common name generally given by them to
this malady. That it may be excited by the bite
of reptiles, or even higher animals, is not impos-
sible. Dr. Latham mentions a case produced by
the bite of a rat ; and it not infrequently arises,
as remarked byCHESSLOEN and Latham, from
carbuncles, or chronic abscesses, where it may be
presumed that a partial absorption of morbid
matter takes place. Faanc supposes that the
morbid matter occasioning the disease acts by in-
ducing a morbid irritability of the lymphatic
system, owing to which every other part of the
frame is exhausted of its nutrition ; that the
fluids, thus morbidly absorbed, are rapidly con-
veyed into the circulation, particularly the chyle,
to the kidneys, which concur in the morbid ac-
tion ; that the cutaneous and other exhalations are
hence completely arrested ; and that the flux of
saccharine urine is thus produced. This is cer-
tainly a more plausible doctrine than that on
which it is evidently founded ; but, even conceding
the morbid excitement of the lymphatic system
and of the kidneys, the origin of this excitement
in a morbid virus or matter is much more gra-
tuitous, and the cause of the saccharine properties
of the urine is wholly unexplained.

20. 4th. Dr. Clarkb, apd more recently Dr.
Marsh, impute the disease, in a more especial
manner than has been done by other pathologists,
to the cutaneous surface, which, indeed, may be
viewed as an important or^an of the animal eco-
nomy i and they cpnsider it " as a sweat driven
in upon the kidneys, where this morbid deter-
mination keeps up a profuse diKharge." This
opinion seems to nave been partially entertained
by RiiTKR, SroEfxsR, and Kxchtrr, who, whilst
they ascribed diabetes, as we have seen, in part to
a morbid state of the kidnevs, conceived that a de-
praved function of the skin was also concerned
in its production. There can be no doubt that
suppresaon of the cutaneous functions is an early
change, and that it contributes to the perpetu-
ation and aggravation of the malady.

21. 6th. Others refer diabetes to a dyscrasy or
morbid condition of the blood, arising Irom a dis-
eased state of the assimilating powers of the frame.
This doctrine is not materially different from that
which was proposed by Wilus and Sydxnram,
and more recently bv Placs, Dbsavlt, and
Latham ; and, as well as being more accordant
with the procession of morbid phenomena, has a
more obvious relation to the exciting causes, ter-
minations, and morbid appearances in fatal cases,
than any of the theories now reviewed. Accord-
ing to this doctrine, diabetes is not to be imputed
10 the derangemeot of i single organ or system of

vessels merely, but rather to defective eaergr of
the whole frame, particularly impeding the nl-
vaoced stages of the processes of digeitisD sad
assimilation. That the blood is not in a bsskkr
state, and the chyle imperlectly asrimilslsd to i,
as well as the cnuns of the whoM drcRlatttg mm
de6oient, is sufficiently manifested in the appetr-
ances which the blood presents when takes fraa
the patient durinr life, and when observed ia lU
vessels after death. Upon examiniBg specwnrw
of the blood taken from diabetic patients, HM.
Hrnrt and Sovbriban found the quantity of iu
fibrine and albumen one fourth las thaniitf-
signed to healthy blood by Brrxruos asd
Dabcxt; and Bacbetoni remaiied that oil of
almonds passed off with the urine, unchaontl a
its passage through the digestive and aminiilifin^
organs. The state of the blood, also, in the rcisi
and cavities of the heart, is aomewfaat pecolisr —
generally being semi-fluid, sometimes lesenblioK
treacle, and very darl^-coloored. That this ftiie
is not primary, but is a consequence of deficieat
vital energy of the organic nerves, and of tW
assimilating organs, in connection with inpeM
exhalation and secretion from all smrfacei sai
orvans excepting the kidneys, seems most pro-
bable. HurxLAvn supposes, that, owing to dr
changed action of the kidoeys, and the unssBB»-
lated state of the chyle with the hktod, the fonwr
of these fluids, with the nutritions parts of tk
latter, containing the saccharine priariptes, ait
excreted with the urine, and ooeaaion the phe>
nomena of the disease. This opinion, in its {*>
neral bearing, comes as near the tmth, pcthap.
as any that has been offered ; but still it admiii e4
reference to antecedent disonler.

22. 6th. According to the ezpeiimeiits of Mr.
M'Grbcob, the healthy stomacn geneiBlea »c>
charine matter to a limited extent, and the no-
mach of a diabetic patient produces it in esoe*^
In the healthy person, this matter woderpa
further changes in the progress of sssimilatinr.,
but, in the diabetic, it undergoes no sach chaa^
but is carried with the chyle into the cimlanAc.
and is eliminated by the kidneys. Owing to dc^•
cient or exhausted influence of the nerves sapph-
ing the assimilating viscera and Taecular syRm.
the chyle and saccharine matter contained b f,
are not perfectly changed into blood, nor are ihi^
nutritious parts of the blood attracted bv, as J
identified with, the virions structures. Tna i^x-
perfect performance of the asamilating faociioci
must necessarily be attended by deficienrr of t^
the secretions and excretions exceptiag the v.-
nary, particularly the cutaneoos, the pulRioesTt
the intestinal, and the hepatic, as both claiaei at
functions are under the inflnenoe of the orgto^
system of nerves. Thus a redundancy of neU u
matter and of imperfectly elaborated chyle matt
be the result, a portioR of which will be earricJ
off by the kidneys, as in ordinary cutmmitaat»
for aa long as these emundories relaifl t^er
powers, they are the appropriated sale^-valtcs uf
the vascular system, oy eliminating wateiy.fs*
line, and other matters, when they beeone cxre^'
sive. These states and changes aoeoRRt lor tW
simple excess of urine ; the more watery aaJ «i>
assimilated parts of the blood being earned of h;
the kidneys, instead of beiag a«mled fnm the
cutaneous, the respiratory, and iRtesaaal mtfun ,
and the action of the kkbeya, betag eaet txc^

BIABETE8— . THEATMiut.

515

with rhubarb, or the compound eitraet of colo* ^
cynth at bed-time, and followed, in the morning,
by an active purgative medicine, will be found of
service. -» fr. M ediciees that act as diuretiet may be
supposed to be cootra-indicated in diabetes. But
they are not necessarily injurious; for, if they
liave a beneficial effect on the body eenerally, or
00 the visceral disorders with which diabetes is as-
sociated, they may even be of benefit ; and if the
action of such medicines on the kidneys be ener-
getic, they may change the morbid action induced
io these organs by tiie disordered state of organic
oervous inflaenoe and of the circulating fluid, and
io this way prove beneficial. Among the different
sobstancestnat have a diuretic effect oo^cAicuni may
be mentioned as having lately been sometimes pre-
scribed in this disease, but chiefly on account of
ila sedative operation. It may be of some service
in promoring the biliary secretion, in inoreasing
the quantity ofureii and uric acid in the urine,
%nil in diminishing the irritability of the frame.
It$ good effects, however, require confirmation,
tod may probably be ensured by combining it
with ammonia or its preparations, or with camphor.

35. //. Nutritntg in various forms have been
itrenuoQsly recommended by Home, Rollo, Du-
n\TaEN, Nxcoi.A8y Oswald, Frank, CHnisriB,
iR'i many others. Dr. Rollo particularly in-
fixed upon the nearly exolusive use of animal
food, with the view of resisting the secretion of
aicchsrine matter, and furnishing the elements of
urea and the animal salts to the blood. There can
be no doubt that the greatest benefit has been
derived from this treatment. It should, however,
be admitted, that it often fails j and that, when it
is too freely indulged in, it sometimes occasions a
diirrhoea, which exhausts or even carries off the
patient. With a knowledge of these occasional
fffeclg. Dr. PnouT recommends it with very
]U(Jicioas restrictions, and to be taken with a
moderate proportion of farinaceous food; and
Frank advises, in addition to it, the decoction of
Iceland moes, or of the althaea officinalis with
milk.

36. /. Besides the foregoing, various other re-

meriie* have been prescribed. The cupri ammo-

n'w^iulphas (in doses of half a grain to a grain

twee or thrice a day), myrrh ^ and va/erran, have

received the commendations of Frank and Rich-

Titt. Aaafetida has been favourably noticed by

^NoLFr; tartar emetic combined with valerian has

•>€en directed by Richter. A combination of

8<w»fcEtida with myrrh and valerian has also been

V'^rj generally used by Continental physicians.

pp. Watt has employed the volatUe alkali ; and

It will certainly often prove an useful adjuvant,

combioed with otiier medicines, particularly with

opium, or with tonics or diaphoretics; and be

^'r\uu:able in combating such nervous or sinking

symptoms, as sometimes occur in the course of

fhe disease. It may, moreover, counteract the

ttnlency to the formation of saccharine matter,

^tn'l promote the animalisation and assimilation of

i'«e chyle, as well as the formation of urea. Even

urea itself has been recently tried as a remedy in

ihii disease by Segalas, but instead of changing

the mellitic urine, it was found to increase its

f}«4ntuy. HvFELAND, sod some other physicians

'3 GennaDy, have prescribed recent ox-gall, in as

'"ge dow as the stomach will bear, and fre-

<iuenily with the effect of causing the disappear-

ance of the saccharine state of the urine during its
use ; the disease, however, has generally returned
upon discontinuing the medicine.

37. K» Bbod' letting in diabetes has been
mentioned as far back as the Commentaries of
Archigenes on Aetius; and it was noticed as
an occasional measure by Le Fevrb and Rollo.
But it is to Dr. Watt, that we are indebted for
the introduction of this practice in a most decided
form. This physician advises full and often-
repeated blood-lettings, with the view of arresting
the inflammatory determination to the kidneys.
This plan has been adopted by Dr. Satterly
and others vrith manifest advantage, whilst it has
failed with some. Drs. Prout and Hupsland
consider it beneficial only in the early and acute
stage of the disease. Dr. Marsh offers a similar
opinion. And my own experience would lead
me to employ it, only when the disease is recent,
the strength of the patient not much exhausted,
and the pulse remains of good strength and
volume. When the patient feels much pain in
the loins, an additional indication is thereby
furnished for resorting to it. Sir David Barry
has advised frequent cupping on the loins in the
course of the disease, — a practice which is de-
serving of adoption in cases of the above descrip-
tion, or when much pain is complained of in that
situation. I have found advantage from the ap-
plication of a number of leeches on the epigas-
trium, and cupping on the hypochondria, both
in relieving the sen<e of pain and heat complained
of in the stomach, and in lessening the quantity
of the urine, and of the saccharine matter con-
tained in it. Depletion, as Dr. Watt first ob-
served, certainly improves the state of the blood,
and renders the weak and imperfect crassamentum
more firm.

38. L. B/tjt«rs and external applieations of a
derivative and irritating nature have been recom-
mended by RiTTER, DxsAULT, Van Swietsk,
Whytt, and Keidlin, to be applied chiefly to
the loins and epigastrium. Frank and Weiz
advise repeated blistering of the sacrum. Setont,
iuues, and moxag have likewise been employed
in the latter situation ; but I believe without any
permanent benefit. The most efficacious modes
of derivation are the vapour bath, warm alkaline
baths, and thick woollen clothing worn next the
skin. Topical applicationg of a tonic and an
astringent nature have also been directed to be
kept constantly applied to the loins by Wnvrr,
Keidlix, and Van Swieten. Of these, how-
ever, I have had no experience. I have, how-
ever, prescribed liniments to this situation, as well
as to the epigastrium, generally composed as
follows : —

No. IGS. H Linimenti CampboraB Comp., Olei Tere-
binth., Lioimenti Saponis Comp., Sa S j-; ruW. Opii Purl
$)• fPulv. Capsici Annul 3s«. ; Olei LimonU iM xxx.
M. Fiat Lfnimentum, cum quo assidud illinantur regie
lumtMtlii et spina dorsi, mane nocteque.

I have found this application extremely useful
in the excessive discharge of albuminous urine,
which is not infrequently met with in young sub-
jects. I have likewise employed it with other
means in the mellitic state of urine ; but it was
difficult to determine what share of the temporary
benefit derived was owing to it.

39. ii. The Treatment in which the Author is
mott dispoHd to conjide. — It is not easy to form

LI 2

516

DIABETES — > TssAivsNT.

to ourselves precise and rational indications of
cure in this disease, particularly as opinions re-
specting \\s nature are not supported by a suffi-
cient number of accurately recorded facts ; nor are
those which have been observed so constantly
present, or ro uniformly grouped, as to permit us
to draw indisputable pathological inferences, for
the basis of therapeutical indications. I shall
therefore state succinctly the method of cure,
which is sanctioned by my own observation, and
by experienced physicians. The remark which
has been made by Dr. Parr, Dr. P rout, .and
others, that this disease should be viewed in a
two-fold light — namely, 1st, as respects its sac-
charine state independently of the increase of its
quantity ; and, 2d, as regards this state in con-
nection with an augmented secretion -^ should be
kept constantly in recollection ; and, although
the discharge of an increased quantity of urine, in
addition to its saccharine condition, generally in-
dicates either a more advanced or a more severe
state of disease, yet we should be aware that the
saccharine change is the more important of the
two ; and that it is much more easy to diminish
the quantity than to improve the quality of this
secretion. Dr. Prout justly remarks, that it is
exceedingly doubtful if there be any remedy that
exerts a specific action in improving the quality
of the urme — at least, there is none at present
known. The improvement can therefore be at-
tempted only by those agents that have a ten-
dency— l«t, To remove tA« morbid affection of the
sUtmach ; 2tui, To restore the general health and
auimilatiie energies of the frame ; and 3rd, To
diminish the quantity of the secretion,

40. These ends are generally all that we can
reach ; and, by attaining them, we sometimes
advance still further, and thereby improve the
quality also of the discharge. There are, how-
ever, other subordinate objects, which, although
they might be accomplished with the fulfilment
of the chief ends now proposed, yet often require
an immediate regard ; and the more especially as
their attainment very frequently promotes the
chief intentions of treatment. These are, — a. To
remove a congested, loaded, or oppressed state
of the vascular system, and reduce the quantity
of the circulating fluid more nearly to a level
with the amount of vital power and assimilative
function. — b. To promote and improve the secre-
tions employed in digestion, and excite the ex-
halatioDs and secretions from the respiratory and
intestinal surfaces. — r. To remove the unper-
spirabie and harsh state of the cutaneous surface,
to increase perspiration ; and thereby to lessen
the determination to the kidneys. — d. To di-
minish the morbid sensibility and irritability of
the frame, with the other morbid phenomena
allied to them. The means which we employ in
attaining both the principal and the subordinate
objects which I have now stated, will, of course,
Tary exceedingly, according to the particular
features of individual cases, and the constitutional
powers of the patient. The previous duration of
the disease — the degree of activity it may pre*
sent — the age of the patient — the state of the
circulation — and the particular condition of the
urine, as respects both its density and quantity,
should individually and collectively be considered
by the practitioner as circumstances calculated
greatly to modify the means of cure ; and should

weigh 80 entirely with the judictoiu, is to kad
them to consider even the best practical laggei*
tions which can be offered as applicable merelj
to some cases, and as requiring to be varied, ao^
rendered appropriate to others. Il mast be ob-
vious that we cannot endeavour to attain, mrietim,
the ends now proposed ; for a judicious and is
active treatment will often fulfil two or moic of
them contemporaneously.

41. I have already noticed the opiaiou o!
Dr. Watt and others ($ 37.) as to blood-lettiBg.
In cases of recent occurrenoe, with aa score
state of the circulation, and pain in the l«ias
with much heat and pain in the epi«stnaD,tf
where congestion or oppression of the vascular
system exisu (§ 40. a), I consider geaenl
blood-letting, repeated aa often as the ebeoa-
stances may require, as requisite to failil tbe
intention stated above {§ 40. a). The frequeoc}
of, or even the propriety of repeating, the open-
tion will depend much upon the appearaoees of
the blood drawn, and the effects produced br it.
If the crasis of the blood be weak — the coagslaa
being loose, and dark — I hare seen no beortt
derived from it until the vital energies have hta
somewhat excited by appropriate means. If.
however, doubts respecting the propriety of a
repetition be entertained, cup|Hng upon tbe lou}*,
or upon the hypochondria, or the applicatioo U
leeches on the epigastrium, according S0 ibe
sensations of the patient may direct, the practiee
should be substituted, and carried to an extcd,
as respects quantity and frequency of repetitioa.
on which the observation of the practitioner will
enable him to decide. In protracted oases, vbea
the disease occurs in old subjects, when the tle-
bility b great, and the pulse quick, snull. ot
weak, general blood-letting is not producuveot
benefit. If, even in these cases, much paia, wg-
derness, or fulness be complained of about tW
epigastrium, local depletion, as now recoaunended.
may be employed in its vicinity. It will oftro
happen that blood-letting — especiaUy g«nenl
blood-letting — will, at first, either be ioadmisBibl^.
or of little or no service; and yet it will sah*^
quently prove of very great benefit, after the otkr
parts of the treatment have prepared the sTfteo
for it. I'hia fact should not be overlooked st sii;
period of the disease, even in the most unproniaiac;
cases.

42. Immediately after depletion, a cooiplU'
evacuation of the bowels, either by a fiill dow (•<
castor oil and of spirits of turpentine, or by i^
following pill, repeated according to cirtom*
stances, will generally be directed with ail>u*
tage: —

No. 166. B Bxtr. Colocrnth. Co. 3m.; Tfsdf. l^*-
euanh« gr. Uj. : Saponis QutlL fr. viij. ; Old Ct«ivu*
Tiglii TTl IJ. M. Fiant Pilule x]j. Capiat diia* tn^
et r(n)eUutur bins quarts qu4qae bori donee plfo^ ^ ^
Jiccrtt al?tta.

Tlie bowels being freely evacuated by tbe al^'tc
means, assisted in more obstinate cases by r*iv*-
muta. of which I believe those with from oor t>'
two ounces of turpentine to be the most etficacica*
a full dose of opium with camphor shoald be 'J*
bibited, or of the put vis ipecacuanhc coffipotuts*.
or the following : —

No. 167. H Camphorw rat* sr. v. ; PoIt. Ii

S-. J. ; PuW. Opiigr.U- 1 1^»lT.II^fth• «.▼[,. MorO-i
cacl«, rel Conserv. Rosar., q. t. at fnt Bolat, *»i**
sumenduf.

DIAPHRAGM — Imflaumation or.

519

Parii. IMiL— W. Proutt Inquiry into the Nature and
Treatment of Diabetes, Calculus. Ac. 2d edit. Lond.
1925. —Rockour^ Diction, de BI£d. toI. ti.^HeHuieHf

io Load. Med. Reppe. toI. xix. p. S65 Carter^ in Ibid.

ToL XX. p. 390. ~-D. Barry t see Lancet, No. 238. p. 926.

^R. FeneAla, On Diab., ftc. 8to. Lond. 1825 Vauque-

Un ec S^atat HTEtcMrpartt ta ArchiTea G^nt^r. de Mede-
due, t. vi. p. fiS5. — Loftttrm, in Ibid. toI. xvili. p. 432. ;
el in B^pert. Gioer. d'Anat et Phjrs. vol, ii. p. 356. -^
Starkest In Tranaac. of Irish College of Fhj*. vol. Iv.
p379.— AMiUaW. DicHoa. de MM. et Chir. Prat.
Tol. vi. p. 249. — M. Goodt Stud^ of Med. by Cooper ^
ToL T. p. 491. — Btrndt. Encyclop. Worterb. de Med.
\ris«entch. art. Diabetes — ilmdrtMrfonf.in Annali UnlTer.
dl Med. Apr. 1885. ~ Maatand^ in Lond. Med. Gas.
Tol.XTil. p. 900.~iirGr««or. In Lond. Med. Gax. iroLxx.
Mar 13 and 20, 1837. — R, ffY//«>. Urinary DiseaM^a and
their Treatment, 8to. Lond. 1838, p. 196.

DIAGNOSIS. See Symptomatology.
DIAPHRAGM (from iut^Acaw, I separate).—
Syn. 'Twifffjut, ArUtotle. Aiaf fayfAu, J^enc*
Septum trantvemim, Lat. Der Zwergmuakel,
Ger. Diaphragme, Fr. Midriff, Eog.
1. When we ooosider the tnusculo-teodiaous
ttraetore, and varied connectioos of the dia^
pliragiD, — that it is situated between three serous
membranes, and attached to the vertebral columo,
tbe ribs and their cartilages, — that it is traversed
by the most remarkable nerves and blood-vessels
of the body, and itself provided with important
vessels and nerves, that it is in more or less
direct contact with the lungs, the heart, the
liver, stomach, pancreas, kidneys, and spleen;
sod intimately aarociated by its nerves, its ves-
sels, and its functions, not only with the mucous
»iTha of the respiratory organs, as well as with
Ihese organs themselves, but also with the diges-
tive and large secreting viscera^^ts importance
)Q a pathological point of view must be appa-
rent The extent of its organic and functional
Telatioos are such, that agents acting on either
tbe uteroal or ioternal surfaces of the body
most necessarily influence its actions. It cannot,
therefore, be a matter of surprise to find it
frequeotly subject to disorder ; but I am at a
Imb to coaoeive the reason for the very general
neglect with which even its most serious diseases
b&ve been treated. This can be owing only to
tbe cireumstanoe of their being imperfectly
understood, or referred to some one of the
ftdjoioiog organs, and viewed as merely symp-
tomatic or secoQilary affections.
!• Irflammation of the Dyaphragv. —
Sym. Dhj^ngmitu (HUdenbrand, J. Frank,
Ate); PttraphrenittM, Paraphrotynit (Rufus
Kphestus, et Auct. Vet.); Diaphragmite,
Paraphrinhie, Fr. ; ZwergmuBkell^Enttiin'
rfa»g, Ger.

Classip, III. Class, I. Ouder (Author)*
2* l^tnv. — AcuU pain and eonitriction of the
kwr part of the thoraXt extending to the back and
""''ft increated upon retjnration and raiting the
^jf trtet, with tingnltnt, eonvuisive dittortion of
^ht engtet of the mouth, and very acttte iuflamma-
^fever,

3. i. Seat. — Inffammation of only the mus-
CQlo-teDdinous structure of the diaphragm is a very
^f* disease, particularly in its primary form ; and
1 believe is very seldom met with, excepting upon
the disappearance of rheumatism from some exter-
wl part, or after penetrating wounds and other
*J*^*1 injuries. As a consecutive or secondary
Jncction, and especially in conjunction with ih-
nammatioQ of one or more of its serous membranes,
^ trequently oecun, although often either entirely

overlooked, or mistaken for inBammation of some
one of the adjoining viscera. The advantages of
being able to distinguish it in practice are not di-
minished on this account ; and it often becomes of
great importance to ascertain its existence, whe-
ther as a primary or as a consecutive disease.

4. I believe tnat inflammation may originate in
the cellular tissue connecting the serous membranes
reflected over the diaphragm to its musculo-tendi-
nous structure, in which case the disease will ex-
tend chiefly to either one or both of those surfaces;
but that, in the more frequent states of diaphrag-
mitis, — particularly its consecutive form, — the
inflammation commences io one of the serous sur-
faces, and extends thence, through the medium of
the sub-serous cellular tissue, more or less to the
other structures of the or^an.

5. ii. The Causes of diaphragmitis, particularly
in its consecutive forms, are generally those which
are productive of pleurisy, pneumonia, hepatitis,
or peritonitis. In addition to those, I may adduce
others, which have a more evident influence in
producing this disease, viz. punctured and other
wounds; external injuries and fractures of the
lower ribs ; concussions of the trunk, particularly
from missing steps on descending stairs, or from
failing upon the hips ; immoderate laughter; vio-
lent retchings ; continued crying and weeping ;
ob.«>tinate singultus ; currents of cold air, when the
body is perspiring ; the incautious use of cold
drinks, ices, &c. ; the suppression of painful emo-
tions ; violent efforts of any description ; the re-
pression or metastasis of rheumatism ; the stop-
page of accustomed discharges; and the drying up
of old eruptions or ulcers by external applications.
Instances of the occurrence of inflammation of tbe
diaphragm from the repression of rheumatism have
been recorded by Paterson ( Mem. of Med. Society
of London, vol. v. No. 32.) and Portal (Anat,
iSSd. t. ii. p. 444.); and from healing up old
sores, suppressing gout, £cc., by Aaskow Act. Reg.
Soe, Med, Hafn, t. i. p. 205.), Boisseau {Notvgra"
phie Organ* t. xi. p. 620.), Wendt, Selle, and
others. Hildenbhand considers the habit of
wearing tightly laced corsets a cause of the disease.
I doubt not that it is, at least, a predisposing cause.

6. iii. Symptoms, Complications, &c. — A,
Either after rigors, chills, horripilations, &c., or
consequent upon disease of some one of the abdo-
minal or thoracic viscera, the patient experiences
violent, sharp, burning pain, tension, and cord-like
constriction, at the lower part of the thorax, parti-
cularly beneath the sternum and hypochondria,
and stretching to the loins, — increased and de-
scending lower during inspiration — diminished
and ascending during expiration, — augmented by
coughing, sneezing, fulness of stomach, and pres-
sure on the abdomen ; likewise by vomiting, by
the expulsion of the fsces or urine, and by bend-
ing the trunk of the body in any direction. The
breathing is short, frequent, anxious, small, and
performed entirely by the intercostal muscles, the
abdomen being nearly motionless. The hypochon-
dria fall inwards, or are retracted, and, with the
precordia, are sensible to pressure. There are
frequently painful and difficult deglutition, re-
ferrible to the lower part of tbe oesophagus and
cardia ; great anxiety, with occasional interriipted
sighs ; singultus, particularly towards the close of
the disease , involuntary retraction of the angles of
the mouth, or risus sardonicus ; delirium, which is

L14

DIARRHSA — iDioratBM.

■pirmloTf idukIis prciaatiDB the tipulnoo ottbc
ioapirad txi, aod oooMquenlTy prtxIueiDg * Tiricly
' ' ly. (See iitt. Hiocur.)

. PiHiLTtiB or the diipbragin

diiphngin i
' m. and c

id oooMque
of aiphjiv. (See Htt. Hit

a:). Y. P.HILY

patible with the d
only duriDi; the Uit

r b; whatever ■Da]' inttmipt Ibe
functiooa/orinjure (hepantguni. t haie met
nilh a can where it followed, at a remate peiiod,
fraoluie b; niuKDiir aelian oF the deDtaled cer-
vioal vertebra, « *eHfied oa diMeotton by Profn-
*or R. Qdaiti a ad myiatr.

na — OsIn, De Loth MKet Li.
-Mi—Mrr.

nlrupbrcnl-

_ IMS. — W«*r(, ln'M*ni.d«rAMd.dr»*rLlc;

i;si, p.M Scilranffr. Do Inrlani, Dlipli. Goct. int.

suit. Ratio Mtd. tU. p.SSS. — D( Wa™, IUHd Mfd
r«, I. p. M., Mr.li. p. h -L. A- Bhrb^, D,u. ds. la

M, Spec. Slit. Pir.Jl!™lll\lil RailonelQ el CurlUoii™

TK^^m^, •--fiamm. Pmkt, Aum. U(»r dl« Mot

liam. In Act. Hafli, toL I p. MA, -

tbe teach, and in Umparatun iocnawil, W
occMooaJly iha UDol* aie ^teeded bj eiucti piu
io tb* tract bF Iha inteatmae, and acmapUHj
wilb Yomiiing, or with faiotint, or lapotbiuii
thej are al**!* without effort, bat an nKl) it-
Yoluota^. l!aeb ETaoeatioa relie*e> (•( a ta>
the patieal'a unciainea, which, bo*«tat. n>«
retiuna. The diachargca are aaaallj eapwu
oBenaire, and feeulaiit at Enl ; battfaaj fcHbt-
come moreicaniT,*M«rj,ortBsco>a— (An ii
proportiBD Io the freqaenoj of IbaeaUilotiKu-
tion, afMreach of which Ibe patiaai ktb am
and more weakantd. Their number nrio fno
three or roar, to twenty or ihii^ia ibetvciii
foHr boura, butlbqi are not as DRao Tndidu a-
night aa in ibe du. Al the oommeonami ~
the aiiaoh, and S aligbt caaea, ibe p«l« it p-
narally not niateriallj aflecled ; bat whta iiibiI'
ing or much gripiitg pain ia preaeot. it ii crit
increaied in fraqntnoj. At an adtannd punt
it ia uauallj amall. mk, and aomewbal lew-
rated ; the coaDtmance baiog pola, tU Mi

Ifmp^, iJe D.mph. Smo « Mor.
P. >r«», Do dur. Horn. Murh.

le.^Wilni,

Dbque.'l. U.' p.llT.— Vo^Mjii Fatbid!

DIARRHCEA. — Syh. i&iifh'- f"™ *<*ffi--

I flow IbrOHgh, hi and fim), DkrHita Co-

caUria, JUtana GotlrM, Galen. iU(Hiiali».

HM, Aleionder of Trallee. Dtfiuxit, Caeliua

Auretiua. Alvi Fluoi, ftatrii Prvflmimtn,

Auct. Lat. CDHn di Vnln, Ditrntmunl. Fr.

DtT DurtlifaU, BaucA^HH, Dunhleuf, Gma.

CiatTM, Ilal. A Putmg, Lannuu.lfc.

CLAHrr. — 3. Clou, Nerroiu Diaaaaeai 3.

' OnUr, Spaaoiodia ARoctiona (Cuiiaa),

1. Cbm, biaeaaeaof (he Digeati>e Func-

lion ; I . Order, ASacting tin DlfeatiTa

Ciiial (daod),

t. DenN. — FrviMHt, ItetiT fluid akinttm-

ruiUimi, withoi, " "

3. Although
pendent or ud

occur ea an inda>
iplainl, jet may it
aa BO oocaikiDal or eieo caramon aymp-
toin, in HVeral maladlea. Ur. Cni.i.aH, whibrt
be admitled diurrbcEa ai a apecific diaeeae, vel
viewed it aa alwaja aynptomatio of other patbo-
logical aula. ''-'— • ■ ■

bedi

Thai it ia ao ia moel
ul that it alao ia, ia aome inatancea,
cl both of ita primary

— by- the eflecta of
appeoraneea obaennl in fatal caaea.

3. I. STHPTD.HBiHn Vimianii orDuKBBOLj.
— Thia diaeaae ia uaually preceded by Taiioua
dvBpcplic jycnptoma, aometimea by alight nauaea,
freqaenlly by uneaaineio in diSercni -parti of Ihe
abdomen, by flatulence, and by pain, partieulariy
before an eYBcoatieniakcipUee. iDteYencuae,

tioaa Taiy lamartably aa to tb« neliue of '>
matters campanng tbem, Ibeir colour, eaamuut.
amell, lod olhar appeuaocea, doc only ia difftni'
caaea, bal eTcn in the aama caae, al dilbu'
perioda, Naealogiata baYa genenlly ditidedi>
diaeaie inlo Yarieliea or epeoiea, fouaded on iw
different alaUe of tbe diaobaifaa. But tbs it aci
a aalirfaotoiy baiia of claaHficatiaa, aa tbe appaar-
ance* of tbe OYacaabooa do Dot dopasd apoa ik-
finite pathological oondiliaDa, allho^^h faroHts.'
imponant ladieatiooa of the aeat aad Malt c
dieeaae, Tbe moat commonef tb«e appMrav*
are, the ftndnt, wbioh laially precedts u
otbera ; the Uluw ,- the mtttnu ; the lanw : iw
ehyhiH ) or uHili ; and ihe iinaric. Bal trr-
prartilionei muat baYeobeened ibainu aetj y -^
tbeie diachargea praaant ihemaeleee daiug u-
fereot periodi of tbe dinoN, bal that l*e e> ag •
oflheoi may eo-«aiat ; Ibua the eYtraaiiMa i»
Dot infraqaBa(ly,*t tbeaama lime biliow.Ban*'.
and leroua ; or lecaleDl, biliosa, aad miuoea ; ■'
watery and bilioua.

i. IcrorATRic DiAiaaa*. — Cuwr. |l-
Cliu, I, Oania (Aulktr).

4. DeriH. — CxpiiM, ftnUnt, aad frr^-
toKamliani, mMtlnea prawfed ky r^T^H' *'"

■DBtltldHl tgJlWtT.

5. A. Di»TTt,gm ff JrriMlinu — Tha krt
of the diaeaae compfina moel ot the mm* drn ^ •
nated feculent by aulbora. and Mroed i>. >"^-
arrea by Sai'vaou, D. Cnfmlmm. by Cnuv
and D.Fma, by Goon, — (a) It la nauUy m"
by any alimulatiog or irritaliag lubalaan »■
ceiTOd into the ilomacb ; by loo grtal a laif ''
or quanlily of food or drink, or eieo by a n-i
qveaiil^ of that which b anwholeMwie, sr ■>"
may duagree with the patient'* dialheM. or ■!
the eiialiag «lile of ihe digetliee organ; bi ''■ '
digealible YCgetabhti, particularly eoraott'^
meluDs, aalada, &o. ; by venou* acid l^u^, p''
ticnlarly pluma, pioe-applea, &•.( by bcchLk-
gtDttMed iathtpHiM*fa,«iid IbeqeaM;^^

524

BI ARRHCEA — Symptomatic.

tafants constitutes what is usually called the
tcatery gripe* (§ 15.)> and sometimes gives rise to
one or more intus-susceptioos ; or it passes into
chronic diarrhoea, with disease of the mucous and
mesenteric glands ; or into slow remittent fever,
marasmus, and fatal eihaustion.

10. C. Diarrhtta from txcited or inflammatory
Action of the mucout FMlieUi (Catarrhvs Inte*»
tinorum, of various authors ; D. Catarrhalis, of
BoERiiAAVE ; D. Mucota, of Cvllsv, Good, &c. ;
Ctrliaca Mucosa, Sauvages). — (a) This form
generally appears in the course of functional dis-
order of the digestive organs, particularly indiges-
tion, hypochondriasis, costiveoess, and colicky
affections ; which may be viewed as predisposing
to it, by favouring the accumulation of mucous
sondes in the follicles and on the internal surface
of the bowels; and is excited by the causes
already enumerated, especially those of the pre-
ceding variety ($ 9.). It occurs most frequently
in old persons, or in those who have suffered
from chronic disorders of the digestive organs ;
and in children, particularly during the period of
first dentition. — (b) The stooit often consist en-
tirely of thin gelatinous mucus ; frequently, also,
of thick mucus, and a considerable quantity of
watery or serous fluid ; sometimes the mucus is
mixed with this fluid and thin feculent matter, or
is accompanied with small pellets of fsces ; and
occasionally it has the appearance of a semi-
transparent mucilage, passing into a muco-
puriform matter. The consistence of the motions
varies much ; and in s^me cases they are very
offensive, but in othen without any odour.
In many instances they have a greenish or yel-
lowish green colour; in others, an- orange or
yellow tint: in a few eases, they are nearly
colourless, or white, and thin, constituting the X>.
Albaoi Hillary ; the F/uxui Caliacus of some
writers: the Atbum Atoi Profluvium of Piso; the
JD. Pituitosa of Savvaoes ; the I). Caliaea of Cul-
LKN ; the D, Chytoea, or Laceta, of several
authon. These appearances are chiefly attribut-
able to the morbid action of the mucous folHcles
in some part of the digestive tube, most probably
in the colon : to the presence or absence of the
biliary and pancreatic secretions ; and to the states
of these secretions. This, as well as the preced-
ing variety, may or may not be attended by fe-
bnle symptoms, may assume the acute character,
and may pass into the chronic form, the mucus
discharges in this latter case often presenting a
light, whitish, or mnco-puriform appearance.—
(c) When mucous diarrnoea continues for some
time, or becomes chronic, it occasions emaciation;
a dry, harhh, or foul skin ; and, in children, gives
rise to marasmus, disease of the mesenteric glands,
&c. When it becomes chronic, the stools some-
times assume a whitish, or mucilage-like, or grey-
ish appearance, evincing the absence of bile ; or
they pass into a muoo-puriform state, occasionally
streaked with blood ; or they contain long whitish
shreds, or threads ; and consist either altogether
of these matters, particularly if the disease be
seated low in the large intestines, or of an ad-
mixture of thin feculent matter with them, par-
ticularly when the upper portions of the colon and
termination of the ihum are affected. In some
cases of this form, occurring during«diflicuU den-
tition, or alter the nse of calomel or mercurials, or
upon the suppression of ptyalism, the stools have

consisted of a thin, ropy, mucus, ojf a iramlaccfit
hue, and have seemed to be chiefly sagneBted
pancreatic secretion. In children espectaUjr.ubfo
mucous diarrhoea has assumed the ckronie ions .
the evacuations often present the chybnt or nulki
appearance just noticed, — the ChyUmt DiaMffx
or Dbwbes and otheni. This state is attnbvteJ
by them to the presence of chyme, or imperfect^
eloborated chyle, which the lacteals refuse to atv-
sorb; and to the absence of Inle: to ^^kL
causes it is very probably partly owing, as wdl ;j
partly to the morbid secretions of the mucous «ii:-
face and follicles. W hateverappearance this wk^
may assume, it is frequently followed by the ovit.

1 1 . D. DiarrhoMfrom Ulceration if the mut* i
FoUicle»'^{a) occurs either coosecniively of '.r
two foregoing varieties, or to the course of severil
febrile or chronic diseases ; in which cases, bo«-
ever, it is very often preceded by serous or mocmL*
evacuations, or by both. But ulceratioii idit
take place without any such indication, and writ.-
out the bowels being much, or even at all/ re-
laxed.— (ft) The stools are usually mi]'">
puriform, streaked with blood ; sometimes cc»-
taining shreds or threads of albuminous nutter
and mixed with thin, watery feces, particulir*
when the disease is seated in the small mtestioe^ v
caecum. When the Urge intestines are daet}
affected, the muco-pnriform discharges maj con-
tain little or no feculent matters ; or these mantr*
may form distinct portions of the 8tools,or but cv -
sist of detached pellets. In some instances.the «toc !>
have been very dark, grumous, watery, and ktt c :
and, occasionally, merely thin, serous, or muonc*.
or both, varying in colour, and more or le^ kct-
lent and ofiensive ; and yet ulceration has never*
theless existed. In rarer cases, they have \fcr.
quite black, grumous, and melanoid ; or men-
bling itik, probably from the admixture of blo>''
exuded in the small intestines, and changed bjtif
action of the secretions— whether bealibV r
morbid. — (c) In this variety of dxarrhora, tbe
emaciation becomes extreme, and the skio v-
sumes a dr^, harsh, foul, or lurid appesracrr
The pulse, in its latter stages, is quick, smali, t-^
weak. Aphtha; sometimes appear on the lip( i»^
tongue ; and hectic fever, with exhaustion, prevnls.

12. £. Diarrho'a with the Ditekarge of nmlu r *
Ingcita ; Lientery (AtttrtifUL, Gr. ; Luhnatei.
vel Levitai Jntettinorum, Lat. ; D. Lie*ierita, ^
CuLLKN ; the Lienteria of Sauvaoes and oibcM
— (a) OCCUR more frequently in chiUrem, hf^cn
the period of the second dentition, than at U'*.'
epocns ; and it is generally th« coosequeore or «?>
quela of inflammatory irritation of the di<^e^ > i
mucous surface, aud disease of the roesrti'err
glands — of the advanced stages of these pAt^<>-
logical states. It is mo«t common during the ^^i
dentition, particularly when the canine and molar
teeth are about to appear ; and, in ibis c1a«> i^
patients^ as well as in adults (in which latter n •
comparatively rare), it either foUowi dyseo>'-TT.
or is a concomitant of the last stages, or chncc^
states, of one of the preceding varieties, — c^'v
monly of the seroiti or mncotu — than a prir.*'n
form of the disease. It is eeueed by the ane re-
mote agents which induce tbc^ tts^rifDarrrm-
ditions ; and it evidently depends upon a hr ^ '
state of increased peristaltic action, and dto^ec*
vital function of the Aomacb and doodemur, i<
that which obtains b the intcsiiacs; the M

DIARRH (E A — Notices of Reusoiss rzcom ubn ded by Authors.

533

(he iotestiiial macous coat. The treatment
should therefore be directed, in such cases, with
the intentions of diminishing inflammatory action
ID this part by moderate local depletions, of
eqoalUing the circulation and secretions by ex-
teroa] derifatiTes and relaxants, and by diapho-
retics and diaretics, and of supporting the
powers of life, whenever they become depressed,
by diffusible and permanent stimulants. I may
state as the result of experience, that, when this
complication follows an imperfect developement,
or retrocession, of the cutaneous eruption, even
moderate depletions are not well borne, unless
they be accompanied by warm diaphoretics and
di^sible stimulants ; and that, of the latter me-
dicioes (which are very generally appropriate),
full doses of ammonia, or of camphor, or of
both, in some instances combined with nitrate
of potash, in others with alkaline carbonates or
magnesia, in most with demulcents and emollient
diluents, in several with laxatives, and in many
vith aromatics, or tonics and antiseptics, have
proved the most beneficial. — (€)W hen a diarrhoea
that is not critical accompaniei or followi remittent,
coHtinuid, or adynamic fevers, the evacuations
being watery, muddy, dark-coloured, or otherwise
morbid, the hydrarg.cum creta, with ipecacuanha,
ctimpbor, and cretaceous substances; or the tere-
bintbioates and the balsams, with vegetable or
nineral astringents; also tonics and antiseptics,
the nitric and hydro-chlOric acids, or both, or rhu-
barb with magnesia ; the chlorate^ with demul-
cents; external derivatives with warm rubefacient
and stimolating liniments, &c., are the chief re-
medies, and the most likely to prevent the extensive
■loughy ulcerations that sometimes attend the
(iianrbcca that super\'enes either during, or subse-
quently to, these diseases.

39. Colliquative diarrhoea is sometimes not
^ly controlled ; and even when roost readily
repressed, the constitutional disturbance may be
thereby increased. It is most benefited by small
doses of the sulphates of copper and of zinc (F.577.
^7')> by the mineral astringents generally, and
by the cretaceous and demulcent preparations,
rombined with camphor, aromatics, and opiates,
or with tonic and astringent infusions and decoc-
tiom, which, at the same time that they alleviate
Ihe ivmptoms, also support the vital energies.
Bat the adoption and combination of these, or the
choice of other remedies already or about to be
noticed, shoul(^ depend mainly upon the nature of
(he prnnary disease, of which the diarrhoea is, in
(bis »tate, merely an advanced symptom.

40. CaMtiont, i^e, — TYkQ eriiical manifestation
of diarrhcea should never be interfered with, un-
^ it either proceed so far as to depress the vital
eoeigiei, or be attended by signs of inflammatory
disease of the mucous siuface and follicles, in
which case the treatment recommended for the
varieties indicative of such disease and its conse-
qoeoces should be prescribed. When diarrhoea
occurs b gouty or asthmatic peraons, or in those
^fs plethoric habit of body, or who have a ten-
'lency to, or have suffered from , cerebral affections,
^ hepatic disorders ; or in the leuco-phlegmatic
<^nd hydropic diathesis ; it ought to be treated with
D^ttch caution ; and should be only at first mode-
•^^f if very severe, by mild purgatives or laxa-
tives ; by depletions, diaphoretics, and diuretics ;
^1 ft regulated diet ^ and by warm clothing,

according to the circumstances of the case, be-
cause the sudden arrest of the evacuations by
opiates and astringents may be attended by some
risk.

41. vii. Notices of particular Hemedies

RECOMMENDED BY AuTHORS, Uc*'^ A. Bleeding

has been advised by Goto gnus (Ds Vensuct. in
Diarrh, Rom. 1604.); by Horstius (0pp. i\u
p. 68.) ; by Zacutus Lucitanus {Med, Pr, Hitt,
l.ii. p. 734.) ; in the bilious variety, and by
Sydenham. It is obviously requisite in the in-
flammatory states of the disease, whether acute or
chronic, and preferably by leeches applied to the
abdomen, to the sacrum, or to the verge of the
anus, particularly when tenesmus is present.

42. JB. Refrigerants are always beneficial in
the serous and mucous varieties, and when the
complaint is attended by increased heat or excited
circulation, and erect papillae of the tongue ; and
they may be combined with demulcents and
opiates (F. 36.821.838.886.) according to the
cireumstances of the case. Of this class of medi-
cines the nitrate of potash or cf soda, camphor
(F. 431.), the muriate of ammonia (F. 352. 431.),
borax (F. 209. 630. 867.), variously combined,
and the tepid fratA,*are the most appropriate. Reca-
MiER (Annuaire Mid, Chirurg, vol. i. p. 113.)
recommends nitre with the oxyde of bismuth, and
opiated aromatics. Hvfeland prefers the muriate
of ammonia (Stark, Archiv. b. i.st. 3. p. 93.) in
the inflammatory states, and when it accompanies
fever ; and Zadiq combines it with mucilaginous
substances (Joum, der Erfind. st. xxi. p. 57.).

43. C. Laxatives and mild purgatives have al-
ready been sufficiently noticed. Those of an irri-
tating nature are not unfrequent causes of the
complaint, and ought never to be prescribed.
Even castor, olive, or almond oil, if they be in the
least acrid or rancid, will be productive of much
mischief. I have seen enteritis supervene on dinr-
rhoea from this cause. In the chronic states of
the disease, sulphur, with cream of tartar and
sub-borate of soda in the form of electuary
(F.790.), and conjoined with aromatics, is often
the best laxative that can be employed. It has
been preferred by Lange (Miscell, Vefit, p. 29.)
and It possesses the advantage of relaxing the
skin.

44. D. Diaphoretics Bre of much benefit in all
the febrile states of the disorder, particularly the
serous variety, and are advantageously combined
with refrigerants. They have been adopted by
Sydenham, Diemerbroeck {Observat. et Curat,
No. 64.), Lentin (Beverage, b.iv. p. 332.), Osi-
ANDER (Denkwurdigheiten,h.i\. p. 179.), &c.
The chief of this class are James's powder, ipe-
cacuanha, camphor, carbonate and acetate of
ammonia, spiritus setheris nitrici (F. 394. 840.),
&c. Ipecacuanha, particularly when associated
with nitrate of potash, canophor, and opium, is one
of the most certain and eflicient remedies we can
prescribe in all the acute forms of the disease ;
and it is also a very useful adjuvant of other
medicines (see F. 39. 495. 642. 744. 924.). It has
been very generally used, and particularly by
Linn^us (Amoen. Acad, UpsaL vol. viii. p. 246.),
FoTHEnGiLL {Med, Observat, and Inquir, vol. vi.
art. 18.), Baldincer, (N, Magazin. b. xix.
p. 404.), Stark, Loefpler (Beytrdge, b.i.), and
Broussais (Loccit, in Bibli,), either in the com-
binations now noticed, or in those constituting the

M m3

DIGESTIVE CANAL— FtJKcnoNAL Disorders op.

537

of tbe mme colour in the healthy state. It maj
be— (a) perfectly whit§ or whituh, although this
state does not imply that functtooal disorder did
not exist daring hfe. — (6) It may present various
tints or d^reet of eotaur, without ceasing to be
wood, depending, 1. on the performance of the
digestire prooesses, shortly before or at the time
of death ; 2. on the congestion to which iotemai
rascolar parts are liable at the last agony or
moments of life; 3. on mechanical obstacles to
the return of blood in the veins existing a longer
or shorter period before dissolution ; 4. on the
gravitation of the blood to depending parts ; 5. on
the exudation of blood through the parietes of
the venels; 6. on the exudation ot this fluid
through the capsule of the spleen; 7 on the
pses existing in the canal at the time of death ;
6. 00 the developement of other gases at a
remoter period, when putrefaction commences;
9. oQ the combination of the colouring matter of
the bile present in the digestive tube, with parts
of its mucous surface ; and 10. on the medicinal
or qther ingesta, which may change its colour so
u to resemble the morbid state. Some of the
roloure produced by these causes cannot be con-
foaoded vrith that resultine from inflammation ;
others veiy nearly resemble it, especially those
occtuooed by the 1. 2. and 4. and certain va-
rieiies of 3. and 5. Those states of tiie digestive
surface that most nearly resemble inflammation,
roa; in respect of it be denominated pauive, M.
Bn.LARi> has given the following diagnotis be-
tween pamte and active or inflammatory redness
of the villous or digestive mucous coat.

Ii^ammatorff. PasHw.

a. With or without loanl- a. Tho same.
^ thickening of the
mrmbraoe.

ft. lodilfereDtlr hi a de> b. Almost always In a de.
PcndioK or ^vated part pendiog part.

(. Withoat general ii^cc- c. With general injection
tion of the abdomiDal of the abdominal vesiels,
veuek, and without ttnj and with au obstacle to
t'brtado to the course of the course of the blood ;
theblood; sometimes con. rarelf beins an i«olated
listing hi only a slight lo- local injection, hut tn-
ul injectioo. queotly occupying a fold

of the intestine, or the
whole intestine.

^ With considerable ten- d. A power of raising the
dcrnessofthesttb-moeous mucous membrane in
tiuae, and a capabili^ of shreds only, which is the
fn^'tag the mucous coat case in heaJth.
io large patches.

<• With thickening and c. Without abundance or
a|Mindaoce of the intes- thickening of ^the Intes-
tinal mocus } and some. tinal mucus ; but some-
tiiBcs with saagolneous times with sanguineous
eihalatkm. 'exudation.

6. Thk diagnosis refers merely to the differences
hetween rcrfnew .from inflammatory irritation and
^Beas from passive coneestioa. The various
rnulu of inflammation of the mucous membrane
are entirely left out of the question. This tissue
"eldom experiences any change in density within
*i>e period which usually elapses between death
>ad the examinatioo. Therefore, tofUning can
very seldom be justly considered a pott mortem
<^Qge. In respect, however, of the stomach,
the ease has been supposed to be otbenvise, and
upon good grounds. The observations of J.
Hunter and Allam Burns on the human subject ;
of Carlislk, Cooper, and Wilson Philip, on
rabbiii; of Adams, Brbtonneav, aodTnossEAV,
on dogs; and of Spallanzani on fishes; show
that the solvent action of the juices of the stomach
^y be exated npon Mif, within twenty-four

hours from death, so as not only to soften its
villous coat, but to dissolve both it and the coats
exterior to it, until the organ is perforated or de-
stroyed in one oi* more places. The possibility of
this occurrence is shown by the experiments of
Stevens, Lovsll, and others, demonstrating the
solvent power of these juices ; and that it actually
takes place, is established by the experiments of
Drs. Uamersr and Carswell, as well as by the
sound health of the subjects of it at tbe time of
death, and the absence of inflammatory appear-
ances around the destroyed part, or in the peritoneal
coat. The healthy state of the other tissues com-
posing the parietes of the digestive canal, and the
natural capiacity and position of its diflPerent parts,
require no remark.

7. 1. Functional Disorders. — ^The disposition,
which has prevailed for many years, and which is
still so manifest in medical literature and practice,
to impute every morbid condition to inflammatory
action, and changes of structure, has been dis-
played more in this branch of pathology than in
any other. Since the appearance of the writings of
Marcus, and especially since the promulgation of
the doctrine of Broussais, all the states of
disorder referrible, directly, or sympathetically, to
the digestive organs, have beien considered by
many to arise from inflammatory irritation and
action, or their consequences, in various grades
or states of activity ; and even those who have not
adopted the views of this very zealous writer, have
too generally overlooked the primary and con-
trolling influence of the vital endowment in the
origin and removal, not only of the diseases of the
alimentary canal, but of its related viscera, and,
indeed, of those of all otherorp^ans. The pathologist
who observes closely tbe action of the numerous
agents which either merely change the conditions
of life, as manifested in the sensitive and con-
tractile systems, or which produce alterations of
structure cognisable by the senses, and who notes
the manner in which primary impressions aflfect
related and even remote parts, must have olten
remarked, that some connection subsists between
the nature of the agent, the particular system
acted upon, and the effect produced ; that the
more obvious and palpable lesions are generally
remote and often only contingent results; and
that alterations apparently identical are often
associated with, even when they are not the con-
sequences of, very different states of sensibility
and contractility, as well as of the other manifest-
ations of vital power. It is necessary to our
enquiries into tbe morbid states of a part, which,
with reference to the formative ana vegetative
processes especially, is primarily and essentially
vital, and which, from its intimate connection with
the organic system of nerves, powerfully influences,
whilst it is itself influenced by, the vital endow-
.ment or appropriate influence of thb system, —
of a part especially devoted to the preparation of
the materials for the reparation of the structures,
and the support and perpetuation of^life, — to
view its changes of function and of structure ac-
cordingly, and with strict reference to the foregoing
considerations.

8. i. Change* in the Detirefor Food and Drink»
— If the alimentary canal be admitted to be, of
all parts of the economy, that in which identity
of lesion tbe least infers identity of symptoms,
the same admission should be extended to the

DIQESTIVE CANAL— HyramopRT of its Timuu: 643

secretioDfl, is placed between the peritoneal and

When thtfl latter occun, the follicle becomes
diiteoded by iti tecretion, in some cases, to such
an extent as to form large globular tumours.
The parietes of the bypertropnied follicle may
also be transformed into a fibrous, or fibro-car-
tilaginoas, or even a cartilaginous tissue, thereby
aQgiDsnting their thickness, — a change justly
imputed by M. GanoaiN to chronic inflammation.
Hypertrophy of the follicles is most common in
the inferior part of the ilium, in the csseum, in the
Rctom and colon, and in the duodenum, but is
rarely met with in the stomach. It is most fre-
quently a oonseqaence of diarrhaui, dymntery, and
gastric feven (which see) ; and may be mistaken
for tufts of enlarged white villi, and for small
white bodies, consisting of the rudiments of vahuUt
ronnitmtet. It ii very common after the bowel
tomplatnti of children, amongst whom, however,
the follicles are always more manifest than in
adttlla.

30. (6) Hypertrophy of tk§ mb-viUoui tittust
may be more or less general throughout one bf
the prindpal divisions of the digestive canal, or it
may be circumscribed. It is not unusual to find,
after chrooic diarrhoea or dysentery, the tuihtnueoiu
ulUlar tUtuM much more apparent than usual, or
even two or throe lines in thickness, in the colon
or rectum, or both. It is then denser than natu-
ral, sometimes with more or less regularly arranged
fibres, or plates, of a pale or pearly white colour,
and without any erident blood-vessels. It is often
of a homogeneous semi-cartilaginouS'like texture ;
but when thus generally tnlargid and indurated,
the hypertrophy is never so great as when it is
circumscribed. When it forms, in some part of

mucous coats.

31. This lesion is generally the consequence of
inflammatory irritation long kept up or frequently
reproduced in the mucous membrane, which may
be sound, no change of it having existed, or that
which formerly existed having ceased. More fre-
quently, however, it is either injected, indurated,
softened, ulcerated, or entirely eroded in the hy-
pertrophied part. Hypertrophy of the sub-mucous
tissue is most frequent in tne stomach and large
intestines, particularly the rectum, where it may
be either diffused or circumscribed ; and the least
so in the small intestines, in which it is commonly
circumscribed. It is rarely met with in infants.
MM. BiLLARD and Andral have, however, ob-
served it in them ; and I have seen it in the colon
of children a few years of age, who had lon^ been
aflTected with chronic diarrhoea. It seldom is seen
in the stomach before thirty ; but it is common
in this viscus between the ages of thirty-five
and fdxty-five, especially near the pylorus and
cardia.

32. (e) The mv$cular coat k sometimes hyper-
trophied, either alone, or along with the submu-
cous tissue. In the former case, the pyloric orifice
of the stomach is its chief seat (Cruveiliii£r, R.
Pros, Louis, Bouillaud, Akdral, &c.), and is
much increased in thickness from this circumstance.
In hypertrophy of the sub-mucous tissue, the mus-
cular coat, instead of disappearing before the in-
creasing bulk and induration of the cellular tissue
that surrounds and penetrates it, as most frequently
occurs, and as above described, is sometimes also
hypertrophied. In this case, when a section is

the canal, a tumour, elevating the mucous surface made of the diseased part, the hypertrophied mus-

by its thickness, it constitutes the chanee to which
the term teirrhut has been Tery generally applied,
and difTen from the diffused hypertrophy only in
bemg circumscribed, and many times thicker. That
the tumoor occasioned by the circumscribed hy-
pertrophy, whether existing in the cardia or pylo-
rus, is not the result of the production of a new
tissue, but arises from enlargement and induration
—owing to excesnve irritation — chiefly of the
sub-mucous tissue, is manifest in the early states
of the lesion. This may continue to be the only
change ; but often ulterior alterations take place,
and t new structure is developed ; the part becomes
vascular, is sometimes divided into lobes, and
morbid secretions are poured into its substance,
whereby it acquires the appearance of areolae and
cells containing these secretions; the fibriles of
the cellular tissue between them becoming at the
Atne time more and more hardened and hypertro-
phied. Frequently the hypertrophy is not confined
to the tub-mucous tissue, but is extended to the
ti^^e connecting the muscular and peritoneal
coats; hardened, with fibres running between and
separating the fasciculi of the interpMOsed muscular
co%t, and thereby connecting both layers of hy-
pertrophied cellular substance. M. Andral
confers these fibres to consist of the cellular
tittue placed between the muscular fibres, also in
a ftate of hypertrophy ; the latter structure gradu-
ally disappearing bemre the progressive increase
and induration of the former. At last, all ap-
p<ranoce of muscle is lost, and a mass either of
<imply hypertrophied and indurated cellular tissue,
or of this substance further and consecutively al-
tered, chiefly by the deposition into it of morbid

cular coat may be traced, in the form of a bluish
semitransparent layer, placed between two other
layers of a whitish colour, consisting of the sub-
mucous and sub-peritoneal cellular tissue also in a
state of hypertrophy. This central or muscular
layer is traversed by lines of the same colour
as the layers on each side of it ; the enlargement
and induration thus extending to the muscular
coat, and through its fibres, by means of their in-
terposed cellular tissue, to that connecting it with
the peritoneum. This lesion is most frequent in
the stomach, particularly near the pylorus, and
constitutes, as well as the preceding states ($ 27.)

— often with various alterations of %ecretion super-
added—-what is usually called teirrhut, (See
Stomach — Diteatet of.)

33. C. Hypertrophy of the nervet and vessels. —
(a) The nervet supplying the gastro-intestinal
canal are very rarely enlarged. M. Andral has
never observed any such change in them. M^. H.
Prus, however, found, in a case of circumscribed
hypertrophy of the sub-mucous tissue and muscu-
lar coat {teirrhut) of a part of the body of the
stomach, the right oesophagsan branch of the
pneumo-gastric nerve increased to twice its bulk,
from the cardia to its disappearance in the tumour.
It should be recollected, that the state of the nerves
is seldom enquired after in pott mortem inspections,
and that to ascertain the condition of the ganglial
nerves requires the most minute research, which
can seldom be devoted under such circumstances.

— (6) The blflod'vestelt of the gastro-intestinal
tube are very often large and dilated ; but this is
not hypertrophy. Their parietes are very rarely
thickened. IVI. Andral found, in two cases of

DIGESTIVE CANAL— Morbid Sicretions in.

549

torn, althoRgh not eonstantly or generally con-
nected with any one pathological state. In-
creased eibaladon of the intestinal gases is,
however, a very frequent, although not a con-
stant, result of inflammatory imtation of the
villoQS membrane, or of disease of Pryer's
glands; but it may also proceed from extreme
debility, manifested especially in the organic
nenrous system, and by the bloodless state of the
digestive canal found after death. Hysteria,
lij{xicboodriasis, asthma, flatulent and lead colic,
rabidity, and other affections, are characterised
b^ great accumulations of air in the intestines,
without any sign of vascular irritation of the
villoos suriace. These gaseous collections are
generally greatest in the large intestines ; but they
abo take place in the stomach and small intes-
tines, partieularly in the latter, as observed in the
last BtagM of typhoid fevers, and of various other
acute diseases. The meteorismus of fever 4ias
been imputed bv Broitssais to disease, especially
ulceration of the intestines ; but, although the
connection is frequent, it is by no means general,
and, even when observed, both pathological states
are merely associated efiects of the same anterior
change, via. diminished viul power, expreased
partienlarlv in the oi^ganic nervous system and
viscera influenoed by it. The formation of air
in tbe digestive canal has been chiefly attributed,
in the article on Couc, to exhalation from the
villous suriiMe. The flatus may also arise partly
from the chemical reaction of the diversified and
heterogeneous substances taken into the stomach,
as they are acted upon by the secretions- and are
propeUed along the canal, and a portion of air is
commoDly swallowed with the ingesta.

45. (6) TheHuids and seeretions foreign to th§
ijgntm eanal in health, but which are some-
times found in it, are, blood, pus, coagulable
l^mph, melanotic matter, tubercular matter, oon-
ciete or fluid latty matter, a thick albuminous
nibitaace, calculous concretions, and worms.—
«. ^ood is occasioDally found in the stomach and
intestines, both in a fluid and coagulated state,
and in very Tariable quantity. The causes of
iti efliision on the free surface of the villous
ooat are— 1st, Atony of the extreme vessels,
and diminiihed vital cohesion of the coat ; — 2d,
A neehanieal obstacle to the return of the blood,
panicalarly in the vena portse ;— 3d, Inflamma-
tioo or irritation of the villous membrane in
▼arions states of intensity and morbid association,
BQperyening either spontaneously, or caused by
imtatiBg ingesta ; -'4th, A morbid* or dissolved
Xati or the blood itself, most frequently, how-
ever, aasodated.with the 1st state, as in scurvy,
the black vomit of yellow fever, and purpura
bamonhagica ; — 6tb, The erosion of the coats
of a bloofvosel in the seat of an ulcer ; — 6th,
Disetw of the coats of a blood-vessel, independ-
ody of any lerion of the Ttllous coat;— and
7tb, (mm having been ivrallowed, as in cases of
exociKva hamoptysis, hmmorrhage from the
'■necs, he. When the sanguineous effusion
proceeds from the third source, it majr be either
^ tli|ht, the mueus covering the villous sur-
face being merely tinged with it, or very con-
i^i^ble, aoGonfing to the various oonoomitant
riTconstaneca under which it may uke place.
l^fifA and tirth sources are the most rare, but
Mt w ru« at M. Amdsal luppoies, the sixth

beins entirely overlooked by him. M. Frost*
Dr. Abercrombie, and others, have detailed in-
stances of the former ; and a case of the latter,
from atheromatous deposit in the Coats of an
arterial vessel disposing it to rupture, very recently
occurred in my own practice. (^See Hjmiorriiagr
— ^^rom the Digestive CanaL)

46. 0. Puriform matter is but rarely met
with on the villous surface, iitttead of the mucus
usually secreted 'by it, in any appreciable quan-
tity. It is muoh more commonly found in the
follicles, either in an inflamed state of this coat,
or independently of any marked injection of its
vessels. When the follicles contain this fluid,
they generally present the appearances already
described ($ 22. c, 36. s.)', especially the conoidal
and pustular state, the puriform matter escaping on
incisini them. — y. Dr. Monro describes a brown
fluid like cocoa, which he has seen in some in-
stances voided in large quantity during life
from the stomach. In a fatal case, this viscus
was very large, and half filled with this fluid, its
coats and ^joining viscera being sound. — h
CoagulabU lymph, in vsribus grades of density,
and in the form of false membranes, is also
sometimes found on the gastro-intestinal villous
surface ; but not so of&n as in the mouth,
pharynx, and cesophagus. I have observed it
most frequently in the form of whitish flocculent
or thin membranous-like patches and shreds,
covering the inflamed or mrtially injected sur-
face, in fatal cases of scarlet fever, vriih gastro-
intestinal symptoms. In sub-acute inflammatory
affections of the digestive organs, either with or
without diarrhoea or dysentery, as in the cases
described by Baillib, Powrli., Good, Annes-
LRY, Lelvt, Bxllard, &c., the false membrane
is occasionally so complete as to form a tube of
various dimensions, which, when evacuated with
the stools, has been mistaken for a ^hacelated
portion of intestine, or for its mucous coat. Dr.
GoDMAv found it covering the whole villous sur-
face of the stomach ; and Mr. Howship remarked
a similar production in a child that had acci-
dentally swallowed boiling water. M. Andral
thinks that it may sometimes proceed from a
morbid secretion of the mucous follioes; but, as
in the other situations in which it is seen, it evi-
dently arises from inflammatory action ^ the
villous or mucous coat itself, the exhalant vessels
of which, in the inflamed state, throw out co-
agulable lymph instead of their usual watery or
serous exhalation ; these vessels also sometimes
secreting puriform matter, in a modified form of
disease. — i. The gastro-intestinal mucous coat
sometimes exudes a black matter, the melanotis of
modem writers. This substance exists either in
a fluid form, on the free surface of the mem-
brane, or combined with its tissue, or in both
forms in the same or different parts of the canal.
When merely deposited on the free surface of
this coat, it can generally be washed oflT; the
matter composing it staining linen. But when
it is infiltrated or combined with this tunic, it
cannot be removed by ablution, and it does not
stain linen. It is most apparent at the bottom
of the lacunae in the duodenum, or in the sum*
mits of the villi, or in the margins of the orifices
of Peykr's elands, or in the bottoms of small
ulcers. — Z' Tubereuhui matfsr is sometimes found
io the follicles, the intestines being studded with

Nn 3

DIGESTIVE CANAL— BnuooiuniT akd Rxrtssiicis to m Lxsiovs.

565

of thorn allintioM, •■d the trmtmmtt ihey »•
qoire, becaoie the imm leaoM, wntcd io diflfereot
pvn of tlM eaoftl, are attended by diffBrcnt phe-
Mneua, and elent modified meau ef cure ^
nkerenoe beiii|^ nede to ihe cbaDges here de-
Kribed. TWralere, the diaeaaee. of the dig^-
life caaal shoeld be elao studied in tbe feUowing
wtiektf, whieb coBtaiD moat of wbat ia knowa
respectiog them : — Cmcun, Colic ano iLsva,

CoiON, CONCaBTlOllS, COiUTI PATIOM , Dl ABRHOt A ,
DcODKNUM, DWBIfTXBY, FsVEBS, iH^tQEBnON,

Imtsnvwt, (EaopHAOuSy PaRrroffEUM, Fra-
MTsx, RiCTUM, Stomacb, WoRiie, fice.

Bnuoa AMD Raras. — i. GamaAb TaatATisaa.—
WaUMckmidi, Dt Vcotric ct Inte«t ITotbla. Marii. 101~
KroMSt De IntcAt corumque If orbiA. Jenc. 1684. — Olit-
m, Otrcnliift et InUsUniA, tr. ii.— J. M. Hqffhtann, Dto.
nwitMCarn. Hum. AmML PAilioi. ftc 4ta Altd. 17 1& —
iiMKr. in lfatf«r*f BiblkiCh . Med. PncL iiL p. 46L— P<wrr,
Exereitat. de OIaihI. Inttst. par. iL p. 80.— ^tfo^pM, De
l^micA lalart. VtUaw iwo Morb. Ac. Jena, 17S1. ; et De
Colo iDteit Mult Mocb. NMo, ftc. Leipa. 171& — Hal-
Ur, MocU Aliqui Ventric. in Cadar. OfaaervatL Ooct.
I7«.-LMteMf, HiAt Anat MM. 1. i. obMnr.40a. et
patmm. ~ Tf— tiy Ue Mwb. InlMi. fte. Tub. 1707.—
S. Sdndifort, Oteenr. Anat Path, i voIa. 4ta ; L. B. 1777,
Sro. -^C F. Ladwig, Prime Lines Anat FUhol. 8va
Lap. 1785^— rie»#^f!iyr, Anat. Faib. In EncycL H6.
ttediqu^ 4t0^ partA, 17a».~jr. BaUte, liie Mortx
AittL of the Hum. Bodj, Sth cd. Lond. 1818. — ^. B,
PdteTt Apboriimen aua der FaUioI. Anat Ac. Wien.
l«HL~PrMf, MM. EeUir^epar rObwnrat et TOuvert
iiet Carpi, a tomca. Paria. mk^Xadc, In JUiPi Ar-
ctiiv.lT. p.381^j: CrmveUAkr. Sur I'Anat Patbolog.
ac 2 rob. 8vo. Paris, 1816. ; et MM. Eelalrte par I'Anat
(ft Phyi. Path. cap. i. ParU, 188t ; ct Anat Path, du
Cocpi Hum. 1. L—zv. Paria, 1787-31— AvMfaA, Uiat
«• Phlcnnasiet Cbroalmiat, tte. t. It cap. 1. et tea. —
An- io J. JaAmoMlr Med-Chinirg. Rer. vol. ii. p. 1. —
i- ifercramMr, in Ed^ Med. and Suig. Journ. Na 84w ; et
Oil. of acoDMcb and Abd. Viscera, 8vo. £din. 18S& —
Tadfro^ Rechercfaea Anat Pathol, ftc. 3 t. 8to.
Pwit, UOSL -. Andrml. Beeherehat inr 1* Anat. PathoL da
Ciaai INfB«ii;fte. in Nouv. Jom.de Mid. t xv. p. 193. s
<t LoihL Med. HepOA. toL xlx. p. S48w ttteq.; et Anat
PttboL 8vo. VOL if. par 1. «f jw. — J. J?. PalUtta, Exer-
et. Pidiol. ftoL 410. Mod. 1W0.7 — Merat, in Diet, dee
SdCQect MM. t xxxviii. p. 158 — X. iMoAa/, Anat Pa^
thol. td. par Btiueau^ 8vo. Paris, 1825. — A. N. Ge%.
dm. Hlit Anat des InflAmmat toL I. p. 48S. 699. 691.
* ffatti, Nouv. BibUoth. MM. t ix. p. IT 8881 — FamU^
M, UwL ml T. pk 16B. — BfUord, De U Memb.
Haquew GAsCnvInteat dana I'Etat Fathoiog. Ac. 8va
Puu, lfl25..-&vrdb». In Rev. MM. t. H. 1884. pi 909.—
/. iaanlcy and ^IsrtMr, in Beiearebea, ftc. Dim of Warm
Climates, voL ii. pL aa, «< am. — Craigie, ElemenU of
^. and Pathol Anat Svo. 1828, p. 684l — J*. Amutrong^
MntL AaaL eTtbe Bow«b» Liver, and Stomach, 1. i.— iH.
ioML 18S& — il MiNSfV, Morbid Anat of the Gullet,
itanacb, aM InteAttnes. 8d. 8va Edin. 1830.

il. LBHoaa e» FuvcnoM and CiacuLATioir. -^ A. Qf
WAml A0dfte,Iiii.Med.17OO,p.l73. — l>eJniesM0r,
<>ai.deSpasma Intcet £rC 174L ; et De Consensu Pri.

ia«r. Vlar. ftc lUla, 17S4 SchneUer^e Ardore Ven.

(rvttlf, fte. Arg. ITSd — Dannenberg. De Asthenia Ven-
Modi ct iflitst fte. Jaoit. 1801. — Wiesmr, De Spaamo
JoitikuU. Vit 1B08.— i^wdta, in Mem. de la Sac.
Jled. d'Emulation, t iL p. 86. — Oteynt, Duk Hoapi Rep.
vol tv. p. 2S2. — Mtttfariamtt in Olasf . MM. Joum. vol U.
P.170L

A or GrrnteMNs. — Blesima, ObaervaL MM. Bar.
pv.l B.Sl. — lltt^^miM, Op. tvi. P.2S3. — SXo^Rat
wd. par. viil. p. |S». — Kmemf^t AbhandL die Kxank.
bnt (t Untaricba. ftn. jMsstin.— Anv. In Act. Ra|. See.
Med. Hafin. vol i. p. 1 la, et voL ii. n. 279. — Bkuland,
I'wtip VascuL fta Inteet IVnuium Tunids, ftc. Traj.
>d Sh. 1797, p. 14 -1 Mick^KU*, Med. BibUothek, bi 1. at &
»;S71. {Wkkmt paim 0r otJkr timt.) — YeUol§» ia Trans,
or Med^Chinuf . Soc. vol. iv. p.K8 — Trouueam, De la
D«thm«iit«itte, ftc. In Arehivea de MM. t a. p.tf7. 169.
7 A Qnmmmd^ tai Jdom. Compl. do Diet dea 8e. MM.
Joljr* lWn.,^frAwJrf/j»iaiin, GbAerv. MM. t IL p. 98-18L
-Colteaaii, in Aivhiv. G^n. de MM. t i. p. 278. —
,^. d. C. Lmtdtmi, In B^. MM. t U. 1898, pi 189. 398.
O/anesKA ailUMn.)— l^MTSi; Affcfaivcs 06n.de MM.
t iviL pt 4a iMmc/oUiclet.)

m. AvmoraY, HTPSBTmorar, awd iKOoaATioir. —
^rWr^t CbyMofia, p. Ma (if/r^plly.)~JftM^/, SepoIcK
'a!^ ••vil- oh.5& UttnipAr.) — AcAfldr, Obaerv. 1. iU.
i^^ iMnpkM*)^FoMl, DeCalloaiUteVent exPotua
SpjT. Abusu. lip.. 1771. _ better, Aphorismen, i. p. 172
^*9i, fJkinkmt0bt»eaied^tA€tMittarMume.)^L«*

wMUmg, De PtIwd Carclaomatoio. lag. 1777. — Sherwimt
in Mem. of MM. Soc. of Lond. voL it p. S7. — TkitetUmt^
Med. ttM Chlruri. Bemerk. 1. p. 908L — AMh#(b' Be.
merkungan, th. L pi 35. — Portel. MMb. aw PIua Blalad..

veLlil. p.1 iSaOlk. Series of Eag. Cml Ui. lab. 6, 7

Ctogwet, in Bullet, de la Soc. de MM. 1810, No. 7. p. 106. ...

Founder, In finWIaf « Joum. da MM. May, 181S Datr^

Imc, Joum. de MM. t at p.49a — ShmIA, in MM. Cooa*
munlc ft& vol L No. 29. — abna. In Ibki. Na 88.— Oir-
rtttm, in Mem. of MM. Soc. of Lond* t. v. n. 16.— flSatter,
Opuao. Path. oba. SfiL {F^vm mbnue qfaeidt.)^JMi, Ar-
chiv. t d. Pbya. Il Iv. p. 381. — ICara, Aichiv. C d. Pract
Med. b. iU. p. 67 — Girdleatone. in MM and Phys. Joum.
vol. x1. p. 13.— J. Holmes, In Ibid. vol. xxvUL p. 170.—
W. G. IkmUf In IbM. vol. xax. p.516.— #. Ckardei, Dee
Dfigfoerat. SclrrbeuAeA de TEstomac. Paria* 1006 -, et in

Suart. Joura. of For. Med. ft& voL U. -> JDmAe, in Edin.
[ed. and Suig. Joum. voL ii. p. 417. — M Hm, In Ibid.
voL xli. piS7&-'GrwNAow, In Ibid. voL xvii p. 378k— £oatfib
Bttm. et Bech. ft& 8vo. p. 120. ; et Arehivm Q^n^raka.
ftc; t iv. n.536 — BoadUmmi, In R6v. MM. Mars, 1887 —
R. Fra$t KecherelMa Nouv. aur Cancer de I'Ertomac, fte.
6vo. Paris, 1888.

Iv. SommNo, UuraaATioH, Eaoaioir» PaafoaAnoWr
ftc — Bimet, SefMlclu. L iii. sect. xl. obs. 2, 3, 4, ftc —•
MorgagtUt Sisd. ct Caua. Morbk cpu xaav. art 15. — Dum
vemgh Mim. de I'AcM desScien. 1701 p. 27. — As««ttiA»
De Tunica ViUosss RenovaUone, Ac. Altd. 1735i-^
Ftiend, Comment de Fiebrlbus, p. 148. — AsMttfrnr, in
/falkr'A ColL DisA. Pract vol. 111. n. SB.'— JI. £o»a, Sdln..
MM. Essays, vol. L p. 291. — Vmn SuHete», Comment ftc.
M ^!955. — D. Monro, EssAys PhyA and Lit vol. Ul.
p.516. — GmrMa, Ulc Inteat Caaus, ftc Tbb. 1759.—
UemUmd, Hist Annt MM. L ii. obs» 7ia — Geqghm,
HlAt de U Soc R. de MM. M 17»i 1781, p. 168. — Aifv*
Act Reg. Soc MM Hafti. t i. pi 280. — raroit, Mem. or
MM Soc of Land, vol IL n. SS.-.l'Md, in Ibid. vol. vl.
p. 128.— JHurrottw, in Med. Facta and Obaerv. vol. v.
n. 17. ; et in Trans, of Irish AcM. voL iv. n. 18. iFI$tula
open, eatem.) — LaalmaaaA. Diss. Med.Xhir. Miscel.

Ultr. 178& — ifaUcr. Omiag. Pathot oba. 28 Cndek*.

tkamka, Anat of Absorb. VcsaelA, ftc. p. lX3w — Van der
Kalk, ObAcrvAt varii Argument ftc Oion. 179S. — Go*
dot, in Journ. de MM t xL p. 146 — Jaeominelle, in Ibid,
t xc n 909. — Hflltf, hi Ibid. Contin. iv. p. 108. —lieUL
Do Uker. in Ventc Pcnet Ac Held. 1788L — StofL Rat
MM. L p. 266., a p. 409, viL p. 164 — J. Hamter, Ptiilof.
Trana. voL Ixii. p. 444.'; et Obmrv. oq Animal OBeo-
nomy, 2d edit p. 886.— A Gooek^ Med. and Sur^ Ob*
serv. Ac ; ct in Edin. MM. Comment vol. iL p. 373. —
C. 8n^ftK MM. Communicat voL vil. p. 467.— Jdkniav,;On
Morbid PoiaonA, Ac. 0dM p. 30.— laidtP^ri. De Lum.
briciA-lntast Perforant Lips. 1798: —X F. Frank, AcU
Inatitut Clin. Viln. Ann. II. p. 7. ; at De Cur. Horn.
Bfoib. L vi. par. L pk 13L — JV^Z^cma, in Ed. MM Com.
ment. vol IL pc 78. ~-iV»«l% Saaio d*Oaaervaaioni, t i.
— A«|iMMestf, Sect Cadav, PaUiol. 1805* p. 19 — A. Gck
rard, X}m Perfor. Sp<Mitan^ de rEstomac, Ac. 8vo.
Paris, 1803.— J. Msore, in MM. and Phya. Joum. vol. iil.

p. 611 A. BeUot, in Ibid. vol. zzU. p. 398 W. Cooke^

Ibid. vol. XXX. p.337. — O. JB. Male, in Ibid. vol. xiii.

p. 164 CMwj^r. HaiU, et Leraaa, in Bullet, de I'EcoIo

de MM. de Paris, 1808, p. 41.— il. Bunu, in Edin. MM.
and Surg. Joum. vol. vi. p. 137.— KrAm, in Uom*t Ar- '

chiv. Jan. 1812, p. 12 — ihtmiut, in Ibki. 1812, p. 162 .

F. Davia, in Lond. MM. Rev. vol. v. p. 256. — J2wg«r, in.
HMand o. Himl^a Joum. d. Pract. Heilk. May, 1811. |
et In Lond. MM. Repoa. voL x. p. 416. — Giiren, in
Uafeiamd u. Hhmfy'i Joum. d. Pr. Heilk. July. 1611.—
mdutiUe, In Ibid. Feb. 1812, p. 45. — Mareut, in ^e-
merid. d. Heilk. b. i. at S — LaUewtand, Observ. Rith.
ftc. 8vo. PArlA, 1818. 4to. — StMtx, in HMfeSaturi Joum.

d. Pr. Heilk. b. xxiv. p. 83 Sekenk, In Ibid. b. xxvit.

p. 89 Zetter, De Nat. Moibi Ventrlc Infant. Perforan*

tiA. Tub. 1818.— Ih'esdbe/, In Journ. de MM Contin.
t xi. — F. BkadetAa Uom'i Arehiv. Sep. et Oct. 1822,
n. 238. — Laisme, Cooaid. MM Leg. sur lee EroAiona eC
Perfor. de I'Estomac, 8vo. p. 163. — C Brwnat*, Bullet,
de U Soc Philomath. Sept 1823, p. 156 — UaaUamd, in
Cambridg^Philoaoph. Trans, vol. 1. p»287.-^. Gairduer,
CAses of EroaiooA And PerfbntionA of Aliment Cao. Ac.
TmnA. of Edin. MM..Chir. Soc vol. i. p. 311. {Jm abia
memoir.)^ P. C A. Lottit, M6m. et Recherehm AoAt
Path. Ac. 8vo. Paris, 1826, p. 1. 186. ; et in Archives de
MM. t. i. p. 17., et t V. p. 5. ; et Lond. MM. Repoa.
vol. X3M»n. 154 ^LemaOoU, in Arehivm da MM voL vi.
p. 6& — T^oiUet, in ifid. t iz . p. 5. — EUrmaier, in Ibid.

t xviii. p. 4OT BuUier, in Ibid. t. ii. p. 380 — Lisle, in

IMd. t. XX. p. 43S. — Qtattealer, in Nouv. Joum. de MM.
t Iv. a 295i ^ Hemett, in MM and Pbyc Joum. voL Ivi.
p. 97.^ Ckambers, in Ibid, p^ 354. ; and in Lond. Med.
Gaxette, vol ii. p. 513. — J7r/gA/, MMIcaI ReportA,
vol L 4ta. p. 178. — W. E. Homer, in Aracr. Joum. of
MM Sctcn. Feb. 18S&— Xormtfc, in lUv. MMicale, t. U
18^4. p. 379. — Canttet, in Ibid, t iv. 1825* p. 527. ; et in
Archtvee de MM. t. xviil. p. 487. — Sest^ Joum. Heb.
dQmad.daMM t L p. S16. — JRttmftVir, EittB. Med. and

DISEASE— PBBDiivoiRimr to— ^tioloot.

ttmiae, or olherwin ud^ those whieh preceded
it, woA which, elthoii^h the piiacipel or exctttnff
aiuet, woe inwiffiniirBl, until thus reinforced,
fvllj to prodeee the doMee. Ovring, also, to
the coediiioii of the frmme, no effect will some-
tinm Mkm one, twot or eveo three ezcitiDg
ciucs ; tad vnlU a greeler nnmher are brouffht
iotDoptnUioQ, DO miscbief will often result. Ihe
ctfecti pndeeed faw various animal and vegetable
cihilalioos on di£mat individuals, or upon the
nme pcnoo at dirtinet periods, under difierent
iltitf of mind and predmposition ; and by the
icttoa of nameious eoneurrenl» aooessory, and
detenuniDg causss; fully illustrate this position.
It is chiefly owing to a want of knowledge of the
doctrine of causation, that so much error and
diferesce of opivion prevail respecting infectious
lod oon-inleetious diseeses. On the other hand,
penoM amy be eo very easily aiected, that
ctua of Ihs slightest nature, and such as are
deteroiaiBg or acceseery in the majority of
6Mei, sre priedpaf in respect of them ; and in-
floencei which are nsnally ^redoponjig are often,
is iBch persons, the esoitin^ causes of disease.
Alw ihom whieh are nmot§ in their operation on
MUDS eoMlilutions, are dimet or immediate in
respect of othen. Examples of this are found
io the dimaaes of the lunn, liver, stomach, and
Well. In considcwng the ageois which afiect
cither the functiooe, or the orgamsatson, I shall
int notice those which generally predispMs the
system to disease ; Dcxt those which exeiie dis-
tise in a diieet or immediate manner ; afterwards
such Si are specific, or prodnee determinate
ntelts; the cnects of their opeiation on the
^iog fnune beii^ obvions, and often admitting
^bttog foreseen { and lastly those oircumstanees
which sometimes determine, reinforoe, or call into
ictioa. exdtiog or specific agents.

10.i.Ov TBB pnanurosmo C«vsn or D»-
SAu.— These nay be classed — 1st, into such as
SK proper or peruliar to individuals, and the or-
caaifltsnees in which they are placed; 2d, into
scch u are net proper or peculiar to individuals,
bttt which may alfect various persons, and even
Mfflben of penona* but individually and ooea-
iiooaUj ; aaa« Sdt into such as are general, and
•fleet mors or Icsa all who are exposed to them.
*-.i. Thsse wkidi mrt peadiar to tk§ mdnidtml^
>o(l to the drcumstanoe in which he is plseed,
•od which mi^ he called the individual predis-
poiiog fsnses, aas — 1st, >original conformation
*od beredilary praditposition, aae, sex; tempeim-
acots, or^nal and acquired ; bsbit and consti-
^tion ; trades, jirnfessinns, aakd circumstances of
I'fe. &e. ; and* 3d, the vanoue external and inter-
Ml sgealB^ and orcooMtances modifying the slate
of the foadions,'—- as previous function^ disorder,
*Bd eonvalesoeiiee from disease; and the preg-
Mat and puerperal sutcs.

II. a,, Original eonformatien and hereditanf
^•di^pmitimu — It is generally obeerved, thet the
onialitetiooe. temperameoti, and diathesis of the
Spring doKly aesemhle the parent; and that
whstever diqiosstion to disorder, whether of fune-
tioa or of stmcture, the latter may have poe-
MSMd, is liable to evince itmlf in the former.
From this drcmmsHnoe having been very gene*
>AUy remarked in respcet of certain maliulies,
they have been teraMd hereditary. But it must
AM be supposed that childrea are actually born

559

with the diseases of their parents. This is but
seldom remaiked; although, in rare instances, I
have observed the commencement of tubercles in
the lungs of a new-born infant by a consumptive
mother; and small-pox and syphilis are some-
times communicated to the fcetus in vitro, occa-
sioning in some instances its premature birth,
and even its death, either previously to or about
the natttial termination of jutero-gesiatioo. Hy-
drocephalus, cataract, and various imperfoctions
of the organ of heering, and, indeed, of other
organs of sense, are not infrequently congenita],
or examplee of diMUse from ongimal con/orsi-
mtion; but, in such casee» it is rare that the
parent is similarly effected at the time, although
the hereditary prraispdsition, as about to be ex-
plained, exists nevenhelesB ; and, as respects the
first of these, a tendency merely to the disease
conU have cxieted at an early age in the parents.
It should be kept in recolleetion, therefore, that
the foetus tn Micro may be affected by several
cachectic, inflammatory, or even fiebrile diseases,
eommumeatod by the parents, or supervening
ocadoniaUff : but, of those which are thus com-
municated, even the majority are not, properlv
speaking, hereditary; smd thoee whieh are acci-
dental do not depend upon the constitution of
the parents, or the ailments experienoed by thei
mother during the period of gertation. Om*
goaUal dtMoattt are consequently divisible into —
let. Those which occur in the foetus, without
any participation on the part of the parents,—
as imperfoct developement of organs, inflam-
mations, eflmions of fluid in various parts, &c. ;
2d, Diseases iu which the foetus participates with
tlte mother, owing to their conteminating influ-
ence, or their extension throughout her oiganis-
ation, — as syphilis, small-pox, fevers, 5cc. ; 3dly,
Those that aibct the foetus from a constitutional
liability in one or both perents,-— as hydrooe-
phalus, cataract, tubercles, &c

12. Most commonly, however, the child is bom
free from disease ; but, inheriting the constitution
aiui diathesis of the parent, has that condition
of function and organisation which renders it
more sueeeptible of impreesioos produced by the
exciting causes <of certain maladies. Exsmples
of tbie may be contemplated daily in reepect of
diseases of the lungs anfl brain ; the constitutioa
and functions of theie viseera disposing them or
rendering them more prone to experience those
derangements by which the parent or parents
had l^en affected. In some instances this pre-
disposition may be more strongly nmrked io the
ehud than in the parent ; and in other eases the
predispositiott may be extremriy slight, and only
brought to light by the operation of the mofu
energetic agents*

13. The predisposition of the oflbpring gene-
rally evinces itself more strongly at certain ages
than at others, according to the kind of morbid
constitution or predis|)asition which it may in-
herit, the causes to which it is exposed, and the
nature of the malady which results. Thus, the
disposition to hiydnegpfuiku, coRmistonc, idiotcy,
riAsti, ter^uia, eaiaraet, &c., is most apparent
soon after birth, and at early epochs of life ; to
epiltptif, hiimm i hmgt, and pulmonary coweumplfofs,
about the age of puberty, or previously, or soon
afier; to goutt atihmaf and angina pcctortf, in
adult and mature age ; to intanity, apophxtf, and

DISEASE^-FnEfitsposiTioK to — Etiology.

fi63'

28. (f) ImUkaet and Uf0 great et^rtian, both
predispoie to mad eccaaioa 4isea«e ; whilst mo-
denleesaGae»espeeiaily io the open air, inoreases
the tntipn of the frmme. Fstigve generally
favoon the impreaaioo of cauaes which produce
acute affeetioDS, as fevers and ioflammaUons ;
whilst indolence and sedentary occupations dis-
pose to chronic maladies« as ^ongestioos of tlie
liver and abdominal organs, to corpulency, apo-
pleiy, hs^monlioidal anectioos, and derangements
characterised by dininiahed tone of the nervous
and vascular systems.

29. (k) Sle^. — The wont of this restorer of
the vital energies favours the invasion of fevers,
ioflaoiniations of the brain, and disordered mani-
festations of mind ; whilst too much sleep, and the
horizontal poatvre too long retained, or too fre-
qoeotly assumed, predispose to apoplexy, paraly-
sis, sofieaing of the brain, io6ammatioo of the
cerebrvm or of its coverings, and afiections of the
Udoeys. Many, also, of the causes of acute dis-
esRs make their impression during sleep, when
the body is relaxed, and thereby exposed to their
iQvasion. On the other hand, early rising pro-
notes botb mental and corporeal energy. It has
been remailbed by the actuaries of Life Insurance
Companies, that early rising is, of all habits, the
■Mst ooodttoive to longevity ; all long livers being
early rivers.

30. (k) Due vegulation of the ttmper, the
poniMif, and dairtt, and a proper conduct of the
iiM^NMlion, are also necessary to resist exciting
csDics. Indulgence of temper and passion not
o&ly predispose to disease, but also frequently di-
rectly exdle it, particularly in nervous, irritable,
and saoguine temperaments. Diseases of the
2ieart, brain, liver, atomach, and bowels, often ori-
giastc in these sources. Uncontrolled passions of
every description occaaon numerous functional
uid slmctoral cbanges, seated chiefly in the
viscera of the large cavities. Mocleration in eating
sod drinking, in sleep, in the indulgence of those
•ppedtes, feelings* psosioos, and desires which have
weo implanted in our natures by a wise Provi-
dence for our advantage, gratiHcation, social im-
provement, and happioess ; an equable state of
tbe mind, with oonndenee in our powers ; and
Utt pleasant excitement accompanying a well-
'tgulatcd cootso of application to business or
Kwly ; are the best means of resisting tlte impres-
Moos of ioiuTiotts agents.

31. C. Gttmral pndupmng Causrs. — Of these,
the most universal in their operation are certain
conititatioos of tbe atmosphere. Besides the
vuittions in tbe temperature and dr}'ne8s of the
air, its «(ctftrieiai candkUmt also vary extremely ;
^ut as yet we are not possessed of sufBcieot data
toeuhle us to state with precision bow far these
eooditioDs may predispose to, or directly excite,
<^acs8e, or what particular change in our bodies
Ksolt from certain electrical states of the atmo-
*phcre. But that tbe electrical conditions, to-
gether with a more or less humid state of the air,
are cooneeted, in the relation of cause and efiect,
*ith tbe pievalence of dweascj is extremely pro-
UUe, althovgh not satisCsctorily demonstrated,
^koic conditions which predispose to disease are
"^lat, tesBperatttfe ; 3d, humidity ; 3d, these two
states eonjjoiQed ; and, 4th, electrical conditions
of this fluid. Two very important subjects, very
mtimitely allied to these, and which act both as

predisposing, exciting, and specific causes, viz.>
ENDEMIC and EPIDEMIC influcnces, are considered
in separate articles.

32. (a) Temperature has a considerable infiu-.
ence in generating a predisposition to certain
diseases. Thus, in low states of atmospheric tem-
perature the functions of respiration are fully and
actively performed, especially as respects the
blood ; and tbe diseases observed in sucb circum-
stances are of an inflammatory nature, are seated
chiefly io the respiratory organs, and are charac*
tcrised, unless when tbe reduction of temperature
is remarkably great, or the air very moist, by
reaction of the powers of life on the causes whicn
excite them. Very wtrm states of the air impede
the changes which the blood undergoes in the
lungs; and, by thereby furnishing abundant ma-
terials for the formation of bile, occasion an in-
creased secretion of this fluid. Hence bilious
diseases are most prevalent during high atmo-
spheric temperature. This efiect upon the blood
is still more marked, if warmth be conjoined with
moisture ($ 34). Under those circumstances,
bilious fevers, hepatic diseases, dysentery, diar?
rhcea, and cholera prevail.

33. (b) Moisture. — In dry ttates of tbe air,
changes are fully eflTected on the blood by respira-
tion ; its watery portions are more freely carried off
from the exhaling surfaces -y its purity is increased,
its congestion and excessive fulness prevented ; and
consequently, the vital energies are promoted ;
and the depressing causes of disease, as infectious
animal etfluvia, and terrestrial exhalations, make
much less impression on the system. Disorders
occurring in this state of air assume chiefly a phlo*
gistic or sthenic character, and affect most fre-
quently the organs of respiration and the nervons
system. A very moUt itat€ of atmosphere causes
opposite effects. It fails of producing to the fulf
extent the requisite changes m the blood, and of
carrying off the fluids exhaled from the surfacesj
especially of the lungs; thereby rendering the
powers of life more languid, and the system con-
sequently more open to the invasion of the ex-
citing causes. Less moisture, also, being exhaled,
the elements of biliary secretion, and the watery
portion of the bloo^ become n^undant in the
vascular system. H^nce an abundant secretion
of bile, fevers, affections of the liver, and deter-
mination of fluids to the intestinal canal &c. are
promoted. (See art. Cumats.)

34. (c) Temperature and moisture cfnjoined,'^
That varm and humid states of air are individur
ally active as predisponents of disorder, has been
shown ; but it is when they are conjoined, that
they are especially injurious. A warm and humid
atmosphere dissolves and accumulates themecifie
causes,, such as animal and vegetable effluvia;
assists their operation ; and favours a rapid trans*
fer of electricity from tbe earth's surface, and th?
change in the condition and the accumulation of
it in the air. resulting therefrom. It has been shown
by the experiments of Frout, Fyffe, Allen, and
Pepys, in an artificially increased temperature,
and by those I made in an intertropical atmo-
sphere, that heat remarkably diminishes the changes
effected by respiration on the blood ; and these
chances are further diminished by warmth asso-
ciated with moisture, which, moreover, promotes
the passage of positive electricity from toe body*
And as tbe researches of Ritter show that the

O o2

564

DISEASE — Predisposition to — ^tiolooV.

electricity of the positive pole heightens, whilst
that of die nc^tive depresses, the actions of life,
the ultimate effect of humid atmospheric warmth,
as respects both the state of the circulating fluid
and the locomotive electricity of the body, will be
to lower the whole circle of vital manifestation*,
and to dispose to, or even to induce, diseases of a
low character — to occasion adynamic, continued,
and remittent fevers, or agues of a pernicious and
congestive kind, or dysentery, cholera, chronic
asthma, diairhoea, and affections of the liver and
spleen. A moist and warm air may, therefore,
be stated to be doubly injurious, inasmuch as it is
of itself an extremely active predisposing and ex-
citiog cause, and as it is the means of dissolving
vegetable and animal miasms, — of marsh, infec-
tious, and pestiferous emanations, — and the ve-
hicle or medium in which they act injuriously on
the frame.

35. (d) A moderately cold and a dry air in-
creases the respiratory actions, and the energies
of the system ; proving what is commonly called
a bracing atmo!«phere. Diseases usually assume
an acute, sthenic, or phlogistic form ; and the
respiratory oi^ans are liable to suffer. — la cold
and moist states of air, rheumatism, gout, nerv-
ous affections, scrofula, and glandular diseases,
intermittent and adynamic fevers, erysipelas,
dropsies, anasarca, and chronic disorders and
fiongestions, often prevail, especially in low, ill-
ventilated, and marshy places. The positive
electricity being rapidly carried off by induction
from the bodv, a salutary stimulus, and one which
experiments liave shown to be productive of in-
creased activity of all the animal functions, may
be supposed to be lost. Bbt when the air is very
dry, the transit of electricity from the surface of
the earth and from the body is impeded; this
fluid accumulating until a moister state of air
diminishes its quantity, and changes the re-
lation subsisting between the electrical condition
of the frame and that of the atmospheie. In very
dry and warm ttatet of air diseases less frequently
prevail than when it is both warm and moist ; and
are more frequently characterised by increased
vascular action. Inflammatory fevers, inflamma-
tions of the brain, liver, and stomach, -are then
most prevalent.

36. (e) Sol-lunar inflvence, — Considerable
importance has been attached to the influence of
the sun and moon in creating a morbid predis-
position. Close observation of the relation aub-
aisting between the prevalence of fever and dysen-
tery, and the full and change of the moon, has
apparently established some degree of connection
between them in warm climates, particularly in
the eastern hemisphere ; but the manner of ex-
plaining this circumstance has been by no means
aatisfactory. Some impute it to a direct lunar
influence; and adduce in support of their opinion
the fact, that dead animal matter, when ex-
posed to the moon's rays, more speedily suffers
decomposition than when protected from them.
Others, who favour sol-lunar influence, argue that
it proceeds from the height of the tides, at full
and change of the moon, occasioning the rivers
on the coasts to inundate their banks, and to de-
posit vegeto-animal matter, which ia rapidly
decomposed, when the water retires and leaves
the low ground exposed to the sun's influence.
But if the relation tubsistiog between the preva- 1

lence of disease, and the inoon*a chaagv we**
owing to this c&reumatance, it could hold oaly ia
respect of parts situated in the low alluvial cma>
tries on the coast, and not in districts iolaad tod
much elevated above the level of the sea. Tkii,
however, is not the case ; for obaervadoa bis i^on
the influence, whatever it nay be, to baas power
ful in high ami inland coantries as in dirtrictaoatk
sea-shore.

37. (f) Lighi and euntkine. -—That the power
of the tun't directed and refracted rays, in the pn>
duction aud removal of disease, ia by no bcsii
inconsiderable, is proved by their influence oo tlw
vegetable and animal kingdoms ; and by the cfeen
which ensue in the economy when they are cs-
tirely excluded. These effects have beendaoibed
in the articles on the Blood ($ 47.;, and Dk-
BiLiTY ($6. c). The vital deprcanoo, atlcsded
by increased sensibility, mobility, and sasoepti-
bdily to impressions, and the anaemia and ga^
ral cachexy, which ultimately resoU fnn ik
protracted exclusion of light, are sufficient proo£i
of the beneflcial influence of the saa's nji
upon the frame. But additional and mora dir«€i
evidence ia furnished in the greater activitj of
the vital functions in spring; and in thefoiti
excitement of the frame of the aged and debOh
tated, and indeed of both the miods and the bo&i
of all, by sunshine ; light, as ordafatd sad lep-
lated by nature, being a salutary stssiilei, sad
necesbary to the energetic and healthy perforaaas
of all the functions. The ezdtiog ana dc|iwiBg
effects of the excess and absence of l^ght icipeA-
ively prove its influence over all the «r]^anie aad
mental manifestations, and oooioquently as power
in predisposing to, and even exciting, diseise—
the intense or continued action of light inonlioafelj
exciting the nervous and vascnbv systems, nd
producmg disorders of this kind ; its abatractiat
weakening all the mental and bodily faadioH^
and favouring the occurrence of disBam of de-
bility. It is obvious from this, that light, aspedaliv
sunshine — and even its abstnietaoD — nay be
made subservient to the removal of diseas
in its individual capacity, or ia aworiali
a pure, dry, and tempeiale, or wann air,
by suitable exercise, and change of locabi; .
and that the partial abstraetioa of one or bod
ef these requisites to the due or eneigetie per*
formance of the functions, must be uliaBsidv
followed by disease, however remote the cfect.
or numerous the intermediate links in the cfasa
of causation.

38. ii. Tbb kxcitiko Cavsss.— Tbcse bvt
been called occasional by some wniters, and £rori
by others, determining by several, and priaetftl
by a few writers. I shall divide this cbn cf
causes into — (a) thoae which aia scrwipiol is
their operation ; and (6) those which an tptf^*
or whose influence is followed by specific and d^
terminate results. The isauses already described,
dispose the body to the action of tfaoM abotf t»
be noticed ; either by impeding, mnfifyiBL or
interrupting some one or more of the vital w'
tions, or by changing the conatitation or orf**~
isation of the tvvues or organs whieh are ikc
instromentt of the functions under the domiam
of life. But the predispooing causes may, »tbtf
by their activity, or by tneir acting ia oombnsw
or in close succession, of themselves, prodaoe di^
ease, without the aid of any of tiboK wUch ait

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kr.'J w!;h wfr'sk •::-'::•*. re otzmt^; at lobrtcn,
[/.u->«ls lakC. .Sd-t.c L-.nd> are c«ea poiiami,
e-p4.'.-)iily in war:n cKoiatt^: and otbcrt pisdaei
tii-onhr t';or.-i bein? cut of uAson, ai nhnoa,
tmut, ckc. J be injurious action of b«h ii fi*
f.rti.cJ r-)iitt^y u{>on ttie «>tcTnach and bowcb; fe*
nfriiilly in the ii.*rm of ci.oicra, aticndcd by
oxlrf-nif' vital de])nr«6ion ; and soiceTimcs bj aa
eruption on the ^kln. I'hat the potMOoiiB de-
ments arc {.arttally absorbed into, and act partly
til roup Ii, the circulation, may be inferred from
their cfiert--, und from iheir ppculiar odour boo;
aftiTwanU delected in the cutaueons tecretioH.
The mcui.s of preventing and connteracting tin
ill i-fTi'dH of tifrli are stated in the article PoiMVf.
I'rfietnhlef, even, will aleo disorder the digcfiiva
or;:uits if ihcy be allowed to run to seed, or grow
too far, or if kept too long after they have been
ri-ntnved from the soil.

'17. y, CVxi/.iri/ and rmir/imeNts. >— Animal sub-

DIS£AS£ — Specific Causes or—- Etiology.

569

latioD. All th« depresuog emotions of mind have
an especial efiect upon &e circuladoD, upon the
nutrition of the frame, and indeed upon all the
fvoctioos dependent upon the organic nervous
system ; and favoor chronic and asthenic diseases
of the heart, particularly passive dilatation and
ealar^ement of its cavities, indigestion, and con-
stipstion; also chlorosis, pulmonary consurop-
tioo, hysteria, and tubercles, early in life; and
hjpochondnasas, melancholia, chronic diseases
of the liver, ^eeo, and pancreas, and cancerous
or other mahgaant diseases, at mature or advanced
ages. — ^. Surprise, friffht, terror, anger, and
mdignation, are not inuequently productive of
ipoplexy, paralysis, epilepsy, convulsions, syn-
cope, violent palpitations, painful or acute af-
fectioiis of the heart, disorJers of the stomach,
lirer, and bowels, hysteria, abortions, derange-
ment of the uterine fuoctioiis, and of the mani-
festations of mind.— I. Great mental excite-
ment, unlooked-for success, the sudden accession
of fortune, extreme joy, and all the pleasurable
emotions carried to excess, are not infrequent
csiiMs of insanity, of phreoitis, epileptic convul-
aoni, hysteria, and catale]isy. — (. An impro-
per conduct, and an insufficient control, not only
cf Ihe sentiments and emotions, but also of the
imagination, are amongst the most common
catues of disorder in the manifestations of mind,
at well as of the other maladies enumerated
aboTs («, ^)..— «. Inordinate indulgence of the
■exaal appetite occasions epilepsy, loss of me-
mory, tod mental and corporeal debility, impo-
teocy, diseases of the testes, prostate gland, and
viuary bladder, and affections of the heart and
lungs in males; and in females, inflammation
of the ovaria and uterus, fluor aJbus, hysteria,
chioroHs, melancholy, irregular convulsions,
organic or scirrhous changes in the uterus, dis-
eases of the ovaria, and sterility, &c. (See art
AoE, § 24.) — ^. Peru>n8 who have bran habi-
tuated to excessive sexual indulgence, and
become alto^ther continent, are liable to noc-
lunuil emiiuoos, to impotency, convulsive and
other nervous daeases, and to disordered mental
miftifestxtions. — i. Numerous acts of volition
injudiciously attempted or directed may be pro-
doctiTe of the moat dangerous injuries and disease ;
a« violent muscular efforts, of sprains, aneurisms,
hemorrhages, inflammation and caries of the
vertebr«, or inflammation of the intervertebral
>ubstaoces. Positions with the head low, or on
the back, and especially such as are uneasy or
nnoaiDral, too long retained, or too freouently
asnimed, give rise to cerebral disorder and curv-
atares of £he spine ; and encumbered, obstructed,
or too rapid and protracted movements, produce
injurious acceleration of the circulation, exhaus-
tion, with other ill eflecu.

^> £« Tkt chemical avd mechanical causes
of diteaae ie<{uire little notice here ; the former
of these having received attention in the articles
on Asm TXT, and Poisons; and the latter on that
of AsTs AKD £jiPLOYM£NTS, 08 Ca%uet of Diteau,
y{«) Chemical agenti are injurious — 1st, by their
infiuence on the functions of the part with which
they come in contact, their effects varying with
their indiridual properties ; 2d, by the change
they jiroduoe in the structure itself, either in
conbmiog with it, or otherwise changing its
coQsiiiatioD, so as to render jt incapable of ito

healthy offices ; and, 3d, by totally destroying the
nervous and vital influence, and intimate organis-
ation of the part. — {b) Of mwhaidcal cautes and
Positions impeding, upon physical principles, the
ux or reflux of the circulation and secreted fluids,
continued pressure of various grades, and unna^'
tural ligatures of parts, are the most common, and
act slowly, and often insensibly and unremit-
tingly. Shocks or concussions of a part or of
the whole of the body, or other kinds of external
violence, not only occasion the division, fracture,
dislocation, bruise, and comminution of external'
parts, but also the rupture, laceration, haemor-
rhage, displacement, vital depression, or extinction
of function of internal viscera, as of the urinary
bladder, liver, spleen, stomach, and bowels, brain,
spinal chord, &c.

55. iii. The Spscinc Causes of Disease. — Of
the causes which may be thus termed, emanations
from the soil are, perhaps, tlie most common. — A,
The miatmata arising from stagnant water, par-
tially covering the soil, or covered by vegetating
substances ; from vegetable matter in a state of
decomposition ; from moist absorbent soils exposed
to the sun*s rays ; from the muddy and foul bot-
toms of lakes, marshes, and lagoons, or the marshy
banks of rivers and canals ; and from low grounds
which have been partially inundated by the ocean
or by rivers ; are productive of agues, enlarge-
ments of the spleen, of the liver, and even of all
the glands, of rheumatism, catarrh, &c., in cold
or temperate climates ; and in addition to these,
of remittents, bilious and gastric fevers, dysentery,
cholera, diarrhcea, and hepatitis, in warm climates
and seasons, according to the predisposition of the
patient, and the cireumstances which have aided
the action of the efficient cause on the system.

56. B, When dead animal mattert or exuvis
mix with vegetable substances, and putrefy along
with them, in a warm and moist air, the efflu-
vium assumes a more noxiot^ form, especially if
the air stagnates in the vicinity of its source ;
and it becomes more certainly productive of die-
ease than that which proceeds from the decom-
position of vegetable matter only; the effects
produced by it being oflen of a more' adynamic
or malignant character. In warm countries, the
localities enumerated above abound with dead
animal bodies, and the exuvis of immense swarms
of insects; and hence may be inferred the reason
wherefore terrestrial emanations in these climates
give rise to more severe forms of intermittent and
remittent fevers^ depress more remarkably the
vital powers, derange more the vascular system,
and more sensibly affect the blood and the secre-
tions, than the miasmata exhaled from similar
places in northern latitudes. The water of low,
moist, and marshy places is also productive of
various maladies, particularly of dysenteiy, chro-
nic diarrhcea, diseases of the spleen, Guinea-
worm, &c. These causes and effects, with what
is at present known of their operation, are more
fully discussed in the arts. Endeuic Influence,
and Fevers.

57. C. Emanations from animal matter only,
the air being in other respects uncontaminated, or
frequently renewed, are seldom productive of any
serious maladies. But when they burst forth
suddenly, in a close and moist air, the effects are
sometimes most pernicious. It has been recorded,
that fevers of a very malignant kind have attacked

DISEASE -^GcKiBiiLDoenixm or-^PATBOotNY.

671

neot, uatH a ebonge of weatiier — from dr^ to
rooHt, &C. — or depretsiDg mental impreauoDS,
or cold aod fatigue, or reoereal eKceaaes, or io
short, any dabUiiatiD^ mflvcnce, oocur to aid ita
operatioD and deterauDO ita action ; and if no anch
coDseeutiva eaofeB aid the principle or apecific
cause, in a few daya from the ezpoaore to it, dia-
ctse mil often not appear. 1 nave freqaently
sees thit exemplified in a very itriking manner :
coe instaooe on a large ioale will be rafficieot.
Between twenty and thirty pereona were ezpoaed
iJl flight, without cover, to the air of one of the
DMMi fatal lonroea of miaamata furnished by a
wftrm climate, dsfiog the unhealthy aeason, but
were Mon aAarwarda removed to aea — far from
aaj fbrthar ezpoanre to this specific cause. They
coDUDttcd well for aiz or seven days, when about
blf their aumber experienced great fiitigne. Ail
tbcK were nearly simultaneously— on the fol*
bwinifday^— setaed with remittent fever ; whilst
UuMe who had nel been aubjeeted to this conse-
cstire caoae, with the eieeption of two, who were
lot sttaclLed till aeveral days subsequently, en^
tirely escaped, although all had been equally
txpowd to the specific cause of that form of fever.
Fonher illuatraiiona from my experience in dif<*
feieat climates, and of various diseases might be
adduced; but the simple statement of the above
fact is leffioient. The practical importance of it,
howefer, should not be overlooked ; for it showa
—what I have frequently believed has been suc-
ttttfolly practised— > namely, that a person who
bis been sobjeeied to the impression of a specific
w say otiier exciting cause, may escape its effects,
il Ite iBiBiediately fortify the system against it,
tad avoid exposure, for some time subeequently,
to all other injurious agents, especially those
whieh lower the vital energies of the frame. Per-
soos even who experience tike sensations more
immediately caused by exciting agents of a spe-
eifie kind, aa infectioua emanations, will often
caeapa by observing this precaution, and having
KKOQfK to a restorative regimen, with the usual
awaaa of promoting all the secreting and excreting
fttsctions of the fiwne, aa shown in the arL
Fetim — Prephylaetie Meam.

62. It ii unnecessary to enumerate the causes
which most commonly come in aid of the exciting
ageotf of disease. Tfaiey comprise nearly all those
>h«ady adduced aa predisposing the system to,
ai well as oocasaonally exciting, morbid action ;
ftrtiealarly such aa depress vital power, by their
"pccifie propertiee and immediate impression ; the
ahstiaction of reouisite or accustomed stimuli, aa
of warmth, fboa, &c. ; whatever impedea the
faactioBa of le^iration, digestion, assimilation,
aad excntioD ; all weakening dischargee ; de-
fcsibg affecliona of mind, particularly fear of
hciag affected by the cauae to which the person
*aa exposed ; and all circurastancea in any way
detangmg the aecualomed tenor of the mind, and
habits o( life,

fi3« III. Gkmxbai* Docrarea or DiszAsr, on
Piniooxiiy (from anSd^* disease, and yMdm, 1
gcader, or prodnce). — An examination of the
*7<iens of medicine propoaed aioce the revival of
laamiag in Europe, or even of those advanced in
■Mdere times, would occupy more of my limits
(bta I could devote to the subject. I shall,
thefeCote, proceed at once to the developement
«f those general views of disease, wiiich obsanr.

ation and reflection have suggested to me, and
convinced me to be of importance, not only in
estimating aright the exact state of the more com-
mon specUic maladies, but in forming safe opiniona
respecting those more anomalous or complicated
affections, which frequently present themselves to
the practirioner.

64. I have already contended ( § 7.), that,
with few exceptions, which have been particular-
ised, tlie causea of disease Jirtt modify the mani-
festations of Ufg in some one or mora of the sys-
tems and organs with which it is allied ; or, in
other words, first disorder the functions with
which they have a direct relation ; and that, after
a period of longer or shorter duration, the disorder
of functbn becomes a cauae of further disorder in
related or associated organs, and ultimately, if
eircamataneea obtain hereafter to be noticed, of
change of structure either in the primair seat of
disorder, or in that consecutively affected. From
this, and what haa been already stated, it will ap-
pear that a great proportion— nay, all -^ of those
disorders of internal parte which have been
viewed as rnlrinsttf predispoeing and exciting
causes of disease, are, in truth, pathological
eonditioiis, or ezistiDg states of disease, induced
by ^some one or more of the causes specified
above, and ready to produce further disease, or to
lead on to a salutary change, according as the ex-
isting state of vital power or resistance, and the
influences or agents acting on it, may determine
the proceasion of phenomena, or incline the ba-
lance. These primary or early changes, or morbid
conditions, may very aptly be termed steondary or
patAoiflgtca/ causes, when they give rise to ulterior
change either of function or structure ; but they
are so diversified, that but little notice can be taken
of tbem here, beyond what is necessary to the con-
sideration of general principles; their different
forms being more intimately viewed in the articles
on specific diseases. It may, however, be remarked
that they often exist in latent, or almost imper-
ceptible, states, and predispose the frame to the
invasion of causes to which it otherwise might have
been exposed with impunity.

65. 1 he great fault of all systems of pathology,
down even to tiie most recent has been tbeir con-
fined or narrow principles, and consequently their
inadequacy to the -explanation of all the statea
of morbid action constantly occurring. BnowN
and his foUowen admitted but two modificationa
of the vital manifestations from the normal state,
viz. depression and excitement, whilst he substi-
tuted an inappropriate and single term as a sign
for those manifestations, which are as obviously
and frequently changed in kind as in degree. Dr.
pAany referred the chief states of disease to the
vascular system and to changea in its states of
action, without sufficient reference to the nervous
system, as controlling and even causing these
changes, especially to the organic nervous system,
with which the vascular is so intimately con-
nected ; whilst his contemporaries, who con-
sidered that disease originates in the nervous, and
afleota the vascular, system consecutively,
viewed the cerebro-spinal axis, and its varioua
prolongations in the form of nemes of sens-
ation and volition, as the parts primarily im-
pressed. Considering, however, as stated in the
article on DsBiLrrv ( $ 13.), that the intimate
association of the organic nervoua system witb

DISEASE — GxMEKAL Doctrine or — Patuooeny.'

573

59- B. Of excitement and reactum. — No
cireomstftnce has tended more to prevent the ac-
qnisitioii of wnnd principles in pathology than
tke terms introdoced by Bbown and hu foU
Iow«n,aDd the meaning attached to them. In-
ked, it was a matted of no small difficulty to
trnve at a precise idea of what meaning they
did convey ; for a single word was in itself an
b}'polbcsas; and "cxritaM/ity" — accumulated,
fcibaosted, &e. — " sentibUity,'* ** mteeptibUity,*'
ke. were made to perform more than actually
UJs to iheir lot. As, however, these terms are
btquently employed in medicine, and cannot
BOW be conveniently discarded, it will be as well
to stale the idea that should be attached to
them. SenaihUUv is the faculty of receiving im-
fiKssioos, and of being conscious of them. £x-
titaMittf, the power of beio^ excited by stimuli
or irritaots, whether consciousness attend the
let or not ; consciousness generally follow-
ing tiietr application to organs of sensation and
rolition, or of animal life ; but not when applied
10 thoM of involuntary motion, or of vegetative
bfe, unless the excitation be carried to a great
i^gbt. Suieeptibility is the power not only of
fweiving impressions, but of bein^ affected by
tbera, whether the agents be physical or moral,
tad whatever may be their mode of operation ;
eoDscioasoess either attending or not attending
Ae act, according to the nature of the agent,
<od the organ it affects. Here it will be per-
ceived, that tennbility implies a certain faculty ;
tuitabHity the power of acting only in one direc-
fion ; and tuMceptibility of being affected in
every way, according to the nature of the cause ;
lod that the meanmgs are the same, whetlier-
ibese terms be applied to a single organ or to the
wbole frame ; ^ey representing intimately allied
naoirestations of life in organised parts. The
■tales, moreover, which these terms represent,
>R variottsly modified in different persons, ac-
cordbg to temperament and constitution ; but
^7 ve still more remarkably altered by the
CiQses enumerated above, as well as by the suc-
oetsive changes characterising diseases ; and
benee they bMome important signs of the condi-
tion of vital power, and of the progress of func-
tiooal and organic change. When existing in a
^ manifest or extreme degree, they are of
tbcmaelves important pathological states, and in
tbis respect they deserve notice.

70. Sensibility, excitability, and susceptibility,

&re great or especially prominent in delicate,

<^iHtated, nervous, and irritable persons, and are

morbidly inereated by whatever lowers the ge-

Denl amount of vital power, if the functions of

tbe brain be not impeded, or by excited action

^ any put of the cerebro-spinal axis not at-

!^<^ by pressure^ They are much less lively

ui tbe tobnst, lymphatic, and phlegmatic constitu-

^piu ; and are more or lessdiiraoished in congestive

^"caics, particularly those of tbe brain ; in many

c^Ks of vital exhaustion, when the blood be-

<!oi&es contaminated ; or when pressure takes

pUee in an^ part of the cerebrospinal centres

^ prolongations. They are likewise temporarily

or pennaneotly impaired by the intense, frequent,

^ continued impression or action of the same im-

piessioos; and are restored or heightened by

tbe abstraction of those wUch are of a lively or

intense kind. Although e7Ci'(a6i/t<j^ is easily and

quickly roused in the delicate and nervous fsyune,
and in states of simple debility, as specified
above, yet it is more rapidly exhausted or alto-
gether extinguished -, whilst, on the other hand.
It is much less readily brought into action in the
robust ; but when once rouned, it is either more
enemtic or longer sustained than in the debili-
tated. In these states of disease, which I have
denominated secondary and complicated debility,
and especially when the oerebro-spinal centres
are congested or pressed upon, or when the cir-
culating fluid be<M>me8 contaminated, the excit-
ability is either much diminished or altogether
lost, — chiefly, however, as respects voluutaiy
organs, when the nervous system of animal life
is affected; involuntary parts still admitting of
excitation, although not so readily as in health.
Susceptibility, even more remarkably than the
two other powers, is increased by debility and
novelty of impression, and diminished by a robust
and due manifestation of vital power ; by a repe-
tition of the same effect, whether it be stimulant
or depriment, unless each succeeding application
of the same agent be made before that of its an-
tecedent had altogether ceased ; as evinced by
both the causes of disease and the operation of
stimulating and narcotic remedies. The com-
plete manner in which the susceptibility to be
affected by certain causes of disease is destroyed
by their full and adequate action, is shown by seve-
ral of the specific agents.

71. Excitement may be of two kinds, accord-
ing to the manner of its occurrence : it may di-
rectly follow the impression of the exciting or
irritating cause, in which case it is primary or
direct ; or it may follow as a more or less remote
effect of agents which lower the action 'either of
a part or of the frame throughout, when it con-
stitutes what is called secondary, or reaction, as in
the case of the vascular excitement following the
application of severe cold to a part, or the whole,
of the external surface. It is necessary to dis-
tinguish between these two grand conditions or
manifestations of excitement ; for the secondary,
or that following indirectly the impression of
lowering or sedative agents, may be variously
modified throuebout by the nature of the primary
impression, and its moide of action. Hence one
cause for the distinction here made. There are,
besides, numerous other modifications of excite-
ment, whether primary or secondary, referrible to
the nature of the agent, and the parts of the
body on which they have directly acted. The
excitement caused by mental emotions is different
in its progress, duration, and consequences, from
that following the ingestion of spirituous or other
stimuli ; and this latter, and indeed both, are
different from the increased action following
sympatheticallv the irritation of some organ or
viscus. In the first, the cerebro-nervous and
vascular sjrstems are simply excited, the excite-
ment terminating in slight exhaustion, unless
some part has been injured during its conti-
nuance. In the second, these systems are more
than simply excited. A more manifest febrile
state continues for some time subsequently, with
concomitant lesion of the digestive functions or
viscera, owing to the passage of a portion of the
morbid agent into tlie circulation, and to tbe
more immediate lesion experienced by the parts
on- which it made its primary impression. In

DIS£AS£ — GammAis Docrsnni or— >PAra€QBinr. '

674

the third, tb« cikeiteBent » more efpeowlly ez»
pre«ed in the oi^gaaie nervoui and vascular
systemt— the chief faeton of life-— owiog to
its extension to the whole of these systems, from
the part in which it originated, and still exists :
hence its duration depends upon the primary
lesion, and there is, in addition to the general or
sympathetic excitement, disordered function of
the part primarily afiected, as well as of those
more intimately allied to it. Even from what has
now been stated will appear the importance, in
pathological and therapeutical pcnnts of view, of
instituting a comprehensive analysis of those slates
of vital action to which the term excitement has
been applied, and wluch bears a veiy wide and
often inae6nite signification.

73. («) Primary or dir$et txdtewunt is one
of the most frequent efiects produced by the
agents which surround the body. It may pro*
ceed from such only as are eaCemal to the frame,
and to the part which it excites, or from such as
era internal or intrinsie. Its phenomena and eon-
sequences vary as it arises from causes acting
chiefly upon the organic nervous and vascular
systems, and their immediately related organs—
upon the organs and functions of oiganic life—
and aiTecting them principally ; or from such as
act primarily upon tlie cerebrospinal system, and
organs of animal life, as tho^ of sensation, re-
flection, volition, contractility, &e. But the
modifications which spring from other sources,
especially from the properties of the agent, the
intensity of its operatioo, and the number of
parts affected by it, are too numerous for a super-
ficial view, even if the knowledge requisite to
the attempt were attained. I must therefore
content myself with noticing merely a few of
the more prominent features of this condition
of life.

73. «. Exeitemtnt <jf ths tjftiems and argant of
vegetative life gives nse to various changes anid
phenomena, according to the nature of the im-
pression, and its intensity. — Gentle excitation
of the digettive eanal increases the tone or in-
ieosible contractility not only of it, but also of
all the circulating system, of the hollow viscera,
and of fibrous or muscular parts. If the stimulus
be considerably greater, either the same effect
is produced, or the excitensent is conoentnled in
the digestive viscera, and proportionately with-
drawn from other parts. If the excitement be
still greater, and be of a kind that irritates the
villous surface, the secretions of this surface are
augmented, and the muscular coats of the canal
roused to more or less energetic action, followed
by the excretion of their contents.

74. Excitement of the ooscuiar efftlem is ge-
nerally a consequence of stimuli applied to the
digestive surface, of irritation of any kmd afiecting
the tissues, of local inflammation, of stimulating
aubstances conveyed into the current of the cir-
culation, of muscular exertion, and of the lively
mental emotions, directly increasing the heart's
action. The grade, duration, and dBTects of ex-
citement originating in this lystem, vary with the
cause and the state of the body at the time. Its

Sntiest, and, at the same time, most permanent,
rm is caused by the action of a pure, dry, and
temperate atmosphere oo the blood oreulatiog in
the lungs ; whilst the moat tumultuous and the
most iiguriotts, as respects its effects on the heait

and blood-vessels, on the bleed itself and ostht
functionB of vital organs, is that prodaesd by »
ordinate or continued maacalar exortiea ; sad b«
the absorption of various sdmulaltB| sad im.
taling aufastanees into the Uood. ViolctttsR.
cise affects the craais of the eiKmlaiiqg kU
(see Blood, § 134.), causes its itwuliun tfms^
the capillary caaala of soft and ywnaf ^mm,
as the mucous snr&oes and the parcndijM d
the viscera, induces inflammatiea of the hssit lai
arteries, and excites similar disease in piedsipoNf
organs. Irritating or excitinr snhslaacM «»
veyed into the bltwd, inflame um iaterasl tsifai
of the heart and arteries, alter the esaHsini d
this fluid, occaabn various acute and dmnie it-
eases of the vessels (see arts. Annans, Huir.
and VxiNs),and ofken severely aicct the fascMt
of secreting and excreting viscera, iaor£aiidt
exciting or inflaming those depwalira stpa
which carry them out of the iyslen.

75. The portal dreuiatiom, and the fiiv. t*
which it is distributed, may hm opecisUy a-
cited, owing to the quantity of stimahanff.
morbid, effete, or foreign BMttem canrisd m.
or generated in, the blowl whieh ia astnrasd bm
the digestive canal and other abdoonnal vi«fi.
These may not only inflame the portsl nmk
but also the substance of the liver; or, «ha tk
materials and dements of these vesseb are sf i
less irritating kind, may give riae to rnertid!; »
creased secretion of bile, or to vaiioas oi|isr
changes and adventitions formatjei in

76. The aUarbent system as
co-exiitently excited with the
Ind^, inordinately increased vaaenlar acnps s
generally attended by a prepoftionale inKtifKi
of the abaoibeots — both lymphatic and hfiMl
Whilst it is frequently obarrvnfale that a «^
action of the artimal is acoosnpanied with fntt
activitjr of the absorbent system. It weald mm
as if diminisbed organic aetioo, or that iisK »
suiting from an inssJicient exertion of the oifait
nervous influence on the artnfial and
systems — the chief source of
tural cohesion, and other vital
leaves, in cotMeqneace of the nnasal melerslo
being then held together by n vsenker attrtctsi
than in an opposite state of thiainJuencs, a|imi0
proportion of efiele maieriala,by whidi the sfaaf^
ent vesseb are exdted to ii

77. Excitement of
parte is eharaeteiised by
of dther a permanent or
kind -« or rsther of the vi
states between sthenic and asthenie, as mstiisc
the extremes —-and is genemUy oeeaasned W
irritants of the surface covering the hailov no^
des, and more rarely by direct eadtatooad tk
nerves supplying them, and by aethidsiMv d
the blood, affecting dther thesi or the «n«
supplying them. The asthenic or deaic fcm^
spasm is most commonly associnled srilkexhai^rf
vital power, or an impora state of the tarahi*
ittg and eecreled fluids, the trdtaMsly ef tfc*
stnictnrss bdns more easily uded mpm m a^tk
than in robust frames ; and hence, wmb ■
is more rardy conjoined with
witli debility of other
that, in moat spasmodic
ncoessary to this state of
ooocentntion of nn «ndn€ pnpoitian ef

«««

DlSEASE-^GiNSftAL DocTiUNS or*^FATBoo8vr.

675

powerin the Derret mpplyiog the affected mutclei,
ind in the ramclei tbttnaelvee, and a pfoportioo*
itfi abitnetioD of it from other parta ; and that
wbflo the eieitabUity of an unaflTected structure or
nitem a eoeigetiGally roused, the pre-existing
norbid ezatesMOt will be derived firomt orsubside
is, the parts in which it was sealed.

78. The excitement of ssetiftiii; vtsesra mnd
giaitii piessBts various modifications and grades,
according to the eaose which induced it, and the
elemealary system espeeiaUy affected. If the
orginic nerves supplying them be chiefly excited,
tbe tpeoial functioos t£ey perform will be avg-
nented— their secretions will be abundant. In
this case the ezdlement will be more particularly
limited to tbe organs whose excitability has been
aetad upon; the morbid condition consisting
ebiefly of a conoeatration of vital manifestation or
accioB in them and derivation of it firom other
fiteera, thus occasioning one of the forms of
DtBiuTT specified in that article ($8, 9.), the
ioereaaed aeereticm geaemll]|r preventing the oe*
csnence of febrile coeamotion or acute sympa-
thetic disorder, unless it be carried very far. But
whea the excitement is sealed principally in the
blood-vessels, and assnmes the form of infiamma-
tioDf the specific function of the secreting surface
or srgaa will be variously altered; the fluid
•iahonted, in this case, by a secreting surface,
beiqg either increased or quite changed from tbe
utural atate, or botb, acconiing to the decree and
km. of the excited vascular action with which
it is afiected ; and that secreted bv glandular
ttrwrteres being also either much altered, dimi-
aiilied, or entirely aappressed, as in cases of in-
dammation of tiM kidneys, salivary glands, &c. ;
this form of excitement not giving rise to the state
of vital coooentratioo observed m respect of the
l<vmer, but fnqiientlf to general or sympathetic
febrile oommotion. Excitement of secreting vis-
cera, then, assumes two forms, vix. that affecting
chiefly the organic nerves — the ejreitefnsnl rf
imtation, whicn is always attended by augmented
■^cretioB, and inoeased determination of the cir-
culation to the part thus affected, but not neces-
sarily by true mflammation, altbDugh this may
WW; and that aflreetin| the arteries and capil-
lariea — the neittmmU of inflammation, whicn is
accompeniedvrith altered secretion, always in kind
^ fieqaaallyin quantity, — the quantity being
I'fttt increased in mucous surfaces, and remark-
ably dininiahed from glandular organs.

79. The excitement of the generatne organt
oay proceed from the accumulation and irri-
tation of their proper secretions, from mental
cnotioDs, and from the excitation of adjoining
ttdrelaied parts, as when the rectum or urinary
bladder is stimnlatod. It is, more especially at
us conuneneement, a purely nervous change;
tbe nerves of organic life which chiefly supply
tbeso ofgaas being excited, either through the
Dsdiaai of the brain and sensorinm, or in a
<^u«ct nanoer, and as above sUted. There is no
{art of the eeoncmy which furnishes so evident
s pfoof as this does of the influence of the organic
^^Bves a|MNi the local or genoal circulation ;
^eir emtatieQ being here shown to be followed,
ttol«i the suieeptifaility and excitability be en-
b(^y exhaosled, by inoRMed deteimination, vaa-
csbr actioa, and vital expaaaion of the tissues ;
imtation of this diss of nerves evidently deter-

mining also in other parts of tbe body, particularly;
in mucous glandular and cellular structures, aa
well as in these organs* increased flux of blood,
and occasioning the torgidity or vital expansion
of the vascular canals running between the ex*
tretnities of the arteries and the ladicles of the
veins. The influence of sexual excitement upoA
all the other functions, especially at the period
of puberty, and subsequently ; its sympathetiQ
action on the rest of the nervous system giving
rise to various disorders, particularly to the
numerous forms of hysteria, anomalous, convul-
sions, epilepsy, catalepsy, &c. ; and its more
direct operation in producing roeoorrhagia, fluor
albus, inflammatory and organic changes of the
ovaria and uterus, besides other disorders in both
sexes, more especially referrible to premature,
too frequently repeateid, or too exccmve stimula*
tion, and consequent exhaustion of tbe excitability
of those organs ; are circumstances familiar to the
practitioner.

. 80. $. EteiUmeHt ef the erg^ut of animal lift
may arise from intrinsic or organic changes, as
from the condition of the organic nerves and ves«
sels distributed to tbem, or of the blood itself; or
from causes affecting the instruments of 8ensatioo«
the general sensibility of the frame, or any of
the mental manifestations ; or from those which
excite to mental or physical exertion. Intrinsic
changes may occur in the organic nerves and
vessels, influencing the circulattoa through the
brain, without any very obvious cause ; and these
may be such as wili excite not only this part, but
all others depending upon 'it for their functions*
It is more than probable, that with the brain, as
vrith other viscera, the excitation may be seated
chiefly in the organic nerves distributeid to it, and
henoe assume more of an irritative state, or of an
exaltation of function, without any particular
lesion, as when it is simply excited by vinous or
spirituoos liquors : or the excitement may extend
to, and priocipsily affect the blood-vessels ; giving
rise, according to its degree, to certain states <J
inflammatory action, and to |[eneml febrile com-
motion, with more or less lesion of function. Ji
is almost unnecessary to observe that either of
those forms of excitement, related as now ex-
plained, or both of them ooistaneously, may ori<r
ginate in the exercise of those faculties, of which
this organ is the instrument under the endowment
of life. It often falk to the physician' to trace
the progress of excitement in relation to the brain,
from the lively exercise of function characterising
talent and genius, into exaltations, approaching
to morbid* of one or mM« of the roentaJ manifestt
ations; and next, into inflammatory action or
mania ; and lastly, into a state indicating mental
collapse, or structural change. The influence,
particularly in susceptible persons^ of livelv or of
violent impressions upon the instruments of sena-
ation, in exciting tbe nervous centres, with which
these instruments are in constant communication,
is shown, not only by the effects of loud noises^
and of a strong light, but also by violent or painful
stimulation of any portion of the sentient system
distributed throughout the frame. The sympa*
thetic operetion of external injuries, of extenaiva
burns or scalds, of loag-euataiaed or suppressed
pain and suiierin||;s, in exciting an irritative stata
of the oerebro^pmal axis and its membranes, in
increasing their vasjoularity, and even in giving

676

DISEASE — General Doctrinx of — Pathooimy.

rise to effusion, with the related phenomena of
deliriam, tremefaciens, mania, general febrile
action, or convulsions, is not the less true or im-
portant, from its beine overlooked, and the exact
■eat and nature of the consecutive suffering, as
well as the more immediate cause of death, l^ing
misunderstood.

81. Excitement of the voluntary muaelet and
loe&motive orgam takes place either from voli-
tion, or from causes acting in opposition to it.
Exercise promotes the synovial secretions, and
the developement of the muscular structures and
of their energies. But long-continued exertion
increases the flux of blood to the related parts of
the cerebro-spinal axis, and to the muscles them-
selves. The morbid excitement, however, of vo-
luntary muscles, which removes them out of the
control of the will, has never been satisfactorily
explained. Their more asthenic, or clonic anormal
actions, which have been usually denominated
convulsions, have been frequently traced to obvious
lesion in the brain ; but they have likewise been
as truly referred to causes seated in the prima via,
irritating the organic nerves, and, through them,
the voluntary nerves. The almost universal state
of sthenic spasm, called tetanus, has been ascribed
to inflammatory excitement of the arachnoid and
other membranes of the spinal chord, from the
circumstance of its having Men detected in several
cases, and by myself in two instances. But this
change is as probably a consequence of the mus-
cular excitation, as the cause of it. How, then,
does this state of muscular action originate ? The
answer is not easy. But when we consider the
oonnection — anatomically and physiologically —
subsisting between the muscular, the voluntary
nervous, and the organic nervous, systems, the
reasons wherefore irritants acting on either of the
latter will affect the former, or those affecting
the muscles themselves, or even their tendons,
will, in certain circumstances, through the me-
dium of the nervous systems, excite general mus-
cular contractions of a permanent or recurring
kind, will not appear so far beyond our compre-
hension. If we connect the causes of these af-
fections with the earlier phenomena, we shall
generally find, even when the exciting agent has
acted on an external part, that the organic or
sympathetic nerves have been thereby irritated ;
and that, owing to their influence on the volun-
tary nerves, a state of spastic action is kept up
in the voluntary muscles, or recurs in them at
intervals, the brain itself being afllected only in
those cases which present lesions of its func-
tions. This opinion, published by me in 1821,
subse<^uent eiperienee — pathological and the-
rapeutical— haj confirmed, particularly in respect
of those cases in which the brain is free from
disease. (See arts. ComruLsiONs, Tetanus.)
It follows, therefore, as corollaries from the
foregoing, that whatever irritates the voluntary
nervous s^jfstem, or makes an extraordinarv demand
upon its influence, or any of its functions, will
excite it, in that part especially upon which the
particular influence or function called into oper-
ation depends, or with which the part principally
acted on is in communication ; and will determine
to it an increased flow of blood, which may, in
certain circumstances, go on to inflammation or
structural change ; and that irritation propagated
to the volantsjy nerves will so expreis itfeelf

DKVP

upon the muscles they Mipply as to gin riie
to various states of spastic actioD, acnwdisg «
it originates in the syrapathede nerves, or k
the brain, or is connected with other clnsfv,
functional or structural. TTioa, wetsl cs«u»a
excites and determines the eircalatioB to the Iwsd ,
muscular exertion to the spinal chofd ; and loou
irritation occasionally givea rise, throegk tiw
medium of the organic and Toliialary botmi
systems, to spasmMie action of the moscks di
volition, of either a remittent, iatcragiieat, or
continued form.

82. (6) Secondary or indhtet oMiUnnat, m r^
aetion, is that state of increased funelioB or hat-
tions following the impression of eawes of t^-
pressing or sedative kind: as when the
of life, having been for an indefinile
or less lower^ by cold, by terrestrial
or by the effluvium from the sick, react apeo ttt
state of depression, and give rise to rums
phenomena characterised by excstemeat, vkiek
thus becomes one of the tenninatioiH of dinr:
DsBiLrrY (see that article). Great divotfr d
opinion has existed as to the way in whiek ti«
economy reacts upon injurious and dcmmai
agents. The vii modieatris notvnt, vital leai-
ance, the conservative powers of life, with ocbe
terms, have been substituted as explaailiDeB v
what admits not of explanatioD, either by mn^
however expressive they may be, or by aay otke;
means. We can merely express wtet sffiw)
to be a law of nature, and describe ceAus re-
sulting phenomena. We believe that the vps-
isation is built up and kept together by the t>!
and intimate alliance of life, and that this pro*
ciple or endowment may be noodified by dmftf
in the structures, the instruments of lis faodiocPv
— that, in short, so intimate is d|e uoioe «f I4r
with all the organs and ttssues, that it is con-
stantly influencing them, according to its ▼sits;
states, and being itself influeneed by thtn, v
they become changed, both in reqsect of its kni
alliances and its general eoadition. Atd f >
that we can know respecting vital rttttttaet a'
rtaetion must resolve itself into the geaeisl c-
ferences, vis. 1st, I1iat the innate power* d tk
vital principle, and the intimacy of its unisa ^
its material instruments, are such that it oppwa.
by means of these allmnces^-by its niuirf»'>
ations throughout the oiganisatioo, and bv tW
mutual dependence and recifMoentive iaisart
—and by the manner in which it is iafiocscv^
or modified by changes in its allied 0f|aBs,---iD-
pressions of an injurious nature, the iuluaiiy ^
which is not so great as immedisiiely Is dvolft
its connection with the structures, or at core u
overwhelm its energies ; and that, whikt it ihtR-
by roufit the further progress of change, it st ihi
same time restores th^t which has been indseed ,
these phenomena constituiini^ what hss htn
called mta/resittasiM: 2d, That when the nsrW
impression is energetic, a sufcesMan of chssfo
generally follow in some part of the ecosent
owing to the circumstances now eddeeed, esk^
lated to remove the primary impeeaseo. sad is
more immediate effects, to recover the lost ko*
lance of vital action, and to reetoic the iapc^^
or interrupted functions, -» to these chssfci d<
terms rtoetion and meondary smtMnaf hsrt hrra
applied ; which, however, aciay be varisosly •*•
dined, in form as well as in degree and daissss

578

I)IS£AS£— OfiNtftAL DocTftnrc 69 -^ PAtSOOtKY.

tains in tbe robust. In the phlegmatic, lymphatic,
and cachectic constitution, it is excited less per-
fectly and with greater difKcultv, and often as-
sumes a modified form, particufarly as respects
its terminations. When excitement arises directly
from a cause that is constantly present, ns when
an irritating body is lodged in the intestines, or
in any of the tissues, it generally is continued,
sometimes remittent, and of long duration ; but
when it occurs indireetlvt or from a depressing
Cause, it may be either imperfect, or of short
duration, the consequent exhaustion being great.
Thi<> is evinced by diseases arising from malaria ;
reaction being less perfect, and vital depression
with its effects more remarkable, when the cause
continues to operate, owin? to the residence of
the patient in the locality which generates it. Ex-
citement is, moreover, modified by states of the
air — humidity lowering it, and a dry, pure
air developing it -^ by mental emotions, by tbe
condition of the circulating fluid as respects
purity, and by previous health and habits. How
these will influence the occurrence and courae
either of primary excitement or of reaction, is
evident. The state of the vascular system as to
fulness has al$o a great influence upon both :
plethora favours local excitement and determin-
ation; whilst, when very great, it prevents the
free developement of reaction, and disposes to
dangerous internal congestions in circumstances
that would have otherwise induced a free and
salutary reaction. The condition of the secretiom,
also, has a marked influence in the production
and duration of increased vital action. The
accumulation of morbid secretions in the prima
via or in the biliary apparatus may either im-
pede the occurrence, or shorten the duration, of
excitement ; or may determine it more especially
to these parts. The state of the circulating fluid
itself, particularly in respect o( purity, will mainly
influence this manifestation of vital power. If it
contain stimulating elements in excess, reaction
will be rapidly and strongly developed. But if
materials of an opposite kind be carried into or
developed in it, neither primary nor secondary
excitement may at all appear ; the conditions
of life throughout the structures being thereby
depressed and modified, and the living solids ulti-
mately rendered unfit for the performance of their
functions.

86. D, The consequences and terminatiofis of
eicitement, primary or secondary, — (a) The con-
sequences of excitement are — Ist, Various morbid
productions or plastic formations, capable of or-
ganisation in certain situations, particularly when
the vascular system has been affected in a sub-
acute form ; as the formation of coagulahle lymph,
and albuminous exudations in the form of false
membranes, &c. ; ^ 2d, The exudation of sangui-
neous, or sero-sanguineous, or muco-albuminous
fluids ; as in cases of acute irritation of mucous
surfaces ; — 3d, The production of various changes
in the structures (nee Inflammation), and ad-
ventitious formation?. — (fe) The terminations of
excitement are varied according to the system or
tissue principally affected, the nature of the cause,
and the concurrent circumstances. It has been
stated as a general axiom, that excitement ter-
minates in eihautfion, the degree of which is pro-
portionate to the height lo which the former had
been carried. But there are numerous exceptions

to this, especialv as reapecti reaetiott; wbieli
may be very slight, and yet the exhaustion w
be extreme. The nature of the chief csq».
numerous influences connected with tbe eoa«tf<
tution of the patient, the aunxmnding media, s%i
the mental affections, will modi^ tbe rentlLv— •
a. Excitement, in any of its fonfls, msv gra-
dually subside into a slight and chronic grade, r
which it may give rise to certain cbaojes ia t>:
nutrition or secretions of the tissaes aflectfi^ ; !<
morbid depositions, and efliisioiM in shut ciTttie^
or the parenchyma of organs ; or to mctviini
secretions from mucous and elauduler pam.—
0, It may also pass more rapidly into exnaintKa
expressed more especially either in one of tfc-
nervous systems, or in the capillary and vtKah'
system, or in the absorbent system, acoonrinf *.'
one or other of these had t>een principallT do-
eased. (As to the effects of exhausdoo ctt tb
different functions, organs, and stractnres, see t%t
article on Dkbiltty, § 10 — ^25.)

87. 2d. Or pbritebtbd States or Vm.
Power. — Having considered the simpler chu^n
of the conditions of life, as manifested m tbe hw-
tions and characterising disease, those wbleh a**^
more complicated are next to be ditcuaed ; aei
it remains to be shown, thai th§condHimu*9dm.-
terial aUiancet of life may not only bi dtangei n
degree, but also in kind — the change in kic-'
being, in some cases, unconnected with eitSft
excess or defect of action ; and, in others, ssrc-
ciated with the one or the other ; but more fn-
<^uently with depression, or an irre^lar £»tri«-
tion of the vital energies, and coneentraiioa ''
them towards particular parts. The cooditipb-^ ii
life present three ttates or stages ofekang* in h*.
without any reference to degrees of aclioo: —
1st, Modifications in function, or vital mtoi^-
alion, the proper offices of the part being vitistrc!
but the structure not being seosably chaofi^^
2d, Modifications of function, in conne^ioB nt-
chan|re in the constitution of tbe part ; ib^ af^
ral tissues having been metamorphosed hv •*'
alteration of their nutrition or secretions, sod I •
adventitious formations. 3d, Modifieatioa* c
function and organisation in several parU,or.^
the whole of the frame; generally attended U ■
vitiation of the cireulating fluids.

88. ii. T*he eotiditiont of life may he iM^t''-
in kind, without any ritible alteratitm aftinitt'^
This state is often the commencemeat of 't-
others now particularised ; but it also frcqwrtj.'
proceeds no further, or one form of it may n-^U
pass into another, or terminate in bealtK. i>
slighter grades are more especially seated iat^-
moving powers; the organic and cttt)»9^f'^
nervous influences, and the vital ffitipcrties of 'xi-
tractile parts, being chiefly aflfected ; preseat r.
accordingly, a great variety of morbid pbeoos^:^.
not strictly referrible lo either excitement or V
bility, but consisting chiefly of alteratioDS of '''
sensibility of these systems; of pain aad sri '^
in their numerous forms; of cerebral alfiH'tt ^*
and disordered mental manifestations; ofl<^^'
of the contractile and locomotive orvans ; of&"'^
fications of the sensible and iosensihle contra^ '•
of parts, of their susceptihility and excitab/'*^
ana of many changes in the state of tbe ^ ~*-
tions and excretions, independently of Umm i"
relate to quantity. In its more exqainif ^'^
widely diffused forms, this state pfpom ^^

560

DISEASE — ALTERATIONt OF £xBALAT10N AND SbCACTIOK.

vancing slowly to the coDdition now being con-
sidered, as carcinomatous and their allied diseases ;
or taking place in a more rapid and violent form,
as malignant or adynamic levers, the effects of
animal poisons, &c. It would seem that all de-
teriorations of the conditions of life are either
consequences of, or otherwise related to, depression
of them. If we trace the progress of those ma-
ladies in which the change in kind is the most
conspicuous, we shall find that vital depression is a
characteristic of the impression of their exciting
causes, even although these causes may also irri-
tate the vascular system, or impart irritating pro-
perties to the. circulating fluids; for extreme
depression of the manifestations of life — of its
conservative and restorative properties especially
•^is frequently conjoined with an apparently
high, and, as respects rapidity of action, extreme
vascular excitement. When great depression is
the attendant upon vital and structural deterio-
rations, the sensible properties of the circulating
fluid and of the tissues — the crasis of the one,
and the vital cohesion of the other — experience
rapidly progressive changes, until the bond of
union between life and structure is dissolved :
alterations of a very conspicuous kind taking
place in various parts of the body some time
before death. (See article Debility, $ 11. 26.)
92. (6) The excitement which is sometimes
associated with an alteration of the conditions
and material alliances of life is essentially morbid,
and is different from that which attends an other-
wise unchanged or non-deteriorated state of the
vital powers. This morbid excitement is gene-
rally expressed in particular systems and organs ;
the vital actions of the rest of the frame being
proportionately lowered ; but, whether it affect
chiefly the nervous or the vascular systems, or
take place primarily or consecutively, it soon ter-
minates in profound exhaustion, and in a more
or less complete vitiation of the conditions and
alliances of life. This is illustrated by the ad-
vanced states of adynamic and epidemic fevers,
by plague, &c« in an extreme degree; and by
the worst forms of erysipelas and eruptive fevers
in a less conspicuous manner. The excitement
thus associated with other vital and material al-
terations, may proceed directly from its efficient
cause, wliich may excite or irritate, ^whilst it
otherwise affects, the organic nervous and vas-
cular systems ; or it may take place indirectly, or
consecutively on depression, and be mora or less
a state of reaction, developed by changes in the
circulating fluids, arising either from the absorption
of irritating materials, or the uninterrupted elimi-
nation of hurtful elements. But in either case a
progressive deterioration is observed ; the morbid
conditions of life affect the secreting and excreting
functions, and consecutively vitiate the circulat-
ing fluids, and even the living solids: and the
irritating or vitiated state of the former excites
the vascular system ; and thus alterations of the
one reciprocally increase those of the otliers,
either until the alliance of life with the structures
can no longer bo preserved, or until, in con-
sequence of the exhaustion of the vascular action,
which had been excited by the changes in the
circulating fluid, and of the effects of this fluid on
the secreting and excreting organs, the balance of
vital excitement is inclined in their favour, a new
action takes place, their functions are resumed.

morbid matters are thereby eliminated fron tk
system, and health is uhimately reAored; t^
change being either ushered in by critical pkcso-
mena, or promoted by remedies, the operationf of
which are merely an artificial or subsbtuted OtiiL
(See art Crisis.)

93. IV. Disease or tub Fluids and Souss
oaiGiNATiKO in altxaed CoNvmoMs or Lin,

AND OENKRALLY IN THOSE ALBBAOT MSCt«9l».

— Morbid exhalation, secretioa, aad nuiiitiaD
may be viewed as stages of the same orgiaif
action ; exhalation passing into aecretioo, ssd
seci^tion into nutrition. Thus we perceive the
natural exhalations, during didease, assume uc
characters of a secreted or elaborated flaid.
and certain morbid secretions beoome more or
less organised. I shall therefore notice — U.
The simpler changes of exhalation and srcretioo ;
2d, Simple modifications of nutritiou; dd, Pk-
ternatural exhalation and secretion, comprteii^
the transformations and misplacements of tbcM'
fluids ; 4th, Preternatural or metamorphosed nvm-
tion j 6th, Adventitious formations, or prododitf*,
foreign to the economy — consisting of secretioa

— (a) insusceptible, and (6) susc^>tible, of «•
ganisation ; and, 6th, Of destnictwa of parts.

94. i. The biupleb Alterations or Ei«
HALATION AND Secretion. — I bavo cousdefei
in distinct articles, on account of their great vm-
portance, morbid states of the Blood, ukd Con-
gestions of this fluid. 1 shall here bnefly nabct
changes in the exhalations and secretioiHk — A.Tt*
exhalations into shut cavities, or in the areolvof u<
cellular tissue, may be increased from the follow-
ing changes : — 1st, From deficient tone, rderriolr
either to the exhaling vessels and pores, or to im-
perfect vital cohesion of the tissoea, or to both
2d, From deficient, action of the abaorbentft, de-
pending on diminished vital power, or oa ob-
structions in their course : 8d, From increased
determination of blood in the vesaels disthbsied
to these parts: 4th, From inflammatory scIka
terminating in, or being followed by, effuswa : ots.
From obstructed and retarded circulalioa of i^
venous blood returning from these places, pir-
ticularly in the liver, in the heart, ittDg», &c. ;
the consequent nervous and capillary disteoaon
favouring augmented exhalation: 6th, Fran
increased vascular or rather serous plelbon,oiiis$
to the obstruction of some emuoctory,— as siu-
sarca, from the sudden arrest of the cutaneous asJ
pulmonary exhalations ; and this, as well as uCucr
forms of drojpsy, from inflammatory or stntctanl
disease of the kidneys: 7th, From the sodfito
arrest of an accustomed discham from the psi*
mo nary or digestive mucous suitaoes, the rauHiJ
exhalation being determined to the coatfoosi
serous surfaces ; and 8th, From two or men o(
the foregoing states conjoined. (See art. DsonO

95. B. Alterations !tf the seeretioms depciul —
Ist, upon the state of the organic nervoos ia-
fluence ; 2dly, upon vascular action ; and, 3(i v.
upon the condition of the blood itself — upon (^
chief factors rf organic aetiom mnd life; aod tkci
are thus indications of the maoifcstabonft ci
this principle. They may be — «. more or W
dimiiiished, — as from causes which lower tbr
orranic nervous influence, or retard the cir-
culation ; B, or more or less increami, chieil/ ^^
agents which alter the diatritmtion or ddcmuA-
atioa of oiganic influence, and conseqaeoil; vf

DISEASE— Alteiiations of Exhalation and Secretion.

681

the circulation and Tascnlar action, either by ex-
citing the secreting structures themselves, 'and
their intimately allied parts, or by depressing,
impeding, or obstructing the functions of distant
and especially of other secreting organs, and from
a superabundance in the blood of the elements of
which the increased secretion is formed ; y, or
more or less ottered from the healthy state, inde-
pendently of diminution or increase of quantity,
— as when the conditions of life are modified
otherwise than in grade, and when the circulating
fluid is vitiated, either generally, or merely in
respect of the greater abundance of some one
element; ^. or both diminished in quantity and
aUtred in quality, owing chiefly to lowered as
well as modiiied vital power, to changes in the.
blood, and to morbid vascular action or inflam-
mation of the secreting organ ; i . or lastly, they
may be both inerea$ed and vitiated, either from
B morbid distribution, and alteration of vital in-
fluence and action owing to the impression of
causes on remote but related organs, or from irri-
tation or excitement of the nervous influence of
tl)e secreting structure itself, by agents acting
either exteriorly to the vessels, or interiorly
through the medium of the blood. Thus, various
substances received into the digestive canal will
increase and alter the secretions of its mucous
surface ; and the accumulation of the elements of
bile in the blood, with other effete matters, will
excite the liver, and give rise to an abundant as
welt as acrid or otherwise morbid bile. Such
seem to be the chief pathohgicaL ttatet on which
nH>rbid secretions depend.

96. From what has been stated, it will be evi-
dent that, although alterations of the secretions
are often dependent upon vascular action in its
various states, from augmented determination to
inflammation and its results, and upon conditions
of the blood, organic nervous influence has also a
mailed effect in generating them, and even in
ofiginating the vascular disturbances to which
^ have been most generally assigned by authors.
And although the secretions are constantly and
conspicuous^ disorder^ in fevers and inflam-
mations, yet they are also often remarkably
altered in other diaeases ; and, in some, even con-
stitute the most prominent change from the
healthy state. In fevers and inflammations, the
secretions are more acutely affected, but are
more disposed to a spontaneous and salutary
change, than in' chronic disorders. In those ma-
ladies in which their alterations form the chief
pathological stale, their natural conditions are
very slowly restored ; and, even when the restorar
itoo is effected, their derangement is apt to
recur from the slightest causes. This is exem-
plified in diarrhoea, diabetes, and several other
chronic diseases.

d7. (a) The recrementitwus, as the salivary,
pancreatic, and gastric secretions ; or the partly
recreroeatitiotts and excrementitious, as the biliary
and intestinal secretions ; are more or less altered
in most diseases, and from a diversity of causes.
Agent», whose operations may be sufficient to
excite the organic nerves, but not to produce
wflammaiory action ; or whose properties are
calculated to afliect the influence of these nerves,
lathet than the action of the capillary vessels;
^^7 give rise to an increase or other change of
the KcretioDa in preference to ioflammatioo.

Thus, aromatics and stimulants will excite the
flow of the gastric juices, but will not occasion
inflammation unless taken in very large quan-
tities ; various substances will increase the in-
testinal secretions, but not inflame the villous
surface; and mercury, in small or moderate
doses, will remarkably augment the salivary fluid,
but, in excessive doses, will inflame the glands
and diminish the secretion. The effects of sti-
mulants upon parts related or contiguous to those
to which they are applied, also show the influence
of the nerves on the secretions, — as the action of
certain odours and savours on the salivary and
gastric secretions, and of various purgatives on the
biliary fluid. Even mental emotions affect the
secretions through the medium of the related or-
ganic nerves supplying secreting structures ; and
this effect is not limited to the recrementitioua
fluids, but is also extended to those which are en-
tirely excrementitious, as the urine, the sweat,
&c. The influence of mental anxiety in pro-
ducing both diuresis and enuresis, and of hysteria
in occasioning the former, is well known. Defi-
ciency of the recrementitious fluids caus^
dyspeptic, hypochondriacal, and other diseases of
the digestive organs ; impedes or otherwise modifies
sanguifaction and nutrition ; and favours the pro-
duction of nervous affections. Morbid states of
the biliary secretion are amongst the most im-
portant in pathology. Impure air, want of
exercise, increased temperature, rich or full living,
stimulating liquors, &c., change both the quantity
and the quality of this fluid ; rendering it either
more copious, or of a deeper colour, and of a
more acrid quality, than m the healthy state.
Its more languid circulation throush the ducts,
or its undue retention in the gall-bladder, owing
either to indolent habitsi or to exhausted powers
of digestion and assimilation, favo^irs the absorp-
tion of its more aqueous parts, increases its con-
sistence, disposes certain of its oonstituents to
crystallise or to concrete into calculi, and gives
rise to various chronic disorders of the liver and
of its related viscera. Obstructions to its passage
or discharge, and various other circumstances,
favouring its absorption on the one hand ; and
torpor of the liver, or suspended action of this
viscus preventing its secretion on the other, and
causing the accumulation of its constituents iu the
circulation ; are important pathological conditions,
and constitute no mean part of several acute and
chronic maladies, besides those in which the biliary
fluid is more especially disordered. (See Concrb^
TiONS — BiUary ; Jaundice, and Liver.)

98. {b} The iecretiom which are elaborated by
the intestinal mucous surface are often remarkably
changed, both in quantity and kind. Diarrhoea,
dysentery, and cholera, present extreme increase
and alteration, not merel^ of these, but frequently
also of those poured into the digestive canal
from the coUatuious viscera, originating in the
pathological states adduced above (j 95.) ; and
illustrate the action of morbid secretions upon
the surfaces with which they may come in con-
tact. When these secretions are produced in
lai^ quantity and altered quality, whether from
a modifled and excited condition of the vital
actions, or from both, or from these conjoined
with an impure state of the blood, the effects fol-
lowing their passage over the villous surface are
often very severe, and even disorganising. Thus

Pp3

683

DIS£AS£ — Altzratiovs of Exralatiok akd Secbstiov.

an altered state of the salivary fluid inflames
and ulcerates the mouth, tongue, and gums ; and
the irruption of a large quantity of acrid bile
irritates the duodenum, excites severe vomitings
and purgings, sometimes with spasms of the vo-
luntary muscles owing to the irritation of the
visceral nerves acting upon the related spinal
nerves, and, in more chronic cases when morbid
secretion is prolonged, even excoriates the intes*
tinal surface. A similar effect very probably is
occasioned by the intestinal fluids themselves, as
shown in dyaentery. But the injjurious opera-
tion of the fluids poured into the digestive canal
does not arise only from their morbid increase.
Diminished secretion, if it be attended by the
accumulation and retention of the fluid in the
secreting viscera, and of the mucus on the
villous surface, may prove equally detrimental,
but more insidiously and slowly. Morbid in-
crease of these fluids is usually an acute, and
diminution of them a chronic, disorder. The
latter is generally accompanied with alterations
in their properties, especially if they are long re-
tained. Wlien the retention and alteration take
place in respect of the mucus contained in either
the solitaiT or aggregated follicles, dangerous or
even fatal ulcerations, or other organic changes,
may be the results. Their accumulations on the
intestinal surface favour the production of worms,
indigestion, constipation, cohc, &c. The manner
in which one secretion may be greatly increased,
whilst the rest are suppressed, is remarkably il-
lustrated in pestilential cholera. In this malady
it would seem as if the efficient cause suppressed
the vital manifestations of all other organs, de-
termined the remaining vital influence and cir-
culation to the digestive canal, and occasioned an
uncommon increase and alteration of its exha-
lations ; the serous portion of the blood being in
great part evacuated in this situation, leaving a
portion of its albumen lining the intestinal surface
in the form of a muco«albuminou8 and tenacious
exudation.

99. (e) The 9xcr«nuntitiovg secretions are also
altered by the pathological stales already speci-
fled ($ 96.). The changes of these, as well as
of the foregoing fluids, are important agents in
continuing or aggravating disease, and furnish
some of the chief indications of its nature, pro-
gress, and terminations. — As the office of the
organs which secrete this class of fluids is to
expel those elements which are effete, and would
be injurious to the frame if retained in the blood,
it must necessarily follow, that any interruption to
this function, and especially a complete obstruction
or suppression of it, must be highly injurious.
The dropsical effusions in various cavities follow-
ing interruption to the action of the kidneys, and
the more acute effects of entire suppression of
their functions, fully illustrate this. As a large
quantity of ingested matters is carried into the
blood, either directly from the stomach, or along
with the chyle, and discharged from it by the
emunctories, it is evident, not only that the kind
of ingesta will affect very remarkably the pro-
perties of the excretions, but that obstruction
or even interruption of any one of them will be
followed by serious effects, unless some other
organ perform an additional office, vicarious of
that which is suppressed ; and even in this case,
will generally ultimately arisot

100. «. The mfiuintal «9a<iial«eii, iBdeveii the
lochia f may be conaidered as excrementitipas ae*
cretions, interruption or morbid incnase of Uma
being followed by similar conseqoeaoes to tkeit
arising out of suppressed peitpirotkw. Thtt
the menstrual discharge has eseeotiaUy a depui'
lory effect upon the blood, is shown by the alter,
ations whicn it undergoes from morind stales ai
the circulation ; thus, I have aeen copioas eats*
menia, the fluid being remarkably offeoHve, im-
tating, and otherwise sensibly aftofed fran tke
natural state, form the crisia of eriaipelas, aad
fevers; and a copious, offensive, and esoofisiae
lochia evidently the means of prevaotaog tW
accession of those adynamic and maligDaBt d]»>
eases which often affect ^erperal famues, owte^
to the respiration of tha impure air generated I17
several females confined in one lyin^ia apait*
ment. The oatamenia, moreover, ia diauniskd,
increased, vitiated, or changed into a senws or
mucoua secretion*-into floor albtt»-~by the save
agents and pathological conditions ($ 95.) as aftct
the other excretions.

101. ^. Morbid states of the pertphmtim, in-
dependently of its increase or deereaae, are ssi
infrequent attendants on both acute and cbraoic
maladies. They may even acoompnay appa-
rently sound health, particularly when the boireh
are habitually constipated ; thia evaenatioo bosf
soinetimes so offensive, or Iwth copious and off»-
sive, as to render the peraon thus aAcftd t
nuisance to those near niro. In this case, the
skin evidentiy performs an oiBoe vicaiioas of tit
diminution of the intestinal secretioos. The ptf>
spiration is generally promoted by exeiled vaal
action of the cutaneous surface ; in which eaae a
is fluid and warm. But it may also be lasrb
augmented by a very opposite eondifioo of vital
power, as by syncope, tne skin being cold nd
clammy ; or by the extreme vaacnlar depteaww.
occasioned by excessive fear. In these caws, ibt
lost tone of the integuments, and of the ex-
creting pores, allows the escape of a poitiDD c'
the fluids contained in the superficial vtmt^
This change also occurs in many instaares ci
extreme vital depreasion, and shMtly before dnik
in many diseases. It is a patho^omonie synpiom
of pestilential cholera, to which it is ooii le-
markable; the cold, wet, livid, and sbraak
surface, being the result not only of tbe soppraind
vital powers, but also of the circulatioB of ftatea*
blood.

102. y. The uriftary, of all the cxciebeoa^ •
the least frequently suppressed ; the cooseqacare*
of such a state being, if not aoon lemoitd. th«
most dangerous, or rapidly fatal. Whibt tL»
excretion is very much influenced by the qaaontv
and nature of the ingeata, and by the teaperstarr
and humidity of the air, it is also varkrasly aharod
by disorders of digestion, sanguifactioa, and or-
eolation ; but more particolariy by the caudiMM
of the blood itself, by changes in 'the nerroo« '»-
fluence, and by injuries to the spinal cord, ifa
the other hand, interruptions of the urinary ds-
charge affect the quantity and quaKly of the
circulating fluid, disorder the ntrrous'i^rffMswv
ultimately increase the exhalations and the otk#T
secretions, and change tlie conatttutioo of the
soft solids. The other pathologieal lalatioa* y
diseased urine are fully explained in tbe
DiABBTsa and Uhikb,

DISEASE— Metamorpiiossj) or transforuzd Nutrition.

685

trataitkm of one tissue into another *- is of a less
(impie kind than that noticed above ($ 103.) — a,
M. Andral has shown that the same principle of
developement which obtains in the foetus, extends
also to the morbid transformations of the natural
tissues; and that as the cellular is the matrix of
the other textures, so it may, from disease, be
changed into most of the other simple structures.
There are, howeTer, certain facts connected with
such alterations deserving notice : — 1st. Cellular
t»ue, in being changed into some other, no further
a/Tects the proper texture of the organ, which it
either in?ests or of which it forms the parenchyma,
than in causiog its atrophy in some cases. — 2d.
Cellular tissue cannot be transformed into the
ocrvoos, unless in situations where the latter pre-
viously existed : thus, nerves that are divided, and
of which a portion is removed, are first connected
by cellular tissue, and subsequently by the ex-
temion of medullary substance from each divided
extremity.— 3d. Other tissues, whose continuity
has been resolved, have the breach repaired, in
the fim instance, by means of the production
of cosgulable lymph, which passes into the state
of cellular tissue ; this latter being frequently af-
terwards transformed into a texture analogous to
that which was divided ; thus, divided muscles are
reuDtted bva fibrous tissue ; and so on, as respects
bone, cartilage, &c. — 4th. The nature of the trans-
fonnatiou of cellular tissue is sometimes regulated
by the functions of the part : thus, when sub-
jected to friction, it becomes a serous membrane ;
when exposed to external agents, it becomes
trgunentary, &c. — 5th. Other tissues, besides
the cellular, may be transformed, but the alter-
ations are similar to the natural changes they
experience in the processes of foetal growth ; car-
tilage heing converted into bone, the mucous tis-
sue into the cutaneous ; or a reverse course may
be followed, in respect both of these textures and
of the muscular tissue, which can be changed
only to the fibrous. Hence the metamorphoses
of cartilaginous, osseous, fibrous, muscular,
catancous, and mucous structures are much more
restricted than those of the cellular. — 6tl\. All
tj«ttes, when remarkably atrophied, present evi-
dence of degeneration towards their primitive or
rudimentary state, vix. to cellular tissue.

111.^. The eautei of the mutation of one tissue
into cnother are not easily ascertained. Some
have ascribed it to inflammation or irritation.
Hy ascribing it to modified nutrition, we merely
ezpreu an obvious fact, the cause of which is
fhereby not more nearly approached. It certainly
is tK>t occasioned by inflammation, although se-
veal of the transformations may be accidental or
contingent consequences of that condition, espe-
cially in its slighter grades; for, however we
Qtay irritate, or determine blood to a part, we
^ball not transform it, unless under circumstances
i<lentical with those that are concerned in the
production of those alterations. The series of
analogous changes that take place in the foetus is
ttot connected |ither with irritation, or with in-
flai&mation, or with opposite states of organic
action. We can, therefore, impute the mcta-
morphom only to modifications in the conditions
and manifestations of life influencing the nutri-
tion of the orgaa or part ; for we know that in-
crease of function, or of vital manifestation, will
often occasioQ a transformatioa of nutrition in a

certain direction— will change cellular tissue to
a higher srade of structure, as in the develope-
ment of the organs of the foetus; whilst the
diminution or privation of function — that is, of its
due vital endowment,— will transform the organ
which performed it into a more rudimentary tissue :
thus, a part becomes atrophied from being unex-
ercised, an unemployed muscle is reduced to a
pale fibrous structure, and an impervious artery
or duct to cellular tissue. In brieny noticing the
specific metamorphoses of tissue, I shall com-
mence with the simplest, and generally the
earliest change, in the ascending scale of trans-
formation.

112. (a) The cellular tissM having always
existed as the matrix of the compound structures
and organs, it is obvious, when, owing to sus-
pended or abolished function, the superadded
organisation devoted to such function is lost, that
the cellular tissue will then remain as the pri-
mitive structural base. This is shown by the
evidence already adduced. The coagulable
lymph exuded during inflammation of serous
surfaces may become organised into cellular, and
even into serous tissue, and be the matrix of
certain other changes ($ 140.).

113. (fr) Theseroiif tiifii«,and the cellular, are
often transformed one into the other. Cellular
substance may have serous cysts developed in it,
in almost any part of the body, either from
friction or pressure ; or from the lodgement of a
foreign body, or the existence of a coagulum, &c«
But, independently of these causes, it may have
cysts of various dimensions formed in it, either
where it invests the diflPerent organs, or enters
into their internal structure ; the parenchymatous
organs sometimes being either partly or altogether
transformed into a serous sac, or having these
productions attached to them. When thus de-
veloped, they have been attributed to irritation
by some, to a diminution of the natural action by
others, and to perverted action by several patholo-
gists. There can be no doubt of the last being
the case, whether other states of action may
accompany it or not.

114. A. Serouteystt y%ry from the size of a mil-
let-seed to that of a child's head ; they exist either
singly or in clusters, have their external surface
in contact with the organ in which they afe pro-
duced, and are either intimately connected with
the cellular tissue surrounding them, or entirely
without any organised connection. Red vessels
are seldom seen passing into them. The struc-
tures immediately surrounding them may retain
their natural appearance; or may lose it for a
time and regain it ; or may be shrunk and con-
densed ; or be altogether atrophied, and expand-
ed over the cyst, as in the liver, brain, lungs ;
or be merely congested, or moreover be softened,
indurated, or surrounded by pus, or by tuber-
cular matter, or by blood. In tliis last case,
the cysts themselves are^sometimes broken down,
or partially destroyed. The investing cellular
tissue may also become fibrous, cartilaginous,
osseous, or even calcareous ; and additional
layers thus may be superimposed on the original
cyst. The internal surface of the cysts may be
smooth, or may present changes altogether similar
to those which serous membranes experience
from disease ; it may be uneven, rugoee, granu-
lated, covert by specks of concrete albumen, or

DISEASE «-MsTAMORPHOaBD OB TRANSFORMED NlTTIUTlON.

587

either as vaamm, or at membranes ; and of tbem-
»lves, or with the serous or the fibrous transform-
atioM, or with both, may form the cysts or en-
velopes of these secretioiiB.— 2d. Jn the ttructur§
^' 'partnekymataus orgam, the cartilaginous pro>
dactions are formed, like the fibrous tissue, at
the ex])eiise of the cellular. They may be de-
posiied in masses, or in the form of envelopes of
various morbid secretions. Whilst cartilage u
most frequently formed beneath serous mem-
bfanes, these membranes themselves never ex-
perience this change. It is rarely produced in
the cellular tissue under the mucous or villous
costs; and very rarely in these coats themselves,
iQd.then only consequently upon repeated or
prolonged irritation. The osseous tissue may
liao be transformed into cartilage. But in re-
spect of the change of muscle, and of pareochy*
Dtlous visoera — as the liver, spleen, kidneys,
&e.— into cartilage, it is more probable that the
developemeot of this substance in the cellular
tissue merely causes the disappearance of the
proper structure in the part thus altered. There
i4, however, Kttle doubt of a portion of brain
being sometimes changed into cartilage.— 3rd. Jn
Mvitiet lintd by werout or tynovtat mtmhrann,
cartilages have been found, either entirely loose,
or attached by a membranous prolongation or
pedicle to some part of the parietes. 1 hey vary
from the smallest size to that of a bean, and are
of different forms. They are generally homo*
geneonsaod elastic, and sometimes' they contain
osaeous points in their interior. They have been
found in the peritoneal cavity, by Lasnnec and
Andbal; within the serous membrane of the
brain ; within the tunica vaginalis testis; in nearly
ail i^ articnlaiions, but most frequently in the
knee and shoulder jotots ; and even loose in the
interior of serous cysts, by An oral. As to their
formation, this pathologist thinks, " that they de-
rive their origin from their fluid exhaled in serous
ukI synovial cavities;" whilst Bxclard and
Laenhec suppose that they are originally formed
on the external surface of the membraoes lining
these cavities, and that they gradually protrude
before them the portion of membrane covering
them, thereby giving rise to the pedicles by which
ihey are sometimes attached to the sides of the
cavities. Morbid cartilaginous formations vary
from a fiBro-cartilaginous or mixed state, to one
pnrely cartilaginous, in which the internal struc-
ture is perfectly homogeneous; they also vary in
c They occur in the following situations

firmn

in some one of these states : — 1st, In false articu-
lations ; 3d, At the extremities of bones of which
a portion had been long previously amputated ;
«^* In the situation of ligaments belonging to an-
ebylosed joints ; 4th, In cicatrices; 5th, In com-
pound tumoura of the uterus, ovaries, and thy-
roid ; 6th, In the form of incrustations or patches
in the parietes of arteries ; 7th, In the cysts and
envelopes of morbid formations ; 8tli, In certain
pvenciiymatous organs; 9th, In the interior of
articulations ; and 10th, In serous cavities, both
Batural and morbid.

1211. (/) Oisif'orm formations differ in form,
and somewhat in constitution, from the natural
osseous tiasoe ; and are generally confined to the
cellular, the fibrous, and cartilaginous tissues.
~ «. The oeUuUr iubttanet is not susceptible of
this change in all parts of the body ; for ossific

deposits have not been found in the sub-mucous,
although frequently in the sub-serous, cellular
tissue; the serous membrane apparently still
covering the osseous formations, ana giving them
a smooth pale surface. This change has been
found in the sub-serous tissue in every part of the
frame ; and it generally begins with slight thicken-
ing, and the infiltration of a turbid fluid ; morbid
nutrition, very evidently in this instanoe, and, in*
deedi in most other cases, as I have above con-
tended, commencing in vitiated secretion. The
connecting cellular tissue between the coats of
arteries, especially that below its serous coat, is
still more frequently ossified than the foregoing^
Also the cellular substance surrounding fistulous
openings, foreign substances, and adventitious
secretions or productions, often become incrusted
by plates, or grains, or complete layers of osseous
matter. Thus tubercles, hydatids, &c. are some-
times contained in osseous envelopes.

123. 0, Omfieation of Jibroutand eartHaginoui
textures is a part of the process of developement in
foetal and early life; and the process goes on
through life, although generally in an imperoepti*
ble manner, until old age advances, when it ex«
tends more rapidly, and seizes on additional parts
of these textures ; the fibrous tissue of the arterial
system, and the cartilages of the ribs, larynx,
trachea, &c., being then often conyerted into bone.
But when parts not liable to this change in old age
are affected by it, or when those disposed to it are
prematurely transformed, the circumstance is re-
ferrible to disease. The experiments of MM.
Cruvrilhier and Rayeii show that a certain
degree of inflammatory action or vascular in-
jection of fibrous, fibro-cai)ilaginous, or oarti</
laginous tissues precedes the osseous deposit ; and
hence the reason that fractures or injuries are
often followed by osaification of the atliacent
parts of these textures ; and that simple irntation
of a slight but continued form has given origin to
thi% alteration. But, in many instances, no cause
or appearance of inflammatory irritation could be
traced to the ossified part ; as when the coats of
arteries, the dura mater, the capsule of the spleen,
&c. are thus affected.

124. y. The form, texture, and oonstilution of
ossiform formations vary much, both from one
another and from the natural structure. As to
form, they are — Ist, Gi'antt^r,and either isolated

or in groups, their number being extremelj^ vari-
ous, and sometimes remarkably great ; their size
extends from a minute point to that of a pea ;
they are rounded, with either a smooth or a rough
surface. — 2d, LamelUfarm or fiism6rant/briii -^
developed in the adherent surface of serous mem«
branes, or in the parietes of cysts, &c. — of vari-
ous sizes, and sometimes of several inches in dia-
meter, and consisting of thin irregular plates. —
Sd^ Amorphous,'^ genenWy found either alone,
or in conjunction with other morbid productions
in the parenchymatous organs; they consist
more or a phosphato-calcareooa deposition,
than of an ossiform formation. Their texture
is — 1st, Homogeneous; and without fibres or any
division into compact and spongy parts; 2nd,
Obscurely ^frrous or radiatetl, and more nearly
resembhng the natural flat bones. The con-
stitutioH of natural bones is generally uniform ;
but that of the ossiform productions varies re-*
markably in respect both of their earthy or saline

DISEASE— *Adv£ntxtious Sxcritions and PRODucnoss.

689

riginate either in changes in the nutrition of the
iiural tittues, the adventitious secretion being
consequent leston ; or in the production of new
jbiitauces, alterations of nutrition being later
iiioDS ; or even the secretions, as well as the na-
ifftl tissues in which they are elaborated, may
nder^go subsequent transformations. So extremely
iveisified are the causes which induce these
wjises; the states of vital manifestation and of
ixiiinx action by which they are attended at
leir origin and in their progress; and so re-
tarkably are they modified in their course by ez-
Toal agents and intrinsic states of action ; and,
lureover, so ioseosibly do they pass into one
Qother, and so frequently and variously are they
3oplica(ed; that any arrangement must neces-
irily be arbitrary, and a choice of difficulties.
lefcrence, however, to the varying characters of
le adventitious formations having been had in
yt articles upon specific morbid structures, and
poa the varymg alterations which the principal
^aes and organs present, I shnll here only take
general view of tliem, in the following order : —
it, Secretions adventitious to the frame, and
evo'ul of organisation : 2d, Adventitious secie-
ODs associated with morbid nutrition ; or those
list are apparently organised, but which depend
pen the adjoining tissues for their vitality : and,
d, Those which become organised, and possess an
sdependeot life.

130. A, Secretiom adventitious to the frame,
nd iacapabU of organiiation or v<ta/t(y.«— These
absUiQces present no trace of fibres, laminae,
tuials, or areola; ; they are of various degrees of
oosisiency ; and certain of them change either
rom a fluid to a solid state, or from the latter to the
umer. They •consist chiefly of albumen, gela-
ioe, and the usual salts found in the serum of the
>tood. The substances that fall under this de-
ception are : — 1 . Pus ; 2. Tubercle ; 3. Fatty
nailer; 4. Glue-like matter, or the colloid mat-
trofLAEKNEc; 5. Melanosis, or black matter;
^»d, 6. Saline ingredients. These may exist
^iher singly, or variously associated.

131. (a) Put. — This term has been applied
^ a morbid secretion, whose physical properties
rary considerably. That form of it which is
uually secreted in a state of the constitution not
totarkably depressed or vitiated, is a homogeneous
cream-like fluid, of a yellowish white colour, faint
!<neil. and slightly sweetish taste. But it often
lit-paru far from this state ; and even that which
& accreted from the same surface, may be very
remarkably changed in a very short period, gene-
rally owing to modifications of vital power and
«ttscuiar action. Sometimes it very closely re-
^<^bies a thick cream ; at others a mixture of
Curds and whey ; and at others a turbid serum, or
% grumous sanies, or the dregs of wine. Occa-
uooally it seems disposed to become solid, and to
^^•iurae the appearance of tubercle. At one time
it is quite inodorous, at another very foetid. Its
(^luur also changes from white to yellow, from
gretn to red ; or this order is reversed. In some
instances, it is yellowish green, or yellowish
lirown, and other related shades. The following
are it& rarietiet, according to its physical proper-
\)tt% : >-> 1. Creamy, homogeneous, or laudable pus ;
2. Curd-like pus ; 3. Serous pus, or sero-puriform
n^aiter; 4. Muciform pus, or glairy puriform
i^atter, or puriform mucus; 5. Bloody pus ; and.

6. Concrete or laidaceous pus. These alterations
are ^chiefly attributable to the texture in which it
is secreted, to the degree of local irritation or ac-
tion, to the period it has been retained, to the
general state of vital ener^ and vascular action,
to the condition of the circulating fluid, and to
the diathesis and constitution of the patient. But
these varieties often run into one another, showing
that any arrangement of the physical appearances
of this secretion must necessarily be arbitrary.
In the scrofulous diathesis, however, it often pre-
sents certain distinctive characters, and inchnes
nearer to the curd-like variety, or seems more
disposed to become solid, from the absorption of
its serous portion, when it has been some time shut
up. But the most specific difierences that exist
in pus are not to be ascertained by chemical re-
search, nor external appearances. Two portions
of this fluid, identical in every respect, will pro-
duce very dissimilar eflfects : when introiluced
beneath the cuticle, one will occasion merely a
slight irritation ; the other a most dangerous con-
stitutional malady* capable of disseminating itself
through thousands.

132. Pus has been found in every tissue, struc-
ture, and organ of the body, and in all the vessels,
and in the blood itself, both imperfectly mixed,
and in the centre of clots. It may exist in the
tissues and parenchymatous organs, either col-
lected in the form of abscesses, or disseminated
and infiltrated through their structure. When
formed in muscular, nervous, and ev^n in some
other structures, it is in reality furnished by the
connecting cellular tissue, which is the chief seat
of the inflammatory action producing it. ^ In a
great majority of cases, its presence, either in dis-
tinct collections, or in a state of infiltration, is ac-
companied with signs of irritation or inflammatory
action ; but instances occur, in which it is attended
by no such appearances. The opinion, that it
could be formed only where there is ulceration,
has been shown to be unfounded : for it may be
secreted on the surfaces of membranes, without
any breach of continuity ; or collected in the
parenchyma of the organs, without any appear-
ance of inflammation ; or infiltrated between the
fibres and in the areolae of the tissues, without
any loss of substance. It is met with in the
second and last of these forms in the consecutive
states ot tuppuration, or when puriform or sanious
matters have passed inti> the circulation, from
distant parts, or from disease of the veins, &c.
When the production of pus has been preceded by
any degree of vascular irritation, the surrounding
tissues present — 1st, various grades of injection ;
2d, various shades of colouration ; 3d, different
degrees of softening; 4th, solutions of continuity,
which may either have preceded or followed the
purulent secretion ; 5th, the disappearance of the
proper structure of the part, and its degeneration
into cellular tissue, in the areola of which the pus
is infiltrated. (For the various distinctive cna-
racters of pus, the pathological states which gene-
rate it, the symptoms that precede and accompany
its formation, and the means of protecting the
frame against its contamination, see the articles
Abscess, § 7. et teq, ; Implammation, and Svp-

PtJRATIOK.)

133. (b) TuhercU especially illustrates several
of the pathological inferences stated above rela-
tive to the constitutional conditions favouring

DIS£A8£— C6HNSCT10K bbtwssn Altbhationb or I'luidi and Solids.

693

nodead above, th« oi*gamc molecules are thereby
preveated bom being so pedectly assimilated, or
10 highly animaliaea, and indeed vitalised, as in
health; and that, the vital attraction requisite to
doe nutrition beUw n^kly or insufficiently ex-
erted, they proceed to arrange themselves acoord-
iog to the grade of vitality they possess, into much
inferior beings in the scale of creation ?

