(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "A Dictionary of practical medicine v. 4"

Google 



This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 

to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 

are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 

publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 
We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liabili^ can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 

at |http: //books .google .com/I 



.'V 

^' ■'...■' 







ttmSD BY BfORUWOOBB AHD CO. 

vxw-man iQVABa 



■nil 



Cvn -B« 3uiiir7*nsi im ear^ 
3kiuiul HI!, iir -m* aib* ir -iums 

War -luuLA ^um. -na 



JU^vassa WK 






«ta 






nut if ua Uvn. -sccei 

Tf -xnitisrvanifiBC tump) xcirzxiur ii lacars.— <vuc 
-npm iciisr ninn . imx :aia«lii» turf -rM 

±im tfieai rSie jidrauc^ 'wr^* ^Stiej wflsr ■p'sc iuihbt it ■£• jmufic ta i2c&:!!i. 

ai^ii!m:--Jr«Laasatf? «ainud!ieii3ii^'jur-a t3tft^ fiseiniil?. that dier s&ccJi 

W wtil aj^vpwtti a x ; ^urUj. aa: ae? ijnivfii m AiiLeu. ji tu tw vtudi an? 
tfiqnUy. E^flC SMf vbanid, ae c^ joyi: jui:: 



soai: iIJH iii.'inniiit xmiu ; 






Faux«i2i: 



*- y>m cfo B« aMChjciLs 






COVLST. 



rt^ fcl(cti ncBfte, obiemTerit ; 



■ac ampiitt* text 



tatit we xBttC^t qvaatun «fie sarurx criice, 
'' Notch Oeaaxch. 



" McB's quUfintku uhd csdorccsu, tbcos^ of chtfBKlrct Iwt slimier, ud uB«<quI to th« 
work, f ct, vben propcrlf and RfcJu^f aaed aoi app/kd, are capftb^e of bnaxuur socb !ht=^ 
bdOR the jadgmeiif, and into practice^ as lie eitneflxtj- rcEWte from tht onliuarr Kue a=d 

Bacox, JpJk^rum. 3. 



f» 



" For there are wandcren o'er etemttr 
Whoae Urfc goes on and oa, and anchored ne*cr shall be.** 






• •• 

• • 



• 



• i 
I 



GALL BLADDER AND DUCTS — Inaction op. 



2 

times occasion veiy serioiis disease in the gall- 
bladder or ducts, owing to an acrimony acquired 
by it in the way iust stated (§ %,) ; — and (c) 
that, when the bile is thus accumulated or re- 
tained, as well as altered in quality, the conse- j 
quent disorder, either in the biliary passages, or i 
in the digestive canal, when it has reached the 
latter situation, will be the more severe. — The 
difficulty, however, of formine a correct opinion 
as to the complaint, when Uie gall-bladder or 
ducts are its seats, should not be forgotten -, for, 
owing to the relations noticed above ($ 1.), it 
often is impossible to chstinguish disease of either 
the one or the other, from that of the liver or 
duodenum, unless the passs^e of bile into the 
intestines is altogether interrupted ; and even then 
the exact nature and extent of lesion are equally 
difficult of recognition. 

II. Inaction of the Gall-bladder and 
Ducts. — Accumulation of Bile in the Gall' 
bladder and Duett from local Asthenia. 
CLASsir.-^ I. Class, I. Order (ilut/ior). 

7. Charact. — Fulness f weight, or uneasiness 
in the epigastrium and hypochondrium ; Jlatulence 
or symptoms of dyspepsia ; a pale, slightly lurid, 
or muddy complexion ; scanty or morbid excretion 
of biU in the stools, frequently with debility and 
depr^on cfmind. 

8. i. When the functions of the liver, or those of 
the stomach and duodenum, are impaired, the 
gall-bladder and ducts necessarily participate 
in the disorder \ and the bile is liable to accu- 
mulate in them. — The accumulation may arise 
from one or more of the following conditions : — 
1st. Impaired tonic contractility of the coats of 
the gall-bladder, and perhaps also of the ducts. — 
2d. A congested or tumefied state of the mucous 
membrane at the outlet of the common duct, and 
in the duodenum. — 3d. Inspissation of the bile 
in the |all-bladder and ducts, from the morbid 
state of the secretion, or from the absorption of 
its more fluid parts, whilst retained in these situ- 
ations. — 4th. Spasm of the ducts themselves : — 
andT^Blh. Temporary or constant occlusion of 
the ducts from inflammation, or from the presence 
of biliary calculi, either in them or in the gall- 
bladder. 

9. A, The first of these pathological states is 
of frequent occurrence, in a moderate degree. 
When the contractility of the coats of the biliary 
passages, or of the gall-bladder, is impaired, in 
connection with torpor of the liver, and debility 
of the stomach and duodenum, the bile is imper- 
fectly excreted, or it accumulates in these situ- 
ations. The consequent distension, or the irritating 
properties the bile acquires by the retention, or 
some other cause, excites the contractility of 
these parts, and occasions the collected secretion 
to be thrown into the duodenum, where it pro- 
duces more or less disorder, owing to its acridity, 
and to the very intimate and extensive relations 
of this intestine with the rest of the oeconomy. 
When the bile has thus accumulated, a very 
genUe aperient will often be the cause of a violent 
action on both the stomach and bowels ; this 
secretion, particularly if rendered acrid by long 
retention, and by the influence of temperature or 
season, giving rise to all the characters of bilious 
cholera, when its rapid flow into the duodenum 
has been thus procured. 

10. B^ That congestion, or a tumefied condition. 



of the mucous membrane of the duodenum will 
occasion accumulations of bile in the ducts and 
gall-bladder, is at least extremely probable ; for 
the aperture of the common duct in this viscus 
being thereby narrowed, a diminished discharge 
of bile into it will result, particularly if this secre- 
tion be thicker or more viscid than natural. — In 
cases, therefore, of acute or chronic duodenitis, 
or of irritation of the internal surface of the duo- 
denum, particularly if there also exist spasm either 
of this viscus or of the common duct, an impeded 
or interrupted flow of bile into the digestive canal, 
with consequent accumulation of it throughout 
the biliary passages, with or without jaundice, 
will very generally supervene. (See art. Duode- 
num, § 12.) 

1 1 . C. That the bile becomes inspissated and 
often more acrid, by retention in any of its pas- 
sages, may likewise be conceded. The fact is 
even demonstrated, not only by observation dur- 
ing the life of the patient, but also by the ap- 
pearances after death. In such cases, it is with 
some difficulty that the secretion can be forced 
along the ducts, or from the gall-bladder along the 
cystic canal. In an inactive state of the liver, 
the hepatic ducts are unable to discharge the bile 
which passes into them ; and this fluid, during 
its collection and retention, is liable to be par- 
tially absorbed. Owing to this absorption, or tr 
the state of the secretion at the time of iXa pro- 
duction, or to both, inspissation, viscidity, and 
increased acrimony of it may take place before 
it passes out of the liver, or reaches the larger 
ducts or gall-bladder ; and even concretions may 
form in it from the same circumstances, in any 
of these situations. (See art. Concretions — Bi» 
liary.) 

12. D. Spasm of the common or cystic duct 
may give rise to retention, and be followed by the 
same series of changes as have been just men- 
tioned ; but the evidence of the occurrence of 
spasm is much less complete than that of the 
other pathological states. It seems, however, 
probable that the passage of an acrid secretion 
along the cystic and common ducts, will so irri- 
tate them as to give rise to spastic constriction of 
them. This effect is produced upon other canals 
by irritating matters ; and it may therefore be 
inferred, th^^ similar result will accrue in this 
situation from the operation of these agents. That 
it does occasionally take place, has been demon- 
strated in some instances by post mortem inspec- 
tions. — That inflammation of the ducts is often 
followed by accumulation of bile in the gall- 
bladder and hepatic ducts, will be shown here- 

I after ; it may, however, be stated, that a persist- 
. ence, or a higher grade, of the same cause — 
I the acridity of the bile — as sometipies occasions 
I spasm or constriction of the ducts, will even in- 
duce inflammation of them and its consequences. 
: — It has been often found, upon examination after 
' death, that collections of bile have arisen from 
tumours, or morbid enlargements of the pancreas, 
I pressing upon, or even obliterating, the ducts, 
' particularly the common duct. Several instances 
I of this kind have occurred to me in practice. 
I That biliary concretions, in the common, the 
I cystic, or the hepatic ducts, often produce «mi- 
lar effects, is a sufficiently established fact in 
pathology. 

13. ii. The symptoms of accumulatioiis of bile io 



GALL BLADDER AND DUCTS — ALTUunoHi of. 



25. i. The Symptoms of inflammation of the gall 
bladder or ducts are extremely fallacious. This 
dibeaae may be either acute, sub-acute, or chronic ; 
and, in either of these states, it is generally con- 
secutive of inflammation of the concave surface 
of the liver, or of obstructious of the ducts, or of 
the irritation of biliary concretions ; and hence its 
approach is slow and insidious, or the symptoms 
attending it are merely an aggravation of those 
produced by the antecedent disorder. This is 
especially the case when it occurs in a chronic or 
■UD-acute form. Chills or rigors may or may not 
not occur ; but they are generally preceded by 
pain, more or less severe and acute* in the situation 
mentioned above. Vomitioe is frequently pre- 
sent, and the matters ejected are often greenish. 
There is great tenderness at the epigastrium ; and 
pressure is apt to excite vomiting. Severe colicky 
pains are felt in the upper regions of the abdomen ; 
and jaundice sometimes appears suddenly. The 
attendant fever is characterised by a small or con- 
stricted pulse ; by evening exacerbations ; by a 
very dark, turbid, and scanty urine, and by thirst. 
The stools are generally devoid of bile. These are 
the most constant symptoms of inflammation of 
this viscus ', but they are not altogether to be de- 
pended upon ; for they are usually present in 
nepatitis, and even in duodenitis or gastritis. — 
Another circumstance, which adds to the diffi- 
culty of diagnosis, be»des its mode of accesuon, 
is its frequent complication with these diseases, or 
with dropsical effusion, especially in the abdomi- 
nal cavity. But inflammation of the gall bladder 
or ducts is often consequent upon excessive dis- 
tension ; and, when this is the case, the charac- 
teristic symptoms commonly follow a more or 
less distinct tumour in some one of the situations 
I have noticed above ; and the nature of the com- 
plaint is thereby made manifest ; jaundice and 
white stools, with very dark urine, being then 
seldom or never wanting. 

26. ii. Changei contecutive of Inflammation of 
the Gall-bladder, ^c. — These are various. I shall 
take a brief view of the most common. — (a) 
Suppuration, ulceration, and softening, are not 
infrequent. The gall-bladder may be almost 
fillerl with pus from inflammation of its internal 
surface ; but the admixture of pus with the bile, 
and ulceration, are more common. Cases of this 
kind have been noticed by Vetter, Moroaoni, 
Amyand, Walter, Mokamd, Frank, Baillie, 
SoEMMEHRiNG, Martin Solon, and Andral. 
The ulceration may pass into perforation, or 
even rupture, without any very considerable 
distennion of the viscus havmg previously occur- 
red ; the bile being eflused in the peritoneal 
cavity, or into some adjoining viscus, in the man- 
ner already noticed ($19.). In cases of ulcer- 
ation and rupture, softening is not often absent; 
and probably it favours the latter occurrence.— 
(6) Gangrene is a very rare occurrence. I have 
seen it mentioned only by J. P. Frank. — (c) 
When inflammation cither commences in, or ex- 
tends to, the more external coats of the gall-blad- 
der, adliesions of it take place to adjoining parts. It 
has been seen adhering to the peritoneum*, by Bloch , 
Petit, fitc. — to the omentum, by Walter — to 
the duodenum, by Ludwio, Frank, Porral, 
Reynaud, myself, and others — to the colon, by 
Waltee, &c. — and to the liver, by Annesley, 
myself, and several writers. Thes€ adhesions 



may exist either with or without dieteomm, or tkt 
presence of biliary concretions ; but either, or 
both, are often obwerved, or have maniiotly ex- 
isted at one period or other of the disease. — {i) 
Thickening of the coats of the viscus is evidently 
a consequence of inflammation in some one of ils 
grades. It has been remarked by Schkau, 
Walter, J. P. Frank, Soemmerrino, Anoeal, 
and myself. Stoll and Leveiixik have noticsd 
the thickening, conjoined with a eartiUginsu 
induration, — (e) Ossifie deposits in its coats have 
been found by Rhodxus* Waltsb, Murray, 
Grandchaup, Mollinelli, Baxlue, and Ax- 
oral. 

27. There are various other alterations of am 
gall-bladder which do not necessarily arise from 
any grade or mode of inflammatioDy and which 
may be noticed at this place. — «. The nil- 
bladder may be hupertrophied in respect both of 
its capacity and the thickness of its coats. Tke 
simple distension arising from obstruction of tke 
common duct cannot be justly called hypertrophy, 
although some French pathologbts nave thM 
denonunated it. — 0. A trophy, or wasting, of it is 
not uncommon, even as a consequence of chrane 
inflammation affecting either itself or the docM^ 
particularly the cystic duct. Instances of lUi 
change are recorded by Muroaoni, Waltk% 
Rossr, SoEMMERRiNO, UnFBLAHO and^AxoEAb 
In these cases, the passage of bile into or from it 
having been prevented, tne portion of this floid 
contained by it has been absorbed, and the fmiie< 
tions of the viscus having ceased, its structure has 
gradually wasted, until it has almost disappeaiel 
— y. Instances, in which the gall-bladder has bees 
either congenitally vmnting, or has Hisappe&ni 
from antecedent disease, have been adduced by 
Ferneuus, Marcellus Donatus, ScBEira^ 
IIuber,Morgaoni,Jaeqer, LoDwio.SAMDiruBr, 
Zeiolee, Baldinoer, Lemeby, Boulet, Tasoi- 

ONI,ToZZETTI,LlTTRE,WlEDEMANN,OTrO,DKXST, 

&c. — That this viscus may entirely disappear, in 
the same manner as it becomes atrophied, may be 
I admitted. When only atrophy has occured, there is 
I still some little cavity left ; but when the bladder 
has disappeared, the cystic duct is reduced to a 
fibrous chord terminating in a mass of cellnlir 
tissue. — I. The coats of the galUbladder may, 
moreover, be infiltrated with serum, or contain 
tuberculouSf or calcareous matters. 

28. iii. The Ducts — the hepatic, cystic, and 
common — are liable to all the changes noticed 
with reference to the gall-bladder — to dbtensioo, 
obstruction, inflammation, thickening, ulceration, 
iK>ftening, perforation, rupture, hypei trophy, atro- 
phy, obliteration, &c. — The symptoms how- 
ever, attending these lesions during life are veiy 

; equivocal. The symptoms, proceeding from in- 
i flammation closely resemble those enumerated 
as indicating inflammation of the gall-bladder. 
Most of the changes, to which the ducts are 
obnoxious, are the effects either of concretions 
obstructing and irritating them, or of inflammatiim 
having extended to, or been excited in, them. 
Inflammation, whether it extends to them from 
the duodenum, or from any other part, or arises 
from the acrimony of the secretion passing along 
them, is equally accompanied by swelling of their 
coats, and by more or less complete obstruction 
of their canals, often with softening or ulceration. 
— » Constriction or narrowing from this cause has 



10 



GANGRENE — rmox Ihjlaumahos, 



forface. — GaogicneoftliktiHiieiicitlierdi^iuftl 
or eircuaueribed. In the diffused form, h gene- 
rally ocean in external parts, and moat commonly 
Ibllovf erjBpelas, and diffdsed inflammation of 
tbo cellular tiMoe from abrasions, wounds, ponc- 
twcs, and the inoculation of morbid or putrid 
natter, as by wounds in dissection. In these 
cases the inflammation spreads rapidly and ex- 
tensively, terminates quickly in gangrene, and 
often extends to the blood-vessek, tendons, apo- 
neuroMs, and lymphatics. These resist, for a longer 
time, the disorganising process; and are often 
seen, especially in tl^ extremities, running in 
the midst of decomposed cellular tissue, and of 
cAised fluids. If the inflammation affect the in- 
terior of a considerable venous or arterial trunk, 
particularly that which chieflj supplies a limb, 
the circulation through it is mterrupted by the 
lymph efliued in its canal, and the entire part 
l!eyond the seat of obstruction is struck by gan- 
grene. In the internal viscera, gangrene very 
seldom occurs in a diflTused form, unless in cases 
where erysipelas extends to the fauces and parynx, 
or in the more malignant cases of angina. 

9. Circum$eribtd gangrene of &e cellular 
tissue is seen in that connected with the integu- 
ments, in the common boil, and in carbuncle. 
When gangrene is observed in the cellular tissue 
of internal organs, it almost always is circum- 
scribed. When the tubmueoui tUtue is its seat, 
it generally is in spots or patches of various di- 
menflons, and is consecutive of inflammation 
which has commenced in the mucous membrane, 
and extended thence to the submucous tissue. 
In such cases, particularly in dysentery, con- 
siderable portions of the mucous surface are de- 
tached, owing to gangrene of its subjacent tissue. 
— Although gangrene of the tubeerou$ cellular tu- 
f us is more or \em circumscribed, yet it is often ex- 
tensive ; but, in these latter instances, the serous 
membrane is also implicated. This is especially 
the case when the sub-peritoneal tissue is the 
seat of lesion. It is rarely, however, that 
the inflammation of it, which terminates in this 
manner, commences in the peritoneum, unless in 
some cases of strangulation from hernia or intro- 
suscejption. It commonly either originates in the 
cellular tissue itself, or extends to it from adjoin- 
ing parts. Indeed, this is always the case in re- 
spect of the subperitoneal tissue of the lumbar, 
iuac, and pelvic regions. 

10. y, ilucaus memhranet are sometimes found 
gangrenous; but not so frequently as was supposed 
by the older writers, who mistook softening, dis- 
colouration from the imbibition of morbid secre- 
tions, and even albuminous exudations thrown 
out on their surfaces, in the form of false mem- 
branes, for sphacelation. — Gangrene of this mem- 
brane is generally circumscribed, often very 
limited, and seated chiefly in the throat, the lower 
pait of the ilium, in the caecum, the sigmoid 
flexure of the colon, and in the rectum. The 
inflammation producing it commences, and is 
chiefly seated, in the mucous tissue itself, or in 
the follicles, or in both. The gangrene may be 
limited to either of these, or may extend to both, 
and even to the subjacent cellular tissue. Where 
thus changed, the mucous membrane at first 
presents an ash grey or greyish yellow colour, 
which often changes to brown or black ; but the 
gangrened part may be tinged by the secretions 



or other substances applied to it, especially bj 
the bile, or by the blood.— The part surrounding 
the slough k generally congested, of a brownish 
red, or of a purple, or livid nue. Dr. Carswell 
remarks that, when the inflammation has been 
confined to the agminated, or Pever*s, follicles, 
and when the greater part, or the whole, of the 
follicle has sloughed, little congestion or inflam- 
matory redness may remain. If these glands are 
already the seat of disease — as in continued and 
hectic feverB, consumption, 6lc. — a slight attack 
of inflammation may destroy their vitality, and 
little or no vascularity may be observed around 
them after death. The mucous surface of the 
bronchi is rarely the seat of gangrene, and only 
consecutively of inflammation of adjoining parts. 
— Gangrene of the mucous surface of the uterus 
and vagina is not infrequently seen in dissections 
after puerperal fevers. (See Puerperal Diseases, 
and Lterus.) 

11.1. Serous membranesiie the seats of gangrene, 
only consecutively of this, or of some other cause, 
as suppuration, ulceration, &c. in the subserous 
Ussue, as noticed above (§ 9.). When ulcer- 
ation of any part of the digestive canal extends to 
the peritoneal surface, this membrane, having lost 
the supply of blood from the subjacent tissue, 
sometimes experiences sloughing at the bottom of 
the ulcer, and consequent peiforation. But this 
is observed chiefly when the ulcer is large, and 
the patient's habit of body cachectic ; and most 
frequently in the lower part of the ilium. — The 
pleura is more rarely the seat of gangrene than 
the peritoneum ; and the costal pleura is still 
more rarely aflfected than the pulmonary pleura. 
Gangrene of the latter is met vrith as a result of 
the softening of tubercles situated immediately un- 
derneath the pleura, or of gangrene of a subjacent 
portion of the lungs. — The serous memlvanes of 
the brain are gangrenous only as a consequence 
of severe injury; particularly when the mem- 
branes are exposed, and when the part is affected 
by erysipelas or hospital gangrene. Thb latter 
cause of gangrene oi the cerebral serous mem- 
branes has been noticed by Mr. Copland Hut- 
chison. When the serous membrane is sphace- 
lated, it assumes an ash grey or slate colour ; but it 
may be variously tinged by bile, blood, or morbid 
matters. It is also soft and spongy, and is readily 
detached from the surrounding Ussues, which are 
usually more or less injected. 

12. c. Fibrous tissues become gangrenous only in 
consequence of tlis lesion in the immediately ad- 
joining parts. — 1 he muscular tissueia very rarely 
seized by gangrene after inflammation. The 
muscular tunics of the digestive canal are some- 
times, however, thus affected, owing to the ex- 
tension of gangrene from the associated tissues, 
as in the case of sloughing ulcers commencing 
in the internal coats of the tube. If recovery 
take place after a portion of the muscular tunic 
has been thus destroyed, the cicatrix which is 
formed contracts, as Dr. Carswell has stated, 
and the diameter of the canal is permanently 
lessened. — The heart is, perhaps, never even 
partially gangrenous whilst life continues; and 
the arteries and veins are never the seat of this 
change until the surrounding cellular tissue, and 
cellular coats of these vessels, are destroyed by it. 
Gangrene of the brain, of the lungs, of the liver, 
of the spleen, of the kidneys, of the uterus, £cc. is 



12 



GANGRENE — fhom Obstructed Circulation. 



very slight causes will occasion engorgement of 
portions of the integuments, or of internal viscera, 
followed by the changes already described as 
constituting gangrene and sphacelus ; and local 
congestions will sometimes occur and be followed 
by loss of vitality, without any obvious cause, or 
any obstruction to the circulation, or manifest 
increase of vascular action in the part ; whatever 
action may appear being of an irntable, asthenic, 
or extremely weak kind. The gangrenous or 
asthenic form of fumnculif and the humid or 
phagedenic sores met with in the mouth, gums, 
cheeks, genitals, &c., of unhealthy children, are 
illustrations of this variety — the chief charac- 
teristics of which are, depressed organic nervous 
or vital power; imperfect or asthenic vascular 
action, both previous to, and attendant upon, the 
gangrenous lesion ; and a poor or vitiated state of 
the circulating fluids. (See Scurvy; and Thrush 
— Gangrenous.) 

17. iii. Gangrene from O^tructed Circu- 
lation. — The arteries may be incapable of con- 
veying blood to, and the veins of returning it from, 
a part. In the preceding varieties of gangrene, 
the organic nerves and capillaries are the pri- 
mary and chief seats of the lesion. In this variety, 
they are consecutively affected, owing to the 
obstruction which causes it either cutting off 
their supply of blood, or preventing the return of 
it. — The changes which take place in either case 
are somewhat different, particularly as to the 
order of their procession. When the blood is sent 
in insuflicient quantity to, or is entirely prevented 
from arriving at, an organ or part, the effect upon 
the nervous and vascular organisation of it must 
be such as to cause its atrophy or death ; for the 
fluid requisite to nutrition and life is no longer 
supplied to it. But when the return of the blood 
is obstructed by lesions of venous trunks, or by 
tumours pressing upon them, or by disease of the 
heart, an undue accumulation of blood takes 
place in the capillaries and veins beneath the 
•eat of obstruction; the blood stagnates more 
or less ; the capillaries are distended beyond 
their powers of reaction, and their tonicity 
is exhausted; effusion supervenes in the more 
porous and yielding tissues ; the organic nerv- 
ous and vital power of the part, already 
impaired by the stagnation of the capillary 
circulation and the venous properties of the 
blood, are still further depressea by the pro- 
gressive effusion and distension; and at last, 
if the obstruction become complete, the vital ma- 
nifestations of both nerves and capillaries are 
entirely extinguished. The varieties which thus 
proceed from these different pathological states 
require separate notic&o. 

IS, A, Gangrene from ObstructUm cf Arte- 
ri€t» — A ligature placed around an arterial trunk, 
when the circulation is not supplied by collateral 
or anastomosing branches ; the rupture of the in- 
ternal and middle coats of an artery, occasioning 
obstruction of its canal ; inflammation , followed 
by the accumulation of fibrinous lymph in its 
interior, and obliteration of the vessel ; and osseous 
or fibrinous deposits in its coats or in its cavity ; 
are the circumstances which give rise to this 
variety. — a. Gangrene from rupture of the 
internal eoatt of an artery has been described by 
Professors Turner and Carswell. The rup- 
ture of these coats is obviously the result of pre- 



vious disease. But, however produced, it is ma- 
nifest that the lacerated part, with the lymph 
effused from it, will often prove a nucleus around 
which a fibrinous coagulum will form, and in- 
crease until the circulation in the vessel is en- 
tirely obstructed. The gangrene will be merely 
contingent upon this occurrence;' for the coagulum 
may not entirely obstruct the vessel ; or the ob- 
struction may be complete, and yet the circulation 
may be earned on by collateral, or by enlarged 
anastomoang vessels. — An abstract of one of 
the cases detailed by Mr. Turner will illustrate 
the progress of gangrene from this cause, as it 
agrees with one which I had an opportunity of 
seeing, and in which amputation was performed. 
About half an hour after rupture of the popliteal 
artery, no pulsation could be felt in any of the 
arteries of the foot, nor in the ham. The foot 
was cold. No pain was excited by pressure on 
any part of the limb ; but cramp-like pains were 
felt m the calf of the leg. The following morning 
the foot was pale and cold, and the integuments 
below the ankle were entirely void of sensation, 
even when pinched or tickled. The muscles of the 
foot seemed to have lost their power of contraction. 
The next day, mottled purple patches appeared 
on the instep and fore-part of the ankle, and gra- 
dually extended over tne whole foot, till the sur- 
face, by the fifth day, was entirely livid. With 
the progress of discolouration, the foot swelled 
slightly, became cedematous, and seemed some- 
what warmer. On the seventh day, several tense, 
globular vesications appeared on the foot, some 
filled with reddish, and others with pellucid se- 
rum. They increased in number, and extended 
to the calf of the lee. About the ninth day, the 
soft parts above the ankle were livid, the dis- 
colouration proceeding upwards to the calf of the 
leg, and soon afterwards nearly to the knee. The 
soft parts adjoining the discoloured skin were 
swollen, and very painful on pressure, but no 
redness nor any inflammatory line between the 
gangrened and living parts appeared. The dis> 
coloured parts were completely insensible. The 
patient had been much reduced by his previous 
illness ; but with the progress of the gangrene* 
weakness, tendency to faint, copious sweatings, 
quick and feeble pulse, became very prominent 
symptoms, which were followed by cough, labo- 
rious breathing, and death upon attempting to 
sit up in bed. — The coats of the artery were found, 
torn, thickened, and the canal filled by fibiine, 
lymph, and coagulated blood. 

19. b. Inflammation of the internal coals of 
an artery t particularly of one or more considerable 
branches, is followed by effects similar to those 
just described ; especially if the obstruction of 
their canals, by lymph and coagula, be complete. 
Gangrene from this cause has been noticed m the 
article on Inflammation of Arteries (§ 29.). 
It may occur in internal viscera, as well as in ex- 
ternal parts, although the evidence of its existence 
in the former is not so complete as may be desired. 
The gangrene that sometimes attacks a portion of 
the lungs may probably arise from this cause, but 
there is no satisfactory proof of such being the 
case. It does not, however, appear unreasonable 
to infer that, in some constitutions and habits of 
body, inflammation may extend from the substance 
of the lungs to the blood-vessels themselvei — 
arteries or veins — and that the inflamed pan may 



16 



GANGRENE — FBOM Pozsoyi. 



if not developed. It is not until the frozen part 
is thawcJ» or exposed to heat, Uiat gangrene is 
manifested. Tlie vitality, reduced or extinguished 
by the diminution of temperature, cannot be re- 
stored in all the affected tissues. The blood 
becomes again Huid, but it has lost its crasis, and 
separates into serum and coagulum in the smaller 
ve*i»elH. .Sen^iibility, motion, and animal life do 
Dot return, 'i'lie skin covering the part assumes 
a livid or hrownitth red colour ; phlyctentp appear 
on its hurfacc ; with grey, purplish, or black spots, 
indicating the passage of the ganijrcne into spha- 
celus. 'J he livine parts closely adjoining the gan- 
grene are now injected and inflamed ; the vascular 
reaction which they experience exhausting the 
remaining vitul properties, especially of the ca- 
pillaries, and extending the mortification, as in 
gangrene from inflammation. In slight cases, 
although con>;e]ation may have taken place, the 
circulation and sensibility of the part is often re- 
stored ; a tingling or pricking sensation is felt ; 
reaction supervenes, and even becomes excessive ; 
and, owing to previous reduction of vital power, 
and the ronsfcutive action, exhaustion of the 
affected structure, followed by lost power of the 
capillaries, (iiniinished cohesion of the tissues, 
coagulation or other change of the blood in them, 
and by gangrene, soon afterwards appears. In 
these cases, the external changes are altogether 
similar to those just described ; but the extent of 
mortification dn{>ends upon the constitution of the 
patient, and the violence of the antecedent and 
attendant inflammation. 

31. vi. GANcnKNE FuoM Poisons. — The poi- 
sonous substances to which attention will be here 
directe<l, are — 1st. Diseased vegetable produc- 
tions ; 'id. Diseased or decomposed animal mat- 
ters ; and, 3d. The {loisons generated by certain 
animals. — yl. (ianfi^rene from Diseased Grain is 
soinetimes seen among those who live chiefly on 
rye. Of the general effects of this and of other 
grains, when used in a diseased, unripe, injured, 
or mouldy state, some notice is taken in the article 
KaofnisM. l)ut the influence of tpurred ri/e in 
caiisinv gangrene ref|uire8 a particular notice at 
this nlace. Spurred rue, when used with the 
Bounu grain as food, produces, according to the 
quantity, somewhat oiflTerent effects — either row- 
vutaive ergotism, or gangi-enous ergotism. ])ut 
both these species of disorder may be associated, 
or the former may be followed by the latter, 
cither of them existing in various grades. Indeed, 
the gangrenous disease is generally preceded, 
or even attended, by some degree of spasmodic 
affection. 

'32. A. Gangrenous Krgotism — Xecrosisttstala' 
ginea, Sauvaoes — Gangrtne des Solognois — has 
been observed both sporadically and epidemically. 
It has been supposed that the epidemics which ap- 
peared in various parts of Europe during the 
middle ages, and were denominate<l Ignu Sacer, 
Saint Anthonu*8 Fire, Mai des Ardent , &c., were 
occurrences of this variety of ergotism in a severe 
as well as epidemic form. The gangrene and 
separation of the limbs mentioned with respect 
to them countenance this supposition. It was 
not, however, until the epidemic of ITesse, in 
1696, that the eflfects of spurred rye on the occo- 
nomy were fully recognised by physicians. In 
1 63U, an epidemic gangrene appeared in Solognc, 
and was traced to this cause by Tuuillier. 



Subsequent occurrencet of tbii malady, is dif> 
ferent parts of France, Switierland, and Germany, 
have been described in connection with this cum, 
by Perrault, DoDABT,BBUX7mi, Nobl, Lmbo, 
Dun A MEL, Salebnb, Read, and others. — Thi 
experiments performed by Tiessieb in 1780, ui 
the facts detailed by Ianson in 1818, have far- 
ther elucidated this subject. 

33. Gangrenous disease from the nseof ^uniA 
rye generally commences with vertigo, faistncHk 
diminished sensibility, and slight convnlsive m 
spasmodic movements — with the chief symplBM 
of spasmodic ergotism. But it is sometinwi Mt 
preceded by any of these. In this case, it is 
ushered in by lassitude aod weakness of the lom 
extremities, with deep-seated pain, increased by 
heat, and aggravated during night. There ait 
occasionally, at this period, slight swelling, ImC 
without redness ; and, in some instances, eteii t 
waning of the extremities. The tempcratna, 
motions, and sensibility, of the parts are aftep> 
wards lost, although the deep-seated pam itil 
continues. The integuments now become wiinUed 
from the shrinking of the parts contained bj thea. 
Phlyctenae appear on the surface; the skin ai> 
sumes a violet, livid, or black hue — not, bow- 
ever, in all the places affected, but first in tka 
heel, feet, or various parts of the thighs or 1^ 
Sometimes the gangrene extends from the vf> 
per portions of the limbs to their extremitiei; 
or from the more internal structures to the ia^ 
guments ; and in other cases it proceeds from tha 
toes upwards. When it reaches thetrenk,aii 
often before it advances so far, the patient uAm, 
It generally proceeds gradually, and n not linuM 
to the lower extremities, the upper being oAn 
affected. When it is arrested, an inflammatej 
circle forms around the dead part; and, at tba 
points of separation, an abundant and very fiedd 
suppuration is established. — The gangrened por- 
tions are dry, hard, and shrunk. A whole finb 
may be thrown off in this state without the \am 
of a drop of blood. 

34. Gangrenous ergotism seems, from the eariy 
efl*ect produced by its cause upon the nerroa 
system — from the spasmodic contractions, in- 
sensibility, weakness of mind, and fatuity, often 
accompanying it — to arise, in a great measoxc, 
from lesion of this system. The circulating floidi 
are evidently also deteriorated ; the affectioB of 
the nervous system being probably caused by the 
change in the blood. \\ hatever that change it, 
it may be supposed to affect also the blood-vessels, 
particularly tnot<e most removed from the centre 
of the circulation. But the vessels, as well as 
the internal viscera of persons who have died of 
this disease, have not been investigated. In this 
state of ignorance as to the morbid appearances 
after death, several opinions have been hazarded 
as to the nature of tne alterations which termi- 
nate in this manner. Some suppose that inflam- 
mation of the blood-vessels is produced; and 
others contend that the existence of inflammatory 
action is not indicatetl by the descriptions given 
by observers of the disease. Without the data 
furnished by the minute examination of the blood- 
vessels and nerves after death, all speculation 
as to the nature of the disease must be incon- 
clusive. 

35. B. Gangrene from Dueaad or Decnmpottd 
Animal Matters, — Mortification may take plac« 



18 



GANGRENE— Constitutional Symptoms. 



40. d. The morbid fluids and secretions of 
several of the lower animals often produce very 
serious eflects when applied to the denuded sur- 
face, or even to the sound skin ; and these efTects 
are generally attended or followed by gangrene 
of the part with which they come in contact. 
The occurrence of Malignant Pustule (see the 
article) is an illustration of this fact. The ap- 
plication of the blood or raw flesh of a diseased 
animal to a part will often occasion gangrenous 
inflammation of it, although the flesh of these 
animals may be eaten with impunity when cooked. 
Of this, various instances have b^n adduced by 
MoRAND, DupUY, Leuret, Hamont, and others. 
I believe tliat, in all cases of the production of 
gangrene by morbid secretions and other fluids — 
whether of the lower animals or of man — the local 
as well as the constitutional effects produced by 
them are most virulent, when they either proceed 
directly from the living animal, or act veiy soon 
after death; and that they are less injurious 
when they have undergone the changes constitut- 
ing incipient putridity or decomposition. 

41. C. Gangrene from poiiom generated in 
healthy animalst as in the viper, rattlesnake, &c., 
commences and proceeds with amazing rapidity, 
upon insertion of the poison, and with remarkable 
depression of the vital manifestations of the con- 
stitution, as well as of the part thus inoculated. 
The insertion of the poison induces intense pain, 
which rapidly extends ; swelling and hardness of 
the cellular tissue ; dark redness at the point of 
injury, soon followed by a spreading livid dis- 
colouration; and diminution of temperature. — 
The skin is rapidly covered by phlyctene ; the 
cellular tissue becomes soft, and crepitates on 
pressure ; and the puncture discharges an offien- 
■ive sanious fluid. Almost immediately upon 
inoculation of the poison, and co-ordinately with 
the rapidity and extent of the local action, an 
Intense effect is produced upon the whole frame 
(J 50.). 

42. II. Of the Constitutional Symptoms 
OP Gangrene. — The states of vital manifest- 
ation throughout the system, vary somewhat in 
each of the forms and circumstances, in which 
ffangrene and sphacelus appear. I shall, there- 
fore, take a very brief view of those which are 
usually seen in most intimate union with each of 
these forms. — A, Mortification from inflammaliim 
presents no uniform relation to the severity of 
the local action, or of the sympathetic constitu- 
tional disturbance, although such relation obtains 
in a general way. — Inflammation of much inten- 
sity, in a constitution previously debilitated, or in 
t habit of body already cachectic, or during a 
deteriorated state of the circulating fluids, is al- 
ways more or less liable to terminate in gangrene. 
Its occurrence also, in a highly sanguine, irrita- 
ble, and plethoric state of the system, particularly 
when this state has been induced by living highly, 
or by the excessive use of intoxicating liquors, 
is a no less unfavourable circumstance ; and, 
equally with the foregoing liabilities, should be 
taken into account when symptoms indicative of 
this termination appear. In the former class of 
occasions, in which gangrene may occur, the 

10th day flrom the attack of the gangrene The whole of 

Mr. C HirrcBisoN*! obMnrations on thii disease are re. 

saft» ofaaet tatcnaivt experience, and are very inter. 



inflammation, although slight or limited, may 
nevertheless be excessive, relatively to the state 
of vital power and of resistance to injurious im* 
pressions or actions : in the latter, there is always 
a disposition to intensity of action so great as to 
quickly exhaust the vital properties of the vessels ; 
if this intensity be not promptly reduced, and the 
consequent exhaustion either anticipated or 
promptly met by local or general means appro- 
priate to the peculiarities ot the case. 

43. To detect the commencement of gangrene 
in any internal viscus is by no means so easy as 
it has been represented by many writers, who, 
merely copyine or compihng from one another, 
have thereby often perpetuated error. The tuddem 
iinkingt so often insisted upon, attends vaiioos 
other pathological conditions besides gangrene; 
and, even when it is observed in connection with 
this lesion, it may be the attendant of that change 
in the state of vital power, of which gangrene is 
only one of the remote consequences. — When 
this symptom appears somewhat suddenly, it indi* 
cates one or moi-e of three states ; — a. It may de> 
pend upon the depression of organic nervous power, 
generally as well as locally ; — B . It may arise 
from commencing gangrene ; — y. And it may be 
caused by the passage of morbid or putrid mattar 
into the blood. The pulse varies on the accesnoa 
of gangrene, with the previous grade of local action 
and of attendant fever. When action has been 
very high, the pulse retains its frequency, bet 
becomes weak, small, soft, and very compressible^ 
and ultimately irregular, intermittent, or even 
slow, just before death. When there ^has beei 
but little previous fever, the pulse is very feeUe, 
undulating, unequal, intermittent, and slow; bet 
it is readily affected, in either case, by mental ar 
physical impressions. The animal heat makg 
rapidly with the pulse when gangrene supenreaes; 
the extremities becoming cold, and the sorfaoe 
covered with a clammy perspiraticm or sweatp 
which is cold and raw as aissolution draws near. 
If the antecedent symptomatic fever have been 
slight, the mind may be undisturbed to the vc^ 
last ; if severe, delirium, picking at the beil- 
clothes, stupor, coma ; accumulations of mncoei 
sordes on the tongue, teeth, and lips ; fcjetor of tki 
breath, and even of the body ; and unconscioH 
evacuations, for a longer or shorter time beftn 
death, are not infrequent. 

44. Besides these, various other tympumt 
appear, but without any uniformity or constescy. 
These are, faintness or syncope, particularly wWe 
the head is raised ; hiccup; vomitings, somtii— 
without severe retchings, or a passive rejectioe ef 
matters from the stomach ; a peculiar nngiei" 
ous odour exhaled from the body, and mmilhl 
excretions ; a sunk, collapsed, pinched, and eaU 
state of the features ; a dusky, lurid, and mm^ 
times a jaundiced, appearance of the skin ; typ 
panitic distension of the abdomen ; ofleMfi 
eructations; an emphysematous state of paMi 
wandering delirium, especially at night, w variatt 
passing delusions; tremblings or ahadderiB|Pi 
and restlessness, or laborious hurried re^iiaM* 
An offensive gangrenous odour of the expired fk 
is very remarkable when gangrene occnis in Al 
lungs ; but it may accompany this lenoaieMy. 
other part, if a portion of the morind w dafli* 
posed matters pass into the circulatioii. la 4 
case, all the ezcretionf — pulmonaiy^ 



20 



GANGRENE — Prognosis. 



of the gan^ene, and the rapidity of its accession 
and extension. Where want, improper food, and 
intemperance have already produced their effects 
on the frame, the constitutional commotion attend- 
ant upon the injuries produced by the extremes 
of temperature, generally presents more of a 
nervous character throughout, than in other cir- 
camstance?, with a rapid, small, weak and irregu- 
lar pulse ; and frequently with tremor, delirium, 
or even both, or with more or less agitation. — 
c. Chemical agentt affect the system chiefly by the 
inflammation they excite in the part to which 
they are applied ; unless the injury is extensive 
or violent, when the symptomatic effects will 
nearly resemble those caused by extensive burns 

a 48.). 

50. £. Gangretie from poisons is always pre- 
ceded and attended by severe constitutional af- 
fection. — a. That occasioned by spurred rye is 
generally preceded by lassitude, faintness, weak- 
ness of the senses, vertigo, spasms, and symptoms 
of general adynamia, manifested both in the vital 
and animal functions. Sleep is prevented, by the 
severe pains in the limbs. The powers of mind 
are generally impaired ; and, with the appearance 
of gangrene in the extremities, all these symptoms 
are increased, until the patient sinks into insen- 
sibility, or dies in a state of syncope. — 6. Gan- 
grene from putrid or diseased animal matters is 
prececfed, as well as attended, by the severe con- 
stitutional effects, described in the articles on 
Diffuse Inflammation of the Cellular Tissue, 
Erysipelas, Malignant Pustule — either of 
which may be produced by these matters — and 
more fully elucidated in those on Putro^dynamic 
Fever, and Animal Poisons. 

51. e. Hospital gangrene is dXwAyBtiitended by 
adynamic fever; and, in the circumstances al- 
luded to above ($ 38.), it is often preceded by 
more or less depression of nervous and vital 
power, although rarely by prominent febrile 
symptoms. Derangement of the digestive func- 
tions, sometimes diarrhoea, a quick and feeble 
pulse, and physical and mental depression, gene- 
rally usher in, and attend, the early progress of 
this ganerene. Dr. Hennen states, that men 
who had borne amputation without a groan, 
shrunk at the washing of their sores, shuddered 
at the sight of a dead comrade, and even pre- 
dicted their own dissolution, sinking into sullen 
despair. Towards a fatal close, prostration of 
all the vital manifestations, faintings, diarrhoea, 
vomiting, hiccup, delirium, discolouration of the 
general surface, insensibility, coma, cold clammy 
sweats, involuntary evacuations, &c. successively 
appear. 

52. d. The poisons of reptiles occasion a sense 
of sinking at the epigastrium, oppression in the 
prsecordia, laborious breathing, vertigo ; pains in 
various parts of the body, particularly in the 
stomach. Dowels and head ; vomitings, diarrhoea ; 
impaired vision and sensation ; with a small, 
feeole or intermittent pulse. To these succeed, 
extreme sinking and anxiety at the epigastrium 
and precordia, great thirst, syncope, singultus, 
offensive foetid breath, a jaundiced or sallow 
state of the skin, coldness of the extremities and 
of the general surface, clammy sweats, insensi- 
bility, and death, unless the progress of vital 
depression be arrested by the most energetic 



53. III. Prognosis. — The proenosis, although 
generally unfavourable, varies with the different 
circumstances in which gan^ne presents itself; 
and the extent to which it has proceeded.— 
a. Gangrene consequent upon inflammatory actien 
is commonly fatal when an internal organ is af- 
fected, especially when the general excitement 
suddenly subsides, the pulse becoming quickly 
feeble, small, or thready; the features pinched 
or collapsed ; th"; surface lurid, sallow, or livid ; 
the respiration laborious or diflBcult; and the 
perspiration or other excretions foetid and gan- 
grenous. Sin^ltus, rejection of the contents of 
the stomach without effort, syncope, and involun- 
tary evacuations, are indications of the near ap- 
proach of dissolution. But all these phenomena 
are often manifestations merely of that state of 
local and general derangement, of which gangrene 
is the immediate result, rather than of gangrene 
itself — at least of gangrene to any extent ; fior 
dissolution may take place before this lesion ii 
fully developed. — When this form of grangene 
is external, its extent is less an indication of 
danger, than the character of the constitntioaal 
disorder, and the disposition evinced by this lesion 
to extend. — In all cases, the habit of body, the 
age, modes of living and previous health of the 
patient, and the exciting cause and character of 
the previous inflammation, should be taken into 
account. If these are favourable, if vitd actum 
be not very depressed, and if a disposition to 
form coagulable lymph and to arrest the disoiie 
appear, recovery may be expected. 

54. b. Gangrene from debility , from diseam ef 
the nerves, and from obstructions of the arteries 
or of the veins, should receive a guarded, if not 
always an unfavourable, prognosis ; for, in thcsi 
circumstances, although some cases may recover, 
the great majority will terminate fatally. When 
it occurs from ossification and obstruction ef thi 
arteries, or from disease of the heart, a fatal resslt 
will surely follow ; although it may be deferred 
for some time, in a few instances. — c. When it if 
produced by any of the more common physieel 
agents noticed above, a much more favourable 
event may be anticipated, unless the intensity of 
the cause, and the extent to which it has acted, 
have given a very severe shock to the system, 
have depressed vital power beyond the abdity of 
resistance, and induced low nervous fever with 
cerebral affection. 

55. d. Gangrene from the use of spurred mt 
requires a cautious opinion as to the result ; W 
when the disease produced by this agent his 

I given rise to this alteration, matters will frequently 
have gone too far to admit even of amelioration^— 
Nor is the prognosis very different, when the de- 
leterious effects of any of the animal poisimf men- 
I tioned above have become so manifest as to be 
j attended by gangrene. The most energetic means 
' alone can then arrest the progress to dissolution ; 
and these may be rejected from the stomach, or 
fail, even when retained, of rallying the poweii 
of life. In every circumstance in which gangrene 
occurs, irritability of the stomach is a most dtn- 
gerous symptom. — In hospital gangrene, how- 
ever, removal of the patient to a pure air, and an 
appropriate treatment, at an early stage of tbs 
disease, will be attended by succew, in the am* 
jority of cases. 

56. «. Of all the circumstances that ilwiiki bt 



S3 GANGRENE — Thkatmeii t. 

recommended for (rangrene without sufficient ; usually present requires the ezhibibon of 0|ntn 
reference to the states of vascular action and of in large doses, frequently with camphor, cr in^ 
vital powt-r ; or to tlie eHect either of them mav monia. or the subcarbiMi&tes of the fixed akiliei 
produce upon thc^c ^tute*. and upon the disposi- and warm aromatics. Even on the threaiened 
tion to limit or tu e&tend the local disease ; or to accession of this le»ion, local depletions majbi 
the influence they may eiert in favouring the still required. Purgatives are generally beseficiaL 
contamination of the circulating fluids or in Warm anodyne fomentations may be applied to 
depurating the blood, ami in promoting the func- the limb, at this period ; and the other extenal 
tions of the principal secreting and excreting remedies of which mention will be made ken- 
organs, after should be afterwards employed, parties 
60. d. If the pulse be weak or soft, and the sk'n larly if the part pass into spnacelatioD. Ii 
cool or moderately warm, the preparations of other respects, the treatment should be coi> 
cinchona, serpcntaria, and the mur ate of am- . ducted conformably with the principles developci 
monia ; or the sulphate of quinine with camphor above. 

or ether ; or the infusions of cascarilla, or of va- 63. D, The treatment of gangntu fr^it 4- 

lerian,ur of calamus aromaticus, with the chlorate structrd rircu/ation, through either the vesKhi 

of potash and chloric ether, will be rc([ui«ite. or the heart, depends much upon the seat aid 

At the same time, the excretions should be pro- cause of obstruction. — If inflammation of tki 

moted by stomachic purgatives, as the compound arteries and veins be concerned in prodocingii^ 

infusions of gentian and senna, with the alkaline the means of cure ought to have reference to tki 

subcarbonat..8, and ammonia. — In a case which states of vascular action and of %-ital enerfj, M 

was ably treated by IMr. Moiti.i.v of New Caven- , in gangrene from inflammation ; but, in res*Mt 

dish Street, to which 1 was callcl, this treatment to phlebitis especially, vital power and resistaiei 

wa4 immediately efficacious. When diarrhoea is should be so liberally supported, as to ensblete 

present, opium siiould l>e added to these tonics ; vessels to form coa^^ulable lymph, in order M 

or the chlorate of lime may be prescribed. In limit the extension of the lesion, and prevent tki 

cases where the attendant iiiflammatoiy fever is contamination of the fluids. — When it is caaMi 

about to pa«s into the nervous or putro>advnamic by $traugulation of, or preuure upon, the^'di^ 

states especially if the gangrene have gone on the treatment must entirely depend upon ihl 

to sphacelus, the exhibit-on of these, or of other states of vascular action and of vital power. Thi 

tonics and stimulants, •ihould not be delayi d too former ought not to be allowed to continue Ug^ 

long, otherwise the adjoining vessels may not be nor should the latter be permitted to sink, withoat 

enabknl to exert that degree of sthenic action having recourse to means to support the ON^ 

requisite to the formation of coao^lablc lymph, and to lower the other. — For senile gangiea^ 

whereby the extension of the lesion may be or that ari>ing from owf/lfriilii>fi of, and impeM 

limited, and the absorption of morbid matters and circulation in, the arteries, little beyond palliauw 

the consetiuent contamination of the blood pre- of the urgent symptoms can be eflTected. Iki 

vented. The stomach may become so irritable, same remark applies to that caused by ^ifsnt^ 

when viul depression is not arreote<l sufficiently the heart. Opium or the salts of morphia, eilbtf 

early, as not to retain the medicines most likely alone or conjoined with camphor, musk, ammoniat 

to be serviceable. This occurrence should be as or similar substances; the alkaline subcarbonata* 

far as possible prevcntt d, as l>eing most dangerous or the sub-boratc of soda, with anodynes ; toiucfi 

in itself, and as favourintr the passage of antispasmodics, or stimulants, conjoined wiiii 

morbid matters into the ciiculation. \V hen it has these; attention to the digestive and exrrciiDf 

appeared, I know nothinv^ more efficacious in functions; the horizontal position; and fiuin- 

diminishing it than ammonia, lar;rc doses of ccous or milk diet may be severally imployed ii 

Cayenne pepper, and opium, gencMliycombined, both these forms of gangrene, 

and given in the form of pill. Warm wine and 64. K. Gangrenejrom phusical agenti shonU 

water, or brandy and water, with Cayenne, or ' be treated according to existing states of local 

other hot spices ; or the acetate or muriate of and general action and of vital power, wbick 

morphia, with aromatics, may likewise be em- have l)een shown above to differ very materially 

ployed. Upon the whole, inllanimatory gangrene, according to the severity, seal, and duration M 

at an advanced stai;e, or gant^ienc consecjuent the injury. — That caused by burns reqoirci 

upon asthenic inflamniatiun, or attended by the blooilletiing. if the vascular excitement be great* 

usual symptoms of adynamic fever, re(|uircs a liut action, in these cases, although high, uiel- 

very similar treatment to that which I have ad- dom attended by much power. Therefore va»- 

vised in the advanced periods of Putro-adtftiamic cular depletion should be practised in moderatioa 

FivtR (sec that aitide). and with caution; the ncrvoua excitement and 

61. B. The con«.tiiutional treatment of gan- irritability of the system retjuiring the chief attea- 
grene from dehilitu and jleterioralion of the cir- tion ; for, if allowed to proceed, they increase 
dilating fluids (^16.) consists chielly in the ex- remarkably the severity and extent of the local 
hibition of tonics and stimulants ; of the chlo- injury. When the shock sustained by the con* 
rates of potash, and of so<la ; of camphor, musk, stituiion has been severe, depletions will be ioja* 
and ammonia, with o;num and capsicum ; and of riou-. In these ca^e-*, restoratives ought to be 
the other restoratives' mentioned above (>i 60.) ; administered, generally with opium or other ano- 
and differs in no respect from that advised, in dynes. These latter are required, in most caiff, 
difl'usive inflammation of the cellular (f*s»c, in and they should be aided by such local neani 
the adynamic stales of ertt^ipeluf, and in the a<i will allay the painful heat and ^nsibdity cf 
typhoid forms of fever. the part. In severe injuries of this kind, the 

62. C. When diteauofthe nerves threatens the ' alarm of the patient, and the excitement directly 
production of gangrene, the morbid sensibility I produced by them, commonly occasion an appear- 



u 



GANGRENE — Treatment op Hospital. 



f tate of the circulating fluid is overlooked in these 
views, yet they are correct in the main, and form 
the basis of a rational and successful practice in 
this and several other maladies. 

69. 0, Before I proceed succinctly to state the 
practice I would recommend conformably with 
these opinionsi and with the results of observation. 
I shall briefly notice the constitutional means ad* 
▼ised for this disease by some experienced writers. 
On the first manifestation of hospital gangrene, 
imetia are recommended by Pouteau* Dus- 
8AussoY,BRiGos,THGiisoN,and H£NNEN,and are 
evidently of service, at this period, when there are 
signs of biliary derangement. — Bloodletting is 
considered injurious or productive of little benefit 
by Blackadder, Thomson, and Bogoie, whilst 
Dr. Hennen and Mr. Welbank consider that mo- 
derate depletion is serviceable early in the attack, 
and in strong plethoric persons ; and that the risk 
of the disease attacking the lancet-wound may be 
prevented by accurate closure* and by allowing 
the bandage to remain undisturbed until the ci- 
catrix is completely formed. — Purgatives are di- 
rected by Dr. Boooie and other writers, but they 
should be warm and stomachic, or conjoined with 
tonics, stimulants, or aromatics, and exhibited 
early in the disease. It is chiefly after morbid 
secretions have been evacuated by the early exhi- 
bition of emetics and purgatives, that advantage 
from tonics and stimulants will be most appa- 
rent ; and it is probably from an insuflicient at- 
tention having been paid to this circumstance, that 
so much difference of opinion exists as to the pro- 
priety of using these latter remedies. 

70. Cinchona alone, or in various states of com- 
bination, is praised for its good effects in this 
disease by Boyer, and numerous experienced 
writers, whilst Hennen and Welbank considers 
that it is iniurious. It is recommended in con- 
junction with the alkaline subcarbonates by Van 
Wy, and Saviard ; and with camphor, by Fla- 
jANi. — CampW is much used in this form of gan- 
grene by Continental practitioners. Pouteau, 
CoNRADi, WxNZEL, and Ontyd prescribe it in 
large doses. I have seen much advantage de- 
rived from it ; but I prefer to give it in the forms 
of combination to be mentioned hereafter. — The 
artenieal solution is directed by Otto. It may be 
employed in similar states of constitution, to those 
in which cinchona or sulphate of quinine may be 
prescribed. — Arnica, cascaritla, and various other 
stimulants and aromatics are recommended by 
various authors, but they are useful merely as ad- 
juvants of other more active means. — Acids are 
noticed in favourable terms by Mr. S. Cooper, 
and several other writers ; but I have much doubt 
of any benefit being derived from their internal 
use. The hydrochloric and nitric acids, or a com- 
bination of both, promise most advantages of this 
class of medicines. — Of the propriety of exhibiting 
opiates there can be no doubt ; and roost writers 
agree on this point, and difler only as to the 
period of having recourse to them. Dr. Thom- 
son prefers them in the form of Dover's powder. 

71 . y. From observation of the results of different 
modes of practice in hospital gangrene, rather 
than from my own active experience, I would 
advise the adoption of a practice consonant 
with the views stated above. Having evacuated 
morbid secretions and fscal accumulations by 
emetica and warm stomachic purgatives, and di- 



rected a small or moderate bloodlettiDg, in anck 
cases only as are attended by excessive action and 
signs of plethora, I would advise the decoction of 
bark or the sulphate of quinine, in modes of com- 
bination appropriate to the peculiarities of the case. 
If vascular action continue very much excited, the 
decoction of bark may be conjoined with the nitrate 
of potash, the solution of the acetate of am- 
monia, and the spirits of nitric ether, or with the 
muriate of ammonia and chloric ether. When 
vascular action presents diminished tone, the sul- 
phate of quinine may be exhibited in the com* 
pound infusion of roses ; or in the form of pill 
with camphor. Where the pulse is weak and 
quick, the evacuations offensive, and the di*pot- 
ition of the gangrene to extend very evident, the 
decoction of bark should be combined with the 
chlorate of potash, and compound tincture of 
bark ; and if anxiety, pain, or irntability be present, 
the tincture of opium or the muriate of morphii 
may be added. The great frequency of pulse, 
and loaded state of the tongue, generally observed 
in hospital gangrene, even indicate the propriety 
of having recourse to these and similar Tenaedm, 
or to wine, in some cases. Regard should 
also be paid to the previous habits oi the patient; 
and persons addictc» to spirituous liquors may be 
allowed them, but in duel^ prescribed quantitiet. 
If the stomach become imtable, the treatment 
I have advised above ( $ 60.) may be employed, 
or spiced wine may be given ; or soda water, 
spruce or ginger beer, or Seltxer water, may aeve< 
rally be made vehicles of tonic, stimulant* caiduc, 
or aromatic substances. 

72. If diarrhoea appear, and threaten to ex- 
haust the powers of the constitution, opium, or 
the compound tincture of camphor, snouldbe 
given in full doses, with the tonic and antiseptic 
remedies already mentioned ; or the chloride of 
lime may be used internally with tonics and aro* 
matics, or with camphor, and the warm spices, 
or administered in mucilaginous and emollient 
enemata. If delirium supervene, exhaustion of 
nervous power, with or without deterioration of 
the circulating fluids, may be inferred to exist ; 
and camphor with opium, or henbane, the decoc- 
tion of bark, with the alkaline subcarbonates and 
tincture of serpentaria, wine, and the other re- 
medies recommended for Putro-adynamicTKWt, 
and the low forms of Delirium (see these articles), 
should be prescribed with a decision commen- 
surate with the urgency of the case. Camphor, 
in order to be beneficial in hospital gangrene, 
ought to be taken either in frequent, or in large 
doses. If vascular action be much excited, it 
will be advantageously conjoined with the nitrate 
of poush, or nitrate of soda, or the alkaline sub- 
carbonates, or other saline refrigerants. If vas- 
cular action be weak or impaired, and vital power 
manifestly reduced, it should be combined with 

I the preparations of cinchona, or of serpentaria, 
or with the chlorides and aromatics. Cascarilla, 
j cinchona, or arnica may be severally employed, 
I in similar forms of combination, appropriately to 
! the circumstances of the case. 

73. In this form of gangrene especially, pro- 
phylactic measures founded upon a knowledge of 
the causes specified above ( § 38.) should be 
strictly enforced; and, as toon as the disease 
manifests itself, the patient should be removed into 
a well ventilated and dry apartment, and the 



26 GASTRO-EXTERIC DISEASE. 

dis«tibl. diet only »honld b. pre«=ribed. If the ] ^ ^-l^rfj^T^^^^l^^^ Jjc 
patient enjoy not a pure and ilry air, he shouia, it ; » ^7 '. j^f Apuard^ .Sur la 6aii;!r. bvont , in Bifaiiath. 
DObfililc be n'movi'd to a situation posseasinj; llii» i Slrd^L Uiv.etlxv. ; el in Lond. Med. Kepoi. t ail p. sax 
Kvan.a,e. lIUmin.Ul.ouM be curoura««i.and t« rSA^JSS'vS'vW^i^&C^S^. SS?'-* 

(ianR. H|iontan.« in JMirn. de» Progr6a det Scirnon MMi. 
C4ltf». t. X. p. 1 'K>.— Sitme^ in Eilin. Mwl. and Sure Joura. 
Apr. 1»28. — AUT'ft in Archivn Gin^r. de MM. t air. 
n. 17.; —Larreif^'m IWil. t xiT. |». S-iZ. — B>«d/«ir, la 
Ihid. t xviii. |L 563.— i7. Listtm, ElcmenU of SuifciT, 
8vo. I»nii. 1N3^. — Begin, Diet de Mvd. ec de Cbic. 
(art. GaHgreHe^t- ix- H«r- 1833.— if. CarmfO, P^ 
tholcigtCAl An. tomjr, r«>c viL (Araf<«4ca/MM). fcL 
I/miL 18a5. ; and in.' Cycloik of Pi act. Med. tuL tiL 
IK 124 



dc .ai»gr«n«elSi.h:Mi'lJd;vprM Curat loiif.hvt.. Mor.Ibi.i. j| (jAifCBEWE FaoM CoLii. — Lagorer, Det Elftt* H- 
—P. Ftibr t, l)i« liaiiKr. ci S|»hMfl«). Ut-ti niiiiiatio, 4lo. 1 neraux dii Fn>id, rt «le« Moyrni de rappder A la Vielct 



his contidence insured, by the attention of bU at- 
tendaat!^, and the btarin^ of his physirian. 

BlXLIiKl. A>n KrFKE. — i. OABHiXI-.NE I.E-MEaALLT. CH- 
tu$A v.rap W n. :>♦. — /li-/i««, iVtrali. i*. »erin li. i>a|». :'<& 
— rauius .««»«<•/<!. I. »*■ I'- HI — 0» tbtiMitm^ S>nnp. 1. vii. 
C. '/7. — .-irnvJiii'i, rafion. 1. iv ten. iii. tract, i. rap 15.— 



Af A 

itn. 



MoHt ';:naH i, l)i* HiTpi-te, (iaii jr<riia, S|>liaci»lo, &C. 

VfNict. l.'»h!>. — Ftihi icius Hitt/tintis, Do (.iaiiKrvna et 
SJiiiaretft. ilas 'ftt v<im IIi>i»4i'ii iiiul Kalton Kraiui, J^o. Svo. 
Colon. l:A*i jciCViit ii. (mw. 88, ^! ».—./. /«fi/i/««if.<, <}"•*.* »« 
dc >aiixr«nc vtSph:M-i'li divorra C'iiratioiii>,hv(i. Flor.IHi.'lt 




Treatikc on (ianur.niN &c hvo. NottuiKhani, i,j4.— | 4,4 (jANUMR.xoi.-HKaoaTiHM.— t'.X Langimt, Dctaif^ 
MurfiafiHi, Dc StKl. ft I au-t. .Morb. K\mt I v. art. ij, '-5. — Morlxirnm vx UsuClavorum Seralinorum CainiMnic,hv& 
S f Umti f r, ihii. H i. - kirUaHtt, Inquiry into the l»ri>K>iil i.u„'rii«r, 1717. — Z>i«Affli*M-/, M<ta. de I'Aoui. dct Sri- 
Stalcof Mini icalSurBtry, vol iL — f. «ir.-*m»y, Ira itcdc en.-i-n, 1748. — C. IVMaatom, PhiL TraMLl76?. — E 
lalianKr^ne, li'mo I'ar. 174'».— J /ft;ii.«, Particular* of a >/«!«■/, Sur lo Traitpmcnt de la Gangrene •Mwqui 
Family all of whom MilKrwi under « .MortiHcation ot the ■ ^t^uin. j^ y ^.age d" S-'»K»e Ergot6, 8va Dijon, 177L 




GanRrjpi'ia .Mcta*t..lira. ,l'pwL 17?*7. — iJ^if/ m/j, vol. i. o'«c"jtiW"'sur iV Hour n lure d' H^^^ StrasMW 

' —J. /.ir//r, F.vijy on the Malignant CnnUgioui I'mr IB 

thv- N'avv, Mo. I^Hid. l-Uil — ('. R.J. Grommier, Ud 

^ I kur la Pmirnture d' Ilopiliil, M-o. Vjit. IhlO.— J. Crtu, 

Cine, t X p. '.ir.1 — f. n/r/Yr. l)l.»crv_ on (ianKreiie* or j skrtth.« ol the Mwliral SkhooU of Pans ^ S^ ^^^ 

MortilkMtions, Kvo WarniiKton, l.'.M). — J Huntt-r, A | jhi.-.. — //. IVcUhani, Meti. aiut (kir. Tranf. vol. xi. 8tft 

Treatise 011 the IJIiwkI, liifl.tminatioii, ^r. 4to. I^oiid. ' . . — . . 
17»ii —lluUdxtoti^ in IMiiloi". Transwui. \ol In. \}.'2 — Iiiu 



p -zM. — Mcx'i, in Act. Hc»r. Sh-. .Mi^il. Hain. v»l. i. — 
llagfndoru^ Cent iii- ()l«. -iS. — /^ I'ordtrr, in Journal 
do M.iU-cine, t. ix. p. 11. — Uarlue, in Jciunial de Mcvle- 



I^ind. ISJI.— ./. Ik/ptcM, Sur la Omipl cation deiPUi* 

- , et dcb I'lcd.c:* connue* »oui» le Nomdc Poumturcd*H6. 

fiiiHit!:tf, in Journal de .M^ilecine, I ix. ii. .ft •<. — //.i/rr, . ..jj.,!^ j^vo. Par. 18i:». — P. J. B. I'anfoutrrat, Cowiil. 
1)1-^. on li.ingreiie and Mortihration I'hildtUlph. 17l»/. j nur la <iaiigrOne Huinide, ou Pourriture d' l]6|iit«l, b*A 
— Hit/r/aHd, Journal der Pr. ATineylc. b. 11. n. m.;>. — ; j.j,^. IHI.".. — ./. ('. /f.Ni/n/. Ueber den Hospitalbran.l.Svoi 
t'. W/iw/v, Abh..mllunK ueber den Hraiid der Wjiihcii ' Mainz. IHt.O. — «. //. (ictjon, Ucber den Ho*p.talbrJDd| 
und Haiten Tbeile, Svo. t;.)et'. 1,1>» — A. d. .Nif/wm/i/i, 1 y^„ H.imburgb. 1817.—//. //. B/acttittd^. 0\mfTMMm 



Abliandlniigvom HiandeundlI«'iIiiii'iliiMlcdc^..enKMi,Svi». , „„ phag-ulsena GangraniB^, 8vo. 
Wien. ISiJl.— //nvAf/, CoiiMd. ration* Mir Tl vige du , /^.,,; snlla Cmcrena TontagioMX 
ChailMMi en Mctlivine, Journal <ieii.ra' ile .MtHbrine, q„ni,o, Ih'il). i. F. OiirUr, Trai 




Rrin.'Js'is.— T*'- i 

o NiiM> Comiair, hva \ 
Traits du Tyi»hu» 'nraim* 



Aiidiorum l*e»Unn (.aiij:raM 

tro I^thili. Vil.-b. l«iK;.-C. /IViiV, Ob*, on Oaii^r. , Altt'reJ SeHsihilitU of. 

and Moriiliuitions Ac. l.on.l. l,'n_y;. /. H'Jli^tW .-x iriji'/- rkict-Acr c^- 

DiK-trin.'P de (ianjirina Iki-xn K\|rt»»Uio, 4io. I.ei|i* UAM KU-K*N 1 I^Ull^ IJl^r^Aott, — oYs. 

1«„7. — F. ncbtnini, .^ur li=. lau^e^.t l- I'l-itenient de Ciii>tiO'eiitrnlii, Giislro-nitirHf, IJroussais. 

la tiaiiKrfine, 8vo. I'ar. l-S*/!*. — ilfi'/cr, lra:ie deB >Ia» 1 ., ^, 11 ^ ^. 

lad.e* Cbir. t. 1 p .:■.•■. P..r. ISI*.* - /^w/w../,,, D.ct. i (- i Aj^ML- ObNFRAL rAlIlOI.OGY. 

(I 's Science^ Med.c.-iK's t. Mii. IKJ;'. — .'. Ihiinch, I'rtVis 1. Iho d:9ea>e8 of ilic Stomach and lotestioes 
l,,cinenuire de:* Mala.lits ( liir. tip. l.U Kc i'ar 1 ^^0 irenlcd of in separate artiele-. But uot infre- 
1816 — HehrcanU l)"t. «le* >c. Mid. ,ait. (rdnrniu) 1 . 1 .1 ' i 1 • . .■ .. «.-.— 

t. xvii. Par. IMo. /. 7A(.wij.m', Letiurt* en li.ilain- 'luently loth the Muinach and intestines aie more 

Illation, p. 4."xl i7 fi-q Ktiin. ihi;. — ./. Ihntif-n, Vtmu or U-js.i flee ted at the same time bv inflammatory 

— J. H. .lawi's, 0\y-. on the Prinriple* ol Intlaninia. ti\ely of Other diseases, altnuUiih not in tlic »aroe 
tion. p. i-JL. i:b7. \c. ^vo. I^»nd. iS'-'l. — ,/. CrujH'r, Suv- ' niaiimr, or in the same depree. — Inflammatory 

lBSirriit:'ir('l.u^.<no"lic.mUs «'. ."'"kr "VsTT - /' .li-'-'^T co<.xUtinK in the .lumarh and intestincN 
A'rt//«-n6rttii*irr, Kxp riinentrt cirra Miluni S.-.ng. et Va- ahliwil>:)i not SO Common, as M. lilnns.sAlS has 
ftoruin in Inllain. M«mai"bi, lsy<; 4ic>. — OVHrfii/i Hi.t. contended, is Certainly vetv frequently ob>erved, 
Anat del Inflain. Pan*. 18'Jo, 'J t — /SHartf.lrnm.'t, . ,, . •'..1 Vi * • • .^ 

SKMiioiTsur unc Aifoit.on <iangrtneu>c p.irt.culM^rc I i5|.e..ully in amneclioa with other complamls. 
anx Knfan*. (Journ.-il c'oirplementaire, Hi: t I. — | Kv(n when appearing; as the cont>ecuiive aihnent, 
Aflvr./>c/«riw i)irt.dcM^iic.nc,i.vm imi>orlancc is often so great as to require 

L..Ch. Bocke. Journal Hebduinadairc (Juin, IH 0,.— . .1 ... ji l« S . •. • r •«- 

Af. /'. Aiuiry, Joum. dot Progrii dcs Scieucct Med, t. x. atlenUon to be directed chiefly U) it in formmg 



28 



GASTRO-ENTERIC DISEASE— Pathoiogt. 



dent to produce the latter, when the fonner is 
preient. 

6. 6. Dariog a number of yearB, I had almost 
daily occasion, at the Infirmary for Children, to 
enter against the names of some of the patients, 
gtutnhcatdrrkml Jever, or gastrO'hronehUie irri- 
tation or iujlammatiam, according to the features 
of the case, as the names of the affections for 
which they were admitted. In these, it was 
difficult, if not impossible, to determine which 
was the primary disoider ; but it was always 
erident that the complication was attended by 
nach danger, the more especially as it occurred 
chiefly in debilitated or delicate children, and 
extended to the bronchi of both lungs. In many 
instances, the affection of the mucous membrane 
appeared to be universal, and the progress to a 
fiittd issue was rery rapid. Gastro-enteric irri- 
tation, although it can scarcely be considered as a 
cause of tubercular eontumptiant unless when it 
has continued long, is a very frequent concomi- 
tant of the early, as well as of the advanced 
stages of this malady. I have often observed that, 
when the former has been aggravated by impro- 
per diet or treatment, the latter has also been 
exasperated. (See Tubercular Consumption.) 

7. e. Even the occurrence of pneunumia may be 
favoured by disorder of the digestive canal ; and, 
in this care, the pneumonia may assume a nervous 
or low character, constituting the Pneumonia 
nervoia of the older writers. The association of 
disorder of the digestive mucous surface with 
affections of the respiratory organs, although 
more generally neglected than might have been 
expected from the sute of science at the present 
day, has long attracted some attention, as evinced 
by the notices taken of it by the older and mo- 
dem writers, by the names Stomach-cough, Ver- 
nUnout Couaht and Dytptptie PhthiiU. In hoop- 
ing cought It is often difficult to decide whether 
the digestive or the respiratory mucous surface 
be the most affected : the vomiting in which 
paroxysms of cough terminate in various affec- 
tions of the chest, is perhaps as much owing to 
attendant gastric irritation, as to the convulsive 
action of the respiratory organs. In all cases, 
therefore, in which we have reason to dread the 
origin or association of pulmonary, or cerebral 
dis^ue, with gastro-intestinal irritation, inquiries 
ought to be made for the symptoms by which this 
latter is indicated. When pain, tenderness, or 
tension at the epigastrium, or in the abdomen, 
are present ; and particularly if the pain be in- 
creased on pressure, or be attended by nausea, 
flatulency, or acrid eructations, or occasional 
vomiting, and an irregular state of the bowels, 
the existence of gastro-enteric inflammation 
should be inferred, and the treatment ought to 
be directed to its removal. The means of cure, 
also, required for the pulmonary complication 
should be so devised as not to increase, if they 
may not diminish, the gastric irritation The 
diet of the patient oueht to be prescribed with 
similar intentions. When pulmonary affections 
are thus complicated, the treatment of them by 
means of tartarised antimony is frequently inju- 
rious, particularly in children, as tending both to 
aggravate the gastric disorder, and the nervous 
depression often attendant upon them. Even 
when pneumonia is thus associated, the tartar 
emei/c nuty he dispensed with ; and, as Dr. W, 



Stokxs justly advises, the strength of the patient 
must be supported by a fuinaceons food, jellies, 
and broths, even whilst local depletions, and 
external derivatives, are being employed. The 
coonection of gastro-enteric irritation with tuber- 
cular consumption is one of the most important 
topics in practical medicine, and one which has 
been imperfectly understood, and, with a veij 
few exceptions, overlooked, by writers in this 
country. As the subject, however, belongs es- 
penally to thb disease, in its practical bearings. 
It is considered under that heao. 

8. III. Gastro-emterie Irritation often induces 
severe disorder of the vascular system, — This, 
perhaps, is the most common occurrence met 
with m practice. The febrile disturbances con- 
sequent upon irritating ingesta are so frequent, 
and so generally admitted, as hardly to require 
notice. Amongst children, they are constantly 
appearing, and almost as constantly are removed 
by means appropriate to the cause of irritation. 
If this be indigestible substances, an emetic, or 
purgative, will be the most efficacious, and by no 
means the most unsafe, treatment that can be 
adopted, notwithstanding the horror entertained 
by Broussais and his followers of these medi- 
ernes. In such cases, the disorder subsides on 
the removal of its cause ; but when it is induced 
by the inordinate use of stimuli, or by other 
causes that have either ceased to act, or admit 
not of so ready a removal, it will be better to 
leave the case to nature, than prescribe this 
treatment. In these circumstances, refrigerants, 
cooling diaphoretics, and mild sedatives with 
emollients, are the most appropriate. The nitrate 
of potash, or the nitrate of^ soda, the alkalme 
subcarbonates, the muriate of ammonia in small 
doses, sulphate of potash, and ipecacuanha, are 
severally of use, particularly in mucilaginous or 
emollient vehicles ; but the bowels should be 
kept freely open by mild, oleaginous, or refrige- 
rant purgatives. 

9. I have already insisted upon the fact, that 
purgatives or laxatives, when judiciously selected, 
will rather diminish than increase gastro-enteric 
irritation. Some doubts may exist as to the 
operation of calomel in this way ; but an exten- 
sive and diversified experience of this substance, 
and the experiments performed with it by Mr. 
Annesley, have convinced me that in full doses 
it diminishes irritation and inflammation in the 
stomach and small intestines, whilst it increases, 
or even excites, these morbid states in the laige 
bowels, and depresses nervous power, or augments 
the general susceptibility and irritability of the 
frame, especially it frequently exhibited, or con- 
tinued for a considerable time. 

10. IV. The Connection oj Gmstro-^nterie 
Disorder with Fevers, is sufficiently illustrated 
in the articles on these diseases. It has formed 
the basis of M. Broussais' pathology of fever. 
Little, therefore, need be added at this place 
respecting it. The fact, however, must be ad- 
mitted, that gastro-enteric inflammation, in more 
or less manifest grades, is one of the most promi- 
nent and constant phenomena of the invasion of 
exanthematous fevers ; and that a somewhat 
sim lar state of vascular injection, or irritation, 
exists at this period in the stomach, and upper 
portions of the intestinal canal, to that which 
subsequently appears on the cutaneous surface : 



9f> GLAXDEUS. 

that in thi4 rlimif«. iSftpAf.uIly. th^^ patro-«acerx i1m dbflerviid: bnt it m amHcesuy to ^mon 
mot* frMjii^ntly ^r^rt^i*'^ 'nac fiii.o»4 tri« r.i»3a::i: aaa -jj rftiw^u it. Haw mr jastro-enienc imta<- 
Afr«-'t.on. In «r4rni ' i.nr.4:^4, tr.« r.^^r -.^^^ Tif rn.it r.on nay .axiueace rfae 4ate»or onnarv excreton, 
protf-rf^iy oMiir.4. a.t>iOii^ri riO'. Vj :r.«i •iVrr*: v-jrv a.13 aever 'jtrea « fully liliu^nuiMi u a to be de- 

!r#!ri#-Mliy Ul.*ivwl i»y ri.;ir.y p. -4i tit.. -.Mr* wao *irni. W lu «« imuw jr die 4abjt*ct is dcnv«d 
iMv#! wr.tj'ri on irit«tfOf>ir:al 'ii.-«.^«ir-. rrjin tnt» Pi^urhea of Dr. Phoct ; and it is to 

M. /', I unt rli.f^A*: f,i thf. m^s^uric 2>iiir:.i j >» :iopeil :.iat r.ni* fcwanrii: piiysican wJl pro* 
gfrK'r4liy iri'lii/rrl \,y tUf. ir^-r^-i^-.ut rei-.u:.#:ar* or i:r^/i m a:s iave»n^anuiu :ntu t. There can be 
prrn-tunrf f«f ir'<-'trf»-<:nr^rir trntition ar.il ^.'iriim- m .iouit ^lat jl siaie •it cnrrauc imratioii, or of 
rrMtiori, o f*'ri ronn'-f t^'l, ho»fc'«^r. witri varicu* i.-.rammatijry er^isni, 01" the Jiffestive mucoiu 
otltT * liTfi' uu of fji-iorrl' r, in 4iirfir;i:ntly «vtf1«(ic, 4iirfj,je. w:il hq uDpcde uie fiuxcnoru of diseftkm 
mirl no/r vry ^'f rirr4lly Sftuiitif'rl. Ar^il y*:! I inil L>>:m.'.aLon, oa to cau^e a auperabuadanct 
h«ivr ffri, '-t^if: iill; ;•* Mri farly ^.ricA (A my of injurial:» Ji the :jioo«i. calcuiated to excite or 
pr.iMi* *', thi^ Mi,ii4fly in»f«;'i ^> p'lr^ativ^-*, ome- to ■:i=i3rli»r tne ai?coa« n the idiioev*. and reqoir- 
Iifiif4 f.| H v»ry a/rifl fi^tijr*-. 1 h*- enUrjf^-mtnt inj tj b< el.miaaied from lae circulatioD. When 
Nii'l i»\i*UiuUi,utti \\t*-w. ulan<N,<U:p*:nilin^chj#:tiy ihL* ilMnier or tie r*>a;ro-enreric ftiiHace is at- 
iiri thi- dih-iUttu »i( lli« flii,M-tiv*r rriucou^i -surface, itr.lel. 14 it not iairei;'ieatly is. with a cra^in^or 
r iiri lii< rfii,«-ilM"l only l»y thf pntvioim rfrtnoval of morbid- y exnted ipoifCte. toud is taken in larzer 
lhi« nIIi'Mkiii, rifirl Wy tlif^ proviTfitiori 01 ItA rff.ur- qiantty than it can be iL^e^ted ; and mach iin- 
tfttiMi V\ lirii III 14 I ii'l M ol»Uiru:rJ liy U>ral df:- perftctly fortr.e«i chyie yi carried into the blood, 

iili iMiiio . liy tr\t t^i'i4U\* rofijoifiwl with tlift aUa- wht:re it ricire* di9.jnit:r of the liver, of the kid- 
iiiii niiIk iiilHintiti-H, i|i«Ma( urfhlia, and demul- n<:y4. ami of the ^kia. m the course of the eine- 
11 Mil. iiimI liy «iiit.ilil<' dii'.t ntu\ Tv./im*:u ; the lion of the anjL«4milatefi matters by th«<c orEau. 
fiiiHii iiiivi' flit* 441' fif thr {{Urid<« oftc-n gradually — To th:^ <oarce may be traced! in mauT ia- 
di«iip|i'-iii-*. stance^, not only the morbui conditious^of thenrine, 

Ifi VI. Thr t'nnHtriwn of (iantro-enteric In- and of the kidoey^ theni<«elve». bat al<« the pro- 
fhimmiiiHm uiih l)i*fuuMi»f the .Sfc/n.ioniuch more du'^tion of an attack of G«.'«f. in a regular or ir- 
b,iiiiiiiiil ihiiii prrii ritiorifrN in tint country in ppo^e. regular form. 

II 14 f liiifly iiwiti^' to thiT irritu!iori ot the dii^entivt; 17. The therapeuticul indications, and eTca tht 
If Mil fill! miilHrr 111 varioiiH i;rai)<!'« of ^wc.Tiiy, that meam flf cure, for these variiiu^ eX'^ro-enteric coo- 
thr I III .11 If •fill 4 rflli-f noil rfm4t4 mi loiij; the treat- . plications, may be readily inferred from what hai 
fill III |iii'«riilif'<l (or it4 tiMiioval. I huvi: rfp<:at- ' iM^n stated above. — More precise informatiott will, 
(illy w'l-ii I iiM'* ol iT/fiiiB, iiml of other olMinate however, be obtained as to the^e topic», and iito 
ili4rii4r« III ilii- «hiii roiiiplirriW-d with thi: Hligiitf.T the ctiuut of the jni^tro-eateric disorder, bv it* 
niid liioii- rliioiiir k'"'!'"* "' KMHtro-i'iiHTitm, I he ! ferring to the articles Gorr, Indicfstiov, I^tes- 
liilln lii-inx ivMi Ml pioiiiiiM'rit (im to be ir.dirarcd ' tini.s, Stomach. &c. 

by i.|.ii:.i4ii'w |.4iii .iiid H-mliTm.Mi; yi-t arsenical, | p,,^,^^ ^^^ RKr£«.-itvrfiw«t n>|ffrr, De Itata 
01 ollii-i iitiliiliiiC iiMdirilim, Wt'TP iixlilbitcd ill no ■ Murmn, hro. Goett. ITnH.— W. H-mnimje, Botcbrribaqf 

ili'iilly rB»i4|Ki4lilii: both Ilii- iiilTnal UlKl rxHrnai ^ ,„r i^ Inflaminati'tn* Chronique« de» Vi4cOra'VCE««- * 
Nnnlinii* llii'V wi'M! roiiliiiiiid wilh a j/i-rfert , Med. t. i), Svo. Cirtre*. \'^fL ~ A. PrtU tt E. H A, 

iH.i,... ..I ,i„„ .■,,,.iM».,.h.y. r,...n ti... a.i,,,.ti..n ^^r;Jp"Tp;Z''\7yri:^^.'^^:T^:%ii 

III Ilif4i' 13414, III uiiiitmI or loral ili-pletioim, ol , kvo, Pir. I'Vi.l — f A/in iw, Cnn«ul'ratinnt fur h G* 
irliii'iiiiiit MH'di(-iiir4. of warm and in(-dicati:d 1 trn.Fjitcritp, 4to. Montp IStZl. — /^r/rry. T>e liG»ii» 
, , ■ , J r i» I ... ,.r..i.r:'itn dii.t all I^'itt'Tito ilw Knfflna, 4to Par. Iv.'l . — . JTaMr. Diet 

diiiifdiT liiiA MMiii aln-r diHajipcared. 1 lie cliicl lani^ IV la Membrane Mufturii^e GAstm-InlertiBali 
riii4<Mmoi iliviM«M'«of the Kkiii provinj; W) ob-ti- ' «l«m I'Ktil Sain el.lan* i'Eut Inflainra^^^ Pjr: 

nail-. flii> M. I hN form of romplwdlion , 2d. ,,,,^,„ ^j. p.^ ,r.^,^ g ^„,, . ,^.^ 3 ^^,^ . ^^ ^ 
'i III' ifilliimmalory di.ilheHm and va^'iilur plethora , Phlfumaiiios ou InltMni. Chmnique^, Ac. 3t. 8vi\ Park, 
..1 . «i r... . '1.1 'i'lii> rii>cili>rt of tlii«u> ' I'«'>^s4tn rdit. : Tnitc de Physiol, apciliqu^ k laFatho- 

rhiinwliiminulhrm ; .M. I In ^ni^nrt ol iihjm. j^^ij g ,. ^vo. ' Pnris IWt. : Ccrnimem. 5« ProiwiiioM 

pnlholociiiil U'.'.oniilioim, Olid the udopllun >" de4»atholoKie. Ac. «L 8vo. Pari*, 18SV: Lrrturc«,tnM. 
com iiiM-nie of iiiHiipiopiiiite liieailH <»f run- ; — : lalinl bv fin/Zy, in Med. and Surg. Jnurn. toI. viiL patum. 

A.t I... '1. , ....,1 ,,..fii„i.M ikirii<Mii:iilv . — fif^ytt-ttmt in Joum. de« Progrvs dc« Science! MHi- 

4lh. Iiiatliiilmn lodirl aiidMKiiii..|i.parli<ul.iily ^^,^.^^ t viil. p.2.Vi-/». C A 1^,'s, M^m. ou R*. 

a« re4|H-i-t4 till* iiM* ol Uliimnl lood.aiid ritmiulatin^r , rherchcii Anatomico P.ithrlngiqucs sur Ptii*icur« Mall* 
iK-viMBum Hiid nnirlin of dul ; - and /itli. An in- *>•'•■•. Aft'Hva Paris 18yrl ; et Recherche* Anat Pith. 
-. ir : . I 4 r.i » •. . <.r «u ^.titl'itlon •""" I'* Phtlii*io, 8vo. Pari*, IS^^i. — Amlrai, Oiniqiic 

Willi, lent olwi viilion of the Kt.iteM of BSMiiiul.ltJoii y^-^ - j„„,p^ p„,i,^ jj^^ o., edit, mstim. - tt\ StUfS, 

and excretioii, with the viiw of petfecting the art. (iattnfrHtrrUft, in Cyclop, of Pract. Medicine, 

oiiner, ami of promoting the latter. y"); " 1>;*^*- '"?"*)**'•■. ^^.'?i*'* JI**- ^/c'ii ^"^ ^'" 

!/• fit «./ ■*. . M ■.- • i't ^ tnte Mid Gasln>.Enti nte,) t Ix. Pan*. 18S3L 

W). \ II. ( firomr (iusho-enterttit nojtfn a$so- | u -1 

rintfil wilh Afi'ectiimn ofthelirnito-uriiiarii i)r^av%, G LA N I) FIRS. 

HM'/ wiih (it'ut, — \Vc Bomciimes observe leuror- ' Ci.asihif. — ITI.Ci.ass, TII.Obder (^Authcr, 

tli(ra and other uteriic disorders eonneeletl with «ee Classif. in Preface). 

{THHlrir iirititiuii ; the former nioflt frequently; 1. Df.riN. — VoKCutar injection, and chancry 
>rins( indured, or favoured in lU orcurreiiec, by , i«>r« of the membrane of the note^ frontal sinut, 
the JHtter. DilHcult or ninnty ineii««truation ia and pnrt$ adjoining* tcith a prof use offensive dit- 
oeen4ionally traced to the same cuum*. In these charge, and pnHnlar eruptions, or tubercular and 
ca«H)«, the meiinH calculated to relieve the disorder ' gangrenous ulcers in various parts, preceded 6y 
of the di{{e«tivo mucous nurface, are generally constitutional diMnder, attended hit J'eier of a leu 
moHt efticaciou4 for removing tho iiyni])athetic | or malignant character, und produced hy conta- 
■ITection. A nimilar awociation of the disorders ,gion, 
of the digoitive and urinary patsagei is sometimes | 2. Glanders until lately was considered exda- 



32 



GLANDERS— Forms op. 



with severe pain in the joints and limbs, and with 
the other symptoms attending the invasion of the 

}>receding vanetv. Small tumours arise in dif- 
erent parts of the body, but are more numerous 
on one side than on the other, and have a glossy 
red appearance, which soon changes to a dan 
brown. They also affect the head, or even the 
face, and chiefly on one side. They are painful, 
soon crack on the surface, and exude a thin 
acrid sanies : they vary in size, and are generally 
accompanied by phlyzaceous pustules in different 
parts of the body. Perspiration is free, copious, 
and foetid ; and the stools are watery, offensive, 
or otherwise morbid. The fauces are injected, 
and of a purplish hue ; thirst is great ; the tonp^ue 
foul, loaded, and dark-coloured ; the pulse quick, 
and easily compressed, afterwards small, and 
scarcely perceptible; and the other symptoms 
attending a fatal termination soon afterwards ap- 
pear, as in the preceding form. On inspection 
after death, the tumours are found deeply seated. 
On removing the gangrenous integument covering 
them, a layer of brown glutinous matter is seen 
covering small white tul^rcles, having the same 
appearance as those found in the frontal sinuses, 
and nasal cavities, in acute simple glanders. 
These tubercles on the forehead or scalp are 
generally connected with the pericranium ; but, 
on the limbs, with the fascie. — In some cases, 
on dividing the larger livid or gangrenous tu- 
mours, down to the bone, the muscles appear 
decomposed, are of a dark colour, exhale a peculiar 
foetid odour, and contain specks of purulent mat- 
ter, as it were infiltrated through their substance. 
Underneath these muscles, clusters of circular 
grey tuliercles are also found, firmly attached to 
the periosteum, and resembling those that are 
more superficial, as in the pericranium, &c. The 
muscles generally, even those remote from the 
tumours, are blanched, flabby, or softened, and 
the cellular tissue is infiltrated with a yel- 
lowish serum. The Schneiderian membrane, 
frontal sinuses, and parts adjoining, are sometimes 
thickened, or studded with white tubercles. The 
blood is dark, fluid, and decomposed; and the 
heart flabby and pale. 

9. W hen acute farcy is conjoined with acute 
glanders, the affection of the nares and respira- 
tory organs, the phlyzaceous pustules around the 
nose and mouth, and the consequent foetid, sani- 
ous discharge, and disorganisation, are associated 
with the foregoing phenomena ; but the consti- 
tutional symptoms are not thereby otherwise 
changed, than in being aggravated, or rendered 
more malignant, or more rapid in their progress 
to dissolution. — In such coses, the morbid ap- 
pearances of the nares, fauces, and respiratory 
surfaces attending the acute glanders, are super- 
added to those characterising acute farcy. 

10. iii. The Chronic Forms of Glanders, — Sim- 
ple chronic glanders is confined chiefly to one nos- 
tril, and is characterised by a glutinous and very 
offensive discharge, the foetor being peculiar, and 
remarkably disagreeable. There are itching, with 
a constant desire to blow the nose, and a sens- 
ation of stufling. In the slightest sute of the 
disease, these may be the pnncipal symptoms ; 
but, in an advanced stage, or in severer cases, 
there are pain between the eyes and down the 
nose, with suffusion of the eyes, and ulceration 
€/ ibe Sdmeiderian membrane; the diKharge 



being copious, puriform, or sanious. These 
symptoms are usually preceded by shiverings, 
giddmess, and by weakness and pains of the 
limbs ; and are followed by more or less consti- 
tutional disturbance. As the disease proceeds, 
purulent collections form indifferent parts. There 
are, moreover, loss of appetite, nausea, swimming, 
or pains of the head, occasionally wanderings of 
the mind, pains in the back and limbs, thick, 
discoloured, or foetid urine, and slimy, or other- 
wise morbid evacuations. From this state, the 
patient may slowly recover, after an indefinite 
period, or may sink gradually, from prostration 
of all the vital powers, with appearances of con- 
tamination of the circulating and secreted fluids. 

11. Chronic farcy glanders are generally pre- 
ceded and accompanied by chills or rigors, and 
achiug pains through the body and limbs, resem- 
bling rheuroatisro. Tumours gradually form about 
the face, trunk, and limbs ; these break and give 
rise to an unhealthy discharge ; and are attemled 
or followed by disease of the absorbents and 
glands, or by purulent collections in the joints, 
or in various parts of the body. The disease may 
commence in this manner, and thus terminate ; 
or it may pass into the state of chronic glanders ; 
or, in other words, the affection of the respiratory 
passages characterising simple glanders maybe 
superadded ; or, it may commence in this latter 
form, and be followed by the symptoms more 
especially marking the chronic form of farcy. In 
either case, the matter produces, as shown by the 
experiments of Mr. Coleman and others, Vcute 
glanders or farcy indifferently. 

12. iv. The Nature of' this Disease may be inferred 
from the history here given of it. It is evidently 
the result of a specific morbid matter, conta- 
minating the surfaces and parts to which it is 
applied, affecting the organic functions, and giving 
nse to the changes characteristic of it. The state 
of the blood has not been sufficiently attended to 
in the history of the cases which have been put 
upon record. In several of those that occurred 
in Germany, the blood taken at an early period 
of the disease, appeared to be cupped or buffed ; 
but it afterwards seemed deficient as to crasia, or 
partially dissolved, and very dark. In the variety 
of farcy, the absorbents, as well as the glands, 
appear to be much affected, probably owing to 
the passage of morbid matter along them ; but 
there is much yet to learn as to the history of the 
disease, and the lesions which it occasions, and 
still more, as to its treatment. 

13. V. The Prognosis of the acute varieties of 
glanders is extremely unfavourable; all the cases 
observed in the human subject having terminated 
fatally. The chronic states of the malady seem 
not much less dangerous. Two or three, bow- 
ever, of these which have been recorded, appear 
to have recovered. In one of those mentioned 
by Mr. Travers, the patient was cured by means, 
one of the principal effects of which was to pro- 
duce frequent vomiting. Dr. Elliotson remarks, 
in his last paper on this disease, that its occurrence 
in the human subject is by no means of extreme 
rarity ; and that, since the publication of his for^ 
mer paper, upwards of a dozen cases had been 
mentioned to him by medical men. 

14. II. Treatment. — Our knowledge of the 
treatment of this malady has not been much ad- 

I vanced by the experience we have hitherto bad 



38 



GOUT — Irregular. 



admit that they require a different mode of treat- 
ment. 2dly. The knowledge we possess, however 
imperfect it may he, as to the changes and ap- 
pearances consequent upon fatal internal disease ' 
m gouty persons, is conclusive of a material i 
difference between them and those following more i 
common maladies ; and, ddly. The juoantia and i 
ttedentia in the former are often very different 
from those in the latter. 

17. A. Specific or anomalous affections often 
precede the external manifestation in a complete 
or imperfect form of acute or chronic gout. They 
may i>e either in every respect similar to other 
affections of the same seat, or very different and 
peculiar. In the former case, the external ap- 
pearance of gout seems critical, and has been 
viewed as such by many writers ; in the latter, 
it appears as the external manifestation of a consti- 
tutional disorder previously implicating the func- 
tions or sensibility of one or more internal organs. 
— In perusingthe older writers, numerousinstances 
present themsel/es of gout supervening upon, 
and appearing critical in, inflammatory and severe 
internal complaints. Morgaom considered him- 
self cured of an ophthalmia that had resisted 
treatment, by an attack of gout. Dr. Baillir 
mentions a case of palpitation of the heart dis- 
appearing upon the occurrence of the gouty 
paroxysm ; but these are not rare occurrences, 
indeed, palpitations of the heart are frequently ' 
symptomatic of the disorder of the digestive 
organs ushering in the seizure. Affections of 
the urinary organs, erysipelas, asthma, and other 
diseases, have likewise been removed by a re- 
p^lar fit of gout. One of the most mterest- 
iDg illustrations of the succesnon and critical 
influence of gout upon dangerous internal disease, 
occurred to a medical gentleman whom I at- 
tended in 1824. He was seized in the evening 
with s^ptams of complete congestive apoplexy, 
for which he was bled and purged, but without 
restoration of his consciousness. On the follow- 
ing morning, gout suddenly appeared for the 
fir^t time, with great intensity in the ball of the 
great toe of the right foot, and instantly removed 
all the apoplectic symptoms, the mental functions 
being perfectly clear and undisturbed on my see- 
ing him very shortly afterwards. When gout 
assumes a regular character, such antecedent 
affections appear merely as unusual precursors 
of the paroxy>sm, ushering in either the first 
seizure, or an attack in persons who had been 
previously affected by it. 

18. B. Retrocedent or displaced Gout — rece- 
dentt or iransferredy or metastatic Gout — Podagra 
retrocedens — P. retrograda, Cullen — P. com* 
plicata. Good. — a, Duripg the gouty paroxysm 
in either its acute or chronic form, it some- 
times happens that an internal organ becomes 
suddenly and dangerously affected, the external 
disease being either much mitigated, or having en- 
tirely disappeared. It has been disputed whether 
the mtemal disorder arises from the suppression 
or subsidence of the external affection, or whe- 
ther the latter disappears in consequence of 
the occurrence of the former. Either may take 
place, as evinced by the succession of morbid 
phenomena, in different cases : the development 
of disorder in an internal organ, deriving it from 
external parts in some instances ; and the sup- 
premon of the external manifestation of a con- 



stitutional disease, determining it to an interna 
predisposed viscus in others. When retrocession 
occurs in the height of an acute paroxysm, the 
superinduced malady is generally also acute, and 
rapid in its course; but when it takes place in the 
chronic form, it U often less severe and mire 
prolonged. The internal affections, which thus 
arise, are generally caused by the patient's mi- 
prudence, by his habit of body and tempera- 
ment, by previous disorder, or by injudicious 
treatment and management. The stomach is 
most liable to be affected, severe pain and spa^m, 
with sickness, being complained of. The tntest-aes 
may be also attacked, either alone or in conjunc* 
tion with the stomach, with all the symptoms of 
acute inflammation : either form of disease ottea 
pursuing a violent or rapidly fatal course. Severs 
pain in the head, and symptoms of inflammation 
of the brain and its membranes, stupor, coma, apo- 
plexy, epilepsy, or palsy, supervene in some cases, 
especially in those who have previously evinced 
a tendency to these maladies. In other instances, 
affections of the che^t appear; particularly d^-e- 
pnoea, sense of suffocation, oppression at the 
prsecordia, with or without cough or expectora^ 
tion. In some, pain or constriction in the region 
of the heart, violent palpitations, oppressed breath- 
ing, urgent anxiety, syncope, or leipothymia, 
&c. occur, indicating a serious affection of the 
heart or pc-ricardium. In a case of this description 
recorded by Mr. Krown, and which terminated 
fatally some months after the disappearance of 
gout, the pericardium was thickened, and con- 
staining six ounces of bloody serum ; the heart 
~was greatly enlarged, and its substance was pale* 
soft, flaccid and attenuated, its internal mem- 
brane being of a deep violet colour ; honeycombed 
ulcers were also observed at the root, and in the 
arch of the aorta. Other diseases of an inflam- 
matory, spasmodic, or nervous character, ot of 
these mixed, may follow the disappearance ot the 
external gouty affection, more particularly dyt- 
enter}', hepatitis, Jipritonitis, and various afiec- 
Uons of the urinary or uterine organs. Dr. 
Cullen mentions strangury, catarrhus vesics* 
and hemorrhoidal affections, amongst those not 
infrequently alternating with gout ; and instances 
have occurred to myself, as well as to Sir ۥ 
ScuDAMORE, Mr. HowsHip, and many others, 
of the transference of the morbid action to the 
kidneys, causing suppression of urine, or inflam- 
mation with partial suppression ; or to the nedi 
of the bladder with severe spasm, or even to the 
prostate gland. Mr. Howsiiip mentions, that 
when gout is transferred to the kidneys, the urine 
becomes albuminous, as well as scanty. Dr. 
Home states, that a gentleman, who exposed 
himself to cold and wet, whilst affected by gout 
in the feet, was in a few hours afterwards affected 
by enteritis, which proved fatal in twelve hours ; 
and SirC.ScuDAMORE mentions, that Dr. Parrt 
met with two instances of extravasation in the brain 
in the same winter, after repelling gout from the 
extremities by immersing them in cold water. 

1 9. 6. The information we possesses to the lesions 
produced by the transference of the morbid ac- 
tion to an internal part, is extremely imperfect ; 
many who have the opportunity, not giving them- 
selves the trouble to inquire respecting ttwm, or 
supposing that little or no alteration m^ be ez« 
pected in such cases. Others^ agaM^ befaere that 



42 



GOUT — Causes. 



ScvDAHORB mentions a case at 8 years of age. 
I treate.1 one, many years ago, at 1 1 ; and am 
at present attending a boy of 9, recovering from a 
severe attack in the foot. Very early seizures 
have generally been observed where the heredi- 
tary predisposition has been strong. In the two 
cases just alluded to, it existed in both parents ; 
and, in one of them, there was great precocity of 
intellect. In some cases, where the distease ap- 
peared very soon after puberty, premature or ex- 
cessive venereal indulgences seemed to me to 
have aided in its production. 

31. e. The male sex is much more disposed to 
gout than the female. — Hippocrates mentions 
the non-liability of females until the cessation of 
the menses. This, however, is not correct ; for 
cases occur at an early age in the plethoric 
through indolence and high feeding, and in those 
who have not had children. I met with an in- 
stance of it in a female of 27 years of age, who 
was thus predisposed. Dr. Gregory observed, 
in his Lectures, that females subject to gout had 
experienced menorrhagia, or had biecome plethoric 
from ingurgitation ; and Dr. Cullev has re- 
marked, that robust and masculine females, before 
the menses have ceased, or those in whom they 
have been very abundant, are not infrequently 
attacked. The instances of gout which 1 have 
•een in this sex, previously to the change of life, 
have been chiefly in those who had suffered fre- 
quent or excessive menstrual evacuations, who 
had lived very fully and indolently, and who had 
not t>een pregnant. The relative immunity of 
females is evidently owing to their temperance, 
to their periodical evacuations, and to the dis- 
charges and secretions connected with child- 
bearing. 

32. d. Habit of body and temfterament. — Gouty 
persons are said to have capacious and circular 
chests, with large full veins, and loose soiids ; 
but to this rule there must evidently be numerous 
exceptions. Sydenham remarks, that the gross 
and corpulent, and those with large heads, are 
most frequently affected. J. P. Frank states, 
that the gouty conformation consists of a large 
and full body, voluminous head, large bone, and 
thick skin. Sir C. Scudamore found that, of 
226 males, 64 were tall and corpulent, 41 middle 
height and corpulent, 25 short and corpulent, 
28 middle stature and bulk, 14 tall and middle 
bulk, 21 short and middle bulk, &c. ; and that 
of 28 ft*males, 9 were tall and corpulent, 8 short 
and corpulent, 4 middle height and corpulent, 
and 4 short anH slight. Corpulence usually pre- 
cedes the disease, and often increases with the 
progress of it. The gouty generally posses good 
constitutions, abused by indulgence. The san- 
guineo-nervous and irritable temperaments are (he 
most liable to be attacked by gout, although 
other diatheses may be also affected. — Cado- 
OAN ascribed gout to three causes, which gene- 
lally act conjointly ; namely, indolence, intem- 
jteranee, and vexation, 1'aking these in their wide 
signification, their importance cannot be contro- 
verted. In whatever statiim of life they prevail, 
particularly indolence and mtemperance, gout 
will appear as one of the most frequent results ; 
hence it is not infrequent in butchers, innkeepers, 
and publicans; and in butlers, coachmen, and 
porters in wealthy families, as well as in the more 
etqr dastet of society. It is, in short, met with 



in all occupations which conduce to intctinty 
and repletion. 

33. tf. Venereal excettet are amongst the most 
unequivocally predispos.ng causes, especially if 
associated with the intemperate use of animal food 
and of wine ; for whilst the former species of 
excess exhausts the nervous power, the latter oc- 
casions plethora, and both combine to impair the 
functions of digestion, assimilation, and excre- 
tion ; hence the ancients said that gout was the 
daughter of Bacchus and Venus. The wines 
which favour most the production of gout, are 
champagne, new port, and the clarets ; but other 
wines have more or less influence, anid are mors 

firoductive of the disease than malt or spirituous 
iquors. Strong malt liquor disposes to it even more 
than spirits. Dr.CuLLEN justly remarks, that gout 
never attacks those following laborious occupa- 
tioni«, or wlio live chiefly on vegetable food, or use 
neitherwine nor other fermented liquors. Scbenck, 
Van Swieten, and other authors, have adduced 
numerous instances of persons, who, during a life 
of luxury and indolence, had been subject to this 
disease, but had never afterwards suffered from it 
when their circumstances required them to live 
abstemiously and laboriously. In countries where 
animal food, and vinous or intoxicating liqnws, 
are little used, gout is almost unknown. The 
habit of partaking of a great quantity or variety 
of animal food Is not less influential than other 
kinds of intemperance in causing the disease. 
Severe study has been considered to predispose 4o 
it ; but this cause is merely apparent or indirect, 
others of a less doubtful kind also existing. The 
depressing passions are not without influence, in- 
asmuch as they weaken nervous energy and the 
functions of digestion and excretion. A cold and 
variable climate favours, also, in some degree, 
the formation of the gouty diathesis; and the 
changeable weather in spring and autumn, and 
the cold winds and humid atmosphere of these 
seasons, have a similar effect. The disease is 
comparatively rare within the tropics, unless 
amongst those who have indulged in those habits 
which are most influential in predisposing to it; 
and vet two of the severest cases I ever saw, oc- 
curred nearly under the equator in Africa. 

34. f. Functional disorder of the digestive or- 
gans is one of the most universal causes of gout 
Many of the causes already noticed, and of those 
about to be mentioned, act partly by weakening 
these organs, and favouring congestion of, or in- 
flammatory determination to, the mucous surface. 
It is not, however, a state of inflammation of this 
surface, but rather of vascular erethism, that is 
thereby generated. Hen(*e the appetite, instead of 
being impaired, is often increased ; and the patient 
is prompted to take more food than the stomach 
and collatitious vi>icera can digest and assimilate. 
When the appetite is impaired, owing to the di- 
gestive mucous surface having assumed a more 
inflammatory state, frequent attempts are but too 
often made to excite it by stimulating and savory 
articles of diet ; and the miscrhief is thereby aug- 
mented. Even where functional disorder only 
exists, inflammatory irritation is superadded, at- 
tended by the severer symptoms of indigestion — 
by acrid eructations ; by painful distension and 
soreness of the epigastrium ; by congestion and 
impaired action of the liver ; by interruptions of 
the passage of bile into th« duodenum, accnmula- 



46 



GOUT— Treatment ov Acxm. 



the absence of swelling, he prescribed chologogue 
purgatives, consisting chiefly of cathartics and 
uitters conjoined, and cooling anodyne appli- 
cations to the affected parts, with spare diet. 
When occasioned by a phlegmatic humour, indi- 
cated by the absence of heat and redness, he 
considered calefacients to be beneficial, and refri- 
gerants injurious ; and recommended a com- 
bination of purgatives and attenuants, as helle- 
bore, thyme, cumin, &c. After purging, he 
directed warm attenuants internally, and cale- 
facient anodyne cataplasms to the external affec- 
tion. When there was general fulness of blood, 
or determination to the affected joint, he advised 
bloodletting, aod abstinence from wine and ani- 
mal food, and discutients to the part. He has 
remarked, that some insist upon taking medicines 
to allay at once the violence of their pains, not 
choosing to submit to a methodical treatment ; 
but that he does not approve of this practice. 
For this purpose, he adds, the hermodactylut is 
particularly trusted to; and he admits that it 
seldom fails to remove a paroxysm ; but he also 
affirms that it occasions more frequent returns of 
it. The identity of hermodactylus and colchicum 
is highly probable, as maintained by Prosper Al- 
piNus, Sir H. HALPORD,and others. Alexander 
has furthtf stated, that some endeavour to correct 
the prejudicial effscts of this medicine by adding 
to it cumin, mastic, or ^nger, thinking that its 
action is narcotic ; but this he affirms to be a mis- 
take ; for in that case it could not prove cathartic. 
He admits, however, that these things may cor- 
rect its bad effects upon the stomach ; and he 
therefore prescribes a combination of the hermo- 
dactylus with aniseed, pepper, and myrrh, or 
with aloes, scammony, elatenum, colocynth, &c. 
He preferred, however, the coronofodium (which 
Mr. Adams, in his learned commentaries on 
Pavlus, believes to be the buckthorn plantain or 
plantago eoronopus), as it procures evacuations 
and relief from pain, without injuring the stomach. 

46. Pavlus iEciNETA advised a nearly similar 
method to that adopted by Alexander. He 
employed chologogue purgatives for the evacu- 
ation of bilious humours, when he inferred gout 
to arise from this cause ; and numerous cooling 
and anodyne cataplasms to the affected part, with 
& refrigerant and diluent diet, avoiding repletion 
and the use of heating dishes or liquors, as well 
as mental emotions and venereal indulgences. In 
the sanguineous form of the disease, and in the 
first attacks, he enjoined bloodletting and purg- 
atives ; the latter consisting chiefly of a combin- 
ation of colocynth, aloes, black hellebore, and 
scammony. Some, he has remarked, have re- 
course to purging with hermodactylus ; but it is 
bad for the stomach, producing nausea and ano- 
rexia, although it removes the disease very 
speedily. In gout from a mixture of humours, he 
also had recourse to depletions in early attacks ; 
but, after frequent seizures, he considered the loss 
of blood injurious. Besides these, he directed 
a variety of both internal and external means ; 
many of which deserve adoption, and are similar 
to those hereafter to be noticed. With respect 
to profhylaxiMt he advised a moderate use of wine, 
exercise, and frictions of the joints, morning and 
evening, with oil triturated with salt. 

47. The opinions of the Arabian physicians 
differ not materiaJly from those of the Greeks. — 



Serapion, AvicxmrA, and Rbasxs ncoa a uuAbk 
evacuations and the hermodactvlns. — Ualy As- 
BAS directed bloodletting in cases proceeding 
from sanguineous plethora ; and uaed cooling 
applications to the joints. Kor the bilious de- 
fluxion, he prescribed emetics and drastic purg- 
atives, consisting of scammony, aloes, colocynth, 
and hermodactylus ; and for the seroos or phleg- 
matic defluxion, very nearly the same means, tuB 
local applications being varied. The treatment 
adopted by Alsaharavius was almost identical 
with that pursued by Alexander, Paulus, and 
IIaly Abbas. 

48. Demetrius Pspaoomenos has justly re- 
marked that the prophiflaxi* of gout is eaaly 
prescribed, but followed with great difficulty. It 
consists in great moderation in eating and drink* 
ing, and in avoiding indigestion. Viewing the 
disease as one of repletion, he ordered evacuations 
for its cure, consisting of emetics, bloodlettings 
and purgatives, and with a very judicious refer- 
ence to the form and stage of the disease. He 
forbade the use of strong emetics ; but Tomiting 
by gentle means he had recourse to at the com- 
mencement. In early attacks, and at their begin- 
ning, when there was evidence of plethora, he 
prescribed bloodletting; but he considered it 
prejudicial in other circumstances, or rauch in- 
ferior to active purging. He was favourable to 
the use of hermodactylus as a purgative, and 
combined it with aromatici. In other respects 
his treatment was similar to that of Alexander. 

49. The reader will observe, from what has 
been iust stated, how little has been added to oar 
knowledge of this subject by the numerous pro- 
ductions that have appeared since the revival of 
learning in Europe ; and that, although there is 
much that is trifling, a little that is absurd, and 
something that is questionable, in the doctrinal 
and treatment of gout adopted by the ancients* 
there is also much deserving of commeodation 
and adoption. 

50. ii. Tr^tment of Acvte Gout. — The ta* 
dieation$ are — 1st. To avert a threatened attack; 
— 2d. To alleviate the symptoms during the 
paroxysm ; — and, 3d. To prevent the return of 
the disease, by suitable regimen and medical 
treatment, after the paroxysm has ceased. — A, 
In order to avert, or to render more mild, a 
threatened attack, the premmiHory symptom 
should be treated promptly and judiciously. Much 
sufferin<T and injury to the constitution have 
arisen from the idea that the paroxysm is a salu- 
tary effort of nature, and that the pievention of it 
may be followed by serious consequences. There 
is, however, some truth in the opinion ; for, as I 
have shown, the external affection beiuj; the oat> 
ward manifestation of constitutional disease, the 
suppreraion or prevention of it in an external part 
may lead to results still more severe than the 
impeDdin<7 attack. But it is the suppression of 
the paroxysm by means which leave the constitn- 
tional disorders untouched, or which increase 
them, that is injurious, and not the prevention of 
it by remedies directed to the removal of these 
internal disorders themselves, in which the attack 
originates. A large dose of an acro-narcotic, as 
of colchicum, veratrum or veratria, aconftum, &C., 
has often the effect of suppressing the morbid 
sensibility, and with it the irritative vascular 
action of the seizure ; and thus frees tht patient 



48 



GOUT — Treatuzxt of Acvrt. 



the circulatioD in thi^ organ, and increase its ex- 
cri'ting function, should bi- selected. With this 
vi«w, from five to ten {irains of calomel, with 
four or five of Jamb«*< ponder, maybe givvn at bed- 
time, and the draught pr^^cribt-d above (§ dl<)j 
farl? on the following nioruinj. If thi-:>€ do not 
act in the coufm: of a few hours, a dofk: of maj;- 
ncsia, and of buluhati' of ma;^nt-$ia in any aromatic 
water* may be men, and re^teatcd until the lx>wels 
arc fre<dy ojwncil. J 'ur^ii vcs were actively cm- 
ploye«l in );out by the aocitMit*, itratrvm and 
Kfnuxiuctyiui iiavme bei-n chieHy Uaed with this 
inUsntiou. Kiia7.i:3 ad\Lsed a catliartic to be 
repeated ei(;ht times. Uivlkii-!*. Kildun, Tin- 
LKNii'MfCAiiocAN.and mo»t English writurs, have 
recommended Uiem. Scuikeuku prefcrn-d the 
prG(Kirdtions of rhubarb ; and thb^e, conjoined 
witli magnesia, or any of the other purgauves in 
common ui^o, may be proscrilied. Sir C. Set da- 
MohK pre!K:nl)e<9 i\w dtlchicum inthetir-t a]>erient 
draught, giving from one to two drachitis of the 
acetic prrparation. neutralised by magnesia, and 
conjoined with the sulphate of magnesia* This 
medicinu he re])caLs at intcr\'als of four, six, or 
eight houre, accenting to its action, and the 
urgency of the symptoms. Although this is 
amongst the mildent of the preparations of cuU 
chicum, e^^pocially when its acetic acid is ncu- 
tralixctd by magnesia, yet I have seen it, in thi:* 
dow, productive of serious effects ; and it is more powder, or some other antimonial, with or withooi 



weak conatitutioiial power, the combinatioii of 
colchicum with antacids, and wann stomaehici. 
or the spiritus colchici ammoniatai, will be moA 
appropriate ; and either the ittfusion of lenna, or 
of rhubarb, or the decoction of aloes, may be 
added to them, in euch quanti^ as may be re- 
quired to operate freely on the bowels. 

No. i:>i H InfuSb Cufcphiloc., IdAm. Soina Cam, 
ai 3vJ ; MAgneii. CaUnnata Bi. ; T^ncrt. Kad. ODkhSl, 
^^\ x«v. .«cl Accti Colcbici 5t».) ; Spiritui PimatCi^a. 
M. Fiat iLiiutua, ter in die cumcndu*. 

Nil. i£^ lofuvi Aurantior. Cump., Inrim Rbei, ii 34,- 
Mafrnn. CartMNi. 9j. ; Vini Scmioii Colchici 3m. [^A 
•SiiirtL Colcliici Ammon. 1T\ xxxr.) : TinrL CardamoB. 
Comp 3 J. M. F^dt HaUAtut, sexta quA^ne hori in* 
mendiu. 

Ntt.)2.3ii. Dccflcti Aloc4 Comp. SvU-; Aqu* Mcnth. 
Virid. 3 iv«ii. ; Tinct. Seniiuit Colchici 3 n. ; S^ML As. 
moniic Arom. 3). M. Fiat Haiutua. 

Na ^iS7. SodiB Sulvcuixm. 3m. : Vlni Cokhid (nl 
Spirit. Colchici Amnioo.^ 3 a& ; IiiftMi Scniuc Cobu, 
liiAxki AuraoL Comp., S& 3 vl ; SpML Lsvud. Conali 
M. Fiat Haustua. 

56. It will often be nccesary, eipedaliy 
when the coonteoance is sallow or bilious, the 
hypochondria and epigastrium full, or tender on 
pressure, to exhibit on alternate nights, or em 
every night, a dose of calomel, or of blae niU, 
with James's powder. But care should be tuen 
that the mercury does not produce its specific ae* 
tion, wliich very generally will be prevented by the 
active exhibition of the purgatives just mentioned. 
Where much febrile excitement exists, Jamei*! 



likely to be injurious when it fails in acting upon 
Die buwel»; for in th» case its intluence is exerted 
upon the nervouM system, and not upon the ex- 
creting tunctbns» — the morbid sensibility being 
partially suppressi.Hl by it, but the source of din- 
order rrmainmi: unt*)uclietl. The consequences 
ore, either a friKjuent a-iurn of the fits, or a coii- 
iinnanci^ of the inu*mal affections in acTRravateJ 
forms, or the supeivcntiou of some one o( tiie 
imnrular slate.-* of tlie disease. Wiiere biliary 
acruraulntion or congestion of the liver exisu*, a 



an anodyne, according to circumstances, sbonld 
lx> prcscfibed ; and if nervous power be mocb 
reduced, two or three grains of camphor may be 
either substituted for these, or conjoined iritk 
them. The colchicum may be given in the form 
of iiill,the powder being combined with camphor 
ana the watery extract of aloes, or the aloes and 
myrrii pill, three or four doses being taken in the 
24 hours, and as mnch of the purgative as will 
ojwrate suiHciently on the bowels. The actioo 
of colchicum is exerted chiefly on the digestiie 



Inr^u dose of colchicum, unleA conjoined with mucous surface and liver, tiie secreting hue* 
an aciiv(> stomachic purpative, may, m the early '• lions of which it manifestly augments. When 
sta},^! of the (laroxyi^m. so suddenly suitpre-^ it, j it does not pass auickly off by the bowels, itii 
as to pve rise to the serious aHectious aliudtd to partially absorbed, and increases the functioM d 
under thn heafl of retrocodent and misplaced tlie kidneys. It was employed by the andenls, 
t:out(f 1B.21.). — Thw is no suppositious case, for < and physicians of the middle ages, and eotcnd 
two such instances have faUcn within my own into the composition of most of the gout spcrifici 
iibservation, one of which has been already ad- | of every epoch. Stokkcx introduced it into k- 
verted to ( $ 19.). ; gular practice in modern times, and used it cliicfiy 

ftC>. In t-arly tits of the disease, when much j as a diuretic. Mr. Want brought it into use is 
inllaminaUirv- excitimcnt exist-*, coUhinnn may . 1815 as a cure for pout. Since then it has brtn 
Ih? conjiiined witli the coolinij saline pur<:nitlves, | verypenprally,aiidbui too ot^cn injudiciously, eBi> 
n\u\ \\ii\i xniv^nvA'X, :et Sir C.!i>i'L'D.\.MoiiK advises ; ; ployi.d in thi-J and in other diseases, 
but the ilo'^i should Ih» much leS'J Uuin jie-t iiiou- 57. Catharties are not equally suited toallca.«tf. 
linm-il, and niijiht y4!ldoin to fXceLtl half :i draclnii Where the bowels are very toi}iid, the liver con- 
fif any of the Huid pn;|v,i rations; and it should ' ^'t->:ted,;ind the tongue loaded, they (sec .4f>fra(jtr, 
not Ih» i^iven inon- ln'«|ueiitly than thrice in llie i F. 101. 2(>6. 378. 4150.) are necessary, andiiii 
day, until the eli\:els a it ub!ie.r\ed; a-* even in ' chiefly by Ihcia that we can remove the excre- 
this <inantity, I have st-eti it have, in st nie con- ! nu nlitious matters abounding in the circulatioD. 
stitotions, a very rcmailibly s(^lalivl' inltucnce, j l^ut in other instances, particularly when these 
' producing even* serious s)ni]}U>m.s. In sr\eral - disordt-rs do not exist, or when thct bowels are 
periuiuh, and tbrte of these mendurs of the pro- 1 easily relaxed, or are irritable, and when the 
fession,' I have observed that even twenty drons j piticnt is nervous and debilitated, aiH^ricnts or 
of the mildest preparations of colcliiruni could j laxatives, and saline medicines ^nth the alkali in 
not Ih> tnken without niO'>tdibtn-SNing internal in i- excess, or calcinetl ma)rnesia with or without 
tation, and n sens*.- of sinking* Ixjing proiluctrd. . colchicum, will be more Hirviccable tlian active 
This effi'ct still more fivtiueiitly occurs in the . pui-jrat ives unless conjoinul with tonics, aioroaticfi 
>nic or chronic Ftati^s of the disease. I'hcrefore, or stimulants. — Neutral salts, taken so as to act 

gently upon the bowels, have generally alM a 
refrigerant effect ; and being partially absorbed, 



atonic 



-when the patient is oitlier advanci>d iu life, or 
Iiaa suffcrou n>]icatcd attack^, or is poK5css(.Hl of 



ftO 



GOUT — Treatment or Acute. 



Ma ECUS, and others ; and, in the above circum- 
stances, they jnay be serviceable ; but in persons 
of weakly habits, and in the more protracted 
cases, their effects should be carefully watched. 
In most instances, the saline aperients and diure- 
tics prescribed above prove sufficiently refriger- 
ant ; and the more cooling diaphoretics, particu- 
larly, camphor julep, the solution of the acetate 
of ammonia, and spirits of nitric ether, have a 
similar effect. 

61. e. Narcatict have been long employed dur- 
ing the h^ghtofthe paroxysm, both internally and 
to the affected part. Abtius, Zacvtus Lusftanus, 
Mayerne, De Launay, and manv others have re- 
commended them. — Opium, either in its crude 
state, or in the form of Dover *s powder, or of 
Sydenham's laudanum, has been preferred by Db 

HSXDE, DOEMLINC, NuNN, WaRNER, MaTTU£I, 

KiNGLAKE, Marcus, Sutton, Guildert, &c. 
Several writers have, however, chosen either the 
black drop, or BATTLEv'ti solution, whilst con- 
temporary practitioners have recourse more fre- 
quently to the acetate or muriate of morphia. 
More advantage, however, will accrue from the 
judicious combination of the opium with other 
remedies, than from a selectioa of either of these 
preparations. Opiates ought never to be pre- 
scribed until faecal accumulations and morbid 
secretions have been evacuated. If prescribed 
earlier, or otherwise improperly used, they are 
liable to the same objections as have been urged 
against colchicum — one of the effects of which, it 
should be recollected, is anodyne. Dr. Cullen 
remarks, that although they mitigate the severity 
of the fit, they occasion its return with greater 
violence ; but this objection holds equally strong 
in respect of all narcotic and anodyne substances 
employed without sufficient regard to the removal 
of those morbid conditions of the internal visceia 
upon which the disease chiefly depends. It is, 
therefore, indispensable to a successful treatment, 
to evacuate morbid matters previously to the use 
of these medicines ; and to promote the action of 
excreting organs, whilst we employ them. In 
weakly habits, or where there seems to be a state 
of asthenic or irritative action in the fit, and par- 
ticularly if the external affection shifts its seat, 
the opiate should be conjoined with camphor, in 
doses proportioned to the urgency of the nervous 
symptoms, or of vital depression. This combin- 
ation will promote the cutaneous excretion ; the 
camphor preventing any tendency to the retro- 
cession or suppression of the parox^m that may 
exist, or that the opium may occasion. Hamil- 
ton, Plenciz, ana some other writers have ad- 
vised calomel to be conjoined with the opium. 
When chronic disease of the liver is present, the 
practice is judicious ; but purgatives should also 
be prescribed, and the effects carefully watched. 
The mercurial ought to be withdrawn when relief 
is obtained, or as soon as it evinces its specific 
action. Where there is much febrile excitement, 
the opiate will be usefully conjoined with James's 
powder, or other antimonials, or with ipecacuanha 
and refrigerants. The acetate or muriate of 
morphia should be preferred when opium occa- 
sions headach, gastnc disorder, or otrier unplea- 
sant effects ; and e^ker may be given with aroma- 
tics, camphor, &c., according to the peculiarities 
of the case. A large dose of the extract of white 
P*fpp^ may be directed in nmilar circumstances. 



62. Aeonitum has been recommended chiefly 
by Continental physicians, and is certainly a roe- 
dicine of neater efficacy than is generally sap- 
posed in this country. It has been favourably no- 
ticed by STOELLER,BoEHMEB,REiNHOLD,STOEacx, 
Quarin,Stoll,Vogel,Collin,Murray,Tbice* 
NESS, Warburg, Zadio, Barthez, and Brbea; 
but it is more appropriate to old or chronic cases, 
or to weak habits of body, than to recent attacks 
attended with general vascular excitement. The 

E>wdered leaves, or the extract, may be used. 
esides its narcotic effect, it produces a very de- 
cided action on the skin. Belladonna has like- 
wise been prescribed by Zieoler, Boetscbei, 
and MoNCH ; Conium, by Percival, Solenandei, 
Coste and Thickness ; the Humulut LuptUut, 
by Freake ; and the Laetuearium, by Duncan 
and ScuoAMORE. Hvofcj^amtM is, however, pre* 
ferable to either of these, when it b desirable to 
av oid constipation of the bowels. I have, how- 
ever, seen the belladonna very serviceable in two 
or three instances ; and in these it produced its 
specific eruption on the skin. 

63. C. Local Treatmetit in ike Paroxysm. — c 
Leeches have been applied to the inflamed part by 
VVerlofii, De Haen, BoYER,and Mackintosh; 
and even scarifications have been advised bySAi^ 
muth, Thilemus, Rieolin, Hoffmann, Baube, 
Reusner, and Watts. Sir C. Scudaxore re- 
marks, that he has seen, in a few cases, the apjdica- 
tion of leeches followed by the sudden trensitioQ 
of the inflammation to the other limb, indicating 
that the constitutional causes were not relieved 
by the local loss of blood ; and that he has ge- 
nerally found the debility of parts and oedema 
both greater and more lasting after this practice. 
In three in&tanccs, where he directed blood to bt 
taken from the distended veins near the foot, mm 
increase, rather than diminution, of pain was the 
consequence in two, and much local weaknes 
in the third of them. — Blitters applied to the 
affected part have been recommended by Bov- 

VART, RiFDLIN, RUd StBVENSON. TrEMFEL COB- 

siders them injurious ; and Dr. Cullen admili 
the occasional efficacy both of them and of urti- 
cation, but considers them hazardous. They an 
sometimes, however, useful in the more chronic or 
asthenic states of the disease. — Moxa, as a local 
application to gouty joints, has been resorted to 
in Eastern countries from time immemorial, and 
appears to have been known to Hippoceat» 
and subsequent ancient writers. Amongst the 
moderns, Bose, Ten Rhyne, Thilenius, Peoi- 

LIN, TUEVENO, ACERBI, PaLLAS, KaEMPPHi 

V ALENTiNi, and Ingram have noticed it. Sir W. 
Temple ( Works, vol. iii.) derived benefit frtm 
it in his own case. 

64. b. Fomentations and poultices^ both simph 
and medicated, have been long advised for goat 
HoRNUNO and Riedlin have directed fomeot- 
ations with an infusion of tobacco, and Kunrati 
poultices with the leaves of hyoscyamus; but, 
although they may relieve the pain, they relax 
and weaken the parts. Alexander TraluakO 
has stated, that they occasion a chronic state of 
disease, and favour the formation of concretiooi* 
Poppy fomentation, the vapour of hot water im- 
pregnated with aromatic herbs, and various cmol* 
lient herbs and flowers used in the form of 
poultice, have been recommended. Or0uiio 
nas advised the application of Uie infused flowon 



i 



54 



GOUT — Treatmsnt of CnnoNic. 



served ; but symptoms of atonic gout, or apoplexy, 
or asthma, or dropsy, supervened. He remarks, 
that the prevention of the disease depends much 
on supporting the tone of the stomach, and avoid- 
in? indigestion ; that costiveness, by occasioning 
this latter, is hurtful and should be avoided ; and 
that much purging is injurious. — The aperients 
he recommends arc, aloes, rhubarb, magnesia, and 
precipitated sulphur, as they may suit particular 
cases. — Sulphur is recommended for the preven- 
tion of the fit by TuLPius, RuLAND, Grant, Gar- 
diner, and QuARiN. Hufei.and advises it to be 
conjoined with guaiacum, in a quantity sufficient 
to act moderately on the bowels. 1 here is no 
doubt of sulphur and magnesia being both 
safe and efficacious, in preventing the return 
of the disease, when aided by suitable diet and 
regimen. 

75. c. Chaljibeate$ have been considered as ex- 
tremely efficacious in preventing the fit, especially 
when conjoined with the alkaline subcarbo nates, 
and when the bowels are kept open during their 
use. The preparations of hop are also of service; 
but they require, equally with chalybeates, qui- 
nine, and other tonics, an abstemious and tem- 
perate diet, and exercise in the open air. Of 
tonic, stimulating, and heating medicines, given 
vdth the view of preventing the paroxysm, it may 
be stated, that they are dangerous in the plethoric 
and robust, inasmuch as they increase vascular 
fulness and action ; and that, if they be resorted 
to, in such persons especially, abstinence, and the 
free action of all the emunctories, should be ob- 
served. In some cases — particularly in nervous, 
irritable, and delicate constitutions — a moderate 
quantity of wine, or either of the tonics in most 
common use, as the preparations of cinchona, or 
of the aromatic or bitter substances, or of iron, or 
of hop, &c., is almost indispensable ', but the use 
of purgatives and the rest of the treatment should 
also be enforced. 

76. ii. Treatment of Chronic Gout. — This 
state of disease has been shown to occur either 
primarily, or consecutively on the acute. — A, 
In the former case, the powers of the constitution 
are insufficient to produce the disease in asthenic 
form ; and either the nervous, or the lymphatic, 
or phlegmatic temperament, is generally predo- 
minant. The indicationt of cure should be founded 
upon a careful estimate of the condition of the 
several functions, especially those concerned in 
excretion. Vascular plethora is seldom present 
in such a degree as to require general depletion. 
The imperfect perfoimance of the digestive, assi- 
milating, and excreting functions, and defective 
nervous power, indicate the employment of me- 
dicines calculated to increase these functions. 
When the biliary secretions are scanty or ob- 
structed, a full dose of calomel, of camphor, or 
James's powder, and hyoscjramus, may be given at 
bed-time, and a purgative draught at an early hour 
in the morning. To these may be added, during 
the day, saline, aperient, and diuretic medicines, 
with an alkali, or magnesia. It will frequently be 
necessary to soothe nervous irritation by the exhi- 
bition of a narcotic. The preparations of opium, 
especially Dover's powder, or morphine con- 
joined with camphor or aromatics, will generally 
give relief, especially after morbid secretions and 
excremientitious matters are evacuated. But they 
cooftipate the bowels ; the other narcotics may 



therefore be tried. It will, however, be found 
frequently preferable to continue the opiate, and 
to obviate its effects by one of the stomachic 
aperients prescribed above, taken early each 
morning. 

77. Tonics, and heating or stimulating medi- 
cines, tend rather to fix than to remove the disease ; 
and are always injurious, if excrementitious mat- 
ters have not been carried off. An alterative and 
aperient pill, as the hydrargyrum cum creta, Cas* 
tile soap, and extract of taraxacum ; or Plum- 
MER'spiil, with either of the same adjuncts ; may 
be taken at bed-time, and a small or moderate 
dose of any of the preparations of colchicum in the 
morning and at mid-day, with any of the stomachic 
aperients as prescribed above ($50.68.). — In tlus 
form of the disease especially, the spiritnscolcbici 
ammoniatus is a useful medicine. But either of 
the other preparations may be used, coojoin«d 
with magnesia, or with any of the alkaline sub* 
carbonates, and with saline or stomachic aperients. 
Sir C. ScuDAMORE recommends a draught with 
compound tincture of benzoin and magnesia to be 
given once or twice a day, or the compound de- 
coction of aloes, with an equal proportion of the 
infusion of cascarilla or of gentian. When the 
secretions are restored to a healthy state, and 
debility of stomach with general depression it the 
principal ailment, gentle tonics, aided by suitable 
diet, and moderate exercise in the open air, are 
necessary ; but a too full and stimulating dirt, or 
heating regimen, should be avoided. In the 
summer and autumn, the warm sea bath, twice 
or thrice a week, will be serviceable. 

78. B. Chronic gout cofuequent upon thtaeuU, 
especially after repeated invasions of the latter 
have impaired the constitutional powers, is gen^ 
rally attended by obstinate disorder of the mges- 
tive and excreting functions, with more or lea 
disturbance of the nervous system. Vascular 
plethora is oftener present in this variety of chronic 
gout, than in the preceding ; and the local afiec- 
tion is readily increased by the internal use of 
stimulants ; but alterative aperients, conjoined widi 
colchicum and diuretics, as just recommended 
{ ($77.), will generally be efficacious. Whentht 
bowels are very torpid, the purgatives mentiomd 
above {§ 50. 54. 56.) should be given in sucb 
doses as may be sufficient. Sir C. ScuoAM^ai 
advises the addition of guaiacum to the purgativs 
in such cases ; and, when little or no fever is pre- 
sent, it will prove beneficial. If congestion exirt 
in the liver, head, or kidneys, cupping will be 
necessary. When pain in the stomach, or tende^ 
ness in the epigastrium, is complained of, leechd 
applied on this region, and followed by a rube- 
facient epithem, or blister, will be requisite. If 
the urine be scanty, high-coloured, and thick» 
cupping over the kidneys, and the use of activo 
diuretics, will be of great service. Besides the 
saline substances already noticed, small dooesof 
turpentine, or a decoction or infusion of the pioe 
sprouts or tops, as directed by Barthez, may bo 
^ven at short intervals ; or the preparations of 
juniper, or the sweet spirits of nitre, may be added 
to saline and alkaline medicines. When theHver 
continues torpid, or the bile deficient, and tbo 
urine thick, the compound calomel pill, widi 
soap, should be given at night, and the extract 
of taraxacum added to the medicine pr^acfibed 
during the day. 



56 



GOUT — Tbbatment or Ibregulab. 



still continue, the calomel, camphor, and opium 
may be repeated, after an interval short in pro- 
portion to the seventy of the case ; the feet should 
be plunged in hot water to which a large quan- 
tity of mustard flour and salt are added, or be en- 
veloped in sinapisms ; and flannels wrung out of 
very hot water, and soaked with spirits of turpen- 
tine, should be applied over the abdomen ; or cro- 
ton oil rubbed over the stomach. Sir C. Sou da- 
more directs the saline draught with colchicum 
to be given and repeated ; but I doubt the propriety 
of giving this medicine in ca<es of consecutive 
gouty anection of the stomach or intestines. 

84. b. Although the internal affection will often 
assume a nervous or spasmodic character — espe- 
cially in the constitutions mentioned in connection 
with it, and at the commencement of the seizure, 
before vascular reaction has taken place — yet 
active congestion or inflammatory determination is 
not infrequent, particularly in more plethoric and 
irritable habits. — Much care and discrimination 
are required to ascertain the presence or absence 
of these states ; and either is to be inferred chiefly 
from the causes of retrocession, from the state of 
the pulse and of vascular repleUon, and from the 
tenderness, fulness, or tension, and temperature, 
of the regions containing the affected organ. The 
patient's sensations, and the symptoms connected 
with the excreting functions, ought also to be 
careful ly estimated 1 f, from these, infia minatory 
action of the stomach, intestines or kidneys be 
inferred, bloodletting, accorling to the strength 
and habit of body of the patient, must be promptly 
put in practice. But vascular depletions are 
neither so well borne in such cases, nor so suc- 
cessful, as for inflammations occurring primarily, 
or in previously healthy persons. The amount 
and repetition of depletion must depend entirely 
upon the circumstances of the case ;• but, in every 
instance, depletion should be aided by the deriv- 
atives and hot epithems just recommended. A full 
dose of calomel, with a few grains of camphor, 
and two of opium, should also be adminii>teied, 
and repeated within two or three hours, if indi- 
cations of relief are not observed. After one 
general bloodletting, local depleUon by cupping 
or leeches may be employed, and repeated in 
severe cases, or in plethoric persons. In some 
instances, the powers of the circulation can bear 
only local depletions. — When much flatulent 
distension, and severe colicky pains, either attend 
the internal seizure, or remain after the above 
means are employed, equal parts of oil and tur- 
pentineandof castoroil(3iv.to3vj. of each) may 
be given on the surface of an aromatic water, 
with or without a warm tincture, or aromatic 
spirit ; and an enema containing the same oil 
may be administered a few hours afterwards, to 
promote its operation. 

85. c. The internal attack, although nervous or 
spasmodic at its commencement, may become 
congestive, or even inflammatory, as vascular 
reaction supervenes. This fact should not be 
overlooked ; for the seizure that is benefited by 
stimulants at the beginning, owing to this circum- 
stance, may require depletions in its progress. 
The internsd afTectinn may even present a mixed 
character — one in which it is difficult to deter- 
mine whether the nervous, or the spasmodic, or 
the congestive, or the inflammatory symptoms 
predominate, la these casesi it will be necessary 



to have recoune to antispaflmodict and narcotict 
or anodynes, whilst vascular depletions and eva- 
cuations are being employed. — Having treated 
several cases of retrocedent gout, and being there* 
by induced to observe closely, and to reflect upon, 
the phenomena attending it, and the effects of 
the treatment adopted, 1 am morally convinced, 
that exclusive views as to either the nervous or 
the inflammatory character -of the internal affec- 
tions, are incorrect; and that it requires the 
utmost acumen on the part of the practitioner 
to discriminate between these states, and to detect 
their varying shades. In the more spasmodic 
forms of these aflfections, especially when imfrfi- 
cating the stomach, opium and camphor are most 
valuable remedies ; but I have seen great benefit 
also accrue from hydrocyanic acid given in re- 
peated doses with camphor and aromatics. 

86. d. When the consecutive seizure is experi- 
enced in the heart or lungs, the same principle 
of practice should be observed. \\ hen the heart 
is aflTected, the restlessness, anxiety at the pre- 
cordia, and alarm of the patient, are most dis- 
tressing. 1 have lately seen two cases of tbii 
kind. In both, the action of this organ was frer 
queut, irregular, fluttering and weak ; in one, it 
intermitted every fourth beat, the three intervening 

I strokes being succesmvely weaker. In both these 
J I am convinced, from the character of the symp- 
toms, that depletions would have caused a fiitil 
result. Camphor and opium, with aromatics and 
external derivatives, were prescribed for both, 
and in a few hours the anection was remov- 
ed. In the cases also referred to above ($ 19.), 
this and similar modes of practice were equally 
beneficial. 

87. e. When apoplectic, epileptic, or convulsiM 
seizures follow the retrocession of gout, vascular 
depletion is frequently requisite, especially in 
apoplexy. But, even in it, discrimination is im- 
peratively called for. If the head be cool, and 
the action of the carotids weak, an entirely op- 
posite treatment to depiction is required. — In toe 
epileptic or convulsive seizures, depletions are 
often unnecessary, and sometimes injurious. Even 
when manifestly indicated, they require muck 
caution, and ought not to be prescribed in large 
quantity. In both the apoplectic and epileptic 
attacks, purgatives, and cathartic enemata, ener- 
getic derivation to the lower extremities, aod 
camphor, are beneficial ; but narcotics should be 
withheld, especially ih the former, although, when 
conjoined with antispasmodics and cardiacs, they 
are sometimes of service. — When the retrocesaon 
of gout has been caused by cold, vascular de- 
pletion is more frequently useful, than in other 
circumstances ; but the utmost caution is necessary 
as to the extent to which it is carried. Derivations 
by sinapisms, mustard pediluvia, croton oil, &cc., 
however, ought to be most actively employed. 

88./. If the kidneys or neck of the bladder are 
affected upon the retrocession of gout, the treat- 
ment will depend entirely upon the concomitant 
phenomena. If the urine be suppressed, or pain 
or tenderness be felt in the region of the kidneys, 
or numbness in one or both thighs, cupping on 
the loins, followed by a blister in the same situ- 
ation, will be requisite ; but the latter should be 
removed after a few hours, or sinapisms subsd- 
tuted. — Derivation to the lower extremities, and 
small doses of camphor internally, with diuretics, 



^SM^ 



59 GOUT — Trratmest. 

cationB of vaicular fulness and of increased i the same combination ought to be adminirtered 
action are present. A gentleman of regular ' as an enema, in order to promote this effect. Nei* 
habits, and of a full and large make, had the ther of these substances, however, nor camphor, 
consequences of chronic goul in his lower ex- ammonia, ether, opium, nor any of the other sti- 
tremiues, but had not experienced a regular j mulants and antispasmodics previously mentioned, 
paroxysm for some years. My attendance was ' should be confided in alone, or unaided by active 
required on account of determination of blood and persevering external derivation. 
to the head. The excretions were free» bilious, 94. iv. Of Mineral and ThermullVatert in Gtrnt, 
and natural. Desirous of removing the disorder — Mineral watera are beneficial — Ist, by present- 
by active alvine evacuations, I conjoined small ing a return of the paroxysm ; 2dly, in cases of a 
doses of colchicum with the purgatives ; but they tonic and misplaced gout, by giving tone to the 
occasioned a distressing sense of sinking at the digestive and assimilatmg functions, and therein 
epigastrium, and nausea. I soon afterwards found either removing the internal affection, or ena- 
that depletion could not be dispensed with ; and bling the system to develope the disease in the 
nearly thirty ounces of blood were taken from extremities. — a. Respecting the ^th waten, 
the nape by cupping, without any tendency to Dr. B a hlow makes several very judicious obsenr* 
syncope; and he soon recovered. — In all cases ations. In gouty cases, he remarks, espedally 
of doubt, this medicine should be prescribed in where the stomach is very weak, and requires 
small doses, which may be increased ; but, as some substitute for the wine and stimulants relin- 
with digitalis, an accumulating effect may result; \ quished,the Bath waters give tonetothe stomach, 
and it ought to be carefully watched. When, improve appetite, and renovate strength. They 
however, increased vascular action exists, in the thus accomplish unequivocal good, not by the 
irregular forms of the disease, it may be cauti- mere establishment of gout in the extremities, but 
ously used. by reducing it to its simpler and more manage- 

93. Dr. Barlow remarks, " that the complex able state through the amendment effected intht 
conditions and alleged varieties of gout are refer- ' general health. In general, it may be inferred, 
rible not intrinsically to gout, but to the state of ; from what has been written on Bath waters ia 
constitution in which it occurs." This is all that [ gout by Falconek, Gibbls, Barxx)w, and Scvd- 
is meant ; for no modern pathologist intends to ! amorj::, that they are either injurious or of little 
convey any other idea than that internal affections i service, where plethora, disease of the liver, or 
supervening in that state of constitution which determination to the head exists, and that these 
occasions gout, are generally more or less modified states should be removed before they are resorted 
by thia circumstance. It is to the improvement to ; but that they are of service in debilitated, 
of this state of constitution, that treatment should' j nervous, and irritable habits ; and for those ano- 
be directed ; and, after arriving at rational infer- . malous or internal affections frequently attackiof 
ences as to its nature, the means of cure will i gouty constitutions. When these affections occai 
readily suggest themselves. — Having seen that ; in weak and nervous persons, and are unconnected 
the constitution or diathesis, which has been called with plethora, or active visceral disease, the ia* 
gouty, in order to prevent circumlocution, consists tcinal and external uses of these waters are bene- 
in debility associated with imperfect secretion and ', ficial, especially if due attention be paid to thi 
excretion, and consequently with fulness of blood excreting functions. — When gout has debilitated 
or with redundancy of excrementitious matters — the limbs, and weakened the constitution, so that 
the ultimate products of assimilation in the cir- , the nervous system is depressed, and the circu- 
culation — the treatment should obviously be di- lation languid, a course of warm sea-bathiog, 
rerted with reference to the predominance of either with frictions of the weakened limbs, and sea air. 
of these states. Although what has generally may be tried, or may precede the use of the 
been called misplaced guut, may thus be viewed waters of Hath or Buxton. —Where swellings are 
as internal affections occurring in the gouty dia- seated in the vicinity of the joints, the Buxtoa 
thesis, and although they sometimes present little ' bath^, or pumping of the Buxton waters on the 
deviation from those appearing in other circum- affected parts, are generally serviceable, especially 
stances, yet a very remarkable difference is often ; if proper friction and shampooing be used imme- 
observed — the symptoms being very different, diately afterwards. — 6.SirC.ScL'nAMOREobsenrei 
and often peculiar, and the juvantia and lacdentia that the waters of Cheltenham prove highly bene- 
beingalsodifferent. — The predominance of debility : ficial to gouty {>crson.H, particularly when coo- 
and spasm in many of the«e affections induced joined with alteratives and proper regimen. When 
Sprlngel, Cui.LEN, and SciiMiniMANN to pre- the precursory symptoms are tedious, or assuine 
scribe musk for them; and the success of the the form of what is usually called misplaced goat, 
treatment is a presumption of the justness ot their their stimulating properties often excite a paioi- 
views,at least in respect of the cases in which it was ysm, but it is generally slight. The water iioA* 
employed. — In addition to other stimulants and seems most suitable to gouty patient^, especially 
antispasmodics successfully resorted to in similar at the commencement of a course of these waters* 
circumstances, most of which have been noticed — r.The waters of Ltfamin^tou and Hamm-gut* are 
above, I may state, that a solution o( pho8ph(yrus ' not much inferior to those of Cheltenham, wbco 
in ether has been advised by Trampei. and Hite- they act sufliciently on the bowels, or when their 
land; aconifum and nux vomica^ by Stoerck, my- j operation is aided by aperients. They seem, how- 
self, and others ; the »pmi8o( turpentine ^ by Tiieo- j ever, in the circumstances just alluded to, to have 
nosivs and Goon ; and large doses of olive oil, by | considerable influence in exciting a fit of the 
Brbfalo, Marino, and Malacarne. If tur- 1 disease, 
pentine, however, be resorted to, castor or olive ! 95. d. The artificial mineral watert atBrigfalov, 



oil should be given with it, in a quantity sufficient 



io produce a full operation on the bowels; and [ Em$, and CarUUad waters, may alto be employed 



especially the Seidsehutt, the Muritnbad, the 



62 



HiEMORRHAGE — VAicvLAa Action w* 



tion, hare been adduced in proof of their very 
intimate connection, if not of their identity : they 
both very frequently arise from the same predis- 
posing and exciting causes ; both are idiopathic 
or pnmary, and symptomatic or consecutive; 
both are either sthemc or asthenic, acute or 
chronic, active or passive ; they both affect chiefly 
the same organs; and both require the same 
treatment. Notwithstanding these resemblances, 
hemorrhage is far from being the same disease 
as inflammation, as will appear in the sequel 
($ 13. 15.). 

6. In a great majority of instances, haemor- 
rhage is merely a symptom, continent upon a 
variety of affections, the primary ailment being 
chiefly important to the pnysician. This is the 
case, no less when it takes place as an exhalation 
from mucous surfaces, as when it occurs from 
disease of the vessels, or into serous cavities, or 
the parenchyma of organs. — If we enter into an 
analysis of the pathological relations of haemor- 
rhages, we shall find that, in comparatively few 
cases, are they strictly primary or idiopathic. 
This term, therefore, must have a relative ac- 
ceptation as regards them. Even when proceeding 
from the capillaries of mucous surfaces, and 
when perfectly independent of organic lesion of 
the vessels or of that surface, haemorrhage is a 
consequence of antecedent changes ; and it is 
indispensable to the due consideration of the 
subject, that the nature of these changes should 
be understood. They may be referred to four 
general heads ; namely — 1st. To the states of 
organic nervous power and vital action ; — ^2d. To 
the state of structure in which the haemorrhage 
takes place ; — 3d. To the state of the circulating 
organs and vessels;— 4th. To the conditions of 
the blood ; — and, 5th. To any two or more of 
these conjoined. 

7. i. Of the States of Organic Nervout Powers 
or TonCt and of Va$cular Actiont in Hitmorrhaget, 
— Although nervous power may be either excited 
or depressed in the seat of haemorrhage, it is rarely 
the former, even when vascular action is in- 
creased, unless an irregular distribution or deter* 
mination of it to the part take place, from its 
suppression in some other situation, or from local 
imtation. Vascular action, however, is much 
more frequently increased than depressed, not 
only in the part, but throughout the system ; and 
this increase is generally much above the state of 
organic nervous power or tone. Owing to this 
circumstance — to the deficient tone of the ex- 
treme vessels, and to the imperfect resistance op- 
posed by them to the increased action of the 
neart — is to be attributed, in part« the occurrence 
of haemorrhage ; or, in other words, vascular ac- 
tion overcomes the resistance opposed to it by the 
vital tone of the capillaries of the part in which 
haemorrhage takes place. The frequent increase 
of action m this class of diseases induced Dr. 
CuLLEN to arrange ihem amongst febrile com- 
plaints. But this increase is not general ; and, 
even when it exists, it is often consecutive upon, 
or produced by, the sanguineous discharge. — 
When haemorrhages are accompanied by excited 
action, the vascular excitement is frequently 
manifested chiefly in the parts affected, and in 
those adjoining them, in the form of active de- 
termination or congestion. Thus, in epistaxis, 
hmmojAymB, hacmatemesis, htemorrhoicis, &c., 



there is excited action in, or d B tenaina tfam to, the 
organs or structures in the vicinity of the gnrlace 
from which the blood is discharged, although tiM 
circulation in other parts of tfia frame nuybe 
natural, or even below the usual standard. This 
circumstance, in connection with the antecedeat 
and concomitant phenomena of haemorrhafes, 
indicates an irregular diatribotioB of vital action, 
generally attended by deficient organic nervou 
power or tone— an increase of vascular action it 
certain parts, and a diminution of it in otben, 
rather than a state of general febrile commotioB. 
In many instances, also, more espedallj in the 
symptomatic varieties, the extravasation is in- 
accompanied by increased action, and, as we 
shall see hereafter, is more freouently the resDh 
either of a morbid condition of the textures, or of 
the vessels themselves, or of impeded return of 
the blood, in connection frequently with plethora, 
local or general, and with other morbid states 
about to be noticed. 

8. Whilst, however, we observe, thus ffe> 
quently, an irregular distribution of vital actioa 
through the frame, the increased action, when 
increase exists, being in the seat and vicinity of 
haemorrhage, it most be admitted that iebiile 
commotion also sometimes exists and ushen in 
the sanguineous discharge. It would seem as if, 
in many of these cases, the febrile excitement ac- 
cidentally produced, had given rise, owing to the 
increase of the via h tergo, to the extravasatioa ; 
the impaired tone of the extreme vessels being ia- 
suflkient to antagonise the action of the heart. 

9. In many cases, the haemorrhage is all^ 
gether the result of irritation, particularly wbea 
applied to a mucous surface ; but, in these, the 
sanguineous discharge is very slight, or is meiely 
a part of the evacuation that takes place. Hen 
the extreme vessels become enlarged or dilated, 
owing to that state of vital expansion which 
mucous and erectile tissues assume when sab* 
jected to irritants or stimuli. From the expansion 
thus induced, an increased momentum of blood 
in the enlarged capillaries, and the determinatioa 
of the circulating fluid to this quartei\ neeeaaa 
rily result. If we apply any irritating substance 
to a mucous surface, the nerves of the part ara 
excited, their vital manifestations are at first aug- 
mented, and the capillaries are ultimately ex- 
panded or enlarged ; the tissue assuming mon 
or less of increased volume. This erectile state, 
which all vasculair parts present in a greater or 
less degree, according to their vascularity, and 
the extent to which they are supplied with or- 
ganic nerves, generally subsides when the irri* 
tation is withdrawn ; but if it continues to act 
energetically, and especially if it affect the actioa 
of the heart, and thereby occasion general irri- 
tation or febrile commotion, the expansion of the 
extreme vessels may proceed so far as to solicit, 
upon hydraulic principles, so great a flux of 
blood through them as may overcome their power 
of vital resistance, or may occasion the exudatioa 
of this fluid through their pores, which, owing to 
their distension, acquire an increased diameter, 
and allow the red particles of the blood to exude* 
This result is still more likely to occur, wbea 
organic nervous power is deficient or depressed, ai 
it fretjuently is in the constitutions and circum- 
stances in which haemorrhages occur. 

10. The effect thus produced by material irri* 



64 



HAEMORRHAGE •» States or the Blood iir. 



demonstrated by the occurrence of hemorrhages 
as a consequence of softening of the mucous sur- 
faces, or of cellular and parenchymatous struc- 
tures, or of serous membranes; particularly when 
their vital cohesion has been diminished by con- 
stitutional disease, and when the impulse or action 
of the heart and arteries has been increased by 
any external or internal cause. The sanguineous 
discharges occurring in dysentery, scurvy* pur- 
pura hemorrhagica, fever, &c., are familiar in- 
stances of the influence of deficient cohesion of 
the'tissues in the production of hemorrhage; 
and epistaxis, hemoptysis, hemorrhoids, &;c., 
illustrate a combination of this state with in- 
creased vascular action, in which both the heart 
and arteries participate. 

15. iii. Of Changes in the circulating Organs 
and Vessels in the Production of Hitnunrhage, — 
As to the state of the capillaries in hemorrhage, 
it is unnecessary to advance much beyond what I 
have al ready stated (§ 1 3 .), because t heir conditions 
are very intimately associated with the states of 
nervous power and of vascular action charac- 
terising the attack. In all the more idiopathic 
hemorrhages, the vessels cannot be said to un- 
dergo any rupture. Their minuter ramifications 
and extremities seem to be dilated, and their 
pores, whether lateral or terminal, so far enlarged 
by the deficient tone and cohesion of their pa- 
rietes, and of the tissues in which they terminate, 
as to admit of the exudation of a l&rge portion of 
the blood flowing through tliem. This state of 
the capillaries in the seat of hemorrhage is, how- 
ever, generally associated with other important 
changes in the circulation, and in the blood itself. 
The changes in the circulating organs vary in the 
different states of hemorrhage. Those which 

5 recede and induce the discharge are generally 
ifferent from those which accompany it, and 
ought to be carefully distinguished. They are 
principally the following : — 1st. Increased action 
of the heart, and general febrile commotion, as 
above explained - as in active, sthenic, or febrile 
hemorrhages, — 2d. Determination of blood to 
the seat of hemorrhage ; or active congestion of 
its capillaries and larger vessels, with symptoms 
of excited action of the part and its vicinity 
chiefly — as m sub-acute cases.— 3d. Very fre- 
quent or very weakened action of the heart, with 
depressed nervous power, impaired tone of the 
circulation, and lax ty of the soft solids — as in 
asthenic, passive, or non-febrile hemorrhages, — 
4th. Impeded circulation, and consequent con- 
gestion of the venous system, arising from disease 
of the heart. — 5th. Interrupted circulation through 
the liver, or impeded return of blood from any 
viscus or part — as in some symptomatic hemor- 
rhages, 

16. The Jirst, second, and third of these states 
have been sufliciently explained. — In the Jirst 
and second, however, the dependence of the 
hemorrhage upon inordinate action and hyper- 
trophy of the neart should not be overlooked ; 
effusion of blood within the cranium or into the 
lungs being occasionally caused by this organic 
lesion. — The second pathological state of the cir- 
culating system commonly precedes the discharge, 
or exists chiefly at its commencement — is fre- 
quently the immediate cause of the hemorrhage 
and is generally removed by it, as in epistaxis, 
Sic, — ^In the fourth of the above states, the he- 



morrhage is entirely owing to the venous conges* 
tion or plethora induced by the cardiac disease. 
Extravasations of blood from this cause, generally 
assume states intermediate between active and 
passive. The obstruction to the circulatioB 
through some one of the cavities of the hetit, 
extends its influence to the venous capillariss, 
and the?e also become congested. The action of 
the heart and arteries being unimpaired, or even 
increased, by the obstacle to the circulaiioe 
through the veins, the congestion of the capillaiies 
is thereby augmented, until, at last, their con. 
tents partially exude through their parietes oi 
pores in the situations where they are of the 
greatest tenuity, or are weakest, or the least su^ 
ported by the structures in which they are distn- 
buted. This form of hemorrhage is anala^ous 
to the inflammatory action which occanonally 
takes place under similar circumstances; and 
differs from it chiefly in respect of the states of 
vital cohesion and tone in the vessels and tissMS 
affected, and of the fluids discharged from the 
diseased parts. Where inflammatory action is 
the consecutive affection, the orgamc nervous 
power of the part, and the tone of the capillaries, 
have not been overpowered by the congestion or 
local plethora to which they had been subiectedf 
but re-act upon the causes of distension. When, 
however, hemonhage is the result, we may infai 
either that the tonic action of the capillaries has 
been overcome, and the blood has exuded throagh 
them, as just stated ; or that the cohesion of tie 
tissue has been so weakened as to deprive the 
capillaries of the necessary support, and thos to 
favour their dilatation and the consequent effara; 
but it is very probable that this result more fie* 
quently arises from the co-existence of both \h&m 
changes, than from either of them singly. Thk 
reasoning equally applies to the hemorrfasgss 
consequent upon obstructed circulation througk 
the liver, or interrupted return of blood thuMgh 
any part of the venous system. A large proMF- 
tion of cases of hematemesis, of intestinal ns* 
morrhages, of hemorriioids, of hemoptysis, aaii 
of extravasations into parenchymatous orgaaii 
are cauiied in part, if not altogether, by this stats 
of the circulation ; although debility, vascalir 

{>leihora, &c. are also often concerned more or 
ess in their production. 

17. iv. Of the States of the Blood in Htnut- 
rhages. — Changes in the circulating fluid, u Is 
quantity and crasis, are more concerned in tks 

{>roduction of hemorrhage, than modem wriicii 
lave admitted. — In the first of the patbols- 
gical states of the circulating system (§ 15i 
16.), the blood possesses nearly its natural crasiii 
and, when vascular excitement is consideiaUi^ 
it often presents similar appearances to tboM 
in inflammation, and is not remarkably ds- 
ficient in fibrine. In this state of the diseHl» 
especially, marked evidence of vascular pletboia 
has preceded and ushered in the attack. — In tks 
second state of the circulation (§ 15.), the blosd 
may be of natural appearance, or it may paitt* 
cipate slightly in the inflammatory or stneDk 
characters ; or its crassamentum may be looMk 
and either large or small, ibr the quantity if 
scrum. Its fibrine may be also more or less dci> 
cient. In this state, general as well as local pb* 
thora usually exists at the commencenent of ihl 
seizure. 



73 Il^MOARHAGE FROM THE SKIN — Curau. 

C. J. Miwr, SfiWfuilUchn Hrmdhuch lur F^kHininiii fluid from pari er tht leiaU of tlu nilaMiw 

— T.frrtital, Bttifi, 4f. toI. ll. n IBS.—/. Pllul,tio. "H" ''J thtculicll. 

Hfniib. PhlioMph. I li. p. s^. — J. P. IV. Fi-m, On 69. HKmonWe very rarely Ukei pl«i:e tnm 

TSS^Z.iriS:^Lfitt,^§i^i^:r^£l^m ^^^ ^hoU of the cuLniu. ,i.rf«e ; Ui nrdj 

iea&— A IVaia^, UDUmichunnn uetar die Enchci- even from a limited part. The effusion o( blood 

nuns, Ac d« BlutflUijM, gra leij* J80S-^_J|;T. under Ihe cuticle, as IQ bcu:v¥ and paTpuia.&c, 

Jama. A TnuUe on the proceu einnlojBl bj Nature ■. .--r , A . <. . _ . " i .. ' .\.-i...i 



i''d°'ided jlTterlo, ^ diffurent from Ihe farm now being cooaidtrad, 

._. ri*^*"' "" '" "*■ '" '*'''<^'' it iseilernal tolbistiwue. — Wheaiha 

S!;SS'c^Hii,^n'^^ F2S;ilti*M5-"Tp£f',.° h'^["0,"l'a|e i* r,om the cutaneou. ™ifii«,g 



In euippiwriin ihc H»inonhu[ei ftc , 

Sio. Lond, INS. — F, tl. O. Lrtmaa, Eiul lUT let He. in ivhich It 19 eilernal to Ibis 



lAWOUlivn cxining in ceiuin FuDlhn, kwl ■iiu rnvB. ,, . - _ 

JouSTjuI., IS*. ; MistlU;(w.YDi,vl.-i»rfai,Tr.!if rally It aeeumea the fan 

dM Hfmonhuia, Sto. Fir. ISM. — SfrnVrg, ffi>r>i'> ur perepi ration. I'ba lituationi to which it . 

tTl &'SlV(^£r5'r'™V"i-^7i^'ti|::; "»' f^^i—tiy 1™''--!. -'™- the r«« or cbrtk 

•to. ftnrti,l80e. — £1, G. ^, flinUrr, WeSpwIrlleThe. the anterior part» of the chest »ad annpitaj tfc» 

^_,, -.,. --™ .1^ ^ -.,.. ...^ ..., w ^„ . „i|i„, the groins, the ambJlitoi; 



D**'mbI. «»1 Phj..'!j«iVn. Jut w3s;--J««(o«. 'nepalmsofthehi 

B^Mautt Jaim. der PruL Milllmnde, b, lii. 4 «. Ihe heele, toea, aod nngers. It maj occur m 

P-I??-Hjrt*>"|f. Joum dtr ftictlKtiBi Hei^unde. [||e„ aituationa mlhaul any abrasion of lb 

Mjk. t TlL 3 It p. «T.- CinrtrKk, Jhifilatd imd cuucle or change in th« akin ; bnt it aiw Mnc 

iAa&r'iJournil.lSia, lfw,p.llfi.— SpounHTf, MBni'f times proceeds, both in these and in other puti, 

M «ii"Sm trNP,^;LS''*l£^'.f^''i*'l» from cLactrices, HBvi, or other alteratioa rf 

ehlT. 1811, aept PL 517. — nftw, BffmV Atcni». lai^, ' * 

Jus. p. S, 0. £ ISTm. —J. Imhi, TV^l* d« H*mor- Btrucliire. 

^-^„T_ 1^ laog. i.(^« flrtrfrtrt.. Diet. GO. HiemarrhaBe from the calane 



noticed by Bet 

), WepfCR, SCHLNCI, GjinUAKNUB, KCTKI. 

'TEN, SrAiiL, PuiOLD, and KicnTxa: lada 

^-liS'lSt ^ c'"«.'5.-';ri^S;S;u"?rp."u.'S'. V,:;, fe- caace or i, are given in the E,/ie»ewi, Am- 

'^ ■ ■ ■n.iSH — U.Ihiierl.VBUT. BitiliDth. dtmia Nutvrm CtiruKoram. I ncTcr ■»» H 

'■i^Jrf^in'''Mer™'c£rr 'St i">«»nce of it. My leanied and sueotiGc bimt, 

-H.a Jamrtm, Joum. Oct Profiji ^'- ^V- Hutchinson, informed me that, dariif 

L.l.p.HO.,t-vXpl"" -- - ■'■' ■-■ ■■ 



'tt^rotii 



e UkraiD< 



Pelisson. IthasoccuTTed iarareiostancadD 
epileptic convulsions : 1 !>a w a case of this kind, D» 
uharges of blood from the Bainnc and m'pplaw 
^,7. .AsblUdH. Med. Chlrurg. Kerlew, vol Lp. I4S., Ibid, mnrn fivniiitnt nnilltnv^ liwin ukpn Kv ^ntnv« 

™i.U.p.«*.;ibW.vol.iit. p-SiS.. lbid.nJ.xiiL P.1M. ™™ irequEni.anu iia»e ijeen seen By acHiwl, 



nll§.— &'CM(n,'On Hmdiiirj H»ninrrh.(e.Nc.nh '""horse, whose sweat, upon most occwom 

jtmer. Med. uhI Suit. Jouin. 1898. and JDutn. dH Pro. eiertion, was ranguineous ; and was nearly jib. 

nb del SdnKM M^ L »iiL p. 61 — C^emrl IH" do blood upon p-cal eiertion. It was Reaeral, ai 

l^kj:^'MTl^J;^J^JmmM«Zo«^ unatlendedb,anjolhe..ignofdisease.-Hw»^ 

chahies dM Htnwrrliaila, !>ok Svo. Pirii, li!S.— lage fiomtlie/arehas been observed by Voo 

tlL''''iSl»!s*l *t1l1""'^'^"'^ """"■''""' ^'^"^"^ lihasoctUTTedinrareioBtancw 
Dcctilnei MMkalra! kt. 8< 

"V'sSTTiiinJ.xiil- tlM. T'° '■■^17'-''"""—','™"'«>=""/«^»"— 

, ibid. VOL XTll.p ee.H7.3ST., AhATDS 1.I'S1TANUS, Oiircellds DoNiTn 

Ibid. VOL «. »S1., Ibid. voluT, im^ IbUl. vol.iL MEn«t.iNVS,VAMiFR Wiel,1'*nsbolvs,PhI- 

fTifa!rvolt!™A*?°iSll5L^ U»,,B,«nj.,Ntl.}IorFH»NN, ScnoRT.. T...^ 

Mtte, voL Ix. n. iiM. Sai—Na^, in Ibid. voL lilL Demui, RiCHTtn, Weoelin, Jac-ossoh, hI 

?''2;Ti~£ir^'t£i''"''^ 1 "S^^i^'b^™'* ■"?«"■ Hasmorrhage from the unAiIinu ka 

ftaSSJrf M«k^S.7> MLW~pS,i.£lpk1iSi't M'^u're'l <:l'i«fly in yo-nR children, or dnriaglkt 

— J. F. Lutiiii*, Tnlxt d'Aiuiioinle Pstholoiliiue, t. L first weeks or months of infanc}. Cases of tlit 

■'■ M m «^' ^»-««Sl.' Cn 5?fti2L*MSl ™l''ll' '■'"'* '"'"= ^^^ "'"'"<* **? FA.Ricrus, Sntj™, 

E«id.l8:B.-i[.Ca'nBrt(V"l'»"»"™oftheHcn«nti.)i Riofokd. and othen, and have generally teiai- 

Fanniof IHieMe,fucG. Load. ISSS. natcd fatally. Mr. I'dut has detailed a c«a 

HsHORRUACEs COKSIDEBEO WITH HEIPECT TO which thus terminated, and nbich wu the iM 

THriB Seits. in one family. Eiudations of blood from te 

ST, la treating of hemorrhage, as regards the armpits, grains, and ottemilios, especiallj te' 

■ituations in which it lakes place, I shall notice lingers and toes. havebeen remarkedby Wins^ 

it— First, /n pom ufciefc ndmit nf"lA««(wna/ Zacutvb Li'aiiASLS, Mercslin, PIagikooU, 

diK^arge of Ihe tffustd blood, as from the skin, Asn, Mvsgf.avf, Ab-I1eerb. IEiedi.in, B:tnM- 

and from the mucous surfaces; the latter of these Li!iv3,Oiti.ovm!>, Wntrr, and Thilesiis. B^ 

comprising the most important of the diseases moirhnge from culaneous nevi. and fnm At 

usually denominated hcntorrhagic. — Second, cicatrices of ulcers, is not an infrequent occap 

In trout or iftu* taciliet, tieetuarii;! follaictd bg rence, especially in females in whom the a* 

a gmtrr or Itu aecumMlatian of tke igiiitd hlo-Kt. menia are suppressed. In this case it WCOM^ 

Tninn, It tAi arnlar I mho nr pareachifma Ihe form of vicarious mcnslruatioD, 

H. — In discusnng the particular 6l.i. Coil'm. — Culaneous he morrhig«i 



rf Ihe 1 

Aiims of 



hemorrhage according to this arrange- evidently more or lo'is connected with ibe toll -^i 
reference will be made lo the vila.1 con- of the constitution and of the circulation. llW 1 
, morbid relatiana upon which hcmor- have been seen at all ages, and more fiequon,^ 

e shown, above, more or less lodcpcnd. in females than in males. Tin j i m^ "^ 

RBnAOTFROH THE Ssiv. — SvN, lis- appcar aftor thfl Buppressionor cessaliou ofaB**-"^ 
tomcd lianguineous or other dischargeii BM ^ 
especially the menstrual. When they take pkM'/ 
from the breasts, they often recur periodica!^) 



74 



HAEMORRHAGE FROM THE NOSE — Causeb. 



tension, dryness, heat, or of titillation or itching 
of the nostrib. Not infrec^uently, especially in 
the more passive or asthenic states, the hemor- 
rhage occurs without any premonition, or merely 
after a slight touch or local irritation. The cha- 
racter of the pulse varies with the degree of vas- 
cular action and of vital power ; and in proportion 
tothe grades of both it is mil, strong, and rebound- 
ing. According, also, as both action and power 
are weakened, the pulse becomes frequent, soft, 
compressible, open, small, and undulating. The 
older writers considered that a dicrotic or rebound- 
ing pulse indicated the occurrence of this, or of 
some other hemorrhage ; but no great dependence 
can be placed upon this symptom. 

68. B. The hsemorrhage may take place from one 
or both nostrib ; but in the latter case it is greater 
from one tlian the other. The quantity of blood 
discharged may vary from a few drops to many 
pounds ; and, in the more obstinate passive states, 
the patient may be reduced to the utmost danger, 
or may be carried off in a few hours» or days, ac- 
cording to the continuance or violence of the dis- 
charge. In some cases, a fibrinous and more or 
less firm coagulum attaches itself to the part 
whence the hemorrhage proceeds, and occa- 
sionally hangs out of the nostrils over the upper 
lip, or down mto the posterior fauces. As long 
as this remains attached, the discharge continues 
suppressed ; but when removed prematurely or 
otherwise, it returns, even with increased violence 
and danger. The disease may be continued, 
remittetit, and recurrent, or intermittent. In this 
last case it may return irregularly or periodically, 

69. C. The more active or simply sthenic epis- 
tBLXis'iBohensymptomatic or critical ofseveral acute 
diseases, attended by increased action ; especially 
the more inflammatory kinds of fever, and inflam- 
mations of the brain, or of the lungs, &c. — The 
passive forms are itec{\3itix\\y symptomatic oise\^T9\ 
cachectic maladies; and of the last stages of 
malignant or low fevers. — Many writers, even as 
recent as the Franks, suppose that, in ca<%cs of 
epistaxis consequent upon enlargements or ob. 
structions of the liver, or of the spleen, the hemor- 
rhage is generally upon the same side as tlie 
enlarged viscus. 

70. ii. Causes. — A. Epistaxis occurs most fre- 
quently in children and young persons, especially 
in its more idiopathic states. It affects most com- 
monly the sanguine, irritable, the plethoric, and flo- 
rid ; and those possessed of great talents, of delicate 
or relaxed fibres, of weak constitutional powers, 
and of much sensibility. After ten or twelve years 
of age, it is oftener observed in the male than fe- 
male sex. It is not infrequent in males about the 
change to the decline of life ; and then, as well 
as at later periods, often prevents more serious 
hemorrhagic or inflammatory attacks. Kpistaxis 
is also often dependent upon peculiarity of con- 
stitution or diatnesis, and is consequently, often 
hereditary, or observed in several of the descend- 
ants of the same parents, or members of the same I 
.family. — At advanced ages, it is most common ! 
in those who live luxuriously and partake largely 
of wine or malt liquors. In the more mature 
periods of life, it is most freouently symptomatic, 
or dependent upon disease of the heart, of the liver, 
spleen, or of some other viscus -, or consequent 
UDon the disappearance of some sanguineous or ' 

oAer evacuation, i 



71. B. The exciting causes are extremely na<* 
merous and diversified ; for whatever favours an 
increased flux of blood to the head, and to the 
pituitary membrane ; or retards the return of this 
fluid from these parts; or occasions general ple- 
thora ; or weakens the vital cohesion of this 
membrane, or the tone of the vessels tamified in 
it, may occasion hemorrhage from it, when the 
predisposition already exists. — a. The exUmtl 
causes are — injuries ; irritants or excitants inhalid 
into the nostrils; stimulating vapours or gasOf 
fractures of adjoining parts ; exposure of the fius 
to fires or furnaces, or of the head to the su'f 
rays, either uncovered, or with a black or metaUie 
hat or cap. — b. The internal raiuei are — what* 
ever increases the flow of blood to the head, tl 
anger, shame, or other states of mental ezcitemttit 
or mental disorder ; protracted study, and grett 
exertions-of the mind ; stooping, or a low or de- 
pending position of the head; frequent sneesng; 
catarrh ; febrile, inflammatory, and exanthemaHwi 
diseases ; headachs, and rheumatic affectioiis sf 
the face ; — whatever retards the return of blood, 
as deep sighs, exertions of the voice, langhinf, 
singing, crying, &c.; playing on wind instru- 
ments; severe cough or difficulty of breathing; 
sadden terror ; disease of the heart or adjoimiY 
large vessels ; tumours pressing upon the jugulir 
veins, or other causes of obstruction to the cir^ 
culation in them, or in the subclavians ; coa- 
gestion of the lungs ; neckcloths or collars won 
too tightly,around the neck,&LC ;— whatever eavM 
absolute or relative plethora, as too full fiviifi 
the ingur^tation of large quantities of wine, sr 
other exciting liquors ; the suppression of te- 
customed evacuations, especially the catameniil 
and hemorrhoidal, &c. ; — whatever interfem 
with the equal distribution of the blood, as weo- 
ing tight clothe^ or cor?ets, obstructions in any if 
the large viscera, the gravid uterus, excessive^ 
tension of the stomach or bowels, or enlargemeflt 
of the spleen, epileptic or convulsive seixan^ 
cold applied to the extremities, suppreaskm 9t 
retention of the natural discharges, ana unnatmt 
positions of the body ; — whatever weakeoi thi 
tone of the vessels in the pituitarv membrane, ui 
diminishes the crasis of the blood, as the advaaoei 
states of low fevers, scurvy, and other cacbectie 
maladies, frequent returns of the complaint, &c;'- 
whatcver determines the blood to the superficid 
parts of the body, as diminished pressure of thi 
air, high range of atmospheric heat, &c. Thi 
epidemic prevalence of epistaxis (which is of nff 
raic occurrence) may be attributed to this M 
cause. (See Moroaoni, Epist.xiv, ch. 25.) 

72. r.The blood is chiefly exuded from the capt 
laries of the pituitary membrane, as in heaflf" 
rhages from other mucous surfaces: but At 
question frequently agitated, as to whether it pio* 
cecds from artenal or venous capillaries ctt 
hardly be solved ; nor does it deserve thetnmUi 
of inquiry. J. P. Frank observes, that be IM 
frequently seen a varicose state of the vdu tfttf 
cases of chronic epistaxis. The more importHi 
considerations as to the pathologv of the a iw i l^ . 
are those which relate — 1st, to the states of ?■■• 
cular action, and vital tone attendant upon it;-^ 
2d, to the constitution arid habit of body of Ai 
patient ; — 3d, to previous attacks of hsmonte^ 
either from the nose or from other puts;— r^* 
to antecedent and associated dtsorders, or to 



76 



HEMORRHAGE FROM THE NOSE— Treatment. 



sitting posture, with the head held backwards ; cold 
applied to the face ; or a piece of cold metal placed 
between the nape of the neck and the clothes; and 
cooling drinks, especially those with acids, nitre, 
&c. ; will be sufficient to arrest the discharge. 

78. c. When active epistaxis has proceeded so 
far as to require to be arrested, and has still con- 
tinued, notwithstanding the foregoing means, the 
treatment then called for is also appropriate to 
the passive or atonic states of the disease. In these 
circumstances, the chief reliance must be placed 
upon astringents, applied to the pituitary mem- 
brane, and taken internally with tonics ; upon 
pressure made locally ; and upon the insufflation 
of substances into the nostrils, that may promote 
the coagulation of the eifused blood. A solution 
of the acetate of lead , or of the sulphate or acetate 
of zinc, or of the sulphate of iron or of copper, 
or of the sulphate of alumina, or of the vegetable 
or mineral acids, or of the pyroligneous acid with 
kr^osote, or of any of the numerous vegetable as- 
tringents (§40.45.), may be injected into the nos- 
trils ; or lint, moistened with either of them, 
introduced ; but whilst astringents are boing used 
locally, the exhibition of them internally should 
not be neglected. The superacetatc of lead, with 
acetic acid, and small doses of opium, may be 
given internally; or other astringents may be 
taken with tonics; or small doses of spirits of 
turpentine resorted to, in the manner above recom- 
mended ($ 41.). 

79. Finely levigated astringent powders, espe- 
cially those of alum and of gall-nuts, may be 
blown through a quill into the nostrils ; or sub- 
stances of a glutinous nature may be employed 
in this manner, particularly powdered gums, as 
tragacanth or acacia ; or astringents may be con- 
joined with these. Finely powdered charcoal 
may be employed in the same way. Pungent 
or irritating substances are often of less service 
than the powdered gums, which will» without ex- 
citing the ^chneiderian membrane, favour the 
coagulation of the blood on its surface. Plugging 
the nostrils with lint moistened wilh some as- 
tringent solution, is sometimes successful ; but 
when the hxmorrhage proceeds from the more 
posterior parts of the nares, it will fail, unless the 
lint be pushed so far backwards as to reach nearly 
to the pharynx. Care, however, ought to be 
taken that it does not irritate this part. —J. P. 
Frank advises a piece of the intestine of a pig, 
closed at one end, to be introduced into the 
nostrils, and injected with a cold fluid.— Some 
writers recommend thick mucilage, others a paste 
with charcoal or with astringents, and others the 
white of egg, to be conveyed into the posterior 
nares, in order to coagulate the efTused blood. — 
When a coagulum has formed, either spontane- 
ously, or by any of the foregoing means, it ought 
not to be disturbed for three or four days, or even 
longer, lest the hnemorrhage return. 

80. d. Besides the above measures, others have 
been advised. — In order to derive from the seat 
of haemorrhage, Zacutus Lusitanus directs the 
cautery to the lower extremities; Chrkstien, 
warm pediluvia, with mustard flower put into the 
water ; I3orf.mj, bruised nettles to the feet and 
hands; Niemann blisters to the nape, and Cuf/a 
to the arms ; Rifdun, the exhibition of active 
cathartics; and Chlius AirRFi.iANus, cupping 
on the occiput, Galen on the hypochondnum, 



and FoRESTus on the extremities. ^Vith the view 
of constringing the extreme vessels, cold drinks 
are prescribed by Hoffmann ; cold injec- 
tions through the nostrils, by Morand and 
MoRCAONi; the immersion of the head in cold 
water, by Darwin ; cold glysters, by LKirrHifEE 
and Anurieu ; and cold applications to the geni> 
tals, by Diemerbroece, Thkden, and Merciu. 
In adtlition to the local astringents already no- 
ticed, powdered agaric is recommended by Kock- 
ARD ; writing ink, by Riedlin ; lemon juice, by 
Blankard; and spider's web, with vinegar, by 
Ciiesneau. The introduction of plugs moistened 
with spirits of wine is directed by Moroaoni and 
Rath, and with the expressed joice of the com* 
mon nettle, by Pr^votivs ; and plugs con- 
sisting of dough, or chalk-paste, by Avicbnna 
and Diemerbroece. The mjection of a stmg 
solution of isinglass is prescribed by Lentui; 
and carded lint, drawn or pushed into the pos- 
terior nares, is employed by Audovin. 