147. vi. OrDBsmocTioii or oroanhkd Pasts.
— Thii may taite place in three ways : — 1st. By
latefsdtial absorption, by means of which the part
ii fiist atrttphud^ and afterwards altogether re-
moved ; — 3d. By superficial absorption, or uleera'
tim, whieh may be consequent on inflammation,
or may proceed from the pressure of adjoining
psils, and from loss of vital cohesion in circum-
Kribed portions of membranes or superficial tis-
net :^ 3d. By martifieatHm, owing to intense
grades of inflammation, either absolutely or rela-
tively to the state of local or general vital energy,
—to a dertruetion of the nervous influence of the
put,^^to interruption of the circulation from dis-
ctK of the vessels, — to pressure impeding both
nervoDs power and vascular action, — and to
generally depressed vital power, asiociated fre-
qoently with a morbid conoition of the blood, and
sometimes with diseased blood-vessels, or with ex-
temsl pressure : hence the readiness of the occur-
teoce of any <of the forms of mortification in old
>ge, during dynamic and exanthematous fevers,
mm erysnelas, from deficient or unwholesome
food, and from syphilis or mercurial cachexy ; —
utd 4th. By the softening and swelling arising
from the greatly diminished or lost vital cohesion
of cellttltt and ad^MMO parts, and their infiltration
with a serous fluid (comprising the Noma, or
vatery ametr,of authors) giving rise to a form of
<l>sor|^nisation difiSerent from the foregoing, that
often passes rapidly into a state of jelly-like solu-
lioa and gangrenous erosion, particularly in the
lip«i che^s, and genitals of children. A similar
destruction sometoMS also takes place in the sto-
mach ; and the true softening of the brain, in
iu extreme states, seems to be of the same nature.
Iltii species of disorsanisatioo is intermediate
belireen uloeratioo and gangrene. (See Atro-
phy, CxLLULAu TissvBy Ganorsks, Softenxno,
and Ulcxratxon.)

148. v.. CoNMKcnoN or Morrid Actions
AKD or Oroamic Lesiovs with States or the
Blood..— Depressed and- perverted states of vital
power have been shown to be often connected
with s deficiency, or vitiated state of the circulat-
ion fluid, in chronic and cachectic diseases, and
^tli ezcrementitious plethora, or the accumula-
Hon of the constituents of the various secretions in
^e blood in the early and advanced stages of
ferers. (See Blood, and Debility.) Primaiy
excitement, in either its local or general forms, is
often caused, or at least favoured, by va$cular
p^&OTu ; and reaction, or secondary excitement.
With loeal determinations or inflammatory action,
1^ frequently produced by this condition, existine
^ther absolutely or relatively, or associated with
^ secumulation in the blood of the constituents
of the secretions and excretions, owing to the
intermption of these functions, as in the stage of
»«aciJon in fevers (J 85.).

149. The ooonectbo of the Utimt cf jerretton
with the states of the eireulaiwn is one of the
most unportant topics in pathology, and has

therefore been noticed in this ( $ 95. et uq,) and
other articles. The superabundance and trans-
formations of one or two of the natural secretions
are sometimes owing to the alteration, interrup-
tion, or suppression of others, — to the derange-
ment of the balance of healthy action, and to the
consequent plethora or vitiation of the circulating
mass. Thus, morbid states of the cutaneous or
of the intestinal secretions are often caused by
inactive function of the kidneys or liver; and
alterations of the urine, or of the bile, are fre-
quently produced by suppression of the perspir-
ation, or of the secretions from mucous surfaces.
Morbid increase of the exhalations, particularly
those poured into serous cavities, or into the
areole of cellular parts, is, in many iostances,
connected with gtvurai pUthora, as well as with
loeal eongettioHS, and deficient excretion ; whilst
the transition of congestions into inflammations,
and the transformation of these exhalations into
a fibrinous, or fibro-albumiuous substance, by
sthenic inflammatory action, are promoted by the
abundance of this constituent in the blood, and
the general exuberance of this fluid. When the
recrementitious secretions are imperfectly elabo-
rated owing to depressed vital power, the func-
tions of chylifaction, sanguifaction, nutrition, and
depuration are also im^ed; the usual results
being insufficient excretion, an impure state of
the blood, and ultimately slow irritative fever,
marasmus, anasmia, and other chronic dbeases.
In such cases the morbid phenomena proceed in a
circle, or rather act and react upon each other,
either until vascu)ar excitement is produced by
the state of the circulating fluid, and the secreting
and excreting functions are thereby restored, as
shown in the article Crisis ($ 16.), or until
some organic chanees supervenes. If we attempt
to trace the procession of morbid actions, we shall
often find tnat depressed vital power aiSects the
secretions subservient to sanguifaction; these
modify the quality, and ultimately the quantity
of the blood ; the altered condition of this fluid
disorders the vascular actions and depurating func-
tions, whilst it further deranges the nutritious
secretions ; and thus the evil continues to increase
until the living solids become changed, and in-
capable of performing their prescribed actions.

150. In connection with the various leiion$ of
nutrition whieh have been brought into view, the
bbod can seldom long retain its healthy state.
But the change is evidently, in the first instance,
that of quality rather than of quantity, although
it is> very difficult to show in what respect the

3uality is modified. Excessive excretion and
ischargo^ will often, however, sensibly diminish
the quantity of this fluid before any other change
either in it or in the functions of nutrition becomes
apparent. Local alterations of secretion and nu-
trition conjoined, whether originating in the
organic nervous influence of the part, or in the
quality of the blood circulating through it, ulti-
mately change both the one and the other, and
generally in a way that cannot be mistaken. In
many instances the alteration of the blood is evi-
dently owing to the absorption of the molecules
which had been depositeu, secreted, or combined
in the morbid structure, and removed in the usual
course of that transition of the solids into fluids,
which obtains in the living economy, equally
with the transition of fluids into solids. Animal

I)I8£AS£— Typi ok Foam ot.

S95

Cor ao fmieliiiita time — vai^iog from a few hottrt
to aerertl dayf , weeks, or, in local malacJet, even
to some monthi — preeentiog slight modificationB
aod vacillatioDiy tending either to a favourable
Of ttofavooxahlo termination. — (b) Of the period
of orim, in which new phenomena appear, indi-
etiinf either a aalotaiy or fatal isiue* The whole
duration of this stage ia, in febrile diaeasea, gene-
rally aborter than that of the fiist ; but there are
Dumeroaa exceptiooa to this rule.-— C« The third
$itgif or that of niCLiKBt consiata -» (a) of the
ftriod of 4eertmMt, or gshmtstian in which the
i^mptoma aubaide more or leaa rapidly, and the
Tttal organa begin to reawne their funotiona, in
livottrable eaaea ; or the eneigiea of life to atnk,
io thoae of an opposite teodenoy. — (6) Of the
period of am«a/cac«ia«0, in which the remaining
inoea and oonaequencea of the malady diaappear,
aod the vital and animal functions regain their
healthy oondition and balance*

153. There may be aome doubts of the pro-
piiety of adopting certain of the above sub-
divinona, u they are chiefly applicable to febrile
diieaaea ; but tliey likewiae obtain in aome other
maJadiea. In those in which they are leaa re-
niariuble — namely, in organic diseases — any
dhriaion mto stages can seldom be adopted with
advantage, or be made otherwise than in an ar-
bitrary manner. In these maladies, and, indeed,
in some others, the second or formative period of
the firat stage may not be manifeat ; nor the aecond,
or eritieal period of the aecond stage ; and many
BMy (|Tieation the proprie^ of making cmiM^Cfoancs
a penod of the disease. But I beliare, that,
during the lestoiation of the various functions,
there still remain certain pathological states or
degrees of diaoRler, requiiin^ the attention of the
practitioDer ; and, in many instances, a marked
teodcDey to relapee upon expoaure to the exciting
eaoics of the malady. For pathological reaaona,
therefore, as well as on account of the future
health of the patient, convalescence should be
alwaya treated as a period of diaeaae.

164. ii. Gradm ef i4eit<m.— The terma aciivt
and foiRM have been much employed io pa-
thology, an4 often without regara to precision.
They ahould have reference only to the kind of
vital action characteriaing disease, and not to
iti duration ; with which, however, they have
been too frequently confounded. Thus the term
Active has been often employed synonymously
with acute, and paasive with chronic But,
altbotigh an active disease is generally acute,
it is not so alwaya or neceasaiily, and may even
he of a chronic duration ; whilst the most pas-
sive maladies, aa respects the grade of vital
ection, may be meet acute with reference to their
coDthmanee. It ahould never be overlooked,
m oor appreciation of pathological conditioos,
that medical terms are only conventioDa] or ar-
bitrary ligns, employed, often too indefinitely,
to convey oar ideas of certain ever-varying con-
ditiom of vital manifestation and organic change ;
and that, in using the words active and passive,
we thonld restrict them entirely to the expression
of grades of vital action, and view them as pos-
*ewag an arbitrary aa well as a relative import,
ioatmuch as there is every intermediate degree
hetwwQ the meat active and the most passive
»AteR of disease.

155. iii. Of the Type or Form cf Dieeaee,^-

The rj^ is the order of succession observed to
obtain among certain morbid phenomena; and
admits of modification from vanous causes, with-
out the intrinsic nature of the phenomena being
essentially affected. It has commonly been
divided into the periodie and the emtinued ; the
former being subdivided into several specific
forma. — A. Of the periodic type, and the periodi*
city of morlnd octiom* — The intermiaaions or re*
.missions of morbid phenomena, and their return
or exacerbations after regular or nearly regular
periods, constitute their periodicity ; aod are
characteristic features of a number of diseases.
These features, are, however, more or less modi-
fied and marked in certain mkladiesthanin others,
in respect both to the paroxysms or accessions of
morbid action, and to the intervals which separate
them \ and hence periodic maladies admit of various
modes of arrangement, of which, however, that
into the febrile and non-febrUe (pyrexial and apy*
rsria/) seems to be the preferable. The former
are characterised by the regular stages of febrile
action which the paroxysm presents in most in-
stances, and the definite duration of the intervale
or remissions : the latter are remarkable for the
suddenness of attack, and their evident dependence
upon, and affection of, the nervotu system ; aa
well aa for the less regularity of their intervals.
Of the various modifications, which these two
classes of disease present, sufficient notice has
been taken in the articles on Fxvebs, and on the
nervous disorders which possess this feature,
especially Asthma, Epilxpsy, Hystema, aod
Neuralgic Afpectioks.

156* The cause of the periodicity of many
diseases has never been satisfactorily assigned.
Some have imputed it to the daily alternation of
the erect and supine postures ; others to the action
of light, or, in other words, to solar influence.
There is a certain tendency to periodicity in almost
all diseases, in which the nervous functions are
more or less affected, and even in convalescence}
the remisaions being often acarcelji perceptible,
and the exacerbations generallv aaauming the
tertian type. The periodicity of morbid actiona
cannot be explained othervriae than by referring it
to a law of the animal economy ; and, aa thoae
maladiea, in which the nervoua aystems are pri-
marily and chiefly affected, are most remarkably
periodic, we may infer theX it ia especially de-
pendent on these systems. This law obtains to a
certain extent in health, as respects the perform-
ance of many of the vital functions ; its existence
in disease, in a more evident or modified form,
should not therefore be a matter of surprise, par-
ticularly when the functions of those systems on
which It is more immediately dependent are
principally affected. It is most distinct, and the
intervals roost complete, in maladies consisting
especially of disturbance of the organic and ce-
rebro-spinal functions, and in those in which the
excretions are not much impeded, and the blood >
consequently not materially altered from the
healthy state, or where the other causes to which
the continued type is attributed (^ 157.) do not
exist.

157. B. TAecontiRHedlyp^consiaU of an unin-
terrupted succession of the morbid phenomena,',
from the irruption of the disease to its termination.
Some maladies present a nearly regular intensity
during their course, and have therefor^ been called

Qq2

696

DISEASE ^ Doe ATioN or Mosbid AcnoNt— Tseiovatioiii.

by the older writers " morhieontiiunUt" Olheri
evince slight morning remissions, with exacerba-
tions in the afternoon or towards evening : others,
in addition to these, experience some degree of
exasperation on certain, most frequently on alter-
nate, days ; and others, as some kmds of fever, as-
sume at first a remittent form, but soon become con-
tinued, and at last again slightly remittent during
convalesoenee. Even the more strictly continued
febrile diseases evince a remitting or periodic type,
in some degree, during decline or early conva-
lescence. It would seem that a marked tendency
to periodicity exists in all diseases, and that the
continued type is imposed -~ (a) by a high degree
of inflammatoiy action ; (6) by impeded or inter-
rupted secretion and excretion, and consei^uent
alteration of the quality and Quantity of the circu-
lating fluid. Thence it may be inferred, that the
type will be the more evidently continued, the
greater the pathological states to which I have
chiefly imputed it ; and that, as in respect of other
medical terms, continued or p«rtodic are usually
employed in an arbitrary manner, — the one type
passing into the other, the regujarly periodic and
the continued forming the extremes of the scale,
between which there is every grade, ascending
from the former, or regularly intermittent, through
the less perfect and the remittent, until the oon-
tinued is reached.

158. iv. Of th§ Duration tf Morbid ActUmt, —
The period intervening between the actual irrup-
tion and the termination of disease is of veiy
various length. Hamorrhages sometimes continue
only a few minutes, cholera a few hours, whilst
asthma, rheumatism, and gout, may remain the
greater f>art of life. Some maladies, originatine
in infection, have a specific duration, as smalf
pox, measles, typhus, &c. If we calculate from
the time when the exciting cause made its im-
pression, many diseases, whose length often
appears de^oite, will present a much less uniform
character. Thus, in plague and other pestilen-
tial maladies, the efiluvium from the sick has
sensibly affected the healthy, and terminated ex-
istence in a few hours from its impression, whilst
other persons have not been seized by the fully
formedf malady until many days after exposure
to its cause. Marsh miasmata have, in some
instances, not produced ague until several weeks
af^r their impression was made on the frame ; and
the rabid virus has sometimes not occasioned its
dreadful effects until many months after its inocu-
lation. If we comprise the time that elapses from
the first, manifestation of functional disorder, to
its termination from fatal organic lesion, the dur-
ation of numerous diseases will not infrequently
form no mean portion of the usually allotted period
of exiilence. Some maladies of a slight and febrile
kind, depending upon disturbance of the stomach
or bowels, occasionally subside in a few hours,*or
in a day or two, and uom this circumstance have
been called ephemeral,

159. A, The term* acute and chronic are very
arbitrarily employed to designate the duration of
morbid actions ; and, owing to the circumstances
of their being often used as general but loose
characteristics of disease, they have been mis-
taken by the inexperienced as indicating the
existence of two forms, between which there is
none intermediate. To this misconception me-
dical writings have contributed, chiefly by de-

scribing merely these two eonditieEs as nfW
and ttnvaryin| forms, instead of cftnuiilffiag ikm
as arbitrary signs employed to indicate the oon
extreme states, in respect of duration, betvcca
which there may exist every intermediale dt^ree.
Many employ these tenns, to expnss not mh
the duration of morbid action, Imt also ill p»»
or intensity. Of this little need be coaphiwd,
if the meaning attached tQ the woids be pf«>
viottsly aoigned. Nnmeroas writers, uofnmi
with the vague manner in which these appeUi>
tions have btea nsed, have endenvoEred to fm
them a greater degree of preeisioB by adjouiai^
qualifying epithets to them. — (a) Daasei ksH
been generally viewed as aeuia, when thsj vt
not prolonged beyond forty days; soBte wiittn
subdividing those thus charaeicrised, into tk
" matt acute,'* when they tcnniaEte in three «
four days, — into the " very acute," when they io
not continue longer than seven daya,— into ike
"eimply acute," when they endvre fisr feaitsr:
days, — and into the "euh^aemu," when ttef
reach forty days. — (6) Maladies which are p«-
lon^ b^ond the last term have bEea assalh
deswnated ehremc ; but ther hardly admit of a
similar subdivision to the aoove, tbeir dan&ia
being indefinitely prolonged, llie sabdiTm
of them into functional and ermauie, if the dii>
tinctioB could be made during life, ««oU be *i
practical importance ; but, althoEgh it Bi|kt be
made in diseases of some orgaBSa it cannot »
readily in respect of others: besidca, most chresie
ailments are nrst functional, and so grEdaallj »n
imperceptibly run into organic dmnge, tbat u
line of demarcation can m drawn bdiveea tfte
two states.

160. VII. Or THE Tbeminatioms or Diskasi.—
Morbid actions end ultimately in two ways: \P.
In health ; 2d, Death. But before tamiastat;
in either, they may assume other forvw, or sli»>
gether distinct characters; giving rme to «ba!
may be called the succession, tSe tnnsitioa «
conversion, and the metastasis of diaesae.— t.
The return to health consists in the icsloratiaa u
all the functions. It takes place in ways pen*
liar to the nature of the malady, and ooo»*

ritly in vei^ divenified modes.— (e) In leeti
aes, and in those simple pathological stue
consistii^ of debility, excitement, exhansiioo, ^c.
the terminations in health are the most Snd.
Nervous affections and hsemorrhagca cosaBoah
end by the mere cessation of the phenoacaa d
which they ooosist; and a similar occoncBct
obtains in respect of simple eongestioas sad
various functional oomplaiotsi as jauBdicc, di»>
orders of the stomach and bowels, Ace. la thr
restoration, however, of inflammations to t^
healthy state, the changes are more Eaaen».
th*e various phenomena of which this IsMsa a
composed either disappearing in aoccesasa ts4
gradually, that is, in reeolmtion ; or giving m i*
other alterations of a more or leso seiioEs or i*-
organising kind ; and these to new secrecioBi saJ
states of nutrition, as purulent collections, ole<T-
ation, sphacelation, and ultimately to the pro-
ductions of coagulable lymph, gmnuktiov, vd
cicatrisation*— (6) Jn febriU and <wistiiii(i«-
maladies, the return to health is genefally \U
result of a series of ch^qges in the scoso»j>
however rapidly it may take place ; and ii om*
ally chtrtctensed, fiil, by tho fnbsidcDce or

DISEASE— X18 RsLAnovs, SvccsanoM, Avn Compucatxoiis.

6d7

exhaustion of the morbid state constitatiDg the
chief pathological condition, and, tecond, by the
ratoration of the aecietiog and excreting func-
boos, the interruption of which constituted one
of the chief featnras of disease. (See Caxsis.) —
(c) In organic tttiant, the restoration of the
health is less frequentlj efieeted, either by natrne
or by art, than in the preceding classes of disease,
and is usnallT the result of modifications of the
secretions and nutrition of the part different from
those in which the organic alterations originated,
CoQsequently the return to the natural structure
is geoerally slowly, and often only partially, ac-
complished^-*is always aided by a due mani-
festation of the vital ener|;ies and performance of
the lecretmg and excreting functions,-^ and is
frequently fivoured by irritation of, and deriva-
tioo to, some remote tissue or viscus, occurring
spootaneooslv, or excited by art.

161. In all diseases, the restoration to health is as
much owing to thoTital energy, as to subsidence of
the particular morbid actions wliich constitute them .
Thus, acute or sub-acute inflammations occasion
various chanses of structure ; yet the mere disap-
pearance of Uie inflammation does not constitute
the return to health. The organic lesions still
coQtiDoe ; but these are ultimately removed in the
cotme of that constant nrocess of'^attraction from,
ud dissolution into, tJie blood, of the special
noleeoks of the tissues. Secretion and nutrition
bsTebeen shown to be not the mere deposition of
organic particles, but a constant circulation of
these particles from the blood into various fluid
and solid forms, and back again into the blood,
after hatmg retained these forms for a longer or
shorter period ; and, as the organic molecules are
identified with the various structures, in virtue of
the rital influence and attraction which actuate
these structures, it follows that the more this in-
Boenoe is exerted, the more will nutrition be per-
fected, and any aberration from the healthy form
avoided and restored. Consequently, in the course
of ihis process, the natural type of formation will be
preserved, and any morbid production be removed.
—(a) Various phenomena (^critical changet) of a
very marked eharacter indicate the termination of
acQte diseases in health ; and have received, from
their importance, the attention of physicians.
{Me Crisis.) — (6) As the functions become
re-established, and the pathognomonic symptoms
tubside, and at last disappear, so the dechne of dis-
ease passes into eonvauseence, in which, at first,
inore or leas of the phenomena constituting the
<lKorder, and of debility, not merely of the organ
chiefij affected, but also of the rest of the frame,
still remain y the functional or the organic lesion
RTadaally disappearing as the manifestations of
life throughodt the system become more and more
developed, or attain their healthy state and balance.
(See Desiutv, $ 43.)

16*2. JB. The termination in death takes place in
Virions ways, both in aeiits and chronic diseases.
It may occur in the former more or less suddenly
*^<i) from rapid sinking of the vital powers, as in
adynamic fevers ; (6) or from fatal haemorrhage be-
K>re exhaustion has reached its utmost, as in some
diveases of the lungs and digestive canal ; (c) or
from pressure on, or interrupted circulation
through, the brain, accompanied with convulsions,
or coma, or with both, as in various diseases of
^ organ; (d) or from profounii or prolonged

syncope and sudden cessation of the heart's ac-
tion, as upon quickly assuming or retaining the
erect posture in states of exhaustion ; (^e) or lastly,
from atphyxy, as pointed out in that article. Death
may also occur much more slowly in acute mala-
dies, owing to the gradual sinking and abolition of
the vital manifestations ; giving rise to the collapsed
countenance, the frequent, weak, and unequal
pulse and respiration ; the Ion of animal heat, and
cold clammy perspirations, the resolution of the
sphincters, and insensibility, the cadaverous smell,
occ. observed some hours previously to, and usher-
ing in, dissolution. In some chronic maladies,
death often occurs suddenly, as in organic diseases
of the heart, large blood-vessels and lungs, owing
to effusion into the pericardium, interruption of
the heart's contractions, to rupture of its cavities
or valves, to bursting of aneurisms or profuse
hsemorrhages, to suffocation from effusion into the
bronchi, or into the pleural cavities, &c. More
frequently, however, death takes place slowly in
this class of maladies ; and is chiefly owing^ to the
exhaustion of the vital energies, or to the disorgan-
isation of some important part, and the interruption
of a vital function, disordering and ultimately
obstructing others ; as when fluid is slowly effused
in any of the large cavities.

163. VIII. Or THE Relations, Successions,
AND Con PLICATIONS OP DisBAsx. — A. The rela-
tions of disease are not easily explained in many
instances ; in others, however, they are more ob-
vious. It cannot be shown wherefore a state of
erethism, or inflammatory irritation of the diges-
tive mucous surface, should frequently co-exist
with acute or chronic eruptions on the skin
otherwise than by supposing tnat the state of the
circulating fluid is such as to excite or irritate
the vascular reticulations of both the skin and
villous membrane ; and, although this fluid may
be in excessive quantity in the majority of such
cases, yet quantity merely will not account for the
phenomena, without calling into aid an alteration
of quality ; wliich, while it excites the digestive
mucous surface, also inflames the cutaneous ves-
sels, during the depurating process they exert
upon the blood. But the state of this fluid will
not explain all the relations of complicated mor-
bid actions. The reciprocative influence of the
organic nervous and cerebro-spinal systems, and
of the former and the vascular systems, must be
considered as the earliest and chief sources of
morbid associations. When the dependence of
vascular action, and of the secreting and excreting
functions on the organic nerves, — of the conditions
of the circulating fluid on the states of these
functions, — and of the cerebro-spinal manifest-
ations on both the organic nervous and vascular
systems — on the strictly organic actions, — is duly
considered, the relation and succession of several
morbid conditions will appear as necessary re-
sults of this union. When we perceive the pro-
cesses of digestion, secretion, and defecation imper-
fectly performed — processes essentially dependent
upon the organic nervous influence— should
we be surprised to observe further disorders super-
vene ; and are we not rather to expect morbid
phenomena to present themselves, referrible
to the vascular system, to the circuUting fluid,
to the nutritive functions, and to the purely
animal manifestations 1 When important elimi-
nating processes are either impeded or increased

Qq 3

DISEASE— MsTiSTisiB or.

590

iDfreqne&tly ooomtSM conseeutive changes in
tbc orfflaa which eltborate or retain them. Ob-
itructiona to the dae evacuationB of the urine,
from obaiacles exiiting either in the urethra or
about the neck of the Madder, or in the ureters,
raperioduce alteiations of the kidneys, or of the
bladder itself; and disease of the biliary ducts
commonly aasoetates with it lesions of both the
gsll-Uadder and liver, and of the digestive canal ;
fomishing examples of 9uptrindtio$d eampUea'
tuna (j 166, 3d.).

169. ^d) Changes in the quantity and quality
of the circulating fluid, especially when carried
ftt from the healthy state, although usually the
consequences of disorder of one or more of the
secfeting and assimilating viscera, yet become
tbe causes of co-existent disease of several organs
sod structures, modifying their interstitial secre-
tions, their nutrition, and their vital cohesion and
manifestations; the whole organisation generally
intsenting more or less of change. These com-
plicated effects may assume varied forms, and
implicate particular organs in a more remarkable
mtnoer than the otlm, according as either ple-
thom or ansmia may be associated with the accu-
mslation of excrementitions matters in the blood,
or u the quantity and nature of these matters
may vary — thereby causing diversified humoral
eomplieatwm (< 165, 4th.).

170. (c) — a. When we advert to the circumstance
of diaesse, essentially the same having different
symptoms, and producing varied effects, merely
in consequence of a slight difference in its seat,
ODc reason for the freauency of what should be
called rsther the extension or succession of disease,
than its complication, will be apparent. Thus,
when inflammation of the fauces extends down the
trachea and bronchi, there may be ttther a suc-
ceision of disease, if the inflammation diiiappears
from the former seat as it extends to the latter ;
or a complication, if it exist at the same time in
tU ; and yet the nature of the morbid action is
csKotially the same, as long as tbe vital energies
remain unaltered. When inflammation extends
along tbe digestive mucous surface, or to distinct
parts of it only, a similar succession or compli-
cation, but without difference of the nature of the
^hsesie, also obtains. These are instances of the
tucctttion or complication of emtinuity, — 0, But
^i»«ue may extend from one tissue to another,
mstead of being thus limited to the same, as in
the above instances ; — it may originate in a mem-
hrsoous surfsce, and involve the substance or
psrencbyma of an organ, and ultimately even its
<>PPosite and diflerently organised surface, and
eiiber disappear from tbe former upon aflfectiog
^ latter, or implicate them all simultaneously,
"^^^7 giving nse to a succession or compli-
^Uoo of morbid actions, without altering their
characters, although materially changing their
symptoms. Thus, bronchitis may pass into pneu-
moma, and this latter into jileuritis, or they may
all co-exist ; and inflammation of a part of the
oigestite mucous surface may be extended to the
cellular tissue connecting the coats of the aliment-
?*y tube, and thence to the peritoneum ; and so on
"J respect of other organs, which, equally with
these, not mfrequently furnish examples of the sue-
«w«<w mcompUcatum of contiguity ($ 165, 5th).

171. (f) Irritation and other disorders of an
orgSB or part not infrequently associate with them

a morbid condition pf remote as well as ad|oining
parts. Worms in tlie intestinal canal often mduce
either febrile or convulsive affisctions. Congestion,
inflammatory irritation, erethism, or merely func-
tional excitement of the female organs, msy occa-
sion M>ilepsy, irregular or anomalous forms of
convulsions, hysteria, altered sensibility of the
nerves— referred by some writers to irritation of
the spinal chord — vitiated appetite, and disordered
manifestations of mind. Injury of a tendon or
nerve may produce tetanus; and the accumu-
lation of fsBcal matters in the large bowels may
excite, and be complicated with, various disorders
of the stomach, inflammation and ulceration of
the fauces and pharynx, febrile disturbance,
heemorrhoids, numerous nervous ailments, and
disorders of the uterus. These may be termed the
tympalhetie auociatiom or complications of diseatt,

^7^* (s) T^^^ injudicious treatment often com-
plicates disease, may not be so readily admitted as
the circumstances now adverted to. But I can
state, as the result of observation, that lowering
measures carried too far will occasionally favour
the extension of disordered acdon and structural
change, either by continuity or contiguity ($ 170.),
or by promoting the function of absorption, and the
passage of morbid matters into the blood ($ 169.) ;
and that stimulating remedies used too freely will,
either by their operation on secreting organs and
surfaces, or by irritating the parts to which they
are applied, sometfmes supennduce inflammatory
action in addition to the disease which they were
intended to remove. Thus, arsenic exhibited too
freely, in order to cure agues, has produced in-
flammation of the internal surface of the heart and
arteries ; and bark of quinine, given freely before
morbid secretions and fscal matters have been
carried oflT by purgatives, has superinduced hepa-
titis or dysentery, or both, upon the intermittent
disease for which it was prescribed. Stimulants
and tonics taken in some forms of dyspepsia, aa
complicated functional or structural disease of the
stomach, liver, and bowels ; and astringents im-
prudently employed, have excited inflammation in
the organ whence the discharge, for which they
were exhibited, proceeded, as well as disease in
some related organ.

172. IX. Op the Metastasis of Diseasx. —
Mctastasii (fxtricrraa-if, a change, migration, from
/ufdicTD/bif, I change, or transfer) of disease has
been often improperly confounded with the terms
Metoptosis, EpieenetiSf DiadoxiSf and Mctaschema'
tismus, which have had different meanings at-
tached to them. Metaptosii hss ususlly been
used to mean a change in the nature or state of a
disease, without a change in its seat ; — Epigenesis
the superinduction of another, upon an antecedent,
disease ; the anterior affection not being amelio-
rated by the occurrence ; — Diadoxii, the succession
of a less, to a more, important malady ; — Metat*
cAemotismui, the transformation of disease simply ;
— and Metastoiis, the displacement or disappear-
ance of disease from one part of the frame, and its
seizure of another of more vital importance. It
will be perceived, that the phenomena, which these
terms have been employea to express, have been
already noticed, excepting those which fall under
the last. When rheumatism or gout disappears
from a joint and attacks the head, heart, or sto-
mach ; or when erysipelas, or any febrile or
chronic eruption, forsakes the surface and is fol-

Qq 4

DISEASE— ^CiAcnsigTAKCES xoDtmno trs Form, itc. or.

601

ke,, tii« nnmiaon of tlie eraplion not infre*
qaenily proanceioiie or more of the mbore efieots,
•Del coostittttos the chief diaeaaed tppeannces in
fatal cases.

175. C. There is another form of metastasis, that
coonis chiefly of morbid secretion ; and although
rascoltr action is concerned in producing the
matter found in the secondary seat of disease,
Mill the transfer from the orisioal seat evidently
tikes place through the channel of the circulation.
We oot infrequently obsenre pnmlent or ichoroiis
matter, which has been formed in one part, re-
moved from thenccb and infiltrated, or secreted
aiMl acenmnlated, in another part ; occasioning
couecative absoeaoes (see Abscbss), or some
other structuml change, in a parenchymatons
organ, (V poriform effusion into natural cavities,
la these cases, the passage into, and presence
of morbid matter in, the blood, excite increased
ysscolar action in some part by means of which
it is either evacuated from the system, if the
morbidly excited part be an emunctory ; or infil-
uated umI collected, if it be a parenchymatous
orgaa ; or effused and retained, if it be a serous
orsynorial cavity. Thus, collections of puriform
maiten have been found in the liver, in the
joints, in the lungs, in the brains, &c. after small-
pox, erysipelas, fevers, inflammations of veins, or
of remote or eztemal parts, and after fractures ;
and ofiten without any antecedent disease of the
viscera thus consecutively disorganised, or disorder
referrible to them, proportionate to the extent of
(hsofginisation observea on dissection of fatal cases.

176. D, From the foregoing I conclude, l8t.That
metastases may be divided into — (o) those msui-
lestiDg fully expresMd disordered action, in which
the KosibilitT is more or less excited ; and (fr) those
miMng 01 latent disorganisation, and produced
chiefly through the m«lium of the circulating
fluid: or into — (a) those which aflSect the sub-
>taooe of an organ ; and (0) those which take
place to an excreting suHaee or viscus — as the
*l(in, the intestinal muoons surface, the kidneys,
Md dke salivary glands — and which frequently
terminate favourably by evacuation from the cir-
eulstioo of noxious matters that were the chief
caa«« of the metastasis. — 2d, That they are
brought about— (o) by means of the organic
aervous system, as in gout and rheumatism; —
(i) by the influence of this system of nerves upon
the blood-vessels and capillaries, determining to
various surfaces or structures a preponderating
degree of morbid action and its results, accordiag
to the opermtion of numerous intrinsie and ex-
triDsic causes, as in exantheraatous metastases ; —
{c) by the absorption of hurtful matters into the
eircohting cnrrent, where they excite, internally
>* respects the capillaries, the increased or morbid
•<-tioQ of some secreting surface or emunctory, or
occasion the disorganisation of some predisposed
pareoehymatoos organ.

177. X. ThB ClRCVMSTAllCXS MODirriNG THE

FosM, Com PLICATIONS, Duration, and Termi-
KAnoxs or Piseasb, are as numerous as the
causes, — predisposing, exciting, and determining,
*^ia which it originates. The constitution and
diathens of the patient; a cachectic or vitiated
habit of body ; the continued operation, during
the couRK of the disease, of the causes which in-
duced it ; the depressing passions ; impure or
■tagnant air ; all sudden imntal and physieal per-

tuibations; extremes of temperature; injudicious
treatment and regimen; the use of medicines
which either suddenly or intensely excite, or de-
press, the vital or nervous energies, and weaken
the restorative powers; neglect of evacuations,
and of the state of the secretions and excretions ;
the mffiM diUgentia of the practitioner, or im-
proper interference with the salutary processes of
nature, and with critical evacuations and changes ;
the too early recurrence to a full or stimulating
diet, or exposure during convalescence to any of
the causes specified above ; will not only modify
the states and duration of disease, but also occa-
sion the tueetuion of one disease into another,
render morbid action more or less cmnpUtkted,
transfer it from one structure or organ to another,
and occasion relajpmt of greater or less severity.
(See Physic — Practical Principlei of; and
Sy at ptomatolog Y .}

BiBUOo. AMD RxriB — i. JEtioiooy.^O.S. SUM,
De pMiionilnis Anlmi, kc HaUe, 16SI9. ; eC Pc H«-
redlUria Dlipositlone ad Tar. Afltect. Hals, 1706. —
F. Hifghuam, De Afltwc. Hcredltarlla soranqae Orl-
siiM.^ Hal. ie99. : et Op. Sup. ii. 1. — JL Mead, De
Imperio Soils et Lunc id Corp. Hum. et Morb. tode
oriuDd. Amft 1710. — X. J. Cawterariue^ De H«re-
dltace Morb. Tub. 1718. — J.iL LameM^ De NoxUs
Faludum RffluTiia eorumque RemedJls. Romv, 1717. —
C. G. RMUrr, De PoCesUte Solit in Corpi Hum. Gdt
1747. ; Opusc. voL 1. 1 et de Jcjunlonim et nimi« Sobriet.
Moxis, tn Opttsc vol. ill — Lauit^ Com. le flUt. la Trans-
miBfion de Hal. H«reditalrea. ParU, 1749. — C. G. Stemm
zei, De Somoo ejuaaoe Uin ct AIkuu. Ltpa. I7S5. —
A, £. Bmeekmer, De Blorb. «i rar. Temperamentor. Cod-
ditione oriandU. Hali 1750. ; et De InooDgrul Ourp.
Hotus Inaalubrltate. HaL 1757.— J. Z. Plamer. Do
Peitif. Aquar. Pntretcentiom ExhalatloQibu*. Llpg.
1747. — C*. QMigmm, Tbe SCmct. of the Hum. Body In
relation to Morals, Sd cd. Camb. 1765. — BUttner, De
QualiUt. Corp. Hum. HsrediUrila. Goet. 1755.— AoM^,
De Mortk Farentum in Fcetum tranaeontibus. Erf. 1768.

— O. P, Sigwari^ De Vi Imaglnat. in Prodoc. ct Remov.
Morbit. Tub. 1769. — VamLinaen, De Immod. Mentla
Exerdtatlone. Lugd. Bat 1774 —.H. D. GomMm, De
Regfmlne Mentli quod Medioorum cat Ui. Ed. Argent.
1776. — if. G. Plaxj De Salubrlute et Insalob. Hj&ita-
tionum. Lips. 1781.— W. CuUen, De ASre ejuique Im-
perio in Corp. Hum. Ujm. 1787. — C. P. Ekmbeem, De
Aere Comipto eioaqoe Remedila. GUt. 1789. — C*. «f.

Kd^, De Fomui Vettlment. MorMfera. Vitenib.1789

S.G. Boef, De Noxlt ex nimia Mentis Conteotione. Lipt.
1786.— C G. Base, De Phantasia LntaGrar. Morb. Matre.

Up«. 1786 fVfekmimm, De Morb. HKredltariia. Ert

1788. — C. P, LmthHg, De Terrorii in Corp. Hum. Vi.
Lfpa. 179a — Df Marfe, In Ladwigii Script. NeuroL
vol. iv. p. 379. — GtuneTt De Morb. Typographonim ex
Vitc Genere orlundta. Jen. 1799. — Pieker, De Tem-
perament Horn. 4c. 8to. Goet. 1791 — JontetUt De
Consoet. EflScacia in Horn. Sano et Morb. Hard. 1798.

— MMUer, De Dispositione ad Morb. Hereditaria. Goet.

1794 P, BaUpmr^ On Sol-lunar InOuence, 4rc. 8vo.

Lond. 1795.— J. C. Ebermaier, De Ludi In Corp. Hum.
VlT. prvter Vifum Efflcada. Gfit. 1797. — £. ^orw.
Idem TltuL Got. 1797. — fV. Vamg^am, An Enav, Phi-
lot. and Med., on Modem ClothlnjL Lond. 1793. — C. 6.
Grunett De Coitu, ftc quatenoa Mediconim eat. Jenc,
179>. — J. P. Franks De Pomil. Miieria Mor. Genetrice,
In Roemeri Delect. Opusc. Ital. vol.1. art.8.-..0. Jtlanr,
On tbe Dit. ioddent to Seamen, ftc. Lond. M ed. 1799,
8vo. — Zettermann, De Morb. Hcredltarlli. Jen. 1799.

— F. B. Rtnmet, De I'inf. des Marais et des Etangs tur
U Sant6 de I'Homme. Paris, \9M.^W. P. Baw^ VI
Caloris Frigorisque in Corp. Hum. Gdt. 1803.— JCF*.
Becker, De Efltect Caloris et Frig. est. in Corp. Hum.
Gfit. 1804. — CUtriau, Consider MM. sur les VMemens
des Uomroes, *c. Paria, 1806. — H. W, Dirkten, Die
Lehre Ton den Temperamenten, Ac. MOmb. I804.'J. G.
CabamiSt Rap. du Fhrsique et du Morale de THomme,

t. liL Par /. H. Gekfer/De Adsuetvdine. Lips. 1807

H. Dvtrochet, De I'Habitude ft des Svmpathies. Paris,
1820. — FV-. Heimhm^ Ideen (il>er Idiosyncrasle, Anti.
pathle, ftc. Stend. 1819. —J. A. Shitzer, Ideen fiber das
VerhaltniM der Scelesum Ldbe. Lands. 1607.— F. ffttAr.
iamd. Ubcr Sympatbie. Welm. 181 1. — F. ^. Becker, De
Irse VI in Horn. Sanum et JEgnim. G5t. 1811 — H. Bo"
terISM, Of the Nat. Hist, of the Atmosphere, and on the
Causes of Epidem. 9 vols. ed. 1808.- Forte^ Mtaiolres
sor plus. Msl. t. lU. j>. 181. lOn keredHani prediepoeiMm
to du,)-.Caittard, Bur les Dangers des finsnatlou Bfa*

DROPSY — Patholooy of.

603

FimSiif. PkT. mh-^Battkemt DIm. Qaorandwam
PturoooMiiorum Psflod. Caiua probaUlM. Goet 1792.
~ KMetorida, De Mortis FttrkxIU, *c. Brlang. 1809.

T. SoccnnoNs, ConpucATioivf, aho MsTArrAtis or
Disun. — AmMt/, De Felm Motrke et Morbofa, kc,

0pp. p. 367 Stakl, De MorbU Conaequeatibuft. Hate,

1710. ; et De MetaschematUmit Morborum. Hal. 1707. ;
ft De Merb. CompHcatloiML Hal», 171&.— F. Hqfimmm^
D« Mbrb. TraanniitBtione. HaUe, 1716; Opp. Sa|»p.tt. 1.
» fakr, De Morb. Complicatii et latricatU. Witeb.
iry— ZoMwMr; De Mort>. Complicatii. Wlen. 1719 —
Btekenbmdk, De Merboram In MorbU Pluralitate. Hoit.

1741 HebtmtreHt De BCetaMhaiMtltino Morb. Ups.

1747. -'Sqmer, De Motatiooibiu Morb. Goet. 1747. —
Boekmer, X>e Morb. CrUl MetasUtka. Hal*. 1763 —
SekrcHer, De Febrilibua Metartailbus. Goet. 1764. -.
5aU;4«(l. De MetaMad In BforbU. Jenc, 1771 — Leidm^
frost, De Morb. Complicatii rite d^udlcandli. Dulib.
1719. ; ft in Opaic. toL It. n.!9. — RoetAoet, De Suc-
oiMione Moib. HalVi. mS-^'amiftriM*. De Criil et
Metaiud. Stut^ 1781. ~ Lorry* De Fradpuomra
Nort>. Mutatlonlbcii, et ConvenloDibui. Parli. 1784. ~
SoiM/, De Morb. Metaichematlnnfi. Marb. 1794.—
Wc^art, De OeBli Morb. Mntatlone Homlnum Vita
Bartool tribucoda. Marb. 1797. — St. Coiambe, Bnai lur
let Matastatei. Montp. 1800. — Hkomanm, Annalen ad
ino.— J. D. Btimdity verfueh Ober die Metaetaien, 8Ta

HiBDOf . 1798 Hartagf De Modli et Caniii quibui Hunt

in CorpL Hum. MetaitaMi. Ultr^- 180S. — Kitser, In
BuMamd'i Joan, der Prak. Hellk. Jan. 1%1% ^Ftrriar,
Uedkal HJHortee, vol. tt. n.i. ^Erdmamu, De Meta-
lUiibai. Viteb. 18ia ^ tUgdOkt, art. Melaatatt, in Diet,
des Sden. M6dical«i, t xxxlii. p. 17. -^ScouieUen. in
Jooro. UnlTera. des Sclen. MM. t. xxx. p. 139. — Ckar-
Mrtf. in Jooni. UnWen. ftc t. xxlU. p. 809., et t xxt.
P.7&.

DROPSY. — SvN. "T^pe^^, Th. (Zh,f, water,

aiid»4, aspect, appetrtnce.) Hifdropa, Lat.

HjfdropUie, Fr. Die WasMgrsuehtt Di§ Hy^

dropii§f Germ. IdropisiOf Ital.

CLiflBir. — 3. Ctau, Cachectie Diseases; 2.

Order, lotnmescences (Cullen), 6. ClaUf

Diseases of the Excremental Function ; 2.

Order, AfTecting Internal Surfaces (Good).

TV. Class; I., IL, and III. Orders

(iitftAor).

1 . NosoL. Dbfin. The aceumuiation rf watery
Huid in the natural eawties, or in the celluiar areoUe,
vr in bath, eaut'mg distension, impeded functions
of the affected and adjoining parts,frequently with
ti^tctua^on, sofinete, ^c.

Pathol. Difin. A eoUeetion of flwd arising
titherfrom inereasad exhalation or from dimini^i^
^burpiioH, eaeh of which conditions depend upon
anUcedent ttates ofdisea$e.

2, After having taken a general view of the
nature and treatment of dropsical eflTusion — of
Dropsy in its generic acceptation, — I shall pro-
c^ to consider ita specific forms. By thus view-
ing, in s connected manner, the various species of
dropiy, which have been improperly separated the
OM from the other, mach unnecessary repetition
^i be avoided, and several advantages obtained.

3.I.pAmoLooy of Dropsy.— i. Brirf Historic
cnl View of Opinions. — Different views of dropsical
diseases may be found in several parts of the
vritings ascribed to Hippocrates. There can
be no doubt, however, of the connection between
ibem and a state of active vascular disorder, as
w«ll as of obstructions of the liver and spleen,
baviog been known to him. Erasistratvs is
*>i<i lo have referred these maladies chiefly to
eogorgements of the liver ; and Asclepiades to
Have viewed them as beinff either acute or chronic.
AaET.Evs gave merely a lively description of the
history of dropsies : but Galeu, in the uncon-
iiccted observations on these maladies scattered
through his writings, stated some just views of
their nature. He pointed out the seat of the
ascitic effttsbn ; contended, in opposition to

ERAstnuATUB, that dropsies often depend upon
other causes, and upon disease of other viscera,
beside hepatic obstruction ; and that they fre-
quently proceed from a morbid state of the blood.'
C^Euus AuRELiANcs assigued, as their causes,
lesions not only of the liver, but of the spleen, of
the womb, ana of the large and small intestines,
AxTius made some reference to a cachectic habit
of body in relation to them ; and Albzandbr of
Tralles noticed, but in a superficial manner, their
connection with diseases of the lungs, and with
antecedent fevers and inflammations.

4. Amongst the Arabian writers, little respecting
dropsy beyond what is contained in the works of
their predecessors is to be found . A vicenn a , how-
ever, attributed it to the liver and to the kidneys ;
and stated that the latter, owing to the coldness or
warmth of their temperature, or to obstruction or
induration of their structure, fail to attract or sepa-
rate the watery fl uids. Mesue gave a similar view
to the foregoing, and both agreed in stating that
the liver does not concoct pure, but a watery and
phlegmatic, blood. When we reflect that the
lights of modern science have shown that the liver
is both indirectly end directly concerned in sangui-
faction, that the crasis and vital constitution of
the blood is really aflfected in many states of
dropsy, and that the kidneys are often very de-
monstratively diseased, and in a Wky that may be
expressed in general terms nearly similar to those
used by Avicenna, we must conclude, that some
of the pathological opinions of the ancients are
not so despicable as many of the modems sup-
pose; and that, even in recent, as well as m
bygone, times, there have been more absurd
theories than sound views of morbid actions, and
a greater disposition to generalise from a few im-
perfectly ascertained states of disease, than to
take into account numerous concurrent circum-
stances and morbid associations.

5. Since the ftvival of learning, but little was
added to the knowledge of dropsies, until the
writings of Willis appeared. This very eminent
physician first called in the state of the vessels to
the explanation of these diseases ; and argued that,
whilst the vascular extremities are either too re-
lazed or too constricted, causing thereby an
increased effusion and dimimshed absorption
respectively, the blood itself is oAen altered,
and its circulation impeded by scirrhous tumours,
tubercles, and obstructions in any of the abdomi-
nal viscera. Ettmullbr and Lister adopted
the views of Willis. The experiments of tyin?
the veins, first performed by Lower, confirmed
the opinion promulgated, but not carried its due
length hy Willis, Uiat interruption of the venous
circulation is a chief cause of dropsical effusions.
F. Hoffmann repeated the exoeriments of Lower,
and, as well as Boerhaave ana Van Swieten, ad-
mitted the importance of venous obstruction in the
pathology of dropsies. Morgagni says, " Qua-
cunque causa diutius potest sanguinis aut lymphae
cunum morari, aut oumoris quo cavsB corporis
madent, aut secretionem augere, aut exitum
deinde imminuere morbo buic potest originem
praebere." Lunwio first directed attention to an
atonic state of the vessels as a principal source of
those maladies, and his contemporaiy Milman
assigned as their chief causes a laxity of the fibres,
exhausted power arising from copious evacuations,
and acute diseases passed into the chronic atate.

606

DAOPSV— Apfsaiuncm on DiMscnoiv.

tiiDes owing to eoQComitaot Janndioe, or diieaiO
of the liver occawoning tbo accomalatioo of the
colouring comtitaeots of bile in the fluids; mud
the green, brown, or black colour probobly aniet
from the presence of a portion or the colouring
matter of the blood. The offensive odour, as
well, perhaps, as some of the above alterations,
may be the consequence of the admisBion of air
into the cavirv after tapping, and of the super-
vention of inflammatory action upon this opera*
tioo, or of the long retention in a high tempera^
tore of a fluid containing a large proportion of
animal matter, or of both circumstances con-
joined. The liquid effused into the ovaria is
geoerallj possessed of very different characteis
from those presented by the fluid found in the
pleure or peritoneuin ; and that of chronic hy-
drocephalus and spina bifida is commonly differ-
ent from all othen,—- the liquid found in the ova-
nam, and in the brain, presenting, respectively,
the opposite extremes of fluidity, or rather of
animal matter. As the properties of the fluids are
different not only in the several seats of the effu-
sion, but also according to the sutes of vital action
aeoompanying it, but little importance can be at-
tached to the results of chemical analysis, unless
they be derived from an extensive and diver-
sifled series of cases. These obtained by Vr,
Harcxt, ate not materially different from those
fumiriied by Bostock, Baxbokl, and BxazxLivs,
who found that all the specimens of fluid contain
nearly the sane saline ingredients as the serum of
the blood ; and that the chief difference consistB
in the quantity of animal matter, chiefly albumen
and incoagulable mucus (the osmasome of Bxa-
SBLxus and BAanoxL) they furnish. The follow-
ing table is given by Dr, Marcet : —

Zb 1000 gnb» of flvid.

Fluid or fhrfns bUlda
' Hfdroosphslas •

A«citat -
'■— OTarian dropty -
Hfdrathoraz

•■■B Hydrops Mrlcsntit
-«»- Hydrooefe -
Blister -

I

fleram of Blood

flpwUc

10070
1O06-7
1016-0
1020-2
1012*1
10143
1024-3
I024-]
1029-6

TvMt
iolid

craliu*
lf4

9*2
335

96^6
88*0
80-0

10^

Anfaaal

2-2
1'I2
2ft*l

181B
28-*
71-5

90-8

9-2

8.08

8-4

80

7*8

7-6

8-5

81

9-2

13. B. The kncmt cf lAs vitetra which are con-
nected with the production of dropries, comprise
almost every variety of which these viscera are sus-
ceptible. The heorti its valves and membranes ;
the blood-vessels, paiticniarly, the veins and
lymphatics ; have presented, in different cases and
states of the disease, nearly every alteration describ-
ed in the articles on the morbid anatomy of those
parts. To these I must rofer ; but here may add,
that the absorbent vessels have been found varicose
and otherwise diseased, and the glands in the
vicinity of the blood-vessels indurated and en-
laigeil, by MoaoAoni, Moaroir, Sobmubbiko,
Haasx, Assaumi, Bjcbat, Mascaomi, and Hodg-
soft. The frequency of inflammatory appear*
anoea in the inner membrane of the arteries, and
the presence of ossific depositi io them and in the
aorta, have been remark<^ by Hoftmakn, Franx,
Badxr, and myself. The respiratory organs, the
}M9f, gall-bladder and spleen, present in different
cases all the appearaaces desenbed in the articles
on these viscera. As respects the liver it may be

observed, that those changes and aaifaid ^io>
ductions which interrupt the circalaliaB thna|^
the ramifications of the vena ports^, as remsitad
by Dr. Briomt ; also thenutmec-lihe stsls of in
substance, obstruction of the braachss of iW
hepatic duct by inspisaated ImIo and cholsMoiae
and calculi in the gall-bladder; are the boa
common lesions.

13. The next importaBt chaoges wm dgUtnai
io the kidneys. Moroaori gives a case inm
PiooouiOMUii, in which one oif them bsbg Iseo*
rated from the preeence of calcsdi, the ensi
flowed into the abdomen. Rxas^ (Sdhm^. Ai-
Aaiid^.b.xiv. p.47.) found them scisThous; %uk
Hoxxlard met with numeroos hydauds caotaised
in cysts formed in their snbstuicc. InitusM.
however, were few, in which disease of the kri-
neys was mentioned by authon in coaaeenos
with dropsy, and, when noticed, it was in a v«y
vague and unsatisfactoiy mtiiner, until Dr.
Brioht furnished numerous proofii of the fn-
quency of lesions of stractnre ia these evgiu,
and described their various forma, and relatiooi ti
dropsical effusions. The^rft form wUdb he p«-
tieularises, seems to consist of wasliBg of ib
struotura, and diminished vascularity and fim-
nees, of the kidneys, which are of n yellow msttlsi
appearance externally; their iaternal atractsn
bemg also yellow, slightly tinned with Bey* ^
the tubular portiotts of a Ivhter eoloBr tkm
natural. They contain no morbid deposit, Tbn
change ii connected with a cachectic habit «<
body and debility; the urine being only sh^kih
coagulable. The second form is that in which tit
whole cortical part is converted into agranBlsted
texture* with a morbid intcntitiRl deporii of sa
opaque white substance ; giving, in its carfare
stages, when the tunic is talwn off, an iuumw
of the natural fine mottled appeatmaee of tU
organ; subsequently with innvncnbla sperii
strewed over its surfocCrand distributed thioefh>
out its whole cortical substance, and with tfe^
ciency of its firmness. At a later period, the
grenulated texture shows itself extamalK, om*
rioning irregular projections of the e«rnee. ik«
organ being genemlly somewhat rnlBised Is
the third form of disease, the kidney is quMs rse^
and scabrous, and its surface ripas in mmmuvm
proiections, not larger than a pin's bead, of •
yellow, red, and purplish eolonr. Its sinpr •
often inclined to the lobulated ; it is aoariy «f s
semi-cartilaginous hardness, and it givas gnat n-
sistance to toe knife. The tnbniar poniuw en
drawn near to the eurraoe^ every part of the of|ss
appearing oontncted, and less iiinmUiai dcpoat
bemg preeent than in the foregoing variety. Dr.
Bright connects thess two vavietieB with
lable urine ; and thinks that, as the i
to paM iosenstbly into the other, they are'
monlv grades, or stages of the same oh ^
Besiosa these, there are other lesions of Ike IjdBsv.
found in dropsies: as preteroaturel soAmsb ; ^
strnction of the tubular structure, by a wMr
deposit resembling small coocrstiens; auMfeh—
matter infiltrated or depositad in the oort«al sa^
stance, and in the intentieee bitswan the tabeb
aod, indeed, most of the lesions dcsorlhed ia (ibs
article Kidnbys. It is very justly rsaanrhsd W
Df, J. Gbbooby, that diieese of iheaa ergsi »
chiefly found in those dropstoel paiisMa wW o«
of a stmrnous diathesis, or who vt

JDROPSY— Patbolooioal States which occasxo)^ it.

6b7

fipiritooiii Hquon. The utcraf and ovaria oftan
present nttmenws lettoni of •tractura, but none
that aie apedally oCMinected with dropsy^ except-
ing thote accamulatioDS of fluid whica sometimea
take place ia the latter drgana* and which can
ficaroeij be conaideied aa a species of this disease.
Varioui morbid appearances are also found in the
omeatum and meaentery, particularly in Ascitis.
(See Dbopsy tf tfts J6doMM.)

14. i?. Or TBa cbixp Pathological Statbs
0CCA5IOIIIKO DaoFsus.-— The lesions, to which
dropaical effusion has been imputed in modern
(ifflei, hate been too genoally those alterations of
ttnictiira either preceding or attending it. But
althoagh these are manifestly, important agents in
its causation, yet they are not tno only agents,
for we very ueqiienuy find thero in their most
folly developiKi tbms without any effusion. Of
tbe Domerous remote and pathological causes
eoumeraled above, there is none, which will
singly produce dropsy. And, perhaps, in no
other disease is a greater concourse of causes re-
quisite to ita appearance, than in this. In recent
tiaicB, the changes of stmcture have been investi^
gated, somewhat to the ncgleei of vital condi-
liooa or mamlcBtatioos; and the former has been
too geaetally looked upon, m respect of the
<li8eisee now under conaidention, as proximate
cauaes, ioalead of being viewed as concomitaiit
ksioM resulting from anterior changes implicating
tbe functions of liCe, in one or more of tbe systems
and organs of the fxtme. The assodatioii, how-
ever, of these lesions should not be overlooked ;
lad the ahare which each may have in augment-
iog or perpetuating the other ought to be kepi in
view, bat with a ^nloaophic reference to anterior
conditiona.

15. Up to the esid of the last century, dropaes
were coBsidered as eaaentiaUy depending upon
obstmctions or debility ; although some among
tile aodenls, particularly HxprocmATis, admitted
tltt propriety of bleeding in some cases. Siou.»

StBAK, fiuASSBLLA, ScBMinTMANK, J. P. f UANK,

tad GKAPXNonsaxa, at the epoch now alluded
to, iocnlcated tbe frequent iiwammatory origin
of these diseases. • Wklls, Blackall, Abbb-
caoMBiB, Stoxxb, and Atrb followed in the aame
tfick; and, excepliog a slight dispoastaon to carry
this doctrine loo far, contributed to the advance-
nent of this branch of medical knowledge. At
PKsent it is generally admitted that dropsy may
inas from sar-action, or snb*aclioD, — fimn gene*
ral or local plethora, as well as from obstructed
circaialion*— from deficient excretion, and from
csseasive evacnatioDa rendering the blood thin or
watery. The Mnacrous changea detected in eon*
B<c^ with aqueous efibskm, and allowed to
iat our both it and tbe accumulation of the fluid,
pisy be resolved into a aingle pronositioo, vii.
iocreaaed exhalation and dtouBishea absorption,
which eompffiaes all the viewa promulgated on the
*«bject, the nwiter chiefly in dispute being as to
whtth of theae changes is the accomulatioa of
Arid chiefly owing. It has been attempted to
■'Ule the Msnt by experiaaent and post mortem re-
search . But a matter purely of function — Moos
■odepeadenl on vital action and structural cobe-
mm u cffasiea moat undoubtedly is in many cases,
*>^*s«sr assotiatcd, or otherwise dependent upon
organic ehange — cannol admil of a satisftictesy
«)«idation in Uni

16. Those who favour the doctrine of increased
exhalation argue, that this change usually follows
excited action, or irritation of serous surfaces, or
relaxation of the exhaling pores, or this latter
stale associated with increased action of the
larger vessels ; that the appeerances of the fluid
and the constitutional symptoms indicate tbe ex-
istence of excited action \ and that absorption is
not diminished, is shown by the increasbg emaci*
ation attending the effusion, and by the fact of
this function friog generally augmented with tbe
progress of debility. The believers in diminished
absorption contend that, when the agents of this
function — either lymphatics or veins — are ob-
structed, an accumulation of serum takes place ia
the parts beyond the obstruction ; that when
plethora, general or local, exists, absorption is
diminisbed, as shown by tbe experiments of Ma*
OBNDix and Poobba ; and that, as vascular fulness
and action are removed, this functiott becomes
restoied to its natural activity. Thai the balance
of function — of exhalation — - and absorption -—is
broken, is very obvious; but the question is, to
which is the fault chiefly attributable 1 It is evi*
dent that exhalation preponderates over absorp-
tioh, ia all cases whm vital action or vascuMi

Elethora is increased; and that, on the other
and, diffliniahed absorption chiefly obtains where
the venous or lymphatic cireulalion is either im*
peded or obstructed. These propositions are
proved by experiment, and eonfirmea by repeated
observation and numerous pathological facts. So
that, instead of contending as to which of these
functions is chiefly disordered, it would have been
more coned to admit that either may be more or
less affected in different cases and forms of the dis*
ease, according to the stales of vital energy somI
the nature of concomitant organic chan|ps. Con*
formably, therefore, vrith these facts, rejectmg all
exclusive doctrines, smd following nature as
closely as I am enisled to interpret her actions,
I believe that dropsy may arise as now stated, as
more nrecisely expressed in the article Disease
($ 94.), and as will be more particularly described
in connection with lesions of vital manifestation
and of structure.

17. In considering the pathological states oc*
casioning dropsy, the cmdiltons tf vxlai fkdien
appear equally important with rtriMliinii ehangt,
the more especially as the efiuaioo, even where
the latter is the most obvious, depends as muck
upon the former as upon it ; alterations of vital
manifestatioB giving rise to both the change of
structure and the e&sion, whether or not the effn-
sion be a concomitant or a cooaecutive result.
This consideretion has so forcibly influenced the
ablest writers, as to induce them to arrange the
forms of this disease with strict reference to it;
Thus they have been divided into the ectds and
dtronie, the tthtmc and aafAcnie, the ttnie and
atonie, the oettM and pauhe, the inflam$natorf
and non'mjlammatory or leucophlegmatie, and into
the idiopnihit and tiymptomatie, or the frimary or
sMoadory — aa ihey praceed directly firom tbesr
external causes, or nom some visoenl disease.
These forms are met with in all the seata of
dropsy, but in diilerent degrees of frequency.
Tbe acute, sthenic, or active state — the effu*
sion consequent upon increased determination
and excited aetioB — occure most frequently in the
ovaria and brain, and nasi in the pkana, peiiear-

DROPSY — Secondary or Consecutive.

6oa

the ezhsliog pores, and of the serous abd cellular
tissues, and to increased tenuity, or alterations of
the blood ezisliog independently of any consider-
able structural change. It is sometimes caused
by excessive sanguineous evacuations, or exhaust-
ing dischai^es ; by the suppression of secretions ;
and by a deficient, watery, vegetable, or un-
wholesome diet. The dropsy that sometimes
prevails among the poor in limes of scarcity is
generally of this kind. It ia usually charactered
by a weak, unequal, small, and frequent pulse ;
palen^s of the lips, tongue, and gums ; flsccidity
of the muscles ; anhelation on slight exertion ;
feeblenc9» of the joints ; swellings of the lower
limbs, or anasarca attending or preceding the
effusion into the cavities of the trunk; an un-
b(»lthy appearance of the cutaneous surface;
and absence of those symptoms which indicate
the existence of visceral obstruction or dis-
organiiatioo. The urine does not coagulate by
heat or acids. This form of dropsy is usually
chronic, and is, in adults, most commonly seated
io the abdomen, or in the cellular ti»sue, or in
both ; sometimes appearing in these situations,
particularly the former, after parturition, when it
may sssume a less asthenic form than that now
described. It occurs most frequently in females,
and is occasionally associated with hysteria. I
have seen it supervene on chlorosis. In infants
it usaally takes place in the head, and proceeds
from constitutional disposition or congenital vice^

23. B, Secondary or Consecutive Dropsies-^
Symptomatic Drajuie*"^ Chronic or Paaiie Drop-
fin— vt of most frequent occurrence. They are
sometimes preceded by inflammatory action ; are
seldom, however, attended by acute, but often b}'
Mib-acute or chronic inflammation, or by active
congestion. They are usually of long duration,
aod frequently the effects of complicated organic
change, although generally more immediately de-
pendent upon some specific lesion.

24. (a) Dropsy from disease of the hetfvt is
always preceded, for a long or indefinite period,
by symptoms of disease of this organ. When
effusion commences, early evidence of it is pre-
heated in the countenance, particularly in the
moroiog, in the eyelids; and next in the feet and
ancles, in the evening ; or in the hands and fore-
arm, particularly the left, These partial anasar-
C0U4 swellines usually continue a considerable
time before signs of the accumulation of water in
the chest are manifested, and still longer before
&oy efi'usion takes place in the abdomen. In
some cases, indeed, no fluid is found in this latter
situation. The pulse is frequently, but not
^«ays, much affected long before any anasarca
i» observed. When water collects in the face,
^ods, or arms, after protracted ill-health, and
without pulmonary symptoms, disease of the
heart may be inferred, notwithstanding the re-
regularity of the pulse: but auscultation will
detect its nature. Generally, as the eflusion
mcreases io these parts, so symptoms of its
commencement in the chest or pericardium,
"^ost frequently in both, make their appearance.
Ibe patient at first requires his head and
Moulders more elevated than usual in bed ; and
ft last be cannot lie down, the efi'usion increas-
^% ita the cellular tissue, and extending to
Kvcral or to all the shut cavities. In some
cues, particttlaily when the disease of the heart

Vol, I. •'

is of an active nature, haemoptysis, pneumoniai^
or pleuro-pneumonia, or congestion, takes place
in the lungs in the course of the dropsy, and
favours or mcreases the thoracic efi'usion. WheoT
the cardiac disease consists chiefly of passiva
dilatation and thinning of the cavities, the efifusion
is usually also of a passive kind, or attended by
vascular and general asthenia, a lowering treat-
ment accelerating a fatal issue. Occasionally the
anasan*a disappears, or is diminished, for some
time before death; but the symptoms of the in-
ternal accumulation of fluid become more urgent.
When obstruction in the valves of the left sidd
of the heart exists, congestion of the lungs, with
sudden increase of the efifusion into the pleura,
not unfrequently occurs, and terminates life by
asphyxy. The urinet in this state of the disease,
is often without any albuminous coagulum, or
with very little: but it may, or may not, exist
even in the same case, at difiPereot stages of its
course. This form of dropsy is very frequently
benefited by treatment, or for a time apparently
removed ; but it as often recurs, until the pro-
gress of the primary leaon, and the exhausted
vital energies, at last favour an increased, a more
general, or more sudden effusion, often associated
with pulmonary congestion, and life is thereby
quickly terminated. . When the excreting func-
tions are impeded, the effused fluids may, from
effete or irritating matters being secreted along
with thepa, act injuriously upon the surface or
tissue with which they are in contact ; and, in
this manner, much of the appearance of irritation
or of structural change, observed either in its
course or after death,-may be superinduced.

25. (by Disease of the blood'Vessels and lympha'
tics is often productive of dropsies ; but in many
instances its seat and nature cannot be determined
during the life of the patient, and frequently with
difficulty afterwards. — a. The actions of the
arteries and capillaries are more or less affected
— are obviously increased in acute, and dimi-
nished in passive, dropsies ; — but the change is
one of function ra^ther than of structure. There
are, however, few cases of the chronic or passive
forms of the disease met with in advanced age,
where the arterial sjystem is entirely devoid of
structural lesion. But when we consider the
frequency of alterations in this system in old age,
it becomes a question, whether it be connected
with effusion, otherwise than as both may be
coincident results of anterior disorders. Some
French pathologists, however, believe that the
simple retardation of the circulation, occasioned
by structural change in the arteries, favours effu-
sion into the cellular tissue and serous cavities.

2G. 0. In respect of disease of the veins, it may
be inferred a priori, and pathological facts have
confirmed the inference, that obstructions of them
will occasion dropsical eflTusions, unless a collate-
ral circulation be establi^^hed sufficient to prevent
extreme congestion of the vessels below tne part
where the impediment exists. This position,
acknowledged since its demonstration by Lower,
has been frequently illustrated by the details
of cDses. Raikem found, in two instances,
anasarca of the lower limbs, fibrinous concre-
tions obstructing the vena cava and internal
iliac veins. MunoACM observed a similar state
of the extremities from a tumour which pressed
upon these vessels; and attributes, in some cases,

Kr

610

DROPSY S«CONDA«Y OR COXSKCUTTVB.

dropsy witbiQ the head to pressure upon the superior
Vena cava. Haller states, that compression of the
jugular veins has produced dropsy ot the ventricles
and membranes of the brain. L aennkc found obli-
teration of the vena cava in a case of ascites and
anasarca. I have seen » in two cases, enormous dis-
tention of the thigh and leg, from the pressure of a
psoas abscess upon the iliac vein ; and analogous
facts are recorded by Houoson, D. Davis, BourL-
1.AUD, Vblpeau, Meckel, and Lee. Organic
change about the right side of the heart, or tumours
pressing upon the thoracic portion of tlie vena cava,
will obviously produce a similar, but moT« general
efiect. And 1 believe, with several pathologists.
Chat congestion or engorgement of the large veins,
from dencieot vital power, particularly if it conti-
nue for any time, will, independently of mecha-
nical obstruction, be sufficient to occasion both
increased effusion and accumulation of fluid ;
owing — Ist, to impeded circulation, consequent
dilatation of the smaller vessels, and escape through
the pores of a part of their more fluid contents ;
and, 2d, to diminished absorption ; which M. Ma-
j EN DIE has shown, by experiment, to exist in parts
whose blood-vessels are inordinately congested.
If we allow, with this physiologist, and with se-
veral others, who have furnished evidence in
recent times, that the veins exert an absorbing
function, either directly by their radicles, or by
lymphatic vessels opening into them, we must
necessarily admit that any obstruction, vital or
structural, of the venous circulation, will be fol-
lowed by an accumulation of fluid in parts b^ond
the seat of obstruction.

27. y. Diseases of the lymphatkt, both fnnc-
tiopal and organic, have been viewed, as stated
above, as causes of dropsies. It is obvious that
little beyond the evidence of analogy can be ad-
vanced in favour of impaired function of these
vessels : but when we consider that many of
them open into veins, without passing through
glands, we mav admit that they will experience
the same modifications of function as those vessels
with which they are thus intimately connected.
And when we reflect on the various circumstances
calculated to retard or to entirely obstruct the
circulation in the lymphatics passing through
glands, and conveying their fluids into their prin-
cipal trunks, the admission of impaired function,
in some cases, cannot be unreasonable. Of this
species of lesion, it is obvious that post mariem
research can furnish no positive proof: but of
structural change direct evidence may be ad-
vanced, although the difficulty of obuining it,
even in cases where it mav exist, will necessarily
diminish the amount. It has been considered by
several of the authors mentioned above ($ 26.),
that rupture of the lymphatics; by Morcagni,
AssALiNi, Bichat, Sosmmerrino, &e. that a vari-
cose state of these vessels; by Sciierb and Sa-
viARD, that concretions formed in their principal
trunks; by Haase, Boyer, Hukter, Crvick-

S9AKSS, SoEMUERRING, MaSCAGKI, &C., that

eompression of either them or their glands; by
most of the authorities now named, that obstruc-
tion, destruction, or extirpation of these glands ;
and, lastly, by some of them, that inflammation of
the lymphatics, may severally be followed by
dropsical accumulations. On the other hand,
cases haveb^n adduced by Morton, D. Monro,
CtfLLEN, A. Cooper, Bicbat, and Lasnnec, in
^'<:h the principal lymphatic trunks were ob-

^u:.

strueted without any collections of fluiil having
been formed. — D.Monro and M. Dvptrrrai^
tied the thoracic duct in the lower aaisKals, bat
dropsy was not the consequence ; whibt Mr.
Cheston found it obliterated in a case of aaasarct.
I therefore infer, that alterations of these ▼e«eb
either may, or may not, be the principal patheko*
gical caose of the accumulation of fluid ; that, a
respect of these species of lesioiis, as wcU a* <rf
others, additional changes are frequency reqaai*!
to the production of effusion ; and that, to bsei
instances where disease of these Tcsseb has bees
found in connection with drop^,it has been ratkir
a coincident effect of funetioml or sumctwal
change, or of both, in some vital organ, than the
chief source of the collection of laid, fnm
what has now been stated, it may be eoodaded.
that opinions as to the exclusive opemtion of asv
one set of vessels in producing symptomabc dr«p>
sies are altogether erroneous, and that either cf
them may be concerned in the result, mote espe-
cially the veins.

28. The fluid collected in dropsy frsas c^
struction in the circulation diffen 6tMn the scnrm
of the blood chiefly in containing uaeli las a^*
buroen. It is usually limpid, inodonws, either
colourless or of a citron tint ; and, n sonw
instances, when the obstrnction has ocearrvrf
suddenly, it is slightly coloured by the escape d
a few of the colouring paiticles of the blood. TV
parts containing it are commonly free from as?
material change, excepting in the more chrocx
cases ; and it often collects in Tery oooaidcfahk
quantity, before much disorder referriUa to t^
accumulation is complained of. Hm symptom
will necessarily vary with the aeat and nfmiiry
of the collection, and the parts primarily or cor-
secutively affected. The diagnom of effewe*
depending upon disease of the circolatiBf reswdft
is very difficult in all cases, and neariy inpoitfihii
in many. When it occun in the stmmous ifas-
thesis, or early in life, or is connected with, ct
consequent \|pon, swellings of the lymphatiL
glands, lesions of the lymphatic system soay rts-
sonably be inferred ; and when it commenco as a
local oedema, or is Ihnited to a single limb, <«
continues in the lower extremities wiihont tar
signs of disorder roferrible to the large eaiiitK«.
the obstruction of a considerable veooas traat
may be inferred. If it appear ytrj slowly a
the lower extremities, and increase verr gradoalff.
and be attended by a slow, or nneaaal, or irrep»-
lar pulse, great coldness of the Itmhs, mta or
without discolouration or sores of the Icfs. f^
cularly in aged or gouty penons, the artNs^
system will very generally present S0«eiafii
change, as ossific deposits in some part of its cssb^.

29. (r) DTwptyconnteied^thdtmmattf^lm*^*-
— Either hydrotborax or anasarea, or'boih. ■■/
occur in consequence of pafanonaiy afiecAus.
or merely as coincident effects of the same caaw* :
and in many instances effusion m^ take piart n
the pericardium, in addition to the other fems •!
dropsy. The acute stirtes of anMarca ars rm
infrequently connected with inflammaiien, ca>
gestion, or hepatimtion of the auhstancs of thr
lungs, or with acute bronchitis, particiilarly v^
exposure to cold and moisture, or after scarlsiuis
or measles. In many of th<s9e cases the palmow^
affection is somewhat obscure, the synpioB*
being imperfectly developed ; and, oalc» ao«vi-
tation be used, is liable to be overlooked or b»*

DROPSY — Tbkatment op Phimart.

fits

37. V, PaooKons* — The prognosis in dropsies
will DeoesMiily depend on their form and origin ;
•n the extent and complication of 'the structural
changes occasioning them, the state of vital ma-
nifestatioos, and the habits and age of the patient.
~(a) AnUe and tulhaeute dropsies are generally
much less dangerous than the symptomatic, par-
ticularly when occurring in young persons and in
tolerably sound constitutions; but concomitant
circumstances, more especially their association
with palmonacy disease, and the nature and ex-
tent of that disease, will greatly modify the opinion
to be formed of the immediate or ultimate result.
The form of diopsy which occurs after scarlatina
or measles is much more curable than any other.
Aakenic dropsy, from excessive evacuations or
bsiBorrfaages unconnected with structural change,
or that from insufiicient or unwholesome diet,
gcoerslly admits of cure.

38. (h.y Consecutive or symptomatic dropsies
seldom are permanently removed. Those arising
from oigamc change of the heart may be remedied
for s time, bat Ihey generally recur again and
agaio; jodicioas treatment frequently prolonging
»e, neverthelefis, for several years. When the
effusion proceeds from disease of the lungs, the
prognosis will be formed with strict reference to
H; and on the whole, will be less favourable than
in the foregoing. The same remark applies to
^psy from changes in the vessels. Accumula^
tioQs of fluid from organic lesions of the liver are
bot little under the control of medicine, and
generally terminate fatally sooner or later. Oc-
csflODally, however, exceptions occur; and much
relief is often obtained for a considerable time.
U ben the malady depends chiefly on enlargement
0^ the spleen, a more favourable result has fre>
qneotly been obtained. Dropsy from disease of
ttie uterus and ovaria seldom terminates favourably.
And it would appear that effusions from structural
le^ioDs of the kidneys are the most rapidly and
certaioly fatal. .

39. 11. Treatment. — It will be obvious to
every experienced practitioner, that the distinc-
tions made above are merely the more prominent
feaares by which the malady may be recognised,
«bere the acquaintance with it is imperfect ; but
tbat there are numerous other shades of character
«hich deserve to be known, and by which he will
be in some measure guided in practice, that
■cucelv admit of description. Of this kind more
especially are those ever varying states of vital
power, and grades of vascular action, which de>
maod certain indications of cure, or different
BiodiBcations of treatment, as imperatively as any
well-ascertained alterations of structure. There
^e, perhaps, few diseases that require in the
treatment a stricter reference to the conditions of
^ital power, in connection with changes of its
organic alliances, than those now being considered.
^ 0 ascertain these conditions, and to act strictly
in accordance with them in dropsies, even as re-
spects those slighter modifications that can neither
be iliutrated by examples, nor be made subjects
of precept, will tend more to successful practice,
tban any other object of investigation.

^. i. Or PaiXARY or Idiopathic Dropsies.
— 4. Trgatment of the Acute. — The first object
of investigation will be the state of the disease in
relation to its remote and proximate causes, and
of the constitutional powers of the patient, com-

prising every appreciable change in the vital
tunctions, and in the appearance of the soft solids,
as indicating modifications not merely in the
grade, but also in the kind, of action. By the
inferences derived from this source, the practi-
tioner will be guided in the appropriation of the
means of cure, and in the alterations he may
conceive necessary of the measunes about to
be described. — In this form of the disease, espe-
cially if it be associated with congestion or inflam-
mation of the lungs, if the constitutional powers
be unbroken, and if it have appeared suddenly or
advanced vapidly, a full blaodlelting will be re-
quisite, and may even be repeated. In most
cases, however, local bleeding by cupping will
be preferable to a repetition of the venesection ;
and in more doubtful cases, the local depletion, if
decidedly employed, will be sufficient. If cupping
be prescribed, it should be performed on the part
opposite to the seat of soreness or pain, or at a
distance from it, particularly when the lungs or
pleure are affected. Contemporaneously nearly
with depletion, medicine should be taken to act
upon the secretions, and equalise the circulation ;
and, for this purpose, there is, perhaps, nothing
superior, in the first instance, to calomel, in a/ull
dose, combined with Jame»*t powder, or with a
moderate dose of camphor, or with both. In some
cases, and particularly in persons who have been
addicted to drinking, the calomel will be advan-
tageously eonjoioed with opium. In this class of
subjects, general bloodletting must be employed
with caution. After one or two doses of calomel,
in either of these states of combination, a yurgatioe
draught should be exhibited and repeated, and its
operation promoted by a terebinthinate enema,
(F. 149. 151.). Having removed plethora aixl
reduced the increased action, the good effects of
counter-irritation will be more readily obtained.
The ointment of the potassio-tartrate of antimony
(F. 749.), or the pea issue, are upon the whole to
be preferred ; but they should be employed on the
side oppottte to that where uneasiness is com-
plained of, or at some distance from the most af-
fected part. Whatever external irritant may be
adoptea should be long persisted in. In the course
of treatment, calomel, or blue pill, with either
James's powder or the pofosiio-fartrafc of antimontf,
should be sepeated from time to time, until in-
creased action disappear ; or be regularly continued,
particularly iC the pleursB or pericardium be
affected, until the specific mercurial effects
become manifest; when deobstruent and taline
purgativet may be prescribed, and their effects
promoted by the occasional exhibition of the
enema already recommended. The more cooling
diuretics only should be given at short intervals,
in order to promote the functions of the kidneys.
These will be advantageously associated with
diaphoretics. For the former purpose, the bi-tar-
trate of potash with biborate of soda, the acetate of
potass, and the nitrate of potash alone, or with nitric
ffitber, may be used ; and for the latter, the
camphor julep with liq. amraoniss acetatis, with
vinum anlimonii potassio-tartratis, or acetum col-
chici, and small aoses of opium. In this forpi of
dropsy, I believe that all heating diuretics, as
squills, juniper, seneka-root, horseradish, with their
combinations and preparations, are, more or less in-
jurious, unless vascular action has lapsed into a
state different from the sthenic form with which it

612

DROPSY— Secondary or Consecutive.

oerned in the production of effuBion, especially
those which impede or interrupt their functions.
Of this latter kind seem to he the principal of
those 80 well described by Dr. Bhioht {§ 13.).
Dropsy may arise either from disease of the kid-
neys alone — which seldom occurs, and in which
case it usually commences with anasarca, at
first affecting chiefly the lower extremities —
or from lesions of these organs associated with
those of the heart, or of the lungs, or liver. In
such complicated cases,' the disease of the kidneys
may be either primary or eonueutivt; perhaps,
more frequently, the latter. — a. When it is
consecutive, the dropsy commences, as already
described, in alteratioos of either the circulating
or respiratory systems ; the accession of the affec-
tion of the kidneys being often distinctly indicated
by pains in the loins, sickness, vomiting, occa-
sionally purging, and coagulable urine. In some
instances, however, renal disease may exist with-
out these symptoms being prominent; and co-
agulable ttrine may be present without the kidneys
faiinr particularly implicated. — 0, When the
renal affection is the primary alteration, the
(iropsy commences as anasarca ; but rapidly ex-
tends to the cavities of the pleure and pericar-
dium, of the peritoneum, ana not infrequently of
the arachnoid. In most of these cases, the symp-
toms are more acute, and the progress of the dis-
ease more rapid, than in any of the other forms of
■ymptomattc dropsy . This seems attributable to
the disease of tne kidneys being such as pre-
vents them from removing all, or even a large
proportion, of the injurious elements constantly
requiring elimination from the blood ; to the con-
sequent secretion of a portion of them in the ac-
cumulated fluid ; and to their imparting irritating
properties to it; whereby tt induces inflammatory
action in the serous surfaces containing it, with
jrapid aggravation of all the pbeniynena, and
occasionally a concentratioB of the malady in
one or more of its usual seats. Thus, it la not
uncommon to perceive symptoms of pleuritis or
pericarditis, or even of peritonitis, to accompany,
-or even to precede, the more advanced periods of
the effusion into the respective cavities ; and, as
the disease is increased m one or more of these,
to observe the disappearance of the fluid from the
extremities. In some instances, whene the collec-
tion has formed rapidly in the cavities of the
chest, either preceded or attended by acute
symptoms referrible to this situation and its con-
tained organs, not only the anasarca, but also
the ascites, where one or both have previously
existed, has partially or nearly altogetner disap-
peared, the rapid effusion into titese situations
soon terminating existence. In other instances
of this form of dropsy, effusion on the brain is
superadded to these, and the patient dies comatose.
Dr. Bright and Dr. Gregory remark, tliat there
is great prooencss to salivation from small doses
•f meiGury in dropsy from diseased kidney*.*

3S« (/) Dropsy from disease of the tUerus and
evaria may arise either from the pressure they
produce, when enlarged, or containing tumours,
on the veins and lymphatic glands and vessels ; or
from the extension or disease from them to their
peritoneal covering. I met with a case, in which
ascites was consequent upon chronic inflamma-
tion of the uterus, the peritoneum covering the
• fundus having become consecutively affected ;
and a nearljf similar instMce, in which the effu-

sion into the peritoneum was owing to the sap^

fression of leucorrhcea by astringent injcctioii^
n this latter case, I inferred that the dischsrcc
proceeded from inflammatory irritatioa of the lo-
temal surface of the womb, or of the os uteri, sad
that the treatment had suppieseed the morM
action in these situations, and deterauBed it a
the fundus and peritoneal snrfece ; whence it hii
extended further, and produoed cfToaion into tM
abdominal cavity. But little anasarca wis
present in the$>e cases, and that was eoofioed
chiefly to the feet and ancles. Ascites may pro-
bably likewise follow chronic inflammation of tk«
ovaria, owing to a similar extension of the im>
tative vascular action to the peritoocam. Li<
eessive hemorrhage from the nterns, and afaortioc<,
may also produce dropsy, as stated above ( ^ &. <
Those diseases whidh have been geoenlly <^'
scribed as ovarian and uterine dropii», art
purposely excluded flora the present view v'
the subject.

36. Of the Urine in Dropsies, — Owing to iv
attention that has been paid to this topic in ntv
dem times, and particularly since the imeA-
gations of Wells, Black all* Pnorr, sad
Bright, the state of this secretion has beeoe^*
an important source of information as to the pS'
thological conditions giving rise to dn^>sical (i> *
lections ; although, when viewed elooe, n«r£
less dependence can be placed npon iL Dr.
Welm found that the unne was more or it*
coagulable in the dropsies consequent npoa rtf-
latina, and even from the exhibition of marvn
and that this symptom was most frequcat e
anasarca, it having been remarked in tweoiv-^«'
cases out of thirty-seven. Dr. CBUSTicn^ r4
Dr. I. Gregory also remarked it most cemmK <
in this form of dropsy; and my experience ^e-
cords with theirs. I have seldom teen it i-:
ascites. Dr. Black all considered it as so a:*
tendant upon the acute form of the malady ; ^o <
Dr. Prout, as an indication of irritatioQ. 1^'
B right's cases prove its connection with i"
more advanced states of the ciianges nf the i*'-
neys he has described, independently of w
existence of acute or sthenic vascnlar teixz.
Several physicians have remarked this state of t^
urine in other diseases, unconnected with ]f*t^
of the kidneys ; but admit its freqneney in «r
cireumstsnces, as well as in acute dropiic«. '
have often observed it in acute diseases of cii^'-
dren, where no alteration of the kidneys 9xwt^
and I believe it is not uncommon after the n-
anthemata. The above writers have also r>
ticed a less speciflc gravity of albaminoos tba*.
of healthy unne. As to the dark brown co'mt
which this urine frequently presents in dfo*«},
the inference of Dr. Brigbt, that it arixs fra^
the red globules of the blood, seems to be c«rvci
The presence of albumen may be a«emn'^
either hy boiling, or by the nitric or hvdn>-ch!t -
acids, alcohol, the ferro-pruanate of potash. -
bichloride of mercury. The last re-apfoi ». t-f» *
the whole, the best. The opinion of Dr. Pm i* .
as to the value of Rlbuminons urine as a ster-
tom, will be adopted with advantage; axD^N
that we ought always to be aware of As f*^
sence, as, taken along with the others, it om^ t*
occasionally useful in directing our jod^^eiei'* *
the nature of the disaese ; but that, in the fi*
sent state of our knowledge, it doss ort oidtr*'j
any particular remedy or mode of HvatBcnt-

4^14

DROPSY — Treatment of Primast.

commenced. With this impression, I have usually
preferred those that are the most sedative and
refrigeratiDg, especially foxglove, colchicum, the
wine of tobacco in small doses, and the sptritus
stherisnitrici, as long as any evidence of increased
action remains.

41 . B. Of Sub-acute Dropty, — Those intermedin
ate states of<4he disease, between theacateand the
passive — between the sthenic and asthenic forms
— will necessarily require means appropriate to
the grade of action they may evince. In the
more acute cases, local depletions, and the rest of
the treatment described above, will be most effica-
cious. In these, the judicious exhibition of deri-
vatives and purgatives, followed by diaphoretics
and diuretics, constitute the chief means of cure ;
and, when this state of the disease occurs after
scarlatina or measles, or in connection with
bronchitis, digitalis, the preparations of antimony
with opium, and the warm or tepid bath, in addi-
tion to these medicines, and followed by change
of air, will prove of essential benefit. In the
more sthenic cases of the sub-acute, as well as in
the acute, disease, when it arises firom suppression
of the perspiration, or of the exanthemata, the
warm or tepid bath, or medicated baths, consist-
ing of emollient decoctions, &c., or containing
the sulphuret of potassium, or the carbonate of
soda or of potash, will be serviceable, when em-
ployed after sufficient sanguineous and alvine
evacuations. In the less active states of the
disease arising from the same causes, particularly
from suppressed eruptions, the application, and,
occasionally, the repetition, of a large blister, or
of mustard poultices, or of warm terebinthinate
epithems, at a distance from the seat of 'effusion,
or of irritative action, where the existence of this
latter is inferred, will frequently be productive of
benefit. In those cases which approach the pas-
sim or asthenic character, or in such of the above
which may lapse into it, owing to neglect of
treatment, or to a too active treatment relatively
to the nature of the case, or to constitutional fault,
the means that will be advised for the form of the
disease which is thus characterised ($ 42.) should
be employed. It will sometimes occur, especially
in the intermediate or more doubtful cases, and
even also in the acute, that the more antiphlogistic
means will be productive of little or no benefit,
or will even appear to a^^ravate the symptoms,
although their exhibition seemed clearly indicated.
I have generally observed that the practitioner
has been misled by the great frequency of the
pulse, which he has mistaken for a sign of in-
creased or sub-acute action, instead of viewing
it, when it is at the same time soft, small, and
easily compressed, and when it is .connected with
other signs of depression of vital power, as evi-
dence of great weakness conjoined with increased
irritability of the vascular system. In such cir-
cujnstances, I have found getith UmicM and astrin-
gents, with diobstruent Laxativeit or with alkaline
sub-carbonates; and the moderately stimulating
diuretics, more especially the babamie and tere-
binthinate preparations, with camphorated opiates,
&c. ; and, if the pulse be languia, with frictions
actively, long, or frequently employed ; prove
very beneficial. Sub-acute or acute dropfie«,
appearing after the suppression of the hemor-
rhoidal discharge, require, after moderate blood-
• letting, the active exhibition of ht/dragogue pur-
gatives l and the same states of disease connected

with suppressed menstniation are mort bcaeStri
by a nearly similar treatment, with the wMit^n
of the bi-borate of soda, continDed regulaHv fef
some time. In some cases of tlie loi rtkear
state of sob>acute dropsy, the iaccnial and «i-
ternal use of the nitro^hydro^hlerie mdis ; or a
well-regulated course of Bath watfen, with fiKqucnt
changes of air ; and in others, the artifidal wsim,
of Carlsbad, £ms, or Marienbad ; and when ibe
bowels require frequent aanstanee, tbcSaikdinn

waters ; have proved very senrieeble.

42. C. Treatment of Astkwnit or pmeeim Dvif-
st«f. — In oases wha« the debility is gfv«Bl.
at the same time that vascular aetaon is cttkrr
languid or weak — notwithstandiiig tbat the pa'w
is frequent — and the vital cohcsioa of the oeJfails;
and serous tivnes is dhninished, fosies widi ik«
mineral acids, especially the infcmon of cbieheas
or the sulphate of quinine, sboald be pRseiibrl.
Where a cachectic habit of body ia muiiet,
quinine will probably occasion beat aod fevrrafe-
ness. In such cases, it will be neeesasry to
associate the vegetable tonies with deakehm*tt
and. laxatives ; to exhibit the blue |nI1 or Pu's-
mbr's pill, in small and iieqiieiit ilescs, ^Hk
taraxacum, or the compound ifaooctMMi of vrai'
parilla, the mexereon having been Mtoet. Ix
many of those doubtful caaes of tbie fem d tk
diseaw, where it is difficult to detamuae wbdto
it is primaTy, or associated with obacwe lesiaa ia
the secreting substance of the liver or bdanv.
some advantage will be derived from ■unnte im»
of the bichUmdum hydrargyri, in large quueuoot
of the decoction of sarsaparilla, or of any of ne
species of the emilar. 1 have likewiae, ta f«ri
circumstances, found great service firom nidi**, fu-
ticularly the iodide of potassium and the iodarHini
solution of the iodide, in smaller and much msst
frequent doses than are naually directed.

43. When this form of dropay baaanasa &«■
excessive losses of blood, or baa sapeivcBed ca
chlorosb, the chalybeate prepar&tiame, wilb cU.
lybeate mineral waters, or the artHida] Pr.-
mont and Spa waters, will be of the atM
service. But care should be taken to aacertas
the non-existence of visceral obst/vctien hsfan
they are resorted to, and to preserve tba bovcb
freely open during their use. <WbaD psan
dropsy occurs after ddiveiy or abotlioe, hnv
infusions, and ve^table tonics» the deceebsasf
cinchona with rameral acids, oecaaioMd pa's**
tives, aod the terebinthinate coena, with hsctitm
of the surface and bandages, will be leqaiBiv.
and, if it be accompanied with hysterical eem^
toms, the preparations of juniper, spiriL mAet*
nitrici, or other etherial preparatieas, with torL
camphorse comp., or small doses of opivm. vili
be of much service. In these caaes, the ^
ation of diuretics with bitter or Ionic iai
small doses of the tinetuia camphors Thshara
(F. 708.), or the tioct opii campb. (F. 728.) m4\
generally be advantageous.

44. ii. Treatmsvt or CoivstcimvB oa Shvn
TosiATic Dropsiss. — It IS obvioas that the
intentions of cure in this class of dropsis vbtsM
have strict reference to the nature of Ifat ef|raB.«
lesions concerned in the prodactiQa ef siTstfos.
and to the state of vital eneray and ttnaeni
cohesion; and that they shonM iwapri^ tk
following objects. — 1st. To ivmove thsat kmm
and if this cannot be accomplishrd, ta rsuid thm
increase^ as the chief means of dtatnistofif tk

DROPSY— -Treatment op Conscgutivs ob Symptomatic.

615

eflusioa ; — > 2d. To promote the absorption of the
flaid ftccamalated; — and, 3d. To support the
constitutiooat powers ; as being necessary both to
the due operation of remedies, and to the exertion
of that vital rasiatance which guards the structures
against the impression of hurtful agents, whether
^aerated within the aystem, and acting intrin-
sjeally, or invading them from without.

45w A. Of dropsy contffitent on dUease of the
hurt, — It will be important to aaceitain, as cor-
rectly as the rational and ausculatory signs will
enable us, the nature and seat of the cardiaclesion,
in connection with the seat of effusion, and its
characters in respect of activity. If obstruction
to the circolation be seated in the left side of the
heart, there will very probably be associated with
the effuaioD, congestion of the substance of the
iangs, which will aggravate the hydropic symp-
toms, and render depletion the more necessary.
Also, if the cardiac disease consist, either alto-
gether, or in part, of active enlargement of the
paiieies of the cavities, the dropsy will present
a sthenic character, and require antiphlogistic
remedies; but if the lesions be chiefly passive, —
if there be' dilatation with thinning or softening
of the parietea of the heart, — the constitutionid
symptoms will possess analogous features, and the
disease require an oppoate— ^a tonic, treatment.
It will be evident from these facts merely, that,
in symptomatic, as well as in idiopathic, dropsy,
sod even in that connected with impeded circu-
huioQ through the heart, the strictest reference
shovld be had to the state of vital power and
vascular action, as the principal baais of our
intentions of cure.

46. If a state of sthenic action exist, local

•^<v^(ioR— preferably by cupping; hydragogue

csKhsrtics, aa tlatorium and the eroton ot7, repeated

from time to time ; or even these independently

of depletion ; and subsequently the useof diurfd'cj,

or these at an earlier period where the active and

repeated exhibition of purgatives are not well

^rne ; will frequently remove the accumulation

of flaid. In this state of the disease, digitalis is

the most eflieacious diuretic, especially after local

depletions and purgatives, in the more sthenic

5>^. Debility rather indicates, than contra-

indicaies, the propriety of resorting to it The

iofnsbn is the moat certain preparation of this

Bedieiae. Half an ounce of it two or three times

% (by, sa usually directed, is a much larger dose

^a that recommended of its other preparations ;

Iteoce the reason of its activity, its diuretic ope-

ntiott being heightened by the addition of small

doses of opium. If a tensive pain iu the forehead,

With disturbance of the cerebral functions, come

oa early after its exhibition, it will rarely be of

*^f^^Ctef or it may even be injurious, aa remarked

|>y Dr. Blacsall, and it, therefore, ahould be

immediately relinquished. When there is much

oebilitj, it should also be discontinued upon the

>nt appearanee of an increase of the urine. But

^w great debility is no reason against the use

of this medicine, as Dr. With bring has shown ;

oaly the more caution is required jp its exhi-

httioa. In tuch cases I have usually combined

\ beoeficially with oamphor, a email . quantity

«[f opium, or with cinchona (F. 859.), and

^ vegetable tonics and cordials, or with

'• 708. or 728. Colckicum '» sometimes of

••friee when this form of dropsy assumes a|

stlienic character, or appears in the rheumatic or
gouty diathesis; but it requires much caution.
It is most safe, and at the same time most service-
able, when combined with camphor or ammonia,
or with the alkaline carbonates, and iafusion of
cinchona.

47. When the cardiac disease and its conse-
quent effusion are of a passive kind, and especially
if the constitutional powers are much reduced, a
tonic treatment, in conjunction with stimulating
diuretics, is requisite. The remedies of this de-
scription, already recommended ($ 43.), — the in

fusion of quassia, with the tincture of the sesqui^
chloride of' iron, and tincture of digitalis; the
compound infusion of angelica (F. 219.); the
decoction of broom tops ( If . 75.), with the com-
pound spirit of juniper; the compound decoction
o( taraxacum (F. 77.), with tincture of calumba
or the potassio-tartrate of iron; and either Formulae
570. 781. 859., or the following, will often be
prescribed with benefit : —

No. 179. Ik FotasMB Carbon. 9j. ; Tinct. CiDnamom.
Ca 3j. ; ^irit. JEJther. Nit 3J ; Infusi OenUanoe Comp.
3 j. (veL Decocti Scoparli Corap. 3 J.) ; Aqua Anethl 3iii.
M. Fiat Hauitus ter quotidid luroendua.

Na 180. H Potani? Acetal'u 3 u.— 3 ij. j Tinct. Di-
gitalis Tn viij. ; Tinct. Opli 1^ v. ; Spirit Junip. Comp.
3 J. I Inftisi Quawiae 3 ix. ; Aqu« nme&tc 3 iy. AL Fiat
HauttiM ter quatenrcln die sumenduik
« No. 181. li Camphors t ubactK, Guaiacl Reiinfle, ai
3 J. ; Pulv. Scillae et Pulv. DigiUlit ia gr. xv. ; Opii Purt

ST.; Olei Junlperi nixxij.; Mucitag. Acaciie q. •.
Coiitunde aimul, et distribue ma«am in Pilolaa
vqualea xiviii., quarum capiat bina« ter In die.

No. 182. H rtnct. Digitalis HI x— xr. ; Liquor Am.
mollis Aeetatit 3 iJ. ; Infusi Cinchonae et Miat Cam-
phors aa3vj. ; Tinct Camphors Comp. 3j.i et Spirit.
Aniai 3aa. M. Fiat Hauitua bit quotidi^ alimendua.

48. B, Drop»f from disease of the absorbing
systeats-^veins and lymphatics, — The difficulty of
determining when the effusion is owing to these
causes has been stated above, with such signs aa
sometimes indicate its existence ($ 25. et teq,). In
the more limited states of anasarca, and even ia
ascites, bandages and frictions, assiduously em-
ployed, with Uie internal exhibition of the iodide
of potassium, or of the other preparations of iodine
to be found in the Appendix (F. 234. 723.),
have proved exceedingly beneficial in some casea
in my practice. The decoction of broom tops with
liquor potassse, or this latter in the compound
decoction of sarsapariUa ; equal quantities of the
bi«borate of soda and bi-tartrate of potass in the
deeoctum cydonitB, or decoeturn guaiaci comp, ;
the diuretic drinJa, in the Appendix ( F. 588. et
seq.y ; and frictions with deobstruent Unimetits
(F. 295. 297. 31 1.), will occasionally be of much
service. The carbonate of soda^ or nitrate of
potash, or both, exhibited in tonic infusions, to
which small doses of digitalis are added ; and the
infusion of berberis, or the compound decoction of
taraxacum (F. 76, 77.), with carbonate of potash
or of soda ; or the same alkaline carbonates with
the infusion or mixture of the dtosma crenata
(F. 231. 396.) ; may likewise be employed, with
a prospect of advantage, from their deobstruent
operation. In all cases of this kind, gentle exei^
cise in the open air ; the use of the artificial waters
of Marienbad, and Eger, or of Seltzer or Seid-
schutz; and strict attention to a moderate, di-
gestible, and cooling diet ; will prove of essential
benefit.

49. C. Dropsy connected wi^ pulmonary diS'
eases, — The treatment in this complication should
mainly depend upon the character of the vascular

Rr 4

DROPSY — Remarks on Medicines recommended in.

625

eoiobioation to those in which rhubarb is ap-
propriate (see F. 231. 396.)* '1'^^ marehantia
hemisphericat or liverwort, has been recently
employed with much benefit by Dr. Shortt, in
cases where other remedies had been employed
vrithout advantage. He has, however, found but
little service from its internal use, and has
femployed it chiefly externally as a poulbce. For
tbis purpose it is first boiled, afterwards beat into
a pulp, and mixed with as much linseed meal
as will bringilt tothe consistence of a poultice,
which is spread upon flannel, and applied warm
over the seat of the effusion, repeating the poultice
every twelve hours, until the accumulation of
water is removed. It produces ** copious perspir-
ation, and at the same time acts powerfully on
the kidneys." The sinking sensation it sometimes
occa&ioos is relieved bv the spiritus etheris
oiirici. The effects of this Application are stated
to be increased by allowing the patient warm
and nourishing diluents, and beef tea, &c. Dr.
SjioaTT beheves that this application will be
found to succeed in many cases where the kid-
neys are affected. The bark of the root of ci-
choTia raeemma anquifolia has been lately em-
ployed by M. Lemasson. This bark furnishes
a crystaltisable principle, of a bitter and astrin-
gent taste, soluble in water and alcohol, in which
the virtues of the plant reside. A decoction of
two drachms uf the bark in eight ounces of water
is divided into two doses, which are taken with
an interval of two hours. This generally affects
the kidneys, and the action continues for some
days. As soon as its action begins to diminish,
the same doses are repeated. It is suitable only
to the asthenic sutes of the disease.

81. Cantharides have been recommended in
dropsies, on account of their diuretic action, by
HiprocBATEs, Galkn, Dioscorides, and others
tmong the ancients ; and by Brisbane, Farr,
and several modern writers. Hoffmann, Werl-
HOFr, and Hur eland, gave them with cream of
tartar, the taruric acid, or nitrate of potash,
^ with camphor; and Tulpius in the form of
tincture with spiritus stheris niirici, cardamoms,
^c. They should be exhibited with great cau-
tion, and only in the most asthenic forms of the
dbeaie. Dr. Groenevelt, a licentiate of the
College of Physicians, was committed to Newgate
in 1^3, by the president and censors, on the
plea of mala praxu for prescribing them in diseases
of the urinary organs, although numerous autho-
rities in support of the practice could have been
Educed. Cantharides act upon the kidneys, and
opon the capillary system, chiefly from the ab-
sorption of their active principle, which has been
termed canthariden.

82. The tetherg also act upon the kidneys, es-
P^aily the ipiritui atherii nitrici, and spiritus
•therit sulphurici. I'hev are useful chiefly as
adjuvante of other diureUcs. The sweet spirit of
oitf e is, however, an active diuretic when j udici-
ously combined, or when given while the patient
<-m take exercise in the open air (see F. 169.
1^0, 196. 397.). It may be remarked gene-
nlly respecting the use of diuretics, that the ad-
<^>ioo of smalt do?es of opium, or of the tinctura
op»i comp. (F. 728.) as advised by Hdfeland
and Park • and of out-door exercise, as di-
eted by TissoT ; will much augment their opc-
r<ition. Many of the Continental writers ad-

VoL. I.

vise them to be taken in malt Uquors — a vehicle
which certainly promotes their action, and is not
inappropriate in the asthenic forms of the disease.
It is in these forms principally that Dr. Rush
conceived that any advantage was derived from
this class of medicines; and Deckers, Frize,
MuRsiNNA, and Magennis, seem to have been of
nearly the same opinion, they having recom-
mended them to be given with tonics. *

83. D, Emttict have been employed by several
authors, particularly by Sydenham, Lillie,
J. P. Frank, and Percival, chiefly after other
medicines had failed ; and some advantage has
been said to have accrued from them. Squills
are the emetic most commonly employed, which
probably are partially absorbol, and act also as
a diuretic. Several writers have mentioned in*
stances of the disappearance of dropsy after
spontaneous vomiting; and have looked upon
this circumstance as an indication for exhibiting
emetics. They are scarcely ever used in modern
practice, and probably the cases are few in which
they are indicated. I have seen, however, in-
stances wherein obstinate vomitine supervened
apparently upon the medicines which had been
exhibited as diuretics, particularly digitalis, squills,
and colchicum ; but the good effect that appeared
in these cases was attributable to the preceding
course of medicine, and to the accumulated effects
of these substances upon the system.

84. E. Diaphoretics and sudorifics have been re-
commended by most writers. But in the majority
of cases, particularly in the acute and plethoric,
there is great difficulty in producing perspiration ;
the means which are employed, unless they be
of a contra-stimulant or relaxing nature, tending
rather to excite the vascular system, and to increase
the morbid exhalation, than to relax the surface,
and produce diaphoresis. The potasMio-tartrate of
antimonu, Dover's ptncdert &Q(l spiritus atheris nitrici,
are, perhaps, the best sudorifics that can be em-
ployed; but the former should be given, in the
acute cases, so as to occasion some degree of
nausea ; and the last named, in asthenic cases.
Dover's powder was much confided in by Mudox,
and guaiacum by Chamberlains and Brucx-
MANN. As to the propriety of resorting to toarm
bathingt in order to induce perspiration, much dif-
ference of opinion has existed. Tepid baths were
recommended by Stoll and Frank, in the acute
states of the disease, and vapour baths by Darbey
and others.

85. F, Mineral tmtors, if judiciously directed and
brought in aid of medicine, are often productive of
much benefit, Zacutvs Lusitanus recommends
the internal use of sea tcater ; and there can be no
doubt that it will prove beneficial if persisted in,
particularly in the sub-acute and atonic states of
the disease. In the more asthenic forms of dropsy,
the Bath waters, the mineral waters of Carlsbad,
Ems, Marienbad, and Vichy, and those of Seltter,
are often serviceable. In cases depending chiefly
upon obstruction, and where an aperient action is
desired, the waters of Harrogate Moffat, and
Leamington * may be tried.

* Dr. Loudon, or Leamington, favoured the author
with the result* of an exientive series of experiments
made to ascertain the composition of these waters,, There
are eleven springs of mineral water, seven of which are
purely saline, three sulphureous, and one chalybeate.
The saline contains '098 cubic inches of oxvgen, 763 of
asoCe, 3' 156 of carbonic acid, S4'435 grains of sulphate of

Ss

DROPSY OF THE ABDOMEN— Pathology or.

6^8

tioned above, or from the suppression of an
accostoroed discharge, or of some eruption ; and
often advances rapidly, with symptoms of in-
flammatory or excited action in the peritoneum,
— with pain, tenderness, and sometimes tension of
the abdomen ; a quick, small, hard, or wiry pulse,
and suppression or diminution of all the se-
cretions and excretions. Either consecutively
on, or concomitantly with, these symptoms, ful-
ness of the abdomen is observed, which usually
augments rapidly. At first the increase is most
remarkable m the lower part of the abdomen and
iliac regions when the patient is sitting up, and
the liver is not enlarged ; but it is always diffused
when the patient is in the supine posture, and
without any limitation or tumour. Upon exa-
mining the abdomen by percussion, a somewhat
dull sound is emitted, and the examination occa-
sions pain* The surface of this cavity is gene-
rally ary or harsh, warmer than natural, and
more tender to the touch ; and fluctuation is
very easily perceived by placing one band, or
the index finger, upon the anterior part of either
iliac region whilst the patient is erect or sitting
up, and striking gently, at a little distance, with
one of the fingers of the other hand. Accord-
ing to M. Tarbal, a slight efi'usion will be
detected, and the nature of the disease made
evident by this means, lon^ before it reaches the
height that can be recognised in the usual way
(See Abdomxk, $ 16.). As the accumulation
augments, all the abdominal functions are more
and more disturbed ; and at last respiration be-
comes difiicult, from the pressure of the water
upon the liver and stomach, and the impeded
descent of the diaphragm ; and the patient is
unable to lie down. The abdomen is now large
and prominent in its upper regions, and pushes,
particularly in young 'subjects, the ribs and car-
tilages upwards. Irritability of stomach, anxiety,
restlessness, want of sleep, great quickness of
pulse, sometimes delirium, and ultimately coma
and death, supervene, if temporary or more pro-
longed relief be not obtained from treatment.

93. (6) The tub-aeute form of ascites is milder
in its character and slower in progress than the
foregoing ; and, as well as the acftte, is not an
infrequent sequela of scarlet fever, and more
rarely of measles ; but is, in such cases, always
attended by more or less anasarca. When it
thus occurs, it usually appears gradually, and
commences from seven to fourteen days from the
disappearance of tlie eruption, commonly with
a recurrence of the febrile symptoms, quickness
of pulse, dryness of skin, thirst ; loaded, white,
or rurred tongue ; and diminution or interruption
of the secretions. All the phenomena increase
more gradually, however, than in the acute ; and
are more readily controlled by treatment. In
both these forms of ascites, the urine is scanty,
often pale, and always contains more or less
albumen. The face is generally oedemalous in
the morning, and the ancles in the evening. In
other cases of the sub-acute variety, the effusion
takes place upon the disappearance of some
acute disease, either attendea by free discharges,
or treated by copious depletions ; frequently with
febrile symptoms, and always with interruption
or diminution of the natural secretions, the fluid
parts of the blood being discharged by the in-
creased determination to the peritoneum. In

both the acute and suh^cuie idittpatkk fsrmt cf
ascites,, the accumulation of fluid arises fn:»
increased exhalation — hypercrinta of the ptnio-
neum, according to the phraseology of M. A>-
ORAL — the result either of morbidly exa'tc
vascular action, or of increased detcrmiMtiMi vi
blood, conjoined with a relaxed or weakest^
state of the exhaling vesseband porei.

94. (c) The a$ihenict or possiof, slate of mI^
pathic ascites is the most rare. It occurs d^i%
after profuse hemorrhages and evacoatioaa, »
chloroiic females, or ^lordy before puUrn,
in ill-fed persons, living in cold, low, or das.p
localities; and in those who are excluded 6va
the solar light, or are under the influeoce of ittt
depressing passions, and are employed in ledea-
tary occupations. It usually comncooes «ttu
or IS preceded by, oedema of the ancles, fieeC, asib
legs. It proceeds very slowly ; and is atieoded
by general debility ; cold extremitiea ; m pale lod
sickly countenance ; a cold or cool skin ; a vtsk.
small, quick, or fluttering pulse; pale or Iptini
tongue ', diminished or vitiated appetite ; TSfii>«>
dyspeptic symptoms; and by chlorosis or h}«Um
in females, amongst whom this variety is most fit*
quent. The urinary secretion is more oopiofti, ao-i
the bowels more irregular, and more readily acted
on bv purgatives, in this than in the other fors<.
Whilst lowering measures benefit the two pr^
ceding, they aggravate this variety of the dI^•
ease (see $ 102.).

95. B. Contecutive, or iwtesfafir osriJcs, oc-
curs in either of the acuu or tuh-^mu «ut«%
described above; more frequently the Isutr
($ 93.), when there has been no suppressioB of
the disease on which it is consequent: but whm
any of the febrile exanthemau bhve been prr-
maturelv driven from the surface ; or when the
patient nas been exposed to cold or moisiare, v
both, during convalescence; or if it have supier*
vened upon erysipelas, rheumatfeim, or goot; tuc
acute or sthenic condition is most connoa. It
is much less acute, if it have supervened opca
inflammation of some parenchymatous or adj«<iF-
ing organ; or if it accompany piegnancy. la
other respects the characters and progress of t:M
disease are the same as those suied m respect ot
the idiopathic varieties.

96. C. The tymftomatie, cr comtpliMlt^, ttmUs
of ascites are the most common ; and, like iW
primary or idiopathic, present every graie o/
activity and acuteness. But wbiUt. ia the Isner,
the acute and sub-acute are most frequent, ia ihr
symptomatic, the asthenic slate prcdomittstfv ,
although an irritative form of ioflamiaiUoa i»
sometimes observed to occur in the coune of the
disease, of>en, probably, owing to the irriUDa^
properties of the effused fluid, as shown sbow
(j 34. ). Complicated ascites presents many of tm
organic lesions that occasion symptooutic droy^
($ 12.) ; most commonly structural changes m ike
liver, or vena porta ; in the spleen ; in the oioo-
tery and its glands ; in the kidnevs ; in the ulenM
organs; and in the veins and lymphatics. TW
dropsical collection appears after a loi^« '
shorter period of disease referrible to these oi{a»;
commences imperceptibly, and proceeds siewl; .
and generally without febrile syroptoms uul
towards the fatal close of the disewc. if*-
quently oedema begins in the feet, and tzuai*
upwards to the knees, thighs, scrotaa, or kipv

DROPSY OF CELUJLAR TISSUE— Asthenic.

637

iostaoces, the urine has a brown appearance, from
the presence in it of tome of the red particles of
the blood, f rakk likens it to the washing of
6e$h, owing to this circumstance. It generally
coagulates more or leas on the application of the
usual re-agents.

1*26. la the less favourable cases ttfmptomi of
danger appear from the third to the ninth day
from the commencement of the oedema of the
fuce ; bat after twelve or fourteen days, they very
seldom occur ; convalescence often, under a ju-
dicious treatment, having commenced or pro-
ceeded far by this time. The danger in this form
of aoasarca depends upon its complications. —
1st. CpoQ active congestion, inflammatory action,
or serous infiltration of the substance of the lungs,
as ID the primary form of the disease ($ 122.) ;
d^spooea, sense of oppression, constriction and
anxiety in the chest, with dry cough and inability
to lie down supervening, and indicating the nature
of the complication :•— 2d. On effusion on the brain,
ushered in by faeadach, sickness, and vomiting;
and evinced by dilated pupils, slow pulse, con-
volsioos, strabismus, loss of sight, and other signs
of acute dropsy of the brain : — 3d. On effusion into
the pericanliura, indicated by swellings of the
face, oeck, and hands, fulness of the veins of the
neck, bloated countenance, irregular pulse, leipo-
thyroia, and fulness and tenderness of the inter-
costal spaces, chiefly of the left side : — 4th. On
efTuaon into the pleurc, sometimes also associated
with some effusion into the pericardium, and the
symptoms of hydrothoraz : — and, 5th. On disease
of one or more of the abdominal viscera, either
with or without effusion into the peritoneum ; se-
vere diarrhoBa or dysentery occurring, and, whilst
it carries off the dropsy, causing a chronic disease
of the digestive mucous surface, occasionally with
ulceration and its consequences ; or suppression
of urine from congestion or inflammation of the
kidoeys taking place, and aggravating all the
dropsical symptoms ; or obstruction of the liver
soperinducing an obstinate and dangerous form
of ascites.

127. Anasarca consecutive of scarlatina is most
frequent in children, and is rare in adults. Other
eruptive diseases, beside this, give rise to dropsy
of the cellular tissue, especially measles, ery»i-
P«la^, urticaria, miliary fever, and many chronic
^liaeases of the skin ; owing not only to their
*»pprettion or retrocession, but also to impeded
<«cretion, and to the consequent exerementitial
plethora often attendant, or consequent, upon
them. When it is consecutive of these diseases,
It possesses either the sub-acute character com-
°u)n in that following scarlatina, or the moie
*cate symptoms of the primary form.

128. C. Primary attnenie anatarca is not so fre-
quent as the preceding. It is even questionable
whether or not the asthenic cases, usually con-
iidered as idiopathic, are not depending either
on stnictural change in an important emunc-
^orr, as the kidneys, or on obstruction about the
r ght side of the heart, or congestion of the large
veins and of the lungs. There can be little doubt
that many of them are thus connected ; yet some
in«tances will present themselves, in which the
a«tbenic state is primary, as far as can, be ascer-
tsrned. I'hese are most likely to occur in persons
Ijviog in cold, miasmatous, moist, low, imper-
fectly ventilated^ and dark places; particularly in

those of a lympathic or phlegmatic temperament,
or who lead sedentary lives, and are insufiiciently
nourished ; in those who have experienced copious
losses of blood, or are reduced by chronic or re-
peated discharges, as by hcmorrhagia, diarrhoea,
dysentery, &c., or who, whilst convalescent from
severe exanthematous or other fevers, have been
exposed to cold and humidity; and in persons
under the influence of depressing emotions, or
who have suffered some sudden alarm. This form
of the disease may accompany retention of the
menses, or chlorosis ; and it may supervene also,
in debilitated states of the frame, upon obstructions
of the catamenial or hasmorrhoiaal evacuations.
Many of such cases, however, will approach
very nearly to the sub-acute form, and derive
benefit from evacuations. The cases of anasarca
produced by terror, * disappointment, surprise,
mental distress, &c., and termed spasmodic by
Landrx Beauvais, and some other writers, ap-
pear to belong chiefly to this variety. That these
and similar causes are sometimes followed by
snasarca, cannot be disputed ; but I question the
dependence of the disease on spasm. Even
granting the existence of spasm, what are the
parts affected by it, and how does it act ? Con-
vulsions will sometimes occasion oedema of cel-
lular parts; but^they will also, during their
continuance, sometimes remove the effusion, as
observed by Dr. Wclls. The causes which are
supposed to act by spasm, merely derange or
impede the circulation through the heart and
lungs, occasionally also rendering the hepatic
circulation more languid or difficult than natural,
whilst they lower the vital tone of the extreme
vessels, particularly in weak and irritable consti-
tutions, and interrupt the excretory functions,
thereby inducing the conditions of the vascular
system most favourable to the occurrence of
serous effusion. Cases rapidly produced by
fright have been recorded by Tissor, Desessart,
BxAUCHXNE, Breschet, Bateman, and others ;
and numerous instances connected with disor-
dered or delayed menstruation, and the exhaust-
ing diseases mentioned above, have been adduced
by Plater, Riedlin, Forestus Piso, Wilms,
Eller, HorPMANN, Sauvages, Leib, Melitsch,
and later writers.

129. Asthenic anasarca generally appears
slowly, and with all the signs of debility and
laxity of the soft solids : whilst the sthenic dis-
ease often forms rapidly, and with many of the
symptoms of fever, or increased action. The
infiltration usually commences in the lower ex-
tremities ; sometimes in the face, or in both ; slowly
extends over more or less of the body; and is
most remsrkable, as well as most early, in those

1>arts of the cellular tissue which are the most
ax, as the eyelids, genitals, &c. The pulse is
small, soft, and occasionally slow ; the skin be-
comes paler, whiter, and colder than usual. The
surface pits much more easily on pressure, and
retains the impression longer than in the acute
or sub-acute forms. At first, the infiltration of
the lower extremities is most remarkable at
night, and nearly disappears in the morning;
but it subsequently returns earlier in the day,
and to a greater extent, and is incompletely or
partially dispersed by the horizontal posture ;
the reverse taking place as to the oedema of the
face. Ultimately it becomes much more con-

638

DROPSY OF CELLULAR TISSUE— Tbeatmekt.

siderablei more general, and more permanent,
sometimes with signs of coincident or consecutive
effusion into one or more of the serous cavities.
But the collection is very rarely so great, or so
complicated, in primary asthenic anasarca as in
tlie symptomatic. The urine is in small quantity,
and seldom contains albumen. The bowels are
either sluggish or irregular ; more commonly the
former.

130. D. S\fmptcmatie anasarca may present
either acute, sub-acute, or chronic characters.
But it is most frequently chronic, passive, and
asthenic, and nearly resembles the primary
asthenic variety now described, as respects tl)e
constitutional powers. When, however, anasarca
is complicated with, or consecutive on, aeut$
di»ea$ai of ih€ lutigt (§ 29.), it is also acute or
8ub>acute ; but it is rather, in this case, a con-
comitant effect of the exciting causes of the
pulmonary disease, than a symptomatic affec-
tion. Organic changes of the heart and k:dneys
are the most frequent sources of symptomatic
anasarca. I shall, therefore, notice this com-
plication more closely than the others. — (a)
Anasarca generally supervenes on chronic lesiom
of' the heart f and especially towards the close of
life ; usually commencing in the face, particu-
larly in the eyelids, and uppn rising in the
morning. Sometimes the ancles begin first to
swell, and occasionally both the face and ancles —
the former in the morning, and the latter in the
evening. The infiltration gradually increases
and extends; effusion into the pleure, or into
the pericardium, or into both, also taking place
either simultaneously or subsequently.

131. (b) Anasarca caused by diteaie of the
kidneyt is very seldom seen nnassociated with
effusion into one or more of the serous cavities.
It is, when thus complicated, attended by pain
in the loins, by sickness, vomiting and diarrhoea :
it usually commences in the lower extremities ;
and is commonly in consequence of irregular
and drunken habits, or of the scrofulous dia-
thesis. It is very liable to recur, and is seldom
permanently removed (§ 34.). Anasarca is also
sometimes a consequence of chronic disease of the
lungs, particularly chronic bronchitis, bronehor-
rhasa, chronic pleurittM, and tuherctdar phthisis.
In these cases, the infiltration commences either
in the face or in the lower extremities, only oc-
casionally extends as high as the thighs or hips,
and seldom becomes general ; but is often asso-
ciated with effusion into the cavities of the chest.
Organic changes of the liver and uterine organs
but rarely occasion anasarca, until after effusion
into the cavity of the peritoneum. The ob-
servations already offered respecting the con-
nection of dropsy with disease of the blood-
vessels and lymphatics ($ 27.) are entirely appli-
cable to this species of the disease. Although
complete obliteration of one even of the largest
venous trunks has taken place, serous effusion
will not necessarily follow, especially if a col-
lateral circulation be established. A remarkable
instance of this is recorded by Mr. NViiaon,
where the vena cava was entirely obstructed, but
no vestige of serous effusion existed, — evidently
proving that other pathological conditions, beside
venous obstruction, are requisite to the occur-
rence of effusion ; whilst in the case of obliterated
cava published by Labknec, ascites and anasarca

of the lower limbs existed. Of the agetkcy &f
disease of the vascular systems in cansiav local
or partial anasarca, sufficient notice has b«>*£
taken (§ 25. et seq^X The caHses, wterhid effeKr-
anees, and pn^natist in anasarca, have been 4*-
scribed under' these beads in the early pan of itid
article ($8. 14.37.).

132. iii.TRSATMBNT. — lst« Of partial or km
Anasarca. — After removing the remote casf<^
(^8.), the next object that we have to aUtie. b
to restore the natural secretions and excretM&<.
when any of these are in fault, and to reao««
the pathological state on which the afltettv.
depends. The restoration of the aecretioos %\
bf attempted by the means appropiiate to t' o*
chiefly disordered, — by purgatives, diaretm, dn-
phoretics, deobstruents, &c., as the intestinai. tKp
renal , the perspiratory, and the biliary sccte&am^.
may indicate more or less of disorder or of uii«^
ruption. If the oedema depend upon the artkn *-•
or rheumatic diathesis, after the use of ti>v*
means, colchicum intemaUy, and iodine «stt">
nally, may be prescribed, and aided by the wp-
port of bandages : if it proceed from amamarrkt
or the final disappearance of the catameva. «
moderate bloodletting, general or local, sK^'.pI
precede the means directed to act on the $e«^-
tions. In many of such cases, as w^D a^ .
others where there is no obstruction to tt» cs*.>
menia, particularly in females who have b»
children, or who are subject to conslipaiinn, *z '.
fecal accumulations in the large bowels, ibf
femoral veins are either chronically ioAan^:.
obstructed, or varicofle. Tbeir oonrae sl^e>s *
therefore, be carefully examined ; and if ci
hardness or tenderness exist, leeches oufht \*
be applied. In old or chronic caaea, howew
the veins will either feel hard and obstrod*^
without much pain, or they will be nearly obtu-
rated, the superficial vesMls being diAeoded s~-
vaiicoee, and the surface of the limb sooNntm^
purplish or dotted with dark red spots, ev*^*
tumid, and unyielding to the touch ; psia si-
stiffness being referred chie6y to the lower pa*:
of the leg and ancle. In several saeh case-. I
have prescribed, with mariied beneSt, dfobstntrj
purgatives, the biborate of soda, and iodtft- .
causing the patient to wear a laeed stoci>':
and to have frequent recoune to fncdoas. !'-
nefit will be derived also from frictioos ^ t
mercurial liniments, united to one of tbose thr*
to be referred to; and from a eoune ai }»>>'
aperient medicines. W h?n the dkacAsc &. ? :
veins is connected with marked debSitt t*
weak powers of digestion and annubiioB, srM
tonics, chalybeates, frictions with adnnikr^v
and deobstruent liniments (^ 65.)* will acrvlc '•
a cure. (See PfiLECMAsiA Dolexs end \ ii^
— Diseases of.')

133. The connection of oedema witib ««tf-i^
rh<ra, independently of ohitruetiam in tka insi.
quires a persevering internal vie of w6n», tt •
the biborate of soda, with tonic apencat- •
the compound decoctioii of aloes, &e., p«*n '
by general or local depletion when st;^ of :■
thora or internal congestion ere praaent. I'
when there are chlorotic appeenacea ef "
countenaoiie and surface, or im^br onar-* ^
ations of hysteria, with great mobiliiT of tW tri'-
cular, and susceptibility of the aerfoes. si o c
a weaky soft, open, 9r nadaiatiaf polie, «^

DROPSY OF THE CHEST — Pathology op.

64 i

* So. 4S1., et ceat. 1. obs. 31 . (Omseguent on measiet.) — >
J. SpoHy Aphoruml Kovi Hippocr. 1689. p. 392. (.Blocd-
tetliMg.y—Bonett Med. Scptentrlon. 1. iii. sect. 21. p. 723.;
vt Pulji^thef, I. iv. cap. 46. S9. {AntiphlogisticM.) —
Cot it FtUan, Ergo L«ucophl<*gmatt« Levet Scarinca-
tionei. Parii, 1738. — Cuenault^ Ergo Leucophl. Leves
Scarif. Paris, 1750. — A<iet^ Ergo I^ucophlegmatUe LeTes
Scariflcatiooa. Faria, 1758 — Cartkevser, De Leuco-

pblegmatia. Fr. 1760 Livinntan, Edin. Med. and

Pbfs. Etsayf, toI. il. p. 407. — Pienen, Act. et Obsenr.

Mid. p. 87. 107 StoU, Rat. Med. par. ifi. p. 302 Mis,

Ob». Cbirarg. fate. l—Saupagrs, Nos. M^th. vol. IL p. 470.
—Tktitiuui, Med. u. Chirurg. Bemerk. p. 169 — ClusUm,
Philoc. Transac 1780m>. 323. 57ti. (Thoracic duct obliter-
atrd.)—Bang, in Act. Keg. Med. Soc. Haun. voL ilL p. 1 18.
— AatJtow, Uk Ibid. toI. lil. art. 15. — Hartmannt De
AnaAarca. Lad Sulph. et Acid. Sulph. &c. Fr. 1787 —
Dove, In Edln. Med. Comment, vol. xviit. p. 135. — 7*ox-
vui, Raocolta, Ac. No. 4. {RecomnMmdt bli*UT$ in the
aaaiarca conuqneni on tearlatina.) — Tode, M«d. Chir.

Kiblioih. b. t. p. 432 J. P. Frank, De Cur. Horn. Mor-

Ml. 1. UL p. 79. — Chalmers, On the Dis. of South Ca-
roUiu. vd. il. p. 20. — Vteu$$eux, in Joum. de Mftd. Con.

tin. t. iii. p. 3 Leib, in Philad. Tfaniac. vol. i. p. I.—

JiarciUf Magaain flir Specielle Therapie, b. ii. p. 342 —
Meiiuck, in Siark't Archir. b. iii. p. 724 — BcraucA^e.in
Joum. Gtoir. de MM. t. xxxli.p. i7\.-^fVindmann, in
HMjtUmdu. Himlu'* Joum. d. Pr. Heilk. Oct. 1809 —
Sacimretaer, in Allgem. Med. Ann. MarL 1811, p. 243.
—Dfunsart, Recuell de Dissert, et Obsenr. de Med.
Prat. Parts, 181 1 . _J. WiUon, in Trans, of Soc. for Imp.
of Mi>d. and Chir. Knowledge, vol. Ui. p. 65.— W. C. WelU.

io Ibid p. 167. et 187 D.C. F.Hartes, De Hydr. Inflam-

Buturio, in Opera Minora, toI. L p. 339. — Gairdner, Ed.
Med. and Snrg. Journ. toI. alv. p. 4n.-^ Steele, in Ibid.
>ol. xtL p. 545. _ Landr4'Beauvai$, Diet, de Med. t. ii.

p. \^^Laennec, Archiv. G^n^r. de M6d. t. vi. p. 619

Koenig,\n Hnjeland'i Joum. July, 1829. ; and Archiv.
ti^^r. de MM. I. xxi. Pl 449 — Venable*, in Lond. Med.

(iaxette, vol. T.p. 397 Beattju in Trans, of Assoc. Phys.

»f IrHand, vol. It. p. 23 J. BouiUaud, in Diet, de Med.

pt Chir. Prat. t. ii. p. 320. (See also the BiBLiooaAPUY
AND REFBaKHCES to Dropsiet In Genere.)

VII. Dropsy of the Cavities op the Chest.

143. Defin. — Seme of oppreuion in the chest ;
urgent dyspnoM on exercise or in the horizontal
jmture; Ucid lips: edematous countenance and
utremities; weak^smalt, and irregular pulse ; dis'
turbed sleep, tvith sudden sturtings, ^c.

144. As dropsy of the pericardium is so very
geoerally coDoected with more or lesi efTusion
ioto the cavities of the pleurae, that we seldom
fad the one without the other, although in vary-
ing grades and relative proportions; and as the
former, as well aa the latter, is a very frequent
coosequence of structural change in the substance
of the lungs, or in the pleurae, or io the heart
itself and its valves; I shall, therefore, describe
tbem 9s species of the same genus. The difficulty,
also, of determining whether the fluid is chiefly, or
Altogether, in the pericardium, or in the pleurs,
(veo in cases where it is limited to one only, u an
additional reason for considering hydro«pericar-
diam and hydrothorax in connection with each
other. It is principally, however, when the eflfu-
&ion is symptomauc of structural lesions of the
tlttmric viscera, or of a more generally morbid
^te of the frame, that we find them co>existent,
>od without any remarkable preponderance in
favour of either the one or the other. But when
effusion is the more immediate result, or the se-
quela, of inflammatory action, or of a state of
orgaoic action, closely allied to inflammation in
etther the pericardium or pleurae, it is geneialty
limited accordingly, and it often accumulates to a
y«7 gfeat extent.

'. i)Rop6Y opthePbricardi^vm. — Syn. Hydrops
Perirar^i, Hydro-pericardii, hydro-pericardia ^
U Vidro-pericardium (from W«p, water, and
irs^iMp^oT, pericardium) of Authors; Hert-
hentehoasaertueht. Germ. ; Hydro-piricarde, Fr,
i)ropty a/* the Heart, Eng.
Vol, I.

145. Defin. — Oppressive dyspnaa, with a sense
of veigkt and tremor referred to the region of the
heart ; anxiety ; inability to retain the supine pos'
ture ; ueak, irregular, or intermitting pulse ; livid
and adema tous countenance ; distension of the jugu-
lar veins; leipothymia ; fulness of the epigastrium,
and of the anterior intercostal spaces; percussion
enUttiug a dull sound, and auscultation furnishing
a Joint and difused sound, over all the cardiac
region.

146. A. It is obvious that pathologists ought to
agree as to the least quantity of fluid in the peri-
cardium that should be considered to constitute
dropsy of its cavity. Vesalius states, that it
always contains a small quantity of water in
health, and that he had observed it in criminals
who had been quartered while alive. Lower en-
tertains a similar opinion. F. Hoffmann, how-
ever, comes to a different conclusion ; he having
observed no fluid in the pericardium of healthy
animals; whilst Littrb found some in the ani-
mals on which he experimented. Halleh believes
that this cavity contains a fluid destined to facili-
tate the functions of the heart, butgivea no opinion
as to its quantity, in health. He remarks, that it
may be greatly increased in various diseases, and
that it may be absorbed, {Elementa Physiol, ^c.
4to. vol. i. p. 292.). Senac infers that, in the
natural state, the pericardium contains no fluid ;
he having found none in several cases in which
this membrane and the heart were both healthy.
Cohvisart, Testa, J. P. Franx, Kreysio, Ber-
TXN, Louis, Ei^liotson, Hope, &c., appear to have
adopted the opinion of Haller, in considering
that this cavity always contains a little fluid ;
but they differ in some respects as to the amount
which should be viewed as constituting dropsy
of it. M. CoRvisART believes that, when it reacnes
six or seven ounces, hydro-pericardium exists.
This inference has been adopted by Pinel, Ber-
TiN, Elliotson, and Hope, who think that this
quantity will give rise to symptoms indicating,
although with great uncertainty, the seat of ef-
fusion ; whilst Laennec concludes that double or
triple this quantity may not admit of a correct
diagnosis. Much, however, will depend upon
the rapidity of its collection, and the nature of
the pathological states either causing it, or con-
nected with it. A larger quantity than that now
named, has sometimes accumulated without
having induced such symptoms as could enable the
practitioner to decide as to the exact nature and
seat of the disease, particularly when chronic
aflPections of the lungs or heart have accompa-
nied it.

147. From one to five or six ounces of fluid
are sometimes found in the pericardium, in several
maladies either of adjoining or of remote organs,
especially in persons who have died of phthisis.
This collection, obviously greater-— at least, the
higher amount — than exists in health, seldom
gives rise to specific symptoms, although the
larger quantity may occasion much disorder. It
may, indeed, form very shortly before death, and
may merely be contingent on the changes imme-
diately preceding dissolution, particularly when
the malady destroys life by asphyxia, or when
congestion of the lungs and disorder of the re.<pi-
ratory actions have been present for a short time
previously ; and its amount may even be increased

' subsequently to the fatal issne. When fluid collects

Tt

DROPSY OF THE CHEST — Pathology of Hydrothohax.

645

action of the air upon the inflained or otherwise
diseased membraoe; and hence the impropriety
(and probable cause of failure in several cases)
of leaving a canula in the opening, or of intro-
ducing a tent sponge. I state this from having
seen this practice adopted in cases of paracen-
tesis, and carefully observed the anteceuent and
consequent states of diseased action. I would,
therefore, submit, when the last resource of an !
operation is attempted, that it should be per-
formed with the utmoat precautions against the
introduction of the external air; and that the
opening should be carefully and accurately
closed, and kept closed, instantly upon the dis-
charge of the fluid ; and that, instead of pre-
serving an opening for its continued flow, the^
operation should be repeated when it becomes*
really necessary. (See Heart and P£ricar-

DIl'JJ.)

BiaiioQ. andRbfbb. — Go^^, De hoc. Af. 1. v. —
SartAolmy An»t. Reform. 1. ii. p. 25^.— Pi«o, De ScroaiB
Mofb. OtMenr. et ConsiL sect. iii. capi i.^-Diemerbroeck^
Up. Omn. 1685, p. 615. — RManus. A nth Topograph u.
P^ru, 1619, L vi. cap. 7. {Reeommendt to tap the pericar-
dt»m.)—H. Stutmia^ Prelect. Pract. pan ii. cap. L p. 648.
fd Jr'ic. 1690 — F. Hqffnumn, De Hydr. Fcricardii. Hai«,
1*^. ; et Opp. 8upp. hLci. — Bon^, Sepulchretum, &c.
1- ii. Met i. Ob. 101., et sect ii. otn 15. — Mereker, De
Hydrocardia. Ultraj. 171 1.— Dwernry^ Mdm. de V Acad.

R07. dea Seien. 1703, p. 158 Senac^ IVaite dela Struct, et

(1e> les Maladies du C<sur,4to. Pam, 1749, t. ii. k ir. cap.
6 - Mamget, Tlieat. Anat vol. ii. p. 1727. — Laneisi, De
Motu Cordis et Aneur. Roras, 1728. — Morgagni, De
Caiu.&c. epiflt, avL art. 20., alto epiat. xvii. xxiti. xxxvi.
xtxviL ^ Meekely in M^m. de 1* Acad, det Scion, k Ber.
hn, 1755, p. 56 — Lentin, Beytrage, b. ii. p. 61 . {Recom-
^*f»i$ pmrgativeg. dfureticM, and itimuianta) — Lieutaudt
Hi%t. Aoat. M&l. 1. ii. obtenr. 61 1. 621. 648. 663. 683. 857-

■^Swiini, InttituL Med. Pract. vol. Iv. cap. 5 SidrfH*

in Art. Med. Sueclcorum, t i. p. 407. {^ffvs. in pericard.
<f»i».]—Sandifort, Obaerr. Anat. Pract vol. i. p^ 40.,vol.iv.
p. U/9.—J. P. FramA, De Curand. Horn. Morbts, vol. v.
p. 'H\.— Qauirrit, Animad. in Morb. Chron. p. 99.—
HeiMcke, De Hydr. Pericardii, 8vo. Erf. 1709. — For-
taj, Anat. Hedicale,!. iii. p. 11. — Conradi, in Amemann^M
Mj^ajin, b. i. p. 81. {^dvhes paracentesis,) — Landvoigkl,

I)e tlydr. Pericardii dignotcendo. Hals, 1798 DesauU^

IKuvretChirurg. &c. t. ii. p. 304 — Corvisartt Traits dei

M^. du C«eur, Ac. Parii, 1816, ed. 3d 7V«ra, Delle

Malattie del Cuore, &C. vol. iii. Bol. X^W.^Kreytig, Die
Krankiietten d. Hersens, &c. b. iii. Berlin, 1817.— If'ooc/,
in Lond. Med. and Phyn. Joum. vol. Ixi. p. 406. {Two
quarU of fluid ^msed.)—HenRent in Edin.Med. and Surg.
Jouro. vol. XVI. p. 539. {^u$. into pericard. onlv.) — Hen-

dertoH, in Ibid. p. 535 Laenntrc^ Au^cult. Med. t. ii.

y. «J70. 2d. edit. ; et Translat. by Forbes^ p. tuS.^Jtard,

in I>ict. dcs Sdencec Mid. t. xxii. p. SfS Herat^in Ibid.

t. xl.p. JK>.,-^Romero, in Ibid. p. 371. — J. Franks Praxeos
Jledic« Univers. Pr»cep. vol. li. parts ii. sect. ii. p.l68. —
Raifrr, in Diet, de MM. t. xi. p. 394.— J. BouiUaud, Diet.

de .MtnI.et Cbir. Prat. t. x.p. 157 Ar/m.Traiti des Mai.

du Ccpur, Ac. 8vo. Parii, 1824. — Portai, Obcerv. lur la
Nat. et Mtr le Traltement de I'Hydr. t. ii. p. 131.

ii. Daopsr or the pLEtJRAL Cavitifs. —
Syn. Hifdrotkorax (u^wp, y«-ater ; &«p«^, the
chest), Hydropg Saceomm Pleura, Auct. var. ;
Dropsy of the Pleura; Hydrqp'nie de la Poi-
tnue, Fr. ; Brustwassenucht, Germ.; Idro*
pUia di Petto, ItaK ; Water in the Chest.

158. Defik. — Dyspnaa and opjn-ewon m the
chfit, increated by the harixontal poiture and ex-
ereUe, irttA <gdema commencing in the eyelids and
anelts ; startings from sleep ; the spunds on per-
cuttion being dalt^ ond the respiratory murmur
not heard on auscuttation ,

159. Hydrothorax has been divided into idio-
pothie or primary, and symptomatic. It is very
nrely primary, as M. Lasnnec has observed-^
that is, without pre<ezistiog disease of the pleura?,
ianga, heart, or large vessels. But it is often
<tm«fcitifr« of increased vascular action, or in-
flammatory irritation of the pieuras, without any

Iesioi\ of other parts, particularly when it follows
the eruptive fevers ; and it may be a termination
of pleuritis, especially in the lymphatic or phleg*
matic temperament, and in the cachectic habit
of body. Its symptomatic or complicated states
are the most common. As the consecutive hy-
drothorax, in all its forms, is eenerally acute or
8ub>acute, or assesses more or less of the sthenic
characters, it will be considered as such ; whilst
the symptomatic will be viewed as a passive,
chronic, or asthenic disease.

160. A, Acute AND sub-acvte Hyorothohax }
Injiammatory Hydrothorax, Hydro-pleuritis, or
Hydro-pleurisy, of Rayer. — That this form of
pleural dropsy consists of increased exhalation
from the pleura;, depending upon increased vas-
cular action and determination to this surface,
will be admitted ; but that it is identical with
inflammation, of an acute and healthy kind, may
be questioned. The symptoms, local and con-
stitutional, in hydrothorax of the most acute
kind, and in pleuritis — either the pulmonary or
costal — are certainly not identical, particularly
in respect of severity. Ilcnce, although much
similarity exists, as far as mere vascular injec-
tion, or determination of the circulation, is con-
cerned ; and althougit pleurisy may terminate
in, or give rise to, serous effusion m many in-
stances ; yet the kind of organic action affecting
the pleurae, and the attendant constitutional dis-
turbance, are not the same in both. The differ-
ence has already been alluded to (§ 18.); but I
may here add, that the formative processes — the
kind and grade of organic vascular action — cha-
racterising pleuritis, are not observed either in
the local lesions or in the constitutional afTection
of acute hydrothorax, unless when the eflPusion
supervenes on external injuries and inflamma-
tion, or is an earlier attendant on a modified
condition of such disease. The consecutive states
of acute pleural dropsy, as it may be studied
after scarlatina, either during life, or in the mor-
bid appearances, illustrate this view^ and prove
that there is, as respects both the conditions of
the effused fluid, and the changes in the pleurae,
a difference in the kind of organic action whence
they have proceeded, from true inflammation,
and that such difference is evMently connected
with constitutional causes. It is very commun
to observe that, when an attack or attacks of
either pneumonia or pleuritis have been re-
moved by treatment, a slight exposure to their
exciting causes, or irregularities on the part of
the patient, before the diseased vessels have re-
gained their healthy tone and action, will give
rise to a less acute, or a smothering, state of di.s-
ease, either attended by, or quickly' terminating
in, eff'usion ; the reduced powers of the constitu-
tion, the lost tone of the exhaling pores, and the
geneial or local excited action, favouring this par-
ticular malady — this morbidly increased serous
exhalation — in preference to any other. In
this way acute or sub-acute hydrothorax super-
venes on a state of the frame which has not
recovered from previous disease — more particu-
larly from eruptive fevers — or which hai been
impaired by age, excesses, or irregularities ; the
powers of life, and the organic actioc^ t^t'rcon
depending, being insufficient to develope sthe-nic
or phlogistic inflammation, I'hc iuferencts, then,
from the causes, accession, phenomena, and coq-

Tt3

646

DROPSY OF THE CHEST— Diagnosis of HYDnOTiioRix.

comitant chaoges observed in the acute or iub'
acttts disease, are, that it is not identical with
healthy inflammation, although frequently so
nearly allied to it as to appear either as a ter-
mination, or as a lower grade, or as a modification
of it ; and that it i^ often connected with, even
although it may not be dependent upon, the
nature of the preceding malady, in which the
secretions and excretions have been interrupted,
and not sufficiently restored.

161. That inflammation of the bronchi, or of
the substance of the lungs, will sometimes be
propagated to the pleurie, generally in conse-
quence of constitational fault or injudicious ma-
nagement, and give rise to effusion into their
cavities, is well known ; that inflammation of the
surface of the liver, or of the peritoneum, or of
both, will occasionally extend to the pleurae, par-
ticularly in debilitated or cachectic subjects, and,
having reached this situation, terminate in effu-
sion, I have often reraaiked ; and that the state
of vascular action, whose similiarity or connection
with true inflammation has been noticed, but
whose identity with it has been denied, will occur
in the pleure in various states of seauence and of
complication, has been a matter of daily observa-
tion, and may be readily illustrated from the pages
of BoNET, MoROACKi, Stoll, Lepois, Lieutaud,
Leroux, and many other of the writers referred
to. In some localities, also, and during certain
epidemics, it bas been remarked that peripneu-
mony has evinced a remarkable tendency to ter-
minate in thb manner. Dr. Romero states, that
on the coast of Andalusia, hydrothorax and hy-
dro-pericardium are endemic, owing chiefly to the
prevalence of hot and humid winds, and sudden
atmosphenc vicissitudes, particularly among those
who are ill fed, or live on unwholesome food,
and are given to intoxication or irregularities;
and M. Pariset observed this form of hydro-
thorax prevalent in Geneva, in 1803, — the symp-
toms being so lieht that the patient's appetite and
ability of attending to his affairs continued until
the pleural collection induced violent oppression.
He states, that the number who died among the
French conscripts was very considerable, — the ef-
fused fluid being limpid and inodorous, and the
pleura greyish and thickened, and the lung com-
pressed, or condensed.

162. The morbid appeaiances in the acute form
of hydrothorax, whether it has been connected
with inflammation, or active congestion of the
substance of the lungs ; or has proceeded from a
modified form of pleuritis, either occuriing pri-
marily, or consecutively on an eruptive fever, or
after the suppression of some chronic disease of
the skin, or of an accustomed discharge ; are
usually the following : — 'Ihejlnid presents everv
shade of colour already remarked ($ 11.) — is
sometimes turbid, muddy, reddish, sanguineous,
whey-like, or sero-purulent ; but more frequently
transparent, of a citron tint, with filaments or
numerous albuminous flocculi floating in it. The
membrane is internally reddened, or injected,
thickened and somewhat softened, and occasion-
ally covered by an albuminous, granulated, or
tuberculous exudation. The lungs are genemlly
compressed, condensed, hepatised, or tubercu-
latea ; and present appearances of chronic inflam-
mation. Tne causes of this form of hydrothorax
are the same aa those described above ($6, 9. 19.).

163. B. Symptomatic, passive, ob coa^ii-
GATED HvDROTuoRAX. — This fflste of di«ea.«e i»

dependent upon some obstacle to the cxrmlznoii
of the blood, or lymph. Its cooDection witii d.l a-
tation of the cavities ; with hypertrophy, atrc^ph}.
&c. of the substance, and with alteratioiis of tb*
valves, &c. of the heart ; has been loog since poiotrd

out by BoNET, MOROAONI, LlEUTAl'D, Mirxii

Sandifort, &c. Disproportion between the capa-
cities of the cavities, ossification of the vahres, ao'l
various other lesions of tliis organ, have bets
still more minutely examined in relatioD to tk
production of hydrothorax, by Cortisakt. L«ih-
NFC, Testa, Krevsio, Bbrttm, and mhetK
Varicose dilatation, also, of the veins of the \nM^\
^nd compresnon or obliteration ^of tbeo, fna
chronic pneumonia, or tubercular and other pro-
ductions, are sometimes the immediate cause of
effusion. The dependence of this form iti lijt
disease upon alterations of the lymphatie!i, either
in their glands or in their trunks, once so sirooji)
insisted upon by the able pathologists alrtaJj
named in connection with this doctrine (^V'.
although not improbable, has not been cstabli»b«d
so as to admit it otherwise than as an oeeaiioui.
and by no means frequent, occurreoee.

164. The fluid effused in this form of byir^
thorax is commonly transparent, coknirles, or of
a citron tint ; in rarer cases, it is of a light brown,
or reddish hue, or even sanguineous ; its qnaatai
varying from a few ounces to ten or tvdTt
pounds, in both the cavities. In some case^. •
quantity of aeriform fluid hf also present. (Nt
art. Pleura.). On the evaciation of the serve .
the pleurs are generally observed to be soqdu .
or merely paler, or somewhat softer, than natapl.
When the accumulation has been great, th^
lungs are generally pushed up to the venebnl
column, are hardly crepttoos, and are oecaw«-
ally pale as if macerated ; but they soBetioM^
admit of being distended by insnfllatioD, whet
they have not been inflamed and hepatised. h
this form of the disease, effusion frequently talk:*
place into the pericardium, as a ooexisleat i¥M.h
of the same organic changes; and occaaoeinf
some fluid is also found in the abdomen, or <«cfi
within the bead ; bat more comnonly ia tke
cellular tissue, constituting a more or leas cms-
plicated or general state of dropsy. M. Riti*
justly remarks, that anasarca, bydro-pericaidboi.
and ascites, are more frequently associated viti
hydrothorax when it is caused by organic leioc-
of the heart, than when it is consequent vpcQ
alterations of the lungs.

165. C. Diagnosis. — As hydrothorax is irrr-
rally produced by anterior disease, it follows it>'t '
will not become manifest until some days, orc't'
some weeks or months, aAerwaids ; Or, in ca<««'f
organic change of the heart or lungs, not ac^I a
few days or weeks previously to death, tut
with the aid of pereussdoa and auscuhalioB. nil
collections of fluid are ascertained whh n*f\
difficulty, and are marked by the rrwpuiaa c
the lesions that cause them. But wnes the Ac-
cumulation is considerable, it b generally eftv^i
by phenomena which are proper to it. The paiff*<
feels an oppre^onand difficulty of bivathimr. ;n«i
in proportion to it* quantity. He geaenlly *'»
upon the affected side, leaving the beahh) e^
unincumbered in its functions. Wh^-o tht f-*-'
is in both cavities, the respintion is Aitt c*^

DROPSY, CONGENITAL— Patholoov of.

649

or never resorted to, excepting ia empyema. In
some states of the acute duease, especially when
the elfasioD is principally in one cavity, and is
col attended by organic changes in the lungs or
heart, of a necessarily fatal or dangerous kind,
the coodition of the patient in other respects not
contra-iadicating the propriety of performing it,
thifl operation may be as siifely and beneficially
practised on the thorax as on the abdomen ; the
same risks — and no greater — existing in respect
of the one as of the other. It has been recom-
mended by GOOLA, DUVBRNEY, BlANCHI, De-
LAPORTB, MORELAND, HuBTTBR, MORANO, LuL-

LiER, J. P. Fbanb, Mursixna, Bell, Romeeo,

aod AncHER,and practised successfully by nearly

all of them. The chief danger proceeds from the

introduction and action of the air; but not so

much from its preventing the dilatation of the

ioD^, as from its action on the diseased pleura,

and the fluid effused from it, as shown above

($ 157, \ (See arts. Lungs, and Pleoha.)

BiBLioo. A!fD Rbprl— Gov/a, Ergo in Thoracii quam
In Abdom. Hjrdr. Paracentesis tutior. Paris, 16^(4.—
BalUmimt.Opera, «oI. 1. p. 13 — BartAoUn, Hist. Anat. vol.

".p. 7. G^-^Rfverfus, obs. i. 60 Wi/Zi* Phartnac. Rat

h. j. li.^Dufermry^ In M<m. de I'Acad. Roy. de Scien.de
Parii, 1709, p. 197. (Paracentesis.) — Bonet^ Sepulchret.
1- ii. i. i. obs. 73. 94., s. ii. ob. 7.*^. et scq.—Biancht\ IHstor.
Hepat.i. p.662.— AforY<^;iu',De Sed. et Caus.cp. x.a.ll.,
q>. xii. a. 3.— 40. — iSn-gtT^ Sur THydr. de la Pcltrine.
P-mi. 1736. {.ParacciUcsi* ree(nitmended.)~-BopiUrt, Sur
riijdr. de la Poitrine, &c. Des. 4to. \7!».—^torand, in
McTo. de I'Acad. de Chirurg. t. ii. p.547. — Avenbruggett
Invent. Novum, ex Percussione Ttioracis ut Signo, in-
lem. Mort>i Pcct. deiegendl. Vind. 1761. — Moreland,
in niiioa. Trans. 1766, p. 302.— Sauvagcs.Vo: Meth.
t i. p. 688. —Gonter^ De Diagnosi Morb. Pect. Vico.
)7^. _ Aiston, Ediu. Me<i. Essays, vol. t. part ii. p. 609.

— Simton,\n Ibid. p. 6^. — Lieutaudy Hist. Anat. M6d.

I. ii. Ob. to7. 875 Deiaporie, Ergo Hydropl Pectoris

Paracentesis. Paris, 1774 De Haen, Rat. Med. pars v.

c- 3., pars vl. c. 4., pars ix. c. 12 — S/oil^ Rat. Med. pars i.
p 23^>.(13/&f.fi» tJke ltftpUura.\et pars ii. p.378.,pars iil.
p- '-I., pars rtl. p. 216. ; et Prslect. vol. i. p. 80. — Vailis-

nrri, Opera4ii.p.lB5. MS Seite, N. Beytrage, b. i. p.l2l .

—RicktfT^ in Comment. Soc. Goet. vol. il. {Comptieaied
viik eareinoma mamrrue.) — Bockmer^ De Hydr. Pec-
tori,. Hal. 17^.— HUUer, Obserr. Med. No. 3'.. (^Cured
^ paraeemt, ), et No. M.^LetUom^ in Mem. of Med. Soc.

"f I>jod. vol. i Knebrl, De Hydrothorace, 4to. Witt.

\7jy — Pident, Practische Annal. st. 1. p. 46. — Rei/^

MciBor. Clinic. fa»c. iv. No. 8 J. P. Franks Interp.

ninic, i. p. 118. (ISpinU of water,) i et Act. Inst. Clin.

Viln. Ann. U. p. 26i6. — Darwin^ Zoonomia, vol. ii

Harlet, Opera Minora Acad. vol. i. p. 383. 8vo. lrt|5.

Hydrotkorax phiogistieus.) — A. G. Rtekter, Die Spe-
H^e Thcrapie, t. Ui p. 199.— fFendt, Annal. des Klin.
la«ttt. heft. 1. p. 61. (SfuiUs wiik tartar, iron and arom. )

— AiUenrietk, Observat. in Hydrothoracera, Ac. Tub.
UCj. _ Sp€tngenberg, in Hom'% Archiv. 1809. p. 40. —
h»puj/,\tk Journ. Gtakt. de Med. t. xxxiii. p. 19. {Digi-
tilit wtth anafeetida and sqtu'Us.) — BtUm, De Hydr.
P«Ktoris. Wurc. 1806. — Larrty^ In Mem. de la 8oc.
Mrd. d'&nulation,t. vf. p. 354. {\6ptntM qf water.)— Lui-
i'fr, in Journ. de MM. Contin. t.xvii. p.321 . {Paracente.
ci».)—}iur$innet^ Journ. f.d. Chlrurg. b. vi. st. 2. p. 6.10.
—L. Macleam, On the Nat. Causes, and Cure of Hydro-
t&orax,8vo. Ladb. 1810.— Rev .in Edin. Med. Journ. vol.vi.
V 474. — Robertson, in Ibid. vol. x. p. 295. — Hall, in
ibid. vol. vlii. p. 903.— Henderson, in Ibid. vol. xvi.p..'y29.
-^Hamilton, On the Prepar. and Administntlon of Di-
7iulis,ftc. Ldnd. 8vo. 1810. — //K/'e/aiMf, intloum. der
Pract. Heilk. May, 1812, p. 24. {Caiomelwitk oxide qfxhtc
and opimm.) — Hard, in IMct. des Sciences MM. t. xxii.
P- 4<i!i.— J?rMm«, In Journ. des Prog. t. xvii.p.v60. (D/-
et^aiis and tsietncarium, in large and frequent doses.) —

Icimnee, On Dbt. of the Chest. Transl. 3d ed. p. 491

L^omt, Cours sur les G^n6ralit6s de la MM. Pratique,
t. Til. p. 96. et sea. — Laydet, Archives Grn^r. de Med.

t. If. p. 430 Rayrr, in Diet, de Med. t. xi. p. 460.—

J. Prank, Praxcos Medicv, Ac. vol. ii. pars li. sect i.
I* <*7.V {See also tke BiBUOGBArar (t^DaoFSY; and qf

l>tOr»T OV THB PKBICAKOIL'M.)

VI 11. Dropsy, Congenital (Hydrops Congeni-
tttt ; Dropsy (f the Fartusantl new-born Infant,).
174. Detis.-^ Effusion of' u-aterif Jiuid in the

temus cavities, or ceUular tissue ^ generally con-

sequent upon disease of the mother , or upon organic
change in the appendages, or in some of the viscera,
of the fcetus,OT upon both causes,

175. Congenital effusions of fluid are found —
(a) in the ventricles, or between the membranes
of the encephalon ; (6) between the membranes
of or in the spinal cord ; (c) within both the
head and the spinal canal, in the same case;
{d) in the abdominal cavity ; (e) in the sub-
cutaneous and other parts of the cellular tissue ;
(/) in the cavities of the chest — the pericardiac
and pleural ; and, generally, in the above se-
quence, as respects frequency of occurrence.
They are observed in the foetus at the full term
of utero-geatation, and in abortions chiefly during
the middle and latter months ; and are, with the
associated diseases either of the uterus or of the
appendages of the foetus, the cause of its death, or
of Its premature expulsion.

176. i. Congenital Hydrocephalus (ffydro-
ceph, congenitus) sometimes appears, as other
forms of congenital dropsy, dependent upon dis-
ease of the uterus, or on constitutional taint in
the parent or parents, or upon organic change in
the placenta or umbilical chord. In rare in-
stances it has been associated with ascites in the
mother, or with dropsy of the amnion ; but it more
frequently occurs without any such connection.
In these latter cases, it may be imputed to a mor-
bid action seated in, and more strictly limited to.
the membranes, or internal cavities of the brain.
It is often attended by an arrest of the formation
of the encephalon at some stage of the process ;
but, in other cases, the brain is fully, if not more
than usually, developed. When the fluid effused,
either in the general cavity of the arachnoid, or in
the ventricle^, is considerable in amount, the ossi-
fication of the cranial bones is interrupted gene-
rally towards their sutures, but occasionally in
other parts ; and, in these situations, the mem-
branes are often protruded to a greater or less
extent, forming, with the sealp, a watery tumour
(hydrencephalocele), which may be large at birth,
or scarcely perceptible, and may subsequently
disappear altogether, or become larger. When
the effusion is chiefly in the ventricles, the dis-
tended cerebral substance, and the membranes,
with more or. less of the fluid, constitute the
tumour ; unless the effusion has taken place pre-
»viously to, and thereby prevented, the develop-
ment of the cerebral substance and hemispheres^.
Hence the character of the rupture depends upon
the situation of the fluid ; and its form, upon the
size of the aperture through which it presses.
Some forms of the disease approach to hemi-
cephaly ; a large portion of the cranium being
wanting, and the protruding brain being covered
by a thin membrane. In other cases, the opening
is small, narrow, or cleft-like, and the protrusion
is either small, or has a narrow neck ; the fluid
being, in such cases, usually eflTused between the
membranes. These ruptures are most frequent
in the back of the head, in diflTerent parts of the
occipital bone, and in the lambdoidal suture ; and
less frequently in the top, sides, and front of the
cranium. {See the Cases, and Writers referred
to.).

177. Congenital hydrocephalus arises at va-
rious epochs of fontnl existence. At the earliest
{XM-iods, it interferes more or less with, or entirely
arrests, the formation of the brain, and cranial

652

DROPSY, ENCYSTED — Causes and Patroloot of.

possible ; that, if any local medication be resorted
to, a simple discutient lotion — as one of vinegar,
rose water, and spirit, or liq. amroon. acetatis —
or a defensive and di»cutient plaster, with gentle
pressure, will be found the safest and most suc-
cessful ; — that, in addition to this, the abdominal
secretions and excretions should be promoted, by
means the least calculated to lower the vital
powers; — that a healthy wet-nurse should be
provided, to whom a gentle course of iodine may
be administered ; — that change of air, or resi-
dence in a warm and dry air and locality, be
directed ; — and that the mfant should wear soft
flannel next the skin, and be warmly clothed.
These have been the means I have employed in
most of the cases of the disease I have treated ;
and they have often prolonged life, and dimi-
nished the tumour, although, in many instances,
I was unable to learn the ultimate result.
When the exterior of the tumour becomes in-
flamed, or the integuments thinned and disposed
to ulceration, puncture may be then resorted to,
as in the case recorded by Mr. Abernethy ; but
care should be taken to close the opening accu-
rately after each o)^ration, and to protect the
part from the air and external injury by suitable
applications. (Sec Dropsy of the Head —
Treatment of Chronic.)

188. (c) As to the treatment of the other forms
of congenital dropsy, but little need be added to
the above. In some instances, it may be requi-
site to commence with the application of one or
two leeches. Purgatives are generally requisite,
and should be often repeated, and alternated
with, or followed by, diaphoretics and diuretics,
and assisted by the use of slightly alkaline baths,
of a temperature ranging from 85° to 94^. Many
of the cases of these forms of congenital dropsy
are beyond the reach of medical aid ; but, when
the infant is in other respects well formed and
strong, the existence of active congestion in, or of
vascular determination to, some one of the viscera
of the cavity in which the collection is formed, or
of inflammatory irritation in the serous membrane,
may be suspected, and moderate local depletions,
and active alvine evacuations, aided by means
calculated to relax the cutaneous surface, should
be employed.

BiBLlOCi. AND RuriR.-^i. COXOBNIT. DrOPSY OF THE

Head. — . JRvyxcA, Thesaur. Anat. ii. ato:52 — Blaneard^
Anat. Pract. Rar. cent.l.ob«.ro., cent. ii. cto$. 15.— Hrt/fer,
Di»put. Anatotn. t. vi. p. 3a0. — 5oci», Diwert. de Fcrtu

Mydropico. Ba«. 1751 Gehi<ry De Partu diffinli ex

Hydrope Fcetfis. Lips. 17(fi Marcorel^ Mftm. pre*, i,

I'AcAd. t. Iv. p. 458.— Orfirr, Recueil Period, t. vi. p.S89.

— Memte, in Nova Acta Acad. Nat. Cur. vol. xi. pan ii.
». 44.) — Pcnada, Sogxio d*Osftervasioni e Memorie, 4to.
Padua, 17U3. — Osiandtr, Handbuch der Entt^ndungsk.
&c. part ii. p. 'iQ\. {In an embryo qf two or three months.)

— H. Earle, in Medico. Chirurg. Trans, vol. vU. p. 427.
^Rudoiphi^ Tab. i. flg. 1. (/it a faetu* tff two months.) —
Meckel^' Handbuch der Path. Anat. b. 1. p. SiX). {Oyn-
sidersthat all cases qf chronic hydroceph. are congenital.)
— A. J. H'enxel, De Hydrocephalo Congenito, 8vo. Ber.
lH'i3. <- J. Frank, Praxeos Medicse Vniventt Prsecepta,
&c. pan. ii. vol. i. sect. 1. p. 251. — E. nomson, Lond.
Med. Repos. Nov. 1824. — Meckett IK-scriptio MonstnN
rum nonnul. &c. 4to. Lips. 1896, p. A3. {In afcetus <tfn»
weeks) — Biilard, Dea Nal. des Enfaus Nouveaux«D^,
etc. Paris, 1828, p. 451. ^ A. W. Otto, Comp. of Patl).

Anat. by South, p. 37S CoMcal, Lancette Fran^aise,

No. 7R lft33.

Ii. CoKGBif. Dropsy or tiir Spiwx.— Ruysck, Observ.
Anat. Chir. ol)i. »♦, 35, »?. — Bonet^ Sepulcbret. I. L
sect. XTi. obs. 4. {With hydroceph. *i — Rochstetter, De
iipina Bifida. Alt. 1703. — Satzmamn, l)c Quibusdani
'1*111

umoribus tunicatis extern. Arg. 1709. — Morgagni, De
r. ot S. M. epl»t. xii. xWlll. — Halter, Element. Physiol
vol iv. p. VI .^ Portal., Mem. de TAcad. des !teieDC«s, an.

1 1770, 1771. ( With hydroceph.) —Warner, Otem. m S«-.
gery. I^nd. 1784, p. 136.-5/410, Rat. Hei.pai« tv
p. 47. ( With hydr,ic^.)—Oehme, De Mofb. Rwrot \r

Lipa. 1773 Sandifortt in Otweffv. Anat. VyOtt/t. i t

cap. i Obertemfer, in Stark'* N. Arciiiv. tit,-

buctsh vol. ii. par. ir. p. 694 Okes^ As Actoqe: <

Spina Bifida, &c. Caxnbr. 1810.— Arlra, in Jb^-*«
Chirurg.. Biblioth. b. is. p. 185. ( The whole af«ni 1^.;*.
spinous processes being wasUing.) — MiehMu,ia t*/
b. vi. p. 133.— </. P. Frank^ De CunuMl. Hoa-Vgit t r
pan 1. p. 1S6. — Moeckel, De Hydrorrliacbitide («■<■».
Utio. Lips. 1822. — Abemttl^, Sutg. aod Fhywii b-
says, part i. p. 75. —Meckel^ Handbuch d. Patbaf
Anatom. b. L p. 35. Sl.—PaUOiay Exerdt. Path, a^ ■
art & Nov. 18V). — A. Cooper, Tlraiw. of Med..Oi.npr
Society, vol. ii. p. S2I. — Nenendosf, De SptD» B.^»
Curatione radicali. Berol. ISSa — raeem-Beriifk^-
Storia dl una Idrorachia. Fav. 1820. — Jmkes, n %<
and Phys. Jouro. Feb. 1829_ Jo*. Firmnk, Pnxen «-.
Univen. Praecept vol. i. pan it. aect. ii. cap. ^.^Bat
in Journ. des Progris dea Scien. M£d. L v. — Br^n
London Med. Repository, ed. by Copland. Aof . 1^.-4 -
Oitivier, Trait6 de la Moelle Epini^re et de tcs Mat. t
p. Wi. — Dugfs, in K^vue MMicale, Ac ApriJ. 1«£ •
Otto, Com|>end. Anatom. Pathol. 8va Bresl. IC^ •.%•
sttlts of the e^aminaium qf thirtp-lkree coars. >-. Brev^' ■
ton, in Edin. Med. and Surg. loam. vol. xvii.p ^ -
Locock, in Ibid. vol. xviii. p. S78. — Lirnds^, to liM
Med. Repos. Jan. 18%. — Billard, Traite dcj 9bL rt«
Enfans, &c. pi 591. — S. Malins, in Liverpool Wet^ i-u
vol. i. p. 27.

iii. Co.^GRN. Dropsy op tiir Cavitirii optvi Ta'««i
Ahdomek, &c. — Blancardt Op. cat. cent. L o£a ^. -
Reidlin, Lin. Mid. 16B6. p. X, ; EphecMr. >iaL Co-
dec i. ann. i. obs. 42., cent II. ann. iii. obs. i'*l - i
Haen, Opusc. gusedam inoedit. pan i. p. %. — JImc. J«<^

de M^d. Chir. et Pharm. t. xvii. p. ISO Tiumkit

Stark** Archiv. &c. b..vi. p. 396.—Ottimer, in ARh.v

Gen^r. de M6d. t. viii. p. 383 Andry^ ia Joan <■*

Proff. des Scien. M^d. Sd ser. t. i. p. fdS. _ X. L<
Med. Gaxette, vol. vii.p. 38-5 — Petii.Mengin,\o (mx.«i
MMicale de Paris. No. 50. 1833. {Omt ca»e ^ aMma-
dropsy, and another qfency^d.)

IX. Dropsy, Encysted. — Syk. HjfHrrps >am
ius ; Hiidrops Cysticus, AocL vxp.; Die *w*
wasursueht, Germ. ; HydroptM tnk^e. It

189. Defin. — The fluid eneOtted in a rvd,:^'
neruUy of' a serout ttrtieturt internally, **^ •
adventitious formation ; giving rite to local f«.s>
toms resembling those cauud by ejfuwm into Mt^-*
cavities,

190. The origin of srroiu ciftts m &tscit^
the article Disease ($ 114.) ; it therefore pRbai*'
only to notice those exceanve oollectiofit oi t-a<.
in them, which are distinguished with Aftrair
from accumulations ia natural cavities. IV r
cysted productions, which either cootaia ne^ '
leca consistent secretions, or are of so mall ^i
as not materially to affect the bulk of the cz-
in which they are seated, or the faoct>oo« r
parts adjoining, are considered in eoooectioB «^
the other lesions of their respective «ra2& -
the view about to be taken of encysted cchV
tion of fluids, mention will be nade oqI>
those which possess, in many respects, a drp^
character, and which have generally bren i-
sidered as such by writers aod praciijiv.
although even they may possess no trac cm •
to this distinction.

191. A. Causes. — The causes of roxrr.
dropsy have generally no influence ta pivi»-'*>v
the encysted. The same state of action, to wr ■
the formation of the cyst iu the ftnt iasiaarr » '
be attributed, evidently is the maia ag«at n i-'
secretion of its accumulated contents. CH «* '
this state consists, and of the causes ia w^

it orij^inates, but little is realU known. ^^ -
remarking on this and nmilar changes ••
DisKASE, $ HI.), I stated tlMt the oryra
serous cyst#cannot be considered as truly u»'^'
matory ; but that it may be imputed to a iB«a^
nutrition, frequently coancclcd with s ««•*

DHOPSY, ENCYSTED, OF THE OVARIUM — Causes, Symptoms, etc. 655

bineJ krge dropefcal cysU, and even in the
same cyat with the watery collection : the cyat
in which the hair aod fatty substance had been
furoied having subsequently become the seat of
(iro|Kiical eiTuuoD.

'i02. B, Causes. — (a) The predispo»ing causet
tKf the scrofulous diathesis ; debility, however
ioduced; freqaeot or excessive menstruation, and
venereal iudulgeoces. The disease occasionally
commences as early as the first appearance of
puberty. J. P. Frank saw it at thirteen, and
M. Itard at fonrieen years of age. AIarjoliv
states, that it may begin before puberty ; but
1 know of DO such occurrence. It is mof^t com-
moQ between the ages of twenty and fifty. It
may commence soon after the cessation of tlie
catamenia ; but, although chronic cases of it are
fouDd in very old females, yet it rarely originates
at an age much beyond fifty. It often follows
abortions.

203 (6) The exciting causes have not been
satisfactorily shown : but it has been very gene-
rally imputed to external injuries, succusttions of
the pelvis, the mismanagement of parturition and
abortions ; or to cold, fnghl, and anxiety of mind.
Frum much attention to this disease, I have
iaferred that it is occasionally consequent upon
inflammatory action in the ovaria or uterus, or
roDoected with this change in its earlier stages.
Hence its causes may be considered to be, in
Aome cases, those in which inflammatory ac-
tion in these organs generally originates. Yet
tbere are numerous objections to this view ; for
even when the tenderness and pain in the region
of the ovaria, accompanying its commencement,
■« greatest, there its also a frequently recurring
2od copious menstruation, indicating an excited,
lather ihao an inflamed, state of these organs.
From various considerations, and a review of the
CTcumstaoces in which the disease seemed to
originate, it is not improbable that it is connected
with an often excited, but an imperfectly gratified,
sexual appetite. Hence it} frequency in females
^bo are sterile, or whose state of health is insufii-
cient to the developement of a healthy and vigo-
rous orgasm, owing either to premature and illicit
indulgences, or to previous disease.

204. C. Symptoms ano Prooress. — Ovarian
dropsy is very commonly far advanced before
recourse is had to medicine. It usually cora-
nences with irregularity of the menstrual dis-
charge, and disorder of the excretion of urine,
*hich is either votiled frequently, or is long re-
tained. Tliere is also severe pain in the loins,
With pain, teodernefB, and swelling in one or both
iliac regions. In some instances, the pain shoots
through the abdomen, and down the thighs; and
Dcca^onally there is numbness, haemorrhoids, or
complete strangury, owing to the pressure of the
^n.ar;^ed ovarium before it rises out of the pelvis,
the cataroenia, at this period, is frequently either
copwuj or of too frequent occurrence ; but it is
^^ly altogether suppre^ssed. Various hysterical
tyoiptoms also come on ; aod disappear at a later
^lage. The bowels are usually costive ; but they
ire sometimes irregular, or relaxed. As the ma-
ady proceeds, the patient experiences various
ly»pcptic symptoms, and often nausea and vomit-
o^S as in the early months of pregnancy. The
nanimaa also enlarge, and the areolae around the
'>pples aasame a darker shade. Dr. Seymovu

states, that, when both ovaria are affected, the
cutamenia are always absent ; t)ut, when one only
is diseased, this evacuation is either absent or irre-
gular. This does not agree with ray experience,
the results of which I have just now given, as
regards the early stages of the disease ; but, as
respects the last stages, particularly in the more
chronic cases, the observations of this physician
seem to be correct. With the increase of the
tumour, various inflammatory phenomena, referri-
ble chiefly to the peritoneum, and commencing
in the pelvis, but often extending upwards to parts
of the abdomen, supervene.

205. The progreu of the tumour and abdominal
enlargement is extremely various. Occasionally
the ovarium, whether it consist of a number of
cysts, or of one or few, increases very slowly. It
sometimes remains long stationary ; afterwards
augments rapidly, and fills, ultimately, the whole
abdomen \ and in rai'er instances it recedes, or
even entirely disappears. It proceeds more re->
gularly, however, m most cases, until it gives
rise to appearances rendering the diagnosis very
diflicult. The general health, as already stated
in respect of encysted dropsies, continues but little
impaired, until the morbid accumulation has ad-
vanced so far as to disturb the functions of ad-
joining viscera ; but this is not uniformly the
case ; for the means used to cure it not infre-
quently are sources of disorder, deranging the
natural functiocs, and thereby favouring the in-
crease of the disease. When the collection rises
as high as the epigastric region, and the abdomi-
nal distension is great, the functions of the
stomach are often completely overturned, and
the constitutional powers rapidly sink : singular
and unexpected changes, however, sometimes
occur, even in the most chronic cases. Dr.
Baillje mentions an instance of its spontaneous
disappearance, after it bad existed thirty years ;
the patient remaining, .subsequently, m good
health. The accumulated fluid is also occasionally
discharged into some part of the large intestines,
having previously formed adhesions with it ; or
into the vagina, pressure on the tumour increas-
ing the discharge. Instances of this have ac-
curred to Dr. Ellxotson, Dr. Montcomery,
myself, and others. In a case treated by me some
years ago, and put upon a course of iodine, the
catamenia wercf profuse every fortnight or three
weeks. The tumour, which filled the whole ab-
domen, remained long stationary, and ultimately
burst into the large intestines. It did not return
again until upward84)f a twelvemonth : ultimately
the patient was so much benefited as to leave off
treatment. Dr. Seymour adduces an instance,
in which the morbid collection was discharged
both by the intestines and by the vagina, and
recovery took place. Sometimes it forms adhe-
sions to the abdominal parietes, and bursts exter-
nally at the umbilicus. A permanent cure is often
efliected by judicious management under the fore-
going circumstances. A case was seen by me, in «•
which adhesion of the tumour took place, to the

Earts adjoining the puncture by which its contents
ad been drawn on. 'i'he cicatrix ulcerated, and
the fluid was aflerwards discharged by degrees
through the opening, and the paUent recovered.
A nearly similar instance of recovery occurred in
the pract'ce of Mr. Barnwell. When the fluid
finds its way into the peritoneal cavity, the result

DROPSY, ENCYSTED, OF THE FALLOPIAN TUBE.

667

used externally. In this caw it should be rubbed
upoD the iDskles of the thighs ; where, if it should
produce irritation of the mteguments, the effect
wiil be tlie more aalutarj.

200. CaikarHct and dktreties have no influ-
ence npon the disease, further than to accelerate
its pnigiesi, if they be used in such a manner
i» to weaken the poivera of life. Purgatives of a
tooic kind, however, may tie casplo^ to e%'acuate
fecal matters, and to promote the intestinal se-
cretiou; but suck only., as are not calculated to
excite orirriutethe large bowels, should be se-
'eeted; as the bitartrate of potash with oon-
fectioo of senna, or the infusion of calumba or of
geotiao with infusion of sennab As to diuretia, 1
have seen no benefit derived from them, with the
exception of those which possess tonic and astrin-
f*Dt properties, as the balttms and terebinthinates ;
the litter of which have been productive of benefit,
psrticiilarly when used in the form of liniment or
epitbem. Camphor and narcotics are also useful
P^Kativcs, especially opiates. The liquor patat$it,
u4 Bsandish's alkaUne totution, in. suitable
vehicles, and aided by saisaparilla, by loca^ de-
pieiioQs when tenderness in the situation of the
tamocr is pereeived,and by setons, have also been
^ gnat serviee in some cases in which I have
preaeribed them* The good effecto of vomit-
H in swelled or inflamed testicle have induced
•Noe practitioners to have recourse to emetict in
^ early stage of this malady. Dr. Pbbcival
'econls a ease in which they proved of service ; but
I ktre bad no experience of the practice. Mr.
^iBNETBT prevented the reaccumulation of the
Bald after frntmr, by repeated blistering. Dn
lliMiLToiv (On Meteurial Mmlicinei, ^c. p. 203.)
itstes that be has cured seven cases by percussion,
>r paitiog, for a long time daily, on tne tumour,
^0? > bandage so a» to make constant compres-
>os, giving a solutioB of the muriate pf lime, and
noplojiog the vrarm batb. Many instances will,
lowever, be found to confirm the opinion of
^' W. HviTRR (M«d. Obtero. and Inquirm,
ol-ii. p. 41.) '^ihat the patient will have the
*ect chance of living longest under it, who does
Ik least to get rid of iu'* In addition to the above
icut, but little can be attempted with much
opes of sacoeaa. The chief objects are to sup-
^ the vital eneigiea throughout the frame,^to
'"note a healthy asiimilatioo, and the excretion
f effete matlens,— to ward oflF all irritation, phy-
cal and moral, from, the uterine ofgans, — to
wpt a light, cooU and moderately nourishing
i^r— to enpige the mind agreeably, — to reside
t \ dry, airy, moderately warm, or temperate
*e^, — to take aegnlar but gentle exercise in
« open air,— and to have frequent change of
*ne and atmespheve.

210. FarsesHtMM io some instances becomes
tperaiive, owing to the urgency of the symptoms,
t^ularly after it has been once performed ^ and
<e tsiirpatian of the tcunour has been recom-
eoded by Vamoxk Haab, Dblapob'px.Morand,
occKBfSiEBOLD; und practised by L'Avmonier,
arm, Lizahs, Bluwdsll, Gbanvillx, M'Dow-
.. and DiEFVBWBiicH. Of these measores a brief
itice is required. — (a) The observations which
tte been already offered on forofuttm apply to
e treatment of ovarian dropsy even more fully
in to any other. It ofbn accelerates a fatal issue
inducing inflammation of the sac. Of this I
Vol. I.

saw a remariuri>le instance many years ago in a
near relative. Dr. J. Johnson has adduced an ex-
ample of it (Msdfco-CAtrurgicai RevUw, vol. xi.
p. 258.). Ut, Macintosh refers to one in his
practice (Practie$rf PAyric, vol. ii. p. 374.) ; and
many others have been reeorded, and observed by
experienced practitioners. I thcirefore agree with
Dr. DxNMAN, thatparacentesisought to be deferred
as lon^ as possible. In such circumstances, this
operation oocaaionally gives temporary relief; but
there is a frequently recurring necessity for its
repetition until the patient sinks. It has been pro-
posed to effect a* radical cure by evacuating the
matter, and either laying open the tumour, or keep-
ing a eaaula inserted in the wound. Lb Dran
mentions two cases which recovered from great suf-
fering'Consequent on this measure ; and analogous
examples, have been recorded by Houstok, Voi-
soN, and Portal. But these are few compared
with the numerous instances in which it has either
failed, or accelerated a fiital issue by the severe in-
flammation and constitutional disturbance thereby
induced. In two oases in which I was consulted,
a canula had been left in the puncture, and ra-
pidly produced these effects ; toe introduction of
air and the mechanical irritation having inflamed
the cyst and peritoneum, and converted the se-
cretion to a foul j. foetid, and ichorooa discharge:
both rapidly proved fatal.. It has likewise been
proposed to inject the c^st. Dr. Dxnman men-
tions a case in which thu was practised, bat the
patient died on the sixth day afterwards*

211. The extirpation of the tumour, although
entertained by the older surgeons,, was discounte-
nanced by Moroagni, Db Habn, Sahatieb, and
Mu-bat. L'Aumonieb, of Uouen, however, per-
formed this operation successfully towards the
close of the last century ; and it has recently been
practised by Dr. Smith and Dr. Macdowal, of
the United States, with a like result. Notwith-
standing the«fnvourable issue of these esses, I
stated, m the Medical Repotitory, at the time of
their publication, reasons against resorting to this
measure. The issue of several cases in which it
has since been performed, both in this and other
countries, confirms the opinion I then expressed.
The operation' has no chance of succeeding unless
it be resorted to during that stage, at which a judi-
cious constitutional treatment may either delay, or
even remove the disease : and. 1 believe that the
case» io which it has succeeded are such as would
have terminated favourably if they had been left to
nature or to medical management.. The results of
the cases io which it was performed by Mr. Lizars
and Dr. BLUNDBLL,are well known ; and I may add
that it has likewise been attempted at least five
times at Berlin, by Dieffbnbaoh, Ohrysmbr,
and Martini (Graefb and Waltbbr's Jaum,
b. xii. h. i.), and, excepting in one instance, it en-
tirely failed. Three ot the patients died in con-
sequence of the opeaation.. In one case the
surgeon did not proceed in the operation, on find-
ing the tumour adherent on all sides«

212. ii. Dropsy op tub FAbLOPiAN Tube —
Hydropt tufo/u — is not to be distinguished from
ovarian dropsy ; nor, indeed,, does it differ from it
further than that, instead of the cyst beinff in the
ovary itself, it is developed in the fold of the liga-
ment, near the uterus, or close to the ovarium, or
to the fimbriated extremities of the tube ; these ex-
tremities being either adherent to the ovarium, or

Uu

DROPSY, ACUTE, IN THE HEAD— Hmtoby op.

eei

226. Lit. Hist. — Acvte hydrenceplnhis, doU
withstsnding tiie resMriL of nippocratM already
referred t», wbb formerly confounded with cere-
bral fever, or lever with determination to the
braiD. A caae, in which it is acearately de-
fcribed, but connderedr as one of fever merely,
WS8 pablished by Dr. Sv. Clair, in 1733, in the
Edm. Mtd^ Ettayi and Oburnationt, vol. ii.

£. 297. Mr. J. Paisley of Glasgow, in the fol-
iwiagyear (in Ibid. vol. iii. p. 333.)a recorded a
case, with the p«rt morl«m examination, and first-
recognised it as a specifie form of disMse. It
was ool, however, until the appearance, in 1768,
of Dr. Wbttt's **Obtervatunu tm the Bropty rf
tht Brain,*' that the history of the malady and its
Batuiewere made subjects of investigation. The
observations of Dr» Fotobroill {Med. Ohserv.
end Jnpur. vol. iv.) cootrifonted something to the
knowledge of its symplemv; but those of Dr.
Watmn^ in the same work, furnished evidence
merely of its extreme danger. Dr Dobson's
case, pubysbed in V775 (IMd. vol. vi.),was va-
luable, inasroueh as it showed' the possibility —
at the time, veiy generally doubted — of curing
tbe daeaae ; and of the influenoe of mercury in
bringiog about this result. Harris, however,
l»d long before stated, as Dr. Chktnb has re-
marked, that a physieian of- experience had saved
children in fevers attended by unusual stupor,
and even eoma, by giving them mereurhu d%Utu
81 times sublimed.

227. The opinion of Whttt, that- the disease
depends upon laaity of the exhalants, or upon a
watery state of the blood, had been ^nerally
received, untilDr. Quitf, in 1779, maintained that
it is allied to inflammation, — a doctrine which
bad sQggested itself both to Dr. Witherivo and
Dr. Rush, before Dx. Quii«*s views had become
known. I>r« Withering stated evplicidy, that
the malady originates in inflammation} and that
(be water fmind » the ventrieles of the brain is
sot its eauae, but its consequenoe. Dr. Rush
made an important addition to its history, by
ibowiog that- it nay be produced by other dis-
<»BCs, espeeially by fevers, rheumatism, pulmo-
Dtnr consumption, tbe exanthemata, and^ worms ;
sod that death may^npervene, preceded by liv-
drocephalie symptoms, and little or no water be
found ia the ventrieles,— circumstances which
will be felly enquired into in the sequel. Dr.
p£RCiVAL demonstrated its frequent cenneclien
with scrofula, and seemed impressed- with the
"le& -that it is not altogether identical with in-
flammation in its nature. Its inflammatory origin
was afterwardi supported by Dr. Patterson and'
Dr. Gabhett, aftnough neither appeared to con-
^der it advisable to carry the depletory and anti-
pblogisiiG treatment so far as suoh a dootrine
might have^ warranted. This last writer believed
^ ia hydrocephalus, a local inflammation with-
out Doeh general sthenic diathesis obtains ; and
^t a depletory treatment*, injudiciously em-
ployed, may weaken the general tone of the
system, and increase the eflRUion, without materi-
aHj diaiiiishiog the local morbid' action, for the
fnnoval ef which such means are employed. Of
the justice of this view there can be no doubt.
The local action, which has been called inflam-
Datory, merely because- it is attended by injec-
tioo of blood-vessels, has been too generally
treated as tnna inflammation occurring in a ,

healthy constitution, and without reference eithe''
to the series of vessels affected, or to the grade
or the product of action ; and, what is equally
important, without regard also to the diathesii,
or state of vital manifestation and power. It is
unnecessary to notice here the opinions of more
recent writers, as the chief of them are referred
to in their proper places.

228. Descriptive History.— The Freeursory
or Early Symptomt of acute hydrocephalus are
remarkably diversified, owing to the circumstance
of their dependence upon disorder of the digestive
organs, or of the circulation in the brain and
membranes; and it is chiefly owing to the pre-
dominance of the symptoms referribie to one or
other of these parts that the disease has been
divided^by some writers into the primary or idio-
pathic, and the secondary or symptomatic. The
possibility, however, of making the distinction in
practice, is not* so easy as some writers would
make it appear. For the dependence of the
functione of the liver, and digestive organs,, upon
the state of circulation in the eneephalon, and
of the latter on the former,. is so very intimate,
that it is often impossible to ascertain which is
primarily affected. The majority of writers on
the disease in this country, consider that the diges-
tive organs are the first to betray disorder ;. whilst
the French pathologists and Dr. A-bsrcrombib
believe that- the morbid action very frequently
commences either primarily or simuHaneously in
the brain itself; I am convinced, that the- true
acute hydrocephalus originates more frequently
in the eneephalon, than the abdominal functions
indicate, and at a- period anterior to the disorder
which these functions manifest, «— such dis-
order often proceeding from the silent morbid
action in the brain, reacting on it, and promoting
the evolution of those changes- constitutifig the
disease ; and that^ when hydrocephalic symptoms '
supervene more suddenly and violently, and with-
oot-much previous disorder of the chylopoietic
viscera, or nervous system, they have a mere
intimate relation to acute or sub-acute inflam-
mation of the brain and its membranes, than to
those states of morbid action whi^h terminate in
copious effusion, and to. whieh the term hydro-
oephahis is more strictly applicable. The chief
exceptions to these inferences will* be found in
those who itihent a peeuliar morbid diathesis or
predisposition to the malady-^ who are scrofu-
lous or weakly constituted, — and in these the
brain and its membranes will-* often coetaneously
suffer, in a greater or less degree, with one or
more of' the digestive organs ;>tbeHezcited action
it experiences being either attended,', or soon fol-
b wed, by deficient power, and b^ relaxation of
the exhaling surfaces^ In tbesCiC^ees, as well
as in those in whieh it is usherec^ in, or predis-
posed to, by derangements of thK^ abdominal vis-
cera, it does not, as in truo cephalitis,, readily
occur in- a previously healthy oonstitution, but
chiefly in stales of* pre-existing ailment, or as a
consequence of inflammatory action arising under
such circumstances,—- in which not only the
chylopoietic viscera imperfectly perform their
functions, but also the organic nervous system
is weak, and the capillary vessels and exhalants
are so deficient in tone as to be readily relaxed
or exhausted when over-excited. In other words,
that aottle hydrocephalus is a consequeaeo of

Uu 3

DROPSY, ACUTE, IN THE HEAD — Foiims and Stages of.

603

procured mth difficaity, this change depending
chiefly upon the morbid condition of the secretions
poured into the digestive canal : tlie urine is
scanty and turbid, and has often a milky appear-
ance (Odler, Coindet, and Vxedsseux). The
erect posture or motion, particularly rotating the
head, bnngs on sickness and retchings, without
the appearance of offensive matters. There are
ako great fretfulness and resUessoess; contracted
pupils ; frowning, or knitting of the brows ; in-
ability to sit up ; a whining or moaning noise when
lyiog down ; and sometimes a slight cough, with
irregolsr snspirioos breathing. The sleep is short
and restless ; the infant rolls its head on the pil-
low, or oHen wakens with a scream or crying, and
raises its hands to its head. The nostrils and lips
are dry and cracked. This period 13 very variable
in duration, but it usually continues from ten to
fifteen days.

232. (6) Steond stage, — The pulse, from
being very quick, excitable, irregular, and weak,
now becomes slower— sometimes as slow as
natural, or even more so ; but chiefly when the
patient is in the horisontal position; for if he
attempt to ait up, it generally acquires its former
frequency. The sensibility is now remarkably
impaired: sopor or stupor gradually supervenes,
with dilated pupils, squinting, and imperfect or
double viaon. The eyes are dull, heavy, vacant
or staring ; the eyelids drooping or half closed.
Sickuesi or retchings are now less frequent, unless
the child be rmsed up, when one or both often
occur. The excretions are passed unconsciously,
and are scanty, and procured with difficulty. The
stupor is inteirupted by exclamations, or shrill
picreiog screams; the hands, which are tremulous,
being raised to the head or neck, or occupied in
picking the lips or nostrils. Emaciation pro-
ceeds rapidly ; but food is generally swallowed
greedily when presented. These symptoms are,
however, by no means uniform ; for tne pupil is
frequently, particularly at first, oscillatory, or,
although dilated, affected by light. The stupor,
also, is not always coostnnt ; nor does the pulse
always become slow. Deep inspirations, hectic
flufrfaiDgs of the cheeks, catchings of the muscles,
cold extremities, low delirium, and an almost total
Mppresibn of urine, are occasionally observed.
The duTtttiou of this period varies from four or
five days to two weeks.

233. (c) Th» third stage has been generally re-
cognised by the returning frequency of pulse,
which is often remarkably rapid, thready, and
weak; by the occurrence of general or partial
convalaions ; by paralysis of one side or limb ; by
twitching of one or more of the muscles ; and by
raffasion of the eyes, the eyelids being motion-
los, and the cornea becoming dim and' filmy.
Often, when one side is paralysed, the other is
note or less convulsed. The patient is now
either insensible or delirious. He rolls his head
00 the pillow, grinds his teeth, moves the unpai-
red hand in the air, and moans or breathes heavily
ud hurriedly. Alternate flushings and pallor,
or flushes of one cheek, the other being pale ;
irregular distribution of the circulation; partial
sweats; cold extremities; irregular, or stertorous
breathing; an eruption of vesicles about the
AoQth, or on the face and upper part of the chest
(FoBMEY, GosLis, ScHMALz, Raimann, and
myself); colliqpae of th« coantenanoe; blueness

or paleness of the lips ; and more rarely, spha-
celating sores ; are remarked towards the close of
the disease. I'he dilatation of the pupil and
strabismus generally continue througoout this
stage, which may terminate fatally (generally in a
violent convulsion) in a few hours, or it may last
for ten or twelve days or even longer. Such is .
the common course of the most frequent form of
the disease, which comprises the Nervous and
Gastric of Bkachet; and which may cither
originate in the encephalon, or in the digestive
organs. But it is seldom that the early history
of the case is so precise as to enable the physician
to draw a correct inference as to its commence-
ment. In some instances, I have observed slight
symptoms of cerebral disease, for some weeks, or
even months, after repeated attacks of congestion
or of inflammatory action within the head, of a
well marked character, but supposed to have
been removed by treatment. In .some of these
cases, the disorder of the digestive oi^rans was so
evident as to give rise to the idea of the primary
affection of these viscera, indicating the difficulty
of ascertaining the parts first deranged. The in-
formation furnished, in most instances, seldom
enables us to carry our pathological analysis
sufficiently far back to eonoect the early ail-
ments with their causes ; and, consequently, wet
often fail in ascertaining the quarter where disease
commences.

234. B. The Infiammatory variety, or the
second form of Dr. Chsyxb>, of M« Coindet, and
of HopFSNGAHTNBR, is morc acute than the pre<-
ceding. The precursory symptoms are generally
of short duration, and sometimes so slight as to
be overlooked. This variety nearly resembles
fever, with predominant affection of the head ;
and in many cases it is not to be distinguished
from inflammation of the brain and its membranes
(see Brain, § 174. ei M9«), the disease being
merely a modification of inflammatory action, de-
pending upon diathesis, and previous- state of
health ; and, owing to these circumstances, giving
rise to effusion. After the child has been drooping
for a short time, fever, with slight, short, and irre-
gular remissions, flushings, severe hesdachs, in*
creased heat and sometimes soreness of the scalp,
augmented sensibility, thirst, hot skin» brilliancy of
the eyes, and tenderness over the abdomen, super-
vene ; the pulse being rapid, hard, or small ; and
the tongue white or loaded. Stupor or unwilling*
ness to be roused, alteniating with violent screams,
and complaints of the head and belly ; great irri-
tability of the stomach ; retching readily brought on
by changes of position or by sitting up ; a morbid
and scanty state of the alvine evacuations; avacant,
dejected, or heavy expression of the eyes ; a pained
and terrified look; occasional cramps of the extre-
mities ; and diminution of all the secretions and ex«^
crelions ; commonly characterise this form of the
malady. This first stage is usually accompanied
with many of the phenomena of the first period of
the foregoing variety : the chief difference being in
the more febrile condition of that now under const-
deration,in the earlier and more evident connection
of the symptoms with the brain, and in the shorter
continuance of this stage. As soon as the changes
which attend the second period, vis, dilated pupils,
strabismus, stupor, diminished frequency of pulse,
&e. appear, the progress of this is in all respects
the same as that of the first variety ; the stages being

U u 4

670

DROPSY, ACUTE, IN THE HEAD— Pathological Opi?;ioks.

to grapple with the obvious malady, until we
know more of its antecedent pathological states.
If we adopt the views of M. Rostah, no changes,
excepting those immediately consequent upon
remote causes, will be considered essential.

258. Several writers, observing the history and
lesions of hydrocephalus to diflPer in several re-
spects from inflammation, yet still to resemble it
very closely, have viewed it as a peculiar form of
inflammatory action affecting the more interior
surfaces and substance of the brain. Thus, Con-
RADi termed it Encephalitis txudatoria infantilis;
Brachet, Hydrot^haUte, or watery inflammation
of the brain ; and Coindst, Cifpkalite interne hy-
drene^phalite. Other writers, particularly Aber-
NETiiY, Curry, Cusyns, Yeats, Thomson, &c.,
have considered it as most commonly proceeding
from disease in the digestive organs, and seldom
arising from primary inflammatory action in the
brain or its membranes. This opinion has been
carried too far, for I have often bad evidence to
convince roe, that morbid action had been pro-
ceeding in the twain long before it was suspected,
and that one of its chief effects was to disorder
the liver and digestive canal ; this sympathetic
disorder being frequently considered as primary,
and its reaction on the brain as the sympathetic
production of hydrocephalus. I believe that the
malady often originates in the substance of the
brain ; and that, conformably with what is ob-
served in respect of lesions of this structure, the
digestive viscera, frequently at one time the roost
remarkably deranged, are merely sympatlietically
affected. Formey and Dr. Shearmah have
viewed the eff'usion as a couseaueoce of simple
excitement of the cerebral circulation entirely in-
dependent of inflammation. The latter writer has
considered it to be contingent on various diseases,
and to arise from a diversity of causes ; but that
its occurrence is chiefly owing to the predisposition
or previous state of the membranes, — the essential
character of the disease consisting in that previous
state or predispontion which, in connection with
nn excited state of the circulation, gives rise to
increased exhalation or effusion. Dr. C. Smyth
bas argued against inflammation, and in favour of
debility as the cause of the effusiou • but whilst
he bas strenaously contended for the latter patho-
logical condition as respects the tone of the ex-
treme vessels, he bas admitted the existence of
accelerated circulation, and its influence in pro-
ducing the disease. There is one inference, how-
ever, in which nearly all modern pathologists
agree, viz., that the effusion itself does not consti-
tute the malady, but is only its consequence, —
contributing to the production of the more ad-
vanced symptoms, but in a less degree than many
suppose.

259. Pathological Inferences,'^ (a) The first or
nervous form of acute hydrocephalus is frequently
consequent upon changes in the substance of the
brain, in the membranes lining the ventricles, and
in the vessels and circulation of the encephalon,
probably arising from the state of the organic
nervous influence supplied to this quarter, and to
the perversion of the vital actions. (See Disease,
§ 87 — 92.) — (6) That these changes often com-
mence gradually, or almost imperceptibly, and
proceed far before they disorder the functions,
either of organic or of animal life, in a remarkable
degree ; and when such disorder becomes manifest,

it is often difficult to trace the euafler ia which r
has originated, owing to the intimate dcpeitdac«
of both classes of functions upon the orfuic ner-
vous system. — ^(e) That th« chanp^ ollNened ol
dissection in this variety have evideallT bees i^
progress a considerable time belbre cmod hi
taken place ; the effusion being the ooosaqtcHt
of these chaiiges»[aaBistcd by thephysieal coadss^
of the encephalon. — {d} That nervoas, ai m
as inflammatory and consecutive, hydrocepU)v
being merely contingent upon lesions^ the 9ns»f
nervous influence of the eirculabM, aad oif tk
substance and membranes of the bnin, such ^•
sions actually constitute Ibe disease dafiag ^
. early periods. — (•) That the nature of the oe^
bral affection, and the exact stale of vtmiW ac-
tion, in these periods, are not menliest; bstu :
be at all inflammatory — which admits of dsp«'je

— the vascular action possesses mora of u &*•
thenic or ataxic, than ot a sthenic, ckaract«f. r
is attended by a perverted, rather thaa by • <«•
namic, state of vital power; end by iopcriift
performance df the digestive and aatiBUaia:
functions. — (/) That, althoegh the >rtf >^
of the disease be consecutive of changes ia tbc rr-
cuUtion, or in the organic nertous inloeoee .'
the brain, the resulting phenomena nay be ko
as to be mistaken for the ezciung caoKi , <•«
organs of locomotion may be an eefsebleii m '•*
occasion falls, which will aggravate the nisji7
affection, and develope a state of sab-iosaes''
tion, or of vascular reaction in the cncepbk:^
and its usual consequences, via. ddanuBatsB '.'
blood, injection of vessels, and cffutioe af •£*•*
fluid ; or the viscera of digestion and aapd^-
tion may become so eongoted, or «ther«)sc i*-
ordered, as to appear the peita priaMfily tSee^-

— (g) That when this form is coineideot mik ir
consecutive of, congestion, ia6amBalio8»oretl'.*
disorders of the digestive and chylopoietic nce^
effusion into the ventricles eannot bt tknd m
the earliest changes that take place witfan iv
head ; but that this effusion is merely eon«qx'-t
upon similar changes to these which ban br«
already alluded to {d, e) ; the lesions ia tbc dx>^
tive organs, as well as the earlier allentiaoi <•
the brain, being, very probaWy » coatanawit ip» *
of pre-existing disorder of the system, or cf cc-
stitutional vice. — (fc)lB whatever qaaikrc^^
order commences, it is probable that, sonetsxi
at least, the sensorial power beccmes cxkarB<
possibly coetaneously with the snpcrresnaa c
the second stage, and the eerebrmi tiaMc i'-*-'
more or less wasted ; bnt it is dificah ts ^^
whether this wasting be the oooaeqacace, or i -
cause, of the effusion into the ventricles. ^ F^"
sibly the latter.— (■) That, in the cariy itap sj
the disease, as well as in its progrem, tlM tasr. jj
excitement, or febrile distarbenoe, atieoilinf c ^
characterised by genenl adynanin or ptr«ff^ >
of vital power. — {k) That great ccfebiaJ cv?H
ment does not necessarily imply the tt^act A
inflammatory action in the encephalon ; fiv »* **
lerated circulation in a vreakcned stale o( <-
frame, and susceptible conditii» of the scihiv*']
and nervous system generallv, will pradece <%"
bral excitement, particularly towards (hr c-'*
of febrile or protracted dtseases; bei tb^s *
stead of being inflammation, is a state ten -
ferent from, or sometimes even oppostd to. s

I shown by the l^dentia and /atm«b«, s»

i<

DROPSY, ACUTE, IN THE HE AD — Treatment.

673

ueDoed. When 'the diaeaM has been detected
sufficiently eerly, and when it has followed pre-
vious attaoks of congestion or inflammatory aetion
in the head, the febrile excitement being neither
general, eontinaed, nor well marked, the applica-
tion of kljstcre behind the ears, and of leeches
around, or close to, the blisters, has been of
noch aerrice. But it will be requisite to. repkat
this practice every second or third day, or oftener,
and to carry il as far as the circumstances of- the
case may warrapt. If the cerebral affection
appear to have been induced by disease of the
digestive and chylopoietic viscera, a blister should
be placed on the epigastrium or right hypochon*
drium, and leeches applied around it, as soon as
redntsB is caused by it ; when it ought to be re-
moved. This method may be repeated, according
to circumstances, after intervals of one, two, or
thfeedays: it possesses great advantages in this
Etate of the disease, inasmuch as, whilst it relieves
the gastric symptoms and the affeetion of the
liver, it is a most energetic derivative from the
head, without reducing vital power so far as ge-
neral depletion does ; for genesal. bleeding, how-
ever early employed in Ihis. variety, is seldom
productive of much benefit. Indeed, 1/ have
Ken it detrimental in many, instances ;. and I
consider both it, and local depletion, if carried to
iny considerable extent, as decidedly injurious
in some states of this form, particularly in weak
and cachectic children.

268. B, Cathartics. — The discharge o^morbid
secretions and fiecal collections should be pro-
cared as early as possible by remedies calculated,
at the same time, to derive from the brain, and
to diminish vascvilar plethora' and excitement.
The fulfilment, of this intention is appropriate to
all the states of the disease. A large dose of
calomel, either alone or with James's powder,
ought to be immediately exhibited, and, after
three hours, repeated with the addition of toasted
jalap, or scammony ; and its operation should be
promoted b^ an active terebiotninate enema. If
the irritability of stomach be suoh as to prevent
the retention of medicine taken by the toouth,
vascular depletion, a blister or mustard cataplasm
on the epieastrium, and an active eathartioene-
ott, will often remeve it. Galomel, in full doses,
^11 geoeralfy be retained, under any circum-
stances ; bat, in conjunction with oathartica, it is
frequently ejected, unless after the measures now
■Uted. Eiaterium, in small and • repeated doses^
has been suggested by Dr. Elliotsoiv ;. but it,
u well as eroUm oil^ will seldom be kept on the
stomach. When retained, they are occastonally
of use. I have seen most advantage derived
from the latter, when it has been added to the
terebinthiaata enema, or applied over the abdo-
men as a rubefacient. Dr. ChEyne found a
drachm or two of magnesia saturated with lemon
juice, given efery two or three hours, most use-
fal in such circumstances ; and I believe that
^ will act more certainly than irritating purg-
J^vcs, partieulariy if a full dose of calomel have
ween taken a few hours previously. A ^rruel or
broth enema containing some purgative salt
may also be administered two or three times in
the course of die day ; and ff the bowels be very
torpid, and the sopor considerable, the terebinthi-
nate eoen^ should be repeated daily, or even
oitener. Saline purgatives may also be given in

Vol. I.

the infusion of senna^ when they can be retained.
Active cathamia at the eemmeneemeat of the
disease,.after vasculaadepletion haa been instituted
to an extent which the nature of the case demands,
will have a more decided eflect than any othev
means whatevepi

269. C. CM af/plkatiani to the bead, the
hair having been removed from it, should be em*
ployed in the manner, and vrith. the precautions,
direoled in the article BnAisf^ $ 192., whenever
the temperature- of the head will admit of them.
But, like the measures already^ adaised, it is only
early io' the disease, and in the iaflammatory
states more especially,, thai they are pieduetive
of much benefit. Io these states they may be
used sinuiltaneously with the tepid semicupium
or pedilttvia, salt and mustard having been added
tothewater^. Rush,.Qvin, Covmlahi, Formxy,
GoELtSi and nearly all the vsritars on the disease,
are favourable to cold applications in its treat-
ment ; and,, in some Ibrm or other,- they are ap-
propriate to most of its states..

270. D. MereurJats. — These ar% perhaps, the
next important means that can be employed.
They have been very generally- paescribea since
they were first adopt^i by Daasow and Hay-
OAaxH, and subsequently by Eabon, Macxie,
Reewb, Lettsom, Hoopea, HoprxNOXRTNEn,
FxRRiAR, and more recent writers. Early in the

firtt stage of the disease, oalomeli given every
three or four hoursy in fully dases, either alone or
with James's powder, ia small quantities, is, in
ordinary eircumstaaces, the best pfooaration.
In children under one or two years, neilner sali-
vation, nor mach intestinal disorder, will be pro-
duced by it. In those above three or four years,
its specific actionmiay be obtataed,. bat with little
certainty, even although it be conjoined with
c»ium or the compound ipecacuanha powder.
When no essential benefit has accrued fnem the
foregoing means,, and the bowels have been folly
purged as directed above (§*266.), then calomel
may be given with, digitalis and nareoties,. or with
the latter only, particuhurly- opium or byosoya-
mus, with the view of fulfillmg the third and
Jifth intentions of cure ($ 263.).. But in y4>ung
children, especially when the bowels ara griped,
or are irritable, the hydrmrg. cum sreta, with small
doses of compound ipecacuanha powder (i¥. 653.),
will be most serviceable. The bowels, however,
should always be kept sufiiciently free by either of
the enemata recommended ($268.). I may add,
that calomel has been prescribed with cantbarides,
by DoBSOM ; with James's powder, .by Camp-
BSf.1.;. with opium, by Leib and others; with
digitalis, after local depletions, by Weaver,
GoBLJs, and Fischrr; with digitaKsi and arnica,
by J. P. Franx ; and with active iMiBgatives (in
which, form I believe that it is mofit'i' generally
beneficial)^ by Hupxlano, Cbsynb, Abbrcrom-
BiE, and many others. Dr. Mbrriman and my-
self have given very small doses of the bkhUmde
of mercaiy, ev«ry four or five hours, vrith ad-
vantage. In the second stage, this is one of the
best preparations that can be prescribed ; but it
requires much caution ; and, in this period of the
JirstBXid third facms of the disease, it should. be
prescribed in tonic and diuretic infusions.. T-ha
utmost care should be taken in exhibitiJig mercu-
rials in these forms, pariiculaxly in oaohectiq
subjects, and where the powers of life asQ- much

DROPSY, CHRONIC, IN THE HEAD — Tbbatmbiit.

683

tared the head at the upper third of the lamb^
doidal sotnie. The woand continued to dis-
ehar^ flaid for aeverftl dajt, and it afterwards
perfectly recovered from the diaeaee. In the
tame work, for April and Noyember, 1630, the
operation of panctore is ftated to have been
succenfttlly performed in St Bartholomew's Hos-
pitil. GsAin (his Joum. for 1831, b. zv.
p. 3.) punctured the head of an infant hydro-
cephalic from birth, in the fourth month, and re-
peated the operatbn about eleven times during
flx mootht. The fluid was allowed to escape
slowly eseh time; the canula being removed,
and tbe wound closed, as soofa as the pulse became
weak. Alter the last puncture, the sutures closed.
Tbe child could walk and speak when a year old.
At the age of two jears and a half, it was shown
to the Medioo-Chinirgical Society of Berlin.
Mr. RussBL (Edin, Mid. and Surg, Joum. July,
1832, p. 43.) operated on a girleieht months old,
bydrocephalic from birth, and whose head was
twenty*three inches in circumference, when he first
punctured it. The operation was repeated four
times, after intervals of about ten days ; but the
qnaotity of fluid withdrawn each time was small.
After the last puncture, calomel was eiven so as
to alTect the mouth ; when the hydrocephalic symp-
toms diaaopeared, and ossification of^ the sutures
proceeded. The case is stated to have been
cured. Dr. Cokqubst is reported, in a con-
temporary work, to have operated in nine cases,
— anccessfully in four of them- The greatest
Dumber of punctures in one case were five, and
tbe intervals between them from two to six weeks.
Tbe largest total quantity of water removed was
fifty-acven ounces, by five operations; and the
largest quantity at one time, twenty ounces. The
trocar was introduced through the coronal suture,
below the anterior fontanelle, and the wound care-
fuHy closed after each evacuation. Pressure was
made by means of strips of adhesive plaster.

310. The cases in which I have been con-
cerned in directing the operation, have all been
unfavourable to its success. Medical treatment
M been actively and perseveriogly employed in
all of them ; and it is therefore probable, that such
of them as admitted of recovery were amongst
tbe Domber that was cured. Whilst in those in
*bich the operation was resorted to, and which
*ere mostly congenital, either the stale of the
braio and its envelopes precluded recovery, or the
circQmvtances in which out-door patients of public
charities are placed were such as to render this
operation leas successful than it otherwise might
have been.

3ll.y. Having stated tbe evidence we at present
possess of tbe success Of the operation, inferences as
^ the propriety of performmg it may be eaaly
Irawo. Those who argue against it contend — (a)
Jut it is apt toinduoe an irritative stateof inflamma-
ioQ in the substance or membranes of the brain,
>articQlar1y in the weakened and other\vise predis-
XMed systems of such subjects— 1st, by the me-
'hanical injury done to those structures; and
^ly* by the entrance of air through the puoc-
ore ; — (6) that the collapse consequent upon
he removal of the fluid is injurious to the organ
">d aystem ; — (e) that the operation cannot
hange the state of the organ or function giving
i^ to accumulation ; and hence that it cannot
e permanently aocoessfnl ;— and (<2) that the in-

stances of auceess from it are not so numeroua as
those from medical treatment.

312. Those in favour of the operation, on the
other hand, argue — (a) that greater injury than
that by the puncture is often done to the brain
and membranes, without bad consequences ; «- ( 6)
that the air may be prevented from entering by
the aperture ; — (e) that danger from collapse is
readily obviated ; — (d) that cures from medical
treatment, in an advanced stage, and when the
head has become greatly enlarped, are very rare,
and are then most likely to be obtained by an oper-
ation ; — (s) that the instances of success on record
are soflacient to warrant its performance.

313. ^. From much experience, I conclude that
inflammatory irritation of the brain and its mem-
branes doies follow the operation in some instances ;
that the state of these parts, and of the system,
favours its occurrence ; and that the encephalic
structures are in a very different condition m this,
disease, both mechanically and vitally,— -but es*
pecially as to proneness to inflammatory action,
and softening, — from what they are in health.—
(o) Whilst, therefore, I so far agree with those who
argue for the operation, as to advise it to be tried
after tbe measures I have detailed above have
failed, yet I would not reoommeod its perform-
ance early in the disease — 1st, because medical
treatment has then sometimes effected a cure, es-
pecially when the head has not been very greatly
enlarged ; and, 2dly, because, when the fluid is in
the ventricles, as it generally is in cases com-
mencing after birth, a neater depth of brain must
be penetrated to reach it at an early, than at a
later, period. — (6) When punctures are resorted
to, medical treatment must not be abandoned,
or even relaxed : for we should still endeavour,
according to the principles explained above, to
remove the disposition to effusion, as well as to
promote absorption ; and, as a certain degree of
pressure is requisite to the healthy performance of
the cerebral functions, strips of piaster, as are
already directed ($306.), should be applied around
and over tbe whole scalp, in order to prevent the
collapse consequent upon the operation. — (c) I
believe that the punctures ought not to be fre-
quent, nor much fluid withdrawn at one time;
that gentle pressure should be made arouncl
the cranium auring the discharge ; that the dis-
charge ought to be stoppedi and the puncture
accurately closed, so as to prevent the entrance
of air, as soon as the pulse be^ns to sink ; and
that restoratives shoula be exhibited, in order to
prevent con vuleions, or other nervous symptoms.—
{d) The operation seems to be best performed by
a small trocar, or grooved needle ; but it is diflicuft
to withdraw any fluid with the latter, as the sur-
rounding pressure fills up the groove. The appli-
cation of a cupping glass may, however, procure
a discharge. A thin trocar, with a two-edged or
lancet-shaped extremity, — not a thick triangular
pointed instrument, — is preferable, upon the
whole.

314. d. Urgent nfmptomt, especially convul-
sions and inflammatory action, require to be
palliated or removed. -^ a. Convulsions should be
treated according to the manner described in that
article, particularly by the terebinthinated me-
dicines and enemata already prescribed ($ 299.) ;
by these, conjoined with the syrup of white
poppies, or this latter with the oxide of sine ; by

DRUNKENNESS.

685

llin,!8U,p.8&; IbM. 1812, dl 85— SdUi^, in Ibid.
Sept. 1811 — Si feMamM, in IMd. Feb. 1812.— Tkommm,
in Lond. Ued. RepM. toL i. p. la — Cloquett in Ibid,
vol. ix. p. 410 — J. CkejpUt Euays on Hyditicep. Acutus,
hf. Cd ed. 8va Loud. 1819. — J. R CohkM, Uiva. lur
I'llydrenciph. ou Clphalite interne Hjdrenc^halique,
8fa Gen. 18i& — CWe, in Tnuie. of Bfcd.-ChinirK.
Soc ?ol. ii. p. 17. — AeroM, in Ibid. toL vili. — FoserUi
Ibid. Toi. ix. p. 35*. {Pmraeenietit.) — J. C. Smith, On
Hjrdrracenh. or Oropeyof the Brain, Sra Lond. 181i.
^XaaorU in Giomale delta Soc. Med-Chirur^- di Pamu,
roi. ii. Ko.«— L. X Godif, Ueber d. VorfUeltcb«tefi
Krankht d. KindL Alten. 8vo. 18^1824 Wieo. : a1«o
00 Hjdr. Acuttu, or Inflammatory Water on the Head,

trjiuiatcd by R. GoocM, 8vo. Land. 1821 G. D. YeaU,

Of the eirly Symatonli that lead to Water on the Brain,
2d ed. Svo. Lond. 1823L— J. Cooke, Treatiae on Nenrou*
f)i«nNs, Ac vol. i. p. 579. — H%fetamd, in Kouv. Journ.
deMed. t xiL pc 4S. «- J. CrampUm, in TYans. of Irish
CoUf^e of phj«. Tol. i. p. 176. —J. B. Ewannm, in Ibid.
vol IT. PL 155 — MUU, in Ibid. toI. ▼. p. SSO. --lUtrd,
io Diet dc< Scieo. MM. L xxii. a 2ia — Duncan, in
iVaai of Med..Chlrurg. Soc of Edia vol. i. pu «J5. —

^Ulfr, in Ibid. voLiL pi 243 FaUoi, in Bfed.-Chirurg.

Rcr. vol. il p. 902. — Opoenheim, in Edin. Mod. and
.^urx. Joum. vol. xxlx. p. SQS. — O. Blame^ in Med. and
Hhyi Journ. Oct. 1821.— Hood, in Edin. Med. and Sure.

Jvum. Oct. 1821 Guertent et Bretcket, io Diet deM£d.

r. xi. D, SOa S30. — Garditn, Tr. d*Accoucbcm. et de«
MaL det Femmee et des Enfans, 5d ed. t It. p. 189. —
Htfmamtt, Med. and Pbya. Joum. toL xl. p. 599.—^
GtrOettome and CoUerUm, in Ibid. voL xlviL pi 183. —
Ritkr, Morbi Hvdrocephali Hiatoria, 8va Ber. 1824. _
J.lAbercrvnMe, Vract. Researches oq Dis. of the Brain
and Spin. Chord, sect. vi. p^30. ; and Edin. Med. and
Sma. Joum. toL xir. pi S92. — A. JXmis, in Diet, de
MM. etChir. Prat t x. p 130. ; et in Ephemeridea M4d.
de Montpellier, 1 1. pu 292.. t. U. pi 192-275. — Ckarpen-
Her, io Med. and Sur:g. Journ. and Rcpoa. voL ir. p. 36. ;
and ArchiTes Oiner. de M6d. t xxi. p. 315i -^Dance, in
Arch. G§ii. &c t. xxL p. 506., t xxii. p. 295. — Loben-
titi^LSbd, Die Erkenntniss und Heilung der Gehim-
etitauadunf^ des innem Waaserkopfes u. der Krampf.
krafikheiten im Kindlichen Alter. Leipa. 181& — D. A.
a. Rickter, Die Spedelle Tberapie, ftc. b. iii. pi 158. —
'. .V. Ab. HUdembramd, Inatitut Fractico-Medies, t. iii.
Ii88L — Moir/, in Hand, der Path. Anat bi i. p. 260.

^Brrtehet, in Siagemdie't Joum. dePhyiioL vol. I p. 92,
vol ii. p. 2G8., VOL iii. p. 241. — Bttrdaek, Vom Leben
Qod Bau dcsGehima, b. iii. p. 514.— J. L. Bracket, Sur

i

Hjdrocephalite, ou Hydr. AicUe dea Vent du 6erv.

'va Pana, 1819.— Forf^, in kied.-Chirarg. Journ. and

Rev. No. iii.— IF. Skf^amum, On the Nature, Cautca, and

Trealaeot of Water in the Brain, 8vo. Lond. 1825. —

Akerxrotnbie, On Dia. ofthe Brain and Spinal Chord,

^. p. 126. ef »eq.—l/nderuiood. On Diaeasea of Children,

el by Met i iumn, Bro. Lond. 1827, pi 357. note by editor.

— i. Shnro, Moridd AnalODiv ofthe Brain, vol. i. ; Hy.

drooephalua, 8vo. Bdin. 1827. — Lcurat, Sur lea Causes,

li Nature, et le Traitement de THydroceph. Algiie, ftc.

L^UM. 1868. — C Uimljf and Langenbeck, in Comnent

Sue. Rcf. Scient Got. Recent, vol. vi. Class. Phys.

p. GL et 73. pL 1—5. — J. Machntoik, in Lancet, No.

947. p 237-466.*— Omqaest, in (Ibid, for 1830. — Grtat-

oud, in Ibid. No. 9». p. 238L —JSUiaimm, in Medical

tiuettcvoL xi. PL 405. 435 Graefc, in his and Wal-

thfr't Joum. fUr Chimrgie, 1831, fai xv. p. 3.— Trait, in
'J>ana of Provin. Med. Asaoetat voL 1. 1833. — Cra^,
in Edin. Med. and Surg. Joum. July. 1832. (An intereMHng
cate^ witk remark$.) — Smstel, in Itiid. Julv, 1832, p. 4S.
- y. W. Oppenkeim, in Rutr% Mag. f. d. Oesammte
Hedk. b. xxiv., reviewed in Edin. Med. and Surg. Journ.
vd. xxix. p. 3S58., where arguments for and against puno*
ture are adduced.

DRUNKENNESS — Intoxicatiok. — Syn.
Temutentia, Plioy, Plater, &c. Paraphro9yne
ttmulenta, Sfiuvages. £6rartos, Lat. Ivreste,
Fr. Trunkenheit, Rau$ch, Germ. Ebhro, Ital.
Ehriety, Inebriation,
Ctassir. III. Class, I. Order (Author.')

1. Dsnx. — Mental excitement, followed by <(m-
pm" or coma, from the exceteive ute of fermented or
di$tilUd Uquort,

2. The frequent occorrence of intoxicatioD,
either casmally or as a confiimed babit, would
ia»tify the DotJee I am about to take of it, even
iodppendently of its inriuence in causing and
modifjfiog disease. But it is chie6y to the more
complete states of intoxication, and especially
ibose demanding medical care, that attenuon wifl '

be here directed. DrankenneM, in its variooa
phases — from the daily indul^noe in more •
vinous or spirituous fluids than is required, bUt
short of ancting the nervous system in a very
evident maimer,, up to that degree of excess by
which the senses and intellects become obscured
or entirely lost — predisposes to many diseases,
and directly causes others. Slighter excesses in
the use of fermented liquors — particularljr wine
and malt liquors •— occasion plethora, with all
the consequent ills, especially gout, apoplexy,
paralysis, and congestion of the abdommal vis
cera. Greater excesses, and the too free use o
spirits, exhaust nervous and vital power, io*
ducine tremors, nervousness, delirium tremens^
encephalitis, paralysis, and insanity ; occasion
affections of ihe digestive organs, particularly
unorexia and dyspepsia, diarrhoea and dysentery,
inflammation, and structural changes ofthe biliary
organs; and produce disorders of the urinary and
sexual functions, even sterility and impotency ;
and, ultimately, lesions of the kidneys, and
dropsies.

3. Drunkenness is not a vice of recent date,
although it may have become more common with
the progress and diffusion of luxury. We 6nd it
mentioned in the early history of the Jews ; and
TAcrrus informs us that it was prevalent amongst
the ancient Germans. It is tolerably evident, from
the ancient lyric and dramatic poets and satirists,
that it was by no means infrequent amongst the
higher classes in Greece and Rome. Hippocrates
notices its worst states, both in his Aphorumt and
in his Prognmties; and it does not appear to have
been considered a very eulpablesort of indulgence
even by some of the sages of antiquity. Plato
cautions against allowing wine to youths at an
earlier age than eighteen years, and against be-
coming mtoxicated before forty; but, after this
age, he considered some degree of indulgence in
this way pardonable. This was possibly, also,
the opimon of SocuAlte.

*' Hoc quoque virtutem quondatn oertamlne, magnum
Socratem paimam promendsse ferunt."

CosN. Gall. Eleg. 1. ver. 49.

And Horace states, that Cato the Censor often
warmed his virtues by wine.

** Narratur et prisd Catonis
tepd mero caluisse virtus.'*

It is evident that the vice increased amongst the
ancients witli the diffusion of luxu^ ; until, at
last, even the ladies occasionally followed the
example so generally set them. Valerius
HIaximus (I. il. cap. i.) states, that in the earlier
periods of Roman history, the women seldom
drank; and Seneca (Epist. 95.) remarks, that
at a later period, they indulged so freely in this
way, that they became neariy as subject to the
diseases occasioned by the practice as the men.
Erroneous opinions as to the effects of intoxication
upon the frame seem to have been very early
entertained, and were generally prevalent in the
fifteenth and sixteenth centuries. Moktaiomk
mentions, that the celebrated Sylvius informed
him that an occasional debauch was beneficial,
inasmuch as it roused the energies of the stomach ;
an opinion long entertained by medical men,
but zealously combated by MM. Homhets and
Langloia. There can be no doubt, however,
that, as expressed by the late Dr. Grigory, an
occasional excess is, upon the whole, less injurious

DUODENUM — FcKCTiONAL Disorder op — Pathology.

dre said to have used coididoq salt for this par-
zKMe; aod the Romans surrouoded tlieir heeds
by wreaths, formed of various refreshing plants.
Nothing further, however, may be said on this
topic, than that iotoiication, and perhaps various
coosecutive ill effects, will not so readily be pro*
duced when wine is taken upon a very large
meal; but if this become a habit, it will very
speedily induce gout or apoplexy. Cold applica-
tions, or cold spon^ng tiie head, i^ill also deUy
or prevent intoxication, unless excess be carried to
(0 a worse than lieastly length.

Bnuoo. Aim Rbvbb. — Uippocrciea, Aph. v. & ; De
Xorb. ii. xxiL S— 4. ; Predict, ii. 9,^—9R^~ Horace, Ode
SI. 1. iiL T. II.— LuerelHu, I. ill v. 475. ^ Stromer, De-
CTiu Medics de Ebrictate. LifM. 1531. — WiUiek, Prob-

I«D. de Etiruur. Affect. eC Moritu Fr. 1543 Montaigne,

Eoau, I. u. cap. 2. — Magirat, De VinolentU ejiuque
BUUf. Fr. 1618. — Homtmett^ Non ergo ungulla Meiul-
bui aemd repetiU EbrieCai MlubriiL Paria, 1643. —
Ltmglou^ Non erao unqium Ebrietu lalubrit. Paris,
1665. — Boffinek, De Ebrletate et Crapula. Jen. 1667. —
H'n^, obMfT. p. 7. -> fVaiiUekmkU^ de BbrieUte et

intoiaitJbut aliquot c(}oa aifectlbas. Geess. 1677

EttmUUer, De TemuleDtia. LIpi. 1678 Hannemann, De

Utu ct Abutu Inebriantium. Kiel, 1679. — Ra$t^Ebrieu$
tncdicd conddarata. Reg. 1688. _ Alberti^ Therania
Uedica. UaUe. 17S1, 4Ca p. 1033. : et De EbrieUte F<».
miiunim. liaue, 1737.— EbrieUtu Bneomium, or the
PriUe of DrunkenncM, ftc.. 8va Lond. 1794 and 181S.
-r«riAr«wr, Dc Noxa et UtiliUte EbrieUUi. Fr. 1740.
—Denun, Zoonomia,vol. UL p. 497. — Ptainert DeEbri-
MUte. Lipt. nm.-^ Trotter, Evay, Med. Philotopb.
and Cbcmlcal, oo DnmkeoneM, and Ita Ellbcts on the
Body, 8ro. Loud. 1804. — Volgki, Mag. fUr den Neuctt.
Zuitaod der Nat. b. iU. p. 9S6^Gtrara, Med. and Vhj.

Joum. Aug. 18S1 B. MaensBh, Anatomy of Drunken-

Dm, ad cd. ISmo. 1819. — J^. Ogaion, On the more ad-
vanced Stages of Intoxication. £din. Med. and Surg.
Joum. vol xl.p. 976. — JTfyvMt, Praxeos Med. Univ.
PreccpU, Tol. i. para Ii. 'oct I. p. 671.

DUODENUM — Its Dxseasss.

1. That the duodenum performs an important
partin various diseases, and that it is itself the chief
seat of serious ailments, which are with great diffi-
nilty, or not at all, distinguishable from disorders
of the stomach, pancreas, gall-ducts, liver, or right
trih of the colon , cannot be doubted. Some writers,
e»peciatlj Dr. Yeats, Brousbais, and his fol-
lowers, suppose that affections of this viseos may
be ascertained by attentive observation. They
iDsj in some cases ; but with no degree of cer-
Uiat^ ; for, after the most diligent investigation of
a train of phenomena apparently emanating from
this organ, the inferences we shall arrive at will
oTtea possess only a certain degree of probability ;
for the same, or very similar symptoms, may pro-
ceed from the other viscem now named. It must,
however, be admitted, that serious disorder of the
doodenum will seldom exist without the functions
of these organs being more or less disordered, as
Veil as those of the stomach and small intestines ;
sod ultimately organic change may be propagated
to a greater or leas extent from this viscus to one
or more of them. It becomes, therefore, a mat-
ter of great importance to be acquainted with the
•ymptoms occasioDed by the more common patho-
logical conditions of the duodenum, although we
are at the same time convinced that these symp-
toms may be produced by changes in some one or
more of the immediatelv adjoining organs. With
•1) this uncertain^, however, the experienced
observer will often come to just conclusions as to
the seat and nature of the disease, founds on his
knowledge of the functions and morbid relations of
tliH sod the surrounding part^. The duodenum
is liable to all the functional and organic changes
4e»cnbed in the article Dioan-ivE Canal, but in
different relative degrees of frequency.
Vou I,

I. Functional Disorder op the Ditodekum.
Classip.-^ I. Class, I. Order (i4u(Aor).

2. i. Pathology. — (a) It is extremely probable
that impaired function of this viscus gives rise to
various symptoms of indigetiion ; warranting the
designation of duodenal dyhpeptia, if they could be
distinguished from those proceeding from the
stomach. But, granting tnat they can, we have
no proof that the duodenum is the sole, orthe chief
seat of disorder, even in those cases which seem
to admit of the least degree of doubt of such being
the case. For, owing to the intimate structuru
connection — by continuity of tissues, blood-ves-
sels and nerves — even functional disorder cannot
exist to any sensible amount in it without being
extended to the stomach, intestines, pancreas, and
biliary organs. Aithenia, or deficient vital action
of the duodenum, may be inferred in cases charac-
terised by an unimpaired, irregular, or ravenous
appetite ; by constipation, and a deficient secre-
tion and excretion of bile, the stools being light-
coloured, greyish, or foetid ; by a loaded sediment-
ous urine ; by a feeling of langour and drowsi-
ness, with fulness at the ri^^ht epigastrium, and
oppression and sense of distension towards the
ri^nt hypochondrium, or right shoulder-blade, or
lorn, two or three hours after a full meal ; occa-
sionally by head-ache or vertigo ; or by pain, or
a bunting sensation in the soles of the feet ; by
absence of fever, and a pale or foul lurid appear-
ance of the cutaneous surface. But, in this state
of disorder, the collatitious parts are coetaneously,
and some of them even co-ordinately, affected. In
attempting a fine aeries of pathological analysis, let
us not be carried away either by flights of imagina-
ation or by efforts at mathematical precision, and
attribute to a single orpan what proceeds from seve-
ral. But let us merely endeavour to interpret the
phenomena of nature aright, according as they
actually exist, and not as we suppose, or would
have them to be. (See Indigestion.)

3. (fr) Accumulations of scrrdes, the presence
of acid and acrid mattert, of toormt, or of morbid
bile, may very probably take place in the duode-
num as a consequence of indigestion, or atony of
the stomach, or of torpor of the liver, or even of
the preceding affection ; mav irritate more or less
its mucous surface ; and, from its nervous and
other structural connections, disorder the func-
tions of digestion, chylification, assimilation, and
fscation; but the tnsembU of symptoms that
result can seldom be dbtioguished from those pro-
ceeding from disease of the stomach, pam;reas, and
biliary organs, owing to the reasons already
assigned. These reasons will also explain the
fact that irritations sealed primarily in this part
may be propagated, along the digestive tube, to
the stomach on the one hand, and to the intestines
on the other ; and along the ducts, to the Uver and
gall-bladder on the one side, and to the pancreas
on the other: and I believe further, that fre-
quent repetitions of such irritations, occasioned
either by the nature of the ingests, or by the
state of the secretions poured into it, may take
place without this viscus suffering materially in
structure; and yet the disorder propagated from
it to its collatitious organs may terminate in struc-
tural change of them. Such results are most
likely to supervene in those who partake of a
highly seasoned and stimulating diet ; who indulge
in vinous or spirituous liquors, or take too much

690

DUODENUM — Inflammation op — pAinoLOCY.

or improper food. Irritation of the duodenum
very probably constitutes a part of certain forma
of dyspepsia ; and even pi/rosix, and other ailments
frequently imputed to the stomach and the biliary
apparatus may, with equal justice, be referred to
this viscus i but it cannot l>e said to be the only
part in fault, or even that priniarily disordered ;
for it may be affected simultaneously with its re-
lated organs by changes primarily implicating its
nerves and circulation.

4. ii. Treatment. — But little need be here
added to what is advanced on this topic in the
article Inoioestiov. It is obviously of importance
to promote the functions of the duodenum by
those means which are the best calculated to pro-
cure a due secretion of bile ; as this fluid is essen-
tially requisite both to the performance of those
functions, and to the preservation of the tissues of
the viscus in their heaithy condition. But at the
same time accumulations of fscal or morbid mat-
ters in the bowels should be removed. A full
dose of blue pill, or of hydrargyrum cum creta,
should be given at bedtime with the common pur-
gative extract, and in the morning any of the
aperient medicines in the Appendix, particularly
F. 266. 382. 872. Dr. Yeats recommends either
the infusion of chamomile flowers, with the wine
of aloes and liquor potassse, or an infusion of
quassia and senna witn sulphate of potass, taken
morning and nlid-day. These, or F. 506. 547.562.
will be appropriate in most cases. But in those in
which irntation is presumed to exist,I have preferred
the following, which may be given daily, or on al-
ternate days, until the evacuations become natural.

No. 196. R Pilul. Hydrarg. gr. tij. ; Pulv. Ipecacuanha

B. n.— J. ; Extr. Colocynth Comp. ; Extr. HvcMCjami,
irr. y. ; Saponii Duri. gr. J. M. Fiant Pilule due
horA somni luniend*.

No. 197. H Sode carlx>n. gr. xij. ; Extr. Taraxaci 3 j. ;
InfiM. CalumtMe et InAu. Senn« Comp. aa 3 h. : Spirit.
Ammon. Arom. 3 m. \ Tinct. Cardam. Comp. 3 1. M.
Fiat Hauatua prlrao mane capiendus.

5. When these fail of fully evacuating the
bowels, the stoola still continuing unnatural, or
devoid of healthy bile, it will be advantageous to
exhibit a full dose of calomel at bedtime, with
the extracts of colocynth and hyoscyamus, and a
grain of ipecacuanha; and a draught with the
compound infusions of gentian and senna, with
some neutral salt in the morning. Having evacu-
ated morbid matters, it will be requisite to give
tone to the digestive organs, and to preserve a
healthy secretion of bile, by prescribing two or
three grains of hydrargyrum cum creta, or one or
two of blue pill, at night, with extract of tarax-
acum, or with soap ; and the infusion of calumba
or any other tonic, or the decoction of sarsaparilla
with taraxacum, in the course of the day. When
the mercurial is relinquished, small doses of the
nitro-hydrochluric acids, with the spiritus stheris
nitrici, or the chloric sther, may be taken in the
infusion of cinchona. A course of Carlsbad, or
of any other alterative and aperient waters, either
alone or assisted by the above alterative pill, par-
ticularly when the biliary secretion continues dis-
ordered, will often be adopted with advantage.

6. As much benefit will often accrue from a
well-ordered diet and regimen, as from medicine
in this complaint, the patient should be careful
to partake only of light food in moderate quantity,
and at regular hours. He should masticate slowly
and perfectly, avoid malt and spirituous liquors,
and partake sparingly of wine. He ought to es-

tablish regular and habitual evacuations of ik
bowels, and take active exercise in the opea air.
Horse exercise, and the eoereetie emplojiiicot of
the muscles of the trunk and upper extirau&e<,
are preferable to walking. The sbower-bsik, ta
cold plunge bath, followed by frictioaa of tkc rt'
face, will also prove of great service.

II. Inplaumation or the DuooKurH, itc
their Kesults.

Classip. — III. Clak, I. Oaora (Amthar.

7. i. Jnflammaiory Irritatien of the Dundnm.
(a) The uneasiness or sense of fulnen and wvifM
which sometimes follows a meal in the come «t
two, three, or four hours, occasionally wit^tdt^^-
seated, dull pain, or feeling of dcsteorion is tb
r(ght hypochondrium, and extending to the nt^
epigastrium, and backwards to the liglit «lMHibtr-
blade, may depend upon ehr&nie or taA-ans^ in-
flammatory irritation or action in the duodemis .

and, if nausea or vomiting, or pain on firm piv^
sure directed towards the situation of the int^^t-y.
accompany these svmptoma, the latter stale nn
probably exists, either as a primary aflectiM), «-
as a consequence of the disoraers already Dout <i
and of affections propagated from the stomacb 'J
adjoining organs. The above inferenee vil! I.
further confirmed, if the tongue be losiieii ^
furred at its root, its edges and point bene rv*\
and the (Apills erect ; if the appelile be nnr-
paired, or even sometimes ravenons; if the ptie^
of the hands and soles be hot, and the eoaoicBift.t
and cutaneous surface more or less vnhealthv , ifi
the bowels relaxed, eriped, and the stools erode ct
offensive. Chronic Inflammation of the doodeDor .
especially affecting its mucous siufacc.is geoen'^*
atsociated with disorder of the stoandi, bt*a'>
organs, and intestines; and often with ckm"
eruptions of the skin, particularly Amts,^'n.:r'
pityriasis, and acne. The bowels are u these c?*^
usually irritated or irregular, the evacuations oi^v
sive and otherwise disordered, very rarely latir.'.
occasionally containing much unhealthy bix. ''
evincing a deficincy or obstruction of tbis*e('"
tion. The skin is dry or hanih. There are n^
frequently slight fever, sometimes with cbillbe^.
increased thirst, a gnawing sensation at ftona'S
or cravings for food, and variable eapricioBs ty
petite. The spirits are often dejected, and «c i-
sionally disturbed by bvpocboodnacal or fisr.'w
feelings. This state of disorder is not ioff«<;s':
in females, and is in them often complicated «
scanty, painful, and difficult menstruasioa. e^J^-
ciiilly in unmarried females ; and with bcada'**^^
and various nervous complaints (SeeI»iKCi»T^
— Irritative and Inflammatory SiaUa of),

8. (6) It has been supposed that ekaUf* r*
hilumt diatrhara are chiefly owing to tbe i^'t*
inflammatory irntation of the intemnl snrCir^ •
the duodenum by the morbid iccreliow pec*-
into it f and doubtless such is the case ia s r" '
measure. But it should not be overlooked, ^• *
the organic nerves supplying the digestive t* *
are morbidly impressed at the same msp by (V^
secretions, and tnat the same agenlsq«irkl> $fr \
by their presence, the whole canal, altheu^b i-'
impression is more directly and powcrfaUv »•'
upon the mucous surface and nerves of cbii p"'
In cholera, and certain kinds of fommimf, t^r
fore, where the internal coals of tbe tfnM'b -
violently irritated, the conseqncal pfaeaorans i*«
not to be imputed altogether, or cv« ebicc^ ' •

DUODENUM — Acute lNrLA3iMATtoN op — Symptoms.

ti91

l^i^ circninfftance ; but in a greet measure, and
someu'mes chiefly, to the change produced in the
nerves of the organ, and propagated throughout
the system to which they belong, as well as to the
porti which they directly or indirectly influence.

9. ii. Acute InfiammatioH of the Duoden*im, —
Duodenitis (Ditodenite, Fr.) may be inferred with
macb probability, but with no certainty ; for
acute disease of the liver and of the gall-ducts, or
of the pancreas or of the pylorus, will give rise to
very nearly the same phenomena. I believe that
irute inflammation is not frequent in this viscus,
or. if it be, that it does not so often give rise to
disorj^oisation, as in other parts of the digestive
canal. There can be no doubt that acute, sub-
acute, and chronic inflammations are sometimes
propagated to it from the stomach on the one side,
and from the intestines on the other, as well as
^m other adjoining parts ; and it would appear
from cases which I have examined, and from
some recorded by M. Andral {Archives Gjin, de
^id. t. vi. p. 161.; and Ctinique M4di€ak, t. iv.
p. 344.), that inflammatiott may commence in the
mucous surface of the duodenum, extend along
the ducts, giving rise to obstructions of their
canals, either with or without jaundice, and even
advance to the organs to which they belong. We
more frequently, however, meet with the conse-
quences of inflammations of these parts, in pott
fnortem examinations, than with the early inflam-
niatory appearances themselves ; whilst some of
the aisociated lesions admit of doubts being enter-
tained whether they be the results of inflamma-
tions, or of acme other state of action ; but that
inflammation, in one or other of its forms, often
Xiends these alterations, cannot be denied. Thus
«e occasionally observe thickening and injection
of the mucous and submucous coats of this viscus,
^iih obliteration of the common ducts, and these
ilientioos with lesions of the biliary organs, a
ttirrhoua or enlarged state of the pancreas, or ad-
^oaa of this last with the duodenum, or of the
luodeDum to other adjoining parts. Scirrhus
>r the pylorus not infrequently extends a con-
•vlerable way along this intestine ; and enlarge-
nent3 of its mucous glands, or ulcerations, to
*hich it is less liable than almost any part of the
u.'e^tive canal, are also observed in some in-
^ances in the parts more nearly adjoining it ; but
►e »ery rarely meet with a case presenting evi-
'ence of acute inflammation, and its undoubted
Kuits, upon dissection, confined altogether to the
oodenum.

10. Symptoms, "^a. Duodenitis, in any of its
>rms, is, therefore, very seldom limited, unless at
i commencement, to this viscus ; and, owing to
>e varied connections of this part of the canal, it
^y implicate more than one part of very different
ructures and functions. It may originate in any
f the funcCiomd dtsorders already noticed ; or
)ay directly proceed from the kind and quantity
the iogesta, whether food, drink, medicines,
' poisons ; or from the irritating effects of the
cretions poured into it from the liver or pan-
CSS. Admitting, with BaoussAis, Anoral,
0L<»8EAu, AbeHcrombie, Rostan, and others,
e difficulty of recognising the disease during
e, the existence of a dull, deep-seated, and
ttpging pain, in a diieetion from the epigastrium
the right hypochondriuro, right shoulder-blade,
d loin, increased upon pressure made on these

regions, or upon torsion of the spine ; sometimes
but little felt, excepting in these circumstances,
and two or three houn after a meal, when it occa-
sionally becomes severe, and is attended or fol-
lowed by sickness or vomiting ; a sense of heat,
or of gnawing, or of a foreign body in the region
of the duodenum; great thirst; unimpaired or
even a ravenous appetite ; and an irregular or re-
laxed state of the bowels, the evacuations being
copious, crude, unnatural, and offensive, are strong
evidences of inflammatory action in the duodenum,
especially when attended by febrile commotion of
the system, similar to that already described (§ 7.),
and by emaciation : but, in such cases, the imme-
diately collatitious organs may also be diseased.
Even in the more severe states of inflammation of
this viscus, the pain and sickness may be very ur-
gent a few hours after a meal, and yet but little
complained of at other times, as in the rare case
related by Dr. Irvine, where the duodenum only
WBS inflamed and extensively ulcerated.

ll.fr. More frequently, acute duodenitis is con-
sequent upon gastritis ; or oompUcated either with
it, or with a similar change in the jejunum and
ilium, or with both. When it has arisen from the
extension of inflammation from the inferior surface
of the liver, or biliary apparatus, or when this
latter proceeds from it, the stomach generally par-
ticipates in the disorder, at least of function.
When an irritative or inflammatory state of action
extends from the inflamed duodenum to the liver,
the pain rises often high in the right hypochon-
drium, sometimes to the right side of the thorax,
especially after a meal ; and is attended by bilious
vomiting, occasionally with bilious stools or diar-
rhoea, followed by constipation, nidorous eruct-
ations, prolonged digestion, a bitter taste in the
mouth, a yellow coated tongue, and a slight yel-
lowness of the conjunctiva, and unhealthy or yel-
low appearance of the skin. (See Jaumdics.)

12. c. The coruequenees of inflammatory action
in the mucous surface of the duodenum are, its
extension — 1st, to the stomach or small intestines,
or to both ; and, 2d, to the ducts, occasioning,
first, obstruction or obliteration of them ; and, ul-
timately, congestion, engorgement, enlargement,
or various other lesions either of the liver or of
the pancreas, or of both, with jauni/ice, and other
contingent changes. When the inflammatory ac-
tion attacks the whole thickness of the parietes of
the intestine, whether originating in its mucous
coat, or extended to its more exterior tunics from
collatitious parts, the pancreas, pylorus, duode-
num, ducts, and even the liver and colon, not in-
frequently become accreted or welded into one
mass ; in which the pancreas is often remarkably
enlarged, hardened, or sdrrhous, the ducts obli-
terated or obstructed, and the accreted serous sur-
faces and cellular tissue hypertrophied, or indu-
rated, or granulated and tubercuiated. A case
of this description, of which I kept notes at the
time, occurred in a dispensary patient, in 1820 ;
since when, I have met with several others — two
of them with Mr. Paintbr and Mr. By am. In
three ca.'ies of this description, recorded by Dr.
Bright, and in one by Mr. Lloyd, fatty mat-
ters were voided in the stools ; but this phenome-
non either did not exist, or was overlooked in
those which occurred in my practice. The in-
stances adduced by Dr. Bright presented
ulceration of the duodenum, which this able

Y y 2

DYSENTERY — Seat and Forms of.

693

cretions, a large plaster, consisting of the ammo-
Diactim pisster with mercury, and the compound
pitch plister, in equal proportions, or of the former
oaly, should be placed over the epigastrium and
right hypochondrium, and renewed after a week.
Id some cases, the opium plaster may be substi-
tuted for the latter; particularly if the bowels be
initated. When there is much irritation of the
nervoos system accompanying the disorder of the
digestive canal, much benefit will accrue from the
hydrocyanic acid exhibited in demulcent or dia-
phoretic vehicles, as the camphor or almond mix-
ture, or in both ; and from the following, especi-
ally after morbid secretions have been evacuated
by the foregoing means : —

Ka 196. H Camphorw rum et futecta cr. Ti.i— vtij.
terccum Hacnette usts 3 J., ct Sod« cartMn. fvel Potatue
cartx 91J. ; dcin adde, InAui Valeriana (vel Aq. Mentha
Virid; 5 viij. ; Tinct Colchlci CompoaiL 3 it. ; Syrupi
Pipaverit3 iij. M. Fiat Mitt, cuju* coeh. ij. larga bit
terve quoCidil nimantur.

18. Having removed the inflammatory state, by
tbew aod other medicines appropriate to the pe-
cDtiarities of the case, a similar treatment to that
recommended in functional disorder of this viscus
($ 4.) may be adopted, and nearly the same diet
tod regimen pursued. At first, however, ,very
tight, and chielly farinaceous, articles of diet
Kboald be taken, and the beverage should consist
of small glasses of spruce beer, or Seltxer or soda
water, and the bowels regulated by an aperient
and tonic pill (F. 558. 561, 562.), or by lave-
ments of warm water. As the general health im-
j)roves, a more generous diet, and a small quan-
tity of wine, may be taken ; regular and active
exercise in the open air being enjoyed. After the
more protracted cases, or when the secretions and
alvioe evacuations still continue, or readily be-
come disordered, a course of taraxacum, with mi-
nute do«es of a mild mercurial, subsequently of
the nitro-muriatic acids, with compound decoction
of sarsaparilla ; or a course of eitner the Harrow-
gate, or the Marienbad, or the Carlsbad mineral
waters may be tried.

BiBLioo. AND RBrnn.— F. HqffiHaim^ De Intett. Duod.
nulturum Ualorum Sede, in Opp. vol vL — > Boimaxoti,
Trana. of the Acad, of Bologna, lliS. — SckmUel, Oe
I>>gnitatc Duodeni in DUudicandii et Curandis Morbia.
&L 1757.— il. Monro, Edin. Med. Euayi, vol. Iv. ed.
1758. — CUiuuen, in Sand(fort*t Tbewurut, toL ili. 177&
— frarren, in Med. Trans. oTCoL of Pbya. yoI. iv. p. 833.
—Perruw, Medical HiMorica, voL iL p. 87.-»0. D. Teats,
to Med. Trana. of CoL of Pliyi. vol vi. p. 325. — Boeke
•t Sammm, Nout. EMmeni de PatltoL Medico-Chlrun.
Ac 8va I^ris, 188S, 1 1. p. 48& ~ Irvhie, in Phtladeiphia

Med. Journ. Aug. 1884 C. Brom$ai$, Sur la Duodeoite

ChroQique, 8to. Paris, 18S5i — iZo6tfr<i, in Nouv. Bit»-
liotb. Mid. Juin, 188S. — F. B. Boiueam, Noaographie
Orsanique. 8to. Paris, 188% t. i. in 389. — C. Haathngt,
Midland Med. Reporter for May, 1889, p. 9BII'-' Streeien,
in Ibid, for Noremlwr, 1889.— J. Abererombt'e, Researehes
<"> Dis. of the SUimach and Abdom. Viscera, &c. Edin.
ia30. 8d ed. p. 103. — P. J. V. Brotuaait, Comnent. det
l^ropositioDS de Pathologie, tte. 8vo. Paris, 1889, t. i.
P-^. — JI..0Wg*i,Obscrv. connected with Dis. of the
Duodenum and Pancreas, Ac, in Trans, of Med. and
Oiirutp Soc voL xtIIL pi 1. — £. A. JJowd, in Ibid.
p. &7.~r. J. Tbdd, Id Cyclop, of Pract Med. vol. i.

DYSENTERY. Syn. — AwnmfU, Gr.

Difmnteria (^from Kf, difficulty, and '^!f^>
an mieilijis). Diffieultat Jnte$iinorum ; Tor-
mina, Celsus. Rheumatiimut intettinorum
eum UleerB, Celios Aurelianus. Fluxut
Cruentut eum Tenetmo; Fluxut Dytentericvt ;
Flumen Dyientericum ; Teneunut, Auct. Var.
Dyuenterie, Flux de Sang, Fr. Die Ruhr,
Germ. DUaenterie, Ital. Bloody Flux.
Clsssif. — I Clau, 5 Oritfsr (Cullen),

3 Clau, 2 Order (Good). III. Class,

I. and II. Orders (ilutAor, in Preface),

l.NosoL. Defin. Tormina, followed by strain'

ing and scanty mucout and bloody stools, containing

little or no fieoal matters; and attended by febrile

disturbance*

2. Path. Depin. — Inflammatory action tf a
sthenic or asthenic kind, seated in the mucous ttir*

face of the intestines, chiefly of the large intestines,
I accompanied vrith more or less constitutional dit^
, turbance, and retention or disorder of the natural
secretions and excretions,

3. Litt, Hist. — Dysentery, owing to its preva-
lence in ancient as well as in modem times, has
attracted a large share of the attention of medical
writers. Hippocrates {Opera, edit. Vandbr Lin-
den, vol. i. p. 252., vol. ii. p. 101. 176. et pastim)
notices it in various places, both as a sporadic and
as an epidemic disease ; and in such a way aa
shows tnat he was acquainted with several of its
pathological states and relations, and even with
Its complication with functional and organic dis-
ease of the Kver. Celsus (DeMed. 1. iv. cap. 15.)
mentions it by the name of tormina, as distinct
from tenesmus, from lientery {levitas intestine-
rum), and from diarrhoea. Aretxus (De Sig. et
Caus. Morb. Diut. 1. ii. cap. 9. ed. Boerhaave,
p. 59.) attributed the complaint, with Hippo-
crates, to ulceration of the intestines ; and was
tlie first to describe it in an accurate and connected
manner. Galen ( De Caus, Sympt. I. iii. cap. 7.),
although, perhaps, not the first to distinguish the
different forms of the disease, has furnished us
with the earliest attempt of this kind that we
possess. He particularities a sanguineous, an A«-
patic, an atrabilious, and an ulcerated variety.
Subsequent writers, — Greek, Latin, or Arabian,
— down to the commencement of the sixteenth
century, when the writings of the celebrated
Fernel first appeared, added but little to the ma-
terials scatterea through the works of Galen.
From Fernel to the prcfent age, the disease has
been nearly as well understood, as respects both
its nature and treatment, as at the present time.
The numerous epidemics, however, that have oc-
curred, and been deteribed by experienced writers,
from the time of this physician, have furnished
diversified facts, illustraUve of its varied forms and
of its treatment.

4. I. Seat and Forms op the Disease. — A.
The ancient writers, from Hippocrates to Avi-
CBNKA, considered dysentery to be teated in the
internal coats of the intestines— particularly the
large intestines— and attributed it too generally
to erosion and ulceration. Calivs Aurelianus,
Abtius, Alexander Trallianvs, and others,
who wrote between Galen and Avicenna, enter-
tained the same view as to its nature and seat, and
imputed the modifications it presented to thepar-
ticular part of the bowels chiefly affected. Tney
even attempted, and not without some degree of
justice, and even of accuracy, to point out, from
the character of the discharges and the appear-
ance of the blood in the stools, its seat in the
small intestines, in the colon, or in the rectum.
AiETius (Tetrabibl. iii. s. i. cap. 43.) believed that
the jejunum is sometimes the part chiefly diseased,
and described the symptoms — many of them
really concomitants of inflammation of tlie mu-
cous surface of the rmall intestines — that cha-
racterised this variety. Similar

Y y 3

views were

DYSENTERY, ACUTE — Causes — Svmptoms.

695

rially ID the arraDgeroent of the acute states.
ZiMXBRMAXN particttlarises the inflammatory,
malignant, putnd, and ehronie states. Ricbter
describes Che simple, inflammaUny, Inlious, and
nervous forms; and Kbkyssio adds to these the
yitKitaus or mucous, and the fmtrid or malignant.
MM. FouRNiBR and Yaiuy adopt nearly the
asme division as Krbtssig, but they adduce
ia tdditioD. the association of the disease with
tvphus and ague, Scbmidtmann distinguishes
tlie simple, the inflammatory, the bilious, and
Inlious-injiammatory, the nervous, and the putrid
varieties. M. Yignes, one of the most recent
aod experienced writers on dyMntery, considers,
fiisl, its benign or purely inflammatory states, under
the denomination of mucous and bilious; and,
next, its malignant forms, comprising the typhoid,
adiinamie, ataxic, and complicated* In the de-
scription I am about to give of the disease, I shall
follow a nearly similar arrangement to the most
approved of those adopted by the ablest and most
experienced of my predecessors. In the ^rst
place, those acute forms will be noticed which are
tiw most simple, which are more or less sthenic
or iaflammatory, and in which the vital energies
are either not materially affected, or not per-
verted to the extent of subduing the natural ten-
(leocy of the economy to resolution and to a
restoration of the healthy action. Secondly, the
sAihenif, or more unfavourable and complicated
iiates, which have been variously denominated,
accordiDg to the predominance of certain charac-
ters, arising out of particular circumstances and
epidemic influences, will be considered. Thirdly,
the ehronie and eompUcated forms will be de-
Jorihed.

II. Of Acute Dysentery. — ^i. Its Simple, Sthe-
nic, oa PURELY Inflammatury States.
Classip. — III. Class, I. Order.

8. Dkhnw — ToTiMna, tenesmus, mucous or bloody
ttoals, and a sense of heat or pain in the colon and
rectum, with tejulemeu on pressure, and symptom'
otic fever ; the nervous, circulatittg, and muscular
Junctions not indicating vital depression until late
in the disease,

9. A. Causes. — (a) The predisposing causes of
tlie sthenic states of the disease are chiefly high
raoges of temperature following wet and cold
seasons ; whatever favours the production and
accttmuiation of morbid secretions in the biliary
apparatus and prima via ; debility of the digestive
organs, particularly of the intestinal canal ; a ple-
tboric state of the vascular system ; unnatural
flexures of the colon favouring fiecal accumu-
latioDs in the bowels ; neglect of the functions of
litgestion and fecation : the habitual use of spirit-
uous liquors, or other inebriating beverages in
etcess ; rich food, and highly seasoned cookery.
Dysentery is generally most common in autumn
and in the beginning of winter ; in persons of the
rheumatic diathe«s ; and in those who have un-
dergone great fatigue ; or who have been recently
aifected by continued, remittent, or intermittent
fevers ; but, in svch circumstance?, it is as often
of an asthenic as of a sthenic kind.

10. (6) The exciting causes of the sthenic forms
of lite disease are 4rankenne9s ; exposure to vicis-
ntadesof climate or of temperature, and especially
to cold and moisture, or to the night-dews ; sleep-
iog in the open air, and more particularly on the
ground, without sufficient protection inteivening.

or without reouisite covering, as in the case of
armies in the neld ; wearing damp or wet clothes,
or too thin clothing ; acerb, acid, unripe, or over-
ripe and stale fruit and vegetables ; raw, cold,
and indigestible fruit, &c., as cucumbers, melons,
pine-apples, &c. j the stones and seeds of fruit ;
unwholesome food, especially unripe or blighted
corn or rice; and acid or unwholesome driiuc, as
sour or bad beer and wine. The exhalations
from wet, cold, and clay soils and marshes, or
from the banks of lakes, rivers, and canals ; and
the use of marsh, stagnant, or brackish water for
drink, with many of the causes mentioned in con-
nection with the other forms of thedisease ($ 22.6.),
will also produce this form in persons of a san-
guineous and plethoric constitution. Mr. An-
NESLEY states, that dysentery became, at one time,
remarkably prevalent amongst the British troops
in India to which he was attached, and that, upon
investigation, he traced it to their eating the pork
of the country with their breakfasts. Upon a stop
being put to this practice, the disease altogether
dbappeared.

ll.B. Symptoms and Progress. — Sthenic dys-
entery presents various states and grades of severity,
depending upon the nature ef the cause, the state of
the secretions, and the degree of inflammatory irri-
tation or of spasmodic action of the bowels result-
ing therefrom . It is often preceded by constipation
when occurring sporadically, and frequently by
diarrhoea when arising from endemic or epidemic
causes ; but in many instances the dysenteric
symptoms appear from the first, and are attended
by chills or rigors. When it is caused by endemic
causes, or is epidemic, the inflammatory symptoms
may be very slight, and yet the constitutional dis-
turbance and morbid action of the bowels very con-
siderable ; or the irritation and inflammation may
be along the small as well as the large intestines.

12. (a) The milder state of the complaint, espe-
cially as it occurs sporadically in Europe, com-
mences either with liauid and feculent or with
mucous stools, the latter being occasionally
streaked with blood, and always becoming so in a
few days. Generally, horripilations or chills pre-
cede, accompany, or follow these evacuations,
which are consequent upon gripings and a sense
of increased action in the course of the colon ; and
are often passed with heat and scalding in the rec-
tum, followed by straining or tenesmus. The stools
are frequent ; commonly from eight or ten to
more than double this number in twenty-four
hours, and are streaked with more or less blood.
They subsequently become less mucous, more
watery, and sometimes contain traces of fsculent
matter. There is little or no pain in the abdomen
between the calls to stool, but often an irksome sen-
sation is felt in the situation of the sigmoid flexure
of the colon and of the rectum. The pulse is
either very slightly affected, or quick ana small ;
the tongue is generally loaded or furred ; and the
thirst increased. The appetite is frequently not
much, or even not at all impaired. This slightest
grade of the disease may terminate favourably in
from six to nine days, or it may pass into a chronic
form, '^Relapses, and organic changes in the large
bowels, sometimes also follow it.

13. (6) In its more severe states, dysentery is
pieceded either by diarrhoea, or by disorder of the
stoipach and bowels; or by nausea, flatulence,
constipation, and occasionally vomiting. These

Y y 4

DYSENTERY, HYP£R.ACUTE~STiint)M8.

697

violeat, nor the mbdomea teue or tender, the
rectum mtj be conndered the chief leet oif the
disease ; the lecretiona poured out in the upper
parts of the intestinal canal having produced, fint,
irritation, and afterwarde, inflammation of this
part But, if there exist much primary constitu-
tooal disturbance, this inference should not be
drawn ; for, in such cases, the mucous surface of
both the small and the large bowels may be
soioiuly affected, and }ret these symptoms may
not be present in any evident degree. Cases will
tbo occur, characteriMd by tormina, twisting
paios about the umbilicus, borborygmi, tension of
ibe abdomen, mora or less febrile commotion, and
frequent calls to stool ; the evacuations being
macoQS, bloody, and subsequently waterv, &e. ;
aod yet little or no tenesmus will exist in these
the seat of disease is chiefly the ilium, the c«cum,
sod upper part of the colon ; which often become
speedily ulcerated if the morbid action be not
inesled. When, in addition to these s^motoms,
tenesmus is urgent, the rectum and sigmoid nexure
oi the colon are also affected.

15. In this form of disease, the quantity of
Dtttters evacuated from the bowels is extremely
raiions. In severe or advanced cases, from
twenty to thirty* or even forty, efforts at stool are
loiaetinies made in the twenty-four hours, and
often without any further dischaive than a little
mocoQs and blood ; but occasionally much serous
or watery matter, with broken-down faeces, slime,
mucus, and blood, is voided, exhausting and
emaristing the patienL In some instances, the
evacuations are muco-puriform, more or less
etreaked with blood, without the least trace of
fxoes; and in others, they contain scybalc It
would teem, that the retained feces are frequently
broken down or semi-dissolved by, and mixed up
with, the serous and sero-sanguineous fluid exhaled
fn» the irritated mucoae surface ; and hence the
iufrequency of scybalm in many states of the dis-
ease. The eYacuationa are often very offensive
fmn the commencement, but as frequently they
are not manifestly so. They Keaerally become
idJbd, or have a peculiar raw cadaverous odour in
the last stage of the worst cases ; especially when
portions of the mucous surface are sloughed off.
They are aometimes uf a singularly variegated hue ;
coDsiating of glairy mucus, with a ^rreenish or ge-
latinoos substance, resembling morbid bile ; seldom
with pQie bile ; often without any trace of this
secretion ; occtfnonally with large pieces of albu*
mioouB concretions of coagulated lymph or fibrine,
formed upon the internal surface of the bowel, and
afterwards detached j and either with streaks of
fluid blood, or with small dark coagula. When
tbe blood is in large quantity, and is fluid and
diattoct from the other mattera, it is evidently
pwued out by the lower parts of the large boweb.
When consisting of dark grurooos clots, intimately
xnxed with the discharges, it probably proceeds
from the cecum, or upper portion of the colon.
It may, or may not, even when most copious,
depend upon ulceration ; but it most commonly is
<soded from the irritated mucous suKace, espe-
cially early in the disease. It maybe veryabun-
<lsot, even at this stage, and continue so till death,
pvticularly in drunkards ; or it may be trifling
tbroQgbottt ; or l>e copious only at the close of the

dlMMC.

16. The state of the a^domm also varies. In

some, tension with fulness, proceedmg ^nerallv'
from fsBcal accumulations ; and flatus is much
complained of from the commencement. In
others, the abdomen is natural in size. Pain and
tenderness on pressure are uncertain symptoms in
the early stage of the disease. When it is fixed
in one place, we should suspect inflammation or
disorganisation to be proceeaing there. It is, in
the plethoric, most frequently complained of in
the hypogastrium and region of the caecum ; and
it may often be traced up the right side and in
the course of the colon. Often there is little or
no pain, nor even soreness ; the patient bearing
pressure without expressing any uneasiness, and
yet, upon examination after death, the morbid ap-
pearances will be as extensive, in respect of tne
inner surface of the bowel, at least, as in those
who complained of the greatest pain ; the chief
difference being in the more complete limitation of
the lesions to ue mucous surface in those cases
wherein no pain was felt. It is chiefly in the last
stage, when inflammatonr action has extended to
the serous surface of the bowels, that fulness, pain,
and tenderness of the abdomen have been com-
plained of.

17. (c) Htfptr-acHU dyttnttry, or dymntery in
EurcpeanM removed to warm eountriet, is generally
oeca$ioned by a too rich and stimulating diet, and
a regimen entirely unsuited to the climate ; by the
too free use of ardent and intoxicating liquors ;
by exposure to the night air, or to cold and mois-
ture ; and by the endemic and other causes men-
tioned above ($$ 9, 10.). It often assumes the
severe character now described ; and, in persons
who are plethoric, who have neglected their
bowels, have lived highljr, or are of a phlogistic
diathesis, or who possess ri^d fibres and great ir-
ritability, it puts on a still more violent or a
iuper'oeuteform* In them, the sense of heat and
soreness ; the tormina, fixed pain of the hypogas-
trium, the tension of the the abdomen, the conti-
nual calls to sCbol, and the straining, are most dis-
tressing. The region of the csecum is full and
tender. The tongue is white, loaded, excited;
sometimes clean and natural, but afterwards dry.
The skin and pul^are frequently, at first, and for
some time, very little affected ; the constitutional
disorder not being commensurate with the severity
of the local symptoms; but the former subse-
quently becomes dry or hot, and the latter quick,
hard, and small. In many cases, the disease be-
gins as common diarrhoea ; in others, it comes on
suddenly, and rapidly reaches its acm^ ; and then
the thirst is excessive ; the urine scanty, voided
with great pain, or altogether suppressed ; the testes
drawn up to the abdominal ring ; the stools mu-
cous, slimy, streaked with florid blood, sometimes
attended by prohfrnu ani, and rapidly passing to
watery, serous, or ichorous discarges, resembling
the washings of raw beef, in which float particles,
or even large shreds of coagulable lymph, thrown
off from the acutely inflamed surface, often with
copious discharges of blood. Great depression of
spirits, nausea, vomiting of bilious matters, and
distressmg flatulence or borborygmi, which aggra-
vate the tormina, are also present, and, in many
of the fatal cases, continue to the last. In some of
these the inflammatory action extends to the sub-
mucous coats, and detaches portions of the mucous
tissue, which come away in the stools, in the last
stage, or even hang from the rectum ; any effort

DYSENTERY, ASTHENIC _ Foaais and Symptoms.

699

preserved io Unkt, and in autumn, afler warm
raminen, in colder countries, dysentery is the
most common result. The water of the Seine at
Paris, from this cause, often produces the disease ;
ud Dr. M. Barry states, that such of the ioha-
biUtntt of Cork as used the water of the river
Lee^ which receives the contents of the sewers,
and is, moreover, braciush from the tide, are
subject to a very fatal dysentery ; and that, at the
time to which he especially refers, at least one in
three of those affected died of it. I have no
doubt that the dysentery epidemic in London
dufiog several successive autumns after the great
plague, was owing to the same causes, as well as
to tbe eihahitions from the burying^grounds, which
received the bodies of those who died of that
pestilence; and that the prevalence of the disease
iQ besiegiDg, as well as beseiged armies, is
cau^ by the exhalations from the decomposition
of tbe dead ; by the impure state of the water,
from decomposed animal matter carried into it;
by night exposure; irreguhir living, deficient
food or ciothmgr and the other contingencies on
eneampmeots and operations in the field ; and by
crowded and ill-ventilated barracks, &c. The
frequent occurrence and fatality of dysentery in
fleets ID former times, evidently arose from tbe
putrid state of the water, and the foul and stag-
uaut air between decks, sometimes breathed by
several buaUred persons. During the slave trade
dysentery was, and even now is, among the nume-
rous small vessels engaged io this disgusting traffic,
the cbief pestilence ; one half of those conveyed
io these floating receptacles of misery, on some
occasions, having died of it during tlie passage
across the Atlantic. It may be here mentioned,
that ilie dark races, particularly negroes, are more
liable to dysentery than any other disease ; that
it assumes an extremely low or putrid form in
them, when confined in ill-ventilated situations ;
sod that, when a number, even of those in health,
are shut np in such places, the cutaneous secre-
tioDs, which are so abundant and offensive in
these rsces, accumulate in and vitiate the sur-
rouodiog air, so that if it be not frequently renewed,
the systems of those thus circumstanced are therebv
iufected^and, instead of an infectious typhus, which
voukl be the result in tbe European constitution,
a putrid dysentery, spreading rapidly through all
breathing the impure air, is developed. I had, in
1817, an opportunity of writnessiog what I now
state. The disease is considered by the native
Africans as infectitious as small-pox, and is dreaded
by them equally with it ; these two being the
most fatal diseases to which they are liable.

24. $, The contagion of dysentery has been much
disputed ; chiefly owine to the circumstances of
the different forms of the disease not having been
distinguished with any degree of precision, and of
the loose notions attached to the words contagion
sod infection^ by those who espoused different
sdes of the question. In the article iNrEcnoN,
these terms, and their true value, are attempted
to be estimated with more precinon than hereto*
^« As respects this malady, it may be stated,
sa the result of observation and acquaintance with
what has been written, that the sthenic forms are
teldom or never infectious — and chiefly for this
fvaaoa, that the circumstances in which they
occur are unfavourable both to the generation of
infectious emanaliooa, and to their accumulation.

concentration, and operation, in healtli^ persons—
that, in short, they, like all other sthenic maladies,
do not evolve infectious effluvia, because the
vital energies are not depressed nor perverted to
such a degree, even in their advanced stages, as
to give rise to the depravation of the circulating
and secreted fluids requisite to the production of
infectious emanations, these changes taking place
only when some one or more of the causes which
produce these effects— the causes of the asthenic
states — come into operation ; — that febrile dis-
eases, attended by depravation of vital power and of
the fluids, evolve efliiA^ia capable, under favourable
circumstances, of infecting or contaminating those
disposed to be impressed by them ; — and that, as
the asthenic forms of dysentery are characterised by
these properties, and as the emanations disengaged
in their advanced stages become cognisable to the
senses, as well as by their effects, it must be
inferred, that these forms are infectious on occasions
favourable to the action of the emanations which
proceed from them. These inferences, founded
on an important pathological principle, are con-
firmed by enlightened and most numerous observa-
tions ; and, independently of such confirmation,
this principle most be shown to be unfounded
before the inferences drawn from it can be denied.
Thus it will appear that the great difference of
opinion that has existed on this subject is to be
referred, first, to the fact that certain states only
of the disease are infectious, and these chiefly in
circumstances favourable to the development
and operation of the infectious emanation ; and,
secondly to tbe incorrect notions entertained re-
specting contagion and infection ; many believing
because the disease is not propagated by me-
diate or immediate contact of the diseased person,
or of a palpable secretion or virus, that therefore
no contagion nor infection is produced by it.
But the spread of dysentery very closely resembles
that of scarlatina or measles, which cannot be
propagated by innoculation, or by the application,
either direct or indirect, of the morbid secretions
to a confined part of the external surface ; and
yet the efliuvium from the sick or the fscal
evacuations, floating in a close or stagnant air,
will readily induce the disease, in penons who,
constitutionally, or from the influence of con-
rent causes, are disposed to it, and who breath
tbe air thus contaminated. In such cases, the
effluvium operates, as in other infectious diseases,
chiefly through the medium of the respiratory
organs ; the svstem being affected, although not
very manifestly, before tlie dysenteric symptoms
are developed. Several respectable authors, how«
ever, have conceived it to be propagated, when
persons repair to the water-closet or night-chair
used by dysenteric patients, by the action of the
infected air or efliuvium upon the anus, the affec-
tion extending upwards, along the rectum. Hufs-
LAND and some others state, that they have seen
the complaint communicated by the pipe of an
enema apparatus. But, in most of the instances
of the infectious disease that I some years ago
had an opportunity of seeing, constitutional dis-
turbance, and often diarrhoea, preceded the fully-
formed dysentery.

25. fi. Forms AND Symptoms. — «. The simpU
asthenic or adynamic dynentery. This variety is one
of the most common, particularly in this country.
It may occur sporadically in delicate persons.

D YSEN TEtt V — Epidemics.

703

in Qpon the bowelft. It commonly arises^ spora-
HicuUy, from cold and moisture — from suppression

34. Haligaant dyientenr wm prevalent in Jamaica, in
1771. Dr. Wright found antisepUci, eipecially a satu-
rated lolutlon of common salt in lime-juice, taken in aro-
outic or iweeteoed water, most serriceable.

35. MM. Makkt, Durand, and Cailb state, that the
epidtfTDic throughout France, in the autumn of 1779, was
on illustration of the aphorism of Uippocbatui, — ** Hiems
>k!ci et aqullonia, Ter autem pluTiosum et australe;
tMce«M! eat fieri febret acatas et dysentarias masime," —
aod BSfumed an inflammatory, bilious, and malignant
form ; the second and third bdnx very infectious. In
inanr places, children, females, and the aged were prin-
dpafly affected. Blood-letting, which was repeated in
ume esses ; laxatives, with tamarinds and manna ; rou-
dUges and emolUents, in the form of drink and in clys-
(«n ; camphor and anodynes, lime, and gum- water ;
nochoiu, with camphor and the anodyne liauor. were
prncribed according to the form and stage of tne disease.

36. BiRMSTiBi. records that diarrhoea prevailed, in the
«priDg and summer of 1780, on the Rhine ; and was fol-
lawed. In autumn by a violent dysenteric epidemic of a
b«li(Mu sdynamic form — the symptoms being entirely the
saiae, but more intense than I have described them.
Evacttatioos by ipecacuanha and rhubarb, mucilages and
diaphoretics, and, towards the close, cascariUa and opium,
were conlided in.

37. In the vears 1785 and 1786, the disease, in simply
asthcoic and malignant forms (4 25. 27.}, was general
through the Venetian states — chiefly in females and
children (Capoviixa). Fomentations, mucilaginous in-
jectioQs, emc^lient drinks, ipecacuanha, rhubarb, almond
oil, al>M>rbeQts, and, afterwards, cinchona, wine, opiates,
ud ojtriogents, were most beneflcial.

34. The epidemic in Champagne, especially in the
French, Prussian, and Austrian armies, during the au-
ttuDo of 1793, assumed inflammatory, bilious, malignant,
aiul tfphoid forms, according to the causes and circum-
ttances in operation ; and was remarkably fatal among
both men and horses (Cbamseru). Bleeding in some ;
ipecacuanha, antimonials, emollients, cinchona, rhubarb,
taraarinds, lemonade, &c., were principally employed.

3;^. The dysentery that prevafled in the army of Italy
(DkjGEMKrris) was rarely inflammatory ; but very gene-
rally malignant, arising from endemic causes concurring
vitb extreme fatigue and exposure. Aromadcs, vege-
table adds, and opiates ; antiseptic and anodyne enemiOa,
ciochona^and simarouba,were most frequently prescrit)ed.

40. HcpBLAXD states that it was epidemic at Jena, in
I'i^'i. in the simply asthenic and malignant forms. He
tnated it most successfully by ipecacuanha and extract
of oux Tomica. it watf infecdous in favourable drcum.
ituices.

41. ScHwiyrMANN states that djrsentery was epidemic,
through the north of Crermany, in 180U ; and so pre-
Tah>Qt in the town In which he resided, that very few
(^sped. It assumed inflammatory, bilious, nervous, and
aulifpant forms, according to circumstances, and the
conttitation, Ac, of those affected. Bleeding in some
cax^ ; gentle emetics in others ; opium nearly in all ;
and camphor, decoction of bark, various astringents,
tonics, and antiseptics were employed. Arnica was given
Id the malignant cases, but with little benefit ; and tama-
rinds, cream of tartar, manna, or other mild purgatives,
v«r« also exhibited.

43. Dysentery, chiefly in the bilious-inflammatory
pu>ing into the adynamic form, was remarkably pre-
valent and fatal, at the Cape of Good Hope, in 1804
(LicuTK>«sTEiN) ( and was often associated with inflam-
mattoQ and structural change of the liver. This epidemic
va« at first very injudiciously treated by stimulants,
iitrlgents, and antispasmodics ; and one in four died.
IV mortality was subseouently reduced one half, by
raeuif of small doses of calomel and opium, gi^en every
Iwur or two ; sometimes with camphor and rubefacients.

43. This disease was very prevalent in Holland, in
■'^'9, particularly in the Brituh troops composing the
Walcheren expcnition ; and proceeded chiefly from en-
demic causes, and often either followed, or was converted
into, intermittent or remittent fe?er (Davis, Dawson). ^
ii was frequently associated with disease of the liver and
M'le«o ; and presented the inflammatory, asthenic, and
bilious forms. Bleeding, purgatives, calomel, and sudori-
tics were chiefly employed i bat the disease was too gene-
rally iniudldoualy treated.

41. Dysentery became epidemic, in and aroimd Vienna,
in autumn, 1B09, particularly in the French army^j and
assumed, according to circumstances, an inflammatory,
bili'jus, aitynamlc, typhoid, or malignant form ( Vionks).
It often was infectloua ; and few of the medical ofllcers
<^apcd. Ipecacuanha, opium, emollients, clysters, sina-
pisms, ami misters ; camphor, aether, arnica, serpentaria,
rinchona. valerian, and aromatics, variously combined,
appear to have been chiefly emplo]rod.

of the function of the skin, which is in Ihem a
much more important excreting organ than in the

45. The more simple asthoilc states of dysentery wera
prevalent In Flanders, in July, 1810 (Tonnbubb); and,
m the summer of 1811, in various parts of the north of
France (Caron). In some villages, nearly all the Inha-
bltants were attacked the same day. Ipecacuanha, gentle
purgatives, rhubarb, calumba, simarouba, mucilaginous
clysters, opiates with diaphoretics, warm baths, arnica,
aromatics, UoprMANN*a anodyne, &c., were generally
employed. Favourable changes occurred between the
tenth and fifteenth days. The disease sometimes passed
into entirltis, and was occasionally followed by dropsy.

46. Dr. PiSANi states, that dysmtery of an asthenic
kind, but presenting either inflammatory, malignant, or
nervous symptoms, was so prevalent in the garrison of
Mantua, in 1811 and 1812, that about 1000 cases were
received into the hospital. It first appeared in some
felons ; f^om whom it extended to the soldiers in the
wards, and by them was conveyed into the barracks. The
medical attendants and assistants were attacked; but
those who had«oo communication with the sick escaped.
Small depletions, ipecacuanha, laxatives, emollients:
with nitre, fomentations, mucilaginous clysters, neutral
salts, rhubarb, Hoppm arm's anodyne, camphor, and wine,
according to the features of the disease, were most em-
ployed. Ventilations and;fumlgations were also resorted to.

47. In the expedition to New Orleans, dysentery, owing
to cold, moist, and miasmatous air, wet clothing, and the
use of foul, brackish water, and fatigue, was Uie most
fatal disease, assuming Iniuunmatory, bilious, asthenic,
and malignant forms. Bleeding, emollients, foment-
ations, opium, Dover's powder, and very large doses of
calomel, appear to have been principally confided in. In
fatal cases, the liver was frequently found diseased ; and
the colon very slightly ulcerated, but not spbacelitted. -*
{Edm. Mtd. Joum. vol. xil. p. 136.)

48. Dvsenterv, although it may not be said to have
been epidemic in the strict sense of the word, was the
most latal disease in the British army during the Penin-
sular war. It was often connected with intermittents and
remittents, and frequently supervened on these and other
forms of fever (Sir J. M'Gbigor) ; and attacked con.
valescents. It assumed InflammjUory, billons, typhoid,
or malignant and chronic forms, according to the causes
and concurrent circumstances. It was roost prevalent and
fatal at Ciudad Rodrlgo, which was obliged to be made
an hospital station for a time ; and where, shortly be-
fore, '* nearly 20,000 bodies were calculated to have been

Eut Into the earth, either In the town or under Its walls,
1 a few montiu." It was unhealthy. Independently ot
this circumstance. It was commonly treated by vene-
section, in the first stage ; and by the warm bath, full
doses of Dover's powder every hour, calomel and opium
at night, sulphate of magnesia, in broth, in the morning •
in the second stage, by demulcents, aromaUcs, <^ium,
astringents, tonics, and flannel rollers.

49. This disease has been more or less prevalent In some
part or other of Ireland, owing to the presence of endemio
and even of epidemic causes. During 1817, 1818, and 1819,
it was, coiUointly with fever, epidemic throughout the
island. The seasons were cold and wet ; and, with this
cause, famine, unwholesome food, and infection con-
curred. It was very often consequent upon the early
stage of fever, or it appeared as a crisis of fever, or it
occurred during convalescence. It was Infectiotu in cir-
cumstances favouring this property ; and presented In-
flammatory characters, but often associated with the
asthenic diathesis. It was treated chiefly by moderate
bleeding, Ipecacuanha, the warm bath, opium In doses of
four or five grains, calomel with opium, copaiba mixture,
and farinaceous diet (Chkynb).

50. It was prevalent In several parts of Ireland, in 1822,
at the same time with low fever, owing to scanty and bad
food. It commenced with debility, pain about the umbi-
licus, mucous dejections, general cachexia, rapid and
weak pulse, &c. ; on which tne pathognomonic symptoms
supervened in an adynamic form. It was very nital until
wholesome and nutritious food was obtained (Dr.GsAVEi,
in Trans, oj Irish Col. qf Phys. vol. iv. p. 429.)

51. It was again prevalent In Dublin and the vicinity,
in the autumn of 1825, after great heat and drought ; aif-
fected first the better classes ; sometimes appeared as
fever for two or three days, and then passed into dysen-
tery ; or it occurred during convalescence fh>m fever, and
was infectious ( Dr. O'Bribn). It was of an asthenic and
complicated form ; the skin being of a dirty or dark hue,
and harsh to the touch ; and was very oenerally treated
by bleeding. In robust persons, at an early stage ; by the
warm bath, aud friction of the surlhce with camphorated
oil ; by calomel gr. x., and opium gr. ij., repeated In eight
hours, and followed by purgatives, especially castor oil
with 'a few drops of laudanum ; by flannel rollers around
the abdomen ; and by Dover's powder, and the repetition
of one or more of these mejans, according to circumstances.

704

DYSENTERY — ITS Tvpe.

white races; from insufiicieDt and unwholesome
food ; and, endemicaily from bad water, marsh
effluvia, and animal and vegetable emanations
floating in a moist atmosphere. It assumes some
one of the asthenic forms, according to the causes
which produce it, and the circumstances which
influence it in its progress. Even- when it appears
sporadically, it is more liable to become infectious
than in Europeans, owing to its passing more
readily into a low, malignant, or putrid form, on
occasions of imperfect ventilation or crowding of
the sick. In such circumstances, it is sometimes
quite pestilential in the rapidity of its dissemination
and the extent of its fatality. In its sporadic
states, it is frequently attoeiatid with rheumatism,
or the one passes into the other; both generally
arising from the same exciting causes » from cold
and moisture. It is also very often compUeated
with worms, especially the round worm, in the
jtrima via ; these being paned with the stools in
the advanced stage of the more severe and danger-
ous cases ; and, m its less severe grades, it some-
times assumes intermittent or remittent types.

31 . When dysentery attacks the dark races spo-
radieaUy, and sometimes, when it seises Europeans
who have resided very long in a warm climate, it
frequently commences with chills and much febrile
reaction or irritation, the vascular excitement
rapidly passing into an adynamic state — into
great prostration of the vital and animal actions,
and depression of spirits. The pulse is, at first,
more or less quick and irritable — sometimes
sharp and full ; but it always becomes, in the space
of one, two, or three days, small and soft. The
rapidity of the change is seldom owing either to
the loss of blood from the bowels, or to the quantity
of matters evacuated, but rather to these conjoined
with the exhaustion produced by the causes of the
complaint, by the severity of the tormina, the want
of sleep, and by the febrile irritation of the system,
in less vigorous constitutions than those of the
white race. In this class of patients, flatulence,
nausea, sometimes porracious or bilious vomiting,
quick small pulse, and occasionally scybalous
evacuations, often containing worms, are very

52. The disesfe was epidemic, in same parts of France,
in the autumn and winter of 1826 (M BiT Dbnovkb, La-
MBRciaa, and BfXNVBMu) ; and wai, in leveral placet, pro-
pagated by the exhalations fW>m the sick and the eva-
cuations ; children, females, the weak, lU-fed, the aged,
and those living near unhealthy and moist localitiet, be.
ing chiefly attacked. It assumed inflammatory, asthenic,
and malignant forms ; and, in sereral places, the small
Intestines and stomach were also aflhcted. it was treated
chiefly by local depletions, o^um, repeated application of
blisters and demolcents. Tonics and antiseptics were
required in the advanced stages and chronic states.

53. It again prevailed, ill some parts of that kingdom,
in October, 1 827 ; and was, in several localities, attributed
to the water, which abounded with decayed animal and
vegetable matters, animalculae, &c. (M. Gompaony;. It
presented either inflammatory, mucous, asthenic, or
malignant characters; and was treated by leeches,
opiates, demulcents, and, afterwards, by camphor and
cinchona.

54. The disease was epidemic in Glasgow, in the *iif»i»np
of lt)27, in a slmplv asthenic and mild form. Opiates, ca-
lomel and opium, ipecacuanha, demulcent enemata, blis-
ters, warm baths, astringents, and tntter tonics were most
serriceable. Bleeding, unless by leeches, was T«ry seldom
required, and was oroen iojurious (Wilson, BaowN, and

MACrAELAint.)

55. Infectious dysentery, in adynamic or typhoid forms,
has flrequently appeared in ships, in prisons, and where-
ever many persons have been collected in ill -ventilated,
and particularly in moist and miasmatous situations. In-
stances of such occurrence^ are so numerous, have been
•o often noticed, and are so well known, that It i« un-
necessary to refer to them.

early obeerved ; the svrfare of the bodj beef
shrunk, the superficial veins deprived of blood, umI
the extremities moutened bj a colfiquative «wtii.
In these persons, however mllaaimatflry the dn-
ease may be at its commencement, it sooa eihaoi&i
vital power, and passes into the astbeox fom ,
and, in seasoned Europeans, is awnetiuietcBSte-
gent on, %n6eomplieated with; fiaeaseof the hti.
or of the spleen, or even ofien of tiw absoiicK
glands ; or n consequent oo fevers, both perioAr
and continued, either in their eonne, or dmai
convalescence from them.

32. III. Op THE Ttpb or DvsifrraT.— TW
inflammatory typhoid, and more asafigoant fam
of the disease, are generally eoatinved, orohersR)?
remittent. But the other forms Biay imbc
an obviously remittent, or even an iaitfminrfi
type, owing rather to the coacnrreaee of tk«
causes to which periodicity in fever is owio|, mti
those on which the dyaenterie phenomcm m
more immediately dependent, than to the pndif^
tion of two distinct kinds of disease. He b«e
seen, that dysentery often arises fnm ewfcw
causes, very nearly similar to those wfaiek p^
duce periodic fevers ; the eanset of the Infer
chiefly impressing the nervona system, tlMse d
the former vitiating the secreted and eatvi^i
fluids, and disoidenng the fuDCtieas of tbt boetk
Therefore, when both kinds of eanaes coocv. k
they frequently do, in unhealthy sitaitiooi uW
seasons, a form of disease is direedy psodsre^.^.
which many of the characters of both Skt^'*
are blended. In such casea the ingesttoa ti^
water, or of unwholesome food, and coM f^i
moisture, contaminate the fluids, detemiite tkr
to, and irritate, the prima via ; whilst «)«■
concurring with these caoses, impresses the »^
vous system so as to impart a ccrtam d^rec ai ^
riodicity to the morbid actiona resvlting fno ^
combined agents. It also not vnfrequcotly occrv^
that during the progress of agues and reaioeflt*.
the secretions accumulated in, or powed iat*. tt
intestines will acquire such irritating or ncf"
properties as to superinduce dyaeotefT, vhiek «»'
often for a while reuin the periodic chaiaritf ; b«.
in most instances, a continued or obocarely Rcr-
tent type will be the consequence of thisdani''
A distinctly intermitting type ia incompabhle w\ i
either a considerable extent of inflamoistiM. e
much depravation of the circulating fluid *, tod •»
or other, or even both, of these changes obuffi i
those forms of this disease which I have ftatO' '•^
be generally exempt from this character. It •
frequently observed, that when animal or iaferttx-
emanations enter largely into the causes of *>'
disease, it asftumes a continued and more w^"
a malignant character. Numerous iostsoco, d^»
trative of these views, came before me ia «srs
climates ; and the histories of the epideoir ocr*^-
rences of the disease, when examined ia tbci: ^
tails, further confirm them. Sir J. Bf 'Guooji. a
his excellent review of the diseases of rhtvrj
during the Peninsular war, states, that, is ^
hospiuls in the Alemtejo and Esdcmadvn. ^
type of dyi^entery was intermittent ; that it htrt'*
remittent in July, August, and Septcmbrr. »Wt
the army advanced rapidly and remained co»«^«'
stationary in the two (^stiles ; and that it wa» n <*
tinned, typhoid, and very latal,at Ciadad R*iq;<^
where the sick were exposed to the eflatiaa tt-
tricated by twenty thounnd deid bodiafc Iitn*<

DYSENTERY — its Com plications — Hepatxc.

705

«c Ibe disease presendog incieased grades of
severity as the causes augmented in intensity.

33. IV. Complications. — Having considered
the forms of dysentery depending more directly
upon the nature of the predisposing, eicitiog and
coocuneot caases, I now proceed to notice those
complications occasionally observed, especially in
unhealiby seasons and localities. Many writers
conceive that the asthenic varieties described above
are complicationaof simple dysenterv with different
kinds of lever i and that, when tney are infec-
tious, it is not the dysentery but the fever which
possesses this property. Some authoia suppose
that the typhoid variety especially is a compli-
caiioD of this description. But, if such be the
csiie, wherefore should the disorder which is com-
maoicated be alwaya dysentery and not fever 1
Moreover, this form of Jysentery is often present
where a case of typhus cannot be found, 'i'he
fsct is incontrovertible, that the asthenic forms,
some of which are considered as complications by
many writen, are direct, and necessary, and uni-
form results of certain diversified but concurrent
causes; and not contingent associations of two
dueaaes capable of separate existences, such as
those about to be descnbed : thus, cold and mois-
ture will of themselves sometimes occasion simple
iaflammatory dysentery — as frequently occurs,
where no other ca.uaeB can be in operation ; bat
wbeo, with cold and moisture, there concur mala-
m, unwholesome food or water, or emanations
cootamioating the fluids, as is often the case, the
disease assumes some one of the more severe and
asthenic forms ; the nervous and circulating func-
tioos havmg been thereby more seriously im-
pressed. The local affection is occasioned, in
these ca^cs, by the nature of the ingesta, or by the
iQorbid secretions consequent upon the action of
the exciting causes, or by the retention of morbid
or faecal matters, or by two or all of these com-
bined. (See i 70 — 72.) The complications of
which more particular notice will be here taken are
niost commonly ooeanoned by the endemic causes of
djseQtery, and are those — (a) with diseases of the
liver, spleen, and aome other abdominal viscera ;
— (6) with jaundice ; — (c) with scurvy, or scor-
butic dysentery ; — (d) with worms in the prima
via;^(§) with hsmorrhoids; — and (/) with
rheamatism.

M, A, Dyientery amplicated with Diteauofths
LiveTf Spleen, &c. — Hepatic Dyuntery of writers
on iotertropica] diseases. — (a) I have already no-
ticed an asthenic form in which the bile is excreted
toore or less in excesa, or is otherwise disordered.
1 0 this form, which is frequently epidemic, there
b«s generally taken place, for some time pre-
viously, an accumulation of this fluid in the biliary
apparatus, without any actual disease of the liver ;
the discharge of much altered or acrid bile con-
tribtttioff, probably, with other morbid secretions
and actions, to the production or perpetuation of
the dysenteric symptoms. But, in the complication
now about to be considered, the liver is ^nerally
inflamed, enlarged, or otherwise altered m struc-
ture, either previously to, coetaneously with, or
consecutively on, the dysenteric affection. Al-
thoDgh this association of diseases of distinct but
related organs is m<Mt frequent in the sub-acute
aod chronic states, it sometimes also occurs in any
of the acute forms, as well in temperate as in
warm climates ; but oftener in the latter than in

Vol. I.

the former. It is also consequent upon agues,
remittents, and continued fevers; ana it is evi-
dently often produced by endemic causes, es-
pecially in persons addicted to ardent spirits.
When hepatic dysentery proceeds from these
causes, the spleen is sometimes also diseased, as
well as the pancreas, and mesenteric glands. Sir
J. M'GaiGOR states, that in the fatal oases of
dysentery that occurred in the Peninsula, the
spleen was as often diseased as the liver ; and that
both the pancreas and meBenteri<;A|ands were also
frequently enlarj^ or otherwise changed. When
acute dysentery is eompittaied with disease of the
liver, this latter is frequently likewise, of an acute
or siib-acute character ; and consists chiefly of in-
flammation of the substance of the organ ; abscess
and the chronic rhanges of this viscos being more
commonly associated with sub-acute and chronic
dysentery than with the acute.

35. a. AcuU hepatic Dytcmterif generally com-
mences with horripilations, chills or rigors, fol-
lowed by pains in the forehead ; bilioua vomiting ;
bilious and variously coloured stools, voided with
scalding at the anus, and urgent tenesmus. The
discharges are often at first greenish, greenish
black, or reddi«h brown andoehre-like ; or watery,
with a greenish frothy slime on the surftuse. A
fixed pain, weight, or uneasiness, increased on
pressure, is generally felt in the epigastrium, fre-
quently extending to the right hypoehondrium,
right scapula, or top of the ri^ht shoulder ; with
a sense of pressure or tension in the right side of
the thorax, anxiety at the precordia, fits of dys-
pnoea, or a dry teazing cough, vertiso, and an
accelerated and irritable pulse, particularly at
night, when the patient beisomca very restless, and
the calls to stool more frequent and distressing.
The tongue is at first white, the papillse erect, or
covered by a yellowish fur. At an advanced
stage, it is clean, dry, smooth, red, or lobulated ;
or it is covered at tlie root with a dark erust. The
skin is dry, harsh, of a dirty appearance, and hot ;
or it is covered by a greasy perspiration, copious
sweats sometimes occurring in the last stage of
the malady. There is great thirst, and desire of
cold fluids. In other respecu, the progress of the
disease is similar to the more inflammatory form
described above ($ 13.) ; but it often presents a
greater range of symptoms in different cases, or at
different stsges of the same case.

36. 0. In the above form of hepatic dyaentery,
the affections of the large bowels and liver seem
to be nearly ccetaneous; but, more frequently,
the hepatic disease follows dysentery, or does not
appear until this latter begins to decline. In
these cases, the patient is irritable, the cheeks
present a hectic nu»h, and, upon examining the
abdomen, the riffht reetut abdaminii muscle resists
pressure by an involuntary action. Little or no
enlargement of the organ is at first felt ; but either
enlargement or tenderness becomes manifest, es-
pecially when blood has entirely disappeared from
the stools, which are senerally scanty, viscid, and
dark. This form of the complication is evidently
caused by the sudden cessation of the dysenteric
affection ; which being very intimately dependent
upon the excretion of morbid matters from the
circulation and the economy in general, cannot be
abruptly suppressed^ without inducing oontinued or
remittent fever, or inflammation, congestion, or en-
largement of excreting organSt Both these mo*

Z I

708

DYSENTERY, CHRONIC— Compucatioks or.

loDgationt of, the acute, tbey mmy be the aeqaelB
of any of the forms of diarrhoea, of oouunoa or
pestilential cholera, and of fevers that have been
neglected in their early stages, or improperly
treated. When it occurs primarily*, which is com-
paratively rare, it may, after a considerable time,
assume the acute characters,

46. m. The Symptomt of chronic dysentery differ
chiefly in dc^gree from those characteriang the
more simple inflammatory form of the acute dis-
ease ($ 12, 13.); The fever of the latter generally
subsides, especially during the day ; and the ap-
petite and strength frequently return for a time.
Tormina and tenesmus either altogether disappear,
or are present in a slight deme ; but sharp,
griping pains, and sorancss in the abdomen, are
often complained of. The stools are more or less
serous, mucous, muoo-puriform, or gelatinous ;
contain some fluid fsMsulent matter, or ill-digested
substaoces ; and vary from a white albuminous, or
white of egg, appearance, to a dark olive green or
greenish black ; being sometimes marbled, or one
day like chalk and water, and on another like a
dark jellv, or the green fat of a turtle. Blood is
often either so intimatelv mixed with the evacua-
tion as to give it an unirarm brick-red colour, oris
Quite distinct and fluid, or partially coagulated.
The pnriform or mnco-puriform matter geoerally
exists as small streaks ; but this matter may not
be detected, although ulceration of the large
bowels is present. The discharges are more
copious than in acute dysentery, but much leas
finequent ; being commonly from three or four to
ten or twdve in the twenw-four hours. The
pulse is not accelerated io the early part of the
day, but it usually becomes quicker towards even-
ingr ; and is feeble, unequal, and sometimes slow,
or intermitting. The tongue is often dark red or
glossy ; the countenance sunk and anxious ; the
surface cold, lurid, dirty, harsh, dry, or even
scaly; the body emaciated; and tfaia abdomen
bard, tumid, not veiy painful on pressure^ except-
ing dM>ut the cacum or sigmoid flexure of the
colon, with griping pains in the course of the
colon. In the more advanced stases of the dis-
ease, the feet and legs become oedematous ; the
lips and surface exsaaguineous ; the surface and
the evacuations exhale a peculiar, offensive, and
sub- acid odour; sometimes jaundice or ascites
supervenes, and the patient at last sinks under
the irritation and hectic symptoms, after many
weeks or even months of mntmued or remittent
suffering.

47. S, Chronic dysentery sometimes assumes
a modified character, which is essentially the
same as the ulcerated and lienteric forms of
DiAuaHcsA (§ 11, 12.). In these cases, the
mucous follicles and coat of the small, as well as
of the large, intcMines are affected ; but in warm
climates and unhealthy situations, disease extends
much further, and generally comprises lesions
either of the Uver, spleen, pancreas, mesenteric
glands, or of two or more of theie. Repeated
attacks of dysentery, in these places, frequently
terminate in chronic dysenteric diarrhoa in a
simple or complicated state ; and I have seen
cases where it has continued for yean, with slight
remissions ; the stools being lienteric, copious, and
crude, and the appetite ravenous. In some
oases of this protracted state of disease, especially
where the stools aia gleety or mucous, and voided

with tenesmus, but without tecmiaa, the netaoi
only is affected ; one or more akcrt being
seated at a greater or len distance fram il*
anus. The sub-acute and chronic Isras src sol
infrequent in ehildrtn, are m them oftea irom
panied by proeidtntia oHt, and are geneiaU} a*
flammatoiy, particularly when oeewriog lyuisiii
cally. Ckrmie dymtifry in the dcrJk f««
assumes the appearance of a gleety diichsi|t
from the bowels, and depends upon deiemt
tone of the veasels and follicles of the maa^
mucous suKace, rather than upon inflamasia^
actbn.

48. ii. C«i»p(ioaliffM of Ckrgmie Dymuinif in
most frequent in countries within the tropiei, a^
in places abounding with tnnwtiial f ****'*~
(a)When chronic dysentery is eomplicslsd mtk
diasosi of tkt Uvtr, the svmploins oA«a apfsoerk
those of diarrhoea ; and the hepatic afleeoos ii
generally latent, insidious, and also chreoic ; tkc
internal structure of the orgao being chiefly i«>
plicated. In this state of disease, the evaraitiow
are frequent ; attended by griping pains abset \k
umbilicus; and are of a dark peea cstoor,
indicating a morbid state of the bde; ot d i
pale clay colour, showing torpor of the bver of
obstruction of the ducts. In some caees, tiM
are dirty, watery, and offensive ; and is otbcri.
of a whitish appearance : whence has Mtka (tc
term " lohiu jltu.** These last seam like rb&.k
or lime mixed in a dirty fluid, or iatsfneiaii
between this and whiles of eggs; occsmosI^)
they resemble cream or yeast ; and they sie o<m
slimy, and contain broken-down, clay.cok>oi«J
feces, and half-digested salwtaoces. IVm
sometimes continue for a long time; or lU;
change to a darker colour, appareniJy ffoai s pi^
tial discharge of bile or the medicines takes ; uA
afterwards return to their former hac. fhp
state of the dejections is evidently ewisf lo tk
obstruction of bile, to the conseqitent irnfor'
ment of chylifaction, and to the mowed ud
morbid secretion of the follicnlar glands uA
mucous surface. In addition lo these the pstaest
complains of tightness, fulness, or opnfuiis it
the epigastrium and lower part of the taoru, jtt*
ticularly on the risht side ; aod of slight cfcsii{
exacerbations of fever. The otcs hate bt'
<iuently a pearly appearance ; andtbe couatensser
is livid or sallow. ThisoomplicatioQ is oAea enmt
by the exoesrive use of spintuooa and other iaisi-
icating liquors ; and by the concurrence of tM
causes of hepatitis with those of dyseaierj,
and it frequently is cwusgusat upon Mpsua,
upon intermittent, remittent, or cootianed fe«ca.
and u[)on the acute disease, when it arises fnm
endemic causes. The dysenteric ijunjtomi m
manifestly occssiooed or perpetuated cuber bjr i
morbid condition, or by deficieocT.or telsl «>
struction, of bile: this secretion being inditntaii
ble to the due performance of the siiBSBilirnf
processes, and to the healthy state of the bscss>
surfaces and follicles. In other cases of thii cm-
plication, the enlargement of the liver, or the syvf>
toms of hepatic disease, are less eaaivoosi, la^
approach more nearly those stated above (^3i- <
(See, also, Livan— - J&secii in.)

49. (a) —a. When chronic dysentery Cslkivi
the diseases juit now mentioned, or the prajoafW
or intense operation of endemic earner it mtj
become associated with *torhmti^ sym|i(em«i ^

DYSENTERY ^PATHOLootCAt Inpbrbnceb rcspsctimo.

713

Dain more tiolest, particulirlv Aroand the um-
biiiciis, duA in thk diaose ; toe mattera reoeired
mto the stomach being ejected from it without
ociiiDg eitker a desire for ttool, or tenesmus. If
tiboald, howerer, be kept in recollection, that the
bilioQf or endemic colic of warm climates (see
Couc, $ 16b) in some cases differs but little from
dyKQtcry, and that chie6y at respects the more
complete retention of the morbia secretioos and
eicretioDs, as will be seen from the history of both
di

67. (() Imtermmi HmmorrheMi sometimes give
rise to symptoms resembling dysentery, — or rather
to tenesmus, an affection entirely of the rectum,
the seat of these internal tumo«rB. The tenesmus
of hsmorrboids, whether attended by discbarges
of blood or not, is strictly a local complaint, is
ttldoo lefere or preceded by tormina, or frequent
calls to stool, or much constitutional disorder;
tod is a simple obstruction to the passage of con-
sisteot stools, which are not mucous, and not
streaked with blood, which, if pused at all at
stool, is entirely distinct from the weal evacuation ;
the hemorrhoidal tumours of^n protruding at the
time. These, independently of the different cir-
cuiBstaDoes under which both diaeases occur, and
the history of their progress, are sufficient to dis-
tiogaish them from one another.

^. iX. Pathological Inpbrbmces. — i.TRB
Mooa or Opxration or tbb CAcsas.— There
is, perhaps,no other diaease which requires a more
Kccnraie analysis of its pathological conditions,
with strict reference to their cavses, than dysentery,
for these causes induce so very different states of
morbid action in connection with that which espe*
ciallj constitutes the malady, that the practitioner
^11 often attempt in vain either to limit its spread,
ID eircomstances requiring this precaution, or to
■nest its prugruas in particular cases, without being
uquaiDted with the operation of its diversified
ctaies upon the system, and the nature of the
effects they induce.

^* 1st. Operation cf eautet which ditpou to
tkt dimue {§ 9. 22.). — These, when their nature
B koown,and their mode of operation ascertained,
may be sometimes averted, and an attack thereby
peveoted, especially when the malady is preva-
Icot. — (a) Hi^ ranges of temperature, and con-
«qoeotJy hot seasons (Piso, Hillary; Strom,
HursLAND, &c.) and climates, so very generally
pi^dispoae to dysentery, that it roost commonly
occora either during, or subsequent to, these states
of atmosphere. The effects of a high temperature
open the pulmonary functions, and consecutively
opoQ the blood, and the bilianr and other secretions
>od eicretions, are such, as fully explained in the
irticle Disease ($ 92—34.)) as ereatly to increase
and disorder these latter, especmlly when the cir-
coUtion is determined towards the abdominal or-
gans by exposure to cold, or when assisted by
other concurrent causes, — (6) Peculiar states of
^r, eoonecied with the epidemic manifestations of

thediseBSe(HcXBAli, HoRTff, SciiMIDTMANN,&C.),

tod with certain features which different epidemics
^l^ present, whether referred to noxious exhala-
tioos fioating in this fluid, or to extreme humidity,
or to electrical conditions of it afl^ting the electfx>-
motiTe BUtes of our frames, most probably influ-
xes the organic or vital actions, especially the
circahuiag and secreting functions, in such a roan-
i^-* ilthougli slightly or latently — aa to render

them remarkably liable to this species of disorder
upon exposure to any of the exciting causes. And
it is not improbable that these states, as well as
Jiigh ranges of temperature, favour the production
and accumulation of morbid secretions in the bi-
liary appaiatus and in the prima via; and that
these secretions, aided by consecutive causes, in-
duce that form of action constituting the disease,
although tending to their evacuation from the
frame. — (c) An asthenic or exhausted state of
the constitution, and of the digestive canal in par-
ticular, insisted upon by Marcus, has certainly
no mean influence as a predisposing cause, as
shown by the greater prevalence of the disease in
-persons of this description in all climates and in
most epidemicB, in soMieiB af^er very fatiguing
marches, and in convalescents from fevers and
other diseases. — (d) To these may be added the
use of intoxicating fluids, as disordering both the
digestive mucous surface and the secretions
poured into the intestinal canal.

70. U, Cfthe operation of eautet which, either
individuaUy or conjointly , excite Hu di$ea*e, — A,
Thorn which act ioeaUy, or affect chiefly the targe
froiMfs.^-(a) Many of these irritate or inflame
the mucous surfece of Ihe caecum, colon, and
rectum. These bowels perform chiefly an ex-
creting function; and consequently, when the
excretions which are proper to them, as well as
those which are poured into them from the small
intestines, are allowed to accumulate, irritation or
inflammation of the mucous surface, with in-
ordinate action of the muscular coats, may be
expected to occur. Irritating purgatives, injudi-
ciously prescribed ; a dose of rancid castor oil ;
foreign bodies lodged in the intestines; the too
liberal use of fruit, especiallv that which is unripe

(HORST, GiRTANNBR, M'URIOOR, &C.), Or the

fruit of hot climates (BiJCHNER, Twining, my-
self, &c.} ; various indigestible substances ; un-
cooked or imperfectly cooked meat or other food ;
pork ; sour or bad wine ; minute insects, or their
ova and animalcules, in the water used for drink
(LiNNCUs, Sebastian, May, Latreille); and
intestinal worms (constituting the Dytenteria
verminoea of Bonst, May, and Baume) ;
seem to act in this manner. — (fr) Several
agents determine inflammatory irritation of, and
an inordinate flux of fluids to, the mucous sur-
face of the large bowels, and their usual results.
The causes Just enumerated necessarily act in
this manner, although not so immediately, nor to
the same extent, as the following : — Exposure to
cold, or cold and moisture, especially curing or
immediately after great atmospheric warmth, has
been considered by Buchner, Stoll, Fischer,
Larrey, and others, to produce the disease, and
at the same time to impose on it a rheumatic cha-
racter; whilst OsiANOER considers that, of itself,
cold will not have this effect ; and that the pre-
sence of morbid matters in the prima via, or the
concurrence of some other cause, is necessary to
its operation. The influence of the causes of
common catarrh, insisted on by Strom, Schle-
CEL, and Neumann, although not so great as
these writers supp08e> is often well marked, espe-
cially in sporadic cases, and in some seasons.
These, and several other authors, consider that
the disease is catarrh, or catarrhal inflammation,
of the large bowels, from remarking its prevalence
about the same time as that affectioD. The sup-

714

DYSENTERY — Pathological iKnoBKcra imvECTiyo.

piewoa of other evacuations, or tbe dryiog up of
accustomed discbarges, and misplaced gout ^Mvs-
GRAVE, Stoll, &c.) — the DjfteHteria artkniim
of SAuvAGEs-o^are probably also coDceroed in
its production in some instances ; contingent cir-
cumstances causing tbe determination of morbid
action to this quarter.

71. B, Catu€$ which diwrdtr lA« sserstiraf
poured into tAs intt$tmal etinal, and thereby affect
U$ muceui turf ace, — (a) Suppression of the
secretions and excretions poured into the large
boweU, espedally the biliary fluid, and accumu*
lations of mucus m the follicles, are not altogether
without effect in causing or prolonging ihe disease,
especially some of its protracted states; and
several of the exciting agents, particularly cold,
moisture, and malaria, partly act in this vray.
In many cases, both sporadic and epidemic* the
absence of bile from the stools is a prominent
symptom ; the free discharge of this fluid being
generally followed by more or less rapid amend-
ment. Defidencv of this secretion evidently
renders the chyle irritating or otherwise hurtful to
the bowels ; their mucous surface and £DUicles
being moreover deprived of tbe salutary influence
which a Ijealtby state of this secretion exerts upon
tbem ; whilst accumulations of mucus in these
glands irritate or inflame them, and favour the
chanees they usually present in fatal chronic cases.
— (6^ Other causes may operate by cbangiog one
or more of the secretions poured into the large
bowels, either in quantity or quality. Thus, excess,
and acridity with excess, or even vrith diminution,
of these secretions, may irritate or excoriate the
villous surface of the large bowels, during a pro-
longed retention of tbem occastoned by the con-
formation of the c«cum and colon, and by the
apasmodic action of the m oscular fasciculi of tbe
latter. Many endemic causes act by disordering
or vitiating the abdominal secretions and excretions,
especially those of the liver (Foustek, Wxnoxl-
BTADT, ]!iscH£K» Bbijnino, &c.) ; aud antecedent
diseases, as agues, remittents (PazycLa, Hunter,
J. M'Grigor, Ferguson, &c.), and continued
or epidemic fevers (Cheyne, O'Brien, &c.},
operate in a similar manner. Pre-existing affec-
tions, also, of the collatitious viscera, particularly
of the liver (Piso, Mknjotus, Jumcseb, Boag,
BiANCBi, J. Johnson, &c.) and Pancreas, have
a still more common and manifest agency ; and
it is probable that the influence of imagination,
fear, and terror, mentioned by Hcftman, Vooel,
Haroens, and Nadmanii, is exerted through the
medium of the secreting organs, as well as upon
the bowels themselves.

72. C. Other cautes ttem to affect the inte$tmal
mucout turface, the tecretiont poured into the
canal, and the circulating fluids, ditnrdering,
altOf the organic nervous injiuence by which these
are conlrotled or mod^ed, — (a) The use of
unripe and blighted grain (Wright, Gedner,
&c.) ; of the flesh, and especially the viscera, of
diseased animals (HoxprNSR, &c.)i famine and
unwholesome food (Muhlius, DsiGENBTrzs,
VioNBS, Graves, &c.); water holding putrid
animal and alkaline subittanoes in solution (Pao-
copivs, Rbodxus, Moeoling, Birnbaum, Bell,
&c.) ; and stale fruit or vegetables act in this
complex manner ; putrid water especially exert-
ing a septic action upon tbe digestive mucous
surface, upon the circulation, and, ultimately.

upon the toft solids. — (^b) The eaacM wblc^ pf*-
duoe scurvy also give nse to tcorUBtae ApcMcn
($ 39.), by a nearly similar iDods of oMittic&.
'^-^ (c) Morbid matters absorbed firsia BteHAriBi^
burtaces and parts, especiallj from iloiigiuBi^.
malignant, or pb^edenic ulccn, by coaiaiv-
nating tbe blood, <fisorder ths secretioas, pesR'l
into, and those elaborated by, the intsMiDal out.,
so as frequently to occasioB asthenic dpatm
or diarrhoea. Of this form of the dawase, soar-
rous instances occurred in naval and amy ksif-
tab during the war. Mr. Coplanb UvTaw-9
has devot^ a chapter of his able ** Praetk^ C^
MTtMilions on Surgery," to ibis proecanaa of mat-
bid action, as it oocurred in the navy, darisf L»
extensive public serviee.

73. D. Ldutly, tome eauees, «»d tkeeiihtmm
energetic, affect the drcuiatiam, aud, thnm^'i
the tecreliout poured into the boweU; nttiuaidi
eontauunating, more or iete, the eekds « arfi «j
fly ids, and disorganiting the intettitml nmi^ >t

the disease be not arretted in itk pregrm.^^**
Miasmatous exhalations (Libo, ICrstw*» M^
cuAicLis, &c.) y the emanations fram aaioal ei-
uvic (Oslanoer, &c); or a mixtaic of boch
( Annxslet, myself, and otheia) ; and tbe eia-
vium proceeding from the bodies of a mwha >a
persons oonfin«i in small space, and is t (kn
air ^Atcheson, &c.) ; bv vitiating tbe air tscd a
respiration, aflfect the whole BiaM of blood u i
circulates through the lungs ; those o^ss*, «*p
cially the liver, whose offiee it is to efiausik •-
jurious matters from the circulatiea. aad ikici^
to preserve the purity of this fluid, uett/eui*
forming, £rem the morbid eleoieBtifaraiibeA)^
in it, acrid, septic, or otherwise sseibid sbctHmc*.
which, as actually proved by expcrimcat, vnliir
and excoriate the tissues with which tbcf kusis
any time in contact. — {b) No doubt as i*
entertained by any one whose raop of dmt-
vatiun has embraced the more asthenic vBiieUfs d
the disease of the emanatiooa wbicb piscv^
either from the bodies of the aflecrted, or iom &•
fscal discharges in dnminslaiiceB of coon«*
tratioo, and of predisposition on the part of tW*
exposed to them, beii^ capable of pfodarisf iv
spreading the malady, either in the SBaaBCf m*
stated in respect of other animal emaaaDoat,'
through the medium of tbe aaJiva and apptf |tf*
tion of the digestive canal. The cootagnw f>
perties of dysentery have been keenly &eui^
Willis, Piso, Stoll, Horn, Yai»»is nu*,
Renton, Baluncall, &C., asserting tbst it ^^^
not possess these properties ; and Hoaniiv. }*-
Rssixrs, Hillary, Morton, Pringle, B^iR^ •
Bruning, Balpour, J. HvNTRR, Cbusoi*
OsiANOER, Neumann, Boner, Habti, H***

GSKS, G. BlaNE, HuFELANO, PEM^Af ^''

cHAicLis, Halloran, Pools, Chribb, Cli**^
ciiisoN, Rutuervoro, Jones, and othcfs, coMff^
ing that it generally is infectious, espsiasU; v!^
epidemic, or when ocoorring in caB|is ae^^
snips, and under drcumatanoes cootsassd *
above ($ 24.), and more fully ilbutraied a u«
article iNriccnoN. I believe that the vir«» ^*
bited at these places are cooformable vii^ ^1^
entertained by every well informed sad etfe^
eoced observer and writer at tbe ptiseafds^.

74. ii. Morris Con Dmoxs. — A. It a "^
sible to contemplate aiirht tha changctcsstftt*'
ing the various lomia and stigti of the ^euee,*^^

DYS£NT£RY — Pathological Infsiisncie* Mtrwcnva.

715

from its caues and their modes of operalion. —
(«) Maoy of these affect more or leae immedi-
ite]y the Iv^ge bowels* without any previous
coB$tiiutioDal deraogemeut (§ 70. A»); and ac-
cordiogly the mormd action is chieflj local,
ftbeoic, or phlogistic in its character, as described
aoder the m species of the disiease ($12, 13.),
and, ia many instances, is simply inflammation
of the cecum and large intestines,— (6) In cases
prodttcsd by suppression or vitiation of the secre-
tions poured into the bowels ($71. B.), prcTious
diwnler, of either a latent or manifest kind, is ne-
ceaairily present; diarrhoea frequently ushering in
the disease ; and the local affection, as well as
the coostitutionaJ disturbance, evincing more or
leas of sthenic or asthenic characters, according to
the state of the patient and the nature and concorw
reace of the causes. Some of these are also conse-
CQtive, complicated, chronic, or even symptomatic,
hepatic dysentery belon^ng to this class of cases.
— («) In most such cases, and in many of the
sixaple as well as of the most severe forms, conges-
tioQ of the portal vesseb, and obstruction of this
part of ihe ciiculatioB, are ooooemed in the pro-
dueiiott and perpe* lation of the dysenteric symp-
toffls.— (^) Altboagh dysentery is frequently oc-
casioned by offending matters in the prima vin, as
believed by Syobnbam, and many others, vet
thete matiers are not so generally retained, either
io the form of scybaJa, or in any other state, as
CcLLXM, and many more recent writers, seem to
tave fupposed. — («) There appears not to be
sufiicieDt evidence of the inflammatory forms being
rheamatir io their nature, as suggested by Vogler,
^TOLL, RicBTaa, Fischer, Sims, Scrmidtmank,
HrrsLiND, Harobns, &c. ; although both com-
piaiots are sometimes allied, especially in respect
of the exciting causes, as justly remarked by
Akcnsioi, &c., and are occasionally associated, or
consecutive the one of the other. — (/) In cases
thst proceed from unwholesome food or water
(§ 72. C), and in those caused by animal exhal-
ttions aod infectious effluvia ($ 73. D.)» although
there may be at the commencement excited vas-
ealar action, the circulating and secreted fluids,
aod ultimately the soft solids, become more or
less contaminated, and the disease assumes either
a staply asthenic, or malignant form, disorgania-
atioQ of the internal surface of the lar^ bowels
olWn taking place earlier than in other cases,
with the exception of the hyper-acute inflaro-
Dstory form met with in hot climates. In most
of tbcK malignant cases, the vitiated or morbid
natteis either conveyed into, or generated in, the
cirrulatioo, in the process of their discharee by
the emunctorics give rise to an acrid orexcoruting
^te of Ihe excretions (or the morbid action ex-
cited in the secreting organs and surface occasions
this change in the fluids they elaborate, as occurs
io conrza, Ace), together with an increase of their
qoantity ; but these changes frequently occasion
St the commencement merely diarrhoea; the
dysenteric symptoms being consequent upon the
evacuation of the intestinal contents, and caused
h^ the excoriatioo of the mucous surface, by the
ntiated secretiona, aod by the irriution of the
moseuhtr coat ; the local disorder reacting upon
the constitutional disturbance.

75. B, In the early stage of most forms of the
disease, the irritating effecto of the morbid se-
cretions and ezcretioos are fiist exerted upon the

cecum aod rectum ; the latter being often so
soasmodically constricted as not to allow the dis-
charge of the more solid matters that may exi^t
in the bowels ; the retention of these and of the
fluid secretions ioereaain^ the diseased action in
the Ua^e, and ultimately in the small, intestines ;
ulceration, excoriation, sphacelation, 6te, being
frequently the result.— (a) In thoae cases which
originate in a morbid state of the secretions, &c.
{§ 74. 6. c), fsBcal matters are generally fully
evacuated before the tenesmus, distinctive of thit
affection of the rectum, comes on; the only
morbid nwtters retained being thoae thrown out
upon the mucous surface of the intestines, and
poured into them from the oollatitioos viscera;
but these are so vitiated and injnrioos, that their
correction or evacuation becomes indispensable.

— ^6) In the asthenic varieties, to which most of
such oases bebng, the dysenteric symptoms are
consequences chiefly of the vitiated secretions
poured into the lai^e bowels ; this vitiation result-
ing from constitutional disorder, and the state of
the circulating fluid: these morbid oonditionB
should, therefore, be made objects of primary
attention in the treatment of the disease. —
(c) The matters poured into, and retained io, the
large bowels, in asthenic cases especially, are to
be considered as formed of elements which would
be speedily noxious if retained in the circula-
tion : they are excretions, in the strictest sense of
the word, removed chiefly by the liver and di-
gestive mucous surface; occasioning, from the
morbid elements of which they are composed,
aod acrid properties they possess, severe irrita-
tion of the parts upon which they are retained,
or along which they pass, in the progress of their
discliarge from the body. — (d) Granting that
the dysenteric phenomena are thus produced, and
that the morbid matters causing them are thus
formed, it is manifest, that the mere suppression of
these phenomena, or the retention of tlie morbid
excretions, must be followed by disorganising
effects upon the large bowels ;. and that the sup-
pression of the secretions, being an arrest of too
depurating fuoctions, must be productive of a still
more serious change in the circulating fluid, and
ultimately in all Uie soft solids. — (e) In many
cases of all the forms of the disease, the excreting
function of the skin is more or less completely
put a stop to, and that of the kidneys materially
impeded ; the excretions of the intestinal canal,
and frequently those of the liver, being in
excess, as well as otherwise disordered, — con-
ditions, equally with the foregoing, requiring to
be made the basis of therapeuti<»l indications.

— (/) Whilst, therefore, the cutaneous and
urioary excretions are interrupted, the sudden
arrest of thoae poured into the intestinal tube
would endanger the patient, by increasing the
morbid state of the circulation, and by super-
inducing either fever of a bad form, or inflamma-
tion and its consequences in the abdominal organs,
or dropsy. — (g) In the varieties consequent upon
a moroid state of the secretions poured into the
bowels, the small intestines are freouently also
diseased, but in a less degree than Uie large, as
they present no obstacle to the speedy transit of
these secretions along them, excepting near the
caecum, where they are usually more utered than
in any other part.

76. C. The moot frequent auoeiatum of dyun^

716

DYSENTERY — PATfiot.ooicAL Ivnuwscn KtsPBcrwc.

tny, and one often very imperfectly mmnifested
by symptoros, is that with diMoce rf th$ Uver,
— (a) The hepatic affection may be primary, in
which case it is either funetumal or ttruetural ;
the/ttiietuma< diaerder consbting — «. of torpid or
rappressed function and passive congestion ; or,
0, of increased secretion, and of the vascular de-
termtnatioo reanistte to soeh increase ^— 4bef(nie-
tnral dueate bemg — a. atutt, or consisting of active
congestion, or inflammation, or of abscess in the
snbstance of the oi)^n ; or, 0, ehrmiie, with vari-
ous alterations, occaaionine obstructed circulation
through the portal vessels, and an insufficient
as well as a morbid biliary secretion : in these
states, the bowel complaint mcy be viewed as
aymptomatie of the hepatic disease. -~ (6) The af-
fection of the liver may be a eactanmmt tffect,
with that of the bowels, of the same causes : in
this case, the former will be of the/anctiMiaf and
acute kinds enumerated above ; abtcett occasion*
ally supervening in the advanced stages of the
associated malady. This form of complication is
most common in warm countries, where, the
causes of both diseases being nearly the same,
these associated results may reasonably be ex*
pected. — (e) The hepatic change may be amae-
quent up&n the dysenteric malady, especially in its
more chronic states. In cases of this description,
the substance of the liver is either inflamed, soft-
ened, and discoloured ; or it contains one or more
purulent collections, with or without any sur-
rounding eyst; the matter being sometimes in-
filtrated into the softened, and apparently not in-
flamed stmcture of the organ. Here the hepatic
change is contingent upon the bowel disease, in
its advanced stagen, ana is favoured by constitu-
tional vice or injudicious treatment, or both ; and
occasionally by the nature of the predisposing and
exciting causes, as by habits of intemperance.
In these three states of this important com-
plication, the symptoms are oflen obscure. In
the^rsc and $econd, they are frequently very iqa-
niffst; but, in the third especially, they seldom
admit of more than suspicion, arising from the
obstinacy of the disease, the lurid and lightly
jaundiced appearance of the surface, the morbid
state of the biliary and other secretions, and the
irregular or heciic form of febrile disturbance ;
chilL, rigors, or even horripilations, being seldom
felt. The severity, also, or the dysentenc symp**
toms sometimes masks, or draws off the attention
of both patient and physician from, the hepatic
disorder.

77. The frequency of the third, latent, or su-
perinduced form {§ 76. e.) of hepatic eompUeation ,
especially in the more chronic cases of dysentery,
has given it much practical importance ; and,
as a knowledge of the manner in which it arises
is necessary both to its prevention, and to its
removal, several attempts at explaining the oc-
currence have been made. These have been
remarkably vague and unsatisfactory. I shall
therefore state, with but little reference to them, the
only ways in which it can he brought about. —
1st. The irritation and increased vascular action
in the intestinal canal must necessarily be fol-
lowed by augmented circulation through the
portal vessels^ by a more copious secretion of
Dtle, and, if at this time the liver be congested,
or its ducts loaded, and especially if the blood
abound with excrementitious elementsi by an

acrid and morbid» as well as augmented, stcww.
— -Sd. The absorption of injariovB iagMte, or M
morbid matters formed or retamad in ths pnm
via ; or of purifbrm matter fma the inflaacd «r ^V
cerated mucous surfi^e, into the meseaierie ve»
and portal cireolation, must aeersaarily be p-
ductive of the following cfeli: — >«- A viMied,
or an increased, or both a viliBiad tad ir-
creased, secretion of bile; — 0, IiriiaiieB of ^
stmcture of the Kver, followed hy iBflamaaiim «
softening, often rapidly paaung mo sappaniiar
without much tumefaction or previoM idw
or phlogistic action 'i^^y. The deposiiifln sri^
tration of puriform matter in the sabstanet «f (k
organ, cspedallv when a parifarm ft«id ii earrinf
from the aiseased boweb ;— ^. lufbrnmatoryartioe,
and its consequences, in the vessels aloof vhr^
the morbid matten pass, and on the bksd iferr
contain.-— 9d. It is extremely probable tkn >&>
flaromatioo extends from the uicensed mnce»v
submucous membranes to the radielcs of tht ?«<
and from thence along their ramiflcalisn «t^
trunks, the product of the morbid actio* mvK
with and contaminating the blood whirh mi-
lates to the liver, as in the foregoing— the M —
case, and producing the same efncis, tbe r-
flammatory action extending more or kw to lir
ramifications of the portal vesMla. It seemt 9^1
probable that the above are the chief node* c
which disease of the liver is superindoeed ia r<«
course of dysentery ; and that one or all of tiy-
more or less obtain, in difl^rent cases, or ttcc r
the same ease. Wtthont, however, deom t*'
the procession of morbid action contended v^
some writers, and about to be noticed.

takes place, I may state, ia sopport of the }^

ceding, that M. Ribes ( HHme MH, 1625. L r

p. 5. «< ieq,) found puriform matter ro the tcv.

and inflammation of their coat, in sevcfsl n»«

where purulent collections bad formed in ik

liver after ulceration of the inner surface cf '^

bowels. M. Gendriit (^HiH. AnaU in M»-

mat. t. i. p. 707.) observed similar chaogcs ia tw

veins in the vicinity of intestinal nicer*; i-'

M. AifDRAL {Anat, PatM. voL ii. p. 4tl.^<^

tected false membranes lining the raniificsnca» ■<

the vena portc, in a person who diedfreva dipe^

of the bowels and liver. The very freqaeat n^

lections of pus, and puriform infiltrstioni is %*•*

mesenteric glands, in the protracted states of i^

sentery, should also not be overlooked, is «:

porting the above inferences, e»pfciallj if «r *J^

into account the intimate connectioo of th« }*"

of the absorbent system with the veins ceatribaa 4

to form the portal system. — 4th. It has bees »«^

posed by M. Baoossiiis and his follower, rb*

mflammatory action extends ftrHea the smaH \ai^

tines, along the bile ducts* to the Irver ; aad ntw

cases, that have been observed hj him, Mr. ^*

WESLEY, M. AivDRAL, aod myoclf; where oAr-

matory action or ita resnlts were seen it ^

common and cystic ducts, wonld seem lo ia«<^*

this vievr, if they coold not bcotherwJK sccotvM.'

for. It may be admitted, that the exteaioa '^

disease to tlie small intestines, is very freqsrot r

the hepatic complication ; but it is most proftsf 't

excited, as stated above ($ 75. c). by oorM \^

which also may have produced the iaflaoaasti^

appearances occasionally observed ia tfcc^s<*-*

by which it is excretecL-— flth. The ffritaow *

the bowels, or the opefatioa of sahsiaBev fi^

PYS£NT£RY — Tbkatmbnt op its Acvtb Statxs.

717

> cue the ftimwi, may be sufficient to excite %
fmpatbeiic irriuiioD, end iti occeaioDel conse-
aeace — soppnntion — in an aatbenic state of
te system, in an oivan so intimately connected,
1 its ctrculatioB and nervous inflnence, with the
owels, as the liver is. This» certainly, may pos-
ibly occur, but we have no proof of it ; nor, in-
ecd, does it idmit of nnexeeptionable evidence.
t ii, however, very likely that the constant, or in*
udicious, nse of calomel and irritating purgatives,
rbeo the substance of the liver is congested, and
b« bowels in a state of irritation, may give nse to
bsc^ or other stinctural change in the liver;
rkJst, on the other band, a similar practice during
epstic diiease, ma^ superinduce dysentery, with^
vX isffloving the pnmary complaint.

78. D, Ckrmie as well as other forms of dysen-
try may be ssnociated with dieease of the spleen,
ancress, or meseuterie glands ; either, or even
U, of which may occur, and indeed, often does
ccur, in the same case, especially where endemic
auaesirein operation, — the hepatic complica-
ioo beiog sometimes also superadded. — (a) As
wpects the disease of the tplten and pancreoi,
he procession of morbid phenomena is not often
Duifest; but these lesions are most frequently
eca where dysentery has arisen from these causes,
»r has been consequent upon periodic or con-
itued fevers; the splenetic enlargement having
)fka preceded the bowel affection. — (6) In re-
ipect of the lesionti of the meteuterie giandt, there
;iD be DO doubt of their being the results of intes-
ioaJ irritation or ulceration ; the most remarkable
^toge:(, especially purulent collections, having
Keo seen in those corresponding to the seat of
arge ulcers.

79. £. Relapm, or repeated atUcks af^ the
atieat has once had the disease, are very com-
Doo, especially if he remain exposed to the en-
lemie or other excitiog causes, as in hot climates
tsd during campaigns or sieges ; or if he be ad-
iieted to intoxicating liquors. They are also fre-
{uent when the complaint has been associated
nth affections of the liver, or spleen, or conse-
jueot apoo obstinate intermittenU, and when rs-
wvery had not taken place until after it had
Mwmed a chronic state. In such circumstances,
%bt errors of diet, or exposure to cold, and noxi«
>ui emaoations, will often speedily reproduce it.
The Dumeroos relapiet observed m unnealthy lo-
Ajitiei, and amongst soldiers and sailors, are
:bie6y attributable to a too early discharge from
nedical care, and return to irregular habits and
Qjurious exposures ; and to the abrupt resumption
H a stimulating diet.

60. X. Trbatmbnt. — Towards the close of the
ist century, and at the commencement of this,
be treatment of dysentery, as set forth in various
Mpexs and works, by authorities con6ded in at the
ioM, was absolutely below the standard furnished
Dy the ancients, and by writers in the sixteenth
iod seventeenth centuries, not merely in respect of
he knowledge and appropriation of'^ therapeutical
nnos, but even as regards the justness ot patho-
ogical views; without which, indeed, no me-
Itcinal agent can be even safely prescribed. If
^ny one think this assertion paradoxical, let him
rei«r to the sources pointed out to him in the
>«}uel ; and, with a slight allowance for phrase-
ology! he will percdve that, as to this disease, as
well u to many others, knowledge has not been

always pragreasive; and that the unsound and
narrow doctrines in medicine thtX sprang up soon
after the middle of the last century, have con-
tributed not merely to its retardation, but to its
retrogression. The cant about experience, so
recently raised, and kept up bv those the least en-
titled to the distinction it should rationally oonfer^
threatens an equal, although very difierent, obsta^
de to the progress of medical knowledge, by being
made without reference to the fact, that experience
in medicine consists not in opportunities, or the
number of objects seen, or even in the repetition
of the saoM experiments or observations ; but* in
the qualities of the mind of the observer ; in due
preparation for the task by literature, philosophy,
and science ; and in the application of them to the
objects successively investigated. Thus qualified,
opportunities will seldom m wanting, and the re-
sults will soon accumulate so as to enrich the mind
of the inquirer to an extent to which the empirically
— the ignorantly experienced, will ever remain a
stranger; and will be of such a description, as
can he attained only by a mind so constituted, and
so instructed.

81. i. Or AcuTB DysaNTSay^-— 7%« gmunU sii-
dieolioiu of €ur; are — 1st, To remove the causes
predisposing, exciting, and concurring ; and when
It is requiate, orcircumstaoces will permit, to place
the patient in a pure and open air.— 2d. To sub-
due inflammatory action by antiphlogistic measures
when its presence is rationsdiy inferred, or when
the state of the attendant oonstiiutional alTectioa
will admit of them, or to the extent to which it
may be benefited by them. — 3d. To promote the
excretions of the skin and kidnejrs, and to deter-
mine the circulation to the cutaneous surface.^
4th. To remove, by eentle and appropriate means,
the morbid matters Siat may remain or collect in
the prima via, and to dilute and correct them. —
5th. To protect the mucous surface of the bowels
from their irritating and excoriating action. ^ 6th.
To correct the morbid condition of the circulating
and secreted fluids, in the asthenic and malignant
varieties, or whenever this condition may be in-
ferred, conformably with the views explained in
the articles Blooo, Dxeiuty, Disbasb, and Sym-
ptomatology.— 7th. To support vital power,
if it fail in the progress of the sthenic forms, and
early in the asthenic varieties, as being indispen-
sably requisite to the correction of a morbid state
of the fluids. -|- And 8th. To palliate urgent

I symptoipar or to arrest such as are atteqded by
immediate danger, as soon as they appear. An
appropriate use of energetic means wul generally
accomplish, simultaneously, two or more of theie
intentions.

82. il.TaBATMBiiiT or tub Sthenic Fobms. —
(a) BUedin^, general, or local, or both, according
to the seventy of the disease and constitution of
the patient, and repeated accordingly, is generally
requisite. The application of a number of leeches
to the abdomen in the slighter cases, or after
vensBsection in the more severe attacks, and of
fomentations, or warm poultices, frequently re-
newed, after the leeches nave fallen off, will give
much relief. If tenesmus or dysuria be urgent,
and pain be felt along the sacrum, the leeches may
be placed there or on the perineum, or cupping
on these parts may be directed. Although vas-
cular depletion is most serviceable early in the
disease, yet it should not in these forms, be

718

DYSENTERY— TatATaiEJiT or its Acun Statis*

neglected in the tdvanoed •tans, when it has
been either omitted, or directed in loo small a
quantity, unless the symptoms are such as contra-
indicate it. When fixed pain is felt in the region
of the cacum, or in the course of the colon,
leeches should be repeatedly applied until it is
lemofed.

83. (h) Purgativtt ami ioArttsci have been
long reoommended, and employed with a most
injurious want of discrimination, on the sapposi-
tioD that the disesse is caused, and kept up, by
the lodgment of fecal matters in the colon ; and
yet, notwithstanding the general fiillacy of the
views which led to their employment, when ju-
diciously selected and combined, they are often of
much service. It must be obvious that such pur-
gatives asset prineipallv on the colon and rectum
are not suited to an inflammatory disease of these
parts ; and that, when there can be no collectioii
of fsBcal or morbid matters to remove, the exhi-
bition of them will merely aggravate the symp-
toms. It is, therefore, most important to ascertain,
upon entering on the treatment of a case of the
disease, as fares may be done, whether or no such
mattera may exist to the extent of requiring these
lemedies. If the patient has been seised after a
constipated or even natural state of the bowels, if
baldness and fulness can be felt in any part of the
colon or cmcum upon careful examination of the
naked abdomen by the band ; if, together with these,
the tongue be much loaded, and the matters
evacuated offensive from the commenoement ; if
the patientoomplain of a sense of stuffing or fulness
in the course of the lar^e bowels, and if pellets of
teces be evacuated } suitable evacuants are indi-
cated. But, if the disease has been preceded by
diarrhoea, or by free fecal dischar^ as it fre-
quently is, they should either be withheld for a
ume, or very cautiously employed ; the selection
also being made with much care. When the
patient is well informed, his sensations and account
of the early symptoms should be duly weighed and
attended to. Much mischief may arise, and dis-
c^redit be reflected on the practitioner, by neglect-
ing this very obvious indication — bv following
blindly the dicutes of either unsound theory or
worthless authority, instead of being guided by
common sense. I have repeatedly known persons
who have been accounted ignorant, but who were not
iieoes.4arily without sound sense, complain bitterly,
and lose all confidence in their medical attendant,
and hopes of recovery, when directed to take ca-
thartics, ttTter, as they have expressed it, their
tnsidcs had been nearly purged out of them.—
When, hovrever, the patient has not had any fe-
culent diitcharges for a coasidersble time, during
the progress of the disease, although they may
have been copious and frequent before the acces-
sion of the dysenteric symptoms, a mild pui^gative
should be prescribed, as being much less irritating
than the retention, even for a short time, of morbid
excretions; and its operation should be promoted
by an emollient enema. Cooling or oleaginous
purgatives are preferable to others : and perfectly
sweet castor or olive oil ; or the following pre-
paration, recommended by Vogsl, and praisea by
SciiMiDTiiANN ; or Formula 144. and 790. ; or
either of the subjoined electuaries; may be
tried: —

No. 199. B E&Cr. Jalapa Rmln. gr. alj. ; 8a

y. ?J. : tcre prate cum Old (HWc (vrl Ol. Ui
m)r|(lal.Duic.) S U- Capiat 3 ■•• «nnl nocte.

tp^ VenH.
Vd Ol. Uni. vel OL

N& SCO. I^ Pulv. Jalap. 5 H. t Polsaw BLInt 3 1.) .
PuW. IpccacuanhK g r. j. ; tcrv bene itevl, ct iSSc 1M« ■
Rad. Oijcyrrh. 5>s. ; «ynipl Zingiberii (f«l 'n«»>* .
Comnon.) $wt. u. Fiat EtecL, aii^ aaaaltf «»•
diuin.

Mo. aOI. R Potaaw BUtart. is Pnlr. frit. S jia- . H.
taauB Vitrati«3 j. ; Confcct Saam SU> ; ^J^^- Aunrnt.
^ a. ut fiat BcctuartHM, ei^ua capiat CMii.> nL i^ m^
nirna \ Miper liibUa doae mtat. iS^

Ko. SOS. H Magnet. Calcin. 5 j. ; Camptem mibtem

E. I). ; tere ct adde Vint lpecMiwsiih» 5 )•■; a^
sntlia VIrM. S ▼•)«> $ 8jmipi Aomtfii J «. n^ Ib^
ci^ua capiat cocli. iU. larga, cum doK ficct. npo tn-
icrlpCi.

If castor oil be employed, it will be ^iridble 'd

exhibit it on the surface of some mucO^i&oc^ ■>

emollient vehicle, and to add to it a few drcr[» J

laudanum. Whatever may be the pursimt p *

scribed, it should be assisted by cmolheot ^

laxative injections, such as F. 144. ; or of te/><

water ; or fat mutton broth, well strained; or h>

seed, or sweet, or almond oU. Tenesmus a «c«>

times aggravated by large enemata. They «!«•• -^

therefore, be of small bulk ; or the irritation »ivS'->

be first allayed by an opiate, or an opisird i J

litharge (see F. 682, 683.), or a bdtsdvsv.

suppository.

84. (c) Rrfrigerantt may be exhibited, eiili
alone, or with diaphoretics and diuretict, sa. i
emullient and mucilaginous vehicles ( F. 8(^
especially after the aU>ve means have bcoi r*
ployed, and when there are much fever tsd «->•
of internal heat. The nitrate of poUsh m*y '*
given with ipecacuanha and opium (F.643.
with small doses of camphor (F. 96.460.), i:
of ipecacuanha (F. 39.); or, in »latio« «
spirit, ether, nit (F. 436.). liquor ammooic m'.
and opiates. The hydrochlorate of ammoon »>
likewise be exhibited, as in F. 352. and 431.

86. (d) Ojnata, Bfe. are produciisc of t»*
greatest benefit, after depletion ; and fbomM «
prescribed in large doses. If faecal matt*<«l^^'
been carried off, during the diarrhcea oftn s«fv^-
ing in the disease, they ought to be cxhtbJr^
directly after depletion ; and , in all caitf* « ^
the operation of a pur^tive« But mirk •>
depend upon the medicines that may be p *«
with them. Oflhese, ipecaenMmhm is the wo*, t ■
portant. From two to four grains of opism ^■*^
as much ipecacuanha should be prescribed i f «
dose ; and, if not retismed, repeated ia s (i*"*
time. These should be taken in the (ora •
pill, which may be washed down by a refn^^ft
and emollient draught ; or the tpecacusi)b i-'
be given in a similar vehicle, with from tl.irf,» '^
forty drops of the tine, opii comp, ( F. 729 ). »"
repeated according to circumstances. Tks« rf* -
cine will ameliorate the symptoms mad de«<To ▼
to the cutaneous surface, espectallv if a« «^ -
be promoted by the slightly werm 4atA, or » «-
copium or hip-bath ; and by frictioos of tfce •■••
face subsequently. After a decided f^e^ *■
been produced by these, Dovaa's powdrr »i» "
prescribed at short intervals, so as to keep v? ^'
action on the skin ; and the abdoacn sbwiU >
swathed in flannel. Opiates may be eo^^i^
also in the mucilaginous enemato already ^<^'
mended (F. 143. 147. 152.), and ia the faw •
suppository.

86. («) External derivathtt and nh*»*^'-^
are sometimes of service after depletioo aa^ '
above nr.eans have been duly croplovrd. A '■*•
blister may be placed upon the abdoasra , U
should be removed as soon as it has frafk'*
rednesa, and be followed by warm b«sd • •

DYSENTERY— Trbatmsxt op m Acuts States.

719

water poHhices. The tarpentine epitliein will be
feoad still more generally of lue, end will not so
much iocrease t£e irritatton ezperieoced in the
vrioary panages aa the blister frequently does.
Id eases where this symptom is severe, mucilages
with soda, nitre, small doses of camphor, and
opinm, will give relieC When it is urgent, tenea-
mas is also a prominent feature ; the means al-
ready advised, espeoially local depletions, either
from the sacrum, or from the perineum, small
emollient and oooling injeetions, and opiate sup-
{KKitories, being the principal remedies. If toe
•tiieme forms of the disease yield not lo the treat-
meot now advised, or if it pan into the chronic
tUUe, recourse must be had to such of the methods
of cure, and medicines, hereafter to be noticed,
V msy teem moat appropriate to the circumstances
of the esse. When much debility is complained
of, after tormina and tenesmus have been re-
moved by an antiphlogistic treatment, mild bitters,
as the infusion of ealumba, or infusion of cinchona,
with liqaor ammonisB aoetatis, tinctura camphoro)
compos., and small doses of the vinum ipeeacu-
aohc, will be productive of much benefit. Cos-
tiveoeas should be carefully guarded against, by
the occasional exhibition of a gentle purgative, as
directed above ($ 83.), and of aperient and emol-
lient encmata.

87. AmMg EuropemHt ia hot elimates, the dis-
ease m^aires a prompt and decided use of anti-
phlogistic remedies, inasmuch as the inflammatory
aetioa v, in these cafes, more intense, and arrives
more rapidly at an unfavourable termination.
The treatment, however, in principle, is the same
ai that advised above. The good effects of large
doaes of ipecacuanha and laudanum — from half
adnchato a drachm of each — after bleeding,
have been shown by Mr. Playpair; sind of
amaller doaes — from three to seven or eight, with
as equal (quantity of some bitter extract— -also
after requisite depletions, have been found equally
heoeficial by Balm a in and Twimino ; whilst the
impropriety of an indiscriminate use of mercury,
MpecisUy calomel, in this disease even as it oc-
ean in India, haa been acknowledged by these
writers, Mr. Anneslby, and others. Although
djaentery, ia persons thus circumstanced, as-
Munea ttie inflammatory form, or that of colonitit
(as it hu been improperly called by some writers,
u the rectum, csscum, and often the small intes-
tines, sre also affected), especially soon after their
migration to a hoi climate ; yet the attendant con-
ibtutiooal affection is not always of a sthenic
hind, bat frequently assumes either the simple
aathenie ($ 25.), or the bilio-adynamic ($ 28.),
or mali^Qk forms; especially in those who
have rended long in the country, and where the
emleniic causes abound. In many cases, also,
the symptoms are acutely inflammatory at the
commencement, and rapidly pass into a very
asthenic state, even before either of the unfavour-
ite chaages pointed out above have begun.
Id SQch, the antiphlogistic treatment should be
early employed, and exhaustion met, as soon as
its signs appear, by the remedies about to be
fecommeoded for the asthenic varieties. In some
instances, also, particularly in persons circum-
sunoed a^ now staled, the dysenteric affection is
entirely symptomatic, either of abscess in the
hver, or of interrupted circulation through the
ramifications of the vena portse, — pathological

conditions which should be carefully investi-
gated, as they require very different plans of cure.
(See LivEB— Chnmie Infiammatum and Suppwr,

68. B. Op tbb Asthsnic Foima. — («) In the
simpU atikenie form, ipoeaeumihm with opimm, the
tMrm both, and gentle jmrgatwet with aperient
and tmoUiant easiiMto, conformably with the
views now stated (f 83.), will frequently remove
all disorder. In most instances it will be requi-
site, and partieularly if the biliarv secretion be
obstructed or vitiated, to give a full dose of ealo*
m§l (from ten to fifteen grains) with two or three
pains of opium, and one of ipecacuanha, a few
noun before the purgative is exhibited ; and, when
dull and constant pain is felt in any part of the
abdomen, or lendemess on pressure, a number of
leeehei should be applied, and be followed by the
warm turpentine epithem. Venaesection has beim
found injurious in this form of dysentery, especi-
ally when epidemic during very moist seasons.
An ipecacuanha smttie will often be of service at
the commencement ; but if retching become ur-
gent, opium in the form of pill, sinapisms on the
epigastrium, croton oil rubbed on the abdomen ;
tne warm bath, or hip bath, or semicupium ; and
nitre, with emollients ; will both relieve this symp-
tom, and allay the tormina and tenesmus. Muci-
laginous mixturest with paregoric elixir and vinum
ipecacuanhae, are generally serviceable. Emol-
lient clysters and tuppont€ri€$, with opium, are
also requisite. I have seen the preparations of
hop productive of great relief in this form. They
may he prescribed with camphor mixture and
liquor ammonie aoetatis, or with emoUientt
(t. 839, 840. 871.) and dt«ir«<irt. In the more
severe cases, or when the disease does not yield
to the above remedies, full doses of camphor ^ with
opium, or with Dovbb's powder, or with the
addition of nitrt ( F. 36. 39.), may be given every
five or six hours, and pieces of flannel made warm
and moistened with either of the Unimentt, (F. 297.
307. 31 1.), be kept upon the abdomen until relief
is obtained. AlthouKh fsscal malten and disor-
dered secretions may have been evacuated before
the dysentery symptoms had appeared, yet it will
be necessary to have recourse to mild purgativeg,
from time to time during the progress of the dis-
ease, in ordet to excite the functions of the excret-
ing organs, and to evacuate such morbid secre-
tions as msy have collected. The purgatives and
aperient enemata recommended above (§ 83.)
may be exhibited, or the compound infusion of
senna, with an equal quantity of infusion of
calumba or gentian, and a little soluble tartar and
compound tircture of cardamoms. If the disease
be likely to become obstinate, equal quantities of
Ittrpsntine and oaitor oil, taken on the surface of
milk, or of an aromatic water, and repeated every
second or third day, will be most efficacious.
After the tormina and tenesmus are removed,
intVd biUer$ and lonf«t ; and, in some cases, ««•
irinnnt toniei and a6aor6ffiiCf , with the treatment
advised in the article Diarrhcba ($29—33.),
will generally remove all remaining disorder, if
the state of the secretions and of the bowels be '
duly attended to. If the complaint degenerate
into a chronic form ; or debility become a pro-
minent feature; and if the excretions indicate,
with the state of the surface and tongue, a pro-
gressive deterioration of the fluids and. soft solids ;

DYSENTERY — Tbeatmbnt op its CouPLiciiTKD States*

nv

the manaer above directed ($ 89.), occasionally
resorted to. If this tariety be characterised by
great vital depretsion, the treatmeot already
directed (691.; must be employed. In all its
itates, and stages, it will be reouisite to evacuate
the morbid bile that is secretea, and to correct
the diseased action in the liver ; but beyond
one or two fall doses of calomel, either with or
without opium, this medicine should not be
persisted in ; as it increases the irritation of the
colon and rectum, and depresses vital energy.
The bydrafgymm cum cretA, as now directed,
will be more efficacious ; especially when assisted
hj the above means, and by emollient and muci-
kgioous diluents.

93. in lAe Drk Raeet, dysentery assnmes the
amply asthenic or malignant forms. In them,
tlie treatment may safely be commenced by an
ipecacuanha emetic, and followed by a purgative,
tbe varm buth, and warm dtaphcretia. Early in
the disease, calomel with rhubarb and ginger ; or
powdered jalap with cream of tartar and some
warm spioe, will be appropriate ; but eoemata
are also required. The habits and modes of living
generally adopted by these races, independently
of their more ux fibre, and much leas tendency to
ioflammaCory action, require an earlier and more
actife use of tonics, stimulants, astringents, and
aromatic spices, with opium, than can often be
safely attempted among Europeans. Purgatives,
alw, sfaoQld be of a more stomachic and warm
^ind, a«nhe fudictioDs of the skin especially pro-
moted. Tbe combination of ipecacuanha with
tonics, astringents, opiates, and absorbents, ao-
cordia? to the peculiarities of the case, is
eeoeraJly extremely efficacious after faecal matters
rave been evacuated. Camphor, cateehu, the
bot spioes, and warm clothing, with the rest of
tbe tooie and astringent treatment advised for the
tArosie ftate, and in DiARanaA ($37.), should
be resorted to, aa aoon m exhaustion supervenes,
or when the disease becomes protracted. To
Earopeans long resident in hot climates, a nearly
similar method to that now recommended is
■pplicable, if the hepatic functions be regular;
but, u in them the liver is very seldom unaffected,
tbe means directed for the chronic form, which it
tiiualiy assumes, is more generally appropriate ;
and the treatment should chiefly depend upon
tbe nature of the primary or attendant hepatic
disease.

94. C. TasATMBirr or the Compucatbo States.
^(a) Tbe association of acute dytantery with in-
^ummaium tf the liver (§ 34.) rei^oires decided
(umI early general or local depletion, or both,
followed by cooling purgatives, sufficient merely
for ihe evacnatibn ot morbid secretions. In this
complication, the morbid state of the bile, and
the rest of the hepatic symptoms, are the conse-
quence of inflammation, ana can be removed only
by antiphUigistie treatment, and not by inordinate
doses of mercury, which will merely over-excite
an already excited organ, and accelerate sup-
puration. Refrigerant, therefore, and cooling
iperientA, as the bitart. and Urtmte of potash,
taiaariods, manna, or the potassio-tartrate of soda ;
aotimo&ial or ipecacuanha diaphoretics; small
do-ses of camphor, with nitre ana opium ; cooling
and emollient enemata, and a very low diet ; coo-
Mitute the principal means of cure. When the pa-
tient complains much of burning heat or soreness
Vol. 1.

in the abdomen, with scalding, &c. in the anus an4
urethra, the nitrate of potash, with carbooate of
soda, and spirit, asther. nit., in emollient vehicles ;
the hydrocnlorate of ammonia in mucilaginous
mixtures ; suppositories of opium ; and local de-
pletions, followed by the warm terebinthinate
fomentation over the abdomen ; are chiefly to be
depended upoo. If blisters be applied, they should
be surrounded by a number of leeches, the former
being removed as soon as they have pitxiuced red*
ness, and succeeded by warm poultices. As the
substance of the Uver is generally more or less
acutely inflamed in this complication, and as mer-
curials will not readily produce their specific
effects, or act beneficiaUy, whilst this state con-
tinues, but will rather increase it, the exhibition
of them with this intention can only occasion
abscess, irritative fever, and exhaustion ; and fur-
nish one of the most injurious proofs of the
" rrimta ditigentia," which is but too common in
the treatment of this as well as of hepatic disease.
Can any practice be more empirical than to give
the same substance to subdue over-excitement,
which we find the most active in rousing torpid
function, of an organ ? Having removed tbe acute
symptoms by the above means, the insertion of
one or two selons in either side, and keeping up a
free discharge from them for a long time, with
appropriate diet and reeimen, and change to a
healthy air, will generally complete the recovery.
When the dysenteric affection is merely symptom-
atie cf ahieeu in the liver, the treatment advised
for this condition (see Livxn — Suppuration of)
should be employed.

95. (6) The wmpUcatlon utith diseate of the
qtleen is most common after iotermittent and re-
mittent fevers, and in unhealthy localities; and
the symptoms are either but little inflammatory or
more or leas asthenic. Local depletions even are
seldom required in its treatment Warm sto-
machic aperients, as cinchona with rhubarb,
ipecacuanha, and aromatics; emollient enemata
with anodynes ; tbe warm bath, followed by fric-
tions of the abdomen with either of the liniments,
F. 297. 311., upon coming out of it ; ipecacuanha
with strychnia or sulphate of quinine, or sulphate
of iron, or with tonic extracts ; camphor with warm
diaphoretics, and the medicines directed for the
more chronic states, which it more frequently
assumes, or passes into ; are the most appropriate
in this state of the complaint. When ayaenlery
follows eontintied or penodie fever, disease of the
liver or spleen, or of both, should be dreaded, as
well as Its rapid termination in ulceration ; and
means, conformably with what has now been ad-
vanced, should accordingly be promptly put in

1>ractice. The most efficacious of these, are early
ocal depletions—- but only when the symptoms
clearly indicate the propriety of resorting to tliem ;
the terebinthinate epithem applied to the abdomen,
or large blisters, followed by poultices, and re-
peated according to the urgency of the case ; with
the rest of the treatment directed for the asthenic
states, according to the peculiarities of the case.

96. (e) The association of acute dysentery tcilh
scurvy, requires the removal of the exciting
causes ; a suitable diet, especially fresh meat and
vegetables ; the liberal use of lime juice, with
sugar, mucilage, and opium ; the bi-carbooate of
potash or soda in effervescence, with an excess of
lime juice, particularly when the secretions re-

3 A

D YS£NT£RY — Trbatmbnt of its Cubomic Statu.

723

purgttUvtf, aided by Itzative clysten, will be re-
quired, and should be repeated UDtil the coUectioD

is evacuated.

100. ii. TbSATMEKT op THC Sva-ACVTE AND

Cubomic Forms. — ij. Of tkg more timpU Mata.
—The hutntiant of eun by which we are guided
in the acute, shoald, with little modification, be
entertUBed in the chronic, forms. 'When the
rrmptODs cootinning after an acute attack consist
chiefly of either frequent or oopioiis evacuations,
withovt tormina or straining, the appetite, pulse,
■ad strength improving, or remaining unimpaired,
sMringenls or opiates should not be prescribed ;
for the discharges are the means of bringing about
a resoJation of the inflamed and tumefied viaoera.
In such cases, the stools are usually of a good
colour, and are feculent and fluid. But, if the
motions be attended by abdominal soreness, in-
creased on pressure ; or by a sense of beat ; or by
griinog, tormina, or tenesmus ; if they be slimy,
or noguineous; and if the patient complain of
thint, with fever and restlessness at night ; nature
leqaires the judicious assistance of art. Here
vascuUr depletion, most firequentlv local, although
it may have already been practised, and more espe-
cially if it have not been resorted to, is required
to ao eitent which the constitutional symptoms
will indicate. If, however, the strength is too
far sunk, or the asthenic characters are too pro-
minent to admit of this measure, the warm epi-
tbem already described ($ 89.), or blisters to
the abdomen, followed by a succession of poul-
tices, and these by the warm bath, a thick flannel
bandage around the abdomen, and stimulating
frictions of the surface, and of the lower limbs,
will sometimes be serviceable.

101. In all cases, the state of the biliary secre-
tion and of the liver should be carefully ez-
•nined. [f the investigation furnish no proof of
•eate disease, or of abscess of this viscus, and if
the bile be scanty or altogether obstructed, cam-
phorated mercurial frictions on the hypochon-
drinm, blue pill or hydrargyrum cum cretft, with
ipecacuanha or Dovzft's powder at bedtime, and
s mild purgative, such as cream of tartar, with
coofection of senna and extract of taraxacum in
the. form of electuary, in the morning, will often
increase and improve the bile. If mercurials
have not been previously used, and if no tender-
nets or soreness be felt in the region of the liver,
nor oppression of breathing, dry cough, nor recur-
ring chills or horripilations alternating with hectic
flashings, &c., one or two full doses of calomel,
with or without opium, may precede these medi-
cines; the operation of which may be assisted,
and the state of the large bowels improved, by
emollient and oleaginous injections. After these
means have been tried without benefit, the em-
plastnim ammoniaci cum hvdrargjrro may be
placed over the abdomen ; and one or two grains
of hydrai^. com cret4, or of blue pill, with one of
ipecacuanha, and as much camphor, taken thrice
aaily, with m draught containing a drachm of the
extract of taraxacum, or consisimg of the decoc-
^n of the recent root. As long as the stools are
deficient in bile, astringent tonics will seldom
pnoTe permanently aerviceable ; but if the above
medicines run off too rapidly in the stools, the com-
pound tinctiire of opium should be added to them.

102. When the foregoing means have failed,
nitric acid frilb opium or laudanum ; and the ap-

plication of the nitro'hydroehlorie aad lotion over
the hypochondria and abdomen, may be tried ; or,
instead of the nitric, thenitro-hydrochloric acid may
be taken internally, in a very weak state of solu-
tion, or employed as an enema, with the laudanum,
F. 729. Enemata consisting of a weak infusion of
ipecacuanha, or of the decoctum lini, with muci-
lage, or of both, may be administered once or twice
a day, while the acids are taken. If these fail,
and if the debility be great, tlie ekhrutett especially
thoae of potassa or lime, may be given by the
mouth, or in clysters.

103. In the advanced stages, the infusion of
cinchona, of cinchona and rhubarb, either with or
without laudanum, or of catechu with aromatics
and warm spices, are generally requisite, more
especially in the dark races ; the same preparations
being also ad vantaseously administered as enemata ,
either vrith or without mucilaginous substances.
When the disease, like agleety mscharge, proceeds
from relaxation of the internal surface of the large
bowels, and a habit of increased secretion, these
means will prove of essential service. In many
cases, the disorder is kept up either by too great
indulgence in food, or by the use of stimulating
liquors. The diet should, therefore, be restricted ;
and the digestion of what is taken promoted
either by the above medicines, or by the sul-

i>hate of quinine or the sulphate of xinc in the
brm of pill, with inspissated ox-gall, or other
medicines suited to the case. If we succeed in
controlling the increased action of the bowels, an
opposite state should be carefully guarded against,
bv the occasional exhibition of the means directed
above (§ 83.); or of the draught and enema
already mentioned ($ 90.). Inattention to this

J precaution, and errors in diet and regimen, are
requently productive of relapses.

104. If diarrhoea continue after the acute
symptoms longer than seems sufficient for the
resolution of inflammatory action in the large
bowels, and of congestion of the portal vessels, we
may suspect that ue quantity or kind of aliment
is such aa the digestive organs, and the biliary
and other secretions, are incapable of changing
into healthy chyle,-— a large oroportion of it en-
tering into such acid or acria combinations as its
constituents dispose it to form. In these cases, the
stools are frothy, have a sour odour, or are lien-
teric ; and tonics, with mild mercurials and anta*
cids ; the sulphate of quinine, as above recom-
mended ; the balsams with magnesia, and the
liquor potasssB, or the sesqui-carbonate of am-
monia, with tonic infusions, aromatics, and small
doses of Sydx^!am*8 laudanum (F. 729.) ; are
required ; whilst the abdomen and hypochondria
are sponged with the nitro-hydrochloric solution ;
and the large bowels fortified by the tonic and
mndlaginous injections already mentioned.

105. In the cases denominated " WhU§ fl%tx"
from the muoo-purulent and ^leety appearance of
the discharge from the muciparous glands, and
the absence of bile, a similar treatment to the
above is required ; with an occasional dose of
calomel, or frequent and small doses of the
mildest mercurials, as above directed (§ 101 •)•
The infusion of either cusparia, catechu, sima-
rouba, calumba, rhubarb, cinnamon, &c., vrith
vinum ipecacuanhe, aromatics, absorbents, and
astringents, according to circumstances ; the chlo-
rates, or nitre with soda and emollients, in aro-

3A 2

734

DYS£NT£RY ^ Theatuskt op its Chromic Statcs.

matic vehicles, and in clysters; assafcetida, with
camphor and mucilage) in enemata ; and the daily
use of the salt-water warm bath, followed by
frictions of the surface with a rubefacient and de-
obstruent liniment (F. 3ll.)i aod a flannel roller
around the abdomen $ may also be resorted to.

106. If the evacuations indicate ulceration
($ 54.) -» which, indeed, is seldom altogether
wanting in protracted cases — the above treatment,
or mucilaginous mixtures with either of the bal-
sams ; emollient clysters, and the repeated appli-
cations of large blisters, or rubefacients, to the
abdomen, or the insertion of setons, are chiefly to
be relied on, with the other means advised in the
treatment of Diabriicea (§ 32.), arising from this
pathological state.

107. A form of chronic dysentery depends upon,
or is kept up by, ulceration, or even by a nngle
large ulcer, in the rectum, with or without pro-
lapsui ani {§ 47.), the abdominal symptoms being
slight, but the tenesmus constant and painful.
For it, small injections of a solution of the sul-
phate of zinc, or nitrate of silver, or dilute nitric
acid with opium, or acetate of lead, with pyrolig-
neous acid and laudanum ; or of paregoric elixir
with mucilage ; or of simple camphor mixture ;
the balsams, or sulphur with cream of tartar,
and tonics with deobstruents, being taken inter-
nally, and a gently open state of the bowels
preserved ; will remove the disorder. In nearly
ail the more simple states of chronic dysentery,
also, the same treatment may be appropriately
employed as is recommended in the cbronic states
of diarrhoea, lientery, &c. (See Diarrhcea, § 29
— 33. and §4\,etseq.)

108. B, The complications of chronic dysentery
are much more common than the simple statM ;
and the most frequent are those with chronic
afl*ections of the liver, with disease of the mesen-
teric glands, and with enlargement of the pancreas
and spleeu. — (a) If the liver be free from acute
disease of its substance, or from purulent form-
ations ([see Liver — Injlam. and Suppurat. of),
mercurials are often essentially requisite. But,
even in such cases, they have been much too
liberally employed, on the supposition that sali-
vation is indispensable to the cure of this com-
plication. VV here, however, these forms of hepatic
disease exist, they should almost altogether be
proscribed ; and also, where the powers of the
system are much reduced, even in the simple
states of the disease, the extention of inflammatory
irritation to the mesenteric and portal veins, or
the absorption of morbid matters from the bowels
(§ 77.), and consequent disease — especially
purulent collections — in the liver, may be fa-
voured or induced by prescribing them so as to
produce their specific effects.

109. (fl) We often have little or no proof of the
pre3ence of chronic change in the liver, beyond
the torpid state of its functions already noticed
($ 48.), viewed in connection with the habits of
the patient, and the history of his former com-
plaints, and of his present attack { but, in these,
mild mercurials, in frequent and small quantities,
in conjunction with alteratives and deobstruents
($101.), especially minute quantities of antimony,
with ammoniacum, soap, and opium ; or these
with taraxacum in full doses ; or this latter with
the infusion of calumba ; will be found the safest
as well ns the most efficacious remedies, parti

cularly when assisted by a camphorated mercuml
ointment or liniment applied over the hypochoa-
dria ; or by the nitro-hydrochloric add aiolatioB,
employed either as a wHsh, a lotaoo, or on tkc
surface of warm poultices ; or by repealed bftv
ten ; or by issues or setons, and the ammoBMcal
and mercurial plaster over the abdomen. «r s
combination of it with other deobsiruent and warn
plasters. In these cases, we moat be guided U
the evidence we may have of change of the liter,
and direct our treatment to its removal, cooform-
ably with the views suied in the article oa the
diseases of that visens. When the ttoeb art
frothy, and deflcient in bile, the hydrar^niv
cum cretH, or the bine pill, will be aid»-»tagcMaly
combined with inspissated ox-gmll, extract of ts*
raxacum, and aroall doses of Dover's powdrr.v
opium . I'he carbonates of tlie alkalies, or bdMr.u
of soda, may ako be given with vegetable toAK:*.
ipecacuanha, and the preparafaons of bop *, cither
of the liniments (F. 296. 311.), alone, er wkk i\e
mercurial liniment, bein;? daily rebbcd upno 6r
abdomen, or applied by means of a pieoe of ilav
nel mobteoed with it and placed vnd«fr w)«6-
leather, — which will protect the clotbea from :'..
and prevent its evaporation. lo the Ibrerrv
states of hepatic complication, change of air, hone
exercise, or travellinir, and a regulated diet sod
regimen, will materially assist the treatneot.

1 10. 0. A sub-acute, slight, or clmmic fbrii d
dysentery is sometimes merely symptemimtie of tht
advanced states of hepatic abscess, and oerv*
more frequently than the very acnte conpTmUD-)
allttdedto above ($94.). It requires either aamil.r
treatment to that now stated, or siropW soppon et
the powers of life, in order to enable them to otc->
come the disease. The arrest of the disciiar^ j
this state of the complaint frequently increase* ite
hepatic malady, or occasions severe eoBstttvtioeJ
disturbance. Gentle tonic* and rtstoiatives, I pt
or farinaceous food, and such astringents, aoodTnc^,
and emollients as will merely control and soo<i
the bowel affection, until the above trealiDctti, c
that recommended for tuppvrution of ike Lin?,
shall remove the principal or primary disease, s'\
the most deserving of confidence.