81 . The internal use of the acetate of lead, with 
opium, is advised by Reynolds and Latham; 
of the phosphoric acid, by Herder ; of the aro- 
matic sulphuric acid, by Hufeland ; and of tbs 
ergot of rye, by Sfajrani, Cabini, Ryan, and 
Negri. — The first of these may be employed in 
either the active or passive states of the disetie; 
but the phosphoric acid is admissible only in thi 
latter. I n passive epistaxis, camphor with opiom ; 
the spirits of turpentine, in small and freqaait 
doses, with aroraatics and restoratives ; the chlo- 
rates of potash or of lime ; the sulphate of qu- 
nine with camphor, &c. ; aasafoetida wilk 
myrrh, and opiates in small quantity (Sydbit- 
iiam), are amongst the most energetic medidiMs 
that can be taken internally; but external nusua 
ought also to be resorted to. 

82. e. If epistaxis be vicarious of menstruatioB, 
the return of an attack should be prevented only 
by endeavouring to restore the catamenial m* 
ciiarge. If it l>e periodic, especially in penooi 
who have suffered from agues, congestion or es- 
largement of the liver or spleen should bedreadcd; 
and if either be found to exist, dcobstruent j^inf- 
atives, followed by tonics, particularly quuuBe 
or the other preparations of cinchona, or Fowlis^ 
solution of arsenic, ought to be prescribed; bat 
local depletions should be freely employed previ- 
ously to these, whenever the liver is the seat ot nieb 
disorder. When epistaxis occurs in a^ed perNSS, 
either the early suppression of the discharge, or 
its continuance, may be followed by serious resolti* 
It is generally connected with a disordered stall 
of the circulation within the cranium in sick 
case<«. \N'hat has been stated above will indicHa 
the circumstances in which it will be advitaUt 
to interfere ; but repeated blistering behind tbe 
ears, in some instances cupping in this situatiM, 
a setou in the nape, and other measures wind 
the ])eculiarities of the case will suggest, with a 
suitable regimen, ought not to be neglected. 

83./. If the haemorrhage from the nares seens to 
be critical, tlic ob.«ervations offered in the axtide 
Crisis are altogether applicable. AVhenit^ 
pears in the last stage of low fevers, or in 8cwy> 
or in purpura, and is merely the conset^nencs 
of the lost tone of the extreme vessels, with di- 
minished vital cohesion of the mucous surtoif 
and a deteriorated state of the blood, the ttcat* 
ment directed for the passive form of epistaxis or 



J 



78 



HiEMORRHAGE FROM THE MOUTH AND THROAT. 



which the discharge was produced by a combin- 
ation of mercury and belladonna. Hirsch, Frank, 
and others, have met with periodic hsmorrhage 
from this part, vicarious of menstruation. Fatal 
effusions from the gums have been seen by Hor- 
snus, Fabricius Hiloanus, and several more 
recent writers. — The occurrence of hemorrhage in 
this situation in purpura hsmorrhagica, scurvy, 
and the diseases adverted to above ($ 86.), is 
too well«known to require further notice. 

88. c. Hsmorrhage from the tongue very rarely 
takes place to any very considerable amount, un- 
less in cases of injury of the raninal veins or ar- 
teries, as in dividmg the frttnum lingutet when it 
may prove (atal. Slighter injuries from the teeth, 
especially durine epileptic fits, seldom cause more 
than small discharges of blood. But the more 
serious diseases to which the tongue is liable (see 
art. Tongue) may be followed by dangerous or 
even fatal hemorrhage. Such instances are re- 
corded by Platsr and others. Mari saw 
24 lbs. of blood discharged from this part ; and 
J. P. Frank met with a case of gloisitist which, 
upon passing into gangrene, terminated fatally 
with profuse hasmorrhage. 

89. d. Hemorrhage from the pa/a<« and/aures 
to a very connderable amount has been observed 
bv BuNDL, VooEL, Frank, and Kluige. J. P. 
Frank believes it generally to proceed from a 
varicose state of the veins in this situation ; and 
hence the appellation, Ha^morrhoide* Oris, applied 
to it by VoosL and Bundl. He mentions an in- 
stance in a young man, who, for many years, 
suffered repeated attacks of hemorrhaere from this 
state of the veins of the palate ; and who was per- 
manently cured, after a profuse discharge, by a 
strong solution of alum. Portal met with a 
case where the hemorrhage took place from the 
uwla, — A more or less copious cftusion of bloG<l 
may also proceed from the velum palati orionsiU, 
especially in the course of cachectic diseases, or 
a« a couMecjuence of a varicose state of the veins 
of the part, or of those in the vicinity. 

90. 0. Effusions of blood from the surface of 
the vharytix occur more frequently than is com- 
monly supposed, and are overlooked in conse- 
ciuencr oftlie Huid having passed into the stomach. 
When the hemorrhage from this situation is very 
considerable, the quantity of blood which is swal- 
lowed is often so large as to cause vomiting, and 
to lead to the supposition that the stomach is the 
seat of the disease. The small veins in the 
pharynx are not infrequently varicose or ob- 
structed ; and when this is the case, hemor- 
rhage sometimes takes place from compara- 
tively slight causes. The most dangerous dis- 
charges from this part occur in the advancevi 
staee of putro-adynamic fevers, and of cynanche 
maligna, in which the pharynx is more or less 
affected. J. P. Frank has noticed the occasional 
supervention of pharyngeal hemorrhage inde- 
pendently of those diseases : but the subject has 
been overlooked by other writers. Some years 
ago, I attended a lady, about 70 years of age, 
residing at St. John's Wood, who complained of 
dyspeptic disorder complicated with psoriasis and 
sore throat. The veins of the pharynx were reti- 
culated and varicose. I was afterwards called to 
her suddenly on account of a very severe he- 
morrhage, attended by vomiting and cough. 
3Iucb of the blood evidently was brought up 



from the stomach, but a great part paaed directly 
from the throat. The cough arose from the irri- 
tation caused by the fluid on the epiglottis and 
pharynx. The effusion was arrested (or a time 
by powerful astringents. Two days afterwards, 
the hemorrhage returned more violently than 
before, and terminated life before 1 feached her. 
On examination after death, the pharynx was 
found softened, black, and studded with soft 
aphthous ulcerations, between which dark Uood 
was infiltrated. The veins of this part were nu- 
merous and dilated. I'he stomach contained a 
considerable quantity of blood. The upper part 
of the oesophagus was softened and congested ii 
its internal surface. In this case, the blood had 
passed into the stomachy the position in bed hav* 
ing favoured this occurrence, and had irritated 
this organ so as to produce vomiting. 

91. i. The Symitums and Diagnosis of he- 
morrhage from the mouth or throat are not always 
as distinct as may be supposed, particulariy as 
respects the source of the discharge. The symp- 
toms preceding the effusion are very unceitaia; 
and are those most commonly indicating con- 
gestion of the head or adjoining parts, or disease 
in one or other of the above sitaations. Headachy 
vertigo, noises in the ears; soreness, irritation, 
titillation, tension, or a sense of fulness or beat in 
the throat ; a bloated appearance of the coun- 
tenance, and throbbings of the vessels in the 
vicinity, sometimes usher in the hemorrhage. If 
the patient be in bed when attacked, the imtation 
of the fluid on the glottis causes cough ; and the 
passage of it into the stomach is followed hy 
vomUing, when the quantity is considerable, or the 
stomach irritable. If hemorrhage take place 
from the pharynx whilst the patient is asleep, the 
blood will flow into the stomach ; and the fint 
intimation of the occurrence will often be the vo* 
miting of blood. Hence the utmost care is required 
to distinguish this species of attack from h^mcf' 
tysii on the one hand, and from h<emattmesU on 
the other, as it may closely simulate either. lo 
order to do this, the mouth ought to be well 
washed by a slightly astringent and colourleis 
fluid, or the throat gargled, and afterwards care- 
fully examined. If the hemorrhage be too ce- 
pious to admit of inspection of the mouth and 
throat, the patient should lean forwards, so as to 
allow the blood a free passage from the mouth; 
and if it flow without coughing or retching, and is 
neither frothy or very florid, nor very dark or 
grumons, there can be no doubt as to the situatioa 
whence it proceeds. If the patient feel it coll^ 
in the throat, and create a dii^po&ition to deglu- 
tition, or if he require no effort to bring or hawk it 
up, it manifestly proceeds from the fauces or pha- 
rynx. — In many instances, causing the patient ta 
drink some fluid instantly before examining the 
throat will assist the diagnosis; and in others, the 
history of the case will be sufficient to settle the 
question. — When the fauces or pharynx is the seal 
of the discharge, deglutition of food or drink, (a 
the use of a gargle, either before or d«ring the 
hemorrhage, will cause more or less pain. (See 
Diagnptis of HEMOPTYSIS and H^vimatuiesis.) 

92. ii. I'he Causes of stomatorrhagia are those 
of hemorrhages generally ; but more especially, 
previous diseases of a cachectic or malignant cha- 
racter ; affections of the gums and teeth ; repealed 
attacks of sore throat, particularly when connected 



80 



IliEMORRIIAGE FROM THE RESPIRATORY ORGANS. 



shorter time before the attack. In some instances, 
neither cough, nor difiiculty of breathing, nor 
any symptom rcferrible to the chest, has been 
complained of ; or it has existed in so slii;ht a de- 
gree as to escape the observation of the friends of 
the patient ; and vet the roost extensive clianges 
had taken place in the lungs, and caused the 
haemorrhage. A case of this kind was attended 
by Mr. Busiilll, Dr. Clakk, and myself, whilst 
this article passed through the pre>s. Such in- 
stances, however, are not uncommon, a^ shown 
by Rhodius, ]Mi:LLFi), Wedel, Cjrambeuo, tlie 
]■ RANKS, J^ouis, Clark, and others. 

99. B. Pragresi. — As the blood rises to the 
larynx, a sense of titillation is felt in the trachea, 
or of irritation in the throat, with dyspnoea ; 
and a gurgling or bubbling sensation in the chest 
or trichca ; and the blood is either hawked or 
coughed up, exciting a sweetish-salt taste. As 
soon as this occurs, much alarm is sometimes 
caused, particularly in delicate or nervous per- 
sons ; aiKl several of the general symptoms, par- 
ticularly those connected with the action of the 
heart and pulse, are owing chiefly to this circum- 
stance. When the blood is m considerable 
quantity, the discharge of it is attended with a 
fieeling of suffocation ; the chest is forcibly di- 
lated, a convulsive reaction or cough follows, 
and this fluid is ejected from both the mouth and 
nostrils. In some instances, the irritation at the 
top of the pharynx, and in the fauces, excites 
retchings -, and in others, the blood, as it collects 
in the pharynx, is instinctively swallowed -f. and, 
vhen it has accumulated in the stomach, causes 
vomiting ; and gives rise to a suspicion, from this 
circumstance, and from the pn*sence of portions 
of ingesta, &c. as sliown hereafter (§ 118.), that 
the haemorrhage is seated in the stomach. Oc- 
casionally the blood is brought up without any 
eflbrt whatever, beyond a strong expiration, 
which it accompanies in a full stream ; and when 
retelling or full vomiting is occasione<l in the 
manner just stated, another and often a greater 
discharge of blood from the lungs attends it. 

100. The quantity thus discharged, varies 
from a few drops to many pounds. Rhodivs 
(Obi, cent. ii. 31.) saw 23 lbs. lost in three 
hours; Pezold ((>/»«. Mi»d.-C/iir. No. 49.) and 
Zacciiiroli (Weioel's Ital, Bihlinth, b. iii. 
p. 154.) ob8( rved larger quantities during a much 
longer period. J. Frank {Pi'ai. Med.S^c. ii. 
2. 1. p. 417.) had a patient who lost 192 ounces 
in twenty-four hours; and a friend of my own 
experienced nearly as great a discharge in the 
same time, and afterwards recovered. When the 
blood is not considerable as to quantity, it is 
frothy or contains bubbles of air, and is of a 
florid hue ; when it is very abundant, it is fluid, 
generally more or less florid, but not frothy : it 
is seldom mixed with muco-puiiform matter, 
unless it be small in quantity, and it then is 
often semi-coagulated, and of a darker or brown- 
ish tint ; but, towards the termination of an at- 
tack, this appearance is very common. — If the 
hemorrhage Is very great, extreme faintness, or 
even full syncope, may come on : but a sense of 
depression, or sinking, with a quick, sibilous, and 
short respiration ; a small, weak, interrupted 
voice and speech ; and coldness of the extremi- 
ties ; are more commonly complained of. Occa- 
sionally, the least exertion of the voice* or of the 



body, or a flt of coughing, increases or brings hack 
the discharge ; but as often it returns without 
any such cause. 

101. In some instances, the attack is foUoweii 
by great frequency of the pulse, and generally 
excited vascular action, with heat of skin, thim, 
6lv, ; although the pulse had been perfectly tu- 
tu ral before or at the time of seizure. In these, 
the congestion of the substance of the lungs con- 
nected with the production of the hsmoptfai 
has passed into inflammatory action, in one or 
several parts of the organ ; or rather, the infiltrt- 
tion of a portion of the efTuscd bl<Mxl through the 
smaller bronchi has excited inflammation of them, 
as demonstrated by the sthethoscope and by &- 
section. In many cases, especially when the 
hemorrhage occurs in weak or lax frames, and 
scrofulous or tubercular state of the lunji^, not 
only the external discharge of the blood, but aho 
its passage along the bronchi into the more de- 
pending parts of the organ, and even its inBltrif- 
tion into the substance of the lungs, or its effhsioa 
in the distinct form of pulmonar}' apoplexy, takes 
place, as 1 have several times recognised duiii^ 
life, and ascertained afterwards by dissection. 

102. An attack of hemoptysis may be lo 
severe and sudden as to suffocate the patient be- 
fore a large quantity of blood is lost ; or so con- 
tinued as to destroy life by the loss of this fluid. 
Only one violent seizure may occur — the patient 
recovering peifcctly, without suflfcring maferially, 
after the immediate eflects have passed off: bit 
this is seldom tiie case ; more or less disease of 
the lungs, althou^^h unapparcnt to the friends 
previous to the attack, following rapidly after- 
wards. In some instances, particularly when 
tubercles have proceeded to softening, &c. withovt 
exciting luuch disorder, the hemorrhagic con* 
gestion, infiltration, and atonic inflammarion ef 
the substance of the lun^s, attendant and conse- 
quent upon the seizure, soon destroys life. In 
several in.<^tanccs to which 1 have been called, 
the patients had pursued their usual avocation 
unconscious of ailment, been attacked by hemop- 
tpis, and died in three or four weeks afterwards in 
consequence of these associated lesions of thelungi. 
In the case above alluded to ($ 98.), death took 
place 26 days after the attack. More frequently 
the hemoptysis is followed by pulmonary ctHi- 
sumption in a much less rapid form. When the 
blood is ejectefl in small quantity, or of a brown 
colour, or is mixed with a rose-coloured lymph, or 
mucus, latent inflammation or active congestioa 
most likely will be found to exist in the $ul»tanco 
of the lungs; and this inference ought not to be 
doubted, it febrile symptoms, with cough, be pre- 
sent, or if the blood taken from the arm be 
buffed. — In a few instances, the lymph efToaed 
from the vessels towanls the close of the attack, 
is moulded into the form of several bronchi, and 
is expectorated in this state ; in others, crctaceons 
or other earthy concretions, conse(|uent on the 
degeneration, or the partial absorption, of tubers 
cles» or even ossific matter?, are brought up with 
thij blood, or soon afterwards ; but most frequently, 
and especially when the hemorrhage is scanty, 
or towards its closi^ or after more than one 
attack, muco-puriform matter, with or without 
minute portions of softened tubercular substance, 
may be detected ; and these become more mani- 
fest as the blood disappears. 



82 



HAEMORRHAGE FROM THE RESPIRATORY ORGANS. 



morrhage. There is no doubt of the influence of 
premature and excessive venereal indulgences, 
and more especially of solitary vices of this kind, 
in favouring the occurrence of this and its allied 
diseases. 

109. B. The Exciting; Catuet arc chiefly ex- 
ternal injury ; fracture oflhe bones of the thorax ; 
wounds of the chest and lungs ; falls or concus- 
sions on the chest ; physical efforts, particularly 
in liftin? or carrying great weights ; compression 
of the thorax by strait-lacing, &c. ; runmng, es- 
pecially agunst the wind, and hunting; pro- 
tracted exercise with the arms, great exertions of 
the voice, reading aloud, or speaking for a long 
time ; playing on wind instruments ; inhaling 
irritating fumes, as those of acids, &c., or particles 
of dust, as in various occupations (see art. Arts 
and Employments, § 40.) ; foreign bodies fallen 
or drawn into the trachea and bronchi ; cold in 
any form or mode of application ; rarefaction, or 
great dryness of the atmosphere ; the suppression 
of other sanguineous discharges ; anger, and the 
more violent mental omotions ; venereal excesses ; 
terror, frightful dreams, or sudden surprise ; sc- 
Tere fits of cough, of laughter, or of sneezing ; 
straining at stool ; and changes in the state of the 
blood. Besides these, many of the lesions just 
mentioned (§104, et.seq.) act as exciting causes, 
especially tubercles and their consequences ; alter- 
ations of the vessels ehher in the seat of haemor- 
rhage, or near the centre of circulation ; and diffi- 
cult or impeded passage of blood through the 
heart, pulmonary vein, or aorta, &c. 

1 10. C. The teat of hemorrhage, in cases of hs- 
moptysis, has not always been recognised with 
precision. Previous to the writings of Biciiat, 
the effusion was very generally supposed to pro- 
ceed from a ruptured or ulcerated vessel, arterial 
or venous. Subsequently it has been generally 
referred to exudation from the capillaries of the 
bronchial membrane. I believe that at present 
it is too exclusively imputed to this source ; and 
that, although this is much the most common 
mode of its production, it not infrequently pro- 
ceeds from an ulcerated or diseased vessel, par- 
ticularly when the discharge is sudden, very 
copious, or rapidly fatal. — It has '.been supposed 
by some, that the blood is exudcd,ffom the general 
surface of an ulcerated cavity, when this lesion 
has preceded the discharge. This may possibly 
be the case in a very few instances ; but, when 
the cavity is the seat of hemorrhage, one vessel, 
or a few only, are most likely its source. In 
most of the cases of hemorrhage, in connection 
with cavities in the lungs, that I have seen, the 
internal surfaces of these cavities, or fistulous 
ulcers, appeared not in a state indicating that 
haemorrhage either had, or could have, taken 
place from them. The circumstance of the small 
bronchi being filled with blood, or their mem- 
brane being deeply tinged, or oven injected or 
inflamed, is no proof of the discharge having 
taken pjace from them, as the blood, when once 
effused, even as high up as the trachea, will fre- 
quently gravitate or pass downwards into the 
minute air-vessels, especially when the lungs arc 
in a state of disease or of debility, and will dis- 
colour, irritate, or even inflame them.* 

* This, M wcU a« other points conncrteil with httinn- 
ptysis, are very justly stated by the elder Fkwk : — " Si 
multos, ct ex rasis contipicuis, majure cum iinpclu cruor 



111. J. P. Frakx has endeavoured to establish 
a variety of hsmoptysig under the denomination 
of tracheal, from its seat. Admitting the occa- 
sional occurrence of haemorrhage from Uiis sito- 
ation, it rarely can be distin^iahed from other 
states of the disease, even with the aid of per- 
cussion and of auscultation ; for, as this very able 
and practical writer has shown with ^reat truth 
and originality, a conaderable portion of die 
blood effused in this situation passes down into 
the bronchi, and gives rise to the samepheDomeu 
as depend upon the more common forms of the ma- 
lady. This, however, he concedes. In cases, alio, 
of profuse haemorrhage from the pharjrnx or puts 
adjoining, a portion of the blood may escape into 
the trachea, descend into the bronchi, ana aito^ 
wards be coughed up, thereby simulating haiDO- 
ptysis. The blood may thus pass into the lungi 
as well as into the stomach ($91. 99.), and may 
either be coughed up, or both coughed or vomited 
up, thereby simulating true hemoptysis; or, if 
the quantity be great, it may suffocate the patioit 
Dr. Watson mentions a case which he saw, ia 
which suffocation occurred from the passage of 
blood into the respiratory passages, from an ulce^ 
ated opening into one of the lingual arteries, the 
bronchi containing a considerable quantity of thb 
fluid. From the foregoing, therefore, it may be 
inferred, that the blood in true hemoptysis pio* 
ceeds from one or other of the following sourcei: 
— 1st, From the mucous membrane of thebiot* 
chi — Bronchial hemorrhage. — 2d, From tbt 
substance of the lung, constituting the pulmooaij 
apoplexy of Laesnec, or, more correctly, Fsl* 
monary Hemorrhage, — 3d, From an ulccrald 
or tuberculous cavity, one or more veuels harag 
been eroded or ruptured. — 4th, From vntnnm 
of the aorta, or of some other artery. 

112. D, Certain Pathological EelatiimM rf Se- 
moptifsis have been very generally overlooked by 
writers on this and other pulmonary diseases.— 
a. The intimate connection, however, existing be- 
tween it and tubercles in the lungs has been voy 
diligently investigated by Louis, Andbal, ud 
others. Andral refers to cases of haemoptyMiB 
which there appeared to be no evidence of the 
previous existence of tubercles in the hinA* 
Such cases arc rare, and are to be referred emj 
to extreme congestion of the lungs. Instancei 
are certainly not infrequent, of the hsemorrlia^ 
occurring in a state of apparent health ; bat,m 
many of these, tubercles in an early stage of their 
existence may have previously beien formed, or 
even have been detected upon close exarainatifls* 

in bronchium ruit ; ex hoe, in alia, vicina, altiani, » 
surgit ; ex istis, per ramos bronrhiorum lateraku, ie- 
divert, in subjeetam pulmonis affbcti, aut etUm in sib^ 
sub«tantiain dcscendit, ac novo rcflexu, sub lUHM 
anxietatis ad praK»rdia sensu, violcnta diaphraanatistfr 
tione, Rcd intcrdura sine tussi manifcsta, et per sawn qod 
expiratiunero rortiorcm, torrentis adinstar, per tradicaa, 
larynfrem, per oris, et narium per ostia, tam fliudni ae 
floridus, quain partiin concretus, obseurus, buwisia 
spcctaculo prncipitat. Sub taiito rnioris ad (kaeet 'm- 
petu, pars ejus, in pharyngem regurgitan*, aomirMH, oC 
vidimus, violcntura sirpc provocat, cibotque, foraitas w^ 
triculo contentos, nov« sanguinis undsp, per tmhisai 
simul expulssp, commistos, cxpellit, ac valMum medko^ 
tussis ipsum liliquando per vomitum cruentum tzeiMib 
non ignaro, quo demum ex cavo sanguis acaturiat, Mi- 
tandi arguracntum relinquit. Hoc dutNa non bibm fa 
caiiu, quo tusiis violenta prsrivit, ac, istlus ob inpcini^ 
sanguis non modo pulmonum, scd simul nariun t tali 
expcllitur, urgebimt ; aut furilo pulmo,ob Pares criiwiliii 

Kofluvii in<ioii», cum magno judicii errore, dodafabttar.' 
e Curand. Horn. Morb. fc. class v. ord. iiL gta.& feOft 



84 



H-EMORRHAGE FROM THE RESPIRATORY ORGANS. 



but also its pleura, giving rise to albuminous ex- 
udation, ana adhesions to the costal pleura. I 
have not infrequently found, upon dissection of 
cases of haBOioptysis, not only tubercles in every 
stage ef their progress and results, but also in- 
flammations of the substance of the lungs, and of 
the pleura*, with all the structural consequences, 
and ^et, in some cases, no pain had been felt so 
severe as would have directed attention to an 
affection of the pleura. 

117. b. It is not unusual to see hsmoptysis 
in the course of severe hooping coughs especially 
when this latter disease affects persons near, or 
after, the period of puberty. In children the hic- 
moptysis is generally slight; but in erown-up 
persons it is often a dangerous or fatal compli- 
cation of hooping cough. — b. It is occasionally 
observed as a consequence of enlargement or con- 
gettions of the iiver and spUen ; these affections 
in some measure causing the pulmonary hemor- 
rhage, by deranging the circulation through the 
lungs, or heart, or both. In most of such cases 
the functions of the heart arc intermediately dis- 
turbed. Where the hxmopt^'sis is consequent 
upon haemorrhoids, obstructions of the liver may 
be anticipated. This connection has been no- 
ticed by JBaillou, Morgagni, Stoll, Landre 
Beauvais, and others. Sauvages makes very 
particular mention of the occasional dependence 
of haemoptysis upon enlargements of the spleen. 
The connection between haemoptysis and ha" 
morrhoidal affections Is generally, one of sequence 
rather than of association; tbc 'former following 
the latter, or sometimes occurring after operations 
for these, and for fistula in ano. The connection 
with amenorrhea is generally that of cause and 
effect ; but the pulmonary disease and the attend- 
ant hsemorrhase^more frequently give rise to the 
suppression of uie catamenia than ttiis latter occa- 
sions the haemoptysis. — c. Pulmonary hsemor- 
rhage has also, in rare cases, appeared in gouty 
persons, or in connection with irregular or misplaced 
gout. In these, calcareous concretions have some- 
times been expectorated with the blood, or have been 
found in the lungs on dissection. — d. The symp- 
tomatic occurrence of haemoptysis in the course of 
measleSt of putro-adynamic jeverSf of scurvj^ pur- 
pura , and pestilentiail diseases, requires no remark. 

118. iii. Diagnosis. — It will often be difficult 
to determine whether or tiot the blood discharged 

* As the article wiu goin^ through the preM, a hoy, 
aged 15, of a icrofuloiu iliathcRiM, who had t)een long 
under ray care with tul)erciilarphthi«is, died with proAisc 
hamorrhage nrom the lung». Excavations in this organ, | 
wiU) accretion of the pleura, had been recognised some ' 
months before his deatn. Ho had not complaineil of jMiin j 
in any part of the thorax. The body was examined in 
my presence by Mr. Herbrrt Barkp.r, twelve hours t 
«rter.death. Numerous cavities with lhi(;k linings were i 
found dispersed through both lungs ; the small inter- 
Tcning spaces being studded by crude tubercles. Each 
lung contained between thirty aiid forty ulcerated ca. | 
vitiet, varving fh)ra the size of a bean to that of a large j 
orange: thot>e on the right side l)eing the largest, and | 
from this side the hemorrhage had taken place. The ■ 
cavities on the left side were filled by pus of various 
colour and concistcnca Those on the right were filled 
chiefly by coagulated and fluid blood, the latter mixed 
with pus in some places. I1ie right pulmonary pleura was 
•o firmly adherent to the costal and diaphragmatic pleura*, 
that this lung could not be removed from the chest until , 
all the costu pleura was removed from the |>arietes to j 
which it was attached. In this case the heart par- > 
tici|i«ted, in ita unusual atrophy, in the extreme cmaci. i 
ation of the body. The stomach, as in many cases of pro. 
fuse or fatal haemorrhage fh>m the \\mt^\ contained a 
large quantity of blood, thus illustrating the statements 
madeaboTe: 



proceeds from the bronchi, or from the nares, 
throat, pharynx, or stomach, owing to the cir- 
cumstances msisted upon in other parts of this 
article ($91. 99.). Tne remarks there made, in 
illustration of this, render it unnecessary to enter 
much further into the subject. — a. iVhen tbe 
blood is florid, frothy, or contains babbles of lir, 
or is mixed with muco-puriform matters, then all 
doubt will be removed. The history of tbe case, 
and the premonitory and attendant phenomeaa, 
are generally such as to remove all difficulty, 
unless when the patient has been previousiT la 
good health, or wnen the blood is or a dark hie, 
or when a large portion of it has been swalloired, 
and is thrown up by vomiting. In these cases, 
it will very commonly be found upon auscaltatian 
that blood is present, ^ther in the large bronchi, 
causing a bubbling rattle, or in the small tami- 
fication.4, with loss of the respiratory sounds, and 
with dulness on percussion. Phthisical indica- 
tions, also, referable to the constitution, hava 
generally preceded the attack ; and symptoms of 
disorder of the respiratory organs have ushered it 
in, and accompanied it. 

119. 6. When the accumulation of blood io 
the pharynx from the fauces or adjoining parti 
excites cough, or escapes into the trachea or broB- 
chi, the difficulty of determining with [weciaioB 
the source of the discharge is generally great. la 
these the practitioner will be guided chiefly bf 
the state of the patient just before the attack, m 
by the premonitory symptoms. The abj«ncesf 
disease within the chest, as indicated by aus- 
cultation and percussion, an attentive examin- 
ation of the mouth and throat, and a close obserr- 
atlon of the phenomena attending the discharge of 
blood, will greatly assist the diagnosis ($ 91.99.).* 

120. iv. Prognosis. — Hemoptysis is alwaji I 
a serious disease, and attended by danger in moit 
circumstances. This character, however, doei 
not so much depend upon the ha:morrhage, ii 
upon the pathological state or lesion, of which it 

i«^ the consequence. The opinion as to the rmilt 
will, thercfore,be chiefly formed from the infereacs 
as to its source. Wherever there is any obvioii 
sign of tubercular disease, and when dyspnoea or 
pulmonary symptoms have preceded the attack, 
a most unfavourable prognosis should be given. 
The question merely relates to the period wbieli 
may elapse from the occurrence of hcmorrh^ 
to a fatal termination ; and this will depend mun 
u|K)n the season, upon the progress of the pvl- 
niunary Irsions, and various other circumstsnces. 
— The cause of the disease should also be takea 
into consideration, and the pathological states 
which complicate the hemorrhage. When tfaeie 
is reason to infer that venereal excesses, and more 
especially solitary venereal vices, have induced 
the malady, as thoy very frequently do, we nay 
infer that tubercles have preceded the attack; 
and should consequently formamost unfavonraUs 
progno>is, especially when the diathesis is obvi- 
ously scrofulous or haimorrhagic. The circunw 



^ PAixrs ^uiNBTA remarks, that if the \AooA he Mhf 
and light, it comes fVom the trachea ; but ir it 1>e blwa 
or grumou^, and if there is pain in the part, it is (torn Uw 
thorax. If it is l)rought up by hawliing, it is from the 

Italatc or parts about the pharynx. If it flow fhrnitht 
lead, it is evaruatetl with ticklmg and cough, for itraas 
down into the windpipe, and is again bnnightitp; mtdk 
discharges being generally prccedrd by an acrid lifflmiif, 
and by hcadach or heariuess. (L iii rh. 31.) 



86 



HiEMORRHAGE FROM THE RESPIRATORY ORGANS. 



from the upper part of the body, and the patient 
ought to be seated upright in a chair, in order to 
facilitate the discharge of the blood from the lungs. 
In a recumbent, or even reclining posture, the 
blood will more readily pass along the bronchi, 
and fill the smaller ramiiicaUons, than when the 
chest is erect, and its movements during re- 
spiration unimpeded. If the patient be robust or 
young, if he have not suffered long from pul- 
monary disease, and if the haemorrhage has not 
been very great, bloodletting ought to be imme- 
diately peiformed in the arm from a large orifice, 
until an impression is made upon the pulse, or 
faintness ensue. Whilst the blood is flowing, the 
bared chest may be sprinkled with cold water, 
or sponged with vinegar ; and any astringent the 
earliest procured, as vinegar slightly diluted, may 
be taken internally. — The quantity of blood to 
be abstracted, and the repetition of the operation, 
must entirely depend upon the effects produced 
by it, and the judgment of the practitioner ; but 
he will be guided in this by the constitution and 
. state of the patient, by the indications of active 
congestion, or inflammatory determination, by the 
continuance and violence of the hajmorrhage, by 
the antecedent symptoms, and by the information 
be may obtain as to the causes and pathological 
relations of the seizure. If the patient be delicate, 
or enfeebled by previous disease* or if the haemor- 
rhage has continued so long as to render venesection 
a hazardous measure, or if bloodletting has been al- 
ready resorted to, or repeated, cupping should be 
substituted. Where further abstraction of blood, 
even by cupping, cannot be ventured on, dry-cup- 
ping, as advised by Hippocrates and most of iht 
ancients, and in modem times' by Horns and 
Weidemann, ought to be^dopted. When tlie least 
delay may increase the danger, it may be very efli- 
cientlyand promptly performed with some common 
beer glasses, or other similar means, several being 
applied, either between the shoulders or upon the 
breast. I have oflcn used dry-cupping, in addi- 
tion to venesection, with marked advantage ; 
sometimes covering the back and shoulders by 
the substitutes just mentioned. If the haemor- 
rhage be connected with suppression of the cata- 
menia or haemorrhoids, the feet should be plunged 
in warm water, and a vein opened in each foot. 
If the haemoptysis is moderate, a number of 
leeches may be applied to the tops of the thighs, 
or around the anus. The derivation produced 
by these means, and the effects of the latter in 
restoring the suppressed discharge, should not be 
neglected. Celsus advises cupping to be per- 
formed in these situations, especially when the 
disease is thus associated. 

127. 6. It often happens, when haemopty- 
sis ceases, after a small or a single bloodlet- 
ting, or when the pulse rises in strength and 
frequency, that the haemorrhage returns in one, 
two, or three days, or after a longer interval. 
This mostly occurs in youn^ or plethoric per- 
sons, where the discharge is connected with 
congestion of the lungs, or when the first at* 
tack has been slight, and the venesection suffi- 
cient merely to give a greater freedom of vascular 
action, without removing the pulmonary con- 
gestion or determination. In these cases, blood- 
letting should be repeated, in order to prevent a 
renewed attack, especially if the pulse rise after 
the first depletion, and if signs of inflammatory 



action in the lungs or bronchi appear. The pa- 
tient should be carefully watched after the nnt 
dischaige, and daily examined by the stethoscope 
and by percussion ; and, upon the first indication 
of returning haemorrhage, or of supervening in- 
flammation, blood ought to be taken away in one 
or other of the modes just stated, according to 
the peculiarities of the case. 

128. Where the antecedent disease, thequsn- 
tity of blood discharged or removed by vene- 
section, and the manifest asthenia, from tiMss or 
other causes, forbid further depietton, recoone 
must be had to derivatioet, (Utringentt, and ui^ 
tives, generally simultaneously or in combinatioQ. 
Indeed, even in those cases which evince in- 
creased action, and require decided or repeated 
depiction, these, as well as refrigerants, ought Is 
be brought as early as possible into simultaneooi 
or successive action. The feet and hands oaghl 
to be plunged in warm water ; and, if venesection 
be not performed in the former situation, mustaid 
or salt, or both, should be added to the water. 
An enema with an ounce, or an ounce and a half, 
of spirits of turpentine, should be adnunistered 
forthwith; and other means appropriate to the 
case prescribed. But as to these means, aauch 
difference of opinion will necessarily exist. The 
internal use of astrin^nts is generally adopted; 
but those usually employed can have little effect, 
excepting in slight or protracted cases ; and evea 
powerful astringents taken into the stomach will 
have little or no influence upon the bleedingpait 
before a number of hours have elapsed. Froa 
observing the rapidity with which oil of turpentine 
is absorbed, and passes off by the kidneys and 
lungs, I have been induced to employ this medicine 
in preference to others as an astringent in hemo- 
ptysis; prescribing it in small or large doiei, 
according to circumstances, and as it seemed 

j desirable to act at the same time more or lea 
decidedly upon the bowels or kidneys. 

129. In advising sponging with vinegar tod 
rose-water, or sprinkling cold water on the bretst, 
I had especial reference to thesympatheticinflaeace 
these may have upon the bleeding surface, and tlie 
reaction in the skin which they subsequently occt- 
sion, especially when they are also applied to tbe 
face. When these means have not succeeded, I 
have, on several occasions, prescribed rubefaciesli^ 
instead of cold applications, to the chest ; as these 
last are more frequently injurious than beneficial 
in such cases. An epitliem,with oil of turpentine, 
either tepid or warm, allowed to remain on the 
breast, or between the shoulders, until itocci* 
sions a burning sensation and redness, is the nibe> 
facient I have preferretl, as the quickest in its ope* 
ration, and the most conducive to the removal sf 
congestion or of inflammatory action. The vapoir 
also of the turpentine is diffused around the pt- 
tient, and being inhaled during inspiration, aMfU 
in constringing the vessels of the bleedine surftee. 
Where there appears any objection to ^is tppli- 
cation, a sinapism, or a piece of flannel sooud 
with either of the liniments (F. 296. 311.), may 
be placed upon the chest. Blisters may idso be 
resorted to. I agree with Lentin, Ravoi, and 
Pekcivat., in the propriety of applying them ts 
the back or between tne shoulders. 

1 30. c. Besides the above means, others may be 
employed ; the practitioner being guided in Ins 
selection by the peculiarities of the case, tnd «•• 



92 



HiEMOKRHAGE FROM THE STOMACH. 



chondria, but without that degree of fuluess, tu- 
mefaction, pain, or tenderness in the hypochondria, 
which attends upon serious disease of the spleen 
or liver, and which accompanies the third variety 
(§ 151.). This form of hsmatemesis in de- 
licate constitutions, or in those predisposed to 
hemorrhagic disease, occanonally follows upon 
acrid or irritating substances taken into the sto- 
mach. Thus it has been produced by the irri- 
tation of an emetic, and by acrid poisons. War- 
ton, Glisson, and Hoffmann, have observed it 
occasioned by the use of irritating emmenagogues. 
It may assume a chronic, remittent, or periodic 
character. In two instances, in which it was 
occasioned by the daily excessive use of intoxi- 
cating liquors, it recurred every morning for 
several weeks ; and, in one of them, was fol- 
lowed by a most violent attack of gout. 

149. B.Succedaneous or Vicarioiu Hamatemais. 
— This form of the disease is not of infrequent 
occurrence. It is noticed by several autnors, 
»id particularly by Ballonivs, Hoffmann, 

FORESTUS, WllYTT, KlEDLIN, ThOMANN, PiNEL, 

and others, and has come before every experienced 
practitioner oftener than once. It generally arises 
from those causes which suppress suddenly, or 
prevent the return of, the mmistrual discharge, 
or the hemorrhoidal flux. It may even replace 
an habitual epiMtaxis, or occur in females in the 
form of misplaced catamenia, this part of the 
uterine functions not having appeared. In the 
majority, however, of such cases, tne haematemesis 
has been occasioned by some evident cause, and 
in its subsequent occurrence, it has assumed a 
periodic or vicarious form. This form may even 
manifest itself from the commencement, as where 
it has occurred instead of the catamenial evacu- 
ation, which has either not appeared, or been but 
imperfectly established. 

160. From whatever cause this state' of the dis- 
ease may proceed, it evidently arrests or prevents 
the discharge the place of which it supplies ; 
and, although it cannot be generally shown to 
depend upon previously existing disease of the 
stomach, or of the viscera intimately connected 
with this organ, yet we may suppose that the mu- 
cous surface and vessels of the stomach have been 
disposed to experience congestion, local deter- 
mination, or the morbid conditions on which hae- 
morrhage has been shown above to depend. 
Possibly, also, the morbid states of the surround- 
ing viscera may have been such as to assist in 
producing the hemorrhage, although these states 
cannot be generally recognised, owing either to 
their slight extent, and the obscure or imper- 
fectly developed phenomena attending them, or 
to our imperfect powers of observation. W hen 
hsmatemesis is consequent upon, or vicarious of, 
hemorrhoids, particularly in aged or intemperate 
persons, a morbid state of the liver, as respects 
either its functions or its structure, as well as of 
the stomach, may reasonably be inferred, so far at 
least as to lead to an intimate examination of the 
state of this organ. Admitting the frequency of 
this morbid relation, we cannot, however, infer 
its constant existence, seeing that we often fail 
in detecting it, and of observing it after the hs- 
matemesis has ceased. It seems, therefore, more 
correct to infer that, in cases of this description, 
the sanguineous effusion is often a consequence 
of inflammatory congestion of the villous coat of 



the stomach and duodenum, which has takoi 
place more suddenly, and induced more rapidly 
the effusion than in some other forms of the 
disease. 

151. C. Hdmatemetit from Diteateoftki Kti- 
cera connected with the Stomach. — The vomitiag 
of blood in this form of the disease is eymjitematk 
of congestion or structural change of the spleen, 
liver, or pancreas, or even of some other abds* 
minal viscus. This is the most frequent form of hs- 
matemesis. A congested state of the stomach, nd 
even also of the duodenum, being caused by ob- 
structed circulation through, or other disease of, 
one or more of these viscera, any accidental ini* 
tation, or whatever increases the congestkm m 
the internal surface of the stomach, may occtMi 
the effusion of blood from it. Moat frequotly, 
perhaps, the hemorrhage is produced by obstii^ 
tion, enlargement, or some other lesion of thi 
spleen, the anastomoses of the vessels of tkii 
organ with those of the stomach favouring ill 
occurrence. When hemateraesis arises dm 
disease of the liver or spleen, the history of tW 
case, the presence of fulness or tumefaction, In* 
demess or pain, in the hypochondria and Sf^ 
gastrium ; symptomatic pains about the shovldoi 
or shoulder-blades, an unhealthly or sallow iMl 
of the countenance, and chronic functional fti 
order of the stomach and bowels, will geneiaJff 
be observed. The discharge of blood in this fm . 
of hsmatemesis has sometimes acted as a criiial-; 
evacuation, the symptoms of congestion of Iftlj 
liver or spleen, or of both, which had 
having been removed by it, and health i 
Instances of this kind have been recorded by Oil 
Haen, Frank, Portal, Pinsl, Scumiotiumm 
aind others, and have occurred to myself, 
ticularly in persons who had suffered long 
ague. More frequently, however, the ha 
rhage has furnished only a temporary advaatifik] 
the disease of the liver or spleen, which it htii 
relieved, again returning, followed by an amckj 
of hsmatemesis and another period of relief; " ' 
terminating fatally, dissection disclosing the I 
tent of the disease of which the hemorrhage ' 
merely a symptom. In this variety, the '* 
thrown up is generally of a dark colour, and < 
fluid or grumous, and consisting of small 
The stools are also morbid — frequently 
pitchy or grumous, loose, and very oi~ 
The hemorrhage is often preceded by, 
cated with, or followed by, dropsy of the 
men, or of the lower extremities, or both; 
rarely with hydrothorax, unless it have foil 
the effusion into the peritoneal cavity. In 
instances, obstinate diarrhoea or dyaenteiy 
supervened, especially in warm or 
climates. 

162. 1 agree with Tralles (Deusu Opii,' 

p. 29.), who has strongly insisted on the fiti^ 
quently active or sthenic state of the vesseli if^ 
hsmatemesis, that, in the preceding fonns, 
impeded or obstructed return of blood 
the veins frequently occasions an aut 
action of the arteries ; and, as the blood car 
pass in suflficient quantity, or with requisite C 
rity, by the veins, that it is determined i 
greater impetus into the extreme arterial ei 
laries, thereby dilating their exhaling poras, % 
being effused into the cavity of the organ. fft__ 
degree of vascular reaction may also take jibciB 



.▼sLU 




104 HEMORRHAGE FROM THE URINARY ORGANS— CAUsts. 

sometimes V3ith smaU fibrinous eoagula, the patient (and their relation to the seat of bttroorrhigei 
generally complaining of uneasy sensations in the • and, 3d. The pathological states of which hena* 
region of the kidneys or bladder, turia is the consequence. — A, The t(rii»«iiiajcoD* 

204. i. The Causes of hsmaturiaare — external tain much or little blood ; or the fluid evacaisd 
ii\juries on the loins, hypogastrium or perinaaum; from the bladder may be almost entirely blood, 
falls, or concus^ons of the trunk ; prolonged or Its colour may be either red, or brownish red,ot 
severe exercise on horseback ; riding in carriages nearly black or inky. Sometimes the urine is pMB< 
over a rough or broken pavement; violent nuis* ed^uttaXtmwithpainandscaldin|^;andwithaeofr 
cular exertions; — Internal irritants, as calculi, stant or frequent recurrence of the desire to aapty 
formed in the kidneys or bladder, and acrid sub- | the bladder, although but little or even no vrm 
stances taken into the stomach, absorbed into the j is contained in it. At others,the blood and vrin 
blood, and carried to the kidneys, as turpentine, - are retained in large quantity, efforts at etiei* 
cantharidcs, savine, and various other medicines ; ! ation being ineffectual, owing to coagula obitnicl* 
—and whatever inflames, or causes congestion of ing the outlet from the bladder or being lodged ii 
the urinary organs, as the application of culd, the '. the urethra. Even when the obstacle is nmovii 
suppression of accustomed discharges, &c. — , by a sound or catheter, the urine often prasNii 
JIasmaturia may also be produced by the concur- a bloody, sanguineous, or chocolate appearucs 
rent influence of plethora, venereal excesses, vio- for several days, although the haemorrhage may 
lent fits of passion, &c. ; but the most common have ccase'l, and is sometimes extremely otfeinifi 
causes are organic changes implicating the kid- from the decomposition of the clots reiuned in 
neys or bladder; general cachexia, as scuryy and the bladder, or froflh the action of the urine i^oa 
■purpura; malignant and cxanthematous fevers ;, them. Occasionally this fluid is grumons, wy 
and even still more common are calculous form- I dark, or even black, or contains a number of 
ations and the other internal irritants specifled : small brown coagula. In some cases, fibrinosssa^ 
above. — This disease is most frequent in males, stances of various forms and sizes are eYacnalod, 
in persons advanced in life and m the aged; in | consisting of the fibrine of the effused Uoo^ 
plethoric habits and sanguineous or irritable tem- moulded or changed by the parts through whidi 
peraments ; in the scrofulous and calculous dia- | they have passed. In others, a stringy or gcb* 
thesis; in those who pass an indolent and luxurious tinous substance, with dark coagula, or black 
life, and who are addicted to venereal indulgences, ' grumous matter, is observed in the urine; mi 
and to the intemperate use of intoxicating liquors. 1 occasionally mucous, muco-puriform, or graTsI^ 

205. a. Idiopathic haimaturm is extremely rare. ' matters are also found. 
CuLLEN states that he never met with it. J. P. | 207. H, 'Ihe symptoms of haematuria vary irilfc 
Frank rarely saw it. Unless when caused by the seat of haemorrhage, (a). When theAcufaMi 
cantharides or turpentine, it is certainly very I are the parts chiefly affected, the attack is otuaftf 
s^dom observed ; and even when thus induced preceded or attended by chills or rigors ; by eoUh 
the haemorrhage is generally scanty, and the | ness of the extremitie;*, and particularly of ite 
consequence of inflammatory irritation. In- j hands; by deep-seated pain, or a sense of weighs 
deed, hematuria is often merely a symptom of' or of tension, or of heat in the loins ; by genoil 
inflammation of cither the kidneys or urinary blad- lassitude ; and often by anxicty,or colicky piini it 
dcr, the quantity of blood cfl^used being small., the abdomen; by fi-equent desire to pass the arias ; 
— 6. {Supplemental httmaiuria, or that which . sometimes by numbness in one or both thigb^ 
is vicarious of the catamenia, or of ha;morrhoids, , and pain in the couisc of the ureters, or by naosM 
is equally rare, although its occurrence has been ' or retchings. If cantharides or savine have bSM 
much insisted upon by foreign writers ; and taken, a burning heat is felt in the urinary ps^ 
U is extremely probable that organic lesion is sages, with priapism, scalding, and pain on d»" 
more or less concerned in the production even of ! charging the urine, &c. — (6). When the blmidr 
this variety. Choppart, however, mentions an is the seat of haemorrhage, a frequent desire, ir 
instance of haematuria consequent upon irregular I great difliculty, to excrete the urine; tenesmiii,ar 
menstruation, in which the urinary organs pre- ! pain or heat about the anus ; a sense of teoaioa tf 
sented no change after death. — r. Critical htrma- | of warmth, with itching above or behind the ptMk 
turia is seldom observed, although Forestus, : or of dragging in this situation; pain or achim 
EttmI'ller, Amatl's Lvsitanus, M a rcellus , in the perineum, frequently with febrile sympMi 
DoNATUS, Zacltis Lusitanvs, Hoffmann,' or nausea, and constipation of the bowelSi'M 
JuN'CKER, C'.iopi'\KT, Latoi R, &c., insist on its complaineil of. The severity of the local tjtf 
impoilance during inflammatory fevers, and in | toms, as well as the state of constitutional fl^ 
plethoric |)er;»ons. They also consider that, of order, vary extremely, according to the gradsiif 
all critical haemorrhages, it should be the least vital power and of sthenic or asthenic vascshf 
interfered with. When lia;maturia is actually action, and to the organic changes or Dataifi' 
critical, it seems to depend upon a similar state | the local irritation of which the hnmorrhageiit 
of local action and of vascular fulness, general consequence. 

or local, to that which obtains in the more idio- I 208. The above symptoms,especia]Iy when Av 
pathic and vicarious states of the disease. — It is | precede the attack, indicate inflamioatoiy '^^ 
chiefly, therefore, as a symptom of previous dis- "* ' " * 

ease, local or constitutional, or even of both, but 
especially of urinary calculi, that haematuria is 
met with in practice. 

206. ii. The Description of haematuria com- 
prises— 1st The appearances of the urine and of 
the blood contained in it; 2d. The symptoms 
Mttemiing this morbid state of urinary excretion, 



tion or active congestion of the urinary oigMk »'. 
But sometimes the haemorrhage takes piaea laA 
dcnly, and in great abundance, without any pi> 
cursory sign. In some cases, also, tbesympMrt 
are very obscure. In most of th^, hoiweror^) 
will be found that the blood comeo from thcti^ 
neys, and that its effusion is caused by cakaBil 
these organs. Even wkqn th« blood is disch8i|rf 



1 



106 U.CMORRHAGE INTO TBE BLADDER— Tbia 



nroductiaiu in tbete organs. In mne cases am- . posing the arterial capillarios ami Mfiiiiiiii ip 
ing from this caase, the hemorrhage has heen paratas of the kidneja to be rdaacd lo a osfrai 
ezcesBTe, the nrioary bladder beinz distended by safident to allow nd vlobnles of the Uood ti 
flaid and coagulated blood, espectaily when the escape with the excreted vine, the Uack eobw 
effusion has taken place from this nscas. or from arising from the actkm of an acid, or of the sdM 
the prostate ^land. An interesting instance of ingre&nts of the urine on thoM globaks. 
hemorrhage mto the bladder from fungoid tu- 313. When blood is preeent in the wine in ny 
mours connected with the prostate, where it was considerable quantity, a portion of it sinks to thi 
nece w ary to perform the high operation in order bottom of the vesKl, and the trannaieBCj of 
to remove large and firm coagula that had formed, the secretion is dutnrbed. The reddish pinkani 
is recorded by Mr. Copland Hrrcnisoy {Lnd. without blood is generally clear. A mixlwe d 
Med. Repos. toI. zxii. p. 128 } — In some cases of urine and blood tinges a piece of white rag dippdl 
malignant disease of the urinary organs, the into it of a red cokmr. Dr. WaTaoii ubsmw 
colouring parts of the blood appear as a reddish that, upon boiling urine containing blood, a bnui 
sediment in the urine. — f. S^ffening rf the kid" coagulum will be funed, and that the fluidiMt 
ntyt, or the internal tunica of the bladder may be will regain the natural colour of urine. HVmi 
fofiowed by hematuria, without being suspected the black hue depends upon the pr eae nc e of bill, 
during the life of the patient: but these lesions it passes to a yellowish or greeniui lint upon dOi- 
are very rare. — g. Ulrtratiim of the inner coats tion with water ; if it proceeds from blood, a lit 
rf the bladder very rarely occurs, unleK as a con- dish colour becomes apparent, eapecndlj if alildi 
sequence of timpU cyttitii, or of cyftiiis associated sobcarbonate of soda be added. 
with calculi in this \-i«cus ; or without very mani- 214. iv. Paoovosis. — The prognoeia must d^ 
fest symptoms of these diseases. In these cases, the pend chiefly upon the pathologioal states pndncflg 
hematuria is preceded by such symptoms for a the hematuria. If these consist principally ai 
looser or shorter period, and the urine haf been inflammatory action or irritation, or of actire 
loaded by mucous or muco-puriform matter. — h. gestion, a severe, although not neceMurily a 
A varicoie Uate of the rrins. particularly about gerons, disease is indicated. If there be erid 
the neck of the bladder, has been noticed by se- ' of calculi in the kidneys or bladder, a aaiih 
veral writers as a cause of hematuria {^Hemor- similar opinion may be formed, but nrach wB 
rhoides ivsirr , auct. var.). and by some in connec- ' depend upon the circumstancea of the CMe, lai 
tion with the eouty diathesis ; but this change is the states of associated disorder, pa^ticulaily af 
Teiy seldom observed. — i. Other organic liiom these organs. If hematuria occur in agedpar- 
of the kidneys have been mentioned as causes of sons and broken down constitutions, or if tioa 
hematuria ; but they can be merely suspected du- be reason to infer the eiistence of malignant ar 
r'ng life, unless they' be attended by, or consist serious organic change in any part of thenriHiy 
of, tumoura of the oigan, and give rise to pain in passages, the prognosis must be very lubvoai^ 
the loins and numbness of the thigh of the same able. The amount of hemonha^ is in iinlf j 
side, with the appearances of the urine alread]^ rarely fatal, although the retention of c^ 
noticed ($ 208.) ; and even then, their nature will agula in the bladder is always dangerous, aid 
seldom be fully ascertained. often fatal, from the consequences which resrit, 

212. iii. DiAGvosi5. The urine may present ap- particularly as respects the eicretion of ariM. 
pearauccs very closely resembling hematuria and When hematuria appears in the coarse of ad^ 
yet be perfectly fri«e from blood. The internal use of naraic, continued or exanthematic fevers, or n 
various veszetable substances, e«peciallv the prick- purpura. &c. an unfavourable opinion of the it> 
ly pear ( Cactut ttftu ntia ), beet-root, m adder, sonel , suit should be entertained, 
logwood, &c., will give a red colour to the urine, 216. v. Treatment. — a. When bloody uiiM 
that will be distinguished with great difficulty proceeds from inflamnutor}* irritatioii or adiia 
from that produced by blood. The reddish pink congestion, or is supplemental of some other saa- 
hue of the urine in some inflammatory diseases, guineous discharge, and especially when it ia aW 
will hardly be confounded with hematuria. — tended by severe pain or symptomatic fever, ar 
The dark, black, or inky state of the urine, noticed increased vascular action, bloodletting, and parti- 
by several writers, may arise either from the pre- cularly cupping on the loins, or perineum, accsii* 
sence of blood, or from the principal elements of ing to the seat of the chief affection, should be piae* 
bile being excreted by the kidneys i^iih the urine, ti^d. In these, as well as in other circomstanee^ 
whilst tl^ liver is obstructed or incapable of demulcent diluents, and oleaginous or mild ape* 
performing iu functions, as in jaundice. Cases in rieot-, are more or less beneficial. When acrid 
which black urine has been voided, are recorded substances have caused the complaint, theas tie 
by Uhodius, Schenck, Sailless, Bonet, Cow- especially required; and the almond emulM, 
PEB, HiEDLiN, Bartholi!c, lx)MMivs, Stoll, the gums. the decoction of atthan, the infuaen 
Nicolai,Marcet, E. Thompson and myijelf. Ga- of linseed, &c. may be abundantly eihibiied, 
LEAZzi met with it complicated with hematemesis. either alone or with small doses of camphor, or 
BoNET, after recording a case in which the urine with paregoric elixir« When the hemonhagaii 
had the appearance of mk, states, that he has ob- induced by calculi, local depletions, and deBal- ^ 
served this in hypochondriasb, where it has oc- cents, conjoined with the opiates or other ana* 
caaionally proved critical. In a case treated by dynes, or these latter, either with the alkaline lafc- 
me fifteen years ago, a perfectly black sediment carbonates, or with diluted muriatic add, aeceid- 
was deposited after the urine had stood some time, ing to the sute of the urine, the vrarm bath, aarf 
I'his condition of the urine may be pro luced either emollient enemata, will generally be of aenrioi. 
inthevray just stated, or in the manner I have ex- 216. b. When hematuria presents a psei** 
plained when detailing the case just alluded to character — when it is attended by great oekSy 
(Lend, Med. R«/ms.vo1. xviii. p. 161.) — by sup- ' or vascular asthenia, or supervenea in the coeiH* 



1. -..I. 



.-i.:i iT.OM THE UTERUS — Cacsu. 

.,... ., y ;»-. ^|ij imprecation mnd the puerpenl tUtei b, 

:?= ""t-- !*:•€' *:*jtr, 1*1. 5(A^ic or arfire-— depending npoo 

- i-^t • . !•»<.: >^.Ternii nation of Mood U>, or npon inflimmatorf 

■ -• ! -:.-:•>• :?*.:a!!on oi, the uterus ; or, 2d. Atthenie or^u- 

.->-« •?;. 2r>.n^ from impurvd tone of the nteriM 

-*'^ (f-^!* and parietes; or, 3d. Si^mprimiatic gf 

'•:•! : 'ra.::. r legion. But before the phenomena nsbfr- 

z^ .:. or a::eadiD£^ thew ftates of the disease ue 

«:^'r.Sr>i, the causes which induce them mav be 



. •• 



-]»;•-" 






•» 



..• V 



i. Cause$. — a. The predifpntLing etum 
« '.. r. are more especially concerned in the pio- 
:2.t..*~ •>:' 'Jii- form of uterine hapmorrhagt, an 
''r >:«--*i« at which the men«es first appear aad 
i: •»'. :\ x'iif-y altogether cease; the nien«nid 
:►- •-- T\tni**-]ve< : general or local plethon*; 

• \ -.^?.*e ?<:ni:hihiy of the uterus, ansin;; eitiier 
"•.:•.. >-:j:r.ai coQtormation, or from inordinalB 
^:'. :•.' f\c Mnt.nt. or mai^turbation ; frequenter 
■ - . : .- M.-l-i^earing, or abortions, especially if 
i-j -IT-- fivei-ded each oilier rapidly; con- 
*— - .1 c' !nr abdomen bv light comets ( M Ar- 
--•--•.. R KS<>'£ ' : too mucK warmth applied to 
*: : . «•:: :4krt> of the trunk and thighs ; venr bel 

- L«-:« : :-.e habitual uae of exciting liquors, ef 

- * i-i L'ih-A^aioned dishes; and a frequent 
-•?>: :c- warm bath?. These predispose chiefly 

• ••- n-tf- I.-: {folates of uterine hsmonhMe, 
■- -■ *.:■' •'. '!-^wir.j favour the occurrence of M 
"-""•- p:^« .# :\>rm«; — e«peciallv weakness ef 
-.-.*?•-:..-. .-{rneral debility, an J cachexia ; the 

: .»: . v.n\;^rament ; imperfect or unwhole- 

- --r 1 : .'>*r:»rnt ; chronic or exce«4re diN 
i-:-:*. r-i'*.:.'j'arlT prolonged lactation; tk 

-:"**?>-- T-iwiior.*. as grief, sadness, anxiety, 
-. - .\ •. . ::r 2b?r^ oi rvlaxing beverages, Air. 
1- . i"-'. •• i :.•■- fz^it n^ causf$ arc, stimulation ef 
■ '.z. • • : -i >.v- .".ir -y-jtf'm generally, or of the uterior 
.-.■•-• 1 vi-- .u'.ar. bv the *«se of hot baths, rf 
: • \ .:::•• " • uor*. of acrid purgative*, w •• 
-- T -. 's«.~i.^\:-o. aal by excessive sexual iodd- 
- . ^'-^ • "• "-C «>" hor«<:back, or in an iinei^ 
. i" '.:*: . pr. .;::-ird dancin;; ; running, or wait 
-: vo •*• . ■ i":^: heary weights, and phyficil 
- ^\ —.;-•.• i-y knd; .«hoeks or concussifmrf 
;- : : —.- » . 'il!* o". the thigh* or hips ; exciuM 
-I ." .—:.'!..■: .:" :•.•? sexual organic, by injeciioei» 
J r-.'»< r.:-i :- -•:?p..>-.:orifs : the morevioli-ntm* 
•>-^: ni .r;...! t-*. 15 anjijr, frijrhi.atc. Sfanert* 
i« lo fcr4 to a • a?c :z nhirh it was induced byt 
*i:muiatinj ^s-i>*arv : and oli«trnction or relw 



• % 



"fi-r" 



\\ -f:i !••«» ar:.ir: of" liic t:* ~.*c* mav U' tlie cause of hieiwr' 



K».MV. »• •. -.^.. ■• -i a: :"•- ". ^-.r y r.t.i.-*, m itrf^ndt-ntly cf any moans being vcdM 

^. ^^^ *J ^.^ . . * . •*. V- » •. • : i.r \: »: rt::...ne tliis ob*tn:«.::»:n. a* shown by Drsofr 
.. — .-MX.: \ /x^ » • • '^ t' i ••'^■•'■■- '•.'•«■-••- .V5 u\ and LrcocK. it is. also, not unusail 






»"l > •■ 



ior n:clri>-h.TnioTrhas;ia to oc«*ur wiihinthcfif* 

X ••.*: . \ I..-: ::c tor'nijhi at'ttr n-arriacie, o^peciaUy when thisri* 

4 . • •• .i\ -v ha.-. Utn jerlormcd shortly Inrforc the period rf 

v'i •. .•• I •*».•• ■ * i **.*••.. A ft-ualo in«li«po«ition. It has been supposed thai 

%K..v% 1 nu* V \ N v-xx . % ,* I". • v. .»•»;••:; '^xu-il con^re>sdurngthi< period is apt to indue 

%... ,.\sxU»-.- V . •• -4 v" -' ''^" '• '•'* *■■•«■ '^'^ aitark of this diWa«e. Certain causes, aK 

..«.«. .«««<vv .% »Ji vui V w • *i""<> \•^^\, may occasion it, by affecting related organs, isd 

.^ »^.4 ». » »» ix v'-.t .'.»" V '.•• u/h t:v:iby actin:; synipathttically upon the uteraf* 

.., ,*v •» •*. » '.. v:' -v- • ^^ -e: vwt tru'v V *>-i>iN-Ho-f h adduces insfanrcs of it barisf 

.» »v 1. I' ••.»•.' % i- .\:v.'r. or as bt\n p:o«li:ctti by worm* in the intestinef. * 

■,^ ;v vwv iia^o *itn it Juvourcd, if not excited, hv ascarid* 



• V » » » %» 



k^t«>.. «. .. ^ . » » ■'.■ :.»%•- "^loir ami Finckf oliservid uterine hxmtf' 

■ *• »♦ . . »: .'. -I. 'i- » ■'.»''. *oM » !ii.i.t> uiiu<iiia!ly provulont during the hili(^^ i** 

'^•'u •. *. , .• „•»••* . o-.'vl ".'. .•v.i'.Kd. t!m»rtiaror\ tVirr j»f 177H. CiF.Nnivov. (''»vii*p'' 

U « ..^.^ . V,.. -...o* •n. « •••. *»ii'i.K. and IlorFNFR, rcmarke<l it ocra'ionallj 

■*'«•*% *i«.i..-.».'k*.% «. • • • »i>^ '■ u'.uvtiMt'Ctcd to attend gastric and bilious diseases: andZl^ 



110 



HEMORRHAGE; PUERPERAL UTERINE. 



turned and symptomfttic irritative fever continued. 
An examination was made some days afterwards, 
and another tumour was found passing into the 
ragina. This, which was distinct from the former 
in structure and form, came away soon after- 
wards, and the recovery was progressive and 
complete. In this case, the tumours were most 
probably developed beneath the internal lining 
of the uterus, and thrown off, in the course of 
the treatment which was adopted for the arrest 
of the hsmorrhage. 

231. The iymptcmi of uterine haemorrhage at 
this advanced epoch of life, are not different from 
those ah-eady described (§ 227.). But they are 
more generally caused by organic lesions of the 
womb, than uterine hemorrhage at the preceding 
epoch, and complicated with the symptoms which 
more particularly appertain to the associated 
lesion. Indeed this constitutes the chief malady ; 
the haemorrhage being only the contingent, but 
often the more immediately dangerous, or most 
alarming, occurrence. The consideration, how- 
ever, of these associated lesions cannot be entered 
upon at this place. It is fully entertained in the 
article upon diaaset of the Uterus. 

232. IV. Op Puerperal Uterine Hemor- 
rhage. — Under this head is comprised haemor- 
rhage during pregnancy or parturition, and after 
delivery, — The changes that then take place 
in the uteruf, and particularly soon after par- 
turition, sufficiently account for the frequency 
of metro-haemorrhagia, at these periods. — Du- 
ring pregnancy there is an actual increase of 
the vitality as well as of the bulk of the uterus 
— a state of orgasm of which vital activity and 
vascular determination are the chief elements. 
Hence the active nature of the haBmorrha?es that 
take place from it at this epoch. Besides, this 
viscus contains an organised and living body, 
presenting intimate relations with it, and opposing 
certain of the circumstances which favour san- 
guineous effusions from it. The vascular con- 
nection between the uterus and placenta becoming 
more developed as pregnancy advances, it follows 
that the detachment of a portion or the whole of 
the placenta or ovum will give rise to a more 
profuse hemorrhage in the advanced, than in the 
earlier months of this period ; but as soon as the 
uterus has thrown off its contents, and in pro- 
portion as the uterus contracts, the disposition to 
effusion will become less, until it altogether 
ceases. Hemorrhage during pregnancy or after 
delivery may proceed, either from the numerous 
minute decidual vessels, which connect the ovum 
to the internal surface of the uterus, and are 
necessarily torn when the ovum is either partially 
or altogether separated, or from the semilunar 
openings seen in the inner surface of the uterus, 
when the placenta is removed, or from both 
sources. Ihe opinions of pathologists are di- 
vided on this subject ; but as long as the exact 
offices of these openings are undetermined, no 
preciM inference can be arrived at as to this 
question. However it may be settled, the treat- 
ment to be adopted is unaffected by it, inasmuch 
as the fact is unquestioned, that it is to the partial 
or entire detachment of the placenta from the 
uterus, that uterine hemorrhage, at an advanced 
period of pregnancy, is generally to be attri- 
buted. 

233. Previously to the consideration of true 



puerperal uterine hmnonliagief thediipttted tooie 
as to the touree of the Um rf bicod nmsinnii^ 
observed in the earlier months of pregnancy aay 
be briefly referred to. Thb species of diidiai|a 
has been considered as a tme llMnitnial evaai- 
ation from that part of the nterns, to which the 
ovum has not become puticalarlj attached bj 
means of the placenta, and that it eteapa 
through the imperfectly closed of uierif owing ts 
the softness of the mucous or albnminons aecn* 
tion which fills it. But if this were the can, m 
may reasonably infer, that it would also ocear m 
many instances, in which the os nteri prenMi 
a complete obstacle to its exit, and in which il 
would accumulate and assume the fenn of iMBw 
nal hemorrhage. Having met with two or tluM 
instances in which I was enabled to inauire liNo 
the phenomena attending this kind of oiwhaige, 
I am of opinion, that it proceeds from the oervii 
and OS uteri, external to the limits to which the 
deciduous membrane extends ; and that it de- 
pends upon the active vascular determinatioa, ef 
which the uterus is the seat during the eariy 
months of pregnancy. In some cases, this & 
charge takes place only once, about the ua«l 
monthly period, in others ofteoer ; it is genefaliy 
slieht, and of short duration; seldcmi conadv^ 
able. It of^en passes into a somewhat piofui 
leucorrhoea ; and this circumstance indicala 
that it proceeds from the same seat, and depends 
upon a nearly similar state of vascular action, m 
that secretion. 

234. Puerperal uterine hmmorrhagt m sobw- 
what different as to its causes, prognoas, aad 
indications of cure, in the different periods ii 
which it occurs : — Ist. It may appear ftsfsrt Cfct 
sixth month of Pregnancy, aiKi it is thfSi nae- 
rally active, or dependent upon vascular drici^ 
minatioo, or a molimen hemorrhagieum ; no^ 
timbs mechanical, or owing to a local injuiror 
violence, which has occasioned the partial or 
general separation of the attachments of the foetus, 
and connected with abortion, the risk of which it 
announces. — 2d. During the three or four Uot 
months of pregnancy it may, in some cases, be 
connected with the same causes, or changes; 
but it more frequently depends upon the attach- 
ment of the placenta upon, or very near to, the 
mouth of the womb. 3d. It is chiefly to this 
jcause, and to some others about to be noticed, 

that hemorrhage takes place during parturitiei^] 
— and, 4th, It is to imperfect contraction of 
the uterus, that its occurrence after delivery is to 
be attributed. 

235. Besides these divisions, there is anotho 
to which some attention should be <Urected. 
This is into internal, and external, uterine hemor- 
rhage. The former often takes place after de- 
livery at the full time, and after abortions ; hot 
its occurence during pregnancy, and whilst the 
foetus and its envelopes fill tlie uterus, has been 
disputed. M. Desohmeaux observes that, in 
internal hemorrhage during pregnancy, the blood 
is effused either between the utenui and mem- 
branes, or within the membranes. When seated 
between the ovum and uterus it depends upon 
the same causes as external hemorrhage, W 
certain circumstances have opposed the discharge 
of the blood. Albinus found the placenta de- 
tached, and a large quantity of coagulated blood 
interposed between it and the uterus; its circom- 



113 HiEMORRHAGE FROM THE UTERUS — Paoonosxs. 

the uterus contracts, and returns during the weight, and be overlooked, if she be ezbaiutad 
intervals between the pains. and carelessly attended. This variety of hsmor- 
241. D. Ilitnwrrhaf^e after Delivery, — This rhagc occurs in every degroc of severity, and ii 
may occur previously lu the expulsion of thu cithci gradual, draining, and continued; or rapid, 
placenta or subsequently, a. When it takes violent, alarming and even speedily fatal; or 
place before the placenta is thrown off, it is usually remittent, intermittent, &c. It is accompaiiicd 
owing to one or other of the following circum- with all the symptoms already noticed in Con- 
stances, or at least it is met with in connection nection with this {§ 228.), and otlter severe forms 



with them. 1st. To torpor of the organ ; — 2d. 



of haemorrhage, and is followed by most of tht 



To a partial detachment of one part of the pla* phenomena caused by extreme losses of bi.ood, 
centa and undue adhesion of another ; — 3d. To as described in thati4r(ic^($53. et seq.). Whiiit 
irregular or spasmodic contraction of the womb, internal or concealed haynorrhage is almost oni- 
It scarcely ever proceeds from the chord, unless fonnly dependent upon a total want of Qterine 
in cases of twins, when it may possibly take action, the external form arises either from that 
place. But it may arise from laceration of the ] state, or from imperfect, irregular, or traiuiait 
uterus or vagina, —b. After the expulsion of the contractions, and from either of these states in 
placenta, flooding generally proceeds from im- connection with vascular determination to tba 
perfect contraction, or torpor, of the womb. It | womb. When slight, continued or drainiog, it 
may, however, be connected with inversion, or may be kept up by the retention of a portion of the 
with retention of a portion of the placenta, or of placenta or membranes, or of fibrinous coagula, 
the membranes, in the cavity or mcuth of the m the uterus. It is important to keep in lecoU 
organ ; and in a few cases it appears to depend . lection these pathological states, as upon tbem 
upon active determination of blood to the uterine the appropriate use of remedies entirely de- 
vessels, art insisted upon by (joocii, after some pends. 

Continental writers. Thc>ie states of the uUtus, 244. ii. PiiociNOsis. — The . circumstancei 
especially flaccidity, may be readily inferred from which indicate a favourable or unfavourable it- 
a careful examination and observation of the suit in other hsemorrhages, also apply to the 
symptoms. Whether the haemorrhage takes . difirrcnt forms of uterine hemorrhage. But the 
place before or after the expulsion of the placenta, ' condition of the uterus, in both the unimpr^nated 
It may be either internal or external, \ and puerperal states, and the period of gestatioDi 

242. c. Internal uterine hamorrhage^iifteT dii' with vanous other related circumstances, mot 
livery, may thus take place before the expHlHon be considered in reference to particular caiek 
of the placenta or afterwards, or it may he A, In uterine hemorrhage occurring indepn* 
favourer! by the retention of the placenta or of dently of the puerperal states, the progaauiAaM 
the membranes, or of both, partly in the neck entirely depend upon the nature of the cauM, 
and mouth of the womb, and partly in the vagina, the states of the uterus, the severity of the lyiDp- 
I'hat this form of haemoirhage should be early i torn s, the duration of the disease, and the stiengu 
detected and remedied, is of the utmost im- of the patient. When it is induced by occa- 
portance. The uterus upon external examination sional causes of a passing or accidental natore, 
will be found soft, roundish, and increasing in danger will arise only from the quantity of tht 
bulk, so as often to approach, or even to pass, discharge. If it proceed from causes which hvn 
the umbilicus, it may even ultimately attain inoditied the constitution, and endowed it with a 
the dimensions it had just pos^^tssed, and be fol- : tendency to hu'morrhaixe, or occasioned an habit- 
lowed by the death of the female, or by a pro- ual discharge, the treatment will generally pipfe 
longed and dirticult recovery. Whenever pallor ditHcuIt or unsatisfactory. That variety, which 
of the countenance and lips, vertigo or swim- occurs in girls at the periods of puberty, cam 
mings, noises in the ears, a sense of sinking, spontantou.sly as the menses become r^ular;* 
nausea, or retching ; a very lapid and irregular and that which takes place at the critical ageoif 
pulse, a quick anxious or gasping rc'jpiratirm ; woman, also disappears with the monthly indii- 
rcstl^sness, jactitation, ^c. su|M.-rvene. whilst positions, if the womb be free from organic 
the lochia are not more than usually abundant, changes. W hen it proceeils from these changei^ 
or are diminished, internal haemorrhage to a most the prognosis should he guarded, even when ci^ 
dangero\is extent may l)e inferred ; and a careful cum>taiices admit of it not being unfavourable* 
examination of the abdomen ou;^ht to be. made. In these case^dan<:er may arise from the hsmtf- 
In order to a^^certain the cause of tlie retention of rlia^^e, as well as from the nature of the lesioD flf 
the effused blood, the expulsion of all the plarc-uta the uterus ; but more fre(|uenlly this latter is tlw 
and membianes should be proved ; as well as chief source of risk, unless where the rooiM 
the presence or absence of a portion of these, or formal ion admits of removal, as in the caM of 
of coagula, in the os uteri and vaj:ina. At the polupus uteri. (See ar^ Uterus.) 

same tnne, 'listcnsion of tlie uterus by effused 24o. B. I'terine hamorrhage during thtpHf- 
blood must not be confounded with tlie existence jicral states is often one of the most alarming IB^ 
of another child in the womb, or wiih nieteoris- speedily fatal of the maladies peculiar to femaki* 
nms, or with a distended urinary bladder, either Accoiding to I^uzos, it is rarely fatal before Aa 
of which cannot be mistaken if attention be di- tifth month of gestation. Experience hag showi 
recte<l to it, and to the existence of the symptoms the justice of the remark ; yet 1 have seen lifeii 
just enumerated. imminent peril at this early period. Flooding ii 

243. d. Eiternal Jituuling after delivery of the more dangerous the nearer it occurs to tk 
both the fatus and placenta is not to be mis- natuial ]:eriod of delivery, whether previoniJyiff 
taken, if due attention be paid the patient ; for subsequently to this process. As respects thi 
the blood may collect and coagulate in the centre fcctus, however, the chances of its prMervatioB 
of the bed, in the depression produced by her ' diminish with the length of the time to the petM^ 



114 



HiEMORRHAGE FROM THE UTERUS — Tbbatmbiit. 



I have, therefore, bad recourse, in eitreme or 
prolonged cases, to the spirits of turpentine, either 
in a draught, or in an enema, or in the form of 
epithem or fomentation applied over the bvpo- 
gastrium ; and always with success. — 1 his 
practice was fintt adopted by me in 1819, in 
metro-hemorrbagia occurring after delivery, and 
has been pursued by me in other hasmor- 
rhages, whenever it was considered advisable 
speedily to arrest them. In 1820, I publicly 
recommended this treatment ; and 1 know, that 
it has succeeded with those who were thus led to 
employ it. 

250. e. When the hsmorrhage is iympto- 
matie of organic diteate of the uterus, it is gene- 
rally prolonged, or returns frequently, and is 
injurious more from this circumftance, than from 
its violence at any particular time. It is also 
often remittent, or periodic, the intervals varying 
in diflferent cases; but the discharge generally 
subsides spontaneously after local plethora or 
determination is removed, and returns again as 
soon as the organic change ha-s established vas- 
cular fluxion, or congestion in the uterine organs. 
Although merely a symptom t)f the existing or- 
ganic lesion ', yet its frequent recurrence, and the 
consequent ansmia, sinking, and serious nerv- 
ous symptoms, reouire that it should receive 
the chief attention m the treatment ; — and that 
tonics* astringents, restoratives and anodynes, 
should be liberally, but appropriately, exhibited. 
When the haemorrhage is symptomatic of ulcer- 
ation, or of malignant disease, injections, per 
vaginam, with the solutions of the chlorides, 
particularly of the chloride of lime, or with 
pyroligneous vinegar, or with solutions of kr^- 
osote should be resorted to, in addition to the 
means just mentioned. When it is occasioned 
by a polypus, or by a tumour on which a liga- 
ture may be placed, then this ought to be applied. 

251. The third intention, v\z., to prevent the 
return of mttro-hemorrhagia, need hardly be 
enforced in the accidental form of the disease ; 
but it is of the first importance in the constitu- 
tional, habitual, or periodic states. In order to 
fulfil it, the remote causes ought to be removed 
or avoided ; and the patient be placed upon a 
strict diet and regimen. Every source of local 
and of general and mental irritation should be 
shunned. The horizontal posture ought to be 
retained as long as possible for some time pre- 
viously to, and during, the discharge ; and, in 
the intervals only, gentle exercise should be taken 
in the open air. The food ousht to consist -chiefly 
of mucilaginous and Tarinacenus articles, of easy 
digestion; and asses' milk, with Seltzer water, as 
advised by Huffmann may be used both as a be- 
verage, and as an article of diet. The patient 
should be kept cool ; she ought to sleep on a 
mattrass, rise tarlv, or remove to a couch : and, 
if she be married, lie apart from her husband. 
If the hsmorrhage be active and dependent 
chiefly upon general or local plethora, a small 
bloodletting from the arm may be resorted to just 
before the expected accemion of the hsmorrhage ; 
or small and frequent doses of ipecacuanha, so 
as to occasion either nausea or vomiting, may be 
tried as directed by Hoffmann, HANuic, IIolst, 
Dalberg, and others. — In cases depending 
chieAv upon debility, the preparations of cincho- 
na^ of iron, or of other tonics ; the cold plunge 



or shower bath and falt-water bfttb ; the miaenl 
waters of Tunbridge or of Bath ; the iactitioii 
waters of Pyrmont, Spa, or of Seltxer, end e light 
diet ; will be of great service. When the iccnr- 
rence of the discnarge is owing to organic Modi 
cold bathing is inappropriate, end the miaenl 
waters just mentioned reouire to be tried wilk 
circumspection. Those of Ems of Cariibad, or if 
Marienbad, however, will often be employed with 
benefit. 

252. C. Treatment of puerpgral nutro-kmuf' 
rhagia, — a. PreviouUif to the tilth wvmtk, ■!>• 
rine hsmorrhage shonld be treated eltontkr 
as described in the article Abostion. If Ik 
fcctus and membranes have entirely come awaj, 
and the discharge continue from a petiive stall 
of the uterus, the exhibition of spirit of ta^ 
pen tine in an enema, will rarely fail of arreHiHi 
It ; but the practitioner should ascertain that ■• 
part of the placenta or membranes remiun in thi 
uterus or vagina, causing irritation and prdoDgiBf 
the discharge. When the uterus is thus iaa^ 
tivc, after abortions, the teeale cornutumot bene, 
or the spirits of turpentine may likewiee be ci* 
hibited tu procure its contraction. 

253. DfisoRMEAux considers that hsnnonfcigi 
may take place in the early months of prccnaBcyf 
so as partially to detach the placenta, but tMt 
the clot that is formed between it and the ateni 
will often arrest the hemorrhage and adhcaoe if 
the detached portion subsequent! v occur ; and W 
refers to a case by Noortiiwyc, in support of Im 
opinion. On tins ground he advises having t^ 
course, at the earlier periods of geetatioa, li 
plugging the vagina, as recommended by Li* 
Rorx, after bleeding and the usual mcaM rf 
arresting the hemorrhage have failed. (Sal 
Abortion, f 26. et seq.) At these p^iods, ik 
uterus is still more or less unyielding, and tk 
resistance to further effusion is consideiabifc 
liut, in slight attacks, or at the commeoceBC■^ 
the obstacle afforded by the plug may hasleo tk 
complete detachment of the ovum, by &voBfiig 
th(i accumulation of blood between it and tk 
uterus ; and either a copious internal heaMT* 
rhage may thereby be produced, or the 0fVi» 
being detached, may fa^ prevented by it fiea 
being thrown off, and be retained for a long pa* 
riud.'icecping up irritation and hsmorrhage, ore 
continued draining with occasional i lauiueliiML 
or a putrid discharge. Indeed, this occoneeei 
is not rare in the early months, independently if 
the plug, although the use of it before the eafni* 
sion of the ovum, and when the oe uteri i*asft 
or yielding, is more likely to occasion than W 
prevent it. W hen, however, the os nteri is finw 
and the discharge copious, it is often t^ Mrvki; 
but it is chiefly after the ovum is expelled, it 
cases of flooding before the fifUi month, AH 
plugging is most efficacious, if efiicienllv §»• 
ployed. Care should be taken that the pTic dp 
not press injuriously upon the urethra : Mr* 
Inoleuy directs that it should remain undktmkA 
for twenty-four hours or longer ; but the nMr- 
vention of internal hemorrhage should be ttj^ 
in view, and the case carefully watched. 

254. When the blood escapes in mall qM** 
tity only, and there are no pains present, and vf 
disposition in the os uteri to dilate, the taa^ir 
tutional powers being unimpaired, an tttM^ 
should be made to,prevei>t a return of the dHr 






.1 



116 



HJEMORRHAGE FROM THE UTERUS— TisATnuit. 



LOCQUX, DSNXAN, MeREIMAN, D. DaVIS, 

Blundell, Lee, Ramsbotham, Swbatman, 
&D(] others; but if the discharge should Btill 
continue, and the pains become more and more 
feeble, and the patient exhausted, delivery roust 
be accomplished by turning, by the forceps, or 
even by embryotomy, according to the circum- 
stances of the case. In less imminent cases, 
the ergot of rye and other means already men- 
tioned (§264.) may be tried before recourse be 
had to the?e operations. Mr. Ingleby, however, 
considers that many of this description of cases 
are occasioned by the injudicious use of the er- 
got; but, when it is employed for the arrest of 
the discharge, and for the purpose of procuring 
uterine action, this objection does not apply 
either to it, or to other means intended to exert 
a similar operation. Af^er the liquor amnii has 
escaped, the os uteri still remaining rigid, there 
are objections to the exhibition of the ergot : and 
in sucli a case, plugging the vagina, as advistrd 
by Burns, Dewees, Capuron, Gardien, Da- 
vis, &c., may be resorted to, with the aid of fric- 
tion and moderate pressure on the abdomen in 
order to increase uterine action. The possible 
occurrence} however, of internal hnmorrhage 
should not be overlooked ; and if this take place, 
the still more active interference iust mentioned 
must not be delayed. But the plug should not 
supersede rupturing the membranes when flood- 
inc; occurs at the commencement of labour at the 
full time. 

259./. Hemorrhage after the itirih ff th€ 
Jvtutt and before the expulsion of the placenta, 
is frequent and often sudden and profuse. In 
this case, strong pressure should be made over the 
hypogastrium in order to exci'e uterine action. A 
binder ought to be firmly applied over the abdo- 
men, several folded napkins being placed under 
it, so that the fundus uteri be compressed. Dr. 11. 
Lfk advises the hand afterwards to be introduced 
to remove the placenta, but the removal of it 
should not be attempted until contraction of the 
uterus commences. After contraction, and the 
expulsion or withdrawal of the placenta, he di- 
rects a cloth wet with cold vinegar and water to 
be applied to tlie external parts, cold acidulated 
drinks to he given from time to time, and the 
patient to he preserved for two or three hours in 
a state of perfect repose. This plan will gene- 
rally succeed when the hmmorrhage and reten- 
tion of the placenta are caused by inactivity of 
the uterus. But when irregular artton of the 
organ, or spa<»mo<lic contraction of the ot intet' 
tjiim or eiternum uieri, retains the placenta 
pither altogether or partially, and thus causes in- 
ternal ha»morrhage, additional means, especially 
the exhibition of opium by the mouth, are re- 
quired. The pas^ge of the hand, in order to 
remove the placnta, then demands caution and 
perseverance. If it cannot be accomplished, the 
turpentine enema, or embrocation, will generally 
aid in removing the difficulty. If the flooding 
ari?:e from morbid adhesion of a portion of the 
placenta, the adhesion must be separated by the 
hand, in a manner that will readily suggest itself. 
Dr. T. Ramsbotiiam attributes these adhesions 
to partial separation of the placenta during preg- 
nancy, from some accidental cause, followed by 
a slight discharge, the extravasated blood ez- 
citinf iziiSammation of the separated surfaces 



with effusion of lymph, and conteqiMiit agfif* 
tination of them . This opinion is probably comr t 
260. g. Fiooding aj'ttr th9 erpuUian ^ tkept^ 
eenta requires a modified practice acconting u 
|jt arises. — 1st. From atony of tbe-utems; — 
|2d. From imperfect or remitting contractioei ; 
I — 3d. From a portion of the placenta left in tkt 
I uterus : — and, 4th. From inversion of the oigu. 
As in htemorrhage pievioutdy to the complete o- 
pulsion of the placenta, so in thi^ the blood may be 
retained in the cavity of the viacns, by coagala, 
or by a portion of the secnndines lodged in tie ei 
uten or vagina. In every case, therefore, the 
state of the uterus and the integrity of the pla- 
centa should be ascertained. — where sinple 
atony of the uterus is the chief cause, consiaal 
and well directed pressure on the fundus men, 
especially by the hand, the sudden mpplicalin 
of cold, or effusion of co4d water ; the torpeothi 
enema, or draught ; the er&Qt, &c. ; are tbe 
most efficacious means. If the hcmorrhan be 
internal, from any of the causes just sta^, thi 
same measures will generally procure their n- 
moval, by contracting the uterus ; but if then 
fail, they should be removed by th« hand« The 
draining or recurring hemorrhage, the espolsMi 
of clots, the offensive nature of the dischaT|ib 
and the constitutiooal efiects consequent opoa 
the presence of a portion of the placenta in Ihi 
uterus, demand at first the same means as <Aa 
states of the disease ; but afterwards, and per- 
ticularly when serious con.stitutionaI symptow 
supervene, indicating a remarkable dimiinrtiaL 
and marked vitiation, of the vital carreat, v 
diiional or other remedies should be «mploj«di 
Weik solutions of the chloride of Kme, or tf 
soda, should then be injected per vmgifMm, m 
even into the uterus ; and the decoction of 
chona with the chlorate of potash, or with 

atic arid ; camphor in frequent doses; an 

sional enema with spirits of turpeutine, ordrtaghl 
with the same and castor oil ; the sub-borite tf 
soda, and other means calculated to support thl 
vital energies, to increase the excreting nioctioMi 
: and to enable the uterus to contract and ifi^ 
I charge the matters retained in it, should ke pn> 
scribed. 

I 2G1. The occurrence of hsmorrtiace tiff 
' deliver}', whilst the uterus appeare to be coi* 
I tracted, upon which Dr. Gooch has so iiniieG» 
; sarily insisted, is nothing more than its coonertioi 
, with an imperfect, remitting, or irrefnilar coi> 
' traction, in some cases, and with determimiiM 
of blood in others ; states previously knowo ti 
the profession, and requiring, at most, but % 
: modification only of the means insisted upon m 
the coun*e of this article. In these, as well M 
\ in other cases, the application of pounded ice ki0 
l>een much prai«ed ; but the continued appliei' 
tion of great cold is less beneficial than the shock 
produced by the affusion of moderately eold 
water, or by dashing a wet napkin fipen tbt 
hypoga>trium and external parts. Indeed Ibt 
former may cause an imperfect or irregihf 
contraction to pass into a state of relazatioo, and 
thereby perpetuate the haemorrhage. Witk re- 
spect to the hour-glass contraction of the nt 
insisted upon by Dr. Burns and othera» id 
nection with flooding, the perspicacioiu «fr 
; of Dr. Malins should be borne in mind. T^ 
\ acute physician observes that, as the contncdd* 



118 



HiEMORRHAGE FROM THE UTERUS — TaBJiTMBifT. 



prolonged without being ezceanve ; and when it is 
unconnected with pregnancy or active determin- 
ation to the uterus. In these circumstances, and 
when thediseaie is periodiCfthepreparationsof cin- . 
duma have been prescribed by StroJem, Staree, j 
Duncan, Bano, Picqub, &c. ; the tincture of ; 
nnnamon by PlbncKi VoosLp and Schneider ; . 
and the tulphate of iron, and other chalybeates, 
by Rath, Thilenius, and Doemmkc. The i 
Bulphate of quinine with sulphuric acid and tine- i 
ture of cinnamon, or with sulphate of iron in the I 
form of pill, will be given with advantage in ' 
many cases of this description. 

268. /. Ipecacuanha m small doses has been 
much used by Pauusey, De Meza, Bruce, 
HoLST, Loefpler, Stoll, Dalbero, Dbnman, 
and others ; and small quantities of tartar emetic 
have been recommended by Chalmers. The 
former of the5e may be useful when the uterus 
contracts irregularly, and when the placenta is 
retained from this cause. But it is chiefly in 
combination with opium, or in fre((uently re- 
peated doees, that any advantage can be ex- 
pected from it. In hsmorrhage after delivery, 
out little benefit will be derived from opium, 
especially if given in large quantity, or depended 
upon chiefly. When thus exhibited it will 
rather impair than promote the contractions of 
the uterus. Yet circumstances will sometimes 
arise to justify the praises of opium expressed by 
HoRsnus, Heister, Young, Smellie, RANoii, 
Ciiesneau, and Gartiishore, especially in ute- 
rine hemorrhage unconnected with pregnancy, 
or in that occurring in the earlier months of 
gestation. In these cases it may be given with 
dilute sulphuric acid (Aaseow) ; or in clj/sterg, 
as directed by Mr. Copland. H.ircee advised 
it to be used in injections thrown into the vagina 
• — a method by no means to be advocated : and 
every practitioner of experience will be aware of 
the danger of administering opium, unlera in very 
«mall quantity, in the form oi enema. 

269. g. In pauivemetro-h(e morrhagia, ip?LV\icu- 
larly when the powers of life are depressed or ex- 
hausted, brandy or otlier spirits have been retK)rted 
to by many practitioners, often in large quan- 
tity. Stimulants of this description are apt to 
give rise to a very serious aflfection of the head, 
and to protract convalescence. Ammonia , or 
camphor (Ettmui.ler), is less objectionable in 
such circumstances ; and a judicious recourse to 
^irits of turpentine, as adviised above, is much 
more efficacious, and less hazardous. — Of other 
internal medicines recommended by writers, no 
further notice than the simple enumeration of 
them need be taken. The fungut militensis has 
been mentioned by Linnaa's; the bursa pa^toris, 
by De Meza; the geum urbanum, by STRttisM ; 
the decoction of the fruit of the hippocastanus, by 
Hufeland; tannin, by Cavaliku; tavine, by 
Rave, Fiest, and Wedeeind; purgalirest by 
Lentin, Stracx, and Covradi ; and the pimpi- 
nella, by Riedlin. Whatever effects thet^e may 
produce in the hasmorrhages occurring inde- 
pendently of pregnancy, but little benefit can he 
expected from them in those supervening during 
the puerperal states. 

270. A. Various external meant of arresting 
flooding after delivery have been adopted, and 
frequently with success. Frietum of the abdomen f 
particularly when the uterus contracts either 



imperfectly or irregularly, and eampnuwH over 
the fundus of the organ by the hand, or by em- 
prestes, bandages, &c., have been very properiy 
insisted upon by Levret, Tallony, Zelleb, 
VooEL, Smellie, Osiandeb, Inolbbt, Rahi- 
botham, R. Lee, and by moat modem writen. 
Lobpleb directed that pressure should be nude 
by means of a sand-bag. Dr. D. Davu aad 
Dr. Beatty have recommended bandaut eon- 
strutted on purpose. Pressure on ihedescfod- 
ing aorta, through the abdominal parietes, hw 
been favourably mentioned by Latovb and 1in 
gleby. Plovcouet advised the pressun to ba 
made by the hand introduced into the relaxed 
uterus ; and Eichelbbrger has adduced an ia- 
stance of the success of this method. J^jeOitm 
of various kinds into the uterus have been ea- 
ployed. Prosper Alpixus, TniLENiui, and 
Pasta prescribed the mineral acida much dh 
luted ; Galen, the juice of the plantmgo; Abtboc^ 
diluted vinegar; and Koe, astringent infiHiaas» 
in this way. Fieuz directs the hand wet wiA 
vinegar ; VVendelstatt, lint moistened witt 
much-<iiluted sulphuric acid ', and M. Gobat, a 
decorticated or clivided lemon, to be puM 
the uterus. 

27 1 . i. Piu^s or tampons, moistened with YBii 
astringent fluids, have been very genenlly le* 
sorted to since tlie praises bestowed on them by 
A. Parky, Hoffmann, Lbroux, TuiLBHlii* 
TnioicK, Held, Loei-fler, Hvmbbro* and 
Smeluk. Some modern British authoiv havit 
however, supposed, that the addition of ailria- 
gents is unnecessary, although they approve of 
the plug in nearly the same circumstances in 
which I have recommended it above ($ 358.)» 
namely, when the os uteri is rigid; Soft lint or 
sponge may be used \ but in such a manner ai 
to Hll completely the upper part of the vagina. 

272. k. When all other mean^i have failed^ 
when tlie face is blanche<l ; respiration is scareefy 
audible, or gasping or hurried ; the pulse almoil 
imperceptible or gone ; the eEtremities cold or 
clammy; the power of deglutition lost — Irwsf- 
fusion AJiould be reported to, although the chanM 
of success from it are few. Dr. Hamilton kii, 
however, seen recovery take place from this ftm 
by the ordinary means ; but so fortunate an ifloe 

* is rare. Tho question only is, whether the pne- 
titiuner should still persist in the use of some of 
the more appropriate means, or have reconrttto 

, transfusion. The contingencies of resortiBr H 
it ought not to be kept out of view; for. if lir 

Sass into the vein, immediate death will foUov. 
Milebitis may evi>n supervene although theop^ 
ration has succeeded, and carry off the pttiert 
The propriety and success of this measure haft^ 
however, been so far established by Dr. Burv* 
DEi.L, Inoi.kov, and by some others, who hivi 
attempted it in circumstances of moredoabtU 
propriety, as to justify the having recourKtoil 
as an uliimum ^ed ancept remediumm 

273. /. The prevention of uterine h^merrhegi, 
particularly in the puerperal states, is a subject 
of great importance. In the early mondis, dN 

I precaution:! recommended in the article on Aaoe- 
! TioN (^ 26. et $eq,) should be adopted. In onkr 
I to prevent h&morrhage after delivery, Dr« Bbatit 
I and others advi«e an appropriate binder to ki 

• pa<^sed loosely round the alxiomen, and drawl 
tight ad circumstances may require. I am coo- 



120 



HiEMORRHAOE INTO SEROUS CAVITIES. 



changes in the blood ; — and, 6th, From the co- 
•zisterice of the last two conditiona. Hemor- 
rhage may occur from the first, second, or third 
of these causes, without any manifest indispos- 
ition, or disorder sufficient to induce the patient 
to resort to medical advice ; but it never appears 
as the consequence of the other pathological 
states, unless in the advanced stage of the most 
dangerous, depressing, or malignant maladies. 
When the haemorrhage occurs from the former of 
these, it is often to a very great amount ; but it 
very rarely is excessive when it proceeds from 
the latter states. In all, the existence of the 
extravasation is to be inferred from the presence 
of the eoiutitutional tymptomt ($ 25.) usually 
produced by profuse hemorrhages. When the 
states of vital power and of the blood cause san- 
guineous exudation into the shut cavities, ecchy- 
moses or pelechie in other parts of the body, and 
hemorrhage from mucous canals, are very gene- 
rally also obwrved. 

276. i. Hjcmorriiage prom the serous 
Membranes of the Brain or Spinal Chord 
very rarely occurs unless as a consequence of 
concussions or injuries of the head or spine; or 
from violent exertion, particularly in warm wea- 
ther, or under a hot sun. Sanguineous effusion 
between the membranes may, however, follow 
the rupture of small superficial aneurisms or 
varices, and the growth of malignant or other 
tumours, or the occurrence of ulceration, impli- 
cating the membranes. Hemorrhage in the&e 
situations cause apoplexy and paraplegia, or 
other comatose and paralytic states. 1 have 
seen very slight effusion in the spinal canal in a 
case of tetanus ; and Dr. Thomson observed it 
in a case of rabies. Bon ft, Morcagni, and 
Ollivier, have seen effusion simultaneously be- 
tween the membranes of the brain and spinal 
chord. (See arts. Apoplexy, Brain (§ 26.), 
Palsy, and Spinal Chord.) 

276. ii. Haimorriiage into the Pericar- 
dium may take place without rupture of the 
heart or large vetttsels within the pericardium, 
although more or less manifest rupture is tlie 
most frequent cauiiO. — Rupture of the parietts of 
one or otner of the cavities of the heart has been 
observed by Salzmanx, AIoroagni, Morano, 
Portal, Cor visa rt, Lalnnec, and several 
others enumerated in the subjoined references. 
In the larger proportion of these cases, the pre- 
existent lesions which occasionally give rise to 
rupture have existed. (See art. Heart.) But 
rupture of the coronary artery (Vikidet), of the 
vena cava ^Wright), or of one of the pulmonary 
veins, or ot an aortal aneuri«m, or perforation uf 
the aorta ( Fiohati), within the pericardium, may 
be the source of hemorrhage. Several instances 
of these are referred to below. Blood may also 
be effused, or rather exuded into the pericar- 
dium, in greater or less quantity, or mixed with 
more or less water, without lacemtion or rupture 
of any vessel. Cases of this kind have been 
observed by Vater, Baaoer, Sandifort, 
Db Ha en, Thomson, Hooper, myself, and 
others (see references) ; and occur chiefly in 
the advanced stages of adynamic, scorbutic, 
potro-adynamic, or malignant diseases. Some- 
times the blood is poured out between the 
layers of the pericardium, forming sanguineous 
?0ficles or ecchymoies. (Moroagni, Dl la 



Fa ye, Stoll.) When hamorrht^ nto tha 
pericardium arises from any of the kisda of rap- 
ture just enumerated, death generally tikes 
place suddenly ; but when it is exuded, as jut 
stated, the already depressed vital power is in- 
creased, and the oppressed action of the heart ii 
more slowly abolished by the efiiuion. 

277. iiL Hcmorrhaob inio the PLEuasL 
Cavities has been observed by MoboaohIi 
Plenciz, Caldani, Stoll, Fbanb, Jodkiob, 

' myself, and others. It most fieqnenily aiiNi 

; from rupture of an aortal aneurism within ^ 

I thorax. In this case, the blood is effused* in thi 

I first instance, into the posterior mediaMBBH, 

: death seldom occurring until the accamnlaUd 

blood lacerates this part, and opens the way to 

suddenly fatal effusion into one of the pleniai 

cavities. The aneurism may be so large asH 

' occasion symptoms which will lead to its lerog^ 

nition ; or it may be so small, and attended 1^ 

so little disorder, as to escape detection, aa in tM 

case of Sir David Barry, an eminent mcBibff 

of the profession. In him, the symptoni befcn, 

and the appearances after, death illustrated tUi 

procession of the morbid phenomena. Hmwaf' 

rhage into the pleural sac may proceed, aliOb 

from erosion or ulceration of the aorta (Moi« 

OAGM, Portal) ; from rupture of the palnoauy 

vein (Eicken) ; from rupture of the vena cava 

(Portal) ; or from rupture, or a varicose ttbot, 

of some of the veins near the pleural sarfMi 

(Caldani, Portal, &ec.). Hemorrhage into thi 

thorax is frequently consequent upon frBCtaraiif 

' the nbs and wounds ; and many of the insUBfli^ 

I where it seems to have arisen spontaneously, haM 

> been induced or hastened by external injarfic 

I muscular exertion. — More or less blood nay to 

j eiuded from the surface of the pleura, in staM 

' of very intense inflammation attended by di> 

minished vital resistance, or during the advaaeel 

staees of putro-adynamic fevers and of octoi 

malignant diseases. But these are comparativflj 

rare occurrences; and the blood effused is seldsa 

pure, but mixed with much serum or watery extol- 

ntion ; or, rather, the effused serum is moreortoi 

deeply coloured by an admixture of red particlsfc 

278. iv. Hj^imorrii AGE INTO TUB PaRrrovKsi 
! Cavity, like hemorrhages into other serous can> 
' ties, seldom occurs, unless as a coiiseqaeaci rf 
I external injuries or wounds. It sometimes depend 

upon rupture of a larze veswl, or the lacciadsa 

i of some viscus, especially the spleen, liver, ii 
stomach ; but it may proceed from other leMMa 
Ballomvs^ Portal, Uamel, and othen, bait 

\ rocoided instances of its occurrence from raptan 
of the spleen ; a case of which has come nadir 
my own observation. Ayrault mentions an ii* 
stance in which it arose from ulceration of sqm 
of the vessels of this vi^icus. Blanb found im 

'■' proceed fiom the surface of the liver. Wtoa 
the spleen or liver is engorged or enlarged, ate 
repeated attacks of at^uc, particularly in warn 
or miaematous countries, a comparatively sEgk 

' external inj'jiry, or a concussion of the tru^, mf 
occasion laceration or rupture of either, with extn* 

I vasation of blood in the abdomen. Heroonliigs 
in this situation may arise, also, from operatien 
for strangulated hernia, especially when a portM 
of omentum has been removed ; or from pi» 
centesis m cases of ascites (Bxllocq), or of si* 

I cysted dropsy. Rupture of an aortal aneari 



122 



HEMORRHOIDS — Patholooy. 



coarse of the daBgerovs constitntional maladies 
juBt mentioned. Al. Robert (Nouv, Biblioth, 
Mid. t. ii. p. 74. 1826) records a case in which 
he found blood effiMed in the substance of the 
brain, lungs, liver, pancreas, and kidneys; but 
the pre-ezistent constitutional di89rder was cha- 
racterised by extreme adynamia, manifested especi- 
ally in the vascular system and circulating fluids. 
280. Hemorrhage into the areolar tiisuet par- 
ticularly in those parts of it that possess the 
membranous form, giving rise to ecchymoses, 
petechias, &c., occur chiefly in purpura, icurva, 
and the last stages of malignant ezanthematous 
and other fevers ; and in these diseases hemor- 
rhage generally takes place, also, from mucous 
surfaces, and sometimes, likewise, into the sub- 
stance of one or more organs. In these cases, 
the blood is dark, dissolved, or deficient in crasis, 
and incapable of coagulating. The instances of 
" Universal Hdtmorrhage" {Iltfm, UHiversalu) 
recorded by several writers of the sixteenth and 
seventeenth centuries are entirely to be referred 
to the above maladies, oj: to a scorbutic, conjoined 
with a hemorrhagic, diathesis, generated roost 

{irobably by the nature of the food and modes of 
iving, and to the putro-adynamic state which 
ezanthematous and typhoid fevers then frequently 
assumed. (See arts. Apoplkxy, Drain, Lungs, 
Palsy, Purpura, Scurvy, &c.) 

H.EMORRHOIDS.-SYN.Al^op;o«ff(from«i,ua, 
blood and pooc, a flux), Hippocrates, Gulen, 
Celsus. Hamorrhoit, I'liny, Linneus, Sagar, 
Sauvagcs, Culleo. Hamorrhoides, Juncker. 
Fluxut HiBmorrhoidalit, Hoffmann. Proctor- 
rhea, Auct. var. Proctalgia llamorrhoidalit, 
Macbridc. Marisca, Good. Htcmorrhisehesii, 
Ploucquet. li<tmttrrha:a Vasorum Hdemorrhoi- 
da^iiim, Swediaur. Hemorrho'ides, Vluxlicmor- 
rho'iJalt Fr. Goldad-'rjiuu, Hdmorrhoiden, 
Germ. Morice, Ital. Piles. 

Classif. — 1. Class, Febrile Diseases; 4. 
Order, Hemorrhages (Culien), 1. Class, 
Diseases of Digestive Organs ; 1. Order, 
AflTocting the Alimentary Canal {Gmxi). 
II. Ci.ASi>, l\^ OnozR (Author). 

1. Defis. — Pain, tension, weight, heat, or 
other uneasy sensation, referred to the rectum and 
anus, accompanied or followed by tumours in these 
parts, or bif ajiow of blood from them when the 
patient is at stiwl ; recurring after interials, and 
iometimes periodically. 

2. Preliminary liemarks. — There are few 
diseases upon which so much has l>cen written 
— ignorantly and doj^atically writt n — as upon 
hemorrhoids. In modern times, the pathology 
and treatment of this disease have been too gene- 
rally viewed in a limited point of view, and 
usurped by persons who have endeavoured to 
convmcc the public that they have made it the 
subject of especial investigation, or even of ex- 
clusive study. — Judging, however, fn»m their 
writin<^, more mischief than benefit has thus 
arisen from the mechanical division of labour 
they have adopted; and not only have they 
failed in arlvancing our knowledge as to the na- 
ture and treatment of the malady, with which 
they profess so intimate an acquaintance, but they 
have actually overlooked, or been ignorant of, 
the part it occupies in the circle of morbid action, 
and they have frequently, even when affonling 



temporary benefit by empiricml metns, or by local 
or surgical aid, caused roost senous consiqiiea t 
mischief. Those affected by this complaint an 
unable to foresee the conseauences tbat mn rt- 
salt from injudicious intflnerence, espedaUy if 
appropriate medical treatment be not aflexwanls 
pursued ; and, whilst immediate relief, whai 
procured, is made a matter of high comniend- 
ation, both by those who receive, and by these wbo 
administer it. the remote or contingent bad cft rti 
are rarely traced by them to thdr origih, tndni 
of^en of such a nature as to terminate all umhot* 

3. Of those who have professed an infufidi 
cure for hemorrhoids, there have been few who 
appear, from their writings, to have boon ae* 
quainted with the nature of the complaint; widi 
the relation in which it often stands tootber imp* 
bid conditions ; with its frequent existence as Hm 
more manifest part of a more imnprtant and coo- 
cealed state of disease, and witn the moat sail 
and appropriate means of removin|[ it. Th^ 
have viewed it as a local disorder which is lo M 
cured by local or surgical treatment, and not aa 
a visceral disease often depending upon laienft ar 
extensive morbid conditions, to which sunieal 
mea<^ures may prove injurious ; and for lAick 
such measures are at most only occasionally » 
quired, and then as adjuvants merely of a stnclif 
medical, and often constitutioiuJ, traatBaat 
Owing to an imperfect knowledge of the variads 
of hemorrhoidal tumours, and of their patbolo|^ 
cal relations — a. Fatal hemorrhage has not » 
frequently resulted from excising or pnnctuiif 
them ; — b. Enteritis, peritonitis, and evon iali^ 
nal phlebitis have followed the extirpotion af 
them by ligature ; — and, c. Fatal diseases of tha 
brain, or of the lungs, or even of the liver, bait 
ari*«n from the permanent stoppage of a disdNi|a 
by these means, to which the system had bccoM 
habituated, and which had warded off tlMsa 
and other serious maladies. This evaeoaM 
being arrested by these or other local measara^ 
the safety valve to an overloaded state of ika 
vascular system is permanently closed ; and i 
source of local derivation and of discharge^ Alt 
had preserved a vital organ from iropeodugdih 
or>;anisation, is cut off, without either preparim 
the system for the changes thereby prodncad, tf 
subsitituting some other evacuation m its phMi 
Persons who thus extend the division of labaar 
principle to a science which admits not of I 
with advantage cither to the branch which is te 
attempted to he cultivated, or to those upon whoH 
it is practised, may reply, that they have sasoai 
mischief result from the means they employ; bai 
the mischief in such cases is s rictly of a meificil 
nature, is often remote, an<l falls not witlun tkl 
sph. re of those who thus unscientificallj irf 
empirically limit the practice of tlieir piaiN* 
idon. Division of labour may improve maaarf 
dexterity, or may extend mechanical contrivaBea; 
but it cannot improve pathological knowlad|^ 
nor illustrate the relations or associaticma of M^ 
bid actions, nor lead to truly scientific, and A 
and appropriate, and permanently bonefiriali 
modes of cure. 

4. I. Pathological History op thi Di^ 
EASE. — The term hecmorrhoidSf sig^nifying, Ha* 
rally, a flow of blood, was made use of by UV' 
pocRATEs ; and, down even to the preaem tiMt 
has been applied to a dilatation of the veiaa iA 



I 



124 



HiEMORRHOIDS — VARitnif . 



either cases they often contain a central cavity 
filled with fluid or coagulated blood, of a dark 
colour. Thii* canity is either smooth or granu- 
lated, and minute vessels may be traced into it; 
Mr. Calveiit states that it has no direct con- 
nection with any larger vessels. It is usually 
small ; generally about the size of a pej, but 
sometimes that of a bean, or walnut, or even 
larger. More frequently, however, there is no 
regular cavity or cyst ; ^e substance of the tu- 
mour being as if infiltrated with blood, which 
becomes coagulated and dark : but this ap- 
pearance is not owing to extravasation, but 
rather to dilatation of a numl)er of small vessels 
which traverse the Ussue in the direction of the 
axis of the rectum, as, upon dividing the part 
longitudinally, numerous dark streaks are seen in 
its substance, whil>t a section made transversely 
sho<»s only small roundish specks. 

10. The patient is usually made sensible of 
the development of these tumours, by a peculiar 
pricking or stinging sensation, within or at the 
margin of the anus ; and one or more ar^ found 
slightly elevated, or pre^^sed downwards by the 
sphincter. The increase of these tumours takes 
place more by elongation than by expansion, and 
they assume a conical form, and are larger than 
their necks. Sometimes blood is exhaled from 
their surface ; in other cases, or on other occa- 
nons, a serous fluid is exuded; and occasionally 
they are entirely dry, especially when they are 
external. In either case they generally disap- 
pear in two, three, orfour days ; but return agam 
at an uncertain or at a regular period, and in- 
crease in size, becoming firmer in texture. After 
some blood is evacuated from them, or after the 
determination of blood to the parts has ceased, 
they collap«ie, leaving small pendulous flaps of 
skin, which ultimately disappear if the tumours 
have been small ; but if they have been large, 
the^e flaps continue conspicuous, and give a pro- 
iecting and irregular margin to the anus. Having 
been strangulate<l by the sphincter, or repeatedly 
engorged witii blood or lymph, or chronically in- 
flamed, these tumours become more solid and 
almost permanent, are a source of constant dis- 
comfort, and give rise to several of the conse- 
quences and complications about to be noticed 
($ 20.). 

11. The permanent state of the tumours is 
owing partly to the development of capillary 
▼essels, and partly to the efl'used blood and 
lymph becommg orfanived ; this latter circum- 
stance especially giving rise to the excrescences, 
or irregular mas« of tumours found around the 
anus in those subject to hemorrhoids. — Occa- 
sionally the tumours acquire a very great size, 
arising from the effusion of much blood in the 
central cavity, and of blood and l^mph in the 
cuticular envelopes. Instances of the enormous 
size of these tumours have been recorded by 
SciiMUCKER, Calvert, and other writers about 
to be referred to. 

12. 6. Hsmorrhoidal tumours farmed b\i a 
varicose state of' the veins of the rectum are not so 
common as those just described. They seldom 
attract attention until they have made some pro- 
gress, for the distension takes place verv gradually, 
without causing much sympathetic dititurbance, 
or materially increasing previous disorder. They 
art not so disposed to enlarge at particular pe- 



riods, and are more permiDent and len ptinfil 
than the form already noticed. They are cob- 
monly of a dark or bluish colour, and soft aad 
elastic to the touch. When compressed by tiw 
finger they become sensibly less, bat retun ft 
their former sta e when the pressure is remoftd. 
They are round and broad at the base, and oAoi 
distributed in irregular or ill-defined claitoik 
They evince little disposition to bleed, eales 
when ruptured or injureid. They appear cnradsd 
together, extend up the rectum, are mora or Isa 
internal, or become external chiefly during csih 
tiveness, or when the patieiK is straining at slealt 
or after a fecal evacuation ; whilst the §otmm 
kind is limited, and generally external, or wilhii 
the reach of the finger. Vamalya, LvBVia, 
Petit, Rjchehand, BEGiN,CALVKRT,modelliti% 
have seen hemorrhoidal varices extend uu i m i fc 
along the rectum to the colon, especially u pi^ 
sons who had experienced obstruction of toepoittl 
circulation. M, Blgin observes that, in maA 
cases, the dilated superficial, submucous, er MJ^ 
cutaneous veins are only the smaller partof thtn 
surrounding the rectum. Sometimes the low 
part of this intestine appears as if plnngei ■ 
the middle of a network of dilated and eofOMi 
veins, forming a thick vascular ring, the ii 
or (.nocture of which may give rise to 
hemorrhages. M. Hicherako found, vpoa 
section, those varicose tumours filled wiihc' 
blood, and their interiors continuous with 
portions of the veins which retained their 
size. I'hese dilated vessels presented allciMlrif 
a state of distension and their natural caltaf 
and were continued in every direction, 
plexus around the outlet of the bowel, the 
portions being covered only by the •^w'jb'I 
cous membrane. 

13. As the varicose tumours arise frcMn 
of the causes that produce the preceding 
(<^ 9.), and as both varieties occupy nearly lit 
same situation, it may be reasonably wferredlllt 
they may exist together, or that the latter Mf 
often give rise to the former in connectioawilhK 
Mow this is sometimes the case ; inflamanMff 
irritation, supervening in the course of the ni 
cose form of the disease, superinducing the smi^ 
r<r, or the first variety of tumour, and theidf 
obscuring the vaiicose character of the fci 
Or a diflerent procedure, as Mr. Caltcbt 

[>ose9, may take place ; the veins becoming 
ati'd in consequence of the previous fomatioi 
the cellular tumours. These complications of il 
tumours can be ascertained only by a careMM* 
amination. and by attention to the bistoi7»|i^ 
gres<, and symptomatic relations of the case. 

14. c. A third form of httmorrhoidal ti* 
mours, of an erectile character, was first M 
by Sir Jamfs Kari.e, and more particultify i^ 
scribed by Mr. Comes. These tumouis mtf 
d fferent sizes ; are soft and spongy to the 
of a purplish colour, with a number of 
but distinct, ves^^Is on the surface of each. Oa^ 
two, or more of these tumours protrude thividk 
the anus when the patient is at stool. Eirijl 
the disease the protruded parts retire spoBlW 
ously ; but, in advanced stages, they reqnit I 
be replaced by the hand. Alvine eracnitin i 
followed by pain, which, especially whtu 4 
disease is prolonged, does not cetee for tMi 
three hours ; and u attended by Iosms of IM 



\ 



126 



HAEMORRHOIDS — Coniequeiices amd Coaii'tiCATioyi. 



glands of the part takes place. These varieties 
of colourless discharge are most frequent when 
there is little or no hsmorrhagei and when the 
disease is associated Miith asearidet, or with 
leueorrhaa, or with pregnancy, 

20. iv. Of the Coiuequence* and Ccmplications 
of HttmorrhoidSf local and comtUutional. — A. 
Inflammation is one of the most frequent morbid 
associations of haemorrhoids. It is attended by 
more or less swelling and redness of the lower 
part of the rectum and anus ; by throbbing and 
by increased sensibility and heat, aggravated by 
the passage of fsces. The sanguineous discharge 
is slight or absent ; but if it become abundant, 
the symptoms subside. A mucous discharge is, 
however, not uncommon. Sometimes the in- 
flammation is severe, and implicates, not merely 
the mucous membrane and subjacent cellular 
tissue, but also in a slighter degree the prostate 
gland and neck of iho bladder, occasioning much 
pain in the perineum, sacrum, &c., with dysuria, 
or even strangury. The irritation may even 
extend to the womb in females. The tumilied 
state of the lower part of the intestine in these 
cases, together with the inflamed tumours, and 
the spasmodic constriction of the sphincter, pro- 
duces obstinate constipation and straining or 
tenesmus. Not infrequently the protrusion of the 
tumours, when internal, with a portion of the 
mucous membrane, follows the action of the 
bowels, and the inflamed tumours, being strangu- 
lated by the sphincter, become remarkably (lainful, 
or even ultimately slough. With the severity 
of the local symptoms, the constitution generally 
sympathises; ana febrile symptoms are developed, 
particularly in irritable or nervous temperaments. 

21. B. Fisturn or rhagadet of the anu» arc 
not uncommon in cases of hsmorrhoidal tumours. 
They may commence in small longitudinal ul- 
cerations ; but they more frequently seem to take 
place as follows- — When the tumours are large 
and numerous, hardened fa>cal matters, in pass- 
ing forcibly between them, crack or slightly tear 
them at their ba«es, the chronic inflammation 
in this situation hardening and rendering the 
tissues less yielding to any distending power. 
These fissures are most apt to occur when the 
tumours are situated upon the sphincter. Ttiey 
ire usually slight at first, but they enlarge, 
owing to the frequent operation of the causc-s that j 
produced them and to the lodgment of faical | 
matters, and occasion great pain, which continues ! 
for some hours after each htool, and spasmodic 
constriction of the sphincter. Herpetic or other 
chronic eruptions sometimes also appear about the 
anus, and favour the supervention of these fi-^sures, 
by rendering the surface harder and less capable 
of distension, or by diminishing its vital cohesion. 
Fissures of the anus mostly occur as a con- 
sequence of the first and third variety of haemor- : 
rhoidal tumour. 

22. C. Ulcerutum *or aliceti, frequently pas- 
ting into Jittula^ often follows hemorrhoids, par- 
ticularly when inflammation occurs. When the 
inflammation is superficial, affecting chiefly the 
mucous membrane, it gives fise to ulceration in 
one or more points, especially in the situation of 
the tumours ; and it may penetrate deeply, or be 
followed by small abscesses, either in these tumours 
or ift tlMsr vicinity. When the inflammation is 
more deeply seated, implicatiog the cellular and 



adipose tissues, m absceai then fonai vtij i«Hiil| 
ana often rapidly. Pain, tension, and beat aboel 
the anus are then severe, and with the thfob* 
bings, extend up the pelvis. When the abacessii 
anterior to the anus, and presses upon the uretkia, 
and parts adjoining the neck of the bladder, tW 
suffering is very great, and sometimes is ■*>f*Hlfli 
by strangury or total retention of urine. Ths 
abscess, in the female occasionallyiextends to oas 
of the labia, or even breaks into the vaginaf or paaai 
into fistula in that, or in an adjoining situatiQk 
Of this I have seen several instances. — (8m 
art. Rectum.) 

23. D. Hitmorrhmdal tene$mut, or ipamuik 
constriction of the sphincter, frequtntly wA 
protrusion of the mucous coat of the. rectum, n a 
common complication of hsmorrhoidal affectiBM^ 
particularly when the tumours are inflamed, m 
when there are fissures between them (f 21.)i 
If the tumours are seated within, or above dn 
sphincter, or if the mucous or submucooa lisna 
are much tumified or infiltrated by inflammalwf 
determination, the actions of the parts of tki 
bowel above this, or the efforts at expelling fined 
matters, are attended by much tenesmus aiA 
often cause a protrusion of the tumours and ti^ 
mified parts, sometimes to the extent of paitiri 
invagination of the rectum. When the spniDdv 
is spasmodically constricted, in co ns e qn te 
either of the irritation of the internal surface of thi 
intestine, or of fissures in the anus, the veins 01 
grasped so firiuly by it as to give rise to t csS" 
gcsted or varicose state of those eztenml ts, si 
below, the constriction, and the disease is thv^ 
by aggravated and prolonged. I'his irritiUstf 
spasmodic state of the sphincter may exist in np»b* 
ous persons, without fissure or inflammatioo, 
be attended by great pain, as shown by 
DupUYTRKN ; but it most commonly is asiodi 
with one or both of these morbid states, as well ■ 
with a bloody or colourless discharge, and with k» 
morrhoidal tumours, or with either of themonlyi 

24. E. The pain of hg:morrhoiils varies ■ 
character in diflferent cases. In some it is csii 
stant ; aggravated upon passing a motion, and I 
attended by heat and throbbing : it is then owi^ 
chiefly to inflammation. In others it is iotensi^ 
tent, extremely severe at times ; comes on nl 
ceases suddenly ; is eased by pressure ; and is ift 
nervous character. This kind of pain is ote 
connected with spasmoiiic constriction of iki 
sphincter, and was denominated proctalgia kff 
Saw AGES. The pain is often also connected wis 
fissure, as shown by Buyer, Merat, Mosnoiii 
and others ; and is then pungent, lancinadsi, 
cutting, lacerating or peculiar, and greatljsf* 
gravated by tlie action of the bowels. In ntsy 
cases, the pain extends to the insidcs o/ the bipi 
and the back of the thighs, or to the uriniy 
organs and urethra ; and occasionally up Iss 
pelvis into the abdomen. Indeed coUaai pmii 
often of a severe kind, usher in an hsmorrhoiU 
attack, as well as supervene in its course, or ipa 
certain modes of curing it, as upon the nppbcfr 
lion of ligatures on the tumours. 

25. F. Irritation or inflammation of the 9tA 
of the bladder and prostate ; painful aflectioas rf 
these parts of the urethra, and of the vesieila 
seminaies : diflicult or painful micturitioa : » 
tention of urine ; and prolapse of a portion of tkl 
rectum ; are not infrequent compLicatioDB «f 



128 



HEMORRHOIDS — Pxooiiosm— TisATMurr. 



the diseate. Sedentary occupations, and indo- 
lence with Insurious nourishment, must, as Dr. 
J. Johnson remarks, either find some outlet to 
the superabundant fluids, or bring on a train of 
diseases. Hsumorrhoids and gout are the com- 
mon consequences of this state of things. Many 
people who have led an active life for many 
years, on leaving off business and indulging in 
repose, become, for the first time, affect&l with 
piles. The sitting posture, retained for many 
nours in succession or habitually, particularly on 
warm or soft cushions; full or rich food ; beating 
or stimulating diet, and intoxicating beverages ; 
inordinate excitement of the sexual organs ; ha- 
bitual constipation, and the use of warm or irri- 
tating lavements, and strait corsets, not only 
predispose to, but often also directly proluce this 
complamt. It is owing to the association of 
several of thi^se causes that piles are so common 
amongst persons occupied at the desk, and 
amongst tailors and shoemakers, as well as 
among the inhabitants of Turkey and of other 
eastern countries. It has been very often re- 
marked, that hsmorrhoids are more prevalent in 
spring and summer than in winter; and this 
appears to be the case. A disordered state of the 
alimentary canal and of the liver, and the sup- 
presMon of other discharges, have a great in- 
fluence in favouring an attack. 

30. 6. The oeca»innal exciting eauset are — 1st, 
Whatever inordinately excites the rectum and 
lower part of the colon , particularly too large or 
too often-repeated doses of calomel, aloes, colo- 
cynth, black hellebore, camboge, or scammony ; 
occasionally, also, of rhubarb, the neutral sul- 
phates, and of any other purgative injudiciously 
prescribed or exerting a drastic action ; the pac- 
lage of acrid bile ; the irritation caused by 
worms; many of the substances said to be em- 
menagogue; all the preparations of mercury in 
large or frequent doses ; the liquor arsenicalis 
when thus employed ; and the inappropriate 
use of chalybeates ; — 2d, Whatever prevents 
the return of blood through the hremurrhoidal 
vein«, as constipation, the lodgment of hanl- 
ened fsces in the rectum or lower parts of 
the colon, and repeated efforts at evacuation ; 
torpor, congestion, or structural lesions of the 
liver, and obstructed circulation through the por- 
tal system ; the pressure of a pregnant, enlarged, 
or displaced uterus, or of a diseased ovarium ; 
and disease of the prostate or sphincter ani ; — 
3d, Whatever excites and determines an increased 
flow of blood to the Fcxual and urinary organs, as 
venereal excesses, spirituous liquors, the irrita- 
tion of calculi, of cantharides, ficc. ; — 4th, Ex- 
ternal irritation of adjoining parts ; prolonged 
walks in hot weather ; riding in coaches, or on 
horses or mules without a saddle, — " Nam solet 
a nudo surgere ficus equo*' (Martial 1. xiv. 
epig. 86.); and the frequent application of 
leeches to the anus; — and, 5th, The local in- 
fluence of cold or warmth, as sitting on the 
ground, or on stone seats or on damp cu«>hions, 
and the habit of standing with the back to the 
fire. — Besides the foregoing, various other cir- 
cumstances occasionally cause this complaint, as 
the more violent mental emotions, both excitirg 
and depressing ; errors of diet and of regimen ; 
inordinate excesses of any kind ; and diseases of 
other organs, particularly those of the lungs or 



liver. Hsmorrkoida are, nonowtir, 
critical in other maladies, especially in kmn 
and in inflammations of the brain, or of aoy of 
the viscera lodged in the thoracic and abdomual 
cavities. Owing generally to the aasociatioo oC 
several of the above causes, this complaint k 
very common in the upper classes of society, ia 
both its simple and more complicated states ; aad 
iience the number of treatises which have ap* 
peared on it and its consequences. 

31. IV. Prognosis. — A favourable opiiui 
of the result may generally be entertaiocd in all 
the simple sutes of this affection, partiralaiiy 
when the patient is not far advanced in life, whM 
the constitution is not in fault; and when the 
lungs, the liver, and brain present no tendency It 
disease. In other circumstances, and when At 
complaint is periodic, the removaJ of it, howcnr 
cautiously effected, may be followed by seiioH 
effects, and especially by diseases of the Inigk 
(See j 3.30.) In all cases, the prognoabshoaU 
be founded upon a knowledge of the cavaas, af 
the form, and of the complication of the diMHikr. 
If the causes t>e not obviated, either thediMMi 
w.ll return after a time, or it will be followed by t 
more serious malady. The extent and freqneacyif 
the discharge must always be taken into ac 
as well as the form of hasroorrhoidal ta: 
The mo*v common variety of tumour is 
attended by any risk, unless in the ci 
just alluded to, or when otherwise complictld^ 
locally or constitutionally. But the 
tumours require a more cautiona or 
opinion ; for, under the most judicious 
ment, the more prominent or distended paiti rf 
the vessels may burst by a thinning prooesi, aid 
occasion profuse ha^morrhage. Tbey are, akib 
generally connected with more or lest viseni 
disease or constitutional disorder. The pingiwii 
should not be materially different from that JMl 
stated, when the complaint is complicated wiA 
injiammution, for some one of its terminatioafc ■ 
abscess, ulcerations, or fissures between the tl*' 
mours, fistula, spasm of the sphincter, prolifHi 
or invagination of a ponion of the bowel, hI 
even perinanent stricture of the rectum, Hf 
take place, however judicious the treatment m^ 
be, and occasion very great or prolonged wtSth 
ing, if not imminent danger. When the ca» 
plaint is connected with visceral diseaie, ni 
especially with pulmonary disease, the opisia 
should be formed chiefly with reference to aim- 
sociation ; and the hsmorrhoidal affection sbosU 
be so managed as to prove a derivation from As 
internal malady, and to prevent its increase. 

32. V. Trfatment. — A. The preprielji d 
iujrpreuing the httmmrhoidal diicharge osn 
always to be considered when entering apoBM 
treatment of it. Cvli.en erred egreflpooly ii 
considering the complaint as generwiy kali 
and in recommending a local treatment; aadii 
this he has been too closely followed by saipeil 
writers. I'his practice, as Dr. J. Jobnsoii flb* 
serves, of removing the disease as speedily M 
possible, is very well in sound constitutions; M 
where there is any defect in the system, or oini 
predisposed to disease, we should be caRftl ■ 
avoiding the sudden stoppage of the hc■i^ 
rhofdal movement or discharge. Himcaini 
observed that this complaint ofUn praieclBd ihi 
system from other malames; and a ■milAropMi, 



130 



Hi£MORKIiOIDS'TKEiiTx«NT. 



cram. Derivatives, eBpecially sinapisms, the ■ 
terebinthicate epithem, or blisters, may be placed \ 
on these or other parts of the surface ; and as- 
tringent or cold lotions, or injections, may be 
emploved. — 0. In the pai$ive form, the acetate > 
of lead with opium ; the preparations of cinchona 
with the mineral acids, of the sulphate of qui- < 
nine in the compound infusion of roses > the ' 
tincture of the muriate of iron, and other chaly- i 
beates ; the balsams of Pern or of Copaiba, m 
large or repeated doses, or the terebinthinates, j 
and the oil of turpentine, administered either by j 
the mouth or in enemata, are the most eAica- . 
cious means of arresting the discharge. (See art. ■ 
Hamorhiuce, § 45. €t My.) — y. riugging the \ 
rectum, and the actual cautery^ have been recom- 
mended in extreme circum<:tances. If the source 
of haemorrhage is above the sphincter, a fatal in- 
ternal discharge may follow from having recourse 
to the former of these. It is not practicable to 
retort to the latter, unless the spot whence the 
blood issues can be brought into view. 

36. b. The colourless mucous discharge (§\9,) 
from the anus, although a frequent attendant 
vpon piles, is not necessarily so, as it may be 
occasioned by ascarides, &c. If it accompany 
internal or external tumours, and be independent 
•f inflammation, slightly astringent and detergent 
injections ; the internal use of the balsams, or of 
the spirits of turpentine, or of the balsams or 
terebinthinates combined with magnesia ; and an 
occasional recourse to the stomachic aperient 
mentioned above ($33.), will generally remove 
it. When it is connected with inflammatory 
irritation, the means about to be stated {§ 42.) is 
most appropriate. 

37. b. Treatment of the Ila^morrhoidal Tn- 
mourt. — In all cases,'thc parts should be care- 
fully examined by the practitioner, since the 
accounts given by patients themselves are very 
fallacious. Besides, the particular kind of tu- 
mour must be ascertained l>efore the means of 
cure can be appropriately directed. Whether 
the piles be internal or external, or both, the 
anus should be washed with cold water after 
each evacuation ; or with yellow soap and water, 
as suggested, in the course of some excellent 
remarks on the treatment of the disease, by Mr. 
Mayo. If the piles be internal, this should be 
done before they are returned. If they cannot 
be returned, or are permanently protruded, or 
altogether external, whatever may oe their form, 
preuure is one of the best remedies that can be 
applied to them. After each evacuation, and 
having thoroughly cleansed the parts, a conical 
pad, or piece of ivory, made to slide along a 
bandage or handkerchief, should be passed be- 
tween the nates, and fastened above to a cincture 
or belt worn around the loins, in the form of the 
T banda^. The pad may be provided 'with a 
concentnc wire spring, the more internal coils of 
which rise in a conical form. This is the best 
external mode of employing pressure. — When 
the tumours are inteiiial, and protrude at stool, 
dragging the mucous coat with them, or when 
they consist chiefly of varicose veins, a short 
metallic bougie, of an oval fo«i, with a short 
slender neck, and a conical base to press upon 
the anui externally, may be attached to the 
bandage, carefully introduced into the rectum. 
Mod worn occasionally. Pressure will thus be 



made both above and within the sphincter, ti 
well as without it. When introduced, the part 
of the bougie which rises above the qihincter 
bein^ oval, varying in diameter with the peci- 
liariues of the case, and being manT timei m 
thick as its slender neck grasped by this nuKlCf 
necessarily, from its shape, retains itself widui 
the rectum y diaws up with it the external ti« 
mours and prolapsed portion of the bowel, aid 
presses its conical base externally against the 
anus, and upon the tumours or enlaced voai 
external to the sphincter. This combtnatioB of 
the internal with the estemat method of makiig 
pressure on the anus was introduced by Mr. 
Mackenzie into practice, and is often cxtroMly 
eflicacious in the treatment of hBrnorrboidt, vi 
of the prolapsus attending them. 

36. Before having recourse to dthcr ef thcM, 
it will often be of service to waeh oat the tvLU m 
immediately after each evacuation, by injecliai 
some cold or tepid water, with or without a km 
grains of sulphate of zinc dissolved in it ; and, if tto 
parts be painful or irritable, a little cold 
or of a slightly anodyne or astringent 
or of any other most appropriate to the 
stances of the case, should be applied to the m^ 
face of the bougie, when about to introdaee iL 
At the same time, the bowels onght to be hql 
gently open by any mild or cootiug pwnlift 
that will not irritate the rectum. I naveiMii 
equal parts of the compound inftisiona of gcste 
and of senna, with the soluble tartar, &e. tdkai 
at bed-time, the most beneficial, when ^ ^- 
gestive organs were weak ; and one or two M 
spoonfuls of either of the following electaaiin|-( 
of one of those in the ilppendix ( F. 82. 98.), M 
most serviceable when plethora or hepatie fc'' 
onler was present, or even when there WM % 
manifest tendency to them. 



Na 843. H Potaiw Supertart in PuW. 3 J. , y, .». 
pnecipitaL 3 ij> — iv. ; Confect. Sraiue S ij. ; wrn^ Afc 
raiuii re\ Zingib. q. *. ut fiat Etactuarium molM 

No. S43. R PoUMa* Nitratii 3U- ; CoDfcct Som^ 
S;|rruu 'ZiiiRiberii, U^J w.; Succi Splan SanlMCi Si 
Tiat Elcctuarium. 

39. These electuaries may be varioosly ho 
fled, according to circumstances ; and the tt 
fectio pi peris nigri may be substituted for I 
syrup, or the inspissated juice of the 
or a small quantity of it may be taken 
thrice daily, when there is much relaiatkm if' 

Ean<, or m cold, languid, or leucophli 
abits. Aperient medicines, in hsmoi 
cases, should always be taken at bed-tiBe» 
such doses as to operate only once, or at 
twice, in the morning. Subsequent irritatios^ 
the bowels during the day will thus be 
especially if the rectum be washed out 
ment after passing a motion. W* hen it 
sary to have recourse to the short bougie ( 
ed aliove (^37.), it should then be int 
its passage being facilitated by an anodyaf 
slightly astringent ointment or pomade. 

40. When the tumours are internal eml " 
trudc only at stool, and when they contt^ 
notwithstanding the use of the conitilBtti 
treatment advised above, aided by the 
employing pressure, just described, the n 
them by an operation may be entertunsdl; ^ 
certainly ougnt not to be practised, nnloi m 
clearly ascertained that they belong loAe^ 
variety ($ 9.), and never, if they pm^ 



133 



IliEMORRHOIDS -- TnEA tm£nt. 



Bates should be given internally, in the form of 
pill, with magnesia, in quantity sufficient to keep 
the bowels gently open . 

44. h. Fissures or cracks between the tumours 
are attended either by exquisite pain, or by spas- 
modic constriction of the sphincter. More fre- 
quently both these latter morbid states are pre- 
sent; and occasionally the patient is tolerably 
free from both. When the lesion is thus simple, 
the treatment recommended for ulceration will 
often be sufficient ; the local application of borax 
dissolved in honey will also be of service, as a 
substitute for an ointnient ; but when cither pain 
or spasm of the sphincter is complained of, other 
means arc required. In these cases L Imve found 
the addition of the extract of Mladonna to any 
of the ointments usually prescrilxHl give almost 
immediate relief. If a large propoition of the ex- 
tract be employed, the effects ought to be care- 
fully watched. Due attention to the functions 
of digestion and of excreuon, and to existing con- 
stitutional symptoms, is always necessary. In 
less severe cases of this description, the extract of 
hyocyamus may be tried, before having recourse 
to the belladonna. M. Boyer and most surgeons 
in this country have advised a complete division 
of the sphincter ani muscle for the removal of 
this complunt. 1 have treated five cases of fis- 
sured anus since 1822, when the first came under 
my care. In all these the operation had been 
recommended ; and yet they perfectly recovered 
in a short time, and without a single exception, 
by means of a purely medical treatment. Strict 
injunctions as to diet and regimen ; the daily 
evacuation of the bowels, and afterwards washing 
out the rectum by emollient injections ; careful 
ablution of the external parts, and the application 
of an appropriate ointment or cerate with bella- 
donna ; attention to the functions of the digestive 
and assimilating organs, and to constitutional 
symptoms, and the removal of general or local 
plethora, constituted the treatment. The bella- 
donna was added to various kinds of ointment, 
according to the peculiarities of the ca^^e. In all 
it affected the pupils, and in two, it produced its 
characteristic eruption on the skin. Several years 
after I first employed this medicine for fissure 
with painful spasm of the sphincter, the account 
of M. Dipuvtren's treatment of this affection by 
the same means appeared in the medical jour- 
nals of Paris. 

4f5. G. Htemorrhoidal pains and spasmodic 
stricture of the rectum, generally connected with 
fissure or ulceration at the ba^es of the tumours, 
must be treated in the manner just stated (^ 44.). 
The pains are often intermittent, but very acute, 
during their continuance. Sometimes they ex- 
tend down to the feel and ankle-%, and even oc- 
casionally a<isume a neuralgic character in these 
or other parts of the lower extremities, or ^ive 
rise to spasm in various parts, e<(|)ecially in nervous 
or hysterical females. Some interesting instances 
of such affections have been recorded by Sir H. C. 
Brodif, and have been observed by myself. In 
such cases, much benefit will generally accrue 
from taking the confectio piperis nigri, twice or 
thrice daily ; and from adopting the constitutional 
and local treatment just recommended. This 
medicine may also be conjoined with an anodyne, 
and the bowels regulated by the medicines 
MJreadf tugrgeBl^. M. Monteo ax strongly ad- 



vices having recourse to the " d<nuh$a9eendanU i ^ 
or the forcible dashing of cold water against the 
anus, and to cold injections. In order to render 
the evacuation more easy, he directs the lavement 
to be thrown up when the inclination to stool 
takes place. Emollient injections may also be 
tried, either to facilitate the discharge, or to cleanie 
the rectum afterwards ; and sup/MniCorici with the 
ceratum plumbi compositum, and opium, or strain* 
moniura, or belladonna, or any other narcotic niy 
be occasionally introduced into the rectum, ud 
they will seldom fail of giving relief. Great cam 
ought to be taken in the administration of narcotici 
in lavements in the treatment of this or any other 
state of the complaint as they are often rapidly ab- 
sorl)ed into the circulation, from the rectum and 
colon, and without having undergone any change. 
I have known half a grain of the belladonna, ia 
one case, and thirty drops of laudanum in another, 
produce the most serious effects. When, how- 
ever, either of these, or any other narcotic is 
prescribed in an ointment, pomade, or auppoiitaijr 
no unpleasant results will follow. 

46. //. TenCimui, strangurif, and ctmMifth 
lion often depend upon the same patholegicel 
states. — a. The tenesmus is generally owing to 
inflammatory irritation and conges^on of the imer 
coats of the rectum, conjoined with spasmotfe 
action of the muscular tunic. It will, with fev 
exceptions, be removed by the means just direclii 
r § 42. 45.). In lesit acute, or more obbiinaiecaNi^ 
the belladonna plaster may be applied to tht 
perineum or sacrum. Five or six grains of iki 
extract of poppies, or one or two drachms of At - 
syrup, may also be occasionally thrown into iht 
rectum, with any tepid emollient enema; era. 
suppository of the kind just stated may soiinii— 
be introduced. — 6. If ttraugurit or diisurmm' 
pervene, it is to be imputed to the extension of tki 
affection of the rectum to the neck of the bladdtf»^ 
or to the prostrate and urethra ; and it will |h^ 
nerally be found th.it it will be removed ff^ 
relieved by the treatment recommended for 
mus. — r. Cnnstipution also frequently procwiij 
from the same local changes as occasion 1 
and strangury, and from tumours or enlarged! 
con^e^ted vessels obstructing the canal of ikti 
intestine. In either case, there is more or ' 
obstacle to the passage of a consistent mol 
and much pain attending it. If these 
toms be allowed to continue, the complaint 
be aifgravatcfl ; or they will give rise to 
more K'rious chan>:es. In removing then,! 
milder laxatives will be found more senri 
I than active purgatives ; but those which tcti 
I upon the liver should be selected. lUer 
aggravate and even bring on tenesmus, and 
I fore cannot be employed, with the excepM^ 
I hydrargyrum cum creta. This may be takcif 
. small doses at bed-time, with ipecacuanba 
I hyosc\amus, or with extract of taraxacum. S 
I one of the electuaries already prescribed (} 3f" 
or the decoction of taraxacum with the i 
j carbonate of soda* or the tartrate of poiaib * 
I tincture of senna and syrup of roses, or of Mr 
I may l>e given, and continued for some liBB*> 
, Seidlitz powder taken about an hour befon b^ 
fast is also one of the best aperients in fed 
I rhoidal cases. A frequent recoune to * 
< lavements is injurious in this compIaii4''i 
( relax the parts, and solicit the circoitlioo to V 



134 



HAIR — ALTERATIONS OF— Pathology. 



Soath Carolina, vol. I. p. 100.— Lo^jBHeVt BeytraRe, bi i — 
J. C. Stuntxrr, Ueberdie Goldene Ader, Uro. Wien. 1788. 

— J. B. Batter,'D^ Hsmorrhoidibiui, 8vo. Vien. i7S!).-- 
N. R. MoUior^ Abhandlung ueber die Harmorrh. 8vo. 
Leips. 179a — K. A. Bitxius, Uraachen und Rehand. 
lungsait der Hvmorrh. 8va Hamb. 1794. — fV. Dc Kr. 
TVnJfco, Hbt H«m. 8va S t Wien 17M-fl3.— G. HUdf 
hrumdtt Ueber die blinden Hamorrboiden, 8va Erl. 1795. 

— J. Ware, Kemarlu on Fiitula Lachrrmalit, and H«. 
morrhoids. Bra Lond. 1798.— J. G. Knebfl, Abhand. 
lung ueber die Hemorrhoidal kranlcheit, &c. 8va 
BresL 1799. — J. C. A. Recamier. Eaui sur let Hsnior. 
rhoidec, 8vo Parla. I8ua — tr. Culten, Works by J. 
Thonutm, VOL L p. tKS., vol iL p. S13. 967. S70. S7.t. — 
Sckimieker. Vermiichte Schriften, b. i. jx 87. — G. W. 
Becker, Die Hamorrhoiden. Weitsenr. 8to. 1H(H. — 
J. W. H. ConraMt Von den Hcmorrhoiden. Marb. 
Sva 190^^ Petitt CEuvret Po^thumes, t. ii. p. 1S3. — 
Sckmueker, in Rickler'i Chinirg. Ribliothek. b. v. p. 231. 

— Momteggia, InUituL Chirurgiche, Parte tcna. Milan, 
1805, p. 521. — VogcL in Saliburger Chir. Med. Zeituiig, 
3791. iL p. 235. — MIchalis, Hn/eiantTs Journ. der Pr. 
Heilkunde, b. xiL 4 it p. Sa^Joerdeiu, in IJitfeUnttri 
Journ. der Pract Araneyk. b. iv. p. 228. — Hcnnine, in 
MufelatuTi Journ. der Pract. Ileilk. bi x. ft. 2. p. 1^. — 
Hv^iiand, in Ibid.bi ix. at. a p. I(i6 — Horn, N. Archiv. 
b. L p. 12a 277. ; eC BeitrAgecur Med. Klinik. b. ii. d.432. 
•—B.De Larrogue, Traltd de llannonrhoides. Paris, 
1812. — F. A. Muff. Die Hcmorrhoiden, 8va Mannh. 
1802. — G. W. Becker^ Die Hsmorrhoiden, 8va Wcis. 
1804. — J. W. H. Conradi, Von die Hsmorrhoidcn, 8vo. 
Mart). 1804w — J. £ar/tf, Observ. on Haemorrhoidal Ex- 
crescences, 8Ta Lond. 1807. — A. Portal, M(? moires sur 
la Nature et le Traitement de plusieurs Maladies, L v. 

— J. F. C. Alhreeht, Die Hcmorrhoiden, ihrc Bc- 
handlung, &c. 8va Hamb. 1809.— Pk. PineL Nosograph. 
PhikMophique, t iiL u 45d. — D. G. A. tUeht^r, Die 
nccielle Tn^rapie, b. IiL pi 344>. -^ L, J. Schmidtmann, 
Summa Obs. Med. vol. It. IIl 410. — J. Kirb^, OlMerva- 
tiona on the Treatment of Haemorrhoidal Kxcresccnces, 
8va Lond. 1817. —J. Abemethy, Surgical Works, vol. ii. 
p. i34. — if . J. Hr Mont^re, Diet den Sc. M^d. Art. H^. 
morrhoides, t. xx. 'Pans, 1817 ; et Des Hemorrhoidcs, 
Traits analytique, &c. 8vo. Par. 1819. — G. M. At L. 
Bam, Uet>er die Erken. &c. der Haemorrh. 8vo. Gicss. 
1821. — r. Copland, Obs. on the Diseases of the Rectum 
and Anus, 8vo. Lond 1824, 3d ed. p. 55. — J. Jokngon, 
In Medico-Chirurg. Review, voL ii. p. 273. — J. HoitMhip, 
Pract Observ. on the Disea»es of the lower Intestines 
and Anus, 8va 3d ed. Lond. 1824, p. S07. — IV. Wh^e, 
Observ. on Strictures of the Rectum and other Afll-c 
tiona, 8vo. Bath, 1824, 4th ed. p. 111.— G. Calvert, Pract. 
Treat on Hemorrhoids and other Dis. of tlic Rectum 
and Anus. 8vo. I^ond. 1824. — C. J. Kock, Die Diiit und 
Lebensonfnung fQr Hiimorrhoid. I'.'ma Lcipi. 18^. — 
J. M. Gooit. Study of Medicine, voL i. p. »)4. — F. G. 
BoUseau, Nosograph. Organique, tL p. (»49. n.5a — y|. 
Bompardt Trait6 des Maladies des voles Digestive*, 2S9. 
6«8.— F. Salmon, Pract Essay on Contract, of the Rec- 
tum, Piles, &c. 8vo. Lond. I82H; and Pract Observ. on 
Prolapsus of the Rectum. 8vo. Lond. 18.'jl. — 3/. /,. Rot- 
tan, Trait6 616mentaire dc Diagnotrtic, de Prognostic,&c., 
t IL p. 530. — B. V. BrodL', in Lond. Med. Gazette, vol. v. 
p. 556. . C, Saucerotte, Nouveau Traite des H<:nior. 
rhoidcs. 8va Par. 18Sa — //. Mayo, Obs. on the Dis- 

nf the Rectum and Anus, 8vo. Lond. 18-:2, p 58. ; 



and Outlines oi Human Pathology, 8va 1835-(>, p. 347.— 
Bigln, Diet de Med. et Chir. Pract t. ix. Par. 18.'^ -,. 
Burme. Cyc. of Pract Med. voL iv. SuppL Lond. 1835. 
(See ado the BiBkioo. and Refer, of the art Rectum.} 

HAIR — ALTERATIONS OF. 

Classif. — General Patiiolocy — 5i/n?p- 
tomatology ; jEtiology : — Special Pa- 
thology, and TiiERAPEiiTics. 
1. The hair being an appendage of the skin, 
and the natural covering of one of the most 
important parts of the bodv* material changes in 
its state or appearance are interesting to the me- 
dical practitioner, as furnishing indications of se- 
veral pathological conditions. Nor is tlic growth 
or removal of the hair devoid of importance, 
especially in certain diseases, and in convales- 
cence from dangerous maladies. The various 
alterations presented bythe hair are rarely primary 
or idiopathic, and seldom even depend upon local 
changes raeiely ; but are usually the more remote 
consequences of debility and chronic disorder of 
the dUgeslivo organs, frequently associated \%nth 
Muperiaduced a&ctions of the skin and of the 



pilous follicles, and occasionally also with general 
cachexia. In many instances where the nair un- 
dergoes a marked change, the nails likewise pre- 
sent more or less alteration. 

2. I. Effects of Removing the Haib. — The 
consequences of removing the hair depends, lit, 
upon the quantity of hair removed from, and left 
upon, tlie scalp ; 2dly, upon the states of the 
system and of the circulation in the head at the 
time of removal. W hen a person is in good beahb 
at the time, little further results from cutting off 
the hair than headach, cold in the head, or esr^ 
ach, or sore throat. M. Joordan states, dm 
when the long hair worn by the soldiers in the 
revolutionary war was cut off in all the icgi- 

I ments, many complained of headachs of seienl 
weeks' continuance ; but he was not aware of 
any fatal effect beitig produced. The removal of 
the hair in cases of inflammatory excitement of 
the brain, or in that sthenic state of vascihr 
action which requirc-f^ having recourse to coM»< 
plications or the cold affusion, can seMooi d 
productive of injury, although it seems my 
doubtful if it be so beneficial as is very cooh 
monly supposed ; but it is very different io otlMi 
circumstances. In adynamic, nervous, low, m 
typhoid fevers, or in exanthematoos fevenp» 
seating these characters — and still more especnil|f 
during early convalescence from these, the n- 
moval of a large quantity of the hair very cIm 
to the scalp sometimes aggravates the symplMa 
During the advanced stages of these diseases, III 
circulation in the scalp, and the perspiratioD bm 
it, are checked, and congestion, or eveo senv 
effusion, is either thereby favoured, or iiid«a4 
or increased. Therefore, in these low staiM rf 
action and of vital power, the hair should notk 
shaved or closely cut from the scalp, unloswha 
a blister is about to be applied in this sitittiosb 
During convalescence from these or other te 
gerous maladies, the early removal, of the kir, 
particularly when long or thick, is not without nt 
Skger, Vassal, Lanoix, Alibert, JovaDAK,ni 
others, have met with dangeroas and even viA 
rapidly fatal effects from this measure. ThenA 
from it is great in proportion to the quaolitffrf 
hair removed, and of the perspiration proceefil| 
from the scalp. I have seen, in several instsoM^ 
ill effects follow the removal of long thick 
from the heads of delicate children and feiehi 
In children thus constituted, the hair 
always be kept short; and, if it be allowed 
become abundant, it ought not to be closely crtH 
at once. Whenever much hair is lenioted, %/■ 
warm covering to the scalp should be immedble^:: 
substituted, and worn for some time ideiwiiilfc, , 
Persons strongly constituted, and taking ifgihrj 

exercise in the open air, may not ezpenncc 

disonler from the neglect of this prvcautJoa; 
the weak, or the exhausted, or convalescents, 
generally suffer if they act contrary to this 
vice. 

3. Persons in the habit of wearing long 
I have often been affected with rheumatic peaii 
I the face, or with sore throat, upon shaving tk^^ 
I off. In several cases of frequently lecnrruf,^ 

of chronic sore-throat, weanne the beard aaM 



wearing 
the chin and upon the throat has prevented a 
turn of this complaint. 

4. On the other hand, the rvminwl of tfte . 
or keeping it closely cut, is often prodncthe M 



136 



HAIR — F£LTiNO OR Matting of— Preterkaturil Colovr ow. 



I have never seen either of those affections of the 
hair unconnected with disorder of these functions. 
12> III. Frltinc OR Mattinjd of the Hair 
•— Falie Plica, — The long hair of persons, who 
have neglected it, frequently becomes felted, or 
inextricably interlaced. Females after long ill- 
nenes are subject to it, particularly in Poland, 
and other countries where cleanliness in respect 
to the head b so much neglected. It is some- 
what favoured by a morbid secretion from the 
scalp, and is occasionally met with in connection 
- with porrigoj'acoia and other chronic affections of 
this part. It has been particularly noticed by 
Davidson, Kreuzer, Boyer, Gasc, and other 
writers on Plicae and been confounded by many 
authorswith that disease. Jourdan and Rayer 
• have, however, pointed out the great differences 
between them. Felting of the hair occurs in- 
dependently of any alteration of the hair itself or 
of its bulbs, and without the constitutional and 
local disorder ushering in or attending plica, 
(See § 34.) — The remedy for it is obvious. 
IV. Loss OF Colour of the Hair. — Syn. 
Canities; rioXton};, ire^lMrtCf (from IToXof, white, 
hoary); TrichosispolinsiSf Good ; Cant/ia, Auct. 

13. Defin. Hairs prematurely grey, hoary, or 
white, 

14. i. History. — Loss of colour of the hair may 
be accidental, premature, or senile ; and it may be 
partial or general. The hair begins to be grey first 
at its free extremities ; but it often changes in that 
portion which is nearest the skin. This latter 
circumstance shows that the hair has been first 
secreted of its natural colour, and afterwards 
secreted grey or white, in consequence of an affec- 
tion of its bulbs, and is frequently observed when 
the loss of colour has been preceded by eczema, or 
any other chronic affection of the scalp. Men 
usually begin to get grey about forty, many be- 
tween thirty and forty, and some not until a more 
advanced age. The occurrence of gray hairs in 
persons under thirty is not rare ; and I know two 
individualfi, one a male, the other a female, con- 
siderably upward:) of seventy, who have thick 
dark hair, without any being grey. The hair of 
the head is that which first loses its colour fiom 
age, the change usually commencing on the 
temple^. The white hairs are at first few, but they 
soon multiply. When they fall out, they are 
seldom reproduced, so that baldness often follows 
canities. Females generally retain the colour of 
their hair longer than males, and the fair longer 
than the dark ; but fair hair often falls out at an 
early age. 

15. Canities, cither partial or general, is very 
rarely congenital, or observed in childhood. The 
very fair, or almost white hair, with which fair 
children are sometimes born, is not the change 
under consideration. Greyncss of parts only — 
in tufts — has been often noticed, and is owing 
to some affection of the scalp in those parts. 
This partial loss of colour may occur on the nead, 
in the beard, or in other situations. Instances 
of this kind, and of the change takinf^ place on 
one side only, have been recorded by Lorry, 
LuDwio, Haof.dorn, Raver, and otheis, and are 
by no means rare. Loss of colour of the hair 
commonly is gradual and slow ; but in some 
cases the change has taken place in a few hours, 
or in the course of a single night. The case of 
Jditnr Queea of Scotland nas been oft«n adduced* 



and others are mentioned by VoioBm., Bichat, 
Cassan, and Rater. When hair grows from 
cicatrices without pigment, it is colourless, and 
in general or partial leucopathia, the hair is white 
or grey in most instances. In senile canitirs, 
however, the scalp seldom participates in the Ion 
of colour. 

1(). ii. Cavses. — A, The remote amut of pro- 
mature canities are — disappointments, anxiety of 
mind, extreme or protracted grief; nnezpected 
and unpleasant intelligence ; fear, fright, or ter- 
ror : great mental exertion ; paroxysms of rage « 
anger ; severe, repeated, or continued headachi; 
rheumatism of the head and toothach ; the alli 
from the evaporation of salt-water from the htir; 
eczema and other chronic eruptions of the icalp; 
over indulgence of the sexual appetite ; exca»> 
ive hiemorrhage or other discharges, mercnriil 
courses, and an hereditary predisposition. 

17. fi. Blanching of the hair appears to arm 
from a diminished secretion of the colooraf 
matter by the bulbs or follicles. Dr. Macartvxt 
thinks very justly that an organic action most bi 
admitted to exist in the substance of the hair, ii 
order to account for the changes to which it isia^ 
ject, and which sometimes takes place so JW^kStj 
as otherwise not to admit of explanation. N. 
Rayer states, *' that grey hairs have been nidii 
be without marrow or matter m their inteiioif, ii 
place of which there is an empty canaL" Vh 
thop says that the bulbs of tnose hairs wM 
have become white are ramewhat atrophied, aid 
Xyr, Macartney thinks that the change is ovflf 
to the absorption of the colouring matter wkeas 
takes place rapidly. 

IB. iii. Treatment. — When canities istheia* 
suit of a^e and of partiil or general leiicopit)M,k 
cannot be made tne subject of medical treatiMil*. : 
Hut when it is partial or depends upon chnwie 
inflammation of the scalp having extended to Al 
bulbs of the hair, the removal of this state, ud 
of the white hairs, is sometimes followed bylki 
production of hairs of the natural colour. Va* ' 
rious means of dyeing the hair have been reso 
to ; but these arc unworthy uf notice. Applifii- ^ 
tionsto the hair, with the view of preventing it fiM' 
becoming grey or falling oflT, have been freqoeo^ 
employed. Amongst these, the prepared manofV 
of the ox or deer, bears' grease, honey-water, nd 
substances mentioned hereafter ($ 32.), are mtit 
deserving notice. 

V. Prefernatural Colour of the Haii.— 
Syn. Miscoloured Hair; Trichosis Dee^K 
Good. 
19. The hair may be changed from a vnr 

light to a very dark colour. Instances of tlM J 
have been adduced by A lire rt and other*, aW 
are not infrequent. It may be also changed tot 
reddi«h yellow, and even to green or blue, ft 
has likewise been obi^erved of a spotted or variih 
gated hue; this, however, is not uncooBii* 
H lir that has become grey has. in very iM 
cases, been changed to black. The instaaoaiil 
which the hair has been said to have been giMi 
or blue have most probably arisen from theactioi 
of metallic fumes on hair of a light colour. Til 
subject is more fully discussed by M. RaycIi- 
but it is not deserving of further notice. 

VI. The Want or Loss of Hair. — Sys. A 
pe 'ia; 'AXauirtKia (from «X«siif , a fox), Gaki; 
Area, Celsus, Gangrtna Al9p9eiM, Yoai|| 



140 HAIR — Trichqmatose — Diagnosis — Treatuemt. 

37. The scalp is sore to the touch, excessively | forty or forty-five of the former class; and three 
sensible and itchy ; a clammy offensive sweat ' out of ninety or a hundred of the latter. He 
exudes from it, and agglutinates the hair, which assigns the same proportions to Lithuania Mi to 
loses its lustre and appears thickened, softened or VVdnsiw, and the same to Volhynia and the 
distended by a glutinous fluid of a reddish or Ukrame as to Cracow. Schlegel, Gasc, Hart- 
brownish colour. This fluid is produced at the mann, and other recent writers, consider that the 
extremities of the bulbs, and is transmitted to tlie disease is not nearly so frequent as here stated, 
ends of the hair. A peculiar offensive smell This malady appears in the human species pri- 
attends this exudation from the hair and scalp, marily ; and it is said also to affect the lower 
The hair is matted or agglutinated in different animals; but there has been no proof adduced of 
ways — sometimes in single locks, of various its transmission from the former to the laiter. It 
thickness and length, resembling ropes — male has been supposed to be contagious, but dw 
phca — plica multiformis. Occasionally the hair opinion has been shown to have been unfounded, 
is stuck together in one mass or cue. Plica I 40. a. Amonpst the remote raicfes of pKca, 
caudifarmis ; and in other instances it is felted wearing the hair long and applying to it oils and 
into a mass or cake, of various sizes — Female ointments, often rancid (Giliblkt) ; neglect 
plica. The hair of the beard, pubis, and axilla*, of personal cleanliness ; keeping the head wann 
may also present similar appearances. When or covered with thick woollen or fur caps ; usiof 
thus diseased, the hair often acquires a great heating aromatic substances to the head, aoa 
length. Instances of its reaching the length of covering it with warm applications and dresses 
some yards are adduced by the writers referred to with the view of procuring a critical disrhaige 
at the end of this article. Professor KAiTsriiMiDT from it, especially m rheumatic or otlier diseasn 
possesses the pubes of a female, the hair of which of this part, are the most influential. Schlxcei 
may have readily reached round the body. The imputes plica chiefly to the use of semi-putrid 
surface of the scalp is often covered witli super- fish, and damp residences; and doubtless these 
ficial ulcerations, or with incrustations formea by often concur with the foregoing in predispoiiB' 
the morbid exudation; and numbers of pediculi to, or in exciting, the affection, 
are frequently seen in this and in uther parts of 41.6. M. Jourdan considers this complaint, 
the body. The naiU of the hands and feet com- in respect of its riatiiret to consist of an increase 
monly become long, hooked, yellowish, livid or of the vital functions of the bulbs of the hair and 
black. of their secretions, with augmented senribilitf. 

38. Meckel injected the scalps of tyo persons I3aldinolr imputes it to rheumatic acrimoDv.at' 
who died with plica, but none of the injection tended by an incroased secretion from the bulbi. 
reached the bulbs of the hair. J. Frank and France, Wolframm and Larrey view it as a 
La Fontaine found the hair-buU»smuch enlarged, consequence of, or as connected with, secoadaiy 
and full of a yellowish glutinous fluid; Gii.iiii.iit syphilis; and many of the writers referred to, 
also observed them distended by a dark fetid as a critical dis.-harge, determined to the haiiy 
matter. Sciilegf.l states that the hairs arc en- scalp, by the concurrence of several of the causes 
largeH, and filled with a yellowish brown fluid ; just enumerated. By most of the authors, how- 
and RoLFiNcii and Vicat say that they are so ever, who have closely watched this affection, it 
frequently distended with this fluid as to burst, has been considered as sui genesis, and as seated 
and to discharge it externally. Similar changes essentially in the bulbs of the hair. Sliilegil, i 
have been observed by Gasc and others. JVI. La Fontainf, Ruuin, Ciuvufton, Movtok, 
Blandiv remarked the bulbs to rise above the and numerous others have shown, that it I* not 
level of the skin, within the infundibuliform a product of neglect or dirt, otherwise it would 
cavity of the root of the hair, as the papilla or have been seen in other countries as well as ia 
bulb of the feather elongates and produ«'rs the Poland ; that the bulbs of the hair exude a peo 
quill in the youngj bird (Haykr). M. Sfdii.i.ot liar viscid secretion which may be seen issuing 
found, on examining trichomatous hair with from them when the morbid hair is removed; 
a microscope, the internal canals much larper that they are found swollen and acutely sensible; 
than in healthy hair, and the cellular cavities that it is often attended by a similar change in 
near the canal much more distin.'t than usual, the nails; that it i^ frequently a maiked cri^sof 
That the hair neither bleeds when divide^l, nor is other maladies ; and that it cannot be quickly 
sensible, has been shown by Hover and others, removed without danger. Much of the difference 
The moi bid sensibility attending the complaint ifl ofo])inionas to the origin and nature of plica, 
seated in the scalp and hair-bulbs. and as to the consequence of removing it, hu 

39. ii. Causfs. — Plica is said to have first ap- arisen from confounding the false Q$ 12.) with the 
peared in Poland near the end of the thirteenth true disease. 

century. The earliest writers on the dijieasc speak 42. iii. Diagnosis. — The precursory and chi- 

of it as well known. It is now wearing out. It has racteristic symptoms are such as readily disiin- 

alu-ays been more frequent on the banks of the guish true plica, from the false or the felting ^ 

Vistula and Borysthenes, and in damp and marshy the hair causcil by neglect of cleanliness, kc, 

places, than in other parts of Poland. Very rare and from every other affection. The agglutin- 

instances of it have been met with in Holland, ationof the hair by a nauseous exudation from its 
Saxony, and some other places in Germany, its . roots, the enlargements of the bulbs, the swelling 

endemic origin seems well established. La Fon- and softening of the hair it-^elf, and the attendant 

TATNK states that, in the provinces of Cracow and alteration of the nails, are peculiar to this coo*" 

Sandomir, plica affecu the peasantry, beggars, plaint. 

and Jews, in the proportion of two thirds in ten ; 43. iv. Tri atmfnt. — The occurrence of plic* 

the upper classes m that of two in thirty or forty, in persons affected with various serious diseases 
In Warsaw and the ▼icinity,it attacks four out of ! has sometimes proved beneficial. In such caM* 



1 



144 HEADACH — Nervous — Congestive — Cavses. 

8}fmpathetic, from disorder of the uterine and 
urinary organs 



10. i. Nf.nvovs IIeadach. — A. Cau$e$.\ 
— a. This tariff V ia mostly frequent in females > 
in persons of the nervous temperament, and in 
those |K>ssessing high susceptibility, and delicate 
constitutions. Venereal excesses, masturbation, 
intestinal worms, the abuse of calomel or other 
mercurials, and whatever deprer»>e4 or exhausts 
nervous or vital energy, predifpose to il. — //. I 
It is often excited by exposure to cold, or to cold 
and humidity conjoined ; by northerly or easterly ; 
winds ; by the more extreme electrical states ot the 
air, or by sudden vicbsitudcs of the^e states ; by 
prolonged or excessive lactation ; by lossus of 
blood, monorrhagia, leucorrhsa, or other dis- ' 
charges; by low diet and prolonged fasting ; by [ 
the depressmg passions, alarm, tear, grief, and , 
anxiety of mind ; by want of sleep, or inordinate ' 
mental or physical exertion ; by the improper use 
of mercury or other depressants, as tobacco, di- 
gitalia, &c.; by various odours or mephitic 
vapours or gases ; and by the impure air of 
crowded or insu6Sciently ventilated rooms. Sleep- 
ing in apartments containing plants in flower, the 
fumes of burning charcoal, or of turp^mtine, and [ 
recently painted rooms not infre<|uently caui>c it. . 
The irritation of adjoining parts, as caries of the j 
teeth and disease of their fangs sometimes also i 
occasion it, especially on the same side of the head j 
as the seat of irritation. I have seen the most ; 
intense state of this affection produced by the in- j 
judicious application of cold to the head, by too : 
copious depletion, by floodings, and by a residence ; 
in low, cold, and humid localities. Nervous I 
headach is common to females during the cata- ; 
mcnia, especially when excessive or too frequent. 
It is often, also, indirectly caused by intoxicating 
liquors. IIeimmann very justly notice.s it, as ar 
not infrequent attendant upon general a/itrmm, 
resulting from disease or improper treatment. 1 j 
believe that some degree of celehral anttmia very ' 
often attends, if it does not produce, this variety 
of headach. 

1 1. i3. Nervous headach is often sudden in its 
attack and termination ; is frequently acute, ex- 
cruciating, lancinating or darting; sometimes con- ' 
strictive, or attended by a sensation of the temples 
being pressed together ; occasionally accompanied 
with voitigo, a feeling of sinking and dieud of 
falling, or with great nervous agitation or restless- 
ness, and sometimes conhned or limited to a 
narrow space. '1 he patient is incapable of i houg ht 
and of physical and mental exertion. The si^ht 
is often dim or impaired ; dark spots or meshes 
moving before the eyes. In some instances the 
eyes become sunk, and the countenance de^>res.sed ' 
or collapsed. The pulse is small, occasionally 
frequent, but generally languid, and always com- j 
pressible. The pulsation of the caiotids is small 
or weak. 1 he head is cool, ar.d the fiice more 
pallid than natural. The stomach is liable to 
disonler, especially to acidity and flatulence, and 
the bowels arc often costive. This headach is 
frequently worse in the morning and through the 
day, and abates in the evening. During severe 
attacks, wakefulness, dizziness, loss of memory, 
general susceptibility of the nervous system, &c. are 
usually complained of. 

12,ii. Congestive Hvadacii. — The state of the 
circulation within the head \ the manner in which 



the blood is returned from the brain ; the partiil 
protection of the parts contained in the ciaoiiua 
from the physical influences exerted upon the rat 
of the general surface ; and the periodical changn 
in the position of the head, and io the exerciie of 
the functions of the brain, would »eem, on t n* 
pcrflcial view, to favour the occurrence of coo- 
gestion io this part. Yet, if these circumstancii 
be more closely contemplated, there is at kaik 
equal evidence, that they essentially tend it 
preserve the brain from pa.'*sive congestion ontU 
one hand, and inflammatory deteimiQatioD oaihs 
other, as well as from the more serious contiogn- 
cies consequent upon that minute division of tkt 
extreme vessels required for tlie exerciM of tht 
various cerebral functions. The congestion oc- 
casioning this form of headach is seldom general, 
but commoniy limited to. or seated chiefly in,oaa 
hemisphere or lobe of the brain, or one or Don 
lobes, either in their vertical or basilar aspect. 

13. A, Causes. — Congestive headach is prodand 
by pre-existent disorder, especially by repetid 
attacks of nervous or dyspeptic headach, and of 
active determination of blood to the braio. ll 
often follows adynamic fevers, phrenitis, coa- 
gestions of the lungs, and impeded circulatiQa 
riirough the heart; and it is not infreqwolif 
caused by the circum'^tances that sometimes gin 
rise to nervous headach, particularly the depm* 
sing passions, cold and humidity, miasDiti, 
noxious gases, mephitic vapours, and crowdrf 
rooms. The use of opium, belladonna, acooiiia, 
and other narcotics, occasionally also producoid 
especially in certain idiosyncrasies, or in lai|i 
do-cs. 1 ight neckcloths, stooping, and a too loir 
position of the head during sleep, also occaii<nitt 
'Ihe heada.'hs following the inordinate nae of 
intoxicating liquors are to be referred to this aid 
tile preceding variety, rather than to disorder of 
the digestive organs or any other pathological 
st;itc. i*rolu!iged or intense mental occupaiioa 
often gives rise to congestive headach ; the repeatid 
or continued determination of blood to the braia, 
thereby produced, passing into congestion, owiB| 
to exhaustion of nervous power; and this fWi, 
if allowed to continue, or frequently prodnccdt 
often terminates in apoplexy or palsy, i his variety 
is most fre(|uently observed in persons advanctd 
in life, and in those who ha\e exhausted their 
vital enerj;ies and injured their con>titution3 by 
di>sipalion or intemperance. 

14. B. The mo^t characteristic «i/mp(omf of tlui 
variety are — the dull, giavativc pain, and senseof 
weight in the heal ; frequently stupor, heavioeB* 
or giddiness ; dimness of sight; buzzing, ringiofi 
or humming noises in the ears; ami hcavinewor 
pallor of the countenance. The pain is often 
referied to one part of the head chiefly, pn^ 
bably owin<; to the congestion being greater ffl 
one pait than in another (§ 12.). The patient 
experiences great increa-H} of vertigo when 
looking up, or when stooping or looking down 
from an eminence; he sometimes complamsofa 
sense of coldness in the head, of fatigue or prostra- 
tion of strcnicth, cohlness of the extremities, and 
of susccptibifity of the nervous system. Sleep il 
often sound, heavy or snoring ; occasionally ttii 
disturbed or restless, and attended by dreams, or 
by convulsive movements. The spirits are do- 
pressed, or almost hypochondriacal. The puhi 
19 languid, weak, or small, occasioDally accele- 



148 H£ADACH — Intermiitznt — Hypochondsiacal. 



matic inflammation of one or both eyes. It is 
generally aggravated in the evening, and alle- 
viated in the morning, and by wanntn. There is 
no increase of the temperature of the scalp, or 
augmented action of the arteries of the head, 



semble neuralgia. Indeed, intermittent headach 
and neuralgic affections almost insensibly pus 
into each other ; the paroxysms of the latter 
being, however, much more intense and of 
shorter duration than those of the latter ; and 



unless the affection be complicated with excited ■ they both frequently proceed from the same pic- 

vascular acUon in the internal membranes. If it I disposing and exciting causes, namely, disorder 

be thus complicated, these symptoms are also .of the stomach, bowels, and biliary organs, and 

present; and, as Dr. Elliotson justly observes, | exposure to malaria, or to cold damp winds, &e. 

there are likewise giddiness, drowsiness, and in- 33. ix Hysterical and Sympathetic Heao- 

temal throbbings. This associated disorder is sel- acii. — The pain in the head is one of the os- 

dom ameliorates) by warmth ; and the face is often ; merous forms in which hysteria manifests itidf. 

flushed, the eyes injected, and the vessels loaded. It is generally limited to a small space, or to a 

31. B, Arthritic Headach is met with in per- single spot ; and is often described as resembling 

sons who are subject to the irregular forms of , a wedge or nail driven into the cranium or prai- 

gout ; and, in those who have an hereditary or ! ing upon the brain — Ciuvus, &c. It is cooi- 

an acquired predisposition to this malady, it may monly sympathetic of irritation of the uteriat 

be the first manifestation of the gouty affection, organs, and associated with irregularity of ths 

Of this I have seen more than one instance, both ' uterine discharge — with painful, scanty, or ei* 

in males, and in females about the change of life. ' cessive menstruation, or with leucorrhoea; sod 

It is not an unusual form of misplaced or of re- with flatulent borborygmi, or with the globus hj- 

trocedent gout, in persons who have had the stericus. I have seen it also connected with wsrw 

disease in its more regular form**', but who ne- . in the intestines, with the irritation of calculi in tbs 

gleet the air, exercise, and regimen necessary to kidneYs,and with tenderness, and other indieatioBS 

the developemcnt of a re^lar paroxism ; and it . of inflammatory irritation, of parts of the spiaal 

is often a aangerous affection. '1 he pain is severe, : chord and membranes. — Indeed, affectioos rf 

and attended by a sense of fulness and of heat or ! the spine seldom exist without pain in the besd, 

burning in the head ; by remarkable tenderness, \ in some one of its forms, being occasionally felt 

and by increased heat of the scalp ; by giddiness I 34. x. Hypochondriacal. Headach. — raiaof 

dimness of sight, and fear of approaching insensi- I the head is often one of the most dbtres^og i^ii* 

bility, especially upon stooping ; by sounds in t)ie ! ptoms of which hypochondriacal and melaocMGE 

ears, great acuteness of hearing, and intolerance > persons complain, and is exaggerated bythemiflli 

of not^es ; by flushes of heat in the face ; by ! the most intense suffering that can be imaginsd; 

irritability of temper and restlessness ; and by j and yet, when heir attention is directed to odw 

confusion of thought and loss of memory. 1'here objects of interest, or when they are oUi0> 



are also flatulence and disordered digestion ; . wise excited, this part of their miseries 

costiveness ; a morbid state of the stools, and of altogether forgotten, or for the time removiL 

the biliary secretion ; and scanty high-coloured Their minds brood upon the cause and coaN- 

urine, which deposits a copious reddish sediment. , quences of the pains referred to this sitaatiMt 

The ton^c is generally loaded, and its papill» until they firmly believe the very worst resnlt>« 

excited; and the pulse is eitlicr natural, as to A patient, some time since, called upon me to 

frequency, and full, or accelerated and hard, or know whether or not I considered the paio (• 

oppressed. If this affection is not removed, it depend upon organic change ; and, although ■! 

may pass into effusion, with comatose or apo- opinion was that this was not the source of ihl 

plectic symptoms. (See Gout — Irregular Forms affection, yet several visits were afterwards flttdl 

of, $ 16.) to me with the same object. Another mon 

32. viii. Intermittf.nt Headach — Cfpha- recently came under my care, with the Sm 

lalgia Periodica t Avicionim — Febris Intermittens belief that the headach would terminate in ia- 

eephalica larcata, J.Frank — usually presents sanity or idiot ism. Such cases are, however, Mt 

the same characters as the functional varieties rare ; and although the fears, which subseqoaidj 

already described, especially the nervous and become the firm convictions, of the patient, an 

dyspeptic, and differs from them only in respect fulfilled in some instances, or even impel then to 

of periodicity. But it may be not merely func- suicide in others, yet recovery is not infrequently 

tional ; for the pain caused by chronic inflamma- effected by judicious treatment and managesBeiiL 

tion of the membranes, or even by organic lesion The source and character of the pain m sndi 

within the cranium, may assume, at their early cases are ascertained with difficulty, as the pt* 

stages an intermittent type. A strict investiga- tients' accounts are often exaggerated ; but an 

tion of the causes, and of the states of the various most frequently dependant, as far as I have ob> 

functions, is therefore requisite to a knowledge of served, upon the state of the nervous system, ■ 

the natyre of the affection. When the headach connection with chronic disorder of the digodit, 

proceeds from terrestrial exhalations, or from cold, canal and biliary organs. The organic oerroM 

raw, easterly or northfrly winds, and attacks per- energy is manifestly impaired, and all the fbae- 

sons who have been affected with agues or remit- tions which chiefly depend upon it. Bat I ban 

tent fevers, it generally returns daily, either in seen cases furnishing evidence of congestioo» « 

the morning or about noon ; but it may observe of chronic inflammatory' action, of the brain or sf 

a tertian or quartan form. It is often limited to its membranes, and have found a treatment busd 

a particular part of the head, — frequently to the on this view more or less beneficial, 

forehead, or to one brow, or to the brow and | 35. xi. Of Hemicrama, and Partial jjiv 

orbit — brow-ague. It is sometimes seated in Nmhaigtc Headachs. — These can scarcely W 






one half of the head. The pain is occasionally so i considered as distinct varieties of headacht 
severe and so limited in extent, as closely to re« much as the pains proceeding from the patholr 



150 IIEADACH — Treatment. 

moved by mild or stomachic purgatives, which exercise in the open air; will prove mostierrice* 
should afterwards be prescribed occasionally, in able. Local bloodletting will leldom be re- 
conjunction with deobstruents, in order to pre- quired, even in small quantity; blisten bebinl 
servo the excreting functions in a state of healthy the ears will be productive of benefit, in logM 
activity. Whilst the head ought not to be kept cases; and the eflTusionof tepid water onthe beid, 
too warm, the impression of cold must be pre- in others. As the patients strength improve, 
vented, at least until the organic functions have cold sponging the head or the shower batn, lai 
acquired their usual tune. In most instances, friction of the scalp, will be useful in preventiM 
the milder tonics may be given, with the alkaline a return of the affection. Where there is mnci 
subcarbonatcs, or the aromatic spirit of ammonia, irritability, the combination of hyoscyamns, or rf 
and with carminatives. The diet should be light small doses of the powder or extract of bellt* 
and nourishing, the occasional cause? avoided, donna, with the medicines just named, and strict 
and gentle exercise in the open air daily taken, attention to diet, air, and exercise, will genenJl| 
In slight cases, these means, and a due regu- l>e found of advantage. 

lation of the digestive functions, will remove the 42. 6. When this form of hcadach affecti Mr- 
disorder ; but, if they fail, those about to be sons whose vital powers have been exhaoited bj 
noticed should be resorted to. dissipation and unrestrained indulgences, or than 

40. Nervous headach may prove obstinate, of a Icucophlegmalic habit of body, the treatnol 
or it may be unu<%ually violent from the com- should be still more lestorative, tonic, or stimn* 
mcncement, or gradually become so. If, in these lant than the foregoing ($41.). Even lool 
cases, the sym|)toros, especially those connected depletions will be iniurious, and the cold af* 
with the organic functions, the senses and cere- fusion on the head will be of little service, voImi 
bral manifestations, evince neither vascular ac- the affection has followed the use of narcotics, or 
tion nor organic lesion within the cranium, tonics when the head is hot. Cordial stomachic apo- 
conjoined with anodynes, antispasnioiiics, or car- rients, warm spiced wine, or coffee ; the prepay 
minatives, according to the peculiarities of the atiuns of ammonia, or of camphor, or of valenaii 
case, should be resorted to. The preparations of or of arnica, &c.; stimulating pediluvia; tad 
cinchona, of valerian, of arnica, of assafuetida, blisters behind the ears, or on the templei, or 
and of ammonia ; camphor in full doses ; the ! even on the head, in extreme cases; are amongil 
aethers ; the carbonate of iron, the nitrate of the most appropriate remedies in cases of tUi 
silver, 6cc., are then severally indicated, and kind. After these have relieved the more & 
may be given with opium, or with the acetate or tressing symptoms, the complete removal of thi 
muriate of morphia, or with hyoscyamus, or with I disorder, and the prevention of a return of it,iBi9 
belladonna, according; to circumstances. If there | be attempted, by promoting the digesUve, IH 
be prolonged watchfulness, a suitable narcotic ; assimilating, and the excreting functions ; by di 
should be exhibited at, or shortly before, bed- ; use of tonics — of the preparations of bavk or rf 
time. I have found the following medicines of i iron ; and by mild chalybeate and Crated nuM* 
great benefit in some very severe cases of this ral water;:, liut, before these are prescribed, ik 
kind, the pills (No. 245.) liaving been taken, in secretions and excretions should be freely evaei- 
addition to the mixture (No. 246.)i during the ; ated, and their morbid states corrected, by tlta^ 
violence of the attack. An increased dose of the alives and mild purgatives (F. 205. 266l43(l)i 
pills, or the anodyne <lraught, may also be given - And, during the course of restorative medidoei, 
at night. FormuliE 24, 25. 36. 269. 3<)7. 423. these should be frequently resorted to. The 6c- 
539. 555. prescribed in the Appendix, also, may titious mineral waters of Carlsbad, MarieDb&d,« 
prove useful in this variety of headach. of Pyrmont or Spa, subsequently may be cii- 

Na 245. R Camphora? ras.r gr. xij— xviij. ; Extracii ^'O^^lv tried ; but those of Seidschutz or Poll* 
HyoMcyami 3 m. j Conscrv. liosaruin q. s. ut fiant Piluloc should, in many cases, precede the use of tbeie. 
Xij., quorum capiat dua», quarta vol qumta qiiaquc liora. 4*^ - Whon onnfrocfit.a k<i«/i.^l. «»«..« m 

No <i4fi. H InfuM Valefianaj 3x.: &xlajSul>. carbon- ,. ^'^\ ^' V ^'^^ congestive headach OCCUTl m 
ati« gr. xij. ; Spirituji Aminotiiie fu?tid. 5j. ; Spiritus '"^ plethonc, the mdolent, and well-fed ; B 
Lavand Coinp. Il] xx. ; Tinct. Aumntii Co. 3j. M. persons about or past middle age, or who hart 
Fiat Haustus qnartiB, quintis vel scxti* horis *unnendu«. ! exuorienccd obstrui-tinn*! of thp lHor *xr nf^nvf. 