111. y. When purulent matter cwflsris it '*'
liver, in an advanced stage of dyeentery, the oc-
currence can be explained only as mttcnpted the* r
($. 77.) ; and, during the life of the palieni, l s
symptoms will seldom warrant more than a svpp -
sition of its having taken place. The Ihcts, t^ a
bad habit of body, and an asthenic etaite of ite
powers of life, are the chief causes of d» tkaar^
tion into the blood of morbid matters from the «c«*
of disease, and of the extension of iniiaBiBati-.
from an ulcerated part along the veins ; and tut
these changes induce those observed in the hnt is
such cases, should be kept in view ia the tieatiert:
of the advanced stages or dysentery, — particabr*?
as it has been satisfactorily shown that a iarr^jv^
portion of unfavourable cases termiaaie faesl'i.
owing to the contamination of the ctiralsnr;
fluid produced in this manner, either with or w-t^
out the concomitant lesions of the liver, ef «^^
particular notioe has been taken. Cottfermstli.
therefore, with these liicts, the remedies 1 hi*r
shown, in the article Veins, to be most e£eK^«^
in arrestittg the extention of inflaBmatMe eis::,
them, in preventing or connlenciiQ^ the csetk-
minalion of the bloM, and in ■Bppattif the nix

730

DYSENTERY — Treatmint advised by Authors.

much service either with or without opium, espe-
cially in the asthenic states, and'as they occur in
the dark races. Goeden (in Hoan< Archiv,
Mart. 1812, p. 284. and 323.). prescribes tartaric
acid with refrigerants, and opium , Bang, tul-
phuric acid with mucilage ; Amnesley, the nitra»
hydrochloric acids, with anodynes ; and M'Grioor
and Hope, nitric acid with opium ; Uiis last being
chiefly appropriate to chronic cases, and those as-
sociated with disease of the coUatitious viscera.
BiRNSTiBL directs alum conjoined with camphor ;
Loos (Horn's Archiv. Jftn, 1810, p. 193.) alum
with tormentiUa root ; Hunnius, MiCHAicus
(HuFELAND, Journ. dcr Pr, Arsncyk, b. vL
p. 280.), and Hargbns {Ibid. b. vii. p. 137.),
alum with mucilages, opium, &o., chiefly in the
chronic and atonic states; Mosblet and Jack-
son, alum with sulphate of zinc, by the mouth
and injections ; and Adair, alum with spermaceti,
or gum, opium, and aromatics, in epidemic dysen-
tery occurring among negroes. Lime vntcr with
milk, or with mucilages, is praised by Grainger,
Brefeld, and Lange ; but is most serviceable in
the chronic and asthenic states, and in the form
of enema ; in which cases, various other astrin-
gents are recommended, especially after morbid
matters are evacuated. In this manner the pre-
parations of catechu are directed by Bravde
(Tode's Med, Journ. b. z. n. I.) and others : kino,
by Weber ; the infusion of galU with opium* by
Elliotson and Roots ; hxmataxylan with cinna-
mon and other aromatics, by Pringlb and
Wendt ; the tormentiUa root, by Hoffmann ; the
lythrum taUcaria, by Quarin and Garoanb ; the
root of the ledum palustre, by Biornlund ; betel,
by Peron ; the inner bark of the brucea antidy-
senterioa, by several writers ; and the decoction of
the pomegranate bark, or of the rind of the fruit, by
the ancients, and by many modern authors* All
these, especially torroentilla, catechu, and betel,
are advantageously combined with ipecacuanha
or Dover's powder. Several mineral astringents
are also exhibited, especially in the asthenic and
chronic states, or in far advanced stages ; inter-
nally as well as in enemaUi. Arsenic, and Uie rust
of capper, are prescribed by Galen, Rhazes, and
most of the ancients ; and the sulphates of zinc, of
capper, and of iron; and the nitrate of silver,
either with or without opium j by the authorities
referred to in the article Diarrhoea ($50.). The
acetate of lead is recommended by Fbrneuus,
Camerarius, and Nardius, and is now frequently
employed, in pills, draughts, or injections, gene-
rally with opium and ipecacuanha, both in the
acute and chronic forms ; particularly the latter.
It should be recollected, when prescribing astrin-
gents in this disease, that they are injurious when
exhibited early in the acut^ states, and whilst there
is much fever, or when morbid matters remain to
be evacuated. In other circumstances, they fre-
quently are of much service ; particularly when
altered secretions and accumulated excretions are
discharged from time to time by a judicious exhi-
bition of mild purgatives ; and when they are con-
joined with demulcents, with ipecacuanha, or with
absorbents, or with anodynes, according to the
forms of the disease and the state of the patient.
Morton found them injurious, although they di-
minished the diicharges ; in the malignant or col-
liquative epidemic of 166G ; and similar results
have been remarked by others.

131. H. Tonics are required in neulj the mmt

states of the disease as astringeals ; bat they are

less frequently injurious, as they do aot w eoff-

pletely suppress the discharge from the iste^ticai

mucous surface as astringents qsbiII} do. iL.i

admit, alao, of similar comUnalions with uodjao,

demulcents, and absorbents, to those fosod otft

serviceable with astringents ; and poeieM tbe d-

ditiooal advantage of promoting the operatibA,

and, in some instances, counteracting the ill t«&*

sequences that might result from the cxkibaL-x.

of pui^atives or anerients. In tbe asthenic kn.\

they may be exhibited as eariy as the masiA

matters are evacuated* particularly in coojinaus

with ipecacuanlia, or diaphoretics and opuk«,

and when evacuation should be prooMied, btj

are beneficially associated with lazativck Cd<

ckona is praised by Wbytt, Lines, Cuai* ilJ

Douglas (De Dyeent. Putrida, ed. 1766, p. 3^

Bang prescribes it with rhubarb {Art. Reg* ^^

Med, HauH, vol. u p. 105.) ; Scumidtma^k, «'•

ipecacuanha; Wuvtt, Quarin, and ?ui^<i,

with catechu and ipecacuanha, after bieedioii:^.

alvine evacuation; and Morton with ofdia.

Heuermann restricts it to dysenterr rollo«.f;

fevers ; and Cull en advises it chiefly vhea ti.

disease assumes an intermitting or retDittisg ch»-

racter. Hueham and Prinole prescribed an i.*

fusion of it and serpentaria, with great beoett. a

the asthenic and malignant states, and dcrx

convalescence. Marcos considen tbe bark 'j-

jurious; which it doubtless is in tbe early fta^. v

the inflammatory forms. Most of the other toeir^

are recommended by authors, and admit of iiE>l.'

forms of exhibition, in the states which re^«-'"-

the lighter preparations of bark ; for wheit i^

infusion or decoction of cinchoiia, with h*^'-*-

ammonia acetatis, vinum ipecacuanha, aad tti^

dynes, are of service, the other tonic iaftac*

will also be of use. Indeed, some of thee, m

the infusion of ca/ujn6a (Pebcival andMLSu^*

or of the cusparia 6ar/e (Branoe, m UeaaM

Magta, b. xxviii. p. 1101.), will be ^nkrt.

in certain forms of the disease, cspecisl^} •

the combination now stated, in the adruet.

stages of the acute, or in the chronic and t^j^

asthenic forms, where tonics are chiefly re()u.^v'

simarouba (Wright, Goocu, Wendt, Q^*!"

Baumes, Deoner, and Sumeirb) will be &

found an excellent remedy, either alooe, or « -

the medicines just enumerated. Dr. O'b^i'

found it very serviceable in the advanced a^--

or the dysentery that was lately epidrtsk *•

Ireland, in conjunction with opium. Tbe «-'

bark (Loepfler and Osiander), mxsdemt''"

(Weber, and Horn, Archiv. July, ia20.p.3>': '

may be employed in similar oixcumstaoccs, • •

in the same combinations. It shooM c <

be overlooked, that Ionics ought to be pRft ''

by vascular depletions, or aivine evaicufc'-<^^

where either is required; that the piomi'x;

of the latter, by suitable laxatives ronj^'

with, or iotcrvenmg between them, or csl»i^^ »

in enemata, will occasionally be m|ii*r»

especially when the disease proceeds bca •

morbid state of the secretioos ; and lUt ''

should be very cautiously resorted to in thr «i^''

or phlogistic varieties, even in their sd«S'--

stageM.

132. /. Aromatics and AbsffrhnU ut v >-
useful adjuvanuio the advanced periods., er sfiU

732

DYSENTERY — Treatmeot advised by Avtbobs.

to employ it in this manner, in -conj unction with
large doses of laudanum. A few years after-
wards, Mr. Playfair adopted this practice in
India ; he giving from half a drachm to a drachm,
with as much laudanum, and directing this dose
to be repeated again and again if it should be
rejected. Mr. English prescribed from a scruple
to half a drachm, with double thb quantity of
laudanum; and Dr. Bateman confirmed the
propriety of this method in all the staees and
forms of the disease, as he has observed it in this
country. More recently, Mr. Twinino has
modified this practice, and directed from four to
eight — more frequently six — grains of ipecacu-
anha, with nearly as much extract of gentian,
and Of^asionally also with blue pill or calomel,
twice or thrice daily ; premising bleeding and
alvine evacuations m the acute disease, and
resorting to mild purgatives once a day, during
the treatment. I had, in 1817 and 1818, given
from eight to ten grains of ipecacuanha with
opium, and sometimes also with calomel or blue
pill, with the best results ; having at first, by
mistake, prescribed the simple powder for the
compound ; and afterwards continued the practice
when the circumstance and the effects became
known to me. Fischer directs ipecacuanha
when opiates «fail of afTording relief. Rhakojb
(Act, Reg. Soc. Haun. vol. i. p. 33.) combines it
with rhubarb ; and Clabke, ochleobl, and Av'
itfESLSY give it in the form of infusion, which may
also be exhibited as an enema. Dr. Dick praises
it in the dysentery of India ; the bowels being
freely opened by clysters, whilst it is frequently
given by the mouth. It may be conjoined with
nearly every other medicine that can be exhibited
in this disease— with refrigerants and evacuants
in the inBammatory states, and with tonics and
antiseptics in the malignant ; and it will occasion
as much nausea in one or two grains, as in sixty ;
this effect being loss remarkable after its exhi-
bition in the form of pill, and with bitters or
opium, or even with calomel, than when taken in
simple powder.

■ 135. M. Rhubarb may be given eitlier as a
mild purgative, or as a gentle astringent It is
approved of by Borellus (Cent. ii. obs. 82.)
Heister, Riedlin, Pkinole, Jacobs, and
Baker ; is considered injurious by Kortvm,
Jawandt, Weber, Neumann and Mvrsinka,
and is prescribed only in the most advanced
stage by Lino, Stoll, and Richter. It is

▼crKition with a Mr. Wbntworth, who anUted me. 1
formed the design ofgiviog It In Uiver quantitiet. He
Informed me, that a man, who Uvea in the came town
where he did, was uncommonly suooeMful in the cure of
dyienterjr, b^ using (h>m a drachm and a half to two
drachms of ipecacuanha, with laudanum. Mr. W. had
Just prevlouaty to this conversation, given ninety grains
oi the powder, with forty drops of iinct opii, to a man
^v. Iinse life was apparently near a close, anti with whom
e% acu«ints had lieen used. There was a wonderftil atiate.
ment of every symptom In the course of one night; and
a repetition of the medicine in smaller quantities, com.
pleted the cure in a few days. I did not hesitate to ftdlow
this practice ; and gave the ipecacuanha frequently to the
quantity of two drachms, with the addition of sixtv drops
of tinct. opii : and, in many cases, found that a dose or
two was sufficient to remove every dangerous symptom.
It answered the purpoee t)ett when given in the form of
pills ; and if the patient kept still, and lay on his tiaek,
with the head and chest tolerably elevatetl, nausea sel-
dom or ever followed it ; and oftentimes it happened that
he had not a stool the succeeding day. although, pre-
▼iously, the gripings were violent, and the discturget of
bloo.1 frequent and in large quantities." ( Mem. </Hed.
Soe. qf L(md. vol. v. p. «0. )

much praised by PRiNGLE,in the campdjmim ,
especially when exhibited in large docs ^\r'
emetics; and it is often of much tenice m is£
dysentery of chUdrtn, conjoined with h^dnirr-
rum cum creta, and minute doses of ipccacvsahi.
or with alMorbents and Dover's powder, h i*
one of the best pui^ativea in the more Mtbn»
forms; but it is injurious in the early nje««r
the inflammatory disease, or when the bife ^
obstructed ; and it then cHften increaies tbe itte«-
mns, as remarked by WETcoELSTAnr asd njul'.
It is apt, in many constitntioas, to npfMwtk
excretion of bile, even althoogh it msyopc&iA^
bowels ; and, upon the whole, it requires but*.
discrimination in its use.

136. IV. Camphor is fisvourably ni»;iecii \'

BrEFELD, MARCUS,SFOKIZBR(HrrKLAKB, Ar*

der Pr. Heilk, b. v. p. 546.), and Mxxdi()>>m.
Aug. 1810, p. 88.). Cn AMBON dirertt it to br
dissolved in oil ; MicHAitus coaJMos it 9r
opium ; and Osianoer and Thomarh {Amau*
1800, p. 258.) employ it freely, both ioterui*
and externally. It is an excellent adjeixt i
small do«es, to refrigerants or diaphofflic«,n ^
inflammatory or acute states; and, u> iio
doses, with other antiwptics or tonics, m '>
malignant variety, and m the vrmioout r^
rheuroatie complications. It is particalsf); «t •
viceable in the nervous or typhoid slate ; tiW a
the advanced stage, when nervous spsptsn- «>
pervene. It may be given with iprcscwM
either in pills, or in demuloents ; and ia emoi'*'
enemata. In the infections coodition*, it i^ '
seldom be omitted ; and may in these, cspem**
such as are malignant, be given ia doso ot m
or twelve grains.

137. 0. The tereh'mthimaU* are valuiblf *-
medies in the asthenic and chronic fomff. T^*
were reoom mended by the anther (Mtd. r»
Phys. Joum, vol. xlvi. p. 107.), and biw «>«
been emploved by several physidaiM. TW r-
cumstances m which they may be reaoitcd id. i»
the manner of prescribing them, are nnBtfed ^
what has been stated. Tbey are not coatn-#-
dicated in the inflammatory varietias, shWsf
bleeding should be premised ; and, whes n
hibited so as to act gently on the boweU, cr ^
small enemata, they counteract the teadcon >
sloughing or ulceration ; panicnlarly b tkc s-
theme varieties. A oy of tne ftnism* — hot o ^
particularly the Peruvian (F. 843,). Cssfcin*
and copaiba — may be given with araeur^
magnesia, and demulcents ; or with opaie» ; acJ r
administered in enemata. They are sDOfi «cn-^
able in the chronic diseases, especially *'•■
assisted by frictions of the surface^ dcc4Uj«'
plasters, flannel bandages, af»d regulatsd •^'-
When the stools are frequent, and witbest ^'
they are particularly serviceable, the b>df»T
mm cum crelA being taken with Dovxa*s ps*^'
at night ; or they may be alternated wah ct^v
the haematoxylon, catechu, or kioo, in m«rv% '
ous or absorfaient vehicles.

138. P. i4nfii«plirs are praised by Wrsfr* '-
With .a view to its antiseptic as w«ll asio d« « •>
rient operation, Jacsson and CaAVioso b^* '
the use of eharcvat, in doses of half a drscU

a drachm, frequently repeated. It may I* •
vantageously given rubbed up with eamj^*
But the ehU>rat€$ are much more powerful a^s' -
J\(^ chlorate of potash ispi«scfibed byG*s«<v.

EAR — Noun in — Pathology or.

735

Ruhr. Brt a M . Biro, leia — Ltiomr^ In BaU«t.det Sden.
Pbykd'OrUani, 1. 1. 18ia {Cki^tmtmium A» <%«.)—
TmntUer^ De I'EpkL Dyt. qui a rcgni luns 1' Ar^ond. de
Tournav, dam iM An. 1810 at 1811, in Jouni. de M6d.
I. x\m..-a. fVedeJUmd^ Ueber die Ruhr. Frmnlif. 1811.
^-Sek^hr, In Hufdand a BimU^'* Journ. der Hetlk.
S«pt. 1818, p. 88. 46. — /i<M<nRacAtfi-, in Ibid. Aug. 1810.
Meudt, in Ibid. Aug. 1810.^ Iforw, ArchiT. fUr Pr. Me-
Han. b. Ti. p. 91. 19& et 830.^ 0«wdfe«, in Ibid. Mnr.
191S,p. 813.— J. JTOr^fDr, in Edin. Med. and Surg.
Joum. Toi. i. p. 179. (/• Bomhaif.JSatemam^ in Ibid.
vol. V. p. 126., ToL XI. p. Ul. — JnMfirr, in Ibid. toI. ▼.
p. 399.->Li^iblrMlrii»,ln lUd. Tol. tL p.»6*^Ptaafair, In
Ibid. vol. ix. p. 17 — BngiitAt in Ibid. vol. x.p. 458.— Oaw-
fimi, to lUd. TolJiitp. V.—Batemum, in Ree$*» Cydo-
mdla, art. Dgstmltrpi and in Edin. Med. and Surg.
Jouro. ToL It. — Hope, in Sdin. Med. and Surg. Joum.
ToL xxtI. p. dH-'^Bmrke^ in IbM. p. 66.— Somer«, Suggest
for tbc Treat, of Drtent. Load. 8to. 1816. —Bromuait,
iiUt det rhlcgmaslea Chroniquea,8To. ad ed. Paris, 1829.
~J. StGrigor. in Trans.of Med. and Chlrurg.Soo.vol.Ti.
p. 430— FrrgMOM, In Ibid. vol. ti.^Bacot, in Ibid. vol. vii.
-Ckemtt^ia Dublin Horn. ReporU, vol. iU. p. 1 — Barrp^
IQ IM. p. la— PtfTflon, In Ibid. p. 91 — HaUoranAa Ibid.
i>.9. {EfUemie m 1 818 cmtf 1891. >—0'2ir^rn^, in Trana. of

Irish CoU. of Phyt. toI. iv. p. 386 O^BHfn^n Ibid. vol.v.

p. 'tti.^H'Utom and Browi^ Glasgow Med. Joum. vol. L
p. sa ia^iSqqfariane, in Ibid. vol. i. p. 101. — G. Bat-
UngalL, Pract. Observ. on Fever, Dysentery, and Liver
Coraplahatt, 8vo. Sd^ed. Edin. 1823.-^ac*Mm, Hist, and
Cure of Fever, part L ch. 18. p. 394. — 0'^^ld^ On the
Acute and Chronic Dys. of Ireland. Dub. 1899.-6. S.
A«r/An^bnf,DeDyscnterlaBatavi«OrlentaUs,&c.8vo. Ed.
iHiH (lt^eetiom»>}^Fomrmeret Vaid^, lnDict.des Scien.
Mcd.Tol.x.p.31 5. — FirrgiffON,Trans.of Med..Chirurg.Soc.
t. ii. p. 181 — Menion^ in Trans, of Med. and Cblrurg. Soc
ofEJla. vol. il.p. SJA^Pitani, Archives Gfo^r. de MM.
L V. p.S84_7Vo««ffaii,tn Ibid. t.xiiLp.1. (fpA/mnic.)—
D.-nogfr^ in Ibid, pw 444.. et t. xiv. p. 3a (A'pneiMnc.) —
(.oHtpagitfft in Ibid. t. xvii. p. 995. (Endemte.) — L. J.
Schmmmmm, SumuM Observat. Med. ftc. t. i. cap. x.

p. l76.-.#y«Msr. U^v. Med. tiv. 1895, p. 58 L. F^ank,

l>e I'este DTseoterlca,&c. 8vo. Vien. 1890.— CkisAtUm,
Climate and Dis. of Tlrqp. Countries, 8vo. Lond. 1892.
p. it^Bam^U, On Tropical Dyn particularly as It
occun in the East Indies, and on Scorbutic Dys. Ac. 8vo.
Load. 1823. — M. Good, Study of Med. by Cooper, voL ii.
V^ 995.— j0i>«s,in Medico-Chirurg. Review, vo). ill. p. 272.
( Ti/jiAo*d amd imfeetiouM As crew ^ tkip of war.}-^.A.F.
CzMMM, Hlstoira M€d. des Maladies Epidtoimies, &c.
t- iv. p. 90. —J. JaJhuoHj On the Influence of Tropical
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/*• f'tgneit Tnite. Complet de la Dys. et la Duffrh. Ac.

8T0. Paris, 1835 Bentoi^ in Trans, of Edin. Med. and

Chlrurg. Soc. vol. ii. p. 376 EUioUon, In Trans, of

H«d. and CMrarw. Soc. vol. xUi. p. 451 — BaiiUe, Lect.

andObMTV. on M«d. Lond. 1893 J.AnmetUy, Sketches

of tbe most Preval. Diseases of India, Ac. 8vo. 9d edit.
1>^. 1831.—. J. Autteslejff Researches into the
CauMs, Nat. and Treat, of Dis. of India, and of Warm
Climates, Ac. 4to. Lond. 18S8, vol. IL pasimL—Brigki,
Alports of Medical Cases, Ac. 4to. vol. 1. Lond. lSS7,
'• 176 — J. Abererowmbi€, Path, and Pract. Researches on
>b. or the Abdominal Viscera. Ac. 9d edit. Edin. 1830,

£. 236. a uq. — Kregtiig, in Encydopftdisches W5rter-
ichd. Mcdidnlsch. WTssenscb. Ac. b. ix. p. 697. — J.
Bvmpard^ Traits des Mai. des Voles Digestives, Ac. 8vo.
Psm, 1829, p. I2&— Waiih^ in Trans, of Med. and Cbl-
rurg. Society of Edin. vol. iii. p. 612. (On the Scorbutic
t>]ff.mdke Burwwte War.)^ W. Twhtitu, On largeDoses
o( Ipecacnanh* In Dys., in Tk«ns. of Med. and Phys. Soc.
of Calcutta, vol. iv. p. 170. ; andOn the Pathol andTreot.
of the most Important Dis. of Bengal, 8vo. Calcutta.
l«2,p. 1. *^

DYSMENORRHiEA. See Menstruation.
DYSPHAGIA. See Deglutition, Diffi-

tlLT.

DVSPNCEA. See Respiration, &c.

DYSURIA. See Urine, &c.

£AR — Nkrvous Affections of the.

1. Certain diseases of the tar will be here con-
^:dtred; which, althougb sometimes attended by
(iiwrder of hearing ; and often termioating in im-
pavmeot, OF loss of this eeose ; are not oecessarily
accompanied by either. — In the article Hearing,
the affections or this fnnction will be viewed with
Inference to tho lesions producing them, seated in
(HflereDt parts of the organ.
I. \otsES IN tmb Ear. Syn.-t Ttnniria, Sutur-

fus, Semtut, SibUtu, Syrigmm, Bon^mt, Aurium^

\

Avet. Poratfiists iUumria, Good. Dae Ohrcntij-

ficfi, OhrenkUngm, Ger. Tintement, BoiirdoniM-

ment de VOreiUe, Fr. Singing in the Ear.

Classip.— 4. Clau, 2. Order (Good.)^

I. Class, IV. Order (Author),

3. Dbpin.— il ienee of ringing, whittingf or

beating founds in one or both eart, without external

3. i.TheM founds varr in their eftoroders. They
are sometimes sharp, shrill, ringing, and succes-
sive ; occasionally whisaing, roariog, acute, and
continuous; and in other instances, beating or
throbbing. They may be recurrent or intermit-
tent, or devoid even of remissioDS, and be heard
either in one or in both ears. M. Itard — the
highest authority on diseases of the ear — divides
them into, — 1st, The fat$e, or those which have
no existence whatever; and, 2d, the true, or
such as are seated in the interior of the head, or
of the ear, but without being caused by external
sonorous bodies. Tinnitus uurium is most iVe-
quently attended by a slight degree of deafness,
which, in some cases, it produces, and in others
is merely coincident with it. (a) True tinnitus
may proceed from — «. cerebral plethora, con-
gestion, or determination; — 0, the impeded or
obstructed return of blood from parts within the
head ; — and, y, mechanical obstacle to the free
circulation of air in the different compaKments of
the ear; but without completely preventing its
entrance, for then the noise would be replaced by-
simple deafness. When the noises depend upon
the state of the cerebral circulation, they are se-
nerallv beating, heavy, hissing, or whiazmg ; fre-
quently correspond with the pulsation of tbe
carotids, which also is often strong ; and are ar-
rested by pressure of these vessels, {b) False
tinnitus is — «. tdidpafAic, as when a very loud
noise has injured the functions ef the auditory
nerve ; and, 0, symptomatic, when allied to some
nervous affection, often unappreciable in respect
either of its cause or of its nature, or sympathetic
of disorders of some other organs. Thus, this af«
fection often attends indigestion, and hypochon-
driasis, especially in persons devoted to prolonged
and exhausting mental exertions ; sometimes de-
bility or hysteria, particularly in delicate females,
who have suffered from excessive discharges, or
who are addicted to venereal indulgences or ma-
nustapratio; and occasionally disorders of the
prima via, as worms, torpid states of the colon,
6ic. In this variety, the noises are, in some
cases, of a very unusual and even singular kind ;
and in hypochondriacal, nervous, or melancholic
persons, give rise to various fancies or even hallu-
cinations. In the case of a lady, for whom I
was lately consulted at the same time with two
other physicians, and who complained of noises
in the ears after having suffiered in her general
health from too frequent returns of the catemenia,
in excessive quantity, there gradually arose in the
mind of the patient, an idea that persons were
engaged whispering behind her; and ultimately
it took so firm a possession of her mind, that it
amounted to an hallucination, inffuencing both her
judgment and her actions.

4. ii. Noises in the ears are most frequently
earned by iDtemiption to the free circulation of
air through the Eustachian tube. Hence they are
common attendants on catarrhs, and on enlarge-
ment of the glands, &c. in tho" vicinity of the tube ;

ECTHYMA — Acttk — Chrokic — pATHOtoov,

743

f4u/(f, FuroncU Atoniqus, Fr. Erlnenblattem,
Kitgrnde FUehU, Germ, Papulous Scatl,

Classif. — 5. Order, Pustular Eruptions

nViUan). 6. Ciati, Dis. of Excemcnt

runctioDB; 3. Order, Affectiog the Skin

(Good). III. Class, I. Order {Author in

Preface),

1. jywis,'^Antrupiion of large, round, and

diiiinct jfustulei, seated on a hard, elevated, red

base, and terminating in a thick, hard, and dark'

coloured scab, leaving a Uvid tpot or superficial

cicatrix : not contagious,

2, 1. Dbscription. — These pustules are always
discrete, scattered sparingly, and appear succes-
sively in di^erent parts m the body ; and rarely
tensioate in ulceration or tuberculous induration.
I'hey may appear in any part of the body ; but
they are most frequently observed on the limbs,
abdomen, shoulders, breast, and neck — rarely in
the face or scalp. They present modified states,
according to the causes, the age of the patient, and
the seventy of the eruption. These Willan has
arranged mtp Ecthyma Vulgare, £. Infantilis,
£. luridum, and E, Cacheeticum. To these may
be added the Ecthyma Syphiliticum (Frank,
BiETT, Cazenave, Schepel, Todd, &c.), the
sypbiUtic affection sometimes assuming the ecthy-
matous form. M. Rayer has adopted a simpler
and more correct division, viz, into the Acute and
Chronic, which I shall here follow.

3. !• AcvTB Ecthyma ; E, Vulgare, Willan.
— In its simpler and rarer form, ecthyma appears
in some one part of the body, most frequently on
the neck and shoulders, in the form of circum«
scribed reddish elevations, firm to the touch, and
distant from each other. Pus soon is formed at the
summit of these elevations ; and the pustules are
completely developed in three or four days ; their
basis being much inflamed, elevated, large, hard,
and circubr, — ofa bright red in young persons,
and of a livid red in the aged. Their suppurating
summits generally break in one or two days after
their formation ; the purulent matter giving rise to
a brownish or greenish, and very adherent scab.
After one or two weeks, the scabs are detached,
and leave a livid red mark, or occasionally very
superficial cicatrices, of the size of those of small-
pox, but much less deep. The eruption of the
pustales is attended with stinging pains in them ;
sometimes with tumefaction of the adjoining lym-
phatic glands, and is often preceded or accom-
panied by chronic inflammation of the digestive
mucous surface, which may continue after the
healing of the pustules. This variety is seldom
attended by fever,

4* ii. Chronic Ecthyma is much more fre-
quent than the preceding, and always consists of
several successive eruptions on the limbs, neck,
breast, itc, at periods more or less distant. The
pustules present the same characters, and follow
mdividiiaily and independently of each other, the
same course as above descnbed ; some making
their appeaianoe whilst others are suppurating,
or even Dealing. During several months, divers
eruptions are thus formed. Besides the successive
eruptions, the pustules themselves may be more
chronic, their bases assuming large cfimensions,
approaching those of boils, and being tense and
prominent. In these cases, the subjacent cellular
tissue is inflamed, their areolsB becoming hard and
violet-coloured.— EcMjftna luridum of Willan.

Their summits break in eight or ten days, and dis-
charge a little sanious or bloody matter, sometimes
ulcerate slightly, and are covered by hard and
black crusts or scabs, which adhere firmly, and are
surrounded by livid red areolae, which sometimes
remain after the crusts have fallen off; this taking
place in the course of a few weeks ; leaving dark
red spots, or livid cicatrices, after them. If the
scabs are torn away before the period at which they
usually fall off, small indolent ulcere, with callous
borders, giving issue to a sanious fluid, are often
produced. When the pustules remain long sta-
tionary without ulcerating, they are occasionally
followed by violet-coloured tubercles, which may
ultimately suppurate or ulcerate, and more deeply
mark the skin. A symptomatic form of this erup-
tion, which is often tedious and severe, sometimes
attends the cachexia consequent on measles and
other eruptive fevers; but it differs in nothing
from the disease now described, excepting in the
number of thepustules, and the marked constitu-
tional disordelF

5. The successive eruptions characterising tliia
variety are observed chiefly in feeble and ill fed
children — (^Ecthyma Infantile of Willan).-—
When the number of pustules is small, and the suc-
cessive eruptions are distant from each other, there
is generally little or no fever. But when the pus-
tules are numerous, their bases very large and
much inflamed, or if they ulcerate, there is usually

? resent a co-ordinate degree of fever — Ecthyma
^ebrile, E, Cacheeticum, — The febrile symptoms
sometimes precede, and at other times accompany
the severer forms of the eruption, particularly in
unhealthy and aged persons; and are also
attended by gastric and intestinal disorder, — by
anorexia, pam at the epigastrium, irregularity or
constipation of the bowels, a morbid appearance
of the tongue, gums, and fauces, and of the eva-
cuations, headach, pains in the limbs, lassitude,
and by great depression of spirits, — with heat,
stinging, tingling, or itching in the pustules. In
such cases, as well as in other chronic states, this
eruption is often complicated with swellings of
the lymphatic glands, with inflammation of the
conjunctiva, or of the fauces, or of the phaiynx ;
with oedema of the lower extremities; and with
other cutaneous eruptions, especially with rupia
and furunculus. It is also freauently associated
with, or rather symptomatic or, chronic inflam-
mation of the digestive or respiratory mucous
surfaces and biliary derangement. The duration
of chronic ecthyma is always subordinate to the
successive eruptions of pustules, to the habit and
constitution of the patient, and the treatment
employed. It is usually from two to four
months ; but it may be longer or shorter.

6. When syphilitic disease gives rise to erup-
tions with the characters of ecthyma — E, Sy"
philiticwn ; Ptydracia Venerea, J. Frank; Sy^
philide pustuUuse, Phlyiaeie, Biett, Rayer,
&c.; Pustular Venereal Disease, Carmichael
— the pustules are always surrounded by broad,
dark, copper-coloured areolae, and are very
large, indolent, and inclined to ulcerate. The
ulcerations, when the scabs are detached, are
deep, greyish or pale, unhealthy, with abrupt and
violet-coloured edges; but they seldom extend,
the scabs gradually reforming over them, and
being successively detached, until they heal
under approprtate treatment, leaving permanent,

3B 4

ECZEMA — Patholooy.

^1

silways suspect disorder of the digestive and
milating fuoctions ; and if there be> little or no
fever, have recourse to deotistruent alteratives, as
I'i.UMMER's pill, with soap, or taraxacuni, at
bight; a stomachic purgative every second or
third morning, and the decoction of sarsaparilla ;
or mild tonic infusions with soda or potash, in the
course of the day. If we suspect congestion of
the liver, or find tenderness of the stomach on
pressure, small local depletions should be em-
ployed, and repeated according to circumstances,
whilst the above depurating and mildly tonic re-
medies are continued. Mercurials should not be
given ia la^e doses. Flvmmer's pill, blue pill, or
bydrarg. cum creta, with taraxacum, inspissated
ox-gall, guaiacum, and sarsaparilla, are the most
bcQcficial. The occasional exhibition of purg-
atives, or the association of them with tonics, is
also necessary, especially if the stools be morbid,
and the abdominal viscera require to be excited.
In soch cases, a prolonged course of tonic or sto-
machic purgatives is often necessary.

12. e. When the cachectic state is complicated
with some degree of febrile action ($ 6.), the
mild mercurials now particularised should be con-
joioed with James's or Dover's powder ; and sa-
line diaphoretics exhibited at short intervals ; the
morbid secretions and faecal accumulations being
evacuated from time to time, by cooling purg-
atives. If there be tenderness at the epigastrium,
a few leeches applied there will materially assist
these remedies. After these, the infusion or de-
coction of cinchona with liquor ammonis acetatis,
or with the pyroligneous acid, or with nitrate of
potash and carbonate of soda; a course of
tonic infusions, with alkalies and the extract of
taraxacum ; tepid or warm bathing ; the mi-
neral acids with anodynes ; and the other means
particularised in the last paragraph ; may severally
be exhibited. Having removed fever, and eva-
coated morbid matters, more active tonics, as the
quinine in the compound infusion of roses, with
tinctura opii; the decoctum cinchonas with the
mineral acids, or with camphor and ammonia ;
chalybeate preparations, sarsaparilla and guaia-
curo, the balsams and terebinlhinates with maof-
oesia, common tar made into pills with this ab-
^rbent, the bark of the madar root, &c., may be
prescribed.

13. d. The syphylHic form of ecthyma should
he treated in the manner described in the article
Acne (§ 30.). Mr. Carmichaei. does not con-
sider this eruption oa being truly syphilitic, and
therefore confides chiefly in sarsaparilla with an-
timoniab and guaiacum. In a case of this form
of syphilitic eruption, lately attended by my
friend Mr. C. Hctciixnson and myself, bichloride
of mercury, given in sarsaparilla, was required
for its cure, milder means not having succeeded.
Or. A. T. TuoMSON advises this preparation in
oiiottte doses to be given in the decoction of elm-
bark, or in the emulsion of bitter almonds. In
the cases of infiants, some French physicians re-
commend the milk of a goat on which mercurial
ointment has been rubbed. When the child is at
the breast, the nurse should enter upon a gentle
course of the bichloride in the decoction of sar-
saparilla, or in almond emulsion.

14. e. External mAins are sometimes required
to remove the irritation attending the eruption,
>ad to heal such m ulcente. With these inten-

tions, tepid alkaline baths ; fomentations with a de-
coction of poppy-heads; a weak solution of the
chlorinated lime or soda, especially when there is
ulceration ; or solutions of chlorine, or of sulphate
of zinc with hydrocyanic acid, or of the nitro-
hydrocbloric acids, or of nitrate of silver, &c. ;
may severally be employed.* Dr. A.T. Thouson
recommends the following : —

No. 809. Be Plambi AoeUtii 3 m. ; Add! Hydrocytnici
3 iij. ; Unguent! CeUcel S Uj. M. Flat Unguentum
psrtibui cutis nudti applicandum.

15./. The diet in the acute form ought to
be bland and farinaceous, whey and emollient
fluids, or water with a little vinegar, being the
chief beverages. — In the chronic states, light
and nourishing food, if there be no fever, or
after fever is removed, is always requisite. In
the more cachectic cases, a small quantity of
wine should also be allowed. The patient will
always derive benefit from the internal use of tar-
water, which may be taken as the common drink
in these cases. This medicine, which was for-
merly so inordinately praised, and, owing to this
circumstance, now so undeservedly neglected, is
most serviceable in this and many other chronic
affections of the skin. In addition to these, fre-
quent tepid and warm baths, and subsequently
salt-water bathing, exercise in the open air, change
of air, mental recreation, warm and suitable
clothing ; regularity in eating, drinking, and sleep-
ing ; early rising, and a regular state of the bowels,
are important adjuvants.

BiBLioo. AND Rbpkb — Olius, lib. T. Cap. S8.—Patfhu
JBgineta, 1. Ir. cap. 9.—0rfbasius, Synopt. 1. vli. c. 37. —

Avicetma, 1. iv. fen. iii. t i. c. i., et fen. ril. t. Hi. c.i

Hf^^nanHt'. Inititut. Med. 1. iii. cap. 15i. — D. Turner,
Treat, of Dii. incident to the Skin, 5th edit. Lond. 1736.
p. l]8.—Lorr«, Tract, de Morli. Cutaneif, 4to. 1777,
p. S50.— J. P. TroHi, Dc Cur. Horn. Morb. vol. ir. p. 180.
—J, Franks Praxeoc Hed. Univ. Pnecepta, partis primae
ToL secund. p. 432. — Willan, On Ecthrma, 4to — R,
, Euay on!Ven. Dis. confounded wil

Carmichael

onJVen. Dis. confounded with Syphilis,

part I Dub. 1814. ; and on Venereal Diseases, 18i5. —
W. C. Dendfft On the Cutaneous Dis. incidental to Child,
hood, 8to. Lond. 1827, p. 134. -> T. Bateman, Pract.
Synop. of Cutaneous Dis. 7th ed. bv Thornton,^. 257. —
Mfwsont North American Med. and Surg. Jour. 1826.--
Plumbe, Diseases of the Skin, 8d edit p. 440. ~ C. E.
AsteiiH, Essai sur TEcthynia. Paris, 18?7. — P. Rayer,
Trait^ Thtorique et Pratique des Maladies de la Peau,
vol. i. p. 430. — Camenave et Sekedel, Abrte6 Prat des
Mai. de la Peau. 8va Par. 1838, p. 187 — J. Paget, On
Clasflflcation as applied to Dis. of the Skin, &c. 8vo.
Edtn. 1833.

ECZEMA. Syn. — Ectemata (from ix^iot, I

effervesce). Eetesmata, Blancard. Hidroa,

Sauvages, Vogel. Ecphlytis Eetema, Good.

Cytisfna Eczema, Young. Hydrargyria, Alley,

Mercurial Lepra, Mercurial Disease, Moriarty

and Mathias. Hit%btdtterchen, Germ. Dartre

Squameuse humide. Dartre Vive, Hydrargyrie,

Fr. Heat Eruption,

Classif. — 6. Order, Vesicular Eruptions

(WiUan). 1. Group, Eciemata (i4/i6erx).

6. Class, 3. Order {Good), III. Class,

1. OnuEn (Author).

1. Defin. — An eruption rf minute vesicles,
uneontagious, crowded together, and terminating
in the absorption of the finid they contain, or in
superficial ercoriations, with more or less serous
exudation, concreting into thinjiakes or crusts.

2. I. Desckiption. — This eruption rnay be
confined to a single part of the body, or it may
attack several parts, or even the whole surface.
It most frequently appears in the axilla, the in-
sides of the thighs, the groins, hams, &c. When
it IB more general, it often extends over the backs

948

ECZEMA — Pbocnosu — Causes^ Tbeatmekt.

confined . The pustules of impetigo have a larger
base, and contain a thicker fluid, than this variety
of eczema, which is always vesicular at its com-
mencement, its secretion never consisting of true
pus. Impetigo also gives rise to thicker, rougher,
and more unequal crusts than it ; and is never
surrounded by the vesicles of eczema rubrum, as
the £. impetiginodes always is. — (i. Eczema, in
its chronic state, may be confounded with Ucken
agriiu ; but the crusts'formed by the latter are not
Bo large, nor so thin, as the scales of the former ;
and when they fall off, they leave not a red,
smooth, and shining surface ; but a certain rough-
ness, owing to the small prominent papulas, which
are generally evident to the eye, ana always to
the touch. Also, when lichen biecomes dry and
scaly, the* skin is thicker, and more rugose, than
in eczema ; and there are commonly some papulae
scattered about, which, by their peculiar charac-
ters, further distinguish lichen. — e. The vesicles
of the early stages, and their presence around the
patches of excoriation in the latter periods, as
well as the less dry and less friable scales of
chronic eczema, will generally distinguish it from
psoriasis ; in which also the skin is more elevated
or thickened, and more fissured in parts not in-
fluenced by the motions of the joints, than in any
of the states of chronic eczema.

14. III. Prognosis. — In its acute form, this
affection is generally of no great importance :
but in many of its chronic states it often becomes
most distressing ; and sometimes even embitters
exbtence; opposing, for many months, every
known means of cure ; and often returning after
having been apparently altogether removed.
AVhen occasionea by mercury, especially if this
mineral have been employed m large quantity, it
may assume, as shown above, a most dangerous
form ; it therefore requires a guarded, and in some
instances an unfavourable, prognosis, particularly
when pectoral and nervous symptoms are present.

15. IV. Causes. — a. Eczema is most common
in adults ; is somewhat more frequent in females
than in males ; and oftener occurs in spring' and
summer, than in winter. Susceptibility of frame
seems to dispose to it ; and there appears to be a
predisposition in some constitutions, generally
connected with vascular plethora, favouring its
passage into a severe and chronic form. — b. It is
most frequently excited b^r solar or artificial beat ;
by the contact of either mineral, vegetable, or ani-
mal irritants, — especially the oxides of the
metals ; by -mineral or other powders ; by lime,
alkalies, dust, and want of cleanliness ; by sugar,
&c. I have seen it produced on theinsides of the
thighs and parts adjoming, by the contact of the
leucorrhoeal discharge, and l}y the catamenial
fluid. Draughts of cold water when the body is
overheated, acid, acid fruits, pickles, and shell*
fish will also occasion it, especially in some con-
stitutions. Blisters and plasters, and rancid oils
or grease applied to the surface, are also among
its usual causes. It sometimes, however, appears
without any obvious reason ; at other times, it
seems attributable to indigestible and unwhole-
some food, to spirituous liquors and similar errors
in diet ; it being in such cases most obstinate. It
is not contagious : but M. Binr supposes that
it may be communicated in some cases, as when
the exudation continues in contact wiih a healthy
surface. He states, that he has seen it trantmitSed

from, and to the oi^gans of generttun, by leiia.
intercourse. l*he tpec^eform is alwiji ca«r>
by the use of mercurials — internal or utrnv
— but most frequently the latter; aod by ei^
sure to cold during their influence. >Vbe(b€r ?
not the eruption, in such cases, nay be in «c<%t
measure produced by a change in the fanv nW
stance used in oxidizing the metal, is tctj dj&.i;'
to determine.

16. V. Treatment. — The remedies recw-
mended by Willan and Batemak, viz. ha%'.
tonics and acids, I have found more geoenl!* >

i'urious than beneficial. The treatmcat dad".
>y BiETT in his clinical lectures at the " i/«f x
Saint Louif" and by his pupils Rayce, Cjil«*
and ScnEDKL, in their works, is dccidedl; x:-r
rational and successful.— J. The dighttr fn-r
of the acute disease are readily nmoftd bj sizr ;
refrigerants and emoUient diluents, wilb c«i: .
aperients, and tepid bathing. Bat wIkb '>
eruption is more extended, is aceofflpu*«i >
smarting, or assumes the form of the £nr^«
rubrum or £. impetiginodes, tepid alkaUv or » -
phuretted 6alAf — madeby adding froo L^r :
eight ounces of the carbonate of soda or of pD»^
to the water of a whole bath, for aa adc"; ^
four ounces of the sulpharet of potasNvm ;- •*
antiphlogistic regimen ; general biotd^tri'': *
young plethoric or robust persons ; locul kti-^iri
in the vicinity of the excoriatioiii ; sod a^
doses of the wtrate of poiaeh, vrith sade, in «•
laginous diluents; wili(be required ta td^»
the above more gentle means. Emoliint .-
toothing applications should abo be renrted tc. •
agree with Mr. Plvkbx, in avoiding sU ^' -
applications; and with Mr.Birrr, in Ibrbr
the use of sulphur, or repeated doses of otrr.t
in this state of the disease ; an aotiphlogifth: «*
soothing treatment being in eveiy mftti >
most appropriate. I have prescribed with ek
benefit the biborate of soda, with or witJKH.t lU
nitrate of potash, in emollients in the scale i«'^
and after the bowels have been evacastcii, i
nitrate of toda in similar vehicles. lo all <^*
the excittng causes should be ascertaiocd «■! '*-
moved.

17. B. In the ehnmie »t&tes of this ere;f^>.
the antiphlogistic treatment recoomeoded il<*
should be employed, wh«rB it has bero £'"
neglected, or insufficiently tried. P^^f*'
also ought to be frequently resorted to, vbrn *•
tongue is loaded ,aDd the evacuatioBf utMi^p
and repeated daily until they assooie a ba' '
hue. for this pui'pose, a roercurbl prrps^*-
may be exhibited at night, and a pcrp*'
draught in the rooming. If there be nr*
asthenia and a cachectic state of the fnoif. '*^
purgative should be of a tonic and fti«*^-'
kind ; tlie bark of the ma'dar root, or tm^f '*.
lumi, with the nitrate of potash, or v^^
mineral acids, being taken through the ^*
but not until mercurial medidoes bs>< ^
relinquished. Dr. Eluotsoh adviKs, ia »
tion to bleeding and a low diet, the tf^i' "
of mercury until the mouth is afleded; l«t ^"
latter part of this practice does not a|^ *
my experience ; the former I have sl«»v
rected. It is chiefly when the eicofisf^f-
extensive, and the exudation copioas ^ *
depletions have been employed, that oeM «•
to be indic«tcd| mortnd §ccnioom harns "^

tlLEPilAi^TlA •«> thAdifom,

m

tinouB InaUer ; flf it is hAfdeded, pre^ntllig an
iDterme^Ate aUto belweea a laidaoeoua and a
acirrhouB strttctufe, and la more and more denae
aa it approachea the skin. The muscles under-
neath are pale, thiuj or softened* The Ijmphatio
glands and v^Mels present e? idence of disease, but
not uniformly ; and one or more of the principal
veins are generally obatnicted or obliterated, aa
observed in the cases inspected by MM. Bouxl-
LAUD and Gaios.

6. ii. Nmture, Afe. — The struetural alterations
to which elephantiasis is strictly applicable, are
evidently remote effects of various states of mor-
bid action, which have either repeatedly relumed,
or have long continued in the diseased part From
the history of cases, and the changes observed on
dissection, the akin, subjacent cellular tissue, the
absorbents, and the veins, ar6 evidently more or
less implicated ; but it is very difficult to ascertftin
which of these is primarily or chiefly affected.
The principal characteristics of elephantiasis
have manifestly resulted, in several matances,
from disease of the absorbents, or veins, or both.
Tbey have also followed, within the scope of my
own observation, a chronic affection of the skin,
which has extended to the subjacent tissues,
and, sooner or later, to either the veins or the
absorbents, or perhaps to both. I was .lately
consulted by a female of middle age, who,
daring convalescence from a dangerous attack of
continued fever, more than teti years previously,
experienced hard and painful swelling of one of
the lower extremities, depending on disease of the
absorbents or veins, or both, according to the ac-
count she gave. When I saw her, the limb,
below the knee, was very hard,. and enormously
swollen ; and had all the characters of elephant
leg ; the akin being irregular, scabrous, livio, and
fi.«sured. I directed bandages, and the internal
use of iodine ; but after two or three visits, I saw
no more of her, and consequently know nothing
of the result. Some time previously, a similar
ca^e, as respects its origin and history, although
not ao severe, came before me. It had been of
several years' duration ; and had increased gradu-
ally after the acute attack in which it originated.
The limb was hard, dark red, and livid in parts,
somewhat irregular, slightly scaly, and the veins
above the tumefied part enlarged. The affection
of the skin was here consecutive. Considerable
advantage was procured from bandaging, and the
internal use of iodine ; but the enlargement is not
eoUrely removed. The patient is still under my
occasional observation. More than one of the
cases I saw in Africa, seemed, on the other hand,
to originate in a very manifest alteration of the
cataneous surface.

7. M« Ala an considers elephantiasis essenti-
ally to depend upon inflammation of the cutane-
ous and sub-cutaneous absorbing vessels and
Ijmphatics. Dr. Musgrave also views it, as it
occurs in the West Indies, as a consequence of
inflaxDmation of the lymphatics, the inflammation
being accampanied with pungent heat, and with
redness of toe skin, and characterised by great
tendency to metastasis. He states, that it usually
betrays itself in the scrotum, the mammie, or in
some part of the extremities, most frequently about
the ancle, or high up the thish ; and, although at
fir^t circumscribed, it often diffuses itself over the
limb. When the glands are n6t involve, painful

and induntted chords can b« traded to the nearest
cluster ; but, whatever may be its original seat,
the patient is never secure, while the constitutional
disturbance subsists, from a sudden retrocession to
aoine vital organ. He has seen it translated from
the scrotum to the head ; from thentfe, ftfler a few
hours, descend rapidly to the abdomen; again
migrate to the chest ; and retufn, perhaps, to the
encephalon, and prove fatal there ; o^ resume its
more harmless situation, and there run its course.
While occupying an internal viscus, it gives rise
to the usual symptoms of acute inflammation.
Dr. Hillary and Dr. Mvsoravk view the local
affection as a conseauenoe of fever, which com-
monly precedes it for two days. Dr. Hekdy,
however, contends that the fever is symptomatic
of the inflammation of the lymphatic vessels and
glands. During the acute stage of the disease,
either, perhaps, may precede the other ; but it la
most conformable with just views in pathology, to
consider the local change as a consequence of the
constitutional disbrder ; the advanced or chronic
state being the result of repeated attacks of in-
flammation of the lymphatics or veins, and of the
interments, generally existing together, but often
originating in, and continuing more or less con-
fined to, either.

8. Inferences, — According to the descriptions
furnished by Townb, Hillary, Hknoy, Mus-
ORAVE, BouiLLAuo, and Gaide, and to my own
observations, this disease should be viewed — • (a)
as consisting of certain acute, as well as far ad-
vanced or chronic, states, generally connected with
a bad habit of body, and each requiring an appro-
priate method of cure; and, (6^ as arising — a.
most frequently from inflammation of the Ivmpha-
tic system and skin, parti(iularly in warm climates ;
0. from inflammation and obstruction of the veins,
in some instances, with irritation of the skin in
various grades at an advanced period ; and y,
from the extension of inflammation from the skin
to the veins or lymphatics, in other cases. The
tumefaction and hardness are necessary conse-
quences of thickening of the cutis vera and sub-
cuianeous tissue, with deposition of inspissated
lymph in the areole of the latter, whether aririug
from chronic inflammation of these structures or
from inflammation and obstruction of the lym-
phatics or veinsi or from both these species of
alteration.

9. IV. a. The Diagnosis, of elephantiasis id
very easy in the chronic and far advanced state.
In the earlier stages, when commencing in either
of the parts noticed above, it should be viewed as
inflammation of that part, which, in countries
where the disease is endemic, may be followed, if
not properly treated, by the organic changes con-
stituting its fully formed condition. When this
takes place, the great tumefaction and hardness,
and especially the circumstance of pressure not
being followed by pitting, with the alterations
already described ($ 4.), will sufficiently mark
the nature of the disease. — b. The Prognosis is
unfavourable, as respects the removal of the dis-
ease, when it is fully formed, although relief may
be obtained, and persons may live very many
years with it. But it tonds generally to shorten
life, and always to render it much less comfortable.
When it is not far advanced, it may be nearly or
altogether removed by treatment. The result,
however, will very much depeiid upon th«f

760

ENDEMIC INFLUENCES AND DISEASES.

ation ; others may begin with great excitemeat,
rapidly termioatiDg io exhausUon and depravation
of the circulating and secreted fluids ; some pre-
sent great depression from the beginning, the
powers of life never rallying throughout, or vary
imperfectly, with an unnatural state of all the
secretions and soft solids, and a tendency to dis-
solution of their cohesion, which rapidly advances,
especially in warm countries, as soon as respir-
ation ceases. In certain circumstances, particu-
larly when great vicis^tudes of temperature and
weather cooperate with the strictly endemic causes,
or with improper living, impure water, &tc^ dy-
sentery becomes as prevalent as fever, or entirely
usurps its place ; or the fever assumes a dysen-
teric character, or passes completely into dysen-
tery ; this latter malady producing even a greater
rate of mortality than fever itself. ( See art. D vd*

ENTER Y.)

13. B, Whilst rich soils, and warm, low, moist,
and marshy situations, are productive of disease
affecting chiefly the circulating and secreted fluids,
and the abdominal viscera, by lowering vital
power, especially as manifested in the nervous
systems ; elevated, cool, or temperate and dry dis-
tricts favour the developemeut of vital energy,
especially as expressed in the nervous, muscular,
and circulating systems, and in the thoracic vis-
cera ; and produce diseases of a phlogistic cha-
racter, as sthenic inflammations of the lungs and
circulating organs, of the membranes of the brain,
and of the other serous and fibrous structures,
haemorrhages, rheumatism, and fevers of an in-
flammatory type. — ^ These diseases, however, al-
though the most prevalent, can scarcely be said
to be endemic in these latter localities, they being
much less frequent than the maladies of the former
situations. It should, however, be recollected
that the respective endemic influences of districts
are not so deleteriously exerted on the native in-
habitants, as upon those who have lately removed
to them ; and that, though they may affect (he
constitutions of the former class, and give rise to
certain diseases in preference to others, yet those
diseases are not so acute or violent in them, as in
the latter. This circumstance is well illustrated
by what is constantly observed in warm countries
productive of terrestrial emanations. There, the
native inhabitants are either scarcely affected by
them, or are liable only to agues, bowel com-
plaints, enlaigements of tlie spleen, or slight ail-
ments referrible to the large secretiug organs,
excepting on occasions of these exhalations be-
coming more concentrated or energetic than usual.
But persons who have removed thither from healthy
localities, in cold or temperate climates, sooner or
later are seized by feyer, generally of a remittent,
or continued type, often assuming an inflamma-
tory or malignant form, and frequently associated
with violent local determinations; and it is not
until ailer the frame has been assimilated to the
climate by such attacks — usually callec^ the sea-
soning fever — that agues, dysentery, and the
milder forms of disease, appear in such persons.
On the other hand, the inhabitants of low or mias-
mutous situations, who have removed to elevated
and mountainous districts, are much more liable
to diseases of the lungs, to rheumatism, and to
inflammations of a sub-acute or chronic form,
than the natives of these latter places ; and if the
rhange at the same time involves a change from

a high to a low temperature, the liability to pec*
torai maladies is still further iocreaaed.

14. C. When persons have migrated to a couoUj
abounding with the sources of eod»nie djseft*^,
a period of longer or shorter dunAioii, aeoonb^
to the activity and conoentratioii of the nMhria,
and the predisposition *of the iodividaal, asuliy
elapses before they are attacked by these maladjcs.
In Home, and other malaria districts in tht fodtk
of Europe, as well as in many of those in Uk
eastern and western hemispberes, where the u*
halations are not very active, several mootb.or
even a year or- two, pass before the anacck-
mated are seized by fever, unless the eiposan
and predtsposiuon (see Disease — Pr«^M«f
Catisei of) be great« Whilst in many sitsatwas
where the emanations are more conceotratcd. or
consist of an admixture of tbose given off buh
by v^etable and by animal matters iaanteof
decomposition, particularly in warm cbmalM uri
seasons, the 6rst exposure to them is often pri^
ductive of the most active forms of fever, ini a
a very short time after the exposure ocean. Tk»
is commonly observed in respect of yoan^ as-
seasoned sailors and soldiers, who, eonm^ irm
a pure air, in a state of high psedispositioo, ut
often subjected to these emanations in their bm^
active states. Persons trnving in warm mm^
matous districts, from temperate and beatihr
places, are affected with a celerity and tetern
generally in proportion to the fulness ot ibtir
vascular systems, to the rigidity of their fibits.
and to their nearness to the epoch of early aav
hood ; but various exceptions to this occur, aiBas;
out of the habits of individuals, the sascepU!!-
lity of their nervous systems, the extent of ti«7
exposures, and the states of their miadi uJ
morel emotions.

15. D. Although the white races of the spect
will live to an advanced age in warm dacr-^
productive of endemic disease, especially if thrr
have removed thither after the coostitutioD ka»
been fully developed ; yet their offspring will ««7
seldom reach maturity, or survive the epoch »•
childhood,' if they continue to reside w *9^
situations; or, if thev arrive at manhood, thcf
will very rarely reach an advanced age. I^r.
Jackson states, that white persons, bom vA
residing in the more unhealthy districts of Lam:
Georgia, seldom live to forty ; and that, st ?*•
tersburgh, in Virginia, they rarely reach tuten-
five. He saw, at this latter place, a pciMA «tu
was only twenty-one ; and although he had artcr
been confined by severe sickness, yet he «i»
weak and decrepit: so injuriously does tAinje
influence operate upon the constitotMNis of ^
white variety, even when it fail* of indacix
acute disease. Bauca records similsr iastaaM
among the white natives of the banks of the iNiir
in Abyssinia ; and other illustretiooshave bees ob-
served by myself in some parts of Africa. ChiMra
born of European parents in India reqaire lo be «Bt
to Europe to acquire due maturity and strea^th,
for they very seldom arrive at puberty in Ioda« I^
case, however, is different when one of the panst*
belongs to the indigenous inhabitants; b«t tbr»
can be no doubt, tlut, were a ooloay of the «(*t^
races conveyed to the low miasmaioas iocsb^^
within the tropics or in more levpertts n^^
liable to very hot seasons, it would, in a ven ^«
geaaratioas, become cttinct, if inlernaimgv «^

ENDEMIC INFLUENCES AND DISEASES.

761

Bot take place with the natives, or if it were not
supplied from time to fime from more salubrious
places. Whilst a change to a more* unhealthy
climate is best endured by those who have arrived
at fall maturity, change to an equally or a more
healthy climate ia especially beneBcial to very
voung persons, unless in the case of removal of
individuals belonging to the dark races to a tem-
perate country, from the hot climate in whieh they
are indigenous.

16. £. Besides fevers, dysentery, and the slow
blight of the constitutional powers, the localities
above described induce, in the white races, dis-
eases of the spleen, liver, and pancreas, both in
unassociated forms, and as complications with
fevers and dysentery. Among their less obvious
effects may be enumerated scurvy, and foul ulcers
of the lower extremities. The great prevalence
and obstinacy of these latter in miasmatous situ-
ations have not been sufficiently attended to, al-
though Baglivi had noticed the circumstance in
Rome, and Clcobobn in Minorca. Indeed, in
all low places productive of malaria, injuries
and sores of the legs heal with great difficulty,
whilst those of the head recover rapidly. Hippo-
c RATES and Ceuvs seem to have been aware of
this fact. They both noti^ the frequent association
of indolent ulcers of the legs with enlai^ement of
the spleen, — ^whichis remarkably common among
the cultivators of rice-grounds, both in the south
of Earope, and in other quarters of the globe.

17. There are some situations, which do not
fall within the description given above, produc-
tive of diseases almost proper to them, or which
are comparatively rare elsiewhere ; as crrtinum,
bronchoeeU, plica or matted hair, Guinea tu7rm,
tarantvlitm, pellagra, ^c. These depend in great
measure on the water, in conjunction with modes
of living, and various other circumstances. —
(a) Crelinitm (see this article) is endemic in the
deep ill- ventilated valleys of the Alps and Py-
renees, in Carinthiaand the Vallais, in the moun-
tainous parts of Tartary and China, in some parts
of the south of France, and in Salzbourg. It
seems not to have been unknown in this country,
two or three centuries ago, in the situations where
bronchocele and rickets — very nearly allied
diseases — have continued to be common. — (6)
Brunchocele is very frequMit in the situations
DOW particularised, especially in the valleys of
the Alps, where it was equally prevalent in the
times of Pliny and Juvenal ; in Derbyshire ;
in Behar, and some other mountainous districts of
northern India ; in similar situations in Java (S.
Raitles) and Sumatra ; in Bambara, in the
coarse of the Niger (M. Park) ; and in Mexico,
and some other parts of South America (Hum-
boldt). It is most prevalent in females after pu-
berty ; and is, in my opinion, often connected with
interrupted or irregular catamenia. — (c) Plica, or
matted hair, is not noticed by the ancients, and it
is doubtful when it first appeared • — probably
some time between the thirteenth and fifteenth
centuries. It is most common in Poland and
Lithuania ; bnt it is met with occasionally in
Transylvania, Hungary, the southern parts of
Roasia and Tartary, and more rarely in Switzer-
land, Belgium, and Prussia : but it is not so fre-
quent, even in Poland, as it was a century ago. It
proceeds chieBy from want of cleanliness, especi-
ally in respect of the hair, and to wearing too warm

coverings on the head (KERCxiiOPFSy Larry, Ali-
BERT, &c.). There appears to be frequently an
hereditary predisposition to it ; but the cause now
assi^ed is evidently the most influential in pro-
ducmg it, assisted by the use of unwholesome
water (Vicat). It b most common amongst the
poorest classes. According to Dr. L. Kerck-
HOFFs (Med. Trans, of Coll, of Phys, vol. vi.
p. 27.), it is not infectious (see art. Hair). —
(d) Tarantulism (see Chorea, § 18.) was for-
merly endemic in Apulia, but is now by no means
so frequent (Laurent and Merat). This species
of irregular convulsive or hysterical affection, in
which the moral emotions seem more disordered
than the physical powers, was imputed by Sir T.
Browne, Boyle, Kircher, Baglivi, Mead,
and Sauvaoes, entirely to the bite of the taran-
tula spider, which probably is an exciting cause,
in certain states of the nervous system, although
neither the only nor the chief cause. Cornelio,
Serao, and Cirillo, physicians in Naples, and
M. NoLLET, have taken juster views of its origin ;
and refer it rather to the state of the nervous
system, in connection with the moral emotions,
than to this insect. Indeed, it is extremely pro-
bable that it is often feigned, or frequendy occurs,
without any such accident as that to which it is
so commonly imputed ; for very nervous and fan-
ciful females may persuade themselves that they
are stung by this insect, in order to account for
their ailments, conformably with the vulgar opi-
nion, and may thereby induce that form of irre-
gular chorea or hysterical affection to which the
term tarantulism or tarantismus has been applied.
M. Merat (Diet, det Sciences Mid. t. liv. p. 345.)
infers that the inhabitants of Apulia, owing to
situation and climate, are liable to nervous and
spasmodic affections ; and that, among others,
this is apt to supervene, — from their ardent and
choleric dispositions, and their love of dancing
and music. In Calabria and the Apennines, where
chorea and convulsive affections are common,
tarantulism also occurs (Ferrus). — {e) The
Guinea warm {Dracuvculus), the long thin
worm which is sometimes found in the inhabitants
of certain localities, generally under the integu-
ments, and so named from the circumstance of its
having been first accurately ob<;erved in the natives
of Guinea, is now seen m other countries. It
appears from Plutarch to have been met with
in the inhabitants near the Red Sea. It occors
among the negroes in most of the low manthv
situations of intertropical Africa (Welch, Bruck,
Park, &c.) ; in the slaves, and sometimes in the
whites, in the West India islands (Chisholm,
Thomas, &c.) ; in Bombay, and along a great
part of that coast, as well as in some other mari-
time districts of India (M'Grigor, Milne, If.
Scott, Grant, &c.) ; and in the islands of the
Persian Gulf ( K^mpper). — It is observed chieHy
during the months of November, December, Jan-
uary, and February, in both the East and West
Indies. M. Dubois found, in parts of the Car-
natic and Madura, more than one half of the
inhabitants of some villages affected by it. Dr.
Chisiiolm (Edin. Med. and Snrg. Journ, vol. xi,
p. 145.), Dr. Smyttam {Trans, of Med, and
Phys, Soe, of Calcutta, vol. i. p. 179.), Dr.
Anderson, and several others, state that it is met
with chiefly in those who use wells made in argil-
laceous soils, impregnated ^ith salt or percolated

762

ENDEMIC DISEASES — Pretention of.

by sea water. M. Dubois adds, that the inha-
bitants of villages who take water from one well
are subject to this worm, whilst those at the dis-
tance of only half a mile, who resort to a different
well, are not affected by it. Other writers, in
addition to those named above, agree in ascribing
it to brackish waters containing the ova or embryo
of this worm. The circumstance of this animal
having been rarely found out of the human body
has induced Dr. Milne (£<iifi. Afed. and Surg,
Joum, No. 106. p. 1 12.) to suppose that the sub-
stance taken for it has been a mseased lymphatic
vessel ; but the evidence of its independent ezisU
ence furnished by Dr. H. Scott {Med. Chir. Rtv,
vol. iv. p. 182.) and Dr. R. Grant (Edtii. Med,
and Surg, J cum. No. 106. p. 114.) has set the
matter at rest. As to the manner in which this
worm becomes lodged in the sub-cutaneous cel-
lular tissue, much doubt exists. It must either
insinuate itself through the skin from without, or
its ova escape the action of the alimentary juices,
and pass along with the chyle into the circulation,
and thence into the cellular tissue, where, having
attained a certain growth, it excites the irritation

f>recediog its expulsion. But, if it pass by this
atter route, how is it that it is never found in the
cellular or other parts of internal organs, where
it may be expected to produce dangerous, if not
itaul, effects 1

18. F, In low, moist, and cold districts, liable to
frequent vicissitudes of weather and temperature,
catarrhal and rheumatic affections, croup, bron-
chitis, scrofula, rickets, and tubercular diseases,
are more or less prevalent ; and in those similarly
situated on the sea-coast, where the inhabitants live
chiefly on fish — particularly on stale or dried fish,
or the grey kinds-— chronic eruptions on the skin
are common. In large towns and cities, where a
confined and impure air co-operate with the anxie-
ties of business, the exhaustion of mental exer-
tion or of dissipation, the luxuries of refinement,
the conflict of the paasions, and the excitement
of the different moral emotions, disorders of the
nervous system, frequently implicating the mani-
festations of mind, are more common than in the
country, and much more so than in imperfectly
civilised states of society. — My limits will admit
only of a simple reference to other endemic dis-
eases -» to the prevalence of trismus and tetanus
in the West Indies; of elephantiasis in these
blands, and in the East, as well as in Africa ; of
the yaws in the n^o race ; of the pellagra in
Lombardy and the Milanese ; of the beriberi in the
East Indies ; of hepatic colic (see Colic, $ 20.)
in Spain and the West Indies \ and of ophthalmia
in Egypt. Some of these may be imputed to
obvious physical causes; as the ophthalmia of
Egypt to the reflected heat, and the dust in the
air ; or pellagra, and some cutaneous diseases, to
dirty habits and unwholesome food : but there are
others that cannot be explained without ascribing
them to the co-operation of a variety of circum-
stances, as shown in the articles on these maladies.
In illustration of the influence of occupations in
producing a certain train of morbid actions in
those similarly circumstanced, it may be stated,
that amongst the children and young persons
employed in cotton mills, more especially in
Manchester, chorea, which is comparatively a
rare disease, is one of the most common ; scrofula,
tubercles, and debility in all its states, being

likewise very prevalent ; and that, wk. the
what older work-people, ehrooie ifanuastHD,
in all ita forms, is remarkably freqMat. TV
protracted periods of occnpatioin in a veiy ko(
and moist air, and generally in a
ture ; the sodden exposnie to a eoU
on every occaaonof leaving the fiutory ; tiMi tk
want of due sleep, of exercise in the epes »,
and often of suffictent Doariakment, indnwinrtiillj
of various moral causes ; sufficiently ei^laia ik
endemic prevalence of tbeM diieasti in the lv|«
manufiicturiiig town now mcntioncd. (See Ass
ANO Employmbnts — - M Consn af Bmm.)

19. in. Of the Mode if Opemtim ef
Influence en the Kconomif, — ^Tbc cndeai
productive ef the more acvte and mafifasat ^
eases were supposed by Cuixsn to be dim •>
datives, not merely lowering vital power, kit il»
inducing spasm of the extreme capiUans; ad
that, if the vital energy of the eyslem ii ast ct>
tirriy overpowered by them, reaclioa sapervcae^a
order to overcome this spasi, and thus krsr b^
comes developed. Other pathotogisiasap^drt
marsh effluvium acts as a atimiuaat
and that the debility which it obvioady
is either consecutive, or a atate of
Neither of these hypotheses accounts ht the wWi
phenomena which diseases, arising fraia thucsM.
evince throughout their coone, allhsagk «kf
explains many of their symptoms. That weiam
depresses vital power, eontaminates the circibi'
ing and the secreted fluids, and weakeas iIk taI
affinity or cohesion of the soft aolids» ii shows b;
its more immediate, as well as by its eemeeabn.
effects upon the Uving body, and by ihc bet if
dead animal matter running fisster into petR^
tion in situations where it aboonds. In MfW
operation on sores and wounds is often evim
during life. It has been repeatedly proved, ikn
substances fiiibricaied of silk, wooUea, and efcs
of cotton and flax, exposed to marsh eskalstioai
very rapidly undergo decay; silk and woolia
becoming putrid, and cotton and lioen ssnwap
a dingy or yellow hue, and aftsrwuds Issif
their cohesion. These effects are general] j Rfd
and complete, in proportioa to the ouiiitRV ii4
warmth of the air, anid the eonoontntioa of t^
aria in it ; and so well are they known, M.Mo«-
falcon states, that they are generally neofmel
by the more intelligent inh^itaals of Italy nd
the south of France, as indicatioos of the ibhIs'
brity of particular places and seasons.

20. iv. Offfreventing the Prodmetiem ef £odf«*r
Cavjsf , and if counteracting their EffeOe-^A, t^
preventing the generation of wudaria, — («) Dnm^
ing marsh grounds is one of the mett cArtct
modes of preventing the formation of BMhin.
but it should be recollected that uncovered duo
and ditches are fruitful sooroes of eadcsve »-
fluence. — (b) Embankmentt thrown npsgaioff o-
undations from riven and the sea are sho *>
portent means of prevention ; but, if tfaey be a'
quite adequate to the purpose^ they any Hf^
vate the evil, by preventii^ the water irem l^
tiring with sufficient rapidity. — (e) In ■!■>"
admitting of neither of these means beiagewp^*^
then advantage will oAen be derived ftwa f^
ing them entirety vith water } lor lakes do art (^
hue miasmata vntil after the nrad and lal *■
their bottoms and side* have appeared sbsfs i^
surface. Sxkao states, that the o^^atx* c* *

ENDEMIC DISEASES — Prevention op.

763

large town became nnliealthy as soon as the mud
at the bottom of some adjoimog morasses was ex-
posed to the son and airj but that disease dis-
appeared when they were completely inundated.
Dr. RoLLO mentions, that mild mtermittents pre-
vailed in St Lucie during the rains, when the
pools and marshes were filled ; and that danger-
oiis fevers appeared after their slimy surfaces be-
came exposed and completely dry. Mr. Annes-
LSY lecords similar facts in relation to various
places in the East Indies. The ditch round the
iimparts of Geneva was once drained, and sick-
ness prevailed in the vicinity, bnt disappeared
when It was again filled. And the water-courses
and beds of rivers that are dried up in summer, par-
bcttlariy in warm countries, aod thereby become
Kmrces of malignant fevers, are quite innocuous
whea filled (Fxrgoson, &c.). — (d) Clearing the
toil from its more bulky vegetation will be benefi-
cial only when an assiduous cultivation is adopted,
without the necessity of having recourse to a very
tbandant irrigation. In many circumstances,
however, this measure will greatly aggravate the
insalubrity of ndistrict, as shown above, especially
in respect of low swampy places within the tropica,
or near the sea. Facts illustrative of this nave
been often observed in both the old and new
worlds. — (•) Protecting the soil in which large
cities are built, particularly when situate near the
embouchoree of rivers, &c., from the action of the
sun, by a closely laid pavement ^ intersecting the
itrata of earth by la^e deep sewers, conveying
the ezuvie and other impurities beyond the reach
of the inhabitants, and in such a way as to pre-
vent the escape of emanations from them, in the
midst of a dense population ; and removing places
of sepulture beyond the outskirts of cities and
towns ; are measures of the utmost importance to
the health of the community.

21. It is established beyond a doubt, that the
narrow winding streets of towns built in low situa-
tions, or in the vicinity of marshes, are, especially
when the houses are high, actually conducive
to health ; inasmuch as the exhalations trans-
ported from tbence have a less ready access to
all parts of tbem, the horizontal currents of air
being more completely intercepted by the nearest
buil£ngs ; also, when the streets are narrow, and
the houses high, the sun cannot act upon the soil,
which oecessarily becomes saturated with animal
eiuvis, unless deeply intersected and purified by
drains and sewers. The importance of this con-
sideration was not overlooked by the ancients, as
appears from the remark of Tacitts, on the re-
building of Rome after its destruction by Nero.
** Erant tamen, qui crederent, veterem illam for*
laan. salubritati magis conduxisse, quoniam an-
gustias itinemm *et altitude tectorum oon perinde
solis vapore perrumperentur. At nunc patnlam
latitudinem, et nulla umbr& defensam, graviore
sstu ardesoere." {Arm, 1. xv. 43.)

22. B. Whilst the above measures have refer-
ence chiefly to the prevention of the formation of
terrestrial exhalations, there are others that may
be employed to confine them to the toureei whence
tkiy issue, when the former means are ineffectual,
or cannot be put in practice. It is very proba-
ble that many places, the insalubrity of which
was recognised and guarded against by the an-
cients, have actually become more unhealthy in
modem times, owing to the accession of alluvial

soil washed down from the higher grounds in the
vicinity; to the accumulation of decayed or-
ganised matter and mineral detritus at the mouths
of rivers, and in the bottoms of lakes, which have
been thereby converted into marshes ; to the
neglect of the drainage and cultivation which a
former crowded population was enabled to pre-
serve; and to the removal of those screens of
trees which confined the exhalations to the place
that generated them. The importance of these
considerations has been insisted on by Lancisi and
finoccaii, in respect of Italy ; by Mon falcon,
with reference to France ; by Annesley and my-
self, in regard to warm climates; and by M'Ccl-
LOCH, as respects this country. It was remarked
by Puny, and some others among the ancients,
that trees absorb the exhalations which prove in-
jurious to man ; and the observation is perhaps
just; but whether trees simply obstruct the
transit of malaria from its source, and confine it
there, or actually absorb it along with the mois-
ture in the air, and dew which rests on their
leaves ; or whether they act in both ways, in ad-
dition to their shading the soil from the action of
the sun ; the power they possess, in low and marshy
situations, of moderating the generation of mala-
ria, and confining it to its source, is indisputable.
It is, therefore, important to plant trees around^
and more especially to leeward of, unhealthy
places (§ 5.), in order to screen persons living
in their immediate vicinity from their influence.
Owing to the extent to which trees, high houses
and walls, and intervening water, not liable to
become stagnant, protect places near the sources
of malaria from its eflTects, is to be explained the
fact of the inhabitants of one side of a street, or
road, often escaping ague, whilst many of those
living on the other side are afifected ; and of the
crew of one ship being seized with fever, while
those of another, somewhat further removed from
the shore, escaped.

23. C. There are other means, besides those
enumerated, which botit destroy and counteract, or
otherwise remove, the causes of endemic maladies*
— (a) In the case of impure water, filtering it,
especially through charcoal ; boiling it before it is
used, or passing it through lime ; preserving it in
iron tanks on board ships ; and adding to it a
small quantity of either of the chlorurets, when it
cannot be otherwise deprived of a portion of
animal matter; are very important precautions.
When sewers, drains, ditches, and other confined
sources of impure air cannot be removed, or
covered so as to prevent the emission of eflluviay
the chloruret of lime should be thrown into them
from time to lime. A solution of the same sub->
stance, or either of the other chlorurets, ought
also to be liberally employed in the wards of
crowded hospitals, whenever tlie air becomes
close and foul, in order to prevent the prevalence
of fever, dysentery, erysipelas, and gangrene ;
and should also be poured down the privies.
Similar precautions ought also to be employed in
crowded transports aod ships of war, as well as in
camps and besieged towns, more especially if dis-
ease appears. But this means is only subsidiary
to free ventilation, and is most to be confided
in when the latter cannot be established. By
having recourse to these disinfectants, the sickness
that sometimes arises from the leakage of sugar,
or the decomposition of vegetable matter collected

£PH£LIS ^Lekticitlar.

765

'reus. 1756, p. 889. — AKrAOM, De Aere, 8vo. Lond.

'hi. ; et in Philot. Traiu. 175A, p. 528 Liner, On Pre-

rrviDg the Health of'Seamen, 8? o. Lond. 1757 — Binett
In (he Med. CoofttitotioD of Great Britain, 8to. Lond.
)^ —J. Grainger t On the more common West India
Ks. Lond. 1754. — Armiii, Det Mai. lei plus frequentet
Surinam, 8tol Amst. 1765. — RuU^, Histor7 of the
Feather for For^ Yean. 8vo. 1770. — Cartkeuter, De
[orbU Endemlis, 8to. Fr. 1771 — Batu, M orb. Huiunrls

od^m. et Remed. lisdem Familiar. Ultng. 1775 Hun-

T. On the Dts. of the Armr in Jamaica, 8to. Lond. 1796.
J. JIfiXter, On the Preraiung Dis. of Great Biritain, 8yo.

ond. 1775 RoOo. On Preserving the Health In West

tuUes, ISmo. Iiond. 1783. — Toumojt^ Varlis Regionlbus
irii Uorbi. ftc. Nascei, 17S3.— Don UUoa, M«m. Philos.
a I'Am^riqoe, *c. Paris, 1787 — Ha^gartk^ In Philos.
'raiu. 1778. —Ruskt Med. Inquiries and Obsenrations,
nli.t. and 11. ttwnMS. — J. Gregorjf, De Ceeli Mutatione,
ro. Ed. 1776l — Kinotm, On the Temperature of diff.
atUudes. 8to. Load. 1787. — J^'iOir. Medlcinisch Pra-
iche Geomphie, 3 b. 8vo. Leips. 1792—5. — Fabri"

ta«, De l^rb. Bod., in Doerimg, t. t.p. 86 Chmeliu,

tUt dorch Wnssland, Tol.iil. p. 42ft — StUUer, De Caus.
ture ingeni Europ. Multitudo Bataiise pereat, et de

Uli hujiu Remediis. Ooet. 1798 Bmge^ De Morbls

IndemUs Kioriensibas. Jens. 1796. — .^nmy, Medl-
iouche Topographic von Berlin. 8vo. Ber. 1796. — C.
'aUwell, On the uiflSereuces between the Endemic Dis.
rthe United States and those of Europe. Ac. Phil. 1802.
ro — CssjMS, in Mem. de la Soc. MM. d'Emulation,
D. 5. p. 56.— AoAer/son, On the Atmosphere, 2 vols. 8vo.
•Gamftty On the Preservation of Health, 12mo. Lond.
W — GaylM Mor^eau, Moyeni de D^slnfecter I'Air,
ro. Paris. 1801.— Gsiylim et Ckajftal, in Edin. Med.
nd Surg. Joum. vol. il. p. 290. — GiUeMpie, On the Pre-
snratioD of the Health of Seamen, 8vo. Lond. 1798. —
I. Wittam, Reports on the Dis. of London from 1796 to
iiOO, iSmo. Lond. 1801. — W. Heberden. On the In-
reaie and Decrease of Diseases. 4to. Lond. 1803. {Djf-
mUry kad greaUm decreawd if ever and rickett contider-
hfyi apopitq.palnt, and eanntmaiixm, had mereoiedt m
•onrfos.)— fVihUerooilom, Med. Facts, vol. vili. p. 56. ;
od Directions for Hot Climates, 12roo. 1806. — JBMdmr*,

Unual of Health, ISmo. Lond. 1806 Wiltiams, On

le Climate of Great Britain, and its Changes, 8vo.
«Qd. 1807. — Dom^W*, On Malta, 8vo. Lond. 1810.—
'orter. On the Hospitals, Ac. of the Continent, 8vo.

/Mid. 1819 J. Joknton, On the Influence of Civic Life,

edeotary Habits, Ac. 8vo. Lond. 1817. ; on the In-
uence of the Atmosphere, Ac. Lond. 1818. ; on the
Dfluence of Tropical Climates on the Constitut. Ac. 4th
d. Lond. 1827. {,Comiam»a large nuui<tfh\fbrmatum on
ndemic infiuenee and diseau.y-- Mattketet, Diary of an

QTsIid. 8vo. Loml. 1820 G. BUme, in Trans, of Med.

od Chimrg. Soc. of Lond. vol. iv. p. 89. 14ft. ; and Select

)Uiettatlons. 2dedlt. vol.1. p.l47. and 256 A.RoberUon,

> Lood. Med. Repos. vol. I. p. 367. — 7. Bateman, Re-
orti on the Dis. of London, and State of the Weather,
c. from 1804 to 1816. Lond. 1819, 8vOr— J. Douglas, Me-
kal Topography of Upper Canada, 8vo. Lond. 1819. —
'. Copland, MedQcal Topography of the West Coast of
TricL in Joum. of For. Med. vol.ii. p. I. — J. Devixe^
"nitede la Fi^vre Jaone, 8vo. Pari^ 1820.— G. Brocchi,
'ouideraaioni sail* Agro Romano Antico e sul Sito di
loma Antica, 4to. Rom. 1826. ; et Del Stato Fisico de
uolo di Roma, 4to. Rom. 1820.— W. Ferguson^ The
(store and History of Marsh Poison. Trans, of the Roy.
oc. of Edin. 1821.— H, MartkaU, Med. Topography of
'f/lon, Ac 8vo. Lood. 1822.— J. B. Afofi/iifcon, Hlstoire
IMicale des Marais, Ac. 8vo. Paris. 1824. — Speer. On
t>e Ois. of Lower Orders in Dublin, in Dub. Hosp. Rep.

ol-Ui. p. 161 S. M. BaiUy, Traits Anatomfco-Pa-

iMiogfqae dei Flares Intermlttentes, Ac. 8vo. Paris,
H25. _ J. Annealejft Researches into the Causes,
{sture, and Treatment of Diseases of India and of Warm
'ilmat4«, imp. 4to. vol. i. p. 47. et »eq. — M. Doltemann,
HM]uliitlanes Histor. de plerisque apud Belgas Septen.
iooalet Endemida Morb. 4to. Amst. 1824.— J. MaccuU
>cA,On the Product and Propagation of Malaria, Ac. 8vo.
Hind. m'/7. ; and On Remittent and Intermittent Dis-
ftiM, Ac. 2 vols. 8vo. Lond. \9K. — ViUerm4, des Prl-
Mt &c. 8vo. Paris, 1829. — Ra^r, in Archives G6n. de
led. t. iv. p. 477.. et t. v. p. 269. {DU. qf Parit.) — Fer-
w, in Diet, de Mi§d. t. viil. p. 66. — J. Hennen, Sketches
f Med. Topography of Gibraltar, Ionian Islands, Malta,

c. Hro. Lond. 1830 H. BelUnawe, The Sources of

lealth and Disease in Communities, Ac. 12mo. Lond.
tOl — Andrai, in Diet, de MM. et Chlr. Prat, t vii. p.

'NTERITIS. See Intestines — /ti/?<imma-

tion of,
'enuresis. See Ubine — Incontinence of,
^PHEUS. Syn.— 'E4»4Xic (from ivl, and
Sxmc, the son). MaeuUt Fusett, Plenck. Epi-
chrotit EpheUs et Lenticula, Good. Epheli<U$,

Alibert. Ephilide, Fr. Spotted Diicohuration

of the Skin,

Classip. — 10. Gen, 3. Order, 6. Clast,
(Good). 1. Gen, 8. Order, Maculs
{Bateman), I. Class, V. Order,
(^Author),

1 . Defin. — - DitcUourationi oftheekin, varying
from a yeUawieh grey to a dark brown, and from

minute pmntg to large patches, and either scattered,
confluent, or corymbose,

2. I. Forms and History. — Hippocrates
applied the term epbelis to the freckles produced
by the sun ; but he also extended it to the spots
sometiines seen in the faces of pregnant females.
This extension of the term was adopted by Ori*
BAsius, AxTius, AcTUARius, and Gorraus ; and
carried even much further by Plater, Sa wages,
and Alibert. Other words have been employed
by modem writers as a designation either for
ephelis generically, or for certain of its varieties,
as will he stated hereafter ; but, as this appears
to have been the original one, I shall aaopt it
here. The change of colour characterising it is
not seated in the cuticle, but in the pigmentum
which gives the hue to the skin. It seems, in
some instances, connected with a deficient tone of
the extreme vessels ; and is very variable in its
progress, occasionally coming on slowly, some-
times rapidly and extensively. It is often of long
duration, or even permanent ; and in other cases
it soon disappears, either spontaneously or after
the application of some lotion. In itself, it can-
not be considered to require medical interference ;
but certain of its forms are important as symptoms
of internal disorder. It may be divided into two
species — the i«nti'cu/ar and diffused,

i. Lenticular Ephelis. Syn. — Ephelis Len-
ticutaris ; Lentigo, Lenticula, Auct. Lat. ;
EpheUs Lentigo, Sauvages and Todd ; Lentigo
Ephelis, Frank ; Pannus lenticularis, Paget;
Ephelide leutifanne, Alibert ; Freckles,

3. This species is characterised by its fawn or
brown colour, tlie spots being generally very
small, and always under the size of a lentil, dis-
seminated or in clusters; and without any eleva-
tion of the cuticle, or attendant irritation. Dr.
Todd has very properly divided it into two varie-
ties — viz. that which is congenital or dependent
upon the complexion, and consequently sometimes
hereditary ; and that which is caused by the sun.

4. A. Congenite Ephelis; ^oaof, Gr. ; Tdches
de Rousseur, Fr. ; Ephelis Lentigo materna, Todd ;'
Congenite Freckles. — This variety occurs most
frequentlv in persons of a very fair complexion,
with a delicate skin, and yellowish or reddish
hair ; and sometimes in those with a very white
skin, and dark hair and eyes. The spots are len-
ticular, persistent, and not confined to the parts
exposed to the light; but are in some cases aisse-
minated over the body. They frequently do not
become very apparent until some time after birth,
or even not until the child is five or six years old.
The darkness of the discolouration varies as above
(§ 1.), with the colour of the hair or eyes, and
usually remains till old age.

5. B. Solar lenticular Ephelis ; Lenticula So'
lares ; MacuUe Solares, Plenck ; EpheUs a Sole,
Sauvages; Lentigo eutiva, J. Fradk ; Summer-

flecken, Sannensprossen, Ger. ; Evanescent Freckles,
— This is a common lenticular discolouration,
occurring in young persons, especially females.

EPIDEMICS •— Cavsea, etc.

767

coniiected with iiupefieet secretton, ezcretion,aDd
a^imilatioD, these functions should be assisted
by mild, cooling, and alterative purgatives, light
diet, and muderate exercise. Very small and
frequent doses of blue |m11 or hydrare. cum creta,
may be given with Castile soap and taraxacum,
or with the aloes and myrrh pill, if the catamenia
are scanty; or with ox-gall in addition. The
internal use of the crea9at$ may also be tried. I
have prescribed it, in one case of this kind, with
great benefiL Sulphurous mineral waters may
also be taken ; and lotions with the sulphuret of
potaasiom, or with nitre and camphor julap ; or
aulphnieted fumigating baths resorted to.

* Bdlioo. AMD RiFSB. — Hippocrtttei, Pnmot. I. ii.
xxxi. 9. : De AUmento. It. 18. ; De Morb. Mulier, L ii.

IXTiL 6. — Cettutf De Med. 1. ▼!. c. 5 Aetius, Tetrabib.

fi. ler. It. e. 11. — Oribasiut, Synop. 1. Till. cSa.; De
l«c. Aflbct Car. 1. Iv. c. SS. ; et De Vlrtute Simp. 1. ii.
c. 1. iB^terahmmd$.)'~Aetuarim, Meth. Med. 1. iv.
c. I3l~ Smaertus, De Cutis Vitiii, 1. ▼. part Z. — Gor-
r^PUMj Defln. ad Vocem *EtMjt. — Plater, De Superflc.
Corp. Dolore, cap. 17. -^Bender, De Cosmeticis. Arg.
8to. 1764. — Lorry t De Morb. Cutanei*, art. Lentiao. —
Sawages, Nosol. M^tbod. Class i. Gen. 3. — Plenck.lDe

Morb. Cut. Class 1. Sp. 8 AUbert, Plate 26. and 97. —

Baiemtm, Synouis of^Cut.Dis. by A. T. Tkomton^pMl.
— ^. P. Franks De Cur. Horn. Morbis, L It. p. 82. eiseq.
_ J. f^anJkt naxeos Medlcse UnlTers* PraN»pta, pars
prima, vol.lL p. 331. eC Sm. — Raver, Tralt6 Th$or. et
Trat. dm Hal. de la Peau, t. U. p. 906. ; ek Diet, de M€d.
cC Chlr. Prat. t. tU. p. 2e&.^Caxena9e et Sehedel^ Abr^gg
Prai. dea UU. dela Peau, 8yo. p. 370 — Todd, Cyclop, of
Pract. Med. vol. ii. p. 69 — J. Paget^ On the Claasiflcation
of Diaeaaes of the SLin, 8to. p. 51.

EPIDEMICS. — Ejnc^emicPiieasei; 'EmKTiuM,
*Tl9%^fMf^tmt^fMi (firomiiri among, and ^/u,of ,
people). £pul«mta, Efndtmiut, Epidemieus,
Marbi EpideSniei, Morbi Publiei, Morbi Popii-
iares, AucL Lat. fptdcmfs, Fr. Votkikrank'
heit. Germ. Epidemaa, Ital. Epidemy, £pi-
dmdc Ivfluetue, Epidemic Constitutions,

Classip. — General Pathology.
1 . EpiDHiios are such diseoMe* at oceationally
prevail more or leu generally in a community
at the same time or seaton, and depend upon a
common miuc.— They recur at uncertain periods ;
and continue to prevail for a time varying from
two, three, or four months, to as many years, or
even longer. When their spread is most exten-
siveff or throughout countries differently cir-
cnnaataneed as to climate, &c., or when they
are universal in their attack, they have often re-
ceived the appellation of Pandemic (wavVifMo^ or
ir«y9vy«eci from «r«c, all , and K/moc, people). When ,
together with their very general prevalence, they
occasion a very great mortality, they have usually
been denominated pettilential (see art. Pesti-
lence.). Thev are commonly acute and febrile,
n!Kl often rapidly run their course. They appear
mt any season of the year ; but most frequently
in autumn, summer, and spring. They are dis-
tiog^uisbed from endemic maladies by the circum-
stance of these latter being occasioned by pecu-
liarity of situation. But it should be recollected,
that endemic diseases may be converted into
epidemics of a verj fatal kind by those influences,
other obvious or mferred, to which attention will
be directed in this article ; and which, acting
either sc^ratdy or in combination, modify the
character, whibt they canse the prevalence, of

2. I. Cavsbs, &c. -— The Influences whence
epidemies proceed may be traced in many in-
stances ; aiul in others, particularly those that are
pestilential, they cannot be inferred with the same

degree of probability. Certain epidemics have
manifestly arisen out of combinations of circum*
stances, the nature and operation of which admit
not of dispute, whibt some have |Hresented only
certain elements of their causation, others being
wanting to explain fully all the phenomena ob-
served.— A, Amongst the most important ele-
ments of epidemic influences, are those endemic
sources which are amply described in the articles
Climate ($ 3 — 32.); Disease — Causation of ;
and Endemic Influence (§ 5.). These sources
often perform very important parts in the causation
of epidemics, upon the addidon of some other
cause, either manifest or concealed; endemics
bein^ sometimes the parent stock upon which epi-
demics are engrafted ; the latter varying in cha-
racter with the nature of the superadded cause
or causes, especially those which are about to be
noticed. Several of these additional causes may
consist merely of certain changes, from the usual
course of the seasons, which obtain in these local-
ities ; as prolonged drought, or protracted rains ;
and, still more, the former following the latter ;
and particularly if conjoined with increased tem-
perature. As long as the temperature continues
low, very material changes in the state of the
seasons may not be productive of any increase of
disease in unhealthy situations, unless other causes
come into operation, as infection, deficient or
unwholesome food, &c. Hufxland states that,
in 1815 and 1816, in the north of Germany,
the seasons were remarkably wet, and the temper-
ature low, and yet the public health was very
good ; that intermittents and low fevers were
rare, even in marshy localities ; inflammations
and rheumatism being the predominating mala-
dies. In warm countries, however, protracted
and heavy rains generally occasion epidemic dis-
ease, especially in low and marshy places, during
the subsequent hot or dry season, or when great
numbers of persons are crowded in a small space ;
and, moreover, impart to it an asthenic and in-
fectious character. Of diseases oriffinattng in
local sources, becoming infectious and epidemic ,
I could adduce several instances in modern times,
LivT (1. XXV. 26.) states that, during the siege
of Syracuse by Marcellus, 213 years B. C, a
pestilence broke out in both armies ; and that it
occurred in autumn, and in a situation naturally
unhealthy. " At first," he observes, " persons
sickened and died, owing to the unwholesomeness
of the place; afterwards the disease spread by
infection, so that those who were seized were
neglected, or abandoned, and died, or their atten-
dants contracted the disease.'" He further adds,
that the dead affected the sick, and the sick those
in health, with terror and pestiferous stench ;
that the disease was more fatal to the Carthagi-
nians than to the Romans, who, in this long
siege, had become accustomed to the air and
water ; and that, in the same year, an epidemic
visited Rome and the adjoining country, which was
remarkable rather for passing into chronic affec-
tions, than for the mortality it occasioned. Al-
though some of the sources of endemic disease
may, by the aid of concurrent causes, as in the
instance now quoted, give rise to epidemics, yet
pestilential epidemics otherwise originating, as in
infection, have sometimes spared places which
have seemed to abound the most in certain causes
of insalubrity ; but this has occurred only when

768

EPIDEMICS — Causes, trc.

those places have emitted a powerful stench and
ammoDiacal vapours, or other strong odours,
which have either counteracted or neutralised
the exhalations or miasms which have spread the
infection.

3. B. The seasont have a very remarkable influ-
ence upon certain epidemics, as those of yellow
fever and plague; and but little on others, as pesti-
lential cholera, influenza, &c. As respects those
epidemics which are less universal and fatal, the
influence of the seasons is more or less manifest. —
In sprif^, various forms of angina, croup, bron-
chial a flections, inflammations of the lungs and
pleura, catarrhs, rheumatism, hooping cough, ter-
tian or quotidian agues, and the febrile exanthema-
ta, as measles, &c., are usually most prevalent. —
In summ«r, certain of the above diseases will often
remain, with continued fevers of various forms,
erysipelas, smallpox, stomach and bowel com-
plaintSi &c. — In autumn, the diseases of summer
either continue or become more prevalent, espe-
cially cholera, dysentery, and colicky affections ;
and quartan or irregular agues, remittents, sore
throat, scarlatina, inflammations, or obstructions
of the abdominal viscera, &c. are also frequent.
— In tointer, inflammations of the thoracic and
respiratory organs, rheumatism, and low or typhoid
feveraare most common ; and, inclose or crowded
places, infectious effluvia, either from the sick or
from accumulated 61th, are readily generated,
when the air in heated apartments becomes stag-
nant. Hippocrates had remarked that, when the
seasons are regular, diseases are also more regular
in their course; and, unless during the prevalence
of epidemics, the observation appears just.

4. C. The weather has a considerable influence
on the prevalence of the more common diseases.
Protracted droughts are unfavourable to pul-
monary diseases, with the exception of broncnor-
rhoea, and frequently excite mflammations and
inflammatory fevers. During, and soon after,
very wet seasons, gastric, remittent, and inter-
mittent feverti, catarrhal and rheumatic aflPec-
tions, dysentery, diarrhoea, and sore throat, are
often epidemic. The frequent recurrence, or the
continuance, of high and cold winds, occasion
catarrhal, pectoral, inflammatory, and rheumatic
diseases; and warm or hot winds induce remittent
and bilious fevers, cholera, ophthalmia, &c. Calm
humid states of the air promote the spread of con-
tinued fevers, and all infectious and contagious ma-
ladies ; and similar conditions of the atmosphere,
conjoined with great heat, favour the prevalence
of adynamic and malignant fevers of a continued
or remittent type ; whilst very hot and dry seasons
give rise to synochal and ardent fevers, to bilious
remittents, cholera, and inflammations of the liver,
stomach, and bowels.

5. Although the states of the atmosphere here
enumerated very frequently produce the effects
ascribed to them respectively, yet other causes aid
their operation. Writers, from Hippocr atks down-
wards, have attributed too much to irregularities
and sudden vicissitudes of season in the production
of epidemics, more especially of those which are
very general or pestilential. I believe that this
cause is instpimental chiefly in augmenting the
number of cases of the diseases common to a coun-
try ; and that it is very seldom the only, or even
the chief, soujce of wide-spreading or pestilential

-maladies, although it may aid their generation

and diffiision. On this point I cannot agreie with
Dr. Hakcock, M. Foniai, and tome oAber m«-
dem authors. That this dictum of Hippccrate^
was not altogether believed, even to anacAt
times, may be inferred from the freqncnt exrcp-
tions to it adduced by historians and medieai
writers. Tacitus (Annalium, 1. xvL 13.), wbea
noticing the epidemic that raged at Rome in tkc
year 68, states, that there was no nrregulanir
of season or weather to account for it. TW
plague that prevailed so long, and spread so ftmt-
rally, between the middle and end of the mxtk
century, and which has been folly described ^
PrOcopiub and Evaoridb, who were witoesm
of it, was in no way dependent iipon irfegularty
of season, but was evidently propogatad by in-
fection. The following remarks of EvAcajr-
are, according to the ^experience of ereiy candid
observer, perfectly characteristic of an infect»e»
pestilential epidemic : — *' Some perished by ooc*
entering into, or remaining in, the infected boa<ie9 ;
some by touching the sick. Some contracted x^
disease in open market; others, who lied fzva
infected places, remained safe, while tfaey coa-
municated the disease to others, who died. Masy
who remained with the sick, and freely bandied
the dead bodies, did not contract the davax. '
{Ecclet. Hist. 1. iv. cap. 29.). The pestilenre
called the Black Death, which visited nearly al!
the then known world in 1347, 1348, 1349. a^*
1350, was equally independent of irre^ularitv <.i
season or deficiency of food. pAaaam (Jati..
Brit. p. 360.) states, that it first appeared a.
the south of England about Christinas, *\Z<6
and amidst the greatest abundance of proviac*,
TuuANOs and Rrvcaxus, when nocicia|p the rpi-
deroic that broke out in France in 1680. »-
marked that the crops that year were plrtiti%!.
and the sky serene ; so that it was tbonght tkii
the disease vras produced rather bj the i^aear-
of the stars than by the mal^ity of a comp-.
air. Webster (On Epidemic DtsacMB, vol. '
. 323.) admits that the summer in 1665, tz
nghmd, when the plague commenced in Lnr>
don, was very temperate, the weather fine, arj^
the fruits good. All the writers of the day ag-vr
that no cause of pestilence could be observed u.
the states of the' seasons. The epidemn of ox-
own days also prove that, although irf«|^lantfc<<
of seasons and weather may aid tfaa cadr>
mic sources of disease, or increase the |«»>
valence of the common diseases, they are by re
means amongst the chief causes of
maladies.

6. D» In connection with, and ofkea
from, irregularity and inclemency of
whdetome and deficient food sometinM
an important part in the production of
— ti fact which seems to have been well kaowa i
guarded against by the inspired lawgiver, Bl<»r'
In Deuteronomy (ch. szviii.) the Isracii^«.«t
warned against transgressing his laws; aad art
threatened, as a consequence of disobedgacv
with the diseases of Egypt — the bolcb, iWe scat
and the emerods ; maladies known at pnesent, ^/
the names of elephantiafls, ftprasy, and pla;w,
respectively to |»«vail in that oouatry; atwS c
Aumfters (ch. xi«), they are stated to haw bw
seized by pestilence from eating a great tfomuttrr^^
the flesh of quails, which had fallen intu^frwt;
numbers around tbeir camp, after batiaif Wa

I-

770

EPIDEMICS — Cavbbs. etc.

10. h. Other authors have ascribed an unusual
prevalence of disease, or the appearance of pes-
tilential epidemics, chiefly to tne btates of elec-
tricity in the air, and on the earth's surface. That
certain concUtions of this agent should affect the
animal economy, and either predispose it to be
infected by the exciting causes, or of itself be a
principal cause, of disease, is probable ; but we
have no direct proof of any connection between
epidemics and Vnown changes in the electrical
states, either of the air, or of objects on the earth's
surface ; and even granting that such connection
exists, there is no evidence that this a^ent can
produce the morbid effects ascribed to it. It is
impossible to reconcile the- modes in which epi-
demics are observed to diffuse themselves, or toe
peculiar and novel characters they often assume,
or the very opposite physical circumstances in
which they occur, merely with changes in the
electric fluids, often of inappreciable and in-
sensible kinds. Indeed, experience rather shows
that the body may be made the medium of a very
energetic, electrical, or electro-motive, action,
without any injury being inflicted on it; and it b
only when a very powerful and very manifest
current of either the negative or positive electrici-
ties strikes, or passes through it, that life is thereby
in any way affected.

11. c. Numerous instances have occurred of
the lower animals participating in the fatal effects
of an epidemic constitution, and they have been
adduced by modern authors as proofs of the exist-
ence of a noxious effluvium in the air, however it
may have been generated. Thus it has been ob-
served, that epizootics have preceded the preva-
lence of fevers ; that catarrhal affections in horses
have been followed by influenza ; that birds have
either forsaken the vicinity of a town ravaged by
a pestilence, or have fallen dead when flying over
it ; and that numerous species of animals, particu-
larly domestic animals, have died in houses visited
by pestilential maladies. These phenomena have
been adduced as proofs of the existence of some
one of the agencies placed under this head.
Without disputing their actual occurrence, or
attempting to reduce them to their exact dimen-
sions, from which they had been exaggerated for
the purposes of alignment, I vrill receive them
as they nave been described by those who have
adduced them in support of their views. — 1st.
As respects epizootics in connection with epidemic
fevers, Lancisi, Ramazzini, and still more
modern writers, have furnished much information.
It has very frequently been observed, when the
prevailing fevers have been an exaggerated form
of the endemic of the country, or when endemic
sources have been manifestly concerned in their
causation, that the lower animals, especially homed
cattle and sheep, which derive their sustenance
chiefly in places productive of malaria, are the
first to experience its eflect*, when it is more than
usually active or concentrated. This is nothing
more than what might be inferred a priori. We
know that remittent and continued fevers, in
various forms, are frequently epidemic, especially
in marshy countries in the south of Europe ; are
chiefly dependent upon local source?, aided by
heat, crowding, imperfect ventilation, neglect of
cleanliness, and the state of sodety; and are
often either preceded or accompanied by epi-

oties. Such occurrences are as old as the

u

records of history extend ; and have
verted to in the Books of Mosss, as wdl
those of the Prophets. Hombb I»s atgnaliaed tfec
Qonnecbon, and EutrATiinis and Sfo»da»ts
have explained it, in their commeDtanea oo the
Iliad, as satbfactorily as any pbiloaopbcr of the
present day. Evstatbivs, the oelebffBted critie
of the twelfth century, ascribes the iBamif thst
broke out in the Grecian camp, in the tenth year
of the siege of Troy, to immoderale heat and grsv
exhalations : and Da Spondb. or SromnASv*, m
he is commonly called, conceived the eiiei^
stance of the mules and dogs haviq^ been afcfed
before man, to have been owing to their nalaril
quickness of smell, renderinf the ezhalabaas
sooner perceivable and operative ; nad to ihtir
feeding on the earth with prone hends, whetthy
effluvia are more readily inhaled, and hekn they
rise so as to affect man, or become diinsed m
the air.

12. A connection similar to the above, and evi-
dently proceeding from the same fonrcos, eapccially
in warm or dry seasons, eonaeqnent nnen tkt
inundations of low grounds or nanbes, ai mem-
tinned in various places by Lrrv. That the cp-
demics, which were thus eonsequent npoa «r
attended by epizooties, were of the natare I hate
contended for, may be inferred frooa the foUowv^
notice he has recorded of an epidemie fever whka
was remarkably destructive in the year of Rook.
576 : — " Peshlentia, qua priore anno in bow
ingrueiat, eo verterat in hominiua nsosbea. Q«j
inciderant baud fiicile septimum diem sapenhaat
qui superaverant longinquo, maxinw qaaftaac
implicabantnr morbo. Servitia
bantur; eorum strages per omnes
torum erat. Ne Hberorum qoidt
Libitina subfidebat. Cadavera intaeta a
ac vttlturibus, tabes ahsamebat;
stabat nee illo, nee priore anno, in
bourn hominunqiie, wHurium vaqi
(L. xlL 21.) Here the coaunencesaeat of the
aisease amongst the cattle, its snbsidanco ■•• the
intermittent type, its greater prevalenee in ths
lowest classes, and the abaenee of biids of prey
from the infected atmosphere, are proola— let, «f
its having originated in malaria, and poaaeMed il<
characters distinguishing this class of fevcso ; and.
2d, of the effect of the cootamiaatad air assd ^-
eased bodies on animals of pfey. The ibiiatan
epidemic that ravaged Rone in the y«ar A. D.
187, and many parts of Italy, waa aMcmiad, father
than preceded, by a disease m cattle. Hboomav
(L. i.) ascribes it to the great ooncowie of ptoyh.
assembled from ail parts of the earth, aad to aa
unfruitful year, and coaaeqoent
most likely to generate inlM^ioB, panicalari j
aided b^ others whieh are setdon
such circumstances. Althoagb this
of epizooties and €»idenucs may be
as was attempted by EirsrATHiva and
yet it is not improbable, that catlla
gether in a state of disease will generala oa
vium, remarkably injariooa to nsaa ; that ibe om
of the flesh of diseased aaimais, aa aaar he
inferred to have been the cam in the
last noticed, will have a similar
when aided by other noxioos ageata^
causes will occasion
which will spread with grcai
mortality under the

772

EPIPEMICS— Caubxs, etc

imperfect ventilation ; — "Sd. That tbe combin-
ation of these exhalations with tboee emitted
by decayed vegetable matter, and by deep ab-
sorbent soils, gives rise to effects of greater seve-
rity than those occasioned by either operating
separately ; and that the intensity of these effects
will depend upon the temperature, humidity, and
stillness of the air, and other concurrent ciicum-
stances ; — 3d. That emanations from dead animal
matter, in the various states in which it is met
with, are capable of causing, even of them-
selves, serious effects, a« shown in the article
Dysentery (§ 23.) ; and that, when aided by
high ranges of temperature and humidity, they
are ^ften productive of extensive disease, which
usually assumes, especially in a crowded popu-
lation,' and calm atmosphere, infectious proper-
ties ; — 4th. That even when they have not been
the chief element or cause of the epidemic con-
stitution, they have been, not unfrequently, con-
curring agents.

15. It is recorded in the Magdeburgh Hhtory,
that, in the year 394 or 395, swarms of locusts
covered Judea ; and were driven by the wind into
the sea, and washed on the shore of Palestine ;
they filled the air with foetid effluvia, which occa-
sioned pestilence among men and cattle. In this
case, the high temperature of the country, very
probably famine — the frequent consequence of
swarms of these insects — and other causes, con-
curred in the production of this epidemic. It is
likewise stated in the same history, that swarms of
locusts covered a great part of France in 874, and
were driven by the winds into the JBritish Chan-
nel ; and, having been washed on shore, caused
such a stench and sickneas, aided by a famine, as
to destroy about a third of the inhabitants of the
French coast. I have stated that the dystHtnies
{see that article)^ which have been very gene-
rally epidemic immediately after very destruc-
tive pestilences, have been occasioned chiefly
by the exhalations proceeding from the immense
number of dead bodies, and by the presence of
animal matter in the water. It is more, even,
than probable, that pestilences are perpetuated
in large cities from this circumstauce ; and that
the prolonged epidemics, of which Rome, in
her rise, in her acm^, and in her decay, was so
frequently the seat, were partly owing to this
cAuse, which neither burning nor burying the
dead bodies could prevent. During the very
prolonged pestilence that ravaged Rome in 262
and 263, the air is described by Euscbius to have
been so corrupt, as to form on the surface of
objects a mould or tabid dew, such as proceeds
from putrid bodies : — " Ros quidam tabidus e
cadaveribus putridis ; " -— or, as Cedrencs ex-
presses it, *'Ros saniei mortuorum similis ap-
parebat"

16. G. Injection and contagion are amongst tlie
most important agents in the spread of certain
epidemics ; but great misapprehension has existed,
as to the extent of their influence, the exact parts
they perform, and their mutual connection. Man^
writers have erred remarkably in viewing epi-
demic diseases as being necessarily infectious, and
even contagious ; aud others, in considering
them entirely devoid of infectious and contagious
properties. The importance of determining in
how far tney possess either property, and are dif-
fused in consequence ; and tlie great interest of

the subject, in medical, commercial, and political
points of view ; have given Qceasioo to nich sad
to warm discussion — a great part of whtch kai
not been calculated to advance the came of
science, or to elevate the medical chancier is
public estimation. The subject of ooalagion, is
all its relations, is fully discussed in the uticte
IvFEcnoN. I can, therefore, only all ode hridlj
to a few of its connectjons with epideiaic mk^
ladies.

17. 1st. A foul air may be genenled bj (hi
crowding of many into a small Wfmot, etes n
health, but more especially in a state of disesie,
as in hospitalsi &c. ; or by the presenee of saf^
a very few in the same apartment, if their vL
ments be attended by copious dischaigei, n is
puerperal and dysenteric cases, &c.; awl tJui air
may infect those who breathe it in a stale of fn-
disposition, with fever, dysentery, &c.; peisMi
thus infected, communicating the disease to otkn
similarly predisposed, and under the drounnssoBf
about to be stated (f 18. 2d.)» Thvs 1 bait
seen puerperal fever generated in the wardi d
a lying-in- hospital, from the air havmg becoac
vitiated by the discharges; aiid nearly all tk
females, who have been expoeed to the aeoos a(
the contaminated air soon alter delivery, aftcted
by it; the disease being, moreover, coov«yed
from one patient to another by means of tie
accoucheur. Foul and phagaieaic nleer8ti0B,
hospital gangrene, erysipelas, dysentery, iofla»>
mation of veins, &c. may abo be produced, aad
become even epidemic to a certain extent, io thii
way.

18. 2d. Disease may take place spoiadicillj,
or from local cauaea, and, owing to vaiioas a-
cumstances, acting either in close snceesnos «
coetaneously, the circulating and secreted fliidfi,
and even the soft solids, may be ao chsnged doi-
inp[ its course, as to emit an effluvium, coniaiDap
atiog the surrounding air, and thereby infediot
many of those who breathe this air in a soiBcieDUt
contaminated state; and thua it will beprapagaici
to several, and from those to others — eqiaaaU;
under favourable circumstances of leBpeniait,
humidity, electrical conditions, and stillaeai U
the air, and of predisposition on the part of ihotf
who come within the focus of iofectioo. Tbi
disease may become infeeiious mnd epidtmie, aided
by the constitution of the air and other cireais-
stanoes ; and, after a time, cease and cntirel> ^
appear, with the circumstances which ouuituft^

to propagate it.

3d. A person may be either inCscled is tk
manner now stated, or seized by a malady wiki
always evinces infectious properties nnder drci»-
stances favourable to their developcoaeDt, a*
typhoid or adynamic fevers ; or by one ohtuwlj
contagious, and propagated by a palpable tires
as small pox, &c. ; and be removed to a ^kmct
where the physical conditions, .aerial and tcn«»>
trial, as well as (he states and manaeit of the i»>
habitants', favour its spread to others ; or the uat*
bid miasm or matter may be conveyed, bv muat
of some inanimate substance embued with it, (» a
distant place thus circumstaneed, and the ib>
ease be there propagated for a time, then mbBair,
entirely disappear, or again break ont, aecoidtfj
to the concurrence or dtsappearaiice of one or
more of the causes aiding in its dilTeaioa. h
these cases, the disease hwommtpidtmiejnm n-

EPIDEMICS — Constitutions of Authors.

777

36. «. The appearance of swarms of insects has i sion scarcity, and, by the decay of their exuvis
beeo likewiw considered as a forerunner of epi- ' and dead bodiesi to increase the local sources of
demies. After mild and open winters, when the diseases. They have thus contributed to the
cold has not been sufficient to destroy the eggs , causation of an epidemic constitution, and, per-
iod larvae of insects; and during moist and warm < haps, in some instaoces, have directly produced
spriogs and summers, when warmth^ moisture, ' disease. In such cases, they have either preceded
aod aaimal decay have contributed to their ex- ! or attended the commencement of the epidemic.
Uaordinary geoemtion ; various species of both I The common insects of a country have been said
iiHects and reptiles have sonittimes become so to have disappeared during the prevalence of
ottmerotts, especially in low and humid dutricts, pestilence. If this have occurrea, it may be
as to destroy the vegetable productions, to occa- | referred to the operation of the same cause to
j which the disappearance of, or death of, birds

«1th them or increftfing their actlTltT. Tho«e "preTaiUng i ^f* imputed ($ 13.). But the non-infecuoniste,
or minor epidemic diieuet," which these writers (see who have endeavoured to torture an argu-
l)r.HA«cocK.inCjrc/.afPr«rf.3f««.vol.ll.p.8a.)h«ve ; ment in favour of their views out of the latter

Tleved, not merely as the forerunners of pestilence, but , • .« ^ l ». ^_. i »^ ^ai

M «m»erta>lefaitott. must be either epidemic or cnde- I c»'c««nslance, have not ventured to affirm, as

nic, otherwise tlief cannot be said to prevail. If the i they did in respect of the disappearance of birds,

^°"T' 75*^5 "* V'*'!k ^"•JL"'*!!''^! ^ ^^ ^i"^ than an unusual absence of insects or reptiles
are the bets ? — Can they htzr scrutiny ? None have , i , . , ^ f v«

b«en adduced Chat can stand the test. If the latter, the I DM been ever remarked as a forerunner of
circumstance might l>e expected, d priori, occasionally to : peatilence.

afS.Sl?l?SSiSJ^5l.!JS.'?rTfSS'i!2LS'^^^^ ! 37. /a, to the influence of comet., meteo™.
iafectloo. Thedistemper to which this statement is most earthquakes, the breaking out of volcanoes, &c.
applicable, and regarding which it has been especially ' in causing epidemics, or even in indicating their
nude, if yellow fever, as it requires a certain concurrence ^^...^^^ir *u^.^ :- -,^« *k« i<^.* ^..:a^^^^ ^Jr*«uu
of causes for its derel^mentTispecialiy in temperate clu ! approach, there IS not the least evidence, notwith-

mates, which causes are chiefly and commonlr pniductive
of endemic feters. Those causes are also the principal
preditposiog and concurrent agents in the diffusion of the
lofiBctkm of yellow fever, which thereby attacks a large
poportloD of tluMe who might otherwise have been seised
Dj the endemic maladies— the predisposition to infection,
occasioned by those causes, favouring an attack of the
patUenthd epidemic, which thereby takes the place of
tfac endemic disease. Can it be a matter of surprise, or
thottld it not rather be expected — (a) upon the breaking
out of epidemic ydlow fever, which requires a high range
of atmospheric warmth for its existence, and which,
therefore, can occur beyond the tropics only at parti-
cular leaions, which are also those of remittents, that
these latter or other endemic diseases should prevail ? —
(&)or, after great numbers have left the place where it
has uipeared, and the population Is thereby greatly re-
daced ; and when three fourths, or even more, of those
who remained are attacked l>y it, as in the epidemics in
the south of Spain ; that the endemic diseases that pre

standing Noah Websteii's labours to demonstrate
it. Coincidence may have been sometimes re-
marked : but it would require a tolerably uniform
antecedence of the former in respect of the latter,
to show «ny relation between them, either as
cause and effect, or as concurrent results of one
general or pervading cause.

38. III. Notices or some Epidemic Consti-
tutions OF Authors. — In itluttratioti of what
has been already advanced, I will take a brief
view of some epidemics, and the causes to which
they have been chieflv imputed by those who have
recorded them. Epidemics and pestilences of
recent occurrence, as well as some of very early
„^ . , . date, are referred to in other and more appropriate

(0 or that, when the inhabitanu who bad departed have ' lo89 to 1694 were wet, the winters mild, and
returned, and seeing that an attack of one disease does inundations frequent ; and that periodic fevers of

not necessarily preclude an attack of a different disease,
raaittents and other endemic disorders should reappear

an unfavourable kind, and diseases of the bowels.

to a greater or less extent, according to the intensity and I were epidemic ; which he attributes chie6y to the
cwabipaUon of causes producing them, after the pesti- irregularity of the seasons, and to the failure of

lential epidemic has ceased? A careful Investig'ation
>hovs that the phenomena connected with this and other
pniHeaett are aetoaliy such as may be inferred a priori.

the crops. But these were manifestly only a
part of the elements which contributed to the

conformably with the doctrine which imputes them, vis. I cjkii«Ation nf ihM» maladipji • thp warmth nf tht*
piagw. yeiibw fever, and pestilential cholera -the chief ' causation ot these maiaoies , ine warmtn oi the

p(^*tiieDtial epidemics with which we are acquainted ~ to
iofectlon.

The fourth and last statement of the non-Infectionis(s,
to which I shall here allude, is. that <* no pestilential
eptdemic is one form of disease" {Op. cit. p. 82.), or of
UQTarying type ; and they adduce this as an argument of
ttieh rpiderou: being an aggravated form of the diseases
etuieaiie to the place in which it breaks out. But what
u Uie foundation for this statement ? Actually none :
t>r bowerer much the pestilences just enumerated may
*arT b grade and severity, they present, individually,
such spedality of features, wherever they are observed,
u wUv enables the well-educated, the careful, or the
raodid obserrer. to distinguish them m>m diseases which
spproaeb them the nearest in character ; and are as un.
raryiogM small-pox, measles, or scarlet fever— if, Indeed,
they be not much more so. We see these latter Qsaladies
yvy in severity, but thev still preserve the sam6 specific
features ; so do the pestilences in question. We, more-
over, ace the infections of those Csmlliar and domestic
diieucs very limited, or scarcely at all diffusing them-
mves, at certain times and seasons ; and, at others,
spreading rapidly, generally, and in severe forms ; — the
*^ii also observed in respect of pUgue. yellow fever,
And pcstilentUl cholera. The principal cUfference between
y^ epidemic manifestations of these two classes of dis.
tempers Is in the frequency and the seasons of their
appewanoe ; and this is owing to the nature of the causes
coQcurrina to aid the diftision of their respective infec-
tions; and without which aid they could not prevail
tfoenXly, or beeome epidemic

climate, the great quantity of rain, and the fre-
quent inundations, with their more direct results,
being equally, if not much more, powerful
agents. Baolivi describes the epidemic consti-
tution of 1703 to 170d, and imputes it chiefly
to the seasons, which were mild and rainy in
winter and spring, and dry in summer and an*
tumn. Earthquakes were frequently felt during
these three years, in the States of the Church ;
and caused great alarm in the minds of the inha-
bitants, contributing thereby to the prevalence of
disease. He states, that apoplexies and sudden
deaths were very frequent ; and that they had
bee^ also prevalent during 1694 and 1695,
throughout Italy. Although he attributes them
chiefly to irregularity of the seasons, it is more
than probable that the wars, and the attendant
evils, which devastated that country during these
years, were equally concerned in their produc-
tion. CoTVGNo and Sarcone have described an
epidemic, which was very fatal in Naples in
1764, which followed irregularity of seasons,
and a scarcity of grain; aod which appeared

778

EPIDEMICS-* CoKSTXTVTioiia or Autooki.

first amoog the poor, preieDtiag the Tmrions mm-
lignant forms of coDtinued aod remittent fierer.
Bleeding, emetics, purgatives, bark, opium, &c*
were phocipaliy resorted to, bat the mortaiitv
amounted to nearly one half of those affected.
The intermittent, and snbsequently the remittent,
charaoter which the epidemic assumed during its
early progress, proved that- the state of the sea*
sons, and the abundant sources of malaria, which
existed at the time, were concerned in its produc*
tion : but the great malignitv, with tenaeocy to
dissolution, in the fluids and soft soKds, which
characterised its advanced progrem, evinced the
operation of additional agents; and these were
sufficiently apparent in the wretchedness of the
lower classes, the bad quality of the grain, in the
want of deanlinen and the general inattentioo to
iafiBetion, excepting in the religious houses, which
escaped.

39. M. FoDKRx refers to the transactions of
the physicians of Berlin, Augsbourg, Breslau,
Presbourg, and Laybach, to show that the sea*
sons were not the chief causes of the epidemic
constitutioos they describe. Indeed, at numer-
ous periods, as well ss at these, the seasons have
been remarkably irregular, without disease be-
coming epidemic, unless where endemic sources
have been very much increased by such irregu-
larity, or where the evils of war, or scarcity, or
some other element of an epidemic constitution,
have been superadded. When diseases have pre-
▼ailed, they nave not always been influenced by
the state of the weather and seasons alone, more
especially when they have possessed infectious
properties. Sydenham, although he once con-
ceived that the epidemics of this climate could be
acpounted for by means of the sensible states of
the air, subsequently confessed that they depended
less upon these states than upon something in this
fluid that could not be ascertained; a more
extensive observation having proved the ioaccu-
racy of his former opinion, and confirmed the
inference at which HiprocRATss had arrived.
OxopFBOT and others attribute the adynamic and
infectious fevers, dysentery, and scurvy, which
became epidemic in Paris and the surrounding
districts in 1709, to the very severe winter and
spring of that yesr. But a stricter examination
has shown that much more was owing to the
scarcity of provisions, to their increased price
from the imposts of a disastrous wsr, to the op-
pression and poverty of the lower rIaMes, to the
want of cleanliness, and more psrticularly to in-
fection favoured by these circumstances, by the
state of society and manners, and by inattention to
ventilation, &c., than to the severity of the seasons,
to which they had been imputed ; this co-oper-
ation of the elements of an epidemic constitution
protracting as well as extending the prevalence of
these malaidies, as might have been expected, d
priori, during three years, and for some time after
certain of these elements had begun to disappear.
In proof of the accuracy of this view of the mat-
ter, I may add, that the early months of 1716
were equally severe in Paris, and yet no epidemic
occurred; lor the principal causes which came
into operetion in 1709 oid not then exist. In
1796, the winter and spring, in the same part of
Franoe, were very cold ana wet, and grein some-
what scarce ; hot there was little increase of dis-
ease, —scurvy being, as it always was during the

I preceding oentnry and the cariy part of thsUii.

I one of the most common malsdiet of tkatcsaaUT.

I But in 1740, a similar severity of these mmnt

existed, and war aided by the e?ik ef war, fat »

much greater scarcity, amooaiing to fanac n

many places, and by inlieclioo, irith the i«a «

the causes just enumerated ; aai the iMiitei «cn

such as the well-infeaned pmholatist SHght hs«t

' inferred from this coubinatioB ofageMi, mm

I especially when acting upon a pspulaiiw pbf-

I aioally and morally constitnted aaa oroaMmaMd

i as the French of that period were : thoe iwte»

being infectious, adyoamic, and malinaat kwc* .

dysenlety, diarrhoea, and scurvy. Cold sad w

seasons, thick fogs, and winds that have fu^»

over manhy and woody countries, are oAm p*

ductive of epidemic catarrh, hooping eo^gh,v*(

throat, bronchitis, rheomalisB, &e., c^kut

among children, aged penons, and lemalss ; Uk.

as additional agents ooom into opeiBliua— a

scarcity, emanations from animal Miei, oJe -

tion, or whatever depresses the powsn of hie—

so the character of the epidcmio changes, aad if.

maladies above enumerated, or the cxaatkavi.

supervene, and spread widely.

40. The malignant remittent feveis that n^
in the summer and autumn of 1652, ia Ctfi>
hagen (Bartbouw) ; of 1667, in Loadsa (Wu*
us) ; of 1669, in Leyden (Stlvits nx u Bu
of 1^1 , in various parts of Holland (Dsno»
of 1684, in Helmstadt (ScBxuiAaiMxa) ; cf \^^
in Rome (Lakcisi) ; snd of 1737, in Bnu*
(Hann); and which presented soaaewhsiBsdiM
characters, with the variation in the drcra-
stances producing them, were very geocsu.!
imputed to the epidemic eoustituliua ef tkr*
sessons, by the authon just named. B«t vr
evidence they have themselves furniihed d tte
state of the antecedent seasons, and of tkepot
heat and protracted dronsht IbUovinr inss^
tions, and the expoang of places nasrelTy es*««
by water, together with various cooeunot tn
subordinate circumstances, satisfiwiorily soeHs:»
for these epidemics. These dties woe, Cof •
time, owing to these causes, sioiilariy omr-
stanced to plsces within the tropics mnotatH
by the sources of endemie di«ensas ; sod ret-
sequently the prevailing maladies were, is (kr
most prominent features, the aame as ihoK vki?
are common to such places, or which stuck ■>•
seasoned Europeans visiting them. Tka vx
manifestly the case, on these oecaaioos, ss ntu*
Copenhagen, Leyden, aad ether parts of HoihsA
ana Rome. London, in the middle of tke 8t««**
teenth century, was still surrounded by asntn
and low grounds on nearly three of itt "^
These endemic sources, durinc very hot 100101
and autumns, particularly wmq xkem Mkfi
immediately upon wet seasons or inondatioss t -
ways occasioned periodical and toafcaacd h<o
dysentery, &c. ; and, aided by a Cfoinled pre-
lation, want of cleanliness and vcmilitiaB. ^
mannen of the lower dosses, by bobI ud cais
states of the air, and poanbly by certaia ckcinn
conditions, favoured not oaly tM gSDeiatiea i<t^
more common infections levers, Mt ah* tk ^
velopment and propagation of IbreigB isCect*
as that of ]dague, wnen mtroduecd*

41. The fever cbancteriaed by Asorir*"*'SMf
of the digestive mucous surface, — iht .V»ff^
Fever, of Fonxax and othci* ; the W^» **•-

£PID£MICS — Constitutions of Authors.

719

thali-eptdemie*, of Arnold; the Adgncmeningeal'
freer, of PiNSL ; and the Gtutrie, the Catarrhal,
the Munttrie, &c., of ▼arious authon, ^- had
been observed in an epidemic form, on vaiions
occftRODs, somewhat similar to that in which it
oeeufred is Gottiogen in 1760 and 1761, when
itwssaeeomtely observed and described by Rox-
DcaiB and Waolxx. It then assumed a very
Krereform, modified into the remittent, dysen-
teric, Denrons, adynamic, and infectious states by
the dreamstances which concurred in producing
it. These yean, as well as those immediately
preceding them, were very wet, and, moreover,
the epoch of scarcity and war, during which the
city was besieged. Hence it cannot be a matter of
snrpriae that agues, remittents, dysentery, scurvy ;
gubie, sdynamic, and typhoid feven, &e. ;
ibooM have successively appeared ; or that either
sbonld have saccesBivefy predominated ; or that a
kftt of a miied or complicated character, and
Tcry severe form, should have prevailed during
the co-operation of these energetic elements or
>gents of an epidemic constitution. My limits
will not permit me to take a further view of the
epidemic constitutions of authora. Those described
more recently by Huxham, Hxberdxv, Sims, &c.
tre of easy access to most physicians, and furnish
merely illnstratioaa of what has been already ad-
vanced. The epidemics which have occurred
daring the last half oenturv in America and the
soath of Spain are particularly reviewed in the
article on Yellow Fkvxr. I shall, therefore,
o&ly advert to certain topics connected with them,
and fftate soch inferences as observation and study
wggwt.

42. Many of the writers who have either seen
or given an account of the epidemic occurrences
^ yellow fever, as Dkvxzk, Jacxson, Ferguson,
&e. have insisted particularly upon the agency of
miasnu extricated, by a powerful sun, from the
toil, nd of the electrical states of the atmcaphere,
>a ihdr causation. It is very probable that such
ntums emanate from rich deep soils abounding
wnb the elements of vegetable and animal organis-
al^ and life, during very hot seasons, and when
they sre folly exposed to the sun's rays ; it is
^ probable that vicissitudes in the electrical
coDditioBs both of the air and of the bodies
Pjaced on the earth's surface occasionally take
r*ee ; and it is possible that both these agencies
Btay be occasionally coincident, or co-operate in
certain localities. But we possess no evidence,
«ven granting their existence, that they are capa-
hleof prodacing the effects ascribed to them.
Jwir eiiitence, however, is only a matter of
isference from certain phenomena which cannot
^^nnctimes be otherwise satisfactorily explained,
^ not of demonstration; and although the
l"^* of the injurious operation of the former of
tptte are more convincrag than those yet fur-
"»^ in respect of the latter, yet facts are still
wanting to render the evidence in support of it
coanplete. After a personal examination of many
of the localitieB both vrithin and without the
l^pics, to which certain pestilential epidemics
*»ava been altogether ascribed by many writers, I
^"not come to the conclusion, that, under cir-
comirtancea of the kind just stated, these localities
coold ever, of themselves, produce the very
Jteneral and fatal efiecto characterising these pes-
">«nces; that even the warmest sun, the stillest

atmoaphere, and the longest absence of thunder-
storms, which observation has ever shown to have
occurred— > the conditions so strongly insisted
upon bv these writers,— could generate from
them miasms of so noxious a nature as to occa-
sion, by their unaided action, such pestilential
epidemics as have occurred in various parts of
America, and the south of Spain. That endemic
sources of disease, especially the situations alluded
to, give out miasma when foi^ acted on by a hot
sun ; that these miasms often become concentrated
in a humid and calm atmosphere, or after an*
tumnal showers; and occasionally are aided in
their operation upon the human frame by the
electrical states ot the air ; may be admitted ; for
an increased prevalence, and a more severe form,
of fever are often observed in these situations, on
such occasions. But after the most careful con-
sideration long bestowed on the subject, and after
a patient enquiry into the facts recorded, I cannot
believe that these exhalations are the only, or al-
ways the chief, cause of these epidemics. That
infection is a primary agent in the propagation of
the disease, and that an infectious miasm is gene-
rated by tbe sick, cannot, I think, be denied by
the candid enquirer into all the facts connected
with the subject. But 1 believe that, without the
physical changes and the consequent emanations
alluded to, or some other concurrent causes, the
infection would not extend through the commu-
nity, as these emanations, floating in the air, dia«
pose the system to be impressed by the infectious
principle, or otherwise aid its operation ; or, in
circumstances where the terrestrial exhalations
have already produced much disease, the miasms
from the sick become a superadded cause, in-
creasing the severity of the epidemic as well as
the rapidity and universality of its spread. That
an infectious principle is concerned tnus primarily
or consecutively in the production and propaga-
tion of pestilential epidemics, according as it may
be introduced from some other quarter, or gene-
rated by those first affected, appears fully estab-
lished by numerous circumstances independently
of various considerations derived from the nature
of the particular epidemic, and of the antecedent
and consecutive disorders, especially those en-
demic to the place in which it breaks out. Of
^ these considerations, the following seem not the
least important.

43. a. The localities to which certain epi-
demics, as yellow fever, are chiefly confined, have
been, for many successive years, circumstanced,
in respect of season and weather, similarly to the
periods in which that disease has been most de*
structive ; and yet the common endemic of the
country only hss been observed, in the form it
usually puts on in that particular season.— 5. True,
or epidemic yellow fever, differs not merely in de-
gree, but also most essentially and in kind, from
the endemic fever of these localities ; conseouently
the former is not merely an aggravateJ state
of the latter, — the one disease is as different from
the other as small-pox is from measles. — c. On
all occasions on which the non-infectious proper-
ties of yellow fever have been argued for, the
bilious remittent or severer forms of endemic fever
of low situations in warm countries, and the ardent
or seasoning fever of Europeans who have lately
arrived within the tropics, have been assumed as
identical with that malady. 1 his error has arisen

780

EPIDEMICS— OENERilL iKrEBEKCU.

from the occasionally yellow appearaDce of the
skin in the bilious remittent, and the dark or coffee
ground vomiting sometimes seen before death in
it and in the ardent fever. But these changes
are not the same, even in the cases where they
are most prominent, as those in the true yellow
fever; and, as shown in another place, are
owing to very different pathological states. —
d. T hat the very essential difference between these
diseases indicates tjieir different origins; and a
speciality of form in the various quarters where the
epidemic malady has been observed, equally de-
notes its source in a speci6c cause.— •«. That
diseases which arise from terrestrial exhalations
present numerous modi6cations, forms, and types ;
have all a tendency to relapse, or to return in some
form or other, upon exposure to the exciting
cause; and always occasion marked derange-
ment, and ultimately organic change, of the liver,
spleen, or pancreas, or one, or all : whereas the
true or epidemic yellow fever^ independently of
the most irrefragable proofs of infection, possesses
all the attributes of infectious diseases ; attacks
the frame only once, as shown by the most un-
questionable evidence, British and foreign, derived
from the epidemics of Spain and America ; and
leaves no organic changes of these viscera as
'sequelae, even of its most malignant state. —
The manner in which the very different diseases
DOW referred to have been confounded the one
with the other, by those espousing the non-infec-
tious nature of yellow fever, whether from igno-
rance or unfairness, has led to the most senous
consequences to the community ; has misled the
inexperienced, mystified the subjects in dispute,
furnished grounds for a special pleading sort of
argumentation, and, as will be seen in the articles
FsvER and Inpectiov, endangered the safety of
fleets and armies, and even of kingdoms.

44. IV. General Inverences. — a. CivilU'
ation exerts a most decided influence in diminish-
ing the frequency and mortality of epidemics,
especially those that are fatal or pestilential,
as shown by their history at different epochs,
and in different countries holding various grades
in the scale of civilisation, — an amelioration evi-
dently due — a. to a better cultivation of the soil ;
to more extensive commerce, and, consequently,
to the less frequent occurrence of great scarcity,
and to the improved diet and circumstances of the
lower classes in most European countries, in
modem times ; — B. to a favourable change in the
manners and habits of the middle and lower
classes, particularly in regard to cleanliness,
social intercourse, and domestic arrangements;
and to better ventilated and improved dwellings ;
y, — to superior care in the separation and treat-
ment of the affected; and to stricter measures
for the prevention and counteraction of infec*
tion. Owing chiefly to neglect of these circum-
stances, the lowest classes, and the most
wretched amongst these classes, are most fre-
quently attacked — the mortality being also the
greatest among them in proportion to the number
affected.

45. fr. Different aget are not equally affected
by epidemics. The exaothematous fevers and
hooping cough are most prevalent among, and
fatal to, infants and chiiaren; influenza, to the
aged and debilitated. Continued fevers, in ady-
namic and malignant forms, attack chiefly per-

sons from fifteen to fifty ; but are Icsi laiai to
them, than to those of earlier or later ages. Plapc
most frequently seixes adult penoos ef eaHv or
middle life, and generaUj males in aemcwkai

greater numbers than femalea,— - probably e»iDc.
in part, to more exposure, at tUi aga, aad of tbi
male sex, to the predisposng caoaei aod la iaSac-
tion. Yellow fever attacks chiefly tha yaaogaad
middle-aged ; but aparcs odIt tboae who atw
passed through it in former eptaesaiea. Pesiilea-
tial cholera, on the other band, doa» oot so cAbc
attack persons about puberty and the mandiu «-
life, as those that are aged and exhaaaied ; md 4
is usually more fatal in the latter than ti«
former. When an increased activity of cadravc
causes produces epidemie ievera, joaag «:'-
dren often suffer very remarkably ; aaid the BialB<r>
assumes in them, gastiie, cholefie, er djaaaev
forms.

46. c. The morimlUjffrem dkmtm, vhn Ihn
first appear in an epidemic torn, is asaally «<»
great; but diminishes with the freqeency oif tW^
recurrence, especially those wlucli
up ^nce Uie early history of our
which are of a contagious or i
This has been the case with
measles, syphilis, small-pox, and nay probsti
be so with pestilential choleia. It

manifest with regard to pestilences appcsiac
after long intervals : but these are nsaaUy nv%
more fatal at their eommcncemeBt,or derisg th?.
early course, and less so at thenr diylm^ T"'
first introduction of small-pox, atyphihs, Xc
among savage tribes, has been as desiracovc v
the pestilenoes that occurred in the middle apc«.
This can be explained only as briefly scaie4 thtm
($30.).

47. d. Ai to the influemet ef e^
Uit\ont it may be inferred, that the
valence of certain maladies, which fonnaly t«^
epidemically, is in some respects coiapiiWK
by the greater frequency of other diseaac*. hr-
meily of rarer oocuireooe ; or the appeenanr r*
some previously but little or not at all kBowa. — «
Since the introduction of vacionalioo, saail-ps
has rarely prevailed to a great or fetal cxtof
but scarlatina, measles, croap, inflammatioa* ^
the bronchi and lungs, and eerelnml aiecf*
have evidently increased. The benefits, thcR^m
of vaccination may be said to be somewhat e««*-
ratcd. It is remarked by M. Say (Csurs eme^
de Ecotwmu P9Utifne, t. iv. p. 385.), *« Whea «
hear it said, that by saving a bandrad
lives, vaccination has aA&d a buadred
souls to the population, we may smile at the
whilst we applaud the discovery.** M«^«
lee ME has deduced from his researcbsa. fbr
in populous countries, aad partSeaWv ■
large towns and cities, sod in the '
small-pox is fully replaced by
of other dangerous diseases ; but in dirtrirs is
nishing sufteient sabMsteoce and soope fer *
creased popubtbo, and in the higher
this compensatioo is hardly or bat
observed* Indeed, all presenrative i
against the disesiscs of talaacy act
larly,— -in suppressing one cease eC
we more or less increase Ihs activity cf
rest.

46. 0, In civilised countries, ipilsaiir*
though attended by a very great nortahty* •« ^

^

•'•

EPIDEMICS— GsNSRJiL Imfeiisnces.

781

temporarily diminish the population ; for it is
uaitormly obflerved, that the void 'm filled up,
during the neit few years, by a much greater
inoMl average of marriages and births, and by
to iofluz of strangers from other parts, the mor-
ulity leaving more abundant means of subsist-
ence for those who have escaped. Destructive
epidemics are most frequent m low situations
and crowded cities ; and epidemics of a slighter
kind and commoner form often occur in these
and other districts abounding with malaria ; and,
wliether they be aggravated forms of the usual
endemics, or infectious fevers, &c., they all in-
directly tend to augment the number of marriages
and births, whilst they increase the deaths and
diminish the mean duration of life. These re-
fcultsare evidently owing to the more abundant
meaos of sustenance and employment furnished
by these places, than by mountainous and barren
districu; and to the influx from more healthy
parts ; the excess of deaths over births being sup*
plied from the latter source. The fol lowing statistic
return, furnished by M« Bossi, prefect of the de-
partment of the Ain, in France, and which he
has divided into four zones, according to the na-
toK of the locality, illustrates this statement, and
sImws—

1

r

1 Death
anDOAUr
to Inhab.

iMvr.
•nnaall*

to InlMD.

179
145
133
107

IBlrth
•nmallv
to Inhao.

In the hUlT dutricU -
Alone banks of rivers, Ac.
In cuTtiTftted grounds -
In nurthy placet, Ac. -

3S-3
S6-6
24-6
20*8

34*8

27-5
96-1

[For the Pmtntion of Epidemics, see ari. En-
demic Influence ($ 20.) and Infkction.)

BiBLioo. AND RarsB. —Hippocrates, Ut») *Uih *A».
IfWw, Mct. xii. ei teq^ toI. L pi 270. ; et 'Ewtin/uSf,
ol. l p. 653. edit Vamder Linden. Lu^d. Bat. 1665. ^
Vj&aifM, Synop. 1. vL c. 24. — Joann. Canfacuzen, Hii.
or. I. IT. c. 8. eifit. Furia, p. 730. — Gentiiis de Pulgnuo,
^Milia, De Pesle, of»nail. i. U. pp. 7(5, 77. VeneL 1514. —
'A'cazzo di Samto SqAa, Liber de Febribus, fol. Venct.
^U. {He first distnuuisked epidemics from endemies^
^nted oni Aeoriffin ejtke laUer m local UUurie changes ;
•^ rtjerred tke/ormert v4th petlflcnces, to an unknown
ftannforcorrmpiion qfthe air.)— Chalin de Finario, De
"nte Liber, purm Latinitate donatus, k J. Daleehampio.
Aid 1552. ( jUaerU boldly and truly '« that aU epidemie
'urates may become contagioMs^and aU/e9ersepMemie.**)
1-19.— Guidon de Ckauliaeo, Tract xL c. 5. p. 1 la ed.

Mf6. 1572.~iirMralor/, Script. Rer. Ital. vol ill. p. 556

/. A. Florio, Delia Natura de Mali Epidemici, e Modo dl
:urargli, 8»o. Ferrar. 1687 — Femelius, De Abditii Re-
m Cauiif, cap. 13,— T. Farina^Jlut et Occasus Morb.
•tMem. 18mo. Rom. 167SL — F. Gouel^ Ergo in Acutit
lorbii ^demicia COoftitutioniamaximehabenda Ratio
It, 4to. Pari*, IG92. — Sydenham, 0|ierA, et Lugd. Bat
ro. 17SR, passim. — He Heredia, Comment. In Lihros

Itppocrati* de Morb. PoptiL fol. 1688 Mexerav, His.

»rc de France, fol. Paris, 1685. t ii. p. 418. — Barnes,
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Morbia Biliosis Anomalis, ab Anno 1776 ad 1780, &c
12mo. Westph. 1780.— G. Fan Swieten, Constitut. EpU
dcm. et Morbi potissimum Lugd. Bat. OUervati, «c.
edid. M. Stall, 2 vols. 8vo. Lips. 1782. — IV. CoUy, Ac-
count of the late Epidemic Ague in Shropshire, 1784.
Lond. 8vo. 1785. — M. StoU, Rat. Med. passim, et vol iv.

SI 63. 82. 8a &c.— J. BoederermC. G. tVagler,TTsuct'. de
orb. Mucoso denuo recusus, Ac. 12mo. Goet. 1783. ;
Description des Epidimiesqui ontregn^ depuis quelques
Annies dans la Oener. de Paris, avec la Topograph. Ac.
publi^e par Ordre de M. i'lntendant de Paris, Ivo. 1783. {
et Journ. de M£d. t. Ix. p. 289. — Lebrun, Sur les Mai.
E^id. et de les Privcnir, 12mo. Paris, 1784. — Betx,
Precis sur les Mai. Epid^miques, 12mo. Paris, 1787.— ^
Bttumond, Sur le* Epidemics, et quels sont les Rapporta
de Mai. Epid, avec celles qui surviennent au mime Tempa
et qu'on appelle Intercurrentcs. Ac. in M£m. de la Soc.
Royale de MM. t. iv. p. 86. Paris, 1785. — Carrire, in
Ibid. t. iv j>. 215. — Fan der Mye, De Morb. Pc^ular.

Bredanis, Tempore Obsidionis, Ac. 8vo. Jenc, 1792

Hopfmgartner, Beytr. sur Allgemeinen und Besondem
Tbeorie der £pid. Krankh. Ac. Frank. 8vo. 1795. —
PriestleyAn N. Y. Med. Repos. vol. v. art. & — F. Fer*
nandex, Tratado de lai Epidemias, 4to. Madrid, 1794. —
A. F. Hecker, De Constitut. Epid. ex Mutat Corpor.
Humani, Ac. 4to. Erf. 1791. — JBHrdocA, Comment. In
Uippocraiem. de Morb. I^idemicis. Lips. 1798— ilHim-
retth, Versucne fUr die Pratiache Heilk. st. i. p. 86. —
U. LudoUTt De Morb. Epidem. Oeneratione ab ASre
Vitiato, 4to. Erf 1791— ft^'eise, De Causis Epid. Oene.
ralioribus, 4to. Halae, 1797 — Kramer, De Constitut.
Epidem. Acrisque in Morbor. Diagnosin, Ac. 4to. Jena;,
1799.—^. Schraud, De eo quod est in Moib. fi>id. 4to.
Pest. 1803.— ^iNiA Webster, A Brief History of Epidemie
and Pestilential Diseases, with Princip. Phenom. in the
Physical World which precede and accompany them,
2 vols. 8va Lond. 1800— J. De Fillalba, Epidemlologl«
Espafiola, o Ilistoria Cronologla de las Pestes, Contagios,
Epidemias, y Epiiootias que han acaecido en Espafla
desde laVenidade los Cartaginirses hasu el Alio 1801.
Madrid, 1803. — it. //oa«<r. Observat. on the Epidem.
Diseases now prevailing in Lond. Ac. 8vo. Lond. 1803.
— F. Schnurer^ Mater, su ciner Allgemeinen Naturlehre
der Epid. und Coiitagionen, Svo. Tubing. 1810.— Horn,
Archiv. May, 1809, p. 94 — Penada, Saggio d'Osserva.
cioni, vol. iv. et v. — J. Adams, An Inquiry into the
I^ws of Epidemics, 8vo. 1809. — tVUlan^ Reports on the
Dis. of Lond. from 1796 to 1800 ; and Bateman, Reports on
the D is of Lond. and the SUte of the Weather, tntok 1804
to 1816, 8vo. Lond. 1HI9. ; also art. Epidemic, in Bees*u
CycloiMBdia. — G. Blane^ in Trans, of Med. and Chirurg.
Soc. vol. iv. pp. 89. 145 — Uaquart^ in Diet, des Scieocei

I Med. t. xil. p. 467 J. A. F. 0%anam,H\tX. M£d. des Ma.

ladi^ Epidemiques, Ac. 5 torn. 8va Paris, 1817— Finke,

j in Journ. Univers. des Sciences MiA. t. xiii. p. 58 De

I Peyrelongue, in Ibid. t. xxvii. p. 47.— Poureault, in

; Ibid. t. XXV. p. 2.57., et t xxvi. pp. 5. 129 — T. Hancock^

I Researches into the Laws of Pestilence, Ac 8vo. Lond.

1S81. — JmssIs, Causes des Malad. Epidemiques, Moyens

I d'y r#m6dier et de les pr^venir, Ac. 8vo. Paria, 1822.

\ — F.E. Fudert, Lemons sur les Epidemies et I'Hygltoe

I Publique, Ac. 8vo. 4 tomes. Paris, I823.1824. (Avery good

I toorh.) -' Speer, in Dublin Hosp. R«K>its,voL ill. p. 161.

I — Maclean, On Epidemic and Pestilential Diseases, 8vo.

1817, 2 vols. ; and Evils of Quarantine Laws, and Non.

I existence of Pestilential Contagion, Ac. 8vo. Lond. 1824.

; ( fVorks on which little reliance can be placed, as rejects

either the statements they contain, or the medical knowledge

I they betray.)— C. Ferrus, in Diet de M€d. t viii. p. 185.—

Smith, EleroenU of the Etiology and Philosophy^ of EpU .

demies, 8vo. New York, 1824 — DoUemann, Disquisi-

tioncs Historiccde Plerisqucapud Belgas Septentrionales

grid. Morbis, 4to. Amst. 1824. — iffu/ra/, in Diet, de
M, et Chir. Prat. t. vil. p. SiSL. — Bayer, in Archives
G^n^r. de M^d. t iv. p. 477., t v. p. ft® — Auetor. Va-
rii, in Ibid. t. xil. pp. n96. 652., t xiv. p. 446., t xv.
: p. 276., t. xvii. pp. 76. 131. 248. 453., t. xvlA. pp. 122. 2S2.
) 310. 45ft. fi96. — P. a* Manta, De I^idcmus maxime

EPIGASTRIUM— PuLtAnoii m the.

783

nd, in od« at lM$t, there, are bi^pea of recot ery.
Tamonr ia this regioa may be occasioned by
great disteDBioo of the gall-bladder with bile,
bwn obitnicUoii of the coasmon duct ; but, in
this case, it is more circumscribed and distinct
tiiao io abscess of the liver, is unattended by any
appesrance of inflammation of the external pane-
tes, is often pyriCorm, and situated at the lower
part of the region, and to the right, fluctuates ob-
Kurdy, and often dinppeam after appropriate
poiipUTes. Swelling of this part, in lean per-
ioos, may alao be occasioned by enlarged or
idrrhoos pancreas, more rarely by distension
of ihe dnocEenum, and not so often as is supposed
bj tttmoun about the pylorus, because, when
they are sufficiently large to distend this region,
they generally draw this extremity of the stomach
below, ami to the right of it. Fulness of the
cpigistrium is seldom occasioned by distension of
the coioB with flatus, or accumulated feces, or by
ealirged spleen, or by the effusion of fluid, until
after the swelling has appeared to a very consider-
able eiteot in the adjoining regions ; and then it
is groUest at the lower part.

4. iii. PuUatUm in the Epigattrium arises from
the following causes: — «. Nervous susceptibility
tod irritation ; — b. Inflammation of the aorta ;
—c. Aneurism of the aorta, ooaliac, or superior
neieDteric artery ; — d. Adhesion of the peiicar-
diutn to the heart ; — «. Tumours at the root of
the meienteiT ; — f. Tumours of the stomach, and
icirrfaus of the pylorus ; — g. Enlargement of the
pancreas ; — k. Hypertrophy of the heart, parti-
ealarly of its right side ; — f. Eolargement of the
vena cava inferior ; — k. Hepatisation of the
iower portion of the lungs ; — L Enlargement of,
or abscess in, the liver. On the chief of these I
shall ofler a few remarks.

6. a. Nenmu pulmtian of the aorta and coe-
liac arteries is not infrequent. It comes on snd-
deoly ; and often oonlioues long, chiefly in hyste-
rical females, and hypochondriacal men, whose
Benroiis system and digestive oi^gans have been
long debilitated or otherwise disordered. It is
geoeraliy stronger in the morning than in the
evening. Dr. Bailub met with a case that re-
mained for many years. Dr. Valxntxnb Mott
states that of a lady, in whom it occurred as a
certain sign of pregnancy ; but usually left her
after the third month. I have seen it so violent
that the pulsation could be observed through the
dress, ana the patient insisted it could be heard
at some distance. (See Aorta, § 2. tt teq.)

6. 6. Aiuuriau of the aorta and large arteries
nsy occasion pulsation in this region ; but they
fre<{iiently have proved fatal without this symp-
tom being noticed ; and, where it has been re-
marked, Uie pubation has not been strong. Mr.
A. BvBvs states, that aneurism of the cceliac ar-
tery is rarely • cause of this pulsation ; and that,
in about twenty cases of pulsating tnmoun in the
region of this artery, not one of them turned out,
upon dissection, to be disease of this or any other
artery. (See Aorta, § 44.)

7. c. Adhtiion of the pericardium to the heart,
is sometimes a cause of pulsation ; and that it
should be, is obvious. Dr. Morr thinks it one of
the most frequent causes. Dt, Hopb describes
the pulsation as peculiar, and distinguishes it by

8. d. Tumcur$, from enlaT|eement of the
glands at the root, or in the dupiicatures, of the
mesentery, are productive of pulsation when they
become considerable and press upon the aorta, or
coeliac or superior mesenteric artery. A case of
this description is described by Dr. Albers. In
a person whom I attended some time ago, and who
had become very emaciated, a distinct pulsation
in the umbilical region arose from this cause. In-
deed, the pulsation, when thus produced, is rarely
so high up as the epigastrium, and is sometimes
felt in both regions.

9. «. Tumourt developed in the tt4maeh, or at-
tached to its villous coat, and scirrhus of the
pylorus, have been noticed, by Bailub, Bubns,
Monro, Francis, and V. Morr, as occasionally
aftended by pulsation. I cannot, however, agree
with the last writer, in thinking that " the obstruc-
tion to the free passage of blood through the
hardened" and enlarged parts occasions this
symptom ; but believe that, when they press upon
or come in contact with, the large artenes, especi«
ally the aorta, the pulsation is necessarily propa-
gated to the external situation in which it is felt.

10. f, Eniargiment of the panereat, or of the
liver, is probably more frequently a cause of epi-
gastric pulsation, than tumours connected with
the stomach ; the enlarged and indufated viscus
transmitting the pulsation of the aorta, as just
stated. This cause has been noticed by Burns,
Warren, V. Morr, Portal, and myself. Dr*
Sewbll considers that an enlarged pancreas is
always accompanied with pulsation at the epigas-
trium. I think that such is not the case ; and
that, generally, the disease must be far advanced
before this symptom attends it.

11. g. or the other causes of pulsation at the
epi^strium, I need only remark, that cases, in
which it has been occasioned by enlargement of
the vena cava, are mentioned by Sbnac and A.
Burns. Dr. Pbmberton thinks that the flutter-
ing, sometimes felt at this region, is produced by
congestion of the vena portamm, and the undula-
tion communicated to it. Pulsation from hepa-
tisation of the lower margin of the lungs, has been
observed by A. Burns and others. Bertin»
BouiLLAUD, and myself have noticed this as a
symptom of inflammation of the aorta. (See art.
Aorta — Inflam. of.) Its connection with hy^
pertrophy of the heart, particularly of its right side,
requires no remark.

12. iv. In examining the epigastric region,
pressure should at first be very gentle, gradually
increased, and be made in various directions.
When the heart is diseased, it should be directed
under the anterior cartilages of the upper false
ribs ; and, according to the situation of other or-
gans or parts suspected of disorder, the pressure
ought to be directed. When the patient almost
involuntarily throws the muscles underneath into
action, upon commencing the examination, acute
disease of some part or other may be suspected.
The state of the surface, in respect of moisture,
temperature, softness, colour, &c. ; and the sensi-
bility, the elasticity, the degree of depression, ful-
ness, pulsation, &c. of this region ; are equally
deserving of notice. In diflicuU or doubtful cases,
pereuuion, particularly if aided by Piorry's plexi-
meter, will be of service in giving information as

theepithets jogging or trembling; it is synchronous I to the presence of air, or of effused fluids, or of
with the louiidB of the heart. (See PaRscARPiuai.) ] enlargement of the subjacent viscera.

788

EPILEPSY — CoNSEQUBKCxa and Txbminatxoiis.

Mai of French writers — are very varied in cha-
racter. They often precede, for months or years,
the full evolution of the severe form of the dis-
ease. Generally they consist of loss of conscious-
ness, and slight rigidity, spasm, or convulsions of
a few muscles, or of one or more limbs, which
continue only one or two minutes. In still
slighter cases, the patient is seized with vertigo,
loss of consciousness and sensation, and muscular
collapse or slight spasm of a few muscles, and is,
after some seconds, completely restored. In some
instances, the eyes of the patient become fixed
and vacant ; he attempts to articulate, but is un-
able ; loses consciousness for a very few seconds ;
and, upon recovering it, takes up the thread of
discourse which the seizure may have interrupted,
and endeavours to conceal the occurrence. Occa-
Bonally the slight seizures very nearly approxi-
mate those of hysteria, or are associated with se-
Teral hysterical symptoms. In many instances, the
patient does not fall to the ground, although he
may have been standing at the time of attack ; and
in others, consciousness is not entirely abolished,
the patient retaining a vague recollection of what
passed in the seizure, upon recovery from it, as
after temporary delirium or dreaming. These
slighter fits may recur either frequenUy or very
nrely, but they commonly return after short inter-
vals, sind sometimes as often as several times a day.
14. D, Of the intervalt between the paroxvmu.
— After the fit, the patient complains of lassitude,
of soreness of the limbs and of parts that have
been injured, and is pale, sad, and fearful of its
return. la some severe cases, the face is studded,
particularly about the eyes and temples, with
numerous small ecchymoses arising from minute
extravasations from the extreme capillaries of the
rete mucMum during the congestion to which they
had been subjected in the paroxysm. In rare
cases vomiting or purging of blood is observed,
owing roost probaoly to sanguineous exhalation
from the congested capillaries of the digestive mu-
cous surface. Sometimes paralysis of a limb,
more or less complete, or strabismus, or even ir-
regular movements or convulsions, or various Qial-
lucinatioos follow the severer attacks, and continue
several hours, or even days. In a case to which
I was very recently called, paralysis of the left
arm, and severe pain in the right eye-ball and
temple, continued after the fit — the former for
some hours, the latter for several days. Deaf-
ness, vratchfulness, terrifying dreams, slight or
passing delirium, occasional couvukive move-
mento (Arbtaus, &c.), and fits of absence
or forgetful ness, often afflict the patient, either
for some time after an attack, or during the
whole interval. Between the complete parox-
ysms, as well as before their evolution, the slight
seizures described above {§. 13.) in one or other
of their forms --- sometimes so slight ss to amount
merely to vertigo with momenUry loss of con-
sciousness, or spasm of some part — the Vertige
EpiUptique of French writers, are very common.
Various signs of mental alienation often appear,
which generally become more and more remark-
able after successive, more frequent, or severer
attacks, until insanity is the result. Epileptics
commonly experience, daring the intervals, vari-
ous dyspeptic disorders ; but their appetites are
usually very keen, and seldom duly restrained.
J. Faank states, that he has seen persons sufiTer

little disturbance after a fit, and othen iadkj
increased activity of both mind and body, oaiu tti
approaching return ; but this is a laie excnCM ;
the great majority, even of those who sana tk
least, being meapable of devoting thcnselvei i»
any undertaldng with attention ami penevtnaet

15. II. CoNSSQUsvcBs Axo TaaMaiAnoiii. —
Persons long afflicted by the disease, giadoaSy
acquire a peculiar nhysiognomy, owing ts the I^
peated di^nsion of the vessels of the hesd, tod
to the frequent ^Mstic and ooavalsive aciisK di
the muscles of the face during the funjmf.
This is particularly the case in such as sit id<
dieted to masturbioion — a banefal pncticevhicl
is common among epileptics, and, indeed s pns-
cipal cause of their malady. This ilientJos oi
the features has been nodced by Aattxov wii
mentions their pale or leaden compkiioa, ssri tSftf
languid dejected look : but Dumlas and ENriin:
have descnbed it most accurately. Ths iadiridu:
features become coarse ; the lips thick i the U «cr
eyelids swollen ; the eyes unsteady, fuU, ssd pt%>
minent ; the look vacant ; the pupils dilsied : :k
cheeks pale; the finest countenaooei plsis; Ae
muscles of the face subject to twitchiags, or vj^
convulsive movements ; the arms and limbi thimtf
than the rest of the body^ ; and the pit jtnM
The functions of oiganic life likewise m^y^
obesity or emaciation being a commoa i««^-
When the disease appeare or oontiaiMS ths
pubertv. or the fits return fr«qaently, the siab.
as well as the bodily powere become grestly •*-
paired. These conseouencea are, howercr. 4
some respects connected vrith the stales of Dcr\«*
function, and the circulation within tkc ^mi
directly producing the seizures ; the pstbokfio.
conditions, which, at their commcncemeat, tad u
slighter decrees, occasion the epilepcic teaa^
giving rise, m their advanced course lad be^*
ened grades, to various associated Bsli^
After the continuance of the itistssi, the pt^t.
is at first listless, incapable of eotfgcne ti
ertion, and sometimes hypoehoodriacsL Ht *
liable to attacks of stupor, and conplsiv *>
lassitude, flatulency; or various ferns of c
digestion, generally attended by a craviog ipp^
tite; of great torpor of the bowels; of ««<<
and tremors, &c. He is subject ta dcsflMv
amaurosis, and, in prolonged cases, to imgu*
muscular contractions, or paralytic trenor. -
partial paralysb or complete bemiplepi, to '•'
perfections or even loas of speech, to i^ftf^^}
to melancholy, to partial or complete, or lo im^
mitlent or continued insanity, and to Bsais ik
idiotcy.

16. Notwithstanding that epikpsy se)J^
passes into the apoplectic state, until sfhr *«~
peated fiti, yet both maladies may be amicnir
10 the very first seizure. (See § 40.) bstf/;
and mania, although not geneially ^ff^'^
until after several or many attacks, are vj «
the most frequent consequences of epilcp? » ^'
I believe much more so on the CoiDbBCst ^
in this country; whilst apoplexy and psr^!*
ofteoer supervene here than them Vtjt >«^-
TXN states, that penons who have beeoBM no*
at an early age, have been generally fiist cpl^
EsQuiROL has come to a similar ooocloM »•
my experience oonfiims it ; the sctsaits. ^•**-
ever, having been sometimes of an ine|«ltf ^'
vulsive kind, rather than those of tne cpdq*?- ^*

EPILEPSV— Causm.

789

tMs freqaent class of cases, tbe mental faculties
ire gndnally impaired; sensation and memory
ire weakened, the former being often acute;
perception and imagination perverted; various
daUacinations generated ; and the patient lapses
into ft state of mcnrable insanity or iml>ecility, or
panes from the former into the latter. The more
severe the fits, tbe more is this result to be
dreaded. Sometimes violent attacks of mania
follow the paroxysms. Of 289 epileptics in the
Saltjtitriere, in 1813, 80 were maniacal, and 56
in various states of mental alienation and imbe-
cility. In 1822, out of 339 cases in the same
hospital there were two monomaniacs, 30 maniacs,
34 fnrious maniacs, 129 insane for some time
after the paroxysms, 16 constant! v insane, 8
jdbtic ; 50 upon the whole reasonable, but with
impaired memories, and liable to occasional slight
delirium, and tendency to insanity ; and 60 with-
out aberration of intellect, but susceptible, iras-
cible, capricious, obstinate, and presenting some-
thing angular in their characters. As this
institution receives chiefly old and severe cases of
epilepsy, it furnishes sufficient illustrations of the
consequences of this disease. Occasionally the
epileptic mania alternates with melancholia and a
desire to commit suicide ; the mania often preced-
isg tbe paroxysm: Dr. Chetne states tnat he
bas koown epileptics preserve their iotellects to a
veiy old age ; but this is only the exception to
tbe general rule, for they seldom live to a
great age, or retain their faculties when they
reach it

17. The duration of the disease is most uncer-
tain Bod various, and depends upon numerous cir-
comstances connected with the regimen, habits,
and treatment of the patient. Epileptics are roost
injuriously addicted to the indulgence of the ap-
petiteF for food, and for the sex, — practices which
should as much aa possible be guarded against,
as tending qot merely to counteract the good
effects of treatment, but also to induce the un-
favourable consequences of the seizures enu-
neiated above. A favourable termination is
indicated by the fits being slighter, shorter, and
more distant. Sometimes a marked crisis occurs
7-as the return of a suppressed evacuation, par-
^larfy the menfltrual and hemorrhoidal fluxes,
epistaxts,,&c., the reappearance of a repelled
eruption, ficc. An attack of continued fever has
removed the disease,-^ but very rarely when it
lias become confirmed. M.'Esquirol states that
>n 1814, when typhus fever rag^ in the Salp^triere,
although upwards of fifty epileptics were attacked
by it, and but few died, little or no amelioi^tion
*S8 observed in any.

16. A person subject to epileptic fits may die
of other diseases, or of a malady proceeding from
aa increased grade of the same changes, which,
io a less degree, occasioned the fits ; or of the
direct or indirect efiPects of the repeated seizures ;
death taking place sometimes in the intervals,
but more firequently during the-paroxysm or soon
afterwards. When it takes place in the interval,
(t is occasioned by the remote effects of the fits,
n connection with the pathological states inducing
them — by tome one of the diseases consequent
upon them ($ 38. et MfO* ^^ i^ occur during or
ioon after the paroxysms, it is generally owing to
in augmented degree of the same changes
isutlly producing them, or to some further alter-

ation directly proceeding from these changes;
either apoplexy caused by excessive congestion
within the head, or by extravasation of blood in
some situation, or by effusion of serum in the
ventricles or between the membranes of the
brain ; or asphyxy occasioned by similar lesions
affecting the medulla oblongata and upper part
of the spinal chord, being the immediate cause
of dissolution. It has been supposed, that suffo-
cation often occurs in the paroxysm, owing to the
position of the patient, or of the clothes around
him when in bed. But this, I believe, rarely
takes place; and when suffocation, or rather
asphyxy, is met with, it is caused chiefly, if not
altogether, by some one of the changes just
stat^.

19. Ill, Causes. — i. Predisponent, — Heredi*
tary di$poiition is a remarkable predisposing cause
of epilepsy, notwithstanding this kind of influence
has been disputed in respect of it. But although
the father or mother of the patient may never have
had an attack, either of the grand-parents, or
uncles, or aunts, may have been subject to it.
Zacutus Lusitan us (Prax. ad Mir. 1. 1. obs. 36.)
mentions the case of an epileptic man who had
eight children and three grandchildren afflicted
by the disease. Stahl (De Hatred, Diipot, ad
var. Affect, Hals, 1706, n. 48.) and Reiningek
adduce instances of the whole of the members of
a family being attacked bv it at the period of pu-
berty. BoEBHAAVB (Apkonsmt, 10/5.) remans,
that, like several other hereditary maladies, it
often passes over alternate generations; and he
adduces an instance (Prax. Met/, t. v. p. 30.) in
which all the children of an epileptic father died
of it. I had, in 1820, a brother and sister some
time under my care, who inherited the disease
from their father, and they had two other brothers
and one sister also subject to it— in all five. The
fits appeared in all of them about the period of
puberty ; and one of the brothers died about the
age of forty from apoplexy, complicated vrith the
seizure. MM. Boucher and CAaAuviExui state
that in 110 patients, respecting whom they had
made the enquiry, 31 were hereditary cases ; and
M. EsQuiROL found, that in 321 cases of epileptic
insanity, 105 were descended^from either epileptic
or insane parents. Predisposition is often con-
nected with congenital formation. I have seen
the disease in several children, whose heads were
of an oblique or diamond shape, or otherwise ill-
formed ; one side being more elevated than the
other, and either side advancing or receding.
Peculiarity of constitution, or idiotyncraty, seems
to predispose to it, as well as the epochs of ehild^
hood and puberty, at which periocU the nervous
and muscular systems are endowed with their
greatest sutn of sensibility and irritability, and
the whole frame with great susceptibility. Cases,
however, often occur, in which these properties
are rather diminished than increased. After pu-
berty is fully attained, the disposition to the disease
is greatly lessened.

20. The influence of MX is not remarkable ; and
is not manifested until after the second den-
tition. According to Esquirol and Fovillx,
females are more subject to the disease after this
epoch than males. At the end of 1813, 162
male epileptics were in the Bicitre, and 289 female
cases in the SalpStriere, J. Frank found, that
of 75 patients, 40 were females ; but he agrees

3 £ 3

EPILEPSY — PaooNOSKi ^ Tabatmsmt.

799

continued or lecitirent; are more irregular io
their couiae ; and are acoompauied with more or
lew fever, loss of appetite, and ofteo with thirst ;
whilst the latter is less frequent, more periodic,
and attended by much leas disorder of the digestive,
circulating, and asnmilating functions; the one
being anocultft the other a ehnmie, malady. —
(d) In fine, epileptic seizures may be readily dis-
tingvaahfld from all others by — 1st* their com-
mencing with a scream, and sudden and com-
plete loss of seasibiUty ; 2d, the spastic rigidity
of the affected muscles in the first stage ; 3d,
the coBTulfliona being more tetanic than clonicy
unless in severe cases oontplicated with apoplexy ;
4th, the foaming at the mouth, distortion of the
features, and lividity of the oountenance; 5tb,
the pri^Msm and unconscious discharges ; 6th, the
injury sustained by the tongue ; and 7th, the con-
sequent sopor, or mental aberration. The diagnosis
of rcAl from feigMd epilepsy is considered in the
article on Fxignimo Disease.

54. VIII. Pkoonosis.-«- An opinion of the dis-
ease should have reference— 1st, to the recurrence
of the paroxysms ; 2d, to their severity, duration,
and the danger to be apprehended ; and, 3d, to
the nature of the disorder complicated with them.
Of epalrasy generally it may be said, even when the
wnple tiorm, and not very frequent recurrence,
of tne fits indicate no immediate danger, that few
disorders are more intractable, or more liable to
contingent compUcations of a very serious kind.
The danger varies materially in the different
vttritde* and ttatet of the disease, and increases
as the fits return more frequently, as they become
more severs or of longer duration, and as addi-
tional disorder of the nervous system associates
itself with them, — (a) In the simpU forms, the
cerebral symptoms, preceding and following the
fits, are the cnief gwdes in forming a prognosis ;
but what is known of the causes must also be
taken into account. The presence of intense
pain, vigilance, delirium, mania, amaurosis, para-
lytic symptoms, &c., either before or after the
seizure, indicate organic lesions of the brain, and
an unfevourable form of the disease, usually
passing into some one of the complications de-
scribed above. In cases of this kind, considerable
danger is to be apprehended from the paroxysm,
espMially when there is evident plethora. . Here-
ditary piedisjposition, severe injuries of the head,
and the scrofulous diathesis, although not neces-
sarily indicatii^ immediate danger, are also very
unfavourable circumstances.

55. (6) The tympatketie gtaUs, or those associ-
ated with or arising from disease in related organs,
are generally less dangerous than the cerebral
varieties. Of these forms, the roost serious are
the Jfwiai and eardiae ; and the least so, the
fUerine, enteric, and ttomaehic or dytpeptie, but
much will depend upon the amount of disorder
io the respective organs, and jthe habits of the
patient, particularly as to iodoigence of the ap-
petites. When these are under due control, the
fatter three varieties often terminate favourably.
The uterine variety sometimes disappears after
marriage ; but if an attack occurs in the puerperal
states* It is attended by much danger.

56. (e) The etmplieeted varietiet present few
chances of complete recovery, especially the
paralytie and the insane. When, however, the
paralytic symptoms are slight, or pass away soon

after the fit, recovery should not be despaired of ;
and the same ma^ be said of the form attended
by temporary delirium, or by delirium tremeus,
or by temporary mania, or intermitting insanity.
M. EsQUiBOL states, that epilepsy complicated
with continued insanity is never cured. I have
seen complete recovery from the upopleetie variety ;
but this IS a complication also of great, and often
immediate, danger. The intmnsdiots form is
much less dangerous.

57. (d) The fits usually reew most (Vequently
in the cerebral and complicated forms ; and next
in the spinal and cardiac. They are most rare in
the uterine and the nephritic, and in the gastric
and hepatic. Dr. Cheynx thinks that the disease
is most inveterate when it is accompanied with
chronic cutaneous affections. Addiction to mas-
turbation aggravates and prolong it, and often
causes it to pass into the paralytic and maniacal
or insane complications ; but, when it has arisen
from this most baneful and disgusting practice,
and the patient has had resolution enough entirely
to relinquish it, a complete cure will often be ac-
complished. Epileptic seizures from the meta-
stasb of gout or rheumatism, or in persons of the
gouty or rheamatic diathesis, may not return, if
these diseases fix themselves in the extremities.
When the fits arise from the syphilitic infection, a
mercurial course will generally remove them per-
manently. M.CuLLSBisR has recorded several
instances of this.

58. IX. Treatment. ^^i. O/'t As PanKryim.—
The intention is to shorten the fit, or render it less
severe : but this is not easily accomplished ; and
the means usually recommenided for the purpose,
if inappropriately used, may have a very opposite
effect ; and either render the next seizure more
severe, and the interval shorter ; or convert what
would have been a simple, and by no means
serious, paroxysm into a reourring and prolonged
seizure, followed by various unfavourable symp-
toms. ••— Bleeding has been advised in the par-
oxysm; but, unless in the epileptic convulsions
of the puerperal states, or when the fits are
attended by very marked plethora, or cerebral
congeftion, or in a first attack, especially when
consequent upon the suppression of some san-
guineous evacuation, it should be deferred. Be-
sides, it cannot easily be performed in the con-
vulsive stage of the paroxysm, at which time it is
most appropriate. In the just mentioned excepted
circumstances, however, I have directed it with
threat advantage. But in the soporose period of
the fit, it should not be resorted to, unless apo-
plectic symptoms be present. I have seen it, at
this stage, cause a return of the paroxysm as
soon as sensibility had been partially restored.*

• A gentleman, reildtng near Portmen Square, had
been under my oare, la the spring of 183S, for articular
rheumatlfm. He soon recovered, and went out of town.
Toward! the cloie of the year, whilst in Scotland, he had
an epileptic attack ; and was blooded In the arm, and
cupped soon afterwards. This was the second seisare
the first having occurred two or three years before. He
returned to town immediately after this second attack ;
and, when 1 saw him, there appeared no Occasion for
ftuther vascular depletion ; a course of alteratives and
stomachic purgatives was therefore directed. Three or
fbur days afterwards, he had a third seiiure, and was
brought home In the soporose stage of the fit. I did no
see him until about two hours afterwards ; and then a
physician, who had been called In whilst I was sent for,
bad had him cupped largely 1 But, soon after the de-
pletion, and aa tenslbUtty waa returning, the paroxysm

EPILEPSY — Hem A n» ox HEMEtnEs nxcosiMtiKDEfi by AtirnORS.

809

others (F. 186. 212. 423. 845.). It often shortens
the fit, or prevents it altogether, when exhibited
in enemata shortly before the usual period of ac-
cession, as in FormulflB 130. 135 — 138. 151.

87. c. Of animal tubitanees, caitoTf mutk, and
ox-gall are most deserving of notice. — a. Castor
is recommended by Arvtaus, Celsvs, Pliny,
Serapion (apud C«/. AureL p. 352.), K. Digby
( Experimen, Ilied. p. 332.), Moor ( PathoL Cerebri,
p. 211.), Thovvenel (^Sur let Verttu des Subit.
Anim, Me(itcfim.p.357.), TissoT,and Fothebgill.
When anadulterated, and given in full or large
doses, it is ofteo of much service ; especially in. the
asthenic, dyspeptic, and uterine varieties ; and in
the combinations advised in respect of atfsafoetida
and camphor, with which (as well as valerian and
mu»k) it may be conjoined (F. 480. 497. 905.).
— 0. Mu$k is also beneficial in these varieties, or
in the other forms, after evacuations have been
prescribed, and in similar combinations to those
mentioned with reference to the preceding sub-
stance. It is favourably mentioned by Feuerstein,
Van Swxeten, Quarin, Cullbn, Ackermann,
and others, Hannes made a full and successful
trial of its efficacy on his own son (See Nova Acta
Nat. Curiot, vol. v. p. 244.). It shouhl, unless
intended merely as an adjuvant of other means,
be given in much larger doses than usually di-
rected. It may be conjoined with camphor, sul-
phate of zinc, &c — y. The bile of various animals,
particularly of the ox, bear, and dog, has been
noticed by Barthoun, Unzer, Quarik, and
others. Of inspissated ox gall I have had some
experience in this complaint ; but have usually
directed it in combination chiefly with assafcetida,
galbaoum, myrrh, aloes, &c. (F. 558. et seq,)
It is of much service in the states just particular-
ised, and after depletions have been carried far,
or to an injurious extent. In a case of this latter
description, I am now employing it with very
markra advantage.

88. d. Cdd or moU water bathing has been
advised by Cblsus, Calids Aureljanus, Floyer,
I.ENTIN, Ti580T, Rud HuEELAND ; but it requires
caution, and attention to its effects. In young
persons and delicate females, who have not been
accustomed to a plunge bath, the fear or shock
of immersion may bring on the seizure : indeed,
WiEKARD {Observ, Med, Franc. 1775.) and
ToDB (Med. Chir. Bibl, b. i. p. 117.) adduce in-
stances of such an occurrence. The shower-bath,
used daily, commencing with tepid water, and
gradually reducing the temperature, in cases
where the shock may be dreaded, is of much less
equivocal benefit ; and is, in all the varieties, but
in the simple or cerebral forms especially, a very
excellent remedy. When it cannot be employed,
the patient should daily effuse water from a large
sponge over the whole nead and occiput.

89. C. Numerous substances evincing more
of stimulating, than of tonic and antispasmodic,
properties have been prescribed, with occasional
success; but, in general, in combination with one
another, or with medicines producing an Astringent
or tonic effisct. — a. — a. The oil o( hartshorn, or
X>ippel's animal oil, was very generally used, both
iatemally and externally, especially during the last
century, owing to the recommendations chiefly of
X>[PPEL {Disquisit. de Vit<t Animalis Morbo et
yied. ire, p. 89.), Albbrti {De Med. in Motibus
Nat, txacerbatit, Hals, 1718.), Vater {De

Specificor. Ejnlep, Sigillatim Olei Animal. Vir"
tutibus, Vitel. 1725.), Mauchart (De Oleo
Animal, Dippellii, Frib. 1745.), Juch,Kortum,
Bang, Tiiouvenkl, Cullbn, Morand, and Por-
tal. Feuerstein believes that, when it is pure,
and not altered by the action of the air, it is of^en
beneficial. Ackermann considers it possessed of
no small efficacy in the asthenic forms of the
disease, particularly those connected with anemia,
and languor; but hurtful in the irritable and ple-
thoric states. Quarin advises it in the uterine
variety. Tissot, however, thinks it possesses but
little power. — 0. Cajuput oil was prescribed with
benefit by Goetz (in Commerc, Lit, Noric. 1731,
p. 5.), in doses of from two to ten drops on sugar ;
and by Werliiop (Oper. Med. p. 711.), with
cinchona. — y. The oil and other preparations of
amber have been found sometimes useful by Ri-
verius (Prax, Med, p. 32.), Beattie (De Cogno-
scend, et Cur, Morb, ifc. Hals, 1780.), Cullen
(Mat, Medica, vol. ii. p. 361.), and others. The
oils of hartshorn, cajuput, valerian, and amber, are
serviceable chiefly in the simply nervous and as-
thenic states of the disease ; and are useful adju-
vants of other medicines, and are often beneficially
conjoined with narcotics (§ 97.). Besides these,
other oils, both simple and medicated, have been
prescribed ; but they hardly deserve enumeration.

90. b, Pkoxphorus was, I believe, used for
epilepsy first by Kramer (in Commerc. Lit.
Noric, 1733, p. 137.) ; and more recently by
Feuerstein, Quarin, and others. Weikard,
AuTENRiETH, and Hupeland justly view it as a
doubtful and dangerous remedy. Haartmann
(De Noxio Phosph, in Med, ifsu, S^c. Abos,
1773.) gave it in four cases without benefit. — 0,
Cantharides has been tried internally, byMER-
curialis (De Morb. Pueror. 1, i. c. 3.), Zacutus
LusiTANUS (Prax, Admirab. 1. i. obs. 35.), Stoc-
KAR (De Usu Canih, Intemo. Goet. 1784.
p. 34.), and Dr. J. Johnson ( On Derangements
of the Liver, ^c. p. 105.), with occasional advan-
tage. Its external use is, however, more com-
mon, if not more beneficial, in this complaint.

91. r. Gnaiacum, either in decoction or sub-
stance, has been employed by Vesalius ( Haller*8
Bibl, Med, Pract, vol. ii. p. 32.), Willis (De
Morb. Convuls, p. 460.), Sennert (Prax, Med,
1. i. c. 31.), Mercurialis (Respons, et Consult,
1. ii. c. 3.), FoRESTus (Obtei-v, Med. 1. x. obs. 58.
63.), F. Hoffmann (Med, Rat. Syst, t. iv. p. iii.
c. i. p. 21.), and others, who considered it pos-
sessea of much efficacy in this complaint, espe-
cially if connected with a syphilitic taint ; but it
has been neglected by more modern writers.—
y. The flowers of the Cardamine pratensis were
found beneficial by Beroer and Nagel (D« Usu
Med. Card. Prat. ^c. Franc. 1793. p. 13.) ;
but Baker (Trans, of Coll, of Phys, vol. i.
p. 443.), Lysons (Pract, Essays, 6(c. p. 173.),
and GredinGi state it to be inefficacious. The
saturated infusion of the flowers and leaves pro-
duced a copious and foetid perspiration in the
experiments made with it by Beroer (De Remed.
Spec, in Ep. 8^c. Franc. 1795. p. 11.) - ^ The
Arnica montana has likewise been noticed by
Stoerck, and the Serpentaria, by Grublmann,
when the attack has been occasioned by fright.

92. d. The extract of mix vomica was praised by
Sidren (in Acta Med. Silec. t. i. Upsalas, 1783.
p* 367.), Rese (D« Nuce Vomica. Jens, 1788.

818

ERYSIPELAS — GnrsBAL Dncaimoir.

upon the economy, in any one instance; and
it is only in respect of spurred rye that we
have any kind of data that will admit of the
special consideration of the subject. From some
ciroiimstaDoes that have come before roe, I should
infer that unripe grain is productive chiefly of
diarrhcea and dysentery; tnat diseased, impure,
or blighted grain, most frequently occasions af-
fections of the nervous and vascular systems,
with disorder of the digestive or^ns, and con-
tamination of the circulatang fluids; and that
damaged and old grain gives rise principally to
fevers of a malignant or adynamic kind, with
predominance of some one or more of the pre-
ceding aflTections, according to concurrent causes
and circumstances. (See Disease — Cautation
ef; Ganorekb, and Spasm.)

ERYSIPELAS. Syn.— 'Ew»<j,x^<r/ii«. Hip-
pocrates; Iptfo^lmKaf, Gr. (from frofk to
IfVi^Bat M T» friXetf, that it extends to adjoin-
ing parts; or rather, from ifum, 1 draw, and
flrlxaci adjoining; or from IpuSpoc, red, and
wfXec, brown, livid) Ignis Saeer, Lat Pebrit
EtynpelatoMa, Sydenham, Schroeder, &c. fV-
brit Eryapeiaeea, Hoffmann, Vogel, &c. Rota,
Sennert. Ignit Saneti Antonii, Aact ^ar.
Emphtyth Erysipelas, Good. Erysipele, Fr.
Die Rose, der Rothlauf, Germ. ErisipeU, Risi-
pola, Ital. The Rose, St. Anthony's Fire.
Classip. — 1. Class, Febrile Diseases; 3.
Order, Eruptive Diseases (Cullen). 3.
Class, Sanguineous Diseases; 3. Order,
Eruptive Fevers (Gdod). 4. Ordsr, Vesi-
eular Eruptions {WiUan). III. Class,
III. Order (Author, in Preface).

1. Depin. — Asthenic injlammation of the in*
teguments, affecting them more or less deeply and
extensively, with diffused tumefaction, and a die-
pontion to spread, depending upon constitutional
disorder.

2. I. General DESCRiPnoy. — A. Erysi'
pelas* usua]I)r commences with either the local or
the constitutional symptoms more prominently
marked ; but I believe that the local symptoms
never manifest themselves before some disorder
referrible to the vital sources snd centres has
been present, although frequently in too slight a
degree to alarm the patient or come before the
physician. Previous to, or accompanying, a
sense of tension, itching, heat, weight, and un-
easiness, with diffused redness and swelling of the
skin, the patient experiences chills, rigors, dis-
turbance of the functions of the stomach and
bowels, and a quickened circulation. On the
second and third days, the swelling, which was
either slight, or scarcely noticed, increases ra-
pidly, extends superficially, and is warm, shining,
of a yellowish red colour, disappearing moment-
arily during pressure, with a tensive burning pain,
exacerbation of fever towards evening, and remis-
sions in the morning. In addition to these, the
patient complains of frontal headach, drowsiness,

• Some ooDfution has ariien flrom tbs m«nn«r in whicli
tbla diteate andrryfAcvM have been viewed in relation to
each other, and tn which both have lieen clawed. For
while I admit, with Dr. Good, that the term erydpeiaa*
hat been looMly employed in medical wrttlnga. yet I oon.
eeive that it will not add to the precisioo of our know,
ledge to remove cerUin of the varieties of eryMpelat to
the genua erythema, where their local character* aie
chiefly OMuMmL and their more important oonstitu.
Uooal and vital rehtions en overlooked. *''"^»«-

anxiety at the praeeordia, general iMaluihi, sal
pain or aching of the liralM ; aaiMttxia« naaics, or
vomiting ; thirst, and heat or diraess of iks.
The tongue is generally loaded, and sahssqacoilj
dnr ; the bowels are oansdpalcd, and the Botusi
offensive ; the urine is turbid or aafiroa-eoioncd ;
and the pulse full, eoh, frequent, somctJates bnad
and compressible, and tdita oppresssd er im-
p;ular. The disease generally rona its eoane, k
Its more acute forms, between the seveslk sad
fifteenth day. It is sometiaics extended ts fk
twenty-first, but seldom beyond, nnles ia
of relapse or metastasia, or when it
certain anomalons tcnoB, or c
changes of subjacent or internal _
long the fever and incxeaae the danger.

3. B. Erjrsipelas presents plieaoBi
are peculiar to it, and diaringnwh it firon pkk{<
monous inflammation, pn the one band, saa bm
the inflammatory action attendant on rheanshB
and catarrh, on the other. -^e. The eharscttn
of eiysipelatons inflammation are aa ibUows:— «.
The pain is peculiar — ia tensive, biiniiBf,cr
stinging ; is not severe, but is difivsed thrBS|hs«i
the inflamed surface, and is oocasboally ross*
ting.— 0. The redneu is not intense, ss ia pkhf-
mon ; but is either pale, roae-oolonfed, or •( t
pale yellowish hoe — arising, aeemiagly, frn s
more copious and diffuse deposidoo of earn.
slightly tinged with a little Mood. TheifdMa
always disappears on pmaunj, bat qaicUj it>
turns when pressure is renoved ? it is of a deiptf
red when the attendant febrile aetioa ii of t
sthenic kind; and of a more livid has wbcatkc
vital powen are much rednced.— x. Timefeeo^
m always present, and ia aometimes very rcswk*
able, owing to the effusion of serum ints the fs^
cutaneous cellular tissue. It ia, however, diisad,
never acuminated or convex ; but sobwihwi
hard or brawny, aa in the sthtenie or phlogisben*
riety ; and occasionally soft and boggv, ss b ne
oedematous or asthenic variety, or mm tbe a^
jaoent cellular tissue is affected or aappomiBg.

4. b. Erysipelas n etat^ chiefly m the istt^B-
meets; but it presents various aodifiosiMBi.
aooordioff as the more superficial or neie isirfsii
tissues of the skin areespedalhr dissasid. Wbn
the cutis vera k the principa] seat, the eaUsie
tissue underneath is also materially afliscisd
being usually infiltrated with aera:
and sometimes inflamed to a voy
depth in some instances ; whilst the noia
fiaal capillariea likewise partake in ikadiioii^
aoce. Where, on the other hand, iht mrw-
cosius and papillary tissue are the chief MSt,i^
disease is commonly accompanied with vencttsi.
When this occurs, or when n discharge fren i**
surface, or free exfoliation of the cMcle. tika
place, the aevere affection of the subjaesot a>-
lular tissue very rarely is observed.

6. e. Erysipelatous inflammatioahasalwsfi*
tendency to epread l» mdjaming, and oeesflosaih
even to attadt remeU, peris. As loag as ikt ■«•
tastasis, or Various affection of distaalpv*'
confined to the integuments, the prisuiift <pn
and nature of erysipelas is lelaioeo ; bat ai «m
as it has apparently attacked taismal sffis*.
which is sometimes the case, owing to tkcir sf^
existing dispoailion and morbid opodiiisoik sas lo
the operation of sapeiadded eanses, ihca tks
affection of the akia disappMii* aid Ha t»f^

820

ERYSIPELAS —Particvlar Dsscrxptiox.

14. In other parts of the body, the svmptoms
are generally not so severe. The paio, however,
is very great when the disease attacks the mamnus
during lactation, or when it extends to the organt
of gentratum. In these situations, it frequently
implicates the subcutaneous celli^ar tissue and
adjoining glands, and thus closelv approximates in
seat and nature to the primary form of spreading
inflammation of the cellular tissue. When it
occurs in the latter situation, in children between
one and six years of age, it often proves fatal,
either from this circumstance, or from sloughing
ulceration. Where the extremities only are a£
fected, there are generally less pain and constitu-
tional disturbance than in other cases.

15. B. Modifieatiofiu of the local affection, —
The changes which take place in the external
seat of disease, may be classed under four
varieties: the glabrous, vesicular, crustaceous,
and deep-seated. — a. The glabroue local affec-
tbn conusts in a difiused or plane and smooth
tumefaction of the skin, of a rose or yellowish
redness, sometimes versing to a sub- livid hue. —
h. The veticuUtr form is attended with bulla», or
blisters, in parts of the inflamed surface, resem-
bling the vesicles raised by cantharides. Some-
times they are numerous, small, and discrete phlyc
teruB ; at other times confluent, and forming very
laive buU^, containing a yellowish, sometimes
danc, sanguineous, acrid serum, effused between
the rete mttcosum and cuticle, which it elevates.
These vesicles continue to appear during the
course of the disease; are accompanied by an
unpleasant tension, itching, burning, or pain;
and, instead of diminishing, often increase, the in-
flammation and fever. — c. The crmtaeeous form
arises from an early rupture of the cuticle, and
escape of the lymphatic serum effused beneath it,
which exposure to the air forms into crusts, and
under which an acrid fluid collects, and irritates,
or even ulcerates the skin.-— d. In the deep-ttated
and tumefied, the cellular and other subcutaneous
tissues are affected, either by oedema, or by phleg-
monous or diffusive inflammation, tending to dis-
organisation. Whilst the superficial parts of the
integuments are the chief seat of the affection, in
the preceding varieties, the tissues underneath are
principally diseased in this, particularly the cel-
lular and adipose ; and they present every shade
of morbid action, from simple passive oedema, to
inordinate vascular excitement — from the lowest
state of asthenia, to the highest degree of vital
action — either passing rafuidly into suppuration,
or into disorganisation, or spreading extensively
in the course of the cellular tissue, and involving
other adjoining parts, as shown in the article on
Diffusive Inftummation of thit Titsue. It is gene-
rallv observed in this associated or deep-seated
malady, that the skin is but slightly altered, or that
the morbid action in it diminishes, as that in the
subjacent parts increases, especially if the latter be
of a diffusive or septic kind.

16. C. Modijicatioiu connected with the eon-
ttitutional ditturbance, — The forms which the
disease assumes, chiefly result from the states of
the nervous system of the assimilating and ex-
creting organs, and of the circulating fluids, and
from the temperament and habit of body. These
modify the iebrile action, as well as the local
aflection, aided by the existing grades of consti-
tutional power and vital resistance. Erysipelas

consequently presents every intermediate libide
between high vascular action with simply dioB*
nished vital power, and low vascular actioa with
great depression of the vital energies, n lupeett
both the part chiefly diseased, ai^ the sptea is
general. — a. As soon as the moibid sdioa is (be
skin posses a certain height, it generallj encBdi
to the subjacent oellttUr tissue ; and if it occv a
youn^, robust, or plethoric subjects, or if ibe
constitutional powers be not mneh icdsced,
or the nervous system not materially exbs^id
or oppressed ; or if the functions of the digeiim
and excreting organs be not altogether ov9-
powered ; then the disease aMumes more «f lea
of the tthtnie or phUgmonoue charadcr, botb as
to its local appearance and the aimdant fever,
and has a marked tendency to pass bio isppi-
ration, occasionally with destruction of tke tab-
cutaneous oellukr and adipose tiasoes. -> i. Mhn
the disease is attended b^ signs of accaaislattd
sordes in the prima via, with nausea and vsaitiB|,
and a morbid state of the secretions, panieakH;
of the biliary secretion — chancien wktA
it often presents, —it baa received fraoi Cas-
tinental pathologisU, the appelUtioo of gettnc et
biiiout erysipelas. — c. If it present greai depi»
sion or disturbance, especially of the cerebn-
spinal nervous functions, with a pale, evaaeieesi,
and changeable state of the put aflcded, sad
imperfect secretion and excretion ; aad if de-
lirium, coma, sobaultns, &c. supervene; or if tk
local affection spreads rapidly, or if it csiiicljr
disappears, and is followed by internal diaaae ; it
has been called mrvous etyeiptloM, or it au; be
said to be complicated with febrile distartaaec of
the nervous kind. — d. If, owing either to excs-
sive morbid action over vital power, or to a feslty
state of the system at the time of attack, or vbn
it supervenee upon remittent or continued fevcn,
or upon any cachectic malady, or io aged «r
broken-down constitutions, it extends to the nb-
cutaneous structures, and gives rise to mdeaM,«r
terminates in softening or disomnisatkin of thoe
parts, it has received the name w a:dtmaUm,wfU,
or gangrenout erysipelae. This state of the nslsdj
is generally connected with defective aswimht^s
and excretion, with an impore stale of the cff^
culating fluid, and with deficient vital power.

17. i>. The causes tohieh dispose to, or nciu.
the disease, have also great influence in moiUjfH
its characters, both local and general. Hbca
propagated by infectioo, it is prone to asanc s
complicated state, or to be associated vitb is-
flammation of the throat and pharynx of a m^
dangerous character, owing to ils diipoviios to
spread to the larynx and trachea; and wiih <bf
fuse and gangrenous inflammation of thsfvbcsia-
neotts cellular tissue. A similar complieatioa s
also observed during certain epadeoic coaMita*
tions, or when the disease has been oocaooocd by
the contact of animal matters in a stale of deeoa-
positioo , or by other septic agents. Io theie cBse«»
the tumefaction is often great ; and, ahbongk va*e>'
lar excitement may be very ranarkable,vitil pe^
is much depressed, and speedily ovenrkelBcd,
owing chiefly to the morbidstate of ihacircalsiisf
fluids, or to the contaminating and septic opeiaM*
of these causes.

18. HI. DivrsioN Of EavsirsiM.— Th*
disease has been divided by authenk acesnlisr <»
its varioui states, into Jtknk and mm4itfds.

822

ERYSIPELAS — Complicatu).

BssociationS| or more complicated states and
severe degrees, of erysipelas, are those in which
adjoining tissues suffer, or internal organs are
disordered, at the same time that the patho-
gnomonic phenomena •—> the inflammation of the
integuments — continue manifest. For, although
metastasis to internal viscera, or the inflammation
of other parts than of the skin, occurring in ca-
chectic habits, or in those who are subject to
this disease, may, with great propriety, be viewed
as erysipelatous, as respects the nature of the
attendant constitutional affection, yet neither of
them can strictly be considered as such, as re-
gards the part affected. The erysipelatous cha-
•racter, however, of the affection, under both
circumstances, should not be overlooked ; as
thereupon ought to depend, in a great measure,
the choice of remedies.

26. A, y^xXh (Edema, or Effusion into the Suh-
cutaneoui Tunies— £. (Edematodee of authors. —
a. This state of the disease may be consecutive of
the simple varieties, or it may accompany them
from the commencement, when they attack the
face, or the vicinity of the organs of generation ;
effusion, in these case?, always taking place in
the loose cellular tissue. It often, also, su-
pervenes in the progress of anasarcous swellings.
Its primary form occurs chiefly in old persons,
and broken-down constitutions, consecutively of
chronic visceral disease, and in the leucophleg-
matic and dropsical diathesis; the affection of
the skin and suojacent cellular tissue being nearly
coetaneous. The external surface is of a pale
or yellowish red, inclining to brown; generally
smooth and glossy ; and it is seldom tense. It
is but slightly hot or painful ; and sometimes
neither the one nor the other. The swelling in-
creases gradually, extends slowly, and pits slightly
on pressure. Vesications are not common ; and
the vesicles, which are small, numerous, and
flattened, usually appear from the third to the
fifth day ; they break in a day or two, and are
replaced by thin crusts. In the more active
states, a sero-puriform, or puriform, fluid infil-
trates the cellular tissue, or is discharged from
the vesicated surface. The genitals, the face and
scalp, the thighs and legs, are chiefly the seat of
this variety. Dropsical limbs, especially when
the cuticle is cracked or abraded, or after scari-
fications have been made in them, are often af-
fected by it : and, in these circumstances, there
is a marked disposition to gangrene.

27. 6. (Edematous erysipelas terminatet ^ 1st,
in resolution* with absorption of the effused
fluid ; 2d, in suppuration ; and, 3d, in softening,
sloughing, and gangrenous destruction of the
part. — Suppuration occasionally takes place ;
but is generally of an irregular or diffusive kind,
extending in the course of the vesaeh, and be-
tween tendons and muscles; is preceded by a
boggy state of the swelling ; and is often attended
by disorganisation of portions ol the cellular
membrane. — Gangrene is indicated by severe
pain ; and a red and glossy state of the surface,
passing into a livid or Ivaden hue.

28. JB. With Inflammation of the Subcuianoout
Struetttrei -— £r. Phtegvumoium vel Phlegmo^
nodes, Auct. var. ; Diffuse Phlegmon, Di/pur-
TnxN ; Er, Spurium, Pseudo-Erysipelas^ Rust.—
This is a most important and often dangerous

>ease; especially when epidemic, or propa-

gated by infection. It ii yery varied in (ona
and seat ; and presents every grade of setivitj,
from the passive or oedematous state, just df-
scribed, to the most acute grades that npidlj
pass into gangrene ($31.).— When it oecsn
sporadieaUy, its local character is that of "dif-
fused phlegmon ;" the attendant fever b»ag of
an inffamroatory kind, and preceded by tigtn.
In this case, vascular action is more acute ; tk
swelling is greater and more circumscribed ; the
pain and burning more remarkable, and mart
pulsating ; the redness deeper ; the teopcntiin
nigher ; and the dispontion to pass into ssmw*
ration greater, but to change its sitnatkn W
than in other circumstances. Where the sjnp-
toms are very acute, tbe subjacent cellalar asd
adipose tissue frequently are profoundly afecied ,
the fsscisB, the intermuscular aubstance, tad tn»
the fibrous structures, becomioe inflaawd. Is
such cases, disorganisation of tbe cdlalar sod
adipose tissues often rapidly superveoei; (be
part passes from a brawny and tumefied, Is i
flaccid and boggy, state ; and the attendant (ever
changes to a low or adynamic form. H'bes
occurring epidemically, or from infeotioo, tte
local and constitutional symptoms are man
severe ; vital power and resistance are dimiaifb.
ed ; and the disease is often complicated with a t efy
dangerous affection of the throat and adjoisaif
parts. This variety may be divided, as sagjoted
by M. Rayer, into three grades

29. a. In the first, after rigors, and io ceo-
nectbn witli the constitutional symptoms dcsenbcd
above ($2.), tingling, heat, and redacM, fol-
lowed by hard tumefaction of tbe part, begio ts
appear. A stinging pain, tension, and boning best
are complained of in the seat of swelliog ; wkick »
diffused, hard, and deep-seated. After prensg tbi
surface with the finger, the lednev returns sion
slowly than in the superficial and simple disesik
The lymphatic elands often become iofiiaied or
enlai^ed ; and febrile action is folly devekmd.
If, about the fifth or sixth day, tbe ^o be lea
red and tense, or covered by furfurMeoos scskt,
and the swelling subsides, resMutioa has c««-
menced. (Edenus of the cellular tissue, bowenr.
sometimes remains for two or three dajs. Bit
if the pain, about this period, becoose psb*
ating, sttppuration in one or more parts ii si-
evitable. The abscesses thus formed gcaeriDj
give issue to well-digested pus, and heal in a fev
days.

30. b. In the ucond grade of this vaiiety.is-
flammation is more extensive ; and the rrdoes,
heat, pain, and fever are greater. If the diseM
be not arrested, abscesses form, very inadiowlyi
from the sixth to tbe ninth day, or evca esrbrr;
or a sero-puriform fluid infiltrates the ccOslv
tissue, extending lietween the muscles and asdff
the integuments ; and, upon five openiag* has;
made, disorganised portions of this tism tn
discharged with the puriform or ichorMS nsliff>
Fbtulous cavities freauently are ibmcd. p^
issue to a foetid and ichorous pus.— -Somcti'*'
the skin is thinned or detachea, and falls vittas
the margin of the ulceratbn (RavKa). Io tbtfi
cases, the stomach and bowels firec^oeotiy boeoM
irritable ; and tbe patient dies, ather frea tW
exhaustion occasioned by dArrhoea, orhj^^'
tennve suppuration and disorganvsKaoB of the erl*
lular tissue ; or from the absorption of the oMrbn

824

ERYSIPELAS — Lisions in Fatal Cases — Diagnosis.

binDos of the brain, analogous to the vascular
excitement of the skin, often occasioning an in-
creased exhalation of seram : hence the aelirium,
passing frequently into coma. In lAie latter €AT'
cumstance, the cerebral disturbance is the result
rather of depressed vital power, manifested espe-
cially in the cerebral functions, and of the morbid
changes in the blood, than of inflammatory action.
The pulse is frequent, but variable as to fulness
and power. The tongue is at first loaded, red at
the point and edges, and afterwards dry in the
middle, and of a brown or dusky hue. The
excretions are suppressed or impeded; and, in
the worst cases, particularly towards the close,
are passed unconsciously. Tremors, subsultus
of the tendons, floccitation, &c. are then also
observed. A fatal termination occurs generally
from the seventh to the fourteenth day, or later.
A bilious diarrhoea, or copious faeculent and
offensive stools; a free discharge of urine de-
positing a copious sediment; and a general,
warm, and copious perspiration ; are favourable
occurrences.

36. £. With Gastric and Bilious Disorder. —
The bilious nature of erysipelas was strenuously
insisted on by Stoll, Dessau lt, aud others.
Antecedent disorder of the digestive and assi-
milating organs is more or less evident in all the
varieties, but especially in this, which is of com-
mon occurrence during summer and autumn,
when the digestive mucous surface and biliai^
apparatus are most liable to be diseased. It is
generally attended by manifest signs of accu-
mulated sordes and morbid secretions in the pri-
ma via, and of an increased secretion of acrid bile,
especially when the disease is epidemic at the
seasons just mentioned.

37. F. Erysipelas may, moreover, be com-
plicated with inflammatory action of the mucous
surfaces, analogous to that of the skin, giving
rise to a form of bronchitit or gastrHit, Where
it is connected with inflammatory sore throat, it
sometimes extends along either the trachea, or
the oesophagus, or even both, until the lungs, or
the stomach and bowels, are affected ; and, oc-
casionally, along the Eustachian tube, to the
ear ; it thus becoming oomplicated with one, or
even more, of these affections. This connection, first
distinctly pointed out by J. P. Frank, has more
recently been insisted upon by Broussais, El-
LiOTSON, and others. Frahk alludes to instances
in which erysipelatous inflammation extended
from the pudenda, along the vagina, to the uterus,
and even to the bladder. Erysipelas may be
further complicated with inflammation of the lym-
phatics, particularly when caused by breach of
surface ; or with phlebitiSf when consequent upon
injury, or when it has proceeded to suppuration.

38. G. Erysipelas may occur in the course of
continued and remittent fevers ; and it may
appear during convalescence from any of the
exanthemata. — In the first of these associations,
it generally presents an adynamic character, with
nervous or with malignant symptoms ; frequently
attacks the face, throat, and scalp ; or the parts
pressed upon in bed, or irritated by the evacu-
ations ; and is especially disposed to gangrene.
When it supervenes upon remittents, it often
assumes a bilious or gastric form ; and in these,
as well as in exantbematous fevers, it may prove
a salutary crisis, if the pulse do not rise iu fre-

quency ; and if the coebral fanetioiis renaia
undisturbed. In crowded sick wards, tad is
lying-in hospitals, it often occurs in the ptagm
of other diseases, with which it cooseaieatly
becomes complicated. But H n a most dsifcr*
oos circumstance ; as it is, ia those cases, caaeed
by an infected or impure air, which, favoued bj
the depressed state of vital power, or by inper-
fect excretion, has contaminate tbe drcalatiag
and secreted fluids.

39. IV. Lesions in Fatal Cases. —When thi
cellular tissue has not been aeveiely affeded, ik
injection of the integumeots aobaides consideniUy
after death ; and hence the redness of tbe eitcN
nal surface, as well as that of tbe throat, Jm
often nearly or altogether disappeared. Ia addi-
tion to infiltration of the aabcutaiwoas lisna
with serum, or a sero-puriform matter, and occs-
Monal disoigaoisation or gangrene of these and of
the integuments, various internal lestoas aie om*
monly observed. The blood io the iaige reaeh
and cavities of the heart is frequently senuflvid;
and the veins proceeding from the ]>irt dariy
affected, are often inflamed, or ooatiin p»; «
first observed by M. Riaxs, and confirmed by M M.
Dance, Abkott, and by ray own observatiots,
especially when the disease has been comji'iataid
with diffuse suppuration of adjoining ceUthr
parts. In cases that have been atteadsd hj
cephalic affection, the membranes of the bna
are sometimes injected, or inflamed, and the
arachnoid opaque, with seram eflfuaed betvcca
them, and in the ventricles; but, as M. Piobbt
has shown, these lesions are often not olacrved
in this complication. Where the throat has bsea
affected, the faucet, pharifnx, and titf^ef:^
are of a dark or dusky red, or of a livid «f
brown tint ; much softened, sometimes with sissll
patches of dark lymph on their sarfaes ; aad the
subjacent tissues infiltrated with a bloody seian,
or with a sero-puriform matter. Then appear-
ances occasionally extend to tbe Uryu ud
trachea, the submucous tissues beug oedeni*
tons, or infiltrated with similar fluids. — In am
that have been associated with broaehial or pal'
monary disorder, the lunge are coogerted with
a dark semifluid blood ; the bronchi an of a dtfk
red or brown colour, are injected, and often eta-
tain a frothy and bloody fluid ; portioos of ite
lungs being oedematoos, and others P>>^^
hepatised. — The mucous tuifsce of the ifMsn
and intettines is generally injected, of a desp v
dark colour, often softened, and, where the bo«h
had been much affected, abraded, or idlasBfd,
especially in the caecum and rectum. Tbo '■^
and spleen are seldom found in a healthy ctativ
particularly in persons advanced in age; ^
they present no lesions peculiar to this eeophiai,
excepting that those usually resulting horn lottv-
perance are most frequently observed.

39. V. DiAONosiai.— The anteeedeot «•«•
tutional disturbance, with excited vascular aoas
and drowsiness ; — tbe doll or yellovi^ red. tf
rose-colour, of the integuments, tcrattasiiegi" ^
irregular, but well defined reafgia, aod ^'''^p''^
ing, momentarily, on pressure; — the pricosf.
stinging, and burning heat and pun of tho piff|«
sometimes with irregular vesications ; -^tbe titp^
plane, and diffused tumefaction, or tbe p^
swelling and diffused affection of the ca»ihir
tissue in coonectioD with tlie inflaniinaww v vt

648

£ V£ — Inflammation op— Causes.

matter is yellow, whitish yellow, yellowish green,
or reddish yellow ; presents all the characters of
pure pus, excepting in the intervals when the
more sqanty sputa are generally mixed with mucus;
and ultimately becomes more offensive, and as-
sumes deeper shades of colour. I lately attended
a case where abscess formed in the substance of
the right lung presented these well-defined cha-
racters ; yet the patient never coughed during its
formation — although it was so large as to bulge
out the right side of the thorax — nor until the
time of its bursting into the bronchi.

11. D. The appearance of fine, white streaks ;
or the presence oftohitith, or whitish yellow, imall
masies, like boiled rice, in mucous or muco-
puriform sputa, generally indicates the softening
of tubercles : but the earlier and more advanced
stages of phthisis are attended by the very vary-
ing state of the expectoration described in the
article on that malady. Sabulous, ealcareoui, or
tarthjf matUri are sometimes expectorated in
oertam states of pulmonary or phthisical disease ;
but these matters do not indicate the most danger-
ous forms; for I have known several cases where
recovery took place after their discharge. The
presence of hydatid* in the expectoration is very
rare. — Substances that are swallowed, are some-
times coughed up from the trachea, through an
ulcerated communication formed between it and
the oesophagus. Zeviani records a case of this
kind ; and one vras, a few years since, attended
by Mr. By am and myself. The various modi-
fications of the expectoration, during the progress
of pulmonary diseases, are minutely described in
the articles Bboncbi, Hemorbhaoe, Lunos, and
Tubercular Consumption ; and the indications
derived from this source are there duly pointed
out

BiBLioa. AND RxFBR — HkmoeroUt, A|ihorism.iect.vli.
15. — Blum, De Sou to. Basil. 1692. — BuuurcM, in
Fhilos. Trans, n. 963. p. M5. — SamArr, in Ibid. n. 398.
p. 262. — HebensirHt, De Sputo Critioa Lip«. 1749. —

JUnck, De Sputo ut Signo in Morbii. Hard. 17r4

Webel, De &)Utii, in Doerint*» Tract, vol. i. p. 70. —
Cutfifat, in Acta Reg. Soc. Med. Haun. voL i. p. 69. et
76. — Warren^ Trans, of Coll. of Phys. vol. I. p. 4(J7. —
Portal, M^moiret de I'Acad. de Paris, 1780.— be Haen,
ttatio Med. pan ix. p. 49. — Cbia&rttcA, Obser\'. Med.
Stuttg. 1777 — DfJwiH £d. Med. Cormm. vol. ix. p. 254. »
DalbiM, JouriL de MM. t.xi. p. 42. S70.^ZrHaii^in Hera,
dl Matematica e Fisica, t vi. Verona, 1792. — Straek, in
Hif/WaiMrsJoum.d. Pract. Annejfk. b. vii. p.161— ^cAo-

riui, Lond. Med. and Phys. Joum. vol. viii. p. 201 C.

Darwin, in Ibid. vol. iii. p. S74. ; et voL It. p. 49. 1<I& 203.

— Valenifn, Joum.de M£d. Contin. t. xiv. — PMr«<M,
Fhilosoph. Trans. 1900. ^ Gkeune, in Edin. Med. and
Surg. Joum. vol. iv. p. 441.<~^yA;, Sur la Phthisle Pul.
monaire, p. i&.^Dotaie, S^meioTogie G^n^rale, &c t iii.
p. 81. etaeq.'^LaeimeCt Ausculution MMiate, by Forbes,
fuuatm — Andred, Clinique MMlcale, t. ii. et iii. passim.

— IlUr, Lond. Med. Rcpoi. vol. xviii. p. 207. — Rostan,
Cours. de MM. Ciinique, &c. 1. 1. p. 416. — C. J. B. WO-
lUUfU, Cyclop, of Pract Med. vbl.ii. p. 127.

EYE, DISEASES OF THE.— Syn. 'o^aXfj^q,

Oeulut, Dat Auge, Germ. CEil, Fr. Occhio,

Ital.

Classip. Special Patbolooy — Morbid

Structures.

1. The progress of knowledge, in respect of

diseases of the eye, has been very remarkable

since the end of the last century ; owing chiefly

to the researches and writings of Beer, ScuMnyr,

HiMLY, Scarpa, Benedict, Demoubs, Edmokd-

STON, Vetch, Wardrop, AVelleb, Travers,

Guthrie, Mackenub, and Lawrkncb. In the

account that will be here given of these diseases,

those only which are inflammatory, and conae«>

quent upon inflammation, will be coDBdemi.
Functional disorders are treated of in sepante
articles. (See Amaurosis, Siobt, &e.). I be
order in which these maladies will be discoMd,
will difler but little from that adopted in the traly
valuable works of Mr. Lawbbvcx and Mr. Mac-
kenzie ; to which I have much pleasure iastitiBf
my obligations. — The latter of these wxiicn, sad
J. Frank, treat fiist of the dis^a^w of the eyefai*
and lachrymal apparatus, and next of the tn
itself. Mr. Lawrence enters at oaoe upon ike
consideration of the inflammatory diseases of the
tissues of the eye-ball, and conclttdes hb cbasinl
production with those of the appendages. Eitbcr
arrangement is unexceptionable ; b«t 1 sksU U-
low the latter, merely as being more coofrBOQi
with the medical view of the subject, to wbch I
shall chiefly confine myself. The snrgiral trnt*
roent of such of those diaeaaes as requiie it, nusi
be studied in the works now refencd to, or m
Mr.CoopER's Surgical DietitmaryM shall, tfacrv-
fore,^'rst trest of inflammations affecting tbe ei*
temal coats of the eye, and ^Urwardi of tkov
attacking the internal tissues of the organ.
I. Inflammations op thk Eye. — Stw. 0^
thalmia ; LippUudo, Celsiis ; Avgemnlxiadnf,
Germ.; Opkthalmie,Fr,', Oftelmia. Ital.
Classip. — 1. Clan, 2. Ordtr {Culk* ,

3. CUui, 2. Order (^Gcod). lU. Cla*.

I. Order (ilulAor).

2. Dbpin. — Pain in one or bath oye$, tritk en-
cular injection of one or more of their <mitifw>t
tittuet, and comtitutional dieorder.

3. Inflammations of the eye are of vsrieof
grades and kinds : they commeooe in any ooe of
the different tissues forming the oigan ; aod ikry
are thus limited more or less, and for a losfff cr
shorter period of their coume, aooordiBg ts the
temperament, habit of body, and diatheos sf tbe
patient ; to the state of predisposstioo, sad tbe
nature of the exciting canses ; and lo the tretU
ment adopted. Before considering separatdj tbs
diflerent varieties of ophthalmia, I shall >nl tsb
a general view of their caueee ; aod next ei tb«
numerous formi they present, owing to tbe vsried
concurrence of predisposing and excitiag caaaci.

4. i. Causes. — il. The preditpoeing eava of
inflammation of the eye are nearly the ssate ■
those of inflammatory diseases of other oigtsi. ->
(a) Temperament, idioeyncraty, and conieqocBtif
hereditary ditposUiott, evidently favour it* occon
rence. The colour of the eye has apptrentl; ^
little influence, for Dr. Smith found tbe it-
lative proportion of cases in light eyes oesriy tbe
same as in dark eyes.— -(b) Morbid dietkem.
especially the eerefuUiu, has the most remsiisUc
effect, and next the gouty and rheummiie, Thm
not only dispose to, but* also modify, (he dinsM,
and its consequences, and require for it app***
priate modes of treatment — (e) It is difliesii to
determine how far age and $ex have any is^
ence; but advanced age certainly favoaittk
supervention of chronic inflammatioQ o/ thi
organ. — (d) Climate has a much more nasifaM
effect. The excessive coM, and reflected l^bi,
in hyperborean regions ; and the great waivtb,
dryness, and reflected heat of some ee«atrf««
especially Egypt, Arabia, 6cc^ heighieocd bv tk
quantity of fine dust floating in the alneifMTt;
not only predispose to, but excite, epbtbalv*--^
(e) Great exertion of the eyet occaaoas diicaM •■

850

EYE — Inflammation of trk CoKjvKcnrA.

and the ropfftity of the progreBS, of ophthalmia,
vaiy from the slightest increase of vascular
injection and action, and the most prolonged
continuance, up to the most violent and rapid
states in which inBammfciy action is ever mani-
fested. Hence the conventional terms of acute,
ehnnie, and fu5-acuto or intermediate, are to
be viewed with due latitude as to their import
But ophthalmia, like other inflammations, may be
modified in kind or formf as well as in grade and
duration, owing to peculiarity of constitution,
morbid diathesis, the manifestations of vital power,
and the state of the circulating fluids* Thus,
ophthalmia in the scrofulous, gouty, or rheumatic
diathesis, is diflferent from that affecting sound
constitutions; and that occuring in the course
of, or subsequent to, the exanthemata, or during
typhus fever, or after the passage of purulent
matter into the circulation, is individually differ-
ent from ^ther of the foregoing, although the
grade of action and of vascular mjection may be
apparently the same in all. I cannot, therefore,
agree witn Mr. Lawrence, when he infers that
no such distinctions as sthenic and asthenic actu-
ally exist {Treatite, ^e. p. 66.). This conclusion
is the result of considenng inflammation merely
as increased vascular action, and without refer-
ence to the state of local and general vital power.
Bat the phenomena, the progress, and the results
of inflammation, in the various forms and circum-
stances in which it occurs, as well' as the effecis of
treatment, show, that excited vascular action
does not imply increased power; and that the
former often exists, not only without the latter,
but even with a diminution of it, as fully shown
in the articles Disease, Erysipelas, Fever, and
Inflammation.

8. Ophthalmia differs in degree,- at different
periods of its coune. Thus, it may be slight and
prolonged, and suddenly become most violent,
acute, and rapid; or, from the latter, it may
lapse into an indolent, slow, or chronic form;
owing to various contingent causes, to consti-
tutiou, and to the treatment adopted. It -is also
remarkably modified by the tissue in which it is
seated ; by the nature of the predtsposiog and ex-
citing causes ; but its supervention upon, or com-
plication with, other morbid states, or specific
forms of disease ; and by the age, habit of body,
and regimen of the patient Out of these cir-
cumstances arise the numerous varieties distinctly
established by modern writers, and recognised by
every observing practitioner, and the arrangements
of them adoptttl in recent systematic works. The
importance of divisions of this subject is shown
by the different consequences or terminations
usually observed to belong to each of the varie-
ties, and by the modified treatment they indivi-
dually require. Without carrying the subdivision
as far as J. Frank, or too far for practical pur-
poses, I shall firtt consider inflammation of the
external titiues of the eyeball, nest those seated
in the internal titeuee, and taUly the much more
rare occurrence of inflammation of the whole eye.
In treating of inflammation of each of the tissues,
ts common form will be first described > and after-
wards those tpe^ic or modified kinds, it occa-
sionally assumes from peculiarity of cause or of
diathesB.

II. Inflammation of tub External Tissues
OF the Eva.— i. Of the Con/vnctiva. — Syn. |

Conjanctivitie, Macxcnxib> OphAalmia, Qf
numerous writers.

9. Charact. — Redneu, frvta mereaatd tvi-
eularity of the external coat «f the eye, wiA paia,
tumefaction, andfArile disiwhamce of the eyetem ;
the enlarged veeteie tkiftmg their pimtn with the
motion* of the eyeball or eydidt,

10. The muco-cutaneous mcmbraBe 6nt co-
vers the insides of the eyelids, and antefior Aird
of the eyeball, may be iuflaiDed in patieular
parts, or throughout its extent, in every gndc ef
severity, and for various periods of dontiBa.
When this membrane is insamed, the voaeis are
comparatively large, tortnons, and of • searicc
colour. They anastomooe very freely, or fans a
network over the white of the eye, and are diava
aside by dragging the eyelids, or moved by roll-
iog the eyebsJl; whereas, when tlie sclermiia ■
inflamed, the vessels are small, strmiglit, of a

Sink hue, and unsusceptible of motion, eitber bv
ragging the eyelids or rolling the globe. Wbea,
however, the mflammation is so severe that c^
mosis exists, or the conjunctiva bceomea tenad,
aftd the discharge copious and niaoo-p«rakBi»
this distinction cannnot be made, nor, indeed, does
it altogether exist, as the ioflammatory act»9
from contiguity extends more or leas to the selcro-
tica, and even to the iris and the oomeau
A, Mild Inflammation of tbb 0>icjviccnT*.
-—Syn. Catarrhjal Ophthalmm, LAWRcsitn ;
Conjunetbntit pwro-mucoea atmeepkeriem, M a^-
BENZIE ; Conjunctiviltit catarrhmiie*

11. a. I have adopted the appellatioB em-
ployed by Dr. Jacob as the most appropriate ; b*.
although the disease is generally cauwed by n-
-posure to cold, yet it sometiines also arises ethers
wise* It is most common in sprtng^ and aetnaa ,
is sometimes epidemic; aHects yoen^ puamu
oftener than adults ; and fireqoeotiy atfei J i mm.
of the members of a family, or, when it •Pp**'^
in a school, a large number of ebfldrea. Exp»>
sure to currents of cold air, or to the aiflit av .
north-east or easterly winds, and other atmesBhc-
ric influences ; damp feet ; intoxieatm ; ia|:«.
smoky apartments, irritating ▼aponra; and &^
orders or the dig»tive organs; most eemawaly
occasion it^ A person who has once ezpcrienred
an attack, is ve^ liable to a retom of tt ; and I
believe, with Mr. Macxbnzib, thai, in dM mett
severe cases, when the discharige is perifofnii. it
may be propagated by contagioo ; the
passing into the purulent and seven

12. 6. Symptom*, — This form of ophthaliBB
seldom extends deeper than the coDJooctiva. It
may be confined chiefly to the Kds (~
eo9^uncticiti$ catarrkaHa ; and may
the globe (Ophthabno-conJunctiMiitm
It commonly commences in the eyelida,
fersnce of the globe, and extends gredemDy i» ^
cornea, with a sense of stiffness, amaitiDg,
and as if dust had got into the eye. The '
of light and pain are slight ; and the
first is diminished, but it is soon iiirreaded by
watering and increased ledocai, Whea meie
fully developed, the redness is seperfidal, aemt^
what irregular, of a bright acarleC ; and the e»>
larged vessels are snperildal, and are leadily
pushed aside by puAiog the eyelids. lo ibe merf
severe and acute cases, the memfatmaes kccoaw
generally and uniformly red; loiusiimM w■t^
spots of'^ ecchymosb, or with minute

864

EYE— 'Purulent Ophthalmia in Adults.

or iU-nourished iofantB, the astringents about to
be noticed may be at once employed. In every
instance, purgatives ought to be prescribed. One
grain' of hydrargyrum cum creta, or of calomel,
may be given, with three or four of magnesia or
of rhubarb, at bedtime, and a dose of castor oil
in the morning. A small blister may be applied
on the posterior and middle part of the scalp, as
advised by Dr. Montsath ; but it shoula be
removed in five or six hours, and the part care-
fully attended to. The eye should be bathed
frequently with tepid milk and water, and a little
fresh butter, or a mild form of the red precipitate
ointment, applied between the edges of the lids
at night, to prevent their agglutination, and
favour the escape of the discharge.

28. Astringent colly ria are more efficacious,
and safer in this aiFection, than in any other,
especially when resorted to at its commencemenL
But in severe cases, when the inflammation has
proceeded so far as to endanger the cornea, it
will be much safer to premise depletion, than to
enter at once upon the use of astringents. Mr.
Warb recommends a preparation formed by
pouring eight ounces of boiling water on eight
grains each of sulphate of copper and Armenian
bole, and two of camphor. Schmidt prescribes a
lotion of two grains or sulphate of zinc, three drops
of liquor plumbi super-acetatis, twelve drops of
sphitus vini camphoratus, and an ounoe ot dis-
tilled water. Mr. Guthrie directs the nitrate of
silver ointment (^ 49.) to be applied with a brush
over the in^de of the lids. Mr. Mackenzie em-
ploys a collyrium of one grain of bichloride of
mercury and eight ounces of water, three or four
times in the day ; and, having washed off the
discharge by this lotion, he applies, once, or at
most twice, a day,to tlie conjunctiva, a solution of
four grains of lunar caustic, or of six grains of
sulphate of copper, in an ounce of water, by
means of a camel-hair pencil ; preventing the
agglutination of the lids by smearing their edges
at ni^ht with the mild red precipitate ointment
(consisting of from twelve to twenty grains of the
precipitate to the ounce). Dr. Monteath uses
a nearly similar collyrium to that prescribed by
this writer. Mr. Lawrence advises a solution of
from two to ten grains of alum in- an ounce of
water, to be carefully injected between the lids
three or four times in the twenty-four hours, so
as to wash out the purulent secretion ; and after-
wards a soft rag, moistened in the solution, to be
laid over tlie eye for a short time; the bowels
being r^ulated by a mild aperient. If there be
occasion to change the astnngent, he prefers the
lunar caustic solution, gradually increasing its
strength from two grains to the ounce, to four or
six, to be dropped between the lidi twice or thrice
a day.

29. When the cornea has ulcerated or sloughed,
the infant is generally pale, weak, irritable, and
restless ; and tonics are required. The sulphate of
quinine in the form of syrup, and the resinous
extract of bark blended in milk, and given every
three, four, or six hours, are the best preparations.
The solution of the nitrate of silver, or of alum,
may be applied to the eye. Opacity of the cornea
is generally permanent ; but instances of recovery
have occurred. M. Billard mentions a case in
which the recovery was spontaneous.

30. C. PuruUnt Ophthalmia in C/*i7dr«n.— The |

treatment just recommended is moit appropnalc
to newly-bom infants, or to children of ooe, two.
or three years old. In these latter, and in those
somewhat older, the local depletion dioald be
more active, according to their habit of body aad
strength ; and hiisten behind the cara are of
much service. Blisters, unleai empUnred with
caution, and only so far as to produce uigbt red-
ness, and followed by the applicatioo of wmrm
poultices to the part, often are productive of nroeh
trouble in young infants ; in older sobjeeti^ they
are iQore beneficial. In the latter dan of
patients, vascular depletion, accofdaog to the cir-
cumstances of the case and of the patient, purg-
atives, blisters, and astringent appbcationa, eoa-
stitate the chief means of cue. Paruleot oph*
thalmia introduced in large or crowded sehoob or
foundling hospitals, may spread extenavely and
prevail long. Mr. Macgregor has deseribcd itt
prevalence for some yean amooff the chiidfca
of the Military Asylum at Chelsea. It was
most severe in those having red hair, or of the
scrofulous diathesis. It conunenced in the eye-
lids with itching, sticking together of the lids
on waking in the morning, followed, in twenty •
four or thirty-six hours, by a viscid mucous secre-
tion, extension of the inflammation of the cpo-
junctiva oculi, redness of the skin aroaod the «y<,
and a purulent discharge. GeneraJ bleedaf,
leeching, purgatives, blisten behind the ean and
on the nape of the neck, cold lotions, low diet,
and, subsequently, astringent eoUyria, and the
unguentum hydrarg. nitratis, at fim miaed with
twice its quantity of lard, but afterwards of its
full strength, applied to the lids by means of a
camel-hair pencil, were the remediee foaod moA
beneficial.

6. Purulent Ophthalmia in Adults. — Svt.
0/>A. pHTuUnta or purt/brmis, Suypmimtim
Oph,f Egyjftian Oph., Opktkatmo and Bitphmr^
blennorrluBaf Auct. var. ; Opk. emttagiem ;
Oph. catarrhaii* beltiea ; BUpfutrptit glmdm'
laris etntagiMa, Beer; Adsnitii palfiekrmrmm
cffntagiota ; Epid£mie amtagimta Opk, Rosas ;
CoujunciioitU puTo-mucota eoniagiata nsl J^9p-
tiaea, Macxknub ; Pum/siU Opk, m th# J^aUi,
Lawrence.

31. This aflection is essentially the aaae m
that just described as to both nature and seat;
it commences and extends in a siaoilar maancr,
and produces the same ill effects, eepeeiaily as
respects the cornea and iris. Its severity', its
senous oonse<^uences, its contagions properties,
and its extensive prevalence, at the ooottsaeer-
ment of this century, impart to it the higkcsi
interest. Assalini states, that two thinU of ti»
French army in Egypt were affeolcd with the
plaint. Dr. Vetch Ueated 636 cases, ii
relapses, belonging to the second battalioa ef the
52d regiment, from August, 1805, to Augw<,
1806 ; fifty having lost both eyee, and fiarty, oaa
eye : and the ophthalmia dep6t, unties fas aUa
care, contained in the summer of 1806* npwanb
of 900 cases. Mr. MAOoaaooa nentaoaa t^u
the returns of Chelsea and Kilmaiahaaa ho^
piuls furnished 2317 cases; soldiers who had
lost the sight of one eye not heiiig included n
the number: and that, from April to JHetm
ber, 1804. nearly 400 oasea of Ihii diaea*
ocearred in the noyal Military Asylna; and
from that time to the end of 1830. mfmfa4^

656

^TEf* PvitVLEKT OpBT&ALinA 1ft AOULTI.

5ANI, GitAxm, and otliere, produced the disease
repeAtedly in dogs and cats by the appUcatioa of
matter to their eyes ; and M. Outllix introduced
under the eyelids of four blind children the puru-
lent discharge, and the disease was communicated
in each instance.

35. But independently of these inoontforert-
ible facts, others equallT satisfactory may be ad-
duced. It is not denied that the disease extended
from the detachments of the French and English
armies which returned from Egypt, to the troops
in Italy, Sicily, Malta, Gibraltar, France, and
England, which had direct communication with
them ; the proffress of the complaint baring been
clearly traced from the infected detachments to
the fresh troops. The excellent accounts fur-
nished by Dr.jSDM0VD8TON,V«rCH,MAO0RSOOR,

Rust, Waltubh, Musllxb, GRAsrrE, and
others, completely demonstrate its spread by con-
tagion, and show that it extends rapidfy among
soldiers crowded in barracks, using the same
utensils and linen, whilst the officers, who live
separately, are seldom attacked. Rust states
that, ia Mentz, which was nrrisooed by Prus-
sians and Auftrians, it spread extensively among
the fanner; while the latter, whe inhabited sepa-
rate barracks, in a difierent quarter of the town,
entirely escaped. Dr.EDMONDsroN adduces a
most conclusive fiict. In 1782, the Albemarle
ship of war took on board, in the West Indies,
three sailors, with inflamed eyes, from a slave-
ship, in which the disease prevailed. On the
fourth day after their reception, the disorder ap-
peared in the Albemarle; and, by the seventh
morning, twenty-two men were un6t for duty.
Those affected were now separated from the
healthy, and the progrets of the malady was
arrested, and, in the course of a few weeks, en-
tirely ceased. Similar facts to the above may be
adduced ; and most of those about to be noticed
in illustration of points connected with this sub-
ject, fully prove contagion. Numerous instances
nave occurred in civil life, of the disease extend-
ing from one, to all the members of a family ;
and, in the public service, where the eircum-
stances favouring its spread are more numerous
and influential than elsewhere, it has been ar-
rested by separating the diseased from the healthy,
and conBning each perM>n to hit own utensOs,
clothes, and sponges. Mr. Macorkoox states
that, when the complaint was spreading rapidly
in the spring of 1810, among the children of the
Military Asylum, those affected were removed
into a detached buildinff, so as to cut off the
communication between the healthy and diseased ;
and that H afterwards declined. That it did not
arise ftom ihe state of the air, or any other general
cause, is shown by the drenmstance of its preva-
lence among the boys for neady a month, before
the girls were attacked ; and by the fact, that
all Uie adults who did not mix with the sick
escaped, while those who were connected with
them all suflered, the assistant surgeon excepted.
Similar proofs are adduced bj Rust, Walivbr,
and Omoobi, in the works rewned to in the BSb-
iicgraphy, Mr.MAOOREOOR has given a most
convincing account of its extension, oy contagion,
from two boys,Jbrotliei«, in the MiRtary A^um,
in his Memoir reSemd to hereafter.

36. 8d. Tht artpn tf (fts tem,tagwu% property
^ thg RMniisf of, and lAs eircumnanet$Javour»

wg. Us propagtttim, are matlan of grail praclieal
importance, as reelects both prophylaciis aad
curative measures. <^* (a) As 1o the oHgm of the
contagion. Dr. Vitch has made an impertaat
observationt and one which appears to appwath
very nearly to the tr«th. He reomf
whatever cause inflammation of the
may otiginate, when the action is of such at
or deeree as to produce m porulent ifiacbaige
(OpkAaliiuhhimnurrhtBm), the disrhaimi so un^
duoed operates as an ammal virus when applied
to the conjunctiva of a healthy cy«. To IfaiB I
would merely add, of a pradispoeed or
person.— The opinion of Mr. Mackxmzix
with that now stated. He observes, tkat it
scarcely admits of a doubt, that the diockargo m
eoCarrluff ophthalmia, especially when diHiBctly
puriform, if conveyed by a towel, or bj the
nngen. to the eyes of otaer pemoos, will cxato
a conjunctivitis sbll aaore severe, more Hiehartly
puriform, and mora dangerous in ita cflccis, Ihaa
was the original affection. He baa armed at
this conclusion, from having obserred aaaay a»-
stances, in which the diirtise had arisea in oae of
afiunilyfrom atmospheric exposure, aad aevesal
others had become sdfected, it Laving beeo, in th«
firat attacked, comparatively modmte, bat, in
the rest, much snore violent and poiifona.
lar facts have been remarked by myselll
the diwase may arise spontaneooalj, and _
wards extend oy contagion, is evinced by the
following occurrence adduced by M. Gvtlux*
A French slave-ship left the coast of Africa m
1819, with 160 slaves crowded in the hold.
case of ophthalmia existed among
among the crew, when they put fa
fif^n days afierwards it broke c
negroes, and spread mpidly anwag
subsequently among the crew, twcatj-two
number, one only of whom escaped. Oa
pasnge across the Atlantic to the Wi
:they met another slave-ship, the crew of
vras similarly cireumstancea to themselvea. Ki
ly one half of the crew and slaves lost their sight
in one or both eyes.

37. (6) As to the aMRiier of the ^ropapiiaa
of the disease, some difiereooe of opiaiea isca-
tertained. Dr. Vetch believes that it is net
communicable by a contagions
through the medium of the afoaphore
thinks that direct application of matter ia
sary to infection. Mr.MAooRSOoa
similar opinion, although many of his liscts &voar
the conclusion at wuch I ihall arrive ia the
sequel. Musllxr, oo the other hasdv

Ko

oat ia the

that the eonta^on is generally conveyed by the
air, although it necesHuily abo adnMi of be^
propagated by direct contact, and, ia pvaof i
this position, adduces the fact of the -^^j-^' at-
tendants and nurses, notwithstanding their eare
to avoid tlie contact of the diachafge, having
been frequently afiecled. WAuraaa ei
the same opinion, and appeals to sissilar
support of It. Dr. EoMONMroir, the first
who demonstrated the eontagioaa aatare of the
complaint, and attempted to assign the rmaga avl
laws of this property in respect of it, aoMsdsei
that it is contagious, not only by the eaattei ef
the discharge, but also by loaitM, and ihvoagh
the medium oif the atmosphere
range« whoa a Dumber of

858

EYE— Purulent Ophthalmia i3r Adults*

of Beveral days occur before the second becomes
iDflamed. Such are the features of this disease as
it prevailed in the British army, aod as it some-
times occurs ia civil life under certain circum-
stances.

42. (6) The milder or chronic states, — These
were most common on the Continent, both in the
army and in civil society. Mr. Macorbgor, Dr.
Vetch, Professor Walthbr, and Dr. Mueller,
particularly the last, have pointed out, not only
the origin of the complaint, in the conjunctiva of
the lids, but also its long persistence in this part,
in some cases, and its entire limitation to it^ in
others. In all the grades, the inflammation both
begins and terminates in it. — In the slightett
grades, the patient complains of pressure or un-
easiness, with a sense of dust or sand, in the eye ;
but without redness of the globe, or of the exter-
nal surface of the palpebrs. The conjunctiva
tarsi is villous and dark red ; but towards the
globe it is smooth, and its vessels distended. The
eyeball has an irritated appearance : there is an
increased flow of tears, and a mucous secretion,
but little or no pain. The disease may continue
Jong in this mild form, or may yield to treatment
in two or three weeks; or it may pass into a
higher or severer grade. — The seeonaor interme-
diate degree may be an aggravation of the first or
slightest grade, or may commence with all its
characteristic features. The conjunctiva of the
lids has a granular appearance, which becomes
more conspicuous when the inflammatory tension
is abated, and is swollen, dark red, and covered
by a puriform secretion. The lids are tumefied;
the pain is considerable, and as if caused by a
foreign body. This form may continue for weeks
or even months, and pass into the severe or scute
state already described ($41.), owing to atmo-
spheric changes or other causes; unfavourable
consequences to the organ supervening sometimes
in twenty-four or thirty-six hours.

43. (c) The alterations which the conjunctiva
undergoes are of much importance. In the
mildest grade, the membrane appears as if co-
vered with dust, or velvety ; in the severest de-
grees, it seems strewed with rough bodies, or
with mnulations, resembling those of a healing
wound. These bodies exist in great number,
arise by a broad basis, and have a round promi-
nence at first, which becomes flattened or angular
by. pressure against the globe. The largest of
them are in the middle of the lid, the smallest at
the edge and near the angles. They are some-
times crowded very close, and are most remarka-
ble in the upper lid. Their colour varies from the
darkest blood red to the palest brick hue. Muel-
ler considers this change of structure not as a
mere effect of inflammation, but as proper to the
disease, and as connected with the production of the
contagious secretion disseminating the complaint

44. y. Consequences. — 1. Suppuration of the
Cornea, and destruction by ulceration, sometimes
supervene ; the progress of the disease usually
leading to the escape of the humours, and col-
lapse of the globe. — 2. Ulceration frequently
takes place, to the extent, and in the manner, de-
scribed above ($ 24, 25.). — 3. Sloughing of the
cornea rarely or never occurs in this variety. Mr.
Lawrrncx has not met with it, and other writers
do not mention it. — 4. Bursting rf the cornea is
less rare, particularly doriog suppuration or

ulceration. Dr. Vetch met with cases, in wlbdi
the rupture occurred without previoas chaagc ;
the aqueous humour having eacaoed by m clear
division or rent in the oomea, which afterwards
became opacjue, and projected anmitd the open-
ing ; but this oocunence is very aaldosn ofaaerved.
— 5. Interstitial depoeiiiim in the emijiiDCtnral
covering, or the corneal iaminss,
opacity of eveiy degree ; the slighte
disappearing after leoovery.— 6.
thickening tf the mticoiis mtrnkreate eovcriog tht
cornea, with enlargement of its vessels, aad diou-
nution of its transparency. -— 7. Ofmeiiy (nm
cicatrisation of ulcers. — 8. ProUpte ef it his^
partial or total (Stapkylema. raftemummmi — 9.
Adhetion of the iris to ie eormea (SynteUa amte-
rior), eitner with or without pivSapae. — 10.
Staphyloma, general or partial, or other chango,
from extension of the ioflammatioB to
parts of theorsan. — 11. Weakmestar

of the eyes, which usually disappears

later. — 12. Impaired mnon {Awudyapia\ ftiMi^
from numerous causes ; as turgidity of TcsaeU a
the orbit, and surrounding the optic nerves ; slight
alterations of the choro&, retina, or lesks ; wd
lesions within the cranium. — 13. Tkiehemimg,
induration, and granulation of ike tanjtutgtina of
the lids. — 14. Tempwary and pavmawneM u ft wpk%m
and entroptttm. — And, 15. A ^eaf tendemrs to
relapse, upon exposure to very alight cawe».
This last especially occurs, when the palpchnl
conjunctiva has not been restored to its aatwal
state. — a result not readily attained after sevcie
or prolonged attacks, and which VfAvntM
doubts ever to be entirely accomplished. Hence
a person may be conaidoed as cured, b«t expe-
rience a return of the complaint, from
to cold or intoxication, and may spraad the
in the family in which he resides.
1 45. I. Viagiums. — Purulent ophthalmia ia
the adult may be mistaken for the amimrrkal aad
gonorrheal varieties. The peculiar chaafeia the
palpebral conjunctiva, the greet
swelling of the lids, the extreme redness
cular congestion, the profuse puroleet
the long continuance of the compleiat, its tae^
ency to affect the cornea, and the dispositicn ts
relapses, suflieiently distinguish it ffoos eaimrrhei
or mild ophthalmia. NeveiiheleBB, the aiUcit
cases of the former, aad the severest of the laorr,
hardly differ in any respect. Tht specifie eaeie
and nature of gonorrkoBal ophthsJmia, ead ns
uniformly acute and violent form, disiumeiih m
from the purulent variety. There are, btwlm.
other differences, which will be nolioed hcrealkf
($ 59.).

46. s. Treatatent. — (a) Cftke assst ami*, «r
highest grade of the difsajt. — The mUmtm*
should be to arrest the violence of the
tion, and prevent the extensioa of it to the
If the patient be seen suflicieatly early, or hr-
fore the conjunctiva ocuU be much iwiwimerfi ^r
chemosu have appeared, the tieatnent aiiiispJ m
catarrhal ophthalmia will generally sveoead^ Bms^
if the disease be thus far advanced, and has a^
sumed a severe form, the most active ealiphJ»'
gistic means ought to be resorted to. Va-n*,
Moxller, Rust, Walther, Lawi
other experienced writers, recommeed nsneari
carried at once sufficiently far to prodaea a
cided effect upon the ciraiUtiMi, wiAmi

860

EYE— PcRULzvT Ophthalmia in Adults.

.to be removed, and the strong ointment re-applied,
so that the new action that should be set up may
not cease ; the other remedies are likewise to be
continued. In addition to these, he gives calomel
and opium, so as to affect the mouth; and the
other more common remedies.

50. As different writers prescribe different
astringents, and of various grades of strength, it
were desirable that some more precise knowledge
were attained as to which is the safest and most
efficient. Dr. Jacob, after passing acetate of
lead, alum, sulphate of copper, sulphate of zinc,
bichloride of mercury, and lunar caustic in review,
decides in favour of die undiluted liquor plumbi
diacetatis, and strong solutions of alum, or of the
nitrate of silver ; which, however, he recommends
after the painfully acute stage has passed, and in
the chronic or atonic state of the complaint. Mr.
Mackenzie directs a tepid solution of one grain
of corrosive sublimate m eight ounces of water,
to be injected under the lids, for the purpoae
of cleaning the eyesj and, as an astringent,
four grains of the mtrate of silver, or six of the
sulphate of copper, dissolved in an ounce of dis-
tilled water. The solution of alum, or of the bi-
chloride of mercury (j. — ij. gr. to J j.) may like-
wise be tried. Mueller prescribes one, two, or
three drops of sulphuric acid, or two or three
grains of the diacetate of copper, in an ounce of
water. Mr. Brigos states, tnat a minute quantity
of the oleum terebinthins introduced between the
lids every morning, on the point of a camel-
hair pencil, the eye being afterwards bathed with
cold water, is most efficacious in checking the
profuse discharge.

51. It will DO observed, from the foregoing,
that some difference of opinion exists as to when
the use of active astringents should be com-
menced. The majority of authorities, as £d-
MONDSTON, Vetch, Macxbnzib, Lawrence,
Jacob, &c., resorting to local depletions, and
soothing or anodyne applications, m the early,
acutely painful, or active inflammatory stage, and
to strong astringents, when this stage is removed,
and the chronic or atonic condition has com-
menced; whilst some military authorities, as
Melik, O'Halloran, and Guthrie, advise the
adoption of powerful astringents from the begin-
ing. I agree, however, with the former; and
with them consider, that the effects of astringents
should be carefully watched, when' early, or even
at first employed ; and, if the redness be increased
by them, that they should be laid aside for a
time, and antiphlogistic remedies adopted. The
eitrint or red precipitate ointment should be applied
to the edges of the lids at night.

52. In the dark race$, astringents ought to be
early and energetically employed. Among the
negro tribes, vegetable astringents and ttimulantSf
especially lime-juice, are entirely confided in.
The astringents above noticed are, however,
equally appropriate in them ; and the addition of
anodynes, particularly opium and camphor, is also
of service, with pure air, and suitable diet.

53. Blisters to the nape of the neck, or behind
the ears, are sometimes serviceable, especially
when kept open for some time. When the pain is
very distressmg in the acute stage, relief is afforded
by the steam of hot water, to wnich laudanum and
ramphor have been added; and the vinum opii
is often a useful application, when the conjunctiva

is relaxed and painfiil upon tfaA diMppeanace
of the discharge. Evaeu*Hom of tha meuamu
humour by incision has been recoomeooed by
Mr.WARDROP, in order to remove the bvntiBg
pain in the eyes and forehead, aod practised in
twenty-three cases by Mr. Maogreoor, firom a
dread of rupture of the cornea. In the advanced
stage of the disease, exerdae in the open air.
exposure of the eye to as much light as it wiM
bear, and the use of gentle tonics, with a fr«e
state of all the ezcretions, are serviceRblc. 1%
after depletions, the eye becomes irritmble, or the
pain intermittent or periodical, the preparatiew
of bark, with the minsral acids, as Mukllix ad-
vises will be of benefit. If utcerutiom ef the
cornea have commenced, a tonic anU stimnlatiBi^
treatment is required, especially if it spread and
be attended by debility. When eetro^nm of the
lower lid remains after the inflammataoa is gone,
and presents a red fleshy mass, Mr. Lawar^cz
directs the application of the nitrate of nlvcr m
substance to it.

54. (6) Treatmtnt of th* miUer gradM, — If the
inflammation have extended to ue coojoactxra
oculi, however slight, local depUtian^ lev dwt,
and purgatives should be directei. When actbe
disorder is removed by these, the applicalioii d
astringents to the diseaised surface of the eyelidi
should be entered upon, and cootinaed until the
morbid state of this part described above ($ 43. )
is entirely removed. The solutxm of mlnm. or of
nitrate of silver, or of sulphate of copper, the
strength of which should be gradually iocreai«d.
or the undiluted liquor plumbi, ought to be drep-
ped into the eye, once or twice a day, the citrax
ointment beine applied to the mai^ns of the Ikk
at night Exercise in the open air, free ez-
posure of the eyes, and due regulatioa of d the
natural functions are benefidal. Murllxr re-
commends mercurial ointments to be rubbed
over the diseased surface of the lids once i
daily.

55. When the paipHml comjunietha
altered or granulated, in the chronic sL_
above decribed ($ 43.), very active local
are necessary, as the irritation oocasiou
the morbid surface produces vascularity and opa-
city of the cornea, or loosening and thickeaiof of
its conjunctival layer — or psniiuf. With the
change in the snrnioe of the eyelids, may be
associated some one of the unfavourable imI«
of the more violent attacks, as lencona, cyoechis,
anterior, staphyloma, &c. — Mr. LAwmzierE re-
marks that, if the globe be free from irritaxva.
the astringents alrrady specified, partiealarly i
solution of twenty or thirty grains of utnic of
silver in an ounce of water, should be applied n
the rranolated surface, with a cameMiatr penru .
the hds being everted. If this be not sub gat.
escharotics, beginning with the weaker, and y^
oeeding to the strongest, most be used. In csdcr
to prevent their injurious actioo on the coojaa^
tiva oculi, the lids should be everted, ta« dneased
part only touched, aod they ought to be kepi
everted until the eiffect is product. The ^mct'
tate of copper, the sulphate of copper, or the ncnie
of silver— the strongest— should be ligbily ap-

{»lied to the granulated surface, previeiMJy 6««d
rom moisture; and, af^ waitiag a
two, the lid should be carefully
stored. These applieatioiis

bv

EYE — GONORBHCEAL OPHTHALMIA.

861

YedaesB, and swelling, with increased discharge^
and should not be repeated until these effects
liave disappeared, which may not take place for
five, seven, or eight days. In the intervals of
the escharotics, some astringent solution may be
applied. Mr. Lawrence and Professor Wal-
TMEE do not speak very favourably of this plan ;
and are more disposed to depend upon antiphlo-
gistic means in the first instance, and the sub-
secjuent use of astringents, as above directed,
with regulation of diet and of the digestive or-
gans, residence in a pure air, exercise, and a
moderate use of the organ. BApid improvement,
Mr. Lawrence states, sometimes has followed the
substitution of soothing applications for strong
astringents.

C. GoNOftRBCEAL OpBTHALMIA. StN. Go^

norrhaal Inflammation of the Conjunctiva;
Speeifoe Ophthalmia; Conjunctivitis tpecijica;
OphUialntia Gonorrhoica vera, Beer.

56. This it a violent inflammation of the mu-
com membrane of the eyelids and globe, attended
with a profuse discharge of a fluid closely resem-
bling that which issues from the urethTra in gonoT'
rhcsa, and occurring m some kind of connectioti
toith that complaint, — It is the most violent and
rapidly destructive inflammation to which the eye
is subject ; fortunately it is one of the most rare.
It sometimes destroys the eye within a very «hort
time ; or irreparably injures it before medical aid
is resorted to, especially in the lower classes, Mr.
Mackenzie divides it into — 1st, that from inocu-
lation; 2d, from metastasis; and, 3d, without
inoculation or metastasis. Mr. Lawrence distin-
guishes three forms : — a. Acute gonorrhosal in-
flammation of the conjunctiva; — • 6. Mild inflam-
mation of this membrane ; — and, c. Gonorrbceal
inflammation of the sclerotic coat. I shall here
consider chiefly the former ; the third form being
merely rheumatic ophthalmia, occurring, like
other rheumatic affections, in connection with
gonorrhcea.

57. a. Symptoms and Progreu. — Acute gonor-
rhceal ophthalmia presents aU the fully developed
characters of purulent ophthalmia. Mr. Law-
KENCs distinguishes three stages; which, how-
ever, axe not very clearly evinced ; although the
division is judicious. In the first stage, which is
short, the inflammation is conflned to the con-
junctiva, and is attended with a sensation of sand
in the eye, and soreness, stiffness, uneasiness
on exposure to light, and a thin whitish mucous
secretion. Extreme vascular congestion, intense
and general redness, excessive tumefaction of the
conjunctiva, great cheuiosis, and swelling of the
lids, supervene; especially as the disease ap-

E roaches the second stage, which is characterised
y a profuse discharge of thick yellow matter,
closely resembling in its appearance, and in the
stain it communicates to linen, the gonorrhceal
secretion. When the discharge is established,
the inflammation causes effusion into the cellular
tissue connecting the conjunctiva to the sur-
loundiog parts. Hence the very remarkable
chemosis, which is sometimes so extreme, as to
overlap or hide the comes; and the palpebral
swelling and enlargement, which is occasionally
very great. The affection soon exteuds to the
cornea, constituting the third stage, with ago-
nising pain in the globe, orbit, and head, aug-
mented on exposure to light, and attended by

symptomatic inflammatory fever. The danger to
the or^an is now most imminent. The swelling
of the lids and chemosis render it difficult, or even
impossible, to obtain a view of the cornea. When
this is the case, attempts to attain this end should
not be made so as to increase the symptoms.
Although pain is most acute in both the eye and
head, as in other instances when the unyieldiog
cornea is the seat of inflammation ; and although
]>atients often complain of burning paio, of ten-,
sion as if the eye would burst, with deep-seated
sufferiog extending to the brow, forehead, and
head, there are some instances in which little or
no pain is felt. The symptoms are, however,
not equally violent through the whole course of
the complaint ; and the duration of the stages
varies with the constitution and health of the
patient, and the treatment adopted. The first
and second, particularly the first, usually passes
away rapidly.

58. 6. Consequences, — The immediate effects
of the inflammation on the cornea are sloughing,
suppuration, ulceration, and interstitial depo-
sition ; these changes leading to escape of the
humours and collapse of the globe, onliteration
of the anterior chamber, and flattening of the
front of the eye, staphyloma, prolapse of the iris,
obliteration of the pupil, opacity of the cornea,
and anterior adhesion ' of the iris. Sufficient
notice has already been taken of each of these
lesions ; as they do not differ from those super-
vening upon the other varieties of purulent oph-
thalmia, although they more rapidly appear, and
in severer forms, than in them.

59. c. Diagnosis, — The severest grade of purv-
lent ophthalmia closely resembles the acute gonor-
rhasal. In the latter, however, the swelling of
the conjunctiva oculi is greater, and that of the
eyelids somewhat less, than in the former. The
discharge, however, is thicker, and perhaps more
abundant, and tlie constitutional disturbance
greater, in the gonorrhceal, in which the peculiar
granulated change of the conjunctiva of the lida
does not occur. In purulent ophthalmia, the dis«
ease begins in the lids, and advances gradually ;
but in the gonorrhceal, it seems to commence in
the conjunctiva oculi : in one case, Mr. Law-
rence saw it distinctly b^n there; and it at-
tacks most violently and proceeds most rapidly.
The former generally continues long, affects both
eyes, remits, or returns, rarely destroys the eye by
slouehing, and is much less destructive; whilst
the latter more frequently affects only one eye,
and the cqrnea is much oftener destroyed by
slouching. This disease is uncommon, occurs in
single instances, and in persons who have had,
or who still have, gonorrhosa; whilst purulent
ophthalmia usually affects numbers, particularly
when many live together.

60. d. Prognosis, — Nine cases out o^ fourteen
related by Mr. Lawrence in his treatise on this
disease, were seated in one eye ; out of the four-
teen, loss of vision took place in nine cases from
sloughing, suppuration, or opacity of the cornea.
In two cases, 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 m three of the number. This
writer adds, that so short a period intervenes
between the commencement and full develop-
ment of the complaint, that irreparable mischief

862

EYE — GOMOBRBflEAL OraTHALlHA.

is generally done to the eye before aid n resorted
to. In the first or second stage, its progress
may be arrested ; but success even thus early
must not be reckoned upon. If the cornea still
possess its natural clearness, the eye mar be
saved ; but if it have become hazy or dull, and
particularly if it be white or nebulous, serious
consequences will ensue. Sight may, however,
i)e restored after partial sloughing of the cornea;
and ulceration may occur in its circumference
without injury to vision. When both eyes are
successively attacked, the disease is often less
severe in the second, which, therefore, is saved ;
but exceptions to this occasionally occur, the
flight of both being lost.

61. «. Catues, — Dr. Vetch found that the
matter of acute purulent ophthalmia, applied to
the urethra of the same individual, excited no
disease; but that, when it was applied to the
urethra of another person, it produced a virulent
gonorrhoea: he therefore infers that the matter
from the urethra, coming in contact with the
eye of the same individual, would not occasion
gonorrhosal ophthalmia. But Mr. Mackenzie,
Mr. Lawrence, and Dr. Jacob, adduce cases
from their own practice, which were produced in
this way, and refer to others from War drop,
AsTRuc, Allan, and Foot. It has been inci-
dentally mentioned by Scarpa and Beer, that
gonorrhoea! matter applied to the eye excites only
slight inflammation ; but they do not refer to the
source whence it was derived — whether from the
same person or from another — the cases ob-
served by Lawrence and the other writers just
mentioned, show that this statement does not
bold in respect of the same person, and that he
may infect himself, although such . infection is
Dot so frequent, as the inattention of gonorrhoea!

{>atients, particularly in the lower classes, would
ead us to expect ; and the experience of War-
drop, Delpecu, Bacot, Allan, and Mackenzie
fully proves that the disease may be caused by
the application of gonorrhceal matter from a dif-
ferent person, although, for obvious reasons, this
cannot be a frequent occurrence. It is, there-
fore, placed beyond doubt, by the cases observed
by the above writers, that the complaint may be
caused by the contact of gonorrhoea! matter —
1st, from the same individual, and, 2dly, from
another. But as, in the greater proportion of
cases of gonorrhoea! ophthalmia, no application
of matter, either from the same or another in-
dividual, can be traced, in what other way does
the disease arise? It has been very generally
imputed to metastasis in all such ; and the dis-
charge from the urethra has been said to be sup-
pressed by St. Yves, R;chter, Scarpa, and
Beer, but erroneously, as contended by Delpech
and Lawrence. In the cases which this last
writer has recorded, the discharge was not stopped
in any one, although it was generally lessened,
but in some not at all. He therefore concludes
that, since the complaint may occur while the
discharge from the urethra continues, and since
it does not take place when that discharge is
stopped, we cannot admit that it owes its origin
to the cessation of the urethral discharge. This
supposed metastatic form he refers to the state
of the constitution, considering it as analogous to
those successive attacks of different parts which
are observed in gout and rheumatism ) and he

to the

the

remarks that, altbougfa direct iofeetioii opcfiles
equally on the eyes of both sexes, tlui paitie«l«
form seems confined to the male. Bbkr says
that he has observed it only in jom^ robwt, aad
plethoric men.

62. /. Treatment,-^ The antiphlogirtie pbn.
and particularly vascular depietioo, has htm
ried to the utmost extent, aomctiaiea wkb
plete, but as often with only partial, an
Of six oases which Mr. LAwaxiica asw at aa
early period, and treated by exUtuim S&pietim^
general and local, loss of the eye^oeenrred ta aa«
only, -* a most satisfactory evidence of tbe pr»-
priety of the practice. But wbencr
comes late under treatment, tto plan
so violent and rapid is the diseiaae.
cation of strong astringentt and
eye, in order to arrest its progreas, baa
vised, as its consequences have been ao
tive to the organ ; and the nitrate of ail vcr
ment, already described ($ 49.), baa hten le-
commended by Mr. Gumaix. Tbe aoceess af
this practice in the severe puruleot opbtkalma.
warrants its adoption in this ; and actire dcplt-
tions, found so successful by Mr. Lawi
an early stage, may precede it. Ooe
stance, however, may militate againat our
ences in favour of it, namely, the origiaa
principal seat of disease being in toe palpe-
bral conjunctiva, in purulent, ami ia the
junctiva ocbli, in gonorrhoea!, ophthalma,
pathological states are not therefore the an
both. Notwithstanding, lioth modes of ptactwe
may be conjoined vrith advantage, aa Dr. Jmw
suggests. The oleum terebinthmc, dropped miD
the eye, is deserving of triaL

63. Large and repeated bloodlMtimg» inm the
arm or jugular vein, followed by local diplniiiii
and the remedies above advised (^ 03.), are, la
the present state of our knowledge, moat to be
depended upon. But if aloughing or
tion of the cornea have occurred, thia
will be of no service. Mr. Lawrbncx
mercury employed without any
he places no reliance on the reprodaction of tfe
urethral discharge, as advised by ~
Scarpa, and Beer. He also thinks
be of little use. The eyes should be
quently cleansed by the usual m<
the inflammatory symptoms have
pletely and quickly subdued, the effects
off in a little time without astringents
but when the conjunctiva twcomes pole aod
flabby, and the patient pallid and weak, the pa-
rulent discharge being ttill abnndaot, •atrimgt^n
locally, and (<mtci internally, are nanally imoi
mended. When sloughing or nlcention of the
cornea is attended by signa of great dipuwiiw.
quinin§ and generous diet are oeecaaary, and
astrhigent lotions are sometimes of aervieo. Mr.
Lawrence prefers a solution of from two to too
grains of alum in an oanee of water, the aolatioo
of the nitrate of silver, and nodUntod tiqoac
plumbi di'^acetatis.

64. g. Miid gonmrhoMl In/lmmmmttom of tW
Conjunctiva,^^ Mr. Lawrxntr baa deaeribvd a
very slight variety of genoirheeal ophlhalima.
consisting of external nedness of a I>r«g1it aroHct
tint, with distension of the superficial lutlsof ibr
globe, and increased mncoos secretina. In scill
slighter attacks, the redness is not deep

B64

£Y£<— SCROPULOUB Ophthalmu,

thereby occasioned, the child rubs or scratches
the parts, which become sore and pustular, and
produce a discharge which encrusts; the afiec-
tion ultimately extending over the face and
forehead, ana in its wont form resembling
crutta lactea and porrigo larvalit. The ed^ of
the lids are often red, swollen, and painful.
There are sometimes an acrid secretion from,
and excoriation of, the nostrils; with redness
and swelling of the alae nasi and upper lip.
The ears are frequently red and sore, or ex-
coriated behind, and the absorbent glands of
the neck are swollen. The bowels are cos-
tive, the tongue white or furred, the. abdo-
men distended, the breath fcetid, the appetite
is morbid, the head and sometimes the skin are
hot, and the child is restless and grinds its teeth
when asleep. The symptoms are worse during
the day, but remit somewha in the dusk of
evtoing. The inflammation of the eye may sud-
denly subside, and return as suddenly ; and very
slight exciting causes will bring back the com-
plaint ; which may thus continue with slight in-
termission for months, or even for years. The
affection of the eyes may also alternate with some
other disorder, or symptoms in remote parts. In
the more chronic cases, the health suffers greatly
from seclusion from light, air, and exercise ; and
the patient becomes pale, etiolated, and sickly,
with a dry and harah skin.

72. e. The Conuqutnctt of the disease on the
cornea are often serious, although the external
redness may not be greaL The phlyctenular or
pustular elevations in the cornea may subside,
leaving ilight opacity, or considerable thickening
of the corneal conjunctiva with greater and more
permanent opacity ; but they more commonly
ulc€rate, in an irregular form, and with a ragged
edge, the ulcers sometimes extending superficially,
or making their way through the cornea to the
anterior chamber, occasioning prolapse of the
iris. The vessels passing over tne cornea may,
without forming pustules, occasion thickening and
opacity, which may proceed so far as to render
the whole corneal covering thick and vascular
(Paniitu). Opacity from interstitial deposition
may also occur, either with or without enlarge-
ment of the proper corneal vessels ; and, occord-
ing to Dr. Faonisp, a brownish red discoloura-
tion, from interstitial effusion of blood, may super-
vene. In addition to the opacity, the externa]
layers of the cornea may yield from the pressure
from behind, and form an external protunerance
(Staphyloma); or adhesion of the iris to the in-
ternal surface of the cornea may take place. In
some instances, the inflammation extends to the
sclerotic coat and iris, and even to the parts seated
behind them. This occurs most frequently in
prolonged or after repeated attacks; and occa-
sionally is followed by structural change of
these parts, or by dropsical enlargement of the
globe.

73. d. Diagnosis. — The extreme intolerance
of light, and copious flow of tears in connection
with the trifling external redness, the pustular
elevations of the conjunctiva, sufficiently dis-
tinguish this affection, which frequently, also, co«
exists with enlargement of the glands and scro-
fulous irritation of the nostrils, lips, behind the
ears, and in other parts of the body. In many
instances, however^ of conjunctivitis in children.

it is difficult to draw a distifictkm bclwaaa tk«
common and scrofulous forma of the diaaan ;
the characters of the one gradually mer^ag inte
those of the other. Thia is oaora capeeialty the
case when the affection of the cyea ■ mmooMtad
with, or consequent upon, either acote or
cutaneous eruptiona, paiticularly wnA aa
the scalp and facto.

74. «. The PrognomiBfatmirabU, if th«
be not affected, or if superiicial or slighc
owing to deposition between ita lamioa, only
present. Mere vascularity of the conwA wiD dis-
appear ; but if it be attended by thJckcaif aad
opacity, the change will be more or leas per*
manent. If ulceration have takea plK« lo con-
siderable depth or extent in tha conwa, aod
especially if it be accompanied with alfactina of
the iris, or lesion of the sclerotic coal» viaoa will
be more or less impaired.

75./. Trttttment.": ConatHotiooal or iator-
nal means are most important
After the bowels have been freely
course of tonies should be piraecribad, with
atives, to promote and improve the variooa
tions. A full dose of catmH aod rkmimrh, tend
afterwards equal quantities of the compound m-
fusions of gentian and aenoa, or the
decoction of aloes, repeated aocordiag lo
stances, will be most serviceaUe, la
an OMtie will advantageooaly praoede the p«fa»
tives. Having thereby evacuaMmorfasd
and excited the aeoreting and axerabiig
tonics, especially the uUphaU tf f anistf, wili be
productive of the greatest beoefiL Daibif the
course of tonics, the hydraigyram cna cvaia
shouki be given on alternate nights, with the
carbonate of potash and rhubarb or jalap.
If the skin be pale, or the child laagvid and
etiolated, the prsparotimu g^tnow wpecisUy the
tincture ferri ammonio chloridt, the vmom feni,
the ferrum tartarixatum — may be prt/ariedi Aa
electuary of sesqui*oxide of iniD, cinniiiiriino «f
senna, and treacle, may oecasioDaUv ha sshsb-
tuted -» particularly on the day fiiflimis^ that
on whicn the powder was takon. la
stances, the decoction of iork,
may be alternated with these
after mercurials have been laid
with soda, or any of the tonie iiifs
small doses of the iManu tf patmak, nay
be tried.

76. B. Rigunsn and dtst are
items in the treatmenti The patient shoeld ha
warmly clothed, and take re^mr exercise ia Ike
open air, particularly when it ■ dry and hfiriii^
Change of air, occasionally to the
warmp tepid, or eotd hatkimg, are alaa
In weak or irritable children,
bathing, salt having been added to the
in sea water, ahould be first adopted ; and coM
bathing tried as the health irapcovea. The Am
should be duly regulated ; animal food m m^
derate quantity, suitable vtgetabies aod npa
baked fruits, being allowed ; hat all
liquon, indigestible subataoocs, and rieb
or pastry ought to be withheld. Tha warn
oaceous food shouki always coostatBle a ohiaf part
of the diet. The child ought to wear ihrevgh fkm
day a dark shade before the me ; aad sleep as a
dark hot well-aired room, with the head
ably raised.

warm or

868

EYE — RflEUMATXC 4ND ArTHMTIC OpRTBALIIU.

experieoce — • should aloDe decide the question.
Although my experience in this matter has neces*
sarily been limited of late years, yet have I seen
enough even of this complaint, to convince me
that fomentations vrith emollient and anodyne
substances are superior to those which are sim-
ple-^ which consist only of warmth conjoined
with humidity. Therefore, when the jpain and
intolerance of light are great, the disease some-
what advanced, or even established, waim emol-
lient and anodyne applications ought to be
preferred. Scabpa direcU mallows boiled in
tresh milk as a fomentation; or emollient and
anodyn» va^Muri, to be conveyed (to the eye
through an inverted funnel. Mr. Mackbnzui
directs vpiaU frietiant of the forehead and tem-
ples, and the eye to be kept under the influence
of b€lUuionna. Fomentations with a decoction
of poppy- heads and camomile flowers, or marsh-
mallows ; and the vapour of warm water, to which
camphor and the watery extract of opium have
been added ; are generally beneficial m the cir-
cumstances just stated. Dr. Smith remarks, that
when the pain was not alleviated by bloodletting
or by fomentations, much and lasting relief was
procured by exposing the eye, twice or thrice
daily, to tlie steam arising from the following
mixture brought to a boiling heat. It is now
eighteen years since a nearly similar combination,
but with much more opium and camphor than is
here ordered, was prescribed by me with great
relief in a case of the disease.

•No. S19. — R Mitt Camphors S iS- ; Tlnet Opll 5 ml ;
Liq. Ammon. Acet $ ij. ; Aq. Romi. 5 Iv. M.

95. B, The lufr-ocuto and chronic ttatUt Spe-
cially the former, sometimes reauire either vents-
section, or full eupjnng, particularly in young or
robust persons. In most instances, leechet should
be applied to the vicinit^r of the eye ; and some-
times either they or cupping ought to be repeated
oftener than noce. Purgatives should be freely
employed ; and, if the tongue be loaded, and the
evacuations offensive, an emetic should precede
them. Great attention ought to be paid to the
diet ; and animal food must be taken only in small
quantity or nearly relinquished. Ctmnter-irri-
tation IS generally beneficial ; and either open
blisters, pustulation by means of tartar emetic.
setons, or issues, should be directed to the nape of
the neck, behind the ears, or to the temples.
During treatment, the bowels should be freely
opened by stomachic purgatives, particolariy if
ti)e tongue be loaded, and the discharges morbid;
and the regimen as well as the diet rigorously
restricted. If the above treatment have been
actively employed, the complaint will be re-
moved, without the necessity of resorting to a«-
itringent or ttimulating applieatiane. But, in
neglected cases, they are sometimes very bene-
ficial, especially if the affection of the conjunc-
tiva be considerable, after the above measures
have been appropriately prescribed, and when
the complaint is far advanced, or in a chronic
state. The vinum o/ni, dropped into the eye,
was recommended by Mr. Ware ; and is suited
chiefly to chronic cases. The liquid laudanum of
Sydenham (F. 729.), or preparations similar to it,
may also be applied. The collyrium praised by
Conradi, ana which consists of one grain of
bichloride of mercury dissolved in six ounces of
ro»e water, with the addition of a drachm of

mucilage of quince-seeda and half a dnchm or
a drachm of Syoknham'b landanam, ia often of
service. Several other applieationi, aoow of them
much more astringent than the above, have bciew
recommended ; but they are usdeoerving of par-
ticular notice. The astringent oiotmenta* and
solutions found so beneficial in the treatment of
coojjunctivitis ($ 16.50.), may also be employed
in the chronic stales of this complaint, pniticnlariy
under the circumstances just specified.

96. J3. Rbsdmatv;, CATABaHO-RBCoasATic,
AND Arthritic Ophthalmia. Stn. *— Op4t.
Rheumatica et Arthritiea, — Sclerotitis RMmtmm
et Arihritica, — Infiammatwn «f the Eatfrmml
per Tunics in Rheumatic and Gouty Caeuti

97. a. The KAeuinaitc modificatkm of opkibal-
mia. — Sclerotitis Rheumatica or Attnoepherkm of
Mackbnzie — is seated in the external proper
tunics of the eye, as in the common, or phlcg-
monoid, variety just described. The coojnactaw
is only slightly affected ; but the ioflammatM
sometimes extends to the iru,orconiM, or lo both.
but generally in a slight degree. It is commoaJy
caused by cold, or cuneats of air striking the
eyes of persons of a rbeumatic diitheais. It is
not a common afiection, and seldom ariaea frtm
metastatis.

98. h. Symptoms and Couree, — A atingiinig or
tearing paio ia oomplaieed of in the eye. inoeaasd
by heat and by a warm bed, and eKtrading to tW
orbit and adjoining parts of the bead and hga.
The sclerotica is of a roae red, and ahiaea throngh
the conjunctiva, which is more injected thoa
usual. There is an increased flow of tears, aggrn-
vated by changes of temperature. The petn se^
sequently becomes more dull and aehiog, exicads
with greater severity to the Daighbottriag pern,
and lachrymation is aagmeaied. The intoleraaos
of light, which was only slight, is afiarwarda fell
only in a strong light. Dullness or hiiim ss of
the cornea is frequently ohaerved, but is
followed by any senous change. So
phlyctenule ^PP^v ^^ ^^ ooojonctiva ocoli mad
cornea, but thev do not ofken peas into nlcctetioe.
The biliaiy and intestinal functioos are man or
less disordered ; and febrile disturfaaaee is ea^
monly present. The severity and duration of aa
attack vaiy very much. Slight eases soon aabrnde ;
but severer attacks may give lisa lo sritit, mhiek
is, however, rarely acute, unless the diiMB a be
nefflected, when it may go on to effeaon of ooe-
guTable lymph. Rheematic acleroiitia is Mt
attended by afiection of the lids, nor by che-
mosis : it does not give rise to suppuralioB, and
rarely to ulceration, the ulcere being small or
peculiar, and healing readily ; and it
lapses into a very chronic, dight, or
form.

99. c. The Catarrho-rheumatic ophthalmia of
some writers does not diffier materially from tW
common or phlegmonoid inflammation of the p»»
per external tunics ($ 66.X being aented to ike
sclerotica and conjunctiva, ft is usanlly emmmi
by cold, and atmospheric chaagei ; and in the
rheumatic diathesis, very nearly apnioethai, or
merges into, the rheumatic Com ; tM only di^

ference being in the greater aflcctioa of tbe
junctiva, and in the consequent asanifesMHons of
certain catarrhal symptoms.

100. d. ArihrUic Ophthalmia -^ Seierotkk Ar-
thritica, — Arthritic external Opk*. — er iaff%ai-

870

EYE— Inplammition or thx Antsrior Chambxa.

cornea is penetrated ather by ulceration or enp-
puration, the atjueous hamour escapes, the iris
and cornea coming in contact. When the wound
in the cornea is small, it unites by adhesion, and
the aqueous hamour is soon reproduced ; but
when it is large, prolapsus of the iris often results.

107. 6. SulhacuU and chronic Ccmcitii are
common in young penons of a fair complexion and
delicate constitution. The cornea loses its trans-
parency, presents a dull grey colour, or becomes
nazy, nebulous, or nearly opaque; the opacity
commencing at the circumference, and maually
but unequally extending. The nebulous and
opaque spots are sometimes yellowish, as if mat-
ter were formed : and the surface loses its polish,
and seems rough. The circumference of the
cornea is minutely injected with a multitude of
very fine vessels, which impart to it a reddish
brown tint, and occasionally elevate it somewhat.
The conjunctiva often retains its natural pale-
ness, but the sclerotica is minutely injected, par-
ticularly around the cornea. As the brownish
red tint of the circumference of the part increases,
the opacity in its centre becomes greater, and
vision more afTecled. There is generally much
intolerance of light, notwithstanding the diminished
transparency of the cornea, owing to affection of
the sclerotica. A partialform of comeitit, which
is generally of very long duration, is sometimes
met with. Inflammation commences in one or
two spots at the circumference of the cornea,
with pain of the eye, and nebulosity ; others
being affected in succession. Redness is first
observed in the sclerotica, in one or two points ;
and minute vessels extend from these into the
cloudy spots in the cornea; more or less of which
may become thus affected, or entirely opaque.

108. Although the severe and aeuU grades of
comeitis often run into suppuration or ulceration,
the slighter or more chronic states do not termi-
nate in this manner, excepting in sub-acute cases,
where partial or circumscribed points of suppur-
ation may occur. The more severe grades are
attended by much pain in the eye, temples, and
forehead ; ^ with tension-of the organ, white tongue,
and febrile disturbance, particularly at an early
stage ; and thev often pass into the slighter and
chronic states; but the latter also occur primarily.
Chronic comeitis presents much less febrile dis-
order than the acute, and often continues for seve-
ral months, or remits. The inflsmmation some-
times extends to the iris, occasioning adhesion of
its margin to the capsule of the lens.

109. c. Scrofulou* Conmtit — Comeiiit tcro-
fulota, — Inflammation of the cornea in scrofulous
habits has been minutely described by Dr. Fbo-
Rixp and Mr. Mackbnsix ; but its local charac-
ters do not differ from those of the subacute and
chronic forms noticed above ($ 107, 108.), except-
ing that it is more obstinate, and more liable to
return. It is sometimes unattended by redness
of the sclerotica; and the pain is not considerable.
It is most common about the period of puberty,
and is occasionally connected with amenorrhoea in
the female, and with swollen lymphatic glands.
In the more obstinate cases, increased secretion of
the aqueous humour, and consequent enlargement
of the anterior chamber, occasionally supervene.

110. d. Trwimtnt, — «. AeuUcomeitit requires
active depletory and other antiphlogistic mea-
Mres. Cupptflig behind the ears or on the tem-

ples is always necessary. PicrfstlvcB, tad
terwards caUmMi with Jamt^t T^arndtr^
casionallv with opium, until the movth is
are beneficial, e^iecialiy if the iris be
In the more obstinate and dkrsnie caaea,
or the application of a number of leecbea lb Ike
vicinity of the eye, should be repeated oltcarr
than once, and be followed by opca hit
mcntfOt issues. Mr. Lawrxhcr adviai
to be inserted in the temples. Attrimgmt
mulating applications to rensove the opacitj
generally ujurioos. Warm fomemimtiamM
more serviceable, paiticulariy wtth emolUcBt aad
anodyne substances. Emctacs, if die digotnc
organs be loaded ; and dMp4ore(tcs» aasiated by
warm pediluvia, if the skin be dry, and fisvcr pf«-
sent ; are also useful. — $, The ierofuiam»
especially its more chronic states, ia
moat by sarsaparilla, sulphate of quiiuBe,
tion of*^ bark with li<)uor potassB, the
myrrh mixture, the iodide of potusiaiD,
small doses of the bichloride oftaegcarj id
of bark. — - As this variety often eontmi
months, perseverance in die use of these

and changes from the one to the other, a diy «

air, and change of air, with attention to tke stale
of the digestive organs, and a carefully rega-
lated diet, are most requisite.
III. Inplammation op thx IirruMAL Paxti

OF THX Eye. Syn. — Internal Ophthmiamt,

Ophthalmitis Interna, Aoct. var.

111. DxnN. — InJIammmtion of mm or ^rg ^
the internal tiMtuci of the eys, oeemrrimg «itW
primarily, or cemeeutiveltf of external dkeeem^ amd
attended by impaired 0(ft<m, and /raquemtiff by
constitutional disorder,

1 12. In diseases of the internal eye, mrtijumi
dilatation of the pupU is necessary boih to the
investigation of their nature and extent, aui to
their treatment. Mr. Lawxxkcs has given a
learned account of the agents by which dilBtatioe
may be accomplished. Various narcotic vegeta-
bles possess this power, but MImdemma in the
bigh<»t degree. The tincture, extract, dfecoe-
tion, infution, or powder of thb plant may bt
employed for this purpose, either inlemallyp ot
dropped into the eye, or rubbed on the brow or
temple. Hyoseyamus is the next poweffnl sab-
stance. An aqueous solution of the extnets of
either may be nibbed or placed upon the eydfali
or parts in the vicinity, and washed off after re-
maining for about an hour ; or it may be droypsd
into the eye, when a speedy and certain ^
desired,
i. Inflammation or thx AirrxaioR Cm

Syn. — Inflammation of the Capeuie W* the
Aqueous Humour, Wardbop; dgan Capem
/tri<,MACXXNX]x; ITsraro-fritti, Rosas; In^
matian of the Anterior Chancer, LAwmasiGa.

113. Charact.— Di/ttssd muddime
mottled appearance efthe cornea, dimnessof

fullness and tension of the eye, duUmeu of the
slightly ofiUracted pupil, headaeh, white
and fever.

1 14. Inflammation of the membrane of the
aqueous humour is often comsefuemt nnon the «a*
rieties of ophthalmia ahead v described ; beti is
also a primary disease, and b most
this form among children. It eannet be
dered, even when primary, to be eonfined ta the
anterior chamber, or to this BMnhnae^ The

la

812

EYE -~ Idiopathic Iritu— Symptoim and Codbsx.

arthritic diathesis, or snpervemDg in the coune of
syphilitic cachexia.

121. Catuex.—- Prtmarj/ Iritis occufs most
frequcDtlj ia persons of an unsound constitution
— the gouty, rheumatic, and cachectic ; and
hence it presents ceitain modifications hereafter
to be noticed. It rarely occurs in young and
healthy persons ; although it may supervene in
them, upon the other vaneties of ophthalmia. It
is excited by the common^uuises of inflammation
of this organ ($ 5.) > especially by over exer-
tion, and employment of sij^ht on minute or
bright objects.} by external injuries or operations
on the eye ; and by exposure to cold, wet, and
atmospheric vicissitudes. These last are the
common exciting causes in persons imbued with
the syphilitic cachexia, and in those of a rheu-
matic and gouty diathesis. I do not believe 4hst
the use of mercury will cause the complaint, if it
be given so as to affect the mouth.

122. A. loioPAVHic Iritis. ^-a. Symptami
and Couth* — Iritis presents various grades ^'
fei>eri()f,.and periodt if duration. It may hence
be mild or severe ; acute, sub^eutet or ehrouic.
I shall adopt Mr. Macxrnzis'4 division of iritis
into three grades. ^p>. In the first degree, -the
vascularity of the sclerotica is barely perceptible,
and exists only in one or more points, and chiefly
behind the upper lid. The ring of the iris next
the pupil is slightly discolour^; the pupil is
not materially contracted, but is somewhat irre-
gular, without its usual clean and sharp edge,
and is hazy ; and ^the motions of the iris are
limited and slow« Vision is confused and slightly
obscured. There is little or no pain, or aversion
from light. This state x>f iritis may exist for
many weeks, and yet be completely removed by
suitable tceatment.

123. 0, The second degree, or that with evident
External inflammation of the eye, is much more
frequent than the foregoing. A 2one of vascu-
larity is observed in the -sclerotica around the
cornea, the vessels sinking through the sclerotica,
and not advancing into the cornea. The iris,
particularly its inner or smaller rings, is dis-
coloured, either .from injection of its vessels
or the effusion of lymph-; and its anterior sur-
face, instead of being smooth and shining, ap-
pears dull, puckered, and swollen, especially

near the pupillary opening, where it is retracted

toe lens. The pupi*
gular, motionless, and filled with ooagulable

towards toe lens. The pupil is contracted, irre-

lyroph, which generally appears like half-boiled
white of egg. Epiphora and intolerance of light
are considerable, and vision becomes gmatly
impaired. The pain in the eye is constant, and
attended by pain in the orbit and forehead, par-
ticularly at night ; and by the usual symptoms of
inflammatory lever.

124. y. The third degree of iritis presents the
following characters :-* The eye externally is
much more inflamed than in the foregoing
grades; the redness of the conjunctiva beinff
aometimes so great as to mask for a time the red
zone of the sclerotica. Both the smaller and
larger rings of the iris are discoloured ; the an-
terior surface being swollen, puckered, and
bolstered forwards so as to approach the cornea,
excepting its pupillary edge, which is retracted
towards the lens. Red vessels and spots of blood
$re somocunef se^o on the iris, but more fre-

quently in the lymph ooeupyinp liift vciy _
tracted pupil. One or more minnle clevattoas,
of a yellowish colour, which are in aoflw eases
specks of effused lymph, in others small ab-
soesses, appear on the surface of the iria ; •ad
pus discharged from these abscesus, wkh lyaipk,
blood, and serum, sometimes oocvpj the anterior
chamber. The cosnea becomes hexy aad tvbid.
and oecarionally dotted with minaie bcowvah
spots. There are at fisst greet itolMaauL at
light and laclirymation:; and saboequcnlly vinoa
is completely, and geoeraUy peijnanemfc, IciL
Flashes of light in the eye are freqacntly per-
ceived by the patient, indieating the exteosseo of
inflammatioD to the choroid and redaa. Ihe
pain in the orj^n is constant, p;ieat, mad mnt
times eacnidatrng; with pain in the orbift end
eyebrow, increased at *ight. When
with extreme pain, especiuly in jsypUitic
very serious chaoses, even abscess of Ike
rior chamber, disorganiiatbn of the t'
humour, &c. fre(|«ient]y euperveDe. lu U
the inflammation is extended more or l«s to the
internal and external tttsues of the cjne, aad g»»
neral ophthalmitis ($453.) is the vesult.

126. h The diseoiountitm tfthtirie aiMi £ram
vascular injection and effusioo, aad ia «f a yel-
lowish or greenish tint, in light eyea ; or of a
reddish hoe, in dark eyes*: bat it m T&rj fiv-
quently dull, muddy, and dark ; and the ootaral
brilliancy and fibrous arrangement of this part
are lost. The effused iympk is aeea firatattfe
pupillary edge, and aftenrards on the iesHr
circle of the iris ; causing a villoao, foagh, d^
vated, or irregular sorfcoe or outliBe of the p«t.
The lymph may be in distinct masaea of v«y
various sixes on the anterior of the iria, or at m
pupilkry margin ; and, in the mosl
It may fill the pupil or anterior chamher, or
the posterior cnamber. The cahar of the
lymph is sometimes a light yellowish beawa ar
ochrpy ; but a rusty hue is most ooamoo. It a
occasionally of a light dirty yeHowish tint, pBw
ticttlarly when it is abanduit,and filla theaaia^
rior chamber. In this case, or wbes a maS
abscess in the iris is discharged in this aitaatiaa,
a form of hypopyon is the resulL The fiap*i ie
contracted, and becomes more and aaesa so in
the progress of the complaint. Tha ofasluB of
lymph and adhenon render it also aagalar, in^
gular, and fixed at one or more pointa^ aad free
in otliers. It loses its thin, sharp, aad well-
defined edge ; and beconea dull aad cleady, or
otherwise diseoloored.

126. c. The acute states ef iritu are
ia penons of a full habit or robust
after the action of powerful cansea, capedally ie
they continue to act, and the case havo been
neglected at the beginning; and ia cachectic
conditions of the frame. They are atlwaiieii by
the usual characters of severe vaaeBlar aenea ;
especiaHy injection of the vessels, estrano esa*
Uaction of the pupil, effasioa of Imph.dalaMa
of the cornea, external redness, lesa of esfku
violent pain in the eye, and severe headaeh. with
wateh^neas, resUeosness, and febrile
anoe, termmating, in a few days, ta
ation of the interior tiosacf, a«!d ia
loss of vision.^ In ekramic casis, the oeigia of
disease is almost impereeptible, and its
slow. Little or no pain is felt, aad tha

874

EYE •» Sympathetic lams — tstmATuarr,

of turpeniin0 and eoitor oil, or a larger portion of
the former, the specific operation of the calomel
will not be prevented, or even delayed, but the
beneficial eUects^n the disease will be insured.

131. Belladonna is of great benefit in every
stage of the complaint, and should be applied as
directed above (f 112.), contemporaneously with
the exhibition of mercury. Although the pupil
be contracted, and effusion or even adhesion has
taken place, the specific operation of the latter,
and the effects of the former on the iris, will
elongate or even entirely detach the adhesions, if
they are soft or unorganised. In addition to
these, diaphar€tict, diuretict, and warm pediluvia
are beneficial. The bowels ought to be kept
freely open by the substances already noticed.
Turpentino may be used for this purpose, or with
the view of aiding the effects of calomel, or even
as a substitute for it, as advised by Mr. Cabmi-
CHAEL, who prescribes it in drachm doses, three
times a day, suspended in almond emulsion.
*Biutert are of doubtful efficacy -, Mr. Lawrencb
decides against them.

132. B, Sympathetic lams. — a. Syj^ilitie
Jritit, or inflammation of the iris occurring in
persons tainted by the syphilitic poison, is, per-
haps, the most common variety of this disease.
It is a symptom of syphilis in its constitutional
Btage ; and, although sometimes appearing alone,
it M more frequently one of several secondary
symptoms, especially ulcerations of the throat,
eruptions, swellings of the periosteum, pains of
the limbs, affection of the nose, &c. It occurs
most frequently along with the earlier secoodaiy
affections, and sometimes appears before the
primary disorder is cured (Lawrewce). It
rarely occurs as a symptom of syphilis in mfanto,
although secondary syphilis is not infrequent in
them. It may be either actiU or chronic; it is
often associated with inflammation of other internal
tissues of the organ ; and it is most commonly
determined or excited by exposure to cold, exer-
tion of the eye, or external injury.

133. Diagwmt. — The characters and progress
of syphilitic iritis are nearly the same as those of
the idiopathic form ; yet there are ceruin points
of difference, which are frequently observed in
the local ^mptoms, deserving of notice. These
are the tubercular disposition, and Uie reddish
brown discolouration of the lymph effused on the
iris ; the angular form of the pupil, and its di»*
placement towards the root of the nose ; and the
violent exacerbations of pain felt chiefly in the
brow during the night, and in a slighter degree or
not at all in the day. The first and second of
these are, however, not constant ; the last is al-
ways presenU But the most certain diagnosis are,
the concomitance of other syphilitic affections,
and the history of the case.— Lymph is effused
from the margin of the pupil in arthritic iritii,
but not deposited in a distinct form, and the
adhesions are generally white ; and both in it,
and in the idiopathic variety, the pupil com-
monly retains its circular figure and central po-

ntion.

134. b. iirlArilicJrtiii. — Inflammation of the

iris is. frequent in the gouty diathttit, but less so
ID the rhtumatic, unless as a consequence of
rheumatic inflammation of the sclerotica ($ 97.).
In the gouty, it occurs roost commonly in the iris
from the Qoromencement, although often some

Qther tissues of the organ are affected at the saae
time 'y but, in the rheumatic, it rarely begins
in the iris. The gouty wnodijieaiion is geacnlly
acute, and very severe ; the rhtuaiatie, mib^mcmMt,
or chronic, and more mild.'—llie J^nncr gcoc-
rally commences vrith pain of the eye. intoletmnca
of hght, lachiymation, and sonular redness of the
sclerotica. Pains ace felt in the erbtt, brow, and
forehead. The iris soon becomes doU aad de-
coloured; the pupil contracted, and fixed ai oee
or more points to the capsule of the Icds. The
reddish zone in the sclerotiea is of a daU «r
nearly livid tint, and does not adveaee to the
edge of the cornea, but leaves a naiiow what
ring between. After a violent attack, wiA he-
paired visbn, the symptoms subadc, and sight »
restored, the iris being attached to t^ eapssle by
whitish adhesions. This form of iritis oAea n-
turns again and again, the eyes reoorenng alnoM
completely after repeated attaeks. Bir. Lsv-
RENCB met with a case in which the
returned fourteen times ; yet vision
terially impaired, though adhesioDs in each c^
connected the pupillsry edge of the iris to tte
capsule. But frequently a fresh effna
on each attack, until the pupil is more and
contracted, and at last filled with opnaae ad-
ventitious membrane; the texture cm the im.
notwithstanding, generally remaining bat iotit
altered.

135. c, Scrofuloui Jrttis.— This Tariety is eoa-
secutive of strumous ophthalmia (^68.), the id-
flammation extending from the external lanies.
It is commonly prmded and aeoompamad hv
changes in the cornea, preventing the lesinai «f
the iris from being observed. Hence it oAea o-
capes detection until it has completed its coaits.
It very rarely occurs ss a primary affection. Mr.
Macxekzib adduces a case in which the atiaci
seemed primary ; but iu history is not oenclimvc
on this point.

136. Treatmint. — a. The typhiiiiic tamrutf r-
quires local bUedingt and mtreuriaU, as adviiri
for the idiopathic disease, and in similar
binations, until the symptoms and the cm
tional msJady, on which the local one isengialtod,
are entirely removed. TwrpsnClnt may aim he
employed as an auxiliary, and to open mt be«tl%
either as directed by Mr. CAaniCHAEi., er as pra-
scribed by myself ($ 130. 131.). OpimU /rwteM
around the eye, and btlUdomta, are nlao ef grMt
service. Gonoral hhodhttimg is seldom wvi.1
borne in this variety, unless in robost or picchsnc
persons ; but full or repeated cmpping ia olica ac«
cessary.

137. h. Arthritic Jntis.— The
modiJicatioH requires the treatment
in rheumatic inflammation of the external Cacjc«
— especially eiffpmg, Utehing, hiitterimg, mhtr-
ativet, with coUhieum ; and, sobseqneotlj, ct»-
chona or fuiniae, with full doses of esMaraw.
aided by counter-irritation. Turptmtim is al«p
beneficial in this variety; but it thonld he give^
so as to act moderately on the bowels. Mr.
Wallace advises bark to be given froea the ee*-
mencemeot, when this disease follows low frrrrk
— The^imly wwdifieatian will be rea»ov«d b« s
very similar treatment to that now statod. Jtf«r^
curiaU given with any other intention then thai
of removing morbid
are more injurious

876

EYE— Arthritic lyrLAMMATXOM or tbs Intsrnal Tinaok

void, of the hyaloid membnme, of the capsule, &c., |
under the tenns Charoidititt Hyaloiditht Captu-
lU'u, and Lentitit — have been described by Jusng-
KBN, Rosas, and Mackenzie. But admitting,
from analogy, that inflammation may commence
in, and be more or leas confined to, either of these
tissues, for a longer or shorter time, I question
the possibility of their being often distinguished
from retmittf, with which they must necessarily
be in some degree associated. I must refer the
reader to the observations of Mr. Mackbnzie on
Ckoroiditit, He believes that the choroid, al-
though generally affected consecutively upon
iritis, is sometimes primarily and separately in-
flamed. The inference is most probably correct ;
yet experience shows that such a state of disease
can but rarely be recognised. He states tliat
ehorciditis, in its earliest stages, exists without any
signs of disease of the iris, and without any effects
upon the sclerotica and retina beyond those which
must necessarily arise from the pressure of an in-
flamed and swollen membrane. Tne dark colour of
the choroid shows through the sclerotica, which
thus appears blubh or purplish, and distended. The
part most discoloured protrudes, generally, on one
side of the ball, and near the cornea ; and is of a
deep blue tint, with varicose vessels running over
it {ScUrotie Staphytama}, Several such tumours
may surround the cornea, or may protrude on the
posterior hemisphere of the organ. A watery fluid
IS sometimes enused between the choroid and the
retina during its progress ; and redness is observed
in parts of the sclerotica. Although the iris is not
inflamed, it is always narrowed or drawn towards
the portion of the choroid chiefly aflected, causing
displacement of the pupil. There are generally
attendant intolerance of light, pain, hemicrania,
frequently partial opacity of the cornea, dimness of
aij^ht, proceeding to total blindness, and febrile
disturbance, disonier of the digestive organs. The
disease is most common in the scrofulous diathe-
sis ; in those who over-use their eyes, without tak-
ing sufficient exercise, and who expose them to too
much heat and light.

145.6. The Treatment consists of copious blood-
ktling, active cathartiee, mercury aided by tur-
pentine, and eounter-irritatUm, in the earlier
stages; and, subsequently, the internal use of
the preparations of iodine, or the precipitated car-
bonate of iron ; or the iodide of iron, and the
sulphate of quinine.

146. C. Arthritie Inflammation of the Internal
Tunici — Ophthalmitis Arthritica, Bbnbdict and
Rosas. — a. Arthritic iritis frequently is confined
to the iris ; but in gouty persons of very impaired
constitutbn, inflammation is either extended to,
or almost simultaneously appears in, the retina,
the choroid, the lens and its capsule, and the
vitreous humour ; the sclerotica and cornea be-
ing secondarily aflected. It usually attacks
elderly persons, of a full habit, with bloated,
red, purple, and veined faces ; and it generally
termmates in loss of sight, with dilated pupd
and opaque lens or glaucoma. At first the pa-
tient complains of increased sensibility to lignt ;
of lachrymation ; and of a severe burning or tear-
ing pain deep in the globe, with a sensation as if
the eye were too large for the orbit. A dull and
livid redness is obeerved in the sclerotica ; it in-
creases towards the cornea, but is separated from
this part by a narrow white ring. The conjuoo*

tiva afterwards becomes injected, and the tantm.
dull. The pain is now distractinir, Rnd extends
to the orbit, face, and side of the bead : the iris
is dark, assumes a dirty appearaDCCy b inv^-
larly contracted and fixed, tfa« pupil often hnvinf
an oblong or oval fl^re, in the transveive direc-
tion. A greenish discolouration is obeerved deep
in the eye, from loet transparency of the vitreous
humour. The posterior tissues swell aad pvsk
the lens forwards, wedging it into the cfilaied
pupil, and squeezing it even against tbe cornea.
The lens also turns green, yellowish green (^CUm-
eomatoui Cataract), or dull white. The cooges-
tion and swelling of the internal eoata dtsicsd
the sclerotica, or bulge it out in pails ; the
cornea becomes hazy ; and the chaa^ea in the
iris, pupil, and external tissues, impart to tfe
organ a dead appearance. Luminoos flaabes are
frequently perceived in the eye; bat sight b
either much impaired or altogether lost — aoiBe-
times suddenly — from the oommeaoencBt. At
this stage the symptoms frequently aobssde, tbe
irb preservmg its dull hue, the pupil being flsed
and dilated, and sight totally lost. A varieeK
state of tbe vessels in the 'sclerotiea sometDnei
remains; or a dull leaden appearance, wnh sb^
projections or larger bulgings around tbe coraes.
as in choroiditb ($ 144.).

147. Thb disease generally aflecta botb eyes.
either in succession or at once. Its daratioB b
various as well as its severity; and it oHeo ss-
sumes a less violent form tlMin tbat naw de-
scribed, especially when its early symptoaw have
been mitigated by treatment, ia tfaia cav,
sight b more gradually and slowly extingnisfaed :
the pain b less ; and the external changes, par-
ticuiarly the bulgings of the sclerotica, are ctfter
less, or but slight. It b diflicalt to dcteiaiiae
what tissue b primarily aflected ; bnt saoat pre-
bably the choroid, retina, and iris, are alasoct
coetaneously attacked. The early loaa of si^:
indicates an early affection of the retiaa; aad
the equally early tension and pain show itei
congestion and swelling of the choroid b psesuit
from the first.

148. b. The Pro/pidsii b extremely aalbvoar-
able. If the characterbtic symptoms of thb aflse*-
tion be present, and more especially if viaioo be
lost, permanent extinction oi sight will be the
consequence.

149. c. Treatment has hitherto been kmmd la
have little influence on thb disease. Navctlhe-
less, bloodletting ; warn purgatives, with fall dosn
of colehieum ami alkaline carbonates ; reral^aaAi
to the lower extremitiea, or behind tbe aara, ar to
the nape of the neck ; active doses of tarpentia*
both by the mouth and in encmata, so aa to act
efliciently upon the bowels aad vaacalar sysicn ;
subsequently PLUMMxa'spill and the deeacttoa gs*
guaiacum,wiUi the compound tincture of caJchi* ass
and liquor potassB ; and full dosea of sulplkato of
quinine, or of cinchona with or withottt
ice. ; should be fully tried.

160. D. Ja/lamaialioa of ths tafsmai tissMs
after fever sometimes occurs. It has been de-
scribed by Dr. Wallacb aad Dr. Jacob. tH
forty cases which the former observod, thef* srera
only four who had the disease in the lalt ayn. and
only two who had it in both. It may oocar v<rv
soon, or not for some months, after fever ; and n
presents two ttagee ; to the >ErsC of whiflh.

£Y£ — Phliomonoid iNrLAmnnoN ov tbb Ball*

Totic symptoms are alone present ; in the ucond
those of inflammation are superadded. The pe*
riod at which the former commences after fever,
and i|s duration before redness comes on, are
very uncertain. In some cases, dimness of sight
and muicm voUtantet have been present from the
earliest period of convalescence, vet the inflam-
matory stage has not supervened for weeks or
months; and in other instances, the amaurotic
symptoms have not appeared till months after the
fever, and have been soon followed by the second
stage. The inflammatory changes disappear be-
fore the amaurotic symptoms ( Waluice).

151. Dr. Jacob met with seventy or eighty
cases of the disease in one year. It is most fre-
quent among the poor, in young persons and in
females ; and attacks always only one eye. The
affection of the retina havmg been present from
a few days to several weeks, the transparent parts
of the eye become more or less clouded or
opaque; the circumference of the cornea pre-
sents an opaque whiUsh appearance or circle,
resembling the arcus senilis. The anterior cham-
ber seems clouded. The iris is always dull, and
altered in colour ; but tubercles of lymph or ab-
scesses are not seen in it; and it often moves
actively. The pupil is slightly irregular ; yet it
does not contract adhesions, or become closed.
Hypopyon sometimes ensues. In the worst cases,
the lens becomes partially opaque, and presents
an opaline amber colour. When vision is per-
manently lost, it is generally owing to this
change. Impairment or loss of vision is the
earliest symptom ; and there generally are into-
lerance of light, lachrymation, and a stinging or
darting pain through the eye to the temple or
nose. Sometimes the suflTeriog is slight; but
it is usually increased on exposure to strong
light (Jacob).

152. The Treatmtnt recommended by these
two experienced writers is diametrically opposite.
Dr. Wallace found depletion and mercury
insufficient for a cure ; her therefore gave half
a drachm, or a drachm, of bark in powder,
three or four times a day; or the sulphate of
quinine in two grain doses. Dr. Rsxd also
employed bark with success in this sequela of
fever. Dr. Jacob, however, states, that bleed-
ing locally or generally, purgatives and anti-
monials, blisters and opiate stupes, and mer-
curials with opium and belladonna, are the roost
efficacious means of cure. He adds, that the re-
lief from mercury is so certain, that he has trusted
to it almost exclusively, with the assistance of
belladonna. He has generally found two grains
of calomel, with a quarter of a grain of opium, or
five grains of blue |mI1 alone, three times a day,
answer every purpose ; tenderness of the ^ums
coming on in eight or ten days. If the pain be
severe, he combines hyoscyamus or belladonna
with ibe dose taken at bedtime. He tried the
sulphate of quinine in four cases for eight days ;
but finding no relief, he gave mercury, which
effected a cure. The cases occurring after typhus
fever, recorded by Mr. Hewson, and which were
similar to those described by Drs. Wallace,
Reid, and Jacob, readily yielded to mercurial
treatment

IV. Inflammation or tue whole Eye. Syn.

« — Ophthalmitu Idiopathica, Beer ; Ophthal'

mitit UnivertaUs, Wellbb; Jriflanaiiation tf

the Globe, Lawrence; PhkgmoHoid I^ftam
motion of the whole Ball,

153. Charact. — Severe deep-4eated pew; in"
created intental redneu and tuwutf action ; a tente
of tetuion, and a feeling of the organ being too
largo for the orbit, and about, to buret from it ;
early lou of tight, with diteolured irit, and eon»
traeted, immoveable pupil ; twelling and immobility
of tho globe, with'partial protrution of it and the
eyelids; and severe inflammatory fever,

154. A, This severe disease has been well
described by Mr. Lawrence. It consists of
inflammation of the internal and external tissues,
and is not of common occurrence. It is met
with chiefly in very robust constitutions, and
persons of a phlogistic diathesis and full habit of
body. It is most frequent in the right eye, as is
the case with ophthalmic inflammation generally.
Mr. Lawrence states, that of 134 cases of oph-
thalmia commencing in one eye, 95 began in
the right. Generu ophthalmitis is most com-
monly caused by severe injuries of the organ ;
by the explosion of gunpowder before the eye ;
by great heat and light striking upon it;
and fragments of stone, iron, &c. propelled
against it.

155. a. Symptoms and Course, — At the com-
mencement, the characteristic injection of both
the sclerotica and conjunctiva is evident ; with a
severe burning or throbbing pain, and a sense
of burstrng distension. The surface of the organ
is stiff and dry ; but copious lachrymation soon
comes on, and is increased by exposure to light.
The external redness increases; and the con-
junctiva swells into a broad firm ring of chemosis
around the cornea^ which it partially overlaps.
There are intolerance of light, dimness of vision,
contracted pupil, impaired brilliancy of the iris,
and acute sympathetic fever. This constitutes
the first stage of the disease.— The motions of
the globe and lids now become difiScult and
painful; and the pain more and more violent,
extending to the brow, cheek, temple, and head.
The previously blue or grey iris assumes a dull
greenish hue ; and the brown or black, a reddish
tint. The eyeball swells and loses its power of
motion ; the cornea grows muddy, and, by de-
grees, opaque ; but vision is generally lost before
these changes supervene. The ^tient perceives
luminous flashes or sparks in his eye, owing to
disordered action in the retina ; and the vascular
distension of the internal tissues generally occa-
sions a sense of bursting. The deep-seated
swelling and external chemosis partially evert
the inflamed eyelids, which thus resemble, espe-
cially the inferior, a red fleshy mass ; and both
the ball and lids are protruded, and immoveable.
The second stage is now fully developed. — Sym-
pathetic inflammatory fever always accompanies
this severe disease. The local symptoms are
preceded, or attended at their commencement
by chills or rigors, followed by headacb, white
tongue, thirst, hot and dry skin ; and accelerated,
hard, and full pulse. These are increased at
night, and accompanied with watchfulness, and
throbbing in the temple and eye.

156. b. The Consequences, or the second stage,
according to Weller, are suppuration and opa-
city of the cornea, £cc. If the disease be not
arrested* the pain becomes throbbing; delirium
sometimes occurs at night; and chills or rigors

878

EYE — Phleomokoid iKrLAMMAnoif or nti BALL^TftiATKSirr.

are felt, indicatiiig impending snppnration. The
coraea is first a dull white, and then yellow, and
matter is formed. The throbbing and burstiog
pain continues, notwithstanding, for tome days,
until the cornea bursts externally, and gives exit
to the matter ; the coats of the eye collapsing, and
the form of the organ being lost. When the pro-
gress of the diseise has iMen checked by treat-
ment, the cornea remains opaque, and the pupil is
either clos^ or very much contracted, and the
aperture filled by adventitious membrane; vision
being either much impaired or entirely lost. Even
when recovery takes place, with an open pupil
and clear cornea, the retina has genertlly suffered
80 much as to cause some impcarfection of vision
(Lawrence).

157. e. DiagnoRf.— This complaint is chanc*
terised by the simultaneous affection of both the
internal and external tunics ; and is distinguished
from the tifmpathetie wtpulfie indammation above
considered, by the following circumstances: —
(a) Redness, pain, swelling, intolerance of light,
lachrymal discharge, and impaired vision, are all
equally and oo*oMioately developed; but in the
specific iuflammations, one or other of these is
always predominant over the rest, and accom>
panied by some peculiar local and constitutional
affection. — (fr) These symptoms commence at
the same time in an equal degree, and continue
very nearly so throughout; but in the other
ophthalmise, this correspondence is remarked nei-
ther at their commencement, nor during their pro-

'greas. — (c) The course of the malady is regular
and continued, and it always terminates in sup-
puration of the globe, if not arrested by treat-
ment ; whilst the others remit more or less, and
only occasionallv terminate in thb manner. —
(d) Phleg monoid ophthalmitis is always attended
by severe sympathetic fever; but the specific
forms are generally without fever, even when
most severe.

158. d. Treatment, — It is only in the^rfl stage
that we can expect to preserve the sight. In
the teeond ftage, this will rarely be accomplished.
When vision is altogether lost in this penod, the
preservation of the form of the organ can only be
noped for. If symptoms of suppuration have ap-
peared, the eye will be destroyed. In the first
and second stages the most active antiphlogistic
measures, as directed in internal ophthalmia
($ 143.), roust be practised : general bloodletting,
cupping, leeches applied around the eye, and sca-
rification of the protruded lids ; With active cathar-
tics ; calomel and James's powder in full and re-
peated doses ; turpentine given by the mouth, and
m enemata with castor oil ; and belladonna ; con-
stitute the chief remedies. If suppuration have
occurred, the anterior chamber being full of mat-
ter, the evacuation of it by a free opening into the
cornea, will give relief, and not increase the in-
evitable mischief.

159. B, General Ophthalmitii eonteqHent upon
the abiorption of purulent or morbid tnatten into
the circulation, may occur. It has been noticed
chiefly after phlebitis, by Mr. Arnott and Mr.
HiooRNBOTTAM ; aud u most freouent in the puer-
peral state, as a consequence or uterine phleoitis.
The local symptoms in the early sta^ are the
same as in the idiopathic, but leas violent, and
more insidious and rapid, and always terminating
m suppuratiott and slonghiog of the cornea.

The coDilitutbnal fynptoms are very difccst*
and are of a typhoid and adynamic type. AU the
cases that have hitherto been raoorded, bave tar^
minated fatally.

160, C. An IntMrmktmt form of Ophikakmia
has been described by aome wrilen, pariicalarfy
HomtAVV, Curry (Tranu of Mod, mmd Chma-g,
Soe, voLiii. p. 348.), and HavTEB (I^aof,
No. 331. p. 473.); but I af^ree with Mr. Ljw-
RXNcx,in considering a truly intemiittiiig Cotm of
inflammation of any of the tiasnea of tbii segaa
as not to have been made oat. CxacerbatioaB,
relapses, or returns, of the disease, from RC*^
ence or recurrence of the causes, m«y hay« beca
mistaken for an intermitteot form. Freqacntiy
recurring attacks of inflammation la eoiDa ooe or
more of the tissues of the eye, eapecially of ths
conjunctiva, and in slight and chronic fer«s
are sometimes caused by the sympsttfadie imia-
tion of inflamed or carious teeth. -^ Of this &na
of disease, which is not noticed by writetm, I hm%t
seen two or three instances ; the renaoval of ike
adjoining irritation curing that depending mpea :L

161. I should now have proceeded to rwMader
the eonteeutive and maiignant aitormti0mt tf th
tissues ^ the eye; but tMse, in a pracbeaJ po«ac
of view, fall mostly within the prDrioee oitkt
suigeon, a strictly medical treatment having bet
little influence in removing them. The maltf-
nant diseases of this organ are the
observed in other viaoera, and are '
distinct and appropriate heads. The
disorders are treatea of in the aiticlea A:
Palsy, and Sight.

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Oculi cum Profluviis Uteri Matemi, ftc. 4to. Jense,
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torum. Berol. 1888. — G. Thevenev, De Infantum Blcb

pharo-biennorrhoea. Ber. 18*S Smith, in Edin. Med.

and Surg. Journ. No. 6& pi 351.— MeUn, in Lond. Med.
and Phys. Journ vol. liii. p. 184 — W. Mackenuie, in
Ibid. vol. Ivi. p. 387. ; and Glasgow Med. Journ. vol. it
p 418. — Buaii, Trans, of Irish ColL of Phys. vol. iv.
p. 348. ; et Ibid. vol. v. p. 1 — Ammon, R£vue M6d. t iii.
1885. p. 184. — T. A. Ammon^ Monog. f. d. Augenleider

entxtindung Neugeborner Kinder. 8?o. Leipe^ 1885

Mecllinghaui, De Bleohanorrhoea Neonatorum, 8va
Ber. 18^. — Storeh, De Neonatorum Blennorrhcea, 8va
Ber. 1886. —J. Henschel, De Ophth. Neonatorum, 6vo.
Ber. 1887. — Jdbom, De Ophth. recens Natorura, 8va
Ber. 1888. — F. Arnmon, in fiicyclopad. Worterboch
der Mcdicinischen Wissenschaften, b. Iv. p. 89. — ^. il
Seemtt$m, De Contagio Ophth. Neonatorum, Svoi Ber.
1687.

iii. PuauLurr OpvraAuna or Adults.— ^1. Edmond-
tion. Account of the Ophth. which appeared in the Ar<

gyleshire Fencibles, witti Observations on the Egyptian
Ophth. ftc. . Edin. 1803. — P. Macgrqtor, Trans. of^Soc.
for improving Med. and Chirurg. Knowledge, vol. iii.

tbalmie d'Egvpte, A& nuris, 1806, fid cd. 8vo G.

Power, On Agypti - - - -

genettes, Hitt. UMicale de 1*Ann<e d« I'Orient, 8vo.

tian Ophth. ftc. Lond. 1803. — iV»-

p. 2f). et seq. — Savareri, in Journ. Qto. de M£d. t. xvi.
. 818.— HbMicit, in Med. and Phya. Journ. Sept. 1804.—
. AtsaUni, Obeervat iur la PMte, le Flux Dya., et I'Oph-

I

Paris, 180S.— il«M, On theOphthal. that appeared in tho
89th Reg. fte. 8vo. Portaea, 1806. — J. Veteh, On the
Ophthal. as it has appeared in England since the Return
of the Army from Egypt, 8vo. Lond. 1807.— FT. Thomat,
Observ. on the Egyptian Ophth.. and Ophth. Pumlenta.
Lond. 1809 — PmcA, in Edin. Med. and Sura. Journ.
vol. ill. p. 58. 39S. — C F. Forbes, in Ibid. vol. ill. p. 430.
— Farrel, Obaerv. on the Ophth. and its Consequencea.
Lond. 1811 — Larrey, H6m, de Chirurg. Milit vol. iiL
8vo. Paris, 1818. — VoMemi, Storia delr OtUlmla Con-
tagioaad'Egittoesulla sua Propi^asione In Italia, 8vo.
Verona, 181&— ff. Offiotferf, Cennl suU' OtUImia Con.
tagioia d* Egitto e sulla sua Propagasione in lulia, 8va
Mil. 1816.— £ra«n, in Jlics/'s Magaain, b. ii. 1817.—
J. Vetch, Observations on the Treatment, by Sir W.
Adamt, of the Ophthalmic Cases of the Army, 8va
Lond. 1818. — /. Patuida, Mem. Path. Prat tulle Ottal-
mie non sole Eptdemich& ma anrora Contagioae. Fad.
1819 — Kla^tketu, Sur POphth. Contag. qui regno dana

3uclques Bat. de I'Armie de Pays-Bas. Gand, 1819.—
'. y. Butt, Die .£gyptische Augeneiitxiindung unter d.
K. Preuu. Besatiung in Mains. 8to. Berl. 1880.—
J. B. Mneiler, Erfahrung. <lb. d. Contaglfise JEgyptlsche
Angenentstindung, ftc. 8vo. Malni, 1881.— cTfl Grafe,
in Gr. u. Walther, Journ. b. iiL st. 1. p. 105.— ira//A«r. in
Ibid. b. a st i. p 99 — Bust, in his Magasin b. xiv. h. 3.
p.548.—JKafas, Breve Saggio sull' Ottalmia, che negli
Anni 1888, 18x3, ftc. 8vo. Venes. 1884. — C F. Gratfe,
Die E^idemische Contagifise Augenbiennorrhoe ^gyp*
tens, m den Europoiscnen Befreiungsheeren, ftc. fok
Ber. 1883.

iv. GONORXHCBAL AMD SYPHILITIC OPBTBALMIA.

Aitrttc. De Morbis Venereis, 1. 1. p 885. — Mmrat, in
Mem. de la Soc. MM. d. Emulation, Ann. v. p 44ft —
Hitfeland, Journ. d. Pract Hetlk. b. xiv. p. 191.— Ffa/anf,
Coilesiooe d'Osservaxioni, t iv. ob. 7. — S^t^enbrrg,
Von Indicat. b. d. Ophth. Oonorrhoica, in Horn, Archiv,
b. xii. St. 8. 870. — Fiemmmg, in Hi^feiand u. Himiv,
Journ. d. Fr. Heilkunde, May, 181^ p.47.— FooT, Treatise
on Lues Venerea. Lond 1880. p 96. — .£. If . Boehmer,
De Ophth. Syphilitica. Ber. 1881 — IfWa/rr, Syphllitiscb.
Bonorrhcrische AiigenentaUndung, ftc, in Harlet$, Neue
Jahrb. b. xiL st I. p. 107. 1826. — Deipech, Chirurgie
Ciinlque, t i. p. 318. — Asoof , Treatise on Syphilis, ftc.

SI. 138 — W. Lawrence, On the Venereal Diseases of the
Sye, 8vo. Lond. 1830. — Lutardi, in Archives Gte6r.
de M^. t. xvii. p. 596. — J. M. A. Sehon, NosoL Therap.
DartteU. d. GonorrhSischen Augenentttindung, 8vo.
Hamb. 1884. — See also most of the latest S^Sematic
Works, in the Jlrst sect, of Biblioorapht.

V. laiTia, ftc— J. A. Schmidt, Ueber Nachitaar u.
Iritis. Wien. 1801.; and Quarterly Journ. of Foreign
Med. voL L— Jlosr, In Trans, of Med. and Chirurg. Soc
VOL viU. p. 361. — WaUaee, In Ibid. vol. xiv. p ^. _
F. E. Niesar, De Rheumatismi in Ocul. Hum. AActu.
8va Bresl. 1815. — H. B, Schindler, Comment Ophth.
de Iritide Chronica, ftc Vrat 1819. — J. Thomson, in
Edin. Med. and Surg. Journ. vol. xiv. p< 91. — Farre, In
Sounder** Treatise, ftc 8d ed. p. 66. — J. N. Kenskv, De
Iritide in Oenere et ejusque Speciebus, 8vo. Pest. 1880.
—Herxberg, De Iritide. Ber. 1881.-7. Hewson, His-
tory and Treatment of the Ophth. accompanying the Se-
condary Forms of Lues Venerea, 8va Dub. 1824 J. A»

Bobertson, in Edin. Med. and Surg. Journ. Jan. 1885. —
Trovers, in^'his and Coomer** Surgical Essays, partL p.93.
—H. Camuckael, On the EfRcacy of Turpentine in Deep*
seated Inflam. of the Eye, ftc 8to. Dub. 1889. — G. J,

Gttthrie, in Med. Gaaette, vol. iv. p. 509 Jaeob, in

Trans, of Insh Coll. of Phys. vol. v. p. 468. — See also
most of the latest Systematic Works in the yfrs/ section of

the BUUOOBAPHT.

FAINTING. Syn. — A»«ro>//i/;^ta, Hippocrates.
Awo4«X**» Galen. Syncope (from avynirrst,
eoncido)) Deliquium Animi ; Defectio AnU
met, Celsus. Defaitiance, Fr. Die Ohnmacht,
Germ. Swooning.

Classif.— 2. Clan, 2. Order (CulUn).
4. Clais, 4. Order (M. Good). I. Class,
III. Order (Author).

1. DspiN. — Temporary depression of the ani-
mal and vital acticm, with pallor, cold penpiration,
remarkably weak pulse, or absence of pulse at the
wrist ; respiration and sensation also Iteing nearly
abolished for a short time,

2. The terms used by Hippocrates and Ga*
LBN are syoooymons with Syncope, a word of
modem use. Leipothymia has been considered by
later writers, particularly Moroaonx, Dr. Good,

880

FAINTING — DiMBxraoN — Ca vsEf .

and Dr. Aaa, either as the Mme as srncope, or as
signifying a lesser grade of this afllection. The
definition which Sauvages has given, of Uipo-
thymia, aaugns it a specific difiereoce from syn-
cope, or the usual form of swooning or fainting.
He sutes it to be — " Subitanea et brevis virium
dejectio, superstite pulsfis vigors, et cognoscendi
facultate." I have had several opportunities of
observing attentively the whole progress of this
affection ; and I admit the accuracy of this defi-
nition, with the exception of the continuance of
consciousness, which is generally somewhat im-
paired, although not alto^ther lost The pulse is
unaltered from the state m which it was before or
after the seizure, or not materially influenced ; and
in some cases I have found it so strong as to pre-
scribe depletion ; but the respiratory actions are
nearlv abolished. Leipothymia is, therefore, an
affection of the animal and respiratory functions,
that of the heart not being impaired. The slight
or imperfect seizures often observed to precede
fully developed epiUpty^ or to occur between, or
usher in, the severe attacks, and described in that
article ($ 41. 52.), ire examples of the leipo-
thymia of Salvages.

3. Fainting and Swtoning are grades of the
same affection, the latter being a more complete and
prolonged state of the former. Fainting may occur
after veiy short or irregular periods — the Syn-
co!p€ Ttcurrent of Good. It is then often followed
by palpitations of the heart. — Swooning is much
less prone to recur, but is sometimes roTlowed by
severe reaction. Sauvages has divided syncope
into as many varieties as there are principal causes
inducing it. — Dr. Good has adopted a somewhat
similar division. As, however, it varies chiefly in
degree, from whatever cause it proceeds, no fur-
ther distincdon, than that which I have just made,
need be assigned to it.

4. I. Description, £cc. — Fainting is com-
monly preceded by languor, a sense of sinking at
the epigHStrium, anxiety, confusion of intellects,
obscuration of vision, cold partial sweats, giddiness
and ringing in the ears, pallid countenance and
quivering of the lips, and coldness of the ex-
tremities. These may continue for some time,
constituting what is usually called faintness,
and disappear; or they pass into full faindog
or swooning more or less rapidly. It is seldom
that faintinff occurs without these piecursors ;
but when it is fully developed, respirauon almost
ceases, and consciousness is nearly or altogether
lost. The action of the heart, however, still
continues, but feebly ; and, although the pulse
disappears from the wrist, as in full swooning,
it may still be felt in the carotids ; or the heart
will be heard to beat on auscultation. In some
instances, relaxation of the sphincters, and dis-
charge of the excretious, are said to have oc-
currd. But this is rare in swooning, although
it sometimes supervenes in leipothymia, in which
the brain is rather oppressed with blood, than de-
prived of i* ; and in which the pulse retains its
vigour. Sickness, or even vomiting, sometimes
foUows faintness, or accompanies recovery from
fainting.

5. The sensations ushering in syncope are ge-
nerally more or leas distressing to the patient, and
are sometimes described as accompanied by
n feelioff of death. Montaigne {Fttaiif liv. ii.
cap. vi.) found them rather pleasurable than

otherwise ; and therefore iafieii, that those sMead-
ing upon diaaolntion must be nnilar. Caia-
BERET experienced the like CeeliDgs. Tke ^ratim
of the seizure varies from a few seeoads te ooc
or two hours; but commonly from half a wests
to ten or fifteen. It has extenided in some iiMtasea
to several hours. Much longer periods have bees
mentioned by writers ; but tlwir aetnal eccTreatt
is questionable.

0. TAtf CofisffUMectsr Ttmmiiatwatefsjfacope
are — 1st, A retnni of the fnoctioos, reipiiia«
becoming more sensible and often sospiriotts, lad
eructations or vomiting oocasioiiaUy sapervcasif ,
•—2d, Palpitations of the heart, or geacol «»
cular reaction ; — 3d, Hysterical synptoan, «
a fully formed hysterical paroxysm ; — ,4ik, C«-
vulsions, general or partial, with er witboet tab-
sciousness ; but they are much more Ireqsailj
consequent upon leipothymia than upon tree ijt-
cope ; — 5th, Partial, or alight paralysi*, or pro*
longed vertigo ; — 6th, In caaea eoooecicd v<l
passive enlargement of the cavities of the ban,
and attended by a very slow as well ai s mj
weak pulse, coagulation of the fibrinoas pann
of the blood has taken place io these csvilia, lad
afier some time oocaaoiied death; — 7ih, !)«••
lution has occurred in extreme canes, owiag csktr
to the complete depression of oerebrel sad am*
ous power, and the consequent inaclioB of tk
heart ; or to the asthenia and wasting of tkt
parietes of this organ, in coojanclioB widi aerro*
depression. The fifth and sixth of these sie rare ;
instances, however, of the latter, are addaeed
in the article Heart. The terminaiioa ia ds-
solution is not so rare ; and is chieflj[ obscnsd a
caaes of great debility or exbaoslioo frooi ts-
treme or protracted pain, or from partniitiai.
and particularly when a sitting or erect poaui
has been suddenly assumed or too loag leiaiard
in adynamic fevers, and after exhansciBf ^
chaigea or depletions. Some yean sioce 1 ■*
swooning caused by strangulated femoral kciaa.
that pareed into complete leUnos of aua; hosn
duration.

7. II. Causes. — The causes of syncope «t
strictly oceationaU I shall consider then «iti
reference to their operation. — «. Tkt nwm a^K*
act mart iwtmodiateiy on tho wtntui if<**
are chiefly various impresaioos made vpoa tbi
organaof aense, and depreasing morel esMOoia
The odour of variooa flowert, according to tk
idiosyncrasy, sometimes occasioas it >'Aatan*
HiLOANua has seen it produced by the tncll cf
vinegar; and Marcxllvs Ddmatvb, Ij ici
music. The aire of their native land have iadsce^
it in pereons subject to nostalgia. Varioe* u*
pleasant sights, or obiects of avcraioa, bsvc caaied
it — as the sight of blood, of surgical operstioo
or of a corpse ; also sudden terror, fesr, aaxKir.
diaappointment. The impression made bj v-
phitic or ittliectioua emanatioos upon the oenvi •
smell, frequently induce more or leso of fciatoe**
Concussions and injuries of the brain ; blow* spa*
the epigastrium ; shocks of the ^^ho^ ''*^'* '
gyretion ; rotatory motions, and swinging; «ce-
sive or prolonged pain ; pleasnnble irnfiux*
carried to excess, particularly the rezaal or|^s«
the exhaustion consequent upon inerdinsff o-
citement, long fasting, and the - abitractoo ^.r
accustomed stimuli ; likewise opcistt pria^ip*"?
in this way.

883

FAINTING — DiAOHOsM.

and ezcesnvely indulged, are remarkably liable
to faint from the slightest mental or corporeal
cause; and there is reason to believe that the
liability is increased by repetition or the habit of
fainting.

13. Pathologieal Inferences. —^ I. In syncope,
the heart's action never, perhaps, entirely ceases
until it terminates in death.— > 2. In fainting
from haemorrhage, cerebral inBuence, especially
the voluntary powers and volition, is abolished
before the heart's action is reduced to its lowest
state ; but, unless the swoon be complete, sensi-
bility and consciousness are not entirely sus-
pended.— 3. The like obtains in fainting from
moral emotioos and impressions made upon the
senses ; cerebral influence is first diminished, and
instantly afterwards the action of the heart is
weakened, the weakened vascular action still
further impairing cerebral power, until fainting is
the result. — 4. Several causes, both external and
internal, or pathological, particularly those already
specified ( §9.), seem to act coetaneously and
eo-ordinately upon the brain and heart, through
the medium of the organic system of nerves ; whibt
others of the same class of causes (§9.) seem
to influence more immediately and especially
the heart through the same channel. — 5. Cer-
tain causes may suddenly derive the circulating
fluid to the external surface or other parts; and
the sudden diminution of the quanti^ returned
to the heart and propelled to the brain* may in-
duce faintness or full syncope. —6. The sudden
reflux of blood to the right side of the heart, es-
pecially when it superveoes rapidly upon the
states just specified, may occasion fainting, by
overpowering the hearts action, and thereby
diminishing the supply of blood to the brain. —
7. Fainting may arise from inflammation of the
heart, oreifusion into the pericardium. — 8. It
may also occur from the imperfect action of the
heart caused by deficient oiganic nervous power,
particularly of the cardiac nerves, with or without
dilatation of the cavities, and weakness or softness
of the parietes of the organ.— 9. It may be occa-
sioned by circumstances preventing the return of
blood to the heart. — To either of these two last
are to be imputed the fatal cases of syncope related
by Mr. Cbetaubb and Mr. Worthinoton, in
which the cavities of the heart vrere found empty
and relaxed, and the,large veins adjoining devota of
blood.

14. Indeed, death may supervene in any of the
modes in which syncope is produced, especially
when carried to the extreme. Thus I have seen,
in two instances, a moderate dose of the acetate of
morphine occasion loss of voluntary motion, and
scarcely perceptible pulse and respiration — the
characteristic phenomena of swooning. A larger
quantity might have caused death ; its operation
— extended from the stomach to the heart and
brain — being the same, but so great as to put
an end to the functions of these parts. Otoer
causes, inducing any one of the pathological
states now assigned, may act, in favourable cir-
cumstances, and in highly predisposed persons,
80 energetically, as to terminate altogether the
vital actions ; predisposition or pre-existent states
of the frame, such as have been mentioned, being
often as influential in producing the result, as the
more direct cause.

16. III. DiAON0sti.<*- Syncope may be ooo-

fbunded with apopUxy, with the seixom to wluch
the term teipotktfmia is strictlv applicsble, with
asphyxy f with ceilain states of hysteria, wad with
death, — (a) The strong, laboured, or siertoross
breathing, and the full strong puke ; suffideolly
distingu»h apoplexy (see that article, ^ 66.) from
fainting. — b. In Uipathymia, volition and voloft*
tary motion are abolished, and consQoiaiKa
nearly or altogether : but the pulse either is not
afiSected, or is even fuller than usual ; and it u
more frequently the fint sUge of, or ibIloir«d
by, epileptic and apoplectic seizures, thaa tne
syncope. Frequently, also, letpothvmia ii iaL-
roately associated with epilepsy, the former ban;
either the earlier manifestations or the le«r
grade of the latter. — e. In asphyxy, the sctwu
and functions of respiration are the fint to oease :
the circulation of venous blood oontiDuiag Uk
some time, until, owing to the privatioQ of pan
atmospheric air, the passage of blood tbroagfa the
lungs becomes obstructed, as fint shown by Dr.
Williams (£dtn. Med. and Surg.^Joun. Oc.
1823.), when total arrest of the pulmonary ai-
culation, abolition of the cerebral and nenra^«
functions, and lastly, cessation of the hcin'i
action (see Asphyxy, § \4et seq.), are tbecea*
sequences. Respiration ^nd ciicoIatioB in
here quite at an end ; and tlie oounteaanoe uii
general surface are reddish, livid, tumid, orblottd.
whereas in syncope the face and sm&ce ut p«i'
and collapsed, and the reniratpry funetiou a>i
circulation still continue, uthoufh in a low io<i
occasionally almost imperceptibw stale. Id t^i<
former, there is remarkable coogesboo of tk
lungs and head : in the latter, the brain is pttc*
rally insufficiently supplied with blood; sm t^
circulation of the lungs, although laogaid. «
seldom obstructed, and never altogether aimted.
unless a termination in death supervenes. ~i.
Various manifestioos of hysteria either >tn
closely resemble fainting, or are in some wxy tr
other associated with it. The more remsfUb'e
phenomena of hysteria may follow, or precfdr.
fainting, most frequently the former ; but tbe )«•
of motion and sensation often partakes more of ik
characters of leipothymia, than of swoooiag, tb«
pulse at the wrist being but little aflTectcd. Psf^
under the left breast, borborgymi, and a «dm (^
suffocation, which commonly precede the bysten*
cal form of syncope, sufliciently mark iu taian-
and even when these are not present, other n^
soon manifest themselves, especially cbnvaktii>>
weeping, laughing, &c. (See livsTtau.)-*'*
Syncope is rvely so profound as to be mistoirs
for death ; but Pobtal and CoAMBsaxT* «<^
some writers on medical jurisprudence, coanr
in thinking that it may be both co conpleie s^l
prolonged as to endanger premature intenncnt i&
countries where the last nte is early perfoiiDeJ.
Whether or not the action of the beait, wlnti
cannot be altogether abolished even ia n^^
cases, may be detected by the stethoscope. I
am unable to state ; but it surely cannot eoorifin
man]f minutes without detection upon a ttnd
scrutiny, unless death have taken place. 1>*:
state of the cornea, which is soon covered mth a
film, or deprived of ita delicate tran^restT.
and afterwards collapsed ; the appcanart*
of the tliorax upon examinatiDO ; the •^.^'^
yielded by auscultation ; the condition of t^
body ia respect of flexibility, &c. j aw tM

884

FEIGNING DISEASE.

23. B, The removal of tht causes of the affection,
whea these are of a constitutional or structural
kind, roust be attempted after recovery from the
seizure. If it depend upon Debility, the means
advised in that article will be requisite ; and in
other circumstances, the treatment suitable to in-
ferred pathological conditions should be practised,
as pointed out in the places where such condi-
tions are more especially and appropriately con-
sidered. — The prevention of a return of the
affection will be most effectually secured by this
procedure.

BiHLioG. AND RerBR. — Arekeus, Acut. 1. ii. c. 3 —

Aetius, Tetrab. ii. i. i. c. 96 PouJus MgineUi, I. ii. c.36.

—Avicenna,iZw\oii. 1. iii. fen. If. tract, ii. c. G.—Bauduun^
Non ergo omnls S3mcope« eadem Curatio. ParU, 1S73. —
Alhertini, De Affect. Cordis, 1. lil. 4to. Venet. 1618. ~
H'ildkott, Svncopec Natura cC Cura. Argent. 1651 —
Marceflus Donattu^ 1. ti. c. I. p. 90. ^ PrimeroMhu, De
Morbii Mulieruin. 1. iU. c. \0.—De Berger, De Deliquils

Animi. Witeb. 1689 Schcnck, Obserr. I.U. No.S19.22a

— Forestus, I. xvii. obs. 8, 9, 10.— Amatus Lvtitanut,

cent. il. cur. 36 Pahriciut Hildaniu, Opp. p. 990— Za-

cuttu Lutitaniu, Prax. Admlr. 1.1. obs. 135 — Bonri, Se-

Sulchret, I. ii. sect. x. obs. 1. 3. 9 Laneui, De Subit.
lort. p. 136— Riedim, Un. Med. 17C0. p. 226. — Wedel^
De Syncope et Leipothymla, &c. Jeose, 1715.— ra/rr, De
AflfbctuMagno.Mortique proximo, Syncope,^ usqucCausis
et Cura. Witeb. 1723. — HqffinaHn, De Animi DcHauiis.
Opp. vol. viii. p. 273. — Morgagni,De Sed.et Caus. Morb.
epist. XXV. art. 2. 17. — Brmaer, An Syncope Venvsec-
tionl semper sine lUlqua probabili Causa superveniens ab
ea abstincre jubcat. Goet. 1756. {Concludrs in the af-
JlmuUivf.) — Samvaees, Nosol. Methodica, vol.ii. p. 301. —
Senac, Traits du C'oeur, 1. vi. c. \0.— }V/nftt, Works, p. 36.

^Lieutttttd, Hist. Anat. Med. 1. iL obc. 794.708 faliis-

fieri. Opera, vol. Iii. p. 581 — Saillant^ Hist, de la Soc.
Roy. de M6d. ad 1776. p.ZlS. — A'Bergen, An in Pa-

roxysmo Svncoptico Venam Secare liceat ? Fr. 1774

Martin. Nouv. Theorie de Svncope. Paris, 1802. —
Portal, M6m. sur la Nat. et le Traitnnent de Plusieurs
Maladies, t. iv. p. 223. Paris, \S\9.^Ckamberet, in Diet,
dcs Sciences Med. t. liv. p. 85. — JVortkington, Lond.

Med. Rep. vol. xvli. p. 361 Piorry, in Archives GAn£r.

de M6d. t. xii. p. 527. — Jtf. Good, Study of Medicine,
Coaper^i edit. vol. iv. p. 546 — E. Ask, Cyclop, of Pract.
Med. vol. Ii. p. 138. {Em in considering tie action of
the heart to be aitogcther suspended.)

FAUCES. See Throat— Diseases of the,
FA VUS A.ND ACHOR. See Porrigo and Pus-
tules.
FEIGNING DISEASE. — Classif.— Diac-
Nosis.— Syuitoiiatology.

1. Disease may be — Ist, Pretended or simu-
lated, the person being in a state of health ; — 2dly,
Artificially excited, disorder being actually pro-
duced ; — 3dly » Exaggerated in the description and
appearance given of it, the patient being: indis-
posed ; — and, 4thly, Artificiallif and intentionally
increased, or aggravated during its course. In
these /'our modes, disease may be said to he feigned
or simulated*

2. I'he objects desired to be accomplished by
those who undergo the inconvenience, suffering,
and moral degradution of feigning disease, are —
a. To escape from being levied into the public
services \ — 6. To procure a discharge from the
public service ; — c. To obtain both a pennon
and a discharge ; — <f. To enjoy the ease and
comfort bestowed on the sick, and to escape
from hanl work, or unpleasant employment,
mental or corporeal ; — «. To obtain objects of
desire, or to procure compliance with wishes or
caprices ; — /. To avoid punishment ; — g. To
excite compassion or interest ; — h. To deceive.

3. The persons who feign disease with one or
more of these intentions are — «. Soldiers and
sailors; the former being usually called ma/tit-
^«r*rf, the latter j^Z/cm;—^. Slaves and serfs;
— ^. The lowest class of labourers, and mendi-

cants ; — ^. Afembers of benefit iweictiet ; <— f .
Persons who have received acddeotal or in^
tended injury, and desire to obtain increased
compensation for it ; — (. Pnsonera for debt« or
for civil or criminal offences j — n. Young per>
sons of both sexes wishing to escape from the
confinement of school and the labour of ktudy,
or longing for a return to their homes ; — ^. The
spoilt or indulged, who desire to excite inlerefrt.
or to obtain a compliance with their deairea \ — u
and lastly. Those who wish to accomplish objects
of private or political ambition, or to gain particular
ends. — Feigning disease has been reArted to with
the last-mentioned view, very probably from the
earliest times. Am non the son of David, Ulyssi^.
Solon, the elder Brutus, the Roman Cci.k»
(" Desitfingere C^lius podagram," — MAaTiAL.\
"Hotspur's father, old Northumberuino,** the
Constable Bourbon, Pope Julius III., tbe EaH
of Essex, and Raleigh, grace this cUbs of
malingerers,

4. Disease may be so artfully feigned in one
or other of the modes just stated ($ 1.), as to re*
quire the utmost discruninatton and ingcnaity lo
detect the imposture. It is obviooB, as Dr.
Ciieynb remarks, that the discovery of it mdi
be most readily made by those who are the beat
physiologists and pathologista, and most accu-
rately informed respecting the operation of medi>
cinal agents. In doubtful cases, the praciitioaflr
should take into consideration the coostitutioci.
education, information, habits, and probable mo-
tives of the person ; and examine more especially
those symptoms which are counterfeited with the
greatest difficulty, in respect not merely of tkea
individual, but of their correlative, characters.
The frequency and rhythm of the pulse, in cob-
nection with the temperature, colour, and bv«
midity of the skin ; the ex|MesBion of the eyt
and face; and the foetor, colour, and consisteocc
of the excretions ; should especially arrc«t atttn«
tion. A morbid a1>pearance may be commuoi-
caied to the excretions, and to the tongue and
mouth ; but a morbid foetor of the foroicr, an>l
various states of tl^ latter, are counterfeited «uu
^reat difficulty. The intelligent observer will
infer much also from the manner of the simab^
tor; from the consistency of the account gi«ta
by him ; and from the relation one symptoiB
bears to another, in its seat, nature, or severity ;
and will be careful not to lead him to suspect
that the reality of his ailments is for a mooMbi
doubted, until iproofs of detection are oooplcie.
The circumstance of impostors always overactiA^
their part, overloading tneir accounts with no ne-
cessary details, complaining of their Buffering,
and readily falling into the snare of e&nmefancc
incompatible symptoms, when a leading qocstioa
respecting them is put, should not be OTcriookcd.
They are seldom desirous of obtaining mcdk-al
aid, or of submitting to the trealmeot dixvcted ,
and, in ever^ case, strict attention sboald be paid
to the exhibition of the ntedictoes oidcred, which
ought never to be left in the posseasioB of a sb«-
pected person. In doubtful, and eren in real,
cases of feigning, painful or even aevere met*
sures should not be in6icted, as in most instance*,
and especially in the public services, tbe mtoU
of the impostor is made up to eodurs eveft lortui*
rather than give in*

6. The importance of this snbject ia fmvale

886

FEIGNING DISEASE.

in the Cyelojutdia of Fractieal Medicine mentions
tt remarkable instance of deception pn^tised by a
young woman at Edinburgh, and continued from
1817 to 1830. She feigned during that time,
hepatitis, epilepsy, amaurosis, aphonia, deafness,
paralysis, gravel, anasarca, hematemesis, con-
vulsions, gastralgia, dyspnoea, retention of urine,
Yomiting of substances resembling liver, bone,
&c., and at last concluded by excreting bone
from the vagina. Bone was first detected in the
vagina in 1824, whilst introducing the catheter,
and large quantities were passed, or extracted, —
some even from the bladder. She was received
into the hospital in 1825, and the bones which she
passed were believed for a time to be those of an
extra-uterine foetus. She was there detected by
cutting off the supply, and discharged. She after-
wards had recourse to the same practice, but
at last varied it, and had an illegitimate child in
1828.

14. DsAFNEss and Deaf-Dumbness are simu-
lated by those who wish to escape from the army
or navy, or from criminal trials, and by mendi-
cants. They generally lose their bearing sud-
denly -f whereas real deafness is gradual, or the
consequence of s<:;vere illness. The expri^sion
of the countenance and a change in the pulse
often betray the impostor when something of
great importance is said in his hearing. But
some are prepared for this, and are even unmoved
by very sudden noises. Mr. Dunlop states, that
a soldier feigned deafness so well, that firing a
pistol at his ear produced no effect ; but on the
experiment being tried after he had been put to
sleep by opium, he started out of bed. Those
who feign dumbneu, are generally unaware that
if a person has acquired the use of speech, he never
can become dumb, however deaf he may be.
The really dumb acquire an expression of coun-
tenance and gestures which are assumed with
great difficulty, and few have sufficient art and
perseverance to counterfeit deafness and dumb-
ness, so as to avoid detection for any length of
time. Some have attempted even to cause deaf-
ness, by introducing solid bodies into the ear, or
by exciting inflammation of it by irritating matters.
Honey and various other substances have been
employed so as to simulate otorrhoca. The organ
ana the discbarge from it should therefore be care-
fully examined.

15. Deliveky has been pretended, with an
obvious intention, after artificial abdominal en-
largement and sudden subsidence of the tumefac-
tion. In this case the external parts of generation
are moistened by procured blood, and the child of
anotlier substituted as the female's own. This
cheat can be detected only by examining ptr
vaginam. Soon after real delivery, the vagina
will be relaxed as well as the os uteri ; the latter
tumified and tender, and the lochial discharge
fiowinr. But these signs will become less evi-
dent, tne longer the time that has elapsed ; and,
after nine or ten days from parturition, they can-
not be depended upon ; but the well-known state
of the integuments of the abdomen, and the ap-
pearance of the mamma), will aid detection.

16. DnopsY has been simulated by French
conscripts, who have been said to have actually
injectcfl water into the cavity of the pcritoneain,
and thereby produced factitious ascites. — Ana- i
sarcn of the extremities has been cau!Hjd by !

Matures artfully concealed; but the faapoitaie
will be detected upon strict examination of the
naked body, and by the absence of a kneophWjr.
matic or cachectic appearance. CosbioiiA fitied
to the abdomen, and padded clothes, are the
modes resorted to by mendicants ; bat these re-
quire no remark. Instances are mcntioDed bj
Manoetus, Sauvages, and others, of ekrmte
dropsy of the head being simulated by niendicnts,
who have daily blown air under the scalp of chil-
dren through a small perforation at the vertex,
until the scalp became enoimonsly distended.

17. Dysentery and Chronic DiARanai are
often feigned by soldiers and sailon, paiticulari;
in warm climates; and are sometimes actnally
produced by their using irritating sobetanoe*
for the purpose. Mr. Copland Hvtcbuok has
seen even a fatal result follow such practioa. He
ascertained that vinegar and burnt cork were
often used to cause the disease. Suppositories of
soap, and irritating substances introduced into
the rectum, have also been employed to cause
mucous discharges (Cheyne); but dnstie purg-
atives are more frequently taken in sufficiect
quantity for this purpose. The dysenteric eracu-
ation is simulated by breaking down the fecal en-
cuation in the urine, and mixing with it the blood
procured by pricking the gums. The iopostare t$
detected by the cleanness of the linen ; by oblising
the patient to use a night-chair, and by watetuDf
his proceedings.

18. Emaciation-— partial or general. Gat-
rat emaciation and debiiity are sometimes oca*
sioned with the view of avoiding some disagreeaUe
service, or to be sent home from foreign lerriee,
or to procure change of climate. Abstineoce
from *food and sleep, the frequent use of purg-
atives or diaphoretics, especially antimony, aed
excess in spintuous liquors, are the means coia-
monly resorted to. Wasting of a limb is caased
chiefly b^ mendicants, by means of oootinoed
compression ; and the diagnosis between aftifici»l
and real wasting is often very difficult. Detectipa
must depend upon a strict examination, and a ri-
riety of considerationsthereby furnished to the dilj
qualified examiner.

19. Epilepsy is very freanently feigned by
mendicants, by sailors and soldiers, and occiaoo-
ally by females to serve particular ends, lofark
cases it is proper to notice whether the perws
falls to the ground without regard to the sHaauoo
or place ; whether the face be livid, the pavd
fixed, the spasm and convulsions geoeral, w
pulse altered, the insensibility complete, tbe
mouth distorted and frothy ; and whether to^
follow the fit, pacing into heaviness, vertigo, and
exhaustion, as all or most of then sympcons vt
absent, or imperfectly evinced in the simulated di»-
ease. The opportune appearance of, and selected
situation for, the feigned paroxysm, the partial or
successive productbn or the mnscular sctoos.
the scnsibili^ of the iris, the abrupt terminatioo
of the seizure, and the abMnoe of ajmy to tbe
tongue, should also be taken into aocooot
Foaming at the mouth is sometimes imiialed bv
means of soap kept in it ; bat it b ^enviallv
overdone m this case. The real epileptic b de-
sirous of concealing his infirmity; wbibt thr
simulator talks of his disease, and never r»<i?-
•ours to avoid publicity. It is chiefly, hewe'**'"'
by artifice that feigned epilepsy can be fully

889

FEIGNING DISEASE.

been foand so firmly bound around the neck,
as to cause a livid and swollen countenance, and
disorder the heart's action. Dr. Quarrier and
Mr. Copland Hutchison ascertained, that white
hellebore was often used by sailors to produce
this effect ; vomiting, purging, syncope, tremors,
and nervousness, followed by palpitations, being
the usual consequences of a large dose of this
substance. Mr.DuNLOP states, that death was
occasioned in one instance by the use of hellebore
with this intention.

27. Hepatic Disorders are often feigned by
soldiers in warm countries, particularly in India;
and by officers and others desirous of returning to
Europe. If any doubt of the reality of the com-
plaint exist, the person should be undressed, and
carefully examined by percussion and the stetho-
scope. The absence ot enlargement in the region
of the liver, the complexion, and appearance of
the surface and limbs, and the state of the pulse
and respiration, are the circumstances which
should chiefly be considered. It ought not,
however, to be overlooked, that most serious
disease of the liver may ezi^t without enlai^e-
inent ; and this viscus may be considerably en-
larged, and even rise up into the right thorax,
without being felt below the ribs. Hence the
propriety of having recourse to percussion and
auscultation in the investigation, especially when
other proofs of disease are wanting.

28. Hernia and Hydrocele have been simu-
lated by blowing air into the cellular membrane
of the scrotum. Mr. C. Hutchison met with an
instance of hernia being feigned, by elevating the
testes to the external abdominal rings. Detection
in cases of this kind is quite easy.

29. Hysteria is not infrequently feigned. Dr.
DuNGLisoN directs sternutatories to be employed ;
but the affection may be real, although they pro-
duce their usual effect. Detection is by no means
easy, especially when an intelligent female simu-
lates this complaint. In a case to which I was
l&tely called, the moral circumstances and the
symptoms induced me to infer deception ; and I
accordingly took my leave, by simply stating, in
the patient's hearing, that, if recovery was not
complete in a few minutes, the affusion ef cold
spring water over the head and neck would cer-
tainly have the desired effect. It should, how-
ever, be recollected, that females who are really
hysterical are the most prone to feign disease ;
this affection and the desire to simulate others fre-
quently arising from the same cause, viz. uterine
irritation.

30. Jaundice, notwithstandmg the difficulty
of the attempt, has been successfully simulated,
particularly in France, during the late war. Con-
scripts employed an infusion of turmeric to tinge
the skin, munatic acid to give the evacuations a
clay-colour, and rhubarb to heiehten the colour
of th^ urine. But the white of the eye cannot be
changed by art, although smoke has been tried
for this purpose. Washing the surface and pre>
venting access to the materials of deception are the
chief means of detection.

31. iNSANmr in some one of its various forms
— but most frequently mania, melancholy, and
idiocy — is frequently feigned; and detection is
by no menus ensy. There can be no doubt that,
in the public services, pretenders often gained their
ends J and that the really afflicted were some-

times treated as impoators. Nor can tlus be a
matter of surprise, when the great difficulty of
discrimination is considered. Id the pr^ent day,
madness is most commonly feigned with the virw
of esca|Mng from the puiushmeot due to cnm« ;
and the responsibility of the medical exanuoer h
Goosequentty greaL He should, therefore, have
every facility afforded htm, mod take raffioeat
time to the investigatioD, that be may arrive at a
correct conclusion. He aboold eodeaToar to
obtain from the individual a full account ol him-
self; mark its consistency, and place aa lAtelii-
gent watch over him. The expreaaioD of the
countenance, and of the eye ; the gcaiarea aod
manner; the state of the tongue, the appctHe,
and the evacuations ; and especially the dniatMi.
continuance, or frequency of sleep ; ought to be
carefully observed. Certain ezpiesnoDs ot m«b*
tenance and gestures are so peculiar to the ioAae.
that the experienced observer will infer Dttchfraoi
them. Pretenders generally overact their paits;
assume the more violent or disguatiDg forms <d
mania ; do not maintain the deoeptioa when tiMV
believe themselves unobserved; reoommcnoe A
in the society of others ; and possess not the power
of prolonged abstinence from sleep and food so
generally observed in the truly insane. Sonml
sleep soon overpowers the pretender, whereas tbt
insane are remarkably watchful ; sleepleasiM» to
a distressing degree often preceding the dacAee,
and always attending it tnroughout, for moca
longer periods than can ever be endured by a per-
son in health.

32. The insane, during rcmissioDs, are dcBroat
of being considered free from the maUdy. and
often assiduously endeavour to conceal whate%rr
may betray them ; but simulators aeldoa carry
their deception thus far. The real malady uauaUy
commences with slight disorder of the oomottm
modes of thinking and acting; and advaacck
slowly through some hallucinatioo, until at latf
it is either fully developed, or is suddenly esa>-
perated. The feigned disease, on the contrary,
presents not this course; is not prteedeJ l>r
sleepless or restless nights, and by ft contiaoeli
consideration of one topic ; but appears at firtf a
its full violence. The existence or noa-existtact
of the causes of insanity, of previous attacks, ot
pre-existing eccentricity of manner or tbou^t.
of hereditary tendency, of antecedent affecdiw* a*
the brain, of injuries of the head, &c., the cW
racter of the individual, and the motives Ux
feigning, will also be considered by the phy^Jeaa.
Care should be taken not to mier deocpttca.
because the motives for it are apparently strvo; ;
for the circumstances constituting the moi:>o
may be the causes of the real malady. The cos-
tive slate of the bowels; the lai^ dose» if
medicine necessary to move them ; the corapa-
rative insen«bility of the stomach to tartar:xcJ
antimony; the generally more frequent p«K«>.
and the sudden and extreme initauoo on ar^
contradiction, observable in the maniacally la*
sane ; should not be overlooked, as they hariU
adroit of being feigned. Their diAreKurd ot t >
decencies, comforts, and affections of life, ou;bt
also to be taken into account ; for, althoogh tiu^
signs are often also emulated, deception lo rt^
spcct of them Is seldom carried so £ar as in tb«
real malady. A person even of pare chararur,
when truly insane, will often um the $rvi«r>t

690

FEIGNING DISEASE.

ease of the kidney was not suspected by the nu-
merous eminent men whom he consulted ; bot
this organ was, nevertheless, found after death,
filled with calculi. I have met with two or
three instances of the most severe pain, recurring
at irregular intervals, in a particular joint — in
the left shouldec joint in one case, and in the
right knee in anotlier — without any apparent
local or constitutional disturbance ; the tongue
being clean, the bowels regular, the appetite
good, and the flesh and strength undiminished.
An ointment, with a large proportion of veratria,
was employed for some time in one of these
cases, without benefit The most successful
means, in both, were such as improved the diges-
tive and excreting functions. These cases, in
circumstances admitting of the least suspicion,
might have been considered as feigned.

37. I have no doubt that formerly, when the
pathology of the spinal chord and its membranes
was less attended to than now, many ver^
severe affections, occasioned by changes in this
quarter, were viewed as fictitious. — 1 lately at-
tended an intelligent tradesman, advanced in life,
who long complained of severe pains in the
thorax, darting through both sides, and often
backwards to between the shoulders. They were
occasionally most violent, and fixed themselves
for a time in one place, and then in another, of
this cavity. The functions of circulation and
excretion were unaffected, but the respiratory
actions were sometimes disturbed. One day he
was unable to get out of bed ; and another he
came down to his parlour. His complaints were
considered chrome pleurisy, adhesions of the
pleura, rheumatism of the thoracic muscles, &c.
When first called to him, I examined the thorax
by auscultation and percussion. The sounds
furnished by both were perfectly healthy. The
liver was thought to rise rather high ; and the
stools were deficient in bile. Chronic disesse of
tlie liver was, therefore, suspected. Upon ex-
tending the examination to the spine, two of the
spinous processes of the upper dorsal vertebrs were
found very prominent, and pressure in this ntua-
tion caused great pain. The treatment was directed
accordingly, and amendment took place. These
cases evince the importance of a very minute
and extended examination, in ascertaining the
cause of pain, and, consequently, of proving its
reality. When severe pain is complained of by
females in any external or internal part, an opi-
nion as to its reality or nature should not be given
until the spine is carefully examined, and the
state of the uterine functions inquired into. The
existence or non-existence of tenderness, pain, or
fulness in the hypogastric, iliac, and sacral re-
gions, indicating disease of the uterus or ovaria,
ought also to be ascertained ; for if the least sign
of disorder in any of these situations be detect^,
we ought not to infer deception, although it must
be admitted that exaggeration, and even decep-
tion, may be practised nevertheless.

38. Ophthalmia was not infrequently pro-
duced by soldiers and conscripts during the last
war, by means of corrosive sublimate, powdered
alum, quicklime, acids, salt, tobacco, and various
acrid powders and mechanical irritants. The
extreme rapidity of the inflammation, especially
as respects its invasion of the conjunctiva oculi
and cornea, and the circumstance of tfic right

eye only beiog afleeted, slioald eicile laipiciMut.
llie chronic forma of ophthalmia were sbo «x.
cited and kept up by extracting the eydashetaod
applying irritants to the edges of the eyelith.
When entire seclusion of the suspected patient
cannot be obtained, as in the navy, the reeoB-
mendation of Mr. C. Hotchisou to nse the ftnit
waistcoat should be adopted.

39. Palsy and Shaking Palst are aot oAo
feigned. If, with tb^ loss of motion, or the oos-
tinned agitation of a limb, or one half the bodr,
the general health appears to be good, sad the
excretions natural, a watch should be Nt opoc
the patient, and his actions observed wbea ht
thinu himself unnoticed. The cold afoaoe,
electric shocks, moxas, and the actoal cn^,
will often have a wonderful effect in rapicMs
cases. Even the threat of having reooane lo
these means has been sufficient. — In tarn ti
simulated paralysis, detection may be esstlv k-
complished by canang sleep by opium, sod tiea
tickling, irritating, or pinching the rootioole^ ex-
tremity. If the disease be feigned, the limb vi<l
be retracted or withdrawn : ami, apoofint wskee-
ing, it will often be used before tbe patient rcg!-
lects himself.

40. Polypus of th§ Note has been oAea lad-
tated, according to MM. Pxbcy and Lavsim,
by French conscripts, who lusve socceeded bf
introducing the testes of cocks, or the kidaejs cS
hares or rabbits, into the nostrils, and retsuuo;
them there by means of sponge to which they hki
been fastened.

41. PaaoNANCY is often pretended, to gntlfr
the wishes of a husband or relatiotts, to inciviK
interest, to extort money from a panmonr.tod^
prive a legal heir, to*delay the execotioo of poaiib-
raent, and to avoid labour. A carelnl «umioatio8
of the areolae, of the mammsB, of the ombilicw,
and of the as uteri, will generally lead toddcctioo,
at least in the more advanced months. (See Puo*

NANCY.)

42. PoLMONARY DISEASES txe notoftso facwd ,
but I have met with instances^ two in festiaJeft—
in which slight symptoms have been exaggcnti^
into the appearance of dangerous disease, pt'*
ticularly in the description of them, in onkr t«
accomplish particular ends. In such cues, t^a
patient has a frequent and short retpirstioa,
and a hacking cough, with little or no eipcctO'
ration ; complains of the pain on oooghio? '
taking a full inspiration, and of night s«eit«;
evidently desires to be considered very il|^.h»t J
averse from medicine: as heeonsidenit'ipf no
use ; and even resorts to various means to ^
duce emaciation, particularly vinegar, tbe ox>l *
of copper, cream of tartar, tartaric add, ^c«
The state of the pulse, the sounds prodnccd bv
auscultation and percussion; the appareat dr>
spondency, instead of the continued and o
wearied hopes of the patient, chamcterisBff <^'-
real disease; the maAed reluctance to have
recourse to issues, setons, or counter^irrttsL!^ .
and an enquiry into the wishes of the patKiit ^
to regimen, &c. are the chief means of dricrt»i^
In private practice, the physictan sbonM ta^*-
vour to ascertain whether or no the trrtiv^*
directed is strictly followed* particularly (br >
scrtion of isAuc^, setons, &c. ; for if Cl)C« •'
not adopted af^er a coofideal reooarae i^l't' '^
of them, strong suiipioionK of ilerpptHitt ft*-" 'J

692

FEIGNING DISEASE.

of the thigh and leg, resembling elephantiasis,
was sent home from India to be discharged.
A ligature was discovered, and, upon its re-
moval, the swelling gradually subsided. -^ The
detection and prevention of such cases cannot
be difficult.

49. Ulcers artificially caused were remark-
ably frequent in both navy and army, during the
last War. They were generally |>roduced upon
the legs by vanous caustics or irritants, by fric-
tion with sand, by quicklime mixed with soap, by
compression with metallic or other bodies, and by
mineral acids. Arsenic, corrosive sublimate, to-
bacco, &c. have also been used for this purpose.
Mr. C. Hutchison found a halfpenny between
the muscles of a leg which he removed in con-
sequence of extentivfr caries of the tibia following
artificially formed ulcers. Intentional ulcerations
are distinguished from the real, by their borders
beioe less callous, their surfaces more superficial
and less painful, and their disposition to heal,when
secured against tampering, much greater, owing to
their not originating in, or accompanying, con-
stitutional disorder, as in the case of real ulcers.
• — In order to prevent this species of deception,
Mr. C. Hutchison had recourse to a wooden box,
in which he locked up the whole limb ; all other
means, as marked of sealed bandages, &c., having
been found insufficient against the ingenuity of
malingerers.

50. The Urine presents various disorders in
respect of its characters and of its excretion,
which have been artificially produced or feigned
by persons desirous of escaping from the public
services, and by hysterical females. — Incontinence
of Urine was often simulated by sailors and sol-
dfiers. The circumstance of this disorder occur-
ring frequently in this class of persons, who are
mostly young, or in the vigour of life, should
excite suspicions of its reality. The simulator
generally chooses the circumstances and place
suitable to his purposes in allowing the urine to
escape. Laurent and Percy state that the glans
pitiit is always pale and shrivelled in real incon-
tinence, and that the urine never comes away
in a stream. M. Fodere finding that this com-
plaint was becoming epidemic in a regiment, and
that blistering the perineum and other means
did not cure it, directed the penis of every patient
to be tied, and the knot sealed, none but the person
guarding them being allowed to remove the liga-
ture. The penis was observed from time to time,
to ascertain whether or no distension above the
ligature existed, and whether, when it was re-
moved in order to urinate, the discharge took
place guttatim^ as in real incontinence, or in a
stream. The expedient succeeded, and the epi-
demic vanished. (Vol. ii. p. 481.) Percy and
Laurent prescribed twenty lashes to the loins,
with the avowed object of exciting the weakened
organs. It was unnecessary to direct it to a
second case. An army surgeon directed a cold
plunge-bath twice a day with equal success;
and Mr. Hutchison, Mr. Comyns, and Dr. Hen-
NEN caused a strong opiate to be given i^t night,
and the length of time the urine was retained
during sleep to be watched ; for, in real incon-
tinence, the urine passes away after a short time
under all circumstances. The patient may also
be caused to undress and stanu before the me-
dical man at the time when he slates that bis urine |

usually passes off. *In eases of feigning, tbe ab-
dominal muscles will be seen contracting in crd*-r
to expel iK

51. Bloody Urine has been nmnlaled by tb«
ingestion of beet-root, madder, the extract of H:-
wood, the fruit of the prickly pear, the Ind a
fig, &c. But blood is more (reqnently mnrd
with the urine. Percy and LAURtJiT state, tbs:
conscripts have injected blood into the blatiic
in order to imitate haFmaturia. This dmasc '^ '^
even been occasioned by having reooorvr ^
cantharides. A boy in Staffordshire, in 16 IT
having accused a woman of bewitelung hi?.
feigned various maladies; and, amot^vt (rtit .->,
the excretion of black urine. The wisdom of ^.r
ancestors condemned the woman to be baraf, ls
was usual in such cases; but the Bishop of tv
diocese, suspecting imposture, caused the bc*T :•
be watched, when he was detected dipping cd': <
in ink, and afterwards introducing it wiihin ^i*.

Erepuce, in order to give the urine which be pcv
cly voided its dark colour. {Mem. of Llt«r«r^*f.
vol. iv. p. 357.)

62. The excretion of Gravel, and of other di-
stances, has likewise been feigned. In all «■ "
cases, as well as the foregoing, the person sfco
be made to urinate in the presence of tbc p - •
sician. The real existence of gravel b ».--•••
tained beyond doubt, by close inspection and co-
mical analysis. — Stricturei have abo b'-t
feigned ; but the passage of a bougie will a]«'i>
ascertam their reality in the hands of an ««(•-.
surgeon — Supprettion and Betentiam ^' I - "*
have been pretended ; but most freqaeotlv t*
convicts, and hysterical females. The intxt^' . •
tion of the catheter, and a strict watch wiD ^t>r
rally show the state of the case.

53. Utfrine Diseases have been feigoed tV
exaggerated, and I believe more frequently t'^:
is commonly supposed. It was attempted id < :
case in which I was some years ago coD«u]^'i
but the object becoming apparent I withdiw
This kind of simulation is sometimes adopted « '
an evident motive, as dislike of a husband, &e. ; c
in other cases the object is not so apparent. I ^
Thomson, of Edinburgh, mentions an instan'*- >
of a female in a respectable station, who pre:r?. '-
to pass vesicular bodies resembling bjrdat:*!* u
the vagina. They were ascertained to be pre^r< ^
from the intestines of a pig, and were nauk ta re-
semble a string of beads.

54. Varicose Veins have been cansed b% I n-
tures or pressure made in the course of tl»« \»t^- *
trunks. They may also be aggravated, wbee » •
ready present, in a similar way. Attentive tu'xr
ation, and the means advised for utcera ^ ; 4'-.
will generally detect the deception, and prpvr '

55. Wounds have been both pretended •-«
inflicted intentionally. The feigning of w vr..*
has been sometimes practised to avoid the da*i.--
of battle, or to be mentioned in d««p«t. .
Means which may occasion the appeerjrre •
a contusion, as abraidirg or disooioorin^ i'
surface, are chiefly resorted to. Detectwa «
depend upon attendant circumstances ar.d "•
acuteness of the surgeon. Mutilation*, or trt" ■«
tional wounds, are more common Ir rrs««nr«l (->
in order to avoid con<icription into the publtr -
viceif , or to obtain pen'ioni or a dwt« i . •
They are sometimes sImi practised by •^a\* -
mendicant*:, and revengeful prrKfCT^. Ao«l woi. '^

894

F£V£R — Cbabactbbs op.

the time of th^r operation. But, still the more
remarkable phenomena of these separate diseases
proceed in a very different order, and very gene-
rally in so marked a manner, as to be easily dis-
tingaished by the close observer. The most
frequently exciting causes of disorder, viz. mental
distress, atmospherical vidssitudes, exposure to
cold, moisture, &c., shall, according to the state
of the individual at the time, produce an attack of
general disease, unaccompamed by predominant
affection of any particular oi^n ; and the disorder
shall commence and terminate without any com-
plication. In a second individual, a more or less
evident determination of the malady, or even in-
flammation, shall appear in the advanced course of
the general disease, or even during convalescence.
In a third, the local disorder shall be coetaneous,
and more or less co-ordinate with the general
affection, or even outstrip it in violence during its
course. And in a fourth person, local disease alone
shall be primarily caused; on which, as it in-
creases, and as inflammation becomes more fully
developed, symptomatic fever, or the general de-
rangement, shall supervene. These different states
of diseased action follow the same cause, ac-
cording to the disposition, susceptibility, or states
ofthe system «t the time. One person, according
to this proposition, may have the constitutional
derangement complicated with rheumatic, ea-
tnrrhal, bilious, nervous, gastric, or dysenteric
affection; the general disorder being attended
from some early stage of its course, 'or from the
commencement, by a heightened disease of a par-
ticular or?an, or structure, and thereby consti-
tuting varieties of fever, which have been thus
denominated and described by Stoll, De Haen,
Reil, Frank, Hildenbrand, and others, and
have occurred in epidemic forms on various occa-
sions. Another person may have the nervous,
the gastric, or tne dysenteric characters super-
induced in the progress of the disease, owine to
external causes continuing in, or coming into
operation ; or to improper treatment : and a third
may experience, in consequence of the pre-existing
state of a particular organ or texture, an attack of
inflammation, from a similar set of causes to those
which produce idiopathic fever. If, therefore,
the species of disease which arise from one class
of causes are thus varied, owing to the predis-
position of certain oi*gans, or to the susceptibility
of the whole system, their number must neces-
sarily be further increased, and their characters
very materially changed, when the additional
influences of marshy exhalations, epidemic con-
stitutions, or specific infections ana contagions,
cprae into operation. Diseased actions become
not only more varied and extended by such
additional causes, acting either singly or in con-
junction, but also much more complicated and
violent.

4. These inferences may be legitimately de-
duced, from an extensive survey of some of the
cireumstances connected with acute diseases.
Their relation with such deran^ments as have
obtained the appellation febrile, is still more inti-
mate than witn those which, strictly local at
their commencement, induce consecutively gene-
ral disorder. It is necessary, however, to the
proper consideration of the pathology of fever,
that due regard be paid to the nature and extent
of its causes, and ot modifying or determining in-

fluences, as far as they can be aseertai&fed ; ao'l
that a strict reference be bad to the elleets ib-
served to follow the application of both ebsw* of
agents, under opposite or vaiyin^ drcttm^taocm.
It will also be requisite, while such an inquiry it
being prosecnted, that none of the early aod 13-
termediate changea be omitted. Such omisrc^
have but too often vitiated ourspeeuiatioBs oo i^^
nature of disease, and more espeetally of lever ,
for, instead of recognising the eariy changes u-:
states, particularly thoee which more directly s*ve
from external agents, consecutive and grom eSe^
only have more generally been setxed opoo. aeJ
assigned as the cause of disease. Let it not Ik
supposed that inquiries, such as have just b^a
recommended, are productive of no advantace -^
practice. The scientific practitioner wOJ r3i>
sider the most eflectual means of preventing, coo-
trolling, or removing disorderea netioiH, to Sc
indiciOed by a most careful scmtinj into t^c*
nature and extent, and by a jodidoos icf^v .7
into early aberratioos from the health j cood^jwj.
He will view the primary derangements, ia t^
relation they hold with their remote or occas<ri.
causes, on the one hand, and with conaecm ^^
or ultimate leiaons on the other; and will ti^<
trace each individual link of the chain of caasaLL>:
throughout.

5. If it be asked, What has the tzeatsBcat cf
fever gained by our speculations as to its nature '
I would answer, almost every thing. I will t^iym
this in a more demonstrative manner in tSe
sequel, by adducing the opinions which have i-^
merly been held upon the subject, with the prsc-
tice to which they have led. But, indcpendect!^
of the practical results of the inqniry, there ir%
other solid and not le» alluring indoeemer::*
which will operate on the inquisitive and «c-^
tutored mind. An individual poascsang a mttd
so constituted, feels a laudable seal in exaauA tz
into the nature of a class of disorders, which <^-
cerns not only the existence of a single indivvJx^ .
but influenoes also the prosperity of nations ; a:i %
who, entertaining even a moderate idea of tb
responribility which the exercise of his proCev-KO
*involves, can enter upon its practical diaehjr^r*
in respect of this class of diseases csprris'l..
without feeling some desire of extendiai^ t «
knowledge of their nature, in order that t-.
course he punues may be both rational and »«;-
oessfull

6. 1. GxNXRAL View of Fives. — Fevei^ t-e
the most prevalent of all diseases, especially a
some countries and localities ; and their cm'cv*
freouently cannot be avoided nor coantm<-nl
by human foresight or science. They are cMvre
especially prevalent among, aod injunoos to. ^^
human species, ss the history of epidemic, pe^r-
lential, and other fevera fully prove ; and s<
evinced by those infectioos feven which cf'^r.
occur in camps, and follow the rears of arr- ■-<>
during warfare, and which are sometimes iau« V
more destructive than the most fasM- fought bs'-
tles.-^ Epidemic fevers are not, however, eoafi^ v'
to the human spedes; the caosM in wf«-*
the^ originate, and the influence which promo* -^
their extension, frequently affecting also the lowir
animals, — > a circumstance of hnportance in v -
speculations respecting the oripo and nature <.•'
this very important class of maladies.