No. 247. R yuinlna; Sulphatis, Camphora- ra*a«, aa ^'^P^"*-"^*'" **0*'"y^"«ns Ol inellver,or Of anjtfr 

5r. X. ; Extr. AUnit. purif. gr. xij. ; Extr. Hvoscyami 3 m.; Customed evacuaUon ; the treatment should be TOI 

fuciiag. Acacia? q.i. M. Fiant Pilula> xxiv., quarum different from the above. General or local Woo* 

capiat unam, vel dual, vel trw, bw terve m die. i »»• .k /r • r u . i i j 

• „ _ . ,, . , , , , , letting, the affusion of cold water on the head, 

41. B. Congestive Headach should be treated bri^k cathartics, and derivation to the extremilia 




^ , , -_ ^ rnfuliri* 

jjeded return of blood by the veins and sinuses, is promoted. A daily recourse to 'tte~ shower ' ' 
msutficient for the due performance of the several ; will prove of great service. 



functions of this part of the frame. — a. In 
delicate or irritalde j)ersons, stomachic or mild 
purgatives, tepid or cold sponging the head with 



44. d. AVhen this form of headach proceed 
from prolonged or intense mental applicatioac 
exertion, not only should the above means I 



fluids containing aromatic and fragrant sub- adopted, according to the age, strength, habit 

stances, as lavender or Cologne water; deriva- body, and modes of living of the patient; b 

tives, especially warm or stimulating pediluvia; entire relaxation of the mind, change or s 

the internal exhibition of camphor,ammonia, vale- travelling, the amusements of watering placi 

liw, genUe tonics, &c.; light diet, and moderate sea-voyaging, early hours, light lading t 



154 



HEADACH — Remedies becommbnoeo by Authors. 



tic seizare, and hemiplegia, — c. Belladonna has 
been used in somewhat similar cases to those for 
which the aconitum has been exhibited. The 
extract, or the powder of the root or of the leaves, 
may be given, either alone, or with camphor, or 
an aromatic. I prescribed it in a case of hy- 
pochondriacal headach, with much benefit. — 
d, HjfoscyamvLt has likewise been recommended by 
Stoerck, Renard, and others. 1 have found it 
of great use when combined as just stated, or 
when conjoined with ipecacuanha and some 
stimulating antispasmodic, and given in a de- 
cided dose. — e. Conium was directed by Lett- 
SOM ; the distilled (a ure/-uNiter, by J. Frank; 
and the jyrtusie acid, by Good. Digitalit is con- 
sidered by Fkank as very beneficial in the headach 
proceeding from scrofulous disease. — f, Stra- 
moniwn has been prescribed by several writers. I 
have seen it given with benefit. 

57. E. Alterativet are required whenever the 
aflfection of the head appears to depend upon 
a morbid state of the secretions, upon impaired 
action of the chief excreting viscera, or upon an 
impure state of the circulating fluids. — a. Of 
these, mercurials are the most active, and most 
generally used, both internally and externally, 
for this complaint. Calomel was prescribed largely 
by WsPFER, Velscuius, Bang, &c. It is most 
serviceable when the headach depends upon ac- 
cumulations or obstructions of the bile, and a 
torpid state of the bowels, and when conjoined 
with, or followed by, other purgatives. In the 
rheumatic form it is advantageously conjoined 
with antimony and opium. The blue pill may be 
prescribed on similar occasions, and in the same 
manner. The bichloride of mercury was pre- 
ferred by Lentin, De Moneta, Van Swiktev, 
and Gmeliv, especially in the headachs depend- 
ing upon organic lesions within the cranium, or 
upon di&ease of the bones. In these, as well as in 
some other cases, it may be pre«cribcd in a tonic 
tincture or decoction. The iodide of mercurif may 
be used in similar circumstances. Mercurials 
were pushed to salivation by Willis, Lentin, 
NiicK, Banc, Darwin, and Blane; but this 
effect is rarely required unless when the pain 
resists all other means, or proceeds from a syphil- 
itic taint. — 6. Alkalies, particularly the subcar- 
bonatcs of soda or of potash (Thilemus), the 
solution of potash, or BitANrusii's alkaline solu- 
tion, are often of service, when given in tonic or 
aperient infusions or mixtures, and aided by the 
decoction or extract of tararacum. — c. An 
infusion of two or three drachms of the clematis 
vitalba, in a pint of boiling water, was recom- 
mended by Stoerck and Mui.ij.k, to be taken in 
the twenty-four hours. — d. The decoctions of 
sarsaparilla are more deserving of adoption, and 
may be made the vehicles for the exhibition of 
other medicines which produce an alterative effect, 
as the bichloride of mercury, the hydriodate of 
potash, the alkalies, the extract of taraxacum, &c. 
— e. The alkaline chlorides may be also tried. — 
f. The precipitated sulphur will be found bene- 
ficial in the rheumatic form of the complaint, if 
taken daily in sufficient quantity to exert a gentle 
action on the bowels. — g. The preparations of 
colchicum, when given in small doses, and con- 
joined with magnesia, or with sarsaparilla and 
the alkalies, also exert an alterative operation, as 
exphuned above ($ 52.) ; and are of great use in 



the arthritic and rheumatic forma of the aflectioa. 
-— h. Various mineral springs are extremely ier« 
viceable ; but they require to be appropriately 

f prescribed. Those containing iron, fixed air, 
ime, or the alkaline carbonates, are most sutcd 
to the nervous, neuraleic, rheumatic, and dyspep- 
tic varieties ; those holding sulphur, &c., in tw 
rheumatic, arthritic, bilious, hypochondriacal, 
&c. ; and those containing the purgative alts, 
in the bilious, arthritic, hypochondriacal, &c. 

58. F. Derivatives — whether those wbick 
exert an immediate and brief effect, or tfa<M 
which act more slowly but permanently — are of 
great benefit in several forms of headach. -^t. 
To the former class, purgatives may be nid ti 
belong ; as they not only increase secretioii and 
excretion, but also determine the floidi to tlw 
digestive canal. — b, Masticatmries were employed 
for headachs by Celsus, AREXicvs, Forestci, 
MuRALT, and many others ; but they have nov 
fallen into disuse. NeverUieless, they are fre* 
quently of service. — c. The same remark appliei 
to sternutatories, which have been recommended 
by the same writers, and have experienced the 
same fate. The benefit derived from varioM 
cephalic snuffs is undoubt«l, even in cases tint 
have resisted other means; and has led to tkor 
adoption as empirical remedies, in irregular ud 
domestic practice. They are beneficial in eieil* 
ing the olfactory nerves, and thereby the cerebnl 
functions, and in procuring a defluxion from tin 
Schneiderian membrane. — d, Warm pediUtin 
and manuluvia are often resorted to, especially 
when the extremities are cold, or when the pM 
depends upon determination of blood to the head* 
In these circumstances, the addition of mustud 
and of salt to the water will be of service.— <• 
Sinapisms, and stinging with nettles, or tirtttf- 
tions, were employed by the ancients in the treat- 
ment of headach. Celsus, Aret;eus, and others 
directed sinapisms to the head, over the seat of 
pain ; but Themison contended for their applies* 
tion to the lower extremities. — /. Blisters on the 
nape, sometimes on the extremities, are now more 
generally prescribed. — g, Setons and t»»ti«, ia 
these situations, or in the arm, are comrooaly 
recommended in the more obstinate cases of Um 
complaint ; and when the pain is suspected la 
arise from organic lesion. They are prated by 
RiVERius, Zaciti's Lusitanus, Holler, Fa- 
RRicius Hildanus, Heister, PrRMANN, and Di 
IIaen. I have prescribed them in several cam 
with benefit. — h. The tartariicd antimonial citt* 
ment has also been of advantage when applied oa 
the nape of the neck, and its effects on tlie ii- 
teguments fully procured. 

69. G. Topical Means. — a. The applicatioe 
of cold to the head or temples, in various modeh 
has been advised by most writers, when the pain 
proceeds from determination of blood to, or ia- 
flammatoiy action of, the brain or ntembrancff* 
A recourse to the affusion of cold or tepid walef 
on the head ; and the repetition of cither, according 
to the grade of vascular actiofl in it, are often pre- 
ferable to the continued application of great coMt 
which is sometimes productive of mischief. Cokl 
sponging, cold lotions, or epithems, wetting th« 
forehead and temples with ether, or with aromatic 
waters, &c., and the shower bath, are severally 
of benefit, especially in the plethoric or inflav 
matory states of the affection ; but the douche, or 



IGti IIKARING — Impaiied or I.i»t— Patkolocv. 

E"*™^ H»ta, mi. - Vwiiwj^ Di C.ui.« W. ImpairtdoT leil Wrinr. — The jErM of ihm't 

!5SiJ?ibJS;.'W"^iM^J:i V«-^ "«™'^ .mp.o,n«ic, Jd u ob^v«i chidiji. 

ObKrv.lfnlico.Pnn.dn AflkcL CipiiiilnU!iii.ttni«ni. ■tfection o' the bruD, ind m feren (M* ut 

ho. Lond. I'iT^ «rM»>»: HuHum dcr Hrilkundt, «t "notliet place ^«M »rt, £*■, f 2-5; the jtW 

b. i>. p. 17L — nnOmi, (EuTRi Dinntm, L IL IIL — onlv remojiu for diwaMum. 

IMuiaod, ^iM. Aul. MvL 1. 111. obKCT. sa. ri ». _ ine vanoui leuona cauimK dearaen, dti^Uou h 

Airirrite, IiuUiut Hid. pu. lil. p. >i, 15. IS. — V. SMI, tolhe be«t modeoriiupeCtiDK iheeuarenqgired, 

s.va.'si'U'.ffAiifs ?£,""«; "..""I"" "• ^•""! 1— «• b-cmhii,..- 

(rv<(, Workt bf hit Son, p. GW. — Ranor, Art Rrg. 'miticd.tbe diagnosu of BnecUani olthg ninn 

SulMhI, Hi'n. lol III. p. 34S, »tTol. iirp. BU. — Han*, necesMnly be very defective.- 

" — ' — -J- u— — • n— 4 liTB. — ia- tiie """"*'-""- 4...^,.-«. ....... 

ta^Tii 'ibii L irt. p. *3i"— "imi^"ln"iwi t. xiiuL 'he op])miie tiJe, 

p. m — DHwaf''. In 'bli l.lvii^p^.--J. *W*i^ sironglighl reflected inloit.aDd the auridfd 

_■» .^ '"-'.^Mdiich^lii ^.Olim^lBjTOl.^Tj. „g|| upwaids and oulwaidi, whibil Ihe tngna 

_^-^^. — ■%.-.. 1j.. li — i-.i.; ». o... nnuuil n.ii-ranls. The rsji of light iiiij Ihni t» 



I JBOiB HnnicnnUi Nnraur PuU, i:7S.— 7ii- itieraemliruia lymuani caonol be dutiDClIiMti, 

In, JoMft^pMjd^L^vt^Ma-- ^Jg«.Jn,Ibi4 unleu the patieot'ihead be very much iDciiMdlo 

R"nWLlrt.p.M5.-/toMf4, In lUd. t. xiL.IIL the opjiMiie liJe, Ihe ear directed to the niB.oi 

W. — Dmwuj*!, In IWi l.lvii^p^.--J. FiMfr- sirong light reflected into it.aod the aurielfdi 

fjOo Skk HMdKh. Ill Med. ™'^J' "J ™ 'j- well upwaids and oulwauli, whibil Ihe trt|r 
^ JU3.1 una wort*. Mo. p. 5H7. — T- Fcmer, Mbo. He- f . ^.. * i. . ,° 

Dart! on Anenie In Aiut, Periodic Hndiehi, ftr. Svu, prcsaed outwards. 1 he ny> oi light miy Ibi 

EcoiLlTSii. — Jh-arr.H»HBno(itwUtd. SocnfLon. made to fall upon the bottom of the meitiii, 

fi;;;r'i„SJU*VHLir;il':'i'^.:^4«^&ii^ videdthatthee.|einale.rbe„und. Butwb 

lied. CannoiL nLvIlL p. 7, ii.~A.Menn, l^mlbn u the seat of morbid changes, a jpceuJlmi »n 



LvIlL p. 7, ii.~A.Mnin, l^mibn u the seat dI morbid changes, a jpceuJi 
BulD, At — a. Blame, Tiini. tt ■ Sac. for Im- ,\,g ;„ „„\„ ,„ rnniprt Ihp runritum nf Ih* 
■nt «ru»i. KoowlHlje .oL li. p. IW - itoW... •''" ■ ,„ ^, ■ ""*" ""* curraiure oi IM 
*.eMk,CamirAM. age into a straight 




. KliiL la't-a. Ifi. be nearly ruuad, and funnel-shaped, the iuill 

.Min oacU..ll^^.t. or ihP .rm. l-ing blackened, or rendered dia. 



eiunined with the aid of Ik 

speculum, the light of the sua, u recomoicnU 

c .,.^u«»«,. .liMorhiT ^y Dr. KBAiirn, should be preferred; but Ibt 

„ ..!.' Med. aiid Enu. Kshv.,' light n-flecied fram a small mirror maybecB- 

«l. IIL — iMIrr, luHvUml-fJuiimiier Pnct. Hdlk. nloved.* 

i).M.itl>.pLiaL-H'ift'<'irf.)nU-d.l>.aW.atl.MIS<. '4 . „ „. . _ -, 

^ ^ «_-..._.». . ArPnrt.Arsoeiii.li.Cp.ITi.— tehnal E>n. — i. D'litaut nf Ihi Aurirtt, e^ 

"^WS;"!?.*:!'^'^.'^ '■..''. *?;T cially crvsipelatous inflammslion eitendine BiL 



una. nil. >•. nit. in.— inniv, "I '■•IIL or Utd. moie internal pans; . .......u.l.^.^ ..un... ,..- 

Sjl^k''fdidt?KiI?dHHiaii.'K^3i^'8™^^^^ cosionally Ukw place. Dr. KatuEB noiico Ac 

Ms du Cwiiire Aduclle. Naner, IBLI— G»r(rt, likt. ofdeafnesn; but it is veiy rarely wea. 
de »M. t Iv. n 501.— J. Farmtr, OIhit. on ccrlaln 4, ;[ D,,™™ „f ,k, ^..-/.Wri Pb™« isd 

Aaka.oriheHHd,aiMHii.diiclu,l.ina. lAid.ltitt. ,, t" "i™" "? "" '"'""'^J' ri'W'J' •" 

J.Fnui.e^x. Med. Unlverw Ffinepts. I. 11 jilSe.- MrmbraHt of Ihe TymponMin.— All affeclioniof 

W, rai«tu, Eus* on Hndichi. Hvn loud. IBil. — these pans are cither inflammatory, or Ihe ™d«- 

-M^^^ IM^t^^tl^^ll^^^'i^ l"'^"'* "f i"fl»>n"»lion in some one giade »r 

Chord, 3d odlt'i and in J. JOtniM-i Ui'd. Chinirf.Tii!; oiher. allecling one or more of the liuuei in tkji 

ti.w,volaii.tES>i-J..MnMi,lnlbld.«i.Ti.ii.3k situation. The fact is ably suppuritd by D:. 

«t»oLaaiii.p.37a— 0. »'i"Wii-Q)mm*iit.ool>ui.irfthr L-„.„r_ ,,,1,- _„.,i.. ,i.„, .u-iilr .r' I 

Heid.tlTo. Loiul. ]H4-jD^7l»ct,deUM.nt-hiriic>. ^''*"E"p»"'o remarks, that the diliereni lunntol 

Ptm. I. T.— ,r. £UkiiH*, in Lund. HccL Oti. *ul. xL p. «i1. disease (eated in ilie auililory paa^ge dcjwH 

— T^rfw; CjTclo^r ^■"^ji'J'J^ 'W'SlTsSl "'*"'' inflammalion of ihe coruititueal slructura, 

t^^lJ!^ f."^ua !!• .j'ISl _i!^.<. zPL..JI^ and they 



mmiumnuU ckteflt rati,. ^ iraa, nilpiau oTnAuH, ■"'' '""y ^rs charactentlicall 

a*rf£fnbni htUnttBf and ttitTimllf, la kemKratla.)— other strurlure is jflected. - 

«i'ShriV""-™0"ri tbiA ?^M5^?'(fn"'^''Z ''°"-'' "*' ^^^ inflammations can hardly be « 

lliid. p.3» ' R.Caniiir'hael,iu itublin latin. •<( MhI, sidered separate Bt»i" nf ili.oa.» i.ni— . ili 



-Dl.i..p.ai.—«.6rnw»,1n Ibid, wil.iii. 11.131. coalinue after thii inflammation nhicb aaiA 

10* lit ktadacht ^ uaani maKtm.) — li. H. IVraltrr. ,i„,n 1,,. ,i^-„~,„r_l 

fci. ATr«ii«oiiflsl«li.,»r hvo. I^uLiwa- •""" h»» duappenred. 

.^bJ™;, lnLjiimUi:Frui(»iw,Julr, IMJ. 6. A. Lrt/thtmUr injiammatioa <•/ tht «*- 

..^.....L'^ T I 'aril jwiwge generally causes accumulalioos o( 

HEAKIhG — IwpAiari, 0. Lost. brownish fiard wax. OMlructing uK-re or lt» lt« 

CLAsair. — 4. CJuii, 1. Orrfer (CiiJ/m). . 

4. C/«M,a. Ord«- (Uood). lV.Cl.AS», • Writer, on IhodlwM of the e.r^.i.hr» ««(- 

111. OnDEkf^nDinrJ. Mon^ .,l.lK«riou. l.i.tniment., each ftnd.nf ftultjA 

1. These di«»9c of the organ of hearing «?t^?SS5l.^5;^^hrS.m"i "ch uTJI^T^ 

which are not Dcceturil; attended by impaired hn cDiitrmporuin. in Uiii, howCTR, the dnpHid • 

function, were consideted under the article Ear. ™n u^r^hefr JlSSil'MlJciiSt/iSi'iw 

Attblanlace, therefore, diminution, or loSAof hear, hai not been thus dEih^uhiBdi'l.belaBc id ihc^ 

inir — biaf'iiiu —will be considered with refer- "ifii<"r. ■■IbejareniiwaniiinotenttrriiFtoaHsiiil* 

unpp In iSc In^nni which usuallv orrMion ii *•" ■*;«' "f 'hrtr iiloptlon, and cilnce the ulnio« r» 

Mice 10 trie lesions wnicn usually occasion ii, rour i«iho« i.lio.tienij4toei«;roMhontli*iniiii»H" 

and to appropnate IreatmenL 1 lie disorders of VeiHy.oTill «ni|diln, ihtrtfularln miicctef fuBIia- 

beariDg may be divided into — Ist, Eiallalian "''",'' I";* rnoti uncompromiiini, uid the hI ^ 

o/lUf««-i-2d,Depfww«umaf Wring;— 3d, |[™^« '»"•*"'•«•'*««" the eh«.rt.r o( tht f- 



160 



HEARING — Dbavness rnou Affection op Acditort Nkrvci. 



ease in its varioos forms, are fully described in 
the article Ear (see § 14. et ieq.). As deafness 
resulting from yurulent otorrhceat with perforation 
of the membrane of the tympanum, or from </a- 
Junction or lost of the tmall bone* of the ear, or 
from cariet of the otteout structure, belong to the 
more chronic states of otitis, and is discussed in 
the article just referred to (art. Ear, § 19, et ieq., 
and 28. et »eq.), it is unnecessary to recur to the 
subject at this place. 

24. C. Deajneu matf arise from extravasation 
of Mood in the eavitit of the drum. — This lesion 
is usually the result of external injury, of violent 
attacks of sneezing, or of constriction of the neck ; 
but it is chiefly caused by the first of these. In 
cases of this kind, Sir A. Cooplr advised per- 
foration of the membrane ; but the eztravasated 
fluid will either pass off* by the Eustachian tube, or 
be absorbed. Aloreovcr, the deafness and other 
unfavourable symptoms exbting in these cases, 
are not so much dependtnt upon the extravasa- 
tion in the cavity of the ear, as upon the injury 
other parts of the organ, or even the brain and its 
membranes, may have sustained. When, how- 
ever, blood is erased in the drum, inflammatory 
action not infreq 'ently supervenes. 

25. III. Deafnkss from Affkctions of the 
AuDiiOKY Nerves. — Nervous Deafness. — We 
can seMom arrive at just conclusions respecting 
deafness from this cause derived from direct phe- 
nomena* We can infer it on\v from the absence 
of those deviations from the healthy state that 
have already passed under consideration. When, 
in connection with the absence of tiiese lesions, 
ascertained by a minute examination, and by 
having recourse to the air-dauchc, there are in- 
dications of disease within the cranium, or of 
some other malady with which the organ of hear- 
ing may be presumed to sympathise, then the 
existence of deafness from an affection of the 
auditory nerves may be considered as probable. 
In such cases, ti'ere is impaired or lost hearing, 
without any organic deviation in the ear ; the 
lesion being either in the nerves, in their ex- 
pansions in the labyrinth, or in their course 
thither, or in the brain at or near their origins. 
It is always difficult, freciuently impossible, to 
detennine the situation of the lesion ; and still 
more so to ascertain whether the lesion consist of 
simply impaired or lost function of the nerves, or 
of interrupted action, owing to extraneous influ- 
ences or mo bid productions in their vicinity. In 
all cases, however, the absence of organic cliange 
in the car itself should be previously made out. 
Dr. Kramer states that most writers on the dis- 
eases of the ear — that Saunders, Swan, Len- 
TiN, Beck, VsRiNOf J. Frank, and Saissy, have 
been incapable of determining this preliminary 
part of the investigation ; that Curtis, Steven- 
son, and Wright are still worse authorities ; and 
that Itard and Delk.vu are alone deserving of 
any confidence. Having consulted with M. 
Itard, and fretiuently referred to his writings, 
I can bear testimony to his science and candour, 
and to the great value of his contributions to this 
departirent of medical knowledge. 

26. Dr. Kramer, with much of the spirit of 
the craft, but also with the science of the phy- 
sician, severely criticises the writings of his con- 
temporaries; rejects the distinctions of Itard, 
which, however, appear to nie more scientific 



and correct than his own ; and proposes t novel 
division of nervous deafness, and a new mode of 
treatment. He divides it into two form*, —the 
one attended by excitement or erethism — the 
other by torpor. Noise in the ears is alwtyi 
present in the former, but never in the litter. 
This sjmptom is often, however, attendant on 
very different diseases of the ear, but in a very 
indeterminate and inconstant manner. To de- 
termine, therefore, whether deafness with noiw 
in the ear proceeds from disease in the organ, or 
from nervous affection merely, minute inve^ 
tigation and the means of diagnosis already mn- 
tioned must be had recourse to. But these in 
also requisite in the torpid form of nervoui dei^ 
ness. Mr. Swan believes, that many cniei, 
usually imputed to palsy of the anditory nerve, 
are occasioned by chronic thickening of the 
membrane lining the cavity of the tympanno, 
involving the small branches of nerves in tin 
situation. This is not improbable; and,adnut- 
ting it to obtain. Dr. Kramer's mode of dii- 
gpiosis will not always succeed, nor detennim 
the existence or absence of true nervous deafoen. 
On this subject, the views of M. Itard are mora 
pathological, and less empirical, than those of 
Dr. Kramer ; and therefore, in the few observ- 
ations 1 have still to offer, I shall chiefly foUov 
him. 

27. A. Deafness may proceed from eomp r tmit 
of the auditory nerve. — In roost instances, htm' 
ever, this source of the affection cannot be icci- 
rately determined. A tumour may be developed, 
or purulent formations, or extravasated blood, 
may exist, in the course, or in the vicinity, or , 
near the origin, of the seventh pair of nerves, in- 
terrupting the passage of impressions made oa 
the organ to the sensorium ; but this conditiea 
often can be only surmised. Duverney ind 
Sandifort found these nerves pressed upon by 
tumours; and Severinus observed them lor- 
rounded by serum and effused blood. — If the 
tumour or morbid collection be considenblOi 
then the extenstion of paralysis to the nerves of 
vision and of smell may favour the conjecture. 
BoNfrr mentions a case in which heartng and 
sight were lost, and on dissection a tumour wu 
found pressing on the nerves of these senses. 
TiiouANN records a similar instance to this. 
Itard found, in a man who had lost the hearing 
in the left ear, !>mall tumours lying on the coi^ 
responding side of the cerebellum, and neariy 
two ounces of a thick fluid in the ventricle of the 
same side. In cases adduced by Lieutaud, in se- 
veral detailed by Lai.lkmand, and in some seen by 
myself, an abscess had formed in the part of the 
brail adjoining the ear, and, by pressure or conse- 
quent disorganisation, had destroyed the functions 
of the auditory nerve. (See art. Ear, §2l.etteq.) 

28. a. The Symptoms of deafness from com- 
pression of the nerve of hearing are — severe and 
nearly constant headach, vertigo, noise in the ean, 
impaired sight, and weaknes<( of the mental facnl- 
tie>, especially of the memory. The progiesBof 
ti>>s afl'ection is geiierallv very slow, although the 
internal disease producing it is ultimately fatil. 
In several instances mentioned by Itard, it con- 
tinued some years without materially affecting 
the general health. In two instances the above 
symptoms continued upwards of fifteen yean. I 
also have known ca^is nearly as long protracted 



I 






164 



HEART AND PERICARDIUM — Diseibes or. 



BAnmouw, HorriiANN, and Michaxlxs, advised 
warmvapoun, containinff various stimulating sub- 
ttanees, as camphor, ether, &c., to be directed 
intp the meatus. These, however, require much 
caotion and discrimination ; but they may some- ' 
times be of service, especially in catarrhal affec- ' 
tions of the ear, and in idiopathic nervous deaf- | 
ness. Dr. Khamer undervalues these and other 
means, in •order to enhance his own remedy 
(J 45.). 

45. £. li^ftiont into tlu Etutachian tube were 
first recommended by Guizot; but Cllland, in 
1731, ficBt proposed them in a practicable mode, 
namelyv by the nose ; and Watiisn lon^ aAer- 
wards pr»ved:that a favourable result might be 
obtained from the practice. The injection of 
floids into >the 4ube was ud vised by Busson and 
others, to be performed by filling the mouth wih 
the fl«id.; and, having^ firmly ckued the lips and 
nose, by forcing it into the tube. — Air has also 
been directed to be forced into the tube, by 
CLKLAifD and Sims, in the same way, in order 
to remove obstructions of it ; and the smoke of 
tobacco has been similarly used, with the inten- 
tion both-of removing -obstruction, and of exciting 
the organ, in nervous deafness, but with very 
equivocal results : 1 know one instance in which 
it proved decidedly injurious. Injections of 
ineaicated fluids, of vapour, and of air, into the 
Eustachian tube, by means of a suitable appa- 
ratus, have been severally resorted to by Itakd, 
DsLEAV, and Kramer. — Besides injecting air as 
a means of diagnosis. Dr. Kramer throws into 
the tube, through ra catheter introduced into it, 
the vapour o( acetous aether, generated in a proper 
apparatus, at a summer temperature ; but confines 
the practice to cases of nervous deafne>-s charac- 
terised by torpor, or those unattended by noises 
in the ear. He also aids the local means by 
remedies intended to improve the constituliun, 
and the digestive and other functions. 

46. F. iiuuian: Vapour Baths have been much 
recommended in 'deafne<«s, eivpccially witcn it has 
been supposed to originate in exposure to cold ; 
and warm, OTJ'^migatingt or sulphur bath*, have 
likewise been employed in these and other cir- 
cumstances of the affection. Thov may all prove 
injurious in cases connected with conges^tion in 
the head or ears, or with general plethori. 'J hey 
are most serviceable when constitutional com- 
plaints — especially chronic cutaneous eruptions, or 
an obstinately haish and unper^pirable state of the 
general surface — are associated with the deafness ; 
this latter probably depending in part upon a 
somewhat similar state of the ears to that of the 
skin and general system. In these cases they I 
should be cautiously employed, vascular deter- 
minations- to -the head or to the ears having been - 
previously removed, and morbid secretions and 
excretions freely evacuated. 

BiBLioo. AND Rbvbb. — Ceisus, I« vi. c. 7., I. rii. c. 8.— 
Seveniuu, DcRecond. AlMcesx. Nat L iv. c. .Od*— 5^1- 
viiM, P^sx. Med. L ii. c. 8. — ZacHtvs J.uiitanHs, Prax. 
Aduirsb* >• *• o^- 70. — Vatgrtlra, I)c Aurc Humaina, 4to. 
VeneL 1740. — EttmUtter, Open, t ii. p. lilH. — Dirmer' 
hronk, Anat. I. iii. r. 18. — RuiQnd, Curat Kmpir. 
cent ^lii. .c. 55..t— i^tTiM/i Setmlchretum, ftc 1. i. a. xix. 
oba. \. ft $fq. ^ iMtre, in Hvt de I'Acad. des Scicncva, 
1705, p. 53 — Ut^imann, Med. Rat Syst. t iv. |Mir. iv. c fi. 
— a^mU, In Phil. Trant. Nn 461. — Lesckevin, Mdm. 
pour le Prix de I'Acad. de Chinirg. t \x. — Dupemcy, 
l)e OfRano Atutitun, par. iL ct iii. passim. — ytor^agni, 
DeSed. tt Caut. Morb. Ejn iv. K 11., Ko. vi. 4^, Ep. vii. u., i 
Ep. xlviil. 48. — Arffnn, in Holer's l>isfl. Chirurg. t ii. ' 
Vo.^i.^Lieutaud, llict Anat Meil. L iii ol». 128.— 



Stoerck, Liball. d« Ocuta .^ecnad. p. S3L — flUbr, Bi. 
naeot Ph v*iol. t v. p. S36. — 5toAL Rat Med. pw. iL 
p. 397. — Sandwort, OtMcnr. Anat PsttioL L i. pi 11&- 
TViU-a df KrtiotHtx, Hiatoiia Cophoseot eC BafTtcaic. 
Vindob, 1778.— Z. t'ogei, Beobacht und Untenochnv 
Ho. 30. -- Zenker, Mem. of the Med. Soc of Loud. voL iii. 
p. 540. — llafgktoa, in Ibid. voL ilL pi 1. — Sou, In Ibil 
voL i. art 5. — Aekrmumn, In Kliniicli. Ann. voa Jm, 
p. 9^^DesiNOH(ettMe, Traiti des BlaL des Ycux it da 
Oreillet, 8vo. Paris, 17S6. — >f. Scarpa, Ue Anditii ct 
Olfactu. fol. Peru, l78».— C F. L. WUdberg, Vcnocb 
eiticr Abhandlungi ueber die OchftwerkacuK lia 
JuHA, riiih.-^A. Portai^ Coun d'Anat MMiaAe^tlv. 
p. 47u. — Dcsautl, Sur Ic* Mai. V^nerji. VUL — Lam^ 
in Joum. de Mtkl. t Ixxxi. pi .346. — Zetwfl, In IImL L r. 
p. S25i. — i«. Monro, Three Treat on tbe Bnin, Uw 
Eye, ami the Kar. Lcind. VKTi.^A. Coemer, in FUhi. 
Tranx. for IHOU, jx t art 8., and fbr 18oL — Tkamum, 
Annaleii ad 1800, p. 40L -^-FcreuMon, In Med. and nk 
Joum. Mar. iSOii— Hatken, in Philos. IWml voL x£ 
par. i. p. 21.1— Trcvira»mt, in Horn** Aichiv. b. UL pi IK 
— C. E. Fiecker, Abliamll. vom Krebw des Ohm, 4lo. 
Luencb. IKOi. — C F. B. EtlmUlter, Von den Knnkk. 
dea (Mirea, limo. Liib. laUnL — t Y omm tdo t jr , Joan, dff 
Pharmacie, b ix. at ii. p. 136. — 7im^,*De Perfcntiasi 
Tympani, in Goet Ana. 1806, p. MSI.— HmMgnd.Jatn. 
der Pract. Heilk. k xxiv. it iii. p. 16.1L— Naue, ia ML 
t. Kxv. at. iv. p. 164. — J. AT. Aland. Eiaai aur le Catanht 
de n'Oreillp, 8va Par. 1807. — Siamtudr, in Joum. * 
Med. Contin. t ix. pi 106.- P^njiralira, Beinerkunr «■< 
Beobachtung. ueber Gehfir, GenthI, Taubbeit, ke. AL 
tona, 8va 1811. — J. C. Satmdrrs, The Anat and Dk. 
ea«o« of the Ear, Sd ed. 8va Jxmd. 1817. — Moiifafcii^ 
De$longckmmp^ et Marqwt, in Diet dea •rienen lUt 
t xxxviii. Paris, 18ia — Itmrd^ Traitf dct MaL * 
rOreiUe. 8 tomes. 8vo. Paris, 18^1. — J. CVcaL FtaL 
Med. Univerw Prccepta, t iiL p. 88ii. — MTlMm, 
Mtim. sur la Perfor. de la Memb duTympaa 8va Mib 
18^*2.— /.. MWfMT, IMe Krankh. des Ohres und flcMis 
8va LeijM. 18i2a— J. >f. SaUt^, YSanMk nir les MiL* 
rorcillo Interne 8vo. Paris, 18:^7. — HnFelamd, in Kom 
Jnurn. de MM. t xiv. p. ,1— iV. Pimei, Arcbiv. GM* 
M<ki. t vi. p. i47. — J. H. Beck, Krankht-iten d. GM^ 
organs. 8vo. Meidelb. 1827. — Af. Dctcmu, Hiva. iwit 
Cathcritiiinic de la Trompe d* Eusiache. 8vo. Paris, VBL 
— ./. jffvrfir, in Cyck>p. of Prart. Med. vol. ilL— W. in- 
mcr. Die Erkeiintniss und Heilung der Ohrenkmbrltia 
8va. Beriin. IhiVx — Rev. in Bnt and For. Med. Ia 
No. V. p. 79. — A. TurnhutI, Treat, on PainAil and Kbtt. 
nus l>is., und on^ those of the Eye and Ear, 8vo. hwL 
1837 — iSce also Uisuou. and licraiL of art £*a.] 

HEART AND PERICARDIUM — Diswin 
OF THE. — S\N. Kap)i«, Xiaf, X?p, Gr. Or, 
Lat. DasHen,GfiTm. Corur, Fr. Cunrs, lult 
nipjxapJicr, Gr. Pericardium (from nfi, 
around, and xaflU, the heart). Piriearit, 
Fr. Der Ilei'tzheutet, Germ. Pericarfiio,\tkl 
1. 1. IsiRODL'CTonY Ki:.MARK8. — The progrw 
that has been made in the knowledge of dn 
diseases of the heart, may be dated from tbea^ 
p4>arance of the writings of IIartekfels, Boxr, 
ViKvssEux, l.ANCisi, and Rarbeyrac, towudi 
the close of the seventeenth, and at the cob- 
mcncement df the eighteenth, century. Lanqh 
first directed attention to lesions of the valres, 
and to hypertrophy, of the heart, as causes if 
sudden death. JMorcagni, Senac, MiruL, 
JuNCKER, and Spaventi, further advanced oar 
knowledge of these diseases ; but, from the n»^ 
die of the last century, when the work of tha 
last-named writer appeared, until the begioainf 
of the present, when Corvmawt wrote, this dt- 
partment of pathology was completely neglected. 
With Con VIS ART, the recent progress that hu 
liecn made in it may l>e said to have commeoced* 
His work was soon followed by that of A. BciMy 
by the engravings of Haillie, and by the fiai^ 
mcnt of Far RE, in this countiy; and by m 
vvorks of I. Warren, in North America; rf ] 
Tf5ta, in Italy ; of Kretsio, in GermanT; iid 
of Bertin and I^aenkfc, in France. Still noN 
recently, the publications of Loris, AndiaIi 
Williams, Elliotson, Hope, Stoefs, WatsoVi 
I-ATiiAM, CodRioAy, BoiitLAi'D, and th« coa- 



i 



1^ 



HEART— WnoHT and Dimevsions — Sounds. 



mmt as observed by these physiologists. The 
more recent researches of M. Bracket show the 
justness of my views as to the dependence of the 
heart's action upon the ganglial system, and 
which were published twelve years before the 
Appearance of his work upon this system. In 
my publications on this subject, it has been fur- 
ther contended, that irritability does not exist as 
an independent principle, but as one of the vital 
manifestations of this system, exerted througii 
the medium of muscular or fibrous tissues. 

6. B. Such, therefore, being the source of 
the heart's action, the chief seat of action re- 
quires some notice. — I believe that too much 
importance has been attached to the auricles, in 
estimating the motions of the beart ; and that the 
contractile force of these compartments is much 
less than is supposed. From some experiments 
I performed about twenty years ago, I concluded 
that the actions of ^he heart should be referred 
chiefly to the ventricles, and agreed with Ham- 
BERGER in allowing them a dilating power; but 
considered that Dr. Carson pushed thi:} opinion 
too far. I further observed, that if the dilatation 
of the ventricles were a result of a relaxation of 
their parietes merely, the caviUes would not be 
io quickly and perfectly filled by the mechanical 
pressure of the blood as they are ; and dilatation 
would be only the consequence of this pressure, 
and be proportionate to it. But such is not the 
case ; tor, on close observation, the dilatation 
always appears as the cause of the flow of blood. 
The opimon of M. Bouiu.aud nearly agrees with 
the above inferences, published by me in 1824. 
He, however, considers the injecting powers of 
the auricles to contribute to the dilatation of the 
ventricles, and attaches too much importance to 
the elasticity of their muscular parietes in aid- 
ing this action. If the contractions of the auri- 
cles were as energetic as commonly believed, a 
valvular apparatjus would have existed between 
them and the roots of the large vcin». The 
actions of the ventricles should, therefore, be 
viewed in the double light of energetic contrac- 
tion, and active dilatation ; by means of the 
former, the blood is propelled along the arterie;*, 
and, by aid of the latter, it is drawn inio the 
ventricie.«, as well as into the auricles, a current 
from the smaller veins being thus kept up to- 
wards the heart. (See Notes and Appendix to 
M. RicHERAND*s Elements of Physiologiif ^c, 
by the Author.) 

7. ii. Of the Weight and Dimensions of the 
Heart in Health and Disease. — A. It is ob- 
vious that no precise idea can be formed as to 
atrophy and enlargement of this organ, without 
having previously determine'! the dimensions and 
weight of it in health. This M. BoriLLA uu has 
endeavoured to ascertain. The following results 
are abstracts of his researches, and are given in 
the French weights and measures. He considers 
that the common ojunion of the closed hand 
being the size of the heart of the same person is 
very nearly the truth ; and that the opmions of 
Cruveilhier and Lobstein as to the weight 
and size of the healthy organ are neither precise 
nor correct. In fourteen cases — (a) The heart's 
nudium weight was 8 oz., 3 dr. (9 oz. 4 dr.), 
the greatest being 11 oz., and the least 6 oz. 
2 dr., but its weight varies with the' size of the 
person : it alio is less in females than in males. 



The heart cannot be sud to have arrivtd at Sb 
full development until 24 or 25 years of age.— 
(6) The medium circumf'ertnet of tkt ikant, d 
the base of the ventricles, was 8 inches 9 hosi, 
the least being 8 inches, the greatest boar 
10 inches 6 lines. — (r) llie wudium tfctdbun If 
the walls of the left ventricU was .6J lines, tb 
maximum being 8, and the minimum SliMi. 
The medium thickneu of tk$ pariftet «f tkeriAt 
ventricle was 2] lines, the maximum being S|, 
the minimum IJ line. The intsrventntt^ 
partition was 7 lines in thickness. The mtiiam 
thickness of the parietes of the left amri^ ym 
Inline; that of the right, I line. — (i)ll. 
BouiLLAUD confirms the atatement of Luii^ 
LOIS, that the medium capacity of the right taa* 
tricle is somewhat greater than that of the left; 
and that of the right auricle greater than that rf 
the left. — (tf) The circumference ofthsUftem' 
culo-ventricular orifice is about 3 inches 6 Km; 
that of the right, 3 inches 10 lines ; thatof thi 
tentriculo-aortic orifice, 2 inches 5iliMs;tii 
that of the ve/itriculo-pnlmonary orifice, 3 tndba 
7i lines. 

8. fi. Of seven cases of atrophy of the tart 
— (a) The medium weight was 175 grammei(> 
scruples » 7 oz. 2 dr. £ng.) ; the miiiiw 
being 200, the minimum 135 grammes.— (t) 
The diflerent compartments of the organ, ii a 
state of atrophy, generally preserve their niatiii 
dimensions. Sometimes, however, the iieiiBM 
of the ventricles retain their usual thitlriM^ 
chiefly from contracting on themselves and di» 
nishing their capacity. In atrophj, ahob Al 
mean weight of the organ may be much hh 
sened, whilst the dimensions of the whole, « rf 
ceitain compartments of it, may not be aeuihlyi ^ 
or may be only slightly, diminished. -j 

9. C. In hypertrophy of the heart — (a) III := 
mean weight of thirteen cases was 473 gruUMl '^ 
(iicruples) 5 grains ; the maximum being BfM, Z. 
the minimum 338 grammes. — (A) The sMM 
nVcitm/Vrr/tce of the organ was 1 1 inches lOfKaa^ .^ 
the maximum bein^ 12 inches, and the ■■■•-' 
mum 8 inches 10 lines. — (c) The mam (lidt 
ness of the left ventricle was 10^ lines, the 
imum being 1 inch 1 line, the minimum 7 lin 
(d) The mean thickness of the right was 3{ lii 
the maximum being 4 J, the minimum 3 Ui 
The mean thickness of the left and right curie 
was 2^ lines, and 2| lines respectively, — d 
of the interventricular partition being 9^ III 
— (e) The capacity of the left ventricle was gi 
rally more or less increased ; that of the mhK 
was also increased in one third of the cases. ^^ 
three instances the capacity of the venttidhl 
was diminished. — (/)The cirrumfereiueei^ 
left auricula-ventricular orifice was increased i^ 
three cases, in one of them to 4 inches 3 Umi S 
that of the right was augmented in five ifti* 
stances, in one of which it reached 5ii 
9 lines; and that of the ventricuUhpul 
orifice was increased also in five, and 
in one 3 inches 6 lines. 

10. iii. Of the Sounds of the Heart. — lu 
article on Auscultation, I stated the 
opinions as to the sounds of this organ, 
remarked that the subject required faither ilf^ 
vcstigation. Since that time, several aUe ijtj 
quirers have entered upon it, and may be hM 
to have seUled the question. Harvst wkA 




168 



HEART AND PERICARDIUM —Percomion. 



panied by any suck aboormal soQiids, such oc- 
curreQces are extremely rare, and form only the 
exception, and not the rule, as M. Piorry would 
have them to do. It should also be kept it mind 
that the morbid sounds may be produced: by a 
refluent, as well as by an onward, motioQ of the 
blood, as M. Fiuios has contended. 

14. M. BouiLLAun considers that the bellow 
found may proceed from — 1. Narrowing of the 
orifices, with induration of the valves ; — 2. Small- 
ness of the aortic orifice, although the valves are 
quite healthy j--r-3. Polypous exudations, re>uUing: 
from acute inflammation of the endocardium ; — 
4. Irregularity or roughneM of -the surface of the 
valvei, or vegetationn, or calcareous incrustations 
on them ;t-5. Infiltration of the valves from in- 
flammation ; — 6. Adhesions of the auric ulo-vcn- 
iricular valves to the adjacent pa^ietes ; — 7. 
Dilatation of one or more of the heart's orifices, 
with consequent inefiiciency of the valves ; — b. 
liypertrophy, with dilatation of the left ventricles, 
although unattended by narrowing of the orifices ; 
—9. Chlorosis, anemia, and nervous aflcctions of 
the heart, in some instances ; — 10. Extreme debi- 
lity from haemorrhage, or other depressing causes. 
It has been supposed that the bellows sound, 
which is not constant, or is only occasional, in 
the three last circumstances may arise from spasm. 
M.. fiouiLLAUD believes it to depend in these on 
« narrowine of the orifices, to adapt themselves 
to the dimmished quantity of ))lood circulating 
through them. He further considers that all the 
Above cases ate reducible to one common prin- 
ciple, namely, increased friction produced in some 
or them by the direct, in others by the refluent, 
current of the blood ; but most frequently from 
the former cause. From this it is evident — and 
most experienced practitioners must have arrived 
at the bame conclusions, from their own observ- 
ations — that it is impossible to decide, from the 
bellows sound alone, in which of -the orifices, if 
4n any, the lesion is seated. The cO'Cxisteuce of 
4his sound with the systole or diastole, and the 
situation in which it is loudest, may assist the 
■observer, but still no accurate conclusion can 
be formed as to its precise cause. — When tiie 
tawing or rasping sound is heard, the alteration 
may be considered to partake more or less of an 
osseous nature. 

15. C. The suundt prodfUced occasionally bu 
the iurj'acei of the pericardium in a state of 
disease, were overlooked by LAirNNEc, and have 
only recently received attention. It is chiefly 

to COLI.IN, RkYNAUO, IIONOKE, StOKES, WlL- 

LiAMs, Maynk, and Bouii.laud that wc are in- 
debted for observations respecting them. M. 
Bouillavd divides these sounds into three va- 
rieties. — 1st. The rubbing sound, resembles that 
•caused by rubbing together two pieces of silk, or 
of parchment, it is to be distinguished from a 
similar sound produced by the pleura, by its being 
ilouble and synchronous with the heart's action. 
It is most obvious in the systole, and is diflTused 
over a consideiable surface. — 2d. The creaking 
sound, is altogether similar to the creaking of 
leather, or of shoes, or of a saddle. M. Boi'il- 
LAuu remarked it once; M. Andral only once, 
and Dr. Williams in three cases. M. Collin 
and others have also heard it. I have met with 
it in two instances : one of them a boy, about ten 
j^0mn of age; the other a young lady of about 



twenty, who, in 1833, came from BromplM to 
consult me. She had, several months previ- 
ously, experienced an attack of acute pericanlitii; 
and, whilst describing her lymptoms to me,iha 
herself likened the morbid aovod she beard ia tin 

frecordial region to the creakiBg of new shoei. 
heard it distinctly with the una^aiited ear.— 
3d. The seraping sound, u such as may bt 
expected to be produced by nibbing a roogk 
and hard cartilaginous or osseous body agaiart 
the pericardium. Its synchronism with the bmk 
tions of the heart distinguishes it from amilu 
morbid sounds eri^nadng in the pleara. M. 
BouiLLAUD states, that the two first sounds oecir 
only in acute pericarditis. In the two instanni 
I met with, there had exited- the acute fom rf 
this disease ; but it had long before subsided, 
leaving after it organic lesion, or at moat a ckn- 
nic state of inflammation. The friction, or n^ 
biag sound, in its faintest states, oecars is As 
early stages of acute pericarditis, and whilit dN 
membrane is dry. The creaking or leatkifj 
sound seems to arise from thickening or cia- 
densation of the subserous and serous tissuei sf 
the pericardium, especially of the portion ii» 
fleeted over the heart ; and the formation of t 
dense and elastic false membrane, with, perfaapb 
more or less adhesion of the opposite saimk 
The scraping or grating sound is caused bjloMB 
which occur only in the more protracted caiciff 
chronic pericarditis. — When the bellows somI 
is heard in pericarditis, it does not iMiceniii/ 
depend upon this disease, but rather upon m 
coexistence of inflammatory action 4d the io^ 
ternal membrane of the heart, or the esleBsioa of 
it to the fibrous structure of the orifices or of iki 
valves, and the consequent contractioB or oikr 
lesions thereby occasioned. 

16. V. Percussion of the Cardiac Regim U 
best perf(Mrmed with the index finger of the ii* 
employed hand as the medium, or plessiineler. 
In the healthy state, the extent of the dull soaad 
generally varies from an inch and a half to twa 
inches square, which answers precisely to the ex- 
tent to which the heart is disengaged from tha 
lungs. The extent of the dulness increases very 
much in hypertrophy of the orean with or vntib- 
out dilatation of the cavities, in simple dilatatwaa, 
and in congestions of them occurring in varioM 
diseases. It is not unusual to find the dalnea, 
in these circumstances, extending -to five or kx 
inches square. (See art. Auscultation.) 

BiBuou. AMD Rrkrii. — IV. Hatvcff, De Motu ConHf il 
Sang. Circulatione. 4ta P^auk. ]6vK. — J. SmUk, Ki« 
Solomon'f Portraiture of Old Age 8ra Lraod. 160 ^ 
R. Loirer^ I'racUt de Cnrde, item de MoCu ct Coleit 
SdntiuiniK hvo. Lond. 1669.^- A de Vieuuene^ Noofriltf 
DiCfuivcrtet tur le Coeur l.nia Toulouie, 17u&: rt 
Traits Nouv. de la Structure du Coeur. 4Uil TouL I715l- 



IV. Wood, A Mechanical Itlvajr on the Heart 4ta 
178». ^ F. Chirac, De Motu Cordis Advecnria AaalF 
tica. ISina Paris, 17U. — Author, in Lend. Med. Bf«i 
for Mar, 18S2; and Notes and App^ to Richeremft .» 
ments of Phys. &c. u. 611. et snq. Loud. MM. and MB 

— Vatut, in Jouni. Univers. des Sciences 1161 L xsvL 
p. 1(H.— acH^rtN, Archives G^n^r. de MM. L xvL piia 

— W. Stokes, in DubL Joum. of Med. Mcienees, voL& 
p. 5u.. vol. iv. p. Sy.'^ Turner, Trans, of Med. and Cli^ 
urg. Soc. of Edin.vol. iiL p. i»5. — Spitiai, in Edia. Mil 
and Surg. Joum. July, 18»i, p. 132. — CorrUnm,TnM.m 
King's and Queen's Coll. of Phys. Dut>L toL L N. & |i UL 
— X>. niUiamt, in £din. Med. and Sun. Joum. Oct Mfr 

— Pigeaux. Archives G§n^r. de MM. Juil.et Nor. \Vft^ 
Magendie, Lect in Lancet, Feb. 1835. — ArfMm. io IHC 
Sept 1833. —ffonoiM^, Joum. Hebdoin. Na 97.— JImOM 
in Ibid. 1831. — T. Davieg, Lect oo Dis. oTtbe LuMiiia 
Heart, p. 369. — Corlt^. DubL Joura. of Med. SdcMt^ 
VOL iv. p. 84.— C. /. A H'atfame, The PSstholoty andDis- 



170 HEART — Diseases of — Characters and Diagnosis. 

malady, as any other internal part ; and even | life, and yet escape detection after death ; lod 
mare so, as respects rheuinatism, owing to the certain of the changes sometimes obsenred— ei* 



predisposition arLuog out of identity or similarity 
of structure. — 6th. One affection of the heait, 
functional or structural, may occasion another, or 



pecially alterations of colour, fibrinous coagsh 
attached to the valves, &c., and slight effiwoa 
into the pericardium — have either taken pUoi 



an additional lesion. Thus violent palpitations shortly before, or at the period of, dissolatioB, or 
sometimes rupture a muscular column, or tendon, even soon after this issue, 
of the valves, or even the parietes of the heart ! 24. Altliough most of the affections tad 
itself ; and narrowing of an orifice occasions di- lesions of the heart are to be imputed chiefly is 
latation of the cavity behind it, &c. I inflammatory action and its consequences, vuied 

21. Whilst CoHvtsART and Schina have at- by the conditions alluded to, yet they ire not 
tached the greatest share of importance to moral | altogether of this nature, or do not always origia- 
causes in the production of cardiac diseases, and , ate in this way. We have seen above (f 5.), 
undervalued the influence of physical agents, M. that this organ derives its energies chiefly fram 
BouiLLAUO has over-estimated the latter, at the | the ganglial nervous system ; it must, tho^on, 
expense of the former; and they, as well as all . follow that extreme depression or exhaustion of Uni 
other writers, have either entirely overlooked, or system must be attended by a marked alteration 
have scarcely adverted to, several of the antece- j of the functions of the heart : indeed, the evideH 
dent changes, or patholc^ical states, to which I { imperfection of the actions of the latter is one if 
have imputed so much in the causation of these ; the principal indications we possess of the ei- 
maladies. | baustion of the former. And, if this alteration or 

22. ii. Of the Seat and Anatotnieal Charactert ; imperfection of action continues long, or retam 
of Diieatet of the Heart, — A. It is extremely frequently, lesion of structure, especially diUtatioo, 
rare, as M. Bouillaud remarks, to find the softening, thinning, atrophy, &c. of toe parielH 
heart altogether diseased : most commonly a \ of one or more of the compartments of the orgUi 
compartment only, or a portion of -it merely, or j &c., must ultimately take place. Nor is this iIh 
even one of the tissues constituting it, is aflfected. : only mit>chief ; for, alone with it, alteration of tki 
Sometimes one or more valves, or orifices, are j circulating fluid often exists, —this latter still iitf> 
primarily altered ; and in other cases, either the i ther impairing nervous or vital power,— and, ia 
internal or external membrane, or the muscular j connection with both these pathological ooi* 
structure, is changed. In one instance, a cavity ; ditions, inflammatory action, or an altered ilM 
is dilated, and its walls thinned ; in another, it is j of vawular action constituting one of the modlii 
of natural capacity, but its parietes are remark- • conditions usually so denoimnated, occaiiooaUy 
ably thickened ; and in others, the compartments j also takes place in the internal surface of tM 
individually present various lesions, as softening, heart, or in some other of its constituent \jim», 
hardeiung, &c. giving rise to the further changes already alladsi 

23. B. The intinutte nature of the heart's to in general terras, and hereafter to be more pv- 
lesions is not always evident, even on the most ' ticularly noticed. 

minute examination. That they are frequently i 25. iii. The general Charactert and DiagmU 
inflammatory, or of that kind usually so deno- , of Diseases of the Heart, naturally divide thoa- 
minated, cannot admit of doubt; and that they ' selves into — 1st. The Local Signs ; and, 2d. Tko 
still more frequently are the consequences of in- general Sifmptoms, or sympathetic phenonMBa. 
flammation in some one or other of its grades, ' 1 he former have been generally termed pAjfucsf; 
modified, however, by the tissue in which it is . the latter, phii$iological and rational : but the OM 
seated, by the state of vital power attending it, ! class should always be considered in coonectioi 
and by the condition of the circulating fluids, is with the other in the course of practice.— i- 
not less true, although less manifest, than the The local signs are ascertained by autcultatim» 
former proposition. Inflammation affecting a jwcussion, ius^pectiont and piilpitation. Of tba 
serous surface gives rise to results varying with former of these means, sutHcient notice has been 
its intensity and with the state of the constitution, | taken. (See arts. Auscultation, and Chest.)— 
in respect both of organic nervous ener>^y and of The latter requires equal care with the former y 
vascular tone. When the latter remain uniin- , and the sensations communicated to the hand of 
paired, the production of coa^^ulable lymph is a the examiner, as well as those excited in the 
common result; but the lymph, being secreted in patient by the examination, should be atteotirdy 
a fluid state, will often, when the internal mem- ascertained and ostimated. The indications fu^ 
brane of the heart is inflamed, be washed into the ' nished by these means are diversified according to 
current of the circulation before it can be coagu- the nature of the diseases which furnish theiB; 
lated, and no very manifest evidence of the disease but they can be known only by listening to tte 
may be detected after death, although it has existed extent, scat, and nature of the sounds given otf 
in Its most intense form, or even has been the by the organ, or elicitcl by percussion; by (^ 
cause of death. When the inflammatory action serving the form and motions of the prscoidiil 
is co-existent with depressed vital power, and a and adjoining regions ; by feeling the motioB4» 
morbid state of the blood, the fluid secreted by , tremors, or thrills, often existing in these sits- 
the inflamed surface is incapable of coagulating, ations ; and by ascertaining the sensations of thi 
and it readily mixes with, and contaminates, the patient upon pressing between the ribs, or on thi 
vital current ; the seat of disease presenting after prxcordia, or upwards upon the diaphragm, av 
death but little change, beyond dark discolour-^ under the anterior margin of the left floating ribs* 
ation, and softening. In respect both of the 26. B. The general svmptoms, or sym pathiH e 
internal surface, and of the substance of the phenomena, are ascertained from attenbva ob* 
heart, lesion of the capillary action and tone, as servation of the several related functious. — The 
we)} BM of vital cohesion, may have existed during I very intimate relation of the heart to all tba 



172 



HEART — DiBEABEs or— TuEiR Complications. 



preceded by, disorder of other viscera, as well as 
by alteration of vital power and of the circulating 
fluids. But there is another class of cardiac dis^ 
eases, which present different characters, and 
consist, in a great degree, of change of structure, 
often associated, however, with disorder of the 
organic nervous influence, and sometimes also 
with more or less marked alteration of vascular 
action in one or more of the constituent tissues, 
or compartments, of the heart. They may be 
said to proceed from the morbid conditions 
already discussed, especially when these exist in 
sub-acute, or in Aimt or chronic forms. That 
this is the case, will become apparent, when I 
come to describe them individually. It will then 
be fully shown, that impaired, or irregularly ex* 
erted, nervous influence, and morbid vascular 
action, in one or more of the constituent struc- 
tures of the organ, have, together or singly, 
altered their nutrition, or impaired the vital co- 
hesion of the molecules of which they are formed ; 
and that the consequences of altered nutrition 
and impaired vital coheaon chiefly consist of the 
increased or diminished thickness and density, 
the augmented redness and elasticity, the soft- 
ness, the dilatations, ficc, of the parietes of the 
cavities ; and of the fungous or polypous ex- 
crescences, the cartilaginous and osseous form- 
ations, and the different morbid productions, &c., 
found in the heart and pericardium. 

30. B. Conformably with the above view of 
the nature of affections of the heart, I shall 
divide them into — 1st. Disorden which are 
merely nervout, or Junctional, and chiejiy depend" 
ent upon the ttate, or distribution, of the ganglial 
nervous influence, particularly/ in respect of this 
organ ; and under this head will be comprised — 
(a) Impaired and irregular actions of the heart ; 

— and, (h) Elxcessive action of the heart, — 

2d. Diseases in vhieh, cottjointly with tnore or 
less disturbance of the organic nervous injiuence 
distributed to this organ, the biood'Vessels of one or 
wufre of its constituent tissues manifest a perverted 
or morbid actio.i. Under this division will be con- 
sidered — (a) hiflammation of the endocardium 
or internal membrane of the heart ;— - (6) Injiam" 
motion of the j)ericardium ; — and, (c) Injlam- 
motion of the substance of' the hearts or carditis, — 

3d. Organic or consecutive lesions of the heart , re- 
sulting from, and often associated with, one or more 
of the above pathological conditions. Under this 
head will he discussed — (a) Atrophv of the heart ; 

— (6) (Edema of the organ ; — (c) Softening and \ 
hardening cf the structure; — (d) Adventitious ' 
productions in the heart ; — (s) Changes of the di- \ 
mensions of the orifices and valves ; — (f) Changes \ 
in the dimensions of the cavities of the heart ; — (g) 
Hypertrophy of one or more of the compartments ; 

— \h) Hupture and wounds of the heart, Sfc, S^c, 

31. V. Of the Course, Termination, and Dura-- 
tion of Cardiac Disease, — Affections of the heart 
may be acute, sub-acute, or chronic, — A, Those 
which are nervous, or functional, are most fre- 
quently chronic, remittent, or even periodic ; yet 
Uiey are sometimes acute, and of very short 
duration, as in cases of cardiac syncope, &c. ; 
and frequently terminate without any lesion of 
structure, although they occasionally induce it. 
^ B, Inflammaiiont of one or more of the 
constituent tissues of the heart may assume 
Mojr grad^ of Jjiltasit, and pursue accord- 



ingly an acute or chroiue coarse, or evea lay 
of the intermediate or sub-acale suies. Ths 
chronic form may be consequent upon the ante} 
or it, as well as the sub- acute, may appear piimi* 
rily, es])ecially when the inflammatory actk» ii 
limited in extent, or » confined to a single ea» 
stituent tissue of the oigan. Although tbcf mj 
terminate in resolution, yet they most eomnoali 
give rise to organic changes, amongst which mrt 
be ranked the effusions of fluid, 6cc., frcf^andj 
met with in the pericardium. — The more latMM 
sutes of inflammation of either of tbe mfhatA, m 
of the substance of the organ, nay tenaiatie 
faulty in two or three days, wbikt the less seven 
or chronic states may continue months, or evci 
years. But when they become thus pcelooj^ 
It is generally owing to their having passed nls 
organic change, or to a temporary subsideacs 
of the morbid action, and to returns or esacfri>- 
ations of it, under moral or physical influeaeeii 
•— C. Organic lesions of the heart are extrennly 
uncertain as respects their course, duration, ail 
termination. Even when most manifest andel^ 
tensive, their symptoms and progress are bjis 
means uniform ; the most distressing phenomaBi, 
as in inflammations of the organ, often vafyiH, 
disappearing, returning, or pursuing veiT A 
ferent courses, in separate cases, or even in Iks 
same person at different periods. They fre^osil* 
ly, also, present more or leas evident remisMW 
and exacerbations, or even a marked periodiotf. 
This circumstance probably induced Coavfun; 
and especially Ro;»tan, to refer many cases i 
nervous asthma to organic disease of the heart. 
But this circumstance is explained by tbe bA 
already adverted to — that cnange of stmctaia^ 
even when most prominent, is only one of tU 
elements of the cardiac malady, the orgaaie 
nervous energy of the organ being also alwaji 
more or less affected ; and we know that inter* 
mittence, or periodicity, is characteristic of aflee> 
tions of the nervous system. — The exacerbatioH 
or violent paroxysms which patients with or^anie 
Iej»ions of the heart experience, is not, hosrever, 
altogether owing to periodicity of the morW 
action, but is otten excited by mental erootioaf, 
by errors in diet, by over-distension of the MD* 
mach or colon, by neglect of the excreung func- 
tions, and by exj)osure to atmospheric vicissitudes. 
32. vi. The Complications of Diseasa of the 
Heart, are important objects of consideratioa, 
in respect both of the associations of these dis- 
eases with one another, and of their conoectiea 
with other maladies. — A, Nervous affectieiu ti 
the heart are often attendant upon disorden id 
the digestive organs, on flatulency, on congestioai 
of the liver, and on disorder of the resphaioiy ; 
functions. 'Ihey are freouently also obsemd 
in the course of chlorosis, nysteria, and aocmiii 
and are often excited by affections of the wonK : 
and by the puerperal states. Indeed, the numeroei \ 
pathological causes (§ 20.) of cardiac diseaM 
form also complications with them. — B, AetU 
or chronic injlammation of the internal membftas 
of the heart sometimes extends to the ptrica^ 
dium ; and inflammation commencing in tka 
latter surface very frequently reaches the fonur* 
This association of inflammation of both surfucii 
or extension of the morbid action from the oneta 
the other, especially from the external to tki 
internal membrane, is to be ezpliined by the 



174 



HEART — Functional DisoRDsns op the. 



to copious depletions ia the acute or early stage 
of inHammations of the heart, yet their effects 
should be carefully watched ; and they ought to 
be still more cautiously employed in chronic or 
advanced cases ; for there are very few inflam- 
matory diseases, in which they may prove more 
beneKcial, than in these, if they be resorted to at 
the proper time, and in sufficient quantity ; or in 
which they may be more injurious, if too long 
delayed, or ton sparingly employed, or carried too 
far. When prescrib«l in a timid manner, and if 
a decided use of calomel and opium, sometimes 
with antimony, colchicum, or other adjuvants, be 
not adopted, an acute mflammation, which would ■ TabuU exbiben*. 4U>. HaIk, i7dSL — if. le Cmm 

otherwise have entirely subsided, either passes j ?*?•*>" *5**™'**." ^'.?"'-.i*!Il?- J*^ '7^ T,^«-. 

\. • .. .. ^ ' ■ ^ ^ ■ \ Tjim. de Freouentioribus Cordis MortiU. 4ta Vie*. 1771 

into a chrome state, or gives rise to orgamc « j. j. AvXrf. Ratio Mcdmdi Morim aicoH HL 

changes embittering the shortened period of future . guinei. Sva Brctlau, 177J.» F. Petrafg^ Ds Cooli 



Bai. 158a — E. Ruditu, I>e Nat tC Morton Cord. Zm. 
Btitutione. 4ta Venat 1600. — il AlberiM. D« AAct 
Cordi* Llbri Trer. 4to. Venet 1618. — cTfkr^. TMIf 
de U Moiiarchie du Conir en rHomina. 4ca V£m. VtSL 
A. Bulgelim$, De Afifcct .ConUa. 4to. FU. 16S7.~to- 
fifrtMs, Pra&it, L il. par. iU. c. & _ A. Kmmer, Vm.^ 
MortiU qui Cor ct Keq>irat. Organs InlMant. Un. Vte 
17 Id ~ M, Martinext OtMerraC Rara de Cnria 4la 
Madr. 17SJ.— J. M. LameisLDc MoCu C«nlii ct Adm. 
riinutibus. fuL Konue, 1788. ~ M. Bri fcj i fat, Koe?. 
Insert, lur lei Maladies de la PirftriM et dn C^k 
12ma Anut 1741. — J. Senae, TTait^ de la Stmctun 
du Copur, et de les Maladies, S tomes, 4Ca Paris, 1741. 

— J. P. Meckel. Sur les Mai. du Conir, In Hte. * 
I'Acad. de Beriin. 4ta BerL VJbd.^A. Mmimn, Jh 
Ancurif nalicis PrsNrordionun Morbis. 4to. Ubam. I7iL 

— H. Maton, Lectures upon the Heart, Ac. 8va Rni 
}J(». — a F. JMHcker,piu. Cordis Moib propcfoi k 



ezibtence. Yet, whilst thus prompted to decision, 
it must never be overlooked, that in most cases of 
inflammation affecting this viscus, the organic 
nervous energy is more or less impaired or irregu- 
larly determined; and that the most decisive 
measures should, therefore, be directed with the 
utmost circumspection. The other means which 
may be brought in aid of those already noticed, 
are comparatively of so little importance, and re- 
quire to be so varied according to the forms and 
stages of the disease, that no mention need be 
made of them until the specific affections of the 
organ come under consideration. 



Afffectionibus Syntaema. 8vo. Rom*, lT7a'— C. F. Jfr 
ckaiiU*^ Aneurism. Cord. Diso. in Doermg^ TtmcX, voLL 

— JG n'alther, in Nouv. H£m. de I'Aad. dcs fc.1 
Berlin. 4ta Berlin, 1785. — Odjrr, Bfanuri de MMkiM 
Pratique, p. 151. tUrl ~ J. C. ReU^ Dissert. AnaL ^ 
Hist. Cordis Pathoiogicam. 4toi Hale, 17S0.— A. Fortdt 
Anatomie Mgdiule, t iii. 8va Paris, 18r»lb ->. Caton. 
CabanntSt Aper^u sur quclques Affbct. Organiqucs di 
Cwur, &(\ 8va Paris, 1803. — J. X C4trvuart, unlar 
les Maladies du Coeur et des eras Vaisseaus. Svo. IWl 
18UG, Sd cd. 1818 ; translated by He^ 8va Load. Ull 

— iV. A. Petit, Essai sur la MMccine du Ccrar. Im 
Lyon. ISna — Contelle, Eksais sur quelques Causes di 
MaL du CoHir. Hva Paris, 1HI8. — A. Bmnu, Obscn. 
atiuns on soine of the most ftrequent Diseases af tte 
Heart Sva Cklin. ISliQ. » P. J. Peiletam^ in CTiiriMi 
Chirurg. 8vo. Paris, 1810. — A. Tetta, DeUe MidUto 
dc4 Cuore, 3 vols. Bva Bologn. 1811. —J. GcM^ Ofe 
Diseases of the Heart. 8vo. Philadelph. 1612. — £,« Gut 



38. C. The orfffrtic /esioiis of the heart require .. ., , ,^. . „ . 
• «„.«u «,/*«» .....T^i^nt p<»/./«»Mui f /v <i<k»u»:»... *k»., '*«♦ ^ Merat, in Diet des Scit^ices M*d. t r. Sva TUk, 
a much more prudent recourse to depletions than ■ 18,^ _ y^ L^Kreyvm, Die Krankheiton des Henea, S, 

the diseases just dismissed, inasmuch as the|4bde. 8va Berlin, 1814-17.— /« /M.vAtfiissAf.De 



nervous influence, especially that actuating the \ ^"Ji""? MorbU Cordis gignend.s Monea^WieiL im- 
. J* • ■'• J • .L r \ J. H. Jamg$, in I'rans. of Med. and Chirufg. iioditi^ 

organ, is much more impaired, in the former ' — » ■-" - -" » ^ «..^._ .»_..__«.___._..• /r'Trp 



maladies than in the latter. In cases of dilatation 
of one or more of the cavities, even a moderate 
depletion may be followed by a fatal result ; and 
when there is hypertrophy, the heart requires all 
the energy it possesses to overcome the obstacle 
in the way of the circulation. The small but re- 



▼oL vili. p. 43ft. — J. r. »VA/<T, Ucbcr Krankb. dcs H» 
sens., In Beitnge vur Mcdicin, b. i. — H. i7Mdnr, A 
Pract. Treatise on Dis. of the Heart 8va Lond. Ua» 
B^clard et Chomet, Diet de M6d t t. 8va Puis, UK 
— M. Fodiri, in Journ. Complement du Diet dis Sb 
M6d. txxxlL et xxxiv.; ct J. Joknton'g MeiLChirwgi Rcr. 
vol. ii. p. 417. — Hufeland^ in N'ouv. Journ. de MM. t ih. 
p. iiU4 — ./. Johnson, in Trans, of Med. and Chimrc. Ha 
vol. xiii. p. <212. ; and Med .Chirurg. Rev. Nos^ a, A 



peated dopletions, and the antiphloj£istic regimen, . 2°- H'}*\^^ , : ''^^^"'/"**^».^^"*' ?.C.-^J***-9**!I?* 
- A A I \r . . ..5i A J Soc. ofLdm. vol 1. par.L E<hn. lH^4u — nVsAAff, in ibid, 

recommended by \ alsai.va and Albkrtim, and ^ol. iii. p. IK.-R J. Berlin^ Traite des Matediai M 

so generally adopted in organic diseases of tlie 
heart, may be curricil too far, as Corvisart has 
judiciously shown. They may be even most in- 
jurious. There are few means which are 
universally, or even generally, applicable to 
these lesions, excepting mental and physical 

quietude, and attention to the digestive and ex- i '?"*»'• "«»P: Ki'poru.vol. iy.p.jir>S.—J. Brotem,Uti 
^ ^- c ..• 1'-. 1 11 1 -4 Msays on r ever, DiKcascs of the Heart. &c. Sra Lo 

creting functions. \ ital energy seldom arimiUi, i^_ p. j^ Latham, in Lond Med. Gweit^ «L 

in them, of being lowered ; and whatever acts in • - - • -— . -. 

this manner, should be employed with discrimin- 
ation, or appropriately to those states which £>eem 
specially to require it. — In them, also, moral 
training, attention to diet, living in an e<{uable 
temperament, and in a healthy and airy situation, 



Cceur. 8to. faris, 18V4w — //. BUrger, Diamost. 
Hertzkrankheiten. 8vo. Berlin, IS^S. — CH. Pvr§t 
Collect, from his unpubl. Writing*, &c. vol il m 
Lond. l»23.^a. Amtral, Cllnique Mrdicale, Ac t H. 
Paris, 18U<!.; Traii&latcd by G. Spitian, part ii p. £17. LwL 
18'}.5. ; et PrcciM d* An.it Pathologiquc, t ii. 8ta PukL 
18^ — F. Hatrkiru, Hheumatiam and some DliCMCiii 
the Heart conhittered. 8va Loml. 18MS. — R. Aiium,im 

Medical 



IK. 

p. i. et pass American Journ. of Med. Sd., rU iL 

p. 121). — J EUititson, On the Recent Iraprovennits I* 
distinguishing Diseaites of the Heart fbl. Load. IIA — 
J BuuUlaud, Diet de Mid. et Chirurg. Pract tv.— J^ 
Hope. Trcati>e on Diseases of tlie Heart, &c. Sra Load. 
18&i and Cyclop, of Pract Med. vol. W.— T. Datiet,l»' 
tures on the Diseases of the Lungs and Heart. 8va 
I<ond. 18.>5. — J. BouiUaud, Traite Clinique des 



a gently open state of the bowels, and a due \ du Coeur, a tomes, 8va Paris, 18:36. 



secretion of bile, and the careful avoidance of 
whatever excites or aggravates the disorder of the 
heart, are amongst the most generally applicable 
means of treatment. Numerous other measures 
may be employed, but they are applicable only 
to particular legions, and therefore will be men- 
tioned where the treatment of these le:»ions is 
particularly disjcu^sed. 

BiBLioo. AND llcPBR. — Gff//'n, Dc I>x>is AfTcct L ▼. 
c tf. — Je/ius, Tctrab. i. lert iv. c.77. — Aricenna, Canon. 
tract iii. fen. ii. tract i. c. '2. — B. itim/agnaua. Conii. 
de .Xgritud. Cordis, in Op. St-I. fol. Vcn. 14y7. — C 
Vega, De Cord, et llioracis Affect., in Arte Med. fol. 
Lugd. Bat. luCL — C. Bruno, DeCurdc t-t ojui Vitus. 4to. 



III. Of Nervous or Funciion.vl Affecixoiv 

or THE II FART. 

i. Of I.MrAiRF.D on iRnF.ci'i.AR AcTiOir.— 
Ci.As.siF. I. Ci.Ai^, 111. Ordkr (Avthtr), 

39. ])ib.FiN. — The action of' the heart wtargtr 
lesi iveakened or irregular, 'jcith faimneu, or it' 
prfsuion, and often with disi*rder of the dige^ 
orgnna. 

40. The functions of the heart may beimpo^ 
fectly |)erforined in two principal ways: — liL 
Thoy may be simply weakened, but in evay 
grade, until they become extinct, and yetstne- 
tuial lesion may not be detected to account fior 



luscs m 
Otmen. 



I 



176 



HEART — Functional Disorders of — Diagnosis— TncATMiMT. 



8«yeral of its Protsan fonns, especially when the 
uterine functions are disordered, and the cata- 
menia either excessive or obstructed ; — 9th. Irri- 
tation of the spinal chord, or of its nerves, or 
excitement of the uterus or ovaria acting upon 
the heart, either directly by the great sympathetic 
nervous system, or mediately through the spinal : 
chord; the irritation propagated to this latter 
beinff reflected from it along the branches com- 
municating between it and the cardiac and other 
sympathetic ganglia. 

46. Although these may be considered the 
principal causes, yet others sometimes produce 
functional palpitation ; especially several anttet" 
dent diMordtrt, and organic lesions, as— a. Ady- 
namic and nervous fevers ; — b. General plethora 
by overloading the auricles and large vessels ; -~ 
c. Irr^;ular, or misplaced gout, occasioning irri- 
tation of the cardiac nerves, or congestion of the 
large vessels or cavities of the viscus ; — d. Obesity, 
pardcularlv in connection with plethora ; — «. Ob- 
structed circulation through the lungs, owing to 
diseases of their structure, or to eflPusions of fluid 
pressing upon them, or other causes preventing 
their expansion; — /. Enlargements of the ab- 
dominal or pelvic viscera, or eflusions into the 

Seritoneum, preventing the easy descent of the 
iaphragm, or pressing upon that part connected 
with the pericardium, as enlarged or engorged 
liver or spleen, pregnancy, ascites, &c. 

47. D. Count and Duration of Nervous Pal' 
pitation. — a. This affection varies somewhat 
according to the cause which produced it. — a. 
When it proceeds from mental emotions, it is often 
violent, but of very short duration. — 0. When 
it arises from manustupratio, it is not so excessive, 
but it is more prolonged ; or remittent or recur- 
rent. — y. Palpitations si/mpathetie of dyspepsia 
are seldom severe, unless in persons of the nervous 
or irritable temperaments, nor of long duration ; 
but they are readily excited, particularly by a 
full meal, or by indigestible, or flatulent, or fluid 
food. In such cases the action of the heart is 
irregular, as well as excessive, tumultuous or 
fluttering, and attended by anxiety, sometimes by 
pain, and by accelerated breathing or dystpnoea. 
— I, When this aflfection proceeds from mis- 
placed, or retrocedent gout, it is generally severe ; 
more, however, from the attendant sensations, 
than from the violence of the palpitations. The 
action of the heart is excessive, most inegular, or 
tumultuous, and attended by distressing anxiety, 
or sense of sinking or of anguish at the praerordia 
often extending to the epigastrium, and by ex- 
treme restlessness, and a feeling of impending 
dissolution. — i. Palpitation is very often ttn \ 
attendant of hifsteria ; and in this case is excited ; 
or aggravated by the globus hystericus, or by the 
hortiorygmi or intestinal flatulence, characterising | 
the latter affection. A feeling of strangulation \ 
frequently accompanies this form of palpitation : 
and, in two or three instances, I have observed 
an almost sudden swelling of the thyroid gland 
to take place, this part returning to, or nearly to, 
its former state very soon after the attack. In more 
than one of these ca«es, there was evidence of 
co-existent irritation or excitement of the uterine 
organs. Hysterical palpitation sometimes alter- 
nates with raiotness, or is connected with exces- 
live menstruation. It occasionally also follows 
abortions, floodings, &c. — 6. The Duration of 



palpitation is most indefinite. It may contiau 
only a few minutes, or many days. It may bs 
remittent, intermittent, or oTen periodic; batiti 
course is more generally irregular. 

48. £. Diagnosis, — It is often easy to dis- 
tinguish nervous paljntation from that sympton- 
atic of organic lesion ; but Quite as ofleo the 
diagnosis is very difficult. That it should be 
made with accuracy is most important, as respects 
both the treatment, and the immediate happioca 
of the patient ; for many distress themselves and 
aggravate their complaints with fears of aa 
oi]ganic malady, whilst they are aflfected onlv 
with functional disorder. When Derrons pal- 
pitations are prolonged, remittent, or letam 
frequently and are severe, the diagnosis is gen^ 
rally diflicnlt : if attempted during their coa- 
tinuance, it is still more so ; and if deiemd 
until the period of intermission, it it often not 
much less difficult ; for some organic lenons oc- 
casionally present periods, in which the symptom 
are remarkably ameliorated. Vet an attentiTe 
examination of the whole chest by permssioB, 
auscultation, by the eye, and by the touch, will 
generally determine the question with great ac- 
curacy, and show that, in this afiection, the 
heart is not enlarged, and that the blood circi- 
lates freely through its various orifices. The ex- 
tended dulness on percussion, the morbid or 
adventitious sounds, the more or less consoust 
dyspnoea, the venous congestions, the bloated 
state of the countenance, the dropsical effnsioiis, 
6cc., sufficiently mark organic lesion of this organ, 
especially if it have become far advanced. Some- 
tinics, however, great nervous sensibility, or aa 
hysterical affeition, may be attendant upon sone 
degree of alteration of structure ; the palpitation 
recurring in severe paroxysms af^er slight mentsl 
emotions, or other causes affecting the nervoas 
system, and leaving the patient comparatively 
easy, and with few precise or well-marked sym- 
ptoms in the intervals. This is not infrequently 
observed in persons who have been subjects oif 
inflammation of one or more of the constitaeat 
tissues of the heart, that has left behind it sligbt 
structural change in connection with an irritable 
state of the organ, and great susceptibility of tbe 
nervous system. 

49. In addition to these consideratioDJ>, the 
following circumstances may be adduced i» 
distinctive of a functional disorder : — 1st. The 
general prevalence of nervou;; symptoms, sad 
the recurrence of the attack from causes ftcbxf 
on the nervous systems ; — 2d. The return of the 
affection when the patient is quiet, and the relief 
following gentle or moderate exercise in the open 
air, and the means used to improve the digestive 
functions and to restore the nervous energy ;— 
3J. 1'he prolonged and complete intenmsnons 
during an improved state of the general health, 
and the exacerbations consequent upon whatever 
depresses or exhaus's organic nervous power, 
especially upon the operation of any of the causes 
enumerated above ($ 45, 46.) ; — and, 4th. The 
absence of the physical signs characterising any 
of the inflammatory and structural diseases aboat 
to be considered. 

50. F, Treatment, — a. The means pfe- 
scribed for this affection should have a veir strict 
reference to the cau«es which produced it, and 
especially to the pathological state of which it is 



178 



HEART — NxuRiLoic Affictions or — Diagnosis — TmjitMtKT. 



t.l. n.8. (yitrftoith tonfa.)— Latrmrc, Au«cuU. Mediate 
t. ii. p. «37. Paris, 1829. — A. Poi/a/t Mem. sur la Nature 
et 'lYaitement de pluiieurs Maladies, t. iv. p. 173. Paris, 
1819.— Merat. in Diet, des Sciences Medicates, t xxxix. 
p. 134. — J. JuhH*ott*9 Med.-Chirurg. Kcv. vol. iv. p. ,770., 
ToL T. p 277. — Andralt Diet de Medecine, t. xvi. 8vo, 
Paris, 1826. —J. Framkf Praxco* Medics Uiii versa? l»rof. 
cepta, voL ii. pars Ii. sect IL p. 37(). —J. Ilop^, Cyclop, of 
Pract Med. vol. iv. p. 'JCO. —J. Bouiiiaud.TraH^ Cliinque , 
■ur Ics Mai. du Cceur, t ii. p. 4^ 

iii. Painful or Neuralgic ArFrcrioss of the 

Heart. — Classif. II. Class, 1. Order 

{AiUhor), 

63. CiiARACT. — Sudden attacks of anguishing 
jHiin in the cardiac region, returning at inter- 
vals; the actions and sounds of the heart, and 
re^iration, being but little affected. 

54. Iq the same category with the disorders 
just considered may be arranged those painful 
affections which have been considered as neu> 
ralgia of the heart. They might be viewed 
as modifications of Angina Pectoris, and 
arran^red with it, if there were sufficient evi- 
dence to prove that they are actually seated in 
the nerves of this organ. But, as Bolillaud 



attack to be favoured, by exercise, or by uotiiop 
or position ; but, on the contrary, it seemi to 
be benefited by gentle exercise in tbe open air. 
Debility and loss of 6esb generally are lodaccd 
by the excessive sufTering ; but the appetiie ii 
not materially impaired. The powen of fugection 
are, however, weakened, and the bowels are more 
or less sluggish. — This complaint is generally of 
long duration, 1 he shortest period in my cues 
was six or seven months ; and in one, where the 
intervals between the attacks were very connder- 
able, it was as many years. 

56. B. Causes. — Of the six cases above refismd 
to, two were females. They were both unmar- 
ried ; but the catamenia were perfectly regular; 
and neither of them had ever complained of aaj 
hysterical symptom, or bad experienced pain in 
the spine. Of the four males, the two most id* 
vanc'cd in life had formerly had gout ; and in om 
of them, who was under the care of Dr. Roon 
and myself, the cardiac neuralgia was induced 
by grief. The other two were medical piae* 
titloners : one of them had been engaged ia a 



observes, although the functions of the heart lalM)rious practice in the country ; the other Ind 
may be disorde:ed in connection with them, the experienced family contrarieties and disappoint- 
nerves of the adjoining viscera and structures are I ments, and was endowed with the utmost suscn- 
probably as much affected as those of the heart, j tibility and irritability. — The recurrence of tic 
A case of this complaint has been described by attack seems to be favoured by cold, eapediUy 



Dr. Elliotson, and is altogether similar to some 
that have occurred in my practice. Indeed, neu 



by cold east winds ; and there is reason to be- 
lieve that malaria is concerned in causing it la 



ralgia of the cardiac and communicating nerves, ; a violent case, recorded by M. Andral, no tfiM 
or affections intermediate between it and angina of organic lesion was observed on dissection. 



pectoris, are by no means rare. A ca«e of this 
affection came under my care in 1821 ; and 
Muce then I have treated six similar cases : two 
in females between the ages of twenty-five and 
thirty, three in gentlemen somewhat upwards of 
fifty, and a sixth in a physician of about thirty- 
five years of age. 

55. A. Diagnosis, — According to 1 he phono 



57. C. Treatment. — The means of cure ia thii 
afl'eclion are not materially different from thou 
advii-cd for Angina Pectoris, to which it is ii 
intimately allied affection. As in that complaiit, 
so in this, and in Palpitations (§ 50.), tbeiiK 
dications are — 1st. To shorten the attack i-^tL 
To preuent tJie recurrence of it. — a. The reno* 
dies I have found most efiicacious in fulfilling tbt 



mena observed in these cases, this complaint is \ first intention, ?iTC — camphor in large doses iriA 
characterised as follows : — A most acute, luncin- 1 opium, or acetate of morphia ; the prussie mU, 
ating, and anguishing pain is felt to the left of with camphor, or ammonia, or other stimuIatiBg 
the sternum, darting through the region of the antispasmodics, or warm carminatives and tomo; 
heart, often from under the left nipple backwards a full dose of calomel, with camphor, capsietm, 
to the spine or left shoulder-blade. Sometimes and opium, or the muriate of morphia; tibepi»- 
it is confined to this organ ; and occasionally it parations of colchicum conjoined with ammoaiap 
extends to the left biachial plexus, and up the j camphor, the subcarbonate of soda, &c.; aJRif- 
left side of the neck, or left arm, or to other parts i tard poultice applied as hot as it can be endnred 
in the vicinity of the heart. This complaint is ' over the epigastric region ; and a plaster, ccHMri* 
generally intermittent, or remittent, or even pe- | ing cliielly of extract of belladonna and campbdri 
riodic in its character ; the paroxysms arc sudden placed over the prsconlia. I have tried vaiioal 
or almost instantaneous in their accession ; and { narcotics, besides these just named ; but less C0^ 
their duration is very variable. I'hey leave the pa- ' tain advantage has been derived from them tkn 
tient intervals of comparative ease, when the pain from those. The extract or tincture of aconitwh 
is dull or aching, and confine*! to the region of the or of stramonium ; or the powdered root or IctvsK 
heart. They return at various intervals; some- or the extract, of M/aWin/wa; are, however, oftii 
times once or twice in the day, and occasionally of service, e-^pecially when the metlicines j<* 
not for several days. They are attended by the mentioned have failed. 

utmost agony and distress. The actions of the ; 58. b. The second intention has been W 
heart are somewhat accelerated during the fit, answered by purgatives, by mild aod chiHff 
and sometimes more or less irregular or turbu- ' farinaceous food, by abstinence from stiranltliBf 
lent ; but they are also in other instances nearly li<]uors, by tonics conjoined with absorbents U* 
natural. There is no morbid sound, beyond a stimulants, and by external drains or derivatii* 
slight bellows-sound in a few cases, heard on long persisted in. The carbonate of inw, ■ 
auscultation; and the breathing is tranquil. The large doses, the bowels being kept Jreely Opdi 
paroxysm may take place at any period, and has bften sometimes of service. — Dr. El" 
when the patient is perfectly quiet, mentally and i.iotson found benefit from it in one instiBCtt 
physically, and without the occurrence of any but it has failed in other cases ; and equal id- 
cause sufficient to account for the seizure. This vantage has been derived from a combinatioirf 
jiffection does not appear to be aggiavated; or iu ' sulphate of quinine, camphor, and as much ptn**- 



m 



HEART IfTFLAMMATlON 07 THE ENDOClKllIfrX, 



Tentricular vaWe, resembles the glottis or the os 
tiocae, owing to the thickeaing of the margins, 
and projection into the cavity of the ventricle. 
The thickening and induration occasionally ex* 
tend to the tendons or even to the muscular 
columns. The semilunar valves also often stand 
firm and convex, or rigid. These changes have 
been well described by Mr. Adams and M. 
BouiLLAVD. — Dr. Elliotsos remarks that the 
valves of the pulmonary artery sometimes grow 
up so as to leave only a small round or triangular 
opening in their middle. 