7. i, CiiABAcrrBs or FLVUi«~Ilii imfmsiKi

896

FEVER — General DEscntpTiov.

attended by congestion of the vessels of (he head.
It is observed in other diseases ; but it most con-
stantly accompanies fever. — g. The appetites also
are more or leas affected. The appetite for food
is diminished or entirely abolished. In rare cases,
a craving for food has been observed in an ad-
vanced stage of fever, but not throughout its whole
course. The appetite for the sex is also abolished
until convalescence has commenced, when it re-
appears, and is sometimes one of the earliest signs
of amendment. These symptoms probably depend
upon the same cause •■^ upon depressed organic
nervous influence, and consequent deficiency of
the secretions.

14. ii. General Description. — The word
Fever is used in a double sense : it is applied —
1st, to that state of constitutional disiurbance, in
which the above symptoms are primary, essential,
or idiopathic ; and, 2dly, to the general disorder con-
sequent upon, or symptomatic of, some local dis-
ease. In the latter, the febrile symptoms con-
sist chiefly of increased heat and accelerated cir-
culation ; and without these tlie patient is said to
be without fever. But when fever occurs pri-
marily— is a disease sui generis — these two
symptoms areseldom the most prominent, and are
always associated with others, especially those
already noticed, which may be much more mani-
fest than they, and which are either altogether
wanting in symptomatic fever, or not similarly as-
sociated, or only occaMonally present. This
distinction is necessary, particularly as respects the
treatment, and should never be overlooked. Its
importance will be more apparent in the sequel.
I shall first describe fever as a disease tut generis ;
and next, as a symptom of inflammation, or some
other disease of a particular organ or tissue.

15. Ididpatdic Fever presents, during its
whole progress, characteristic symptoms, not con-
sisting merely of increased frequency of circu-
lation and augmented heat, which are sometimes
wanting in certain stages of the disease, but of
other morbid phenomena that are equally im-
portant, that vary in degree and in modes of
association with one another, and that super-
induce other phenomena thereby givihg rise to
the different forms and states in which the disease
occurs ; — it commences with debility and lassitude,
which are followed by chills or rigors ; it is gene-
rally composed of several invasions or exacerbations ;
it implicates the whole of the vital endowments
and faculties, the fluids, and the entire organi-
sation ; it is acute and dangerous in its course,
with lesion of the circulation, with alteration of
the animal heat and of the ucretions, and with
diminution of vital power ; and it is versatile as to
its symptoms and type, with efforts at sudden
changes or crises,

16. 1st, Fever begins with lassitude and debility,
generally followed by chills or rigors* — It origin-
ates in causes which affect the vital energies of the
system, and occasion debility and lassitude as the
earliest and most remakable changes. These are
generally attended by an insuperable feeling of
fatigue upon the least corporeal or mental exertion
by stupidity, loss of nervous and mental energy, by
initability, moroseness, or impatience, and by hea-
viness of the eyes. Upon these supervene various
uneaiiy sensations ; as, anxiety at the precordia,
occasioning frequent full or laboured inspirations ;
a peculiar and general uneasiness and restlessness ^

a feeling of cold, pafticularly along the apoBe,
and differing from the real or ivmal scnsatioo ;
horripilations, Involontary thuddcnngs, and tre-
mors or rigors. The debility giving rise to the
unconouerable sense of iMsHade and fiati»oe
generally precedes the chills for aome indefiDite
time, and accompanies them or continiics after
them. Chills or rigors often return and alteraatc
with flushes, ^nd other incipieot diatorbanoes, for
a variable period.

17. 2d. Fever is very frequemtiy ramfmsnt re
several invaeions or exacerbatlamt, one pttfosy«ai
disposing to others; as in agues and rcmittenu
But even in continued feven a smilar eire«B-
stance very often obtains, as evinced by tlie eves'
ing exacerbations, and the aggravaifon of the
symptoms on alternate days. Some writen, and
more particularly Hildknbband, consider that, as
in remittents, whoein a new invasion sapefTco««
before the previous paroxysm bad asbaided, so ia
continued fevers, one fit runs into another. —
" Continue ergo febres, ai non omnes , sailed
plersque, prssertim critics, e plorimia paroxy«aB»
febrilibus, quorum unus altenim subintnt, eon-
posits sunt."

18. dd. Fever is a disease of all thf viiml en-
dowments, functions and faeuUies, of the jiutos,
and of the whole organisation. — If we trace the
progress of fever, from the operation of ita cawn
through successive changes, we shall find thai
the vital power, which is supreme over the phy-
sical properties and functions of our di&ral
structures is deeply affected throogboat all i»
subordinate manifestations — as the sentikiUtte* a(
the nervous systems, the irritabitity of involoa-
tary and voluntary muscular fibrea, the orgmmte
contractility of membranous parts. Hence pro-
ceed lesions : — (a) Of the organic funeti^m* —
of the respiratory actions and functions, of eim>-
lation ana of the circulating fluids ; of aecnsCKia
and excretion, of digestion, assimilation, sanfr- i-
faction, and nutrition ; of the appetites, both b*>
tural and acquired, &c. — {b) Of the ccrc^rv-
spiualand animal faculties — of the ftiBCtiona ol
sense and voluntary motion, and of the powen oS
mind: the expression of the counleaanoe ard
the attitudes are changed ; the a<'naes cither per-
form their parts imperfectly, or the mind takd aa
insufficient cogniaaooe of their reports ; the attrs-
tion is wavering and quickly fatigued ; the inbe -
lectual powen and slates are languid, feeble, or
otherwise disturbed -, the iodgment ia perverted bf
internal and involuntary impreasiona and concpp>
tions ; and* ultimately all the mental endowmcoai
become exhausted and disoidered, by pavloogt^
wakefulness, or overwhelmed by a ooaticori
sopor. — (c) Of the fluids and whole argamimttmi
— The fluids and soft solids undergo chasfrt
in their appearances, form, and propenica. 1 U
blootl is evidently altered in vanoos ways it
different periods of the disease* Its scrum la oftra
at firet in considerable quantitv, and iia crasai-
mentum loose ; but afterwards tiie latter generally
becomes more firm or cupped ; and iiUi»atx h
again loose, or imperfectly separated (ram Hjc
serum. In many rases it is still more rrauiTi-
ably altered, as shown in the article Bt4^ :>
(§ IB et seq,) both in colour and coBsisfc'iwc.
The secretions, which ara at first chiefly dinunkit^i
in quantity, ultimately are changed ia qualify.
They become more ofleiifive, of a darker eoivaV,

998

F£V£R ^ SVICVTOM ATtC

•come respMtf a depnntory eilbrt of nttara, more
especially as those evacaatioos generaUy ocour
through the medium of organs which eUmtaate
hurtfal materials from the circulatiog fluid.
Hence, one of the safest modes of practice is that
which keeps these salutary processes in view,
avoiding whatever may prevent them, and pro-
moting their evolution ; attending at the same time
to the preservation of the powers of life, and ward-
ing on danger from weakened, over-excited, or
oppressed oi^ns.

33. When we take into consideration the con-
servative inOuence of the vital energy, the salutary
changes brought about by it, and the circum-
stance that every method of cure, or every agent,
cannot act in a similar nmnner in all cases— and
that, even during the most injudicious treatment,
certain of the agents are calculated to meet the
exigencies of some eases, either in supporting the
powers of life, or in favouring or determining
some critical evacuation— the reason will readily
appear, why recovery often takes plaoe in fever
from the most opposite means, or when left
entirely to nature; and we shall easily under-
stand wherefore all do not die who are improperly
treated, and how nature often not only overcomes
the disease, but also the effects of injurious agents
prescribed for it. Of the means which are em-
•ployed in the treatment of fevers, there are not
any which become more dangerous from in-
appropriate use, than the extreme measures fre-
quently resorted to — namely, large depletions
and active stimulants. The former may aestroy,
in a few hours, cases which nature or opposite
measures might have preserved, and the latter
may over-excite, and inflame to disorganisation,
viscera which require to be unloaded, or to have
their actions moderated.

24. It not infrequently, however, happens
that the critical efforts are imperfect owing to
exhausted vital power, or insufficient from the
nature and severity of the disease, or misdirected
or irregularly exerted in consequence of some
«ontrolling or determining influence ; and hence
they become sources of increased disorder, or
superinduce structural change. Such results are
•ometimes favoured by over-active, inefficient, or
inappropriate means of cure ; and very often by
organic lesions having taken place in so great a
degree, and so early in the disease, that the salu-
tary efforts attempted cannot subdue them, but
merely tend in some instances to their aggravation
and danger.

' 36. The event in fevers is directly produced by
critical changes, and indirectly by the assistance
of art : it mfavourahle, if the powers of life remain
unsubdued and act without obstruction ; it is tin-
favcumhU, if they languish or are overwhelmed.
So much are we indebted to the conservative
efforts of lire exerted throug^hout the frame in the
cure of fevers, that more is often to be ascribed
4o this source than to the interference of art ; and
I may add in the words of Professor Hildkn-
3RAND, " Inde eoim pendet, quod miseri ac inepti
medici faroam, quam buccis inflatis non accipere,
eed verecundi naturu magistre reddere deberent,
in febribus sanandis sibi conficiunt. Inde pendet
Quod omnis sects medici, ac oppositarum me-
•deodi rationum adsecta, de felici eventu in febrium
tractatione glorientur. Inde demum pendet, quod
«iuavis theorianim ad febrei emmndas.applioata.

stnatomm sgronim pruliea aunpU ofcie v^
leat." (Vol.1, p. 63.)

26. Symptomatic Favaa. — » Fever may be
a ooncomitaat or an effsct of aaotiier Ammmt^
which would still remain were it Msible to
remove the attendant fever; bat wtueh beiog
removed, the concomitant (ever would cease.
In as far as it coBsista of acoelefalad circulation,
fever may be associated with the majority o<
diseases ; but it is still merely a aincla sympton,
wherefore other phenomena should be preicat
before even symptomatic fsver ought to be ssid
to exist. Whatever irritates or stimubtce tW
circulating system |to a stronger or more froqueai
action, or inflames a partieolar part* ia producUTc
of symptomatic fever. Ita eauso exists
the frame, and more raraly it acta from wi
as irritation or inflammation of particular
the presence of foreign bodim, or of calculi*^
or hurtful iogeeta; the abeorption of hurtful sr
acrid matters, or of cootaminatinf aocretiom;
surgical operations, external lujuciee, aad viokstt
exertion. Fever proceeding from tbeea
has been termed ia/iewsietsry, imtetiee, Je

from irritation, fever ef the va
itfmptomatie inflammaitanf fewer, nfweptommtie/mjer,
ekronie fever, heetie fever, aeoording to the pure-
liar imtation, or local diMase, on whieh A ai-
tends.

27. Fever is eteeeiated with other diwssti ia a
twofold manner f— 1st. EseemtieUy, forming whsi
are called febrile dieeami or ijfmf^vmmtie fnm
strictly speaking ; as in tabe» pMniiMte, in mhir\
it is merely a symptom, but one which is ut^
formly present. 2d. Aeeidentdlitt or comiimgemttk,
not naturally and constantly, but merely fram
the association of, some occasional disturbaacc or
complication, as in amenorrbcea, cUorosiar dron«y.
rheumataJgia, &c.; or as a oonsequenee of tn**-
ment* In symptomatic fevers, the coustitatMiBsi
affection is neither so severe, nor so guBcrally aaJ
equally extended to all the functiona,
tirely implicates the fluids and aoft
idiopathic fever. Hence they are more mduv
traced to their origin— to the irritation in mhic'k
they a rim. The functiotts which ohieAy Baacv
fest disturbance in their progrem are thoae oi
circulation and secretion— the latter oftea vcr^
slightly. Others are also occaaioBally distufM.
as those of the skin and of the nervous sysiem, but
generally in an indirect and slight manner. Cms-
seqoently the chief charaolers of aymptoumtac
fevers are quickened pulae, heat of skin, dimnUr
of its transpiration, aad thirst Tho excrrtioas.
muscular power, and the faculties of miad, aiv
but little altered. The pulse retaiaa giealer tea*
and sharpness, and the general suiCmo m«v
animation than in idiopathic fever. Tba estmai
physiognomy, the posture, the extreraa preitfu-
tioo of muscular power, the profouml allemtJMi*
of the vital endowments of the fluids ami of tl**
ornnimtion itself, characterising the lactrr. mre
either altogether absent, or present ia a vcrv
sUght degree merely, unlem when morbid metirr»
are conveyed into the oiroulatioa deriuf iN
course of certain symptomatic fevers, and thitr»by
vitiate both it and the wit solids, disoideriac •!•«
the different secretions and excretioo«. Scs<>h
occurrences sometimes take place, aad haw felies
repeatedly under my obascvalioB, nanieuAsffiy
when inftammalion ^^teckf tht iaiMWt amtvn ii

as IB

900

$*£V£R--Germal Cocisi.

and 18128, and In mv lectures delivered from
1823 to 1827, particular notice was directed to
the subject, and these symptoms were described
as constituting a most important stage of the dis-
ease, inasmuch as in it the nature of fever would
be most advantageously studied, and either its
subsequent course remaricablv meliorated, or its
further progress prevented, by appropriate and
energetic treatment* (Land, Med. Repos* vol.xxviii.
p. 238. ; and other Kefer. in Bibliog,)

34* The phenomena described above, as cha-
racteristic of idiopathic fever, never proceed
immediately from the remote causes. Ihe im*
pression made by them occasions a succession
of changes before those which really constitute
fever supervene. These early changes, being
productive of those which constitute the deve*
loped disease, may aptly be called fonnativt ;
ajxl the symptoms by wnich they are indicated,
pneunory. The exciting causes of fever seem to
act primarily upon the nervous system of organic
life, thereby producing changes in the vital mani-
festations of the frame, which gradually increase
until they arrive at a certain pitch, and terminate
in one of the modes hereafter to be noticed. The
more intense the exciting causes, the predispos-
ition being equal, the shorter will be the duration
of this period, and the sooner will the lesions con-
stituting fever be broueht about {§ 15.). — (a)
The earliest effect whicn is made manifest after
exposure to the more energetic causes of fever,
as infectious effluvia or noxious exhalations, is a
feeling of constriction or oppression in the chest
or at the precordia, attended by frequent sigh-
ing, gaping, forced and lengthened inspirations,
and by a sense of uneasy depression, or nausea,
evincing the morbid impression made upon the
nervous system through the respiratory organs.
The pulse is weak, slow, irregular, sometimes
remittent or reduplicating, and readily accele-
rated by slight exertion.— (6) The natural and
acquired appetites and desires are diminished ;
nausea is readily excited by food ; and the bowels
are either costive or easily acted upon by purg-
atives; Venus tilet, and all the organic June-
timt are impaired. ' — (c) The patient feels
debilitated and fatigued ; complains of headach,
vertigo, or confusion of ideas ; is morose, low-
spirited, slurginh, indolent, or incapable of exer-
tion and of directing his attention long to any
object; he readily perspires, and his breathing
becomes short and quick, on the least exertion ;
his sleep is unsound and unrefreshing, and he
awakens with a sense of lassitude or with pains
in his back and limbs, — in short, all the eerebro'
tpinal functione are weakened or disordered. -»
(d) The external expression and appearance are
somewhat altered. The countenance and skin
are unusually pale, sallow, or unhealthy ; more
rarely red. The eyes are languid, and deficient
in brilliancy. The breath is foetid or cool ; and
the tongue often loaded. The urine is sometimes
pale and copious; and the cutaneous surface
dry, cool, and harsh. These symptoms vary in
severity, and often are so slight as to escape par- /
ticular attention. They frequently are insuf-
ficient to induce the patient to confine himself. '
---(«) The duration of this stage is various in i
different fevers — from twenty-four hours, as in <
plague and some cases of typhus, to several
weeks, as in agues but it is geuef«lly from thre«

to fourteen days. TbeieyefWuddMilMtcrlkis
period is, the more acute nd the more rapid wiU
be the subsequent progrev of the disease, and
vice versa: then are, however, exeeptioBs to
this. Fever may be cut short in this suge by
active and judicious means ; but not afterwards,
unless occasionally in slight cases. — (f) IV
jMthoUfgieal conditim§ characterising tins sta^,
are, depression of vital power throughout the
frame, with slight internal coogeatioo, partin-
larly of the lunp, liver, &c.; with imperfect
change of the blood in the lungs, and with di>
minished secretion and excretion.

35. B. Stage of Ifuoiiam ; Prmdfhm ttl
Initium FebrU, Auct. var. — (a} Thteold Uege, of
writers — is attended by defaiiity, lassitude, pain-
ful uneasiness, or sinking at the epigMtriion, i
sensation resembling cold! running dowa i^«
back, with formieation or chills exteodiag ofcr
the limbs and eeneral snriace. The palse »
constricted, small, weak, or acoelcnded ; the n'
spiration is slow, irregular, or aospiriocs, tsd
attended by anxiety at the prceordia, and oeo-
aionally by a slight dry cou^. On these s«pe^
vene gapug, sighing, pandiculation ; a seasc d
weight, pain, or constnctioQ in the liead ; t >
diness, moroseoess, depression of spirits, aM
disorder of the senses ; lividity of the lips r^
nails ; pallor of the skin ; the cutis aacerioa, sri
shudderings, rigors, or shiverings, folloved M
or alternating with irregular flushes. After tt-
rigors cease, a sense of chilliness often coatiBt^
for some time, although the skin has bcoooc h t.
These symptoms present various grades sod nci v
ficationsin the different types of fever : in »cs
the feeline of cold is actually attended bj n-
duction of the temperature ; and in other» i^<
heat is not materially, if at all, diminished, or:t ■>
even increased. The former is most connoft't
seen in the cold stage of periodic Icvefs, t^ U:
ter in the invasion of continned ftmn, la : I
however, the cutaneous transpiration is eiu^ *^
arrested, and the skin is harsh and dry. T-
pulmonary exhalation is also diminished, sod I'ti
breath is cold. Copious dischaigca of pale arx<
often take place, evidently arising oat of tu
arrest of the exhalation from the sku and loa:<.
Loss of the appetites, costivenefs, thirst, i«i
occasionally sickness and vomiting, are Bcevt^
present. — (b) The dnratiam of this m^
may be very short ; or it may be for many Uar*.
alternating with slight flushes. The shorter lai
more intense it is, and the severer the r%ors i'<
shorter and severer will be the consequeat i**-
cular reaction, and the more nearly appnsebsc
the inflammatory type ; and the longer in d«r.
ation, the more prolonged will be the fever. 1t«
imperfect evolution of this sU^, or its sliihi «c^
Gurrence, particularly when it is not atteoded !•;
rigors, very genenlly indicates a sevsie na>t -
nant or typhoid state of disease. Id ume f*
the most daogereus cases of ferer, I have leea ti«>
stage so slight, as to be confeuaded with the pi^*
ceding one. This period having supervened, ihf
disease cannot readily be cut short by bloedlctwis:.
emetics, &c. ; although in the slighter csse«, s»i
more ioflammatory type, these means have »'*
ceeded in some instances. — (c) Tbe petkd***-
cal ttatet of the first period are increovd a
this, particularly the general dcpreasioa of tttsl
endowment j the inpnlcd fvoeiioM of the lo^g*.

9(5T

FEVER — Tms' aito fouui.

evemng ezaoerbation, whilst, in others, eztoer-
bations are very manifest ; but this depends much
upon the prevailing epidemic constitution. In
general, fever caused by infection, and compli-
cated with serious visceral disease, or charac-
terised by severe affection of the fluids and soft
solids, is strictly continued ; whilst that produced
by terrestrial emanations assumes somewhat of the
remittent form, although presenting much of the
continued type. — {e) The duration of this state of
vascular reaction is shortest in agues, in which it
does not esceed a very few hours ; and, in con-
tinued fevers, it is brief in proportion to the seve-
rity of the disease. It rarely, even in the more
protracted cases,exceeds fourteen days. — (d) The
pathologieal statet of the early part of this stage
continue in great measure in this part of it ; but
vascular action exceeds vital power, which is
gradually lowered; and the circulating and se-
creted fluids and the solids themselves become
vitiated as already stated, and as will be more
particularly shown in the sequel.

40, D, The period of Crisu ^ Stadium Criteoa
'^Judicium Febru, — Crisis in fevers is a sudden
change taking place at a particular period of the
disease, and terminating it. A crisis is brought
about chiefly by the efforts of nature, or, in other
words, by the febrile action itself inducing changes
in the functions and organs, productive of a salu-
tary effect. Although it often takes place by the
unaided efforts of life, it is frequently aasbted by
art, and should not therefore be preferred before
art judiciously employed. The critical days are
the 2d, 3d, 4th, and 5th (quotidian period);
the 7lh, 9th, and 1 1th (the tertian period) ; the
14th, 17th, and 20th (the quartan period). After
the 20th, crises are obscure, and seldom occur
till the 27th or 28th. Salutary chanees are ob-
served chiefly on the above, unfavourable changes
on the intervening days ; but death may happen
on any day. A very cold climate or season,
or either extreme of temperature, the impure air
of an hospital, the continued operation of the
causes, the complications, great vitiation of the
fluids and solids, an active treatment, interfere
with, retard, or prevent crises. If the exacerbations
be well markea, and vital energy not very much
reduced, a favourable crisis may be more con-
fidently expected. Crises are sometimes inde-
ctfivtf, or consist of several abortive attempts
before the end is attained, especially when the
powers of life are much lowered. When several
critical efforts are required, each succeeding one
renders the task more easy for the next, until the
disease is gradually subdued. (See Crisis, and
Critical Evacuations.')

41. JE. Period or Decline — Decrementum-^
Declinatio, «- Sometimes the decline is prompt
and rapid, especially afler a marked crisis (see
art. Crisis) ; at other times it is gradual and
slow, particularly when only slieht and imperfect
crises nave occurred, or when tne disease termi-
nates in resolution without any very manifest
critical evacuation. In the former case, the de-
cline passes quickly into convalescence ; in the
latter, this stage is often characterised by slight
exacerbations, called by some writers posthumous
crises, which are apt to be misunderstood. In
the fevers of this country, which frequently de-
cline gradually, or in the second of these modes,
the symptoms indicative of vital disturbance ge«

nerally snbode in tlie order In wMi llwy tp-
peared. Organic aehrovs tafldcnee and the
dependent functions are the flnt to be mtoful ;
the respiratory, secreting, and excretini; actioos
become natural; the perspirmtioo more general,
free, and, if it have previously been ofeuivv,
clammy, or pardal, more natural and genkl ;
the tongue begins to clean on the sides and point,
and is more moistened by the oommencmg fetan
of the secretions poored into the moulh ; como aT>kl
delirium subside; and the patient leganis ki^
power over the alvine excretions, if it baa beea
lost; the sensorial (acuities and sleep leappcsr.
and the latter becomes more refreshing ; the loro-
motive powers are freer and more energetic, tb«
patient being enabled to turn upon hia side, t!ip
sense of soreness and lassitude being ititninished ;
the appetites and desires return, and the eacre-
tions are gradually re-established. The artios i/
the heart is the last to subside to its nataraJ fr^
quency, and generally oontinoes long afterwards
to be readily excited b? alight stimvli. TV;
urine is abundant, and deposits a eopioita sed-
ment ; the bowels become free, the motioDs ooo-
sistent and feculent, and the skin gradually as-
sumes a clear and healthy appearance ; tui
emaciation increases rapidly, or now b mmn
apparent ; absorption, more especially of llie less
animalised and less highly organised parts vr
molecules, proceeding rapidly as soon as vaaculxr
reaction subsides.

42. F. CoHvalescenee — Stodinm Refeeti^mis —
ConvaUteentia, — I agree with Ricirm at.^
HiLDENBRAKD in Considering this as a stage ri
fever. The propriety of this view is obvious, e^«-
cially as regards the future health of the natieat.
It is, however, altogether distinct from the ca-
lady, inasmuch as it does not present mnj of thr
constituent phenomena, which still conbmied to
exist in the stage of decline, but merely tboae f(
debility consequent upon acute disease. Dun^.
its early progress, the bulk of the body still coo-
tinues to diminish, or does not increase unLl *.<
is far advanced ; all the symptoms entirely dis-
appear ; the appetites, desires, digestive functiaa*.
the secretions and excretions, are re-establnhH.
but are apt to be disordered, and therefore reqcir
supervision ; the cuticle and soffletimes the m *
are exfoliated, and the hair falls out Irritabiiirt-
and sensibility often are increased ; and tioBiCfri
aurium is sometimes troublesome ; bat these Mib-
side as health is restored. — fUUtptet are apt to orctr
in this period, especially from prematnre ezpoeo'e
or indulgences, or from disorder of the <fige«<iv's
oi^^ans ; but they more rarely follow when fr^tf
arises from infection or from a specific coota^wc*
though other diseases may be thereby oceasioae^.

43. IV. Of tub Ttpm and Forms or Fr* i>-
— i. These are determined by the following rr^
CHmstances : — a. By the previpHM heiattk, the Um-
perament, and habit of body, and vital eaeifj •(
the patient; — fr. By the state of the vanlar
system, particularly as to the existence of f«l-
ness or deficiency of blood; — e. By the ^ptn/c
kind of miasm or cause exeiting fever; — rf. Ry
the prevailing epidemical coostitution;— #. By
other causes, predisposing, exdting. eoacamn;.
and determining ; and by the intensity of t^?
action ; — /. By the eitermal and rnlsnwl — iH*
phj/sieal and moral — injlttenne, to whicft ide
patient is subjected, fnm the period u wWh

904

FEVER— iTsRMXKATioits^AppBARAiiesa Arret Dbatb.

without any critical discharge. This is the most
frequent mode observed in the fevers of this cli-
mate; and results, in a gr^t measure, from the
treatment adopted for them, particularly in their
early stages, which generally interferes with, or
prevents the occurrence of, the natural evacu-
ations constituting crises (see this article). It is
chiefly when artificial evacuations have not been
push^ far, that crises manifest themselves.

47. i3. Terminations in other diseases are owing
m^a, to previous disease, or the condition of par-
ticular viscera at the time of attack ; — 6. to the
severity and concurrence of the causes, and the
intensity of the disease ; — c. to local determi-
Dations supervening during the progress of fever,
giving rise to complications; — d. to improper
treatment, as a too heating regimen, the con-
tinued use of cathartics, or the adoption of such
as are too irritating ; — e. to incomplete or im-
perfect crises; — /. to the too early or too li-
beral use of stimulants or tonics during the
disease, or during convalescence ; -— f . to the
continued operation of the causes dunng treat-
ment ; — h, to the occurrence of new, determin-
ing, or superadded causes, as crowding of the
sick, bad ventilation, mental perturbations, in the
progress of the malady ; — and, t. to neglect, and
to a blind confidence in the efforts of life. The
diseases which may be thus superinduced, are —
d. inflammations of particular organs ; — /3. en-
gorgements, obstructions, and enlargements of
glandular viscera, particularly the spleen or
fiver; — y, effusion of serous fluids into shut ca-
vities, as into the peritoneal and pleural sacs ; —
^. partial or general anasarca ; — i. ulceration or
abrasion of mucous surfaces — chronic diarrhoea
and dysentery ; — (. haemorrhage from mucous
membranes; — ». inflammation of some part of
the vascular system; — d^. apoplectic, paralytic,
or epileptic seizures; — i. mama and insanity in
•ome one of its forms.

48. C, A termination in death is favoured —
a. by constitutional vice, excessive vascular ful-
ness, and a bad habit of body ; — b. by the in-
tensity of the cause and of the disease ; — c. by
the continued operation of the chief causes ; — d.
by the nature of the complication; — «. by neg-
lect or improper treatment; — f. by unfavourable
crises ; — and, h, by the other circumstances just
mentioned (§ 47.) as productive of consecutive
diseases. — This result cannot be imputed to any
single change. Two or even more of the fol-
lowing are evidently concerned in its production :
— a. Extreme suppression of organic, nervous,
or vital power ; — $, Lesions of organs arresting
their functions, and impeding those actions ne-
cessary to continuance of life ; — y. Vitiation of
the fluids, changing the condition of, or destroy-
ing, nervous influence and the rest of the vital
manifestations; — ^. Exhaustion of vital power,
and alterations of the intimate organisation of the
viscera, as in malignant fevers ; — i . Organic
injury sustained by the nervous system, espe-
cially its larger masses ; — (. Diminished or ex-
hausted irritability of the heart, the patient ex-
piring as in fatal syncope ; — n. Suffocation from
effusion into the bronchi ; — d^. Congestion of the
lungs, heart, and large vessels, to an extent beyond
the vital power of these parts to overcome ; — and,
I. Deficiency of blood so considerable as to destroy
|he relative oooditiona of the contained fluid tnd

containing vessels ; for when tlM tonicity, the er-
ganic contractility, of the latter is much inpaiied,
as in the advanced stages of adynamic fievcn, tnd
the amount of circulating fluid is also giestlj le»>
sened, the vessels will be unable to aceonmodiie
themselves to their conlenu, and the coasequeeixs
must necessarily be moot dangerous, if not speedily
fatal.

49. VI. Op thk Appkabamces Arm Dzatu.
— A. — a. Cases have been met with, whereia tk
most careful examination has failed to detect asj
lesion, or striotly morbid appearance, in aoj of
the general systems, or individual textures, or u
the fluids contained in the large vessels. It fflut
be admitted, therefore, that chan^ nay tike
place in the nervous system, or m the bkioJ.
sufficient to cause the most acute disease, orciei
to subvert life, without being so gross as to be
demonstrable to our senses; but allowini^ tb».
the fact now stated is important, inasnacb ss a
most materially affects the quotion as to tSe
nature of fever. — 6. Other caaes have been ob-
served — and much more frequently than the fort*
going— .in which the morbid appeannees mm
not commensurate with the intensity of the fjitp*
toms referrible to their seats, and were quite ta-
suflicient to account for a fatal issue. -—c Fre-
quently also, lesions of parts have been ikcwtpA,
which were not indicated by symptoms, or br
the usual symptoms, or very slightly and imptr-
fectly ; those changes having been more or Ic^*.
or even entirely, latent during life, altboufb
their nature evinced their' existence and progn^
during the advanced stages of the disease. Itu
circumstance may have arisen from an oppfe»il
or exhausted state of the brain ; or from i*n
changes in the circulating fluid tmpeiring fttst-
bility ; or, as Dr. Alison suggests, in bis t<nr
able and lucid exposition of the Patbolo^ o4
Fever, from an enfeebled state of the circvUtioa «t
the time when these local affections take plsee.

50. B. As to the nature of the changes ebsenf^.
opinions are somewhat differenC — Many wiikn
have viewed them as purely inflammatory ; otJien
as consequences of irritation, or of ioflamoMtorf
irritation ; this condition being viewed by then
as a lesser grade or modification of ioflannstios.
It is important to entertain precise ideas as tg
their nature ; and to mark the circumstanoe* n
which they differ from those changes wdkcnisl^j
resulting from pure inflammation, particttisrlv «
occurring in a previously healthy coartitMiios.—
1st. The lemons observed in fevers rarely pre^^
effusions of lymph or pus, especially in the idi*
namic and typhoid fevers,— consequences c«»-
monly following true inflammation ; and tM
cases in which these effusions have been dclcd^.
have been instances of local inflammatioo s«pe^
veoing in the coune of the more Mhenie or is-
flammatory forms of fever. —Odly. The lesioni «
inflammatory appearances have been more sap*'*
ficial, diffused, and attended with a darker dors-
louration. and greater sofieniog of the aftcieJ
and adjoining parts, than in idiopathic iDflsB|B«-
tion.— 3d]y. The appearances thus characiemcd.
differ the more from inflammation, the lower ibt
type of fever and the more vitiated the drcaistng
fluids.— 4thly. They more nesrfy wsemWe en-
sipelatous inflammation, than ao^ other.— ^*5*
They are met with in oertaia iamef aye "^
qucAtly than ta otheia; and^ aiccptiBI doo*"'

006

FI VERkM PSOONMB.

ngns And tendeney of thtte tshiaget, as woll at'
the reputadon of th« physician.— It is often dif*
ficult, owio^ to the mutability of the diaeaie, and
to the liability to err in appreciating those signs
by which changes of the functions and of the or-
ganisation are indicated, particularly when the
chief manifestations of life, and sensibility and or-
ganic contractility, are more or less impaired or
perverted during the course of fe?er. The pro-
gnosis depends, generally, upon the following cir-
cumstances : —a. The nature and intensity of the
predisposing, exciting, and concurring catuet; — 6.
The character of the prevailing epidemic, or epi-
demic constitution ;— c. The type, form, and state
of the disease ; — d. The states of the various
functions, and of nervous and vital energy ; — s.
The congruity of the symptoms, and various con-
tingent phenomena ; — /. The influences, treat-
ment, and regimen to which the patient is sub-
jected;—and, g. The intieal or other changes
which may take place.

58. A.-^a, The predisfHuitum caused by debi-
lity, acute sensibility, or a plethoric and cachectic
habit of body ; a previously morbid, or congested
state of the internal viscera, particularly of the
liver, bowels, and spleen ; and advanced age ; in-
crease the danger from fever. Some epidemiei,
however, most frequently attack the young and
robust, and prove even more fatal to them. But,
although gporadic fev$r may be also common in
this class of patients, it is less dangerous in them
than in the fore^ing. — 6. The exciting agenti,
particularly specific animal miasms; their con-
centrated form ; the concurrence of several
causes, either contemporaneously or in quick
succession ; their prolonged action, or continu-
ance during the disease ; and certain of the cir-
cumstances, inducing unfavourable terminations
($ 48.) ; render the prognosis much more serious.
Some importance should also be attached to the
character of the prevailing epidemic, as respects
its open or insidious form, and the effects follow-
ing a treatment appropriate to the usual states of
the disease.

59. B. — a. The intermittent type is less se-
rious than the remittent, and this latter than the
continued ; but the more the fever is inclined to
change, to become irregular, or to pass into one
of a graver character, the more serious it is.
The more complete the intermission, or the re-
mission, so much less is the danger; and the
more disposed continued fevers are to evince a
remitting form, the more favourable is the cir-
cumstance. The longer fever has continued, the
more difficult will be the cure ; and relapses are
more unfavourable than first attacks. — 6* The
inflammatory and sthenic tpecies are much more
generally favourable than the adynamic forms.
— c. The timpler the fever, the more certainly
will recovery take place ; and the more complicated,
the greater is the danger. The adynamio/orm,
with predominant affection, of an important in-
ternal organ, especially the intestinal mucous
surface, or the brain, or the lungs, is accordingly
amongst the most dangerous ; more especially if
the vascular system and circulating fluids, or the
soft solids, also become vitiated.

60. C. The more that the organic nervoue in*
Jluence is suppressed, diminished, or disordered
throughqut the diflferent viscera, the more unfa- I
vourable should be the prognoiif ; the functions of |

die viscera, the Male ef te fliide tal

and the appearance of the soft toUde, etiAoag llie

extent or the dieorder and of the daager. — A

weak, small, and quick pnlae; e^dark^diy, aad

contracted tongue ; profuae,

and unnatural per^ratiooe ;

flaky, membraniform, and uabealtiiy

coloured, scanty, and brown uriae ; lirU or

discoloured nails, flngets, e^lads, Ups, and soaB, n-

dcpendently of the oold stage ; a disooloured, dark*

and dry mouth and throat; and aa

and penetrating odour proceeding from tbe

— are dangerous symptoms. A pnin «f 130

upwards, unless in the puerperal state, is unfa vev«

able, and so much the more so as it ie ab(»va tks

number. A brown or black ooatiag, and deep.

reddish fissures, or a dark or livid colonr of tke

tongue ; stridor of the teeth ; a movemeDl d ti«

lips and lower Jaw as if eating; firm ckame of

the jaws and hps ; extreme anxiety at tibc nr»-
cordm ; tumefaction, tenderness, or pern of tha

pe-

epigastrium, hypochondria, or

rally ; tympanitic or flatulent distemssoB of tibe

abdomen ; copious or repeated diaehargcs ol bleed

by stool ; a sudden irruption of the

and an equally sudden dwappeaimnee of

moaning, weak, quick, abdominal, or

spiration ; coldness or mwness of the

hiccup; excessive increase, or

irregular distribution, and otherwise mofbsd aata,

of the animal heat ; sunk featuies ; lupid <■»-

eiation ; great difficulty or impossibility of artiar

upon the skin by sinapisms or biielei* ; as cartLv.

or deadened, unnatural, lurid appcanaecef i^

external surface ; yeHowishnem of, or

and livid or purole blotches on, the s

dark mucous sordes on the lips or gume, oi

ous discharges from the latter or from tlm

— are very un&vourable circuoBstanees,

61. D, The unfavourable synptome,
directly depending upon the c«r«6rv-j|MiMi
out tyttem, are, — a. extreme pain of the heed .
excessive sensibility or depression of spirits ; tmnuA
or red countenance, injected watery eyes, c^
tracted brows, &e., quickly passing into delirinia.
sopor, or coma ; prolonged watchfnlnesa, or eariy
somnolency or torpor ; convulsive
trismus or spasms of psirts. great res
continued tossings ; despair of recovery ;
presentiment or feeling that death will ca
0. And still more unmvomuble are, early
indiflTerence, particularly to the issue of the
insensibility or sopor ; profound coma
culty of bein|^ roused ; rolaxatioii of the
and unconscious evacnationB ; excem
muscular power ; inability to retain any
than the supine posture, especial^ early m tht
disease, and in connection with extreme peia ia t^
back and loins ; falling down towards tlw fisot of ihs
bed ; a position of the limbs and body,
upon their gravity, and diliereat fiwm iIm
ally preferred by the patient; iaability la
a posture different from that in wkkb be a
placed ; picking with the finfos at the bed-
clothes ; sobsultuf of the tendoas ; reir kmg aftsr
objecu in the air; alternate dihtatioBe aad eao-
tractions of the nostrils during rteawalieB ; 1^
o( voice or speech ; trembling of the leases, sr
inabiliw to protrude it ; an open mo«A or iclax-
adon of the lower jaw ; diacalty of dcgluikMi ;
and dilatation aad inseMibiiHy of tlw pafiL

a.
aad a

§08

F£V£R— Vi«ws ov rta Axcnam usncmo.

dread wbich gaye rise to Buch a mediam or mode
of deprecatioQ* not only marks the destructive
prevalence of fevers in these countries, but also
indicates the noxious effects of the Pontine Marshes
in the time of the Roman republic.

67. The earliest opinion of the ancient Greeks
respecting the immediate' cause of fever appears
to have been that of Anaxaooras (Plutarch, in
Vita Pericus, p. 155.) ; etiam Aristotle, (De
Cener. Anim. l.iii. cap. 6.)^ the contemporary
of Hippocrates. He attributed all acute dis-
eases to an abundance of bile. Aristotle (D0
Part, Animal, l.iv. c. 2.) combated this doc-
trine; but it became prevalent nevertheless.
Hippocrates, instead of entering into specula-
tions which the want of data and first pnnctples
rendered futile, set a better example, by directing
attention to the varying phenomena of the dis-
ease, and to their relation with the vicissitudes of
season, &c. Plato (Tim^.us, p.497.; et Galen,
Ds Dogmat, Hipp, et Plat. 1. viii. p. 324.) con-
sidered that fevers, and, indeed, all diseases, arose
from a disproportion of the difTefent physical ele-
ments which enter into the composition of the body.
Continued fevers, he supposed to arise from super-
fluity of fire ; a quotidiau from abundance of air ;
a tertian from predominance of water; and a
quartan from that of earth. This is, perhaps,
the first attempt at explaining the tjpes of fever.
It appears to have had but little mfiuenoe, not-
withstanding its universal adoption, in changing
the modes of practice already recommended by
Hippocrates.

68. The dogmatiitt (Galen, de Nat, Hum,
p. 279.) of the following age, in conformity with
their doctrine, conceived fever to proceed from
the abundance of bile, its quantity determining
the type of the disease. The maximum, in their
opinion, produced continued fever of an ardent
cnaracter; a len quantity, quotidians; and the
minimum, quartans. Praxagoras (Ruffus,
lib. i. chap. 33. p. 109.) of Cos, one of the most
faithful followers of Hippocrates, adopted a simi-
lar theory, and endeavoured also to account for
the cold stage of the disease, by supposiog its^
source to exist in the vena cava. This opinion
possesses some features of the more modern doc-
trine of congestion, which no doubt exists, both
iu the vena cava and other large veins, during
the cold stage, as a part of the series constituting
the diseased actions which obtain the name of
fever. Erasistratus was the first who con-
tended for a connection between fever and inflam-
mation (Galsw, Comment, II, in L, de Nat, Hu-
man, p. 27.). He conceived these morbid states
to consist in a transfusion of the blood into the arte-
ries, disturbing the spirit they contain, and giv-
ing it an irregular direction. The former be
believed to arise from the presence of blood in
the large arteries ; the latter, from a con|[estion
(^afkfAxroM-iq) of this fluid in the capillaries
(76id . de Vemuect, adv, Eratist, p. 2.). He was
equally averse from bleeding and purging, which
bad been long and generally in use in the treat-

• The following U from a votive tablet to the god-
deu:— .

FeM . dfint . Febri .

$anetm . FeM . magnm .'
Camitia . Amaia .pro .
JUio . mate . nffhrto . p .

ToMMAsiNi. In Oaovius, Theiaur. |
Roman. Aotiq. t xU. |k dffl, i

ex-

to IjC

I ment of these maladies ; and in aoaisfwiy, •§ k«
supposed, with his theory, recmnBeoded spare
diet, emetics, lavements, wana baths, frietiaas,
&c. (Ibid, p. 15, 16.)

69. Asclepiades, the fopiDdcr of tbe Mathodw
School, adopted a great part of the dectriae ot
Erasistratus respecting the fnadaioental corpw-
cles, and the pneuma or spirit of the do^^maiM^
He explained the heat whicn takes place in fever,
by the motion of these oorpuacles ; aail accovate^
for sensation, pain, &c. by a similar hypotbrsj
(C(ELIVS AuRELIAKUS, 1. 1. c. 15. pp. 46. 48. 57.^
According to him, fever oonsista ia an inercaae ^
heat, and of the pulse {Ibid, I. ii, c. 33. pu 161 >.
The other phenomena of fever and of tnlU»-
mation, he considered to proceed froati a dkpro.
portion between the particles and their pnes.
The elemental^ corpuscles, he sappoaed to pa«
from the lungs into the heart and arteriea, aad »
produce occasionally, during their volasilisai ci
from the body, an obstruction in the chaso«b
through which they cirenlate ; the lai)ger caovic^-
the most obstinate obstruction, and, conaeeatrvr },
the most violent feven : and the leMcr. ali ^btt?
attacks. The type of the diaeaae «
plained after the same manner. The
the intervals between the febrile acc<
more subtile the atoms were supposed
which had become impacted in the
pores (Idsm, Acut, l.i. c. 13. p. 42.).
piADEs conceived that nature could do
of herself in removing this state, aad that z .
must be attempted by the physician. Cru: s
(lib. iii. c. 8. p. 469.) informs us, that ** As.
clepiades ofiicium medici esse dicit, nt tuitj,
ut celeriter, ut jucunde caret." Agreeably ta
this maxim, he prescribed gentle medicines. xrA
dietetic means, instead of the violeot remedies ci
the empirics (C<xu Avrel. jictu, \, i. e. U.
p.^44.). Enemata, bloodletting, dry cuppar.
frictions, gMtation, exercise, bathing, and, awrt
rarely, emetics, were the agenta which ha recom*
mended. (Pliny, lib.xxvi. c.3. p. 392.; Cou
AvRBL. 1. c. et lib. iii. c.8. p. 215.)

70. SoRAKus (CttL. AuasL. ifent. I. ii. e.33.
p. 153.^ conceivM fevers to consist in an abaeiatr
relaxation of the vessels and their pores. Cawit «.
the Eclectic (Cassii Iatreeophi$t^, Nmtmrwin ft
Medieinalet Quettionet, £d. Co>*a. Gxaairaa. Ti-
OUR. 1662.), was of opinion, oQafenaakly w>ti
the chief doctrine of the Methodics, that thej mrm
in consequence of a different arrangemeat tain^
place in the primary and invinble cvHpoaelet;
while he adopted the bypothess of the aora aa-
cient dogmatist, by coosalering the iiiniiMi ia
the temperature to be the resnlt of frieiioa bt*
tween these particles, disengaging thcsr iatcfnJ
beat. The views of fever a&pted by the E^et-
tics, led to few modes of practiee which had aet
been previously employed. HcRODorra (Oai-
RASivs, Collect, l.vi. cap. 28, p.228. «< passu \
the disciple of Acatbinu9, who cmbraeed nore
of the pneumatic system than of any ether, pla««<1
great confidence m warm bathing and in sodo'.
ifics. These he considered to be serriceabW, i y
forti^ing the pneuma or spirit, and aaijtuq; it ij
expel heterogeneous particles. He atiemptrd,
also, to determine, wito more predsioa, iha time
and cireumstances in which bleeding, as reroo-
mended by Hippocrates, ovght to be nrasenbetl.

71. Oauv (Df di/<r. Feb, UUi. fa«m)

910

FEVER-— ViBWi 09 m» HObsmw.

however, hts been fUUed to abow that hu foeta
are more valuabie than his doctfine.

76. TiiOKAB Campamblla *, the celebrated
Italian metaphysioian and petholog|ut of the sii-
teenth centnry, ducardiog the opinions of Aris-
totle, eooceived that the vital spirit, which is
.produced from the most subtile of the animal
.numours, and is nourished bv the blood, is oon-

corned in the production of aU diseases, although
itself undergoes no change, being only irritated
or excited by the aeriform matten and flatuosi-
ties oontained in, or proceeding from, tba Buids.
lie considered that, as respects its nature, fever
.can scarcely be called a oiseaae, since it results
from the reactbn or the efforts of the vital spirit
to resist vitiation and putrefaction of the fluids,
and thus to preserve life. He attributed the
crisis and critical days to lunar iafluence, and
explained the action of remedies on the principle
of their exciting or reduciog Uie temperature of
the body. Van Helmont (D€ Ftbribm, c. 16.
p. 783.) ascribed fever to tbe influence of the
archeus or vital principle. — Although the found-
jiUon of the doctrine, which afterwa^ became so
^erally adopted, owing to the form it assumed
.in the hands of HopniAyN, Cullkn, and others,
was laid by these writers, another theory was
soon afterwards promulgated. Owiog to the in-
creasing enthusiasm wiui which chemistry then
.began to be cultivated, the chgmieal pathology
first proposed by Paracelsus (Op. Omnia Med,
Chemico'Chirurg, 4to. Basil. 15B9.), and sUp>
ported by Sylvius {Op, Med. 4to. AmsL 1679.),
Willis (Op«r. Omnia, 4to. Geneva, 1680.), Ksn-
QER, Borelli (De Motu AnimaL pars i. et ii.),
Wbdel {Physiol, Med, et Pathol, 4to. Jenie,
1679.), and others, obtained a very general sap-
port ; and although all the phenomena of fevers
were not explained by some according to the
principles of this school, yet its doctrines were
conveniently adduced to account for various states
of disorder.

77. It i§ unnecessary to notice the dreamings
of Fludd, Digby, Maxwell, Grxatrakb, and
others, of the sect of the Koaierucians, which
appeared early in the seventeenth century, as to
the nature of fever. It is impossible to cast even
a glance at the raving* of this sect, without en-
tertaioiog ideas the most humiliating of human
nature and intellect. Yet they found followers
in £urope, particularly in Germany, as late as
the middle of the eighteenth oentuiy ; and, even
now, emanations of their doctrine may be trao^
in some of the reveries which have recently been
promulgated in that enquiring countiy. Leav«
log opinions calculated only to excite the most
humihating suggestions respecting the extent of
human knowledge, and equally abasing reflections
on the state of medical science in this country at
that epoch, we arrive at a period presenting opi-
nions more in accordance with calm and unbiassed
reason than those immediately preceding.

78. The writings of Sydekham (Opera Omnia,
Leyd. 1742, 8vo. best edition) tended to dissi-
pate the " thick«coming fancies" of the humoral

* Bom in 1568^ and impri«oned for hit metaphyseal
opinions from 1599 to 1629, when ha waa let at liberty by
Pope UaaAW VII, He •fterward> went to Pari*, whate
ho dtad in 1639. (TlaABoacHi, Storia, *c. t. vlL u, 140. •

irr:ry;a*tgf liaSi "^ * ' ****** '■•• ' ••

n o

♦•„

I and ohamieal patliolonili ; and, aUhen^ ibc-
tured by the chemical nypckhesis, he Mev«rthrie«
directed attention to the opewtiona of aaiare.
Baouvi (Op. Omnia, Vea. 1716, 4lo.>, at a laie
period, trod nearly in the aame path m Svni^-
UAx ; and, like him, atteoded to the pwstaibag
character of epidemics, and viewied tfaov phcao-
mena in oonnectioD vnlh the seaeone aod at7>
spherical vidssitudes. Stabl (Thtorim M*^i,
Vera, 4to. Mate, 1737.), the disopla of Wij»i
forsaking the doctrines of his maaler, adopSAi a
theory in many reepeds sanilar to thau pt«paw«*
by VavHklmoiit((^. Oiimie. Amat. 4lo. 16m
and Camfanslia. The pavehico«heBiieal. c
bio-chemioal, hypothesis or Stasl aobesgytcn
received the aupport of SAVVAoas (NaaaL Meti^
2 vob. 4to. Aaut. 1768.), who, in addition Id 'J.c
efforts of the anima, the incrasMd nobom of tas
fluids, and augmented aecretioD and excfetiaa ^
the satino-solphureous particles, added tka 4Dctruc
of BonaAAvx, of aocelented cirottlstioB u n-
move a mechanieal obstacle.

79. Although recent opioiooa aa to tiM pfDo-
mate cause of fever may be traced paitly to Fia-
NiLtus and othen, yet it is to HovracAjtn ( U
Gmterat. Fe^. Hale, 1715.), the
Stahl, that we are indebted for
ideas. He placed the chief aource of
the nervous system, and considered that cvfti i
afiectione of nervous influence indoee a ftof^
spasm of the extreme vessels, driving tire hiomc
from the capillaries into the large
heart and large arteries - thus
tated. A nearly similar hypothesis
afterwards framed by Bosrhaavi (Piv^:
Acad. 2 vols. GoeU 1744.) from opiuoM ea
tertained at diflbrent periods, more peiticiala
from some of those promulgated by H«'>v-
MANN. BoERBAAvs, adopting no asBgW c-
geoeral principle, to which alone he refivrcd the
different manttestations of fever, kept hit anr«-
tion more especially flied upon the relation nb-
sistin^ between the exciting causes, and the art>u >
they induce in the mtem, explaining at the ntmt
time the latter conformably with the petholeck-
oal doctrines of the tiese. He rened«ied il'ai
a quicker and a stronger notion of dw hea"
was induced, during fever, by an aceaeeDa v-
the influence of the brain and the earobeilem, .a
order to overcome the resirtanoe eftied by lU
smaller vessels ; and that fever was thueisit ai
exertion of Ufe to avert dMth. Cuvvks < Tme
Ltnci of Ptaet. of P^s. vol. i. p. 43.) iU
in a much more saJMaclory
trine of the living solid, as flrst
FsaNXLius, and so ably extended, nad*.
established, by HorvMAWK. The
it to the theoiy of fever, which
by these and other writers, was aooro nwauli
explaiocd by Ccllev, and more oeemnoA^'*
with many of the phenomena. The ofiaao-^
of this vwy aottte and philosophieal phvenA-
held a stricter reference to the cnrlv thmtr^
than had been generally entertained, The rai.««
of fever he supposed to act b^ debiliftttcv *^
nervous energy, inducing dimnushed influtucc fi
the brain, and consecutive atony of die aoperr na
capillaries, accompanied with
of the heart and larger ait^
consequence of this state,
ferthtr iUuatnted and mdiM I9 Cwaa (JKoA

ITTV
91*'

r«'

hi

1

xs'^::^

ii

di2

rEVER— Vrsws of tbk Moo£ftKS«

has distinctly aseribecl fever to inflammfttion of
the brain, he having remarked, in 1757, this organ
especially affected in an epidemic characterised
by malignant symptoms ; and Dr. Wendsl-
STADT, in his description of an epidemic that pre-
vailed in 1794 and 1795 in Wetzlar, attended by
deliriam in some cases, by catarrh or pneumonia
in others, or by both delirium and pneumonia,
considered inflammation of the brain to have oc-
curred from the commencement. Still the exist-
ence of essential fever cannot be said to have
been called in question, until the appearance of
the works of Ploucquet {E^xpogit* Nosobg,
Typhi. Tubing. 1800.) and Clutterbvck (/n-
quiry into the Seat and Nature of Fever, Lond.
1802.), in which this disease is ascribed to inflam-
mation of the substance of the brain. Iliis
doctrine was soon afterwards controverted by
Dr. Beddoes (^Researdtei concern. Fever as eon-
nected with Infiam, 8fe. 8vo.) ; but Marcus, of
Bohemia, forsaking the pathology of Brown,
became a convert to it, and its most zealous sup-
porter (^Ephemer. der HeiUc, b. i. St. 2. 6cc.
1809.) ; and other writers of inferior note es-
poused the doctrine both in Marcus's Epheme-
rides and in Horn's Archives,

84. Shortly afterwards, another theory of fever
made its appearance ; and in France, at least, at-
tracted considerable attention, owing to the copious
writings of BnoussATS and of hb pupils. This
pathologist maintained that the mucous membrane
of the digestive canal is the primary seat of fever,
and presents the most general and unequivocal
lesions after death ; affections of other organs
being merely consequent upon, or sympathetic
of, disease of this part. Although several
writers, especially Rahn (BrieftoeehseltS^c. p. 250.
Zurich, 1787.), and Beddoes (Op. cit. p. 63.),
considered the gastric system most frequently
affected in fevera, it was reserved for Broussais
to conclude that " all the essential fevers of au-
thors are to be B>cribed to gastro-enteritis, simple
or complicated." (Exam, des Doet, Med, c^c,
t. i. p. 34.)

85. These two theories are the most important
of those which have had reference to the local
origin and seat of fever. They are manifestly
founded on narrow views of the deranged^ actions
consequent upon prolonged mental depression
and anxiety — upon change of climate, season,
and weather — upon the operations of endemic
agents and epidemic influences — upon the action
of various infectious miasms — according as each
or several of them may affect persons differently
predisposed, by temperament or diathesis — by
habit of body and constitutional energy — by the
state of the secreting and excreting viscera —
and by the circumstances in which they are
placed. They appear also to be deduced from
mistaken conceptions of tlie actual sequence Df
the disordered actions characterising the various
species of fever— sporadic, endemic, epidemic,
infectious, &c. — however they may be associated
or complicated with more or lees local disease,
either at their commencement, or in their progress.

86. The opinions which have recently been
most adopted on the Continent, especially in
Germany, are those which were taught by J. P.
Frank ( De Curandis Horn. Morbis, 8^e. t. i. p. 34.)
•nd^ V. N. ab Hildenbrand {Imiitut. Pract.

t. i. p. 96.). The fonoflr of these writen

xr.

confesses that he despein ef eonveyiagf uy exact
idea, or even of commg to any wabAcUirj con-
clusion, respecting the proximate caaae of fever.
He thinks, however, that fever may be viewed as
resulting from irriution induoed by aa anacm*-
tomed stimulus, the powers of life leactbig, or
making efforts at reaction, in order to remove A,
Hildenbrand states nearly the same propo«it!09
in different words, in concluding that tne cause (^
fever is to be found in a morbidly incieaaed it-
-action of the vital forces, owing to the irritatiocL
of a morbific stimulus. He further remarks —
1st, That all fevers are caused by an abeolnte or
relative irritatbn, and conseouently timt tlM-r
are all at their commencement irrititiTe;^2Jtv.
That the reaction of fever never follom mar
debility, although it is attended by debility ; aci
that the debility of the vital powers is alwrni*
secondary and the effect of the morbid irntstio'n.
or, adventitious as in the progress of tbe discMr.
— AdmitUn^ that it is diincult to explain al-
though I think it quite possible -^ bow rvaetm
of the vital forces can take place in the eysten ir.
consequence of a cause primariljr pmdecaj
debility, more especially in the pert where the
impression is primariW made ; still it is evidfs:
that all the causes of fever are not positive s&-
muli or irritants in their primary action, aad coo-
sequently that their immediate, effects on fie
surface to wliich they are applied are not ezciciar.
indeed, we have no evidence that the eArr*s
which are proximately consequent vpoo th^r
application, are similar to those which nnilbrtt.lT
result from those stimuli, with the action of whx- ^
we are acquainted. Stimulating effects nnd«ibt.
edly follow, remotely, in a majority of inscnnr?^,
but they supervene in consequence of intem'^
diate operations taking place in the system itst*'t.

87. The opinions of Dr. Jackson are not m»t^
rially different from those of HiLDBNeKANA. itr
considers the material canse of iever to be of en
irritative kind ;-^ that it enters the body byHk-
absorbents of the first pasnges, proceediof^ im.*
the circulation ; and that it produces the lebn :
act by irriutiog the extreme aeries of orgaa--
capillaries, thereby oceastonlog aabveraioo ol t>«
existing mode of action, and giving rise lo chnneMJ
or uanatural forms of action, thmgh wharh t^
different secretions and functions ere dimnuBhni,
increased, or modified, in varions ways and iisg:rfii

88. I am not aware that any opmion bm bm
promulgated different from those now ht^j
stated, up to the period when my own views m
to the pathology of fever were pnblnhed. l>r.
Armstrong was the most copious and leceet
writer on fever at that period ; but, after nn at-
tentive perusal of his work on typhus, and uf hi«
publbhcn lectures, I am unable to asccrtAa
what his views are, or wherein they difllcr Cm
those generally entertained at the time. e«pccu:iT
from those previously published by Chr. Jackouv
excepting that he particularly insists upon eo«-
gestion, as an important pathological state '
some forms of the disease; — but in th» W
merely followed Stabl, Junikeb, R. Srnsaicr...
Jackson, and some other older ae well as ctwt-
temporaiy Continental writers. Upon the wh^^W.
his views, both pathological and piuctienl, am w»
contradictory and vacillating, thai a refeienoe rasK
not be made to them with any degree of centide^cv.

89. XX* Patbolooicai* SxaTy*— 4* The Bmmam

914

fEVER — Patbologt of.

common than the other inflammatory appeaimnoea,
in no way supports this doctrine of fever, inas-
much as it may be present to the extent observed
in most instances or fever, without causing much
disturbance, or it may supervene shortly before
death, or even immediately after dissolution. But
readily granting its existence even early in the
disease, it is merely one of several changes eon-
sequent upon others much more important, as
will appear in the sequel (j 92.).— g. Those who
believe in the inflammatory origin of fever do not
agree respecting the particular viscus which is its
especial seat; some assigning one organ, others
another; the diversified complications, or pre-
dominance of morbid action in one viscus, or
even in several, over others, in different cases and
epidemics (c), ituraishiog them with the only ar-
guments they can assign in favour of their opi-
nions. — h. The changes supervening in the
blood, in the secretions, and in the general organ-
isation, during the progress of fever, cannot be
explained by, or reconciled with, its origin in local
innaromation. — •*. The appearances considered
inflammatory, and to which this clsss of patho-
logists refer in support of their doctrine, most
frequently take place in the progress of fever,
and seldom at its commencement, as shown by a
careful observation of the symptoms. — k. The
tendency to a favourable termination, and to
natural crises, is much more remarkable in
feven, than in tii/?<iiinwrfitmf. — L The general
characters of fevers vary remarkably in different
epidemics and epidemic constitutions, — a cir-
cumstance not remarked in respect of inflamma-
tions, or in a much slighter degree, — and lastly,
the Juvantia and Udenlia, in both respectively,
indicate a great difference between them. The
extent to which depletions can be carried in both,
and the frequent benefit derived from very oppo-
site measures in the former, and which are inju-
rious in the latter, are also no mean proof; for
although vascular depletions are often requisite
to control the local determinations or even in-
flammations which supervene in the course of, or
early in, fevers, yet they cannot, owing to the
state of vital power, be carried so far as in pure
inflammations; and, although evacuations 'are
most necetnry in some epidemics, and tonics or
stimulants injurious, still the former cannot be
practised to the same extent, at least in this cli-
mate, as in the phlegmasise ; whibt in epidemics
of an opposite cnaracter, bleeding is often inju-
rious, ana opposite means are required, — a cir^
cumstance not observed respecting inflammation.
93. B. Certain of the argumenU now urged
are equally applicable to the doetrint of ccnget'
tioH, or irrtgutar dutrihutiim of thg biood, — a.
The espousen of this opinion do not agree among
themselves aa to the chief seat of congestion ; but
granting that congestion very frequently, or even
generally, exists at some period of the disease,
especially in the large vessels adjoining the heart, it
is only one link of the chain of morbid causation
and action, itself being caused and attended by, as
well as inducing, oUier changes equally import-
ant. Besides, those instances which occasionally
occur of remarkably great congestion of the
large vessels of internal viscera, as from asphyxy,
&c., are not followed by the phenomena of idio^
JSathic fever; and although, as 1 shall have to
-How bttniUT, many of the wont forms of ierer

1^
tU

are attended by eongcstioa aa one osly of the
various changea that charaeterisa them, yet others
of a slight kind, as ague, are aooompsaied with
still more remarkable congestion daring the coU
stage of each paroxysm, without further
than the snbseqnent renction which it
developing.-^ ft. When eongeslion 1
iiderable, it is referrible to the aoxiotts iatf
of the exciting causes exerted
organic or gaoglial nervous system, and
cutively upon the Taseular system ; the
the heart being thereby weakened, and tbe
and resiliency of the vessels impssred ; and '
when the morbid impression on the fomer
intense, the effeeta produced upon the faaicr
also severe, congestion being only one of *
effects. — When, in consequence of the
enceof the morbid impreasioa, or eb
rily produced in the ganglial nervoua
efllecta upon the heart and vessels
resulting congestions, with the other
lesions, eith^ cannot be removed,
moved with difficulty ; the heart
unable to exert a due reaetioo ia order to over-
come them ; the vessels beinjr incapablo of that
degree of tonic resistance neoeasar^ lo a beairi»«
circuhuion and a regular distrilmtioa of faload .
and the capillaries being impaired ia oil
functions, owing to the state of nenrona
influencing them, and of the circulatioo in
Thus congestion is established ai one of tko
evident lesions that follow the primary
fever, — but only as one of subordinate ins^

93. C. To the doctrine that impales ievcr lo
th$ direct amiamimaiien of tho eiremimtmg JImtd
hif the material canat, the following objocCBsn
may be urged : — a. The febrile eaoae, aetiof as
a poison, should instantlr aflSeet the appeoinacv
of the blood if it made tta first and piuiayal st-
tack in tliis way ; but, when tlie onnse ia cnv-
getic, the efTects, instead of progreasivriy and
gradually appearing, as they neceewarily woaU
do in this case, instantly maniliest
the functions of the nervous syeioms,
cially of the organic nervons system, nad a the
functions of the orgaas actuated br it. I sfaai..
however, have hereafter to show, that the blood
is the next animal constitoent that lui uiais af-
fected, although frequently in no Very amaJfH
manner, at first, especially when disease dowly
developes itself upon the ezcitiBg caa»s. — It
should not be overlooked, in our reaearcksa «a
this subject, that agenta which especially atfrA
or depress the organic nervoua iaflaei
duce also co-ordinate effects upon the
system and on the blood itself, owing lo IIm
mate oonnectioa subsisting between these t««
systems. — 6. In cases where the OKaksd ob^m^
sion has been already made, either by saalsrw
or by infectious effluvia, the fall develeyeMont c^
the disease may be prevented doling the Stat «r
second stage, by substances whitt
powerful restorative or tonic adaoa od the
ous systems, particularly that of oc^pnio lil
an e#eet that could not result if tke blood
the primary or principal aeat of the
powerful stimulant or lonie vriQ
short an ague, even when giYca at the
ment of the cold stage, — an eflcet tbal
vainly be looked for, if ita chief osat
the blood. ^ e. The

9\G

F£V£R--Fathoxjogt or.

the cauies in which it arose, and the suddenness
and manner of its occurrence, as well as from
various other circumstances, that it does not con-
sist of lesion of structure, we are therefore com-
pelled to adopt the former alternative, and, from
the kind of disorder, to infer the manner in which
the influence actuating the organ is affected.
Thus, observing that respiration, circulation, se-
cretion, and animal heat are primarily and espe-
cially disordered at the commencement of fever,
and that various other morbid phenomena are
consequently produced, and finding no structural
or local change to account for the affection, we
refer it to the state of the influence which actuates
these functions. Anatomical and physiological
evidence concur in showing that the nervous
system of organic life is chiefly concerned in the
production of those functions; and therefore it
may be inferred that this system is first impressed
by the causes of the disease.

96. But it is not merely requisite to show the
particular system first affected, but also to ascer-
tain, as nearly as possible, the nature of the
affection. This, however, can be only a matter
of inference from the kind of disorder manifested
in the functions especially subjected to the in-
- fluenoe of this s}'stem. What, therefore, is the
general character of the disorder which these
functions first evince 1 — 1st. The respiratory
actions are inadequately performed, volition being
often exerted in order fully to dilate the lungs,
and the changes in the blood are imperfectly pro-
duced ; — 2dly .The action of the heart is weakened,
and the tone of the pulmonary vessels lowered,
so that the circulation is languid, irregular, &c.,
and congestion supervenes ; — 3dly. Secretion and
excretion are impeded or interrupted, animal
temperature diminished, and all the functions
indicate at first depression or suppression of the
organic nervous influence, llere is, however,
reason to suppose that this influence may not only
be depretsed, but that it may be otherwise attertd,
according to the cause which affects it, par-
ticularly by specific infectious miasms. It is
chiefly to this circumstance, that the opinions of
JjkCKSOK, Fbank, Hildembrand, and others, re-
specting the initation excited by the material
cause of fever, is to be imputed. Whether the
alteration in question be called an irritation, or
any thing else, is immaterial, if the term adopted
convey any idea of what the change is, in most of
the circumstances in which it occurs. But if by
this irritation be meant a form of excitement, the
term is applicable only to the state of vascular
action often consequent upon, and attended by,
the alteration of nervous influence, and not to the
slate of the influence itself. The whole that we
know of the matter, from observation of the ear-
liest phenomena, is, that the change evinces
diminished power or influence of the system of
nerves actuating the organic functions, and very
freqiiently an otherwise altered or morbid state
of this influence which cannot well be described,
but which is variously modified in different fevers,
and is generally attended by depression ; these con-
ditions still continuing in diverse grades, although
vascular reaction supervenes, which, when it 1^
comes excessive, increases tliem, and, in con-
sequence, hastens on disorganisation. Prom this
it will appear, that the exciting causes of fever
fixst depresa or otherwise alter, or both depress

and alter, the healthy influence exeited by tbc
nervous system of organic life. That they pn-
marily irritate or eieite this syatcn doei oot
appear from the phenomena, unless either of tbeie
states associates itself with some other morbid
condition which deflects it from its usual ferns;
but of this we have little proof, unless it be foosd
in the stage of reaction. This much, hovefer,
is apparent, — that certain cnues seem to depren
the organic nervous influence more than otben;
and that some alter it more from the merelj dy-
namic states, and impress it with a spediciiry
morbid character.

97. But, whilst disorder of this iaflacacc a
thus considered the chief and primary eoastitoeot
of the morbid imprescion maae by the csuct vf
fever upon the economy, it majr be asked, h tiw
impression entirely limited to this quarter! or vt
the cerebro-spinal influence, and the dmlstn^
fluid itself, also partially and primarily aflecKd.'—
1st. As to the former of these, it may be iafefftd.
from a consideration of the circamataace of ik
nerves of one -of our senses being extended ov9
the upper part of the respiratory nassige — the <s-
trance to a most important ana vital oigaa^m
order to convey, by their reports, inlisnalioiii of
the presence of such gases or vapouis, as, if re-
ceived into the lungs, would prove injaiioQi,
that the mote intense causes wUl act in looe
measure upon the brain, although in a c«ib*
paratively slight and evanescent maimer. Tbe
lungs evidently digest the air received iototbra,
as much as the stomach digests the food ; and the
entrances into both organs are guarded by two
sentinels — the senses of smell ai^ taMc — tsksir
cognizance of whatever pa sags into thesB. Bot
in cases where injurious eflccts follow the lo-
gestion of hurtful matters, is it in the stemacb or a
the nerves of taste that the morbid impresuoa » t»
be looked for ! and if it be in the fonner, and not n
the latter, that they are to be found, no moreskouiil
we infer, as heretofore, that the morbid cbaaf« »
firet produced on the brain, and not oa the acrm
of the lungs, when noxious efiecls foUow the ir-
spiration of a tainted or infectious atr — reeallertinc
always, that respiration does not mean simply the
passage of air into and out of the lun^, Mt tk
actual digestion of this air by them, the imporvst
changes excited by its constituents upon the blood
and upon the organic nervous influence, and tkose
effected by this influence upon the biood, and opus
the air received into the organ.

98. From varioits consideratioiis and resevvte
into the subject, in different eUmates, I iafcr, tlm.
although the more iaiense eaascs may aflcct ikc
brain, and thereby heighten and acrelefati l^
effects upon the heart and stomach arisiag ft«B
the impression made upon the orgaaie acrvtw
system, yet their action in this quarter is «**^
escent; and, as I have ahowa ($94.), isst^
cient to explain the phenoateua. Jodgisi btm
my own sensations on having inspired an sir w
loaded vrith infectious eflluvia as to be remarkaliv
offensive to the smell, the morbid imj
first sensibly felt in the laoge tbeoMolvcs; mmh-
ness, weight, or oppresnon in the chert, was »•
stantly felt ; frequent foreible iaspiiatioBS wtit
made, and continued for lone aft«wards to be UMik,
in order fully to dilate the lungs, which feh •• a
they were partially deprived it their raalir
the pulse became weak, and ibe aaiaal

894

F£V£R — Cbakactbbs or.

the time of their operation. But, still the more
remarkable phenomena of these separate diseases
proceed in a very different order, and very gene-
rally in so marked a manner, as to be easily dis-
tinguished by the close observer. The most
frequently exciting causes of disorder, viz. mental
distress, atmospherical vicissitudes, exposure to
cold, moisture, &c., shall, according to the state
of the individual at the time, produce an attack of
general disease, unaccompanied by predominant
affection of any particular organ ; and the disorder
shall commence and. terminate without any com-
plication. In a second individual, a more or leas
evident determination of the malady, or even in-
flammation, shall appear in the ailvanced course of
the general disease, or even during convalescence.
In a third, the local disorder shall be coetaneous,
and more or less co-ordinate with the general
affection, or even outstrip it in violence during its
course. And in a fourth penon, local disease alone
shall be primarily caused; on which, as it in-
creases, and as inflammation becomes more fully
developed, symptomatic fever, or the general de-
rangement, shall supervene. These different states
of diseased action follow the same cause, ac-
cording to the disposition, susceptibility, or states
ofthe system M the time. One person, according
to this proposition, may have the constitutionu
derangement complicated with rhtutnatie, eo'
tarrhal, hilitnu, fiervoutt gastric, or dyunteric
affection; the general disorder being attended
from some early stage of its course, 'or from the
commencement, by a heightened disease of a par-
ticular orean, or structure, and thereby consti-
tuting varieties of fever, which have been thus
denominated and described by Stoll, De Ha en,
Reil, Frank, Hildbn brand, and others, and
have occurred in epidemic forms on various occa-
sions. Another person may have the nervous,
the gastric, or tne dysenteric characters super-
induced in the progress of the disease, owing to
external causes continuing in, or coming into
operation ; or to improper treatment : and a third
may experience, in consequence of the preexisting
state of a particular organ or texture, an attack of
inflammation, from a similar set of causes to those
which produce idiopathic fever. If, therefore,
the species of disease which arise from one class
of causes are thus varied, owing to the predis-
position of certain oi^ns, or to the susceptibility
of the whole system, their number must neces-
sarily be further increased, and their characters
very materially changed, when the additional
influences of marshy exhalations, epidemic con-
stitutions, or specific infections ana contagions,
come into operation. Diseased actions become
not only more varied and extended by such
additional causes, acting either singly or in con-
junction, but also much more complicated and
violent.

4. These inferences may be legitimately de-
duced, from an extensive survey of some of the
circumstances connected with acute diseases.
Their relation with such deran^ments as have
obtained the appellation febrile, is still more inti-
mate than witti those which, strictly local at
their commencement, induce consecutively gene-
ral disorder. It is necessary, however, to the
proper consideration of the pathology of fever,
that due regard be paid to the nature and extent
of its causes, and oi modifying or detennining in-

fluences, as far as they can be asoeitatned ; and
that a strict reference be had to the effects ob-
served to follow the application of both elases of
agents, under opposite or varying circ«m«taoec«.
It will also be requisite, while such an ioquiiy ii
being prosecuted, that none of the early and io-
termeaiate changes be omitted. Soefa onuanooi
have but too often vitiated ourspeculatioiis on the
nature of disease, and more especially of fever ;
for, instead of recogniaog the early changes sad
states, particularly those which more diiectly arise
from external agents, consecutive and graas effects
onlj have more generally been seiaed npon, and
assigned as the cause of disease. Let it not be
supposed that inquiries, such as have just bcea
recommended, are productive of no advantage ia
practice. The scientific practitioner will con-
sider the most effectual means of preventing, eon-
trolling, or removing disordered actions, to be
indicated by a most careful scrutiny into their
nature and extent, and by a judidons ioqiciry
into early aberrations from the healthy cooditioo.
He will view the primary derangements, in the
relation they hold with their remote or oceaaiooa]
causes, on the one hand, and with conseeatiTe
or ultimate legions on the other ; and will thv
trace each individual link of the chain of caosatioa
throughout.

5. If it be asked. What has the treatment of
fever gained by our speculations w to its nature !
I would answer, almost every thing. I will show
this in a more demonstrative manner in the
sequel, by addudng the opinions which have for>
merly been held upon the subject, with the prac-
tice to which they have led. But, indepeadeath
of the practical results of the inquiry, there are
other solid and not lefv allnrinff indaoemeoti
which will operate on the inquisitive and well-
tutored mind. An individual possessing a mind
so constituted, feels a laudable seal in ezaainm*
into the nature of a class of disorders, which coa-
cerns not only the existence of a single individual,
but influences also the prosperity of nations ; and.
who, entertaining even a moderate idea of the
responsibility which the exercise of his profeasioa
"involves, can enter upon its practical disehare««.
in respect of this class of diseases especiallj.
withont feeling some desire of extending b:«
knowledge of their nature, in order that the
course he pursues may be both rational and sac-
oessful?

6. 1. GsNXRAL View op Fsveh. — > Feven are
the most prevalent of all diseases, especially m
some countries and localities ; and their tanan
freouently cannot be avoided nor couotencted
by human foresight or science. They are man
especially prevalent among, and injurious to, the
human species, as the history of epidemic, pe»n>
lential, and other fevers fullv prove ; and m»
evinced by those infectious fevers which oftca
occur in camps, and follow the rears of ancies
during warfare, and which are sometimes much
more destructive than the moat hard- fought bat-
tles.—Epidemic fevers are not, however, conflof d
to the human species; the causes in whx^
they originate, and the influence which promote
their extension, frequently affecting also the \amtt
animals, ^ a circumstance of importance in o.t
speculations respecting the origin and nature i^
tuis very important class of maladies.
7. i. CuABAcnxs or fvrtM* —It k i

896

FE VE R — Genxral Descriptiow.

attended by congestion of the vessels of (he liead.
It is observed in other diseases ; bat it most con-
stantly accompanies fever. — g. The appetites also
are more or less affected. The appetite for food
is diminished or entirely abolished. In rare cases,
a craving for food has been observed in an ad-
vanced stage of fever, but not throughout its whole
course. The appetite for the sex is also abolished
until convalescence has commenced, when it re-
appears, and is sometimes one of the earliest signs
of amendment. These symptoms probably depend
upon the same cause — upon depressed organic
nervous influence, and consequent deBciency of
the secretions.

14. ii. General Description. — The word
Fever is used in a double sense : it is applied —
1st, to that state of constitutional disturbance, in
which the above symptoms are primary, essential,
or idiopathic ; and, 2dly, to the general disorder con-
sequent upon, or symptomatic of, some local dis-
ease. In the latter, the febrile symptoms con-
sist chiefly of increased heat and accelerated cir-
culation ; and without these the patient is said to
be without fever. But when fever occurs pri-
marily— is a disease tui generis — these two
symptoms are seldom the most prominent, and are
always associated with others, especially those
already noticed, which may be much more mani-
fest than they, and which are either altogether
wanting in symptomatic fever, or not similarly as-
sociated, or only occaMonally present. This
distinction is necessary, particularly as respects the
treatment, and should never be overlooked. Its
importance will be more apparent in the sequel.
I shall first describe fever as a disease sui generis ;
and next, as a symptom of inflammation , or some
other disease of a particular organ or tissue.

15. Idiopathic Fever presents, during its
whole progress, characteristic symptoms, not con-
sisting merely of increased freouency of circu-
lation and augmented heat, which are sometimes
wanting in certain stages of the disease, but of
other morbid phenomena that are equally im-
portant, that vary in degree and in modes of
association with one another, and that super-
induce other phenomena thereby givihg rise to
the different forms and states in which the disease
occurs ; —^it commences with debility and lassitude,
which are followed Inf chills or rigors ; it is gene-
rally composed of several invasions or exacerbations ;
it implicates the whole of the vital endowments
and faculties, the fluids, and the entire organi-
sation 'f it is acute and dangerous in its course,
with lesion cf the circulation, with alteration of
the animal heat and of the secretions, and with
diminution of' vital power ; and it is versatile as to
its symptoms and type, with efforts at sudden
changes or crises,

16. 1st, Fever begins with lassitude and debility,
generally followed by chills or rigors, — It origin-
ates in causes which affect the vital energies of the
system, and occosion debility and lassitude as the
earliest and most remakable changes. These are
generally attended by an insuperable feeling of
fatigue upon the least corporeal or mental exertion
by stupidity, loss of nervous and mental energy, by

riitability, moroseness, or impatience, and by hea-
iness of the eyes. Upon these supervene various
neasy sensations ; as, anxiety at the praecordia,
-!ca9ioning frequent full or laboured inspirations ;
peculiar and general uneasiness and restlessness ^

a feeling of cold, particularly along the tpine,
and differing from the real or usual sensation ;
horripilations, involuntary shudderiogs, and tre-
mors or rigors. The debility giving rise to the
unconouerable sense of lassitude and fatigue
§[enerally precedes the chills for aome indefinite
time, and accompanies them or oontiones after
them. Chilis or rigors often return and alternate
with flushes, «nd other incipient disturbances, for
a variable period.

17. 2d. Fever is very frequentUf e^mptmed of
several invasions or exacerhatioiu, one peroxym
disposing to others ; as in agues and remittents.
But even in continued fevers a similar arenai-
stanoe very often obtains, as evinced by the even-
ing exacerbations, and the aggravation of the
symptoms on alternate days. Some writen, and
more particularly Hildenbrand, consider that, as
in remittents, wherein a new invasion supervenes
before the previous paroxysm bad subsidied, so in
continued fevers, one fit runs into another. —
" Continuse ergo febres, si non omncs, talten
plerasque, presertim critics, e plorimis parox7»i&i»
febrilibus, quorum unus altenim subintrat, eom-
posite sunt.

18. 3d. Fever is a disease of all the vitmi «s-
dowments, functions and faculties, ef the fluids,
and of the whUe organhation, — If we trace the
progress of fever, from the operation of its canaes
through successive changes, we shall 6nd that
the vital power, which is supreme over tlie phy-
sical properties and functions of our diAerem
structures is deeply affected throughout all its
subordinate roanueslations — as the mmibiUtits of
the nervous systems, the irritabUity of involun-
tary and voluntary muscular fibres, the orgunu
contractility of membranous parts. Hence pro>
ceed lesions : — (o) Q/ <As organic functiaeu —
of the respiratory actions and functions, of cirru-
lation ana of the circulating fluids ; of aecieiboa
and excretion, of digestion, assimilation, sang\ i-
faction, and nutrition ; of the appetites, both na-
tural and acquired, 6cc. — (fr) Cf the eerehro.
spinal and animal faculties — of the functions ol
sense and voluntary motion, and of the powers of
mind: the expression of the countenance mod
the attitudes are changed ; the si^nses cither per-
form their parts imperfectly, or the raind takes aa
insufficient cognisance of their reports ; the atten-
tion is wavering and quickly fatigued ; the iate'-
lectual powers and states are languid, feeble, ct
otherwise disturbed ; the judgment is perverted bv
interna] and involuntary impresions and concep-
tions ; and* ultimately all the mental eodowaaents
become exhausted and disordered, by prolongrd
wakefulness, or overwhelmed by a ooofmo»l
sopor. — (c) Of the fluids and wh^organimtiam
— The fluids and soft solids undergo cbaBcea
in their appearances, form, and properties. Tbe
blood is evidently altered in vanons way* at
different periods of the disease. Its serum is oiWn
at first in considerable quantity, and its rmma-
mentum loo^e ; but afterwards the latter fpeneially
becomes more firm or cupped ; and ultimately
again loo^, or imperfectly separated ftmn the
serum. In many cases it is still more remnsi-
ably altered, as shown in the article Dum>d
($ 78 s( seq,) both in colour and coosisfemcc.
The s«4rr#(i<mj, which are at first chiefly daainwhtd
in quantity, ultimately are changed ia qnality.
They become more pffeonve, of a darker colour.

F£ V£R •» STM^TOMAnc

«iroe raspMtf a depuratory effort of ntture, more
especially at those evaoaaiiona geoeraUy ocour
through the medhim of organs which eitroiaate
hurtful materials from the cireulatiog fluid.
Hence, one of the safest modes of practice is that
which keeps these salutary processes in view,
avoiding whatever may prevent them, and pro-
noting their erolotion ; attending at the same time
to the preservation of the powers of life, and ward>
ing on danger from weakened, over-excited, or
oppressed organs.

33. When we take into consideration the con-
servative in6uence of the vital energy, the salutary
changes brought about by it, and the circum-
stance that every method of cure, or every agent,
cannot act in a similar manner in all cases -^ and
that, even during the most injudicious treatment,
certain of the agents are calculated to meet the
-exigencies of some cases, either in supporting the
powers of life, or in favouring or dfetermining
■ome critical evacuation -— the reason will readily
appear, why recovery often takes plaoe in fever
from the most opposite means, or when left
entirely to nature; and we shall easily under-
stand wherefore all do not die who are improperly
treated, and how nature often not only overcomes
the disease, but also the effects of injurious agents
prescribed for it. Of the means which are em-
•ployed in the treatment of fevers, there are not
any which become more dangerous from in-
appropriate use, than the extreme measures fre-
quently resorted to — namely, large depletions
and active stimulants. The former may aestroy,
in a few hours, cases which nature or opposite
measures might have preserved, and the latter
may over-excite, and inflame to disorganisation,
viscera which require to be unloaded, or to have
their actions moderated.

24. It not infrequently, however, happens
that the critical efforts are imperfect owing to
exhausted vital power, or insufficient from the
nature and severity of the disease, or misdirected
nr irregularly exerted in consequence of some
controlling or determining influence ; and hence
they become sources of increased disorder, or
superinduce structural change. Such results are
sometimes favoured by over-acdve, inefficient, or
inappropriate means of cure ; and very often by
organic lesions having taken place in so great a
degree, and so early in the disease, that the salu-
tary efforts attempted cannot subdue tliem, but
merely tend in some instances to their aggravation
And danger.

- 35. The event in fevers is directly produced by
critical changes, and indirectly by the assistance
of art : it w favourable, if the powers of life remain
unsubdued and act without obstruction ; it is iin-
favourahle, if they languish or are overwhelmed.
So much are we indebted to the conservative
efforts of life exerted throughout the frame in the
«ure of fevers, that more is often to be ascribed
to this source than to the interference of art ; and
I may add in the words of Professor Hiidbk*
URAND, " Inde enim pendet, quod miseri ac inepti
medici famam, quam buccis inflatis non accipere,
eed verecundi natura» magistrss reddere deberent,
in febribus sanandis sibi coaficiunt. Inde pendet
Quod omnis sectas medici, ac oppositarum me-
•oendi rationum adsecte, de felici eventu in febrium
tractattone glorientur. Inde demum pendet, quod I
qussvis theorianim ad febres euimndtsapplioata, I

sanatomm ttgrorum pradiea txeupk oflhne vb-
leat." (Vol.1, p. 53.)

26. SvMproMSTic Favaa* —> Fever may be
a ooncomitant or an effect of uuribm diasaae,
which wonid still remain were it peasabie to
remove the attendant fever; but wniek being
removed, the conoomitant fever would cease.
In as far as it consists of acoeleryad circulation,
fever may be associated with the majority of
diseases ; but it is still merely a single ajfmptoes,
wherefore other phenomena should be prescst
before even symptomatic fever ought to be ssiil
to exist. Whatever irritates or stimulates the
circulating system ito a stronger or more frequent
action, or inflames a particular part, is productive
of symptomatic fever. Its causa azials withia
the tnme, and more rarely it acta from wiikoot ;
as irritation or inflammation of particular Uasues ;
the presence of foreign bodies, or of ealculi, wonns,
or hurtful ingesta; the absorption of hurtful «r
acrid matters, or of contaminating aocreboos;
surgical operetions, external injuries, and vaolcat
exertion. Fever proceeding from than so«rc«i
has been termed im^mmmtery, trnletwe, /eur,

frem trritatiea, femr ef the vmaeulmr wyutm,
eymptematicinflammatmy fewer, tympUmimUe Jeter,
cknmie fever, hectic fever, aceording to the para-
liar tmtatioo, or local disease, on whieh u at-
tends.

27. Fever is aaoeiated with other dieaases in a
twofold manner f— Ut. Es$entiaUy, forming whst
are called febrile dieeaeei or iywtpte$»atic Jeren
strictly speaking ; as in totes pMrtUnl*, in whkh
it is merely a symptom, but one which is uni.
formly present 2d. Aeeidentallif or cmUinffemtt^.
not naturally and constantly, but merely frin
the association of some occasional disturbance or
complication, as in amenorrhcea, cUoroeia, diopcy.
rheumatalgia, &e. ; or as a ooasequenca of treat-
ment. In symptomatic fevers, the coostttutiMMi
affection u neither so severe, nor so ganerally and
equally extended to all the functions, nor- so ca-
tirely implicates the fluids and eoft solids, as m
idiopathic fever. Hence they are more readily
traced to their origin •« to the irritation in wh»cli
they arise. The functions which chiefly man*
fsst disturbance in their progress are those of
circulation and secretion— the latter ofWa very
slightly. Others are also occasioaally disturbed,
as those of the skin and of the nervous eyalen, bet
generally in an indirect and slight manner. Ceo-
sequently the chief charactere of syuapteeaatic
fevers are quickened pulse, heat of skin, dsaoivfer
of its transpiration, and thirst The excivcions .
muscular power, and the fiaculties of aaiad, aie
but little altered. The pulse retains greater tone
and sharpness, and the general surface man
animation than in idiopathic fever. The exterQaJ
physiognomy, the posture, the extreme prastra-
tioo of muscular power, die profound altaratioto
of the vital endowments of the fluids and ol cV
organisation itself, characterising the latter, art
either altogether absent, or present in a ven
slight degree merely, unless when morbid mattm
are conveyed into the oiienlatioa dufing the
course of certain symptomatic fevers, and Uwfvby
vitiate both it and the soft solids, diaordcriag mhe
the different secretions and excretiou^, Ssrh
occurrences sometimes take place, and have feUea
repeatedly under my obearvatioB, panseulariy
when inflammation i^tackf tba ialnti aarfect of

909

$'£V£R— Gkhsral Cousss.

and 182d, and iii mv lectures delivered from
1823 to 1827, particular notice was directed to
the subject, and these symptoms were described be
as constituting a roost important ^stage of the dis- f vi
ease, inasmuch as in it the nature of fever would
be most advantageously studied, and either its
subsequent course lemailcably meliorated, or its
further progress prevented, by appropriate and
energetic treatment. (^Lond,M9d,Repoi» vol.Jtxviii*
p. 238. ; and other Refer, in Bihliog.)

34. The phenomena described above, as cha-
racteristic of idiopathic fever, never proceed
immediately from the remote causes. Ihe im-
pression made by them occasions a succession
of changes before those which really constitute
fever supervene. These early changes, being

Jiroductive of those which constitute the deve*
oped disease, may aptly be called formative ;
and the symptoms hj which they are indicated,
jtreeunory. The exciting causes of fever seem to
act primarily upon the nervous system of organic
life, thereby producing changes in the vital mani-
festations of the frame, which gradually increase
until they arrive at a certain pitch, and terminate
in one of the modes hereafter to be noticed. The
more intense the exciting causes, the predispos-
ition being equal, the shorter will be the duration
of this period, and the sooner will the lesions con-
stituting fever be broueht about ($ 15.).^>(a)
The earliest effect which is made manifest after
exposure to the more energetic causes of fever,
as infectious effluvia or noxious exhalations, is a
feeling of constriction or oppression in the chest
or at the prascordia, attended by frequent sigh-
ing, gaping, forced and lengthened inspirations,
and by a sense of uneasy depression, or nausea,
evincing the morbid impression made upon the
nervous system through the respiratory organs.
The pulse is weak, slow, irregular, sometimes
remittent or reduplicating, and readily accele-
rated by slight exertion.— -(fr) The natural and
acquired appetites and desires are diminished ;
nausea is readily excited by food ; and the bowels
are either costive or easily acted upon by purg-
atives ; Venus silet, and all the organic June*
tions are impaired. — (c) The patient feels
debilitated and fatigued ; complains of headach,
vertigo, or confusion of ideas ; is morose, low-
spirited, slupish, indolent, or incapable of exer-
tion and of directing his attention long to any
object; he readily perspires, and his breathing
becomes short and quick, on the least exertbn ;
his sleep is unsound and unrefreshing, and he
awakens with a sense of lassitude or with pains
in his back and limbs, — in short, all the oers6ro-
spinal f mictions are weakened or disordered.-—
(d) The external expression and appearance are
somewhat altered. The countenance and skin
are unusually pale, sallow, or unhealthy ; more
rarely red. The eyes are languid, and deficient
in brilliancy. The breath is foetid or cool ; and
the tongue often loaded. The urine is sometimes
pale and copious; and the cutaneous surface
dry, cool, and han»h. These symptoms vaiy in

to fourteen days. The ftverer ud the shorter this
period is, the more acute and the more rapid wUI
be the subsequent progress of the dittaie, and
vice versA: there are, however, exeeptioiis to
this. Fever may be cut short in this sttge by
active and judicious means ; but not afterwards,
unless occasionally in slight eases. — (f) The
pathologiettl amditums characterising this stage,
are, depression of vital power throughout the
frame, with slight internal coogestioo, paiticv*
larly of the lungs, liver, &c.; with imperfect
change of the blood in the lungs, and with (&>
minished secretion and excretion.

35. JB. Stage of Ifwasion ; Prittdfium tH
InitiuM Fehris, Auct. var.— ^a) The cold ttegt, of
writers— is attended by debility, latitude, psia-
ful uneasiness, or sinkm? at the epigastrium, i
sensation resembling cold! running down tb«
back, with formication or chills extending orer
the limbs and general surface. The poise ii
constricted, small, weak, or aceekrated ; the re-
spiration is slow, irregular, or suspirious, ssd
attended by anxiety at the pneoordia, and occa-
sionally by a slight dry cou^h. On these sape^
vene gaping, sighing, pandiculation ; a sentt of
weight, pain, or constriction in the liead ; ^-
diness, moroseoess, depreasioa of spirits, aui
disorder of the senses ; lividity of the lipi sod
nails ; pallor of the skin ; the cutis aosenoa, ami
shudderings, rigors, or shiverings, foltovcd U
or alternating with irregular flushes. After tli<
rigors cease, a sense of chilliness oflen contioafs
for some time, although the skin has become \ki.
These symptoms present various grades and modi-
fications in the different types of fever : in fome
the feeling of cold is actually attended by ^^
duction of the temperature ; and in otben (k
heat is not materially, if at all, diminished, or it is
even increased. The former is most comiDOsljr
seen in the cold stage of periodic fevers, the lat«
ter in the invasion of continued fevers. In all,
however, the cutaneous transpiration b altogether
arrested, and the skin is harsh and dry. Tie
pulmonary exhalation is also diminiehed, and (he
breath is cold. Copious discharges of pale irioe
often take place, evidently arising out of the
arrest of the exhalation from the skin and laa^
Loss of the appetites, costivenefs, thint, sad
occariooally sickness and vomiting, are hkewM
present. — (b) The duratien of this pcnnl
may be very short ; or it may be for many itoar*,
alternating with slight flushes. The shelter tad
more intense it ia, and the severer the rigors iIk
shorter and severer will be the consequent vat-
cular reaction, and the more nearly approecktoe
the inflammatory type ; and the longer ill dor-
stion, the more prolonged will be the fever. The
imperfect evolution of this sta^» or its afifht oc-
currence, particularly when it is not attended b;
rigors, very generally indicates a severe nsl^-
nant or typhoid state of disease. In some «t
the most dangerous cases of fever, I havessca liu
stage so slight, as to be confounded with the piv-
ceding one. This period having supervened, iIm

severity, and often are so slight as to escape par- j disease cannot readily be cut short by bJoodlcCiia^
ticular attention. They frequently ore inauf- 1 emetics, &c. ; although in the slighter cases, sad
ficient to induce the patient to confine himself. \ more ioflammatory type, these means have sor-

'—'(e) The duration of this stage is various in
different feven — from twenty-four hours, as in
plague and aome cases of typhus, to several
weeks, as in ague) but it is genemlly from thi«e

ceeded in aome instances. — (r) The pethei^t
cat states of the first period are increased a
tliis, particularly the general depreKioo of ««al
endowment; the impaled (ttOClinM of the la^r*

soar

FEVER — Ttms avd Foftitft.

evening exa^erbetion, whilst, in others, eztoer-
bations are very manifest ; but this depends much
upon the prevailing epidemic constitution. In
general, fever caused uy infection, and compli*
cated with serious visceral disease, or charac-
terised by severe affection of the fluids and soft
solids, is strictly continued ; whilst that produced
by terrestrial emanations assumes somewhat of the
remittent form, although presenting much of the
continued type.— («) The duration of this state of
vascular reaction is shortest in agues, in which it
does not exceed a very few hours; and, in con-
tinued fevers, it is brief in proportion to the seve-
rity of the disease. It rarely, even in the more
protracted ca8es,exceeds fourteen days.^- (d) The
pathological statet of the early part of thw stage
continue in great measure in this part of it ; but
vascular action exceeds vital power, which is
gradually lowered ; and the circulating and se-
creted fluids and the solids themselves become
vitiated as already stated, and as will be more
particularly shown in the sequel.

40. D. The period of Crisis — Stadium Criseos
'^Judicium Febris, — Crisis in fevers is a sudden
change taking place at a particular period of the
disease, and terminating it. A crisis is brought
about chiefly by the efforts of nature, or, in other
words, by the febrile action itself inducing chanees
in the functions and organs, productive of a salu-
tary effect. Although it often takes place by the
unaided efforts of life, it is frequently assisted by
art, and should not therefore be preferred before
art judiciously employed. The critical days are
the 2d, 3d, 4th, and 5th (quotidian period);
the 7th, 9th, and llth (the tertian period) ; the
14th, 17th, and 20th (the quartan period). After
the 20th, crises are obscure, and seldom occur
till the 27th or 28th. Salutary changes are ob-
served chiefly on the above, unfavourable changes
on the intervening days ; but death may happen
on any day. A very cold climate or season,
or either extreme of temperature, the impure air
of an hospital, the continued operation of the
causes, the complications, great vitiation of the
fluids and solids, an active treatment, interfere
with, retard, or prevent cri^s. If the exacerbations
be well markea, and vital energy not very much
reduced, a favourable crisis may be more con-
fidently expected. Crises are sometimes inde-
cisive, or consist of several abortive attempts
before the end is attained, especially when the
powers of life are much lowered. When several
critical eflPorts are required, each succeeding one
renders the task more easy for the next, until the
disease is gradually subdued. (See Crisis, and
Critical Evacuations,')

41. £. Period of Decline — Decrementum'—
Deelinatio, »- Sometimes the decline is prompt
and rapid, especially after a marked crisis (see
art. Crisis) ; at other times it is gradual and
slow, particularly when only slight and imperfect
crises have occurred, or when the disease termi-
nates in resolution without any very manifest
critical evacuation. In the former case, the de-
cline passes quickly into convalescence ; in the
latter, this stage is often characterised by slight
exacerbations, called by some writers posthumous
crises, which are apt to be misunderstood. In
the feven of this country, which frequently de-
cline gradually, or in the second of these modes,
the symptoms indicative of vital disturbance ge«

nerally sabode in the order ia mhiA they ap»
peared. Organic nehrons infloenee and the
dependent functions are the first to b« featored ;
the respiratory, secreting, and ezcretioi^ actions
become natural; the perspiratioa mofe jreoeral,
free, and, if it have previously been cmtaam,
clammy, or partial, more natural and genial;
the tongue begins to clean on the sides and point,
and is more moistened by the oommendsg retora
of the secretions poured into the mouth ; coma and
delirium subside; and the patient regains his
power over the alvine excretions, if it has been
lost; the sensorial faculties and sleep reappear,
and the latter becomes more refreshing ; the loeiv
motive powers are freer and more energetic, the
patient being enabled to turn upon lus side, the
sense of soreness and lassitude being ifimtniBbed ;
the appetites and desires return, aixl the excre-
tions are gradually re-established. T^e action of
the heart is the last to subside to its natural fre-
quency, and generally continues long afterwards
to be readily excited bv sli^t stimuli. The
urine is abundant, and deposits a copious seg-
ment ; the bowels become free, the motions cock
sistent and feculent, and the slun giadually as-
sumes a clear and healthy appearance ; but
emaciation increases rapidly, or now is mere
apparent ; absorption, more especially of the ks
animalised and less highly organised parts or
molecules, proceeding rapidly as soon as vaacuhr
reaction subsides.

42. F. Convalescence — Stadium Refeeiicnis'—
ConvaUscentia. — I agree with Ricirm and
HiLDENBRAKD iu cousidering this as a stage of
fever. The propriety of this view is obvious, ef^ie-
cially as regards the future health of the patteat.
It is, however, altogether distinct from the ma*
lady, inasmuch as it does not prnent any of the
constituent phenomena, which still contanucd to
exist in the stage of decline, but merely those of
debility consequent upon acute disease. During
its early progress, the bulk of the body still roo-
tinues to diminish, or does not increase until it
is far advanced ; all the symptoms entirely dis-
appear ; the appetites, desires, digestive functmK,
the secretions and excretions, are re-establBh«d.
but are apt to be disordered, and therefore reqmn.
supervision ; the cuticle and sometimes the m \
are exfoliated, and the hair falls ont. IrriiabilaT
and sensibility often are increased ; and tianitni
aurium is sometimes troublesome ; but these sub-
side as health is restored. — Relapses are apt to occur
in this period, especially from premature exponre
or indulgences, or from disorJer of the digestiTe
orpans ; but they more rarely follow when fever
arises from infection or from a specific contagion,
though other diseases may be thereby oceassooed.

43. IV. Or THR Trrxs and Fobms or Frro.
*>i. These are determined by the following <^r-
eumstances : — a. By the previous KmUtk, the tem-
perament, and habit of body, and vital enei^ of
the patient; — ft. By the state of the vaimlar
system, particularly as to the existenee of ful-
ness or deficiency of blood; — e. By the tpetttic
kind of miasm or cause exciting fever ;<»»SP. By
the prevailing epidemical constitution ;—*. By
other causes, predisposing, exciting, coornfricf,
and determining ; and by the intennty of thetr
action ; — /. By the external and inienml — the
phjfsicttl and moral — injluencee, to which the
patient is subjected, from the period at wbkli

904

F£V£R*iTEEtftHATlOm^-ApPBlRANC£^ AFtSft DCATH.

without any critical discharge. Thia is the most
frequent mode observed in the fevers of this cli-
mate; and results, in a gr^t measure, from the
treatment adopted for them, particularly in their
early stages, which generally interferes with, or
prevents the occurrence of, the natural evacu-
ations constituting crises (see this article). It is
chiefly when artificial evacuations have not been
pushed far, that crises manifest themselves.

47. ii. Terminations in other diuases are owing
-^a. to previous disease, or the condition of par*
ticular viscera at the time of attack ; — 6. to the
severity and concurrence of the causes, and the
intensity of the disease ; — c. to local determi-
nations supervening during the progress of fever,
giving rise to complications ; — d. to improper
treatment, as a too heating regimen, the con-
tinued use of cathartics, or the adoption of such
as are too irritating ; — e. to incomplete or im-
perfect crises j — /. to the too early or too li-
beral use of stimulants or tonics during the
disease, or during convalescence ; — ^. to the
contiaued operation of the causes dunag treat-
ment ; — A. to the occurrence of new, determin-
ing, or superadded causes, as crowding of the
sick, bad ventilation, mental perturbations, in the
progress of the malady ; — and, t. to neglect, and
to a blind confidence in the efforts of life. The
diseases which may be thus superinduced, are —
a. inflammations of particular organs ; — 0. en-
gorgements, obstructions, and enlargements of
glandular viscera, particularly the spleen or
liver; — y, eflfusion of serous fluids into shut ca-
vities, as into the peritoneal and pleural sacs ; —
^. partial or general anasarca ; — i . ulceration or
abrasion of mucous surfaces — chronic diarrhoea
and dysentery; — (. hiemorrhage from mucous
membranes; — «. inflammation of some part of
the vascular system; — ^. apoplectic, paralytic,
or epileptic seizures ; — i. mama and insanity in
some one of its forms.

48. C. A terminati(m in death is favoured —
a. by constitutional vice» excessive vascular ful-
ness, and a bad habit of body ; — 6. by the in-
tensity of the cause and of the disease ; — c, by
the continued operation of the chief causes ; — d,
by the nature of the complication; — e, by. neg-
lect or improper treatment ; — f. by unfavourable
crises ; — and, h. by the other circumstances just
mentioned (§ 47.) as productive of consecutive
diseases. — This result cannot be imputed to any
single change. Two or even more of the fol-
lowing are evidently concerned in its production :
— A. Extreme suppression of organic, nervous,
or vital power ; — $, Lesions of organs arresting
their functions, and impeding those actions ne-
cesaary to continuance of life ; — y. Vitiation of
the fluids, changing the condition of, or destroy-
ing, nervous influence and the rest of the vital
manifestations; — h Exhaustion of vital power,
and alterations of the intimate organisation of the
viscera, as in malignant fevers ; — i . Organic
injury sustained by the nervous system, espe-
cially its larger masses ; — (. Diminished or ex-
hausted irritability of the heart, the patient ex*
pirine as in fatal syncope ; — n, Suflfocation from
effusion into the bronchi ; — b. Congestion of the
lungs, heart, and large vessels, to an extent beyond
the vital power of these parts to overcome ; — and,
». Deficiency of blood so considerable as to destroy
)be relative conditions of the contained fluid and

containing vessels ; for when the imaekf, the or-
ganic contractility, of the latter is much unpaired,
as in the advanced sta^ of adynamic feven, and
the amount of circulating fluid is also gready lei-
sened, the vessels will be unable to acoommodaie
themselves to their contents, and the coueqveoces
must necessarily be most dangoous, if not spesdiiy
fatal.

49. VI. Of the Appraeances Arrea DxATn.
— A, — a. Cases have been met with, wbereia the
most careful examination has failed to detect as/
lesion, or strictly morbid appearance, in any of
the general systems, or indivtdual textures, «r is
the fluids contained in the large vessels. It most
be admitted, therefore, that changes otay tske
place in the nervoua system, or in the blood,
sufficient to cause the most acute disease, orereo
to subvert life, without being so grots as to be
demonstrable to our senses ; but allowing tbi».
the fact now stated is important, inasmacb as a
most materially affects the queatioo as to tb«
nature of fever. — b. Other cases have been ob-
served— and much more frequently than the fore«
going — in which the morbid appearances tctn
not commensurate with the intensity of the symp-
toms referrible to their seats, and were quite la-
sufficient to account for a fatal issue. -^c. ¥it-
quently also, lesions of parts have been discovotd,
which were not indicated by symptoms, or bf
the usual symptoms, or very eligbtly and isnper-
fectly; those changes having been more or W,
or even entirely, latent during life, althou^
their nature evinced their 'existence and progre<«
during the advanced stages of the disease. Tbis
circumstance may have arisen from an oppiesKd
or exhausted state of the brmin ; or from the
changes in the circulating fluid impaiiiog seosi*
bility ; or, as Dr. Alison suggests, in his ve/y
able and lucid exposition of the Pathology c(
Fever, from an enfeebled sUte of the circulatioa it
the time when these local affections take ptsce.

60. fi. As to the nature of the ehmnget ebtmei,
opinions are somewhat differenL — Many wriicn
have viewed them as purely inflammatory ; otben
as consequences of irritation, or of iofiamnaio^
irritation; this condition being viewed by ibeo
as a lesser grade or modification of ioflamnatioo.
It is important to entertain precise ideas as lo
their nature ; and to mark the cirenmitanocs m
which they differ from those changes ioditiNilibly
resulting from pure inflammation* paiticnUriy a*
occurring in a previously healthy constitutioft.^
1st. The lesions observed in levers rarely fttsai
effusions of lymph or pus, especially in the adv
namic and typhoid fevers, ^-coosequeoees con*
monljr following true inflamnauon; and iKe
cases in which these effusions have been dstcdct)»
have been instances of local inflammatioo saptf-
vening in the courve of the more sthenic or is*
flammatory forms of fever. ^Sdly. The lesions or
inflammatory appearances have been more sapcr*
ficial, diffused, and attended with a ^^"^^^
louration, and greater softening of the allrcted
and adjoining parts, than in idiopathic iaflsinais-
tton.— 3dly. The appearances thus charactefi«d,
differ the more from inflammation, the lower ib«
type of fever and the more vitiated the caicaUiioK
fluids.— 4thlv. They more nearly leseoble er>*
sipelatous inflammation, than any other.— 5tbly*
They are met with in certain tiamts wm fm-
quently than io othenj «Bd» eiceptiag dtfiocfli

906

FX V£R«^ PMONOtn.

gigttt and tendeney of thtte uhtnges, u w^ll at'
the reputation of tne physidan.— It is often dif-'
fioult, owiDg to the mutability of the diiease» and
to the liability to err in appreciating tboee signs
by which changes of the functions and of the or-
ganisation are indicated, particularly when the
chief manifestations of life, and sensibility and or-
ganic contmctility, are more or less im^red or
perverted during the course of fever. The pro-
gnosis depends, generally, upon the following cir-
cumstances : —a. The nature and intensity of the
predisposing, exciting, and concurring eautei;- — 6.
The character of the prevailing epidemic, or epi-
demic constitution ; — r. The type, form, and state
of the disease ; — d. The states of the various
functions, and of nervous and vital energy ; — «.
The congruity of the symptoms, and various con-
tingent phenomena ; — /. The influences, treat-
ment, and regimen to which the patient is sub-
jected ; — and, g. The entical or other changes
which may take place.

58. A,-^a, The ftredispontion caused by debi-
lity, acute sensibility, or a plethoric and cachectic
habit of body ; a previously morbid, or congested
state of the internal viscera, pcuticularly of the
liver, bowels, and spleen ; and advanced age ; in-
crease the danger from fever. Some ipidemict,
however, most frequently attack the young and
robust, and prove even more fatal to them. But,
although tporadie fever may be also common in
this class of patients, it is less dangerous in them
than in the foregoing. — 6. The exciting agentt,
particularly specific animal miasms; their con-
centrated form ; the concurrence of several
causes, either contemporaneously or in quick
succession ; their prolonged action, or continu-
ance during the disease ; and certain of the cir-
cumstances, inducing unfavourable terminations
($ 48.) ; render the prognosis much more serious.
Some importance should also be attached to the
character of the prevailing epidemic, as respects
its open or insidious form, and the effects follow-
ing a treatment appropriate to the usual states ^f
the disease.

59. B. — a. The intermittent type Is lees se-
rious than the remittent, and this latter than the
continued ; but the more the fever is inclined to
change, to become irregular, or to pass into one
of a graver character, the more serious it is.
The more complete the intermission, or the re-
mis^on, so much less is the danger; and the
more disposed continued fevers are to evince a
remitting form, the more favourable is the cir-
cumstance. The longer fever has continued, the
more difficult will be the cure ; and relapses are
more unfavourable than first attacks. — 6. The
inflammatory and sthenic fpeciei are much more
generally favourable than the adynamic forms.
— c. The simpler the fever, the more certainly
will recovery take place ; and the more ampUeated,
tlie greater is the danger. The adynamic/inn,
with predominant affection f of an important in-
ternal organ, especially the intestinal mucous
surface, or the brain, or the lungs, is accordingly
amongst the most dangerous ; more especially if
the vascular system and circulating fluias, or the
soft solids, also become vitiated.

60. C. The mare that the organic nervout in-
Jiuenee is suppressed, diminished, or disordered
throughqut the different viscera, the more unfa-
vourable should be the prognoais; the fUnctioiisof

the Tisoera, ih% ftate of the fltiidi tad Aentioit,
and the appearance of the soft solidi, •tiaeiag tka
extent of^ the disorder and of Um danger. — A
weak, small, and quick puhw; a dark, dry, and
contracted tongue ; ^fuae, ofleoHve* inaad,
and unnatural penpintiooa ; watery, fiBtid»
flaky, membraniform, and unhealthy euiola ; dis-
coloured, scanty, and brown urine ; liTid er
discoloured nails, fingers, eyelids, lips, and nose, in-
dependently of the cold stage ; a diaoolonred, dark«
and dry mouth and throat; and am oAnave
and penetrating odour proceeding from the neiieot ;
^ are dangerous symptoms. A pulae of 1110 or
upwards, unless in the puerperal state, is unfavear-
able, and so much the moie so as it ia above t^
number. A brown or blade coating, and deep,
reddish fissures, or a dark or livid colour of the
tongue ; stridor of the teeth ; a movement of the
lips and lower Jaw as if eating; firm cloaate «f
the jawa and hps ; extreme anxiety at the nr»-
cordia ; tumefaction, tendemem, or pain of the
epigastrium, hypochondria, or abdomen gene-
rally ; tympanitic or flatulent diftentton of the
abdomen ; copious or repeated discharges of blood
by stool ; a sudden irruption of the catancnaa,
and an equally sudden disappeaia&oe of then ; a
moaning, weak, quick, abdominal, or gaaping re-
spiration ; coldness or rawness of the expired air;
hiccup; excessive increase, or diminutiett, or
irregular distribution, and otherwise mortMl
of Sie animal heat ; sunk features ; rapid
ciation ; great difficulty or impoasibilaly of artia;
upon the skin by sinapisms or olistera ; an enthv,
or deadened, unnatural, lurid appeatanee of the
external surface ; yellowishnem of, or yetecbn
and livid or pnnile blotches oo, the skin; and
dark mucous sordes on the lips or guma, oi
otts discharges from the latter or from tbe
— are very unfavourable circumstanoes*

61. D, The unfavourable symptoma,
directly depending upon the eerebr»^nmi
out nfttem, are, — a, extreme pain of the head ;
excessive sensibility or depression of spirits ; tnmd
or red countenance, injected watery eyes, con-
tracted brows, &c., quidily passing into deliriui.
sopor, or coma ; prolonged watcbfulnem. or early
somnolency or torpor ; convulsive movcmcats.
trismus or spasms of parts, great restlesnees, sod
continued tossings ; clespair of recovery ; and a
presentiment or feding that death will em
6. And still more unnivouiable ate, early
iodiflereoce, particularly to the ifsue of tbe
insensibility or sopor ; profound coma, and di&-
culty of bein^ roused ; relaxation of the apbinetafs^
and unconscious evacuations ; exceesive lom of
muscular power ; inability to retain any ether
than the supine posture, especially early in tl^
disease, and m connection widi extreme pain in the
back and loins ; falling down towards the fiaot of ths
bed ; a pofition of the limbs and body, depcndiaf
upon their gravity, and diilerent firom that
ally preferred by the patient; inability tn m^_
a posture different mrni that in wbicb bs
placed ; picking with the fingers at fhm
clothes; subsultus of the tendons ; catcbinffaAcff
objects in the air; alternate dilatatioQa and eoe*
tractions of the nostrils during leepii alien ; leas
of voice or speech ; trembling of &e tongue, sr
inability to protrude it ; an open month or Maz«
ation of the lower jaw ; difBcolty of deglutilioa ;
and dilatation and mieHibilily of tbe pn^

932

TEVER — Curative Tbeatmekt.

tage will accrue from opeolng the temporal artery
or jugular vein, above toat derived from bleeding
from the arm ; and even this will not be frequently
requisite ; the more especially as an equal or even
greater bene€t, at a less waste of blood, will re-
sult from cupping largely on the nape or over the
mastoid processes, or from leeches in the latter
situation and occiput. Both bleeding and the
cold affusion on the head may be carried to an
injurious length, especially if it be attempted to
remove, or materially to benefit, within an inade-
quately short time, tliis complication ; many of
Uie phenomena of which are dependent upon, and
inseparable from, the fever, and to be removed
only with it. Let not, therefore, this or any
other treatment be mischievously persisted in,
with the mistaken view that it can accomplish
what the nature of the disease renders impossible ;
but at the same time, let it not be insufficiently
employed. Purgatives, especially those with ca-
lomel, with James*s powder, or other antimonials,
should follow early depletions, particularly if this
complication occurs early in the fever; and at
later periods the calomel may be given with
opium, every four or six hours, the bowels freely
opened, and derivatives applied to the insides of
the thighs or calves of the legs. As to the treat-
ment of Coma and Delirium in fever, it is unne-
cessary to add any thing to what I have advanced
in those articles, and at other places in this. It
should, however, be recollected, tliat other com-
plications may coexist with predominant cerebral
afi*ection, particularly in adynamic fevers ; and if
this affection be very severe, or consist of deli-
rium or coma, and more especially if it depend
upon a morbid state of the blood, these complica-
tions may be thereby masked, and proceed to a
fatal height before they are detected. This we
have seen to be the case as respects the lungs and
intestines, and it is not less so as regards the
liver and spleen. Nor should the readiness with
which sphacelation occurs, either from the pres-
sure of the body, or from excoriating discharges,
and inattention to cleanliness, and to the pre-
servation of a dry state of the linen, or from blis-
ters or injuries, be overlooked ; for an early in-
quiry after the first indications of this occurrence
will often prevent much trouble, suffering, and
danger.

166. F. The regimen and rrauagement of pa-
tients in fever are much more essential to re-
covery than is sometimes supposed. Not only
are the purity, dryness, and rapid renewal of the
air deserving of attention, but also its tempera-
ture, which ought to be regulated, as well as
the quantity of the bed-clothes, according to
the states of vascular action and vital power.
The patient should be skreened from too free a
current, particularly of cool air, and especially
in' fevers of low excitement, as the pulmonary
and, indeed, other complications may be induced
by this circumstance. When excitement is fully
developed, the air should be cool, and the clothes
light; but in other conditions, especially when
the temperature of the body does not rise above
natural or is depressed below it, proportionately
increased warmth is necessary, in respect of both
the air and the quantity of bed-clothes. The
room also should be darkened, all noise excluded,
and mental excitement or irritation carefully
avoided. The mouth and gums ought to be

washed from time to time, and the fui^n chaQ|ed
very frequently ; the surface of the body being
sponged with simple or medicated water, of a
temperature in relation to the forms of fever, as
stated above (§ 140.)* All the evacaatiooa ouglit
to be passed in the bed-pan without leaving the
supine posture ; and if they take plare involunta-
rily or unconsciously, oiled silk shoold be plactd
next the bed, and folded sheets underneath the
patient. Care must be taken that reteotioo of
urine or over-dbtension of the bladder docs aoc
occur, without being detected at once and reme-
died. The accounts of the nurse must not be
trusted to in thi«, more than in other matters, bat
the state of the abdomen above the pvbea care-
fully examined. If pressure cause exconation*.
or threaten sloughing, measures ahoald be imiae-
diately taken to prevent further roischief. The
part may be washed, as Dr. Graves advi$«s, *.tb
a solution of ten to fifteen grains of nitrate of
silver in an ounce of water, or with a weak vols-
tion of the super-acetate of lead in spirita of tur-
pentine ; or with this latter and dilute pyrolign^
ous acid ; or it may be covered by defensive
plasters. If sloughmg occur, carrot pooltJecs
copiously sprinkled with the chlorates, pjrtics-
larly of lime, or with spirits of turpentine, or wtfh
kr^osote, must be employed ; or poultices wAfa
bark, to which either of these may be added ; aiui
pressure removed from the part and its im mediate
vicinity by air-pillows, or by the use of Dr. Aa-
NOTT*s hydrostatic bed. But these uopleasaat
occurrences should be prevented, where the ap-
pearance of the soft solids and the proatratmi of
the patient indicate a disposition to tnem, by bat-
ing early recourse to these latter means, and by
supporting vital power by the means appropriate
to existing pathological states.

167. G, The food and drink in fevers tihoidd be
varied with the existing states of va^ular actioa
and power. In periodic fevers, light food may be
allowed in proportion as the apyrexial period m
complete. Out in continued fevers, particalar^y
during the early stages, and whilst excttemcot
continues, no fowl beyond thin water gruel, fresh
whey, and orangeade or lemonade, sbould be
given. The best drinks during excitement aie
those prescribed in the Appendix (F. 592. et mq.),
or any of the mineral acids in sugared water, ukd
flavoured by lemon peel, or weak black tea,aeconl.
ing as they may b^ congruous with the niedicioes
prescribed internally. Thus, care should be takra
not to allow the patient any of the mineral ac»ls»
when calomel, or any of the other preperatioos vi
mercury, is being taken. But when vescolar raw
action is low or imperfect, and vital power coo4-
derably depressed, or when the pulae b very
rapid, tumultuous, and soft, Seltxer or soda water
with old wine, bock, or weak poach, or wioe
whey, spruce beer, brisk bottled stobt or brnk
bottled beer. Ace, according to the pecal'arities of
the case and the previous habits of the patient,
may be allowed. If coma be present, gretm tm a
one of the best beverages that can be allowed .
and if the powers of life be very depressed, it aav
be made into a weak punch ; the patient also be-
ing often roused by talking to him on lively iotef-
esting topics. He may be allowed oraDgen. S*K*^
or lemons sweetened with sugar, particulaHy whea
the mouth is foul and dry ; but eare shoeld W
uken that neither the pulp ncr the atoaci an

934

JEVER, INTERMITTENT — Patholoot.

r. O. Ctoldkagen, De Diagnotl Feb. In Primo Stadlo.
Hal*. 1784.— Ba((M(«'i On the Influence of the Moon in
Fever, 8to. Ed. 1785. — M. SUM, Aphor. de Cognoi. et
Cannd. Febribui, 8to. Vien. 1789 — J. C. Tode, Pract.
Fleberlebre. Kopenh. 1786.— C Didtnuon, Inmiiry into
the Nature and Cause of Fever. Ed. 1785 — K. Sprengrl,
Oaleni Fteberlehre, 8to. Bretl. 1788. — £Vrrr/, Com-
ment In Stotl, Aphorism, de Febr. Ac. Vindob. 1788.—
C. F. Aickter, Bemerk. Uber Fleber. etc. Halle, 1785^ ;
et Beytrage su elner Pract Fieberlehre. Berl. 1795. —
C. Strack, Observat Medidn. de Divers. Febr. ftc.
Francf. 1789.— fitfrl/kar/, De Divisione Febr. Idiopalh.
Lond. 1790. — C. mitnuum, Nene Fieberlehre. Htld.
8va 1800.— A. RoherUon, Essay on Fevers. Lond. 1790.
—J. S. PlotA, De Froxima Febr. Causa. G6t 1790. —
G. Grimaud, Cours Complet des Fi^vres. Montp. 1791.

— Jtfl Herxig, De Febribus in Genere. Colon. 1791.—
J. C, ReiLt Ueber die Erkenntnis. u. Cur. d. Fleber.
Halle, 1793. ; Memorab. Clin. Fasc. vol. iv — C. A. SeuMr,
De Typo Febrili. Got \T96—J. P. Frank, De Curand.
Hom. Morbis Epit voLL— Oallm, Works, ed. by Tkom-
ton, vol. 1. pauim — J. Currie, Mtrd. Reports on the
Eflhcts of Water, oold and warm. In Fever, &c. Llverp.
1797. — HebertUn, Comment, de Morb. Hist, et Curat,
cap. xxxvii. — Ht^fgttfULOik the Prevention of Fevers,
8vo. Bath, 1801.-6. Fardpef, Five Dissertations on
Simple, Intermittent, and Continued Fevers, ftc. 8vo.
1794—1808. — E. Hom, Versuch elner Pract. Nosol. der
Fieber. Brauns. 1800. — G. C. Reich, Von Fleber. u.
dissen Bebandl. Berl. 1800.— W. Fotria, Pract. Treat,
on dlir. Fevers of West Indies. Lond. 180a— Ludttig,
Advers. Pract. vol. ill. p. a : et De Natura Febris. Lips.
1801.— ^CTMioiM, Ueber d. Fieber u. Flebercuren in

Chemischer Hinsicht8vo. Berl. 1801 G.M.iitaif, Ueber

die Relchlsrhe Fleber.Tbeorie. Erlang. 1801.— 7Aos.
ClarJt, Obs«rvat. on the Nat. and Cure of Fevers, Ac
Edin. 1801. 8vo. — (7. C. Reich, On Fever; trans, by
C H. Parry, 8vo. Bath, I80I.— dbrftMlm. De Noso-
graphU Febr. Paris, 1804. — D. Wood, Plain Remarks
on Fever. Lond. WA.'-'ClmtUrhuck, Inquiry Into the
Nat and Seat of Fever. Lond. 1802.— T. Beddoet, Ro-
searches Anat and Pract concerning Fever, as connect,
with Inflam. 8vo. n. ^—Giammmi, De la Nat. des Fibres,
•t de la uneUleure MMiode de les traiter, Ac. Paris,
1808.— J. F. Aekemumn, De Construend. Cocnoscend.
et Curand. Febribus. Helddb. 1800.- F. W. V. Hopfn,
Versuch elner Pract. Fieberlehre. Neum. 1810L —
P. IV. Philip, Treatise on Febrile Diseases, 8vo. Lond.
1799. ; Treatise on Fevers, Ac. 8vo. 4th edit 1896. ; et
Ets«y on the Nature of Fever, Ac. 8vo. Worcest. 1807.

— Siitger, on the Suppression of Fever, 19mo. Lond.
1812. — Stoker, TreatiM on Fever, 8vo. Lond. 1815. —
T. Mitit, On Bloodletting in Fever, 8va 1818. — J. £.
Jckemuum. De Construend. Cognoscend. et Curand.

Febr. Held^ 1809 — Brera, Annotaiionl, Ac. cap. I

J. F. Cuffln, Des Fidvres Essentlelles. Ac Paris, 1811.
..- Pinei, Nosographie Philosophlque, t. L patsim. —
^Pniol^ CBuvres de MM. Prat par Boisteau, iM.pauitn.
'^Foumier et Vaidy, In Diet, des Sciences Mtdicales,
txv. p.S4a— 7. van Rotterdam, On Bloodletting in
Fevers; by J. Tnwlw. Lond. 8vo. 1818.— ifild^5raiid,
Insticut. Pract. MM. t.l. VIen. 1816. — L«f<fom, Me-
moirs of, by T. J. Pettigreuf, vol. 11. pMBim, vol. iU.
p. 177. et pateim. — Aoeroi, Annotaaloni di Medidna
Pratdca. Milano. 1819, p. 49. etptusim. — A. Duncan^
Reports of Practice in CliA. Wards of Infirmary In Edia
8vo. ed. 1818, p. 14. et se^.^A. O. Richter, Die Spedelle
Therapie, Ac. b. 1. — Balmum, On Contagious Fevers,
0vo. Lond. 1818. ; and Reports on the Dis. of Lond. 8vo.
1819.— m^i^. Clinical and Pathol. Reports, Ac. Newry,
1819. — J. Jokmon, Influence of Tropical Climates on
European Constitutions, 4to. edit pateim.^DiokMon, On
the Prevalence of Fever, and on Houses of Recovery,
BrUt IH\9. -'R.Jaekton, History and Cure of Febrile
Diseases, 8vo. S vols. Lond. I8i0. — C. B. Lmeat, The
Prlndp. of Inflam. and Fever, 8vo. Lond. 18:18. — C. F.
Taehtron, Recherches Anatomico-Pathol. sur la MM.
Pratique, vol. IL 8vo. Paris, 1893. — F. Barker, and
J. Cheyne, Report of the Fever lately epidemic m Ire.
land, Ac. 8 vols. 8vo. Dub. 1831 — Author, in Quarterly
Joum. of Fordgn Medicine, vol. ii. p. 433. 1819 and 80,
and vol. ill p. 7. 99.-; Lond. Medical Repository ,Jan.l829,
p.l9.; in Ibid. May 1899, p. 37&; in Ibid. June 1B», p. 488b,
Ibid. S<t»t 1817, p. 836. ; Lond. MM. and Phys. Joura
Dec. 1880. p. 530. ; MMico-Chirurg. Review, vol. viii.
p. 368.- y. Anmesky, Researches into the Diseases
of India and Warm Countries, imp. 4toi vol. ii. p. 409.

— Ckeyne, Report of the Hardwicke Fever Hosp. Ac. ;
Dublin Hospital Reports, voL L p. 1.. et vol. 11. p. 1. et
vol. UL p. I. — Goodimm, fai Ibid, vol L p. 191. — Proud-

Jbot, Ibid. vol. H. p. SM. — d^rrr. In Ibid. vol. 111. p. 161.

— A. Jiartk, in Ibid, vol Iv. p. 434. —Jt. J. Grave* and
W. Stoket, in Ibid. voL v. puil — S. Perctvat^in Transact
of Assodation of King's and Queen's CoU. of Phys.
Dublia, vol.!. p. 843.— O'^W^ In Ibid. vol. L p. 404.,
H vol n. p. 471 — R. Grattan, in ibid. vol. L p. 433.. et
vol. Ui.p.%l&.^5lMler,in Ibid, vol.11, p.897.— /. Barker,

in IbkL vol. U. p. 515.— A. Retd, la Ibid, vol BL p.1 .vet t
p. 96& — If . PukeU, Ibid. voL Ul. p. IM. —J. O'Mnn.
Ibid. vol. 111. p. 44&, vol. V. p. 519^ H Ibid, nrv inxt,
vol.!. p. 368.— A. J. Graves, in lUd. vol.lv. p.408.~8».
tack, in Med..Chirurg. Review, by J. ,hlmmm, vol t^.

p. 54 BaUu, in Ibid vol. viL p. 498. — fj— ilrri, %

Ibid. vol. vl. p. 161 — Hetcett, to Ibid. voLvl. p. l» -
Brom$$aiM, in Ibid. voL vl. p. gae. — (fMeardm, IM
voL X. p. S50., et vol. xi. p. 181. — Stoker, lUd. ni u
p. 337 — J. JoAiMOis, Ibid. vol. xli. p. Sit — Mouth sr4
Tweedie, IMd. vol. xil. p. 385. — Ormriem, Ibid. nrf. ir.
p. 408. — Steoem, Ibid. vol. xvIL p. ttf. — tUtkeU, IM.
vol. xviii. p. 149.— Aooto, lUd. vol. xix. p. SM.— £«ihl^
Ibid. voL xix. p. 544. —J. R. Pmrk, The Palkelofv d
Fever. Ac. 8vo. Lond. 1898.- D. PrAy* Exposit.«i tM
Principles of Pathology, and of the Treat, of iW. Ac. «« .
1823. — y.A. Brera, Do* Coatagi e dHIa Cora 6t' V>n
Afl'etti, Ac. Ac. 9 tom. Padov. 1899. ; et Piolagemsd IX-
nici per servire dHntrMttsioDe teoiwtkaaUo StaAo Pnr>

tlco delU MM. 8vo. PM. 1893 J. X. Gei^rm, Bt^

cberches sur la Nat et Causes prochatoes des Fittm,
9 tom. 8vo. Paris, 1893.^ Comtmmeemu cC il^if. Dxc A
MMedne, t. Ix. p. 1., et t. xtL p. 340. — FneUek, Sewt,
and Pitchqfl, in R^vue Medicate, 1694. 1 1. p. 1 A » -
yon Dekeere, Noov. Biblioth. MMkale, t. ix. p. IGi". a-
— J. C. A, Riecamier, Rccfaercbea Pbyafeloffiqun kt
I'Etat Febrile: en Recherches sor le Traitas. da Csacrr.
t. it p. 885. Paris, 1899: et R«t. MMicalc, 1894. t
p^ 193. — J. Bouittaud, Tniti CUnique et BxpMn. tm
Fidvres ditcs Essentlelles, 8vo. Paris, 189Cl— IT. Snitr,
Patholog. Obaervat. on Contm. Fever, Afii% Tk Vd^
reux. Measles, Ac 8vo. DubUn, 1809.— F. G. Mtimm,
Pyretolofde Phydologiqne, ou Traits dea IMvns^u
4« Mit. Paris, 1831. ; et Noeographie Otnoi^ot. k'
ti. prntOm. Paris, 18S&— TbMMMAaT, &ff' (■!»
e deua Febbre Contlnua. Ac. S t. 8v«k Pisa, 18S ; <i
SuUo State attuale della Nuova Patotogia ltaUiBa,4
Milano, 1897. — Haunetg, Glasgow MeaLJoara. w^ >~
pi ^M.— Bright, ReporU of Med. Casea, Ac. vd. i. pi T^
et ieq. Lond. 1 897, imp. 4to.— f OMans, Lectnvs oe. a
MM Gasette, vol x., and Laacat, vol. xvii. poum.^
Oamny, in Ibid. vd. xvil. p. 107. — F. J. V. >mmm.
Exam, des Doct MM. et dee BysttaMS de Kossl 1 1
Paris, 1896.; ct Commentalresdea Propodt de hifcoiip'*
Ac. 9 tomes, 8vo. Paris, 1699.— .^arfrwl. Cttaiaae Befc-
cale, t. liL iv. ct v. pattim. Park. 1830l — Rodt c< ««••
eon, Nouv. Elfoieos de Pathol. Ilcdie»-Chirwf. l '■
Paris, 1631. — if<w0it,in Ed. Med. and Sarg. ioerm '^
xxvUL pi 994. ; and Principles of Pathology. Edin '.A
p. 161. — /.m^, Edin. MM. and Surg. Jovrm, vd. wis.

&80.— 5. SmUh, Treatise on Fever, tvo. LoM- 1 W -
K/SeloiMf, Conspectus MorboniBL Bcr. 1831.— IVJMa.
Lectures on Practice of Med., la Med. and Soif. J«an
voL V. pMsnn. See also theBiBUooxApaY suliHiai«d "

i: thrsk

the ch^ters on tiie SpeeitU Fbmu ef Fcvsa :
having reference chiefly to Fever geoerally.

Those who wish a fbrtber refenmow f o the sahM ma
consult also the collections of Bomkt, ManGrr, n^
Plodcqcbt, where oomperativdy few of tbeabovt *«ti
will be found, in this case, as in every other tbi«a|ko«K
the work.

XI. Inter urrrBNT Fevbr. Svk. — AiaAii'evn:
m/piToi, Hippocrates ind Galen ; J«Kbi,
Youog and Good ; Kalte Tidber, tnehUidr,
Germ. ; Paludal Ftver, Periodic Feter,'ipt.

171. Dbfin. — The fehriU pktmomtm nw'i
thoir eouroi rapidly, otiernngn crrtata tuttt»^*
utiutUy terminatitig in crises, mnd retuniMf^ «pr
regular apyrtxial intervals,

172. Intermitteols have been dmdei by ■»•
dem writert — into the quotidian, .ttriiou, fu^
tan, &c. ; into vernal and autmmumi, — rats
regular, erratic, and anomalougf — into arfU,
complicated, zodmatked (FooBRi&n, Vaidt.&c .
But in addition to thete ttpbs, which have reJer*
ence merely to the intervaU between the a«r«*
fions of the parozyama, agues narame eextvi
roRMs or eharaetert, which ara atiU bor ib-
portaotthan they are, in a pnclical point of «««•
These have been variously diatinguiihcd bf
writen. J. P. Frsnk has arranged thc« iaio tts
nervous, the gastric, and tfi/faaaialery, the tccnad
and third of these, in being eamplicmted, sAea »•
suming a remittent type. J. Fbawk has ditiid
them into Ist, the evident, and 3nd, the muhi , tb<
former being — a . benign ; b, mailfnant ; e*rtg*^^ >
and, d, irregular, M. ?tytM, Mi claaed iWa

TEVER, INTERMITTfiNl'— Complicated Aocr.

936

many of the symptoms stated abore, as indicating
the formative period of fever (§ 33.), being pre-
sent. Indeed, the interval in every respect cor-
responds with this period. When tne ague
continues some time, although it may not change
its type or formi as it is then prone to do, es-
pecially in warm climates, the patient becomes
weaker, loses flesh, has a sallow hue, and expe-
riences obstructions orenlargementsof the spleen,
liver, mesenteric glands, &c., with a deranged
state of the secretions «nd excretions ; the disease
passing into the complicated states (§ 183.), or
terminating as will appear hereafter ($ 189.).

180. C. The conversion of one type of ague
into another often occurs : tertians and nuartans
changing to quotidians, or to double or tnple ter-
tians and quartans, especially when they becorae
aggravated ; and quotidians into tertians when they
are somewhat ameliorated. Agues, particularly
quotidians, may also be converted into remittents,
or even into the continued type, by the constant
operation of the exciting causes, or by other
powerful determining influences ; but they often
assume a complicated or an irregular form in the
course of transition. When the fits of a quotidian,
or of a double tertian, or of a triple tertian, ap-
proach each other so ' closely that the one is
hardly finished before the next commences, the
fever has been called tub'tntrans, or sub-intrant ;
and diflTers but little from a remittent type, ex-
cepting that the cold and sweating stages may be
somewhat more marked in the former.

181. ii. Inflammatory Ague. — Intermittents
with more or less of inflammatory excitement have
beeu described by Sydenham, Pr ingle, Hux-
HAM, Sells, Fizeao, Boisseau, &c. Mr. An-
VBSLEY and the Author have shown their fre-
quency in warm climates, especially during the
cold seasons, in elevated situations ; and in persons
of a previously healthy constitution. They are
characterised by very severe rigors in the cold
stage, followed by vomitings and intense vascular

•reaction ; unquenchable thirst ; by severe and rend-
ing headach, sometimes with delirium ; by great
heat and by turgescenceof the countenance and of
the whole surface. The reaction during the hot
stage is generally attended, particularly in pie-
thoric persons, by marked determination to, and
vascular turgescenoe of, particular viscera, ac-
cording to accessory or determining causes. Tlte
organs which thus evince a predominance of vas-
cular action, are, the encephalon ; the liver and
stomach, espeeialiy in warm climates, and in au-
tumn in cola countries; the longs and bronchi, in
some instances ; and the uterine organs, in rare
cases. — This form generally assumes a tertian
or quotidian type ; is easily removed if actively
treated, owing to its common occurrence in sound
constituKoas ; but it rapidly passes into organic
change, or into the remittent or continued type, in
hot climales, when neglected or improperly
treated.

182. iii. Ague with oppreued Power, or partak-
ing more or less of an adynamic character, is
often met with in Europeans who have resided
long in hot miasmatous countries ; in debilitated
penons living in low,* marshy, and moist coun-
tries; and in the intemperate; but it rarely occurs
in these in an uncomplicated state. Wliilst vascu-
lar reaction and vital power rise above the standard
presented by $impie ague, in the inflammatory

form; they sink more or less beiosr it, m the
adynamic, — The cold stage is often attended, ia
this latter, by general tremblings, rather than by
strong rigors; and is followed by oanaea and
vomiting ; developing a burning or jmneeat beat
of the skin, wbicn is dry, and occanoaaily some-
what sallow. The pulse is very q«ick ; tb«
tongue loaded, and red at the eogea; and the
epigastrium tender and oppre«ed. This rtaie
nearly approacbei the gattrie variaty of Coab-
nental writers. More frequently, however, tha
form commences with borripilatioiiSr seldom
amounting to trembling or rigors ; often with aaa-
sea and vomiting ; fulness at the epigastnam, and
headach. To these soceeed increued beat, al-
tematinK at first with chills ; a quick, oppseased,
but not hard or full pulse ; somnolency, and im-
perfectly developed and hot and sweating stages.
•—Thirst is not much increased ; the beat b mo-
derate ; the skin is sallow, yellowish, or lurid ; the
urine citron coloured; and the sabeqaeat per-
spiration is scanty, or offensive. —This form
usually assumes a quotidian, doable teftiaa. or

triple quartan type ; more rarely tertian ; and
sometimes erratic. It commences also irregalariy.
either early in the morning, or in the evening, or
at night. The intervalM are attended by moR or
less disorder ; by an unhealthy appearaaoe of the
surface, a loaded tongue, and morbid eacredoos.
The lower grades of affue are mora freqanitlv
complicated (§ 183.) than simple ; or, if tte lat-
ter, they soon superinduce coogestiooa. obattruc-
tions, and oi^nic lesions of important viaoenu
most frequently of the stomach and bowels, of the
spleen, liver, mesenteric glands and pancteaa.

183. iv. Compiicated Ague — Jntermittrmt per^
nicieuie, of the French — IntermitteniaeeamiiMia,
of ToRTi, — the Malignant, of some wrilen —
is very frequent in warm climates, and in manhy
districts in the south of Europe ; and is aomeliaMs
met with in parts of this country. It naaaDy
presents the preceding form as respects the states
of vascular action and power, but it may vnuirTf
more or less of the innammatory character, par-
ticularly in the early paroxysms. It ofWn has
less perfect intermissions than the foregoing fbraiSi
especially- after two or three paroxysms ; is gene-
rally quotidian, double tertian, or triple qnartaa .
and frequently passes into a remittent or aearhr
continued type, especially in Europeans who have
resided long in hot countries, and in the intem-
perate. It appears in two ways; — a. primarily
in a faulty constitution, or in persons witb previous
disorder of some important viscus, — and, A. as
an advanced grade of either of the pgeceding
forms. I'he most freouent eompficationo are with
diseases of — «. the oigestive and biliary organs
and spleen ; 0. of the thoracic viscera ; >. of
the cerebro-spinal functions; and, t, of other
parts.

184. A. With dieeate of tha abdominal ergmm^
asue presents diversified symptoms, according lo the
V1SCU9 especially affected. — a. If the stanack be
particularly diseased, severe, burning pain at the
epigastrium, with tenderness, disteosioa, naasea,
and vomitings, which are increased by whatever is
taken into the stomach ; distressing flatulency ;
dry or red tongue ; high-coloured and scanty
unne ; sallow or depressed countenance ; yellow
streaks around the mouth ; imperfectly dereloped
hot Ft9ge, with a sharp» quick, and cootneicd

M8

F£VEIl, INTEEMITTENT— ApPBABANCBfl — PBdoNQtis.

imptiriog the vital energy and ▼atcular tone of
the viscera of the large cavities, especially those
of the abdomen. Hence arise — Ist, the compli-
cations described above;— -2dlv, remittent or
continued fevers, with more or less affection of
particular organs, or of the circulating and se-
creted fluids'; — 3dly, inflammations or structural
change of internal viscera, superseding the pe-
riodic seizures ; — 4thly, dropsical effusions ; —
6tbly, chronic dysentery and diarrhoea; — and,
6thly, a fatal issue, chiefly in the cold stage,
owing to insurmountable congestion of the lungs,
Jieart, liver, and spleen, or to rupture of this lat-
ter organ.

. 190. The congestions of these viscera, in con-
nection with impaired organic nervous power,
more especially of the liver and spleen, give rise,
by freouent repetition, to enlargements, to a torpid
state of the former, and consequently to engorge-
jnents of the portal vessels and of the hepatic
ducts ; to imperfect secretion and assimilation of
the chyle absorbed and passed into the mesenteric
veins ; to obstructions of the mesenteric glands ;
to obstructed circulation and .its consequences,
through the veins contributing to form the portal
circulation ; and ultimatelv to an unnatural state
of the blood, and structural lesions of the digestive
mucous surfiue, and of the large secreting and
excreting glands. Hence old and complicated
aeues are accompanied with a sallow, sunk or
bloated, and oedematoos countenance ; pale lips ;
foul, loaded tongue ; yellowish, foul, or lurid slun ;
fulness, distension, or tenderness at the epigas-
trium, both hypochondria, and over the abdomen ;
psin and aching between or under the shoulders,
and in the loins ; day-coloured, or dark, watery,
offensive, and otherwise morbid stools, the bowels
being more or less disordered ; dark-coloured and
scanty urine ; great debility and dyspnoea ; and a
weak, irregular, and frequent pulse. If rupture
of the spleen occur, mcuur pain is suddenly felt
in the splenic region ; with diffused fulness, pain,
and tenderness of the abdomen ; small frequent
pulse, cold extremities, syncope, 6cc.

191. B. Appearaneet in Fatal Catet. — Death
may take place either from overpowering con-
gestions in the cold stage, or from rupture of the
spleen ; but it most fre<|ueotly results from the
superinduced disease of internal viscera, in con-
nection with exhausted oi^ganic nervous power,
and sometimes with a morbid state of tlie circulat-
ing fluids, particularly in the adynamic and com-
plicated forms. The chief lesions are seated in
the liver, spleen, digestive mucous surfsce, and
lungB.^a. The liver is often enlarged; its con-
sistence being either increased or diminished ; tu-
bercular or purulent formations being, moreover,
dispersed through its substance. Increased con-
sbtence or density, softening, purulent or tubercu-
lar formations, &c. may also exist separately, or
in various combinations. Engorgement of the
vessels with dark blood ; distension of the hepatic
ducts and gall-bladder, with a dark or greenish
black, thick, and viscid bile; thickening and in-
jection of the ducts and ^U-bladder, he. ; are
often observed in connection with other lesions,
but more especially with enlargement and soften-
ing of the sirtistance of the visous. — b. The tpleen
is often remarkably enlarged. Mosoagni and
OaoTTAKSLLi fouud it to weigh eight pounds. In
some localities, it occuionally reaches an eaor-

j mous size. On the Gold Coast of Afiact it hsi
been found double this weight in Earepeus. I
saw a case in which it was nearly eleven poasdL
Its envelope sometimes presents ap|»eaiaam of
chronic inflammation — b injected, thickened. &ad
almost cartilaginous. Its consistence iatemllf ■
rarely increased ; but is most fiequcatly dime-
ished ; its structure being friable, ofteaer alaon
diffluent, or consisting of a greyish black semif tid
substance, traversed by greyifth fibrous shrsdi or
fibres, and containing a sanguineons flsid of •
purplish hue, or resembling wine leea. lasUoco
nave also occurred where adhesions have fiwiMfi
between the spleen and stomach, and betvceii tW
spleen and colon in others ; and the thick Uuk
blood of this viscus has been thus diickv^
into the digestive canal by niotration, the mMXntn
passed from the bowels or thrown off theftosset
presenting a blackish appearance (Uotiui.
Gastx, Baillt).— c. The digesthe wuumu nr-
face is, in various parts — in the ilium, the ccna.
colon, stomach, duodenum, and oBsopktpi^
more or less altered ; often softened ; tnjtfkt
with dark blood in patchee or spots ; sad oca-
sionally ecchymooed. The macous feUkles in
frequently enlarged or inflamed in variooi futy
UleeratUm is seldom observed, unlesi tke dsoK
has been complicated with diarrhoea or dyicvten .
and then this lesion, with thickening and tofte&icc
of the coats of the bowels, especially of the car.*
and large bowels, and peritoneal mjectioB, • ^
nerally observed. — d. The MMmfcnc giemisKi
sometimes enlarged, and present signs of obtfrr-
tion or of chronic inflammatioa ; more eip«calW
when lesions of the digestive canal arc very R*
markable. — «. The pamcreoM is oocasiossllj o-
laiged, in some instances so as to obstruct bt :>
pressure the common bile-duct. — f, Tbe/««<«
are sometimes congested ; but seldom otka^^
changed, unless pulmonary oompUcatimf bv
existeid, when similar lesions to those descnbe^
above ($ 53.) are observed. — g. The brm la:
its membranei are not often much altered, seks
in the comparatively nre cases in which ooai
has attended the fit ; or apoplexy, or coarvUem,
or paralysis, has occurred in it ; when eoogctf ^'«-
injection of the pia mater, effusions of sens
between the membranes, or in the ventricle*, it
the usual appearances. — h, Drepeieal efw^,
especially in the peritoneal cavity, and eellc<«'
tissue ; a pale, flaccid, or softened state of t^
structure of the heart ; and more or leas diseoloo*
ation of a yellowish, or lurid, or dirty har} tK
sometimes also ol>served, particulariy in the flMn
adynamic or protracted cases.

192. vii. Paooifosis. — It is evident tkst i:
opinion as to the result of ague should dfpct«d n-
pecially upon the form and pathological csodi'jr*
10 which it presents itself. As to these, rootf^
has been advanced to enable the reader to k^^
his own opinion. But in the adynamic and e v
plicated forms especially, and in pnilncied rw^
the diagnosis should be more orleBsuslivesnbN.
or at least very guarded. The ctreumstsare. »'<«
that even in more favourable slates of the Hm^-
a very dsngerous complication, or rtrBit>J»>
chanffe,may occur, ought not to be ovcHoobv.**
apoplexy, coma, paruysis, fatal coBcestios» <*
abdominal or thoracic viscera, or mptnre ti thf
spleen, may supervene. The epidemic prrvsk oes
of the disease, and more paitiailsrl/ the iotfsts^*

940

iFEVER, INTERMITTENT— Tntxtiavr.

either pre-ezistiog or superinduced iuflammttion,
if it be not sufficiently intense to supersede the
iotermiUent type, will be aggravated during the
paroxysm, especially the hot stage of it.

196. b. From attentive observation of the dis-
ease in localities the most fertile in its cause, I
conclude —(a) That paludal exhalations act in the
manner already stated ($ 95. ), and especially aifect
the nervous system of organic life ; — {b) That con-
sequently the organsjwhicb are especially actuated
by this system, experience the chief effects of
the morbid action ; the functions of circulation,
calorification, digestion, secretion, assimilation,
and excretion, evincing the principal disorder, and
the organs performing these functions the chief
lesions i^ protracted, or fatal cases, as shown by
the appearances described above (§ 191.) ; — (c)
That where, owing to the specialty of the ex-
citing cause, and the intensity or continuance of its
operation, its peculiar impression is fully made upon
the organic nervous system, either pre-existing, or
superinduced disease, inflammatory or even struc-
tural, if existing in a slight degree, or in a chronic
form, will not supersede the periodic or intermit-
tent type ; but ii such disease be acute or active,
or associated with high irritability of fibre and
vascular plethora, the type will be either con-
tinued or remittent, or change from the intermit-
tent to either of these types ; — (d) That a similar
conversion of type will result from contamination
of the circulating and secreted fluids when it
reaches a considerable height; — (e) That in lo-
calities productive of malana, the slighter diseases,
especially those consisting chiefly of disordered
function, or of altered sensibility, assume more or
less of the intermittent type; only the most acute
maladies, or those of altered structure, or attended
by contamination of the blood, assuming a purely
continued course ; — (/ ) After viewing the effects
of malaria arising from the various sources pointed
out in the article on Endemic Inplvences ($ 5.),
on the human frame, in the various epochs of ex-
istence -f after considering the nature of the agents
by which such effects may be counteracted, or
removed ; and after the experience of the primary
and consecutive action of this particular cause
upon my own system ; I believe that it has a
primary, specific, and uniform tendency to impair
the energy of all the vital manifestations; — (g)
That the morbid impression having been made by
it, and the formative changes having reached that
pitch necessary to the production of the cold
stage, the consecutive alterations proceed in the
manner stated above ($ 101.), but much more
rapidly and imperfectly, and in a way insufficient to
enace the primary morbid impression made by
the cause upon the organic nervous system ; con-
sequently the morbid state of this system is little
aflected by the successive changes characterising
the paroxysm; and continuing the same after,
as it was before the fit, is equally efficient in
operating a return, after an interval of varying but
of short duration, of the same succession of phe-
nomena.

197. From this last inference, and from previous
observations, it will appear, that each paroxysm
is a complete febrile seizure, the successive and
critical changes of which are insufficient in most
instances for the restoration of health ; that the
disorder remaining after the subisdenoe of the fit
is in every respect similar to that cbaracterising

the formative or premonitory tUge of fevers gtocr-
ally; and that it is necessary to the cure of the
disease, that it should be treated io a oeatily fwj.
lar manner. This view is snpported by tbe Uzi
of relapjaes of continued fevers being conmoa,
when tneir duration is shortened by an active or
very depletory treatment at their comnaeaceinieat.
As to the periodicity of the return, or the cc]api«,
of the febnie paroxysm in ague, it seems to be tW
consequence of the specific nature of the etcirjkg
cause, of the morbid impression made by it upcc
the organic nervoua system ; and of the ooatics-
ance of thb impression, or rather of the mi^.i
state it occasions; for, as long as the mot^i
condition of this system is unefia^d by trratittat.
change of air, or by the full evolution of criu.-aJ
changes, it operates a return of the febrile parox-
ysm after an interval which may be prolong or
shortened by the state of vital power, aad fwcal-
arity of temperament or diathesis. As to sxj
further explanation of the matte r» I can add no-
thing to what is given in the article Di^iu
($ 155—157.).

198. e. The eorueeutivt changes, and the Im: «r
complicated farmt of ague, are manifest const-

auences of repeated seizures, or returns of tiie
isease, in connection with predisposition, and wirb
the intensity and continued operation of \U
cause. Owing to the impaired tonicity of tbe re»-
sels, consequent upon depressed vital power, nd
to the frequent returns or severity of the ooU
stage, congesUons, and subsequently torpor, ob*
struction, and organic change, of interna! visceri.
often take place, the large vessels becoming en-
gorged, and the cavities of the heart itself some-
times softened, or distended and enlarged. — TW
changes ob^^rved in the digestive mucoos sor^t
are chiefly attributable to the same causes, and ifr
the morbid condiuon of the biliary and paBocatc
secretions. The low or adynamic forms are evi-
dently results of the intensity of the canse io re-
lation to predisposition and the state of syviem —
of the continuea operation of the cause, as when tot
patient cannot be removed from the locality prodvc-
tive of the malaria — of complications Mperveoia^
in the course of the disease — and of chafes in lm
circulating and secreted fluids.

199. z. Treatment. — Ague is treated v.6
comparative ease and success, when the pat«o4 ■>
removed into a pure air, and wben it a oedhrr
complicated nor of a low grade. If removal •«
impracticable, it is often very difficult to mao«|v.
and dangerous as respects its conaeqocpcc* cr
sequele, although an unfavourable resalt mat be
long deferred. — The treatment, however, io eiihri
case, naturally divides itself into that applicsbV
— a. to the paroxysm, — 6. to tht infenwi, — aod.
c. to the effecti often consequent upon repeaki
attacks.

200. A, During the porarysM«~-Tbe phncipsl
intentioni that should be kept in view in tbe treat-
ment of the fit, are— 1st, to guard important %t«-
cera from injurious congestions dnrii^ tbe cold
stage ; 2dly, to protect interna] oignns from the
effects of excessive or inflammatory nadioo la
the hot stage ; and, 3dly, to promote an abaoda&t
perspiration in the sweating stage, whereby ti»
vascular system and the internal viscera may be
relieved.

201. a, Treatstfnf^sim^ts o^»#.<^ Tile mesas
advised by Stoll axe bert gaoerally soficicftt.

942

FEVER, INTERMITTENT — TasimiKNT.

nistered, and its operation promoted by diluents.
If it have been given at the beginning of the fit,
and acted freely, it may be dispensed with now.
But it should not be administered if symptoms of
determination to the brain, or of indammatory ac-
tion of the stomach, liver, or spleen, be present.
After its full operation, a large dose of calomel —
from ten to twenty grains — ought to be given ;
and, about four or five hours afterwards, a pur-
gative draught. If theie act not sufficiently in a
tew hours, a cathartic enema should be exhibited.
Having removed local congestions or general
plethora by depietians, and evacuated morbid se-
cretions and fscal accumulations, cinchona or the
iulphaU of quinine may be exhibited, to prevent
the return of the fit. These are almost indispens-
able preliminaries to the quinine or bark, especi-
ally m the complicated and congestive forms :
for, without them, it will either not be retained on
the stomach ; or, if retained, will convert conges-
tions, or slight forms of inflammatory irritation, to
active inflammation, or to structural chanee.

207. 6. If the stomach remain irritable after
the fit ; or if pain or tenderness at the epi^trium,
with other symptoms of inflammatory irritation or
congestion, be present ; the full dose of calomel,
either alone or with opium, ought not to be with-
held ; for, as Mr. Annesley has shown by his
instructive experiments {Sketchet of the Diteaies of
India, ^e. 2d ed. p. 374.), this remedy has the ef-
fect, in large doses, of diminishing vascular action
in the stomach and in the upper portions of the in-
testinal canal. When prescnbea after depletions,
general or local, and the external measures de-
scribed above ($ 203.) f the internal disorder will
be removed, and the quinine, which is almost in-
dispensable to the arrest of the disease, will be re-
tained without uneasiness. If quinine, especially
its sulphate, cannot be procured, the hark in sub-
stance, in large doses, must be substituted ; and
conjoined with ammonia, or camphor, capsicum,
or opium, &c. shortly before the expected acces-
sion of the paroxysm. The decoction with serpen-
taria, the extract, or the compound tincture, may
likewise be employed, but chiefly as an adjuvant.
In every state of the disease, during the exhibition
of quinine or bark, the excretions demand atten-
tion : a full dose of calomel, especially in warm
countries, ought to be given from time to time,
and followed by active purgatives and eoemata.
If the alvine excretions, and the biliary and other
secretions, be not freely promoted during the ex-
hibition of bark or quinine, great risk of superio*
duciog inflammation, congestion, obstruction, and
enlargement of the abdominal viscera, or violent
determination tathe head, will be incurred.

208. c. If the disease have been of long stand-
ing, congestion, obstruction, or enlargement, or
chronic inflammatory action in some abdominal
organ, has probably taken place. In these, the
immediate use of bark or of quinine will be of
doubtful efficacy. The treatment should, there-
fore, be commenced with sufficient local deple-
tions, followed by the external means already no-
ticed (j 203.), and by the repeated exhibition of
purgatives, a full dose of calomel having been
premised and given again at bed-time, as circum-
stances may require. This treatment is especially
indicated in those more severe cases in which the
intermissioos are imperfect, the tongue much

. loaded, and fulness, distension, or ttneasineas in

the upper regions of the abdomen, are oomplaiaed
of. Morbid secretions and local disorder being
removed by these means, tlie sulphate of qnniac
or bark should be prescribed, at first either with
purgatives, or alternately with those which will
act decidedly. It is chiefly to a neglect of this
practice that complications and unfavourable con-
sequences so often follow the use of bark, qaiuoe,
or of ai'senic ; for these often interrupt exctctioa,
and over-excite and inflame loaded, obati acted,
or congested organs.

209. d. When the patient cannot be removed
from the continued influence of malaria daring
the treatment, we must nevertheless trust to tL«
energetic employment of the above aneans ;
thereby removing morbid secretions, impsoving
the secreting and excreting functiooA, stibdoia^
local disease, and making a powerful tonic inpra-
sion upon the or^ic nervous system and dig«-
tive organs. With this last view, the doses of
quinine or bark should be as large as the stomach
will bear, and exhibited shortly before the eapecsai
return of the paroxysm, or immediately after the
sweating stage, when the intermissioos are iboit
or incomplete. Its effects will often be pronolni.
and it will not so readily offend the stonwch, if u
be given with camphor, opium, capsicnni, pepper,
cinnamon, &c. according to die peculiarities of
the case. In these circumstances, as well as when
the disease presents an adynamic form, or is more
or less complicated, enpecially when the tODgoe ii
much loadea, or flabby and pale, the patoxysca
prolonged, and the intermissions imperfect, cak-
mel in full doses, at bed-time, either alone, or «aa
James's powder or opium ; a warm stomscl;ic
purgative the following morning (F. 2I6.266.>.
thereby procuring three or four evacoationa daiJv .
and the quinine alone, or combined in the manner
just stated, during the intermissions, or vntil Uk
accession of the cold stage ; are moat to be «ie-
pended upon. If the spleen be much enlar^g^,
and the patient subject^ to the enervating i^;.-
enoe of malaria, calomel must be given nith
greater caution, and its effects watched. In $«fcb
circumstances, the purgatives selected should Ut
prescribed with a tonic ; as the sulphate of c«>
nine with the sulphate of magnesia ; the decocuca
of bark with the sulphste of magnesia and the
tincture of senna, or with the compound decoc-
tion of aloes ; or the compound infusion of geoikr,
or the infusion or decoction of cinchona with tae
infusion of senna, and warm tinctures.

210. f. In cases of protracted, irrenlar, rota-
plicated and reduplicating ague, as welfas in thive
of a low form, and in those occasioaally follovir^
remittents or continued fever in warm dimaics.
the liver, tpUen, and digeUive anicnau sur^acr. are
generally more or less diseased. The intermiianf i.
even when distinct or perfect, are accompanwd
with great languor, general uneaaiBeas, want of
appetite, a foul or loaded tongue, a sense of op-
pression in the epigastriom and hypochondni.
and unhealthy countenance and skin; the apprr
abdominsl regions being often full, taindlf d. or
tense. Here, local depletions, if they be Bi<
contra-indicated, and calomel, followed by perja-
tives, as already advised, should precede Ibe rs-
hibition of quinine. We must no(« however, ws^
for the removal of these signs of cooffstion aa4
obstruction, before resorting to qaioioe or tka
bark ; for the patient may atok too low, apd vioil

944

FEVER, INTERMITTENT— TttKATMtUT.

Prinole, and Brocklcsby ; and is most appro-
priate to the inflammatory states of ague. Mor-
ton gave a scruple of chamomiUflowerSt ten grains
of salt of wormwood, and as much of the calx of
antimony, every sixth hour; Dr. Ueberden,
myrrh in large doses ; and Dr. Cvlle.v, tormetuil
and gentian with galis.

215. e. The preparations of iron have been
employed, especially the Jerri ammonio'chloridum
by Staiil, Thili.er, Huxham, and Hartmakn.
The cyanide of iron has lately been strongly re-
commended by ZoLLicxorFEH, who prescribed it
in doses of four grains twice or thrice daily. — The
trisnitrate of biimuth has likewise been given by
Henkesen ; photphorui with bark, by Hufeland ;
the flower of iulphnr, in full or large doses, by
RxvERius and De Haeh; powdered carbon, in
doses of two drachms, shortly before the fit, by
Pxerquiv; ammoniated copper, by M'Caoslakd,
BiANCHi, and BnsRA ; Dippel's animal oil, by
Werlhof and Haller ; and cobweb, byPAULiNi,
Grant, and Jacbson. — I have given the chlorate
of potash with benefit in the decoction of bark, and
in the infusion of valerian, with a little tincture of
capsicum. Charcoal was en»ployed in ague by
Jackson, Calvert, and Tully {Edin. Med, and
Surg. Journ, vol. x. p. 15. 403.), and was found of
service when the gastro-intestinal mucous surface
was much affected.

2I6r d. The barkt of various astringent, tonic,
and aromatic trees and plants have been tried,
both before the introduction of the cinchona into
practice, and subsequently as a substitute for it.
The most esteemed of these are the mUow bark.
This substance was prescribed by Closius, Gunz,
Stone, Resenblad. Thilbnius, Hilscher,
Jaxes, Styx, and Whitb; the angutt^vra hark,
by Wilkinson and Brands ; the bark of the Swie-
tenia febrifuga, by Roxburgh ; catearilla bark,
by inscKER and othera; the pomegranate bark,
by Rkhmann ; the bark of the Ilex aquifoUum, by
Rousseau; the barks of the che$tnut fre«,ofthe
elm, and of the oak, by various writers ; and the
earapa bark of South America, which has been
said to have succeeded where cinchona had failed.
Various other stimulating, aromatic, and tonic
vegetables have been employed, and some of them
are still in use, either as adjuvants of the bark, or
of quinine; or in the form of infusion, as vehicles
for other substances. The most useful of these are
quaiMta; terpentariu(LYs6sB, ^e.) ; Calamuiaro-
matieus (Gulbrano, Moseley, and Horn); ar-
nica (Aaskow, &c.) ; and Capsicum annuum
(Bergius and myself). — Ammonia, camphor, the
itthers, castor, musk, myrrh, gineer, black pepper,
garlic, mustard seed, &c. have likewise been em-
ployed, chiefly as adjuncts to more permanent
stimulants and tonics, or in large doses with opium,
shortly before the accession of the fit. Of these,
the most serviceable are camphor and ammonia.
Piperin, the active principle of black pepper, has
been lately employed by Bertini, Gobdini, and
others, in doses of one or two grains, to arrest the
paroxysms ; and salacina, and alkaloid found in
willow bark, has been very recently recommended
as a substitute for quinine. Ignaiius*s bean, and
the preparations of nui vomica were formerly used

as in the djfsentene complication, th« tDmenti],
ipecacuanha, Dover's powder, th« bjdrmrgyrBia
cum creta, and opium, are niefiil adjuDcta to
other medicines.

217. e. I'he mineral aeids, capeciallj Ibe k^
dro and niirochloric, have been giveo hi the
decoction of bark, emcially when tbe liver or
spleen have been enlarged. I have employed
the latter in such cases ; and, in a atete of veiy
weak solution, as a common bevcn^ for the
patient during the intenniMiona. Tbe eulpkmn<
acid, similarly exhibited, has been recomiaeiMM
by Storck and Joerdkns. It is an nscfnl ad-
junct to thesufphate of qainioe« The citric aad
acetic acids have been directed, but ehiady •• u
addition to the drink taken in the hot stagv, a
which, however, acid drinks should not be ukea,
as they tend to diminish the penspiratioo, which m
more or less salutary. — Jtthers, espcciaily tU
sulphuric and hydro-chloric have also been prt-
scnbed in large dosea, either alone, or with cam-
phor and opium, shortly before the paroxysm, wuh
the view of shortening the cold stage (HofTKAA».
Glutton, and Davidson). — The vUatUe atkau
has been likewise employed aimilariy oombiecd.
and with the same intention ; and the wions pre-
parations of antimony have been given before ac^
during the paroxysm, and throogbout the inter-
missions, in conjunction with bark or other Mm-
fuge tonics. Mum was at one time much used b
ague, it having been recommended by ErrnoLLKa .
LiNDT, Mueller, and others. LAMoa and Dm.
Meza prescribed it with aromatics, and selphahc
acid, or ether ; and Adaib, with cinchona. —
The sulphate rf iron has been tried by sevenl
writers ; but is of inferior efficacy to the aulphaic
of zinc, or to the tincture of the seequi'cklmide */
iron. I'he Prtiios verticilLatus, and the bark of the
Prunus Virginiaua, and P. sUvestris, have bees
mentioned in favourable terms by Babton aod
other writers ; the bark of the pine, by BaaxfLtn :
and valerian and grntinii, by Vaidt aaJ
others.

218./. Anodynes have been used in oonjuoctioa
with, and as adjuvants of, antispasmodicB,stiiBK-
lants, and diaphoretics. Opium haa been cxtu-
bited with these, and with antxmonials, »hortl\
before the fit, by M'Causland, Bbcoa, and Ta<.w
UANN ; with camphor, by Senac and Amu.i ><> .
with ipecacuanha and nitre, by Dover; and miv,
aloes and camphor, by Audouard. The extras
of belladonna has been prescribed with bark &3I
other tonics, by Hu pel a no and Erdmav^ ; the
Lauro-cerasus, by hnoMfs Lancrisu ; bitter a/-
monds, by Beroius ; and tbe powdered leaver cf
the Lauras nobilit, by Sir G. Barrr. given ic
doses of two scrupleti, in bitter decoctioss, shorJr
before the paroxysm.

219. g. In old and protracted cases, attended
by infarction of the abdominal viscera, nerrwul.
especially calomel, have been employed in fre-
quent doses, until slight salivation was prodocrd.
by Willis, Staul, Baker, and Lysoxs; and tbr;
propriety of the practice, in some circttmsunc««.
IS confirmed by more modern experience. — Ix
similar cases, repeated /rictiont of toe sorfaec bav«
proved serviceable, especially with some one • '

against ague, by Paullini, Bourieu, Aaskow, ! the liniments prescribea in the Appendix (F. 29('.
CuLLEN, Horn, and Fouquier ; and their ac- 311.). Frictions along the spine, with scimaUL-d;
live principle, strychnia, may also be found useful i substances, have been advised by Havtesxx«k»
in the lower grades of the disease, especially when I Van Swixtsv, Di Haen, Trnka. and olhcn
complicated with diarrhoea; ia which, a« w«U rvhefaeienti and Miftfrt over the epigastrtiia and

646

FEVER, REMITTENT. — Causes.

Intenn. Fernicioiat, ftc. 4to. 1756. ^P. Senact De R«.
oond. Febr. Intermit, turn Remitt Natura. Amit 8vo.
1759. — . Raynal, Sur la M^thode de guerir les Fldv. Ma.
Hgnes Intermit 4to. Paris, 17&-3. — Gtftix, De Curttoe
Salicit Albs Corticl Substituendo. lipa. 177^ — Te*tter^
Febr. Intermit Cito Competceiid. Abitinentia. Paris.
rnS.-^Borrieu, \h Hist de la Soc. Roy. de MMecine ad
177(1 p. StS^—Van Swieien, Commrnt. ad IBQ.—G. Baker,
in Trans, of ColL of Phys. vol iii. p. 141.— D. Monro,
Ibid. voLU. ^.Xo. — Roienblad, De Usu CorticU Sa.
licis in Febr. Intermit Lund. 1782. et Doering, toL 1.

p. 140 ThilatiM, Medicin und Chirurg. Bemcrkung.

p. xad.-'Stoerck, Ann. Med. voL U. p. 163. —G. CZtf-
iwrn, on the Epid. Dis. of Minorca from 1744 to 1794,
8to . Lond. 1779^ 4th ed. .— Ltnmms, in Ameenitat Acad,
▼ol. ix. Upa. 1773. — Bang, in Act. Soc. Med. Harn.
ToL ii. pi 914. — StoU, Aphor. de Feb. p. 133 — Tmka
de KrzowUx, Hist. Febr. Intermit. 8Ta Vindob. 1775.
— L. CkalmerSf on the Weather and Diseases of South
Carolina, 8va Load. 1776. — itCtnuUmd, in Edin. Med.
Comment roL viii. p. 250. — Murray, De Temp. ExbiU
Emetica in Febr. Interm. Max. Opportuna Oposc. vol. It.
n. T^SioU, Ratio Bfed. Ac voL iv. p. 476.— J. C. Fldler,
DeFebr. Intermit Vien. and Prag. 1784.— i>r Mem,
in Acta Soc. Med. Havn. vol. i. p. iS , vol. iii. p. aM. —
De Haen, Rat Med. Par. vol. xl. c. i. — T. Fowler, Med.
Reports on Arsenic in the Cure of Intermitt Ac. 8va
Lond. 1786. — BHrserius, Institut Med. Pract. vol. i.
p. SOO. — O. Kettie, Ed. Med. Comment. voL xix. n. S71. j
and Ann. of Med. vol. L p. 409., voL ii. p. 127.— iW'MMfr,
Expertaa and Observat on the Angustura Bark. Lond.
1191.'— S. James, Observ. on the Bark of a Species of
Willow. Lond. 179:!. — C. Strack, Observst. Med. de
Febr. Intermitt ftc. OlftnU 8to. 1787. — Tkompaon,
Treatise on the Fdiris Intermittens. 8va Lond. 17K7. —
Durand, Sur les Fidvres Intermit Malignes. Par. 1788.

--Bang, Act. Soc Reg. Med. Havn. vol iv. p. 183

Jatkow, in Ibid. vol. ii. n. 19. — Gulbrand, in Ibidi vol. ii.
p,^U&.—Aa*heim, in Ibid, vol iii. p. 37a —BeddoeM, tn
Med. Facts and Observ. vol. viL n. 2. — DavAfsoii, In Ibid,
vol. V. n.7.— Winterbottom, in Ibid. vol. vL n. \. — Rox.
burgh, in Ibid, vol vi. n. 9 — Wright, in Ibid. vol. vii., et
Ann. of Med. for 1797. — IVommr, M6m. sur les Maladies
en Italic, &c. 8vo. Par. 1796. — Darwin, Zoonomia,
▼ol. iii. — Morrit, Med. Observat and Inaniries, vol. iii.
—Ana*, in Ibid. voL v. —ForAfce, Second Diss, on Fevers,
8va Lcmd. 1796. — White, Observ. on the Willow-bark,
8vo. Bath, 1798. — M*Lean, On the Fevers of St Do.
minga — ^ngenberg. Hist. Fedr. Intermitt qu» Anno
1800. Philippot S«viit &C. Wurceb. 1801. — Thomann,
Annalen fur 1800, a 133. — J. Breda, De Variis Opium
Scopo Febriftigo adhlb. Methodis. L. B. 1800.— /XrVmdU,
In hrero, Commentari Medici, t IL n. 2. -Stew, in Nor.
disch. Archiv. b. i. st i. n. 4c — HUtcher, in Tode, Med.
Chirurg. Joum. b. v. st 4. — Brdmann, Horn, N. Archiv.
b. i. p. 249. — AbfN, Ibid. b. IL p. 132. : et b. ill p. S39. —
Ametung, Hitfekmd, Journ. d. Pract. Hellk. b. xviiL st 2.
& 91.^ Ksrrtum, in Ibid. h. xx. st 3. p. 10. — Httfeland,
fbid. b. ix. st 3. p. 101. — Werihttf, De Febr. Ac. sect iv.
1 2. —J. Richard, De Insldiosa Quoruod. Febr. Intermitt
tam Remitt Natura et Curatione^ 8vo. LycHi. 1801. —
Marcut, Magasin fur Therapie Klinik. b. i. b. i. p. 28. —
Fixeau, Joum. O^n. de Med. t xvii. p. 459. — Loretiz,

In lUd. t xxxiU. pk 361 Otto, De Vomit, usu in Febr.

Inteiro. Franc. 1803. — If icAaWis, in Hufeland u.Himiy,
Joum. b. i. oi 107. — P. A. Colombat, Mem. sur uneEpid.
des FIdvres intermitt Adynamico.Taxiques, 8va Paris,
18091 — Cautanceau, Sur les Flares Interm. Pemicieuses
qui ont rtoi§ Epid^m. k Bourdeaux. in 1805. Paris,
1809. — Rehman, Notice sur une Remede propre k rem.
placer la Quinquina. Moscow, 8va 1809.— i7 & Barton,
Collect towards a Mat Med. of the Unit States, 8vo.
Phil. VA\% jtatum. — AUbert, Des Fidvres Pernicicuses
Intermitt 8va Paris, 1809. — Hir<s«t«r, Ann. der Ge.
sammten Medicin. Jan. 1810, pc 596. — Anonm, On the
Walcheren Disease, 8vo. Ipsw. 18 la — Davis, On the
Fever of Walcheren, 8vo. Lond. 18ia — G. Blane,
Trans, of Med. Chir. Soc. vol. Iii.— /Vrrason, in Ibid.
voL Ii. p. 180. — Trmnftf, Ucber d. Wcchselfleber und
ihre Heilart. Wien. 8vo. 1810. —HUdebrandt, in /font's
Archiv. 1811, Sept p. 311.— Vaidy, in Joum. G^n. de
Mid. Cont. t xviii. p. 335. ; et Diet des Sciences MM.
t. XV. p. 9Xk — Detrmellee, Joum. Univers. des Scien.
MM. t xxxii. p. 122. — BaiUy, in R#v. M<id. t ii. 1825,
p. 384. } and Traits Anatomloo-Pathologique des FIftvres
Intermitt. Simples et Pernicieuses, Ac. 8vo. Paris, 1825

i Contains a great mass qT information.)—- Hildenbrand,
nstit Mod. Pract vol. il^J.BouiUatid, Des Fibres dites
Esscntlelles. 8vo. Paris, 1826, p. 510. — AMiemi, Traits
des Fi^vres, p. 532. — P. Bayer, in Diet de MMecine,
t xli. p. m — Puceinoiti, R^vue MM. t UL 1825,
p. 301. {An Account of Agues at Borne from 1819 to 182SL)
Z-Bertini. in Ibid. t. ii. 18^4, p. S9I.— Gordini, Ibid, t.iii.
18S5, p. 313. — Blaud, Nouv. Biblioth. MM. t Iv. p. 257.
^Brachet, Archives G£n6r. de MM. t ix. p. 340.—

Peusaan, in Ibid, t ill. pi 455 Bricheteau. Ibid, t xvl.

<ie2.— lossofsy, Joura. des Progrdi dct Scienc|i MM.

t viii. — P/«r9tite, in Ibid. txlv. p. fiSOL^.*,.-.^-.^
Archives, &c. t xix. p. 523. — Guerin de Mamert, Joum.
des Prog, des Sc. MM. 2d ser. t. IL j». 55.. cc t UL p.
Hard. Journ. Univers. des Scien. MM. t &xxiL
Henketen, Nouv. Joum. de MM. t xii. p. 37.— J
Philadeljdi. Joura. of Med. Sciencea, vol. v. p. flC. (i

state ttfiron, gr. iv— vL) — W. F. Ouumhers, Lecture* a

Lond. Med. Oasecte, vol. 11. p i J. ElUaison, im IMl

VOL X. p. l-'Lobs/ein, Rfoert. Gen. d'Aaat. ct rhiMtJ
t ii. p 339. — Bousseau, Joura. Ucbdom. t iv. p. 433. —
W. Stokes, in EdIn. MM. and Surg. Jodhi. t xx%i. p L
—J. Brourn, in Cyclop, of Pract. MM. voL U. p. Cao.

See also the BiauooRamv to Fever As gemerm'
PLOUCQEf s Refiertorium, which eootains a nui
list of foreign works, down to the commcDCCttcnC '
century, very few of which are here lefanad to.

of

■DSI

XII. RsMrrTENT Fbvkr. Stw.— Etactrfcafiy,
Paroxysmal, SulhcoHtvtual, Eudamie, Emdemiai,
and Endemieat, Favtr, of varioos writem.

225. Dwis.^The ftbriU pkmt
striking $xaeerbaUon$ and remisnans,
oeeurring in the twenty-feur hamrt,

226. This fever, although holding i mM\e
rank between agnee and eontinoed fercf9» tp^
proaches the former most nearly in ha
phenomena, and consequences. It ia
mon in warm climates, and in the
tries without the tropics, in which it
prevalent in summer and autumn. It ia strictly
a disease of locality and climate, and hence very
generally denominated endemic ; but as cfiaaiet
and localities vary remarkably, so is it modiiSed m
character from the mildest form, in which it is
similar to simple ague in eveiy respect hot the
complete remasions, to the more mabgnant alaie»,
in wnich it so nearly approaches yellow fever ia
warm countries and seasons, and coolinaed fiever
in temperate climates, as to have been fieqveoity
confounded with them. To intertropical pra^
titiofters, especially, as well as to those in
perate countries which abound with the
causes of disease, this fever presents grant i
It is not infrequent in tlie vicinity of
and in marshy localities in the sootfaera cooi
England, and Ireland, during the snmi
autumnal months.

227. i. Causes.'— The prtfdiiponfi^ and
eauaet have been noticed above ($ 194.), and
more especially in \h& articles Disxasx (f 31. S&.)
and Endemic Invluences. Dr. CBaHasna baa
supposed that remittents arise from two priDcipnl
sources: — 1st, from marsh-miasmatB ; Sdly^from
sudden vicissitudes of atmospherical teaDpesmtarv
precipitating some other Jeletefions prioeiple
evolved from hidden sources. — Of tfav latter,
however, we can have little or no koowlodge ;
and, even granting the evolution of such a piw-
ciple, we have no evidence of any sources tiem
wnich it can arise different from those pointerf
out in the articles now referred ta. As, there-
fore, the exciting causes of endemic fevecs in
aduiti are chiefly emanations from the soil —
from decaying organic bodies on its sorlMe er
comminglea with it — and from stagnant pnliid
water ; and, as these causes are necesaarily veiled
in concentration, activity, and in their aetaie,
according to the states of the air, and to the
varying proportions of vegetable and eeieial
matters undergoing decay, so it must be iaierved
that the effects produced by them, even when the
constitution of the recipienti is the same, wfl] b«
also varied : but, when we consider the pt^X
variety of habit, organisation, tempcrancal, ami
susceptibility, it must neeewarily be ooncieded
that toe foima and states of fevcn reseltiog horn

948

FEVER, REMITTENT — D«scripti6K-

eoDstant. In the most severe and unfavourable
cues, yellowishnesa of the skin, or vomiting of
matters like cofTee-grounds, or both, occasionally
supervene. Tho bowels, which, before the at-
tack and at its commencement, were torpid, are,
at further advanced stages, irntable ; the evacu-
ations being watery, greenish, and, at last, almost
black ; the urine being very scanty and high
coloured. If the disease be not actively treated
at the commencement, an unfavourable termi-
nation takes place between the third and seventh
days; but it is often prolonged beyond this
period, and it then generally occasions visceral
disease.

231. Such is the inflammatory remittent of
warm climates. A nearly similar fever attacks
unseasoned Europeans lately arrived in the West
Indies and inter-tropical Africa, and often pre-
sents an obscurely remittent or almost continued
type. It has been very generally mistaken for
true yellow fever, owing to the malignant symp-
toms it assumes at an advanced period, or state
of exhaustion consequent upon the vascular ex-
citement of the early stage. The inflammatory
remittent, the bilious inflammatory, the adynamic
or malignant remittent, and the surdent or season-
ing fevers of Europeans lately arrived in warm
countries, are merely modifications of each other,
and differ essentially from epidemic yellow fever,
with which, however, they have been all most
singularly confounded.

232. C. BHiO'iHflatnmatfny remittent fever dif-
fers but little from the foregoing in its characters
and course. It is most prevalent in Europeans
who have not rended long in a warm miasmatous
country, and in low marshy localities, or in
thickly wooded districts. In temperate climates, it
is observed chiefly in the autumns consequent upon
very warm summers ; and in the bilious or bilio-
sanguineous constitutions. It is often dependent
upon the vicissitudes of season, especially wet
seasons following great warmth, or a very hot
summer consequent upon a wet spring ; and it is
often very prevalent or almost epidemic during
the hot months, after very heavy rains, within
the tropics. Violent determination to the brain
characterises the commencement of reaction, in
this variety ; and inordinate aflPection of the liver
and digestive mucous surface, the more advanced
stages. Pain in the head is most severe, espe-
cially in the forehead and sockets of the eyes ; the
conjunctiva is yellow or suffused ; the counte-
nance and skin become dusky or yellow; the
tongue is loaded by a bilious coating ; and the
evacuations are bilious ; especially the matters
thrown off* the stomach. The bowels are at first
costive, but they afterwards often become irritable
or dysenterioally affected. After the vomiting
has continued some time, the appearance of the
•matters is changed, and ultimately assumes in
fatal cases the characters just described ($ 229.).

233. D. The adtfnamic or malignant remittent is
one of the severest and roost fatal of endemic fevers.
— a. It is observed only in places where the en-
demic causes are ooncentrateid or intense relatively
to the state of predisposition ; and is seldom ush-
ered in by shiverings, but generallv by a pro-
longed sense of cold, universal collapse of the
vital powers, and of vascular action. Pain in
the head of a peculiar constrictive kind; mental
*^pressioD and insane delusions; imperfect efforts

at reaction ; remarkable lasjitude and paia id
the loins and limbs, are present at the ooomenec-
ment, with great anxiety, pain, and oppressioa of
the prsBCordia, and nausea, sometimes giving nse
to vomiting, which assists in developing the stage
of excitement, and in partly overcoming tlie inter-
nal congestions. The pube is smalt, conatricted.
or irregular ; the skin becomes dry and r*-^**^
or moist and clammy ; and impresses the hand of
the observer with an acrid or tineling aensBtiwi ;
the eyes are watery and injected ; the loogve is
clammy, moist, or flabby and coated, and after-
wards dry, rough or brown ; the fece is ~
but dusky or purplish : the bowels are
subsequently relaxed or irritable, and the
scanty , high coloured , or suppressed . After twdve
or fottiteen hours, a slight remission is ohsaried,
after which the symptoms are exacerbated ; the
stomach is remarkablv irritable ; the efigminmm
painful and tumid; the breathing hnrried; and
the patient restless and distressed! In tha naore
dangerous cases, hiccup, constant vomitings,
yellowish discolourations of the skm, exadatiDBs
of blood from the digestive mucoaa sarfteea,
low delirium, and death, supervene betwaan the
fourth and seventh days.

234. 6. This variety is variously mad^ud, in
diflTeront circumstances and persons. It eoine-
times assumes more of a cerebral or typheid eh^
racter ; at others, it is frt/iom or gattric, acoofd-
ing to peculiarity of season or ooocentiatioa of
the cause. In some inter-tropical ooantriei it
becomes epidemic, or rather this endemic as osofa
than usually prevalent. Occasiooally the resnis-
saons are indistinct from the commencemeol, and
they generally become so after three or four days.
— A. In some cases the vsacnlar excitement is al
first more or less intense, with remarkable deter-
mination to the head, liver, and stomach, and aM«
niacal delirium, the disease very nearly appsaach-
ing the inflammatory, or bilio-inflammatory fbrasi.
-— ^. In others, vascular reaction is vciylow and
imperfect; the pulse small and quick; the ah-
domen tumid and hot, whilst the extreo
cold or clammy; the evacuations foul,
and oflPensive ; the tongue fuliginous ; the
spongy, or oozing a bloody sanies ; the voinitii^
constant, and ultimately grumoos and dark ; the
stools towards the close, black or pilcby; tha
urine scanty or nearly suppressed ; the aobds
flaccid ; and the skin earthy or discokmred. la
both these states, a yellowness of the swfece new
casionally presents itself about the third or foerth
day, beginning in the conjunctiva, neck, aad
breast. The yellowness often passes to a pale
greenish hue, in patches, shortly before death;
and the soft solids present a liqvcaceat stale,
having lost their vital cohesion.

235. e. In other cases of this form, tha sfmp-
toms are at first mild, and the excitement iaroo-
siderable ; when, after two, three, or four exa-
cerbations, the powers of life appear saddcaly
exhausted ; the pulse becomes weak and flatlefw
ing; the tongue foul, black, and dry; the eva-
cuations offensive; the preatratioD of streagth
extreme; and the fetor of the perspiratiaa r»»
markable. At last, great anxiety ; tendcracas aad
tension of the epigastrium : fulness of tha hypo-
chondria; collaps^ features; a aqaalid or yel-
lowish surface; vomitioff of dark or |
matten, supervene, and iodicite tha

950

FEVER, REMITTENT— DiACNOsn.

more rarely in warm climates. The pulmonary
functions are more or less impaired during the
formative and invading periods; but acute dis-
order is seldom developed until the* period of
excitement, and consists chiefly of bronchitis, ca-
tarrh, and pneumonia, of a nervous or congestive
form. In some cases congestion of the lungs, and
of the bronchial surface, commences during or
shortly before tl)e period of invasion ; and either
partially continues throughout the disease, or
passes mto a low form of inflammatory action,
and even into hepatisation. Rheumatism is also
occasionally complicated with remittents ; and
erysipelas sometimes supervenes when a part is
injured, the cuticle abraded, or the skin divided.
Ulcers and sores not unfrequently take place on
the lower extremities in the course of remittents,
as well as of intermitteots, particularly in low,
wooded, and swampy districts within the tropics.

241. F, The terminations of remittents are —
1st, In restoration of the healthy functions ; —
2d, In a chronic form of remittent ; — 3d, In
organic change of one or several important vis*
cera, particularly of those which manifest predo-
teinant disease during the progress of the fever ; —
4th, In fever of adiflTerent type; — 5th, In dys-
entery;— and, 6th, In death. Although any
of the consequences pointed out above (§ 47. 189.)
may arise, changes of the viscera of the abdo-
minal cavity are by much the most common, in
this class of fevers, as well as in agues. The
Prognosis is apparent from what has been ad-
vanced, and in every respect agrees with what has
been stated on the subject above (§ 57. et seq,).

242. G. The lenons observed after death from
remittents, as respects both their seat and nature,
differ but little from those already described in
connection with agues. They, however, are of
that kind which are generally observed to result
from acute action in connection with deficient
power. The liver is usually injected, remarkably
softened, of a dark colour, friable, and sometimes
enlarged. The spleen. is often so soft as hardly
to admit of being handled. The digestive mucous
surface is softened, injected, ecchymosed, of a
dark hue, and sometimes thickened, abraded, or
even ulcerated in the lower parts of the canal.
The mesenteric glands occasionally, and the pan-
creas more rarely, are enlarged or otherwise
changed. The broTichial lining is generally dark,
injected, and soft. The lungs are sometimes con-
gested, infiltrated, condensed, or inflamed. The
pleura and pericardium often contain some dark
sanguineous serum; and the substance of the
heart is frequently soft, flaccid, and readily torn,
the cavities being occasionally dilated, more es-
pecially after the adynamic states of the disease.
Adhesions between the pleurs are rare. The
changes wt(A in the cranium consist chiefly of con-
gestion of the veins of the pia mater and sinuses,
with a fluid dark blood ; and sometimes of eflTusion
of serum into the ventricles, and between the
membranes. But the lesion of the eocephaloo
are seldom very great, or in relation to the severity
of the cerebral symptoms during life.

243. iii. Diagnosis. — It might be supposed that
the remissions would be a sufficient characteristic
of this fever, and they certainly are so as respects
the remitting type. But the occasional occurrence
of yellowness of the skin, and of black \omit, in
•he advanced slngrs of itf more intense forms, has

been the means of confounding it with two oiker
species of fever, in which also ydlowocs of the
skin and black vomitings occnr — the 6iito-fa-
Jiammatory or ardent fever, which atlKks only
new comers to an inter-tropical conntry, especially
America and Africa — and the tmg mjectimu
yellow fever, which sometimes spreads in a wm
pestilential form. The more intense and ady-
namic forms of remittent, the bilio-inflasiniaiiivy
or ardent seasoning fever of Europeans receatly
arrived in a hot climate, and the true yellow fe»er
arise from different causes, and present dtftreot
phenomena at their commencement and eariy
course, although the character of the symptoms
often approximates in their last itagea.

a. 244. As respects the intense and adynemie
states of marsh remittent, it has been shown abate
that the exacerbations seldom continue above fovr-
teen or eighteen hours, so that one takes place dailj.
varying, however, in intensity, so that they thai
usually present a quotidian or double tertian type;
but in the hilio-iiijiammatory, or ardemt seaseiuni
fever of Europeans, the type is continoed, or i
remission does not occur till after thirty or thirtv-
six hours, a different train of symptoms thea
usually appearing. These two ferers arm from
different causes ; — the remittent always proendi
from malaria in some form ; hence it is coomoB
to all warm countries, and to temperate r^:ioM
in warm seasons, and varies remarkably in tevcmr;
the bHio-inJiammaUnry or ardent fetet may prcK
bably also arise from the same cause, but a b
more especially the effect of temperatsie upoo
European constitutions, or of atmospheric viosk-
tudes and other causes acting ooncurreBtly witii
these ; hence the much greater unifMmity of its
character, in which it nearly approximates to tfe
bilio-inflammatory form of the remittent* Whti4
remittents can, in every instance, be traced to tfr-
restrial exhalations — to the sources described to
the article Endsmic iNrLVSNcas, ardent frrer
often appears where the operation of such canm
has been impossible, and where 1 have endea-
voured in vain to account for its oocarreacc, a*
cepting in the way stated hereafter.

245. 6. These two diseases are the teaionimg ft-
vers of Europeans arrived in a hot climate — > aidest
fever commonly appearing in robust plethoric per-
sons who have emigrated to the West Indies, inter-
tropical Africa, &c. ; the intense forms orrenttteiit,
in those less robust, or who have not been atljck-
ed by ardent fever, and who have been expo««d (o
malaria after their arrival. This statement is iila*-
trated by the following facts, which came aote
my own observation in 1817 and 1618 : — Scoe
young men arrived from Europe in a place withia
the tropics, during the healthy seasoo, and where
no sources of malaria then existed. They sma
were attacked by the common ardent fever, wA
two or three exceptions, and recovered by neass
of the treatment advised for this disease; bat
during the unhealthy season, several of them had
remittent fever ; and those who had not been si-
tacked by the ardent seasoning, had the moit
severe forms of remittent, which was their Ma-
soning. In the East Indies, bilio-gastric fever sod
the inflammatory forms of remittent are the mc'4
frequent fevers in recently arrived European*.
but in the West Indies, arrlcnt fever w the w*4
cominon, especially in the young, pleihorir, ^-r
robu<t — in ihofc much e«jm«e<l to the sanV m«.

952

FEVER, REMITTENT— TaiiTMJtiiT.

"With a due knowledge of disease and of therapeu-
tical agents, but perfectly unbiassed by doctrine or
by the reputed efficacy of certain modes of treat-
ment ; otnerwlse, he may find out, after some un-
toward experience, that neither the doctrine, nor the
practice founded on it, applies to the cases which
he is called upon to treat. I never shall forget
with what bitterness an amiable physician many
years ago told me, on my meeting him in an un-
healthy climate within the tropics, where he had
arrivea some months before myself, of his want of
success in treating the fevers of the country.
Being desirous of the guidance of those who had
written on the disease, he had treated it at first
conformably with the instructions given in books,
and the first nine cases terminated fatally in rapid
succession. The practitioner should observe and
think for himself *, and whilst his mind is open to
the suggestions which works will fumisti, he
should ascertain the states of vital power, and
. of local and general morbid action, in each case,
and employ medicinal agents appropriately to
these, and with promptitude and aedsioo, guided
but not weakened by caution.

248. iv. Treatment. — A. Of the mild remit'
tent, — The treatment of this form differs not mate-
rially from that advised above for agues, espe-
cially when the remissions are distinct. At the
commencement, before reaction is developed, and
when there are no indications, to forbid their ex-
hibition, emetics are generally of great benefit.
After their full operation, a large dose of calomel,
or of calomel and opium, may be given, and an
action produced on the bowels by purgatives and
cathartic enemata. These means having been
repeated until morbid secretions and fsecal accu-
mulations are evacuated, bark or (quinine may be
prescribed, if the remisaions are distinct, and the

f»atient not removed from the unwholesome loca-
ity. But in cases where the previous health and
long residence of the patient in an unhealthy
climate do not forbid it, moderate bleeding in the
stage of excitement will shorten the disease, and
render the remissions more perfect Paring re-
action in the early exacerbations, repeated doses
of Jame^s powder with calomel, or the po<asno-tor-
trateof antimonjf given in solution every hour or
two, or every half hour, in full doses, commencing
it in the cold stage, so as to produce vomiting, and
continuing it in this manner throughout the sub-
sequent reaction, will frequently accelerate a fa-
vourable termination ; and render large vascular
depletion less necessary. In old residents in
warm climates, or in those constantly living in
an unhealthy situation, this medicine will often
supersede bloodletting, if the bowels are early
and freely evacuated. In the mild autumnal
remittent, also, of this climate, a similar treat-
•ment is appropriate; bleeding being required
chiefly in the young, robust, and plethoric. Sub-
sequently, remgeranta, cooling diaphoretics, and
other appropriate means may b^ employed.
' 249. B. In the itiflammatory and bilic-in'
ftammatory forms, the practice, early in the dis-
ease, should be energetic— -a. In the cold stage,
or that of invasion, and when, although there may
.be most severe headach, the heat of the scalp
and the action of the carotids indicate that it is
not inflammatory nor dependent upon fulness of
blood ; and when excessive vascular action in the
stomach and liver has not- yet been developed.

an active mnetic is of efscDtial lenrioe* As Mon
as the stage of excitement is developed, and pffo-
portionately to its excess, and to the degree ia
which vascular action becomes predomaitaat ia
the head, liver, or stomach, ahoald Mmil^iMg,
generally or locally, or both, be pnctieed; the
quantity having relation to the cooctitutioa, nabit
of body, &c. of the patient In order, however,
that depletion may be productive of banefit, it
must be practised early in the dwcswc ; Cor, if
deferred till the excitement has pMlly eshavited
the powers of the system, its good effiseu cmaot
then be obtained ; the nature of the paiholo^eal
states admitting of local depletiom§ ooly, wucb,
however, should be employed in order to re«off
such local congestions as may have takes place.

250. 6. Full doses of calomel, followed hy pv-
gatives (F. 181. 216. 266.) and cathaiUc cncaiata
(F. 140, 141. 150.) are also early reqoiatte; the
first of these having been given soon after the opera-
tion of the emetic, and combined with James's pow-
der. During the vascular excitement, paiticttwrly
when the skin is very hot and dry, toe cerebitl
s^^mptoms strongly mariied, and the abdoadaal
viscera free from congestions, cold appU^atims
should be kept to the head, and the arid a/s-
sion frequently resorted to. When vital power is
much impaired by the impression of the eaeitiDg
causes, or exhausted by the previous exoiteBKat,
and when the abdominal viscera are coggeolBd,
as evinced by the fulness and tenderness of the
hypochondria and epigastrium, the cold afa-
sion is a hazardous measure, the constitationsJ
powers not being always sufficient to hear the
shock, and the overloaded viscera someliniei sal^
feriog further from the external impresnoa. In
such circumstances, especially when the palse ■
quick and irritable and the skin hanh, the tepid
bath, and sponging the surface with oold or tepid
water, will be preferable. A certain degree of
vital power is necessary to a soccessfol applica-
tion of the cold affusion; the surface bcn^ hot
and dry, and the internal viscera doI aerionsly
congested.

2^1. c. When the head is much affected, ieedba
to the temples, behind the ears, and to the ocd-

{>ut, or copping, will be serviceable ; evaperaiiaf
otions, or the cold affusion on the scalp bciB|r
resorted to : but even these may he injarioas i
employed too late, or in slates of exfaaasiiea.
The appearance of the face and eyes, the heat
of the scslp, the expression of the connteoaacc,
and the action of the carotids should paide the
practitioner, and not the degree of deliriam or of
insane delusion ; for these may be roost remarkable
where vascular action in the brain is lowest, as they
depend more upon nervous and cerebral power than
upon vascular action. When much oeai,pain,
tenderness, and fulness of the epi^astriMm or Ajf
chondria, with nausea and vomitioe, are preseot ;
the matters thrown up being viscid or ropy sad
abundant, and yellow, green, or yellowish grecs,
or dark green, or colourless, and mixed with al-
buminous flakes, energetic vascular deplebea
should be early resorted to, otherwise the ritsl
tone of the mucous coat and capillaries af the
stomach will be soon exhausted, and dark gra-
mous vomiting supervene. In these nws, a
large bloodletting from the arm» flijA
el, with two or tbn- If
ipily preicribed.

064

FEVER, REMITTENT— TBiATMEifT.

or eighteen bourSi and followed by the calomel
and opium ; and the bowels ought to be freely
opened. In the worst forms of marsh fever,
particularly in hot climates, the secretions of the
fiver are ofVen interrupted or suppressed, large
doses of calomel and active pui^atives being
especially required in them. It the mouth be-
come aftecled, the circumstance is favourable,
although we should hardly make this a specific
indication unless other intentions be also fulfilled.
The warm bath, followed by frictions of the
surface, or by the terebinthinated epithem on the
abdomen, and by diaphoretics, will also be of great
service.

255. h. Whilst vascular depletions are thus
necessary in the more concentrated and inflam-
matory states, which rapidly pass into the adyna-
mic or malignant form, they are inapplicable to
those in which the powers of the system are
insufficient to produce vascular reaction ; at least,
they should never be employed until efforts at
reaction are made, when a small or moderate
general or local bleeding may be directed, espe-
cially after the warm or vapour bath and frictions
of the surface, with the view of relieving the
overloaded vessels of the large viscera, and of
removing congestion of the venous trunks and
auricles of the heart. If an adynamic state has
continued from the commencement, the skin of the
trunk being harsh and dry, the extremities damp,
the pulse weak and rapid or irregular, the tongue
dark and coated, the bowels disordered or costive,
and the evacuations morbid, the vital energies of
the frame should be roused by means of the hot
or vapour bath ; by assiduous frictions with sti-
mulating liniments (F. 299,300. 311.); and in-
ternal congestions removed by warm diaphoretics,
stimulants, purgatives, and mustard poultices,
or the hot turpentine epithem applied over the
epigastrium and hypochondria, and, in extreme
cases, on the insides of the thighs also. In this
latter class of cases, calomel is still indicated,
especially if the stomach be irritable; but it
should be conjoined with large doses of either
camphor, ammonia, or capsicum, with opium.
Subsequently, the bowels having been very freely
evacuated, and the states of the tongue, of the
pulse, and of the skin not forbidding, bark in de-
coction, or sulphate of quinine, may be pre-
scribed.

256. c. A similar treatment is indicated when
an adynamic or malignant state supervenes on
that of low excitement — when the sVin becomes
yellowish or dusky, and the irritability of the sto-
mach urgent or disposed to pau into the dark
gnimous vomitings, indicating great danger. This
affection of the stomoeh is much more violent when
it is consequent upon excitement than when it
occurs in the course of a fever in which excite-
ment has been imperfectly expressed ; for, in the
former case, the vital power of the organ is ex-
hausted, and the organisation affected; in the
latter, power is simply diminished or suppressed,
restoration being more easy in it than in the
former. In both circumstances, the external de-
rivatives just mentioned, and calomel in the com-
binations specified, are chiefly to be relied upon.
When the vomiting consists of a pumping up of
the contents of the stomach, rather than of active
retchings, cordial stimulants should be employod
in addition to these; and aromatic sptccA, am-

monia, ether, camphor, opium, &c., may be
variously combined. Fluids evdving eubonc
acid, as spruce beer, seltzer>water, aodm-waier,
bottled stout, &c., may also be prescribed. In a
few urgent eases, I have found tnm half aa ooncc
to an ounce of the spirits of turpentiiie, taken on
the surface of milk or anj aromatic water, with
half a drachm of magnesia, allay tbe initebility
of the stomach, lower the pulse, and reodcr the
tongue moist, after other metsnrei had failed;
and I have exhibited this dose, or F. 216., as a
purgative, three or fonr hours after a bolaa ceo-
sistiog of ten or fifteen grains of camphor aad
calomel, with one, two, or three of opian, htd
been taken ; promoting the action of the bewds
by warm cathartic enemata, if necenary.

257. d. In low, miasmatons distncts, bark or
quinine, in suitable combinations, is ofteo necc*-
sary in an advanced stage of the adyoannc stale*.
The former in substance, honvever, or the Utter ia
large doses, generally irritates the stomach, and
it then proves injurious. The infosioo of bark,
therefore, with the chlorate of potash, or with bydiv-
chloric acid or ether ; or the aecoctJoa with hydro*
chlorate of ammonia, or with nitrate of potash. t»i
the solution of the acetate of ammonia ; dioaM he
first employed: and subsequently, the qomias
with acids. But while we thus endcaToar to sap-
port vital power, morbid secretions and facal col-
lections should be fully evacuated, either by miU
purgative draughts, — and preferably by those cf
a stomachic or tonic kind, — or by eoemata, or b^
both. If the combination of the mild preparatioat
of bark with the antiseptics and refngacaots jast ia-
stanced are inefficacious, the more eoergatic pf«-
parations with ether, or the preparatioD of amiB»>
nia, or with aromatics, &cc. must be laaortad to.

258. D. The eompUeaUd states mast be nmed
with reference chiefly to the oondttioD ia whici
vascular action and vital power are maaifesied.
The treatment of the more inflammatoiy compli-
cations has been already described. The eompti-
cations of the more adjrnamic states are so drrcni-
fied, that the measures already recoamcadal, as
well as others about to be noticed, muaa be adapted
to individual circumstances. If an irritable or dy-
senteric state of the bowels occur, morbid sccntiuw
or fecal accumulations have probably caased «<>
ritation of the mucons coat. A fall dose of calo-
mel should therefore be given, if it have beea
neglected, and be followed by a commoa pvrfiaf
draught, by castor oil, or F. 181. 216. 266. ; and.
in a few hours, laxative enemata, aiMi demaimti
should also be administered. After the fall oper-
ation of these, anodynes, with gentle altetatna
and light tonics, or the preparatioat of bark m
quinine in the forms above mentioaed, aMiy ht
exhibited. In (he adynamic states, this compfi-
cation is very unfavourable, especially wfaca the
stools are very dark, black, or otherwi<« awrhid .
and the abdomen swollen and poinfiil. Calotscl.
with camphor and opium, is necessary ia sar^.
and large blisters, or the other external applirs-
tions previously directed (4251.), are especially
indicated. Tonic purgatives, &c. are aW vv>
quisite ; and bark or quinine in large do«», sad
in forms of combination most anpropiiate to tk»
particular class of cases. The other corapUeatieB*
either have been already noticed, or de«Miad r>*
material modification of the treatment. WMW*
seated in the head, thorax, or abdooKn, the tUMt

966

FEVER, REMITTENT— Chronic— TaEATMEKT.

265. B. Th$ tymptonu consist chie6y of greftt
muscular weakness, which often appears unac-
countable, of sinking sensations, and diaitaclination
to exertion. A slight chill is often present in the
forenoon, or about midday, or a creeping cold
down the spine. During the afternoon, evening,
and night, a slight degree of febrile excitement is
manifest, and the palms of the hands become hot
or burning. The tongue b generally white, and
the apex and edges are often somewhat red. The
urine is often pale and abundant in the morning,
and higher coloured, and more frequently voided,
in the evening and night. The patient is some-
times unable to follow his occupations in the
morning ; he wakens unrefreshed, either from a
feverish, restless, or disturbed sleep, or from a
lethargic, dreamy, and prolonged sleep ; he is
fatigued all morning, without knowing where-
fore ; is depressed, anxious, and irritable ; or
complains of want of mentoi energy or ability,
and of dull headach ; and, as the chills and
sinkings of this period pass into a gentle febrile
excitement, he feels more restored in the after-
noon or evening. In the case of a delicate, most
talented, and accomplished female, subject to
this disease, and liable to relapses of it during
cold easterly winds, although the most distress-
ing, sinking, and exhaustion were often felt in the
morning, so that she was hardly able to dress
her&elf, or to get up to breakfast ; yet she often
could in the evening exert and enjoy herself.
The pulse is occasionally not materially disturbed :
it is frequently accelerated and a little hard, in
the course of the exacerbations, but is commonly
weak and slow, in the remissions. The bowels
are generally sluggish; the evacuations slightly
disfftdered; and the appetite, when the heat is
considerable, and the exacerbations very marked,
is much diminished, and generally capricious.
The patient loses flesh during the attacks, and
various anomalous symptoms referrible to the
stomach, bowels, and other abdominal viscera,
often present themselves ; and, when they become
prominent, are liable to be considered and treated
■s the original complaint.

266. In many cases, although these ailments are
both real and distressing, the patient is considered
as either feigning, or hypochondriacal. In these
more especially, and when the course of the com-
plaint is less regular, the time of the day when the
exacerbations and remissions occur, varies much.
If they are tolerably regular, tbe^ often present a
quotidian, tertian, or double tertian character, the
symptoms being worse on alternate days. In the
more chronic cases, the mind becomes irritable or
despondent, and in some instances this latter feel-
ing is most distressing. Dr. Ellxotson confirms
the remark of Dr. Macculloch, that the exacer-
bations are often unobserved from occurring in the
night ; increased heat, oppression of the head, and
depression of spirits, amojnting to hypochondri-
asis, being the chief symptoms. The nights are
frequently the periods ot greatest suffenng. A

Tentleman, who consulted me in the summer of
834, described them as being most dbtressing.
In another case, an inability to think, with con-
fusion of ideas, was complained of; an inflam*
matory dyspepsia, a burning sensation at the
stomach, ana other symptoms of irritation of the
digestive mucous surface; spongincsji of the gums,
and soreness of the tongue, which often becomes

smooth and divested of its papilUe, occasiouallj
appear in the advanced coune of the disease ; aad
ultimately serious disorder of the abdominal organi,
prostration of organic nervous power, and a state
of ill health, amounting to geneia] diaeaae, sapo-
vene.

267. In some instances, this complaint aew
more of the intermittent character, and at dilig-
ent tiroes it seems to vacillate between the rewt-
tent and intermittent types; but there is tv6j
any distinct cold stage or a greater feeling of cokl
than that above mentioned {§ 265.), exeepdog at
the commencement of an attack, or of a relaaie.
Signs of functional disorder of the liver, sm of
torpid function of the colon, ofteo appear, e«pc>
cially in this class of cases ; and the disease ii
frequently considered a form of liver cooaplaiat ;
the heavy or dull headach sometimes atleadiog
it being imputed either to the same loafce, or »
the accompanying affection of the stomach.

268. In conclusion. Dr. Maccullooi dt*
scribes this form of remittent as modiBcd chidlj io
degree and duration, it being often so slight m
to require some attention in tracing its fonn, asd
even its existence. It is apt to become habitiMl,or
to recur at frequent but variable intervals, dttrisp
even an indeBnite coune of many yean; nrfw^
in such a course its characters and synptm
and being in some cases a marked duenie iattf'
mittent, in othen remittent, and io some so bncf
and imperfect in its reroisaioos as to be sIboa
continued. Its acoeasions are of the ofdiaaiy
duration of remittents, and they commonly obierve
the quotidian or double tertian periods. It if,
moreover, often a primary disease : sometiiMs it
is consequent upon ague, or the severe states of
remittent, or even upon continiied fever; sod,
whilst it is especially caused by malaria, io sink
of the slighter modes of this poison, it may po»*
sibly arise from other sonroes ; or, after a fint
attack, a relapse may be caused by cold, OMiitoR*
atmospheric vicissitudes, the lue of cold or drs^
purgatives, vicissitudes of teinperatore, laten-
perance, bloodletting, and exoeaaive evacoatiaH.

269. Treatment. — a. The slighter, pnDarr.
and more recent states of this complaiat are it>
moved by the sulphate of quinine, the pfvpan*
tionsof bark combined appropriately to part^ular
cases, by Fowler's solution of arseoie sad
change of air ; the bowels being duly reguhoed b;
laxatives, or mild pur|(atives combmed with bitter
tonics (F. 266. 562. 572.) But the tuan cbroeie
states, especially when the nenroos §pttm a
much affected and the patient bai beeoM
desponding and hypochondriacal, are traated with
much Ic^s success. If it de^cuciile into roa-
firmed hypochondriasis, the caae'ii one of the
roost difficult that comes before tlie piactitioBcr.
In some instances an active exhibition ef mfp^'tr
of quinint is of great benefit. Dr, Eluotsov sl*
ludes to a case in which five grains were pvca
three tiroes a day without benefit ; hot the 6<m
having been increased to ten grains, relief was pr^
cured. When signs of inflammatory iiritstioo c/
the digestive canal exist, the decoctioa of baik
should be first employed with the nitraleof p8<a^«
or with the hydrocblorate of ammonia; and if tbt
tongue he flabby, and thegumssponKy»asinthecas'
above alluded to, the decoction may be civca with
hydrochloric acid, or with the nifro hydmchkne.
ot vf'ixh the chiaratefifjfoltuh^ The coohuafaoa t'

958

FEVER, REMITTENT, OP CHILDREN ^DncBXPnoN.

the root. Fever supervenee, and is ushered in by
cold, rigors, or chilis ; the child being hot and
restless at night The febrile eucerbations gene-
rally recur in the afternoon, and during the
night; but there are often three fits, one also
occurring in the forenoon; and, in the most
severe cases, the remissions are very indistinct.
During the exacerbations, the child is drowsy ;
and, if it sleeps, starting, moaning, and even
screaming, or incoherence, are observed ; some-
times with vomiting, flatulent distension of the
abdomen, accelerated respiration, and cough.
The pulse varies from 120 to 160, according to
the age. The cheeks are usually flushed ; the
abdomen and palms of the handis being hotter
than other parts of the body. Occasionally, the
paroxysm terminates in a slight perspiration,
which is often partial ; the child falls into a quiet
sleep, and the pulse sinks in frequency. During
the remiasiont he picks his lips or nose ; is irritable,
and without appetite. The bowels are acted upon
with difficulty; the evacuations are generally
unnatural, but present no constant character;
and worms are occasionally voided. The urine
is 'now transparent, of an orange colour, and its
quantity in relation to the fluids taken ; and ail the
other symptoms noticed above are present in an
aggravated form. As the disease declines, the
exacerbations become mild and short, and often
terminate in a gentle perspiration, with a sound
or refreshing sleep ; the urine deposiu a sediment,
and is pale ; the appetite returns ; and tlie stools
assume a healthy aspect. But the pulse remains
frequent, and the flesh and strength are regained
very slowly, unless change to a mild dry air is
adopted. If this form of the disease be either
neglected, or improperly treated, or if the child
remain in a moist or miasmatous situation, organic
change, in some important organ supervenes;
or the complaint passes into the chronic form,
hereafter to be described ; or degenerates into
marasmus from mesenteric disease. It usually
terminates in from two to four weeks in the more
favourable cases.

275. B. The more adynamic variety, or state
of the complaint, is the least common ; except-
ing in low, humid, and miasmatous situations. It
is sometimes prevalent at the same season with
the Cholebic Fever of Infants (see this ar-
ticle), evidently depends upon the same causes as
it, and is a very closely allied complaint, difier-
ing from it merely in the type of the fever, and
the degree in which the digestive canal is afiecled.
This variety commonly begins more suddenly
than the others ; the earlier exacerbation being
attended by the same symptoms as the preceding,
but by greater affection of the bead, and by deli-
rium in the older children ; and quickly passing
into more or less exhaustion. When this change
takes place, the child becomes quiet, or indifierent
to external objects, and indisposed to the least
exertion. He dozes, and is incoherent in the
exacerbations ; and, in the remissions, he lies in
one position, contanlly picking his face, parti-
cularly his lips and nose, until they become sore ;
or keeping his hands in continual motion. He
usually, however, takes both food and drink, al-
though sparingly. The countenance is anxious,
pale, and unhealthy ; the eyes reddish, especially
the edges of the eyelids; the lips are covered
with dark, ragged crusts, or exfoliatioiis of their

epithelium ; the tongue and teeth are loaded with
dark sordes ; the bowels are much disordered —
often irritable ; and the stools are very ofientive.
watery, greennh, or otherwise morbid, aod pn-
ceded by much griping and flatulence ; bosh the
stools and the urine are frequently passed invo-
luntarily. When a favourable change takes place.
the symptoms gradually subside ; tht voiee, whieb
was nearly lost, is regained or beconea slroo^vr :
the eves are more lively ; the tongue is cleaner,
aod the evacuations improve ; the exaeerbaiiow
being shorter, and the remissioiis more pcffect
and prolonged. This variety is generally osorc
chronic than the preceding, bat less so tfaaa
the next. It usually continues fiom one to two
months.

276. C. The chronic form of remittemt in chil-
dren either makes its approach gradnally and
insidiously, or follows the acute. Tbo ebiU
wastes; the abdomen enlarges; tho breath is
offensive, and the strength fails. There is oon-
monly only one exacerbation in the twtmiy^fomt
hours, and it seldom appears before evenm*-.
lasting till morning, and terminating in swceik
The pulse is usually about 100 in the day, bvt
rises to 140 in the evening. The tongue b white
or loaded, but moist, and has often a stfawbcrry
appearance; the bowels are generally eostife.
and the stools always morbid. The child com-
monly keeps up, but is disinclined to move, or
complains of aching in the limbs on ozertioo.
There is little or no appetite or thirst ; mmd the
other phenomena characterising the coBaplaint,
in its common form, are present in varioos i^ndes
of severity. If the disease is not removed, tym-
panitic distension of the abdomen, coadaiMB,
harsh discolouration of the skin, enlarged meren-
teric glands, aphthous sores on the lips and too^ne,
chronic diarrhoea, and lientery anpervcne. H hea
the disease declines, all the symptoms gradually
amend ; the nocturnal exacerbationa alMiie ; cad

convalescence is established alter a period varying
from two to four or five months.

277. This disease is generally sporadic, bnl ■ al«e
sometimes epidemic. It is endemie in esbealthy
localities ; and many of the children bom of Euro-
pean parents in hot or unhealthy clxmates an cot
ofl'by It before they reach their sixth or seventh year.
When it occon epidemically, it nsaally asenuiu
the first or second of the above forms ; and ptovcs
both more rapid in its course, and more dantetoes,
than in the ordinary states. — Dr, Sims, aner do-
scribing the fevers prevalent in London in the
years 1769 and 1770, which seemed chiefly to
result from the endemic sources sunoundiDg ths
metropolis and the state of the seasons, gives a
very graphic account of this complaint, as it ap>
peered epidemically during these years, and aiaal-
taneously with these fevers. As his descriptma
very nearly represents the disease as 1 have sera
it in very low and miasmatoos sitnatioBSy I shall
abridge it at this place. He remarks, thet it was
called by some a worm fever, though woraas were
seldom the cause ; but as that apparently lay in
the stomach aod intestines, the error did not ma-
terially affect the practice. It was most ceaiF»ee
in children of a sallow complexion and thia haW.
who had been over-fed, witn the mistaken view of
supporting and nourishing tbem. — The Wediof
symptoms were, heat, thirst, quick, lull mi1>«,
vomiting, coma, and somelimet alighi coavwawas.

960

FEVER, REMITTENT, OV CHILDREN ^TftEATMiw.

proved by the facts that such depravatioa must
Itself proceed from anterior disorder, and that a
treatment based solely upon the above doctrine
is not generally successful ; a free and healthy
state of the alvine evacuations being often brought
about without the complaint being removed ; —
/. That, in order to cure the complaint with the
least delay and the greatest certainty, it is neces-
sary to evacuate morbid secretions from the jnima
via, to impart energy to the organic nervous sys-
tem, and to change the morbid states of the
various related or dependent organs.

282. vi. 1 REATMENT.— il. The practice advised
by MusoRAVE, Butter, Stms, Pemberton, and
others, although furnishing valuable hints, is
more or less defective ; for, whoever trusts to it
alone, or those whose resources extend no fur-
ther, will occasionally find the disease by no
means so easily managed as they expected, and
will see it prolonged until the treatment is taken
out of their hands, and, by the common sense of
the parent, limited to change of air, and light
nourishment ; which, although amongst the most
efficient remedies, have been very generally over-
looked by writers. In all cases the treatment
should be commenced with a moderate dose of
eahnui and JameiU powder at night, and a suffi-
cient quantity of the bitter aperient mixture
(F. 266.) or of rhubarb and sulphate of potash,
or of rhubarb and magnesia, to act upon the
bowels. If these are inefficient, an enema should
be thrown up ; and from an experience of many
hundred cases, I would recommend for this pur-
pose equal quantities of castor oil and spirits of
turpentine in water-gruel. At first, the above
powder should be repeated every night, or on
alternate nights, and the purgative in the morn-
ing, the injection being also employed every
third or fourth day. At a more advanced stage of
the treatment, and when the evacuations have
improved, they may be prescribed less frequently.
The choice of other means must depend upon the
peculiar features of the case.

283. B. If the disease be of the form in which
it usually presents itself ($ 273.), and the evacu-
ations have been improved by the above means,
an in/Vinon of cinchona , or of eateariUa, or of
valerian, with liquor ammoniie aoetatis, will be
found of great service. If the bowels be still dis-
ordered and torpid, the tulphate of quinine may
be given in a solution of any of the neutral sul-
phates ; and the abdomen rubbed assiduously with
a warm itimulating tiniment ^F. 311.), light nou-
rishing diet, or a course of ass s milk, and change
of air, being afterwards ordered.

284. C. If the complaint be of the acute form
(§ 274.), and the child be plethoric and strong,
a few leecha may be placed over the epigastrium
at the commencement of the treatment, and after-
wards a mustard poultice, or any rubefacient epi-
them may be applied ; but the purgatives just
mentioned, or similar medicines, should be pre-
scribed ; and the solution of acetate of ammonia
with sweet almond emulsion, and camphor mix-
ture, should be taken in the course of the day.
After the more acute symptoms have abated, the
infusion or decoction of cinchona, or the infusion
of easrarilla, or of ealundn, may be given with
small doses of liquor potasss, or of the hydro-
chlorate of ammonia, or the nitrate of potash, or with
Hquor ammonia acetatis, sweet spirits of nitre. Ace.

285. D. W heo the disease assames the nfyBamie
state, above described ($ 275.), and when it ha«
been of long standing, or oonsiderabie exhaas-
tion has supervened, a further modification %( the
treatment is requisite. 1/ the bowels have aei
been sufficiently evacuated, the sbov* meatj
should be employed for the purpoae ; nnd either
the sulphate of quinine, or the preparatians of
bark, or of other tonics, especiaUy cnacariUa,
ought to be taken during the reauaaioiis. la all
the varieties of the complaint the reauMMos
should l»e selected for the exhibition of bark,
quinine, or other tonics, commencing at the sab-
sidence of the exacert>atioo. In this sitaie of
the complaint, I have prescribed, for mmnj yetn,
the chlorate rf potosfc in an infmion of vaienan,
or of cinchona, with great benefit, keraing the
bowels moderately open, and directing tne above
liniment (F. 311.) to be rubbed along the apiae,
qr over the abdomen.

286. £. When much pain is felt, nad the belh
becomes distended with flatus, the eaeoia advi^ii
alMve should be administered ; and either aa ano-
dyne fomentation applied to the abdomen, or the
liniment robbed upon it. Musoaava recoauneads
poultices, or /onwaiottoNs with the wai^ deeoc*
tion of rue and aromatic herbi, A decoeboa of
chamomile flowers, poppy heads, and me, in the
form of fomentation ; and a little sptrit, or od, o<
anise-seed, added to the medicine, will gcsKfallj
give relief. A warm bath at bed-tin»e» or the
semicopium, some salt, or mo«aitl flower, or
both, having been added to the water, will eiea
be serviceable, especially in the low or advaaeed
states of the complaint.

287. Dr. BuTTsa placed much depeadeoee apoa
the extract of eomium, in doses of .one grata ia tht
day for every year that the patieat was old. ia
conjunction with saline aperients. It ia of little
service of itself; but is often an asafol adjaoct
to the medicines already advised, especially if the
child be very peevish, the abdomen pained, or ite
bowels irritable. Dr. Cheynk relied moei apoa
colomel with antimony at bed-time, and the com-
mon purgatives, giving the former more IreDoeatly
if the complaint seemed liable to jpaae intokydro-
oephalus. Dr. Clarke and Dr. PajaaxaiO'%
insisted chiefly on tonic infusions, after the bo«<l»
were freely evacuated. These are feaoml*y
serviceable in the circumstances and comhiaacioas
pointed out, and the addition to tbea of the ex-
tract of conium is also beneficial. In some oM
cases, in which there was reason to suppose that,
in connection vrith debility, there was aooM de-
gree of obstruction of the mesenteric glands, I
have given the iodide of potaeeium inftanially, ia
small doses, with great advantage; bat eaie
should be taken not to prescribe it in doses large
enough to irritate the stomach and bowels, other-
wise It will increase the disorder,

288. F. The regimen and diet coostitate a prin-
cipal part of the treatment. Change of air, as eaHv
as possible, especially to a mild and dry air, and
elevated situation, is always most ocrvioBsble).
Warm clothing, frictions of the surface after ih»
warm baths, and light but aoarishing d»l, art
also very beneficial, particulatly wbca roa<-
valescenoe has commenced. Dariag the com-
plaint, ass's milk, rusks, and weak brocb, are
suiuble food. But, in the acute Ibrm, or at tin
commenoement of the disease* evco thoie wmj be

962

FEVER, HECTIC — Descbiptxon-^Cavbss akd ViBirraes.

meDon which will enable us to recognise their
precise seat and nature, and yet give riae to hectic
fever.

291 . Mr. J. Hunter contended for its idiopathic
existence, by supposing that the constitution may
fall into the same mode of action, without any
local cause whatever, as proceeds from such
cause. This is, however, no argument. He fur-
ther observes, that nothing is more common than
for hectic to exist in patients in whom no local
disease whatever can be traced ; and that, in such
cases, either random suspicions are to be thrown
upon the lungs, liver, kidneys, heart, or me-
senteric glands, as casual i^mptoms may sug-
gest, or Its idiopathic nature must be inferred.
Admitting that there is some truth in this, it
should still be contended, that improved means
of diae^nosis, and a more intimate acquaint-
ance with the origin and relations of morbid 'ac-
tions, have greatly abridged the number of
instances in which no local lesion can be detect-
ed ; and that, instead of this circumstance being
common, it is remarkably rare. It is somewhat
singular, that the same author, — M. Broussais,
— who has written so ably against the existence
of fever as an essential or idiopathic disease,
should have produced, in 1803, a work on hectic
fever, in which its idiopathic nature is strenuously
contended for, and its various forms very mi-
nutely described — the least idiopathic of all
fevers having been considered by him chiefly as
such; — M. Broussais had, however, not then
changed his opinions as to the nature of fever.

292. i. Description. — The early symptoms of
hectic are— emaciation with a pale, and often fiur,
skin ; increased frec^uency of pulse, especially at
noon and evening, with some degree of hardness or
sharpness ; rapid or short respiration on any ex-
ertion ; and increased heat of skin. — The exacerb-
ations are at first very slieht ; but they soon be-
come more evident, particularly in the evening ; are
preceded by a slight or marked chill ; are attended
by increased heat, which is most evident in thehands
and face, the skin beine at first dry ; and terminate
in a free, profuse perspiration, especially the even-
ing paroxysm, which usually subsides in this man-
ner early m the morning. The bowels are costive,
but afterwards readily acted upon ; ultimately they
are relaxed, and colliquative diarrhcea supervenes.
The urine is various, but most freauently pale and
without deposit ; more rarely high-coloured, and
with a lateritious sediment. As the disease ad-
vances, the delicate circumscribed bloom on the
cheek, which was at first only occasional, is more
constant and general, especially during the exa-
cerbations ; the throat and fauces are red, dry, and
irritable ; the tongue is oflen clean, red, smooth,
without papills, and glazed, and ultimately,
with the lips and fauces, is covered by aphthous
exudations; the eyes are sunk in their orbits,
from the absorption of adipose matter, but are
brilliant and expressive, their whites pearly and
clear ; the whole frame is emaciated, and the
temples excavated ; the hair falls out ; the ankles
and sometimes the legs are oedematous ; sleep is
unrefreshing, feverish and disturbed; and de-
bility vnth a sense of lassitude is constant, but
the patient's spirits are unbroken or even san-
guine. At last the diarrhoea and colliquative
sweats become daily more abundant ; the respir-
ation short and precipitate ; and the debility so

great, that the patient often expires wbca attempt-
ing to speak, or on assuming a sitting po8t«ie, Uc.
During the course of Uie disease, the lenMraJ
functions preserve their iotcgrity; but somettiDtf,
towards the close, slight delirium occurs. In thoM
cases especially which depend upoa ofgaaic
change in the respiratory orvans, tbere are more
or less dyspnoea, cough, and expectoratkm ; the
nails become incurvated ; the last joints with the
extremities of the fingers fuuform, and the ex-
pectation of recovery gains stren^gth with tkc
progress of disease. (See Tubercui^r Co!«su«r»

TION.)

293. MM. Broussais, Foornirr, Vai^i,
BoissEAo, CouTAN^EAiT, Rttd sooie Other writen.
have divided hectic into tkrte ttagtt : the Ji.r*
continuing as long as the appetite and stien^l
are not materially impaired, and the rrmninni
are distinct ; the ieeond consisting of a sbsj].
Quick, and frequent pulse, accelerated duna^
tne exacerbations, with debilitating penpiratao«s
burning heat of the palms of the hands and solo
of the feet, and rapid emaciation ; the third m-
pervening with the colliquative diarrhoea, tedecA
of the lower extremities, extreme enciaciatian sad
prostration of strength.

294. ii. The Causes of hectic fever are re-
markably diversified. — It most conunottly pf^*
ceeds from suppuration, iiIceration» chrosiic in-
flammation, excessive action, and irrifeatioa of a
secreting or^n or surface ; from caxiea, nreross,
or structural change of osseous parts ; and frm
slow inflammatory action of any part whaict«r
of the frame. It also attends upon Tariotu ad-
ventitious and malignant productions. Bal a
all these, it is merely a symptom of the extent to
which the constitution is influenced bv the local
change. M. Broussais has distix^uisbed serenl
varieties of hectic according to the nature aad
seat of its principal causes; as, the Gosfric, t&e
Pectoral, the Genital, H^nnorrhagic, C«x«w.m».
Moral, &c. Hildenrrako enunaeraies the iiJ-
lowing : the Inflammatory, Putrid, Nervimt, Ga*>
trie, AtrabiliouM, Pituitou*, Vermimms, Emtn^
mesenteric, and Suppurative, to which auy tc
added the Puerperal. As each of these vaiKtM
attaches to itself more or less importance, and •»
the division adopted by M. BnoosaAis has bc«s
very closely followed by numerous recent wnun.
I shall offer a few remarks in illustration.

295. a. Gastric Hectic is distinguished by aao-
rexia, thirst, dryness of the month. piroUwicvd
and difficult digestion, and more or leas of ih«
usual concomitants of indigestion, especially
eructations, flatulence, acidity, cardialgw, ^c
Sometimes the appetite is unimpaired, or •
even increased, but digestion is laultj. 7^
tongue is loaded, the mouth damny, and tite
taste disordered. There are often uneasincK st
the stomach, tenderness of the epieastrnua, Mzd
frontal or sub-orbitar cephalalgia. 1 he ccmtpUia*
is exasperated by heating food, and the abo^ df
stimulants, which occasion a senae of heat m t*»
stomach, or pain and cardialgta, with acid <r
acrid eructations. Ultimately the patient U-
comes pale; the breath foetid; thebowebcotfjv^.
irregular, or even irritable; and the symntoan «<
hectic fully developed. In ehitdrtn, pickini: »{
the nose, mucous diarrhoea, and ocoaaiaaallr
the expulsion of worms, are also observed . ar^
the disorder is almost identified with, or is mcrr^^ s

964

FEVEE, HECTIC— Proono»ib—Pathom>ot.

— a. Inflammatory Hectic is merely that form of
symptomatic fever which usually attends chronic
inflammation of an internal viscus, or of a deep-
seated part. — 0. Putrid hectic is the fever
sometimes attendinp^ scorbutic affections, or gan-
grenous and spreadmg ulceration, &c. ; or arising
from unwholesome and innutritions food. —
>• Nervous i/ectic is the constitutional disturbance
observed in persons labouring under mental
afflictions, &c. ($ dOO.)> or chronic disorder of
the nervous system, and in chlorotic and hysterical
females. — 8. Atrabiliom Hectic presents itself in
persons 'long subject to disorder of the liver and
other digesUve oi^ans — whose portal circulation
has become congested or obstructed, their bi-
liary and intestinal secretions morbid, and their
digestive canal torpid or overloaded. Such per-
sons are morally and physically depressed ; are
melancholic and hypochondriacal, sallow, squalid,
and thin; are often affected with shortness of
breath, colicky pains, disordered bowels, tenesmus,
and hemorrhoids ; the stools are dark, foetid, and
scybalous, and the abdomen frequently hard or
tense. — i . Pituitous HecticiB merely a modification
of the gastric ($295.), attended by pituitous col-
hiyies in the prima via, owing to imperfect power
of the organic nervous system. It is common in
children, and is characterised by pallor, leuco-
phlegmatic indolence, and torpor ; swollen lym-
phatic glands, increased secretion of mucus;
tumid abdomen ; fluor albus ; the collection of
viscid mucous on the tongue and teeth ; coryza,
mucous diarrhoea, and obscurely remitting and
slight fever. — {. Verminout Hectic is a modi-
fication of the foregoing, or the association with it
of worms in the intestinal canal. It is occasion-
ally ob8e^ved in delicate and relaxed, or rickety,
or scrofulous, children ; and in those who live in
low, damp, close, and unhealthy localities and
apartments, and who are subject to chronic bron-
cnitis or winter catarrhs. — n. The Etitero^mesen-
terie is a modification of the pituitous and gastric,
particularly when occurring in children ; or is
rather the association of enlargement of the me-
senteric glands with the affection of the digestive
mucous surface, chiefly constituting these varieties.
It is hence closely allied to the affection already
described under the head of Infantile Remittent
($278.). — (See also art. Mesenteric Decline.)

302. A. The varieties of hectic which arise, from
the formation of matter in internal viscera, from
tuberculous ulceration, from carious bones, &c.,
from the irritation of foreign substances, and
from chronic inflammation affecting parts possess-
ing a deficient power of reparation, possess gene-
ral features of resemblance, but vary in the more
minute details, and differ not matermlly from the
general description given above ($292.).

303. iii. PnooNOSis. — The duration of hectic
varies from a very few weeks to a number of
years ; but, however lon^, the tendency of the
disease is fatal, unless circumstances occur or
medical means be used to arrest its course — un-
less the causes on which it depends are removed.
— The danger is owing entirely to these causes,
and is great according to their nature. — In cases
of caries, or of other local diseases which admit
of removal, the fever disappears soon after the
separation of the morbid from the healthy parts.
When the disease depends upon the continued or
repeated irritation of a secretmg surface or gland,

asinitsiearua/ and murperal vorietin ($297,298.),
and in the chronic forms of bronchitis and diaxihota,
it generally disappears with the cause witich pro-
duced it, unless serious disease of some imporunt
viscus, as of the lungs, has been superinduced in
its course. But when chronic iiiflammation coo-
tinues to destroy, or to alter the stmcture of»
some vital organ or deep'«eated tisae, or when
the substance of an internal viscus is in a stale ot
suppuration, or when hectic proceeds from tuber-
culous formations, recovery seldom takes place.
Yet, in some of these cases, the powers of lile
continue long to resbt the progress of disorgmai*-
ation ; and occasionally at last are auccesslal, not
only in limiting it, but also in remoTingthe chnf
of whatever changes had taken place. This is de-
monstrated in the adhesions of serous anrlac«, in
the absorption of purulent collections from tike
substance of internal viscera, or in their discbarge*
and in the subsequent cicatrisation of the parts
affected. Both the liver and lungs famish praoCi,
although in rare cases, of soch occnnencciw
£ven a lobe of one of the luoss may be eotirtly
destroyed by suppuration, and the patient recover.
Where the cause is obscure, and we (kmbt whe-
ther the disorder is idiopathic or the conaoqaeaee
of some lesion that eludes detection, the pelirat
being young, and vital power not fiar redaced,
hopes should be entertained. But when stieacth
is tar reduced, emaciation extreme, and colbqaa-
tive diarrhoea or perspiration is present, there ■
little or no chance of recovery.

304. iv. Pathologv. — i4. i he Lt$iomM^fmi^ •
tem^ consist — 1st, of those which caumd the fncr
($ 294.) ; — 2d, of alterations of the mncoua snrfsre
of the digestive canal, upon which the diarrhea

S resent in the last stage mainly depended ; — 3d, of
isease of the lymphatic and mesentefic glands ; —
and, 4th, of redness and inflammatory diooolotxr^
ation of the lining membrane of the heart and largr
vessels. — The various lesions from which th'%
fever may proceed, require no further notice than
has been taken of them in other articlei; but
those which are evidently consequent upon rts
early stages, which aggravate it in its coane.
causing the more severe symptoms charactcriiia^
its latter periods, are deserving of attentioB. —
The changes in the digestive mucous surlace con*
sist chiefly of tubercular depositions, and of nicer-
ation seated more especially in the lower part of tia«
ileum and in the cecum, with softening, and ftr-
quently with superficial redness, of the mucocs
membrane. The ulcers, however, are often un-
attended by redness, thickening, or aneqiiivoeall«
inflammatory appearances ; and are entuely nm'<-
lar to those described in the article Dsoun^i
Canal {i 36. et $eq.). The changes in the ab-
sorbent glands are the same as those described in
the article Lymphatics.

305. The lesions of the circulatiag system have
been overlooked, until notice was directed to them
by BouiLLAUD, who has given the details of a
number of cases of hectic, in which the imcraAi
membrane of the heart, and large vessela. both
arterial and venous, presented mote or lem of ia-
flammatory redness ; the substance of the hcan
itself bein^ often soft and flaccid, and atheroc&a-
tous depositions being sometimes found in the la-
ternal membrane of the arteries. — Several yean
ago, I observed the internal Lining of the pal-
mooary vein, and of its principal bnuichos* of a

966

FEVER, HECTIC— Treatment

ation ; are among the most effectual means of cure. '
Seltzer water, soda water ; the mineral waters of
Pvrmont, Carbbad, of Gielenau , of Ems, of Vichy,
of Bath, of Tunbridge, &c., are severally useful, if
appropriatelv prescribed. — When the disease is
occasioned by suckling, the cure is generally
speedy, if the cause is relinquished before an im-
portant organ becomes affected ; and if a restor-
ative regimen, with change of air, be adopted . I n
auch cases, the mistura ferri composita, and cha-
lybeate waters, or the mineral waters just men-
tioned, are very serviceable.

310. d. The treatment of the other varieties of
hectic is not materially different from that now
stated. — When the disease follows htanorrhaget,
the means of cure should be directed especially
to the pathological state of which the haemorrhage
is the result. (See that article.) — If it be connected
with cittaneout eruptions, the state of the digestive
organs, and of the frame generally, ought to
claim an especial notice ; and if it originate in
mrnital emcttottt, such measures as are the best
calculated to divert the mind from contemplating
the sources and relations of its misery should be
prescribed. — The QtrabiliouSf pituitous, and ver-
minout varieties require the combination of tonics
with warm purgatives (F. 657— 663. 572—676.),
chalybeate mineral waters, and vegetable and
mineral deobstruents.

311. e. When the irritatum and absorption of
morbid nuttier are the causes of hectic, their
sources should be removed ; especially when they
consist of carious bones, diseased joints, puriform
collections, &c. But when.this indication cannot be
accomplished, or when the preservation of a limb
Inquires that every means should be tried, the
treatment ought to be directed with the view <—
Ist, of diminishing irritation ; and, 2dly, of coun-
teracting or resistmg .the contaminating influence
of the morbid secretion on the circulation. — The
Jirst of these is to be fulfilled by a judicious use
of opium, morphine, hop, henbane, hemlock,
&c.; — the second, by medicines which support
rital energy, and .thereby resist the extension of
disease, or projgaote the powers of reparation ; as
digestible nou^shment, dry and pure air, gentle
tonics, antiBejwcs, absorbents, and astringents.
These may be variously conjoined, according to
the pecttbarities of the case — anodynes and nar-
cotics with tonics, and tonics with antiseptics and
absorbents. Thus, the infusion of cinchona may
be prescribed with muriatic acid and the muriate
of morphine ; the infusion of cascarilla with the
solution of the acetate of ammonia and the ace-
tate of morphine ; the tonic infusions or decoctions
with the alkaline sub-carbonates, or with the
solution of potash, or with the chlorates, and the
extract of hop or of hemlock, &c. Camphor may
likewise be conjoined with narcotics, in cretaceous
and absorbent mixtures. When vascular action
becomes much excited, the nitrate of potash,
or the muriate of ammonia, may be given with
such of the foregoing as are cnemically com-
patible with them; and digitalis or tartarised
antimony may be prescribed in the more inflam-
matory cases, and when the bowels are not irri-
tated.

312. /. Various urgent symptonu require to be
palliated during the advanced progress of the
disease. Great heat of skin will oe relieved, and
consequent perspiration diminished, by cold or

tepid sponging the surface with equal parts of
spirits, of solution of the acetate of ammonia, and
of rose water. — Restlessness may be diasialshed
by the anodynes already enumerated, or by pru*-
sic acid, combined with gentle tonics and re£r^«-
rants. Camphor, henbane, and the nitiaie of
potash, or muriate of ammonia, are the most ge-
nerally useful in this state, excepting when the
bowels are relaxed, when opium, hop, or the ex*
tract of poppy should be substituted. When
diarrhcea supervenes, the pathological coodiboDi
to which I have attributed it (§ 306.) sbosld U
kept in view, as a treatment founded upon kfaea
is the most successful in practice ', — we shoald
endeavour, in these cases especially, to counteract
the contaminating influence of morbid sccrttinHi
upon the circulation, and to impart tooe to ihe
digestive mucous surface. The means that are
calculated to fulfil these intentions, are abo re-
storative of vital power, enabling it thereby to
resist the extension of disease. The tonics and
narcotiirs already mentioned ($311.) may be em-
ployed with these views ; or certain of tbcoi nay
be conjoined with the chlorates of lime, potash, <ff
soda ; or with Kr6osote ; or with cretaceous mix-
tures ; or these latter maybe given with ibe com-
pound tinctures of camphor or of opium ; or with
tonic and astringent extracts.

3 1 3. g. The Diet and Regimen ate mostia^Mwtaat
parts of the treatment of hectic ; but they sfeould
be varied, or even different, in its different stales.
In most cases the food should be digestible and
moderately nourishing. The milk of assei. or
milk warm from the cow, goat's milk or whey,
fresh butter-milk, warm milk with one or two
tea-spoonfuls of very old mm in it ; shdl-fisb,
especially oysters ; farinaceous and mudlagtiioas
articles of diet ; jellies, particulariy those maik
with Iceland or Carrageen moss ; and grapes in
considerable quantity -, have severally beea re»
commended, and are more or less beneficial, ac«
cording as they are appropriately prescribed. In
most cases, the patient should taae very gentle
exercise in the open air, when it is mild, and ex-
pose himself to the sun and air as much as possi*
ble without the contingent risks. In some in-
stances, especially those caused by debiUtatiai:
discharges, by caries, &c., old wine, especially
sherry, port, hermitage, and Burgundy, may be
allowed with much l^nefit ; and either old Ma-
deira or sherry may be taken in Seltxer water. It
is in such cases, especially, that the numeral
waters recommended above ($309.) are most
serviceable. (See also the articles Abscess ($55. ).
AasoapTioN ($ 16.), Bux>d ($ 143. et eeq.),
MsssNTXBic Decline, Tubbbci.», TuaaacrL&x

CoySUMPTION, &c.)

BiBUoo. AND RBrsK.— ^c'|nr«,1>eCnlx iL Mm. Lap.
SD.'—Avicenmi, Canon. L Ir. ten. i. tr. 4 can L«-0. CWiw

De HecUcs Febre. fol. Venet 1557 Vrr !]■■■■ Tkw!

tstui de Febre Hectics, 8va LugiL I5G0l — J. MtiMd,
De Hectic«e Cognitiooe et Curatlonc. firC 1fiSl-.Xc
cuhu LMsUanm. Med. Pne«t HUCor. L Iv. n. 4a ..Arcs-
tet, L It. obs. i^^ — VesH, De HecUcm Cardtoca. IXl
1(97. ~ ilor/4M, Phthi«Ma^ L L caa 5cG. £ MasT
De Febre Hectics. HaUe,1699.; et JDe Fcbi HccL A^
•cettum Intern. Cbmite. UaL I7tfi fffiiTfaaM, D^
Febre Lenta. Opera, vol U. {l 1881— fliribflr, De PtalkM
GaMriea. Erf. 1119,^ Brntkard, De FctaribiM Mc«h».
terlcU Acuti«. Boat 17g7. — Bt wi* /,<n%triaL Tfcaort

and Practice ofPhydc, Sri ed. p. 857 JmaU, De H«clk»

Stomachica. Altdorf.l74& — J^v«d^DePhtbia«aH«r.
tic«que Diicriniine et Setaceoruni utnUqiae wik Gwai
nSk^Petit.TniU det Malad. Cblnni. tl p. UX tf^^m
eariee.)—Jfackner,DeHetAieoemn Deiifiia. nulo GMsr
oriundis, Uabr, 1766.^ OrmU, On Fcven. 4c; l^mA.

908

FEVER, CONTINUED— PHOowoOTKjSTMFTOiif,

fever varies with the kind and combination of
causes producing it. Will infectious tj^phus
communicate simple continued fever, or bilious
inflammatory fever, or gastric fever, or climate
fever, or epidemic yellow fever ; or will these
species of continued fever arise from the same
cause, and admit of being resolved into grades
of intensi^ merely 1 No one capable of dis-
tinguishing disease ever saw the typhus miasm
occasion any of these fevers, nor the causes
usually giving rise to either of them produce
typhus. Neither of them is convertible mto the
other; and however closely allied or equally
severe certain varieties of each may be, some-
thing more than difference in intensity is to be
recognised. The causes of each are distinct, the
features of each different, the course and duration
different, the external appearance and internal
le«ons different, and yet no difference as to
severity or intensity may often be ascertained by
the aiblest pathologist. Is it to this assumed dif-
ference of intensity merely that we are to impute
the admitted fact, that, in the very same period or
stage, the treatment which is beneficial in the one
fever is death in the other, — that large depletions
are required at the commencement of one species,
and most injurious at the same period of another i
The very varied, and even opposite, treatment
required in several epidemics, even when the
same organs are prominently affected, cannot be
referred to grades of severity ; for fevers, even of
this climate, may be equally violent or severe,
and terminate fatally after the same duration, and
yet be aggravated, or ameliorated, by opposite
measures. The great pathological truth, — which
ought never to be overlooked, and without a full
recognition of which, in estimating the nature and
treatment of fevers, our experience will be worse
than useless — will be deceptive, and our know-
ledge worthless empiricism, — ^namely, that the
vital manifestations may, all or severally, be va-
riously affected by the causes productive of fever
— may be lowered or heightened, or otherwise
changed ; and that these changes, whether as to
kind or as to degree, should be made the basis of
distinction, in arranging the varieties and forms
of fever, and in devinng indications for their cure.
In the following inquiry, something mone than
intensity of action wul be recognised and made
the grounds of arrangement and treatment, in-
asmuch as each of the several kinds of fever
presents characters having stricter reference to
the nature, than to the ^^rade, of disorder — to the
state of vital manifestation in the several systems
and structures, and to the seat and grouping of
the predominant lesions, much more than tnan
intensity of morbid affection. The arrangement,
therefore, about to be followed, will not materially
diil'er from the sketch already given (§ 44.).
But all the kinds of fever there enumerated
cannot be treated of under this head ; their im-
portance, and, still more, certain peculiarities of
character, as well as o/ the circumstances in which
they occur, requiring, conformably with the form
of this wo'k, that they should be discussed in
separate articles. In considering, therefore, the
various kiu'.ld of continued fever, Uiose only which
are most iDtiroately related to each other will be
comprised under this head ; the more simple states
being first described, and the more complicated
and dangerous forms successively revieweo.

318. ii. Of the Progno$tieSfmiptmuU
Fevers. — a . The countenance. — W hea the ezpras-
sion is serene, confident, clear, and animafd, thf
disease is of a mild and uncomplicatfed kind ; ia
the advanced stages this state indicates a fivoor-
able crisis. If the face is large, injected of a
crimson or dark colour, with prominence of the
eyes, or is agitated and anxious in the early sttge»
of fever, the morbid excitement and deterain-
ation to the head occasioning this appcnimace wiU
speedily exhaust the powers of life, and, ia a
later period, will soon be followed by maHfiwiit
symptoms, or fatal collapse. Wbea the coaa-
tenance is tinged of a yellowish or earthy bne,
or is vrithered-like or sunk, or constricted, and
especially if it exhibit distress, or want of wettaaj
and confidence, extreme danger may be appie-
hended. A full, bloated, waxy, or livid coun-
tenance, particularly if it assume a tawny or
mahogany tinge, indicates very dangeravs eea-
gestion and approaching death.

319. b. Extemat m^'ace. — If tlie akin be soft
and perfect in its sensibdity , its heat not eir<iT(,
although augmented, but withovt a feeling of
pungency or burning; and if its tempeiatnic
be equally diffused ; a mild attack mav be ex-
pected. But when the skin is dry and bank. *•»
if thickened, and the heat ia ardent, caastic, or
unnatural ; if the surface be little sensible, am
readily acted upon by rubefiacients or blirten ,
or if vesicated parts assume a dark or black bac ;
if the heat be ardent in the head or tmak« pir-
ticularly at the epigastrium, and lowered ia ike
extremities ; if the skin be thidtened, apparently
withered, dusky, dark, or livid in parta, or yel-
lowish, flaccid, tawny, streaked of dinmst shadA,
lurid, or otherwise changed from its natural hae ;
if it be damp, greasy, puffy, or bloated, or staddcd
with very dark petechiie, vibices, or blotcbas. or
unusual eruptions ; or if parts pressed vpoa sbov
any tendency to gangrene ; great depieaHoa e^
the vital powers, with contamination ol the cir-
culating fluids, should be infeired, and die danger
considered great. The more florid, however, the
spots are, the k»s is to be feared ; and wbca the
black or violet petechias assnme a brighter tiat,
a more favourable opinion may be formed. Large
black or livid spots are ofWn* attended by dsa-
gerous haemorrhage from the bowels. Snail
dusky brown spots, like freckles, are very un-
favourable signs. Large livid or dark greenKk
marks seldom appear till very near the fatal
period. (HuxBAM.) — If the skin be covered
by warm, general, fluid and copious jwvyij»hi>«
attended by an open or free poise, a fisvoeraUc
issue may be expected. But, if the penfiratisa
be cold, clammy, scanty, or partial, with a nsa-
seous or disagreeable odour, especially if the naisr
be weak, small, very frequent, oppressed, or
irregular, there is much danger. The occnrreorr
of erysipelatous or erythematic inflammation is
the seat of sores or of abraaons ; the bieakii^
out of old ulcers, or the opening of cicatrice* ; or
a foul, gangrenous state of old sores; denote Mak-
ing of the powers of life, and a tendency » a
dissolution of the textures. •— Emmeimti^m^ whoa
moderate, and in due relation to the daratioo of
the disease, is rather favourable ; hot, when tt ii
excessive or rapid, it indicates ulceration in the
bowels. Little or no wasting, or a bloated and a
soft or tumid state of the surface, is very aa*

FEVER, CONTINUED— PEOoHOOTicSniFioia.

970

danger present. Indifference to death » with an
apparent desire of it, and a firm persuasion of
being perfectly frell, are also unfavourable.

324. g. If the 9yeshe calm, or slightly animated,
in the early stages, a mild form of fever may be
expected, — at advanced periods, a favourable
change has commenced. Agitated, wild, ter-
rified, confused, muddy, painful, prominent,
turgid, or suffused eyes, indicate a most severe
disease, at an early sta^e, and great danger in
advanced periods, especially if the whites of the
eyes become of a dusky or dirty yellow. Into-
lerance of light attends cerebral excitement ; and
rolling of the eyes, with a wild, unfixed stare,
often precedes severe delirium or convulsions.
A dull, sluggish state of the eyes, want of ani-
mation, sinking in their sockets, a dark hue of
the conjunctiva, with a sad expression, are un-
favourable. A pearly whiteness, with agitation
and prominency, is a symptom of dangerous cod-
gestion of the lungs and liver ; and, if succeeded
by a dirty yellow hue, or dulness of the cornea,
indicates approaching dissolution. Partial pa-
ralysis of the retina, indicated by black spots, or
other dark objects floating before the eyes ; closure
or falling of the upper eyelid, or dosing with the
eyelids half closed ; are dangerous symptoms. —
Slight deafneu, without pain in the ears, is not
an unfavourable sign.

325. h. The tongue and vMuth furnish important
indications in fevers. — In the course of the milder
forms the tongue is foul, coated with a yellowish
or cream-coloured mucus, and generally furred ;
it is sometimes a little red at the sides and apex,
and rather dry, or moderately moist, in the centre.
In proportion as it departs from these states, the
danger is increased. If it be covered by a milky,
whitish, or mealy coating, and if it be also large,
flabby, or swollen, early in fever, an adynamic or
malignant state of disease may be expected. If
it become rough, dark-coloured, with prominent
papillas, and not particularlv coated, bnt dark
rea, especially towards the siaes, serious affection
of the alimentary canal, or of the liver, should
be feared ; more especially if the symptoms re-
ferrible to the abdomen and these viscera be
^so urgent. If to these appearances be super-
added dryness, and contraction of its breadth,
serious or fatal changes within the head, or large
cavities, have supervened. When the tongue is
white, or coated with the papillae, erect or excited,
and the edges red and hery, vascular action is
then inordinate in some internal organ, although
no other symptom may indicate this state ; and
vascular depletions are required. If it be covered
by a deep yellow coating, congestions of bile in
the biliary ducts and gall bladder are evinced ;
and if this pass quickly into an excited, dry,
and brownish state, the supervention of con-
gestion, or inflammatory action in the substance
of the liver, or the digestive mucous surface, or
in both, with diminished vital power, may be in-
ferred. A dark or brick-coloured, or livid redness
of the tongue, with a glossy surface, or a surface
partially covered by a partly detached coating,
or black crust, or with a dark, scanty, tenacious
mucus in the mouth, or on the teeth, or lips,
show extreme prostration of vital power, with
contamination q( the circulating and secreted
fluids. A leaden-coloured, sodden, or parboiled-

like, flaccid, smooth, enlarged, treamlimf.ordiAi.
nished or shrunk, tongue, are all an^YOurable
signs. If this organ become, ia the iMoyees of
fever, thickly covered by a dark or fahginottf
coating, or exhibit, in addition, deep fiasares,
the apex and sides being of a brownira or dark
hue, the adynamic state is extreme* aod the
digestive mucous surface will readily pass ioia
ulceration or sphacelation, if, indeed, the femef
lesion have not already commenced. -» Vital ex-
haustion, contamination of the fluids, and sole-
tion of the soft solids — the constituents of mazked
malignancy — are evident!? present, if the gaaft
readily bleed when touched, if they and the teeth
are covered with a black viscid mactia ; if the
former discharge a dark dissolved blood, or
ichorous bloody sanies; or if a meular flnid
escape from the nostrik or posterior fauces. As
inky state of the surface of the tongue sflmetiiaei
ushers in these symptoms, and aUo evinces the
malignant condition. On the other band, if the
ton^e becomes cleaner at its edges or apex, or
moister round the margin, particularlj if other
favourable signs appear, a salutary change has
commenced.

326. i. Thirst is often very urgent, or even ia-
satiable ; but, although indicating the intensity of
disease, it is not of itself a dangerous symptom. —
The absence of thirst, especially when the toogoe
and fauces are dry, rough, and parched, is always
an unfavourable sign. A constant demrt of
drink, vet the patient drinking little when it m
given him, and a difiiculty of degtatition, are
very dangerous symptoms.

327. k. The evaeuatiomfrom the boteeU funoA
important signs to guide Uie practitioner ia the
treatment and prognosis. — In the milder htmi
of fever the bowels are readily acted upon, and
the evacuations are generally fecnlent, bat va-
rying in colour and consistence, accoidinf to the
state of the biliary and other secretions, and the

f>urgatives employed. When the stools give re«
ief from uneasiness in the abdomen, or redoce
fulness of it, a mild disease may be expected.
If the most active cathartics are required to pro-
duce evacuation, the stools being watery, scanty,
or otherwise morbid, and voided with a sense of
confinement or diflSculty, the abdomen bemp
full, or tense, or hot and uneasy, a severe fever
may be anticipated, and general or local deple-
tions, or both, are indicated. If copiona feea*
lent stools follow this state, a favourable ciins
may be looked for. Frequent, scanty, bilioas
evacuations, prssenting every variety of cohmr,
from a li?ht green, or gieenxsh yellow, to a
greenish black, sometimes watery, at other tines
mucous and streaked with blood, occasionaUy
feculent and extremely offensive, often accoo*
pany the worst forms of bilious or aatamaal
fevers, and indicate danger, particularly if they
assume a pitchy appearance. When the eUMls
are smooth, dark browo, or blaekiib, like tiende,
the danger is great. When thev are inoawtely
mixed with blood, or bloody sanies, or paraleat
mucus, or are ochrey, very frequent and exhansi-
ing, organic changes in the mucous surface of the
intestines, or in the liver, are evinced. If dis-
chargce of blood are found in the stools, eepe*
ciallv if unmixed with other matteia, uleeraciea
in the large bowels may be inferred. If the

972

FEVER, EPHEMERAL.

actioii of the causes ; — 2dly , to the less rigidity of
their fibres ; — and 3dly, to the periodic discharges
to which they are subject.

X VII.Fevbr, Ardent; Fefrru Ardens. Charact.
— The itagu or teries of febrile phenomena pro-
ceeding with rapidity and regularity ; the period
of excitement hinng very acute, and attended by
greatly inereoied vascular action; no morbid
teminium or infectious miasm being generated
in their course, as observed in modern times,

336. Under the generic denomination of Ardent
Fever may be comprised those more acute forms
of fever which are attended by great vascular ex-
citement, and which, owing to their nature and
severity, generally run their course in from one to
fourteen days, and are but seldom prolonged be-
yond nine or eleven days. They may be divided
into the more ephemenu and the inflammatory.

i. EpHEMBRAL Fkver. Syn. — Diary Fever,
Febricula, Ephemera, Febris diaria, Auct. Var. ;
Simple Fever, Fordycb ; Das eintdgige Fieber,
Germ. ; Fiivre ephemere, Fr. ; Effimero, Ital. ;
Efemera, Span.

337. Charact. — Increased frequency and
strength of pulse ; with heat of skin, headache,
thir^, af^ white excited tongue ; terminating in
perspiration generally within twenty-four hours,

338. Simple Ephemeral Fever may occur in a
very mild and slight form, — the Ephemera mitts
of Or. Good ; or m a much more acute state, —
the £. acuta of this writer. But intermediate
grades between these may also present themsel / es.

339. A. Causes, — The mildest variety is usually
caused b}' excessive or prolonged muscular exer-
tions ; by the more violent passions and emotions
of the mmd ; by protracted study and mental oc-
cupations or excitements ; by vicissitudes of tem-
perature, and exposure to a warm sun ; and by
disorder of the digestive organs, proceeding gene-
rally from thequantity and nature of the ingesta. —
The more acute states usually arise from the above
causes, from a surfeit, from temporary obstruction
or congestion of the biliary organs, from the pre-
sence of fecal collections and morbid excretions
in the prima via, and from violent exercise under
a hot sun.

340. B, Sympt4nns, — a. The milder form of ephe-
meral fever is rarely preceded by chilliness or
rigors; but it generally commences with lassi-
tude, yawning, stretchings, and a sense of irrita-
tion or of undue excitement. The pulse becomes
fre(juent, the skin hot, and the heaa pained. The
patient tosses in bed — is restless ; cannot sleep,
or sleeps in a very disturbed and interrupted man-
ner ; and his tongue and mouth are dry. These
symptoms frequently commence in the afternoon
or evening, and subside, in the course of the suc-
ceeding morning, in a gentle perspiration ; thus
terminating in from eight to fourteen hours. But
often, also, when the cause has been more severe,
and the disorder has come on at a later hour, the
patient continues feverish in the morning after a
restless night; is indisposed to leave his bed;
feels unrefreshed, and unable to make any exer-
tion ; and passes the day in disquiet. Towards
evening, the restlessness and other febrile symp-
toms increase ; but in the night, or at an early
hour in the morning, he falls into a quiet sleep ;
a perspiration breaks out; and he awakens re-

'ed and restored.

341. 6. The more acute ferm often begim — ea*
pecially when it is caused oy disorder of Uie digea-
tive organs, or by cold — with chilUnea or rigors,
succeeded by great heat of skin and throbbcDg
pain of the head. The nulse b frequent, etroag,
and full ; the face is flushed ; the urine bigh-
coloured ; the tongue is white, the papill« erect ;
and the secretions and excretions are dtauniftbed.
These, and the usually attendant symptons — as
restlessness, languor, want of sleep, and general
uneasiness — having continued from twelve to
twenty-four hours, a free perspiration auperreoes,
generally towards morning; the orioe aepOHtsa
sediment; and the disorder disappears. When
this form of fever proceeds from mental emouoos
or excitement, and from expoanre to a hot sun,
or from muscular exertions m warm vreaiber, or
from a rapid transition to a hot climate, it is sel-
dom or never preceded by chills or rigors* and,
if not actively treated by antiphlog^istic remedies,
is often prolonged beyond the p«iod just hkd-
tioned, and assumes all the characters of tiie aext
species — Inflammatory Fever.

342. C. Diagnoitf.— These states of dvoHer
may be mistaken for the commencement of soom
one of the more serious forms of fievcr. Bet tbcy
may readily be distinguished by ascertaining theff
causes ; by the absence of the usual premoiutofy
signs of fever ; by the sthenic and acute vascular
excitement, nervous energy being very little im-
paired ; by the rapid increase of the heart's ac-
tion ; by the slight depression of the mnscnlar
powers ; and by the circumstance of pain being
either hardly complained of in the loins and limbs,
or altogether absent.

343. D. rresfflMnt.— The febrile symptoms soes
subside after the digestive canal is freely evacu-
ated, especially when they have arisen mm the
irritation produced by retamed excretions. When
they are caused by the ingesta, an emetic shoaU
be given immediately, and its opermtaon pfooMNed
by the usual means ; but it is contra-iacncaied ia
all other cases. Afterwards a dose of rf'4Mf>
ought to be administered, and allowed to act
upon the secretions for five or six hours. Cooliaf
saline purgatives, conjoined with snail doses of
antimony, or of ipecacuanha, as advised by
Vatbr and Giakblla, or of the spirits of Mn*-
dbrbr, repeated at short intervals, will then
hasten recovery, and remove the morbid eecietiuBS
which have disposed the frame to these fiebrile
attacks. — When the disorder has been occasioned
chiefly by atmospheric vicissitudes, diapkartties,
especially after tne bowels have been freely eva-
cuated, and a tepid or warm bath, are more par^
ticularly indicated.

344. If the febrile attack have been eaaied by
inordinate mental excitement and eaertaon, or by
fits of passion, by anxiety or other affsctioas of
mind, cold should be applied to the bead, ia
the form either of aAision, of cold waaer, cold
sponging, evaporating lotions, &c. ; the bowels
freely evacuated, and diaphoretics prescribed*— If
it be produced by exposure U>, or by muscalar
exertions under, a hot sun, and whenever vais>
cular action is excessive, or the patient pictharic,
full bloodletting ought to be practasad pre*
viouslv to the last specified means, which
should be assiduously employed, aad aeoam*
panied by cold sponging of the sarfiMe. and
the internal use of refringcnnti and nliae medi*

974

FEVER, INFLAMMATORY — Fo»m«.

gration to warm climates, are — their early age, ple-
thoric habits, and phlogistic diathesis ; inattentioii
to their bowels during the passage, and their use
of salt provisions and spirituous or vinous liquors ;
increased intemperance, and incautious exposure
to the sun and to the night air ; excessive fati^e,
or alternations of indolence and great exertion ;
and suppresed perspiration. Dr. Jackson remarks
that persons thus circumstanced rarely escape an
attack of fever during the first year of their resid-
ence in a tropical country ; and that the fevers that
occur from these causes are often of the most aggra-
vated kind, and rapid in their course, more especially
among troops crowded in barracks or transport
ships, where the heat of the climate is augmented
artificially ; the excess of heat influencing the
febrile form, increasing the violence of the symp-
toms, and retarding the progress of recovery.

350. A Question has arisen, as to whether or
not the inflammatory states of fever in warm
countries are caused by malaria, or by the other
causes now instanced. There can be no doubt
that malaria very frequently produces, in the ple^
thoric, young, and robust, who have recently
arrived m a hot climate, fever of an inflammatory
and continued kind. But it must also be con-
ceded that this fever chiefly occurs, even in persons
thus constituted, during the dry season, and at
times and in places where the existence of ma-
laria is doubtful, or, at least, by no means proved.
It is notoriously admitted that the inflammatory
states of continued fever, in both the East and
West Indies, appear among those soldiers, sailors,
and civilians, who have not been long in a warm
country, and who have not suflTered from disease
since their arrival; and that they take place
chiefly during the dry and warm seasons, and in
situations where the usual eflects of malaria are
never observed. This is the result of the ex-
perience of Jackson, Annesley, Boyle, Twi-
ning, CoNWELL, and of other experienced prac-
titioners in warm countries. It agrees with my
own observations ; and is even admitted by Dr.
Ferguson, who has gone much further than any
one else in assigning malaria as the cause of inter-
tropical fevers. I believe that the other causes as-
si^ed above ($ 346 — 348.) will, in these coun-
tnes especially, produce fever of an inflammatory
or bilio-inflammatory kind, in unacclimated Eu-
ropeans ; but that, when those causes are not
associated with malaria, the fever resulting from
them will generally subside, under judicious
treatment, without evincing those dangerous
symptoms which characterise fevers proceeding
cniefly from terrestrial exhalations. Although
some of the causes, especially those which relate
to atmospheric temperature and climate, are
very different as to their nature and action, vet
they are mainly instrumental in producmg
fevers having many common features, but differ-
ing in severity and duration.

351. B. Fokms. — a. Mild Inflammatory Fe-
ver.— a. The fever which usually arises from cold
and dry states of the air, in cold climates, in
elevated situations, or in temperate countries, from
atmospheric vicissitudes or other causes, assumes
either simple or complicated forms, and is gene-
rally sporadic. Its epidemic occurrence is compa-
ratively rare, especially in its simple state. It

appears chiefly during winter and spring, or
daring north and north-east windf . In its com-

plicated states, which are moat frequent, it Amis
a connecting link between idiopadiic fever, and
visceral inflammation ; the local affection ap-
pearing in the early or advanced coune of
the former, the general disorder, or symptomatic
fever, being consequent upon Uie latter. Thus
inflammatory fever, and local inflammation, arise
most frequently from the same cansei acting apoo
different constitutions, habits of body, and states
of local or general predisposition ; — tiie simple
form of inflammatory fever appearing in the
young, plethoric, and robust, and in theae pos-
sessed ot no local predisposition ; the complicated
form taking place in persons whoae previous
ailments, habits of life, or avocmtiona, nave is-
duced a disposition to predominant action in aoine
important viscus, or from a concurrence or snc-
cession of external causes tending to the more
especial disorder of one or more organs ; and the
primary local inflammation occurring from, a
predisposition of some part so great as to expe-
rience the onus of morbid action from the com-
mencement, or soon after the impresHoo of the
exciting causes, or from the kind and concwieoce
of these causes. — In the /rst case, the whole
frame seems to participate equally in the dis-
ordered action from the beginning : m the tecond,
the disorder is also generu from the fint, with
predominance of it evinced in some organ, either
at a very early period, or in some advanced stage :
in the (nird, the earliest symptoms of **'w>i?p are
referred to a particular viscus, and with the in-
crease of such disease the whole system sym-
pathises.

352. 0. The tymptomt of thb Tariety are
uniform in kind, but vary in severity. The

Sremonitory signs are usually slight, or of brief
uration. Hence the attack seems sodden, and
is commonly ushered in with rigors or chilU
which are of short continuance; and,altliou^
often well marked, are occasionally so slight as
to escape observation or recollection. The rigors
or chills seldom recur, and are rapidly followed
by general vascular reaction : the skin and in-
teguments become full, injected, dry, hot, and
burning ; the countenance full glowing or red,
and animated ; the eyes injected, intoierant of
light, but lively; the puue frequent, strong,
bounding, and full, sometimes hard or oppieascd ;
respiration is frequent, and the expired air hot ;
the nostrils and mouth are dry ; the tongne white,
its papille excited or erect ; and the lips full and
red. The external appearance of the body evinces
increased vital action; the whole snmrc ap-
pears flowing and animated ; the internal senfr-
ations indicate generally increased vascular ac-
tivity ; and all the secretions and excretions axe
diminished or obstructed. The patient complatiis
of great thirst and heat ; of a severe or throbbing
headache and vertigo ; of anxiety at the prseioidia ;
of increased sensibility, especially in respect of
light and noise; of restlessness, watchralness,
and of frightful dreams ; and of nausea or sick-
ness. Taste and smell, owing to imperiect
secretion on the surface of the orsans, are cm-
paired or abolished. The pulse seldom reachc*
110 beats in a minute: and the beat of skin,
although greatly increased, is in due relation with
the activity of the circulation ; and does not im-
part the harsh and unpleasant sensation to t!t^
hand of the observer, that characterises the

976

F£V£R, INFLAMMATORY— Skvbrb Forms.

the symptoms charactexistic ofeither will direct
attention to the complication. The stethoscope
should therefore be employed whenever the
breathing is laboured or oppressed in the inflam-
matory^^ias of fever OMerved in the circum-
stances j^ stated. — This fever may present also
prmninent HepatiCf Gaxtric, and Enfrie diutue ;
but, in such cases, it will very nearly resemble
the forms of fever described under the names
gustro-biliout and mucous.

359. b. Severe IvrhknuAtORY Fever. — The
disease described by the names of Synochus
Cautcnidet, by Gilbert ; of Synocka Oauunlm, by
Manoet; of Synoeha Ardens, by Sauvages; of
EtuUmial Causut, by Moseley ; of Inflammatory
Endtwie, by Dickenson ; of Climate or Seasoning
Fever, by several writers ; and of Endemic Yellow
Fever, by others ; differs from the foregoing or mild
form of inflammatory fever (§ 351.) only in grade,
as insisted on by Jaceson, and proved by my own
observation. This is the disease which most fre*
quently attacks new comers into the West Indies,
more especially sailors and soldiers; and which has,
as already stated ($ 244— <247.), been confounded
by recent writers with the aggravated forms of
bilious fever on the one hand, and with epidemic
or pestilential yellow fever on the other. It was
also prevalent during the last war among the
Britisn troops and sailors in the Mediterranean^
and was described by Burnett, Irvine, Boyle,
Brunton, Down, and others ; but it generally
assumed a milder form than in the West Indies.

360. Whilst the milder form of inflammatory
fever is common among the white and assimilated
European population of warm climates, the severe
or aggravated form occurs amonr those who have
more recently arrived in them, and more especially
among the young, the intemperate, the robust and
plethoric, and those who are exposed to the sun, to
very high temperature, and to the night air. In most
warm climates terrestrial exhalations are also fre-
quently more or less concerned in the causation of
the continued as well as of the remittent types of
fever : the type being determined, as shown above
(§ 43.), by the nature, intensity, and combination
of the causes ; and by circumstances peculiar to
the patientfparticularfy the novel, or the habitual,
operation of the endemic influences to which he
is exposed. But, although malaria may be a
concurrent cause of this fever, especially in re-
spect of persons who have recently arrived in the
West Inoies, yet I believe that, where its oper-
ation is most unequivocal, (he kind of fever pro-
duced by it is different from this,^>remoiutorv and
cold stages preceding reaction, which is much less
violent than in this, the resulting fever being of
the bilious continued form, about to be noticed.
^- My experience fully accords with the obser-
vation of Dr. Stevens, that, when a young
Northern stranger is subjected soon after bis
arrival in the West Indies to the higher ranges
of temperature, his clothes are soon drench^ ;
and that, if he be exposed to a current of air
in this state, the cold produced will constrict the
vessels of the skin, and prove the exciting cause
of fever, which, in favourable circumstances, will
often be the mUd form of inflammatory fever
such as has been described above, and as is often
observed in temperate climates. The causes which
produce a severe afi^tion in young and plethoric
strangen, seldom affect the older fesidents^ and

never the natives of the country or the dark lacci .
Women and children, the aged, ami the weakly,
are much less liable to it than the robust aad ple-
thoric.

361 . «. The hisiory of this form of fever has not
been given with the requisite piecisioa by the
various writers on it ; most of them bavtag nixed
it up, in their descriptions, with the infiamma-
tory varieties of remittmt, and with the more ooo-
tinued states of fever produced by terrestrial at
vegeto-animal exhalations, concomitantly wkk
the other causes of intertropical fevers. — The
aggravated form of inflammatory fever it seldesa
preceded by veiy marked premonitory sympUnM.
The attack is usually sudden. Giddiness, feiat-
ness, and general uneasiness, somebmes, however,
precede it for ten or twelve hours.* 1 here »,
occasionally, a slight and brief chillincaa at the
commencement, especially in the less violent eases,
rapidly followed by a sense of universal beat ; by
flushed face, frontal headache, and vertigo; by
inflamed, heavy eyes, and great sensibility to tight
and sound; by pain in the occiput, neck, back, and
limbs ; and by a strong, full, hard, and aeceler*
ated pulse. A sense c? heat, oppression, pais, or
anxiety, is felt at the prccordia, sometimes with a
dr]^ cough, and pain in the side; resoiratioB ia
quick, laborious, suspirious, or anzioas ; the
tongue is white, excited, and its edges red ; the
&uces are arid, thint urgent, and ^n hot and
dry ; the urine is scanty, the bowels costive ; and
there is generally nausea, but seldom vomiiiag
until some time after the attack. If the diwie
be not mitigated by treatment, the patient becemcs
extremely restless ; the headache is rending and
intense ; vascular acdon is excessive ; and tM beat
very great. Vomiting now supervenes, and fol-
lows the ingestion of whatever is taken bo allay
the urgency of thirst. The matters thrown off are

* Dr. MosauT ttstei that there is a naaB
chiDinen and horror, but never a rteor. Dr. Ji
remarks that there is nere or less of horror and durcsw
ing, iHit the cold is rarely great : Mr. Dicanraosr, thst
there Is increased excitement from the riiuiiamuiMun,
and that a slight chiUiaesa at the onset b obeervtii e«tr
in the slighter cases (^ 351.). Dr. Stbtexs observes la
several places, that there Isnooold stageat th« bcgiooiar ;
and Dr. BauMTON, that languor, detiintT, and opptcoMoa
are oompUlncd of, with chUUneaa. ^Tbis dMCffCfaBej ia
the account of the commeooemeot of a most dangeroHi
disease, and on a point so nccpsasry to a kaovledge of itt
pathoU^y, may be in some measure expUined. Dr.
JACXBON has described this form of fever to r^*"'*^"^
with the more inflammatory states of remittent, from
which it is perfectly distinct The descripCion of the
other writers Is more correct; for in several
which I had an opportunity of obserring the em
ment of the disoraer, no rigors, and hardly any diUls,i
remarked. Even some of those who eemplainod of cbiMs
presented a warmer state of skin than naturaL Tb« pure
climate fever I, therefbre, infer doca not cooiaence wi^
shivering or rigors ; and seldom with ehillmesa,
currents of air, cold, Ac have been oonoemcd In c
it by suddenly checking the pertpiration But the
tinued fever attended with high vascular action^ arisiSM
from malaria and atmos|ri)erlcarhcat and viciwdtndeSt thai
is frequently met with in warm dhnatcs and in hotaa— csi^
is commonly preceded by manifest premonitory tpm^uimm,
and by a cold stage. Ineae two diseases, which nei|uently
resemble each other very cloaely, have Iwco genernly
confounded with one another, more capeciaDy aa tbry
are observed in the West Indies. Nor BbouM this be a
matter of surprise, inasmuch as that very many of the
instances of fever which present themaelvea in aaen la the
public service^ as well as in civil life, arise Ann a cei^
bination of malaria with dimatorlal influcooes, and that
the eaaes which are produced by a oeneuncnee of maeh
causes are perhaps more nunaerotta than those whkb
spring from either alone — from manh fthslstliian en
the one hand, or fttira high teDperataie and ila vMss*.
tudss on the olbsr.

97B

FEVER, INFLAMMATOEY— Tebmiwations, pAra0L60T, etc.

important viscera, but it is not actual infiamma-
^oa — at least, suppuration is never oliserved in
dissection of fatal cases. (For Diagnosis, see §
243—247.; and Yellow Fever.)

368. I. Terminations and Prognosis, — (a) Ar-
dent or severe inflammatory fever, if not arrested
by an early and energetic antiphlogistic treatment,
rapidly t«rmmatcs in exhaustion of vital power, with
alteration of the blood, and organic change of the
internal viscera, manifested especially in certain
tissues. — Ist. A resolution or subsidence ofihe ex-
cited action, without the supervention of the stage
of collapse or exhaustion, seldom occurs, unless
an appropriate treatment has been adopted. VV hen
the period of excitement is early and duljr mode-
rated, the severe symptoms of exhaustion either do
not appear, or are very slight, debility of short
duration being only present ; and the patient rapidly
recovers without any visceral disease. The stage
of exhaustion is great in proportion to the violence
of excitement, and in it the more unfavourable ter-
minations occur. — 2d. Organic change of some im-
portant organ may supervene during excitement,
but rarely to an extent sufficient to produce
death : it consists chiefly of vascular injection ;
discolouration and softening of parts ; effusion of
serum, lymph, or blood ; and takes place most
frequently within the head, and in the digestive
organs. Purulent matter is never formed in this
period, nor subsequently.

369. (6) In the stage of collapse, several
changes occur ; but death is owing rather to their
conjomt influence, than to either singly. — 1st. Ex-
haustion of vital power is always present, but not
to^an extent suflicient of itself to arrest the organic
functions. — 2d. Deterioration or change of the
blood obviously takes place, and is shown by the
state of this flmd both during life and after death ;
but the nature of thb change is not fully ascer-
tained ; whatever may be its nature, it is merely
consequent upon the altered state of organic nerv-
ous influence. — 3d. It is very probable that ex-
haustion of this influence, and the resulting changes
in the blood, so affect the irritability and tonicity
of fibrous and contractile structures as to impair
these vital manifestations, and thereby to favour or
even to induce the alterations observed towards a
fatal close, particularly those affecting the capillary
system and mucous tissues ; for the vital tone of
the extreme vessels and of the digestive mucous
surface being thus impaired, and the blood being
more fluid and dissolved, as well as otherwise
altered, haemorrhage readily occurs, with dis-
colouration of the skin and of membranous parts ;
the blotches, &c. observed during the latter stages,
proceeding from these pathological states. That the
head should appear to suffer especially during the
period of excitement, is a necessary consequence
of the phyacal relations of this part, in connection
with general vascular excitement ; and that the
stomach and digestive mucous surface should
evince predominant disorder at an advanced sta^e,
may be ascribed to the irruption of acrid or viti-
ated secretions, particularly tlie biliary, to the
state of organic nervous power, and to th« changes
induced in the blood.

370. l^. The Prognosis entirely depends upon
the period at which the disease is subjected to ap-
propriate treatment, and upon the violence of the
seizure. — When the stage of excitement has but
recently commenced, the treatment about to be

aane. or

recommended will generally arrest the
but the nearer this stage approaches its
that of exhaustion, the greater is the danger, as
those changes in the orp;amc oervous infiwcoce. is
the blood, and in the vital tonicity of coniraitJc
parts, may be considered as having begun ; aod
active depletions are then not so well eodaivd,
nor productive of the same effects, as at an earlin
period. When symptoms of coUapae ^pyor,
the danger is very great; and in propoRiue
to the progress of this stage and the orwency J
its characteristic phenomena, particularly «!)»-
colouration of the ^n, black vomit, and pas«^<
haemorrhages, it becomes extreme ; rect'T'TT
seldom taking place when these symptoms arv fcL)
developed. — When the cerebral anection is \vr%

remarkable at an early stage, the danger is t%c:i
then great, as the eflects of the treatment ioipc-
ratively required, conjointly with the exhaasTA^
consequent upon excessive action, will tadaic j
state, which, although much less dangeiott» tlaa
that which would indubitably follow unn»trainri
action, is still attended by much risk, and ofU£
requires the prudent exhibition of restcwaiivL^, ^r .

37 1 . The Duration of this fever varies frvc^
two to six or seven days. A fatal termioaUii
commonly takes place on the fourth or fifth d^j.
— On examination, post mortem, more or l««i cr.*
dence of increased vascular action, often amosat-
ing to inflammation, or its consequences, is ch^&st^
in the membranes of the brain, in tbc tntrrcai
surface of the stomach and bowels, and aiMJft
rarely in the pleura and serous membranes of xLg
abdomen. The digestive mucous sar&r« »
studded with numerous dark or eccl^mosed «ipit«.
from which a fluid black blood seems lo ouar.
The liver is frequently congested, sometimes largrf
and softer than natural, and of a dark collar,
owing to the quantity of black blood in its %r^brU.
The spleen is somewhat enlarged, soft, and fria^ye:
and the omentum injected. — ^I'he serous a» vt J
as the mucous surfaces, especially in the aUk--
minal cavity, often present livid or dark patckes.
The blood is every where fluid, black, and d»-
solved. The internal surface of the heart %ac
large vessels, both arteries and veins, was d a
dark red or livid tint in a few cases which 1 rx-
ammed ; but tiiis point requires further in«««b-
gation, as my opportunities were not sufficient Ua
the satisfactory examination of it in respect of tkt
umversality of its occurrence, and the enci
changes on which this appearance depends^

372. C. Nature of the Disease. — Yeren
produced by paludal miasms, or by infectna^
emanations from living or dead animal maiic.
are universally preceded by well-marked symp-
toms, characteristic of the stages of yremnmiti «
($ 33.) and of invasum (j &»). Bat inftsB-
matory fever, especially in its more severe (orai.
is seldom preceaed by more than chiUs, anl><»
cold, or other causes which suddenly am^
the cutaneous excretions, have been conctfaci
in producing it. In these fevers, a pojwc-
ous agent has infected the frame, and luxt
or less depressed its vital energies, particularly S5
they are manifested in the organic nervous m-
tern ; vascular reaction being consequent u}%a
such depression, as shown above {i 95, 9d v
But in this fever, the injurious agent, or pnaua
pathological change, is generated within the ««>•
tern from tlie action of new and unwmiited a^

FEVER, INFLAMMATORY — Pathology, etc.

979

flueDces, generally climatorial or atmospheric.
That this ageot is not of a depressing kind, as
respects its primary operation, is manifest, from
the general absence, at the commencement of the
disease, of those phenomena which indicate this
kind of action. That it is of an irritating or ex-
citing kind, may be inferred, not merely from the
character of the invading symptoms, but also from
the changes primarily induced by the remote
causes. — If we inquire into the nature of these
changes, we shall nnd them — 1st, As respects
the mild inflammatory fever g of cold or tem-
perate climates, to consist — (a) of the organic
and nervous excitement consequent upon the
rapid and increased oxygenation of the blood
daring cold and dry states of the air, probably
aided by the accumulations of the electro-motive
agencies in the system which these states mani-
festly favour; — (6) of the super-abundance of
irritating matters in the circulating fluids resulting
from casual interruptions to one or more of the
eliminating or depurating processes constantly
going on in the animal economy ; — (c) of the
combination of these circumstances or primary
pathological conditions. If we grant that the
former of these obtains, it is very obvious that the
occurrence of the latter will further excite and
increase it ; even a susceptibility to the former,
as marked by high irritability of fibre, may be
readily kindled into morbidly increased action,
by causes of irritation which may have accu-
mulated either within the vessels — in the blood
itself; or external to them — in excreting organs
and surfaces. These pathological states are the
obvious results of concurrent causes, which pri-
marily excite the sensible and susceptible parts of
the frame, and which retard or prevent tne dis-.
charge of irritating materials from the vital cur-
rents which supply and sustain these parts ; the
accumulation of these materials either mcreasing
the excitement, or giving rise to it. It must ne-
cessarily follow that the excitation thus induced
will exhaust itself to a degree, and with a rapidity,
co-ordinate vrith its intensity, and thereby induce
the phenomena characterising the advanced periods
of the disease, which are especially remarkable in
the severe or climate fever of warm countries.

373. 2d. As respects the tevere inflammatory
or climate fever t the procession of phenomena must
necessarily be different, as it generally arises from
causes different, or even opposite, to those just
instanced — from a very high temperature, often
conjoined with rich, nutritious, ana heating food,
stimulating drinks, and suppressed perspiration.
Either of these is alone sufficient to induce the dis-
ease ; but, when they co-operate, the effect is more
certain and severe. They all act in a similar man-
ner ; — they excite the organic nervous system in-
ordinately ; increase the actions of the liver, and
irritate its vessels ; alter the constitution of the
blood, causing it to abound with stimulating and
injurious materials ; and render the secretions and
excretions acrid or morbidly excitine. Thus the
most violent states of this fever often proceed
directly from these causes, without any evidence
of primary subaction or a cold stage, unless de-
pressing agents, such as cold, human effluvia, or
malaria, concur with them in producing disease ;
in which case the consequent fever will present
features modified accordingly. If cold act upon
persons who are under the influence of these ex-

citing causes, a slightly cold stage will often be
directly induced thereby. If animal or vegetable
miasms concur with them, the fever will present
adynamic or malignant characters in proportion
to the activity of either of these agents. But
when the above direct causes of excitement act
solely or principally, their influence upon the
organic nervous system is very energetically ex-
pressed, and manifested throughout the vascular
system, especially that of the brain, liver, and
digestive mucous surface. Thus, inflammatory
fever differs from the other varieties of idiopathic
fever — 1st, in its proceeding from causes, the
primary action of which is exciting or irritating ;
2d, in excitement or irritation being more or less
evinced by it from the commencement.

374. Of the changes that take place in the ad-
vanced period of the disease, the most remarkable
are those affecting the blood, and the digestive
organs. As the stage of excitement merges into
that of*exhaustion, the blood changes from a florid
to a dark colour ; loses its property of separating
into crassamentum and serum, and of firmly co-
agulating ; becomes more fluid ; and seems de-
prived of much of its fibrinous and albuminous
constituents. (See art. Blooo, $ 128.) Ac-
cording to Dr. Stevxns, its saline ingredients are
also greatly diminished. The chief cause of these
alterations is evidentiy exhausted organic, nervous,
or vital power > and this is further evinced by a
loss of the tone of the extreme vessels, and of the
irritability of the moving fibre, always co-ordi-
nately observed in cases presenting this change
in the blood. Among tne most striking con-
sequences of exhaustion of vital power, as thus
manifested in the extreme vessels and blood, are,
discolouration of the skin, and passive hsmor-
rhages from mucous surfaces — phenomena cha-
racterising the last stage of the most unfavourable
cases of the intense disease. The gastric dis-
turbance in the early stages generally proceeds
from excited vascular action, and from the pas-
sage of irritaCiog secretions into the stomach, in
connection vrith an increased susceptibility and
irritability of the organ. In the latter stages, it
more especially results from the morbid secretions
poured into the stomach, and the irritated or in-
flamed state of its villous surface.

375. The source of the black matter passed
from the stomach and bowels in the last stage of
this and of other severe fevers of warm countries,
has been variously stated. Some consider the
black colour to proceed from the exudation of dark
blood, which, in nuxing with the secretions of the
stomach, liver, and bowels, imparts to them a still
darker tint. Some ascribe it chiefly to the bile, and
secretions from thedigestive mucous follicles, which
are often both very dark and thick, in the last stage
of the more malignant kinds of intertropical fevers ;
and others believe it to arise both ways. There
is no doubt that all the secretions poured into the
digestive canal are more or less diseased, par-
ticularly in the latter stages : but it is as clear,
that the black colour mainly depends upon the
state of the blood ; and that all the matter ejected
upwards and downwards, presenting this appear-
ance, does not consist of altered secretions merely,
— a great part of it probably being an exudation
of blood from the mucous surface. I believe, also,
that these matters vary very remarkably in the
ardent climate fever, in the more malignant forms

» 3R 2

980

TEVER, INFLAMMATORY — Theatm»t.

of marsh or endemic fevera, and in the pestilential
yellow fever — the diseases thus characterised.
Dr. Jackson remarks that the secretions from the
digestive mucous surface are ropy and clear during
the early periods, and are bvown or black in the
latter — sometimes black as soot ; and that the
sooty or ink-like colour is chiefly observed where
the head and stomach are simultaneously attacked.
When we consider that tlie blood becomes darker
than natural, as well as otherwise changed, early
in the period of exhaustion, and dhat the liver
and mucous follicles of the digestive canal, with
the kidneys, are the principal organs of depuration,
or channels by which the elements producing
these changes are eliminated from the circulation,
we need not be sdrprised at the secretions, which
these elements go to form, and which these
organs excrete, presenting somewhat similar cha*
racters. K must however be admitted, that the
share which the secretions perform in producing
this phenomenon, or that which the exudation
of blood has in giving rise to it, will vary much in
different varieties or eases of intertropical fevers.
— The rapidi^ with which a dissolution of the
tissues takes place after death, in the severe forms
of climate fever, deserves notice, as marking the
rapidity of vital exhaustion, and as resulting from
the changes of the blood ; these changes commenc-
ing with -the -stage of exhaustion, and advancing
until this fluid is no longer capable of influencing
the nervous system, and of preserving the irritability
of contractile parts — oi4until it poisons, instead
of excitinf^, the sensitive and moving tissues.

376. iii. Treatment.— The means that should
be employed in the 'miiii and upere forms of in-
flammatory fever are the same — the only differ-
ence being in the promptitude and energy with
which they ought to be administered. In the
mild diseases, particularl;^ in cold or temperate
climates, the febrile excitement is much more
prolonged than in the severe, which rapidly ex-
nausts itself by its violence. The necessity,
therefore, of restraining it at its commencement
is great in proportion to its > activity. In the
milder forms, vascular exciWmtnt may continue
several days, and depletions may be practised
with advantage as long as4hi8 state persists ; but,
in the severe, the period in which they can be
employed with benefit passes away sometimes in
a few hours ; and continuie^ seldom beyond the
third, and rarely beyond the < fourth day. As in
the state of excitement, so in that of exhaustioo,
the treatment is the same in all the varieties of
this fever — the only difference being in ^the
choice of means, in the activity with which they
should be employed, and in tne appropriation of
them to the varying circumstances of the case.

377. A, — a. During exoUitMent, and especially
at its commencement, vascular depUtiont should
be practised, and carried as far as the state of the
pulse and other circumstances will permit ; and
m the manner described in -the article Blood
($ 64.). The observations already made on
this subject ($ 128 — 138.) will guide the inex-
perienced practitioner ; but it should not be over-
looked, that, in the intense climate fever, vascular
depletion should be prompt, from a lax^ge orifice,
large, and repeated, to be successful ; and that
the quantity of blood abstracted should depend
chiefly upon the effect produced. Dr. Jackson
justly remarks that it should be taken in quantity

sufficient — whatever may be the amount — to
relax the surface, and set free the eecretiMM.
Less than three pounds is rarely sufiirMt t»
produce this effect ; and six have not been more
than sufficient on some occasiont: b«t what-
ever the amount may be, it will do eompan*
tively little good if we stop short of the qnanLty
which is requisite to eflfect a decided chanre.
If delayed until the excitement is about to icr.
minate in exhaustion, no benefit — or ereu ■i»>
chief — may result from it; for the tonicity of
the vascular system will have then hecomt too
far weakened to admit of the vessels accoa-
modating themselves to a considerable los of
blood. When, therefore, the sjrmpCofDS iadicas-
ing the passage of excitement into eoUa^, or
the deceptive abatement of the febrile actioa tn>
dicating this state, b observed — and particalarty
if yellowish blotches appear about the momih.
face, or breast — the time forbleeding with adtia-
tage has passed. If, however, beadack is <u!l
urgent, the pulse still strong, and the fiBaturef
have not collapsed, blood may yet be abstracted
cautiously and in moderation. WImo the cm-
bral affection is considerable or pecsistive, and a
unattended by marked symptoms of exkattava.
depletion, general or local, may be ivpmed.
Where the headach is particularfy intense —
rending, throbbing, &c. — with hot iafiaoMd
eyes, one bloodletting, however lai^ge or eari).
will seldom be sufficient. In such cafes, tbe
body should be immersed in a tepid, or slighily
warm, bath, and well scrubbed with bnisbes, &r.,
until the cutaneous circulation is rendered ftw.
Cold should also be applied to the head, both
during the bath and suhoequeotly, the hav
having^ been cut off. After the pattern is re-
moved to bed, the vascular action -and hcadark
will often becomeagain excessive ; and.ahhovch
a very few hours only may have elapaed. «iU
require -the repetition .of Teiy large deple-
tions. Spontaneous hemorrhage dniiag esctte-
ment should not be arrested. In the loost se«o*
cases, especially when deierminatioa to the
brain is great, epistaxis often occafs» bat »
generally slight, or almost instantly diea|^pesn.
In these, vascular depletions, aided by the odKr
means appropriate to this state, oo|^t to be mo»(
energetically practised ; lor nothio^ else v^
save from Mital changes takii^ jflaee withia tke
brain, or from mb fatal eiihauslioo, and its «8ecu.
378. Purgat'fvti, in oneform or other, are a m*-
terial part of the subsequent means. Coleirl «nh
JMlap and Jmmesi powdtr may be given, m the fom
of pill, from time 'to time; and, after a few de»f
have been taken, a cathartic enema akoald be
administered, and repeated. As to tbe choice xi
the enema, the practitioner shovM be gaided bv
the progress the disease has made. At as eariv
period, Mtt water, with or withoitt the *'"^^* of
castor oil, or of extract of eolocrath, is approptsir :
subsequently, olive oil and oil of torpeatiae ouy
be sabstitated for the latter. — SwaHiet are aoi
suited to any«tate of this lever; akbovgh they
are often serviceable in levers which have baea
confounded with it, more espedally at the ro»-
mencement of the various forms of narih fever.

379. 6. i?rfr(grrafiCf, when jadicionaly exlMb«to^,
are valuable adjuncts in the period of oTciiomrnT
Those already enumerated, both imSermml aad «r-
fsraol ($ 139^141 .), should be pCfatwriByly^

982

FEVER, INFLAMMATORY— Theatmiot.

tion between the globules of the blood, and con*
sequently of a defective power of coagulating,
and of altered colour, has been shown by Towns,
and by every writer since his time, and is gene-
rally admitted : but the observations of Dr.
Stevens, as to the progresave loss of saline in-
gredients, which the blood undergoes with the
progress of exhaustion, although now published
several years, have not received that confirmation,
for which there have been sufficient time and op-
portunity. They are not, however, therefore,
altogether to be thrown aside, more especially as
my experience has furnished me with facts calcu-
lated to support them in some measure. The
exhaustion in this disease arises, — 1st, from the
previous excitement ; and, 2dly, from the changes
induced in the blood in the course of this stage,
especially at its acme, manifestly depressing
the organic nervous influence, the tomcity of
the vascular system, and the action of the heart
itself, to an extent often incompatible with the
continuance of life. It is in tnis manner that
death generally takes place in the intense cli-
mate fever ; for, however considerable the lesion
which the early excitement may have occa-
sioned in the brain, or digestive organs, death
is seldom the result of it in either of those parts.
It should, moreover, be recollected that the dis-
ease cannot be cured by bloodletting alone,
however necessary it may be to the subduing
of excitement in the early stajge ; for although
this state may be lowered by it, still dangerous
exhaustion may nevertheless superrene with the
characteristic changes of the blood, and all the
consequent phenomena described by the earlier
writers on this fever, particularly by Towns,
Warren, Hume, LijtiNo, Hillary, ficc.

382. a. From these considerations it is manifest
that the intentions of eun, in this stage of the
disease, should be — 1st, to support or rally the
manifestations of life in the different organs — to
oppose the progressive vital exhaustion^ 2dly,to
counteract those changes which take place in the
blood and vascular system. These indications
should be simultaneously carried into effect ; for
the alterations in the state of vascular action and
tone, as well as in the constitution of the blood,
are more or less dependent upon the change in
the organic nervous influence. — At the com-
mencement of this period, and when vascular
action still continues high in the encephalon or
digestive mucous surface, a moderate local de-
pletion may precede measures calculated to fulfil
these intentions : but even this form of depledon
can seldom be carried far-; for the tonicity of the
▼ascular system generally, and especially of the
capillaries supplying the mucous surfaces, is too
far exhausted to admit of that accommodation of
the vessels to a considerable diminution of their
contents which is so requisite to the restoration of a
healthy state of -circulation. The characteristic
phenomena of the last stage — the hsmorrha^
and discoloured blotches — are manifestly owmg
as much to the exhaustion of organic nervous in-
fluence and of irritability, as to the attendant
changes in the blood . It is to these latter changes
almost solely that Dr. Stevens directs his means
of cure in this sta^e ; but it is evident that the vital
conditions on which they depend should receive
equal attention. He states that the quantity of
the muriate of soda is ^eatly diminished in the

last stage of this and other malignant dianscs ;
and that, in order to supply the deficiency, be at
first gave a strong solution af tkus salt with ni-
trate of potash. He subsequently found that th<
chlorate of potash and other active saline agenti
answer the purpose equally well, especially these
which do not irritate the stomach ; and he now
seems to prefer a combination of the nmriale and
carbonate of soda and chlorate of potaab. The
basis of this pathology and treatment is the re-
lation subsisting between the colour of the blood
and the saline matters contained in it. lie
power of certain salts, particularly the muriate cf
soda, the nitiute of potash, the taitrate of potash,
&c., as well as of the alkaline carbonates, u> ren-
der the venous blood florid, and to a^ct tti
fluidity and coagulating powers, was long siaee
fully dfemonstrated by Verueten (vol. u. p. 29. i.
Scbwenee {Hiimatologia, p. 190. ct fmtnm .
Hales (H^mastat, p. 154.), Ellxr (Jfr*. «4
VAead,d€$ Se.de Berlin, t.vii. p.l3.),Ba«aH«*Ti
(Elementa Chymi4t, t. ii. p 378.), Pmr {Lttfr
Seeonde, p. 34.), Haller lEUmenta P&jrsW. t.u.
p. 74.), Sauvaoes (Sur VEffet des MidiuamnM,
p. 37.), and others. A combination of the «irnUc^'
Tpotath and of the muriate of ammunda was alwa)^
employed by Hi lla r y in thb disease, and is appli-
cable to every period of it. Sea water has W«
been a popular remedy for it and oCfacf AVot
Indian fevers, and is very strongly recommended
by Arejula and Mr. N. Dicsenson as an cnena.
Dr. Chisholm employed, in 1798, the ektffrou rf
pota$k, and remarked its effects upon the blood ;
but, as Dr. Stevens justly states, he exhifaitrd
other substances calculated to conntenct its is-
flaence on the disease. But granting that the
colour of the blood is changed to its healthy sole
by these salts, it does not follow either that thej
shall be absorbed into the circulation during the
advanced stage of this fever, or that they shall
have the effect of rallying the exhausted powvn
of life. As to both these circumstances, the san-
guine expectations of Dr. Stevens require coafim-
ation. There can be no doubt that, to he service-
able, these medicines should be giv]en sofficieotiy
early in the exhaustion to allow time for their ab-
sorption ; and that substances which irritate the
digestive mucous surface, and prevent or delay ab-
sorption, should not also be exhibited. In tht
present state of our knowledge, and judging fnw
some experience of the effects of these salts in tb«
advanced stages of other severe fcven, I infer,
that they ought not to be confided in alone, b«t
should be conjoined with such other means as are
calculated to rally or support the vital manifest-
ations, and promote the excreting finnctions —
always recollecting that, in order to preserve the
blood in a State suitable to the continuance of
life, the depurative actions of the variotts emvac-
tories require to be promoted.

383. 6. In the.early stage of exhanstion, Hn*
lary's saline mixture may be prescribed; or the
same salts — the nitrate ofpoiaA and muriait >/
ammonia — may be given in camphor julap ; the

auantity of camphor being regulated accordii^ to
le erade of depression. The cklormte tfftem
may likewise be given in the same vehicle ; orihe
citrate or tartrate of potash or soda, with an «i-
cess of the alkali. It is very importajat, to anad
such means as will increase the irritability aJ
stomach characteriung this stage of the diica^r ,

984

FEVER, BILIO-GASTRIC— DiacHipnoM or.

seasoning fever. It Is observed chiefly in adults
of the bilious or bilio-oanguine temperaments, and
in persons addicted to spirituous liquors. It is a
very prevalent fever in tne countries bordering on
the Mediterranean, in the East Indies, and in
America, and consequently in fleets and armies
an these parts.

389. uastro-bilious |f6ver is eaund chiefly by
exhalations from the soil, or from ve|;etable and
animal matter undeiigoing decomposition, in con-
nection with atmospheric heat ; by exposure to the
sun ; by the ni^ht airs or dews, and the influence
of cold fblJowmg such exposures or excessive
exertion or high ranges of temperature ; by intem-
perance and errors of diet or of regimen ; by ex-
cesses in vinous or spirituous liquors; by great ex-
ertions following inactivity ; by over-eating, or by
a sudden transition from a very poor to a very full
or rich diet, as in the case of soldiers and recruits ;
by anger and other mental emotions ; and by the
causes already enumerated ($ 330. ^.) — It most
frequently, however, arises from the concurrence
of two or more of these causes. The influence
of infection in producing it has been doubted ; but
the experience of Brs. ^enmabk and Boyd, in
ships and hospitals in the Mediterranean, has de-
monstrated its occasional origin in the cause — or
at least the power infection evinces in producing
a severe moclification of it.

390. .i. DcscRiFTiON. — This fever, in robust and
plethoric persons, approaches severe inflammatory
fever on the one hand, and the more inflammatory
forms of femitteiit on the other : or it presents a
predominance of the characters of either, accord-
ing to the intensity of the causes and the pe-
culiar circumstances of the xflected. The chief
difference between inflammatory fever and it, de*
pends.apon the causes whence they respectively
proceed ; the former arising principally from at-
mospheric vicissitudes and climatonal influence,
in connection with suppressed perspiration ; the
latter chiefly froAi marsh and veeeto-animal
miasms (see Diagnosis), Its similanty to, and
connection with, remittents, are refemble to the
origin of both in, the same causes ; the only differ-
ences between them resulting from the intensity
and concurrence of the causes, 'and from indivi-
dual predisposition-^ being differences chiefly of
grade and of type, as shown by Dr. Boyd, and
confirmed by my own observation. That it should
therefore be confounded with these fevers, cannot
be a matter of surprise, and is of little import-
ance as respects the treatment. But when it is
mistaken for the synochoid and adynamic species
with predominant affection of the digestive mu»
cous surface, then the results may be serious.

39.1 . GaUro'biliout fever is nnerally preceded
^y lassitude, nausea or want of appetite; by dull
pains in the back and limbs ; ana by flatulence
and indigestion. The breath is foetid ; the tongue
is fiosffired by a yellowish mucous coating ; the
mouth is clammy, and the taste perverted ; the
bowels are costive, or relaxed, or irregular ; and the
.countenance is pale or somewhat sunk. This state
— the wrtmonitory ttage — may continue several
days, the patient not beine confined to bed ; but
generally in the morning he is seized with chills
or rigors, preceded by a sensation of cold creep-
ing along the spine. To these soon succeed
severe frontal headach, vertigo, nausea, vomit-
ing, burning heat of skin, restlessness, watchful-

ness, slight anxiety at the praBCor£a, pain %tA
oppression inthe epigastrivm, and in one or both
hypochondria, with more or leHeoreneas, fnlnesA,
and tenderness. The eyes are moist and iajeetfdd,
the conjunctiva often yellowish ; the nee '»
flushed ; the breathing oppressed and accelenled ,
the pulse full, large, quick, suid strong, rafdy
hard ; the tongue is clammy, moist, fomd, and
yellowish, with a bitter taste in the month ; the
thirst is urgent, the breath foetid ; the bowek
are obstinately costive, or loose ;'tbe etools biliob,
and the urine scanty and daric . W hen the Btomacb
and bowels are inordinately affected, cefebnl con-
gestion very frequently supervenes at a later period.
As the disease advances, the pulse fieeU leu fiiil.
and is weaker than in health. The tfaixst an!
anxiety are increased ; and the vpper parts of the
body are sometimes covered ^y a proiiue sweat,
whilst the skin still continues hot«

393. If the attack be very seveie, or acglected
at the commencement of reaction, the pain ot
the' head is aggravated^ and a disindination to
answer questions, stupor, and inseasibtlity aj^
pear about the second or third day. The e^ei
are turgid or inflamed.; a bilious yellow tin^t
spreads from the face downwards over the h^-dy ;
the tongue is covered by a thick j^llow cni«t, b
red at its sides, and dry and brown ia the centrt ;
the strength is diminished; nausea with bdjood
vomiting is ofien distressing 4 the pvUe become*
weaker and quicker; and the patient haa an in-
satiable thirst, and desire of cold acidulated fluids.
The urine is very high coloured, voided oAeo, and
produces scalding in passing it. The bowels a»r
either costive or*n>ose.

393. If 4he disease has not been mitigated, t
slight remission occurs on the third, Ibiuth, ornrth
day, generally in the morning; the face and chnt
being covered by perspiration, and the temperature
of the surface reduced. But the symptonw are ex-
asperated towards evening ; the tongue becoming
dner and darker ; the epigastrium and hypochon-
dria more painful, tender, and often also tunid
and tense; the pulse more rapid, constricted, «r
weak. The anxiety at the pnecordia is now
changed into severe pain, aggravated on pretfont.
with oppression and frequent si^rfaiog ; the ooec-
tenaace is sunk ; there is vonuting of putrid cr
offensive bile ; the stools are liquid, greeoisb
brown, foetid, slimy, and occasionally bloody or
dysenteric; the skin is often deeply janodiced,
and emits a putrid bilious odour. The patient is
now collected, but various adynamic and ma-
lignant sjrmptoms appear from the fifth to tiM
seventh or eighth day. These are — tremors of the
extremities, and of the tongue when held out ;
startings of the tendons ; pain about the pubef ,
with inability to pass the urine ; vonuting of a
dark, glairy matter; difficulty of swallowinc.
sometimes swelling andsapporation of the parot <l
glands ; tympanitic distension of the abdomen ; in-
expressive, glassy eyes, dilated pupils ; clammy
sweats, difficult and anxious breathing, and black
tongue. To these succeed delirium, coma, in-
termitting pulse, cold extremities, and death,
sometimes with convulsions. Petechia, Uotch««,
and passive discharges of blood from the no«tnl».
gums, fauces, &c., are but rarely observed.

394. McNfiA'carioNJ.— All the above syraptont*
are not present in the same case, nor always rufi
the same course. In the young, suong, plethc^

986

FEVER, BILIO-GASTRIC— TnBATMEjrr.

Bpects there is little differeDce between it and the
severer forms (§ 230. 232.) of that disease, ex-
cepting that its severity is often greater, and its
duration shorter. Indeed, this is but a variety of
marsh fever, owing its continued and otherwise
modified characters to high temperature and
other concurrent circumstances.

398. As this fever varies from the ardent
seasoning, to the distinctly remittent type, with the
intensity and concurrence of the causes producing
it ; and as it may occur contemporaneously with the
pure climate fever, and with the more inflammatory
forms of remittent -fever, as frequently observed in
the West Indies and Mediterranean during the
hot months, particularly among soldiers and sail-
ors ; so it is often difficult to distinguish between
them. The chief circumstances, however, which
will fix the attention of the practitioner, are —
the manner of invasion; the distinctness, ob-
scurity, or absence of remissions ; the degree of
excitement characterising the early neriod, es-
specially as expressed upon the vascular system ;
the kind of excitement, particularly in respect of
sthenic or asthenic action ; and the state of the
circulating fluid, and of the secretions and excre-
tions.

399. r. From epidemic or pestilential yellow
fever, this disease is distinguished — by passing
into tlie periodic type in many instances, and by
frequently leaving visceral disease behind it ; by
its attacking the same individual oftener than once,
if be have intermediately undergone a change of
locality or climate ; by the more inflammatory or
sthenic character of the period of excitement,
and the much less remarVable change in the
blood and soft solids from the commencement ;
by the headach being confined chiefly to the
temples ; by the yellowness appearing early, and
first in the eyes, and being of bilious origin ; by
much less irritability of the stomach in the ad-
vanced stages ; and by its longer duration — ge-
nerally from five to fourteen days. In pestilential
yellow fever, the yellowness of the skin is not fre-
quent, and is of a pale lemon colour ; the face has a
putrid, bloated, or livid hue; its duration is from
one to five days ; it never passes into the periodic
type, nor leaves visceral disease behind it ; fatal
cases always being attended by the black vomit
at their .close. Moreover, remittent, inflamma-
tory, and bilious fevers are never infectious^ un-
less under peculiarly favourable circumstances,
when the latter may assume this character ; but

• epidemic yellow fever is remarkably infectious ;
and, whilst these are generally benefited by
vascWar depletions during the period of excite*
■wnt, the epidemic malauiy requires a difierent
method of cure.

400. iv. ThftPro^ofif depends upon the intens-
ity and concurrence of the exciting causes ; upon
the severity of the attack; upon the treatment
adopted at the commencement ; upon the state
of vascular reaction ; and upon the complications
that may arise. — o. It may be favourable, if
the attack be mild or simple, the skin moist, the
vomiting moderate, and the matters ejected con-
sist chiefly of mucus or ingesta ; if the tongue
become moist, the bowels loose, and the stools
bilous ; if the nervous and vital powers be not
much reduced ; and if the yellow suflusion be
slight or slow in its progress. — h. An unfa-
•^n*ArabU opinion should be formed, if any of the

more dangerous symptoms eDumerafted above so-
pervene (% 393.) ; especially if the skm be catbet
early or deeply yellow, or the aeittorai fanctknu
early disturbed ; if the period of ezhaosuoo be
attended by deep redneas of the fac«, dulneis of
the eyes, much anxiety, or laborioas nsgintaoa .
by a feeble, creeping, ix intermitting poise ; by
very scanty and dark urine ; great pain, tennoa,
or fulness in the eptffastrium and hypoclMMdna;
difficulty of swallowing; tremors of the toonK
or of the extremities ; by startings of tbc ua-
dons ; involuntary discharges of faces, paitim-
larljir if they be of a black coloar ; ioccasant
vomiting, especially if the egesta be dark, or gieai
in proportion to the ingesta; by petechisB, cb*
lar^ments of the parotids, and coldoesii of tke
extremities.

401. V. TnsATMBNT. — The auffcstioiis are —
1st. To evacuate morbid secretions in the priou
via, and restore the suppressed pewpiratkia. xo
the stages of premonition and invasion; — 2d. To
moderate the vascular reaction atteadaat upon
the period of excitement ; — 3d. To obviate drter-
mination to a vital organ, and mitigate nr^g^tat
symptoms ;— and, 4th. To support the vital powrn
in the consequent exhaustion, — The ftrti indica-
tion is best fulfilled before reaction is developed.
At this time an emetic, followed by diluents, by
the vapour bath, or by warm fomrntarioa>,
sudorijie drinks, and by warm emollient enemsts,
will generally restore the snppiiiwmd pex«psr-
ation, and moderate the consequent leartion.—
Bloodletting is the next important means; bat
the utmost care should be taken not to resoft to
it before reaction has commenced, or when ex-
haustion is about to supervene. Dr. Dskharx
has insuted upon this, and my experieBCc fully
confirms the propriety of the adnce. I hxTc
seen this fever most remarkably ezasperatM,
and almost fatal syncope occasioned, by the ab-
straction of even two or three oances of blood
during the stage of invasion, before vascular ei-
citement was developed. When this patbolop-
cal state has supervened, depletione thonld be
energetically and early practised, but wiib due
regard to the state of the pulse, and to the com-
plications and other circumstances of the ra»v ;
and they ought to be aided by cold applicatioo«
to the head, and purgatives. A full dose (6ob
10 to 20 grains) of calomel may be given imnie*
diately upon the first bloodletting, and afterward*
the tartrate or citrate of soda or of potash nay
be taken, at short intervals, in the state of effer-
vescence, with an excess of the alkalis — As toof
as vascular excitement is energetic, aatiphlo-
gistic remedies should be employed, as recom-
mended above; and, in addition to thoM no*
mentioned, there are none moie desenria^: d
adoption, than small and frequent doses of the
nitrate of potash and muriate of ammoaia.
Cold affusions, and cold spongings of the furface,
are also useful auxiliaries. When internal viscrv^
are oppressed, and reaction is not free and opm.
the tepid bath, or tepid affi^na, will be service-
able.

402. The Meeond indication is to be fattlW
by local depletions, in the first instance, f»Uo««d
by rubefacients, blisters, and the other means
detailed when treating of the remittent form of
bilious fevers (see $ 251, 252— 268. >. — The rf
hauttion in the latter period rai|airea the sacae

088

FEVER, MUCOUS— Causes— fiTMPTOMt—Duoifoas.

ju«t referred, and In others adjoining them, to which
medical men may proceed to lenre, it will be found that
the unaoclimated, according to their constitution*, will
be affected by inflammatory fcTers of varioua grades of
severity, in healthy localities and in hot and drjr seasons—
with bilio-oastric and remittent fevers, of various forms,
in miasroal situations and sickly seasons,— whilst the
acclimated shall escape the first uf these maladies, in the
former of these circumstances, and the second in the lat-
tett or, if attacked, they shall experience only remittents
or intermittentt. The pestilential yellow fever makes no
such distinctions. As already sUted, and as will be here,
after shown, its spread is limited only bv a low range of
temperate, by a previous attack, and bv circumstances
that circumscribe its infection. Whilst the former fevers
are met with in all warm climates, and occur either spo.
radically or endemically in them, and are not infectious,
this last appears only on the intertropical shores of the
Atlantic, or parts adjacent, during not seasons, rages
for a time, and then disappears. Thus, it occurs after
long intervals, prevaib sometimes for years, and then
takes its departure, as will be shown in another place.
When we consider the very different constitutions— orl.
ginal and acquired — of those who Inhabit European
colonies within the tropics,— when we review the appear,
ances of the new-comer, of the old resident, of the Creole,
of the mulatto of various grades, and of the negro, and
take into account the modes of living, the exposures, and
the various other circumstances connected with each
class, and fUrther connect all these with variety of situ,
ation, season, and temperature,— we cannot be surprised
at the very dUEbrcnt forms which fever assumes among
them.

XIX. Mucous on Pituitous Fever. — Syn.
FebrU Mueota, F, Meunterica, Baglivi ;
Morbus Mucosut, Roederer and "Waaler;
Febris Pituitota, Stoll ; Febbr§ gluttnota

fastrica, Sarcone ; Fievre Ad^no-mMng^e,
*inel; Fievre Muqueute, Ft.; Schleimfieber,
Germ.

406. Chabact. — Slight felrile reaction follow-
ing chills, with mucous evacuations, and pains in
the back and limbs, andof'ten with slight remissions,

407. i. Catues, — ^Thi» variety approaches bilio-
gastric fever on the one hand, and the enteric
fonnof synochoid fever, on the other. It may occnr
either sporadically, endemically, or epidemically ;
and, in either case, it may arise from, or pass into,
fever of a periodic type. It may even run into
dysentery ', and, from the severity of the pains in
the limbs attending it, may closely resemble an
atuck of rheumatism. Its characters, both con-
stant and contingent, result from the various
circumstances, both intrinsic and extrinsic to the
patient, concurring to cause it. These are chiefly
— a. The epochs of childhood and old age ; the
female sex ; the lymphatic, leucophlegmatic, and
nervous temperaments ; prolonged watchings -,
excessive fatigue or indolence; languid, weak,
delicate, and pale states of frame ; chlorosis, in-
tcstinal worms, or a cachectic habit of body ; the
debility caused by previous disease, as by agues,
mesenteric obstructions, or by excessive venereal
indulgences. — b. Living in low, humid, cold,
and marshy places ; privation of light and of the
sun's rays; the autumnal season, or prolonged wet
and cold weather; want of cleanliness ; the use
of indigestible vegetables, of unripe fruit, of tainted
animal food, or of unwholesome fish, particularly
shellBsh ; of stagnant, marshy, or impure water ;
the privation of accustomed stimuli ; the abuse of
emeticsor of purgatives ; insufficient nourishment,
&c. The most common of these are cold and
humidity, unhealthy localities, and unwholesome
ingesta. This fever is endemic in the situations
just specified ; and it has occasionally appeared
epidemically during autumn and winter, parti-
cularly after much wet

408. ii. Sifmptt'ms. — Some of the older writers

confounded mucous fever with injlmenta, vtib
catarrhal fevers, and even with braukUis. Bat
more recent obeerven have, with greater propnetr,
confined their description of it to that fonn of
eeneral affection, which is chancleiised by sbffct
febrile excitement and nenross dcprnwinn. with
predominant disorder of the digestive muecna sar-
race, of a sub-acute form, accompanied with ma-
cous or slimy evacuations — admittiB^, iMwrrcr.
the occasional complication of bronchial irritatiga
with it.

409. This fever is preceded by genera] aaeaa-
neas, by a sense of heaviness ; or pains in the linib^,
loss of appetite, disturbed sleep, acid or amd
eructations, and cold or chilliness, which is ir«
felt in the lower extremities. To these socceed,
marked dislike of food, slight thirst, nansea, soae-
times with vomiting of a whitish, tiaasparcnt, and
viscid fluid of a nidorous or acid taste ; a sense of
weight at the epigastrium, with fnlness ; fiatokst
and colicky painSi^ with slight tendcmen in the
abdomen, and relaxed bowels. The tongoc u
usually moist, while, and covered by a Bacons
coating, virith a sickly or unpleasant taste of tk«
mouth; aphthous exudations are occasiooaily
observed on the fauces and lips ; the saliva •
sometimes abundant ; and the breath is foetid and
heavy. The evacuations are mucous, bkhv fre-
quent than natural, sometimes tinged with Mood,
voided with slight tenesmus, and, in childivs,
often with prolapsus aai. In rarer instances, co$-
tiveness, or an irregular state of bowels is observed;
— mucous diarrhoea and costiveneas altenatsn^ ;
and, occasionally, worms are voided. The ame
is either scanty or natural at first, of a citriae
tint, and sometimes passed with pain; it depo-
sits a mucous sediment of a greyish or hnck-
colour at an advanced stage. The tempeniare
of the surface is not much increased, nalos
during the evening exacerbations; and, to-
wards the acme and decline, a gentle ftnfst-
ation {breaks out, especially in the noraing and
daring sleep. A slight cmptioa often ocnirt
during the night, but generallv disappears in the
morning. The pulse is feeble and flnall, hat
seldom much accelerated, unless in the evcoiB^
and night. The patient complains of a seaie of
weight or of pain in the sinciput and occiput ;
with vertigo upon sitting up ; of coofitsioo of
ideas, and somnolency, without the ability is
sleep; of depression, sadness, and restlessness;
of pains and soreness in the hypochondria, in ail
the limbs, and in the joints ; and occasionally of
cough, noise in the ears, and deafness.

410. ill. The Diagnoeie rests upon the circ«»-
stances connected with the origin of the disease ;
on the appearance of the evacuations ; on the co-
licky pains in the bowels ; on the softness, the very
slight acceleiation or slowness, of the pulse ; on
the little increase of the temperature, and the
humidity of the skin ; on the slight degree of
thirst ; and on the very moderate or sub-aruie
character of all the febrile phenomena. In tu
slighter forms, the complaint is commonly de-
scribed as fever from cold, or as a cold in the
bowels and limbs. In some cases, it pieaenta
either a dysenteric or a rheumatic character ; and
is with difficulty distingnished ^m dysentenr.
or from rheumatism in other instances, unless tLt
history of the disease, and the state of the bowtU
and of the evacuations, be closely observed, le

990

FEVER, SWEATING— History.

laxative enemata.— /. Six<fc/t/. to alleviate urgent |
symptoms, or determinations to particular organs

— as to the head, the lungs, or liver — by local de-
pletions, external derivatives, rubefacients, &c. —
g. And, uventhly, to support the powers of life in
the latter period by gentle tonics, light nourish-
ment, and by cinchona or the sulphate of quinine,
especially when the disease presente remissions,
or is disposed to pass into the periodic type, or
into rheumatism, and particularly in humid,
marshy, and unwholesome situations. I have
found the following aperient very serviceable
in this form of fever, when the bowels required to
be gently but freely evacuated. Others, how-
ever, in the Appendix (F. 266.430. 827.), will
equally useful.

Ko.SSS. R Potasne Supertart In pulv. 3).; Pota»»«
Nitratii 3 ij. ; Confect Sennae 3ij. i Syrup. Aurantii 3 J.
M. Fiat Electuarium, cujus capiat Coch. t. vel i]. minima.

BiBLioa. AND Kbpeb. — Avicmna, Canon. Liv. fen. I.
tr ii. c 47. 55.— J. Bockel, Synowi no»ri MorbL quern Febr.
CaUrrh. vocant, Ac. Helma. 1580.— Cravae, De Febr. Ca-
urrhalibus, Ho. Jen. 1676. — C Piw. De Morbis ex Serosa
Colluvie ortis, 4to. Lugd. Bat 1714. — Bagiivi, Prax. Me-
dica, 1. i. cap. 5. ^I.G.De Hah», Febr. Contin. qua? Ann.
1729, UratlsfaviiB gTK6«ats »unt, 4to. Urat 1731.— lloederer
ct Waaler^ TracUt de Morbo Mucoso, &c. Goet 1762. 1783.

— Strack. De Febrc Pituitaia. Mog. 1781. — Knaus^ An.
not quasJam circa Morb. Bit Mucosum Ann. 1783^.
Stuttg. grautat. &c. Stutcg. 1786L—»'iirAtfr*,Di«:rim. in-
ter Febr. Bil. et PituilOMm, Doering^ Tr. voL L— £<i.
ner. Animadvert in Feb. Pituitocas. Regiom. 1789.—
M. StoU, Itatio Med. vol. iii. p. 141. : ct Aphor. de Cogno*.
cend, et Curand. Febr. &c, edit 2d, p. 137. — CotubrvcJk,
Hilt Fcbris Mucotas Ann. 1783-4 Stuttgardiie graMats.
Stuttg. 1790. — Jacobin De Febrc Pltuitcwo-nervoM, Stuttg.
1782 grass. 8vo. Stuttg. 1793. — Stroem^ in AcU Res. Soc.
Med. Havn. vol iv. p. ^i.—SelU, RudiroenU Pyretologic,
Sd edit. IV 2ei2. — Ctfiu, Beschreib. einer Schleimfiebere[n.
demie. Tol>. 1795. — /J«7, Memor. Clinic, faac. i. p. 6. —
Py. De la Fi^vre Muqueuse, Journ. G6n. de Med. t xix.
n.2S9. 1805. — Sorconr, Hist Raisonn^e dea MaL Ob.
aerv. i Naples, par Bdla^. Lyon, 8vo. 180k — Pincl, No-
Bog. Philosoph. t I. p. VSL-^HildenbrantL Inatitut Med.
Pract vol iv. p. 741. — ifoi«ra«, Traite des Fidvres, &c
p. 174w

XX. Fever, Sweatino. — Syw, MiHarit Sw-
datoriay Sudor MUiaris, Miliaria (from mi-
iiwOT, a millet seed). Sudor, Sudor Anglicus,
Sudirr Picardiui, Febrii Sudatoria, F, Helodes
Sudatoria, Sudatio Febris Helodes, F. Miliaris,
F. Ve$icularii, Purpura alba, Auct. var.;
Miliaris, Sauvages and Sagar; Febris Pur^
purata, F. Hoffmann ; La Suette, La Suettt
Miliaire, La Suette Epid^mique, Fievre Mi'
liaire, Pujol, Gastellier, Meniere, &c.; Der
Friesel, Germ. ; Miliary Fever, Sweating Mi-
liaria, Sweating Sickness,
416. Defin. — After lassitude and general un-
easiness, a suddefi attack of febrile disorder, with
most profuse and continued su)eat, frequentlii foU
lowed by an eruption of miliary vesicles, the disease
occurring epidemically and being infectious.

An, I have preferred the name sweating fever
to that of miliary fever, as sweating is the con-
stant and characteristic phenomenon of the disease,
and is present in the mild, as well as in the most
malignant cases ; whereas the miliary eruption is
sometimes wanting in both. This malady should
not be confounded with the febrile affections of
lying-in women, attended by sudamina, that have
improperly been denominated miliary fever, from
the character of the eruption sometimes occurring
as a symptom of them, during hot seasons and a
too heating regimen. This is a specific fever, sel-
dom observed in modern times, m this country,
although frequently prevailing epidemically in
many parts of Continental Europe.

418. i. HisUrry, — The epidemics whidi bare
been variously denominated, as stated in tfae6«atf-
nymes, have manifestly been modificatioiu of tbe
same disease, caused by the varying circwnstaaces
connected with its appearance. — Tbe cpsdimiir
sweating sickness, which appeared between 14&5
and 1 528, and which ravaged d^and in tbese and
several intermediate years, was evidently, as sop-

f»osed by MM. Ozakam and Rayer. a omvI Ti»-
ent form of this malady, in which the sweat was
the most pominent symptom, and the propvM
most rapid and acute. But many cases noiaeed
by Buyer and others, in recent epidemics, wev
similarly characterised. — (a) The epidemics ob-
served in France by Riverivs, during 1618 ; in
Germany by Welscii and Lavgivs, in 1652 ; m
Francfort in 1653 ; in Augsburg in 16G0 ; m
Bavaria in 1666; in Holland by Gnrywst^
in 1666 ; in Hamburgh in 1675 ; in Loodon and
in Edinburgh, towards the end of the sevoiiccath
century, by Hamilton and Sibbald ; in Saxony
in 1694 ; in Hungary in 1697 ; in Pljmoiith bj
Huxham, in 1738 ; in Normandy by La Psc9-
db-la-Cloturb, in 1740; near Mantes bv
QuESNEY, in 1750; in Navarre by Acovsnirtt,
in 1755; in Bayeux from 1769 to 1776; m
Piedmont by Allioni, in 1758, and l»y Da sit-
LONio in 1782 ; and in Toulouse and the vicie^
by Gallct nu Plessis, in 1781 ; were ese»*
tially the same disease. In all these, the fev«
was ushered in by chills, horri|nlatians, and
other premonitory and invading symptome, mhaek
were soon followed by pains m the head, ioias,
and limbs ; by nausea, Bushing, profose sweat,
dyspnoea, and, about the third day, bj a mi-
liary eruption. Numerous other epidenucs that
have presented this form of eruption as a pro-
minent symptom, have been described br wnicrs
who observed them during the two last cen-
turies. But in these it was apparently caosed,
either by a too heating treatment and legimcB, «
by the neglect of evacuations daring the early
stage of the disease ; apd it was not always cm-
nected with excessive sweat. It was, indeed, ia
most cases merely a symptomatic eruption appear-
ing at an advanced period, in a similar muiner ts
petechise, &c., with which it was even sometimes
associated. In the epidemics, however, which I
have above enumerated, the eruption was not a
consequence of neglected evacuations, nor of a
heating regimen, for the treatment was genefaJly
depletory and cooling, and it occurred emilief ia
the disease, although always preceded by pfpfia»
sweat, which was coetaneoos with the vascolar
excitetEent, and always peculiar and offeanve.
So thick a vapour generally surrounded the tack,
arising from tne excessive perspiration^ that tbe
flame of a candle was obscured by it.

419. (fr) The epidemic occurrence of swcatiiii
fever in various parts of Pirardy was fini noticta
in 1718. Since that time- it has fnaqoeatly ap-
peared in that province, and in other parts of
France ; and has more nearly approached, thaa
the epidemics noticed above, the chanrten e/
the sweating nckoeas of the 15th and 16lh cen-
turies, in respect of the rapidity of its coone, the
promise sweat, and the frequent absence of the
miliary eruption. The sweating lever of Picaidy
appears to nave prevailed more or less in Tariom
parts of this province and of Flandeis, from 1719
till 1747. In this year it appeared in Pans; ami

doa

FEVER, SWEATING— Diagnosis— TmEATKWT.

atioD, the crepitating rattle, or a blowing noise in
some of the lobes of the lungs, diminished sono-
rousness of the chest, a full and frequent pulse,
and bloody expectoration or hemoptysis, indicat-
ing inflammation or inflammatory congestion of
the respiratory organs. When the digestive
organs are predominantly diseased, the patient
complains of an acute constrictive patn m the
epigastrium, with urgent anxiety, frequent sigh-
ing, a sense of sufTocation, or of weight in the
chest, and an unusual pulsation in the region of
the stomach. These appear from the commence-
ment, are exacerbated at intervals, and are most
severe just before the eruption. In others, the
symptoms indicate affection of the bowels, with
constipation \ and in some, severe pains are felt in
the hypogastrium, with scanty, hi^ coloured
urine, and difficulty in voiding it. — -This violent
form of the disease may prove fatal in twenty-four
or forty-eight hours, or in three or four days ; but
it commonly runs its course in from one to two
weeks in favourable cases ; sometimes, however,
extending beyond three weeks. During con-
valescence, debility is its chief consequence,
secondary affections being rare. Those that do
occur, are gastro-intestinal disorders, and the
eruption of boils.

422. The alterations of struclurehi.ye been im-
perfectly observed. — When a fatal result has been
preceded by anxiety, pain, or burning in the epi-
gastrium, tne mucous coat of the stomach and
duodenum has been found much injected. In
the cerebral complication, the brain |has been
found congested, the membranes injected, and
the ventricles filled with serum. In the pul-
monary complication, congestion of the lungs,
and hepatization of portions of it, have been re-
marked. Although epidemic visitations of this
disease in France have been frequent in modern
times, and fatal cases very numerous, yet its pa-
thological anatomy has been very imperfectly
investigated. It is evident that death is caused
chiefly by the severity of the complications ac-
companying it.

423. lii. Diagnosis, -^The constant, the profuse,
and the peculiar sweat attending the disease from
the time of its developement, not only characterises
it, but distinguishes it from all other fevers. The
severity of the complications in the intense form,
especially at the time of attack, and upon the
appearance of the eruption, the character of the
eruption, the epidemic prevalence of the malady,
and its infectious nature, further serve to distin-
guish it. The descriptions of the sweating sick'
ness by Caius, Wilus and others prove that it
was a more intense form of this disease than has
been lately observed. The characteristic symp-
toms of the former all exist in the latter; and,
although the eruption is not mentioned in the
sweating sickness, this appears not to have been
a general symptom in recent epidemics. M.
Rayer states it to have been wanting in a great
number of cases, in the epidemic of 1821 -, and
M. Mekisiib makes a similar remark as to that
of 1832.

424. iv. Prognosi*.— Sweating fever, as observed
in modern times, is a mild disease in its simple
form. Predominant affection of any internal
organ will render the prognosis unfavourable,
according to the severity of such affection. How-
ever alai-ming the symptoms, if they decline

upon the appearance of the enipiioD, a &ro«nU*
issue may be anticipated. M . Kateb states Uui.
in 1821, the eruption was independent of un-
tation of the stomach ; that it was ctmflaeot with-
out violent previous pain in the epigastxium ur
nausea ; that it did not always succeed the mo-t
profuse and incessant sweat ; and that it did not
m variably appear in cases where the gastnMa*
testinal disorder was the most remarkable. 1>aI^
was often sudden^ more unexpected than m t(.s
common eruptive fevers,— « and often felkm*^
upon shrivelling of the vesdes. The greased
number of deaths occurred in 1821, between Ujc
ages of 23 and 33. The mortality in male« was
one in thirteen ; and among females, one la
twenty-eight. In the earlier epidemics obsext^i
in Picardy, the mortality was very much greater
than this. It was greatest at the beginning ao-i
decline of the epidemic ; and among baker>>.
smiths, and farriers : but was variable in differeui
townships. The epidemic of 1832 was in maat
instances followed by pestilential cholera. Tuc
latter malady often followed the decline of» ur
convalescence from, the former, and even occa-
sionally appeared in its course; the moctalit)
being thereby much increased.

425. V. Causes, — The theatre of the epidemji
of 1821, was bounded by extensive fore»t«. M.
Rayxr states, that the disease is endemic in »ofr«
situations } and that it may occur sporadicaiW
where it has prevailed epidemically. It has btrc
observed only between 43^ and 60° North latitude
Moist and shady places, excessive bent, and an
atmosphere surcharged with electricity, seem to
favour its irruption. No age gives immnniiT
from an attack ; but adults and females are moU
obnoxious to it. M. MxNiiRB states, that msD>
of those who had the disease in 1821, were agaio
attacked, and died of it, in the epidemic of 1832.
When once engendered, it spreads bw infectidtt.
in the same manner as typhus, scarlatina, and
measles. Unhealthy situations, and the poor in tht
vicinity of the place where it firstappeared, suflfered
in proportion to their proximity, during these two
epidemics. M. Menibrk remarks that, of the an-
merous epidemics which have occurred in Fiaocr.
and in other countries, since 1718, to the pre-
sent time, there is none which shows its otigiD,
either in marsh exhalations, or in unwbolesaome
food.

426. vi. Treatment. — Isolation, temporary m**
gration, and avoidance of the affected, are tkr
only preservative means that can be depended
upon in this malady. — The mild states require
but little aid ; and it is doubtful if medical tmt-
ment will either shorten or alleviate the aturk.
In the severer forms, and where some iDtemal
organ is especially affected, appropriate rem«dK'«
ought to be employed to guard it from daofrr.
If the affection of the head, or of the cheat, or of
the digestive organs, be slight, local dtpUtiems »ill
give relief. If the local complication be severe.
pfeneral bloodlettings, with powerful external and
internal derivatives, as blisters, sinapisas, perg-
ataveSi &c., will be occasionally us^ with sor-
cess. Dut M . Ra yeb remarks, that the ccreUal
affection, when severe, is often rapidly fatal, not-
withstanding the reputed abstraction of blood,
and that the nervous nhenomeoaareoccasiottally
independent of actual inflammation. — After ths
eruption, bloodletting is always injurious ; and U

d94

FEVEK, SYNOCHOID - Cavsm-

species of continued fever. — As, therefore, the
eautei of synochoid, &nd of these forms of typhoid
fever, are often the same — their intensity and
concurrence producing the more severe states of
disease, as well as giving rise to an infectious
miasm — the view which is about to be taken of
them with i^rence to the former species, will
very nearly serve also for the latter.

431. i. Caits^. — A, Of the remote cauus of
the varieties of continued fevers most frequently
observed in this and other temperate climates,
those which precede the operation of the more
effective causes, which are usually internal as
respects the oeconomy, and which« from the cir-
cumstance of their disposing the system to the
operation of these latter caases, have been usually
•called the predUpoting, require first to be no-
iiced. It is often difficult to determine in what
the disposition to be affected by these forms of
fever consistSj and in what manner it is caused.
"To say, with many, that it arises from an increased
?sttsceptibility, does not advance our information
^ne step, and is merely the substitution of one
term for another. Close observation of the cir-
cumstances connected with the origin of these
•diseases will show us, that the disposition to be-
•«ome affected with them is not the result of
•exactly the same circumstances as favour the
appearance of ardent fever. A depressed or weak
sstaie of vital power, especially as manifested in
-the nervous systems, but particularly in that of
«i^;anic life^ seems to be one of the most common
<caus<e8 of predisposition. This is proved by the
-tfact, that perfect health, mental activity and
energy, confidence in yarious means of prevention,
the moderate use of tonics, &c., enable the body
-to resist the impression of the exciting causes,
yaiticularly infectious and mepbitic effluvia ; and
Ittat fear of the disease, despondency, the de-
pressing feelings and emotions, fatigue, increased
:«ensibility, disorder of the digestive and assimi-
lating functions, &c., are amongst the most
•common ocoasions.of these eauses taking effect. —
But, altfeoMgib^iRuoished energy of the powers of
life has a roa^^®^ influence in favouring the oper-
ation of the exciti^^?.^^^^^' y®^ sometning more
ife required j and iliis '^^^^ ^ referred to a cer-
tain ioonstitution nf frame, "^^'^K ". «>fl««»ced
■•««« in a relaliv* manner' ^"^^.^y "^^1?^«
causes. ^»d '*l ^^* times only ^^,J?^^!'
cauieS; *^i wMch often either resists . ^ ^Pf "
Vatm of tteuBuail cftuses altogether, or ^."^°^
l^ly to *•' cwnlMned: action of a greater or

liiaa numberr .■ u

43^. A nwcfc greyer pfedispowtion to be
affected by continued fevers exists between the
ILi of fifteen and thirty-five, than at any oOjer
veHod J the forms of fever being generally of a
k)re inflammatory and acute kmd between these
aces, and in the sanguine, irritable, and plethoric
constitutions; whilst persons past the latter of
these ages, and those of a lymphatic, leucophleg-
matic. or melancholic temperament, are more
liable to experience the lower grades of action.
Scarcity, famine, and, consequently, insufficient
and unwholesome nourishment, among the lower
classes of the community, are the chief causes
of the generation and spread of fevers, especially
those of a simple, low, and infectious character.
Whatever depresses or exhaust* the vital and
mor^l energies, exposes the body to the impression

of the exciting causes. The circumstances wicii
produce this effect «re fully explained in the ar-
ticle DiscASE (§ 21. 23. 27^36.), and in a pre-
vious section (i 64.).

433. The disposition, also, which is generated
by certain epidemic constitutions of the atmo-
sphere and season should not be left oat of coa-
sideraftion. A peculiar diathesis seems to be
gradually and generally induced by the epdeonc
influence,whateverihat influence may be in respect
of its nature ; and this diathesis or change of the
vital manifesUtions of the organisatioo rapidlj
passes into febrile commotion upon the actioa of
one or more of the exciting cnn&es. The cbaoee
thus effected in the diathesis, and increased by
the impression of the exciting causes, may bence
be viewed as the proximate canse, or earbest
pathological state, of the disease; and to hs
continuance or non*continoance alter the febrile
action is fully developed, is often to be impvted
the disposition or indisposition to relapee. This
is more particularly the case in respect of tht
fevers caused by exhalations from the soil and
from decayed vegetable matters. InfectJoos mi-
asms — or the effluvia from the bodies of tbon
in fever — suddenly and remarkably increase the
morbid diathesis ; but when the resulting disease
has been undergone, the morbid diathcsb is ter-
minated, and a disposiiion to a return or relapse is
altogether or nearly lost. Akbough epnlemic
states of the air thus do not favour relapses <rf
infectious fevers, yet they greatly dispose the
system to a first attack upon exposure to the
exciting causes, when the aiathesis has not been
changed by a previous attack.

434. B. The exciting eautee of continued fewr
are upon the whole much better known than tl«
states of the system which dispose to their oper-
ation. They are extremely numerous ; for what-
ever interests the vital energy so as to dictarb
generally its manifestations, and to occasion a
morbid reaction, may be an exciting cause of
fever.— It is unnecessary to enumerate even thr
most influential of them, as they aic addncvtl
with sufficient details, in the articles DicxA^f
($ 65—63.), Endemic Iwfli'encbs, Iwncno*.
and in an early section of this article (i 6S.}.
The chief causes of this clam of fevers are — I<t.
Those which proceed (a) from the soil ; (6) from
its productions in a state of decay ; and (r) fraa
animal matter undergoing decomposition ; either
of these acting separately, or all of them coo-
jointly; — ^2d. Animal miasms — (•) from healthy
p^^sons or animals crowded together, or coofioed
[q imperfectly ventilated situations, ami withoet
due regard to cleanliness ; (h) from penoas la-
bouring under diseases of various kinds in con-
fined apartmento; and (c) from one or siore
persons affected by the disease which the eiluviom
propagates ; — and, 3d. Changes taking place m
one or more of tke various functions, and which
having reached a certain pitch, break out in open
fever. Each of these requires a few remarks.

435. a. Emanations from the soU or its p»o-
ductions in a state of decay, are mo«t frHjuently
productive of periodic fevers ; but they occi-
sionally also give rise to condnoed fever,
cially during certwn sUtes of season and
perature, and in plethoric and robust coD<»ituttoo».
What the conditions are, that occasion the con-
tinued, in preference to the periodic, type, caneoi

e«pe-
tcm-

996

FEVER, SYNOCHOID - Descriptiok of.

kind, is produced. — ^. Preuwus disorder height- nates favourably, even when left to nature; but

ens the severity of the disease, and necessarily it may become complicated in its coune, or

determines its predominant features or compli-

cations, althougn sometimes in an indirect manner.

Thus, it is common to observe bronchitis previous

to, or attending the invasion of, fever, followed

by a remarkable affection of the brain and of the

mucous membrane of the intestines. In this case,

the changes effected by respiration on the blood

are imperfect ; and, consequently, this fluid be-

comes morbid, — disordering first the functions

and ultimately the structure, of the digestive

mucous surface and brain.

440. ii. Description. — Common continued

into a stale of dangerous, or even fatal, exhaas-
tion towards the end of the secotid week, par>
ticularly in weak, aged, and exhausted perMms.
The return of the healthy fonctions b iodicatcd —
a, by the subsidence of the pramineot morbid
actions ; — 6. by the appearance of critical evacu-
ations ; — «. by a quiet and prolonged sleep, out
of which the patient awakens refnosbed, and par-
tially restorer! ; — and, d. by the other phe-
nomena already enumerated ($ 41.), as indicative
of a gradual decline of the disease. The tran»-
ition to a severer form of fever is comiDooly

fever occurs in a simple and complicated form, [owing to the occurrence of a predominaBiaffectioa
presenting various grades of severity ; the severe of the respiratory surfaces, or to the change la*

duced in the circulating and secreted fluids, or
to the affection of the digestive mucous »ar£Ke,
or to the circulation within the bead.

443. B, Severe or dimplieated Sw^uthoid
Fever — Sifnoehus gravier ; Severe Sifm»ektts —
occurs from the same causes that produce the
milder disease, either acting with greater inteoMty,
or aided by additional circumstances. — ^Tbc seve-
ral stages may present a more severe ailectioD of
all the functions, than has been now described,
without any very predominant lesion of a pai-
licnlar organ ; but much more frequently some
important viscus betrays increased disordier, gc*
nerally of an inflammatory or disorganising kind.
Yet this predominant lesion is not altogether
identical with inflammation — certainly not with
the inflammation primarily affecting healthy per-
sons. It is less acute or intense as respects the
symptoms attending it, more asthenic as rcganh
the state of constitutional power, and more dif>

and complicated states passing into, or becoming
identified with, varieties of the adynamic species.
The severe states of common fever have been very
generally imputed to its complications with in-
flammation of internal parts ; but, although its
complications are necessarily severe, yet it may
be equally so without any evidence of local or
predominant affection. 1 his, however, is seldom
the case. — I shall, therefore, first describe the
simple form; and afterwards the more usual
complications and states-of severity.

441. A, Simple Continued Fever — Simple
Fever ; Mild Synochus ; Synoehus mitfor— is usu-
ally preceded by the symptoms described above,
as constituting — a. The preeurtory stage (^ 34.),
especially by lassitude, and a general feeling of
uneasy debiuty, and mental languor. The coun-
tenance Is pale ; the features sharpened, dejected,
or anxious ; and the pulse weak and small. — h.
After an indefinite period, varying from two or

three, to several days, irregular chills, rigors or | funve and sub-acute in its character, than
shivering, commonly alternating with transient i mon phlegmasia. It partakes of more of the
flushings or feelings of heat, are experienced, | features of the erysipelatous than of those of
with the symptoms characteristic of the period of \ common or pure inflammation. Even when the
invasion ($ 35.). This stage is seldom attended . local aflection is more than usually phlogistic ta
by any actual coldness of the surface, particularly i appearance, still it is most important io vmllect,
after it has continued a short time; the chilliness , especially as respects the treatment, tbat it is
being accompanied by increased heat, constric- ' preceded and attended by a more or less se ere
tion, and dryness of the skin. — e. With the , constitutional disturbance, by lesion of the va-
disappearance of the chills, the period of reaction rious manifestations of life, and by a change of
or oi excitement (f 36.), and all the phenomena . the circulating and secreted fluids, — ciicum-
associated with it, supervene. The vertigo, pains I stances arising out of the poisonous influence of
of the head, back, and limbs, and restlessness, ; the febrile cause, and imparting the peculiar
usually present in the preceding stage, are in- ' characters to this affection, — changing it fmm
creased in this. The patient complains of mental the true phlogistic or sthenic inflammatory eon-
confusion and inability; of general uneasiness dition, and determining, accordingly, the coa-
and restlessness ; the countenance becomes full sequent lesions (§ SO.). Instead, therefore, of
and flushed ; the tongue white, foul, loaded, or viewing the complication as the cause of the
furred ; the heat of surface generally rises above severity of the fever, we should rather consider
100^, and the pulse and respiration are fuller, the intensity of the morbid impreaakm made hy
stronger, and more frequent than natural ; the the febrile poison, and the resulting consequences,
pulse being commonly from 90 to 100 or 105 as the principal source of severity and of loral
beats in a minute. Tne fever is now developed, affection, aided bv the predisposed state of coa-
and proceeds, as described above ($36.), usually stitution, and of the viscus especially affected, —
for several days, — its duration varying from two, I shall describe the predominant lesions or corn-
three, or four, days to as many weeks, until it either plications of sy nochoid fever, in the order of their
subsides in consequence of the treatment adopted, usual succession, and of their frequency,
or passes off by means of some critical evacuation 445. a. Synockoid fever with jnrdemiment
{the period of crisis), which most frequently affection of the bronchi and lungs. — This is the
occurs on one of the critical days, from the 3d to most common, and generally the earliest, com«
the 2l8t day from the time of invasion, or that in plication, although it frequently exists only is a
which chills or rigors were first felt. —The stages slight degree. 1 he bronchia] surfcee is ohem
of decline and convalescence commonly advance more or less congested and irritated, and the
in the manner stated above ($ 41, 42.). structure of the lungs sometimes implicated.

443. This mild form of fever generally termi- — This coroplicttion is not necessarily sever* la

998

FEVER, SYNOCHOID— Dmcbiptiow o?.

it may, moreover, be slight or Bub>acute, or re-
markably intense, and in all the intermediate de-
grees.— In the more flight or $ub-acutt forms,
it constitutes the Nervout Fevtr of some writers ;
and, in the more acuU and intents grades, the
Phrenitic or Brain Fei7«r of others. — The former
of these very nearly approach, in their patho-
logical states, the nervous variety of adynamic fe-
ver, denominated Ataxic by Pixel, Neuro-sthenie
by HiLDENBRAND, and Typhut mitior by Cvllen.
449. a. Common continued fever, with pre-
dominant cerebral affection — the Neunhsthmic
of HiLDENBRAND — commeuccs, and proceeds
for two or three days, as the simple or mild
form of the disease. Either then, or at an earlier
period, the patient usually complains of pain in
some part of the head, most frequently in the
temples and forehead, or in the occiput, extending
down the neck. The pain is often constant and
severe, but it is sometimes slight or entirely
wanting ; and it is commonly attended by throb-
bin? of the carotids and temporal artenes, and
flushings of the countenance. In those cases
where no pain is felt, even upon shaking the
head, the cerebral affection may not be less ur-
gent and dangerous : but there is always, in those,
a very early and remarkable giddiness, either with
or without flushing of the face. Occasionally
the pain and giddiness alternate, and the latter
is always distressing when the former is absent.
The expression of the eyes is either heavy and
dull, or morbidly brilliant and animated. The
conjunctiva is generally loaded, injected, and
suflfused, in the former case ; and brighter and
more glistening in the latter. But the eyes are
always more or less sensible to light, the eye-
brows contracted, and lids half closed upon ex-
posure to it. Hearing and the general sensibility
are also more acute. Noises and light inva-
riably increase all the symptoms. The heat of
surface is generally above the natural standard,
especially over the head ; but it is oiien not
augmented on the lower parts of the body. The
patient is watchful and restless, and the expression
of his countenance indicative of suffering. In
the less acute cases, the pulse, the thirst, the
appearances of the tongue and of the evacuations,
are nearly as in the simple form ; and the symp-
toms generally continue, without alteration, ror
several davs. An important change then oc-
curs. In favourable cases, the slumbers, which
were short and disturbed, or attended by a slight
dream)r delirium, become ciuiet, profound, and
refreshing. In unfavourable cases, the pain in
the head changes to a dull, lethardc state, with
a great diminution of the sensibility, and with
increased injection and suffusion of the eyes.
Delirium, if it have not already appeared, now
comes on, attended by moaning or by incoherent
muttering, during short and interrupted slumbers ;
the tongue is loaded, dark, and dry ; and the
thirst is diminished. In from one to three days,
the insensibility passes into coma, unless a fa-
vourable alteration takes place; the pulse be-
comes very quick, and often rises to 120 or
upwards ; the strength sinks ; and the ton^e is
more dry. To these succeed tremors, rolhng of
the head on the pillow, tossing of the hands,
picking at the bedclothes, and the other danger-
ous symptoms consequent upon the more acute
states Of this coroplieation. Even when this

unfavourable change has occaired, a stop isay
be occasionally put to its progiess, altboagh s
generally pursues its onward coone. A oioie
tranc^uil and protracted sleep ; subaidence of the
delinum, or of the tremOTs, or of the frequency
of the pulse ; and a cleaner or more noiit longoc,
commencing at its edges, with an improveseat b
the appearance of the countenance, and in the
state of the skin and of the czcretioas ; are the
usual indications of an arrest of the daageiw
progress of the disease.

450. $. In the more acute states, the oeiebfal
symptoms are severe, and their or oe rasa imptd, m
proportion to the intensity of toe local cosBpli-
cation ; the headach or giddine«,tbe tntolcf«Bcc
of light and noise, and the general scosifailiiy,
being coordinately excessive. The pain in the
back, loins, and limbs, is very great ; the skia m
often intensely hot, and pungent, paiticvlariy
over the scalp, and is occasionally coteied by
penpiration, which is rarely copbos or genetal ;
the eyes are injected, and suffused ; the bfcotbiag
is frequent and suspirious ; the patient is audoos,
uneasy, and remarkably restless; he rolb the
head, and is wholly without sleep. The p«ise is
at first strong, full, or bounding; butgeMially
devoid of the hardness characteristic of prinafy
or pure phrenitis. Sometimes it is oppiesaed ;
and, in the most intense states of compiicatioB,
it is often intermiUent, slow, or not much above
the natural frequency. Within four or fivedaja,
the pain passes into delirium and inwensibili^.
The delirium is sometimes violent, and is th^
soon followed by tremors and insensibility ; aad
these by subsultus tendinum. The inaeasil^ity
increases, and passes into a drowsy lethargy ; the
delirium continuing, but becoming low and
muttering. The patient may still become ob-
servant, and answer when roused ; b«t cosa
supervenes, occasionally with rolling of the eye-
bails or squinting, dilatation of the pnpfls, and
falling of the evelids. The tongue ie now parched
and brown ; the gums and teeth are covered by
a dark mucous sordes ; the evacuatieoa take place
inconsciously and involuntarily ; the reepiratioo
becomes irregular ; the pulse either slow, or re-
markably rapid and feeble, or intermitleDt ; aad
life soon terminated«

451. Between^ these extreme states,
every grade of intensity, the above
being variously modified. In some rates, the
cerebral affection is very insidious, and mon er
less slow ; in others, open, maaifeat, and rapid.
In the former it may be indicated only by giddH
ness and sickness or vomiting; the pnlse in the
carotids, and teroperetore of the head, not bcsag
affected. In a case of this descriptioii, which
lately occurred in my practice (Mr. H. of Fits-
roy Market), all the symptoms subsided inMsntly
upon bloodletting. — It may thus exirt never-
theless, although in a more protracted ffom, and
present but few of the above symptoms, winch,
however, are most frequently observed, hsit art
all of them in the same case. The vaiioas
grades of this complication may be funher aaao-
ciated with considerable bronchial aflcctiea, or
with the disorder of the digestive canal about to
be noticed. In such cases, the pieilwinani
lesion, either in the head, the thorax, or abdeissi.
frequently obscures the othera, mlil tbe treat-
ment, by rabdumg it, rendeit them iBon evidaot.

1000

FEVER, SYNOCHOID— TBKATM£Nr.

in any other. Yet it will be belter to combine
with It the more modem indication, of resorting
to such means as may subdue the more urgent
symptoms, and avert contingent danger. If the
patient be seen as early as the prenundtory and
invading stages, the impending disease may be
averted by the means advised alxive ($ 121, 122.)
— more especially by e»tetic$, warm diaphoretics,
and the vapour bath. But when excitement has
commenced, the treatment should be antiphlo-
gistic. In this stage, we should endeavour, by
a careful examination of the symptoms, to ascer-
tain the existence of local complicatlbns ; and,
having determined their absence, the question
will then be as to having recourse to JtUfodletting.
I have already considered this topic so fully
a 128—139.) that nothing further need be here
advanced. If the nature of the prevailing epi-
demic, or the de^^ree of reaction, require (upte-
tions, the earlier m this stage they are resorted
to the better. But even then they require cau-
tion and discrimination. If the excitement be
slight, and the patient neither robust nor ple-
thoric, and more especially if the causes and
circumstances connected vnth the origin of the
disease be of a depressing nature, they will be
better withheld.

458. The exhibition of emetict in the stage
of excitement was advised by many of the an-
cients, and practised by some of the most recent
vmteis, although objected to by others. The rea-
son of this dirorenoe of opinion is very obvious.
There are states, even of this stage, in which they
will be of service, and others in which they will
be injurious. When reaction is slight — when
the patient is not plethoric, has not experienced
full vomiting, ana does not complain of pain or
of tenderness in the epigastrium or hypochondria
— then emetics may oe exhibited. But if the
excitement be great, with determination to the
head ; and if the patient have already vomited
freely, and more especially if the symptoms just
mentioned be present, they should not be pre-
scribed. (See $ 149.)

459. Purgativei, so much decried by Bbovs-
sAis, and with some justice as respects several
states of liever prevalent in France* are certainly
of very great service in the common continued
fever of this climate, when employed with a
cautious discrimination. Early in this disease,
calomel, either with or without James's povrder,
may be given at night, and a purgative draught
in the morning. At a more advanced stage, calo-
mel, or hydrargyrum cum creta, may be conjoined
with rhubarb. If the stomach be too irritable
to retain the more common purgatives, a full
dose of calomel will generally be retained ; but
its action should be promoted by enemata (see
F. 140. 144.). During the febnie excitement,
and when the bowels are sluggish, the stronger
saline purgatives may be given in solution, in
small aoscs, and at short intervals, vrith refrige-
rants (F. 440, 441.). The remarks already of-
fered upon this subject ($ 150, 151.) will gnide
the practitioner as to the choice of purgatives,
and the extent to which they should be pre-
scribed. In this fever, especially, it can never
be injurious to ^ve them to the extent of freely
evacuating morbid accumulations in the bowels,
and of promoting the alvine secretions and ex-
cretions. When the fvces are very ofienrive.

greater mischief will accrue from aOowm^ th^
to remain, even for a shoit time, in tbe bvweb,
than from too active measuics in cvacoatiBg
them.

460. The remarks that have been ofloed ab«v«
respecting refrigerants ($ 139, 140.), dimpke^
retics ($ 152.), and diuretics (f 163.), aie ca-
tirely applicable to this form of fever. — Tbe eoid
affunen, which formerly attimcted so much more,
and now so much less, attention than it desert es»
is more appropriate in this than in nay other
disease. This practice, although resorted to by
the ancients and in Eastern coantries, was bet
little known in this nutil it was employed bv
W RIGHT and jAcm«ON. The work of Dr. Cuaan
on the subject first brought it into fashioD ; but
now it certainly has not faahioa in its fovoar.
When the excitement is fully developed, and ths
heat of skin above tbe natural standanl, wbea
there n no sense of chilliness, and wben ths
surface is hot and unperspirable, tbe cold aCaaoa
may be employed. Dr. Cuaaix directed water
of the temperature of from 40^ to 60° or 1\P,
and preferred the hoars from six to nine in the
evening for its use. In cases of debUity, the
eooi or tepid affusion is more appropriate. 1
have resorted to cold affusion over iLe whole
body, in several cases of fever, in a warn A
mate ; but I was not induced by its effects is
entertain a high opinion of it. The affbaioo ei
cold, cool, or tepid water on the head, whcA iha
part is promiDeotly affected, and cold i^wngmg
the surface, are more beneficial, and admit of
more general application. Dr. Cue aim believe4
that the general affVision had the effect of lower-
ing the pulse and the morbid heat, of indadof
perspiration and sleep, and of cutting short the
fever. I have never seen it shcoeed aae<|ajv»'
cally in producing the latter effects^ bot have
remarked that the excitement returned shortly
after its use. In the complication with diwuw
of any of the thoracic or abdominal vtsoera, ii
should not be used (§ 141.).

418. h. Of the ComplietttioH*,^; Predomi.
nant affection if the head has received attentioa
above ($ 165.). What 1 have there stated m ap-

J>licable to this complication of common continoed
ever. — Bloodietting is especially veaoisile, bat
its amount, and the mode of pertonaing il«
should entirely depend upon the symptons and
the stage of the dnease. — The cold affusiem en
the head, and purgatives, are the next in import-
ance. When the cerebral affection has beta
preceded or attended by diarrfacta, paigatiies
should be prescribed with caution. Rhaberh
with hydrargyrum cum creta« given so as le
evacuate morbid matters, and promoted by sai^
able enemata (F. 140.), will be then safficient.
When deitrtuia is the princqial synptom, can
should be taken to discriminate accurately the
states of vascular action and vital power. If it
be unattended by increased heat of scalp, the
pulse beinff very quick and soft, and the ooantfr>
nance suiui or pale, and especially if it have
followed intestinal disorder, all lowering agents
should be laid aside, and restoratives with opmics,
and mild nourishment in small quantities* pre-
scribed . W hen fever occurs in persona »<Micted
to spirituous or other mtoxicatug fiquars, the
cereoral affection is apt to become very
and to be attended with delirium and oui

1002

F£V£IU TYPHOID — Mild Vabixtt.

die increftses in a still greater ratio. The pre-
disposition also diminishes as we descend from
puberty to in&ncy» and the mortality diminishes
m a still greater ratio. Thus children and aged
persons are least obnoxious to ihrphoid and in-
fectious fevers : a somewhat diroient law here
obtaining from that which characterises the oper-
ation of exhalations from the soil upon the human
constitution ; these latter affecting the young and
old as well as the middle-aged, and renewing thm
attacks in Yarious forms, whilst typhus feverseldom
occurs oftener than once in the same person.

468. b. The exciting eautes (i 434.) of typhoid
and synochoid fevers are often uie same, excepting
that infections miasms, want and famine, the va-
rious contingencies connected with the operations
of war, and epidemic in6uences, are most con-
cerned in producing the severer varieties about to
be described. — ^The sporadic eases of this fever,
and which generally present either the milder
form, or most of the nervous character, often
originate in the depressing passions, in changes
from the usual habits and modes of life, or in
exposure to novel influences, physical and moral ;
in weak delicate persons of a lax habit of body ;
in persons imperfectly fed, or reduced by previous
disease, or by eihausting discharges, &c. From
these causes especially proceed the adynamic,
slow nervous, or mild typhoid fevers, oRen ob-
served in persons who have recently removed into
large cities, or who live in crowded, low, and
ill ventilated apartments. — The epidemic visit-
ations of typhoid fever are usually of the more
low or severe forms described hereafter.

i. Mild Typhoid Fsvsr. Syn. — Low Nervous
Fever; Simple Typhoid Fever; Simple Adynu'
mie Fever ; Regular Typhus ; Slow Nervous
Fever, Huxham ; Typhus mitior, Cullen ; Fs-
bris nervosa, Auct. ; Languor Pavonicus.

469. A. This form of fever is characterised
chiefly by great languor and debility; by giddiness,
dulness, and confusion of intellect; by a soft,
feeble, and quick pulse ; and by loss of muscular
power, sleeplessness, and low delirium. It usually
commences with similar premonitory symptoms
(period of infection, Hartmann) to those above
described. The patient complains of giddiness,
lassitude, uneasiness at the epigastrium, of nausea
and loss of appetite, of alternate chills and flushes,
and of pain in the back and limbs, — the period of
invasion . The chills are often prolonged , or recur
for two or three days, but seldom amount to rigor.
The skin afterwards becomes warm, but seldom
very hot — the period rf excitement, of irritation
(Naumann), of r«artton (Hartmann), of tn/2ttm-
matory irritation (Goeden) ; the pulse frequent,
full, soft, or weak ; the countenance dull, pallid,
and shrunk, or, occasionally, transiently flushed ;
the head heavy, confused, and giddy; the eye
heavy and devoid of lustre; and the tongue
loaded or covered with a dirty mucus. There
are more or less thirst ; a desire of cold, acid
drink ; sometimes pain at the epigastrium, nausea,
and vomiting ; or an irregular and relaxed state
of the bowels ; and offensive evacuations. Pain
of the head is but little, or not at all, complamed
of, but that of the back and limbs is felt severely.
Tinnitus aurium is generally present. Febrile
uneasiness is great, the restlessness constant, and

the mind more confused. The
short and quick ; and torpor, or cona r^^, is oAea
observed. Occasional flushes occur, in soat
cases, while the extremities are cool. The unac
is pale, of a whey colour, or like small becr>— oc-
casionally scanty. The bowels are either tarpA,
or relaxed, or irregular; and deliquinm, or bmt-
ness, partial sweats, tremors, &c. are compUined
of, on attempt to sit up. Delirium of a low kind,
or consisting of a muttering iacohereocc, occws
about this time; generally, at first, dwing ite
night, but subsequent! V recnning during the day.
The eyes become muddy, afterwards •^^9ff4 or
injected ; and the tongue of a darker fane, dry or
incrusted.

470. From the 7th to the 9th, lOth, or lltk
dajr, the delirium degenerates into stupor — tht
period of prsdomiiuint nareocijai of Navmav^ —
the nervous stage of HiLoaNanANo — the eoiUpss
of CuLLBK and Habtmann ; the pnbe '»■>''«—**
small, weak, and very quick, or unequal ; the hcax
of the skin natural, or diminished, or iireiguiariy
distributed ; the hearing dull ; and tremor, the su-
pine posture, coma, and unconscious evacuatwos.
are soon afterwards observed. Petechiie KMnctinei
appear on the trunk, thighs, &c. Tlie toi^e be-
comes brown or black, mcnisted and fissured, is
protruded with difficulty, and the gunM aad hps
are covered by a dark sordes^— From about the
fourteenth day to a much later period, accoiding
to the character of the epidemic, the peeulaahdM
of the patient, the severity of the early stages,
and the state of internal organs, a favouiabt^
change very often occun in ^1 the symptoms —
the stages of crisis and decline, or of raemery,
([Hartmann)— and is announced by a refresh-
ing sleep, or by a warm and general
or by a gende diarrhoea ; followed by
of delirium, tremor, &c. ; by the tongue bc^
ing moist and clean at its edges, the skm asore
naturel, and the pulse slower ; by returning con-
sciousness ; and by the improved appeaiaftoe of
the countenance, if these changes do not take
place ; or if the sweats are cold and clammy on
the extremities; or if they, or the diarrhoea, be
unattended by amelioration of the symptoms ; a
fatal change should be dreaded, particulartv d
profound coma and great deafness, safasolnit
tendinum, or convulsive or spasmodic nM>v«BBeol&.
difficulty or inability to swallow or lo articulate,
hiccup, involuntary evacuations, retcntioa of
urine, tympanitic abdomen, sliding down in bed ;
very rapid, fluttering, or intermittent pulse ; very
black tongue; and a quick, jerking, laboured
respiration, or other unfavourable symptoms, ap-
pear.

471. JB. The symptoms which dieiimguisk this
form of fever from the synochoid are — the greater
prostrafion of strength from the commeaccinent ;
the mental torpor and confusion of ideas; the
long-continued chilliness, |eneraUy without rigor
or shivering, at its invasion; the moderate m-
crease of temperature afterwards, or its natural
grade ; the pallid and shrunk countenance, ex*

f»res8ive of suffering and debility; the maddy,
ack-lustre eye,* the torpor, giddiness, aadabaencc
of jMun in the head, pasaittg into stupor with
delirium at an early stage ; the quick and small,
or the full, open, and soft pulse, even duiiag the

the want of sleep continued. — ^A bout the third, period of excitement; the early dryncse,'and
*nh, or fifth day, the head is more afiectedi and | dark appearance, of the tongue | the funafkablt

1004

FEVER, TYPHOID — CoiiFUCATioFi.

vital power jb extreme from the commencement,
and 8uch as prevents the developement, and, in
some ca^es, even the least manifestation, of
excitement. The causes of the disease have
given vitality a shock beyond its pow^ of
resistance, or of recovery. Muscular power is
almost entirely annilulated, and the anxiety at
the epigastrium and prscordia is extreme. Re*
spirauon is oppressed, and the pulse is quick,
sometimes irregular, intermittent, or even slow,
and always small, weak, and thready. The
countenance and eyes at first have an intoxicated
appearance : the former being pallid, occasionally
sUgbtly bloated, or livid and dingy ; the latter
being vacant or su£fused, and, i3ierwards, in-
ject^i, ecchymosed, half shut, or open. The
skin, at an early stage, is warm or harsh ', sub-
sequently it is cool, withered, lurid, and, some-
times, studded with petechia or vibices; the
extremities being cool, or even cold, and dingy,
or of a leaden hue. The mind is very much con-
fused at the commencement, and soon passes
into a state of incoherence, delirious muttering,
and coma. The patient is unable to protrude tbe
tongue, owing to deficient power of the muscles
of the organ ; and seldom complains of thirst.
The abdomen is tumid or inflated > the bowels
being relaxed, the stools black and offensive, and,
with the urine, passed unconsciously. The pro-
gress of the disease is usually rapid, and gene-
rally to a fatal termination ; but the prtmonitory
ttage may be protracted, although severe — the
invaiion being sometimes sudden, and resembling
an apoplectic seizure. If the powers of life rally,
recovery may take place; but it is tedious,
and often attended by various consecutive dis-
orders.

478. £. Of other ModifieatUmior peculiar Statet
of Typhoid or Low Nervout Fever, — Various phe-
nomena beside those already described may
accompany this fever, according to the combin-
ation and intensity of the causes, the previous
health of the patient, and the circumstances
affecting him subsequently to the operation of
the exciting agent. — a. When caused by mental
diftreu, detpondeney, £cc., this fever presents cer-
tain peculiarities (ioerving notice. The patient
is dejected, indolent, and incapable of exertion.
He loses his appetite and strength; he cannot
rest at night, or his sleep is disturbed and unre-
freshing ; and he complains of headach, and of
many of the symptoms of a common cold* He
is absent, his mind being constantly occupied
with the subject of his misery. His countenance
assumes an anxious appearance; his healthy
looks vanish; and his absence of mind often
passes into a state of reverie. After several days,
manifest affection of the brain is observed, with
characters varying with the age, strength, con-
dition, and habits of the patient. In the robust,
{>lethoric, and in persons addicted to intoxicating
iquors, it is sudden and violent in its accession ;
the headach and despondency quickly passing
into delirium of an active and constant kind — the
patient calling out, or starting up. and attempting
lo get out of bed. The pulse is quick, firm, and
oppressed, or small ; sometimes soft or irregular.
Muscular power is not so much, nor so early,
reduced as in the other sUtes of the disease, but
there is continual jactitation. In tbe debilitated,
^he aged, or the ill-fed, the cerebral affection is

less violent in its attack, and coomieaoes nan
gradually, often attended by red or suffused tyvt,
or by catarrhal symptoms, or bv dianiKsa ; by
delirium, tremor, great prostratiott of strength,
hurried breathing, weak quick pnlee, snbsiJfas
tendinum, and, sometimes, with a mottled appear-
ance of the surface. In other respects, the pro-
gress of the disease is nearly tbe same as tbe mott
severe cerebral complications already nocictd
($ 475.), but it much more frequently terBiBXba
unfavourably.