68. d. The inflammatory origin of the changes 
BOW described has been doubted by several pa- 
thologists, and even by Laennec; but it has 
been advocated by Frank, Kreysio, Hilden- 
brand, Anoral, Elliotson, Bouillaud, La- 
tham, Watson, and others. Osseous formations 
in the heart have been supposed to occur only 
in advanced age. Bovillaud states, that of 
44 ca^es, 33 occurred in persons under fifty, 
and 19 out of these were observed in per- 
sons under thirty; one being only ten years, 
another seven, and a third ten itionths. I have 
met with this formation in two children, — one of 
seven, the other of ten years ; and in both, the ' 
sjrmptoms, and associated lesions observed on 
dissection, were obviously inflammatory. Indeed, 
the matter is put beyond dispute. — The narrovh' 
ing of the orifices of the heart by chronic inflam- 
mation ii, as remarked by a recent writer, very 
analogous to what takes place in other organs 
from this cause — as in the urethra, and lachrymal 
and biliary ducts, the pylorus, the rectum, &c. ; 
and the hypertrophy of the heart which succeeds, 
may be compared to the thickening of the mus- 
cular coats of the bladder, stomach, and other 
hollow viscera, arising in such circumstances 
from the difficulty of expelling their contents 
owing to the obstruction. When inflammation 
attacks the internal surface of the heart, the 
parts of it about the boundaries of the cavities, 
and near the orifices, or covering them and the 
valves, are most liable to be affected, as com- 
monly observed about the boundaries of other 
cavities and canals. — Biciiat had noticed the 
greater frequency of the lesions just mentioned in 
the left, than in the right, side of the heart. The 
fact is undoubted. M. Bertin considered that 
inflammation and its consequences are more 
likely to be occasioned and maintained by the 
exciting properties of arterial blood, than by the 
inert venous blood returned to the right side of 
the heart. This, however, is not suflScient to 
explain the circumstance ; for inflammations are 
more frequent in veins, than in arteries. 

69. B, Symptoms of Internal Carditis, — a. 
In the Jirst or acute stage, actual pain is seldom 
felt, unless the disease be associated with pericar- 
ditis or with pleuritis; but uneasiness, oppression, 
or anxiety, m the prxcordia, with faintness, is 
always complained of. The physical signs re- 
quire the closest attention. — 1. The prsecordial 
region, in simple endocarditi!«, is shaken by the 
violence of the heart's action, the hand being 
forcibly resisted by the impulse when applied 
over this region. The pulsation** are felt over a 
greater extent than natural, owirfg to the tur- 
gescence of the organ in an inflamed state ; and 
a vibratory tremor, more or less marked, is also 

sometimes felt, — 2. Percussion furnishes a dull 



sound over a greater extent of snrfiiee tkaa 
natural ; from four to nine or twelve sqnare 
inches. But, in order to distingtush this sound 
from that attending effusion into the pericardivm, 
it ia necessary to observe, that it coexists wkh a 
superficial, visible, and sensible pulsation of the 
heart ; the beat being profound, and hardly 
visible or sensible in cases of pericarditie with 
eflfusion. — 3. Aiucultaiion detects a bellowt 
sound, which masks the two normal sounds, or 
one of them only. This sound iythe louder, the 
stronger the action of the heart; and is alio 
rougher, the greater the swelling of the valves, 
and the more abundant or concrete the ezudatioa 
of lymph from the inflamed surface. Somctimce, 
when the palpitations are violent, a metallic 
sound isochronous with the systole of the ven- 
tricle is also heard. — 4. The /orre of the heart's 
contractions is changed both to the eye and to 
the touch, and the frequency equally affected, 
the pulse rising sometimes as high as 140 and 
160, or even higher, in a minute, and becoming 
irregular, uneaual, or intermittent. — 5. Awmal 
heat is generally also increased, but not usually 
in proportion to the augmentation of the circa- 
lation. The arterial pulsations represent only 
ihe frequency, but not the strength, of the hearts 
action in this disease; for, whilst the contractions 
of the heart are energetic, the puiae is generally 
small, soft, and indistinct. This is owing to the 
obstacle opposed to the circulation by the swell- 
ing of the valves or orifices, or both ; or by the 
fibrinous exudations formed around them ; a 
smaller column of blood being thrown into the 
arterial trunks ; hence, probably, arise the pallor, 
anxiety, jactitation, faintness, leipothymia, want 
of consciousness, &c., frequently also observed. 

70. In general, the venous circulation is not 
materially disturbed in this stage of internal car- 
ditis ; but when the above obstacles to the cir- 
culation through the orifices become considerable, 
dyspnoea, a bloated or livid appearance of the face, 
slight oedema of the extremities, and pulmooaiy 
or even cerebral congestion often supervene. Id 
this case, the patient experiences the most dis- 
tressing oppression, cannot lie down in bed, if 
watchful, restless, and subject to a constant jac- 
titation. In the simple form of endocarditis, de* 
lirium seldom occurs ; but temporary wandering 
of the mind, and sudden terror, or unconsciousoeis, 
are occasionally present when the dyspnoea a ex- 
treme. — The digestive functions, the secretions 
and excretions, are also more or le^ impaired; 
and in the more extreme btates, cold sweats often 
break out. 

71. The above symptoms appertain especiallj 
to the acute form of endocarditis, particularljf 
when it is general. But when it is partielt ot 
sub-acute, or chronic , the symptoms are not » 
prominently grouped ; and it is, consequently, 
recognised with greater difficulty. An attentive 
observer, however, will seldom mistake it for aoT 
other disease, excepting pericarditis, with wlucQ ^ 
it is very liable to be confounded, even by tbt 
most experienced. But the error is not material; 
for both diseases very of^en coexist, and the means 
of cure are the same in each. When pericarditis 
is attended by effusion, then it is readily disfis- 
guished from endocarditis by the circumstaoce 
mentioned above ($ 69.) ; but, when it gives nM 
merely to a pseudo-membranous exudatioDi t 



\ 



186 



HEART — Inflammation of the Pbricardivic. 



capillary vessels and larger branches are de- 
veloped beyond their natural size. Sometimes, 
in addition to these changes, a quantity of puri- 
form or sero-puriform matter is found in the 
pericardium ; but more frequently a quantity of 
serum, either limpid, turbid, opaque, flocculent, 
or sanguineous, is met with. — a. The coagulable 
iymph effused in the acute state of the disease, 
generally undergoes various changes in the 
course of this stage. In its place there is some- 
times only found cellular adhesions, general or 
partial, or merely simple bands stretching be- 
tween t.ie opposite surfaces. In other cases, 
organised false membranes cover a portion, or 
even the whole, of the surface, and present a 
vrhitish, milky, or opaline appearance, particu- 
larly when they are limited in extent. In all 
these cases, more or less fluid, such as just de- 
scribed, is also present. Partial or limited false 
membranes arc seen not only on the surface of 
the heart, but frequently also on the parts of the 
lar^e vessels covered by the pericardium, and 
especially over th« root of the aorta. These 
membranes are usually cellulo-fibrous or fibrous ; 
but, in the more chronic cases, they may assume 
the cartilaginous or even the osseous state. In a 
few instances, the heart has appeared as if more 
or less enveloped in an osseous shell. Sometimes 
these changes take place in the fibrous structure 
of the pericardium itself. Occasionally, in place 
of the morbid productions being disposed in the 
form of bands or membranes, they assume that of 
granulations, or excrescences. 
. 90. 0, The eifused fluid and morbid productions 
in the pericardium are often attended by various 
changes in the substance, or in the internal stir- 

J'ace and compartments, of the heart, generally 
resulting from the extension, the pre-existence, or 
the co-existence, of inflammatory action in the&e 
parts, especially in the endocardium. M. Bouii.- 
i.AUD attributes much of the alteration presented 
by the substance of the organ in these cases to 
the compression which the matters in the peri- 
cardium exert, and to the consequent embarrass- 
ment of the heart's action. This is probably the 
case ; but mucii is also owing to the conse- 
quences of associated inflammation of the inter- 
nal surface of the organ ; for, although this 
disease may commence in either surface, it sel- 
dom runs its course in a simple form, or without 
extending to the other, or even to other struc- 
tures. However this may be, it is indisputable, 
that, in a very large proportion of cases of peri- 
carditis, ami especially in those which are chro- 
nic, more or less of the changes characterising, or 
resulting from, internal carditis {§ 66, 67.) are 
also observed, as well as many of those alterations 
which are yet to be considered. — M. Boi'ili.aud 
has noticed atrophu of the heart as one of the 
changes consequent upon membranous produc- 
tions and effusions in the pericardium. This 
change I hiive also remarked, as well as loss of 
the colour — an extreme paleness of the heart's 
substance. This latter change was observed in 
a ca-e publislied by me in liB'il. — But hiiper- 
trnphtf, bcc, of one or more of the compartments 
of the ornan is most frequently seen in connection 
with pericarditis. In some instances, induration 
and thickening of the peiicardiac envelofHi ex- 
tends from the subjacent cellular tissue to the 

muscular structure, or rather, perhaps, to the cel- 



lular tissue connecting the fibres ; and tLe>e puti 
assume, in rare cases, a nearly cartilaginoni 
state. — Softening attended by a dark or deep 
red colour {hrowniik red sof'teming), or by loss of 
colour {yelUncish white softening), of the sub- 
stance of the heart, also is occasionally met wilk 
in pericarditis ; the former most frequently 'in the 
acute state, the latter in the chronic. But tbcse 
and still more remarkable changes are observed 
chiefly in cases of pericarditis aMOciated villi 
acute carditis ($ 109.). The coincidence of f^ 
lowish white softening of the substance of tht 
organ with pericarditis was noticed by LAurac, 
and has been attributed by Boiriu.ADD to iIm 
macerating effect of the serum contained in dM 
pericardium. In a case of rheumatic pericaiw 
ditis, readily recognised during life, this fonn «f 
softening was observed by me on dissection ; bat 
there was scarcely any eflTusion, and there had 
been no evidence of much having existed at aay 
period of the disease, although partial false men- 
oranes had formed. — In thirty-six cases in which 
M. Louis observed effusion in this disease, te 
fluid was sero-sanguineous in four, a turbid seivi 
in nine, sero-puriform in fifteen, and purulent m 
seven. — According to my own obsenratioB, a 
turbid or flocculent serum is most frequently oat 
with; a purulent matter being found chiefly ii 
sub- acute and chronic cases, and independeally 
of any ulceration. (See further, as to Effutm 
of Fluid into the Pericardium,the article, UaoMT 
OF THE Cavities of the Chest, § 148. et teq.) 

91. y. The external surface of the pericardiaa 
is not always free from very decided maiia af 
inflammatory action. — These marks are, ham* 
ever, found chiefly when pericarditis has beat 
preceded, attended,' or followed, by plenxilih 
pleuro-pneumonia, or by inflammation of the aa- 
perior surface of the diaphragm, or of the medi* 
astinum. In cases of this kind, and perhaps aba 
in others of great severity, or where the uaal- 
tached sac has been principally aflfcctcd, coa^ 
lated lymph is not infrequently found uniting the 
external surface of the pericardium to the pleoiib 
a turbid serum being more or less abuDdanliy 
effused into the pleural cavity. Whilst writiaf 
this article, I had an opportunity of examiniBg; 
after death, a remarkable case of this kind ; aai 
another, presenting the same appearances, waa 
brought into the dissecting-room of the Middla- 
sex Hospital Medical School, whilst this sheet 
was about to go to press, the man having died 
suddenly. 

92. ^. When pericarditis does not terminaie'u 
resolution, and in the absorption of wbatefC 
lymph has been effused, the next best teraiia* 
ation that remains, as Dr. Hope observeSf ii 
adhesion of the opposite surfaces ; for, sbooli 
this not take place, the false membrane btcawi 
a secreting surface, effusing more and more Baii 
until the cavity is completely distended, and thi 
action of the heart at last abolished. But, should 
adhesion take place, further effusioli is tbeiebf 
prevented, and life is often prolonged for naay 
months, or even years ; although adhesion oc- 
casions another form of organic change, whidh 
ultimately destroys the patient. — That adUkeiiaa 
occurs in one case and not in another, is eating 
owing to the quality of the lymph, which depcoM 
upon the state of mflammatoty action, and that. ,- 
in its turn, upon the constitutional powers } fcr 



192 



HEART— iNrLAMMATtO!! OF ITS Structuiuu 



ing down, when pressed gently with the €nger. 
li exhaled a putrid odour ; no blood exuded from 
its vessels ; and all its cavities were empty ; the 
large thoracic and abdominal veins being loaded 
with black grumous blood. 

113. b. Softening of the substance of the heart 
is one of the earliest alterations consequent upon 
inflammation of it; but softening, unconnected 
with vascular congestion and discolouration, can- 
not be altogether attributed to this state of morbid 
action. The reddish brown softening sometimes 
observed is manifestly owing to the most acute 
form of inflammation ; the muscular substance of 
the heart being of a reddish, brownish, or livid 
hue, and the connecting cellular tissue injected 
or engorged with dark blood. Sometimes blood, 
of a very dark colour, and more or less altered, 
is found infiltrated between the muscular inter- 
stices, or underneath the serous membranes cover- 
ing the internal and external surfaces of the 
organ ; these membranes participating in the 
morbid action. In a case examined by Mr. 
Stanley, the muscular fibres were found of a 
very dark colour, of a very soft and loose texture, 
and easily separated and torn by the fingers ; the 
nutrient vessels being loaded with venous blood. 
A section of the ventricles presented numerous 
small collections of dark-coloured pus among the 
muscular fasciculi. Some of these were seated 
near to the cavity of the ventricle, while others 
were more superficial, and had elevated the re- 
flected pericardium from the heart. The muscular 
fibres of the auricles were also softened, and 
loaded with dark blood. 

114. d. M. BouiLLAUD has described two 
other varieties of softening of the heart, which he 
believes to arise from inflammation. In the one, 
the muscular structure is of a whitish, or pale 
greuy colour ; in the other, it is of a yelUrw hue. 
— Whitiih or greyish softening he supposes to be 
the second stage of the red<lish brown softening ; 
and to indicate a further advanced stage of car- 
ditis. That such is the case, appears partly 
proved by its connection in some instances with 
suppuration, or purulent infiltration of the mus- 
cular tissue of the organ, although attended by 
much less vascular injection and congestion, than 
the reddish brown softening. Cor visa rt re- 
markf, that carditis renders, after a time, the 
muscular structure of the heart soft and pale ; 
the fibres losing their cohesion, and the connect- 
ing cellular tissue becoming loose, or infiltrated 
by a lymphatico*puriform matter. The parletes 
of the heart are torn with the greatest ease, and 
are broken down with the least pressure. {Op, eit, 
p. 257.) 

115. The third variety, or yellowish softening 
of Laennec and Bouillaud, often is manifestlv 
connected with chronic true carditis, although 
by no means generally. It differs from the 
former (§ 114.) only in its yellow colour; and 
is most frequently greatest in the interventricular 
septum, and the centre of the muscular structure 
of the ventricles ; the parts nearest the internal 
and external surfaces of the organ being less 
evidently changed, or presenting reddened points 
of the healthy consistence. — The second of these 
forms of softening was observed by me in a patient 
who died of the consequences of inflammation of 
the membranes of the spinal chord, many months 
a/Ur hstving experienced an attack of acute car- 



ditis, connected with articular rbenmatiMB (m 
Lond. Med. Repot, vol. zv. p. 26.) ; and, jadff> 
ing from the appearances in that instance, tki 
softening seemed to result frooi a change ia thi 
nutrition of the organ, conseqtient upon the i 
cedent inflammation of it. Booillaud coaii 
that its frequent coincidence with pvnilent 
sion into the pericardium, shows tnat it dcpcadi 
upon this latter circnroatance. The juster lefaN 
ence would be, to impute both the change in ihi 
substance of the organ, and the morbid l e c w t' wt 
from the pericardiac surface, to perverted ?» 
cular action, conjoined with impaired orgnie 
nervous power. That these are the true paih^ 
logical conditions, is shown by the circomrtaaflM 
hi which this, as well as the yellowish variety if 
softening, is found. — I have obsenred them btch, 
— this latter variety especially,— where there hii- 
been no evidence of cardiac diseaie, either at ny 
previous period, or in a chronic form ; and Mf>- 
ticularly in cases of general cachexia, ana d 
constitutional disease, attended by diicolovtliai--i 
of the surface of the body, — by a bloodless, jri»>'' 
lowish, or tallowy or waxy appearance of lh»^« 
integuments, — and by other signs of a poor « ' ' 
deficient state of the blood, consequent upon ii 
paired organic nervous energy and assimilatii^'^ 
as generally seen in the advanced stages of loeA' 
malignant or contaminating maladies. 

116. c. Ulceration if the heart may 
from an abscess, encysted or non-encysted, btp*^ 
ing opened either into one of the cavities, or ' 
the pericardium. In the former case, the ^ 
lent collection, and the subsequent secretioo' 
the diseased part, mix with the blood ; in 
latter, they accumulate in the pericardiac cani 
and increase a prc-existent pericarditis. 
Bouillaud suppcMes that they may <^mii 
ways, and occasion perforation of one of the 
partments of the organ. It is more probable thiV'-; 
after opening in one direction, the tissue 
rounding the abscess gives way, owing to the 
of substance, and to the softening conaeqi 
upon this lesion. That many of the caeti if 
rupture of the heart arise from this circumstueik 
will appear in the sequel. Ulcerations ai 
generally observed in the internal surfisce, 
commonly in that of the left ventricle. In 
mation having commenced in, or extended to,lkV' 
connecting cellular tissue, and having given 
at one or more points, to an effusion of a se 
or puriform fluid sufficient to detach the inteiMl 
membrane from its vascular connections, IIh0^ 
membrane necessarily lo^es its vitality at 
poinU, and yields before the matter underneath Ik 
Erosion of the endocardium, followed by aletf*^ 
ation, and limited softening, &c. of the 
stance of the organ, is thus produced; ik9 
number, extent, and depth of the ulcers bciaf ^ 
various. 

117. Ulceration, in its course through ^J 
substance of the heart, gives rise to cnan^ 
analogous to those observed after nlceratioe ^ 
arteries. The thinned and softened poitieu ^ 
the parietes yields before the ]>re8sure made 1| 
it by the column of blood, and a mnuh 
aneurism f or tumour, varying from the nie of' 
filbert to that of a large orange, is formed,-— i' 
cavity, as in the case of other aneurisms, beingoft** 
in a great measure filled with laraellated cea f^f^ j 
The aneurismal tumours, comequtnt vpoa uk*'' 



194 



HEART — iKFLAMMAtXON OT ITS STRUCTURE — DllOHOSIB. 



from pestilential yellow fever; and in a slighter 
degree from pestilential cholera. (Sec ait. Pesti- 
lences.) 

122. a. Notwithstanding the difficulty of deter- 
mining the existence of carditis, during the life of i 
the patient, Drs. Heim and Kkau^e believe that - 
a diagnosis may be made in some instances ; and, i 
judging from twocaites,in which I was consulted, 
and in which the opinion as to its nature was con- 1 
firmed by the appearances observed after death, I ^ 
nearly concur with them, especially if the disease 
exist m a very acute and fully developed form . 1 n ■ 
this case, the patient experiences a violent pain in 
the region of the heart, with anxiety, preceded or { 
attended by rigors, chills, or tremblings of the 
whole frame. To those succeed increased heat I 
about the prvcordia, or in the trunk, whiUt the , 
extremities and face arc cold, and the whole j 
surface is covered by perspiration, which is cold ' 
on the extremities. The pain is concentiati'd in ' 
the situation of the heait, is lacerating or rending, ■ 
accompanied by tlie utmost agitation and ex^ ■ 
pression of anxiety and distress, sometimes by 
screams, and occasionally by general convulsions 
and swoonings. The paUent feels every pulsation 
of the heart, rolls about to obtain ease, and 
presses his hand forcibly against the prapcordia. 
The chest is elevated, the head thrown back, and 
the face and hands covered with cold sweats. 
There is great thirst, but drink is refused on its 
reaching the lips ; and there is often loquacity, 
passing into delirium as the disease ailvances. 
If no vascular depletion has been practised, the 
pulsations are indistinct, or fluttering, or tu- 
multuous. After bloodletting, the action of the 
heart becomes more developed ; palpitations, at- 
tended by intense suffering, occasionally take 
place, and, at other times, syncope supervenos, or 
they both alternate. Immediately upon opening 
a vein, syncope or convulsions are apt to occur; 
but, upon placing the finger on the orifice till the ! 
patient recovers, the depletion can be carried to 
a great amount, with relief to all the symptoms. 
The pulse varies remarkably, but is gonerally 
unequal or irregular, and remarkably .small and 
weak, or indistinct. There is neither cough nor 
expectoration, nor vomiting ; but a frequent ex- 
pression of pain and diAtrei^s. The pain is in- 
creased by each contraction of the heart, so as to 
cause the patient to complain of palpitations, 
even when the impulse is not sicnsibly increased. 
If the disease is not soon arrested, constant jacti- 
tation, or tremor, rocuriing tits of syncope, deli- 
rium, and death, take place ; or, in consequence 
of the as'^ociation with it of inHammation of the 
internal or external membranes, and of the effu- 
sion of lymph, the ph(rnomeua, local and gene- 
ral, observed in the advanced stages of internal 
and external carditifi, su})crvene and constitute 
the chief characteristics of the malady. When 
acute carditis is associated with cither of the 
other vaiietictt, or pas>;cs into them, then the ! 
local and physical sign** proper to each will be | 
detected accordingly on percussion and auscult- 
ation. 

123. These are the most constant phenomena 
of acute carditis, according to the description of 
Dr. Hfim, and the history of two cases which 
fell under my observation. The seizure is gene- 
rally sudden, and the disease reaches its acme 
about the thhd day. In one of my cases, death 



took place on the fourth day. The patient (who 
was attended also by Dr. Walshx an and ano- 
ther practitioner) was about fifty years of age, 
and of a full habit of body. In the spring of 
1821, whilst labouring under an attack of rbm- 
mat'ism, he was recommended by some perMO to 
take a strong dose of croton oil. He took three 
drops, which produced violent purging and Tomit- 
ing. The rheumatism suddenly ceased, and wu 
speedily followed by the most distressing pain 
and anxiety in the region of the heart, and en* 
tirely conimed to it. There was no moiVid 
sound on auscultation, although nearly all the 
symptoms enumerated above were present. The 

fvatient was repeatedly bled, hut extreme rot- 
essness and jactitation appeared, and death by 
syncope soon afterwards took place. On diHcc- 
tion, the pericardium presented hardly any s^ 
of inflammation ; but the substance of the bait 
was inflamed, and portions of the internal sar&ce 
more slightly. The alterations, however, w«n 
not so exteusive as was anticipated; probably 
owing to the activity of the treatment, as me^cu 
aid was promptly procured and the disease at 
once recognised, and to the rapidity of the fiUal 
termination. In the other case, which occiimd 
more recently, and which was of longer duratioa, 
dark softening, as described above, was-voy 
remarkable, with the usual products of inflam- 
mation on both the internal and external meni- 
branes, particularly the latter. 

124. 6. The contecutive alteratwns on trve 
carditis are even more occult than the acuta 
stage of the disease itself. Indeed, as these alter- 
ations most frequently proceed from a sub-ants 
or chronic state of carditis, or from inflammatioB 
limited to one or two compartments of the orgaa, 
their greater obscurity is to be antidpm. 
When abscess or ulceration is followed by perf'tT' 
alion or rupture^ then sudden death takes pufe, 
unless the alteration occurs in the intenrentrici* 
lar septum. But the symptoms attending thea 
lesions, previously to their reaching a fatal exte^ 
have not been ascertained ; and it is donbtfid 
whether or not they admit of being distingniihei [ 
It is neces^tary to this end, that cases of mis kind ; 
should be carefully observed, and accurately di* 
scribed ; but there is none on record possessed flf 
either of these qualities. The same observatioH 
apply to the sacculated dilatation oraneuritm of iki ^ 
heart ($117.), consequent upon ulceratioQ v 
abscess. In none of the cases of it which hm 
been publL<hed, was this lesion either discovered « 
suspected during life. M. Urf.m:iift meatiaBi 
only the signs that may be expected to occir, 
not those which have been actually obserred; 
and M. Houili.auo advances no further. Inthi 
case detailetl by M. IIkynaud, an affection of ik 
heart was never indicated, the patient haviog 
died of a severe nervous diisease, caused by tin 
oxyde of lea<l, in a manufactory where he wroagfat; 
and the cases adduced by the authors refcmdtB 
hereafter furnish quite as little information. 

125. c. Softening of the heart, consequent apoa 
various grades of inflammatory action, is ia^ 
calod by a few symptoms, which, when duly 
wei;:hed in connection with the previous history 
of the case, may lead the acute physician to pre- 
sume its existence with some truth. Then aja- 
ptoms, however, taken by themselves, of^a at- 
tend other diseases characterised by extrema 



196 



HEART — Inflammations of — Diagnosis. 



unce then ; but nearly as much now is often lost 
by inattention to the physiological or rational sym- 
ptoms, as is gained by ascertaining the physical 
signs. Besides, as I have always resorted to 
auscultation and percussion since 1819, when I 
frequently accompanied Laennfc in his rounds, 
the disease was almost as likely to have been 
detected by me then as now. 

130. The next most frequent pathological 
conditions whence carditis, especially external 
cardit'is, may proceed, are pleurisy and pleura- 
pneumony, Ihe former disease may occur in 
consequence of the extension of the latter; or 
they may both appear almost simultaneously. 
I have even seen pericarditis give rise tx>, or fol- 
lowed by, pUuritis. Inflammations of the heart, 
thus associated, are most commonly caused by 
some one of the numerous modes in which cold is 
applied to the surface — or rather in which the 
animal caloric is carried off — when the body is 
perspiring, eitpecially after exertion or fatigue, 
and in the rheumatic diathesis. — Gout is also 
sometimc-s a cause of carditis ; and, I think, of the 
internal form of the disease, in preference to peri- 
carditis. Internal carditis occasionally appears at 
an advanced stageof,orduringconvalescencefrom, 
either of the eruptive fevers, it, as well as other 
forms of the disease, may also follow other fevers, 
and the complaints mentioned above ($ 20.). 

131. V. The Diagnosis of Inflammatiom of the 
Heart f may be inferred from the description I 
have given of the symptoms attending each of 
the varieties ; but as these varieties are often 
associated with each other, or in some measure 
pass into one another, as the inflammatory action 
predominates more or less in one of the constitu- 
ent tissues of the organ, so the symptoms will 
vary In different cases, and even in different 
penods of the same case. Attention, however, 
to the following circumstances, and groups of 
morbid phenomena, will generally enable the 
practitioner to arrive at a tolerably just conclusion 
as to the nature of the disease : — 1st. The situ- 
ation of the pain, in the more acute cases, and 
the tenderness, soreness, or pain on pressure 
felt in the left and upper part of the epigastrium, 
and in the left anterior intercostal spaces ; — 2d. 
The increase of pain on stretching upwards or 
backwards, and the inability to lie on the left 
side ; — 3d. The frequent extension of pain to 
the left axilla, shoulder, or arm, and the occa- 
sional numbness of the latter ; — 4th. The great- 
ness of the anxiety in proportion to the cough *, 
the anxious, haggard, or peculiar expression of 
countenance ; and the bloated or livid appear- 
ance of the face at a more advanced stage ; — 
5th. The state of the pulse at the wrist examined 
in connection with the actions and impulse of the 
heart ; the great frequency and irregularity of 
the latter, and the smallness, weakness, Uc. of 
the former ; — 6th. The palpitations and tend- 
ency to syncope, or the alternation of these sym- 
ptoms, and their connection with pain, anxiety, 
dyspnoea, restlessness, or jactitation ; — 7tn. 
The signs on percusMon and auscultation, espe- 
cially the sitigle bellows or blowing sounds with 
all its modifications ; and the double Jricliorit 
rubbing and creaking sounds : the former hav- 
ing reference to changes within the heart ; the 
latter to alterations within the pericardium, 
. 132. vi. The CostTLiCATio^s of Inflammations 



of the Heart have been already noticed in gene- 
ral terms ($32.). Inflammation of the intenai 
membrane, whether acute, Bub-acnte, or chnmic, 
is often associated with, or Mves rise to, pertevr- 
ditis, at an early period of its progress ; bat this 
latter is much more frequently complicated with, 
or occasions, the former. Signs of endocarditis are 
more commonly and more early detected in the 
course of pericarditis, than those of pericarditis 
are in the course of endocarditis ; and both may 
be further associated with inflammation of the 
cellular tissue or substance of the hearti or true 
carditis, in various degrees, or to a greater or lest 
extent, as respects the diflferent compartments of 
the organ. — A, Jntemal carditis b much more 
commonly observed in a complicated than in a 
simple state, especially when it is at all advanced. 
It presents itself in connection with the followiag 
diseases and probably in a ratio of frequency ap- 
proaching the order in which I am about to eiii« 
merate them : — 1st. With pericarditis and artici<' 
lar rheumatism ; — 2d. With pericarditis oaly;^* 
3d. W^ith rheumatism only ; — 4th. With pnes* 
monia, pertussis, and pleuritis ; — 5th. nitk 
inflammation of the bloodvessels, especially pUs> 
bitis ; — 6th. With eruptive, or adynamic fevoi; 
— 7th. With purulent collections or caries ia 
distant parts. Internal carditis, when aaoci- 
ated with rheumatism or with pulmonary sr 
pleuritic diseases, is generally also conoectri 
with pericarditis ; but when it supervenes is tbs 
course of phlebitis, or of fever, or from Mm 
cause which contaminates the circulating fioidi, 
then it is generally unconnected with pericaidittt, 
although the substance of the heart may be 
or less implicated, or even softened. • 

133. B. Pericarditis is also much 

frequently met with, even in its early stsges,iB 

a complicated than in a simple form — genienlly 

in connection — 1st. With internal carditis, either 

acute or chronic; — 2d. With articular rhes- 

matism ; — 3d. With both internal carditis and 

rheumatism ; this being oftenest observed ; — 4tli. 

With pleuritis, either pulmonary, diaphragnatiCi 

or costal; — 5th. With pleuro-pneumony ; ^ 

6th. With inflammation' of the- diaphragm V 

mediastinum ; — 7th. With true carditis ; — 8tli» 

With peritonitis; — 9th. With inflammation of 

some one of the abdominal viscera ; — and, 10th. 

With eruptive fevers. Two or more even flf 

these complications may exist in the same caie, 

especially internal and external carditis, pid^ 

ritis and articular rheumatism ; pericarditis, dis* 

phragmitis, and pneumonia, &c. A body vu 

lately brought into the dissecting-room of the 

Middlesex Hospital medical school, in which the 

liver was found inflamed and enlarged. It had 

j formed adhesions with the diaphragm on oM 

side, and with the adjoining viscera on the odicr. 

i Between these viscera and the concave surface 

. of the liver, the adhesions formed a la^ ne 

. containing a turbid scrum. The pertesrrfiw 

I and diaphragm were inflamed, as well as the 

pleura on both sides. The pericardium aod 

, pleural cavities contained much turbid thick 

! serum. — W'hen pericarditis is associated with 

peritonitis or with inflammation of some of the 

abdominal viscera, the additional complicatiooof 

pleuritis, especially diaphragmatic pleoritii ^ 

the same side, is not infrequent. BociUAvp 

adduces an instance of splenitis, diaphngaiii^ 



198 



HEART— -Inflammations of — Treatment. 



whether acute, sub-acute, or chronic, has given j 
rise to effusion, an unfavourable opinion ought to 
be entertained of it, and especially if the patient 
be far advanced in life, or of a cachectic habit 
of body. Whether the effusion be puriform, or 
sero-sanguineous, or pseudo-membranous, or sere- 
albuminous, the question is chiefly as to the 
length of time that may elapse before a fatal 
issue takes place ; much depending upon the sym- 
ptoms and signs indicative of tiie amount of 
effusion, upon the states of the pulse and of the 
respiration, and upon the ^e and vital energies 
of the patient. When the effusion follows rapidly 
upon an acute attack, especially if there has been 
great frequency of pulse, and depressed consti- 
tutional powers, the danger becomes much more 
impending, than when effusion takes place more 
slowly and to a less amount. If pericarditis be 
associated with endocarditis, as indicated by the 
bellows sound, or by any of its moJifications, or 
with pleuritis, pleuro*pneumony, or diaphragmitis, 
the danger is thereby increased very greatly — 
and increased in proportion to the intensity or 
extent of these inflammations. When the sub- 
acute or chronic disease has given rise, at more 
advanced periods, to adhesions, or to false mem- 
branes (§ 107.), the actions of the heart and 
diaphragm may be much disordered, and the 
functions of respiration, and of circulation in re- 
lated or remote parts, greatly disturbed; but 
these consequences are not always observed. 
Patients have lived for years without much dis- 
order being complained of; although more fre- 
quently these functions, particularly the latter, 
are more or less deranged — impeded circulation, 
or effusion into some cavity or organ, sooner or 
later taking place. 

139. C. Of the prognosis of true carditis it is 
unnecessary to speak. If it be presumed to 
exist, the opinion of the result should be unfa- 
vourable, inasmuch as a degree of inflammation 
of the substance of the heart so intense as to be 
recognisable, generally induces the most serious 
changes either on one of the surfaces, or in the 
structure of the organ. If the symptoms of 
tofuning of the heart ($ 125.) be such as to ad- 
mit of recognition, with any degree of confidence, 
the prognosis is extremely unfavourable, unless 
this lesion have taken place in fever, when a 
more favourable opinion may be entertained ; 
recovery sometimes taking place during an ener- 
getic recourse to tonics, clialybeates, change of 
air, ficc. The other conse(|uencos of carditis 
need not be noticed at this place, as they 
rarely admit of recognition during the life of 
patient. 

140. ix. Treatment of Inflammations of 
THE Heart. — The different forms of carditis 
require very nearly the same means of cure, the 
chief modifications consisting in the extent to 
which vascular depletions should be carried, in 
the vaiious circumstances that usually present 
themselves; and in the choice of additional 
agents for averting the more serious changes, 
which are apt to take place. — A. BlttodletUng 
is necessary in the three varieties of carditi.=), and 
especially when either of them is associated with 
pleuritis, or pleuro-pneumony ; but the utmost 
discrimination should be exercised as to its 
amount and repetitions. In all cases, it should 
be employed etu-ljr ia the disease, and the quan- 



tity of blood taken away ougbt to be in due reli- 
tion to the violence of the attack, to the age and 
constitution of the patient, and to tbe effects 
produced. In general, vaicalar depiction may 
be carried further in periearditii, than in interaal 
carditis, and in the complicated, than in the 
simple disease. The practitioaer ought not to 
be deterred from bleeding by the weakneM and 
smallness, or irregularity of the pulse, or by the 
faintness complained of; nor induced to carry it 
too far, by the palpitations, and inordinate un- 

Culse of the heart, and by the cupped and 
uffed state of the blood., if carditis be con- 
nected with rheumatbm, this state of the coagu- 
lum will continue, although depletion be earned 
to inanition. I have seen it greatest in the blood 
last taken, where I was confident that the de- 

fdetion had been carried to a very dangeroai 
ength. In these cases, the disease is partly in 
the blood itself ; there is a redundancy of 
fi brine and albumen, and an increased disposition 
to their coagulation. 

141. fi. Internal carditis, unlets when aKO- 
ciatcd with pericarditis, is not so much benefited 
by very large bloodlettings, as may be supposed, 
although decided depletion, especially early m 
the disea<)e, is required. M. Bouillaud thub 
that this treatment should be carried further ia 
endocarditis, than in pericarditis: but I diftr 
from him in this ; for the danger which he en- 
deavours to avert by repeat^ venesectioM— 
and by them chiefly, if not solely — may be mat 
certainly and safely prevented by the meat 
about to be noticed, when prescribed after mora 
moderate or less frequent depletions than he r^ 
commends. Besides, internal carditis aonetimei 
occurs in cases where bloodletting had beet 
previously and even copiously practised ; u wdl 
as in others where it must be very cautiooily 
and moderately resorted to. In all the fonm 
of carditis, and particularly in pericarditis, it ii 
I often necessary to repeat the venesection oileDer 
than once ; but as often, after one modente 
or copious venesection, cupping will be tbe bat 
mode of abstracting blood. Indeed, asuffidcot 
quantity may be taken away by this mode froa 
I tne first, if the operation be properly perfcffmed* 
. When the symptoms are severe, and the diseSM 
fully developed, the depletion should he prompt, 
: copious, and repeated according to circumstancei; 
I but care ou^ht to be taken not to defer the f^ 
j petition of It until the recurring inflammafioo 
proceeds far: the least indication of unsubdued 
I action, or the earliest sign of a return of the 
disease, requires that this means should be apis 
I cautiously resorted to, aided, however, by tke 
^ remedies about to be noticed. In the circon- 
stances under consideration, nervous excitement, 
or irritation, may be mistaken for unsubdued iip 
Hnumiatory action. This may become a dangcront, 
if not a fatal error ; and acute observation wti 
' enlightened experience can alone guard agaiast 

' 142. C. After bloodletting, the rapid io- 
duction of the mercurial action is of the gieateit 

.importance. With this intention eatonW shoiM 

' be given, every four or six hours, with o^tm 
and small dosea o( turtariud antimonjr.or Jamei^ 
powder, or with colchicum or digitalis* TbeM 
medicines act beneficially, not only by abatiog 

', the morbid action of the heart, but abo by '9- 



206 



HEART — HypERTROpBT or — its Influencbi. 



lesions of the heart, particularly with Buch as 
impede the free egress of the blood from the left 
ventricle y as disease of the aortic orifice, the 
symptoms of cerebral disorder are then much 
less conspicuous; and that dyspnoea, tendency 
to syncope, and dropsical etfusions, are more 
marked. — M. Bouillaud found, out of fifty- 
four cases of hypertrophy, in some of which the 
right ventricle only was affected, and the left 
one not at all, or very little so, that there were 
eleven with cerebral disease, six with apoplexy, 
and five with softening of the brain. In five of 
these eleven, the cerebral arteries were ossified or 
cretaceous at one or more points. In six of these 
cases, the hypertrophy of the left ventricle was 
excentric, in three it was concentric, and in two 
simple, 

171. Dr. Watson (^Lond. Med. Gas, April 6. 
1835.) has made some very judicious remarks upon 
this subject ; but in all the material points, pai^ 
ticularly in the explanation of the connection be- 
tween diseases of the heart and brain, he has been 
anticipated by the observations 1 have offered 
both m the papers referred to above, and in the 
article Apoplexy (§ 96.), where I have suc- 
cinctly given the results of my own investiga- 

.tions. The views there entertained} as Dr. J. 
Johnson has done me the justice of stating 
(Med, Chirurg. Review, April, 1836, p. 5]2.)> 
in an able inquiry into this subject, arc fully con- 
firmed by his own experience, and by the more 
recently published researches of MM. Bouil- 
laud, Urichltkau, and others. — As the para- 
graph referred to in the article Apopllxy has so ' 
fully and completely anticipated the results, at 
which subsequent writers on this subject have 
arrived, I have only to reiiuest the reader to turn 
to it, especially as I have nothing further to add 
to it. 

172. b. The injiuence of cardiac disease on 
pulmotuiru hemorrhage has aUo been adverted 
to in the article H^.mohrhage ($ t30. 115.), M. 
BouiLLAi'D found this form of hsmorrhagc less 
frequently to arise from lesions of the heart, than 
that just noticed. He has adduced only three 
instances in which it seemed to depend upon 
hypertrophy of the right ventricle. And M. 
Bertin, whilst he admits the occasional con- 
nection between pulmonary apoplexy and hyper- 
trophy in this situation, considers it not common. 
A more intimate and more frequent dependence 
of the former on the latter has recently been 
contended for by M. Bricheteau. A different 
view of the connection between pulmonary 
hxm(/rrhaee and cardiac disease has been lately 
entertained by Dr. Wilson and Dr. Watson, 
particularly the latter. The de{)endence of drop- 
sical effusions within the chest upon organic 
lesions in the left side of the heart, has been 
long known ; but the connection between 
hemorrhage from the respiratory surfaces, and 
these lesions, had been entirely overlooked. Mr. 
A. Burns seems to have been the first who took 
a judicious .view of the subject. He observes, 
that the pulmonic vessels, by the congestion oc- 
casioned by cardiac disease, and the continued 
rii ii tergo, are ruptured ; the blood being forced 
into the air-cells, or into the cellular structure of 
the lungs, until this organ appears like liver, or 
sinks in water. Dr. Watson has very fully shown 
that the pulmonary hsmorrhage rarely depends 



upon hypertrophy of the right Yentriclc, hoi 
chiefly upon narrowing of the left auricahH 
ventricular orifice, or rigidity of the mitral valve. 
Indeed, hypertrophy of the right ventricle sekkn 
exists without disease at the origin of the poU 
monary artery sufficient to countenct the in* 
creased action of the ventricle. It is, thereSMc, 
the obstructed return of blood from the lugib 
and but rarely the increased impetus occawmi 
by the hypertrophied right ventncle, that cum 
any of the forms of pulmonary HjwoBBiAOk 
($ 107. 115.). M. Bertxn admita tlM ifr 
fluence of narrowing of the left anriculo-fti^ 
tricular orifice in the production of hi iiiiHiliifi 
into the lungs, and considers the hsmorrb^ 
thus ca\ised to be of a more mdoal and pi^ 
sive kind, than that produced by hypeitnipkj 
of the right ventricle. Dr. Towmbekd (Cjpdhpu 
of Pract, Med. vol. i. p. 138.), states, that if 
twenty- two cases of pulmonary apoplexy ai- 
amined by him, more than two thirds octa i wt 
in persons whose hearts were diseased, aiid ii 
two only of these was the hemorrhage connecUd 
with tubercles ; but he has neglected to aMfli 
the particular lesions of the heart observed ■ 
these cases. The very freouent dependenea rf 
pulmonary apoplexy on cardiac disease hM ben 
msisted upon, also, by Cdoxel, Akdral, Civ> 
vEiLHiER, Bouillaud, Hope, and otbera; bal 
with a great want of precision as retpecli At 
seat and nature of the primary malady. TkH 
cases sometimes occur, in which hypeitnnhyrf 
the right ventricle is associated witli narrowngrf 
the left auriculo- ventricular orifice, in the p»* 
duction of pulmonary hemorrhage, is shows Igr 
an interesting case recorded by Dr. Law (Cffdm 
of Pract, Med. vol. ii. p. 403.). A yoaog Mr 
had repeated hemoptysis, with pa1pitati(»i8,wUn 
were more frequent and profuse until death. BiA 
lungs were found engorged with blood, &c. Hi 
right ventricle was nypertrophied and dilated; 
the left auricle dilated and thickened ; the M 
auriculo- ventricular orifice contracted so as harff 
to admit a quill ; and the left ventricle contiacwL 
The pulmonary artery was dilated and thickaai; 
the aorta was smaller than natural. In this cM 
the congestion of the lungs, consequent sfM 
obstructed circulation through the left side of iki 
heart, had not only caused hemorrhage, batil* ^ 
hypertrophy, of the right ventricle. 

173. It is, moreover, very probable* M I 
have stated in the article Hae:morrhacx(§115^)i 
that when the more powerful moral emotioniii* 
productive of hemoptysis, this effect is owing ii 
often to their impethng the circulation thnm 
the left side of the heart, as to their exciting ns 
action of the right ventricle ; and that, whealiN 
same emotions occasion apoplexy, palsy, or VBJ 
other cerebral disease, they act as frequently I9 
interrupting the current through the right ade,!! 
by inducing inordinate action or hypertrophj cf 
the left ventricle. — It is, however, to be fi^ 
sumed, that the opposite passions produce ojif^ 
site effects upon tne heart, and that,vhilsttinor, 
fear, grief, anxiety, and other depressing paiMM 
impede the circulation through this organ, ad 
cause congestion of its cavities, thereby favoniig 
the occurrence of hemorrhagic or lerooi cfa- 
sions, either in the head or in the chest, tks 
exciting passions, as anger, deure, revenge, &c., 
accelerate and increase the force of the dtco- 



208 



HEAllT — IIvPERTnopiiY of — Tebmikatioxs — "Pnoavosna 



— In simple hypertrophy, the countenance retains 
its complexion, or w more than usually florid ; 
but when there is dilatation, and in proportion 
as the enlargement is complicated with ob- 
structed circulation, and as the obstruction ex- 
tends to the lungs, the lips, cheeks, and even 
the nose, pre-^ent more anu more of a purplish 
tint, and the general surface assumes a sallow and 
cachectic hue. — Apoplectic , paralytic, or con- 
vuUiLe attacks^ and pulmonary lnEmorrhage, have 
been already noticed as consequences of hyper- 
trophy, particularly of its more complicated 
states. Epistaiis sometimes occurs, and prevents 
or defers the occurrence of either of these, or of 
some other serious symptomatic malady. 

178. c. The iign$ and symptoms of hyper- 
trophif of the individual compartments require 
some notice, those just mentioned having refer- 
ence to this change of the ventricles generally. — 
The physical signs of hypertrophy of the auricles 
cannot be stated with any precision in our pre- 
sent knowledge; but, as this change is usually 
associated with hypertrophy of the ventricles, 
the distinction between them is not material. — 
Hypertrophy of the left ventricle may be recog- 
nised by the following signs: — The impul^^e of 
the heart is greatest under the cartilages of the 
fifth, sixth, seventh, and eighth left ribs; and in 
this situation there is the most dulncss on per- 
cussion, and prominence of the thorax. The 
pulse, if there is no obstruction at the aortic 
orifice, is strong, tense, full, vibrating, or hard ; 
the face is flushed, and the patient experiences 
throbbing headachs, giddiness, and sometimes 
even epistaxis. — Hypertrophy of the right ven- 
tricle is attended by a palpitation, or an impulse, 
which is strongest under the lower part of the 
sternum, where, also, is the greatest dulness on 
percussion, especially if this lesion be not asso- 
ciated with hypertrophy of .the left ventricle ; 
and the pul^e possesses neither the force nor 
tension observed in this latter alteration. There 
are commonly more or less dyspnc&a, short breath- 
ing, cough, and subsequently expectoration and 
lividity of the face ; but, as 1 have shown above 
(§ 172.), these symptoms arc still greater, and 
more frequently attended by hsmoptysis, when 
the lungs are congested in consequence of intvr- 
rapted circulation through the left side of the 
heart, with which, however, this form of hyper- 
trophy is occasionally associated. Turgescence, 
pulsation, or undulation of the ju«;ular veins, 
was noticed, as a symptom of this alteration, by 
Lancisi ; was rejected by Corvisart ; but ad- 
mitted by Laf.nnec, and Hope. Beutin and 
Bouii.LAUD consider that it is present chiefly in 
hypertrophy with dilatation, extending to the 
auricle, and when the right auriculo-ventricular 
orifice is imperfectly shut during the systole. 

179. F. Terminatums and Prognoiis, — a. As 
long as hypertrophy continues simple, and mode- 
rate in degree, the patient may experience but 
little inconvenience from it beyona slight dys- 
pnoea and palpitations, particularly on exertion. 
But if intemperate living be indulged in, or great 
corporeal exertion be resorted to, the disease will 
increase rapidly, and will lead to further change 
either of the heart or of the more immediately 
related organs, especially of the brain and lungs. 
The progress of the malady will consequently 
vary with the peculiarities and complications of 



the case, and with the habits, occupattons, and 
treatment of the paUent: — The terminatums of 
hypertrophy depend also very much upon the 
same circumstances. In its ample states, apo- 
plexy and acUve hemorrhages are its occasioiial 
consefiuences ($ 169.) ; but, if these resalt not 
from it, the patient may live many years. When 
hypertrophy is attended by much dilatation, the 
symptoms are more severe, and its course mora 
rapid. It does not so frequently cause apoplexy 
as the foregoing state ; but it is generally accom- 
panied with greater disorder of the respiratory 
functions. Dr. Hope remarks, that, when this 
form of the disease demands, owing to the pal- 
pitations and dyspnoea, periodical bleedings it 
short intervals, it hurries with an uninterrupted 
course to its fatal termination. In the majority 
of such cases, however, bleedings are not tbie ap« 
propriate means of alleviation. 

160. Both the progress and termination of the 
malady, and consequently the prognosb, man 
especially depend upon the pathological cami 
and complications of it. \> hen these coBWt 
of diseased valves or contracted orifices, ths 
hypertrophy and dilataUon usually proceed to a 
greater extent, and the balance of the cim- 
lation is more disturbed than in the simple bt» 
of the complaint. In such cases, congestipu 
and even effusions of blood, or of serum, gese- 
rally supervene, either in the substance of im- 
portant viscera, or on venous or serous surfam, 
and occasion various consecutive maladies, ic^ 
cording to the particular lesion of the heait, $ai 
to the consequent seat of congestion, effusion, a 
infiltration of parenchymatous structures. Hcnei 
result pulmonary hemorrhage, &c.» oedema, or 
effusion into the bronchi, or into the pleanl 
cavities, &c., followed by asphyxy. Abolilioi 
of the functions of the lungs causes stupor, or 
accelerates the alterations which often take |dtce 
in the brain, especially congestion and fan- 
guineous or serous effusions. Or these latter 
arc the first to occur, especially when the pn> 
mary lesion is in the nght side of the heirt 
(§ 169.). 

181. b. The prognosis, it is evident from tke 
foregoing, is generally unfavourablct especially 
in the more complicated cases, in proportion to 
the extent of lesion of the orifices and valves, and 
where hypertrophy is accompanied with adheoen 
of the pericardium. — Debility, age, a cachectic 
habit of body, and disease of the lungs, also in- 
crease the danger, or rather render it m^e isi- 
mincnt. — In the simple states and early stagcf 
of the malady, when the constitution is not im- 
paired, and when the patient can be subjected to 
appropriate treatment, and is so circumstanced 
as to pursue it, the prognosis is much more/i* 
vourahle ; and, although the alteration already 
existing may not be diminished, its progress miy 
be arrested. 

182. G. Treatment. — The circumstancei 
which influence the terminations of hypertropbfi 
and the prognosis of it, should also control the 
treatment. The simple form of the malady, par- 
ticularly in young: and otherwise sound penou, 
requires very different means from the contpli* 
cated, especially when occurring in broken-down 
constitutions: in the former, vateular tfc^ 
tions may be employed, and repeated from time 
to time ; in the latter, they require great caution 



210 HEAUT — Dilatation or its Chambers akd Orifices. 

a free diAchar^ is procured by scions or issues — I atcd than the other parts. The diUtatioiiia more 

which are especially iodicated wheu the hyper- in the transverse than in the longitndiiialdireeuoa 

tropliy iias been consecutive of rheumatic disease ■ of the ventricles ; the heart thereby assnmiiig a 

of the heart, — a gently tonic treatment will be : spherical form, and the apex being nearly eSiced. 

often requisite ; and if any preparation of colchi- i When both the ventricle and auricle of tbewne 

cum be exhibited, it should be given with cam- > side are much dilated, the intermediate orijin n 

phor or ammonia, or even with stomachic or . generally also widened, and the Ttlve infu^eimt 

gentle tonics. 1 to close it. As in cases of hypertrophy, ihc 

ii. Op Dilatation of thf. Ciiambkas and position of the organ is somewhat altered wbei 

Orifices of tiik Heaht. — Syn. Cordis the dilatation is great, it being more or less traH- 

AnettrUma, Dalloniuo, Uaglivi ; Passive AneU' verse, and towards the lcf>. A very slight attei- 

rism of the Heart, Corvisart; Cardieurvsma, tion is suflficicnt to distinguish the distension thit 

Cardiectasis, Auct. ; E.ipansiun of the Heart's takes place, during the last moments of life, fn« 

Cuvtties, 

187. Char AIT. — Slight palpitationSf with 
difspnira and couj^h ; the impulse of the heart 
being tceak and diffused ; the sounds being louder, 
clearer, shorter, and heard over a larger extent of 
the chest, than natural ; and the puLse being weak, 
small, or irregular. 

188. A. Di:scniPTtov. — Dilatation (a) may 
affect e([ually the whole parictes of one or more 
of the cavities; or (h) it may be so confined 
to a portion of the parictes of a chamber 
as to form an aneurismal pouch. — «. The 
first of these varieties usually presents itself 
in three forms : — 1st. ll'if^ thickening of 
the icalls of the compartments j — 2d. With 
a natural state of the walls: — and, 3d. With 
attenuation of the walls, — The first of these 
has l)een considered in connection with hyper- 
trophy ; and most of the remarks made with 
respect to it, also apply to the second of these 
forms. It is chiefly, therefore, to the third, or to 
dilatation with attenuation of the parietes of the 
chambers, that attention is now directed. — The 
muscular substance of the heart \s often healthy, 
although dilated ; but it morv frerjuently is soft, 
flaccid, or even remarkably softened — especially 
when tiic attenuation, as well as dilatation, is 
jireat. Sonu'time? its structure is readilv broken 
down by the pressure of the finjjer, and i* of a 



morbid dilatation. The former is slight, pr 
the appearance of tension, and the muscular nb- 
stance is healthy ; the orean often resuming ill 
natural size when emptied. The latter codshIi 
not only of distension, but also of flaccidHy, 
thinning, and softening of the parietes. 

190. b. Partial dilatation of one of the kent*! 
cavities is but rarely met with. M. BEimi 
states, that he has seen one portion of a cavity 
dilated, and another in its natural state, or evn 
thickened, especially in the right ventricle, Mir 
the pulmonary artery. This is evidently a sligfaWT 
grade of that lesion which has attracted, man 
recently, considerable attention, under the tppil- 
1 at ion of ** false consecutive aneurism'* ( Brescbct), 
** sacculated aneurism,** and " fme aneurism ^ 
the Aeart*' (Olli VI er). This alteration has beet 
observed by Gai.fati, Bvttner, Cobvjsiit, 
Haii.mf, Zanmni, Blrard, Rostav, CauvEit* 
iiiLit, BRLsniKT, J. Johnson, Elliotsov, Aiun, 
Dantf, Keynaud, &c. It was found in iki 
heart of Talma, the celebrated French traseiKai 
It is exactly similar to the aneurism of lii|R 
artorie-i, and has been met with only in the irto> 
rial side of the heart ; and, excepting in a nagle 
case re<?orded by Dr. Kli.ioi«ov, where it exifM 
in the left auricle, alw.iys in the left ventride* 
In many of the case.^ it was found at the ipei; 
in some at tiie base, or at the middle of the to> 



deeper or daiker rod, or of a ])aler or more fawn- ' tricle ; and in others at the front, or side. Ii 
colour than natural. Tlie more reiuarkubh- states tlii-* last situation it was detcctcci m Talma. !b 
of softening: observed in connection with dilata- ! the instances which occurred to IIeynacd vk 



titm have been con<iecutivc of iuflaniiuatiun (»f 
one or other of the surfaces, probably extending, 
in some degree, to the substance of tiie heart ; 
and occurring in debilitated, previously diseased, 

icachectic constitutions. 

189. This lesion of the heart is much rarer 
than dilatation with thickenint;, or with a natui-al 



Klliotsov, two aneurisms were found in Ibi 
same ventticle. ThL« form of anenrismal tanoir 
varies in m'sp from that of a filbert to that of tbr 
heart itself. The larger tumours usually contais 
layers of dense coauula, similar to those wlsek 
fill the cavities of arterial aneurisms. They c<M- 
municate with the ventricle by a more or k0 



state, of the parietes of the cavities; and the 'narrow opening, which, with the whole of dwr 
instances recorded of it are not numerous. I. an- : interior surfaces, is generally lined with a mesH 



<isr, MoiujAGNi, Coiivis\«T, litn-»i.v, KnE\sir:, 
J. FinNK, Lainsh, l.oiis, and IIoit. have 
described but few cases of it. Hchns and 
LAiiXM«; believed that lupture mi'^lit proc:eed 



brane continuous with that of the ventricles. Lfts 
other aneuri&ms, they arc most common in ndill 
males. 

191. r. X)\\aiaiion of the orifices of the keert 'a 



from dilatation ; and Dr. llorr and [)r. Wir.- not less frequent than expansion of the cavitis; 
LiAMs have nut with this occurrence, which is . and often c<H'xists with it. The orifices msf bs 
most likely to take place in aged persons. Dila- dilated in various degrees, as already shows 
tation with attenuation seldom afl'ects one vontii- ' (f 13!'.) ; but generally, when the cLan^^ i* 
cle without the other; but it is more coiiinion, or . very considerable, the valves become insuffiaWt 
greater, in the ri^dit than in the left ventricle. It . for their purposes, and the expansion, owiD|[ to 
more rarely is seated in all the chambers of the the reguriritation into the auricles, extends to 
organ. The attenuation exists in various degrees. ' thL>m. The auriculo-ventricular orifices are noit 
It may be so extreme, that the walls of the ven- freciuently dilated ; but in very rare instances, tte 
tricles hardly are e([ual to two lines at the thickest i arterial orifices have experienced this alterawnia 



parts (Hon: and Chomki.). The ileshy columns 
are usually stretched and spread out. The inter- 



renlrJcuIar septum is proportionately less attcuu- and immediate, of hypertrophy, are also tbofe 



a slight degree. 

ll)'2. Ii. CauMs.— a. Most of the causes, remote 



214 



HEART— CoNTs*e 



heart from iiftax, ii rarely oWrvetl in a tcmark- 
ublo degree. Slight gradeH at' it arc, Iiouevcr, 
not UDCommon, especially in wasliug diseawd, as 
phthisia, mcHntenc obstructiuni, and cliorea, al- 
though tho atrophy of tliia omn ia not so coii- 
ndurablc, nor w rapid, n< m other muwie*. 
Otto allributeE Ibis to the want ol cellular It^nue 
btlwcen the muscular fa».'iculir—PoRiAi.,Tfsi A, 
and Kreviio suggest, that the seeming diiuinu- 
liou, caused b^ the violent contraction of the 
o^an, at the lime of death, should not be con- 
founded with atrophy of it. True atrophy is 
accompanied with attenuation, rafiues^, or pale- 
ness, or liardenin|{ of the structure, or Willi a 
shtirelli'il or wrinkled appearance of the surface 
of the viicus. It may be to considerable as In 
reduce tlio organ tn one halF or one Ihiid its 
natural weight. 'M, Ciiohel found the heart 
not larger Ihan a hen's egg in a man «ho died in 
the hos^HUl La ChariK. A» respects its form — 
lat. One or more of tlie coniparlmenu are at- 
tenualed without any change in their capacities, 
the heart beinc; but slightly diuiinialicd in hulk ; 

— 2d. With attenuation tlieie is much more 
rarely diminution of the caparitien of the cham- 
bers, ihc organ being very much 1e<iscned in size ; 

— and, 3d'. With diminution of the cavhies, the 
parictcs may be of the natural thickness, or even 
above it : tliit is tho most frequent fonn o( 
atrophy. 

309. B. The CninMof atrophy of the heart are — 
1st. Local; — -lA. 3fi«\i(; — and. 3d. tWililu. 
liimaL — a. Of the ^nt, the mo^t common arc 
compression ariringfrom llie pressure of ninttert 
cffuswl into the pericanlium, or from tumoun 
developed in the mediastinum, and constrii-lion 
or other changes of the cnrnnaiy arteries, espe- 
rially ossiKr deposits in their eoits, &C. I iluubt. 
howGVLT, the ioniicnce of compression fcum these 
causo^, as the lieart is very rarelv found atrophicil 
where the |(rratest amount of c^umoii Ims CKisteil 
in the pericardium. In tlic case referred to hi» 
low, where thrre olifiimtly Li extreme atrophy 
from iM-al csu'U'<s iliv previous efliivion never 
(ecmed to have been very gml.' — b. The nam/ 
fOMiti ponnii't of mental anxiety, and all llie do 

• Tbe Killuwliig rvp la diimilar : —A Rlri, it the agcot 
Heven jrvArpi, wa* altnritvd with rbcviutiBm of the Julnta 

tnlliEiwIrarJluin,— lliefurnwr anction inllndiiiF tnr. 
Hilly ■• lairii'snlitii >a> drvrlaimd. The Irrumflil, 
nrntintirif in ihc naif in iiBr. lAl, was (nncinwd, and the 
iliioiir urarly lilMnviTnl. But Ike peitrar^li Ktunied 

lar Liiirrrali ; iniL in ihf Mnmil and third aiiwfts the 

tn* rtulunittid ; rccuTery aveiiinl imiTe rrjnjiietp, ukI the 
iw (MI ditmtHrd. AIhibt etght or nlue imntlii alter- 
wanlsthla ehihl irai biiwRht in iof wUh Ihr Inn half 
■r(be>tsnniiii,aiidlliociiilili|n^(irihr kit lUa.vhkh 
iri'Ctf tutmtt\f iimlulirniiil, ilnailiK hirkBanli Inwards 
till. >|>l^■f,^B B loliim adn}! uhI lunc drprT><loii Id 

an almpliinl'brail In Ik- twtwnii Ihe splu* and Ike 
dvprvMen. ITie qrifrsatrlnm was drawn iitwanlii, and 
upwAiili, OB ndi craiiTaclim of Ihc vmliii*.*. In this 
ra«, whirb was seen aim Iv Mnat or ny oiIIhiiuh at 
tligMuMle»xH(i>piI*l.lbein>e*Ii!d altxrka oTiieftcaT. 
dltis baa kIthi rise to atlbHrDns M Ihe iieticardlinii In 
the heart, anil pmbably also tu the iitcinat to lhi< 
■UDptaT hid lUCRedAl i and the sleniHin hid Iwea 
dian Inwards wiib the Kaitad bean. This chiU was. 

pulaMlnn, of a mnfused k'ind^rfilHl>ly DwinK In the 



ITS CaviTiEs AKt> Oamns. 

Eresung paasioDS, particularly when their actios 
OS been piolonged. — c. The ^anarat caaiti an 
whatever arrests the nutrition of imucnlar atnte- 
tureli and yet the heart seldom participates ii 
the change i>f these parts, or only in a iliglil 
degree. In the diteates jnat menlioned (^ 218.), 
more or lest atrophy issomelimes met with ; bat il 
seldom bears any relation to the wasting of tlit 
voluntary muscles. In a rtie of luberrular nm. 
sumption, in which death occurred iostintaaa- 
eusly, before ulceration had coronwnced, iid 
before emaciation had become connderabla, tba 
heail was small and llabby, and the paiieles if 
'hat attenuated. The bo« 



,arkc<[ c: 



'S of a 



h 1 have 



OS OUM. I 

pnlse is small, thready, and mM i 
there is commonly m 



in peraons who had died after attacks of choiM 
and cliloroas, and after bypochondriaait indd^ 
tress of mind. 

31U. (-. The S,u»i^(«ini are seldom sncl 
indicate, with tolerable certainty, the eiista 
atrophy of the heart, unless it l*e very coi 
able. In this case, the impulse is weak, li 
or small ; the sounds are indistinct, or hiat, ■ | 
proportion as the ci ' 
city ; and there it 
cussioQ, The u ' 
freijucnt ; and tr 

loss of colour. Yet emaciation can hanUy ti I 
reckoned us a ugn of atrophy, as '" ~ ' '~'~ 
iiucntly accompanies hypertrophy of this rniaa. I 

311. /J.Thern-iil>nri'(arthisle.'>ioD>be«Ula j 
dircclcd — 1st, to the remnval of the ci 
far as it can be accomplished ; and, 2dly, to tW 1 
restoration of the liealthy nutrition of the otpl. 1 
The latter of these intentions will be beat » | 
complishcd by nttenUon ^o the digestifs ■>' 
assimilative funitions, and by the use of ckh 
bente laediciocs and mineral waters, with lailw 
eiercise in b dry and Icmpcrale air; and ll 
ulher meaas rei'onimrnded for r'uncliaaal A 
arden {i 60—53.), tat i^uiiing (j 231.), s* 
for dilalatha <$ 200.) of the heail. 

212, iv. C. " - 



Onir 
of one or more of the 

ri'HftHlrie hiiivi 



parietes (% \SL]i 

alri^ihy of tlie heart {j TM.);— 

the prcaiuri! of lumaurs, or of eSiast 

at the companmcati ■ 



3d. fro 

fluids, u 

ihc organ ; - 

lymph ur of iilnine. recent or organised.— Tli 

Aril, letiHiil, and lAirit of these moctnd inbi 

have received alteniion at the places referred la; 

the /aunt will be fully c -^^ 

From whatever of these c~ 

capucity of the c: 






lesion becomes so great as to materially doa^ 
the circulation, especially venous cosnWM. 
■ml serous etTuuons and intjllr^liuns. V\ hen lit 
cavity of the lefl ventricle isduniuislied, tbepihs 
is small, as in narrowing of Ihe aortic orifice, 

313. H. CWfrartwH n/ (he priori of tlie bwl 
may proceed from the same change* as [indMt 
diniinuiiim nf the cavities; but it most freqiMA 
ii a more or less immediate resalt of iaictaM 
caid.'tis, ami allendant upon induration ef At 
valve<. As such it has already been considmd, 
when trca'ing of the chronic states of endoeaidh 
(* iNi, 67,). 

214. C. The Trnifwral of diminished ctpantj 




m, wrhaoii. rite boM Jp p wi yt ia t. I tf^i liai of Ac nnaenlar labMsacc of tbc 

nS. n. r>F :iuaci isd SLSBcmoci !>-: wgu ius'a fattj biHk BnOai to thU &nt 
riLra.imvTii nr nt Hukt. — A. ImjUir tli tm if ttterbti b« Hjnnm lad ¥ic« o'Aiia ■■ oc< 
<inmi iot* tlk< (Mhtli^ TimM ■/" (W Or;** — ' cnnng b ^ miiJiJ. TUi lainii ■ gcDenllji 

iZiCflH «< ri« /rwrt, BMiiLuira '" ' '" 

•no. Th« Titer, booefci, do 



218 HEART AND PERICARDIUM — ADVENTinoirs Formitiom in. 



a^^ persons, and when other consequences of 
this action are not observed. — a. In many cascR, a 
whitish patch appears, cither in the fine cellular 
tissue uniting the enveloping membrane to the 
heart, or between the reflections of the internal 



234. J3. Tubercular Formations have been ver)* 
rarely found in the muscular structure of the 
heart. M. Laennec met with only three or four 
ca>>es ; but Otto and Uouillaud never saw one. 
M. Andhal remarks, that the heart is one of the 



membrane composing the valves, increases in I organs in which tuberculous deposits are inosi 
tjiickneiis, and assumes more and more the cha- ' rarely observed. Instances, however, are tt- 
racters of cartilage, especially in the latter 6itii- curded by Hildanus, Bonct, Morgagm, 
.lUon, The morbid secretion giving rise to thitt PoitT\i..AuTENi<iETii,Si>KNS, Lawrence, Bavll. 
patch ultimately liecomes the seat ot osseous ui .Macukiiaki.. and Ellioison, at the place» 
tiarthy deposits. M. Andrai. divides the ossitonn , referred to beluw. In a man, aged 34, who com- 
formations found in the heart into three sitecies, as j plained of pain in the cheat, cough, ioabilitv to 
they are seated in the cellular, fibrous, or muscu- ; remain in the recumbent posture, and subie- 
lar tissue. — (a) That in the cellular tiuue is the . quently of irregularity of pulse and palpitatiom, 
most common, the portion of it uniting the rctlcc- hypertrophy of the left ventricle, ami tubercoUr 
tions of the internal membrane to the fibrous i formations in the muscular structure, were fouod 
structure of the orifices and valves being most after death. ,(^<''- '!/ Prepar. in MuteumFert 
frequently thus altered. The calcareous phos- ' l*itt,&c. p. 3B.) In an aged man, who died of 
phates are deposited in the cellular tissue, in pulmonary consumption (Di<&. Med. Journ, 
minute grains, or in considerable masses, separ- 1833), a tul>ercular mas^ was found in the pa« 
ating and compressing the surrounding textuies. ! rietcs of tlie lelt auricle obstructing the truniiof 
'J'hey are more rarely met with in the tissue con- j the pulmonary veins. M. Sauzier detected, ii 
necting the muscular fibres ; and they there form a man who died of tubercular disease of the longf, 
either isolated masses, or are connected with the I pancreas, &c., tubercles in a crude state in tLe 
deposits formerl around the orifices. — (b) The ! walls of the auricle, tho pericardium being ad- 
fibrous tissue frequently also becomes the seat of ! herent in the situation where they existed. Mo$t 
the osseous deposit, and chiefly in three points: •— j of the cases of this Icsicm on record have occurred 
1st. In the tendinous zone encircling the left in ]>crsons who were labouring under extenavt 
auriculo-ventricular orifice ; — 2d. In the fibrous tubercular disease of the lungs and other orgaiis: 
structure of tlie valves ; — and, 3d. In the tendons many of them have not been observed with anyd^ 
of the mitral valve. — (c) The third species is ' gree of precision ; and the anatomical description 



the most rare. Indeed, it is doubtful whether the 
muscular fibre ever becomes the seat of this alter 



have generally been very loosely given. — dialer- 
culous productions have been found also in ^ 



ation. It bcems more probable that the deposits, internal surface of the perican/ium, by MuscRirK, 
in the connecting cellular tissue, by their bulk, IIalleu, Voichtfl, Baillie, Orro, andotben. 
compress or partially destroy the nmscular slruc- 235. C. Watery Cysts and Hydatids have been 
ture, thau that this structure is converted into ' detected both in the substance, and on either nftbe 



Mk 



bone. The rare instances on record, especially | surfaces, of the heart. — a. Simple eyitt have 
those adduced by Hi'rns,Rknai;i.i>in. and others infrequently been confounded with hydatids; tbe 
above referred to (i 119.), arc most probably former having been described as instances of the 
merely proofs of the partial destruction of tlie ' latter formation, especially some of those met- 
muscular tissue in the seats of the exre'?<>ive . tioiied by I^onkt, Kvttv, Morcagni, Hiu- 
osseuus or calcareous formations. j mann,S.\lzmann, Clossius, and others, ruini 

232. b. The pericardium very rarely prcscnt-t ' found several hydatids on the base of the heart; 
patchesof the cartilaginous and osseous* trainfoim- i Mfikfi. and Hkrniiardi. large hydatid saniw 
ations. Instances, hnwcvir, of the former have the left ventricle; Price, a large single bydatkl 
been recorded by 1.Jof.i:iiaa\ k. Hiot.an, Haiik- ' in the muscular substance, in a boy who died 
siKRK, ]Moi{ga(;m, S.vviAicD, OiTo, and Ti STA ; suddenly; AntRcnoMuiE, a ba^^ containing two 
ami of the latter have becu observed by Avrivil- ' ounces of albuminous fluid on the left auricle; 
i.ii.s, S.wiAiM), Waitir, FIaimr, Pasta, ■ and TRorrFR, two hydatids within the right «en- 
Si Sac, Pr.osr, Ravku. Lai nm< , aiul Aukii- i tricle. It is, however, doubtful whether il«* 
f:i(OMitiK, in llic fibrous i)r in tin; serous layer. — | were really rases of hydati(U. From the imperfccl 
Fibro-cartilaginous and o^^seous concr<»tions are ^ account given of the most even of these, it maybe 
still more rarely found loose in the cavity of the . inferred, that some of them, at leabt, were merely 
l)i;ri(:ardiuni. They h.ivo l)j;ou detected only by instances of serous cysts. — M. Andrat. remari»p 
L \n;'.om and Otto ; and have probably hail their that these cysts vary from the size of a pea to thitl 
origin in peduncular tumours, which had sub-^e- , of a lar^re hen's egg. They are most frequeoily 
r[uently been hroken of!'. : found between the external surface of the heiri 

•233.r. .S'iV«.<i. — r.A I. NKF.r supposed that cartila- i and iKL-ricardium ; but they are sometimes scea 
ijnuus or osteons formalions in the substance of the on tlie internal surface of one of the chaniberf- 
lieait may be recognised, when very considerable, ' In other cases, they are not visible on either *nr- 
by an aiiginentationand mmliticationof tht'sound. face, and it is only on dividing the lUUKul^ 
i'liat a morbid sound will be heard when the I structure that they are detected. M. Dipuv* 
orifices and valves are implicated, cannot be di?. trf.n saw a number of these cysts imbedded :b 
piited ; but the phenomena consequent upon | the walls of the right auricle, and protrudiog * 
the^e changes, when confined to tiic body of the i considerable way into its cavity. M. AndkiI- 
organ, have not been observed with any precision. , found a cyst, as large as a walnut, in the walb* 
In acase noticed by .M. Ani>r\l, the iFuppositions . the left ventricle, which were iflightly hypcf' 
of LAKNNtc were not confirmed. It is unneces- I trophied. In another ca«e, he detected one oa 
sary to add that these lesions are altogether be- 1 the free surface of the Lining membram of tk 
yond the reacA of treatment, I right ventricle, attached to it by a delicate pedick 



220 



HEART — Polypous Concretions in its CAvnrrtf. 



evidence of disease either ia the heart or lungs. 
After some time he became cedematous, and died 
suddenly. The wall of the right ventricle was 
occupied by a large knotted tumour, extending 
from the apex to the base, projecting very much 
externally, and protruding intemafly into the 
ventricle. The encephaloid substance composing 
it was firm in some points, and soft and diffluent 
in others. Mia^ Path, t. ii. p. 347.) 

241. G. True Seirrhus and Carcinoma of the 
heart are, according to Otto, still doubtful. 
Where the evidence of either has been most con- 
clusive, there has also been seirrhus or carcinoma 
of other parts. Open carcinoma of the heart can 
hardly exist, as death will take place before the 
disease can proceed to this stage. Most writers, 
especially foreign pathologists, have confounded 
true carcinoma with fungoid or encephaloid 
disease ; and cases have been recorded as exam- 
ples of the former, when they were really instances 
of the latter. Of this kind are the cases adduced 
by Laennec, Velpeau, Andral, Cruveiliiikr, 
Ollivier,&c. — Bayle and Cayol never met with 
an instance of seirrhus of the heart. I have seen 
seirrhus in the lungs and pericardium in one 
case, and in the pleura and pericardium in another, 
scirrhous and carcinomatous disease having long 
previously existed in other parts of the body* M. 
Billard found, in an infant only three days old, 
three tumours embedded in the heart, possessing 
the cliaracters of seirrhus. I doubt, however, their 
beine actually seirrhus. M. Kecamier observed 
the heart partially converted into a substance 
resembling the skin of bacon in a person who also 
had cancerous tumours in the lungs. Cases of 
a more doubtful description are recorded by Car- 
CASSONB and Duchateav. Rui,lier states that 
he found cancer in the heart of a person who had 
this malady in other organs; and a somewhat 
similar instance is record^ in the R^vue M^dicale 
(t.i. 1824, p.272.). 

242. H, Melayiosis has also been found in the 
heart and pericardium ; but, in all the instances 
of this kind on record, this production has existed 
also in other parts. — As to the Treatment of ad- 
ventitious productions in the heart, it is unneces- 
sary to offer any remarks. 

243. ix. Of Polypous Concretions in the 
Cavities of the Heart. — Bartoletti and 
PisiNi were the first to impose the name of polypi 
on those concretions of lymph and fibrine which 
are sometimes found in the cavities of the heart 
and large vessels after death. Kkiikring first 
contended that these concretions were different, 
in their nature and mode of formation, from polypi 
of the uterus and nasal fossae, to which Bakto- 
LETTi and PisiM had likened them. But with 
Kkiikring originated the distinction of them into 

J'alfe and true polupi^ — tho former consisting of a 
post mortem coagulation of the fibrinous part of 
the blood, the latter presenting a consistent cel- 
lular or organised appearance, and being formed 
during the life of the paUent. This distinction 
was first questioned by jMoroacni, who denied 
the existence of true polypi of the heart, and in this 
opinion he was followed by I^ieutai'd, Pasta, and 
others. On the other hand, Mang^t, INIat.pighi, 
pFruijK, Peyer, F. Hoffmann, and Fantoni 
maintained that the polypous concretions found 
in the cavities of the heart were to be regarded as 
the more immediate cause of death, and not as 



having been formed at the time of death. The 
opinions of pathologists, however, remmiDed long 
divided on this point, until Cor vu art, Testa, 
Burns, Bertin, Kreysig, Laennec, and othcn 
investigated it somewhat more closely, and as- 
certained that, although these concretioas occa- 
sionally form about the time of death, or immedi- 
ately afterwards, there are others of a different 
kind, which arc produced during the life of the 
patient, and occasion very severe symptoms re- 
ferrible to the heart, but not of a kind whirk 
generally admit of a precise diagnosii. 

244. A, Of the Formation and Kind* of Cardiac 
Polypi, — Polypous concretions are roost n^ueatly 
obscr\'ed in the right cavities of the heart, ud 
oftener in the auricles than in the ventricles. Thii 
is explained by the circumstances which favour 
their production ; especially the stasis of the blood 
in the auricles, the state of the blood when it 
reaches the right auricle, and the extensioo of 
inflammatory action from the venous tninki. 
These three principal causes are especially con- 
cerned in the production of three kinds of cob- 
cretions. — In the heart as well as in the veiiiP, 
and even in the arteries, the fibrinous parts of the 
blood may concrete — 1st, from a conditioB 
purely mechanical ; — 2dly, from an altered state 
of the blood itself, especially from the passage if 
morbid matter into it ; — and, Sdly, from inflaia- 
matory action. — Each of these, as being e^ieciilh 
concerned in the production of three vanetiei a 
cardiac polypi, requires a detailed consideratiofl. 

245. a. Simple Jibrinous coneretiaut — thefihe 
polypi of former writers — are frequently fonod 
in the right cavities of the heart, and sometimei 
extend into the vena cava and pulmonary arterj. . 
They are occasionally entangled in the colomna 
carnes ; but they have no organised or intimtls 
connection with any part of the internal surface of 
the heart with which they are in contact. Thcj 
consist of an inorganised accretion of the fibrinotf 
and albuminous parts of the blood ; are of la 
uniform colour, easily torn, and generally net 
with in patients who have died of chronic diseaies; 
characterised fre(iuently by a deficiency of the 
re<l^particlcs of the blood, or, in cases of marasnrof, 
great debility, or cachexy, and which have bees 
accompanied by obstacles to the circulation, ii 
from disease of the valves and orifices of the heart. 
These concretions may commence during the laat 
moments of existence, or immediately upon disso- 
lution. In ca»es of mechanical obstacle to the 
circulation throusrh either the heart or lungi, the 
fibrinous parts of the blood may concrete in the 
right side of the heart so as to prevent the con- 
tinuance of it!i action. The same result may aHo 
follow the rcmora or stasis of blood in the ri^t 
auricle and vena cava, consequent upon eitreme 
depression of the powers of life, or upon pro* 
longed syncope, &c.; the concretion thus formed 
preventing the restoration of the heart's contrac- 
tions. Under such circumstances, this varietTof 
concretion may be the proximate cause of death, 
although forme<l ^o shortly before, especially is 
diseases of the heart, and during extreme vital 
prostration. 

24(). 6. Fibrinous concretions from the pasmgi 
of morbid secretions into the blood. — During hia* 
guid states of the circulation, or when the fitmnov 
parts of the blood are disposed to coagulate, the 
passage of pus, or of the more comrislent morbid 



222 



HEART— Ruptures or. 



of the heart, tlie phenomena are, in some 
respects, the same ; but congestion of the lungs 
ii a necessary consequence, with dy^pucca, ef- 
fusions into the bronchi, or substance of the 
lungs, £cc. 

249. According to Laennec, the sudden su- 
pervention of an anomalous, confuseil, and obscure 
pulsation, in a patient who previously had pre- 
sented a regular action of the heart, should lead 
to the suspicion of a polypous concretion ; and if 
this disturbance takes place on one side only, this 
indication is almost certain. M. Bouili.ai'd cun« 
aiders that the concretions conse(iuentupOQ inter- 
nal or external carditis, arc indicated by tumul- 
tuous pulsations of the heart, with a dulness or 
obscunty of the attendant sounds, or with a simple, 
or hissing bellows sound; by oppression, dyspnoea, 
or orthopnoea, and extreme anxiety, followed by 
venous congestions, and leipothymia ; and by 
coma, stertorous brcathing,convul$ive movements, 
an indistinct and very small pulse, and coldness 
of the extremities. When the&c phenomena arc 
manifested in the course of an acute disease of 
the heart, particularly during internal carditis, in 
which there had previously been but little irregu- 
larity and oppression of the respiration and cir- 
culation, the existence of a polypous concretion 
is very probable, and especially if the sounds of 
one or more of the cavities are much diminished 
or ol)SCure. — In chronic diseases of the heart, 
attended by habitual dyspnoea, the occurrences of 
an insupportable orthopnoea and anxiety, with 
olMCuration of the sounds, resilessncFS, coldness 
and lividity of the face and extremities, and oc- 
casionally vomiting, also indicate the formation of 
concretions, especially if tliese symptoms have 
supervened without an obvious cause ; and in 
this case it is very probable that the concretions 
exist in the right cavities. 

250. C. The Prognosis and Treatment of poly- 
pous concretions require but few remarks : the 
former is always extremely unfavourable. In- 
deed, it is doubtful whether rerovery ever takes 
place from them, — at least, when the indication^ 
of their existence are tolerably conclusive. i\I. 
Bui'ii.LAVD, however, takes a more favourable 
view of the issue of such casi-:« ; and think<* that 
the more recent, and those which are not of lar^e 
size, may be dissolveil. This writer and M. Lk- 
oRuux suppose that attempts should l>e made to 
prevent the formation of tliese concretions in 
diseases of the heart — both in tho-?e which con- 
sist chiefly of interrupted circulation, and in in- 
flammatory action. With this view they recom- 
mend small bloodlettings from time to time, and 
diluents. It is probable that the disposition of 
the fibrinous portions of the blood to concrete 
may be counU'racted by the exhibition of mercu- 
rials, by the liquor potassa; and the subcarbonatcs 
of the alkalies, and particularly by the sub-borate 
of soda. This last substance 1 have found the 
most certain in preventing the coiij^ul:ition ol ti- 
brine, and in di^solvini^ lym])h ; audit may, theie- 
fore, be prescribed with advantage, not only in the 
iuflammatorydiseasesof the heart, but abo where 

here is reason to suspect the formation of poly- 
pous concretions. 

251. X. Ol' RfPTrars ov iiik IlKAnr. — 
A. Sent and History ot\i!cc. — Iluptureof the heart 
was first observed by HAitvKv. Lancisi and 

AIoBOAGui ithowed tJiat instances of sudden death 



were frequently owing to this cause. As eumtn- 
ations after death became more frequent, cases 
of this occurrence were more commonly met with; 
and at the present epoch of pathological research 
they are by no means rare. — Morgacjii (Epiu, 
xxvii. 10.) remarked that rupture of the left ven- 
trielti is more common than tliat of the right; 
and that this latter is more frequent than rupture 
of the auricles : this is confirmed by the particu- 
lars of the cases which have been since reconled. 
IM. Oi.i.iviEit states, that, out of 49 instaoces, 
the rupture was seated in the left ventricle, in 34 ; 
in the right ventricle, in 8 ; in the left auricle, 
in 2 ; and in the right auricte, in 3 ; and that, in 2 
casi>s, both ventricles presented several rupiiires. 
The results are, however, different in respect of 
ruptures occasioned by external violence. In 11 
instances of this description, the right cavities 
were torn in 8; and the left in 3. In theiell 
cases, the auricles were torn in 6. 

252. In the above 49 instances of sponta- 
neous rupture, the apex was found to be its teat, 
in 9 ; this lesion in the others being nearer the 
base of the organ. The directions of the lacer- 
ations were various : in some the laceration wh 
transverse or oblique, — in others it was longiti- 
dinal or in the direction of the fibres, or of the axis, 
of the organ. In certain cases, it was exteosire 
on the external surface, and very small internally. .1 
In other instances the reverse was observed. The ] 
laceration may occur obliquely through the pti* ' 
rietes, and resemble a sinus, as remarked by Moi- 
r.Ar.Ni. It may even be incomplete, some of tbe 
stretched fibres still remaining and concretioi^ tiie 
opposite edges (Ho!<tan). It may also resemble 
the perforation made by a bullet. It may, more- 
over, involve only one or two of the muscolv 
layers, without penetrating into the cavity ; aod 
it may be limited to a few fasciculi of fibres, or to 
the fleshy columns, or even to the valves.— 
When there is no apparent alteration of the tiisae 
at the place of lupture, it is difficult to detennioe 
whether or not it has taken place from within 
outwards, or in the opposite direction. — The 
nlo^t singular circumstance, in tlic history of thif 
lesion, is the occasional occurrence of two or more 
lacerations, in different degrees, in the same heart. 
lM.Ui.i.iviFit,u|(>on examining into the particolan 
of the nio^t authentic cases, found eight in which 
there were several ruptureif, either in the same 
ventricle or in both. M. Hostas detected two 
lacerations in the left ventiicle ; Morgacm, 
three in the same situation ; Pohtai., the fame 
number in the same place ; Dr. Amibvrnfr, two 
in the left ventricle, ami one in the right ; M. 
Hi, AIT) found two j»enetrating the ventricles, 
two involving only the superficial layer of the 
left, and one the external layer of therighl wn- 
tricle ; and M. Anoral observed five in the 
left ventricle, and a ]MTforntion of the stomach in [ 
the saiiie patient. — Frequently, when the sub^tsoce 
of the or^an is torn, some of the fleshy columM 
corresponding to the rupture are also torn. Is 
some in«itanees the fletihy columns arc alone torn, 
the parietes of the ventricles remaining entire. !■ 
this case the derangement of the circulation be- 
comes extreme, especially if the tendinous corJi 
tittached to the free margin of the valves are rap* 
tured (Oi.MMLit). Instances of this kind aft 
reconled by Corvisart, Laenxec, BiBTiJfi 
Adam», and* others. Ruptures of the heart hM 



224 



HEART -^RuPTUit£8 of-- Syuptcus — Diaonosis. 



likcwuebeen observed by Bouillaud, Townsend, 
and otbera. 

259. g. Ruptures of the Valves arc not infre- 
qucotly met witli, as a coasei^uencc of fragility 
arUio^ from induration and ossification , or from 
softening caused by inflammatory action i but 
previous disease is not always necessary to the 
production of this rupture^ especially when it is 
produced by external violence, or by sudden and 
violent physical eflforts. When, however, it is 
consequent upon slighter grades of these causes, 
or ui>on mental emotions, previous disease of the 
valves, or of the orifices, or of the internal surface, 
of the heart may be inferred ; otherwise they 
would have been inadequate to its production. 
If the rupture of the valve be partial, the patient 
may live a considerable time afterwards ; but ex- 
tensive chronic disease will be the result, owing 
to the local irritation, and to the imperfect func- 
tion of the valve, particularly further structural 
change of the ruptured valve, dilatation, or 
dilatation with hypertrophy, of the chambers of 
the heart, &c. When the rupture is extensive, 
and has been favoured by existing structural 
change, death either follows almost mstantly, or 
takes place in a short time. When the rupture is 
partial, the patient may live for a considerable 
time, with the symptoms of insufficiency of the 
valves ($ 76. 198.). 

2G0. F. Rupture of the Heart from external 
Violence is not a rare occurrence. Contrary to 
what is observed in respect of spontaneous rupture, 
the laceration occasioned by external force is more 
frequently seated in the right, than in the left, 
side of the organ ; and much more commonly in 
the auricles, than in the ventricles. As M. De- 
ZF.1&IERIS has argued, it is very probable that the 
mode in which the rupture is produced by exter- 
nal injury, depends much upon the nature and 
seat of the injury. When the rcjjion of the heart, 
or the thorax, is the seat of the external violence, 
the rupture takes place in the cavities possessed 
of the weakest parictes, and in the most yieldincr 
points of these : but when the injury is of a kind 
to p«:vent the heart from evacuating its contents, 
as li the case of a carriage-wheel passing over the 
trunk, or of any heavy body pressing upon the 
aorta, the muscular efforts of the ventricles to ex- 
pel their contents, may occasion either a partial 
or complete rupture of them, or of the vessel at 
some point between the heart and the part pre5sc<l 
upon. 

2G1. B, The Causes of Rupture of the Heart, 
especially the most material, and those connected 
with tlic pathological stales of the organ, have 
been already stated, and explained onder distinct 
categories. Tiiere are, however, vatious other 
causes which determine, aid, or accelerate these in 
their operation. Violent mental emotions, particu- 
larly anger, fright, terror, unexpected disappoint- 
ments, distressing intelligence suddenly communi- 
cate<l, anxiety, 6lC. ; sudden and violent muscular 
efforUi, and laborious or prolonged physical 
exertions of any kind, particularly in constrained 
positions. I'hc act of coition and straining at 
stool have often occasioned rupture ; a very large 
proportion of the cases of it on record iiaving been 
attributed to tiiese causes. M. Oli.iviku states 
that rupture of the heart occurs more frequently 
in men tlian in women ; but this is not satisfac- 
iaiy'/^ determiacd. It u certainly more common 



in persons far advanced in Iife» than in the young. 
M. Dlaud considers the rupture that takes place 
in old age, as generally the consequence of soft- 
ening of the heart. Several cases recorded by 
him, and by other writers, confirm this; and thoie 
adduced by Cuuvxiluier and Sxmf further 
show, that softening terminaiinp; in rupture of tlie 
left ventricle is often accompanied, in old persons, 
with great accumulation of fat on the surfiioe of 
the organ. 

26*2. C. Symptoms and Diagnasig.^^a, The 
cases hitherto recorded,throw but Tittle light oo.ths 
diagnosis of this lesion. Some of these have fmr- 
nisiicd proofs of disease of the heart for a longer 
or shorter time : whilst others, up to the hnr 
of death, had complained of no symptom indi- 
cative of any affection of the heart or laigi 
vessels. In the instances recorded by Plocg- 
QUET, Olmi, Ciiarpe.stier, and Fiscuer, the 
patients complained, for a short time before death, 
of a violent pain in the left shoulder, extending it 
the arm, and occasionally to the whole tide; 
attended, especially at last, with more or Um 
numbness, and characterised by cxacerbatiflai 
and slight remissions. In some cases, inexpiw- 
sible anxiety and pain have been felt in the pn- 
cordia and epigastrium, with cold extremities and 
cramps, shortly before dissolution. In the ma- 
jority, rupture has produced instant d^th ; bntia 
some this has not been the case. In the instann 
adduced by J. Frank, life was prolong twtlfe 
hours, probably from a coagulum filhng up iki 
laceration for a time. In a case recorded hf 
lU'si-, the rupture was produced by the pasofi 
of a carriage-wheel over the chest, and was seaM 
in the right auricle ; yet the patient snrvivtd 
fourteen hours. 

263. In most of the cases in which the raptait 
is preceded by violent pain, M. Oi.livier tliiob 
that it is produced gradually, from the succcwre 
laceration of several layers or fasciculi of msi- 
cular fibres; and that the pericardium becoaei 
only gradually distended by the effused blood. 
Wiiere the laceration and aperture are at (act 
large, a copious cflusion instantly occurs, fills tic 
pericardium, and abolishes the contractions of the 
organ. 

264. h. When the rupture is seated in thep«rti* 
tions between the auricles or ventricles, a fatal reitk 
may not very rapidly occur. In this caw, the 
venous may be mixed with the arterial blood; 
althougli this may take place only to a small ei- 
tent. — f. In the three cases of rupture ofthefieAf 
columns detailed by Corvisart, a sudden oppres- 
sion and sense of impending suffocation was ibe 
first symptom complained of. The pulse liecame 
une(|ual, irregular, and intermittent ; and the pul- 
sations of the heart confused. This state of dis- 
tress an<l anxiety may continue for some daySi 
before it terminates in death ; or it may endwc 
much longer, and be accompanied with varioH 
signs of organic disease of the heart. — d, Nvplin 
of the viilies will necessarily be attended by mock 
irro^rularity or disorder of the circulation, and by 
a himple, or hissing, or musical bellows souad. 
(Boi'iLT.Ai'i>, Farrall.) 

i 265. As the diagnosis of rupture of the fleih^ 
, columns and valves of the heart, m the pnMrt 
I state of our knowledge, is very imperfect; aal 
; a-* the signs of rupture of the parietes of one of iki 
I cavities are etpiivocal ; notliing can be adduced ai 



I 



..' .'in'ulitinc niiHi.. 
r. .■• thr Mljuiiiili; nrts 

- ir 'invulatuu ibku «- 



d2d 



HEART AND PERICARDIUM — BiBuooRApnT akd REntfttN^xft. 



vii. ADVENTTnoiu P«onrcTioNs ix'tiik Hf.art. — 
ColitmbuM, Dc Re Anatotnica L xv. p. 48!). W^L—Rhoditis, 
Observ. Medic, cent iii. ob.. 4. — ZacntuM LusUanut^ Med. 
Princ. Hift. L ii. n. ^i.^Btancard, AnaL Kar. cent Lobs. 
75. p. I.IS. — Schfnck, Ob*. L ii. N'a ^^Xli — Bartholin^ cent 
ii. HisL 92.— F. Von Hiftien, Obi. Chirurij. cent i. ob. 51. 
Gautius in Botu-ti, Scpulchrctum Anat. I. ii.HCCt i. Addit 
Obi ii.— IK RMtt^. Philoioph. Tran*. ll-iH. p. 5»K. —/.««. 
eitit dc Mort tubitan, ob. iv. p. Idl. — Amr/, L ii. sect, 
vii. oIm. 5il \S2. addit. obs 9. sect viii. olx ^. ; L iii. sect, 
xxi. add. ob. iii ct sect xxxviu ob. 4; 1. iT. sect. i. 6b. lii. 

Pf/i. Aufsatic undUeobachtungcn, vol. Ti. p.TH. — Lieu- 

tam't, voL iL <^. 5M— jJJl — P<riiiMf«i, Saggio sccondo 
d'Osfcrvazioiii e Memone Medico- A natnmichc, 4to. Pa- 
dua, 190O. — Forlani, Obs. Uarior. Med. Pract dec. 1. 
p. 70 dec. ii. p.10. — J. F. Meckel ^ Tab. anat Pathol. 
Fasc. I vol. L tab. & — Walter, In M6m. dc 1* Acad, dc 
Berlin, 17K.5. p. 65. tab. 4. Ar. 2. — Trotter, in Med. and 
Chinn. Essay-s. Jx>nd. 179d— £ph. Nat Cur. dec. i. 
ann. ii. 1761. obs. 5. jn 6 — IMdersen, Dc Hydatidibus, 
G'vtt, IflOK, I). 1 1. — F/iTtfrA, in d. Allg. Annalon. 1811, 
Jul [x M3. " yforeagni^ Ep xxL 4. ; epi xxv. 15. ; e^ 
xi. 11. — S/Ninff^iiM-rff, in Horn Archiv. 1811, July, p i. 
//oMrrmanM,, Fhysiologie, vol. L p. 20^ — &t/xma»i», in 
Holler' $ I>i*putat vol Iv. p. S48.— r/ofSf'M, in Baldin. 
ger'M Magaxin. vol. x. p. iA3, — Portal, Cours d'Anat 
M£dic vol. Iii. p. '-"9. 74.— Tetta, p.&4. 67. 1277, XTS. — 
Dupuytren. in CorvisarV$ Journ. de Mod. vol. v. p. 1J9. 
^Soemmering, Addit to Bafflie, p.21. — D. Prsce, in 
Lond. Med. Chir. Transact vol. xl. p. Ii. ISTJI. —Arndt, 
de l\imortbus Cord, tunicatis, 4to. Rcr. 1817. —'Pelletan. 
Menioires et Obit. iii. n. 3. — Beauchamp, in Recucil 
Periodiquc dc la Suci£t£ de U{>d. il xxviiL —Cruoeilhier, 
vol. i. i>.301. — Andral and Bayle,\xi K^vuc M6dicale 
A-anc. et 6tranKire. Fivrier, 18il.— Mncmichael^ in Lond. 
Med. and Phvs. Journ. Augunt p. S3iK ]H26.-~Wedemeuer, 
in Rust** MaKasin, b.xix. P.n. p. 2J9. — ^u/^^riWA, in 
Tubinger Blatter, voL 1. P. ii. p. 191. — Olto, Selt Beo. 
bach, part i. p. 98. ; l>art ii. p. :A. ; and Path. Anat p S88. 
.^Spens, in bdinb. Med. and Surg. Journ. 1816. vol. xii. 
p, wi^ ^. Lawrence, in Meti. Chir. Transact vol. iii. 
p. 78. — /.A^Nit^t vuL ii. p. Xii. and 334. — Sandifort, Obs. 
Anat. Path. 1. i. c. i. pi 31. ; L iiL c. i. p. 41.— Coslallat, in 
Journ. Hebdom. voL lit p. 10. — Corvigart, p 22.J. — Ber- 
tin, in Bulletin dc la Facult^J de M6dec. 181^ p. 58. — iE7. 
notion. Op. cit. p. .')2. — Bertin, Traite dcs Maladies du 
Copur, p. 232. — TcM/a, p. 314. -^Detruelles, in Revue Me- 
dic. Histor. ct Philos. vol. iv. p.3f)5. Paris, 1821. — Cru~ 
veilhier, Anat. Path. L xix , p. L pi. 4. 

viii. .Mfihillary Funuiis and Carcinoma op tiir 
Heart.— r/irriwiofu*, in Hist et Mem. dc la Soc. Rov. de 
Mddic. 1777, and 1778; Hist p. 2.%!. ami. 1786; Hist 
]!. :3-J0. — Air/sity, Obs. siiigularis Fungi meduUaris In 
Conic; pru?f. Dzondi, 8va Hala*, \hi\. — Hodgion, in 
Savenko, Tenlninon Anat Pathol, dc Molanosi. 4ta Pc- 
lxo\Mi\\,,\h^h—St'gnla$ d' F.tcht'parc,\u Itcvuc MMIc. 1825. 
vol. iv. "p. '^'47. — Ibid, in Nouv. Bullet, dos S<". |>ar la Soc. 
Philoin. May, IK^IT). — (ierson und Julius, Magazin, d. Ausl. 
Litter, d. gCA. ileilk. p. liW. Sep. and Oct, 18i.J, — Staupa^ 
AnweiikUngzur (icrichtlichcnu.Path.UntcniuchungMcn. 
lAMchiiamo, p IW., Svo. Wien, 1827. — Diichatenu, in Jour, 
de Mtrdec. p 243., Oct. ISH). — HuUUr'xw Bulletin dc la 
Fac. I't de la Soc. de Medec. dc Paris, No. 5. p. iSnXJ. 1813 ; 
and ill Journ. dc Medec. Chir. ct Pharm. vol xwii. ]81:i. 
-^'Dupuytrcii, in Ci utfcilhU'r, vol. ii, p. 87. — .Indral and 
Bayfi' in Kevuc M6d., Feb. I8«f4. — Itecamkr, in Ibid. 
Nov. 18^5. — 0//ii'iVrf, De la Moello £piiii(>re c;t de scs 
Malad. i>. 2ti2. 8vo. Paris, l.'*24 ^Velpeau, KxpoMition d'uii 
ca« remarquable de Malad. Cancorc. Kc. 8vo. Paris, 1825. 
C/nirchdl, in Ijond. .Med. and Phys. Jouni. March, 1827. 

ix. Oru.vmc Lf.mio.ns opthk Pkricikuii-m.— ////si:A(r 
et.S'fA//iiVrf«f/,DoExulci'ratinne Poricardii et Cor. Exempio 
ilhis. Jena?, 17*2. —Ueutaud, lliM. Anat Meil. 4to. p. 210. 
—Meckel, Sfem de Berlin 175(1. vol. xii. ii..31. — Btterhaniv, 
vol. ix. p. 41W.— //iz///-r, Add. ad Elein. Phys. p. 128.— .Sa- 
viard, in Journ. des Savans. Ifiyl ; Obs. Ch'ir. i. Iv. p. 25.— 
Aurivillius, in Nov. Act Upsal. vol. L p. 101.— Morgagni, 
DeSctL et C-au*.;Morbor. en. xviii. p. 34. ; xx. 2J). .ll; xxii. 
10. ; xliii. 17. ; xlv. 16 ;; liii. 29. — .SVo//, Rat MeiL viL 
p. 1/2. — Van Doeveren,S\ViCim. Obs. Acad, cap- v.|— AV- 
nuc, Dc Conip, I. vl. cap. ii. — Stoerck, Annus Sledicus ii. 
p. 02. — Chnmbon de Montaux, Markw. Krankenges- 
ehichtcii und LeichenlK-riclitc. Leipz. IVJl. ^Biennayer, 
Mus. Anat. Pathol. Na 4J4 — Portal, Cours d'Anat. 
MciL iii. p. 24 — Hiotanut, Aiithropographia, I. iii. p. 12. 
— Ilautesierk, Recueil d'Obs. vol. il. p. 58.J. — Trsfa, Pe- 
terb. vcrinischtc Abhandl. a. d. Gobiete der Hcilk. 1 ste. 
Samml. p. 2^'. 1821. — If aZ/rr, Olm. Anat p. (W., and 
Anal. Mus. vol. i. p. 148. U!». ^291.— Pasta, Ep. de Cordis 
Polypo, p. 75.—Prost, M^decinc eclairrc par I'iJuverture 
des Corps, i. p. 14<J. — /IA<'rfrc/»iA/>, in Trans, of Med 
Chirurg. Soc. of Ediiib. vol. \. — Hust't Muguzin. f. d. gcs 
Heilk. vol. xvi P. i. p 18.7. —Hayer, in Archiv Gener. de 
M6d. March and April, 182.}. — Rochotu, in Journ. iivn. 
de Med. et Chir. vol xxix. Feb. 1814. Bulletin. P.33.— 
BidoitJils, in Archiv. Gcner. de Medec. Dec. 1823. {See 
a/ja JSibliog. and Rt^fer. to PfiRicARUiris.) 



X. Kd\ ENTrrious Proddctioms n« tvb PKUCAimviL* 
MuMxiaw, in Ptiiloi. Transact. 1685. pi 8GQ. — LcaoisL Di 
Aneurism. I. i. 5 — liailer, Op MiDorau voL HL f, S& — 
Meckel, Mim. del' Acad, de Berlin, 1756. P. 7SL— OMar<; 
in Journ. de Medec 1761. May, voL ztv. pi 401. — AsMft, 
Sepulchrct Anat. lib. ii. sect ii. obs 1& ; accL 8. obk & ; 
l.iii. ; sect SL obs. 21. ; and sect. 37. tibcS.— Mamni, 
Epist xix. 7.— Bomrru, in Hist de 1* Acad, de Pluls, liO 
P. 35.— Foigtet, Path. Anat 1. il p.93(L^Hemer 
Physiologic, vol i. p. 303. — LlemtoMd^ Hitt Anat 
vol. ii. p. S71. — C. Bell, System of Dicaection, ftc ' 



fol. 1796. — Steimbach, De T«nU Hydatitena, MOS. p. J 

— J. r. Bergen, in Act Soc. Med. Havn. voL i. pl9«.— 
Parry, Inquiry into the Symntoau and Causes oftkt 
Syncope Anginosa. Lond. 1801. — 2aciifM. Pnx. aim. 
L iL Obs. 137.'— Black, in Men. of the Med. Iocl if 
London, voL vi. p. 4S. ^ FolkergiU, Med. Ota. aodb. 

Siuiries, vol. v. p. 246. — Horn, in Archiv. C d Xcd. ftw 
ahr. vol. iii. P. i. pi 58. — Kreydg, voL iiL p. Ui- 
Schramm, Comm. PalhoL f!e An^na Pectoris, p. 17, ift 
—Rotfinck, Epitome Method, cognoac. c h. AAct p Ifi 

— iUekter, Deutsche Biblioth. vol. iv. piSJa— toi^ 
vol. ii. p. 34a — Portal, Cmxn d*Anatomia Wfiiwi^ 
VOL iii. ]!. 2X — BaiUie'M Worlci, by H ord^vf, veL L- 
Fotkergill, Med. OtM. and Inq. voL v. piML^ITiCk 
Mem. of Med. Soc. voL iiL ni ia ~ lMektmamm'9, &mA 
Auserles. Abhandl. vol. xvil. pw Sia — J. Coplmmd, m Im 
Mod. RqKM. voL xviL p.Sm.^FitxpmMeij in UadnL 
xvil. p.2»5. — Laennee, De I'Auscult Mid'iate, «iL& 
p. 3iT7. Paris, 1819. — Ger$om and Jaiimt, Ms«n. ii 
Ausland Literatur. d. a. HeUk. 1823L Sept Oct p. W- 
Macmkhaelf in Lond. Med. and Phya. JouniL Aiifi MH 

— Otto, Pathol. Anat. by Somtk, pi £57 Edin. Mai ■! 

Surg. Journ. No. 1I23L pi 882. 319 Smith, Duh. M 

Journ. July 1836. p. 426.— Conigan, in Ilrid. voL Lplii 

— fVatsoH, Med. »ax. 30ch July. 183S. dl 70L — ~ ' 
Med. Chir. Re\'. Oct. 183(x p^ 44& 

xu Polypous Concketio.N8 in the Hsavr.^, 
Epistola do Cordis P6lyp. App. ad Libnim de DUM^ 
4to. Mediol. 1634^ — Malpighi, De Polypo Coidls, MK 
in Op. 11. 1 SJL— fArnf, Questionum de Poly|io Covdis 



i 



Argent. 168a — Gould, in Philoaoph. transw N'a IfiL- 

tt cent iiL hist 17. — Zutfii*i(K 



De ^ 



Bartholiniu. Hist Anat 

De PolyiK) Cordis. \Viteh. 

Med. Rarior. P. vL 

Pol>'po. Witeb. 1 

Lcide, 169J. — Albini, De Polypis.' Franr. !& 

De Polypo Cordis. Giess. 1702. — Ararf, Sepulck, LK 

sect. xi. obs. 6 —De Cruyskerkrm, De Folypo " 

Jjeidai, 1705. — Gohl, De Cordia POlypU ex ~ 

llaeraorrhoidibus. Berlin, 1718. — Beek, Dc Pk 

dis. Uiess. 1718. — Gorz, De Polyposis Cone 

variorum in Pectorc Morborum Causia. Altd 179&* 

Morgagni, Do Sed. et C^aus. Moil}. nd»t xxiv nttL 



. observ. l. — De Serger, 
\Viteb. 1689^— Afwsni, De FOlyps Crfj^ 



VtA 




Grateluup, Dc Polypo Cordis. Argent, I7.'>1.— jI. 

Macofte, l>e Aortas Aneurysmate et Polypo Cocdii^ 

cia, \toV. — Boehnwr, Dejirorcavenda Polyporum Gofr 

ratione. Hala*, 173a — Preston, in PhilosL Traai Ml 

224. — Thomaun, Annales Instituti Medico-cHnici Wic 

ceb. vol. i. p. 101.— .i. Pa^a, Efiiatola dc Cordii Mill 

I in ilubiuin revocato. Bergamo, 17S0. — Jttirli 01 

i Polypo Cordis. Hala>, 1741. — Lofi/Ku/A, De Nifi 

I Infantis Rhachitici. Viteb. 1744. — MWixAom, in FhOk 

Trans. No. 4«)t IVichmann, Idecn zur DiagnostiLk& 

p. Iii2. — rai/j^Aaii. De Polxpo Cordis. &c Edinh. ITK 
•^Portal, Cours d .Anatomic Med. iii. p. 2K. 97.- 



Casus Mfdico-prarticus de Polyiw Cordis, tkc Spire, ilH 
— Conshruch, in I>is«. Fascic. Observ. Med. Slut^ 1771 
— Jm. Pasta, De Sanguine et Sanguineis Concreimiiii 
per Anatoinen indagatis,ct pro Causis Morborum bar 
qun*stionct Mctlicv, 8va Bcrgam. 17Sd — De " 
Rut Med. P. ii. c 7. — Tenipelmam, in Pliilos. 
No. 481. — Maincourt, De Sanguineis LymphatidsiM 
male Polypis dictis Concretionibus in (?onie el in V«b 
|)er vitnin existentibus. Paris, 178P. — Beriios, in JM^ 
/t>/'s Journ. Geii(' rale, &c. voL xxxvL p. ^S&.^-lteitmam, 
De ( Onlis Polyins, hvo. Marin ISOI. — /Ihusw. * 
Ilvfeland's Journ. der Pr. Heilk. b. xxv. st. J. p Im #" 
Pontin, I>ra>s. P. 4/xclius, Dc Cordis Polvpa 4ta V^ 
sal. ISJX"). — /-Vnnl, Act Instit. Clin. Vilii. iiL pH.- 
O'iir/TK r, Path. Med. dc l*olypo Cordis, in Spede 1iiAb-> 
turn. WtirceU 19V). — Ho/tfrwarfHer, in H»ffdm^ 
Journ. der pr. Arz. bt vL n. SSK — Ftormamm* T 
I kun. jbor Pcily. in Herzen, in Svenska Lakare Si 
' iK-is Handlingar. voL Iv. u l(>5. Stockh. 1817. — . 
Do Cordis Poly|w, Svo. Iterol. 1818.— .Vic4«/A!s, to 
land's Journ. der pr. Heilk. b. xviii. st iii. pGo.— 5b 
in Ibid. b. xxv. 2 st. pi 172. — A'irxsr, Zur Kennmiss it 
Htrziwlypen in Horn** Archiv. f. Medic ErfibniK 
. 1818. July and Augu>t pi 116l — Heimekea^ in wL 
. Jan. 1810 p. 28. 132—Schmelehcr, De Polypis CmA^ 
8vo. I.andishuti, 1819. — Deegen, De POlvpis Oofds 
8vn. Hals. 1821. —Bigaeti^ In Aichivca Gen. deMML 
vol, xrii. j». 276. i ct in Jouxo. dct VngtH, Ac Tolb. 









must Ihj directed to the removal of disorder In the 
digestive and biliaiy organs, and to the regimen 

of the patient. 

niDLKw]. AND Rr.PER. — Mtust Dc Re Med. L ▼. c.2fi. 

14. — Scribomiut l.arg¥M, Dc Com. Mod. c. a^ IWX — 
yOniys, Hut. Nat. I. xxvL c. 11. — Oribasni$^ Syno|>*i«, 
L vii. c. SJ. *». -- AethtSf Tvtrab. fccnn. ii. c.ip. 4<). p. 7 »• 
AriccHHit^ Canon, I. iv. fen. Hi. tr. i. c. fi, — Schencky 
DIM. Med. 1. V p.(iJ9. — Tnlphit, OUi. Med. 1. iil. c. 44. — 
Zacutn* Ltisi/aHtti, Mctl. Pr. HUt. L iii. n. !.'». — Huland^ 



Cur. Einp. cent. cap. 5;i. {BaUamum Sulphtirh)-^Turner^ 



1 




234 HICCUP — Causes. 

sulphate of zinc, or of alumina, will often Ims | vulsivc movemcnbi'retum at >hoK intervals, lad 
useful. These may also be presc.ibed in herpes | a™ ?"end«d by painful uneumess at the pm- 
rircinnatus; but in nil oases the chief attention ^^^^ and epigastnum. mcreasing wiih the fre- 

- quency of the convulsive coQtractions and contina- 
ance of the disease. 

3. ii. Cauut, — Hiccup occun frequently ia 
infants and young children. It is not uncommoa 
in a^l persons : and, at these epochs, is geoenlly 
symptomatic of irritation of the stomach or doo- 
denum,or produced by a too precipitate deglutition, 
tlie movements which accomplish this procev 
often taking place in an irritable or spastic miniKr, 
in persons at the two extremes of existence. The 
arrest of the alimentary bolus in the oesopbvQS; 
an insufficiently masticated or dry state of the 
bolus ; an irregular or precipitate performance of 
deglutition, especially, when tlie stomach is empty 
or debilitated ; the ingestion of hiehly seasoned or 
stimulating food or dnnk, or of cold nuids; laugh- 
ter, particularly in hysterical females ; long fartii^ 
and emptiness of the stomach ; irritatine or poi- 
sonous substances in this organ ; worms m the £- 
gestive canal; and wearing strait-laced coneM, 
arc the most common exciting causes of the kfl 
important and idiopathic cases of this affection. 

4. Hiccup may be one of the forma m which 
hysteria manifests itself, particularly when hjs- 
terical patients have been subjected to roeiriil 
emotions, as after crying or laughing. It msy ilio 
follow a fit of cough or vomiting ; or it may be pro- 
duced by sudden frights. But in all these, de- 
bility, especially of the digestive organs, is s pr^ 
disposing cause. It is oflen a symptom of irrintioi 
or inflammation of an adjoining vi<(cus, particuhriy 
of the convex surface of the liver, and of tb 
stomach, especially at its cardiac orifice. It miy 
nri«e from the passage of biliary calculi aloD^ tfcs 
ducts, or from calculi in the kidneys or in their 
pns.<age into the ureters. Strangulation of iotcfMl 
parts, irritating matters in the colon, external is- 
juries and fractures of the ribs, the various itsgei 
of pregnancy, and the suppression of accQStoinied 
di^ic- barges and eruptions, have severally produced 
it. He>idcs, singultus occurs in a great number of 
acute di><easos and fevers, particularly towanbthe 
close of life. It usually attends fiital cas^s of in- 
flammntionof the abdominal viscera, and is gent- 
rally present when hepatitis of the upper or poH 
terior parts of the liver extends to the diapbxagiMlie 
peritoneum, or when abscess of this organ pools 



vertaria rraclica. p !«. — J. T. Kiein, Tentomeii Hen)e. 
tologia*, 4ta Le'nl. 17.V>. — Aaskow^ in Acta. Meg. Soc. 
Me(V. llaun. vol. i. On thr impropriety of rfprlling herpes ^ 
and tkif internal ditordnM resulting Ihert^fromA^ 
LeIUom, in Mcmoiru of Mitiical So<'ioty. of London, 
vol. iii. art Ift— Aduir, In VA\u. Med. Coniiment. voL ix. 
» Xi. [The arsenical snluthn reeommentled).-—Hattt't in 
SWin. dc la Soc. Rtijr. de Med. t. vii. {.Purgatitcs andwarm 
bathing.. — Ilotne, Clinical Kxpcriment*. passim {Sarsa- 

Jtarilln^thc elm bink). — Kahn, Moil. Briofw. b. i. p. iXtl 
)ecttctHUi dMleaMunr.) — Akerman, in Batdinger N. Ma- 
iraiin, b. viii. p. lifl. y,Klin.bark reaimmended ). — D. 
LjfPins, Further OIm. on Calomel, &c. and on Elm-bark, 
8vo. Bath, Iin.'-Huiisicl, I)c Variif IleriHtum »|ioi.-ibUtf, 




dank iw Dartrci, fee Hva Par. 17H«>. — A. Di^fresnoy, I)e« 
Caract. TraltemenL 4«c. det l)artrt'k,&c. Hvo. Pari*. 17»S. 

— p. G. Ihnslcr. Dc Ilenictc <cu Formica Vi-teruro^ 8vo. 
Kilia?. IHi)l. — C*iiifA*fcT,ln Uecueil P^nxlique, «cc. i. vii. 
p.Jtf. — J. P. Frank, l)cCur. Horn. Morbln. 1. W. p. 14«. 
_ Rttyston^ Medical ami Phy»iral Journal, vol xxiii. 

— Mnckeehnie, t>tinbiirKh Medical and Surgical Journal, 
vol. lil. p. 307 — .V. ///I//, in ibid. IS'JO. vol. xvi. p. (&. 
^T. Bateman. Synopjiii of (-utaneou* l)i«ea«e», &c. 
Hvo. and Delineation* of Cut. I)i«. 4to. — Kerres, Journ. 
don I16pitaux, fol. p. 41. — (Sea/fntff, Rev. Mwl. t. x. p. ."i«). 
^ Evans. Patn. and Pract. Keinurks on Ulcer, of (lenltal 
Orft'ini. Ijoih\. lfil'>. p. 'J7. — .V- Plumbe^ Pract. Treat, on 
l)i«. of tin- Skin. Hvo. I/>nd. ISJ*. i». 140. — lelpenu, 
Nouv. liiblioth. Mcil. t. iv. i». 4-J5. — Louix, .Touni. Ileb- 
flom, t. vi. p. ,iiM. — Cazenfiee c tSchedet, Abri'Ke, Pract. 
de M.il. de la Peau. 8va Pari*. 1SC«. — »'. C. Dendy, On 
the Cut. I>i!«. incident to Children. 8vc». IS'.'T. p. i>\. — 
Itol/ialiHS. in F.ivssac's Bullet. de« So. MiM. t. xxii. p.l(i;*i. 

— Joum. HcMom t. vH. p.4.'t; — Journ. Complem. I. xii. 
p. 4.W.— Key. Mwl. .luin.. l-S'jf). — ^. T. ThomsuH^ Atlan 
of Delin. of Cut. Fniptioiif. i*vo. I^uid. 1VJ4. and 
art. Ilerftc in Cyclciii. of Pract. MwL voI.il. p. 4.0. — 
/*. /frrj^r. Theoretical and Pi.ict. Treati»e on the l)i». of 
the .Skin; Trail*, by ii. Ifillif.Svo. Umd. ^Sxi. p-'-M*^ — 
J. (irn'n, Pract C<jm|>eiid. of the l)ia. of the Skin, hvo. 
I^>nd. lKJ.'i. p. 86. 

lllCCUr.- SvN. Aly^ y.iyii;. Hippocrates. 



.SiiiifM //».«, JMiny.Sauva^eS Voijel.Sajrar. Lu^- upon the diaphragm. 
;»in.«, Swediaur. Pnevsis siufiiilttts, ^'oung. j 5. \V hen singultus occurs after a too full mctli 
Clium* singultus^ (iood. Iloqiiet, Fr. (ilttcLseu, ; or after the ingestion of cold or irritating floidSi 
Schlurkeut (ierni. Sinnhii^zor Itul. //trrcrin//, j which is vtr}' common, it is comparatively of fittlc 
hoiket, hicknp, j import, further than that it evinces a debilitited 



(li.A.sjjiF. — 4. (7rt>5, 3. Order (dotul). 
II. (.'la.-s, 111. Oiiurn (Author). 



st:ite of the stomach and increased irritability* 
Hut wiien it follows a meal either frequently or 



1. Dkhn. — All uneasu sensntion at the /ta- ; habitually, chronic inflammation of the rtomscli. 
cordin f'oUoucd /»»/ « rapid coutiactiou of the dia- espeeiiilly tibout the cardiac onficc, or even of tk 
)}hrtii;m,of' tnrineiitartj durnlion, causiiiti an andihle crsojihii^us or duodenum, should be suspected: Of 
iti^piratinn, iterated at short intennls. irritiitinn of the pancreas or biliary ducti! * 

2. i. Description. Althouj;h iiiecup is fre- wouns in the alinicntary canal mnv exist. Wbrt 
(luentlv svmptuinatir. of diin!;erou< mnhiiics, and drjx'nding upon this latter cause, it sometimes ■!* 
is even' a fatal si;rn in these, yet it is oeea«*ionally I ternates with sneezing and pruritiLS of thenortrik 
the chief and primary disorder. \> Inn it is thus ! 6. Authors have wconlcd numerous invtauctt 
idiopathic it u* «renenilly a f^llL^ht iind evanescent j of hiccup continuing from two to thrre diyito 
nfTfction. It con*i<t!« of n sudden and rapid con- : many months, or even longer, in some ciienriA* 
traction of the ri<j)iratory muj-ele^, of tlie dia- out any other verj' prominent symptom of discM; 
plimjrn»e»ii>ecially,instantly followed by relaxation, in others, alternating with sneezing, synco^,* 
thereby causing as rapid an inspinition, wiiich is | hys^teria. \'ariou8 anomalous cases of ths a^ 
audible from its suddenness and force. I'hese con- 1 fection have been recorded by PoTsaiuf, Schkkce, 



236 



HOOPING-COUGH — DEscnxmoN. 



Classif.— 2. Clau. 3. Order (CuHcd). 
2. Oast 2. Order (Good). II. Class, III. 
Order (^Author, in Preface). 

1. Defin. — CmivuUive and suffocative cough, 
accompanied with a reiterated hoop, or coiuisting of 
fnany successive short eipirationsfoUowed by one deep 
and loud inspiration, and these, alternating for se- 
veral times ; occurring in paroxiisms, ending with the 
expectoration of tough phlegm, and frequently with 
vomiting; inf ectious and of ten epidemic ; appearing 
but once during life, 

2. M. GuERSENT defines hooping-cough to be a 
catarrhal affuclion of the air-passages, character- 
ised by sonorous inspirations with imminent suffo- 
cation. The origin of this disease is obscure ; for, 
if the ancients have at all observed it, they have 
not described it so as to enable us to recognise it. 
Doubtless new maladies may develop themselves 
in the progress of the refinements of society, and 
of the changes which the physical and moral 
world have undergone during a lapse of ages. 
This cannot be denied in respect of some of the 
exanthemata, or of diseases propagated by a 
specific virus, as smallpox. But, ei^cepting 
tnese, it is difficult to admit, that those mala- 
dies the spread of which very much depends 
upon atmospheric vicissitudes, and epidemic con- 
stitutions, and upon general susceptibility of the 
species, can have been of modern occurrence 
enUrely. It is not easy to conceive why a disease 
should not have at least occasionally appeared ; 
since the circumstances favouring, and causes 
inducing, it must have been in existence from 
the earliest ages. It may be 'said of hooping- 
cough, as of some other diseases, that, altliough 
the more exact observations and descriptions of 
modern observers have made it known only in 
comparatively recent periods, yet it may have 
existed nevertheless, and have been unknown 
from having been confounded with other maladies 
resembling it. 

3. The passages in Hippocrates that maybe 
referred to this disease» are equally applicable to 
several other catarrhal aflTcctions, or aisorders of 
the respiratory organs. Some of the older writers 
take notice of epidemics, which have been con- 
sidered to have been hooping* cough, especially 
those of 1239 and 1311. But they may have 
been severe catarrhal epidemics, or influenza. 
KosEN thinks, that pertussis passed from tlie Kast 
Indies and Africa mto Kurope ; but of this he 
has furnished no satisfactory proof. According 
to iSlF./.ERAY, it first appeared in France in 1414 ; 
and he has been generally considered as having 
given the earliest account or description of the 
disease. But, upon referring to this writer 
{Abrtge Chron, on Eitrait de Vliist. de France, 
t. iv. p. 65.) there is nothing but the name 
Coqucluche that is applicable to it. Indeed his 
account would have been quite applicable to the 
influenza of January, 1837. The epidemics 
noticed by De Thou, and Pasqiifr, to which 
the same name was given, and which occurred 
in 1510, and 1557, were evidently influenza, and 
not hooping-cough ; and the same remark is appli- 
cable to most of the supposed epidemics of this 
latter disease, during the sixteenth and seventeenth 
centuries. 

4. Wilms was the first who accurately de- 
scribed hooping-cough under the name of " Tussis 

puerorum coovulsiva, seu suffocativa, et nostro ' 



idiomate e^incou^^ vulgo dicta." (Opera Muiit, 
Amst. 1682. vol. ii. p. 169.), and it is only from 
his time that we have any account of the difeue 
that can be relied upon. It was afterwanb 
noticed by Sydenham, (Op.I/mveraa. Lngd. Bat. 
1726. p.3ll.), and by both it was treated of 
as a common disease. It is extremely doobtlU 
that the epidemics of the 15th and 16th cen- 
turies, which proved so very fatal were actually 
this complaint. The imperfect notices made of 
them convey nothing really proTing that they weia 
it. IlosEN confesses, that tie cannot detemBM 
when pertussis first appeared in Sweden; aod, 
as respects this country, there is no accoaat 
earlier than that of Willis which can be received. 

5. I. Description. — Hooping-cough, whether 
in an epidemic or sporadic form, presents neariy 
the same phenomena, particularly when it is lim* 
pie or uncomplicated. But it is modified in mavf 
respects by tne season, climate, conttitntioa or 
habit of body of the patient, and by the compli* 
cations which take place in its early stages. I 
shall, therefore, describe, first, its sim(4e or aa- 
complicated form, and,secondIy, the complicitioM 
which it frequently presents. 

6. i. Simple Hooping-cough. — Pertussis hai 
been divided into two stages by some wrilen, vii., 
the catarrhal and the eonvultive ; and into thne 
by others, the second stage beine divided by die 
latter into the periods of convulsion, and of de- 
cline. A, The stage of development, or the 
catarrhal period, is Keneially announced by sobs 
slight rigors or chills, turgescence of the htt, 
slight redness of the conjunctiva, watering of tbe 
eyes, and the signs of simple coryza. There k 
scarcely any fever, sometimes only, for tweitf- 
four or thirty-sia hours ; but, in some caseii tm 
fever is more marked, and it occasionally assanM 
a quotidian or tertian type. The cough is moK 
or less frequent, comes on in fits, and may at 
this time be taken for common catarrh, or ca- 
tarrhal affection of the trachea and broDchi. 
However, a slight shade of difference may be 
detected in the tone of the voice, which expe- 
rienced observers will recognise as character- 
istic of the disease. The cough is more sodofow, 
and more acute than in bronchitis ; ezpectoratioo 
is scanty, even with adults, and the matter 
brought up is limpid, as at the coramencemeBt 
of catarrhal affections. The anterior part of the 
neck is sometimes uneasy, or even painful, bat 
in other respects there is little complaint, ex- 
cepting a slignt depression of spirits, mon»eoe«. 
heaviness, diminished appetite, . and sluggiik 
bowels. This period generally continues from fife 
to twelve days, and seldom more than fifteen. 

7. B. In the Convulsive, Spasmodic, or Nerva 
Stage, the patients complain frequently of uneas* 
ness or pain under the sternum ; the fits of cough an 
longer, more frequent, particularly at nigbt* and 
commence with unpleasant titilation at the laryoZi 
during which the expiratory and inspiratory move- 
ments are irregular and incomplete, chiefly in very 
young children,who evince considerablediead of the 
attack. This state is attended with anxiety and a 
slight mucous rattle. On the accession of the fit, in- 
fants grasp persons or objects that are near tbemior 
upon awakening from sleep start up. Each acccsMOi 
consists of a very dry, sonorous, spasmodic cou^; 
the contractions of the respiratory muiclei, bang 
so quick, and succeeding each other to lapidlyi 



236 



HOOPING-COUGH— Complications or. 



the pulse and respiration » in the intervals between * 
the paroxysms, and of the expectorated matter, and 
by examining the state of the lungs by means of 
percussion and the stethoscope, that wc can detect 
the complication or judge of its nature and extent. 
In infants with a narrow, or malformed ciicst, 
there are often great dyspnc&a, frequency of pulse 
and of respiration, sometimes even witliout much 
serious disease of the lungs, beyond slight bron- 
chial irritation. The most common com plic;it ions 
of hooping-cough, especially from two or three 
months old to seven or eight years or later, are 
croup, bronchitis^ pneumoniaf pUurxsii, pneumo- 
thoraXt cedema of tlie lungs, hjfdro'lhoraz. In all 
these the respiration is ditHcult, frequent, and em- 
barrassed ; the countenance and extremities are tur- 
gid ; and there is continued frequency of pulse. The 
expectoration terminating the paroxysms, varies ac- 
cording as either of the above lesions is present. 1 1 
is generally much diminished, and, in projportion to 
the severity of the organic disease and of the accom- 
])anying fever. But the extent and nature of the 
complication should be carefully determined by the 
stethoscope and by percussion. In somewhat older 
children, and in those advancing nearer to puberty, 
who are of a scrofulous habit, and hereditarily dis- 
posed to phthisis, hffimoptysis, sometimes to a con- 
siderable extent, takes place, and in these subjects 
particularly, tubercular disease of the lunss is 
not infrecpiently developed, either with or wiUiout 
hsmoptoe. 

11. li. In infants and young children, the func- 
tions of the brain, and the symptoms, indicating 
disturbance of this organ, should be carefully 
watched for, particularly those indicating cerebral 
congestion, hitdi'ocephalus, meningitis, or cerebritis ; 
and if any of these symptoms occur, and e<«pecially 
if attended by continued fever, by screaming, or 
by rolling of the head, or convulsions indicating 
meningitis, or hydrocephalus; or by somnolency, 
falling of the eyelids, cool slate of skin, inability 
or disinclination to move or bo moved, with dilatcil 
pupil, ^c. indicating cerebriiis, deciMve treatment 
should be adopted, as recommended for tlicse 
maladies. 

12. C Diseases of the Abdominal Viscera arc 
much more rarely complicated with hoopin>:^- 
rough than those already mentioned ; however 
diarrhiru, chronic irritation of the stomach and 
Ihwe.ls, remittent fever, injiammation of the mucous 
surface of these organs, are not infrequent at- 
tendantfi upon it. Sometimes, oven, injiammation 
of the peritoneum and mesentery will occur, during 
the advanced stai^es of hooping-cough, and I liuve 
occaMonally also met witli inflammation of the 
csroum and colon, and pericarditis^ 'I'hesc com- 
plicration*, particularly tlio5H? of the dig(?vtive mu- 
cous surface, may suj>erinduce othern, as enlarge- 
ment of the mesenteric glands, and oifections of tiic 
cerebral organs, rapidly terminating in eil'usion. 

13. With ri'spoct to all these complications, it 
mav be generally remarked, that they are attended 
by more or less fever of a continued or remittent 
tyjie, and with paroxysms of cough, more or less 
dry and severe. Sometimes the febrile exaoei bil- 
lions and remissions are well marked, especially 
when the complication is in the abdominal cavity. 
The ex{K.'cturation terminating the tits generally 
diminishes us the complication increases in severity, 
and the vomitings often disapi>ear. The paroxysm:* 

Blfo Mfo foUowtid by more scoublc prostratiou of 



strength. — Having thus taken a general view oC 
complicated pertussis,! shall next more particularly 
notice those complications which mobt commonly 
occur, and which frequently superinduce further 
disease especially in connected or aMociated frac- 
tures. 

14. D. Pertussis associated with Branehitisiiti* 
tremely frequent during spring and winter, and ia 
this climate, especially m the months of February, 
March, and April, owing to the prevalence of 
easterly winds at that season. 1. It may precede 
hoopingcough ; 2. It may be coeval with it; 
and, 3. It may supervene in the course of the 
disease. The last is most common. Whenever 
bronchitis appears, there are always decidedly 
febrile symptoms during the intervals between die 
paroxysms of cough. 1 he breathing is also much 
accelerated, and when examined by auscnltatioa 
is accompanied by the mucous rattle, and oca* 
sional temporary suspension of the respintny 
sound in parts of the lungs, owing to the accuni- 
lation of the mucous secretion for a wh'de in oit 
or more of the bronchial tubes couveying air to 
those parts of the organ. The expectoration aim 
from being clear, whitish, and ropy, bectoM 
more opaque, less fluid, gelatinous, and lc« 
abundant. The paroxysms of cough are moch 
more frequent, and often accompanied with a 
feeling of oppression in the chest, and axe Im 
constantly followed, or even not at all, by reiec* 
tion of the contents of the stomach, i he coot 
sounds well upon percussion, and the patieot \m 
on the side most aflected, or in slighter eum 
on either side. When the bronchi of both hingi 
are generally affected, he is unable to lie on either 
side, or is incapable of lying down at all. 

15. This complication olten terminates fiuallj, 
either from obstruction of the air-tube« by the se- 
en mulat ion of tenacious mucus, together vilh 
spasm about the larynx, occasione<i by the oenoai 
character of the disease, and the irritation of (be 
glutinous secretion, the patient dying asphyued; 
or from congestion of the vessels of the h«id, 
owing to the paroxysms of c^ugh, the obslructJM 
|)roduced by the mucus in the air-piiss:iges, tai 
the diflicult circulation through the lungs; or 
from the inflammatory action having extended 
to the trachea and larynx, or lo the miuali 
bronchi and substance of the lungs, terminaiiif 
in condensation. 6lC. of the structure of die 
organ, ^c. In some cases, owing to the tmi* 
ment employed and constitution of the patieei, 
the acute form of the bronchial aflection gn* 
dually Kubbides until it arrives at a mildtf 
state; when, owing to the incapability of the 
vessels to assume the healthy state, a cbronie 
form of disease continues long afterwards, which 
may be removed, in some cases, by judicious ma* 
naiiement ; but which terminates m uU'crationof 
the mucous membrane, or ^ives rise to tubercles, to 
chronic pleuritis, or other legions in the tboradc 
cavity. J'his complication is frequent from six or 
seven months upwards, and especially durii^ the 
second, third, and fourth years of age. 

16. K. Hooping-cough assticiated with pneuuosu 
and pleuritis, is very frequent in the spnn;;dari^ 
easterly or northerly winds, particularly whrt 
the>e follow heavy falls of rain and open weatbtfi 
It is more common in some epidemics than ii 
others, and is met with at all ages, but most fit- 
([uently from one lo six or seven yean or upvtnk; 



J 



240 



HOOPING-COUGH — Nature and Seat of. 



22. iii. The Appearaneeiobterved in fatal Cases 
of' Pertussis show the nature and extent of the com- 
plications, rather than of the disease iteielf. The 
accounts furnisiied us of the fatal epidemics in 
former ages, contain no details of the appearances 
after deatli ; and even the more recent researches 
of Watt, Marcus, VVaterton, Guibert, Des- 
RUELLEs, G ULRSENT, and othcrs have thrown little 
light upon the nature of the malady, although they 
have illustrated the changes which often supervene 
in its course. The lesions wliich are most con- 
stantly observed, are more or less redness of the 
mucous surface of the trachea and bronchi, with 
considerable tumefaction of the glands at the bi- 
furcation of the latter. These tubes contain a 
considerable quantity of a ropy or more or less 
thick mucus. In the bronchitic complication 
these changes are still more marked, and in infants 
the thymus gland is often unusually large. In- 
flammations of the lungs, or of the pleura, or of 
both, in all their phases and stages ; and effusions 
into the pleural cavities, with or without adhesions 
or false membranes, are not unusual, but are ob- 
served only in cases of the pulmonary complica- 
tions described above. They are generally asso- 
ciated with muco-puriform matter accumulated in 
the bronchi, and splenification or condensation of 
several lobules or portions of the lungs. 

23. When the disease induces chronic bron- 
chitis or tubercular consumption, whether hsm- 
optoe has occurred or not, the mucous membrane 
of the bronchi has been found thickened, softened, 
rarely ulcerated in some points and injected, and 
tubercles liave been observed in all stages of de- 
velopment and softening, and accompanied with 
ulcerated excavations. Tubercular changes are, 
however, not very common in young children. 
Dilatation of the bronchi is sometimes observed ; 
but 1 liavu not met with it so often as Laennec 
believes it to occur. It is to be looked upon as a 
remote consequence of the disease in prolonged 
cases. M. Uhesciiet observed, in two instances, 
injection of the pncunio-gastric nerves : but Mar* 
cus, GuKRSENT, and myself have not found these 
nerves materially changed. 

24. The morbid appearances found witliin the 
cranium have been chiefly consequent upon the 
cerebral complications, and have cons>isted of sof- 
tening of the central parts of the cerebrum ; effusion 
into Uie ventricles, or between and beneath the 
membranes ; congestion of the vessels, &c. As 
far as ray dissections have gone, inflammatory ap- 
pearances have been observed in the medulla ob- 
longata, or in its membranes, even when no other 
remarkable lesion was present within the cranium. 
Whether this change be a conse<}uence of the 
disease or not, is diflicuU to determine ; but there 
can be little doubt tliat those found in the brain 
are merely remotely consecutive lesions. 

25. The stomach usually presents no particular 
lesion; but I have observed inflammatory ap- 
pearances in the oesophagus, and the same have been 
remarked by O/. a nam in his numerous dii>sections 
in the Foundling Hospital at Milan. I have like- 
wise found the mucous surface of the pharynx and 
epiglottis, particularly tlie latter, more or less in- 
flamed, and the subjacent cellular tissue, especially 
attlie base of the epiglottis, infiltrate<l and ucdema- 
tous. The mucous membrane of the intestines, 
particularly of the caecum and colon, has been in 

some insumces uiceratedi and the mesenteric 



glands engorged ; but only in jirotiicted CMi 
passing into infantile remittent fever. Fromtlw 
numerous post mortem examinations I hive mMic, 
I am warranted in stating that most of the ieiioai 
observed by writers in this disease are merely tt- 
fects of the complications of, and diseases eicited 
by, this complaint ; and that the parts most con- 
stantly found altered, are the mucons coveriag sf 
the epiglottis, trachea, and bronchi ; and of the 
pharynx and oesophagus; and, as respecti the 
nervous system, the medulla oblongata and ill 
membranes. 

26. iv. Of the Nature and Seat of Perlusm.— 
Sydenham miputed hooping-cough to the pic- 
sence of a subtile and irritating vapour ia thi 
blood, affecting the lungs and exciting the pa* 
orxysms. Bueu m e ( Cur- Methode der WirktiffiUM, 
Brust krankeiterif Leip. 1788), conceived that it 
proceeded from a peculiar miasma acting clue6j 
on the nerves. LiNSiCUS had previously relemd 
it to the presence of minute insects in the air (IK^ 
sert. Exanthemata Viva, Upsal, 1757) ; an opinioi 
which was partially adopted by Rosensteik, mht, 
however, believed that it was propagated by • 
morbiflc principle emanating from the afiecM, 
and passing into the system of those exposed li 
its influence by the respiratory organs and ith 
mach ; and hence the affection of those visoo^ 
and the irritation of the mucous glands, occaHoa- 
ing an inordinate secretion of phlegm. 

27. Waldschmidt (Jitititut. Medieinm JBs- 
tionalis, 12mo. Marb. 1688), 5toll (RatwM§» 
dendit pars ii. p. 180.) Dane ( Vermek einer Al^ 
gemeinen Geschichte des Keidihustens, S^e. Blirk 
1791), Lentin {Memorabilia, p«38), Faiiois 
and Brouzlt {Sur V Education des Enfant, uit 
p. 25), ascribed the disease chiefly to gastric di^ 
order and saburra, whilst they admitted, paitira- 
larly Danz and Lentin, that the lungs are abs 
much affected, but in a sympathetic manner, ui 
that the other symptomatic disorders accompaay- 
ing it vary exceedingly, whilst the respiratory 
functions are more constantly disturbed. Cbas- 
BON {Des Maladies des Enjans, t. ii. 8vo. Pifii^ 
1799), and Tourtelle {LItmens de Mid. Thi* 
oriqueet Pratique, t.ii.), con»dered penuMSi 
a species of catarrh. I'he former located it in tk 
stomach, and supposed that it is of an a»iheiic 
nature, the cough and other nervous symploai 
being occasioned by the affection of this orgtSi 
The latter extended the gastric disorder to tkt 
lungs, and regarded the disease as a pituitoa 
pneu mo* gastric affection. A similar opinion wii 
enteitained also by Dr. Styx (Hufeland^ JMn. 
d. Pr. Arsneifk. b. \ii. st.iv. p.l77). GiXDin 
( Train des Mai. des Eufaiis, p. 391.) nearly cois- 
cided with Tourtelle in referring it to a nerroM 
irritation, sui generis, causing a pituitous or it- 
creased mucous secretion from the bronchi isi 
stomach with convulsive action of the glottis u' 
diaphragm, and believed that it differs from catink 
chiefly in its cause and the periodicity of its chi^ 
ractcr. The opinion of Millot was not M- 
terially diflerent from the foregoing. He refemd 
the disease to a spasmodic irritation of the stomick 

tmmariiy, and ot the lungs frvmptomatically, vd 
le imputed the cough chiefly to the convalsie 
action of the diaphragm ; but he contended ikM 
the throat and bronchi are also implicated. X- 
Broussais has also argued that the source of tbt 
disease is in the Btomach; buthe coiwidenthtfit 



■ -■■.. u^ 1-1-; I'aun.U bwumfl Mbjett to convuliivc aclioni, which im- 

<-'.■ ■■,t i— '•'A.i- •! ■■i ir. pr-i^ ihe coa^ witb il* peculiar feUurei. Thg 

:. 1 ii^i.c'i'.--. -ii'^. •tr irriantau t\n*<i\ iMace\\ againil the ioflsm- 

; ". ■iirJirr-iT'- .a .f pri- -nal-rr •irii{in ol" llie <U.<eaH. ire equillv ipplici- 

t .: "I «'.'! <1 III: vi.t-ini 9i« Ca thii new; anil the coaitaDl eii»IenCE of 

i";-!.' • r.ria.i.iaa -y. i.ni rfrnbral irrilitwn i* by oo tin-aim proved — (he 

■'■. ■•! *<ii.ii'« Vii'Mi'M -ir ivrrMJiiDtl niperventiuD of Ihiiimtitiati beiog all 

■s':r»: • M n-ir". Tb-M, diat » fully a>«erlain«l. 

r> '." ':i:-.;-;'' i^'i V Iw aa H. Fmin mj lewarche* iiilo Ihe nathoio^ 

-.1 -.;■: Morii. ■» 'i TTai-;!! aii<l trejtmtnt of luiapinf:-Paug)i, during uma 

• ■■ '•.■.~ .■■V-*-;. ''^ IT- >nJ viij.-* prevbiusly to 1823, I wai l«] to CDDud«r 

' .- I "I'j.*. 'Ill "irjcvnitiii Th« medulla olilan>ata or ill niianbranes mj 

::•. ^ 'I- 7 « jiIj: ti> th« eart* implicatnl in ttiit diicafir; cviilcncn of in- 

-.i- ■-, ■'ir-.i* "■) 'm :au of HinnnatoryirHtalioniiftlieM part* hariag been very 

'. 't K .-■>«« • u 1 virw* xeihrralljolHeTveil in the pAil innr(rn iDipiiCtioni 1 

v.i ■ '•. «.f '.1 :a it-.al niilmvls. [con<rcivi.ilthatlhcmorbidini))rowoti 

I !•: -ciT'tl-it^ paroi> or irri'ition occanieneil by the exriling raon ia 

;.;-■* V • M -v'-M '^as- Ihi; upper pattn of tb« letjHralory lurfim, partv. 

:-. '-i-j' .■! -a-: i;r-p**«J«» ruUrly the gloHis and iti vicitiily, affrtlt the 

1-^: '. ''.:•; :~'.ii <}c >Ki:a> re*pinlory nerve', especially the pneumagaittir ; 

:>: l: \'.l '"■•t •envf.'in aa>l that ttie irritation i< eictcnded to the originaol 

13-. M. B-i-*!,:- D'1. the** nerves, where ll agorivates and perpeluatei 

--"I". ;. v. t■■^'(•al:l4 a the primair iBection. Where no predi«posin;, 

if \1. b'jffi iiir-['ar*iT : mncurrvnt, or consecutive caum or influeiwef 

'f.(- tt -I :-f f'-vital -itii favourable to the ilvvelopeiuent of iaflammalary 

•'' ("i! irrn, ilv.i. fliiL anion eilhcr in llie retpiratury oi^atii or in Ibe 

-' I i.'i;a-r-iir7iljniina(ii>n brain exi«t, the mortnd aclioD doe* not praceed 

■■•■i' nwiib 'UK. iiilli an lieyiiod an irritative <lau, and Ihe djaenn pr» 

■t '-.•int. Hr. Uivbij: Krvet > (implc funn. But nhen luch can«r* are 

.-, tito. 1 oi^l. IiiO-l.^ .ilio in iiperation, tlie irritation pai^ei into inflamma- 

ir.Tt tU'iTvv: :h."l[va*e: lorv ai'tion in etlher of thera « '' 



: 4. I ■■iW'-i.- ^'j^r'* It to the brua>>hi aiul Inn^. and in othen from the 

'-r i'-. i-jrt'rh. '•<): -.'nj an meilulia ohlun^ta to ibc brain or its mem lira or*. 

• lis 'V p'fj'f'.* ai.l the Ai the irntUiini inrri'a!«« or extends downirirdi 

:i.- ~Mit T. ^•■•r.i tlie ahm; the nrtpiralniy furfacn on the one hand, 

^•f .'•■<::". '.v.^s'<ive or li> the pharynx nnd gastric murous niifan on 

.■ a ' ■ I ■■* .■■■■;v.ti-t tj be the other, and m it predominaut in Ihe one above 

' ■:*. JT.'. •miM't iw ihe .ilher. so doc« Ihe lii^eaM isiuine more of a 

I'v ■'•1'-.-.' o' rr'piri- hronchitic or ot a pjaslric character; the latter 

'.I -K-r:'. "r ('\'-l'iin'.hy fi>rtu lieio>t the nio<t favaiirahlc, a* lending to 

\ .'o- ^i>:'i>n fmni di'vmbarTBM the bronchi, anil to prevent Ihe ex- 

..' -L- ± i'i':ii lai'liiin of tension oF di^eitc in that direction. When Iha 



244 



HOOPING-COUGH —Simple — Treatment. 



disease to a distant part of the country, and into 
a family where it did not exist, communicating 
it readily to those who had not had it. Like 
all infectious maladies, it is much more rapidly 
propagated during certain constitutions of the 
air, particularly those in which catarrhal com- 
plaints are frequent, or when measles prevail, 
than in others. In its epidemic form, its infec- 
tious property appears to be most fully marked, 
from tne circumstance, probably, of the concur- 
ring causes, whatever they are, being then more 
active, as well as from the predisposition these 
epidemic slates occasion. Pertussis has also been 
frequently observed to follow, epidemically, upon 
epidemic morbilli. When it occurs sporadically, 
and during healthy states of the atmosphere, it 
often fails to be propagated, unless to those most 
predisposed. Moreover, it is often necessary to 
infection that the breath of the affected subject 
should be inspired by the unaffected ; and that 
the disease should, at the time, be fully developed. 
The infectious property seems to diminish as the 
disease declines. Dr. Culi.en and many others 
believed that it disappeared in from four to six 
weeks ; but, as Dr. Elliotson remarks, the period 
cannot be fixed with any precision. It is gene- 
rally from five to seven or nine days, or even 
longer, after exposure to infection, that the cough 
commences. 

40. V. Treatment. — There are few maladies 
against which a greater array and variety of 
means, both medicinal and regimenal, have been 
recommended, than against hooping-cough. Vas' 
cular depletion, emetics, purgatives, diaphoretics, 
antispasmodics, excitant::, internal and external 
irritants, &c., have been severally prescribed as 
unfailing agents, and combined, in infinite forms, 
in the treatment of this complaint. Although 
these may be extremely beneficial, they may be 
also most mischievous ; success entirely depending 
upon their application appropriately to the pecu- 
liarities of imiividual cases. As the disease is va- 
riously modified and complicated, so it cannot be 
removed by a particular class of remedies, or by 
a specific form of treatment. Cleans inappropri- 
ately employed, may convert a simple and slight 
case into one both complicated and dangerous. 
— There are certain considerations requisite to a 
succeitsful treatment of this complaint ; and these 
should always be kept in view, not only in it, but 
also in all other epidemic maladies. I refer especi- 
ally to the constitution and habit of body of the pa- 
tient, to the character of the pri'vailing epidemic, 
to the nature of existing complications, and to the 
period and progress of the disease. It is owing to 
these circumstances, that tiie means which are 
beneficial in one case, or in one season, are often 
injurious in others. Thus the epidemics of spring 
or winter more frequently require vascular de- 
pletion, than those of summer and autumn, whilst 
these latter derive more benefit from emetics than 
the former. So important are the complications 
of pertussis, that the treatment should be mainly 
directed to their prevention or removal ; and 
whatever they may be — whether broncliitis, 
pneumonia, congestion or iniiammalion of the 
brain, &c. — it should be recollected that they are 
much more dangerous, than when occurring pri- 
marily or in a state of previous health, unattended 
by the aggravating circumstances of this com- 
phinU 



41. i. Treatment of Simple Hwpufg^NjL— 
In the slighter cases, little more is required tin 
attention to diet, regimen, and the excictioM^a. 
less the child be plethoric, when additionil Bai 
will be necessary. — a. In the^Vst stage, a doie rf 
rhubarb with hydrarg. cum ciieta or eaimd^vAt 
little ipecacuanha , maybe gi^en every Digfat,ie» 
sionally interposing an emetic. The d'ut ^Mk 
be farinaceous, witli milk. The child onghttok 
confined to a mild, equable temperatore, lodmr 
flannel next the skin, in winter, sprinj;, or aitab' 
If the patient be plethoric, it will be proper, iir 
precaution, to apply leeches, according to luiK 
either behind the ears or over the steraum, HW' 
head, or respiratory organs, may indicate a difM^] 
ition to be affected. In the more severe attan^ 
also, this measure should never be neglected ; 
diaphoretics, with small doses of aHtiwmf, tf rf 
ipecacuanha, ought to be given every foarv 
hours ; the secretions and excrctioas bon^ i 
promoted by calomel and rhubarb evei^ niglCi*^ 
and a stomachic pursatice, or an emetir, cMk* 
second or third mormng, according to drcifr 
stances. 

42. b. In the second stage of simple pBta^ 
an amtdyne may be added to the diaphordicH^ 
ture, and taken every four hours. If no sin ■ 
cerebral or pulmonary affection appear, the Ajiona 
cum crela may be substituted for calomeL ia ■ 
night-powder. It is in this period, that die ticrip 
ment recommended by Dr. Pearson is nwstM 
viceable. This consists of an antimonial emeijt, M> 
lowed by a draught containing a drop of ti 
of opium, five drops of ipecacuanha wine, aad 
grains of carbonate of »^ , for a child of ooe or< 
years of age. This draught is to be repeated i 
four or five hours for several days ; the boveU 
kept open by rhubarb and calomel. As the 
declines, he lessens the opiate, and gives ntn^l 
place of the ipecacuanha wine. This treatmoli 
excellent for children of three or four years of ap 
or upwards : but until they reach two or thm 
yearr, opium ought not to be given. For those* 
the age mentioned by Dr. Pearson, 1 consida 
the extract or syrup of jwppy, or ciminm, or fc» 
bane, to be prelcrable. The liqutn- jiofacur, al* 
will be often advantageously substituted for ik 
soda. The Jecoctum $ctte^tt, or the inj'unta «•! 
eriaua: m.iy be given in this and the next stij 
with some aromatic water, and an anii<pafmo<fi| 
It will be sometimes of service, even in tk 
stage, to exhibit on emetic, if the fits do not um 
nate in vomiting ; and, unless the attack is sligh 
the same diet and regimen, as directed in tliefe 
stage, should be continued in this. A princip 
indication in both is to wotch the first sii;n of ri 
ceral disen.^e, and to op{)ose its acccs>ion by U^n 
applied in cither of the situations just named, ai 
by emetics. In both periods, also, advaniogt? w 
accrue from the warm semicupiiim or pedilu«i 
at bed-time ; but, unless the case become «vei 
it will only be occasionally required. — The e 
creiions should always be promoted by mild i 
stomachic pur^lives. 

43. r. In the f/n'rcf «(a^e, the chief indicatio 
are to strengthen the system, and to supersede il 
convulsive character of the affection, by girii 
tonics with antispasmodics and anodynrs. Tl 
gentler tonics may be first employed, and sncct 
sively those whicn fire more cnei^ciic, io cs 
junction with preparations of po^tpy, or «i 



246 



HOOPING-COUGH— -Specipic Modss op TssAnfnrr. 



prerent thereby the acceation of a formidable 
malady, by a prompt application of efficient 
meant. To wait until the coming evil has fully 
declared itself, is to sacrifice the principal chances 
of success; for all cerebral aflTections that super- 
vene during pertussis/ are much more dangerous 
than those which occur primarily. As soon as 
the complicated affection is removed, change of 
air should be recommended. Nothing is so 
advantageous as a complete change of air for 
children treated in London, or in other large 
towns. 

47. D. Infantile rtmittent ftver generally 
does not appear in connection witn pertussis until 
an advanced stage of the latter. Other associated 
affections, as chronic pulmonartf disease, euriM' 
tures of the spine, rickets, affections of the joints, 
enlargement of the mesenteric or of the absorbent 
glands, ^c, are sometimes also met with in pro- 
tracted cases of hooping-cough, or in the stage of 
decline, particularly when the disease has been 
neglected, or when the morbid affection has been 
perpetuated by habit, or by the neglect of such 
means as are calculated to break the chain of dis- 
ordered action. They often also may be traced to 
constitutional vice or predisposition, and to neglect 
of the excreting functions. Under whatever cir- 
cumstance, either these or the remittent fever may 
occur in the advanced course of hooping-cough, 
debility is a principal element of the complicated 
malady. Tne functions of digestion and respir- 
ation, and consequently assimilation and nutrition, 
having been more or less impaired during the early 
stage of the primary disease, inherent vice, or an 
existing disposition to disorder, the more readily 
manifests itself. As constitutional power sinks, 
maladies, which roost commonly arise from debi- 
lity, make their appearance ; the particular malady 
being determined in its occurrence by hereditary 
taint, or by previous disorder. In many cases, the 
superinduced affection is merely a sequela of per- 
tussis ; but in others, the characteristic symptoms of 
the primary disorder still continue in a very perti- 
nacious manner. 

48. The remittent febrile disorder depends, in 
several instances, upon chronic irritation of the di- 
gestive mucous surface ; in others, upon the state 
of the season or weather, and the influence of ox- 
halations from a humid soil, or upon a moist and 
cold atmosphere; and in some, upon both con- 
joined. But whatever may be the source, it can- 
not be doubted, that debility is an important part 
of the disorder, and that the alvine secretions and 
excretions are much disordered. At the same time, 
therefore, that a treatment appropriate to the affec- 
tion of the digestive canal is requisite, the state of 
constitutional power must receive attention. Purg- 
atives are generally necessary in this complication, 
especially at an early period of it ; but they ought 
to be of a stomachic kind, or combined with tonics, 
and neither be too irritating, nor too pertinaciously 
directed. The compound infusions of gentian and 
of senna, with sulphate of potash ; rhubarb with 
this latter, in an aromatic water; hydrargyrum 
cum creta, or blue pill, with ipecacuanha, at bed- 
time — either of the preceding, or castor oil, being 
taken in the morning ; are amongst the most suit- 
able purgatives ; and they should be repeated ac- 
cording to the state of the stools. If the bowcU 
be iniiable, or dysenteric, a full dose of calomel 

or hydnrg, cum creta, with the compound ipeca- 



cuanha powder,- should be fint given, havi 
some cases premised an ipecwnanha emetic 
hours afterwards, a doie of caitor oil oagfai 
taken, and its operation promoted by an emi 
injection. After the intestinal canal is evic 
irritation should be allayed by mild tonics 
joined with aromatict, absorbents, sedativ 
antispasmodics, according to the peculiari 
the case. PreparationB of cincbona, q* 
chalybeate*, &c. will subsequently be of si 
The decoction of bark, or any tonic infusio 
be advantageously given with liquor potai 
BnANDisa's alkalme solution ; andafterwa 
ammonio-chloride or potastio-tartrate of iro 
change of air, will generally prove most beo 

49. Although this treatment is recomm 
chiefly with the view of preventing hooping 
from lapsing into, or becoming associate( 
infantile remittent, and of removing this < 
cation, yet it will be equally serviceable 
prevention of the other sequetec of the cot 
mentioned above ($ 47.). When affect 
thejttints, rickets, or meeenterie disorder eit 
pervene upon, or follow, an advanced s 
pertussis, the preparations of iodine, and 
means directed for these complainta, sho 
resorted to. Affections of the spine are ge 
owing to weakness of tlie muscles and 1^ 
of the vertebral column, induced by this d 
or to scrofulous inflammation of some poi 
the column itself. When the disorder is a 
able chiefly to the former of these causes, ti 
tonics already recommended, salt wster b 
sea air, and frictions with stimulating lit 
along the spine, will be very serviceable 
when the more solid structure of the coli 
implicated, then the preparations of iodine, 
dish's alkaline solution, or the liquor potan 
change of air, should be severally prescril 
circumstances will suggest. 

60. iii. Of the more Specijic Mtnifs of 
meut advised for Hooping- Cough, and the C 
stances in which they are admissible or apitn- 
— Willis and Sydenham directed bliKMi 
in the plethoric and inflammatory ca«^, < 
of the oxymel of squills, purgatit^es, and hli 
the nape of the neck or between the fho 
Willis also prescribed tontn during thee 
of the complaint. He particulariy notic 
Musats pjfxidatiis, or 3J. Ptfiioides^ tlie 
pifiidatus of TouRNEFORT, or cup-mo$s,as 
popular remedy in hooping-cough, (jr 
remarks that " the powder of this moise, 
for certaine daies together, is a most ccita 
medy for that perillous malady the chia-c 
DiLEN I us praised the powder of it, when freq 
given ; and supported his opinion by the au 
of Willis and Gerarde. Other writer 
prescribed it in the form of decoction io 
Van Woensel (//wt. de la Soc. Rou. de k 
t. ii. p. 294.) recommended it in decoction, 
ened wi\h syrup of mint. Baguvi employ 
the Muscus arhoreus and Af. quemeus m \ 
sis, in the form of decoction ; and a syru 
pared from the decoction exists in the Pi 
copa'ia Wittembergensis, to facilitate its exli 
to children. Stoll (Rat. Med. vol. ri. 
found th^se mosses or lichens, particular! 
throwing on the oak, veiy serviceable in the 
ing-cough which was epidemic in Vienna 
spring of 1775; Frank also pnices it. 



248 



HOOPING-COUGH — Specific Mode* of Treathent. 



and the amount of the dose of it, for a child : in 
combination, however, with calomel, it is much 
less injurious than when given alone. He like- 
wise employed antimonial emetics, mild cathartics, 
cool air, repeated blisters, or the tincture of can- 
tharides internally, warm batliing, the inhalation 
of the steam of warm water containing a little 
vinegar, opiates in small doses, and digitalis. He 
prescribed digitalis, whenever a tendency to in- 
flammation, or to effusion, or to pulmonary con- 
sumption appeared. He considered, with much 
justice, diuretics to be more or less useful in this, 
as in other disorders implicating the respiratory 
organs. Dr. Elliotson has very properly con- 
tended, that, wherever there is oppression of 
breathing, with violent spasmodic attacks of 
cough, accelerated pulse, and sonorous or cre- 
pitous rattle, inflammation of the respiratory or- 
gans is present, and should l)e treated by bleeding, 
by emetics, and by calomel. In such cases, seda- 
tives and antispasmodics ought not to be resorted 
to, until inflammatory action is removed, and the 
secretions and excretions are freely evacuated. — It 
is unnecessary to allude further to the various modi- 
fications of treatment adopted by other experienced 
physicians. I shall, therefore, only notice some of 
the principal remedies prescribed for this complaint. 

65. iv. a. Btoodlettiiig was directed early in 
hooping-cough, by the great majority of writers, 
since tlie time of Sydlniiam to the present day ; 
and frequently even in slight and simple cases, as 
a precautionary measure, particularly in plethoric 
habits. Lettsom has justly remarked, that, if it 
be not resorted to early in the complaint, it is 
seldom of service at an advanced period; but 
cases in which inflammatory affections of the 
lungs or brain arise at this period, furnish excep- 
tions to tjiis rule. Stoll prescribed depletion 
chiefly when the lungs became aflfected. Hupe- 
LAND directed leeches to the chest ; and Wf.DSTEii, 
to the temples, in most ca«es. I have seldom 
omitted to apply them behind the ears, or between 
the nape and occiput, or to prescribe cupping in 
this situation, at an early stage, influenced by the 
reasons stated above (§35.). — Of emetics, men- 
tion has already been made (41. 44.), — Purga- 
tivet have been employed chiefly with the view of 
evacuating accumulations of fa.>ccs, and of pro- 
moting the secretions and excretions. Calomel has 
been very generally recommended, both as an 
aperient and as un alterntive. Fisciifr and 
Haugfns gave it alone ; but it has been more 
generally conjoined with rhubarb or some otiier 
purgative ; and, in the inflammatory complica- 
tions, with James's powder, ipecacuanha, 6tC. 
Dakwin and Stiiofm prescribed it with rhubarb 
and opium ; in which'bombination it is often bene- 
ficial at an advanced sta^^e, and in patients above 
four or five years of age. The frequent use of 
Liiiiiiics or mild purgatives has been much in- 
sisted upon by MiCHAJiMS and Kortum. — C'a- 
thartic or irritaling euemata have been resorted 
to by lIoi.Dfcinf.vNn and IIifvland. 

.')6. b. Diaphoretic}, and e.\pecloraut» hii\e been 
geneially enjployed throu;;h the course of the 
complaint ; the former at the earlier, the latter at 
more advanced, periods. Some of these medi- 
cines promote both perspiration and expectora- 
tion, and are hence the more serviceable in severe 
or complicated states of the complaint. — Anti- 
rftaniah, in hmvM doses, were praised by Fotijer- 



GiLL, Weber, and many bthen. The solution of 
tartar emetic was employed by Hirscukl ; the 
golden sulphuret of antimony was preferred bj 
Closius and Hankes. Van de Sandb uA 
I'NZEii gave it after having premised emetics, 
and IIuLDEFREUND conjoinA it with sngir of 
milk. — The Kermet mineral was prescribed by 
De Haen, Hargenb, Kortum, Hinzb, sad 
Styx. Quarin gave it with the flour of salphor, 
gum-arabic, and extract of liquorice ; but, al- 
though formerly in ^reat repute in febrile and psl- 
monary diseases, it is now seldom employed. Tbe 
followmg powder was once much used on tbi 
Continent for the cure of this complaint : — 

No. S57. R Kerxnes Mineralk, Pulv. Ipccaciumlia,ii 
gr. J. ; Ocul. Cancror. pulv. et Pulv. Acadc iiZ^ 
Terc t)enc, et divide in C&rtulas v)., quarum capiat mm 
lextSs hori*. 

57. This dose was prescribed for a child of obb 
or two years. Much of the virtues of these pov« 
ders was clearly attributable to the ipecaeuaiMt 
which is one of the most serviceable medidott 
employed for hooping-cough. — Hennings is! 
Kkutscu relied chiefly upon it, and gave it in 
minute and frequent doses. Hargems ordered it 
in considerable quantities ; Kkeds, in the form qf 
infusion ; Vooler, with opium, magnesia, gu 
arabic, and sugar; and Pearson, with opiui 
and soda. — Ammoniacum and squills have bees 
used as expectorants ; but they require much eai- 
tion, for, in the more inflammatory states of tba 
complaint, they may aggravate tJie disorder, or 
even favour the occurrence of inflammatorf 
action, in plethoric habits, or when the phlogiitie 
diathesis is present. The oiymel of squills wai 
frequently employed as an emetic, and often witk 
benefit. Hufklano and Sulzek gave it witb 
cinchona and extract of hyoscyamus, in the ad- 
vanced stages of the complaint. 

58. f. Numerous antispasmodics have been pre- 
scribed in the second and third stages, on account 
of the convulsive character of the affection.— 
AssaJ'atida was recommended by Millar; bvt 
was con^iidered useless by IIlilland. Catttr 
was given by Morris and Horn ; muik, br 

CONUADI, (iFSNF.R, WoLFF, VoN BeRCLR, IIlFI- 

LAND, and Horn. Marcus conjoined musk witii 
the sulphuret of antimony and magnesia. Ibe 
oiide of zinc was praised by Cuei.l, PmcivAi, 
and Hart. Sciilidkaiamei. very j udiciously em- 
ployed it after evacuations. AV incklfk ami Tod£ 
gave it with cinchona ; and Starke, wth cream 
of tartar; but, from this combination, tartrate of 
zinc must have been formed. Harcen?, how- 
ever, considered it ineflioacious. 1 have but litlfc 
experience of its effects in this complaint. Cab* 
phor^ in very small doses, with diaplioretics, at M 
early period ; and in larger quantities, witli ano' 
dynes, other antispasmodics, or tonics, is oftto of 
great service, particularly after moderate depk- 
tion and alvine evacuations. The subcarbontta 
of the alkalies were given by Hin/.e, ISIejijbinceIi 
Pearson, and Kkutsch, and are often important 
adjuvants, in conjunction with hyoscyamtts or 
other narcotics, and with rhubarb or other apai* 
ents, in the treatment of the second and third 
stages. I have, however, often preferred dM 
litiuor potiisscL or Brandish's alkaline soluticm; 
es])ei'ially in the scrofulous diathesis, and io cbp 
chectic habits. The subcarbonate of awmmn, 
in small doses, and other prepuratioos of amoiooat 



250 



HOOPING-COUGH — Spscinc Modes op Thsatmivt. 



sine with gre&t benefit in iiome case«; and the 
nitrate of silver, triturated with extract of hop 
or of hyoscyamus, with equal ailvantag^e in others. 
The sulphate of iron was very favourably noticed 
by Dr. Stanger, and is an excellent medicine in 
the thinl stage, or purely nervous state of the 
complaint ; but it is not superior to the other 
preparations of iron, particularly the ammoitio' 
chloride, and the pittassio'tartrate. 

63. g. There are various other medicines which 
have been employed internally against hooping- 
cough ; but these require only a simple enumer- 
ation. Of the Lichen pviidatus, mention has 
already been made ($50.) The Lichen cocciferus 
was recommendi>d by Furbes and Von Woenzel ; 
and the L. hlandicus by Wkber. The lA^dum 
palustre, Tilea Kuropita, and alth<ea officinalis 
were prescribed by Waiilrom, Limn. cub, Wal- 
ter, and Wahlin ; the Geum urbanum, by Keck 
and Buchhaave; Phellandrium aquaticum, by 
Van der Doscii ; an infusion or extract of the 
Narcissus pseudonarcissus, by Dufresnoy ; an 
extract of the Mesembryanthemum, by W knot; 
and an extract of the Cardamine pratensis, by 
CoMHAiHE and Veilleciifze. — /«i»|r/aM was used 
in this complaint, by Heineken and Gautieri ; 
acetate of lead, in small doses, by Forres ; oxitle 
of zinc, with cicuta or belladonna, by Guersent, 
diluteil acetic acid, with sugar, by Han nes; sul- 
phur, by Sydenham, Quarik, and Unzer ; and 
the sulphurel of potassi by several Continental 
physicians. 

64. /*. There are few complaints in which exter- 
nal medication has been so extensively or so benefi- 
cially employed, as in this. Although the inhal- 
ation of simple or medicated watery vapours does 
not strictly come under this head, I may here 
state, that it has been advised by Pearson, Dar- 
win, and others. The observations as to this 
practice, in the article on Injlammatitms of the 
Bronchi (see that article), and as to the medicines 
that may ustrd in ihU manner, entirely apply to 
hoopin^'-cotigh. In the early stage, the vapour 
to be inhaltni should be either simple or merely 
emollient. In the latter stages it may be sligiuly 
impregnated with camphor, or with some nar- 
cotic ; but this practice can seldom be adopted 
for young childien. The inhalatitm, in early or 
inflammatory states of the complaint, of stimulat- 
ing vapours, is always injurious. 

65. i. Kxternal initants of various kinds have 
been prescribctl. BH^^er» were appli<'d to the 
chest, and JM'twcon the shoulders, by De Mi:/: a, 
Paldamus, QuAuiN. and others ; hut the precau- 
tions stated above (^ 44.) should be observed, 
particularly in rases of infants and young chihl- 
ren. Knehei. directed rithefucientii to the nape 
of the neck; Pelaroi-s and IIukkland, to the 
lower extremities ; IIkxninc and Heikkr, to the 
epiL^strium ; and Dvrr, to the soles of the feet. 
\'arious substances have been em])loye(l as ex- 
ternal irritants. Henmno recommended a cata- 
plasm containing scniped hnrseradish ; Struvf, 
a liniment with tincture o( canthurides and tnrttir 
emetic; and Zadic, the tincture of fiinf^er applied 
to the epii^aslrium. Aiuv.nrihu prescribed an 
ointment containing tartar emetic to be rubbed 
upon the chest, or between the shoulders, or u|>on 
the epigastrium ; and this practice was adopted 
by Kelch, Merrem, Nolok:, and .Micimells; 

but Horn aad Schnuidsr found it productive of 



little or no benefit. AuTSKninH hu receiTed 
the credit of being the first to employ tartar 
emetic as an external irritant; but it was thai 
recommende<l long previously, by tlie ol^ Mox- 
Ro. I have seen the incautious use of this oint- 
ment productive of dangerous, and even of faul 
sloughing, in debilitated or cachectic childitn 
and infants. Loebenstein-Loebbl advised a lini- 
ment containing a solution of phosphorus in oil of 
cummin and camphor to be applied on the epiga^ 
trie region. From an extensive experieooe of 
external irritants in the treatment of pertusoi, I 
prefer the semicupium or pediluvium, mustard 
and salt havine been put into the water; the 
occasional application of a tmutard pouUiee to 
the chest or epigastrium; drj/ cupping on tli« 
nape of the neck or between the Mulders; or 
friction with the following /intmeiit along the 
spine, or the application of a piece of fliODcl 
moistened with it, on the ttemum or eptgostrie 
region, according to the peculiarities and compli- 
cations of the case : — 

Na S5fL H Linimentl Caraphone Comn., liuneBti 
Tcrebinthins, ii 3 ^J Tinct Capriri 3 ). ; OW 
Caojuputi 3 Bt.vel 3j. Misce. Fiat linrnieDtum.TclBB' 
brocatio. 

^, Since the introduction of vaccination, lihu 
been proposed by Okes, Cleeve, and Modtain, 
to inoculate with the vaccine matter as a urevent- 
ive and as a cure of hooping-cough. Thid ralh 
ject has been recently agitated, but without ut 
conclusive evidence of benefit having been derived 
from the practice. 

67. k. In the second, but especially in the third, 
stage of the disease, change of air, particularly to 
the sea-side, as recommended by Grboory tfid 
IIuFELAND, and sea-votfaging, are of the utmoet 
advantage. For patients residing on thesea-coart, 
frequent excursions on the water will l)e highly 
beneficial, especially if nausea or vomiting be 
thereby produced. Salt-water bathings com- 
mencing with the warm or tepid bath, and pas^iof^ 
grnduallv to the cold bath or shower bath,viii 
be found very serviceable, if no complicaiioa for- 
bid it. The diet of the patient, in tne first itaee. 
should be antiphlogistic ; and in the second aad 
third it ought to be very light, chiefly farinacfoiu, 
and moderate in quantity. Over-distentionof the 
stomach aggravates the fits, and favours rerebraJ 
congestions. Exposure to cold, or to vicisritudtf 
of weather or temperature, running, &c.. alWi 
may induce inflammatory complications. YouBg 
cluhlren ought to be carefully watched at nirfit, 
and be rai'ted up as soon as the fit is thrfatencd. 
Whenever the phlegm obstructs the ftiuce*, it 
sliould be riMnoved by a small thin piece of while- 
bone, bent in the form of a tongue-scraper, orbf 
the finger of the nurse. 

RiBMoc. AM> RKFK^—Jmahis Lusftamii, CentvL 
;»0. _ fti/iis, ratJjol. ('orcl)r. can. 1«. ct De Mediraaflrt. 
Oprrnt, ]>nr i. mvt. L rap. vl. p. itrP.'—Sjfttfnkam^Fwt-i- 
RciKiiiK ()|K'ra.., Uigd. Bat. 8va IT^vp.SU.— //. Vmw, 
V(>y.i){(> to Madeira and Jamaica, fol. I^ood ITUt.— 
F. If.afwan. Oe Tuj<i ConviiUiva, Opn. .Su|«l. il. Df 
Tii^fii, ill. Hnlr, \1:V2 — Alhcr/i, I)e Tiufi Inhirtiui 
F4)idoinira. IIa1a>, 17'i8. — //vxAaw, OpA L p. !1K 1)i 
>iorbis lOpid. v(»l. ii. p. In. — Rrcndel, Progr. de Twi 
ConvuMva. (ioett. 1747. v. Owp. i. p. 1.59. — /.. C &«f- 
ihUiH, J. B. liitt$cviUe, Ergo Tuui ClangOMD Enciii. 
Par. 1752. ///i//rr, 1). ad H. X. — Ka^kr, DtMertitM 
hur plutiuurs Mnladie* qui ont r^gn^ i Chakm nit 
Mariu', &<•. Parln, 17.'xi. — Tkrod. Furies, De To«ii €•■- 
viiUira. I .din. Svn. 1754. HaUer, D. ad. M. ii. — C& 
ih'//er, Sorutiniuin Phyticcraedirum de TuNl Cmnil' 
Fiva. Roait. Hva 1755. — JoAn HyOimmu, Hbtoriei of 
Wounds of the Head, with Rcmaika on tke CooraWft 



254 



PSEUDO. HYDATID — Pathology. 



arc also altered, and the contained hydatids arc 
often more or less changed. In such caftus, the 
morbid secretion from the internal surface of the 
diseased cyst is destructive to the vitality, first of 
the enveloping or parent hydatid, and consecutively 
of tliose which it contains. 

14. The vitality and independent existence of 
hydatids are shown not only by their reproductive 
powers, but also by the preservation of the animal 
substances composing them from the changes, or 
the decomposition, which these substances always 
undergo when they lose their organic connection 
with living parts. Vet, although thus possessing a 
certain, but a low, amount of vitality, they cannot 
Ik! elevated to the rank of animals ; for they possess 
neither sensibility nor mobility, nlthou<!h their pa- 
rietes present signs of organic contractility. They 
may be viewed, therefore, as the lowest or incipient 
state? of separate animal organisation, from which 
there is a gradual rise in the scale of existence, 
through the vesicular and flattened parasitic worms, 
up to the more perfect animals. 

15. f/. liydutids undergo many consecutive 
chatigea, some of which oiiginate in disease, either 
of their containing cysts, or of themselves. Oc- 
casionally these cysts break, cither exteriorly or 
into a serous cavity, or upon a mucous surface ; 
and tliis occurrence may be either fortunate or 
fatal, according to the situation in which it takes 
place. If the rupture occurs on a cutaneous or 
mucous surface, the admission of air causes pro- 
longed Ruppuration. If it occurs in a serous 
cavity, which is rarely observed, fatal inflammation 
is thereby occasioned. Frequently, however, 
owing to the death of the hydatid, absorption of 
the fluid in the cyst takes place ; the parictes con-, 
tract, and a{)proach towards the centre ; and the 
remiuning contents become n*markubly chnn<rod, 
anfl often assume a tuberculous, putty-likt', 
cliee-sy, or purulent form, the hydatidic mombmnc:) 
beinsr pressi^d together, or ollwfrwise alU'red. Ac- 



entirely or partially in contact with tlie adjicctt 
tissues, are supplied by rheM with the fluid ihcy 
contain, and are nourished by them. Dr. Kui 
has dividerl them into two varieties, viz. tboae 
which consist of ximple ct/tls, or bladders optbk 
of being detached without lesion of structure, ud 
those which are cimjuniHd^ and which appear u 
diverticula from the subjacent membranoiu ci- 
paiLsions, from which a separation at their baaa 
cannot take place without laceration of a put 
essential to the integrity of one or the other.— 
A, Under thejWmer head may be arranged— 111, 
those cysts met with under tlie common integv- 
menls, that contain a sebaceous, atheromatous, or 
meliceritious substance, secreted by the cvst, ind 
causing its distention; — 2dly, those cysts formed by 
complete obstruction of a canal conveying Mcreted 
fluids, as ranula, those found in the labial glands, 
nnd the surface of the kidneys, 6cc. ; -3dly, tboie 
proceeiling from the distention of cells natuitllr 
existing in orgims. by a morbidly increased and 
altered secretion ; as in ovarian dropsy, and disev« 
of the thyroid gland ; — and,4thly , those i«erous cyiti 
often found in the plexus choroides, sometimes is 
the eyelids, more rarely in the lungs, the femile 
mamma, and other parts of the body. These Ivt 
sometimes acquire a large size, especially when 
seatitd near the surface of any of the abdonuoil 
or thoracic viscera, and constitute encysted drap«f. 
The cysts belonging to this class are genenlly 
simple, distinct, and solitary. When two or mm 
of ihem are developed in one part, as in the ptexvi 
choroides, the association is owing to the nme 
cause whicli producefl the one, having likewiw 
0]>cratcd in its neighbourhood, lliis has been tiell 
shown by Dr. Hodgein. (Ma/. Chirurg. Tnts, 
vol. XV. p. 266.). 

17. Tnc formation of this species of cymls, e5p^ 
ciiilly of tho^c which cannot be referred to tl* 
obstruction of canals or onflccs of ducts, has bees 
a subJL'Ct of much speculation. It has been $a|i 



'niiap' 
corling to Hi'\sii, BnEM-jKR, and others, hydatids I po«JtHl by somr, that they are pro<luced by w 
may thus dcy;(.!iuTiite into atheromixtous, sti'utonia- obstruction and consequent dilatation of ahsoH)- 
tons, or mi;lirorous lumours, espL-cialiy when thuy 1 fiits, or of oiIht vessels not admitting the pi<?*f* 
occur in the ovaria. This opinion has Won zca- of red blood. Thi«, however, is only a suppo«itioiL 
lously and ingoniously argued for by Dr. Haiion. j In a paper which I published in 1821 (/W. 
lie siipposes that the hydatid, or vc»iicular form, ' Med. )?f';ms. vol. xv. p. 378.), I sugge«ted their 
is that in which tui)crculou«, scirrhous, sarcomatous, orijjin in effusion into one or more cells of the 
steatomatous, and fungous productions ori;rinatc ; areolar tissue, tlic sintc of the effused or secrelrf 
and that the transformation may take place at any j fluiil, and the changes in the tissue imtneditUlT 
pf.riod, or mav not occurat all. The co-existoncc surroundin;^ and confining the fluid. prtventiDg 
of hydatiils with one or otlur of tiios<> formations tlic diffusion of tlie secretion in the adjoining 
haw boon urpwl in proof of this do«:lrinr ; but there 
has Imm-h no evidence of any of thc^e havincr 
originated in hydatids, nor has the transition of the 
one morbid stnictun* into the oilier been even 
partially (ienionstrate<l. ^I'lie co-existence of these 
different pnxluelions in the same subject, that is 

sometimes observed, and that furnished tlie eliief the collected fluid, and the albuminous portion of 
basis of tlii<i doetrine, is merely a coincidence this fluid will attach iL«clf to and line the nJ^ of 
arising: out of a fully ascertained circumstjmeo, — the cavity thus fornicd. As the eflfusion increaw*! 
that the same states of cotiMitution, of vital activity, this cavity will enlarge ; the parietcs fonntrd by 
and vascular action, which favour the prinluction the impacted areolar tissue will l)econie firmer i™ 
of the one structure, also predispose to the denser ; the albuminous portion of the secrfti(m 
other. will (>ontiuue to attach itself to the parietcs, if it be 

16. II. — Psi;i i)()-IIvDATins, Simpi.i, C'vsts, or , in small quantity, where it will become orgTini«d, 
fe.<ir/f5, have been very coniinonly confonndeel or even converted into a serous surfai'e ; and the 
with true hydatids. From this circumstance it will cyst will present several coats or lamina, thus 
be necessary to take some further notice of th(rm produced from the condensed surrounding tisnfi 
at this place, than has been taken in the article ' and from the successive depositions of albuniinons 
ViasAtfs (f i 13^-1 15.). They are found liiiUet ; pellicles on its internal suiface from the eeeieted 



]>arts, antl giving origin to the parietes of the 
cyst. If scrum accumulates in one or more of 
these cells, owinij cither to morbidly excited 
action, or to impairerl absorption, in coanc-rtion 
with an iin))ermeable state of the surround- 
iiig tis-ue, this latter will be impacted .nroond 



256 



HYDATID — Symptoms — Treatment. 



valves forming: a limit to the vesicles. M. Ani>ual 
has reccatly attributed their orii^n to a deposit of a 
fibrinous clot in the areolar or other ti^sue^. Jle 
supposes that a minute fibrinous concretion, se- 
creted by blood-vesHcU in a state of morbid ac- 
tion, assumes an incipient form of or^i^Hnisation, 
and that hydatids are an advanced grade of such 
or<;anisation. This supposition is supported by the 
well known fact that fibrinous concretions formed 
on serous surfaces, although at iirst amorjihous, 
ultimately become organised. As tlie origin of 
true hydatids is susceptible of the same explanation 
as that of the Vesicular and other Parasitic Worms, 
the reatier is referred to what is advanced on this 
subject in tiie article Woums. 