479. 6. in some cases the fever is comptiaied
with iore throat i and this sympioen ia occasionally
so severe and early as to resemble an attack «f
eynanche maligna . 1 ndeed, cases not infraqucatly
occur, which fully indicate that the one diaea»<
may pass into the other, under favourable
circumstances in respect of predispoaitioii and

causes

la

concurrence of the exciting
other words, that in young persoos, in tbosi
predisposed to sore throat, and in cold aatf
numid states of the air, certain of the exciting
causes of typhoid fevers will somelimcs occmmu
a malignant or putrid inflammation of tbe throat,
ushered in and attended bv this form of fetcr ;
or they will, in such or similar ciirmaatancca,
produce a low fever, in which ioflaounatioa eC
the throat is a contingent complication, and a»>
sumes an asthenic or unfavourable cbanriKr.
owing to the depressed state of vital power, and
morbid condition of the circulation, in which it
occurs. This complication is observed either aa
the most prominent local affection, or m coo-
junction with some other remarkable disords.
especially with the gastric complicataon. In
some instances, it is very severe ; the pkarynx
and upper part of the oesophagus bciug also
more or less affected, and deglntitioa altogefths
prevented.

480. c. Paraltftis may occur, capedaUy ia
the cerebral state of this fever ; and, in tk>
case, the use of one side of the body » geue*
rally lost. If the patient recover from the feve^.
the functions of the paralysed side are ofica
gradually restored. This complicatien may take
place in those cases which commence with pi»>
tracted or severe premonitory sympioa». ngmam.
*which the patient struggles, until he lalb do«m
from exhaustion ; or is tuddtnly seiaed, a» in a
case of apoplexy — the fever running iu eourw.
as after the usual invasion, with chills, ri^or«.
vomitings, &c. When the disease is developed
in this sudden manner, it commonly pffe«r«is
the cerebral character throughout, vrith delmua.
passing into coma, &c. In a case, however. «f
this kind, the cerebral symptoms were suhne-

auently slight, and the disease mild.* In some «tf
le cerebri cases of this fever, the aifectio« of the
mind continues for some days, or ev

* A young Isdj vent loine dUUaoeto vnlt «a ii
frtend, deliiiout kn fever ; mmI luvinf gooc into tNe
chamber, the wrt teiMlMe of a dteaf reeriile odeor
theeurtsiiisof thelMdticiRcdffawa. Sheiooi
complained of alight naoaca, of hredarh, loMof i
and general IsMitude Theie lympCcMDa ctmiiai
dually tn Incmae for six days, daring mhith Uikr ii»e
kept about On the momiog of Uie aeveoUi day ahe
denly fell down without arnie or motlou. 1 wi
thla alate mxjd afterwards, and, vievliif the attart m» ehe
rcault of auddm eongeation of the brain, and bttarm I
learnt tbe above p*rtlculan, I prawHbed a
bloodletting, and purgativea. The hmclioiM of Ihc
■oon returned, ana tbe Aver ran tts eourae ia a vild Shs.
and without ddiilum or proalncnt aObdMo of «ny

FEVER, TYPHOID — CoMPucATioM.

1005

after the bodily functbns are restored. Instaocea
may even occur of permanent insanity being the
consequence. But, in all such cases, hopes of
recovery should be entertained until some weeks,
or even months, have elapsed from the disappear-
ance of the fever.

481. d, Relaptet are not infrequent after the
mild forms of typhoid fever; especially when the
duration of the disease has been shortened by the
treatment, or its couiw materially altered. They
are also much more common in one epidemic than
iQ another. In many instances, particularly
when the procession of the morbid phenomena
has been interrupted by large depletions, or
drastic purgatives, the symptoms become ame-
liorated for a time, but recur with their previous
severity ; the recurrence being different from a
relapse. — This fever, especially its gastric and
enteric states, may pass, or be converted, into
a low or typhoid form of difsentery (see that
article, $ 26, 27.), owing to the influence of the
same circumstances that usually cause relapses ;
especially premature exposure in early convales-
cence ; the use of too much, or of improper,
food ; the continued operation of the exciting
causes; a close, impure, and infectious air; and
suppression of the excretions. — Local affections,
particularly injiamjnationst may also appear
daring convalescence, arising either from the
above causes, or from atmospheric vicissitudes ;
or from whatever may inordinately affect the
nervous and vascular systems. In these cases,
the inflammation is apt to pursue a severe and
rapid course, owing to the unfavourable or de-
bilitated state of constitution in which it occurs.
Bronchitis, often associated with affection of the
8ul>stance of the lungs, and inflammation of the
mucous surface of the bowels, sometimes with
softening and enlargement, or ulceration, of the
mucous follicles, are the roost common diseases
thus contingent on convalescence. Inflammatory
affections of the stomach or liver mav also take
place. When the mucous surface of the intes-
tines is the seat of consecutive disorder, the bowels
generally are more or less relaxed, and the stools
are of an ochrey hue, and offensive. In such
cases, the follicles are especially affected ; are
often ulcerated ; and, although they will generally
heal under judicious treatment, perforation of the
intestines and fatal peritonitis mayiie the result at
a penod more or less remote from the disappear-
ance of the fever.

482. F. Of Peteckiic and exanthematouM £r«p-
tiom in Typhoid Fevers. -— Nervous or typhoid
fevers may occur sporadically or epidemically,
without any petechial or other eruption ; or may
be attended by peteehue or vibices in their pro-
gress, and particularly at an advanced period,
or by an exanthematous eruption at an earlier
stage ; or even by both kinds of cutaneous
affection, either successively or almost coeta-
neously. For many years, or in successive epide-
mics, or even in a single epidemic, typhoid lever
may appear in any one or more of the states just
described ; or it may assume either^of these forms,
associated with one or other, or with both,
of the affections of the skin just mentioned in a
portion of the cases only ; or the affection of the
skin may be one of the most unvarying and chief
characteristics of an epidemic : and, of the cases
composing such an epidemic, some may be of

the mild, others of the complicated or severe
form ; tome may evince more or less reaction or
excitement, others may present depression of the
powers of life and congestion, as prominent phe-
nomena throughout. The above description,
although applicable more especially to the occur-
rence of typhoid fever, independently of any
marked affection of the skin, yet does not the
less applj to the occasional association of the
disease with this affection. Those epidemics, in
which the changes in the skin are very constant
phenomena, sometimes possess other characters,
both in the early and in the advanced stages,
that require an especial notice. Whilst the^e
changes — both petechial and exanthematotts —
have been considered by Hildenbrand, Nao-
MANN, FoDXRx, PEEBLES, and Other experienced
writers, as indications of specific kinds of fever,
which, in the early stages, may present more or
]^s either of inflammatory excitement or of de-
pression of vital power ; they have been viewed, by
many authors, merely as occasional occurrences,
or as modifications met with only in certain epide-
mics, and not as characteristics of distinct varieties.
483. In trying to solve this question, the same
difficulties present themselves that arise in all
attempts to arrange the different varieties and
states of fever in such an order as the more
constant phenomena may warrant, and as may
conduce to appropriate and successful methods
of treatment. If I refer to my own observations,
in different parts of the Continent, some time
after the late war, and in various parts of this
country, both before and subseouentl^, I shall
find — 1st. That petechia and vibices were
either seldom or rarely seen for several years,
and in some epidemics, excepting in the most
severe or malignant cases, or when favoured
by a too stimulant treatment, and a too heating
regimen, during the early stages ; and that, at
other times, they appeared more frequently in the
advanced periods ot the lowest forms of fever, and
even, although much more rarely, towards the
termination of synochoid fever, when antiphlo-
gistic remedies had been neglected in the stage of
excitement. — 2d. That this chsnge, in some epi-
demics, was a very common or even geneial
symptom, occurring in mild as well as in severe
cases, although presenting very different appear-
ances in each ; and that they were sometimes
observed early in the low states of fever, particu-
larly when caused by unwholesome and deficient
fooa, by a foul atmosphere, or by infectious mi-
asms. — 3d. That they were very frequently con-
nected, especially in the plethoric, in the previ-
ously unhealthy, and in persons using much
animal food, with evident change of the circulat-
ing fluids, with predominant disorder of the diges-
tive organs, with a soft, broad, and open pulse,
and with haemorrbagefl from the intestines, and a
tendency to disorganisation of the mucous surface
of the bowels. — 4th. That an exanthematous rash
or eruption was observed in some epidemics, from
the third to the eighth day of the fever, was quite
distinct from petechis, generally appeared earlier,
and was, in some cases, either associated with, or
succeeded by. petechie or vibices, or even both. —
5th . That this exanthema was of a reddish colour,
varying in deepness, and rarely passing to a daik
hue ; that it occurred in cases characterised by
▼ascular reaction in the early stage, as well as in

1006

FEVER, TYPHOID— WITH Futro-adynamia.

those of a very low grade — ia the mild, ia the
complicated, and in tne severe ; that this eruption
was most probably overlooked in many cases
where it existed ; and that it was very generally
confounded with petechis, owing to its late ap-
pearance, or to its colour changing, in a some-
what similar manner to petechis, with the states
of vital power and of the circulatiDg fluids. —
6th. That although the difference between both
these affections of the skin has been insisted
on by iiiLOENBRAND and Naumann, it has
been too widely drawn by them, and without due
reference to the occasional association of both
affections. From these facts, therefore, I am in-
duced to come to the conclusions above stated
($ 482.) ; and, conformably with the views of the
experienced writers just mentioned, to notice
more particularly the states of fever in which
these changes in the skin are observed, without
considering these states as always constituting
distinct species.

iii. Typhoid Fever, wrrn Putro- a dynamic
Characters. Syn. — Putro^adt/namie £'ever,
Ivnx^t f4MTa antwt^twt, Galen ; Synochus Pu-
tris, S. eum Putredine, Febrit eontinua Pu-
trida. Riviere ; F. eontintns Putrida, Selle ;
JF*. Putrida sanguinea, Vogel ; F, coUiguathHi
putrrfaeitns, Quesnoi -, F. Hungariea, F. ner-
voia'putrida, F. asthenica, F. camtagioia; F.
coUiquativa eistn(ia(M, Borsieri; F. Putrida
timplex, Bichter ; F. eharactere putrido aut
mpticot Hildenbrand; F. Petechialis, F. No-
toannialit, F. Caitrtnnt, F. Purpurata ma-
ligna, F. Maligna, F. Carceraria, Pettis Belliea;
Auct. var. ; F. Cotitinens maligna, Huz-
ham ; Dot FaulfieUr, Faulige Fieber, Germ. ;
Fievre gravt, F. Maligne, F. Putride, Fi.;
F. Adynamique, Pinel ; Febhrt Putrida, Ital. ;
Morbo Petaehiale, Cerri ; Febhre PetechiaU,
Rossi ; Febbreepidemiea P€teehiaU,BnffdLi P«-
t^hial Typhut, Camp Fever, Jail Fever, Putrid
Fever, Putrid Malignant Fever, Spotted Fever.
484. Conformably with what 1 have stated above,
I consider this as a variety merely of typhoid fever;
its especial characteristic — the appearance of
petechis and vibices — being contingent upon
certain circumstances and causes tending to con-
taminate the circulating fluids, and to destroy the
tonicity and irritability of contractile tissues, and
appearing only as the effect of a series of anterior
cnanges. Although petechis may occasionally
appear in the advanced stages of other fevers,
particularly those of the typhoid form, yet in
those epidemics which result from famine, war,
unwholesome food, and from air loaded with pu-
trid animal and vegetable matter, or with the
emanations proceeding from a number of persons
shut up in a close atmosphere — causes which are
often conjoined — this symptom is very generally,
if not constantly, observed, and is only one of
the indications of the very serious changes which
have taken place, not only in the blood, but
also in the soft and irritable structures of the
frame. Infection, either directiv or by fomites,
is, however, the chief cause, although cold, hu-
midity, fear of the disease, and the other agents
just noticed, may either generate the fever de
novo, or predispose the system to infection, or aid
its operation after exposure to it. Although cer-
tain epidemics evince a putrid or septic character
at an early period, and thereby justify the appel-

lation generally given to them ; yet this clmacter
is seldom primary, or otherwise than tlie con-
sequence of suppression or exhanstioa of vital
power, the fever commencing in some one of the
forms already described. Indeed, thcie ia no
variety of fever that may not evince a erpbc or
putrid state — 1st, from the vital depireaioa pro-
duced by the exciting canse ; 2d]y, froni exhaus-
tion consequent upon vascular reaction; 3dl«,
from the passage of contaminating maAes* iaio
the blood ; and, 4ihly, from these states conjoinBd.
Hence, when the causes are of a contanunana^
kind, and the influences continuing to operate
after infection have a similar tendency, patrid or
malignant symptoms will arise, whethtf the fever
be synochoid, nervous, ^phoid, or gastric, ta ics
early periods. These fevers are the most prone to
the septic character ; but others, as lemitteat, in-
flammatory, and bilious fevers, may also nssttme
it. This particular character may, or aay not,
be developed, or may appear at a later or earlier
period, owing to the nature and diveraity of the
causes ; to the condition of the internal fnoctioaa
and of the circulating fluids at the time of at-
tack ; to the rigidity or tone, or to the laxity, of
the sof^ S9li£ ; to the violence or absence of
vascular reaction; and to the early tientmenf
and regimen.

485. A, Petechia], or pntro-adynamic fever, ge-
nerally commences with the premonitofy and m-
vading symptoms usually observed in other levers
of a low grade. When an epidemic preseotschnngcs
of a septic or putrid nature, as pcedoasittaat fea-
tures, tne early stages of the fever vary most rt»
markably according to the intensity of the can««i.
and the state of the patient. The period whxh
elapses from infection till the manifestation of
the disease ranges from a few hmirs to five or
six weeks. It is commonly some days, but safi-
cient evidence has been fumisbed. in the Irinh
and other epidemics, that the longest of these
periods may occur. During the time the disease
thus takes to form, the usual premomii^ry sym^
toms are observed, and increase until chilb. horri-
pilations, or rigors are felt. In some instances
the disease commences insidionaly, with or with-
out catarrhal symptoms, becoming gmdnnilr se-
vere and dangerous. In these, it is often dil6ciih
to assign the exact period of at lack. Fatal cases
most frequently begin in this manner, especiaUy
in the plethoric, cachecdc, and peraoos accns-
tomed to full living. In others, after a proicatted
and severe premmutory etage and indistinct symp-
toms of invanon, the fever proceeds with
tions of imperfectly developed reaction, and
assumes a putrid or malignant form. In i
cases, rigors and shiverings snflliciently evince
the period of attack, and quickly give nse to
inordinate reaction, followed by exhaustion and
evidence of change in the fluids and soft struc-
tures. Amongst the moat constant of the early
symptoms are — dull pains in the head, occipm,
back, and limbs ; universal wearincaa, soreness.
and loss of muscular power; confuaioo of mtad ;
pains in the joints and limbs rnsembting rhea-
marism ; fiequent sighing ; nausea or Toasitiaf .
and noises m the ears.

486. The pulse, when resctum is developed, s
full, open, quick, sharp, but soft and easily com-
pressed . Respiration is laboriotts, snapirions, w nh
oppressioa or anxiety at the prmooiSM, and

1008

FEVER, TYPHOID— WITH Putro-adykamia — Duonosis.

particularly when the petechias, or vibices, are of
a dark, or deep purpW colour ; the abdomen tym-
panitic ; and the stools are green, livid, or black,
mixed with dark fluid or grumous blood. In
these, fatal haemorrhagei sometimes occur. The
dysenteric state may take place in mild as well as
in severe cases, at an advanced stage ; with' se-
vere gripings, and dark sanious, bloody, and mu-
cous stools, which are very fcetid and infectious.
The disease may thus pass into the adynamic
form of dysentery. This change was common
in the epidemics lately prevalent in Ireland. -^d.
The complication with mflammation of the/aiMre«
and pharynit or with putrid sore throat, is some-
times observed, and is to be distii^uished from
primary eynanche maligna , by its occurrence in
the course of the fever, or as a contingent affec*
tion ($ 479.).

492. The $e9u«/«of this fever are sometimes se-
rious. They consist chiefly of dysentery, chronic
diarrhcea, dropsies and cedematous swellings of
the extremities, pulmonary consumption, hepatic
obstructions, mania and other forms of insanity,
abscesses in various parts of the body, sloughing
sores, inflammation of veins, particularlyof those
of the extremities, gangrene of the feet, rheu-
matic affections, &c. Most of these result in
great measure from the changes that have
taken place in the blood during the fever; these
changes affecting the blood-vessels, and organs
most susceptible of congestion. — Relaptet are
fre(juent in cases of short duration, and in those
which have been apparently cut short by active
treatment ; and are generally more dangerous than
the first attack. They are more common in males
than in females; and towards the close of an
epidemic, than at its commencement.

493. D, Diagnoiii, or the Changet tohieh mart
ttpeciallyconttiiuU Malignancy orPutro-adynamia
in Fevert. — a. The iecretiom, next after the state
of vital power, indicate incipient dissolution of the
vital cohesion of the blood and soft tissues. — The
urine has first a more viscid and albuminous
appearance than usual. It is frothy, browner,
and less transparent. If thu pathological condi-
tion increases, the urine becomes brown, or dark
brown, clouded, turbid, muddy, and often deposits
a brown sediment. It quickly becomes putrid
or offensive. — ^The faeee are foetid, or have a pu-
trid smell — are dark, fluid, ochrey, or contain
blood. — The sweat is thick, clammy, sometimes
cold, copious, and always offensive ; and occa-
sionally it imparts an ichorous stain to the linen.
— The secretion poured into the mouth is a thick,
viscid, slimy, dirty inucus, of a dark brown co-
lour, that collects over the teeth, edges of the
tongue, and lips.

494. b. The changes observed in the vatcular
iyitem are — an open, broad, soft, compressible,
undulating, or unequal, or a very quick, small,
thready, and irregular pulse ; a more than usu-
ally dark appearance of the superficial veins,
or dark streaks in their course ; and, at an ad-
vanced stage, exudations of dark, dissolved, or
thin blood, or of a bloody sanies, from the outlets
of canals, as the mouth, nostrils, anus, vagina,
&c. — Blood taken from a vein, even previously
to the occurrence of these siffns, is very dark,
thin, sometimes of a black purple hue ; and either
does not separate into coaguium and serum, or
coagulates into a soft, pultaceous, or gelatinous

mass, with imperfect separatxm of the
The fibrinous and albuminotts cooititiicnts an
deficient; and, owing to this circttmstiaoe, to-
gether with the want of vital power in the va*.
cular system, the coaguium wa.ot9 cobeaaoa, the
least agitation causing a partial adviixtttfe of red
particles in the surrounding aemin. — ^As the dis-
solution of the vital cohesion of the arculetiag
fluids and softer solids proceeds, the coUwriag
particles of the blood often fall to the bottom ci
the vessel, or of the gelatinous coaguium, leavxaip
the upper stratum, and the sontmiidmg aerem,
of various shades — sometimes of m gtceanh,
purplish, or reddish hue. Lanormh, Hozjbav,
FoRDYCE, HiLDENBBAND, sud Others, have no-
ticed a peculiar putrid odour of the blood whea
taken from a vein. (See Blood, ^ 110. H ssf . |.
This fluid soon undergoes putre&ctaoo after us
removal from the body. It presents, however,
various anomalies, in particular cases, or in
epidemics ; but it seldom evinces very
ble alterations, excepting as the grosser and
palpable results of anterior changes, which, al-
though evidently of a most important
not of precise recognition ; nor do
ations occur until the symptoms indicate
of constitutional power, imperfect
of absorbed fluids, and lesion of the depurabag
functions. In connection with these chaises,
particularly those of the blood, the tonicity, or
vital cohesion, of the eztieme capillaries 'and
softer solids are very much impaired, occanomnf^
thereby further alterations. The fonciieBs of
the cerebro-spinal nervous system are oAen naore
or less disordered, as in low nervous fevces ; and
the states of the mucous and cellular tissiaes, and
of the skin, are remarkably altered. The eeliular
tissue becomes flaccid, softened, or less oohetent,
and consequently slightly tumid ; and hence iha
bloated appearance in extreme cases ; or cachcctie
fulness ot the surface, in the most fialal states of
the disease. The mucous tissue is discolouied ,
it exhibits a dirty brown, or grey, or livid hoe,
with black ecchymoaed spote.

495. e. The eutan§ou* turfaee is at'first merely
dusky or lurid. But as vital power is further
depressed, a bluish, marbled discolooratioo is
sometimes observed in the •hape of veins. PwUekie
of various depths of shade, tram a lively or dait
red, to a puiplish or brown colour, appear prio-
cipally upon parts usually covered by the clothes.
They are either alone, or attended by the ca-
antheraatous eruption characterising the variKy
next to be noticed ($ 497.), or by dark or per-
plish spots of various sizes. In some cases, the
skin, especially that of the extiemities, becomes
of a dark purple colour. When there is marh
heat of surface in the early st>ge of ezdftemceu
a caustic or morbid sensation is imparted, whsrh
increases whilst the hand remains in contact
with it. When copious svreats follow, a white
miliary eruption, intermingled with petechi*, or
vibices also, sometimes is observed. As the leas-
perature is reduced, an unpleasant raw, cadaver^
ous, or cold feeling is imparted to the head of
the examiner; and the petechia often become
much darker, or more numttoos, or agmgated,
or almost confluent in some parts. In such
cases, passive hgmorrkagest particularly from the
bowels, are not uncommon ; hut they may slie
occur without much change in the am. ' The

lOlO*

F£ V ER, TYPHUS — DESCRipnoir.

without peiechie or anymaiked putrid symptom.
It may, as shown by HiLDSNBRAND,be simple, or
variously complicated ; and, as remarked by Dr.
Peebles, it may be benign throughout, or assume
a mali|;nant character, according to individual
diathesis, the nature of the prevailing epidemic,
or the mode of treatment. It generally presents
itself as an epidemic, is contagious, and runs a
uniform course, unless predominant affection of
some internal organ modifies its course or pro*
longs its duration.

Sx). It has been shown above, that the pe-
teehial affection consists of minute stains or ec>
chymoses, caused by the transudation of blood
from the minute capillaries of the vascular rete
of the skin, owing to the atony of these vessels,
and the alteration of the blood ; that it may occur
in the advanced stage of any fever, even of the
more inflammatory or purely eruptive, when con-
verted into an adynamic or typhoid state, by
improper treatment or the peculiar condition of
the patient ; and that it is not, in any sense of the
word, an eruption, as it has been very improperly
denominated by some writers. This change in
the skin, which has been viewed as one of the
chief indications of incipient putridity, or of a
septic tendency, is very different from the eruption
characterising typhus. The petechia, or cu^
taneous ecchymoses, vary in dimensions from
minute stigmata to large patches or vibieet, and
in the deepness or shade of colour. They very
rarely appear at the commencement, even of the
more putrid or malignant fevers* unless from
peculiar depravity of constitution, or from causes
affecting more especially the circulating fluids-^
as imperfect nourishment, unwholesome food, or
other injurious ingesta.

501. But the exafUhematout truplion attending
true typhus, is as characteristic of it as the erup-
tions ot measles or of scarlatina ; and, although
observed by numerous writers, it has been con-
founded with petechis, with which it is often
associated in tne advanced stages of the fever,
or with miliary eruptions. — Hildenbrand gave
a description of it, as it appeared in the conta-
gious fevers prevalent in Germany during the
commencement of the present century ; and Dr.
Pebbles has recently described it accurately
and minutely, and as he saw it in Italy soon
after the war. His description agrees with my own
observations about the same period. This eruption
appears in the early progress of a fever produced
by human efBuvia, when circumstances occur to
promote them, or to prevent their dissipation.
The animal miasm, whether generated by num-
bers crowded in a small space and confined
air, or proceeding from a person affected by the
disease, should be viewed as a poison* affecting
the human body in a specific manner, and causing
fever with an eruption of a certain form, which
propagates itself by the diffusion of a morbid
effluvium in the surrounding air, or by its re-
tention in various animal productions or porous
substances when shut up from the air.

502. This eruption usually appears from the third
to the seventh oay of the fever, but it may be de-
layed till the twelfth or fourteenth day. It is of a
florid, reddish ,or reddish pink colour ; disappear-
ing on pressure, but soon returning when pressure
is removed . This circumstance is sufficient to dis-
tinguish it from petechia:. The more exuberant

resembles the measles, and has been misUkga far
them ; but it is more papillar, and nmgber to the
touch, being sensibly eievmled to the eye ; and,
although sometimes grouped or enmded. it
does not coalesce so much as meaalcs, bat each
papilla is more or leas separate. It is sm«-
times vesicular, and followed by deei|ea
tion of the cuticle. It is occaaionallj '
and may be then overlooked, and it
approaches more nearly the miliary
Hence it has been mistaken for thi
such cases. It is generally confined to tiae traaik
of the body, the arms, and thighs ; b«t it may
cover nearly all the body. It rarely f rtsili tret
the face or hands. In children, it appears obIt
upon the trunk, or parts of it, and oAca ecaatily.
It is sometimes evanescent, diaappearing in one
part of the day and returning in another (Fsa-
BLss). It may be copbus in soine caeca, and
scanty in others, even in the same family. Owta;
to these circumstances, it may escape iilmuialiaii.
It is not liable to recede early in its eovrae ; bat
if it disappear from injudicions treatDent, or a
faulty state of the system, malignant aympteis
are apt to supervene.

50ll. In some cases, the interatices of the akia
between the papilla are red or erythcmatoas. la
these, there are also increased auffnsioii of tie
eyes, redness of the tongue ai the point and cdf^w.
redness of the fouces, as in mild scarlatina, and
subsequent desquamation of the cuticle. The
duration of this eruption is from three to five days.
When the exantheroe is slight, it disenpaan
without leaving discernible marks ; bet when it
is exuberant, stains are left in the sitnatioii of the
papillsB. If petechia occur in this fever, th«y
seldom are observed before the eighth er tenta
day, and then this eruption has usaally dsn^
peared. When the petechisB are earlier, or the
eruption continues longer, so that both exiat i»>
gether, they are quite distinct and diflereat m
their appearances ; for the latter is never ao dut
or livid as the former generally ia, and the p»-
techis are not attended by the elevation of tte
cuticle and roughness characterising the ermpcian.
The stains left by an exuberant erapliott eencially
become livid when petechise am present : bnttke
eruption itself does not assume a dark tint, as
long as it retains its papillar form, la the saoee
malignant cases, and when petechias appear carhr
in the disease, the colour of the eraptiea may.
however, become deeper, or may change with tha
alteration in the fluids and softer aolids.

504. A. DEscRipnoN. — True typhnaproeeeds m
a more regular and determinate manner than syae-
choid or nervous fevers *, and presents the
stages into which I divided wttr, wk
of it generally. The prtw»atdtonf itegt ev
the same symptoms as are observed to
other fevers, and varies much in daratian. Hil-
denbrand states from three to aeven days ; bet a
much longer time may elapse from the tint of
infection to the occurrence of the atagt «f nraasM.
This period is the commencement of the irbrilc
paroxysms. It beeins with a creeping saiwsnne
over the head and hack, followed by shivennsx
paleness of the surface, the cutis an
vening flushes of heat, heaviness or
the bead, and the usual symptoms of this
After a few hours — seldom more than twelve -
the stage of Traction — the ii^iammaM^ory ol UiLrty-

of

1012

FEVER. TYPHUS — Prookosis.

posed. — a. The anomalaut phenomena observed in
the ttage of invatum, are few. The shivering may
be so slight as hardly to be observed, the fever
seeming to begin at once with increased heat ; or
the rigors may last or return at intervals during
some days. — In the period of reaction, the modi-
fications are often more numerous and striking.
The inflammatory character of this stage is often
greatly increased ; sometimes as respects the vio-
lence of the general symptoms, but at others with
severe local affection. When the head is the
seat of prominent action, the delirium may be
pbrenitic, maniacal, or the stupor may amount to
apoplectic sopor. Inflammation may take place,
either in the iungs^ or in the liver, or in the diges-
tive mucous surface, and be so fully developed as
to resemble idiopathic disease of these viscera,
if the previous fever, stupor, tinnitus aurium, and
peculiar eruption, did not establish the diffesence
between ihem.—Bilio'^astrie affection, also, may
be so prominent as to simulate that form of fever.
But tne stupor and typhomania will assist the
diagnosis, should the eruption be so slight as to
escape observation. The nervous character may
show itself prematurely; especially when the
vital powers are weak, depressed, or speedily ex-
hausted. In these, septic or maligfiant symptoms
may occur. In some cases, the inflammatory
stage may continue to the ninth or even to the
eleventh day.

508. 6. In the nervous stage, various modifica-
tions are also observed. Local affections may con-
tinue through the greater part of this stage, or may
even first appear in it ; particularly those seated
in the intestines, and implicating especially the
mucous follicles. Diarrhoea, or typhoid dysen-
tery, may thua supervene, and be either slight,
severe, or fatal. The former of these affections
is caused by vascular determination to the intes-
tinal mucous surface, consequent upon the sub-
sidence of the eruption, and by the unhealthy bile
secreted by the irritated liver from the impure
blood circulating in it. The dysenteric symptoms
are owing to the morbid action going on in the
lower part of Ihe ileum, in the caecum, and large
bowels. Lumbrici are sometimes passed. But
the principal and roost frequent variations con-
sist in the appearance of numerous petechia and
vibices, or in their increase or deeper hue, if
they had previously been observed, with several
other putro^adynamic changes. In these, the
nervous symptoms may not be more remarkable
than in milder cases.; or these symptoms may be
very prominent, either with or without the oc-
currence or aggravation of the malignant ^r
septic state. Miliary eruptions may also appear
in this stage. In the more unfavourable cases,
the tongue may be shrunk like a piece of burnt
leather, the heat of surface excessive, the diar-
rhoea exhausting, the distension of the abdomen
great, and pains in the bowels severe. Muscb
yoUtantes, picking of the bed-clothes, constant mut-
tering, spasmodic affections, stiffness or cramps of
the extremities, paralysis of the eyelids or tongue,
horror at liquids, may also occur. A black coating
of the tongue and teeth ; factor of the breath, stoob,
and of the body ; dark petechias or vibices; ecchy-
moses or bluish patches ; passive haemorrhages,
and even carbuncles, may appear during this
stage, particularly when circumstances concur to
— <xluce putrid or septic changes in the course

of the fever. Theee severe caoce. if they aie
not fatal before the fourteenth day, often raa ea
to the seventeenth, twenty-fint, or twenty-eightk
day, and generally end in death.

509. e. Sometimef the preerisis on the teveiub
day either does not take place, or is not followed
by any alleviation, or is attended by aggiavaboa
ot the symptoms. If a deciaive eriass take not
place on the fourteenth day, it rarely ha|mefis
till the twenty-first; a crisis between thew dan
being seldom effective. When death occurs, tW
fatal change is either prematmre or procrastiiialcd.
The symptoms accompanying a crisis ate often
variable. Changes in the urine cannot be d»*
pended upon. Discharges from the bowels aie
often copious, without benefit ; and if they con-
tinue so without alleviation of the symptoms.
or are unnatural, ulceration of the tntcsbBal na-
cous surface may be dreaded. A critka] sweat
is sometimes wanting, the patient reoorcn^
nevertheless.

510. tf. ThedeeUne'Of the disease may be pn^
tracted, but never shortened ; and attended by
various symptoms, as a continuation of the «!»-
por, nightly recurrence of deliriam« or liageria;
affections of some one of the thoracic or abdosu-
nal viscera. A new disease, of an inHammatocy
kind, may occur during the stages of decline aad
coovalesceDce, or tubercular consumption nay
supervene ; and relapses are not infrequent in tbie
latter period, owing to a fresh infection. — /2#-
covery may be retarded by the seeeri^ of the
complications, by want of sleep, by errors is
regimen, and by the depressing pawrions.

5 11 . tf. The fore^ing modificatioas refer eatneiy
to aggravating circumstances; but some casu
are so slight, that the patient scarcely keeps h»
bed — a trifling degree of stupor, with scanty erup-
tion, and occasional pains in the bowels, con-
stituting the chief complaint. In the more bcn^
cases, a decisive crisis occasionallT takes place m
early as the eleventh, or even the ninth, day;
but relapses are liable to follow, if the patient be
exposed to a re-infection.

512. V. PaooNOsis or TYrnom Fxvans. The
prognosis will be influenced by the appeaiancc «f
any of those phenomena to which attention hasbeea
directed above ($ 434.). Bntinadditiott Cothesc,
the practitioner will take into the account the pre-
vious condition, the age, and the sex of the patjcnt;
the natuie -of the prevailing eptdemic; and the
influences continuing to operate doting tiealmeat.
As to the manner in which age should affect the
prognosLs, from the beginning, some very interest-
ing facts have been adduced by Dr. Ausov , who
has given the following table in iUnstntioo of
the comparative prevalence and mortality sf
typhus at different ages, as observed in h»
practice : —

83 - . S . . 1 ta 411

149 . . U - . 1 n I.

99 . - 17 . • 1 io

17 - - 7 - - I is

Under 15 yean
J5 to 30 .
30 to 50 .

Above 50 •

TotjU 3«2

57

1 in »:

Of these 342, there were 170 cases of UDple or
mild typhus, in which only three deaths otcmied ;
79 cases presenting prominent afiiBction of the
head, and in these 21 were fatal ; 58 cases with
affection of the pulmonary organs, in which 13
were fatal ; and 35 with abdominal ailectioa, m

1012

FEVER, TYPHUS — PnooNMifl.

poced. — a. The anomalout phenomena obierved in
the stage of invasion, are few. The shiveriDg may
be 80 slight as hardly to be observed, the fever
seemiog to begin at once with increased heat ; or
the rigors may last or return at intervals daring
some days. — In the period of reaction, the modi-
fications are often more numerous and striking.
The inflammatory character of this stage is often
greatly increased ; sometimes as respects the vio-
lence of the general symptoms, but at others with
severe local affection. When the head is the
seat of prominent action, the delirium may be
phrenttic, maniacal, or the stupor may amount to
apoplectic sopor. Inflammation majr take place,
either in the lungs^ or in the liver, or in the diges'
iive mucous surface, and be so fully developed as
to resemble idiopathic disease of these viscera,
if the previous fever, stupor, tinnitus aurium, and
peculiar eruption, did not establish the diffesence
between them.— Bih'o-^oxfric affection, also, may
be so prominent as to simulate that form of fever.
But tne stupor and typhomania will assist the
diagnosis, should the eruption be so slight as to
escape observation. The nervous character may
show itself prematurely ^ especially when the
vital powers are weak, depressed, or speedily ex-
hausted. In these, septic or malignant symptoms
may occur. In some cases, the inflammatory
stage may continue to the ninth or even to the
eleventh day.

508. 6. In the nervous sta|pe, various modifica-
tions are also observed. Local affections may con-
tinue through the ^eater part of this stage, or may
even first appear m it ; particularly those seated
in the intestines, and implicating especially the
mucous follicles. Diarrhoea, or typnoid dysen-
tery, may thus supervene, and be either slight,
severe, or fatal. The former of these affections
is caused by vascular determination to the intes-
tinal mucous surface, consequent upon the sub-
sidence of the eruption, and by the unhealthy bile
secreted by the irritated liver from the impure
blood circulating in it. The dysenteric symptoms
are owing to the morbid action going on in the
lower part of ihe ileum, in the cecum, and large
bowels. Lurabrici are sometimes passed. But
the principal and roost frequent variations con-
sist in the appearance of numerous peteehitt and
vibices, or in their increase or deeper hue, if
they had previously been observed, with several
other putro^adynamic changes. In these, the
nervous symptoms may not be more remarkable
than in milder cases ; or these symptoms may be
very prominent, either with or without the oc-
currence or aggravation of the malignant .or
septic state. Miliary eruptions may also appear
in this stage. In the more unfavourable cases,
the tongue may be shrank like a piece of burnt
leather, the heat of surface excessive, the diar-
rhoea exhausting, the distension of the abdomen
great, and pains in the bowels severe. Muses
volitantes, picking of the bed-clothes, constant mut-
tering, spasmodic affections, stiffness or cramps of
the extremities, paralysis of the eyelids or tongue,
horror at liquids, may also occur. A black coating
of the tongue and teeth ; foetor of the breath, stools,
and of the body ; dark petechise or vibices ; ecchy-
moses or bluish patches ; passive haemorrhages,
and even carbuncles, may appear during this
stage, particularly when circumstances concur to
pro<luce putrid or septic changes in the course

of the fever. These severe cases, if ikey ai«
not &tal before the fourteenth day, oAen ivn oa
to the seventeenth, twenty-first, ot twenty-eighik
day, and generally end in death.

509. e. Sometimes the preeritit on Uie seveatk
day either does not take place, or is not IbUowed
by any alleviation, or is attended by aggravatioa
of the symptoms. If a decisive erisu tike not
place on the fourteenth day, it rarely happoa
till the twenty-first; a crisb between these davs
being seldom effective. When death occvi, the
fatal change is either prematare or procrastiaated.
The symptoms accompanying a crisis are ofta
variable. Changes in the urine cannot be de-
pended upon. Discharges from the boweb are
often copious, without benefit ; and H they ooo-
tinue so without alleviation of the sympUMns,
or are unnalural, ulceration of the intcMxnal ns-
cous surface may be dreaded. A ciitical sweat
is sometimes wanting, the patient lecawaiag
nevertheless.

510. d. The deficits -of the disease may be pro-
tracted, but never shortened; and atteaded by
various symptoms, as a continuation of the ita-
por, nightly recurrence of delirium, or Uageria^
affections of some one of the thoimcic or abdo»-
nal viscera. A new disease, of an inHammatory
kind, may occur during the stages of dwHne and
convalescence, or tubercular consampboo nay
supervene ; and relapses are not infreqaeat ta tka
latter period, owing to a fresh infection. — Re-
covery may be retarded by the scseiity of lbs
complications, by want of sleep, by erron ia
regimen, and by the depressing peaaoiw

511. «. The foreeoingroodificatMas refer enrireiy
to aggravating circumstances; but snaa cases
are so slight, that the patient scarcely keeps has
bed — a trifling degree of stupor, with scanty erup-
tion, and occasional pains in the bowels, cea-
stituting the chief complaint. Ia the anore bca^
cases, a decisive crisis occaaionalW takes place as
early as the eleventh, or even the niatk, day ;
but relapses are liable to follow, if the paticst be
exposed to a re-infection.

512. V. PaoGNOsn or TvrHOiD Fanas. The
prognosis will be influenced by the appearanc* sf
any of those phenomena to which attention ha^bsca
directed above ( § 434 .). Bat in additkia to these,
the practitioner will take into the account the pre-
vious condition, the age, and the sex of the patjeat ;
the nature of the prevailing epid^aic; aad the
influences continuing to operate during treatseat.
As to the manner in which age should aficct the
prognosis, from the beginning, some very ialcfefli-
ing facts have been adduced by Dr. Ausm*, who
has given the following table in illastratova of
the comparative prevalence and mortality ^
typhus at different ages, as observed ia ha
practice : —

Cotes, t}ra*^ ^n^arUti^^

Under 15 yean . 83 - . 9 . . 1 la 411

J5 to 30 . . 149 . . II - . 1 ta t:)

aOtoJO. .SO. -17. .Im3|

AbOfeSO - .17. .7. .!■»£«

Total Stt

57

I

■t

Of these 342, there were 170 casM of aimpte cr
mild typhus, in which only three deaths ocramd .
79 cases presenting prominent affection of tW
head, and in these 21 were fatal ; 56 cases with
affection of the pulmonary organs, ia which IJ
were fatal ; and 35 with abdcmioal affectJDo, xa

1014

FEVEH, TYPHUS — Oboakic Lmioss.

in 4 ; oedema of the membranes, in 7 ; very »light
general softening of the brain, in 6 ; effuidon of
serum in the ventricles, varying &om a drachm
to half an ounce, in 12 ; numerous red points
upon dividing the cerebral substance, in 5 ; in-
creased density of this substance, in 2 ; and the
normal condition, in 15.

518. a. A fatal issue is evidently caused, or ac-
celerated, in some cases, by the severity of the
associated disease o( the respiratory organs, pre-
venting the necessary changes from being effected
in the blood circulating in the lungs. It proceeds
in otheiB chiefly from the influence of the morbid
blood upon the weakened irritability of contrac-
tile tissues, and particularly of the heart; and,
in rare instances, trom perforation of the intestines
inducing general peritonitis, which soon exhausts
the remaining powers of life. The lesions of the
digestive mncous surface evidently aanst in pro-
ducing this effect; but in a much less degree tnan
the depression of organic nervous power and of
irritability, and the deteriorated state of the
blood, with which they are intimately connected,
and of which they are important effects. All
these internal lesions evidently commence in the
course, or even not until the advanced stages, of
the disease ; and, when developed, are analogous
to the sphacelated sores and other alterations
which take place in external parts in the more
malignant cases. These internal as well as ex-
ternal lesions depend upon the anterior changes
in the organic nervous power and irritability, and
in the blood ; they pcesent similar characters ;
and, where even the slighter external lesions are
observed, the existence or occurrence of those
that are internal is to be feared. The most con-
stant of these latter are discolouration and dimi-
nished cohesion of the intestinal tunics, distension
of the intestinal tube by flatus, and enlargement
and ulceration of the follicles, with inflammation
or engorgement of the mesenteric glands. There
are various other lesions associated with those ;
but they are different in different cases.

519. 6. Since Petit and Bretonnbau directed
attention to the almost constant change in the
intestinal mueotu folliclet in typhoid fever, the
subject has been further illustrated by the re-
smirches of Louis, Akoral, Bright, Chomxl,
and others. But, although this lesion b so con-
stant in the low fevers occurring in Paris and
some other parts of France, it is certainly not so
frequent in the same states of fever in this coun-
try ; and, instead of viewing it as intimately con-
nected with the nature of these fevers, I consider
it as only one of several changes superinduced
in the progress of the disease, but one of the most
constant and important. The first alteration
which these follicles present is enlargement or
engorgement, owing to the formation under the
mucous coat of a yellowish-white matter, slightly
friable, which imparts to the agminated follicles
the appearance of a thickened patch, and to the
isolated follicles that of a pustule. To this state,
which is generally preserved till the twelfth or
fifteenth daj[, succe^, in most casesf ulceration,
beginning either in the mucous surface and ex-
tending to the whitbh matter, or in this latter,
which becomes softened and detaches the mucous
coat from the parts underneath. These grades of
^-•von in the follicles almost constantly commence
'm nearest the ileo^cccal valve. From the

eighth to the fifteenth or twentieth 6mj, the ag-
minated patches, which have not expenenoed the
above changes, piesent a reticulated appcaiaace ;
their mucous covering bein^ of a deeper coWor
than natural, softened, partially detached, and
perforated by numerous orifices of enlarged fol-
licles. In proportion as these patches disappear
by ulceration, or by sphacelation, the margins ol
the ulcers become eitner more level, evincing a
disposition to cicatrixatton, or more elevattti,
owing to thickening of the sabmucon^ and mv^
cular tunics. The ulceration generally extends
in width and depth, and sncoetsively invades the
submucous, muscular, and serovs coats ; ending
at last in perforation ; but death most freqncntly
takes place before this last change occurs. E^i-
dence of cicatrisation is, in rare instances, ob-
served, when the disease has been of long dai^
ation. Ulceration does not attack all the patches
containing the enlarged glands ; for reaaJntinn
sometimes takes place, or absorption of the matter
they contained.

520. e. The mouth tongue, and pharynx are (n^
quently covered with a thick mucus, underneath
which the mucous coat is often not manifestly
alten>d. But in some cases, this coat is softened,
discoloured, and studded with a few small rousd
or oval ulcers, most of them not referrible to the
follicles. The arsophagui occasionally is excori-
ated or slightly ulcerated. The aiomick h vari-
ously coloured in its internal surface. It is some-
times pale, most frequently red in variovs grades,
or puiplish or brownish red, occasionnUy ]^low-
ish ; and often the parts of the organ in contact
with the liver and spleen have imbibed the colour
of these viscera. — Softening, or dinunished eo-
heston, of the mucous and submncous tissne^,
throughout the greatest part of the large cvrva-
ture, or even the whole of the stomach, is observed
in a large proportion of cases. The softcaing
seldom extends to all the coats. Sometimes the
mucous tunic is not only softened, bat entirely
destroyed, the cellular tissue or the mnscalar
coat being denuded. It is generally easily de-
tached from the subjacent parts. M . Cnonn.
found, of forty-two cases, more or leas extensive
softening in fourteen. He remarks, that he ob-
served softening of the internal coats of the st»>
mach in the same proportion of fetal cases from
small-pox. — Thickening, and great tenuttjf of the
mucous coat, have also been seen but not so fre
quently as softening. Although M. Lorts met
vrith ulceration of the mucous membrane of the
stomach in four cases, and M. Anosal in ten, yet
M. Chomxl did not find one instance in the fatty-
two inspections, of which he has given the decaiR

521. d.The duodenum vadjefunum have occa-
sionally imbibed the colour of the bile or of ad-
joming viscera. Thev are generally of a deeper
red than the rest of the intestines. The tinui ii
usually more or less red, with numeroos arboris-
ations on the external surface ; but more freqneolJy
the redness is seated chiefly in the mnooos coat,
and particularly in the margins of the valruls
conniventes. in many cases, the redness is dis-
posed in zones, between which the three conts of
the intestine present a remarkable pallor. The
redness and injection are not greater anmnd the
ulcerations and tumid patches of agminalcd fol-
licles, than in other parts. Altentionn of colsvr
are not so common in the lerge, an ia the *a«/i

1014

FEVER, TYPHUS — Oroakic Lbsions.

in 4 ; oedema of the membranes, in 7 ; very plight
general softening of the brain, in 6 ; effusion of
serum in the ventricles, varying from a drachm
to half an ounce, in 12 ; numerous red points
upon dividing the cerebrad substance, in 5 ; in-
creased density of this substance, in 2 ; and the
normal condition, in 15.

518. a. A fatal issue is evidently caused, or ac-
celerated, in some cases, by the severity of the
associated disease of the respiratory organs, pre-
venting the necessary changes from being effected
in the blood circulating in the lungs. It proceeds
in others chiefly from the influence of the morbid
blood upon the weakened irritability of contrac-
tile tissues, and particularly of the heart ; and,
in rare instances, trom perforation of the intestines
inducing general peritonitis, which soon exhausts
the remaining powers of life. The lesions of the
digestive mucous surface evidently assist in pro-
ducing this effect ; but in a much less degree than
the depression of organic nervous power and of
irritability, and the deteriorated state of the
blood, with which they are intimately connected,
and of which they are important effects. All
these internal lesions evidently commence in the
course, or even not until the advanced stages, of
the disease ; and, when developed, are analogous
to the sphacelated sores and other alterations
which tale place in external parts in the more
malignant cases. These internal as well as ex-
ternal lesions depend upon the anterior changes
in the organic nervous power and irritability, and
in the blood ; they pcesent similar characters ;
and, where even the slighter external lesions are
observed, the existence or occurrence of those
that are iuternal is to be feared. The most con-
stant of these latter are discolouration and dimi-
nished cohesion of the intestinal tunics, distension
of the intestinal tube by flatus, and enlargement
and ulceration of the follicles, with inflammation
or engorgement of the mesenteric glands. There
are various other lesions associated with those ;
but they are different in different cases.

519. b. Since Petit and Brbtomnbau directed
attention to the almost constant change in the
intntinal mueoiu foUieUt in typhoid tever, the
subject has been further illustrated by the re-
searches of Louis, Andral, Bright, Chombl,
and others. But, although Uits lesion is so con-
stant in the low fevers occurring in Paris and
some other parts of France, it is certainly not so
frequent in the same states of fever in this coun-
try ; and, instead of viewing it as intimately con-
nected with the nature of these fevers, I consider
it as only one of several changes superinduced
in the progress of the disease, but one of the most
constant and important. The first alteration
which these follicles present is enlargement or
engorgement, owin? to the formation under the
mucous coat of a yellowish-white matter, slightly
friable, which imparts to the agroinated follicles
the appearance of a thickened patch, and to the
isolated follicles that of a pustule. To this state,
which is generally preserved till the twelfth or
fifteenth day, succeeds, in most casesf ulceration,
beginning either in the mucous surface and ex-
tending to the whitish matter, or in this latter,
which becomes softened and detaches the mucous
coat from the parts underneath. These grades of
lesion in the follicles almost constantly commence
in those nearest the ileo>cecal valve. From the

eighth to the fifteenth or twentieth day, the ag-
mmated patches, which have not expeneaced the
above changes, present a reticulated appeanac* ;
their mucous coveriog beio^ of a deeper coWur
than natural, softened, partially detached, and
perforated by numerous orifices of eolargod fol-
licles. In proportion as these patches d^ppear
by ulceration, or by sphacelation, the margins of
the ulcers become either more level, evindag a
disposition to cicatrization, or more elevated,
owing to thickening of the submacoii« and mus-
cular tunics. The ulceration generally extends
in width and depth, and successively invades the
submucous, muscular, and seroas coats ; cndiaf
at last in perforation ; but death most fre<iiictttly
takes place before this last change occurs. Ei i-
dence of cicatrization is, in rare inatsmces, ob-
served, when the disease has been of long duiw
ation. Ulceration does not attack all the patches
containing the enlarged glands; for reaolutioo
sometimes takes place, or absorption of the matter
they contained.

520. e. The mouth to»£u«, and phsryfkx are fre-
quently covered with a Siick mucus, underaeaib
which the mucous coat is often not maaifesdy
altered. But in some cases, this coat is soAcned,
discoloured, and studded with a few small roasd
or oval ulcers, most of them not referribU to the
follicles. The crtophagui occasionally is excori*
ated or slightly ulcerated. The ttomaek u vari-
ously eoUmred in its internal surface. It is some-
times pale, most frequently red in varions grades,
or purplish or brownish red, occasionally jtMow'
ish ; and often the parts of the or^an in coaiact
with the liver and spleen have imbibed the colosr
of these viscera. — Softming, or diminisbed en-
hesion, of the mucous and submucous tissues,
throughout the greatest part of the large carra-
ture, or even the whole of the stomach, is observed
in a large proportion of cases. The softening
seldom extends to all the coats. Sonoetimes the
mucous tunic is not only softened, but entirely
destroyed, the cellular tissue or the moscaUr
coat being denuded. It is generally easily de-
tached from the subjacent parts. M. CaoaKi
found, of forty-two cases, more or leas exteaaive
softening in fourteen. He remariLs, that he ob-
served softening of the internal coats of the st»-
mach in the same proportion of fatal cases from
small-pox. — Thickening, and great Unuiiy of the
mucous coat, have also been seen but not so frt-
quenUy as softening. Although M. Lov» met
with Ulceration of the mucous membrane of the
stomach in four cases, and M. ANoaAL in tea, yet
M. CnoMBL did not find one instance in the iMty-
two inspections, of which he has given the details.

521. d.The duodenum zndJefUHum have occa-
sionally imbibed the colour of the bile or of ad-
joining viscera. Thev are generally of a deeper
red than the rest of t(ie intestines. The iUmm a
usually more or less red, with numerous arbon*-
ations on the external surface ; but more freqaeatly

I the redness i» seated chiefly in the mucous ooat,
I and particularly in the margins of the valvabr
conniventes. In many cases, the redness is de-
posed in zones, between which the three coats of
the intestine present a remarkable pallor. The
redness and injection are not greater anmad ths
ulcerations and tumid patches of agminaled fol-
licles, than in other parts. Alteratioaa of eeloer
are not so common in the Isrgs, aa ta the trntU

1016

FEVER, TYPHUS — Organic Lesioki.

525. g. The imporUmce of the lesions observed
in the retpiratory organs has been alluded to. The
epiglottis has been sometimes seen oedematous.
M, Chouel found it ulcerated, with denudation
of the cartilages, in three cases out of twenty which
were carefully inspected. The larynx, especially
its superior aperture, is occasionally also the seat
of ulceration. When ulceration is observed in
either of these situations, it often also exists in
the pharynx, in which it seems often to have be-
gun ; and it is generally found to consist of several
small but deep ulcere, commencing in the form
of pustules filled with whitish purulent matter,
but without any surrounding injection, or inflam-
matory circle. — The ^ungs are often much dis-
eased ; but the alterations of them most frequently
seen, occur only during the last days of life ; and
are referrible to the predominance of physical,
over the vital, forces, as the disease approaches a
fatal issue. But as congestion of the circulating
fluids occurs in the more depending parts, the
vital cohesion, particularly of tbe parenchymatous
parts of the lungs, becomes diminished, giving
rise to more or less marked softtning of the en-
gorged part. In less frequent instances, it is not
only a simple congestion from stasis of the fluids
that is found, but also indications of pneumonia
in the first or second degree. The pneumonia is
sometimes confined to. two or three lobules; in
which case it may have passed into a suppurative
state before death : in other instances H occupies
a whole lobe, but without any signs of suppur-
ation. (Edema, or even emphysema, of parts of
the lungs, is also occasionaJly remarkeo. The
bronchi are generally red, or of a livid red, or
violet colour. The tint generally deepens in the
small bronchi, and in the direction of the air-cells.
They also contain some mucus. — M. Chomel
gives the following as the state of the lungs in
42 cases : — Congestion, with or without soften-
ing, in 18 ; hepattsation in the first degree, in 3 ;
hepatisation in the second degree on one side, in
2 ; lobular pneumonia, in 3 ; emphysema, in 2 ;
csdema, in 2 ; efliision into the pleura, in 2 ; and
the normal state, in 10.

526. h. The state of the Hood varies much in
fatal cases of nervous, putrid, or typhus fever.
Where the putrid, malignant, or septic characters
have been most remarkable before death, the
changes of the blood have been usually the great-
est.— This fluid is commonly dark, black, difllu-
entj and but rarely in the state of fibrinous clots.
In a few cases, the blood in the heart and large
vessels assumes the form of black coagula, which
are different from those observed in other acute
diseases. This state is evidently owing to the
absence, or great diminution, of fibrine. The
presence of a gaseous fluid in the blood, espe-
cially in that of the veins, is also evident in some
cases. I have observed this circumstance in
death from other diseases, particularly if asphyxy
was the mode in which the fatal event took place.
(See art. Blood, § 110. et seq.)

527. t. The hem-t is often softened and somewhat
discoloured. The softening of this organ varies
from an almost unappreciable, to a most marked ,
degree. In some cases it is so great, that the fingers '
may be pushed through the parietes of the ven- [
tricles with ease. This diminution of cohesion is ;
l^nerallv observed in cases where the changes
in the blood, and softening of the liver and spleen.

have been the most remarkable. Fimecidky, m a
state of softness different from tliAt just bkb-
tioned, is still more frequent. The flaccidity may
exist without very manifest loes of the cohemn
of the structure ; but it is generally atteuled by
some degree of the latter, uid the aolteiimg easy
be great, and yet the flaecidity not very appasvoi,
although this is rare. — ^The eolour of the interail
membrane varies in diflerent cases, and even ia
the opposite sides of the heart in tlie saoie ca^e.
In some, the membrane is ted ; in othen dart,
brown, or livid : it is often colourless, particsiariy
when the heart is softened. It never pretenti
inflammatory appearances, nor the changes im-
mediately proceeding from the inflammatory state.
— The researches of MM. Tboosskau, Rigot
(Archives Gin£r. de Af^. t. zii. — ^xrr.), and
Chomel (Clinique MM, p. 279.), show that ^
redness often found in the aorta, caritics of the
heart, and large veins, in this class of fevers, is
entirely owing to the tinging by, or to iaabibitioa
of, the colounng particl^ of the blood. laflsB-
mation of the heart, or of its membraBes« has sot
been observed in any case of these leren.

528. k. The external changes observed after death
most freouently commence a considerable time
before this event. These consist chiefly of pe-
techis, V ibices, and blotches, varyinc as to axe,
situation, and depth of colour ; and are to be
ascribed to the extravasation of eemra, coloured
with red particles, or of blood itself, into the vas-
cular layer of the skin. Gan^ianoas eschars. aa>l
sphacelus, are met with chiefly in parts pressei
upon by the weight of the body, as the acruai,
shoulder blades, heels, and scalp of the occiput,
or in those to which blisters, sinapisms, or ocher
acrid substances have been applied. Bat these
changes may occur in other situatioBa, althoafk
rarely, and without these causes, as an the iaa^
of the thighs ; unusual pressure, or any other
cause, either dissipating or exhausting the i^oaia-
ing vitality of the part, prodacing these effect*.
Phagedenic sores or ulcers, and enlargemeato of
the absorbent glands, are also observed in ran
instances. These sphacelating or spreading ulcers
often commence in the form of pustules or veiicles
which break, leaving a foul sore which rapidly
spreads. Beudes these, the usual conaeqaearcs
of erysipelas are sometimes observed, or the re-
mains of exanthematous and miliary empboM.
Even emphysema has appeared abortJy belwe,
and has remained after, death.

629. B. Pathologieal cmielKnons, — The »•
position I have made of the orf^anic lewoei,
more especially proceeding from typhoid fcv«»«
suggests some important consideratioiis, relative
not only to the nature, but also to the treat-
ment, of these diseases. Few of these chatt|:cA
become apparent before the seventh day fnm the
invasion* when vascular action has passed ioto
exhaustion, when organic nervous power and
rritability are remarkably lowered, the circalatiag
and secreted fluids are becoma niorhid, and the
powers of vital resistance in great measvre ever-
thrown. If inflammatory action shoold attack
any part, either in this state, or even at an cailier
stage, it will be very different, as to its pbeneoMna.
its progress, and its results, from anflannaatam
occurring primarily, or in a system whose tital
and physical constituents are not materiaDy de-
ranged. It is tho remarkable affectam nf tbcx

1018

FEVER, TYPHOID — TmEATMXMT.

occurred, was mistaken for the cause of the
amendment, instead of being viewed as the effect,
and as one of the signs by which this change is
often indicated.

533. The physicians who, in modem times,
attributed an important part to putridity of the
humours, recognised merely a portion of the mis-
chief, and that often the most remote and con-
tingent, and mistook, in great measure, both its
origin and nature. They bad recourse to cam-
phor, bark, musk, and various preparations, both
vegetable and mineral, possessmg antiseptic pro-
perties ; and, if they had employed them in ap-
propriate ^riods and states of the disease, the
benefit derived from them would have been much
less equivocal. But, mistaking the origin of the
phenomena usually called putrid, they frequently
prescribed these medicines improperly ; and
whilst endeavouring bj an early eihibition of
them to prevent putridity, the^ actually often ac-
celerated or favoured its occurrence.

534. A nearly similar mode of treatment was
advised by Brown, and his once numerous fol-
lowers on the Conrinent ; but it was based upon
a different doctrine— upon the predominance ofthe
asthenic diathesis and its consequences. Although
wine, opium, tonics, and stimulants, were recom-
mended by them, in various forms and combin-
ations, with advantage, in certain states of typhoid
fevers, particularly in the latter stages ; yet the
evils resulting from an early recourse to them
were also sufficiently evident, and at last became
manifest even to the disciples of this school.
That this practice, and the modifications intro-
duced by its partisans, did not prove so injurious
in the treatment of fever, especially on the Con-
tinent, as may be supposed, is accounted for by
the circumstance, that depressed vital power, with
septic changes in the fluios in the last stages, cha-
racterised the much larger proportion of fevers
prevalent for several years after its promulsation.
But the appearance of eianthematic typhus in
the north of Italy, at the close of the last cen-
tury, opened the eyes of Rasori to the impro-
priety of having recourse to stimulants in its treat-
ment, and laid the foundation for the doctrine
and practice of eontru'itimulut. The general
character of the petechial fevers prevalent about
the commencement of the present century in
Italy and Germany, was such as I have deline-
ated in the section on typhus {§ 497.), with more
or less of inflammatory or irritative action in the
stage of excitement; the exanthematous eruption
in this stage being frequently mistaken for petechia,
and the appearance of these, and of other ady*
namic symptoms, being favoured by the vascular
reaction wnich preceded them.

635. The administration of tartariMtdantimumy,
in laree doses, was the principal treatment em-
ployed by Razori. When the patient was young
and robust, and the disease had not reached the
acme of excitement, he directed a moderate
bloodletting at the outset, and, immediately
afterwards, four, six, eight, ten, or twelve grains
of tartar emetic, or even more, in solution. He
prescribed this medicine in smaller doses subse-
quently, or substituted for it the fccrmef mimtral,
conjoined with nitre, and in doses of one grain,
or of a grain and a half, every half hour, or hour,
or every two hours, according to the degree of
vascular excitement. He often gave the tartar

emetic and kermes altenaiely. Rssoni aho
employed purgatives, particularly when the anti-
mony did not act sumciently upon the bowcb ;
preferring neutral salts, manna, and tawarinds,
in larg^e doses, and administering then, m other
cases, in enemata. He enforced a cooliiig regi-
men and severe diet, and allowed only refrigeiant
beverages. The success of this treatment is staled
to have been great ; and its propriety, as w«U as
success, may be admitted, when employed is an
epidemic characterised by high vascular exdie-
ment at its commencement, and when adeptsd
sufficiently early after reaction has taken puce,
and in previously healthy persons. Bnt in
other states of typhoid fever, and in the latis
stages especially, the larse doses of antiBoay
here advtsed appear not, « priori, to be switahfc
means. It should, however, be admittfid, that
the exhibition of tartarised antimony in the ad-
vanced stages of this fever has never been sans-
factorily tried, either in this country or in Fiance
and Germany. That it may be fonnd not so
inappropriate as generally conndered, is an in-
ference which the triab made of it, very re-
cently, by Dr. Graves, of Dublin, fully wnrmat.
636. The pathological tenets lately prevalent
in France have, as M. Chomxl sutea, pteienaed
the treatment of Rasori from being adopeed, or
even tried, in that country. The doctrine of
BaoussAfs was opposed to this and every other
means that seemed to its suppoiteim liiLely to
aggravate the inflammatory action of the digestive
mucous surface, which they suppose to be thn
cause of all fevers. If we examine the piactiea]
tenets of this school, we shall find more than ene
postulatum assumed as fully established, although
admitting not only of doubt, but even of dimoval.
That fever does not depend upon this' lenoa,
although predominant morbid action in the di-
gestive canal may appear in many cases, and in
some feveiB more frequently than in otbcss, has
been already shown. And, granting that thn
morbid action is attended by vascular injeetian
of the mucous membnne, it still remains to be
proved, that it is the same kind of aHection m
inflammation. That it b not the same as
and sthenic inflammation, its phenomcnn
results, as well as the juvantia and
sufficiently prove. Even granting the
of Baoi7SSAis in its fullest range, it still
to be demonstrated, that the treatment advised is
that which is the most beneficial, or thn
appropriate, in the nnnterous and varying
conditions which fevers assume ; and it,
over, should be shown, that the means vrhich the
espousers of this doctrine reprobate, are one vhtt
more prejudicial than those whieh they land. la
a class of diseases so varying, and even oppnsiie,
as to their pathological states, as feven am, net
only in their different fonns, but also in the seam
case at different stages, the success of vaiioas
remedies cannot be predicated fram doctrinal
tenets. However ingenions the theory, and don
the reasoning, by which we are led to practical
inferences, careful experiment and repcnmd ob-
servation are necessary to test the chnnfCter of
any method of cure ; and even were we to adopt
the views of Brovssais, to them tests we ought
to resort before we should decide betneen ths
efllicacy of gum-water and leeehm on the ens
hand, and that of antimony and pnigniivea en

1020

FEVER, TYPHOID— Treatmxkt.

— This treatment will genenlly shorten the chills,
&c. characterising this period, and favour a re-
laxation of the surface, or the occurrence of mo-
derate reaction.

541. c. In the itag« of excitement, the treatment
must altogether depend upon the degree in which
reaction is developed, and the manner in which
the brain, the lungs, or the digestive canal, ap-
pears to suffer. If the fever does not present,
early in this state, the characters of low nervous
fever, to their full extent, or those of an adynamic,
or of a putrid or septic kind, then a small or
moderate bloodletting may be prescribed; but
the effects at tlie time of the operation should be
carefully observed. If the patient be young, or
robust, previously healthy and well fe^, then a
more copious depletion may be practised, if he be
seen early. Even in the lower states of this fever,
if any of the viscera just named be prominently
affected, a local depletion^ either by leeches or by
cupping, may be employed. But if the period of
excitement bie far advanced ; if the fever be sim-
ple or mild ; if it have passed the tenth day ; and
if it be the true or exanthematic typhus, unat-
tended by inflammatory associations ; bloodletting
will seldom be of service, and it may interrupt
the regular and favourable course of the disease,
particularly the Utter form of it. In a large
number of cases, in which M. Louis states blood-
letting to have been tried, and in which it appears
to have been indicated, the advantage procured
by it seems to have been slight ; but sufficient to
increase, to a small amount, the proportion of
recoveries, and to diminish the duration of the
disease. — Emetic* have been advised also in this
stage; and, in cases where the chills return
on successive days, or frequently alternate with
flushes, I believe that they will be found of ser-
vice. HiLDENBRAND directs them in the first,
second, or third day, or even later ; having pre-
mised a bloodletting in the cases indicating it ; and
prefers a large dose of ipecacuanha, with a grain
of tartar emetic. — Next to emetics, ptcr^atiMf are
of advantage. At an early period, or before the
eighth or ninth day, a full dose of calomel, either
alone or with rhubarb, may be given ; or jalap,
with cream of tartar ; and their action promoted
by moderate doses of the neutral salts, or by
manna, tarmarinds, &c., according to circum-
stances. These clear away morbid secretions,
and mucous sordes, from the digestive surface;
which, if allowed to remain, would favour the
occurrence of the morbid changes in the intestines.
If, however, the bowels have been much relaxed,
and still continue so, it will be preferable to give
an occasional dose of hydrargyrum cum creta,
rhubarb, and ipecacuanha, which will promote a
healthy state ot the mucous surface, ana facilitate
the evacuation of morbid secretions. If the bowels
be only gently open, the circumstance is favour-
able ; but an inordinate action of them must be
moderated by the above medicine, or by others
hereafter to be mentioned, lest intestinal ulcer-
ation and perforation be the ultimate result. At
the same time, care should be taken not to produce
a sudden change or constipation, otherwise the
cerebral or nervous symptoms will generally be
much aggravated, and a tendency to effusion on
the brain be produced. — Dianhoretict, suitable to
the state of the symptoms, either variously com-
bined, or associated with diuretics, may be given

♦ ••

The

from time to time. Of these, the more Tefrigeraat,
with small doses of camphor, will be most «rrire-
able ; and either some one of those in the Appcadix
(F. 431. 436. 440. 818. 865.), or the foQowiaf,
may be prescribed : —

Na9S& R Canpborw mm gr.
tit gr. UJ.: Pulr. Acacia gr. IJ.;
M. FUnt PUulc U. quartU horii

Na SSSl B MUt Camphom Sj. i Uq. A
Utit 3 U. i Ammool* Murtatif, gr. Iv. :* Sjnt^
3 J. M. Fiat Hauttua, quartloi^tte hasA em
▼el interdum, Mcundia horit, pilule ct k*irttm',
vidlMit, mimantur.

542. d. In the aermmjsto^f, the debility is
real ; irritability is more exhansted, and the
rium more severely and uniformly affected.
functions of the skin, and frequently those of the
bowels, are also more disturbed than before. The
indications are to support or stimulate the 19^
tem, according to the forms the df
— Blittert may be employed in this
before. They favourably impress tSe
system, check the tendency to diairfacem and
affection of the intestinal mucous surlmce, and
render the skin more perspirable. They are naet
serviceable at the commencement of this stagv ;
and are best applied on the nape of the oeck,
behind both ears, or on the calves of the lc;g.—
Camphor is now one of the best remediea that can
be exhibited. Whilst it promotes ncnrons power,
it relaxes the skin, and noes not increase infiam-
matory action, but rather tends to allay it, ptni-
cularly the nervous and cachectic fenns of ii,
which alone can exist in this disease. It should
be given in larger doses in this stage, more espe-
cially of the malignant or putrid form. Fram
twelve to twenty grains may be exhibited in the
twenty-four hours. HiLosNaaAXD advises* in the
latter part of this stage, medium doses of cam-
phor; or one grain every two hours, with an
infusion of arnica and OMgelica not. He con-
siders that these lessen the stnpor, giddiness, and
delirium ; act favourably on the skin, and preveat
the tendency to diarrhoea. — EiMSttrj are soaetiBBcs
beneficial in this stage, when they have been neg-
lected in the previous one, or contranndicated. —
Purgatives are of service only when the boweb
reqmre assistance. They should be given with
the intention of evacuating morbid mattiers« of
preventing the injurious impremion made by snch
matters upon the intestinal mueous surface, and
of promoting a healthy action of the abdominal
emunctories. Hydrargyrum cum creta, aad rho-
barb, and the infnsbn of the latter with the Bnidcr
saline substances, in a state of efferveeceace, are
the most appropriate. These preserve the tooeof
the digestive mucous surface, whilst they enable
it to throw off fiscal collections. Their actiaa
may be occasionally promoted by emol&ent and
gently laxative enemata. I doubt much the pro-
priety of exhibiting calomel, or any of the drastic
purgatives, in this stage ; and I beUeve that the
more ac*ive neutral salts exhaust the sticngth,
and produce watery stoola, in this period, par-
ticularly if they be exhibited in any qvanttiy. It
is in the common, or synochoid, fona of lever, or
at the commencement of this, that they may be
employed. In the latter stages of low fevers*
calomel and cathartics are apt to increase the
intestinal symptoms, or to determine an iirimtrre
action of toe bowels, liable to teraunnte m the
lesions already noticed.
643. r. When the disease has reached its

1022

FEVER, TYPHOID— Trbatment o? th» Cohpucatiovs.

and camphor, ammonia, ipecacuanha, or other
expectorants, with hyoscyamus, or extract of
poppy, are the principu means we possess.
When, in this complication, the skin is cool and
pale, the pulse very weak and small, and the
features collapsed, the warm expectorants, as
polygala, ammoniacum, ammonia, camphor,
the stimulating tonics, and wine, should be given,
according to tne peculiarities of the case.

546. 0. Predominant affection of the inteitina I
mueou* turfaee should be treated by means similar
to those advised in this complication of synochus ;
and the more especially, as the latter fever, when
thus characterised, either passes into, or is very
nearly allied to, the typhoid form. In the earlv stages
of this complication, a combination of small doses
of hydrargyrum cum creta, rhubarb, and Dover's
powder, with compound cretaceous powder, given
every three or four hours, is generally of service.
If the constitutional symptoms will permit, and
if this affection appear at an early period of the
fever, a local depletion should be premised, and a
blister or sbapism be afterwards placed upon the
abdomen. The terebinthinated epithem, applied
sufficiently hot, and covered so as to prevent eva-
poration, if properly managed, is the most effica-
cious means •-more particularly if the abdomen
be tense, tender, or tympanitic. In this latter
state, an injection with assafoetida, or with the
extract of rue, or with from two drachms to half
an ounce of spirits of turpentine in addition, will
give great relief.

547. In a far advanced stage, diarrhaa, espe-
cially if attended by tension, pain, or flatulent
distension of the abdomen, requires great atten-
tion. If the medicine? just recommended prove
not of service, the ehlorurets, particularly the
chloruret of lime, may be given, with camphor,
and extract of poppies, &c. Mucilaginous injec-
tions, containing syrup of poppies, or laudanum,
or compound tincture of camphor, may also be
administered, and a rubefacient epithem placed
over the alxlomen. — If htemnrrhage from the
bowels occur, it may be ascribed chiefly to ex-
udation from the softened mucous surface, as
shown by the post mortem appearances; and
superaeetate of lead with opium, or acetate of
morphine, or extract of poppy, should be exhi-
bitea, either in the form of pill, or with the pyro-
ligneous acetic acid, in strong camphor julap.
The lead has been recommended, in these cases,
by Drs. Bardesley, Graves, and Stokes. I
have resorted to it in these several combinations,
and have given it in two or three instances with
kr^osote. — I have likewise employed, by the
mouth, and in enemata, the spirits of turpentine,
which generally proves the most active remedvof
any in such circumstances. In some hopeless
cases, it has succeeded contrary to expectations.
In one, however, that recently occurred to me,
although it arrested the hsmorrhage for a time,
there was a return which carried off the pabent.
If the disease be far advanced, or the powers of
life much reduced, the turpentine should be given
in small or moderate doses, and its effects care-
fully watched. I have also prescribed it in con-
junction with kreosote, the acetate of lead and
aromatics, in similar circumstances.

548. 7. Prominent affectum of the hrain may
arise in the course of typhoid fever, either from
congestion within the head, or from the depressed

state of nervous power, unconiiectedwidi infltai-
matory action, or even with vaacnlar deterun-
Btion. This circumstance, long bdievcd by pa-
tholoeists, has been folly confirmed by M. Lotu.
who found, that the presence or absence el defa-
rtum has little or no connection with pereephbfa
organic lesion of the brain. If, however, tktst
be increased heat or severe pain of the head,
spastic contractions of some mosdes, fnshed
face, injected eyes, or other indications of acme
disorder of the cerebral drcnlalion, pniticalarij
in the stage of reaction, the hair abenld be n-
moved, and local depletion resorted to. The keai
ought to be kept cool, by cold sponging, or lonans.
If delirium be attended by these syinptoms, the
same means are required ; and, if^'^it oe, at the
same time, low, insensible, or mattering, a hhrter
should be applied to the neck and nape, or bc^
hind the ears, or to the calves of die leg», or a
sinapism may be substituted in the btier on-
atiott. Whenever the affection of the head is coa*
nected with increased determiontion to it, eipe>
cially in an early stage, stimnlnting Tntrfpner-
dies, as ammonia, musk, or camphor in large
doses, cannot be'of service, and may be injwiow.
The last of these, however, may be need in snsU
doses with nitre, and it may be increased sccsrd-
ing to the degree of stupor, and coolness of tk
scalp. If the delirium depend vpon ezhaarted
nervous power — if it be attended by stnpor ; bf
a weak, soft and very qoick, or aomcwMt slew
pulse ; by a moist skin, or copious peiyratisa ;
or by extreme prostration, pajticularly after the
eighth or tenth day, or in the nervous stage ; caa*
phor in doses of from one to three or firar gniw
every two, three, or four hours ; or the prepv-
ations of valerian, or of jerpcite«ria, or of
or ammonia, or of ether, or trine or

be severally employed as circomstances will sc^'-
gest. In other respects, the treatmeel of the
state, and of sopor and coma, its fieqiieiit it-
tendants and sequents, should be directed, as
explained in the articles Coma ($ 16. 19.), aad
Delirium ($ 16, 17.). — Retemtian i/mrirnkwaj
apt to occur in this state ; therefore, in it tspco-
ally, but also in all others, attention ooght to be

{»aid to the circumstance. If an ondne aoevB*-
ation of water in the bladder be detected opoa
examining the hypogastrhim, it sbonld be
diately drawn off.

549. ^. In the most tevereform of meroooMf
($ 476.), bloodletting is s^om of service, va-
iesM at the commencement of reaction, or froai
the vicinity of the most affected organ. Whca
the skin is very hot, tepid sponging, diaphmttia,
external derit«ltiM, and emollient dUuinie, wick
nitre, or small doses of the ■niriats of mmmmm,
are the most appropriate. The infasiott ef eslmn
may be given as the disease passes into the nin-
ous stage, either with the ammonietod Hmetwm
or with camphor, and murimtie ether, or ether
stimulants. — Hildenbrano advises the armiim
montana with camphor, in this slate. — If cxhasf-
tion increase, and coma come on, these mcdicioei,
or others of a similar kind, may be prescribed n
larger doses, or at shorter intervals ; and a Uisier
applied to the vertex, or occipat, or to dM aapr ;
or a large sinapism to the epigastrioa, or tnsaiet
of the legs. Lallxmavo and MacKiirroai kavr
adduced instances of benefit, in the ccmaiow
state, from pouting boiling water on the lo»t>

1024

FEVER, TYPHOID — Treatmikt of thx Compucatxovs.

555. 1. The occurrence of perforation of the in-
testines, and conBequent peritonitis, should not be
overlooked in the enteric complication, or other
severe forms of low nervous fever. Peritonitis
seldom arises except from this cause, for large
patches of the mucous sarface, with Peyeb's
glands, may be destroyed by ulceration ; and
vet the peritoneum will be unchanged. When,
however, diarrhoea has been suddenly arrested
early in the disease, by an injudicious use of as-
tringents, general peritonitis and effusion may
result, without perforation, and even without ul-
ceration. But this is only one of several bad
coo8e(^uences which may proceed from injudi-
cious mterference. If, m an advanced stage of
fever, and after thirst, diarrhoea, tympanitis, and
great prostration of strength, the patient suddenly
complain of pain in some part of the abdomen,
extending over it, with tenderness, increased dis-
tension, and rapid sinking of the powers of life,
peritonitis has occurred. In this case, large doses
of opium, to palliate the patient's sufferings, are
the only means that can be used with any benefit.
— Dr. Stokes, who has very ably elucidated the
subject of peritonitis from this cause, and its
treatment, directs one grain of opium to be given
every hour, or two hours, until a decided effect
is produced by it ; and afterwards at longer inter-
vals. (Dublin Hosp. Rep, vol. v. ; and Dublin
Jour, of Med. vol. i. p. 125.) When effusion
of the intestinal contents into the peritoneal cavity
occurs, the result must be fatal. But when ad-
hesion of the peritoneum to the opposite surface
takes place previously to the perforation, or when
the perforation is speedily followed by a limited
inflammation and effusion of lymph, recovery is
possible. The formation of coagulable lymph
can hardly, however, be expected in peritonitis
occurring in the course of fever ; as the states of
vital action, and of the circulating fluids, are ge-
nerally incapable of producing it.

556. b, TrMtment of putro-adynamic fever
(§ 484.). — ^The phenomena which especially cha-
racterise this variety, may appear either at an
early stage of fever, or at an advanced period,—
they may be the concomitants, or early conse-
quences, of depressed vital energy, and imperfect
powers of reaction ; or the results of vascular
reaction being so great, relatively to the state of
vital influence, as to exhaust both the irritability
of contractile parts, and the tone of the extreme
vessels. In either case, alterations of the circu-
lating fluids, and deficient vital cohesion of the
soft solids, speedily follow, and coexist with these
changes. In conformity with this view, with the
pathological facts stated above ($ 529.), with a
recognition of the characters of epidemics whioh
have been observed in modern tiroes in different
countries, and with the results of personal observ-
ation, it may be safely inferred, that the treat-
ment of this fever should mainly depend upon
.the state of vital action early in the stage of ex-
citement, and the period of the disease in which
the putro-adynamic signs appear ; and that, in a
practical point of view, it will be, therefore, ad-
vantageous to divide this variety of typhoid fever
into — 1st. The conucutive putrO'tuiynamic, or that
form which is contingent on more or less manifest
reaction ; and, 2d. The prttnafj/ putro-adynamic,
or that which is attended by 'imperfect, or no,
reaction, and in which the characteristic pheno- (

mena appear early in the diaeue. It should,
however, be recollected, that both these fonas
may occur in the same epidemic, or that either
may predominate ; and, moreover, that the lot
or contingent state of putro-adynamia it sone-
times met with in all epidemics, whether thA fever
be common synochoid, typhoid, or ezaathcma-
tous, owing to the causes stated above, and with
a frequency relative to the prevalence of
causes (§ 468.).

557. a. Th^stages of premonition and of i
of this variety, are scarcely different in their cha-
racters from those announcing nervous or typhas
fever. The same means as have been advised
above (§ 540.^ manr, therefore, be resorted to,
with the intention of preventing the further pco-
gress of disease, or of rendering it more mild*-—
When the symptoms of invasion are either indift-
tinct or protracted, the consequent fever is oltee
rendered much less dangerous than it otherwise
might have been, by the adoption of the mcfawrci
already detailed, and more particularly by exhi-
biting an energetic ewnetic, and by promotiag iti
full operation by warm or tepid mucilaginoes di-
luents. Tepid sea toaier, or a weak solutioD oC
common salt in a tepid state, has been employed
with advantage, for the purpose either of pff».
moting the action of the emetic, or of produciag
full vomiting, when there has been oai
sickness.

558. 0, In the corueeutive putro^adyi
when the stage of excitement is more or leas de-
veloped,— when the pulse is frequent, full, m
sharp ; the skin hot, and thirst coosiderable, or
if an internal heat be felt , vascular depletion may
be practised, but with due reference to the cir-
cumstances of the patient, and to the period which
has elapsed from tlie time of invasion. So kmg
as the ciiaracters of putro -adynamia have not ap-
peared, these symptoms fully warrant a cantioes
recourse to depletion ; and m young lobuft per*
sons, even a repetition of it. — If rigors and shiver*
ings are followed by inordinate or turaultiunu
reaction, the necessity of larger depletions is oh-
vious. But, even in this case, they should not
be carried too far, or to the extent of fwodeciflf
syncope; otherwise, in attempting to avoid the
exhaustion consequent upon excesave action, a
quantity of blood may be withdrawn, too greet
for the diminished power of tonic contxectioa
possessed by the blooa-vessels, — the venelt being
incapable, owing to the loss of their tone, to
commodate themselves to, or contract sufficiei
upon, their contents, when the reduction of i
contents is great, — and thus collapee of vascolar
action, and of vital power, may follow.

559. ^. In the primary putro^dynmwtic, or in
cases attended by indistinct signs of invasion, and
by imperfect reaction, we can hardly ventaie
upon depletion, unless indications of congeiiioa
or prominent affection of an important orna pce-
sent themselves. In this instance, local deple-
tions, or dry cupping, may be tried. If petechis
appear early in ttiese cases, or if the pulse be very
compressible, very small, or broad and open ; tf
the skin be cool, damp, or unnatural, yet not hot;
if the tongue be flabby, or covered by a dirty mu-
cous, although the fever is evidently not far ad-
vanced, or is very recently passed the stage of
invasion ; then bleeding should not be attempted.
In this case, very different means most be em-

1026

FEVER, TYPHOID — Exantbxkatovi — TsxAnmrr.

tioQ of cinchona with the compound tincture,
nitrate of potash, and subcarbonate of soda, I
can also speak from experience. When the pro-
Btration of strenp^th is extreme, a pill containing
two or three grams of camphor should be taken
with each dose of either of these, at short intervals.

564. Other tonics, and different combinations
of them from these now mentioned, will frequently
be productiye of great benefit, when morbid ex-
cretions have been evacuated. However specious
the arguments adduced by some writers against
the employment of acids m the putro-adynamic
states of fever, it cannot be denied that ^ood
effects have been produced bv them, especially
when exhibited with powerful tonics. The in-
fusion or decoction of cinchona, with muriatic
acid, or with nitro-muriatic acids, and chloric
«ther (formerly Cluiton's febrifuge); the sul-
phate of quinine with sulphuric acid, and Hoff-
mann's anodyne ; and pyroligneous acid in large
doses, with camphor, the solution of the acetate of
ammonia, and tonic or aromatic infusions, or the
infusion of serpentaria or of arnica, are the most
energetic, and may severally be tried, according to
the peculiarities of the case. A solution of camphor
in acetic acid was a favourite medicine with many
writers on putro-adynamic fever, and was em-
ployed by them both internally and externally.

665. Dr. Stevens's saline treatment is most
appropriate in this form of fever. He directs
twenty grains of the muriate of soda, thirty grains
of the subcarbonate of soda, and eight of the
chlorate of potash, to be given every two or three
hours — or more or less frequently, according to
the urgency of the case — aissolved in water, in
the advanced stages. He believes that, when
these salts are prescribed before the stomach has
ceased to perform its functions, they will not irri-
tate the alimentary canal, but will be absorbed
into die circulation, and correct its morbid state.
One or two table-spoonfuls of common salt may
also be administered occasionally in a tepid gruel
enema. The strength should, at the same time,
be supported by strong beef tea, or the regimen
about to be recommended.

566. (. If putro-adynamic fever be attended by
frtdominant affection of any organ, local deple-
tions, followed by external derivatives, will be
Decewary, particularly in an early stage of the
fever.— At a later period, external derivation,
and the other means advised for the complications
of nervous fever, according to their seat, should be
employed. In this variety, however, a more liberal
use of tonics, oonjotned with the antiseptics just
mentioned, is generally reauired. — when this
or any other form of typhoia fever is complicated
with asthenic inflammation of tht faucet or pha-
rynx, or both, the means aiready recommended
are quite appropriate. In these cases, deglutition
is very difficult, and sometimes impossible. Re-
course to external derivatives, and to injections,
is then urgently required. The action of the
bowels should also be solicited by purgative ene-
mate, unless diarrhoea exist ; and the medicines
that axe indicated should be administered in clys-
ters, and in sufficiently large doses. As the pa-
tient is generally unable to gaigle his throat,
advantage will sometimes accrue from syringing
it with any of the tonic mixtures above prescribed,
or with a eolation of the chloruret of lime or of
krteiote ; and if a part, or the whole, or either

of these, should be swallowed, the more benefit
will be derived.

567. n. If this variety become complicated with
diarrhxa, disorganisation of the digestive mocons
follicles and surface will rapidly take place, if
the treatment be not prompt and judicious. The
means already advised (^ 546. 447.) for this com-
plication must be adopted in this case. It the di-
arrhoea occurs at an early period, it will ge-
nerally be moderated by tonic infusions, vrith the
nitrate of potash, or with the muriate of ammonia,
and the compound tincture of camphor. A com-
bination of ipecacuanha, nitre, camphor, and
opium, or extract of poppy, wUl also often di-
minish or remove it. If h^marrka^ sttpcrvefte
from the bowels, these medicines will sometimes
be sufficient to remove it. In mote urgent
cases, the energetic remedies previously di-
rected ($ 547.), or the pyroligneous acetic aod,
Mrith camphor aod kn^osote, or turpentine. Sec,
should be prescribed by the mouth, and in eae-
mata. When diarrhoea or haemorrhage charac-
terises putro-adynamic fever, the alkaline sub-
carbonates will frequently aggravate or pemiuats
it, and render convalescence protractea. In other
respects, the treatment directed for the comph-
cations of nervous fever, and for its last stages, it
also suitable to this ; these stages requiring cither
the measures just described, or several of those
about to be noticed, with a more or less dinct
reference to the putro-adynamic stale, or Tanooi
combinations of the substances alreadj eauac-
rated ($548-555.).

568. c. TreatmiHt of Exaniktmateu* T^fAmt
($ 497.). — The premonitory and invading pet vtdt
of this fever should be treated as recoma>eoded
above ($ 540.), with the view of arresting or ren-
dering more mild the procession of morbid pheno-
mena.— •.In the ttage of reaction, the txkdirabou
are — (s) to moderate excenive excitement ; {l*}
to guard important organs from the effects of pro>
minent action. — If full vomiting has not occurred
previously, it should be excited by an emetic, si
the commencement of this stase, or on the 6nt,
second, or third, day of it. It, however, ioAa»-
matory signs have become evident, paiticulafly if
the lungs are affected, a moderate b^oodiett^^g
should precede the emetic. The eruptioa, which
generally appears in this period, is usually followed
by slight alleviation of tne symptoms, aiad shonld
therefore be promoted by mild, itpid dilocais,
which may be made either diaphoretic, mucila-
ginous, or acidulous, according to circumstaocei.
As to bloodletting in this disease, it is pemiciwos
in many, if not in most cases ; and not merely u>
the nervous, but even in this stage. In the mild
and regular typhus, it is superfluous : but wbea
a highly inflammatory character marks this period,
or when local action becomes very premioeot or
excessive, it must not be omitted ; otherwise tbs
local affection may run into disorgant^atioa, snd
the nervous stage will be rendered more protracted
or dangerous. The amount, repetition, and nods
of depletion, will depend upon the peculiarities «f
the case. — When the bowels are open in this
stage, purgdttres, unless of the mildest kind, an
unnecessary. Severe pursing is prejodicial. u
it derives from the skm, mterrapts the regsUr
coune of the disease, and risks the prodornoa of
the enteric complicatioD. Tonics aad stiroehntt
are also injurious.

FEVER, TYPHOID — Certain McDTCZNZStsr.

1028

574. (. The nervoue in6ammatioii of the brain is
indicatml by sopor and profound typhomania, and
■hould be combated by blisters on the head ; by
camphor, by arnica, and the means directed for
this affection in nervous fever {§ 548.). If tight-
ness of the chest and dyspnoea occur in the nerv-
ous stage, congestion ofthe weakened vessels of
Uie Lttngt may he inferred. In this state, a small
bleeding, to. the amount of four or six ounces, may
be directed in some cases, and followed in all by
blisters on the chest, and antimonials conjoined
with camphor.

. 575. «. If the jmtro-adynamie character super-
venes and predominates as the nervous stage pro-
ceeds, the debility, equally with the morbid state
of the blood, requires attention. The preparations
of cinchona, either with mineral acid, or with al-
terative neutral sails, large doses of camphorr wine,
opium, and the other means directed tor the ve-
nous phases and complications of this condition,
will be required according to the peculiarities of
individual cases. If diarrhcca or^dtfuatery comes
on in this state, opium in large doses, but at dis-
tant intervals; warm dilute wine, with spices and
other aromatics; mucilaginous and farinaceous
liquids, or gmel, with common salt, taken in small
quantities but often, and administered in enemata,
with syrup or extract of poppies ; and the other
remedies noticed above (^ 553.) ; should be pre-
scribed.— If tinguUut or mtiearitmut occur, they
should be treated conformably with the principles
already explained ($ 554.). — Swellings of the
parotids are unpleasant accidents, even when cri-
tical. They should.be checked at first by keeping
the bowels moderately open,«nd cold applications
to them. If this end be not accomplished, then
suppuration should be promoted by stimulating
poultices ; and the abscess should be early opened,
in order to prevent contamination of the surround-
ing cellular parts. If gangrenous sores appear
in any part, the means directed above ($ 166.),
more particularly the chlorides, kr^osote, pow-
dered Dark, turpentine, &c., either severally, or
variously combined, or in the form of wash,
epithem, or poultice, ought to be promptly and
assiduously .employed.

■576. .iii. 0/* certain M^rficinsi.^c. in Typhoid
Auen.-^4i. ilatimimia/i, especially Jam Es\.pow-
dtr and tartar emetic, are frequently of service in
the early stages of fever : the latter for its emetic
operation, and its febrifuge or contra-stimulant
action during excitement; and the former for this
last effect, in connection with its diaphoretic in-
^ueoce. The remarks already offeree respecting
(these medictaes (§ 162.) are applicable to the nse
of them in the fevers under consideration. It is
chiefly in the early periods, to the more infiam-
natoiY states, in the pulmonary complications,
and either in aid of, or as substitutes for, blood-
lettmg, that they should. be -em ployed, more par-
ticularly taitansed antimony. However, the
results of Razor I's practice, and the recent trials
made of this medicine by Dr. Graves, in the ad-
vanced stage of typhus, indicate the propriety of
having jecourse to it, at a later period, m much
more uberal doses than have been hitherto con-
sidered safe. This able physician, reasoning firom
the good effects ef the medicine in delirium tre-
mens, was induced to resort to it in a case pre-
senting a quick, failing pulse; a black, dry, tre-
mttlotis tongue ; ^panitis j low, mattering deli-

rium; startings of the tendons, and oervous
agitation. He prescribed funr grains of tartar
emetic, in ei^ht-onnce* of camphor jnlap, with a
drachm of tincture of opium — a table ^spoonful
to be taken every second hour. The patient
vomited after the second dose ; and, aflier the
fourth, he fell into a calm sleep, and soon re-
covered. Besides the good effect of this medicine,
that of vomiting at this sta^e of fever, as recom-
mended by many of the older writers, is shown by
this case. Dr. Graves refers to other iBstaocei
(Lone/. Med. and Surg. Journ. vol. vii. p. 541.).
in which tartar emetic and opium prodoced
decided benefit, in most unfisvouraUle states of
the advanced periods of low nervous Cever, and
of exanthematic typhus. The combination of
tartarised antimony with nitre is most appropriatt
in the stage of excitemeat ; but, in the ncnroos
stage, opium seems indispensable to the good
effects of the antimony.

577. b. Of other aitripalogi'sfir and emitrm'^ttm^
lant meam, it is unneceasaiy to add any thing to
what has been already advanced. TUe ronti»-
dictory opinions entertained as to the prophecy,
or amount, of depletion are readily expUiced,
when the various lorms of typhoid frrer, and cir-
cumstances of the ca«e, are taken into consKlrr-
atioo, in connection with the intentions with which
bloodletting on the one hand, and reatmmtim oa
the other, are resorted to ; and with the fact that
both are very frequently required, not only con-
secutively but even simultaneously. This cir-
cumstance was well known to very many of tli«
numerous writers on these fevers dnring-thc three
last centuries, both in this and in foreisn coun-
tries. 'I hey well knew and strenuously incul-
cated the fact, even as late as the days of Clabbs,
that, in order to prevent the accession of the
putro-adynamic state, it is necessary to bleed,
and to use other antiphlogistic remedies, with
decision, early in variou« fevers and epidcBics.
And next to bleeding, Rtire and the mmrmte
of ammonia were held in e^timatioo. Car their
effects -in lowering morbid reaction at the com-
mencement of typhoid fevers, and in pieventiag
putridity in advanced stages. Thus, whiks sirrv
was conjoined with antimonials, ipecacuanha,
small doses of camphor, or with the spints o^
nitric ether, to fulfil the former intention, and to
promote perspiration and the action of tb« kid-
neys, it was given mith tonics and stimulant*.
to produce the latter indication. The writing* of
Delius, Hillary, Haknel, Wood, Rsaoni.aod
many others, f^bow us how very little «e have
hitherto improved upon their practice in these
fevers. The same remark applies to the use of
the muriate rf aumiMiM, whose operation a« a
refrigerant, antiseptic, and tonic rank« it as ooe
of the best and most generally applicable o( taa
many remedies employed in fever.

578. c. As to the use ofalvime traeumtkm; w«

have srrived at similar conclusbns to those %ery

generally acted upon during the seventeeAh and

eighteenth centones, but partially lost ngbt of to-

I wards the close of the latter.— The good effects of

I emetic* at the commencement of typhoid le^exs

I were almost universally admiued. until B»ors»»a

> banished them from his code of therapeutic*. —

I That circumstances sometimes sometimes occcr.

I which either render them unnecessary, or t%tn

\ forbid thtm altogether, hat been allowed ; bat

1030

FEVER, TYPHOID — CEftTAiN Mboicivis nr.

58 1» Arnica hat been very much employed in
Germany in low fevers, and in the nervous stage
of typhus, yet it has not received a satisfactory
trial m Enffland nor in France. Stoll, Fischek,

COLUN, FXERO, MeBCIKR, FrAKK> RlCHTER,

HscKERf HiLDRNRRAND, Rud Other high autho-
rities recommend it, genesally as directed above
($ 569.). QusNTiN prescribes an infusion of it
with valerian. The flowers and the root are most
commonly employed, and usually in the form of
a weak infusion ( F. 222, 223.).

582. In the low nervous form of typhoid fever,
as well as in the nervous stage of ezaotbematic
lyphus, or in that stage and state of the disease
for which the German physicians prescribe arnica,
vaUrian may be employed with advantage. Mat-
mmx, Frize, REXL,THoiiANN,and others recom-
mend it. I have given an infusion of it in several
cases, and made it the vehicle of other medicines,
particularly the chlorate of potash, camphor,
the alkaline subcarbonates, serpentaria (F. 269,
270.), &c. It is indicated in such states of fever
as require a gentle tonic and stimulant of the
nervous influence, especially when the nervous
symptoms are prominent, although the head be
cool, and the pulse weak. In these circumstances
it may be conjoined with camphor, tonics, &c.

583. Strpentaria root was praised by Frizs,
Stoll, Rsil, Marcos, and others, in the ad-
vanced stage of low fevers, and in the circum-
stances just mentioned. It is still used, when
the skin is cool or the pulse is weak, and when
warm stimulating tonics are required. It is most
serviceable in the form of infusion, with aromatics
and tonics (F. 262. 416. 826.). AngtUca root
was recommended by Rril ; imperatoria root,
by HorpMANN ; and the root of eaiamiaarotnatieut
by HiLDSNRRANo. They are very rarely em-
ployed in this country, although they are of
service, particularly in the form of infusion, as
vehicles for other medicines, and on account of
their warm, diaphoretic, and stimulant eflTects.
They may be employed variously combined with
each other, or with camphor, tonics, &c. ; and
are indicated in the same circumstances as re-
quire the use of arnica, viz. in the low nervous
and pntro-adynamic states. Their infusions are
good vehicles for tonics, the chlorates, or alter-
ative salts. I have sometimes prescribed them
with chloric acid and chloric etner, or with the
chlorides of soda and potash.

584. e, CinchofM and other tonics have been
nraised by Hdzham, Lind, Langrisb, Grant,
WssTPDAL, Sims, Vallisnzrx, Casson, For-
DTCE, and most of the writers on fever during the
last century, and by many contemporary authors ;
whilst others have attributed more or less mis-
chief to their use. When the various forms of
tnohoid fevers, their complications, and the very
diiierent pathological states in the successive stages
of their course, are considered, this contrariety of
opinion is easily ezplained. When the nervous
stage has appeared, and when the putro-adynamic
state is pronounced, whether early in the disease,
as in tne putrid or septic variety, or in the ad-
vanced stages of the nervous and ezanthematous,
the preparations of cinchona, and the sulphate nf
juinino, are the best tonics that can be selected,
both for the permanence of their action, and for
their influence in arresting the disposition to col-
liquation that pervades the fluids nod soft solids I

of the frame. In the early states of the
and where the propriety of having reooane to
tonics is a matter of doubt, the injtuiam tf bark,
with the solution of the acetate of ammonia, aad
spirits of nitric ether, or th^decoctiom of cimckaaa,
with nitre and muriate of ammonia(F.437,438.),
will generally prove serviceable.

5&./. The propriety of having recoune to adds
in the states of low fever just alluded to has re-
cently been disputed ; and if the cffecu produced
by them on the blood be considered, as shown by
the experiments of Friend, Eller. GiAyiLLA,
Hallsr, &c., and as stated in the article Blood
($ 135, 136.)> rational doubuof their salotaiy
mflueoce may be entertained : yet tbeezpeiieoce
of most writers is in favour of them, particuiariy
in fevers of a low character. SPAVoaxazac,

HOXHAM, LaNORISH, WoOD, MVRSINNA, R<4W«

ley, Boybr, Raoemachbr, Schlecel, Hobv,
FoROYCE, Bang, Millar, Frave, Uvvelass,
&c. recommend the mineral acids, especially the
muriatic, in the circumstances mentioiied above.
From a careful observation of their eflfects m
many cases, I believe that they will prove bea^
ficiai m some cases, and injurious in others, ac*
cording to the period and sute of fever, and the
mode of prescribing them. If they are given
before the blood has become materially altered,
and the vital energy much ezhausted, b«t after
requisite vascular or alvine evacuations have
been carried sufliciently far — whilst the skia is
still warmer than natunl, and whilst the pube is
broad, open, and compressible, the mineral acids,
with tome infusions, will generally be serviceable.
In this state, the infusion or decoction of cinchona
may be given with muriatic acid and chloric
ether ; or the sulphate of quinine, with infoMoo
of roses and sulphuric acid, or also withsolphnnc
ether. When the prostration is coBsideraUe,
this latter may be the more energetic medicine. la
more doubtful cases, particularly when the heat
of surfttce is great, the infusion of ciochooa or of
valerian may be given with the nitrate of potash,
or with the nitrate of soda, a few drops of mine
acid, and the spirits of nitric ether ; and wWa
the skin is cooler, either of these infusioDa, or sons
one of the others already mentioned, may be pie-
scribed with equal paits of the nUra-mmriatiem^
and the tincture or serpentaria.

586. In the treatment of typhoid fevers it sbosld
never be forgotten that the state of the cimlatiag
fluids depends chiefly, if not entirely, upon that of
the orgsinic nervous influence, and that agents
which apparently deteriorate the blood snay y«i
be of use by administering to this influeocc.' The
carbonic acid gas was supposed by JAxacxs.
FoRTiER, and Pzrcival, to act as an energetic
tonic, when taken into the digestive canal ; aod
they, therefore, directed the use of those flrnds
which contain it most abundantly; and ewa
advised it to be thrown up the rectum. A siaihi
practice was lately recommended by Dr. Cla^^it,
with the view of supplying the blood with this
substance. But M. Cmohsl has shown the
inefficacy of the practice ($ 538.). The acids
which have appeared to me most servieeaUc in
the early period of the sdynaaic, nervonsw ot
putro-adynamic forms, are the muriatic, and tHe
pyroligneous acetic, particuiariy when given ia
the d^oction of bark (F. 388.), or in cither of
the warm stimnlant infiiaions

1032

FEVEB, TYPHOID— CwTAtNMsDiaitcsiy.

healthy discharge of the functions, as the muriate
of soda is, would have been more generally ma-
nifest in these diseases, if other substances, acting
somewhat similarly upon the blood and on the sys-
tem, had not been commonly employed in the treat-
ment of them. I have been led, by the antiseptic
prooerties of certain medicines, to have recourse,
intne latter stages of low fevers, to the most ener-
getic of them, particularly the nitrate of potash,
the chlorate of potash, the muriate of ammonia,
camphor, and the terebintbinates, cinchona, &c.
in various combinations, either with each other,
or with different stimulants and tonics, with the
view of exciting the nervous influence, of support-
ing the powers of life, and of counteracting the
changes^ frequently terroinatiog in a dissolution
of the vital crasis and cohesion of the fluids and
soft solids. But in fever^, which are charac-
terised by excessive action at the commence-
ment of excitement, And by extreme exhaustion,
loss of irritability, and depravation of .the fluids,
in the latter stages, a too early recourse to some
of these medicines may increase the morbid action,
and aggravate local determinations.; while a too
cautious reserve of them, either as to quantity or
as to the period of fever, may allow the diseased
changes to proceed without interruption to a fatal
issue. It is, therefore, imperatively required of
us, that we should determine, by attentive ob-
servation, both the exact period in which medi-
cines of this description should be commenced
with, and the particular substances that should
be first employed. As respects the kinds of fever
just alluded to, as wdl jas those forms which are
either nervous, or more uoiCormly putro-adynamic,
at earlier stages, we are ^at no loss for means,
which are both refrigerant , and antiseptic, and
which may be employed, ^om the commence-
ment, either when excitement is most excessive,
or when it is entirely absent if due care be taken
in the mode of prescribing them. By this early
attention, particularly in putro-adynamic and
inflammatory putrid fevers,io those means .which
may best preserve the fluids from the changes they
are apt to undergo, especially when these fevers
are left to themselves,oriojudiciouslv treated, the
advanced stages are rendered mucn more mild
and even manageable. The more refrigerant of
the substances* formerly termed antiseptics, as
nitrate of potash, nitrate of soda, muriate of am-
monia, &c., when duly administered in the early
course of fever, and combined with or followed
by those which are more stimulant and tonic, as
camphor,cinchona, chloiateof potash, amica,£cc.,
as exhaustion and signs of putro-adynamia ap-
pear, wiU generally prevent the more dangerous
changes in the Huids from taking place. The mu-
riau of amwumia is now seldom Jised internally,
although HorrMAMK, Jacob, Babcbijs&n, Lox-

SICKX, TiSSOT, WUUIOP, MOMRO, HlBSTBKL,

HiLLABT, M'Causlan^, Gmblin, and others,
have recommended it highly in putro-adynamic
feven. I have frequentfy employed it ; and Dr.
CoNWBLX. has found it of great service in the
fevers of India. Schmidt prefers it in such cases
as are attended by diarrhoea.

591. About the time when M. LABAaRAooK
discovered the ehloridn cf toda and of lime, cases
of fever of a putro-adynamic or malignant form
were fireqnenUy occurring in an institution to
irhich I aa conaoltiog phyncitn. I bad made

trial of various methods of treatment, bni fenad
camphor., in large doses, variously combined, and
aided by other means according to the pecu-
liarities of the case, the moit succetsful of aoy.
Shortly afterwards, ^M. Lababbaquk*s procMS
for preparing these chlorides was published at
Paris ; and as early as 1825 I procured them from
Mr. MoRsoN, for the use of this, and another in-
stitution, to which I was physician. I employed
them internally, in enemata, and externally, and
,as disinfectants; and the results were such as
have induced me to have recourse to them e%cr
since, in the various circumstances and di esm
in which I have recommended them in this
work. The ehUn-ids rf soda is a Tmluable medi-
cine in all the typhoid forms of fever, when judi-
ciously prescribed. It may be given early in the
putro^ynamic variety, when excitement ift ia»-
perfect or low, and the skin discoloured, or pelt-
chisB are appearing, and continued tbrongboat
the disease. But when vaAcular reactioa is con-
siderable, or local determination prominent, par-
ticularly in the oervou* and exantbematic varieties,
this substance should be withheld, antil thess
states are subdued, or about to lapse into the
nervous stage. — At first it ought to be prescribed
in small doses, so as not to offend the stomach —
in from ten to fifteen drops of the aolatioa, u
prepared by Labarraquk, every three or fear
nours, in camphor julap or in an aromatic water.
As the disease passes into a state of exhaustion or
of manifest putro-adynamia, or when there are a
lurid skin, low muttering delirium* stnpor, metco-
rismus, black sordes on the tongue, teeth, ^c,
the supine posture, inconsciou^ offensive evac«-
ations, petechias, blotches, a disposition to gan-
grene in parts pressed upon, coma, 5cc., it should
be given in largei doses, or more freqaently, aad
in tonic infusions or decoctions, or with camphor,
serpentana^ or other stimillants and tonics. I
have seen it productive of great benent in such
cases ; but it should be commenced before these
symptoms appear, and be persisted in* as iu good
effects aoe seldom manifest in less than three or
four days, or more ; and it should not sspplaat
the use of vrioe, opium, suitable nonrishmeat,
and other means which the stage of the disease
and peculiarities of the case may suggest. It
should also be frequently administered in enemata ;
and the surface of the boJv ought to be oftea
sponged with a stronger solution of it in warm
water, with the addition of camphor. M. Cao-
MBL has lately given the chloride of soda an
extensive trial ; and he states that it has peoved
more successful in low fevers than any other
means, when per^everingly employed. Dr.G ■ avo
has also recently employed it, and has Iband it
extremely serviceable. It acts, fiivt, on the
tissues with which it is brought in contact, ba a
gentle stimulant and antiseptic ; and is most prs-
bably partially decomposed in the digestive otgaas,
and reoiuced to the state of common salt. In tha
state it is carried into the circulaiioB, wbeie «
supplies the waste of this substance that has taken
place in the early stage of the disease.

592. The eklorid$ of time, in doses of one sr
two grains, may be also employed with ^reet ad-
vantage. When exhibited in solution, it will be
E referable to commence with half a grain every
our, or with a grain every two hours, gra-
dually increasing the quantity at tha

1034

FEVER, TYPHOID — CebtainMkwcinm IN.

Bach actually appears in some measure to have
been the case. The truth, however, seems to
be, that whilst pathologists have lately been
occupied exclusively with the living solids, Dr.
r TEV£NS has concerned himself only with the
blood, and kept too much out of view the influ-
ence of life, especially as manifested in the or-
ganic nervous system, upon both the circulating
and secret fluids.

699. As far as my own observations enable me
to form an opinion as to the respective merits of
these acids, and of the alkaline subcarbonates
and salts, I conclude — 1st, That ih^ae'uU may be
of service early in fever, whilst vascular excite*
ment is considerable, although vital power may
be weak ; that they seldom will be injurious in
this period, as long as the skin continues warmer
than natural, and the blood preserves its colour;
and that but little confidence should be placed
in them when the surface is at, or below, the
natural temperature, or materially discoloured,
unless they be conjoined with substances calcu-
lated to excite the powers of life. 2d, That the
smbearbonates of soda and potash, the solution of
chlorine, and the chlorides, are preferable in the
middle and latter stages, more especially when
the blood appears morbid, the skin discoloured,
and the excretions offensive ; but that the sub-
carbonates should not be trusted to in the last
stages of typhoid fevers, unless conjoined with
substances calculated to support the vital en-
ergies; and that, at this period, chlorine, the
chlorates t and chloridesf should be preferred, as
being more tonic, stimulant, ana antiseptic
tb^n the carbonates. 3d, That the sulphate of
toaa, the phosphate of soda, and the sulphate of
magnesia, are severally of service in the stage of
excitement, when they may be given, at first so
as to act gently on the bowels, and afterwards in
small doses, as refrigerants, or alteratives ; and
that the muriate of potash, the titrates, and ace-
tates may likewise be employed with the latter
intentions. And, 4ih, That circumstances may
occur, in which it will be advantageous to exhibit
the neutral salts with either an acid or an alkali,
as the muriate of soda ; with a vegetable acid,
as prescribed by Morgan ; or with soda, as ad-
vised by Stevens ; or to prescribe saline sub-
stances with an excess of either of their consti-
tuents, as the muriates with an excess of acid or
of alkali.

597. i. Opium, 5fe. — Much difference of opinion
has existed as to the propriety of giving opium in
tvphoid fevers. But when we find Sydenham,

PoLIDOni, ROLRNCK, ScHLEGEL, VaN HoVEN,

and imperfectiT renewed air: the conttant evrnporaUon
from the too fireauentiy washed deckt; water kept in
wooden caaki until it became blackish, inky, stinking, and
nauseoudy putrid ; were causes often in protractetl and
■imultaneous operation. I have never been in a ship in
any other capacity than ai a passenger ; but some of my
voyages have been long, and have affbrded mc occasions
of witnetting, even at the commencement of the nineteenth
century, the existence of some of these causes. For
many years matters have been altered, especially in the
navy. The mutiny at the Nore ; the advance of know,
ledge ; the stricter attention to the supply, preparation,
and qualitv of the provisions ; the preservation of water
in iron tanks, and some other subordinate circumstances ;
bare done more to banish putrid fevers and scurvy fVora
our fleets, than the use of citric acid^or anv other anti-
scorbutic or antiseptic ; and 1 have no doubt that the
Pilf'^?\*'**.'i °C '***•* causes, and the general adoption of
i!ilJi}^^^*'J'V^ ''»""<* *he most certain means of
prevenuog aad of caring these dlscasei.

Home, Horn, Marcus, Latkam, Stoccs,
Graves, &c. favourable to the practice, the
grounds of diswnt from it ought to be carefully
examined. There are circum»tances and states
of fever which forbid its use, but there are others
which as imperatively require it ; and 1 believe
that the objectors err grievously in not dkcriau-
nating between them, and in not studying ether
the conditions which contra-indicate ii, or the
modes of exhibiting it in the cases that would be
benefited by it. Syoenram considered that it
prevented coma, or stupor, when given after vas*
cular and alvine evacuations had teen judkiottFly
employed. OoBET.n7s, Gilchrist, Home, and
Graves combined it with antimonials ; ajMi the
propriety of the practice cannot be doubted, in
the circumstances in which they employed it.
In the present day, the indications for the exhi-
bition of opiates have been so ably stated by two
accomplished physicians — Dr. Latham and Dr.
VV. Stokes — that whatever 1 may advance as to
this subject must in great mea<vure be an echo of
their observations. When the disorder of the
sensorium outruns the other symptoms ; when by
vensBsection or topical blecxling, or by alTins
evacuations and refrigerants, the general aad
local symptoms are relieved, but the delirium
still continues ; when to this state are a fdcd,
tremors, subsultus tendinum, and unre^raioed
evacuations ; when there has been at first high
vascular excitement, and large evacuations have
been required to guard the brain or other organs
from mischief, and wild delirium has followed ;
if the patient has previously been in a delicate
or nervous state ; if he has been addicted to aa
excessive use of spirituous or vinous liqnors, par-
ticularly the former; if the habits of the patient
and his occupations have been such as to inordi-
nately excite and exhaust the sensorium ; or if
the anxieties, the toils, or the debancherics ei
life have previously injured the health, and meca
especially the state of nervous energy ; — in these
several circumstances, should opiates be revolted
to, in the advanced propess of typhoid fcveci,
and of synochoid fever tnat has passed into the
nervous or typhoid state. On most of these. Dr.
Latbam has inttsted with great preciston aad
force ; and I entirely subscribe to the valoe ai
his remarks. Dr. Stokes remarks, that three
circumstances call for the use of opiom in fever :
1st, Where there is persistent watchfulness; 2d,
Where an inflammatory condition of the brain has
existed, and been subdued, but delirium or other
nervous symptoms still remain ; 3d, Where aa
excited state of the sensorium exists withont beat
of scalp, or remarkable throbbing of the artencs
of the head ; and to these I may add a fcwith.
Where there are much relaxation of the boweh,
unrestrained evacuations, tremors, watchfnli
or delirium, or subsultus tendinum.

698. The nude of exhibiting opiates b
times of great importance. In many
or two grains of solid opium may be given, either
alone, or with camphor and nitrate of potash.
The combination with camphor is to be prefcrrvd,
when there b much adynamht, and no inftaauna-
tory determination to the brain. W ben the bowels
are very remarkably disordered, ipecacuanha nay
be added to these. The acetate of mutrpkitie n
often superior to pure opium, when given in d»«a
of from a quarter to half a grain« with can^hor.

FEVER, TYPHOID. — BiBUoauiPHY ikd RsrEaKxcEs.

1038

seoleric glands, are not unusual, particularly
when the patient has been prematurely exposed
to changes of weather, to irregularities of diet,
&c., and when the treatment has been injudicious,
during early convalescence, or too soon reiin-
(juished. In all the varieties, the riskof these affec-
tions is increased by the complications which die
fever presented ; the organ which was prominently
deranged remaining longer weak, or more suscepti-
ble, than others, of being disordered by excitation,
or by injurious agents. Therefore, in cases where
the predominant disorder has been expressed on
the encephalon, particular care should be taken
to preserve the sensorial functions from early ex-
citement or irritation, or undue exercise. W here
the respiratory organs have been much affected,
premature exposure to cold, or to changes of tem-
perature, &c. ought to be guarded against; and
where the digestive organs have manifested the
onus of morbid action, the return to a full or
stimulating diet should be long delayed, and the
most digestible food only ought to be taken, and
in moderate quantity. (See further on this sub-
ject, § 167—170. ; and art. Debilitt, $ 36 — 46.)

BiBLioa AND RarBB. — Hippocratei, De Mortrft, I. i.
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Rat Med. vol. iL p. 2u6., et vol iii p. »«.- StMss, Ob.
servat &c. p. 187. — IV. GnuU, Oba. on the FestilcatMl
Fever, ftc. 8va Lood. 1779. — Home, Med. Fac<a and
Observ. pi 30 — GUekrisL in Ed. Med. Comment voL xl
pi 20.). ; and Ed. Med. EMays, ftr. voL iv. pi 2*1, aad
VOL vi. p. 2& — J. MiUer, On tj)e PrevaU. Dm. of Great
Britain. Lond. 1780L— J. Roberts, Observ. on Frtcn^
8va London, 1781. — JST. GtamneUi, Mem. ddla Feb.
Maligna del Real Convitto de DooaelU di Nap. deiT
Anno 1780, 8v& Napi 1781 — F. Mdmum, Uiquiwj mto
the Source fh>m whifh Scurvy and Putrid Feven ansc»*€
8vo. Lond. 1782.— /f^ysAom, On Jail Fever, flva Load.
1788.; et in Ed. Med. Comment vol viO. p. I9BL —
De tiaen. Eat Med. P. iii p. 45., viU. c X, x. c 5^ —
Bert/nghien, Sulla Febre dette Putrida. Lucca, ITbl. —
Mertens, Beobacht. der Faulen Fieb. Ac p. fla — R. Ro^
bertsom, Obaerv. on tbe Jatl, Honital, or Ship Fcveei
Lond. i78a — ibiiw. in AcU Regit Soc. Med. Uavn. toL
L — iii. passim. — Banau, Observat sur differ. Moy«M
propres i corabattre lea Fiivrea Putridce ct Maltgoc^
Amst 1784.— CDrdbon, Inquiry into the Nacuiv and
Cause of Fever. Edin. 1784. — P. KenrntAn, Aoumnt of a
CoiiUg. Fever at Aylesbury, 178&— T\Mmg, On CbePrto.
cipal Diaeasesof Dublin, u.\it5 et passim. ~^ J. Mmmter,
in Med. l^iisact voL ill p. 3ik — D. CamspbeU, MM,
Observat on the Tvphus, *c. 8va Lancaster, ITKl —
C. Straeir, Obaerv. Med. de Morbo cum Petechtia, *ci tvo.
Carotor. 178a — M. iVaU, Cbn. Observat oo the Uw of
Opium iu Low Fevers, 8va Oxt 1786— Oaoifcie 4e
MofUamjr, Traits de la FT^vre Maligne Simple, Be Pans
n«1, — Forestter, In Joum. de MM. I70& — 5«isrf^/br<
in Med. Observat and Inquiries, vol. Iv. art 24v»«l RoA-
4d, On Continued Fever, 8va Olasg. 17IHL — Jt. Jbmi,
An Inquiry into the Nature and Cut* of Newoua Fc*et,
8vo. Lond. 17bft— .SM/WaiMS, DcacrlBCio FsAmiam Ma^
lig. ftc. Munster, 179L — Caititen, io N. AcU Kcf. Sac
Med. Haun. voL iv. p. 40ri — Van Uotem, OcscBtrhte
einet Epid. Flebers, Ac p. 43. — IT. ifcwsrsoft, InquirT inc*
tbe Nature and Cauatt of Sickness in Sbipa of W«r.
Lond. 1792. —5. Vera, De Febre Nosocoouali. MallaoA
1798 —J. Hatlidap, A short Account of tbe Putrid
Fever, aec 8va Lond. 179d. — CaUm^ Works, by

som, vol. L p. 540l ft nassnHL— > Darwm^ Zoowomia, •«! H
p. 455. — Burserias. Institut Med. Pract eoL It. cafk ML
itc — Ferriar, Med. Htst, and ReflexiODa, voL it |ii 177.
^S.a Foget, HandU der Prak. Aiaiitlwkatnacli. K u.
8Ji — I*'. Bemtds, Vorlcs uebcr Prakt AmtawimaasEk
ii. s. 191 etseq.^B Rusk, Inquinca, Brc voL L pt Ot
— Portal, Mem. sur idosieurs HaL t v. > t. «t ai* ^
J. P. Frank, De Curaad. Horn. Moftii^ 8va vsl t
Clasi. L Ord. L pa«»tM.*X O, Rsokier,

E

1040

FIBROUS TISSUE — Morbid Stati« of.

epU. tjf Paris in 1SS30 — Neumann, Joum. des Progrit
(fe* Sc M^ L ▼■ IK 111. {Of uleeratian qf the intesl. in
typhoid fever.)— Vacquii. R6vue Med. t. iv. Is25, p. 475. ;
et Journ. Comp. det 2sc. Bled, for July, Aug. and Nov.
\9ia. {Of ie9ion$ qf abdom, viMoera in putrid fevers.) —
Lemret, Sur le Uothinent^rite Epidcinique, in Archives
G^ndr. de MM. t. xviii. ui 151. 453. — AA Gendron, in
Ibid, t XX. p. 127. SaS. 361. 599. — Ma^r, In IlMd. t xix.
p^ 611. — ilrdk, in Ibid. voi. I. p. 13)J. — Bretonnean, in
Ibid. L xxi. p. 57. — LoKM, in Journ. Hcbdom. de M#d.
t i. \i. 578. ~ Lobttein, Repert G^ncr. d' Anst ct Phjri.
t. li. P.S42.— ila«or/. Rev. of his Work in Med. and
Phya. Joum. vol. xltiL p. 68. 155. — Omodei, hit Worli
rev. in Joum. Univera. de« Sc MM. t xxiiL pi 69. —
Tommatini^ in Archives G^n. de MM. t vL n. 186. ; and
Med. Gaxette, vol. v. p. 521). — J. Bume, A Practical
Treatise on the Typhus or Adynamic Fever, 8vo. Lond.
182& — F. A. Popken, Hist Epid. Malig. Anno 1836 Fe.
vers Observatv. Brem. 18S7. — Atiaon, in Lancet, No.
337. p. 635. — Baple, lUvue M«d. t ii. !»», ii.8a iPutro-
adffnamic fever -^experiment* with the blood.) -^ Af. Good,

Study or Medicine, by Cooper, voL iL paiHrn Bright,

Reports of Medical Cases, Ac. 4ta Lond. 1887, pc 178. et

SisHm.^ W. Stoker, PathoL Observat. parts i. IL and iil.
n Continoed Fever, Ac 8va DubL 18^ 3a ^P. C. A,
Louia, Kecherches sur la Maladie connue sous le* Noms
de Oaatro.«nt#rit£, Fidvre Putride, Ty]>hoide, Ac 8 torn.
8va Paris, 1829.— 5. Smith, Treatise on Fever, 8va.
London, ISaa — A. Tvoeedie, Clinical lllust. of Fever,
8vo. 1830 i and Cyclopi of Pract Med. vol. it. art Fever.

— Af. E. A. Neumann, Handb. der Medicinischen Cli-
■ique, b iii. Abth. i.^«tlm. — IV. St vnu, Observ. on
the Healthy and Dis. Prop, of the Blood. 8va Lood. 18^
p. 16S. — Aiiiony in Ed. Meil. and Surg. Joum. vol. xxviii.
p. 837. i and Outlines of Pathology, 8va Ed. 18S4, p. SCiS.
et pauim. — R. MiiUtr, Lectures on the Contagious Ty.

ghus £pi<l. in Glasgow, &c. in the Years 18j1 and 1832,
va Olasg. 18:i3. — ElUotaon, in Medical Gazette, vol. x.
p. 145. i and in Lancet, vol xvii. p. 2ufi. 463. — If. P.
Dewees, Practice of Physic, 8va Philad. vol i. — Craigie,
Clinical Reports on Fever, Edin. Med. and Surg. Joum.
vol xl . p. 857. — I^*Pj On the Use of Wine in Fevers,
Ibid. VOL xxxilL p. 8SL — Groees, Lectures, in Med. and
Surg. Joura. voL iiL iv. vi. and vii. passim. — F. Booit,
Memoir of the Life and Medical Opinions of J. Amu
ttroHg, and an Inquiry into the Facta connected with
the Forms of Fever attributed to Malaria, ftc 8va 8 vols.
Lond 1833^91 — A. F. Chomel^ I>e70ns de Clinique M^.
dtcale, ftc. par Genest, Kidvre Typhoide, 8va Paris, 1814.

— fV. Stokes, in Lond. Med. and .surg. Journ. vol. vL et viL

fassim. — ii Grapes, in Ibid. voL vL et vii. passim ; and In
>ublin Joura. of Med and Chexn. Science, vol. viii. p. 136.
— J. H. Peebles^ On Petechial Fevers and Petechial Erun.
tions, Edin. Med. and Surg. Joum. vol. xliv. p. 356. — H.
M^Cormac, An Exposition of the Nature, Treatment, and
Prevention of Continued Fever, 8va Loud. 18:J5.

Fever, Puerperal ; see Puerperal Diseases.
Fever, Scarlet; see Scarlatina.
Fever, Yellow ; see Pestilences.

FIBROUS TISSUE — Alterations of the.
Classip. — Special Pathology — Morbid
Structures.
\. A, The Fibrous System consists — 1st. Of
fibrous membranes — membransE Jibroset — as the
periosteum, the cerebral and spmal dura mater,
the fibrous capsules, the sheaths of tendons, the
aponeurotic expansions, the sclerotica, the capsule
of the corpora cavernosa penis and of the cli-
toris, &c., the tunica albuginea, and the mem-
branes proper to the spleen and kidneys ; — 2dly,
Ofjibrous cords, in which the fibres are formed
into fasciculi — organa fibrosa faseicularia. —
Several of the former should be viewed as com-
pound structures ; as the dura mater, the tunica
albuginea, the fibro-synovial sheaths, &c. ; but
the fibrous, tissue constitutes their chief basis.
With the exception of the fibrous membranes of
a few glandular organs, it is easy to demonstrate
that all the fibrous structures are connected to-
gether, and that the periosteum is the centre and
basis of connection. This tissue consists of
whitish, or grayish, shining, satiny, fibres of
great fineness and strength. These are inter-
woven in various directions, in the first division
of this tissue; and are placed parallel and very

close to each other, in the second. Their cohr
sion is very great. Hence the fibrous tissue is the
strongest in the body. Although it must be
inferred to possess vessels and nerves, yet neither
have been actually traced into it. That it is
endowed with vital properties cannot be dc*
nied ; but it manifests litem obscurely in besltb,
but often very remarkably in the coum, or is a
consequence, of certain diseases. Its pkyscal
properties are most perfect when the povcn of
life are energetic, and are much impured when
these are depressed or exhausted. During pie-
longed debility, and in cases of extreire vital es«
haustion, the cohesion of this tiese is dimiBished,
and laceration or extension of it takes place »tih
less violence. During constitutional disonler. or
contamination of the system by specific maUdiw,
and in the scrofulous or gouty aiathesb, it ofica
becomes the seat of morbid action, aiid tbca
evinces vital properties in a most evideat
manner. Injunes and irritations of this lii»M,
particularly when the vital functions are imjiaind
or disordered, are often the source of the moA
violent and dangerous affections. — ^Tbe fibroos
tissue, however, is, with the exception of the peri-
osteum and the capsules of joints, not very prone
to disease ; and, even when these are ailecteJ, a
scrofulous or syphilitic tain* has been the caoae.

2. B, Leaving out of consideration the con-
genital alterations of this tissue, I will bnefly
notice those changes of it which are osaallv the
result of disease. — a. Fibroos parts are seldon
ffcinner than natural, or atrophica. — b, Tkieinip^
is much more frequent, and is evidently the renlt
of slow inflammatory action. — c. They may
also be expanded or distended by morbidly ib>
creased bulk of the organs which they envelope.
We occasionally meet with this change io ih<
fibrous coverings of the spleen, kidneys, irticalar
capsules, &c. When the expansioo arises from
the accumulation of fluid, it is generally attt oded
with thinninp ; and then, in some cases, the dii-
tension is chiefly in one part only, in the form of
a i*ae, or is irregularly elongated. But the ei«
pansion mav also be conjoined with thickenisf,
as when it has proceeded from the changes oos*
sequent upon an inflammatory state of the coo-
tained parts, in which the fibrous envelope iistlf
had participated, as in diseases of tlie spleen. Ace.
— d. The articular ligaments and capsu'es, how-
ever, are frequently elongated and expandsil
without any internal change, and merely (nm
diminished tone or vital cohesion — in some ca^es
so much so, as to give rise to dislocaUonc. — «.
Fibrous parts may be also too •frort or too Nerrov.
Morbid contractions are observed in tendons tad
ligaments, and are generally the resvlt of iaflasH
matory irritation consequent upon great eiteasoa,
cramp, &c. — J\ The changes of colemr net with
in this structure are generally assedaied wicb
change of organisation, excepting in jaundice.
The morbid colours most frequently i^mmed. tie
various shades of yellow, seldom brown, and
rarely black, as in melanosis.

3. C. The eontiuuity of this straetnre u icme-
times destroyed; but generally from wosodi*
sudden extension, as in oblocations, and external
violence of any kind. Continuity may UkewiN
be destroyed by purulent collections, by tnmoois*
and various morbid depositions between its films ;
but there is here, with a fisw cxccpttoas, lathsr

1042

FIBROUS TISSUE— MoRBtD Sr^nt op.

gelatioouf fluid, or ichonras pus. The internal
articular ligaments, the cartilaginous coverin|;8 of
the bones, and the synovial membrane are entirely
or partially destroyed. The bones either prima-
rily or secondarily uTected are, in a greater or less
d^ree, inflamed, loftened, swollen, and become,
internally carious ; or they are but little swollen,
tolerably hard, yet superficially eroded, or de-
stroyed by caries. Owmg to this carious state of
the heads of the bones, whether attended with
swelling or not, dislocation takes place. The ar-
ticular cavity contains at first a laige ouantity of
thickish, albuminous-like, often a pale reddish
synovia ; and, in Ister stages of the disease, if the
join( be more or lees destroyed by suppuration, a
thin, frequently foul-smelhng, pus, mixed with
blood, cartilage, and cartila^nousfra^ents, fiUup
entirely or partially the cavity of the joint (Orro^.
9. 6, OuifieatMn is frequently observed m
the fibrous structure, particularly in the ligaments
and dura mater, and less frequently in i^e peri-
osteum, the tendons, the fibrous membrane of the
spleen ; and but rarely in the other parts of this
^tem. It is to be viewed as a consequence ge-
nerally of slow inflammation, and occurs in diirer-
ent forms : as in some eases only the fibro-carti-
laginous base of bone is deposited in plates or
roundish-flat prominences ; more frequently phos-
phate of lime is secreted either in distinct spots or
small masses surrounded by a circle or plexus of
vessels, or in the form of splinters, or, lastly, in
larger masses, involving the fibrous tissue equally
throughout. If the articular ligaments undergo
this change, they are then usually Aertened,
occasioning ttiffntu of the joint, or more or less
•ooBplete aitehylent, according to the extent of
the ossification. An §arthy mau, less resembling
teielihan chalk or gypsum, consisting principally
of the urate of soda — gomty tirphus — is often de-
posited in the ligaments, in the neighbouring apo-
neurosis, and periosteum of one or several joints, in
gouty persons, at first in a soft state, but gradu-
ally becoming hard, and often in large ouantity.

9. C. Sphaceiaticn, or gan^r€n§, rarely occurs
as a termination of inflammation. It is met with
primarily in those fibrous parts which are well
supplied with blood-vessels, vis. the periosteum,
dura mater, fibrous envelope of the spleen, &c. In
the tendons, aponeurosis, and articular ligaments,
it very rarely occurs primarily, excepting when
they are exposed to the air by wounds or ulcers, in
which case they often are destroyed and exfoliate
together with the surface of the bones and carti-
lages. Fibrous structures, however, are often
attacked with mortifications in conjunction with,
or in consequence of, gangrene of the adjoining
parts. Antnrax sometimes extends to and de-
stroys fibrous tissues; and when mortification
attacks a limb, the articular ligaments participate
io entirely, that a spontaneous separation often
takes place at a joint.

10. D, Adventitiow produetiom are but rarely
observed in the fibrous system. — a. Enctitt^
tumtnirt seldom form in it, if we except those
bursal tumours which occur on the tendinous
sheaths and articular capsules, and partly between
the tendinous fibres of tne aponeurosis, and espe-
cially on the elbow-joint and knee-cap, and which
have their origin in the mucous bags placed in
these situations. — 6. Tubercular formations are
equally rare in fibrous parts. Scrofulous deposits |

are, however, occasioatUy feud ia tha dan
mater and periosteum. — c. Sat cm— reas and
fungous tumauTi are more frequent in ifatpos
structures, particularly in the periostevm. Fon-
gOQs growths on the tendons are more rare, as are
the sarcomatous swellings upon tho astiailar liga*
ments. — d. Ctnrhuuma, or esiiotr, does not occur
primarily in this system, but attacks it secoadarily
equally with other parts.

11. £. The c*a^ss obmrvod w tka nnrtrefi eT
cavities formed by fibrous membranes are fie*
<|uently marked and important. Morbid collec-
tions, as a watery serum, a gelatinoos fluid, pwi-
form matter, blood, &c., are not iuimuosjiUy
found in the aponeurotic sheathe iuiiiniiiiliny or
sepaiating the muscles in the cavities of joun.
The tynovia also varies exceedingly ;
it is deficientin quantity, so much ao as to
stiflfness, creaking or a peculiar noire of
More commonly it is in unusual quantity, par-
ticularly in all inflammatoiy states of the sy-
novial membrane, but occasionaUy wtthont aay
distinct inflammation, as in the knee-joint, ia
rheumatic, rickety, or syphilitie eubjocte. Scree-
times the effusioo exists to such a dema tkai the
joint is more or less swollen, or eveo (Selocated, or
Its UM prevented. This local state of dtsenre has
usually been called dropsy tf a Joimt, kydrwps
artieularum, hydrarthus, mstieoria. The synonais
occasionally turbid, reddish, watery, aHwiminmn,
gelatinous, £cc., as well as increased in quantity.

12. F. Substances orfutnliltoMS Cot JkesitHotiM
have occasionally been fiMind in the cavions el
joints — a. Blood is rarely oteenred; kot — I.
Pus occurs more frequently, it either having here
produced vrithin the joint itrelf, lion an acute
mflammation of the synovial membrnoe, and ef
the bony cartilages and ligaments fomnag Che
joint, or having made its way into the cavity (loa
without. I have, however, seen cases where ns
has rapidly collected in one or more joints aner
phlebitis, or after the absorption of this flmd 6«a
other and distant parts. It has been snppeeed,
that the pus, in such cases, has been aetitud or
depositea in the cavity of the joint, .
passed into the circulation from the
where it was primarily formed, withovt
inflammation of the joint itself. But the
of this morbid secretion in the blood m^ hate
excited inflammatory action of the sjnoiial mon
brane, rapidly passing into the suppurative stage.
In most of such cases, the parts containing the pre
have been found eroded, and have prerented other
changes usually consequent upon inflarematiea.
even when vascular injection has been ahseac.
The question is, whether such changes have cakea
place previously or subsequently to the setietioa
of pus in the joint 1 That the more advanced of
them are consequent upon the production of this
fluid may be admitted ; but that iuAanunatoiy ia>
jectton and action preceded, and quickly nredaoed.
the purulent collection, seems most prooable.

13.e. Cartilaginous opwcmrtiom, which have gwwa
from the inner or expanded sur&ce of tho synovial
membrane, by necked appeodagre, and been n^
sequently broken ofif, are occasionally ftinnd ia
the cavitire of joints, either entirely loose, «r
attached to them by thin threads. They are at
first soft, then mostly cartilaginous, frmttliBtsff
partly cartilaginous and bony ; more rarely alio-
gether bone ; usually rounded, bnt

as it has

1044

FLATULENCY— Cavsu.

it tends either to induce or to aj|(gTa?ate, — A,
Primaru or idiopathic flatulmiey oftht gtomaeh b
met with cbiefiy when the stomach is emptjTt or
after the process of digesdon in this ▼iscns is com*
pleted ; and is seldom associated either with im-

f aired appetite, or diminished jpowerB of digestion,
t is most troublesome in the morning before
breakfast, or during long fasting; or when an
unusually protracted period has dapsed between
meaU. in such cases, the flatus often rises into
the oesophagus, producing much uneasiness and
often distress, owing to its excretion being pre*
vented by the spasmodic constriction of the upper
part of tnis tube. In swallowing also the more
solid ingesta, the bolus meets the flatus in the
oesophagus, and is interrupted or impeded in its
passage to the stomach. In such circumstances,
A conflict sometimes arises between the descend-
ing ineesta and the ascending flatus, and a ym
painful tjuumodie dytphagia is thereby induced,
until the eructation of air gives relief and allows
the transit of the bolus into the stomach. In this
form of the disorder, the air most probably is ex«
haled, at least in great part, from the mtemal
surface of the organ. In other respects the pa»
tient^s health is not deranged, and the functions of
^ligestion, defecation,, and assimilation are regu-
larlv and perfectly performed. In other instances,
slight defect of organic nervous power, owing to
sexual indulgences, or to sfedentairy occupations,
is the only ^tholoeical state to which this affec-
tion can be imputed.

5. B, The remote cauMi'of flatulency ^re the
nerv^Mis and hypochondriacal temperaments ; and
All the Influences and habits whicn deprenor ex-
haust thi energy of the organic nervous system,
•or lower the tone of the digestive canal, especially
-sedentary oecnpations ;. excessive menUl exertion
and anxie^ ; venereal indulgences ; intemperance
in eating aod dtialdng ; the inj^tion of cold fluids^
particularly wbea the body is overheated; ex-
posure to a co.^<l tVf <>' ^ ^^^ ^° "^°7 ^^y» whilst
the stomach is c^°^P^» ^^ whilst fasting; neglect
> of the functions l>«^ bowels ; the use of bulky
*? ftatulent vegeta'^^ ?' <>f fr«»ts ?«>■• «o un-
uergofermentaUon. i >»lpf »^ly cucumbers, melons,
salads, ficc. : irrtisul* ^* ^f ^^^f ^^^. previous
•-* V* iuease. — *«*t eaUng. and imperfect
•^ !Sf ?!n ^ K^^ to flttule.ey..1^ the

of the ekomaek
is almost a con-

accompanies general dsfciiity.— (O "» aiso

and in the numerous forms of hytierta. in i a»
SVthe flatus often rise, into the <^^?^^^ i "d
whilst the reaction of the coats of the stomach
propels H into this tube, spasmodic constnction of

time; and causes a distressing feeUng of sufloca.
Sr. &c.^(e) Flatulency- an •!«?•» eoiui^
symptom o( inflammatory and «-fJ«»^/f*?«^'
ontrSomach. - (/) 1 1 generally nshers in an
attikof^^ut ,-an3 (g) it both precedes and aU
t^i^aJmatUaffectione.-'ih) It « a common
phenomenon of il the funcUonal, inflammatory,
and organic <fifsaj«f of the liver: and is very cha-
racteristic of accumulations of bile in (be gall

ducU and gall-bladder ; and of tsf^sr eftUhUimy
organe, — (i) It often, also, occurs in Jhtfmmetimmi
and inftummatoTjf dieordert ef Okie isaieli, and
sometimes in affections of the other ■**^"''"'
viscera. — (fc) It not infreqvently evca accom-
panies tkremie dieeaeee of the bram ;-^ (I) and the
aifynamie and maiignantforwu ef fwotr,

7. D.ThepikMMiMM uaoaily chandaklie eT
flatulency vary somewhat with the diMMCs sf
which it is a symptom. In the coozae of diges-
tion, flatus escapes with or wilhovt aeise* sad
often with an acid, bitter, mdoroesy or foetid
odour. Sometiines it is without either odour or
taste ; and at other times it retains the omeD aed
flavour of the ingesta. When constiictiea of the
caidia, or of the lower part of the meephafes,
prevents eructatione, or when the ceale of the
stomach are so weakened, or so oiver-dirtcaded,
as to be incapable of reacting sefllideetly, lei^
fomtic fulness of the epigastrium a»d hypochee
dria, with a painful sense of disteasioo, or u
gastrodyniar treqeent respiratioQr and beefy
or oppression in the lower peits of the
generally complained of* If erectar*
especialWfbr some heuie alter e foil
or rancid matters, or portions of undigested feed,
are frequently regurgitated at the

Cardialgia is then o.ft^n aasocmted with thseernp-
tom. or precedes tho eructations. Wbea lata-
lenoe precedes or atteA^a organic lemstts of the
stomiach, er obatmctions* of the fiver or paacreas,
the symptoms caused by t *wl aasodatsa witk, it
are often severe, Disorde.*e<i »:tioo of the
anxiety, hiccup, gastrodynL^ &c- being not
commonly oboervra.

8. £. The diaordert indncea' er
flatulence of the stomach, ftre va noes ie
habits and constitntioM. When the
much distended by tatus. and es^iedall^
the oesophagus admits and retains ibr a ^
air in its lower part» the feeling ok' "^
dull pain, and the oth^ ranptoms just
are much increased. The aflfiona o^ the
phraffm are impeded, and the regnlaiiiyef ^
circulation through the carities of the hettxt is in-
terrupted by the pressure of the uiii dietiaded
organs. Hence the intermissions and tRegolariiies
of the *|ralse, the sense of annety. fletteiiags,
feeling of suflbcation, and palpitatie *

usorjated with, or consequent upon,
the
U\

femues, various symptomatic disorders,

those now sUted to ansa directly ftem this

are often experienced. The modes of dres^

ticularly the very strait comets used by this sex,

aggravate the disorders cooseoueat leftm ftattUeat

distension.— ^vere pains of the left ode, *«*«^

tions of the lungs, or of the brain,

convulsions, faintness, vertigo, and h

malous complaints, often thus originate, aotoaly

in females, but also in males, espedaUy thoea

who are sedentary, hypochondriacal, aad deUhp

Uted. In tWs class off paisoos more paiticaiariy.

the pressure of the distended stomack pfcveaas

the due action of the bowels, and either impedes

or interrupts tho paMga of fmcal masi«a 6em

i digestive organs. Whtttt attribvlm imamkme
flatulence of the stomach, and, I believe, veiy
stly. In delicate, nervous, and hystmal

1046

TLATULENC Y — Thbathwit.

ation of air in serous caTioes is never, I believe,
observed, excepting as a result of inflammatory
action in some part of their surface that has given \
rise to a secretion of a sero-albuminous fluid ; and
it is not improbable that the air is produced by
the partial decomfxwition of the albuminous por-
tion of the secretion. These occurrences are
more particularly noticed in other places.

15. V. Treatment. — A. In the primary ttateg
of the disorder, attention to diet, and gentle toniet,
vnth mild aperienu, will generally restore the
healthy functions of the stomach and intestines
in a sliort time. If much distress be experienced
from the retention of the flatus, the aadition of
a tarminatioB spirit or oil, as those of anise-seed,
pimenta, nutmeg, or cardamoms, to the above, will
give relief; but the frequent use of heating spices
may be injurious in other circumstances, particu-
larly if the complaint depend upon chronic in-
flammatory action of the digestive mucous sur&ce,
as is frequently the case. The practice of reject-
ing the air, either upwards or downwards, should
not be indulged in« for, although momentary
relief is thereby obtained, an increased disposition
to quorate it is produced, and the evil augmented.
It IS only when air collects to the extent of pro-
ducing much disorder, that its expulsion should
be procured^ — la this case, any of the numerous
carminatives in common use may be given, if
they be not contra-indicated by the presence of
inflammation.. ] n some such instances, however,
the more energetic of them may be exhibited with
advantage in enemata. The extract of ncs, or any
of the tiaential oik, mavbe thus prescribed. —
HuFELAND and othea advise warm dry armnatie
epitkemt to be applied over the abdomen in these
cases ; and Thunbeho recommends the aytput
oi< to be rubbed upon this part, or to be given
internally, when the state of the circulation and
of the animal heat indicates the propriety of ex-
hibiting carminatives. — Charcoal, as suggested by
J. P. Frank, and snagnesia, if not the most effi-
cacious, are among the safest means that can be
used. The same may be said of camphor, and
the terebinthinatei, and the plants which owe
their efficacy to either of these principles. The
gubnitrate of bifm^h is often of great service,
particularly when conjoined with small doses of
ipecacuanha and hyoscyamus.

16. Whenever flatulency oi the stomach or
bowels is unconnected with inflammatory action-^
when the pulse is softer weak, or not increased in
frequency, when the abdomen and hrpochondria
are not painful on preasure, when tne tongue is
moist, or pale, and not red at its edges, and when |
there is no unusual thirst*- then carminatives, '
antispasinodics, stimulants, and tonics, combined
with one anoUier, and with absorbenU and ape- '
rients, will give relief j and they may be either
given by the mouth, or administered in enemata.

But even in these cases, our chief dependence ;

should be placed upon suitable tonics, with the ,
use of the cold salt-water bath, and attention to
the secretions and excretions, for the cure of the
complaint. — If an attentive view of the case
suggesto the existence of in6ammatory irritation
in any part of the alimentary canal, the nitrats I
of* potaih, and the mbearbonate of toda or of
potash, with demuicmU or emoUienti, and weak j
camphor mixture, will be most approoiiate. In
these cases, external dsHusttiw*, gentle frictions

of the abdominal gaihet with warn mft^s
linimenU, as recommended by Wbttt, the tppl^
cation of hot terebinthinale embrocatisas or epi-
thems, or fomentations as used by Daxww, will
be of great service. When the fompJaiai is ess-
nected either with sli^t inflammatory actioo, sr
with imperfect secretion, especially of bik ; sr
with both, as observed in numeroos iasUacei;
deobOruentM, and mild pmrgatim$, will be mnired.
In such cases, the blue ^, or Puiiuixst pdl,
or the hydrargyrum cum cteia, ought to W
given at bedtime, frith soap, ipeeacuanba, asd
taraxacum.

17. B. flatuUHCt in infanU or young daidra
ought to be treated chiefly by apprapiaie fiood
and regimen, and by mild purgatives. Magim»
in dUUioator, or in fennoUwattr, or in oMmmi
water, will fnequenliy give relief; bntaa tlicn-
tive, as the hydrargyrum com creta, will gCBsnilj
be required on alternate ni|[hts. The vara or
tepid bath, followed by frictions of the abdowa
with some warm liniment ; enemata with a little
common salt, and some carminative water; vd
an occasional dose of castor oil* with vim
clothing, and pure dry air, will also be pradactif e
of bend t.

18. C. In the more decidedly mfmptmetii
statet of the eoviplahU, the treatment shooU be
chiefly directed to the diseaae on which itdepeDds.
But u these state* it is generellv moot urgent,
and hence requires the adoption or oKans calcs-
lated to procure immediate relief. If those al-
ready described, employed according to the pocv-
liarities of the case, prove ineffiofiaoes, it his
been recommended by Kucb, PAHAaD,TEtu)«,
and Piohry, to draw off, or to facilitate the escapt
of, the flatus, bv a siphon, or by the iotrododioB
of a flexible hollow tube into the rectum. la woA
instances of difficulty, I have found the tcr^ia-
thinates with aperients, enemata with either ipinn
of turpentine or extract of me, and teiebiathjatte
embrocations or liniments applied to the abdo-
men, succeed in procuring the expulaon of the
flatus, by excitine the action of the aiaacabr
fibres of the canu. — When this oomplaiat de-
pends chiefl? upon debility, and is associated with
other disorders proceeding frtim this soeree, the
means advised m the articles Couc, Cooixra-
NESS, and Debiuty, accordinff as it mav pi^t
more or less of the features of either, shMldb*
prescribed ; and diet and regim^H ought to nccive
due attention.

Bisuoa AND Rbrr. — fftbpacrolM. Qif* K»««.
Opera, voL L Famder Lndeu od. — CMhv Jmi*^.
MortL Chr. L iU. c 2.^ JMm^ Tetralx UL in L cT.
^Pambu JEginetA, L UL <x S& — i>Mv^ OnUn. fW
tuara. Lipt. IfiSa — T. Kentmmm^ De Esbalel Tumm.
et Flatuwhuftc Mo. Uol«, ISn. ^ JEwirfw ^""^T*
Med. Prin. tUtt. L 1. hist 57. — OUmm, Oc Vcol««k«
iDtestinU, tr. U. c SS. — i*. CmmBalmmn, Tammaftkfm,
4to. Paria, 1747.— J. B, Cmreid, Do Airii bfW f
Ventriculum cjueqiie CIrculo, 8va Med. nsa— g f
Ze9iani, TYattado del Flato a Favoro dCfT Ipttlbmerma,
4to. Vrron. 1761. — m^gtt, Worka. bjr Mi Sao, »,57a
fi89. Ac (CoiUmiHt mtn^ Jmt iiimitmttmi)'-FJ
Sehroeder, Mcdidna FUtoun. H Moetor. eiln* m
lantium, 4ta Mattx 177& —lC«Mn*r, AjomM. Ek«.
^589. {JheordingtotkeJtipnemJU^ieimiiAi^m

OfeUdUeaan. Itu vammm mmamf, Mtat, emd^f^^
of mott BmMiem eotmirie$, wko imnigipw^ ■ *f ?f ^
koi $mieet and oiker au wmomn, im oHer <»gy<^ jf -T

Qber Katten, tec pi 9SL-
diuiMB, at. x. pi9&*/'. P.

EfloU de r Air daaa me CoipiL ol .^ - ^ _

FUeuuutlque Avign. I79L — Vmiikertt I^ <>* <^

VIM

FUNGOID DISEASE— DHOUPnmr.

motbn ; a feeling of uncomfiDrtable wa^t gra- 1
Titating to the a£d on which the patient Ues, and
of geneni uneasneas and coldnea in the lower
part of the abdomen ; Baccidity of the ahdonunal
parietei tabaequent to a certain degree of tennon ; 1
tOBtor of the breath, pallor of the countenance, |
lividity of the eyelids or sarrounding circloi and
6acci<uW of the breasts; generally denote the
death of the foetus ; and when the pulsation of
the heart cannot be heard on ausemtation, this
event may be inferred with certainty.

BiBLiOG. AMD Bmrm%.^DeutUt» De Mortlt Fotum.
Halae, 4ta YlOi. — Hoomeveu^ TraMStalus de FcetQi Humanl
MotbU, Sva L. B. 1781 — AumeB.TnAXk de Plet^ri, on
JauDcne del Enfans, 8VO. Farit,18O&^5»r«0r<, Trans,
of Bfed. and Chinug. Sodotr, toL ▼. pt 144b— Lawremect
in Ibid. voL v. p. 16& — J7«y, VtAA, toL ▼!{.> 596. — CftoM-
M«r, in Diet dM Sdenoet HAL t. xtI. p. sa. et L xxxtv.

S898.— M«ra(, In IbUL C xvl. p. 48l— Klrm, Noov.
iblioth. Midicale, July, 1885, pi 9Ul. — Bracket, Joum.
G«n«r. de Hid. Jan. 1SS& — De»rmeaux, Diet de HM.
ToL XT. pL asa— LoAMeAh Repert d*Anat Ac t L pi S8~
UL— 5lfv(fonl, Jouro. des Progrte des Sdcnoea Hfid.
t XTlL p. 96&— r. ifiMf/v, in Ibid, t L N. & 130.— AmcI.
in Ibid, t It. pi 119.— ibimel^, in Ibid. VbAw. Ft 851.—
£re$eket. Diet, de H«d. 1 1. — JUotmeau, Nmnr. BiUioUi.
HM. t Ix. pi 383L — Ge^. SabU-HUiMre, Aichirei G^n^.
de Mfd. t ix. pl41. — JSIiaiH IbidL t xvL p. 661 —
Dupugtrem, in ArchiTes 0<n. de HM. t xiiL p^ 8S., eC
t xvL pk 5G8. } et RcperL G4n. d* Anat. Ae. t iL p. 131.
(Congenital buatkm qf/emnr.) — F. 8. DenU, Rechcrcbea
n^olog. tur FItuieun Haladieedcs Nouveaux.!)^ 8vo.
CommeivT, 1896. — C BtUard, Tnalkk dee Haladiei dee
Enftni Nouveaux^^ ftc. 8va Parta. 18SS, 8d edit—
A. CoUon, ArcbiTet Ofen. de H§d. t xvltL p. 84 — Canut
in Ibid, t XTi. pi 444.— FUmaii, in Ibid, t tL p. 135. 403.
581, et t XT. p. as&— if. JIhigia, Diet HM. et Cbirufs.
Prat t TuL p. 890.

FUNGOID DISEASE. — Syn. iJcmato-otrs-

briform Diuau; MiUUikt Tumour, Monro.

Srft Cancer, AucUYtJ. UpongoidJnftammatum,

Bums. Medullary Sareowta, Abernethy. Car»

cinomaiponfiotttiii, Young. Fungus Uematodeg,

Hey, Wardrop. FMngoul Dutum, A. Cooper.

Fungus Medullarii, Maunoir. Afatiere ciiv-

brifornut Auct. Gall. Carctnome mou st Spot^

gitfttx, Rottx. Tunuur £ne^haloid§, Laennec.

FongNf M6dullair§, Lobstein. Careinut Span-

guiitt«,M. Good. CaTeinomaSanglant€,Canttr

mou, Fr. Der BUUtehtwamtm, Germ. BUedU»g

Fungus,

Classif. — 3. Clou, Sanguineous Diseases ;

4. Order, Cachexies (Good). IV. Class,

IV. GaoBa (Author, in Prrfaee),

1. Depin. — A tumour, or tumourt, eontitting
of a whitith, pulpy, braiii'lihe fufttfoact ; generally
ioft, etrcumteribed, eUutie, or obaeurely fluetU'
ating; gioing rue to large voicular growtkt,
which bleed profusely ; afapaj^ eonaeeted wUh con*
stitutional vice; contaminating the frame, and
terminating fatally,

2. i. DsscRiPTioK. — This is the most malig-
nant formation to which the body is liable. When
it appears covered only by the integuments, and
has not yet acquired coamerable biuk, the surface
of the tumour which it forms is smooth, generally
equal, and not discoloured ; it is commonly soft
And elastic, and -communicates to the touch an
obscure sense of iuctuation. When removed
from the body, the haematoid tumour is senerally
circumscribed, and more or less rounded ; it fre-
quently possesses a capsule of condensed cellular
membrane. — A, M. LAsmiEC has divided the
disease into, 1st, the encysted ; 2dly, the irregular
and uon-encysted ; to which he has addedi odly,
the interstitial impregnation of organs by the cere*
brifonn substance. This last is not mentiooed by
Mr. Wararqp^ who has described this disease

with mat accvaej. M. LsBiniae 1m9
with It in the lungs. It wmj be, ttMnflsra* con-
sidered as a tare lisfm of the dianaa. Wbaa
divided, the subataaee eoib the kBife» aad ia
posed of an opooue, whitish, hoasogcaaw
resembling, in colour and tonsirtfnre, tbe

5ulp. Hence the name, Eneephaloid«givea kbj the
French paUiologists. ItaolMsafki eapoaui isi a
short time to tbe alaDosphere; and when Ae
part b washed away, or when the
ed, a filamentous or fine cellular

3. B. The eontietenee of the hwmatasd
varies in difierent cases, and
■arts of the same asaas — being
dense than the firmest brain, at other
as the brain of a fcetus, as the milt ef a fish, er
even not much firmer than cualaid. Aceoeding
to M. Lobstein, the diflerent degrees of snlWniag
is owing to the progress of the niaeass ; and thw
appears to be goMrally the case. In the JEnt
stage, or that of crudity, the ~ "
the consistence of a finn brain, or of tlio
bate glands ; in the rneond, theconsiiteM
being that of the foetal brain ; in the
preaches that of milt or castard : lo thaoeBsnybe
added zfomrth, when the tumour is aitaaled ea*
temally, or near the saifaee of an otcan or part,
vis. that attended with ulceralionaDd torn nfid pro*
duction of bleeding fungi from the

4. C. The orfoiir of this md
sometimes in the same mass. It is
the colour of the brain; occasionally
it are ndder, and eahfiiit meaa of a
pearance ; and in other cases, parts of k,
a clot of blood. When the hmnataBi
ency^ed, it is readfly detached fnm ils capaale ;
and, in the early etage, is often dividad inla aa*
veral lohea, placed dosdy t«gether,and aepaiafj
by an extremely fine cellular liasoe, whseh seema
to convey the vessels for its nutiitioii. lalha ad-
vanced stages, the division into lobes
The non<«ncj8ted form is, however,
particularly in the'viacera. Tbe m
ing this formation vary froM tbe siae of a pea la
that of the head of a talus at the fall tine.

5. D. The medullary struetnre, aMmwh the
general, is not the only, form obsarved in lEe pi^
manly diseased mass. Some of ^he fisa
ductions are composed of disli&ei parts _
with cellular capsules, and differing m aiaa,
and consistence. Some of these parts
slightly softened glue.; others ba^ oartk j
ticles mixed with the vulpv

of
of

many present insulated noitiaBa of the
consistence of boiled yolk of egg. As te

mcreases, the softening and
racteriaing <the successive stages of ias gwwih
takes place. Diaorganioatioa ganeialy eoui-
mences in the centru parts: eavilias now fens
in it, chie%^ containing blood ; and, irlMa the
blood is washed away, and the taoMMr it
in water, numerous membrai
filaments an seen floating in the

^. If the fiinanid BMss IS silaala mar Iha I
of anj inlemu viseus, diacoloaraliea eC aad
adhesMm to, the oart ooverinff it, foDawed by
ulceration, take plaoe. Bat aa alcaniivt
cess, iosfeead of giving riaa to leas of aabaia
produces a fungous growth, and, as wall aa
the tumour forms exteriorly, the ii
which had hitherto been stoW.

!050

rUNGOXD DISEASE — DtiOMosts and Cokflicatiom.

TpTogrtn of the diwaae may be divided into four
stages. — In the first, the tumour has the con*
sistence of the conglobate glands ; in the taeend, it
is much softer ; in the thirds the softening is still
greater, and amounts to a state of semi-liquefac-
tion, and gives the sensation of fluctuation; in the
fourth, ulceration or vascular fungi arise. — Signs
of general cachexy appear in the second or third
stage, and are very decided in the fourth. — h. The
duratian of this malady is generally some months
at least ; and it may contmue for two or three
years. In the early stages, it is not usually at-
tended by febrile action, or much pain ; and it
may exist for a considerable time without occa-
sioning emaciation ; but there is always more or
less debility. Acceleration of pulse, and emaci-
ation, appear in the advanced stages, often ac-
compamed with effusion into the adjoining ca-
vities, particularly when an internal organ is the
seat ofthe malady, as the liver, uterus, &c. —
In the third and/o«rtA stages, the vital functions
are very manifestly affected. The stomach loses
its power, or rejects the ingesta. The patient ex-

Kinences most severe pain ; and the energies of
e decline. The complexion often assumes a
livid, earthy, or peculiar yellowish hue, or pale
straw colour; the pulse becomes smaller and
weaker ; and at last the patient sinks, generally
without either delirium or insensibility having ex-
isted for any considerable time before death.

13. iii. DxAONOSis and Complications. — This
disease was confounded with cancer until the
commencement of this century, when Buens and
Hey first remarked the difference between them.
They are still considered by some Continental
pathologists, and by Dr. Carswxll, as varieties
or modifications of the same constitutional ma-
lady; and there are several circumstances which
both favour and mUitate aeainst this opinion.
They both occur in similar habits of body and
temperaments ; they often arise spontaneously, or
without any manifest cause, or are traced to the
same exciting agents ; they are both dependent
upon constitutional vice, as well as upon perverted
organic action and secretion in their seats ; and
they both undergo somewhat similar local changes,
and occasion an increasing contamination of the
fluids and soft solids. Moreover, as I have stated
in another place (see article Disease, $ 141 —
144.), and as Dra. Kebb and Carswell have
justly remarked, both may co^exist, or the car-
cinomatous may pass into the fungoid formation.
Dr. Carswell observes, that numerous examples
might be given of scirrhus, medullary sarcoma,
and fungus hsmatodes, as they are commonly
called, originating in the same morbid state, and
passing successively from the one into the other
m the order in which they have been named.
Indeed, these varieties are sometimes met with,
not only in different organs of the same indi-
vidual, but even in the same omn.

14. The points, however, of dissimilaribf are
very striking, as remarked in the article referred
to ($ 141 — 144.) ; and, notwithstanding these cir-
cumstances, are sufficient to ' constitute them
distinct diseases. As these points have not been
brought into view by the able writers just men-
tioned, and as they deserve a fuller notice than
I have bestowed on them in the sketch indicated
above, I shall here state them more fully. — a.
There* is no relation between the hard, incom-

pressible texture of scinrhns, in wUdi
commences, and the ceiebrilbnn, elaslk, aad
soft substance constitating fungoid disease —
fr. Carcinoma commences in sdnrhiw^ whicb
confounds in one mass all the timies which it
invades, and ofien without much increase of b«lk»
although with augmented density ; fangotd dis»
ease alwa]^ consists of a more or leas evidcat
tumour, which seems to destroy every trace of
any other structure. — e, Carcmoma, even m
an advanced stage, when fungous projectiane
sprout from its ulcerated l>arts, presents haX "

tunffoiat

vascularity ; whereas the fungoid disease _
lar^e vessels, and vascular cavities, so that it
denves one of its most common names from tha
circumstance. — d. Fungoid disease attacks or-
gans in which true carcinoma has not hitbcrto
been seen to originate ; as the lungs, the Urer,
the brain, the spinal cord, and the ncrroas
trunks. — s. Cancer affecu the aged, fngoid
disease the young; and the former is attendsd
with more pain at the commencement than the
latter : — and, /. as, MM. MAONOia, LoHmv,
and Velpeau have remarked, there is aomethinf
peculiar in the cachexy attending careanoma. thai
IS not observed in the nmgoid malady ; for it is not
unusual to see persons, labouring under this lattir
affection, possessing their natuiml colour. Tbia,
I. believe, occurs most frequently when some ex-
ternal part only is affected, or when the discaM
has not invaded the digestive or aseimiletiHg or-
gans, or. when absorption of the morbid maiter has
not taken place to a great amount. In a case uom
under my care, the healthy complexion is pre-
served, and yet neither the able practitioaem who
have seen it, nor myself, have any donbtas to its
nature.

15. M. LoBSTBnr asks, with reference to the
question of the identity of these two maladies,
whether, admitting that true cancer sometimes
gives rise to the fungoid formatioa, it thecefore
follows that this latter is the same as eaaoert
May there not exist, simultaneously, tnberealovs
degeneration of the lungs, fungoid disease of the
liver, and fibrous tumours in the womb, withooi
inferring the identity of these three morbid form-
ations 1 Fungoiddisease, therefore, appeals, from
its vascular relations, from its peculiar stmctBie.
and from its eaily characters, its advanced covae
and terminations, to be a distinct malady, althoeffk
it may be consequent upon, or complicated wua,
other alterations of structure. When it ocean
in young subjects, it is always yiiittfjp, or is aoK
preceded nor attended by the carcinomaloos form-
ation. But in persons past the oseridiaa of life«
in whom only scurho-cancer or carcinoma is ascft
with, the fungoid structure is sometimes prodted
eonucutitfely, or in an advanced stage of it, aad
thus occasionally exists as a secondary compHca-
tion with that disease, or as one of the advanced
changes of structure consequent upon the eoneb-
tutional vice. The question, therefore, as to dtf*
ference is reduced to this, that, when faugusJ
disease attacks young persons, it is always a pri-
mary and distmct malady ; and that, wbea it
affects persons advanced m life, it is either pri-
mary, or consecutive of, and complicated wtik.
carcinoma (see art. DiSBAsa,4 141 — 144.). la
a few instances, other moibid fonnaiioaa beades
this have been found associated with the rcr^
brifotm structure, as fibfous tuaonn, sciefole«s

1052

FUNGOID DISEASE — TsiATMXirr.

organ ; •— and, 3dly, That it is met with in ▼easels
having no direct commmnication with an organ
affected with the same disease. The veins, however,
and venous capillaries, axe the only parts of the
▼ascnlar system in which the diseased sabstanoe
is found — sometimes in contact with the internal
surface of the vein, or occasionally united with it
by means of thin colourless fibrme, or even of
very minute blood-vesseb, as in the case of the
cerebriform matter. In the articles referred to,
I have stated that, when this morbid substance is
detected in the blood, it has been absorbed, as
in the case of other morbid secretions ; and the
Accura^ of the opinion seems to be supported
by the fact, that it is found only in the veins
and absorbents; but Dr. Cabswbll believes
that this is not the case, as there are instances
in which the venous blood alone was the seat of
the disuse. If such be actually the case, an
obvious difficulty presents itself; but various
sources of deception arise in the course of minute
r^earches, ana mislead even the most careful.
That the blood is early affected in this and other
malignant diseases, I fully believe ; but that the
cerebriform matter is formed in it, and afterwards
deposited in the parts which are its seats, cannot
be supported by the history and progress of the
local and constitutional affections. If it were
previously formed in the blood, wherefore is it
often deposited only in one situation 1 — where-
fore is It not excreted by the emunctories t —
wherefore does it not always affect a number of
parts simultaneously*! — wherefore is it never
found in the arteries, and so frequently in the ab-
sorbents and veins proceeding from the seat of
disease ? — These, and other questions that mav
be asked, cannot be answered consistently with
this doctrine. I therefore entertain the same
ofnnion as was stated by me in the articles al-
ready referred to, and beueve that, like carcinoma,
it essentially depends upon a debilitated and other-
wise morbid state of the system generally ; and
that the vital actions of the part or parts pnmarily
and specially affected are depraved — that the
nutrition, organic sensibility, and the secreting
function of these parts are remarkably altered,
and that the morbid product which results is par-
tially absorbed into tne circulation, and contami>
nates the fluids and soft solids, sometimes exciting
a similar morbid action in other situations.

20. Conformably with the best ascertained
facts connected with the appearance of the cere-
W9brm matter in the vessels, it would seem, that,
at a somewhat advanced stage of the disease, or
when this structure becomes more or less softened,
the molecules of it pass into the veins and ab-
sorbents leading from the part in which they have
been formed; that they there sometimes are
aggregated into masses sufficiently large to admit
of their recognition ; that, although these masses
are generally found merely in contact with the
internal surface of the veins, they sometimes ad-
here to it by means of the €brine which collects
around them, as in every other instance in which
a semifluid or partially concrete substance, or a
secreted matter of greater consistence than the
blood, passes into the circulation ; and that, when
they thus adhere to the interaal surface of the
veins, minute veAels are ultimately developed in
the fibrinous envelope which has been formed
** round them.— The principal changes observed

in the blood of those affocled by ihm iWsMWt tad
which I have had an opportunity lyf iwMrkiDg in
two cases after death, are, aa anusaal thiniw
a deficiency of fibrine and red partidea— * a stale
of partial anemia — and imperfect coagulatiaa.
This state has been also remaited by B^clabd,
Vblpeau, AwoaAL, and Kcan, wlioae obsefv*
ations respecting the presence of the cerefarifecH
matter, surrounded by a fibrinous eBvalope,ia the
venous blood, fully confirm the view I have takea
of its origin in this situation, and militate agaiaet
its primary formation in this fluid. TSee aiticks
CANcsa, § 26. ; and Dissass, ^ 141.>

21. vii. TEBATMKKr. — This is a wkbj&tt oa
which much cannot be said with any iiope of ad-
vantage. Surfi;ical treatment is of no avail,
strictly medical means of very little more. W
ever excites pain, or irritates the local d'
tends to promote its growth ; and whatev«r lowen
constitutional power, only lays the sjHa
open to contamination. The intentions,
fore, which we should propose to o<
entering upon thetreatmentof thb malady, are —
Ist, to support the powers of life, and thereby to
resif t as long as possible the eztensiott of the dis-
ease ; — 2dry, to promote the secredoos and
excretions, as auxiliary to the first indication ; *>
and, 3dly, to palliate the sufferings of the patteat.

22. A. The firtf of these is founded npoa tha
evident and admitted fact that the Jiwjass is
dependent upon, and associated with, debililT;
and upon the results of observation; and the
means which may be employed to fulfil it need
not be materially different from those speufied ia
the article Cancke ($ 29. st tsf.)* Althoagfa ao
medicine has hitherto proved successful ia cariag
the maladv, yet new remedies, or novd conbin-
ations of tnose that are cAd, should
be directed against it. Besidei
have often prolonged life, or enabled the
to resist its progress for a time. CobH
with these views, the preparations of daehoaa ;
the sulphate of quinine ; the preparatiooa and
compounds of iron, particularly the ~
moniatnm, and the muriated tincture;

{»arilla ; bitter tonic inliisions or
iquor potassse, or the alkaline
and the preparations of iodine, — ^may be severally
used, and combined with sosse one of the
energetic narcotics, particularly the
muriate of morphine, or conium, or
or aconitum. — The preparations of iodmt are the
most successful of any means I have employed, ia
resisting the progress of this morbid roratatiaa.
The ioduret or iodide of iron, and the bydriodata
of potash, should be selected, and takea interaaUy
in small or moderate doses. The external aae of
iodine is often injurious. In a case of this dieeaae,
affecting chiefly the stomach and some othcfs of
the abdominal viscera, lately under my care, a
combination of the acetate of morphine aad kr^
osote palliated the urgent symptoms after oihsr
means had failed. In the still more recent case
of a lady from Wales, who came to town ea
account of malignant disease of the ateanch,
that probably partook of the fuaeoid chaiarlv,
from the size of the tumour aad omer mipioma,
this combination proved serviceable. Tlus lady
had been treated with great disciimiiiatiea by
Mr. SxapH of Welshpool. During her slay ia
London, the acetate or morphine in a dilale

acetate er

1054

FURUNCLE, ASTHENIC — Discurnov.

may tacceed one another more or leas rapidly ;
but they are aeldom attended by fever, unless
they are large or numerouB. When they form in
Che perineum, or near the an«s, difficulty- of
voiding urine is often felt. In other ntuationi,
they may affect the lymphatica proceeding from
their leatB, and the adjoining glands.

6. ii. Cauiu, — The ap^cation of blisters,
IrictioBe with trritatins liniments or ointments,
inattentioa to personu cleanliness, the use of
mlphureous or alkaline baths, and various ante-
ceoent or associated affections, are the usual
causes of this eruption. Furuncle is often con-
ouent upon the decline of, or convalescence from,
nvers, the exanthemata, and inflammatory disease
of the skin ; and it oftien seems to depend upon
weaknett, or chronic inflammatory imtation, of
the digestive organs ; or upon accumulation of
eordes in the jtrima via. In some cases, however,
at occurs without appreciable antecedent disorder.

7. iii. TrMtmmt. — But little is required for
this complaint b^ond attention to the digestive
organs. Accumulations of mucous sordes and
fa^al matters ought to be freely evacuated by an
aperient consisting of e<|ual parts of the com-
pound infusions of gentian uid senna with a
neutral salt or alkaline subcarbonate. A bread
and water poultice, or any other soothing and
relaxing application, may be kept on the part.
H the boil be large, and the pain considerable,
the division of the skin, at the most prominent

Krt, will be of service. When a succession of
ils appears, an emetic may be given, and its
operation promoted by the innision of chamomile
flowers. The above stomachic aperient may be
afterwards continued daily, or on alternate days.
If the eruption still appears from time to time,
gentle tonics may be prescribed. Dr. Fosbrookb
recommends large doses of sulphuric acid. Mr.
Copland Hutchison informed me, that he
found the liquor potasssB, or Brandish's alkaline
solution, in any bitter tonic infusion, most benefi-
cial in these cases. The extract of taraxacum
may be added to a mixture or draught of this
kind, and an alterative pill given at bedtime, and
continued for some days.

8. II. HoROEOLUM— 5tyc; Phyma Hcrdeolun,
Good ; SeUropkthatmia, anKn^o^BaXfjua ; Orgeolet,
Fr. ; GtnUnham, Germ. — is a tmall inflamma'
tory tumour or boil in th^free edge of the eyelids,
mott frequently near the inner ongU of the eye. —
It is in every respect a similar a&ction to furun-
cle, the difference arising entirely from the nature
of its seat. It is seldom larger than a grain of
barley, and is generally smaller, as its name indi-
cates.— lis eauees, progreu, and treatment are in
all respects the same as those of common boil. —
Thu, and the preceding variety of furuncle, are
roost common m young persons, just before or
ioon after puberty, and in adults who eat largely
and take much spirituous liquors. — In scrofulous
constitutions, and persons addicted to intemper-
ance, they assume a chronic form. In such cases,
local applications with camphor are of service.

9. III. AsTHSNic Furuncle — Atonic Furun-
cle; Furoncle Atonique, Guersent — consists of
a email cireunueribed tvoelling of the tkin, in one
or aaveral tituatUmt, with or without livid d/«-
coUmration; followed by a very email purulent
phlyetttna, at the»ummit,and byjiftening, dutruC"
tion, and large porf oration of the eorion under-

and preeedad and attandad by w&adk dtH^
Uty and tow fever.

10. This affection was described by M. Gvee-
SENT, in 1823 ; and early in the same year I saw
two cases of it, with Mr. Painter, in a low street
and ill-ventilated apartment in
Both occurred in unhealthy clnldrea in the
family, and terminated &tally. The bodice
inspected after death. Since then I have
only three other casee, but I have met
somewhat similar, consequent on the applicaboa
of leeches. — All the instances which have oe-
cuned in my practice, as well as thoee seen by
M. Guersent, were in children moch weakeaed
by previous disease ; or in thoee affiseted by gas-
tro-mtestinal irritation, or by chranic disorder ef
the bronchi, or asthenic inflammatioa of the sa^
stance of the lungs. There have always been,
both before and after the appearance of this
eruption, well-marked symptoms of adynamia ; and
coma has generally come on before death.

11. i. Deecription, — This eruption appean
chiefly on the trunk, the lateral parts of the neck,
and insides of the thighs. In the cases which I
have seen, the numlwr of furuncles was consi-
derable— not fewer than five or six ; and, in two
cases, there wctc about twenty. They commence
in small, circumscribed, and hard swellings, of a
livid tint, but sometimes nearly colourless. At
a further advanced stage, very small paratent
phlyctcns appear in their summits, that break,
and leave the skin underneath of a greyish co-
lour, softened, and perforated as in commeo
furunculi. They discharee at first a serous, lan-
guineous, or ichorous fluid. The tumoais soften
and disappear ; and the perforations of the cho-
rion enlarge rapidly, producing, in two or three
days, holes in the integuments, vsryine from thiee
or four, to six or seven, or even dght or mne,
lines in diameter. These perforations are peiieetly
round ; their margins are not elevated, nor thick-
ened, nor injected ; and tbey entirely resemble
the holes mads by a drill or auger. The cellular
tissue is not thrown off in the form of a core,
but is destroyed bya rapid ulceration, or phage-
denic absorption. The bottoms of the nleeri have
a greyish or sanious appearance, and are nearly
diy. There is no discharge from them, nor hav«
they any tendency to scab *, and the perforations
of the integuments frequently proceed down to
the muscles, or sponeuroses, the peculiar strac-
ture of which may often be seen at their bottoms.
The skin forming their margins is pale and sooae-
wbat softened, and the cellular tissue iipmediatcly
beneath the cutaneous margins » often destroved
to the extent of one or two lines. — In the variety
of asthenic furuncle following the bites of leeches
in cachectic and debilitated children, which is
the most common, the perforations of ihe sikin are
at first triangular, but their progress is nearly
the same as that of the spontaneous variety, and
as they enlarge they become entirely circular.
The ulceration attending upon the advanced stage
of disease is seldom very painful. Having reachnl
the extent just described, it remains stationaiy
for a longer or shorter time, and in the more no-
favourable cases shows no disposition to repara-
tion. When it evinces a disposition to heal, the
bottom is more moist, somewnat redder, and more
vivid ; the perforated mareins of the skin become
more closely coimected wiUi the sabjaceBt

1066

FURUNCULAR DISEASES — CABBVMCui—TuAivnT.

affBctions of the larynx or trachea, are eneii*
enced. If it take place in the parietes of the
chest, the most severe pleuritic and pulxnonaiy
symptoms sometimes 8apervene,€rom the extension
of the inflammation internally to the pleura, and
thence even to the lunp. When it attacks the
abdominal parietes, peritonitis has even occurred
in a similar manner. Anthrax may also be asso-
ciated with some other external eruption, espe-
cially with the common furuncle* which may
either precede or accompany it.

18. ii. Cautet, — Anthrax is most common in

Jpring and summer, according to M. Rayer.
t is certainly most frequent in persons past the
meridian of life, and in females about the total
cessation of the menses. High, rich, or gross
living, with insufficient exercise, and a full, gross
habit of body, predispose to it, and even more
directly produce it.-— Causes which deran^ the
digestive and biliary functions, the application of
ecrid or stimulating matters to the sun, neglect
of personal cleanliness, and the bites of insects,
most commonly excite it. It is often a sequela
of small-pox, measles, and typhoid fevers; and
it is a common attendant upon plague, and some-
times even appears in the latter stages of the
putro-adynamic form of hrphoid fever.

19. iiL Diagnam. — Carbuncle is to be dis-
tinguished from the common boil, by the latter
having only a single opening, and bang smaller
and more conical ; ana by several occurring in
succession. The former, on the contrary, is
Ibroader, less acuminated, is perforated by several
openings, is darker, and more gangrenous, and
is generally single when occurring as an idiopathic
dlKtfder. According to Dupuytrxn and Raybr,
however, anthrax is a tumour formed by the con-

?lomeration and confluence of several furuncles.
Carbuncle has very generally been confounded
with malignant pustule, or anthrecion. The latter
belongs to a different order of affections of the
skin ; and is described, as well as distinguished
from anthrax, in the article Pvstvlss.

20. iv. TrmtmMt, — This should be com-
menced with 'die exhibition of an emUie, the
operation of which may be promoted by a tepid
infusion of chamomile flowers. A full dose of
eaUmul and Jam$$*$ ptnctUr should afterwards be
given, and the free action of the bowels promoted
by purga<tvet. Whenever the pulse u stipng,
full, or hard, bhodUttin^, acconiing to the age
and habit of the patient, is requisite, particulany
early m the disease. -LMehet ought also to be
applied around the base of the tumour, and the
bleeding from their bites encouraged by tepid
fomentations. A repetition of the local depletions
may be required even oftener than once. i>i-
aphoMtici, with tartarised antimony and opkum,
if the pain and burning be very severe, snould
afterwards be given, and the bowels kept open by
the occasional exhibition of a pursative. When
the attendant fever is of a low form, or when
gangrene has taken place, and suppuration con-
tinued for some time, especially when the patient
is aged, of a cachectic habit, or is addicted to
intoxication, or is greatly debilitated, the decoction
of cinchmia, with the alkaiin€ tubcarbonatn ; the

tniphMt€ of futiHiie with

with murialie aci</, and Mtne ttktr ; and the
means advised in putro-adynamic fsver, ohe«ld
be prescribed, with light nourishment, wine, &c«
21. The heal tnutmont should consist chiefly

of refrigerant applications in an early stage oC the
swelling. Compresses moistened with equal parts
of pyroligneous acid and rose-water, to inuck
some camphor has been added, should be con-
stantly applied firom the commencement. Th^
generally relieve the pain and burning heat, u
the inflammation still proceeds, a ermeimi imeiamm,
completely across the swelling, and down to iu
base, as advised by DupuTTaxw and Rats»,
shoiUd be made. This will give inibuA relief by
the loss of blood, and by removing the stinsi^-
lation of the vessels and cellnlar tiasne. It also
averts gangrene, facilitates a*healthy suppunliy*
action, and hastens^nanulation and reeovety. The
actual and potentiu cauteries formerly advised.
are now rarely employed. Several Amencnnwriian
recommend the application of bUtUn over the
swelling — the discharge from the snrfsee fevonr-
ing a return of healthy action in the M'rwsti part.

22. When anthrax is eomplieaud with any of
the internal affections indicated above (f I7.)»
the treatment ought to be decided and appraphata
to the morbid associations, as the progress of the
complication is generally rapid, owing to the
unfavourable state of constitution giving rise to
this kmd of local disease. — During rmnmlnrtmrt,
sulphureous baths, and the aperient sulphnieoos
inineral waters, with strict attention to the func-
tions of the digestive organs, and to ditt and
regimm, are usually productive of benefit. I have
found the following medicines of service, when
the patient cannot resort to suitable mineral watcts.

So, 888. R InAiiL Stnnm Compi, InAa. Gent
if 3 t). ; Soda SalM»iboa. cr. xU. ; 8pML Ai
AroiiL>5ML i Tinet CuduniMn. Ca 5h H FM
altamto noctUnu •umcndui.

Na 889. PotMi* Supertart in Pulv. M. ; Sal^barto
Pnedpitat, 3iU.: Conftct Senrm SU; %nip fiacOMrte
q. •. ut flat EhBCtuaiim nolle, cuJiM capiat Cock. j. ai.
aimum, boti Moini quottdMi

BiBUoo. AN0 RsvBB.— I. FuaOHcu. — GMlM, Da Ea
Medica, L ▼. ch. 88.-.Btel««, Anat. Gtoinie^ t. It.
p. 6B7. — Artrooftr, in Edlo. Med. aad Sttry. Joan. vaL
zvUL p. 61 — DognMC, Ur, M^dicale. Snt. IflSB^ |k 4ia.
— IZdmrr, TbeorcC and Pract TUti, on DiacMca cf cha
SktB,V Jt. tratii, pi 5«S. ^Lmam$, FMboL Cbinaft. Li.
pL ML — iWclfraurf, Noai«r. Chlr. L L pc |S3.«-.f»'. Otk,
aon, Inttltutet of Suncfy. PbiML 8va IBM. voL L —
CkeHut, Handfai dar cClr. bi L p. 71 — M G!«rf. Sludy ot
Mad. by Coaptr, vol U. pL SSOl — F. G. Aittmm, N«o-

Cai.

giapbia Onanlqoe, t \w, k 9L— .f. Grtiem, FneL
pand. of Dlk of the Skin. Load. 1835, p SOL

II. AiTBCinc FuBUMcta. — GMenemi, in Ardihrei Gt.
n^rales da MUtdn^ t L pi 39&— 1 And, upon rafefcnarto
the Lomdam Medkmi RepMUorp, for July. 1883^ p. SS., tbat
I dewrilMd thli eniption In the Londoa lledical SoMy,
at the coaiaienoemciit of that year : and that won after,
wards M. ODBBBBirr'a paper rcapaetinf it aiyeaind ia
JrckiKs. It was thus noticed, for the flrU tim^ all
tImalUneoaaly by this pbydcian aad myaeiC

UL Cabboticlb.— Cfino, L ▼. iccC.9BL — <tf. 7M, On
Anthiacw ecu Caitmnculo TracUtu^ Ma. Vcrni ISML
— CP.De Herrera, De Cartouncnlia Aniiaadvarc ISa
PIbUc, 1601 —r. b. UUckelK Ncv York
Phya. Joura. 1815, roL U. p Gl<- J. JL ~

1883, iroL IL p. S7.— i>. Ho$aek. EMaya an V
jcctn N. Y. 1881 vol. iL pi 8KL — / i

lancet, VOL L pi ^'— SaMon, in Diet de M«d ct Snis.
PraL t ilL p. S& — Moiiarite, Diet de MM. 9d «lit
Parii, 1833, art AntkrmM, — Dmpmgirm^ t«C«M> Laneectn
Fran^alM, Mart, 18331 — ilMrr. Opni ell blSML — JL
OMtfea, in Amar. Cyctopior Fnet Med.voL IL p tt~X
GfWMa Opiu, dt p. 270.

Bwn 07 TBI nasT volvmi.

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