23. V. Symptoms. — Tlic formation of hydatids 
beincr attended by no appreciable lesion of function 
or of vascular action, tiic general symptoms are 
most uncertain, if, indeed, they be not entirely 
unascertained, es[>eciaily in the early stages of 
tills malady. Hydatids are developed so slowly 
and so entirely without vascular determination and 
excited uction, that the organs in which tlicy are 
seated adapt themselves to the pressure or slight 
displacement of parts they may occasion. When, 
however, they are seated within the cranium, or 
when their bulk in other situations becomes great, 
then the disorder they may occasion is made more 
manifest ; although, even then, the constitution 
may not sympathise very remarkably with the 
local alteration. It very frequently happens, that 
no idea has been entertained of the existence of 
these productions, in persons who have laboured 
long undt-r sligiit ailments, until detected acci- 
dentally in a post mortem inspection. It is only 
when the hydatidic cyst has actiuired a volume so 
considerable, m to give rise to a palpable or visible 
tumour, that we can suspect its nature. In such 
cases, the su«j)icion is rendered more probable, 
when sonie degree of iluctuatiou, attended with a 
treuMiIous sensation, is pei"cei\ ed. This symptom, 
however, is illusory ; for it attends other deep- 
sc:Ued collections of lluid. When, owioL^ to tlie 
death of the hy'datiils, or to inilanmiulory irritation, 
or rupture of the containm^f cyst, suppuration 
aflects this latter, then hectic fever, discolouration 
of th.^ general surface, emaciilion, and otiier 
attendnnis of orijanic le-ion, take place. It some- 
times h:ipjM:n> that inllamination extends from the 
cy<t to tlio adjoining pails, and that the morbid 
production thus makes iL< way either to the sur- 
face of the body, or into some internal cavity or 
canal. When it opens exteriorly, the nature of 
the malady then becomes manifest, and the re- 
covery of the patient even po.-sible. 

24. \ 1. Tr.t\TMKNr. — Our in»pcrfect know- 
ledge of the causes and symptoms of hydatids 
necessarily renders the prevent'on aiid cure of 
them also very imperfect. Such of the causr.-s as 
jH,'em to bo more fully ascertaim d, should be 
avoided, and those general principles of treatment, 
found to be most successful when the human body 
is the seat of parasitic productions, should be 
adopted. I have shown, in the article Wohms, 
that the chief principle of cure, next to the dis- 
chnrcre of the parasitic animals, is to impart tone 
and vigour to the con<litution, so as to enable it to 
rcsi-t their reproduction or increase, and to throw 
them oflF with the secretions and excretions, when a 
more immediate and direct removal of them cannot 

bif effected. We may consider as axioms in 



pathology and therapeutics, that pansiles fonn, 
multiply, and increase, in proportion as the parent 
becomes weakened, and &a the secretions lod 
excretions accumulate, or are retained ; and tint 
they diminish, and ultimately disappear, with the 
full restoration of the vital power, and of the 
secreting and excreting functions of the animil 
which protluced them. The practicul applicatioa 
of these axioms to hydatids is very manifi^t. The 
principle being admitted, the selection of individuti 
means will de{>end upon the seat of tiiese pro- 
ductions, and upon the peculiarities of individnd 
cases. In most instances, however, the prepw- 
ations of iron, those of iodine, the iodide of in>fl, 
chalybeate mineral waters, camphor, and the 
balsams, the various vegetable and mineral t<mia^ 
and the promotion of the secretions and ezcretioM) 
by a combination of mild purgatives with Mo- 
machics and bitters, will be appropriate. 

25. W^ith res])ect to the propriety of pyneturing 
the hydatidic cyst, in circumstances appearing to 
require this measure, much will depend upoo ki 
seat, with respect to the external surface, to 
serous membranes, and to internal canalit. For, 
where this operation is likely to risk effusion ioto 
an adjoining serous cavity, as into the peritoneu, 
or to induce inflammation of a serous membnar, 
it ought not to be attempted. When tlie rjst b 
seated near, or has reached, the exterior sarbcc; 
when inflammation and adhesion have oblilenHd 
any cavity intervening between it and the exterior; 
and when the integuments have become inflamed 
and acuminated, so as to point out the situatioa 
where only a puncture should be made, then it 
may be undertaken. As to the other poiols of 
treatment, they will come under consideratioo ii 
the places where hydatids, seated iu ^le iotenal 
viscem. are discussed. 

niRi.io<:. AM) Itprrn. — ArcUrus, Mortv Chmn. l.iL 
c-li. i, __ J, p. Wurjfhnin^ in Kphom XaL Ciirio«. Dec 4 
Ann. !». p. 4iT. — 7*. R. Hart ma nu, lii Ibid. Dvt. i. 
Ann. 7. |». /iS — ,/. Canicnr^ Acta Acad. N'at, CuiMi 

vol. iii. \t. :r,l J. Gratfiiiii^ in Ibid. vol. riL p. 4(8- - 

./. C. Poff/, in Il»id. vol. viii. p. ;xs. — .7. //. Kaimrgicaitt 
in Ibul. vol. vi. p. 3iiy.—J. Burg, Misccll. Acad. Sit. 
Curio*. Dee, 1. A. «». et Id. 1678 and UvTf). ^ ♦a- 
J. II. Il!inrrn:t^', in Ibnt. Dec J. A. 2. ICW, p.-.t?.- 
A. C/cv.'r, in Ibid. I>«-. H. A. 1. lt«2. jk ¥). — J. M. lUf 
TuatiH, in Ibid. Dec. *2. A. r*. !<;>>(>. \x 4JU. — G. A. itmt' 
lin, in Ibid. Doc. .J. A. 1. liJlH, p. .Xhl —Jhuhio, EsmJ- 




llnBii 






dc I'Acail. dc«. Scionci-i! do Paris, Ili«it. p. ;{1. IiU^l — 
J. MttfA Mi'ui. dc Paris, IliKi. p. S:7. 1709. — (/. J.D' 
I't-rnri/t in llmi. vol. ii. p 'J78. — R AHAom ab Itartitat, 
Philo*. Irans.irt. IT'.":, p. 17. —.S. Morawl. Mfm. * 
P.iris, p 1;V<. ITJ-J, and p. iiJ. 17^3 — IK JiHttif, Phita. 
Transact. J7i.'.S, |i. W,:. — Mahn-t, M6n». di.' TAcad. 
Pari>. 17:2. in*t. p. '2->. .Mom. p. LVi*.). — .7. I.ir*tut 
in Ibid. 1:M, Hist. p. 74. — C X- )> Cat, Philo«. Tw 
1741, p. 7K\ — ('. Ji'rrwfiaR, in Ibid. J74:\ p. 504 — 
Jr. a,ahaiu, in Il.id. 17 H. p 7(ii>. — Jr. Watson, in Ibii 
1741, p. 7M. — // I). Sparing, S\cnitka Vctusk. A«4 
II.iiull. 174.), H. 3(Jti. ; and Schwrdi«che Akod. AbhairfL 
I74^>, 6. Hht.—Mtof'af^rii, Cau«. ct SmI. ice. €i4itt. xutOL 
>;. 4;'i. — A. P. Kulptn, Schriftcn dcr Kfrlinor tnicikh. 
Xaturf. Frcutulc. b. i. s. 048. — »'. Scott, Mfd. andPfiiloi 
Comment, by a Soc. m P^inbuff^h, vol. v p. 181 »/ A 
\ti/iui/s, Vcibandol. van lict (n;noot»ch. te VlimnjA 
dccl. J. 1)1. 4.'a — ./: Co//rt, Med. Trani.ict. volii r4» • 
— /'. ,^^cMjfA/M#/jt, Cwmmentarii Bononienscii, vol. ilP-L 
c. p. 14J. -■- Dunin/f, Annaln de la Soc dc M^rc. dt 
Montpillicr, vol. xxii. p. iWitl. and X71.~^jMmoritr, Mia- 
do Mcmipeliior, vol. ii. {i. \H. — J. I'aiti/ry, Med. Ekm** 
anil Oliscrvat by a Socirty in Edinburgh, voir. pnlH< 
\Kli'x). — (inattaui, Mem. dc TAcid. del St. ftr. iTfit 
Hist. p. 71. — C. A. JJnnarus, Systcma N*attti«,;vaLL 
p:irs ii. p. IWi. Holm. lliTJ. — /,. (hitrr, Mfm. praeolli 
& I'lniftiL de Paris vol. 1. p. 17G. — /JoaMMte v, IM 
Trausact. vol. ii. 11. 48<\— J. C, UtUom^ Mcfek ofik 



258 



IIYPKRTROPIIY — Cav8e« and Origin — CifARACTERS. 



cessive state of nutrition. This fact is proved by 
the physiological consideration of the subject, 
especially by those employments in which particu- 
lar muscles are principally exercised and conse- 
quently developed. In these instances, volition 
determines a more frecjueut and energetic con- 
traction of certain muscles, and such contractions 
require an increased supply of blood : whence, 
ultimately, results augmented developement. \V hat 
is familiarly demonstrated in the voluntary muscles 
also takes place in the involuntary, under analo- 
gous circumstances ; thus, the constant or repeated 
efforts made by the ventricles of the heart, by the 
parietes of the stomach, by the urinary bladder, or 
even by the intestinal canal, to overcome an 
obstacle placed at their outlet**, or to procure a 
free passi^ for their contents, arc followed by 
excessive developement of their muscular struc- 
tures, and are atiendcd by a relative increase of 
their vascularity. In these instances, the first 
change in the hypertrophied part is manifestly 
excited or increased organic nervous influence. 
This determines not only excessive muscular con- 
traction, but also augmented vascular determina- 
tion, and, as the general result, superabundant 
nutrition. On this point, the opinion of Dr. 
Carswell, who has written with more precision 
on this subject than any of his contemporaries, 
does not materially differ from my own. He 
fully admits that an increased supply of blood is 
necessary to hypertrophy, but has left out of con- 
sideration the snare which the nervous power has 
in the production both of this increase, and of the 
excessive nutrition which follows. He justly 
remarks, that the nature of hypertrophy merits due 
consideration, as involving the principle on which 
the treatment of it should be founded, and as 
establishmg a law directly opposed to ti.e doctrine 
that this lesion is the primary element of certain 
adventitious structures. M. An dr a l has proposed 
this doctrine, and has contended, tiint hypertrophy 
of the cellular tissue forms a necessary condition 
in the production of scirrhus and carcinonm. But, 
although the cellular tissue may be more or loss 
hypertrophied in these mnladics, this alteration is 
associated with others less physiologicnl, and in- 
finitely more morbid than it, in their vital and 
organic relations. 

3. II. Cai'ses AM) Origin. — Hypertrophy, in 
some of its forms, or with reference to certain 
tissues, may depend upon a predisposition existing 
in the organisation. Some persons have an 
hereditary predi«< position to an excessive develope- 
ment of the adipose ti-^sue ; obesity occurring in 
these, however abstemious liiev may l)e. Others 

{)resent also an hereditary predii^position to en- 
argement of the bones, or of the lymphatic, or 
other grlands. The common excitinv canscm of 
liyj>ertrophy are, — J'rstj the increased action of a 
tissue or organ ; seciwdly, the prolonged influence 
of an irritant or stimulus. Either of these classes 
of causes may induce hypertrophy, in its simple or 
complicated forms. 

4. A, Increti^d action or function oi2i\i\ix\.^\\QS 
rise most fie(|uently to hypertrophy in its simple 
form. It then may be considered as purely phu- 
siolof;ical ; thus, the blacksmith has the muscles of 
his arms powerfully developed, and the opera- 
dancer, those of his lower extremities. The hy- 
pertrophy in such cases is frequently attended by 
an atrophy of other muscles, not brought into 



action. The drayman, or coalbetTer, has the 
muscles of the arms and trunk strongly formed, 
whilst those of the legs are imperfectly devel(^>ed, 
their action being confined, or entirely suppressed, 
by the thick-soled shoes they are •ccnstomed to 
wear, and by their shuffling gait. Increased 
function, or action of the heart, is often followed 
by excessive nutrition, even independently of 
lesion of the orifices and valves. Obliteration of 
an arterial, or venous trunk, causes enlmrgemeat 
of the collateral vessels. DestmcUon of ooe 
kidney, or of one lung, gives rise to mailed aug- 
mentation of the size of the other. Obstacles to 
the evacuation of the contents of the hollow 
viscera occasion hypertrophy of the parietes of 
these viscera, owing to the increased action ic- 
quired to overcome these obstacles ; but the 
increased action in such cases operates amilirij 
to that produced by excited function, in the eir* 
cumstances just adverted to. 

5. B. The protracted operation of a moiUi 
stimulus, or irritant, is the most common eane 
of these forms of hypertrophy, which may be 
denominated pathological, and which are most fre- 
quently complicated. These forms were amaged 
by DupuYTREN under the denomination of m* 
tritive irritations. They are not always instsflfla 
of pure hypertrophy ; but, as they often renh 
from a state of chronic inflammation, so they m 
attended with, and even partially dependent apsai 
a deposition of coagulable lymph, which has bfr 
come more or less organised and identified wilk 
the tissues in the areole of which it has bea 
effused. There is every reason to believe, Ihil 
many of the cases of hypertrophy sud to have ben 
observed in the cellular, serous, mucoos, ni 
glandular structures, either singly or complicita|i 
with other lesions, were actually referrible to til 
category. Indeed, it is by no means ean to <fr 
tinguish the enlargement caused by the tmakati 
lymph, which has become thus organised (am 
pure hypertrophy, particularly as respects Ai 
tissues just enumerated, and when other onstf 
lesions are also present in the affected part, fhu, 
however, hypertrophy actually takes place ffM 
prolonged irritation, is proved by the chai^ pi^ 
duced by this cause in the integiimenti, tkk 
mucous, ami serous surfaces, the cellular tim^ 
&c. Most of the forms of associated or ooopfi' 
cnted hypertrophy, noticed in the articles ooik 
pathological anatomy of the different tismetu' 
organs, are referrible to causes which &11 osfa 
thus head. 

6. III. CiiARACTERS.-^a.IncreaseoffrttiAiiMt 
always ciiaracteristic of hypertrophy; forhoHi* 
viscera, as the heart, stomach, urinary bladdtfi 
&e., may have their parietes very.much thickcsei 
without their dimensions being externally vt 
mented. Hypertrophy may exist even althew 
the apparent bulk of the organ is diminiabed.- 1> 
such instances the thickness of the parietes matba 
considered with reference to the external din* 
sions and internal capacity of the organ.— k 1^ 
form also of a tissue or part will also be cbaafcd 
or modified in some degree, but chiefly wbea thi 
hypertrophy is circumscribed. This is deoNS- 
stiate<l most remarkably in cases of hypertinkf 
of the bones, skin, mucous tissues, 5cc. — ^ Tk 
consiUence of the hypertrophied part is geaenUy 
somewhat altered. It is most commonly mn*' 
less increased, particularly in the cellalartiBiei 




' N ilu W iW thoraeie OrrninmltK <«nig«. Jaf ■ of »^— . sr 



iMroMif ftcfinfiaf the pa- JaMify kit few* ; ndthc fUH ia ike hod. or tW 
pracac* the aniarucc irf iwiwtiiii <il fnmmn m the head aad Iwk^ 




■Bcoa tht W»J a^ iMllf. 
tW Rs fad « if «v«ii| bm 



baa BUB, u : tnocd bj hi ^ 

■Toaoa «t mind; i Mean, ud made ot>itcu of namal. hlpitatim 
K ligtitMM ia the i ■ Ml at the epipstnam, and abaBt the nciae 
I Maabditj of the an, and it urn torn u attended with wiw a rt oa a of 
(Mlp, aail roou of the bail. OecanonatW the j ihrabbiaf. eitetxh^ la theeitn> 
tana Bic morbidly aeua aad ialoinaM of light of the d^obn ranctioM Mdl ci 



262 H YPOCHOXDRIASIS — Lesions of Stuictuae » Diioxosis. 

meat or Bupervcntion of organic or fatal visceral • are often met with. A plethoric, engoi^, ur 
disease, a. The fint of these can be accom- congested state of tlie abdominal viscera gcoe- 
plished only slowly, and by judicious recourse to lally, has been remarked by Thedsk, Bvsg« 
medicine, regimen, and moral discipline, b, oral-, and LF.i"iH>La. I have found calculi in 
Critical ecacuationt are rarely observed. Diar- i\ie kid neut in one instance, and enlaiKemeat of 
rhcca, particularly when caused by a copious the prostate gland and disease of the bladder ie 
secretion of bile, and followed by a resolution of ' another. Alterations of the uterui have beeo 
hepatic engorgement or biliary obstruction, occa- noticed by some writers } and I believe that tbcy 
Nonully affords some relief > but it rarely removes are not rare in connection with bypochoodriuii^ 
the complaint, unless it be aided by additional especially after the change of life. 
means. The same remark applies enually to 14. Organic disease of the ktttrt and iarjf 
htemorrhagic discharges. They furnish, however, bUntd-vesseU is not unfreonent in hypoehoDdnMi; 
indications of what should constitute, at least, a but instances in which the atructure aad orifirs 
portion of the treatment in many cases. The and valves of this organ have been aeeoraklj 
spontaneous appearance of cutaneous eruptions examined after their death are remarkably luu 
has been noticed by Boerimave, Lorri, Van It is not improbable that some of the cnaBpi 
SwiETXN, IIeix, and Reil, as favourable occur- ' observed as a consequence of internal carditis 
rences ; and enlargement of the external glands and of chronic in6ammation of the ]ai]ge vesRb, 
hadaUobcenconsideredcriticalbySTOLL, Klein, . woukl be detected in some cases, if a caitfal 
and others. inspection after death were instituted in pcnoH 

12. c. Organic, or fatal visceral disease, is more who had been subject to this complaint. A 
liable to occur in fiypocliondriacs than in other plethoric state of the vascular system genenlly 
persons, or than is commonly supposed. The niis been remarked by Wikneke, and a mj 
parts most frequently undergoing structural le»ion dark and altered state of the blood, by Thilexiui 
arre the stomach, liver, and biliary apparatus, tlte ami Burgciiav. Various le#ioQS have been 
brain and membranes, the large bowels, the heart found in the brain and its membraues, particvlirlr 
and large vessels, the spleen, pancreas, uterus, in coses wherein the patient's chief suffering hM 
and kidneys. Functional ditiordcr of some one of been referred to the head ; but tltese lesicns km 
these, in connection with derangement of its cir- > cither been very different, in different caiei, ir 
culation, and with exalted organic sensibility and \ very imperfectly described ; whilst, in some, littli 
nervous suscepUlMlity, most probably gives origin or no altemtion has been detected. In short, tk 
to most of the patient's sunerings ; and as these j bodies of hypochondriacs have presented lenM 
disorders proceed onwards to organic lesion, the ' as diversified as the complaints made during life; 
malady advances, until this lesion is expressed by but these lesions have been very frequently ow* 
signs, much less equivocal than those attending looked, or no inquiry after them has been mdei 
the earlier stipes of the hypochondriacal affection, owing to the circumstance of the complaints of tUi 
Insane delusions, melancholy, palsy, or epilepsy, ; class of patients having been very generally vievei 
may thus supervene from progressive structural | ns entirely imaginative. 

change ; but the former of these are by no means ! 15. V. Diagnosis. — Tlie diagnosis of hypO' 
80 common as generally believed. Palsy is a not cliundriasis is most difficult ; for tlie complsiotiof 
freciuent, and epilepsy is a coniparativclv rare, the patient arc so distressing, and his suffiefingf 
termination of this malady. Organic lesions of apparently so extreme, that the inexperienced 
the heart and pericardium, as well as of the large practitioner may be deceived by them, lod 
bowels and unnary organs, are, however, ofteuer believe them to proceed from dangerous statei 
observed than has been supposed. The stiuctural of disease, and to require the most energetic re- 
changes, met with in advanced or old cases of medics. This simulation of organic and seriotf 
hypochondriasis, are chiefly the following. maladies, if it be n3t detected, may lead to a mis- 

13. IV. Lf„sion3 of Structlre. — Various chievous treatment. On the other hand, when i 
changes have been observed in the digestive mu- i patient is known to be the subject of hypochon- 
cims surface, the most important of which have | driasis, the circumstance ought not to indoce Qi 
been congestion, partial softening, discoloured to overlook, or to treat carelessly, his sufTeriogs 
spots, and slight ecchymoses. Thickening of the which are generally not only real, but alio dxti 
coHts and induration, or an incipient state of depending upon structural changes, althoneh tbe« 
scliirrus of the pylorus, or cardiac orifice of the ! changes arc either too obscure or too minute to 
stonkach, (Bonit, &c.) have been more rarely be* readily or easily detected. The versatility loJ 
met with. The tiver has presented various lesions, mutations of the hypochondriac's sufferings, and 
the chief of which have been congestion, enlarge- the inconsistency observable between his coo- 
ment of the organ, and dilatation and engorge- plaints and his appearance, and between the loo) 
ment of tlie vena porta; (Liehtaud). I have and general, or constitutional itymptoms, will k** 
found the hejMtic duett and gall bladder dis- , dily suggest the nature of the disease. Vtltf* 
tended, enlarged, and filled with dark inspissated symptoms sometimes continue without clian^''' 
bile. Gall stones have also been found in the and tlx; patient often makes the same compliioi' 
bladder and ducts. Alterations of the spleen In such casc.<«, there is reason to believe that n^l 
have been observed by 13onet and others, and disease exists, although exaggerated by bis morbid 
of the pancreas by H^andis. The large Inmels, sensibility uiid fears, by his imagination \a\M 
especially the sigmoid flexure of the colon, the long been cnnnged with his tJt^nsations iullic>^ 
rucinn and rectum, fre(|uently prest.'iit changes of disorder. The want of lelution betnitn bt* 
siinilur to those noticed with referenrr to the rceliii*;^ and <'(tii.stiluti(iiial symptoms ou^ltt siiO 
di^e^tive mucous surface generally, or are thick- ikiI to be ton iiiui'li Veliud upon; for, in h)^' 
eiied, (tr Mmiewhat cuiitniclcd ; uiul llie coloui I (:h()ii(1ii<t(S, the \a^'ulur system is not retdily 
i» sometimes displaced. HaMuorrhoidul lumour:^ ^ excited to fcbiilii commolioo, although the st^* 



264 



HYPOCHONDUIASIS — C^isrs— Patiioloot. 



temperament or habit of body ; but somewhat 
oflener the nervous, the melancholic, the san- 
guine and tlie bilious ; and persons wito are 
subject to ha;morrho'.d8, to consti(>ation of the 
bowels, and to disorder of the digotive func- 
tions, and who are of a sallow complexion. 
Hereditary influence, or peculiarity of^ consti- 
tution transmitted from the parents, has, per- 
ha])«, some influence in preuisposing to it, as 
Wii.i.is, IIoFrMANN, and others liave contended, 
although not in so remarkable a manner as in some 
other nervous complaints. Employments which 
are sedentary, or prevent due exercise in the open 
air, and which, at the same time, admit of activity 
of mind, also predispose to this complaint. Hence 
the frequency of hypochondriasis in shoemakers and 
tailors. Mental exertion-and fatigue, or prolonged 
or overstrained attention and dcvoUon to a particu- 
lar subject, especially in connection with full living 
relatively to the exercise taken in the open air, 
may be said to be tlie chief sources of predispo- 
sition amongst the educated classes. Owing to 
these circumstances, this has been termed the 
disorder of literary men ; but whoever is engaged 
in active mental pursuits, or in departments of 
business requiring great intellectual exertion, or 
occasioning anxiety of mind, is equally liable 
to it. Dr. Priciiard observes, that agricultural 
labourers, who spend a great portion of their time 
in solitary employment in the country, are fre- 
quently the subjects of this complaint. AUhough 
solitary employment is likely to dispose the mind 
to broo<l over the evils that afflict it, yet much is 
probably also owing to the diet of field labourers, 
and to the influence of humidity and exhalations 
from the soil to which they are cxjwsed, particu- 
larly in the reparation of ditches and hedges. 
The effect of climate in predisposing to hypo- 
chondriasis is not very manifest ; but situations 
which are humid, and productive of terrestrial 
emanations, are apparently nut without some in- 
fluence in the production of it. 

21. ii. The eiciting causes may be divided into 
(a) those which, act more immediately u]>on the 
mind, and consecutively, or through the me<lium 
of the mind, upon the org;inic functions; and (6) 
those which affect primarily tho>e functions, and 
secondarily the mental energies.— a. Whatever 
exhausts, or directly depresses cerebral power, as 
intense application of tlie mind to ditlicult or ab- 
stract subjects, anxieties respecting schemes, spe- 
culations, or objects of ambition ; disappoint- 
ments, sorrow, fright, or sudden alarm ; the de- 
pressing pas -ions, severe losses of fortune or 
fiiends, indulgence of sombre or sad feelings; de- 
votion to mu<>ic and the fine arts, reading medi- 
cal books, &c., and whatever favuurs congestion 
of the brain, as induljiences in bed, the use of 
narcotics, particularly opium, &c., may occasion 
this complaint. 

22. h. The causes which act primarily upon 
the organic nervous system, and functions of the 
or«;dnic viscera are very diveniiHed. Whatever 
iuipsiirs the energy of the system, as the too fre- 
quent or too liberal use of calomel as a purga- 
tive, or of other mercurials; poor, or innutritious 
diet, or the excessive use of ten and slops; a hu- 
mid, clostf, impure, or miasmutous air, 5cc., may 
produce hypochondriasis. Mercurial purgatives, 
although often serviceable by promoting the dis- 
cbarge of bile, and giving relief for a time, yet 



often incrcasff the nervous depreasion and morbid 
sensibility, when frequently resorted to, and in- 
duce or aggra\ate this complaint. Of the origin 
of hypochondriasis in an improper recourse to ca- 
lomel, I have seen several mstance^ Whatever 
inordinately excites, or directly relaxet, the di- 
gestive mucous surface, as acrid cathartics, oAn 
exhibitetl, &c. ; whatever occasions or perpeti- 
ates indigestion, or impedes the functions « n> 
cretion and excretion ; and whatever occasjooi 
plethora of the vascular system gonenlly,orof 
the portal or cerebral vessels in particular, espe- 
ciallv overloading the digestive orgajisby toolaigi 
meals, or by too rich or full living, the roordinUi 
use of animal food, of malt liquors, wine, dec; 
insu6ficient exercise, and inattention to the Kfs* 
nd excreting functions, may give rise to hyp^ 
chondriasis. Whatever induces torpor, or pcm* 
tuates inaction of the depurating organs, whtt 
the organs of supply are stimulaled to ineretnl 
activity, will occasion redundancy of noxiossd^ 
ments, or of the ultimate products of snimiliw- 
tion, in the blood, and will, sooner or kkr, 
especially in connection with vascular pletkor^ 
give rise to this complaint, or to some other, ^ 
pending, equally witn it, upon oppletion of As 
vascular system. Persons who have been sem* 
tomed to active occupation, both physictl iid 
mental, or to much exercise in the open air, opoo 
retiring from business with a competency, ui 
when hoping to enjoy the fruits of industry, m 
often overtaken by this complaint, particuliriy if 
they live fully, and in a comparative state of eiN 
and indolence. The vascular system, which wii 
formerly preserved in a state of fulness, io dis 
relation to nervous power, by the healthy actios 
the different emunctories, now becomes over' 
loaded, particularly the portal vessels. Tha 
cerebral circulation also becomes oppressed, and 
the mental eneruy impaired. 

23. c. Some of the causes act by weakeaiog 
both the organic nervous influence sind the Biiai 
'I'he most injurious of these arc premature sodes- 
cessive sexual indulgences, particularly mlltn^ 
bation. Whenever hypochondriasis appears esriy 
in life, this should be dreaded as having beeo tko 
chief cause. Many of the depressing psMoni, 
and anxiety of mind, act in a similar manner. As 
the early addiction to vicious habits, as well u 
several others of the exciting causes, is more or 
less frequent in all classes of the community, it 
cannot l»e saifl that the effect is confined to tsy 
particular class. I ndeed, hypochondriasis b oftei 
met with in the lower orders, although not so fre- 
quently as in those whose minds are most highly 
cultivated, whose sensibilities are thereby rendered 
acute, and who are either precluded from, or oot 
obliged to take, that exercise which is necesu^ts 
prevent general, lo(»l, or excrementitions plethon. 

24. VII. Patholccy. The ancients appear to 
have observed this complaint chiefly amoogit 
philosophers, poets, and otners endowed with tba 
most acute sensibility, and the most vivid inMr 
gination ; and to have either confounded it with, 
or viewed it as a variety of, melancholy. A us* 
TOTI.R says, that all the ereat men ot his tioe 
were melancholic, that is,liypochoodriac Hir* 
poc rates, Aretjeus, and others, attribete tha 
complaint to an excess of black bile. Dioclu 
refers it to the stomach, and Galen coosidoi it * 
a variety of melancholy, having its origin in thii 



•2firt 



H VPOCHON DRI ASIS — Tmatment. 



34. a. The propriety of having recourse to mitd praised by Bisset, and i^ certainly an approprUie 
nr stomachic purf^tive.4, Hhcn the bowels are laxative, pnrticulariy as the use of it for some time 
^lu>!>:i'«h or turjiid, or the stooU offcn<(ivc, cannot increases all the excretions and especially tbosM 
hv (|iiirttiuiie(l. Vet, in some ca.«es, the gistro- from the skin, bovrcls and liver. 
intfitinnl mucoux surface may be in such a state 37. h. Many of the distressing feelings of ibe 
of irritation or of chronic inflammation, as to re- patient are referrible to trn/atimi in some part of the 
(|uirL' these to be prescribed with caution, and se- digestive mucous membrane. This irritation any 
leoted with judgment. When this state of the exi>t in the reelHm in connection with hsmor- 
digcstive mucous surface is present, leechet i^hould rhoidsi, or in the cxcum, or in any other part of the 
be appliefl to the abtJoinen, or to the anus : refri- canal : but these two are amongst its most com- 
gerauts should al*o be given with muciiaginout mo n seats. In such cases, it is propagated by die 
or emoUient medkines^ (F. 353. 431. 436.821. communicating ramifications of the gangUalnerrcs 
837. 865.) and the functions of the skin pro- to the roots of tlie spinal nerves, or to the spinal 
motc<i by the irarm or la/nmr hath. If the pa- churd, and sensibly expressed in some reaiole 
tient be plethoric, a moderate vennection or cup- part by rejUx tumpathy, as stated in my notes lo 
jiing on the nape of the neck, or a repetition of Kicherano's J^^em^affAf PAjfdo/o^y (p.34. Lond. 
Iceclies to the epigastrium or anus, will be of 1824. 2d ed. 1829.). 1 he AfMorrftmdd/ <f isrAsr^ 
service. Although irritating purgatives are hurt- i has been considered favourable in hypochoodriuii 
ful in this description of cases, yet thow of a mild ! by Alberti, Grant and others; but, is almdy 
or of a cooling kind ought not to be withheld ; and stated ($ 6.), it indicates either general or local ple- 
their operation* may be promoted by enemata. | thora, when it has not been induced by costiveaoi 
'i'he tartrate or sulphate of potash, the carbonate ! Of by acrid purgatives, and potnti to rettrietod 
of soda or magnesia with rhuoarb, either in powder diet. When the hsmorrhmdei are not attended 
or infusion ; or the phosphate of soda, or the tar^ by any discharge, they funush the same indiei- 
trate of potash and soda, may be given with other tions and show Uiat, in addition to low diet, geoent 
subiitanceH, ( F. 440, 441. 868.) according to the . or local bloodletting should be prescribed. Wilk- 



peculiarities of the case. The diet should be re- 
stricted chiefly to mucilaginous or farinaceous 



out these, the removal of the hsemonhoidd if- 
fection may not be entirely devoid of risk to the 



articles, and the beverages consist of simple saline ; hypochondriac, especially if regular ezeidie ia 



or cooling fluids. 

35. In other cases, particularly where the di- 
gestive mucous surface is deficient in tone, and 
when tho states of the epigastrium, of the pulse, 
and of the tongue do not indicate inflammatory' 
irritation, |)urvarirr« or apcrientt of a warmer or 
more stomachic kind than the above may be pre- 
Bcrilted. The infusion of senna, or that of rhu- 
barb, may be given with the infusion of gentian or 
of columba, or of cinchona, or of cnsrnrillu, and 
an aroiiiutic or carminative tincture and a neutral 
salt : or the upcrmnts directed above (§ 34.) may 
bo taken in mint-water. Jn many ca-tes the com- 
pound giilhanum pUl^ or assaf'atuLi, may be con- 
joine<l with the purified evtract of aloes, or with 
rhttfkirh, and the inspissated m-gall (See F. 547, 
648. 558— 5f>3. 572—576.), either at ni^ht, or 
daily witii dinner. I have found the following 
Excellent in hypochondriasis with a torpid state of 



the lur^'o bowels. 

No. l2r>lK H l*ulT. Rhci 3 si. ; 
riilv. Cnptiri, aa gr. vj. ; Extr, 



Pulv. Iitccacuaiihv, 
Aloes purif. 3 j. ; Kxtr. 



the open air be not taken. 

38. c. Simple tacemen$ or enemata have bees tos 
generally neglected in the treatment of thii ooa- 
plaint. The researches of PrNEL, Anneslxy, ud 
of the author, show that the laige bowels ai« Ml 
only disordered in their functions, but also ofia 
altered in structure, or even displaced in thenoii 
severe and chronic cases. The depressed slate if 
or^nic nervous energy, occasioning hypocbos- 
dnasis, permits fiecal and flatulent accumuii' 
tions to form in the ca'cum, cidon and rerfiiiii (m 
these articles), causing inordinate diateosioiu of 
portions of the canal with spasmodic constrictioa 
of adjoining parts. Owing to the fecal rol* 
lections, to the efforts of one part of the boirdto 
propel its contents through a torpid or an ob- 
structei] ])ortion, and to the frequent recurreim 
of these states, displacement of portions of the 
colon, and even partially of the C9Com, are not 
rare. Inonlinate dilatation of the latter vixwii 
also sometimes ob^rvcd. Hnt 1 have remarled, 
in several cases of hypochondriasis compficated 




36. The use of /«irtiir« in hypochonclriasis was ' inonlinate accumulation of faeces, owing to ifci 
ich insisted on by Ulnckart and Lfgikh, and ' obstacle to their discharge, caused by internal b«- 
various substance belonging to this class were re- morrhoids or bv spasm of the sphincter. Oneflf 
commendeil : hut they nn\wc no very particular these had been'treated for stricture of the ifCtSB, 
remark at this place. Magnesia, especially the and a Iwugie frequently passed; but it seldoB 
calrinetl, is well deserving of adoption, when the found iu» wav into the po'rtion of the bowel aboie 
complaint is attended by a ropious dt?posit of salts the dilatation. The intestine was injured hf ito 
in the urine, or by a gouty dialhesi-*. It also re- officious interference; peritonitis supervetfd: 
lievea the Halulencc and di>tension of the epioas- and near the fatal termination of the eatti*** 
tnum and hypoehomlria more certainly than any consulted. Inspection after death fiimiibed a 
other ajK'rient. W hen there is no gasiro-intestina'l strikins; example of this dilated state of the rert«». 
irritation, or it this be slight only, it may be given as well as of the effecUof a species of interfaeoct 
111 mint- water, or in any tonic, stomachic, or aro- generally quite unnecenarv, although eo fi^* 
«wfir vehicle. l*recipiuted sulphur was much . quentlv* practised at the pfetent day by afcw 



270 



HYPOCHONDRIASIS — Treatment. 



indicated, and may be prescribed from the first, if 
the bowels be kept regularly open. In 8uch 
circumstances, vascular depletion is contra-indi- 
cated, and evacuations of any kind ought to be 
cautiously practised. The chalybeate mineral 
waters, soda water, or other waters containing 
fixed air ; the vegetable tonics, with soda ; the 
tincture'cf the sesquichloriiie of iron, taken in'cam- 
phor mixture, &c., are most appropriate in such 
cases, aided by early rising, and exercise in the 
open air. 

44. iv. A Fourth Indication has been advised 
by some writers, viz. to restore to its proper teat or 
form any other complaint, upon the removal or 
spontaneous cessation of which the hypochondriacal 
affection had tupercened. This intention, however, 
cannot be often fulfilled, for an herpetic eruption 
may not be restored, although an artificial erup- 
tion may be easily produced. The restoration of 
an htemorrhoidal flux is more readily procured ; 
but a judicious recourse to local depletions, and to 
suitable diet and regimen, will be still more bene- 
ficial. The developement of the gouty paroxysm, 
when hypochondriasis follows the disappearance 
of gout, has likewise been advised ; but attempts 
to accomplish this do not always succeed : they 
may even aggravate the complaint. The means 
just menUoned will sometimes prove so serviceable, 
as to render such attempts unnecessary ; and yet 
I have seen instancies in which these means have 
failed, and for which I have been obliged to re- 
commend a more liberal diet and regimen, with 
change of air, travelling, &c. When hypochon- 
driasis follows periodic fevers, this indication is 
entirely out of the question. In these cases, as 
well as in those produced by malaria, humidity, 
&c., the chylopoietic viscera are generally in fault, 
and require, especially the biliary organs, strict at- 
tention. If tnis complaint is consequent upon 
suppressed discharges from the uterus, or is even 
associated with an increase of the natural evacu- 
ation, or with a morbid secretion from this organ, 
particularly about the change of life, organic 
change in the uterus may be the cause of the ner- 
vous disorder ; but the restoration of the discharge 
in the one case, or the removal of the morbid se- 
cretion in the other, will have but little cfTcrot, either 
upon the lesion of the uterus, or upon this utfection. 
The nature of this lesion, and the states of the 
vascular system, and of the digestive viscera, will 
require the chief attention in these circumstances. 

45. V. Remedies and Mtulet oj Practice ad- 
vised bu authors, — a. General hloodlettins has 
hardly been noticed by any of the numerous wri- 
ters on hypochondriasis ; and Ln'ai depletions have 
been directed by few excepting to the anu^, in or- 
der to remove haemorrhoiils, or hepatic fulness. 
M, BnoussAis and Dr. (jui.ly, however, recom- 
mend leeches to be applied to the epigastrium 
on account of inflammatory irritation in the di- 
gestive mucous membrane, which they consider to 
exist in most cases of this complaint; and which 
no doubt forms a part of the pathological states in 
many cases. In these, an antiphlogistic regimen 
is always requisite, although too frequently ne- 
glected by both patient and practitioner. 

46. h. Aperients and laxatives are generally 
serviceable when judiciously selected ; but acrid 
purgatives are often injurious, although not to 
the extent believed by Uroussais and his follow- 

er:f, unless they he frequently prescribed. My 



objections to mercurial pargatives (§ 41.) in 
hypochondriasis are not altered by what has been 
advanced by Winthingiiam, Kieff, Cubby, and 
others, in their favour. At the commencement of 
this century, a calomel epidemic prevailed in 
British practice, and this medicine was prescribed 
very generally, and very often injuriously, in thii 
and many other complaints. The repeated dam 
of it directed by the late Dr. Curry, not anfI^ 
quently aggravated the disorder, or converted it 
into melancholia. The much milder meant, how- 
ever, recommended by the late Mr. Abebnetbt, 
namely, an occasional blue-pill at bed-time, tad a 
stomachic aperient in the moming, were oftiemi 
^reat benefit, and were rarely attended by lay 
inconvenience. 

47. h. The propriety of prescribing narenkt 
and anodynes in hypochondriasis has beea 
much discussed. Circumstances often arin to 
require a prudent recourse to ^m, and otlieii 
appear which contra-indicate them. Some of 
them, particularly opium, afford temporary i^, 
and yet are injurious if largely or freqncatlj 
employed. — Opium was recommended 1^ 
Tralles (De Usu Opii, s. iii. p. 35.), Deinei 
(Consult, et 06«.t.i.), and others, and byTniu- 
Nius in conjunction with the mineral acids. Dr. 
CuLLEN considered it injurious. Hypocbondriui 
often resort, and readily become addicted, to it; 
but, unless when under its in6uence, all their dii- 
tressing feelings are aggravated by it. Even when 
used in moderation, it is relinquished with <fiffi- 
cultv. I have met with several instances of hy- 
pochondriasis, presenting in some an hysterical 
character, as in females, and in others, the melaa* 
cholic, in which opiates had been prescribed o^ 
casionally for severe or painful symptoms, and ia 
which calomel had been given as an aperient; and 
in these the patients afterwards h^d resorted to the 
same means without medical advice, until the 
former was regularly taken in excessive doses, evoj 
three or four hours, and the latter every second or 
third night. In two cases, where the acetate of mor- 
phia, and in one, where the muriate had beea 
prescribed, these substances were long aAerwaids 
continued three or four times in the day, od ac- 
count of their effects upon the spirits, and gradoalij 
increased to one or two grains each dose. In net* 
ther of these was there any organic disease detected 
upon the strictest examination, although there «u 
much functional disorder of the digestive orgaitf. 
The strength and healthy looks of these patients 
are now almost restored, by reducing very grada- 
ally the dose of the narcotic : by relinquishiog 
calomel, and by enforcing the practice recoD* 
mended in this article. Yet I fear that the opiate 
will never be entirely given up, and that the doK 
of it will even be increased hereafter. In such 
circumstances no patient can be trusted. The 

(>ractitioner, in order to overcome this noxiontf 
labit, may try the efTect of varying the narcotic, 
of adulterating it, or of combining it with tonics, 
aromatics &c. ; of diverting the mind by amose- 
ment or travel, and of rousing the vital energi^ 
by early rising, exercise, tonics, and light (fi^ 
Persons who have habituated themselves to opial^ 
will, however, rarely tolerate any other narcotic 1 
have prescribed for them huwcyamus, beUadf»»'t 
and conium. The first and last of these weret^*' 
weak : the second seemed for a while to answer, 
but was soon relinquished. These, however, tf^ 



373 HYSTERIC AFFECTIONS. 

taricli I jbri. ill. PocnM B»ticl,lT4a-5(niH-, ld« i HYSTERIC AFFECTIONS.— Stn. i/MftTM; 

HrmelHH^iRhni l&wikhcll «Ih .on d« IHnwucfct "«S. Sufecalia -UleriHa, Suffocatia, Suffaimtit 
Ett. niJ »vbM, De VnlMudiiM « Hnwhondriii, Mulitrum. Vliav AWtclia HiaUricu Willa 



■ifDnH IlK^niUcv, in fuibiu MypKhondclnuin, &c I SUliI. JitAma [/ftri, Van Helmoiit Auntia 

Hmcli'ndriicilnnUnltB.llB. VnulTHL — I>W/rr, AocL var. //uXfru, Saunm, UanKU, V»- 
Prafomu d* Vloo Mudtcii ll;r«li«idrtacli ulutui, gel. C\i\lra. HgptrkmMpa Hyueria, Swtdiinr. 

TA.ZS^"^■f^^^!^KJ!^^SSi^^:i cto«"' %-"". V---5- s-j-'- wj?^. 

I|Bcl>0Dd>1iio,W Lu«,lT9i-i>.i\»M,li:wiiiu Good. Fapfun, MaJ cf« fa Were, .t/wliM 
laAflMkaiVuoRwndepniiSnM. FUU.ITR).- Untiriqv,, Fr. JUulKrlraiiMmt, AfiUltri^ 
ftcMn. VeSLlTM.! .nill*»tdl»Hitm:booili1«,*c, fUman, AnftUig^u. dtr 3lMl(n-, Ceim. If 
Ijglf^ 17H- ft- W^, ObHTTUlou OD NuvowUii. (tniaa, Jlfaf di ilotritt, lul. Fid W" lit 

dec MrpodMBdile. Kofinlufin. ITffl, — X ArrlntlMt, ITirt.itr. 

ATiHlkwDD Hjitcrinlind HneelioBdiUnl AAc. Cumit. — 2. C(u, XcrvoM Dmm<; 1 

t^^\,^TaT^J^"^vSS'^'m'v^^D ""'"■ Spittnodic AffecllDni (C«lln). 

lf:''TWA(r. Di vino MUiDo HrnichaDdiijidt'Hluun^ 4. L'fsu, Dueuesor Lhe XerToui Fub 

4ta. Fnme. 1778 -rf. "-a™, M.«ile.l KHwrdMon (ion; 4. Ord«, AffectLng the StnMral 

Hntcrii uil HnachaiHlnult, Ac Bio. laid. ITTfl— Pn„...r. /f—Jl TI (".... Ill n.... 

J. A. Ortw,«cfcd»Hjpocbimdri»,8™. Dtad 1777. * »»«™ t.''~^% "' '''■•*'■ "'■ "■"» 

— PC. fttfxt, Helhaili of Cure In Ilypodisnilruuii, (.lufAnr, ID Pnfact). 

Hvpodicndntoli, Ac Std. Lm^ iTHl-.— u. tuBUhm, ,1 _ , -jv r. \ .- ^ 

lUSiiVchanukCuiudu AlhcL HypocHaiiilHaiuit, '"• "«' wriftl /wBi, 6u» niw»«/y ^iwntolf* 

Stn. Fir. 1779. — J>r Wna. SoG. Hed. Hivntemli CoUeci. panirwiiwf cAanicla-i (A« uliarlu umallii cm- 

TO). IL n 70.— J. H. SeMHilfMrr, In IbM. ]l 313.— i). Mfuiu. i^irJk . Mnu, nf /imnU unu _^'ll ...n. 

MnAirrin A^""'. IU<^ I'<rl«L <>•■•»«-■<• H^ •>* ""^S '""'"./"'"' W limpM "nut. in« nMffr 

FiriLl.ni. p. M. — OiMrr. In AnnilM de U Sie. de WM«r inygufar mMuni, nnd mnWiy^f mub u 

MewLiMiteiHcdialJounuil,vel.ll,| Jttling of lu/mnl'UH, and nuiKdiiiii wul Minl- 

l^^A;SrK:8™^^"lKl - »■»*'")' '" ■*' <*«■'"« ^ '!/'. -«' prl«V.U, lb. 

die HnnchDndri*, 8». Lcipi. nw. pouni-lng gnat tii$aplU>iUtf r4 tht nnrwi iiiUd, 

HTPod^rlan, W VieB. ITSft onJ n/'imulul.moiiFi.. 

SSSi NJL?rS£rHS»SSd "«i 2. Und<r ,hi. definKion m., b, «,..pd .11 

4W. HoiumlacI, ITtK ITkit mem mtllad muiiii thoeeduorden whicti.rrunthcii'vuiedudcbaH- 

BK3aKiKT£'ffii£ &K."a.i; »«'■»■". ■■■' "•« r.-»n..» »»"., .™. 

nrMIyrochODdrlKen, Btol Duetkh. ItSS.—J.RpiUT, and even to teveril dDDgeroag or (trnc^Innl da- 

On BjMftjniL HnHxIxinlHuU ind Ooui, limo. Lond. eawi, hive puiiled and milled the ineipfrmicti 

ITHS— J<iiii,lnHcm.ar theMed-tliK. o( Lonil. vol. i. c, ,„.-„. „«„! .,iu. • full .nH ..~.,. >V. _h.l> 

- - -(fcr,HDrtilHF|>m'li«iilri*ciSlin(iicI>4||>i«li, Muf^"*" drat [jave a full, and, upon the wboli, 

. ITU. — J. X«r-F/. Ahbinlluw ton cinei a •alistaclory account of hyslentil kR^kWu; 

-JMItriodJMlJB^FIiFllTinhondtirti^ on atreral of their fom« and relaiionf. Ciilu 

nernnKiuike, Ac. Fr.in£t ITHS.— / (iTnit, Bs Karl accurately dcMnbed Iheir more convuliiTeMit). 

ArhUldllH OHI Hnoiinildrie, ll?a. KMmta. ITVl, : 1„,t npulei-tpA ihivu. annmilmo nr irr^irrl.. tnntt 

md Nnuilier UnlFirlcllt ritr HrHiclionilibteii. Ac W ""' "^B'^^'^" '"i?** """"'I'"'; 0[ ImgulK IWM 

timBli.net^J.tl'.L.remI.mer,VmnchaibaeitHy- 0' complaml. which are c(]uallyfreqiieiil and in- 

niirIio^ileBiidlIirtBl(,tlni,Uiillia,1757. — rf.TliwinM. porlant with lh«w. From the deKripIioiB of 

d« !(miiESKl»»rdm. ■ IlanpMr," noB, - J. K. A. I'nn^ S'*""™!!, and some other raeniBntofi, 

laamn, lleiiaBRiiohucliedec MUidaiutc diireh den <> might at once tiv inlerred that Iheir eipenenct 

Mobnock dee (lemclDen Wincn, Hro. UIil 171"J.— as to this diwider was verv iniperrecl - IMI tbn 

' Par. IMC — BiUAv^r, K, Hi( hah and « .11 



l^'ije ^^vK'm«i^M^^^^U^%^ "e** '"""•'•■■^ '" nspctl of it had relKiceiled, iuind 
V. £>MWn>. VoWMli elner A»<|.lio<>^|nIaRlt n.o. "f '>'»'>"B advanced, with the general prognu of 
IlnnKn, IBIH.— W. /.(rmM, llie llniochaiidriu^ a science. Veiy recently, however, lhe able aai 

& r iSV" 5' !&£,"""■« •'•8'"' "•■•" •;.»'• "»-" I-' "•i"; I" 

StuHclMO.- JcA'rvy.aK wAicrdv IIiHBlioBiine, . •inancKr of our liloiature as to hyslena, ami hr- 
'r* ..S* "S'Sv" ■'■ ." jjl J" "Ef^C?'.''**? ""* ' '''''''»' •"*'('>« raore comprehensive tiew of in 
rhoBdde iind ttjiilcfle Dnd deren tleilnt. Hm Xnenau. „,,„„, ^ ,„.,_,,,_, ' 



, IR— J. JfcM.'BMviWfnmiiTi iijnortMmd^riiii.^'^^^^ . . , 

Ac fira. LniHt. Mill — K. J: TAmmetmion, Venarh ; 3. lhe varieties, loimt, and UateiarfajtMicU 
jf2l^'JClri"nw'di.'£M'iJ^%»'ili'^Uir are so numerous, that the diffically o( 

•m^-ltK^U SMiia .!■ una ra^ MiUitla N«^o^ ' deicnbinp and arranging them uveiy^rtal. Tkf 
Siu Favli, 1§1B. — ./. J". Form, lie ritiBodinndrii ei | modifications cnnaenuent upon age. tempcramnl. 
%l N!Si^™d,'^{'hJ™^' tt^%^^S \ '*""'^''' hkbit of bidy, s,a\Hof%ervou7™«- 
ffmx<4,l>tril;pwhnndrieM%l'HyMft£'.ST& Par! I "I'll ily, physical and moral education, and oalt« 
INH. i aB4 Die!, d* Med. t. xL IV. IRU — F. K. , states and grades of ivcicly, are so varioiu. Unl 
Btlmtat, KaHianpiiieOi|tanigue.L l». o. ^m. — FBtlllt. I iiu.v fiinnni nil hs ^......n;.^ ..■,.>.:« Ik. ilniii. ■ 

DicLdc MMrrnTLa. ¥if.liWl.-A«*m/, rye oT i "f?, """**"" he compnsed wiihm the liDMlt" 
Praet. HnL vol. liji -mt. Lond. 11133.— J. /. Amrjh:/, ; ii\\\c\\ I am necewanly confined. Knough.koi'- 

E"?SJE.7of',-he'^m,S?,l!t N^S^^i^vi'^'^.n.^" . '» 'li'^ recognition of the nature of aucLffdiiW 
N«int»lti7, or NenwiiDCH, 8tc Lend. 1SJ7. . as may not fall eiaclly undei any of tbe TatWKI 



274 



HYSTERIA — MoBB sbvkbe Fobms. 



mo0t of the flymptoms of tn epileptic letzure. 
But the acceuion is not lo sudden as in it, and 
many of the premonitory symptoms of Hysteria 
are present. The subsequent eahaustion, stupor, 
or sleep, is also not so great as after a fit of epi- 
lepsy, and the patient rarely injures the tongue 
or foams at the mouth. She is, however, gener- 
ally deprived of consciousness. The face is 
tumid and flushed ; the trunk presents a tetanic 
stiflTneiM, whilst the limbs are tossed in every di- 
rection; and respiration is so laborious and so 
obstructed as apparently to threaten dissolution. 
In some cases, the patient remains for a time 
leeminffly without breathingt the throat and the 
veins of the neck being remarkably swollen and 
distended ; and the action of the heart, irregular, 
hurried, or slow, or entirely interrupted for two or 
three beats. In other instances, sne screams, or 
utters the most disagreeable and unnatural noises, 
and grinds the teelh. M last the convulsions 
cease, and after a period of more or less exhaustion, 
she recovers, often complaining of headach or 
slight fatigue. 

9. In some instances, after a severe fit, or after 
violent nervous agitation, and great disorder of the 
circulating and respiratory functions, the patient 
sinks into a state of coma, or of hysterical apo- 
plexy, depending upon cerebral congestion. In 
other cases, a complete state of collapse takes 
place, respiration being liardly observable, and 
the pulse so weak, slow, and sn^all, as not to be 
felt at the wrist. The surface and extremities be- 
come pale, cold, and inanimate ; and the patient 
continues in tlus almost lifeless state for a consider- 
able time. Some of the instances of supposed death, 
in which persons have been said to nave nearW 
escaped being buried alive, have been of this kind. 
I have seen some instances of this form of hyste- 
ria — h}istencal suncopit — so severe as to occasion 
some alarm, and M. Villermay considers that 
death may supervene upon it. Extreme cases of 
this description have been noticed by Plinv, 
Lakcisi, and others ; the instance in which Ve- 
s ALIUS began to dissect a body lo which life re- 
turned on the.application of the scalpel, was pro- 
bably of the same nature. But cases of hysterical 
coma, or of apoplectic congestion consequent upon 
the hysterical paroxysm, should not be con- 
found^ with these. In hysterical coma, the pulse 
is but little affected ; but in hysterical syncope, 
it can hardly be felt at the wrist. Upon recovery 
from these states, especially from the latter, the 
patient often expcncnces catchings, spasmodic 
contractions of the extremities, shudderings, or 
convulsions of short duration, accompanied by 
forced or irregular respiration* Sometimes the 

J>aroxysm is not only severe, but is attended or 
bllowed by a kind of delirium, or by nymphoma- 
nia of short continuance. 

10. In a few instances, especially where hysteria 
is obviously dependent upon irritation or conges- 
tion of the uterus or ovana, the paroxysms change 
their character and assume the form of eatalepty, 
txtaty, or of MmnambuLitm, or either of these ner- 
vous afiections takes the place of the hysterical 
seizure. I have seen several instances, illustrating 
tJie connection of these with the severer forms of 
hysteria ; and in some, the tenderness in a portion 
of the spinal column, so much insisted on by some 
recent writers, was detected. When these nervous 
M/Jbcthas «jv thuf U90ciat«d« the attack may 



commeooe, either as a iliffht, or u a wenn b|i- 
terical fit, and pass in a Hioit time iato the oiic 
leptie or extalie itate, or it may hem ia the fiona 
of^ extasy, eatalepsy, or aomnambiiliam, and bmi 
into the hysterical convulsion : but I hare u» 
wise seen the paroxysm eonut of ooe of then ii 
its pure or unastociated Hate. Beadea these mm 
severe states of the complaint, varioua sympiaai 
may assume an unusual and diabreMiDg promineaoi ; 
the sense of strangulation in the throat may baio 
great as to occasion the utmost distreat and alam, 
and it may be accompanied by inabili^f of all«* 
ance, by flatulent distension of tha beity, boik> 
lygmi, and remarkable undolatiooa thnraghMt 
the abdomen. Qccasiwially the slighter and » 
verer forms of the complaint will alternate viA 
each other ; and the wter is freqaentU iadHdl 
when the former has existed, by poweinil msMl 
emotions or sudden impresnona, Somedmeitks 
severer fits alternate with km of voice, — A^fkmm 
hytteriea; — or with temporary paralysis of ccftai 
parts, giving rise to dyqihagia, or to ispibams ii 
some instances ; and they may evea tanniailiia 
tpiUpty, m4ntal dtnng$wuiU, orfotuitif^ la MM 
instances of severe hysteria in tlie uooiairiaditil^ 
I have observed puerperal maaia aaperveae ite 
marriage, and follow almost each caafiDcmeilt 
These sutes of hysteria occur not merely in dtt^ 
ent persons, but sometimes in the same pcnoa il 
difi*erent times. Females w ho are liable to, or vhi 
have sufTeml from, the disease, ofiea acqain» 
much sensibility* or become so susceptible, is te 
be strongly affected by every impwaann ikM 
occurs suddenly or by surprise* 

1 1 . In th§ iatervoU between the paromm, thi 

? general health is more or less deranged ; Wibm 
unctions betray more disorder than othen. Oi* 
gestion is impaired, and there is often a ciariif 
after indigestible or hurtful articles, as cheese, c» 
cumber, acid fruit, acids, pickles, &c. ; or sfta 
food at improper hours^ Digestion is usually H* 
tended by flatulence, borborygmi, lowness cttft" 
rits, and proneness to tears. The bowels are coo* 
monly costive ; but they are sometimes lax or 
irregular. The tongue is red at the point asi 
cages, and slightly furred or loaded* or somewhit 
white in the middle and base. The pulse varieii 
the least em5tion or surprise causing great acoe> 
leration of it, or palpitations of the heart. Hm 
catamenia are seldom regular as to quantity, or 
Uie period of appearance. They also ofien ds* 
part from the healthy character, in the varioai 
ways described in Uie artiele JMxiisTauATioyt 
They may moreover be delayed, retained, np* 
pressed, too frequent, excessive ; or they maj m 
painful, difficult, and attended by various pbcas- 
mena, referrible to morbid conditions of the ulefii 
or of the ovaria. They may also be preceded v 
followed by leucorrhoea. So much is the heiUk 
of hysterical females disordered, and so intinia 
a connection often exists between such disoidtf 
and the hysterical paroxysm, that the huter, op^ 
I cially in its slighter forms, seems merely an aof** 
I vation, or an exacerbation, of the more or Ma 
continued complaint, or as an increased states' 
the nervous symptoms. 

12. In those cases, which are more obviotfly 
dependent upon uterine irritation or vascular d^ 
termination to the sexual organs, irregaltf *| 

i painful menstruation is generally observed, •* 
I the diKharge is preeedad or attjaied Ij ;•■* 



^76 



HYSTERIA— IftBEOULAB and AKOMALOut Stati 



them with the ngns evinced by percusnon and aus- 
rultation, the occasiona] appearance of decidedly 
hyf teric nyniptoms, as borM>ryg;mi, clangor intesti- 
norum, the globus hystericus, uterine distarbance, 
and the state of the mind, will here disclose the 
nature of the disease. In this class of cases, there 
is also more or less disorder of the digestive organs, 
and in some, tenderness upon pressure of some of 
the dorsal vertebrse <§ 23.). 

17. c. Pain in thi regions of the stomach and 
tpUen is another frequent manifestation of hys- 
terical disorder, and is often so intense in the 
former that the patient screams, learts forward, 
and expresses the utmost agony. It generally 
comes on suddenly, -and lasts from a few minutes 
to an hour or more. It is increased by pressure, 
although not vefy materially, and the pulse is not 
much affected. This pain may exist without any 
nausea or retching; but the bowels are usually 
costive or irregular. It is sometimes accompanied 
with a sense of beat or irritation in the pharynx, 
or is followed by a burning sensation at the epi- 
gastrium. There seems to be a very intimate 
sympathy between the spleen and the uterus ; irri- 
tation of the latter exciting the sensibility and 
organic contractility of the former in such a man- 
ner, as to occasion a belief that it is actually the 
seat of inflammatory action. The pain (elt in the 
region of the spleen in hysterical eases is never so 
severe as that which is strictly referrible to the 
stomach, and pressure is endured much better in 
the former than inthe latter, and often even gives re- 
lief. In all sueh cases, there is no swellinf? present 
as in splenitis, for which they may be mistaken ; 
but attention to the history of the case, and the 
good effects of tonic and antispasmodic treatment, 
will remove any difficulty as to diagnosis, particu- 
larly if the functions of the uterus receive due 
attention. 

18. d. Pain in the course of the descending 
colon, and in the left iliac region, may be the only 
or principal complaint in irregular hysteria. It 
generally also attends other forms of the disease, 
and is most frequently seated in the region of the 



generally, may be di ate n ded by fiatni, to •• to oc- 
casion much pain, to impede re^NimtioD, and e?en 
to disorder the heart's action. 

20./. Piu'n above tke pubis is sometimes com- 
plained of, but is rarely the only, or even the prin- 
cipal complaint. It » usually attended by moie 
or less tenderness on pressure, and fnlneas in tUs 
situation, with disorder of the eccrelion of wine. 
It is generally associated with colicky pains in the 
abdomen, or in tbe loina, saorum, or adjoiuaf 
parts. It seems to depend upon congestion of lire 
uterus, as it is frequently relieyed 1^ local dtpl^ 
tion, and by the increase and re|[nlmr ratnn mint 
catamenia, which arecommonly imgnlar or seaMf. 
Pain, however, in ihis situatioo may attend an e^ 
cessive discharge, as weU as certain forms of hi- 
corrhea. When it aecompanies the former, k 
depends upon irritation, and is more deddedlj 
nervous, unless in very plethoric fismales, in sdMi 
an excessive discharge proceeds from actire d^ 
termination of blood to the uterine ayMif . la 
some cases of this kind, also, the digeatipe uigM S 
and the functions of the kidneys an mach da- 
ordered. 

21. ^. Irregular hysteria may he wsam^etltdhf 
pain in various parts of tha abdomtn, or ta tb «^ 
domen generally, especially about the period of tki 
catamenia, and when they are difficiut or scaoT^. 
The pain often assumes a colidcy chancier— tts 
Coliea hysterica of yarious authors,— and sbMi 
its situation. When it extends oyer tbe abdo- 
men, it is sometimes accompanied with ezceHve 
tenderness, and great inflation of the bowels. & 
may then be mistaken for peritonitU, AttentieB, 
however, to the pulse, the uterine discbaijo^ 
to the fscal and urinary excretions, and to the 
manner and state of the patient's feelings, viB 
assist the diagnosis. In this form of hjrslerieil 
affiection, a marked incongruity will be obseired 
between certain symptoms: greater pain isd 
tenderness will be felt than the pulse, the toi^se^ 
and the evacuations should indicate ; tbe moit 
urgent symptoms vrill suddenly disappear, and ai 
suddenly return ; the mind will be variable isd 



sigmoid flexure, and is attended and aggravated I susceptible, and some unequivocal hysterical sjai- 
by flatus, which causes a rumbling noise, followed | tom will often arise. The pain and tendemevwrn 
by the globus hystericus, and occasionally by other frequently shift their situation; the urine will be 
nervous t^mptoms. In some instances, the eon- natural,or pale and copious, instead of bong icsoiy 
nection of this pain with uterine disorder is very and high-coloured as in peritonitis ; and the ap- 
obvious ; in others, it is much less so. It is gene- | peamnce of the countenance and the posturetflf 
rally independent of disorder of the bo web, al- the patient will be very diflferent from those ob- 



though irregularity of them is very frequently 
observed. That it is purely nervous, is proved by 
the symptoms, and by the effects of remedies. 
19. e. Tympanitic distention of the intestines is 



served in inflammations seated in the abdoDOiil 
cavity. The existence of some derangem^ ia 
the periods, continuance, quantity, and quality ef 
the uterine discharge, or of pain and difficult of 
not an uncommon symptom in h3rsterical females. ; its accession, or of leucorrhcea, will also tend IB 
Sir B. Brodie states that it has been mistaken for confirm the diagnosis. 

ovarian dropsy, and that the majority of cases of | 22. h. Pain in the region of the kidneys some- 
this disease supposed to be cured by iodine and ! times extending in the course of the ureters, asd 
other remedies have been of this nature. I was I even to the urinary bladder, is occasionally tbe 
the first to employ, and to recommend the use of principal afl*ection in hysterical patients. This jaaa 
iodine in ovarian dropsy, and I have derived great is generally severe and sudden in its attack. WbeA 
benefit from it in several cases ; but I cannot see it extends to the bladder, dysuria is often pKNOl* 
how these affections can be confounded with each j This symptom is liable to be referred to ia* 
other, as tbe diagnosis is remarkably easy. The flammation of the kidneys : but here also a tt e a riw 
absence of fluctuation, and the tympanitic sound ! to the existence of uterine disturbance; themariM^ 
produced by percussion, sufficiently indicate the incongruity of symptoms, particularly between tb0 
cause of distention. It is only when flatus accu- ' state of the pulse, the secretions, and evacusDoo* 
mulates about the sigmoid flexure of the colon or ' onlhe cue hand, and the pain on tbe other ; tbe ft^ 
its the ctBcnm thai there is any resemblance to ^ o\ieBlf\v\K\Ti\E;»,>^'^vaj^'^»Ei%»c«Ki^ 
4fyr^ dnpay; |>Ht other regions, or the abdomeix ^ detieena^Tiol^IbA^aasL^ VD&^fisA^fitassBMOL^iff^ 



280 



HYSTERIA — DuiuTioN ind TxniixNATiofr. 



rence of hyiteria in males during stales of debility. 
I have never met with a case, however, in which 
the complaint was unequivocally developed ; but 
I have seen several nervous affections in males of 
a susceptible and irritable temperament, weak- 
ened by disease, or by over-esertion, that have 
assumed some of the characters of hysteria, 
particularly in its irregular or undeveloped 
state. Cases of hypochondriasis and of melan- 
choly in the male, occasionally present some- 
what of an hysterical character ; thus I have met 
with an instance of hypociiondriasis in a gentle- 
man aged about forty, who complained of pain- 
ful attacks of priapism, of a feehng of stricture 
about the throat, with shedding of tears, miserable 
deprestuon of spirits, &c. ; and yet who could 
readily join in lively and amusing conversation. 
Such instances serve to show the relation ezi«ting 
between hysteria and hypochondriasis— a circum- 
stance not less deserving attention, than the dis- 
tinctions between them. Of the facts adduced and 
alluded to by Sydenham, Hoffmann, Whytt, 
Ferriab, Villermav, Georget, and Conolly, 
favouring the opinion as to the occurrence of 
hysteria in males, the most conclusive is that 
recorded by Mr. Watson (Edtn. Med, and Surg, 
Joum, vol. li. p. 303.). A strong man com- 
plained of giddiness and headacn, and was 
seized with epileptic convulsions. After some 
hours, the symptoms returned with alternate 
laughing and crying, spasms about the throat, 
and inability to speak, although he wa4 perfectly 
sensible. Dr. Trotter states {Medieina Xauticaf 
vol. ii.), that hysteric fits occurred in some 
cases sent to liospital ships, and that they were 
attended " by violent convul^iions, globus, dys- 

fihagia, immoderate risibility, wcepmg and de- 
irium.'* It is very, possible, that unaccustomed 
continence in the male may, in rare cases, and in 
the nervous temperament, give rise to seizures of 
an hysterical nature. I was consulted by a young 
gentleman, who complained of headach and several 
of the symptoms of hysteria, after prolonged periods 
of continence. 1 recommended him to marry : he 
adopted my advice. I saw him two or three 
years afterwards, and he told me he had had no 
return of the complaint. A similar instance to 
that adduced by Dr. Conolly, and which arose 
from intense study, occurred to me some years 
since. I was recently consulted in the case of 
a young man of the nervous temperament, who 
had become early addicted to drunkenness, and 
who relinquished the habit under the guidance 
of his friends. Soon afterwanls, upon the occur- 
rence of a dome -tic calamity, he was attacked 
by a nervous complaint, in which it was difficult 
to determine whether the hypochondriacal or 
hysterical character predominated. 

41. V. Cdmplicated Hysteria. — Hysteria may 
appear, in either its developed or irregular forms, in 
the course of numerous other diseases. It may 
occur at the crisis of, or during recovery from, 
fever or inflammatory diseases ; during the pro- 
gress of, or in early convalescence from, inflam- 
mations of the respini^ry organs ; or in the 
course of pulmonary consumption. It is some- ! 
times complicated with asthma — Hysterical Asth- 
ma ; and is very generally a symptom of, or 
associated with, inflammations of the uterus or 
ovaria, particularly when these take place inde- 
peadeaUyofthe puerperal states. It frequently also 



attends levcorrhoea and stmctanl leabiu of these 
organs. Hysteria may occur during pngDincy ; 
but it is oftener luapended by this state, ai wall 
as by lactation, although it Bometimea appean a 
few weeks after delivery. Its frequent coanectioe 
with irritation of the spinal cord« with fuBdknal 
disorder of the heart, &c.> has been already 
alluded to ; and it is often associated with hypo- 
chondriasis. It is often also consequent upon de> 
rangementaof the digestive ornnfl, especially thov 
in which the gastro-intestinal mucus sarfaee isii 
a state of irritation. It is not infrequently ooa- 
nected with disoivier of the urinary organs, tki 
urinary secretion and excretion being aiicctedia 
various ways, besides that which mote usedly 
characterises the hysteric seizure. When hyMerii 
appears in the course of other maladies, it is ge- 
nerally owing to the temperament and oonilili- 
tion of the patient, and to debility or ezhaustioB ti 
nervous power, from disease or from treatmcat. 
Hence its occurrence after excessive or insfpio* 
priate depletions, after hamorrbages, after piiti- 
rition, and after fevers. 

42. When hysteria is complicated with thM 
or other diseases, or when these affect hysttfical 
females, a prolongation of disease, or farther coa- 

Jdications, and a protraction of convalescence, m 
requently produced. Dr. Conolly justly ve 
marks, that in the course of a long hysterial 
disorder, and yet more readily in the conns if 
fever in an hysterical patient, inflammaloi^ acliii 
may take place at the origin of previously iiritaigl 
nerves, or in the brain, or other organ* : tcDdeiav 
of the spine may become excessive ; anddiMndaei 
sensation and impaired power of motioo Mf 
indicate the existence of something more thia 
mere irritation. These symptoms may disappv 
as the patient gains strength ; but they sometaei 
become more intense and constant, and asnns 
a more serious form than the shifting, evanefcest, 
or local tenderness and pain, affecting viiioM 
parts as described above (§ 14.). 

43.VI. Duration and Terminations.— tt.Tke 
duration of the paroxi/sm of hysteria varies fiw > 
few minutes to many hours ; but the oontinoBBS 
of the complaint is very uncertain. Hystcrii mf 
not again recur after a single seizure, espeeiilly 
if it have been induced by the more powedu 
causes ; but this is seldom the case, for when it 
has once appeared, there is a predisposition toitt 
return in one or other of its various forms, apM 
the recurrence of any of the predisposing or es» 
citing causes. Much, however, will depend apsa 
the general health and circumstances of the p^ 
tient. It may thus re-appear after intervals of va- 
rious duration ; or it may hardly ever be coih 
pletely absent, in some one or other of itsnumeroi* 
modes, during the greater part of the period 
between puberty, or the age of twenty, and th0 
complete cessation of the catamenia. Itseldoss 
occurs even in those subject to it after this latter 
epoch : yet I have seen instances of it induced b^ 
mental emotion, at a much later period of life. A 
very large proportion of the ailments of fenaltf 
duiing the period of uterine activity, hoipeitf 
diversified their characters may be, are really byv 
terical. Hence many females enjoy much Mtf' 
health after this chance has been quite eompl^ 
than they did previously; although about theperioi 
of change, their complaints are often aggravatei 
44. b. The Termmatim§ of hysteria an-lil' 



HYSTERIA— Cadw. 

^ ^ K eonaeeWd, promotntba 

and how mucb tba ievtiral functioiu dcpand npon or niitable •: _. , . ^ 

eacb other, we cuinat woodir that their morbid hoan u to sleejHOf lad iMiag ; u nil i iiinj 
■ffeclianB aboukd often be miied, or iiaeiuibly mode of educatioii, aid (be eidtsment of A* 
nu, Ihe one ioto the Other) tbe effect of thii u JmaginatioD and of tbe enotiaiia, to tike no^lict gf 
indeed thai there are no uoivemldiKiiictioiu, and tbe iotelleetnal powen and moral tiMiiBfli ; 
that ia a few c«m> onlj ate there e»ct limiti too ^reat devolioo to bhuui, and the penidef 
betneen aaalagous or Mmilar dUeaeea. Accarate eidciog noreb) tbe Tarina mcam brwtaekdil 
' «d,aod»«mt8eenAilityb| 



obiervalion aad preciie deuriptioa do much in feeliogs are awakened, a 



eitricaling uVfram Ihii cimriuiDii ; but in ume caiea moled.whilM ewnrmi 

-"' '- '- '-'■- --■■ '- J-"—'-- It coooealed } and ah 

deeirea which Urngleto be ainrMeud, — all mri, 
K) long ai we recogtuie eapedalty at a penod when the powvi of hU, 



BtilJ, we mnMiemaiD in doubt and in diHicolty. It coooealed } and atwlied eadeBvoni* (a 

n ibeie, it will naltei bat little aa to ouireawhii' 



and eatimate with accunc; the nUne, extent, aod ■»! the eonrormatiaD of the body ai« upnadHf 

lelatioDS of the inorbid coadilioii.* developmcnl, to prodnce that atate rf iha uei l u w 

4S.V111. CiDBU — i. /'rnfiipMini'.— HjMeria lynem, of which hjiteiia ia one of ibeHgatfta- 

may be said to be ilmoat peculiar to the /mabtei; quent indicnttotts. About the period of palMr 

I — . rL _ — 1^ (j|j lujjg ij^ j„ fjnialea, »arioni circiuniilaneea conneeted WL 



for the ioatancee of ita ippearance in 

eo rare, and so problematical, ■■ napeclsita fulljr their edacatioa tend la weaken their e 
dereloped and coDvuhine atatea, aa nardly to be to eicite their emotion* and dearea, and to ealli- 
taken into ucconnt. — a.llie anal which leoialea tate their imiginitiTe and more aititeial hcallH^ 
are moat liable to it is from fifteen Id fifty ; and at tbe expence of their leaaoniof aod moial pawn 
eepeciallj from twenty to thirty, and again from 
furly-two to forty-eigiiL It eonnetimea doea not 
occur until the latter epoch ; but it nrely re 



diapOBe to hyitena ; — nerroua, sangnineo-nervoua, _ 

aiid irritable tempenmenta, and peranna of a lai, although the nbject haa been hot r 



, d of life. Hyaterla is ver<r aeldom aubmiued to a Ininrion uid orer-Rfined Bedi «f 

obaerred before puberty; but ronaidering that education, aome will manifeat a peecoeia aa dw»i 

menalruition commencei in aome caaca, particu- lopment of both mind and body ; bnt ia prm>- 

larty in young ladies in boarding-achools, aa eerly tion to precocity will looe and enern be M- 

aa the tenth and elereDth yeara, tbe appearance dent, and -iir"r''liili1j nni ir iniihilitj iiiiiiaad 

of thia complaint, in some one or other of ita In these circunstancea also, ornaie feBKhi%, 

forma equally early, cannot be a matter of aur- particularly aa lelatea to the utenne ayiKn, •>« 

— '— — Ttmperiiment and disfAtiii evidently pre- anumea a piHJomiaaDce powerfully pndifMif 
to hyxterical afTectiona. There can be ao quMii^ , 

. - . , . , . although the subject has been hot rarely a» 

weak, or delicate, impTE«ib]e and soft habit of preached by BriUah medical writen, del laA 

body are moct inbject to it. Aa thia stale of geoce in aolitnry rices and aeinal eidleoHK 

eonalitution is derived from the parenia, the opi- >> not an iafrequenl caute of thia, as well aa«( 

nion of llorrMiSN, Fhanx, and othera, as to its other diwrdcrs. Numerous writers have inM 

occaaional dependence on hereditary predispofi- u^n the propriety of girin^ due eonsidentiea t< 

licD, cannot be disputed. The Fhildren of debi- thn aource of mischieF, as well as to Ihe ^» 

litated, eihaus-ed, or aged parents, and thcwe who and chagrin attending celibacy nnd conliDtKa. 

of an impairni consiitulion, either originally I aeree with Dr. Conollt, in bcKeviBg dat 

from early mana^nient and education, are Kngliah oractiboneffl pay perhaps too tittle alM- 

at likely to be aubject to this disoider. — A tion to these and other related clreumsliaM ; 

" pasaiooi ad 

Eir silent »«»■ 

B*K)ciatcd with delicacy of canformalioD end BUS- ation on the frame, and rhaive the meoeal 

ceptibility of tbe nervous aystem, to the mare writen of other countries with being aomewtal 

irregular forms. fanciful and extravagant 

49. t. There ia perhaps noother malady, which 50. e. Besides the abate, there an Ti 

• , L __.,._ .. , -■ — Ih the »i«io[ 

ondilioDS of the el 

... . _ __..j ..... ious and delicate mode oriians and nervous ayste 

«f liring, and of tearing ; 

the progremiTe steps of life, as yonlh paaaes vm, 

• H. BatniT,iniUitiBiiutihLn(bMireenh;ilerliand are sources of painful moral aBecTiona, espedllir 

aAcli<n<>rihecere£raln»*aua>y.<en,to.hicVheha> '° "'" fnvolons, the v am, and the ntmaintdtf 

gtvoi tke name or etrrtnl mrumptim lurxnmtmlt the sei. These affecOona increnae the mla^ 

jjjj^^.andttalihelaitertaadliordwjaviu^ion.an bility of the nerroua system, and, with nooeteM 

tau.xtrrOnHti'^^^^^^St^iSi'rSukciraS^t older circumatances yet lo be mentioned, dip« 

flianairr), Thenre he Inftaa that thart can Iw ni> Idim. to the nervcua disorden of the more BiIfBSM 

«i1f, and the oiJier^n atur Df the two ner'Tma ■)? [nmnered moles of living ) an earl; or halM 

tnni. Hr nwccDTB atatea that there ia no Ikither mduigence of temper, or of the e iuuti r w a ^ 

:S!a S:s:.w5 "£ S: ssssr; w",*;; J"™ ^ »» "« ■" "■» -■ 'r™' ™ ■* 

In hjrpochondriuli, ihennilUil arMnn l< equiirrcom- >i "hat may appear the bounds of modenM; 

innlHd. HoKc. liL Tba; an KM Mntical aUkMian : lali liiiiiiii. anil laTi liiiiiiiL, iianfliiiLUl ■UihT^ 

oflbacUon. • . > neglect of the requisite eapoBDiq to af/tt ^ 



4epcad« so much as this upon the tuanogimi'ii of cutnstances cotinccted with the tiwisf it 
childhood, and on the moral and physical tdara- tend to develope thew conditions of thi 
tjinof early lile. A luiurious and delicate mode organs and nervous aystem, in which hyit 



284 



HYSTERIA — Pathology. 



fatigue ; and even irritation of remote parts, as 
that connected with cutting the wisdom teeth, 
occasionally induce a seizure. 

55. Mental affections and excitements, especi- 
ally those which act upon the uterine system in 
particular, disappointments in love, unretumed and 
spurned affections, jealousy, anger and other violent 
emotions; protracted expectation, longings after 
objects of desire, tragic representations, frights, 
the sijjht of objects, disgusting or distressing, or 
disagreeable from peculiar mental diathesis, and 
intelligence of a distressing or of an exciting na- 
ture, suddenly communicated, are the most com- 
mon occasions of hysteria, as respects both its 
first appearance, and its subsequent recurrences. 
Several of these emotions affect the uterine or- 
gans, the affection being afterwards reflected 
upon the nervous system generally. Premature 
or physically incongruous marriages ; excited, but 
unsatisfied, desires ; celibacy, and veneris deside- 
rium inane, are also not infrequent causes of the 
complaint. Frank remarits, that *' Ccelibem 
vitam plures sine noxa ducere possunt foeminae, 
sed vix unam illarum invenies, quae prope mari- 
tum impoientem impune decumbere possit. Idem 
de uxoribus, a mantis neglectis, valet." — There 
is no doubt, that the sieht of others in the fit will 
sometimes produce an hysterical seizure. I have 
myself witnessed this on two or three occasions ; 
and in one of these, two females were attacked 
from this circumstance. Ttiis phenomenon has 
been imputed to imitation ; but it may with equal 
propriety be assigned to sympathy, to fear, &c. 
Probably more than one of these feelings are 
concerned in producing it. Severe mental dis- 
tresses, or extreme joy, may also occasion some 
one or other of the forms of the complunt. Im- 
moderate fits of laughing produced by humorous 
or ridiculous occurrences, or crying caused by 
vexation or contrarieties, may also pass into the 
hysterical paroxysm. I have no doubt of the fit 
being often renewed at pleasure, almost as readily 
as tears may be shed, by recalling or adverting 
to various feelin«;8, emotions, or circumstances; and 
I have even seen instances which have convinced 
mc of the fact. Klectrical and warm states of 
the air, and sudden vicissitudes of temperature, 
have been supposed sufficient to produce a seizure. 
The influence of spirituous or vinous potations, 
of stimulating diuretics, and of substances which 
excite or irritate the urinary bladder, in the pro- 
duction of the complaint, is much less doubtful 
than that of atmospheric temperature ; but the 
close, warm, and impure air of crowded rooms 
and as<%mblies, particularly in connection with 
excited feelings or contrarieties, very often occa- 
sions an attack, especially in those who have 
previously experienced it. A similar effect is in 
rarer instances produced by various odours, espe- 
cially in peculiar idiosyncracies. Hiohmore 
states that the fit has been often induced by the 
odour of musk. 

56. IX. Pathology. — The nature of hysteria 
may be in a great measure inferred from what has 
already been stated respecting its symptoms and 
causes ; yet something more explicit still must 
be advanced on this subject. As simple and 
pure hysteria is rarely or almost never fatal, and 
as we therefore have hardly ever an opportunity 
of examining the state of the principal viscera of 

patients who had been subject to this complaint, 



unless they have died of lome intercu i wat or 
associated malady, so proofii have been waniii^ 
in support of any of the doctrinei pr opowd as to 
its nature, and a very wide scope allowed Cor 
vague hypothesis. The ancients uad many of 
the moderns refiened hysteria to the womb ; and 
hence the origin of the name. The ao^eoti, 
however, ascribed properties, powers, fue* 
tions, and motions to the uterus, which modoa 
knowledge has shown to be erroneous ; yeC I n 
disposed to believe that thb organ, inflnencfld ■ 
it most probably is by the nervous and visciltf 
states of the ovaria, performs a very importol 
part in the oeconomy ; and that this isnot coofbei 
to alterations merely of its organic sensibility, bat 
that it extends frequently to its contractility, ni 
to several related organs. 

57. Some recent writers have ascribed bjitcria 
to irritation in the uterus, in the intestinsi, ia 
the brain, or even in other internal viseeni,ee* 
earring in delicate, nervous, or susceptible po^ 
sons. Dr. CoNOLLT remarks, that in all cases sf 
hysteria there is a disordered state of some ssit 
or the whole of the nervous system ; and tUl; 
although this state may be, and very frequendji^ 
induced by uterine irritation, it no less evidndy 
arises, in other cases, from causes prodnctiTe ■ 
irritation in other parts of the body, and also hm 
causes acting directly upon the mind. Iltf 
more or less susceptibility, original or acnM, 
characterises the state of the nervous system m hjh 
terical persons will not be disputed ; yet eves ii 
such persons, the usual exciting causes, or irritsiim 
of different viscera, will not occasion true hyrienol 
symptoms, unless they previously affect the AM 
of organic nervous influence, or of circnlatioo,ii 
the sexual organs. 

58. Willis ascribed hysteria to ctisorder of Ai 
brain, and M. Geohoet has recently adopted thi 
same view, which has been most ably and nlii> 
factorily overthrown by M. Foville. Still bm 
recently Mr. Tate has contended that hjsM 
arises from a morbid state of the spinal eoid, 
connected with disorder of the womb; bnt,«I 
have already remarked, this " morbid state" ii 
but a vague generic term, and that, most pis- 
bably, even when it is most prominent, more d 
altered sensibility than of vascular or stroetofil 
lesion, of this part of the nervous system coa- 
stitutes its essence. However this may be, il- 
tcntive observation of the morbid phenoBMBiu 
especially at their commencement, will showtlMt 
the spinal affection is merely a consecutive ind 
contingent disorder, and one by no meau geas- 
rally, or even very frequently, observed. 1^ 
want of precitiion in the use of terms, and ia tbs 
ideas relating to the pathology of hysteria iMi 
been surpassed by M. An oral, when be mp, 
" As to my opinion respecting the seat of hyiMiif 
I repeat, that it is a nervous complaint, ijmI iW 
its seat is the nervous system ! ** 

59. Although the uterus and its mptnitf 
have been viewed as the chief source of hyMA 
both by the ancients, and by most of the modeA 
yet some difference of opinion exists ss to ihi 
nature of this primary affection. Pixbl, ViuO* 
MAY, LoBSTEiN, aud FoviLLE coiisider thitit* 
entirely nervous, or is an excited state sf thi 
nerves supplying the organs of generatioo. OAtf 
writers, as Addison, Alc, who have adopted Ai 
term uterine irritation, soem to ascribe to kkii 



286 



HYSTERIA' — TisATMSMT. * 



pathetic, and of tlie kiad which I was the fint to 
denominate the reJUx (see NoUt and Appmuiix to 
Richer ANu's EUmtnUof PhyMogyt pp« 34. aiid 
546.) ; and the same views and pathological ex- 
planations given in the articles Chobba and Rb- 
LATEO Affections ($ 15 — 17.), Convulsions 
(^ 46.)> EpiLKPSY ($ 51.), *PPly ^ ^^ different 
varieties of Hystbbia;— t. That* although hys- 
teria is often connected with deficient or irregular 
menstruation, yet this function is sometimes ex- 
cessive, or is occasionally regular, in every respect, 
in hysterical perBons. 

62. X. TasATMBNT. — There are few diseases 
less under the control of medical treatment than 
hysteria; and various circumstances connected 
with it often occur to render the management of 
it not only unsatisfactor]^, but also unpleasant. 
Patients themselves or their friends readily suppose 
that relief should quickly follow a recourie to 
medicine, and conclude, that the proper means 
have not been employed, when relief is not ob- 
tained. They do not consider, — and the fact b 
generally not sufliciently explained in the proper 
quarter, and at the proper time, •— that the com- 
plaint arises from causes which are mostly per- 
manent in their action, or which continoa during 
the treatment, and that in every case the difficulty 
of removing an eflSect, whilst the causes are in 
operation, » very great The candid physician 
also readily admits, that the complaint in its vari- 
ous forms is devcHd of danger, and this circum- 
stance is believed by many to imply a speedy 
cure. Several varieties of it also are calculated to 
excite alarm ; and, if they be not soon removed, the 
knowledge or ability of the physician, under whose 
care they may have come, is impeached ; and some 
other advice is asked, and often in quarters noted 
neither for honesty nor ability. If the patient 
should thus fall into the hands of either the quali- 
fied or the unqualified charlatan, the complaint is 
misrepresented or exaggerated, and alarm is ex- 
cited. The effect, however, is often beneficial, 
although it was as little intended as its source 
was unsuspected. The impression of fear on the 
mind may put a stop to some of the causes, or 
may interrupt the succession of morbid sym- 
puihies. The patient, moreover, after she has 
passed from the care of the scientific practitioner, 
may be subjected to influences of a powerful na- 
ture, moral or physical, or both, and experience 
temporary or some permanent advantages from 
them ; but from whatever source they proceed, or 
by whomsoever administered, — whether by the 
medical empiric, or by the spintual comforter — 
the modern worker of miracles, — the results are 
often equally annoying to the duly qualified prac- 
Utioner. The regular professor of medicine is 
expected to adininiater benefit in all cases, and 
without regard to circumstances. If he fail, and 
the patient, under very different circumstances 
and influenced by very different feelings, receive 
benefit from the manipulations of a charlatan, 
whose means are more striking or imposing, 
or more suited to the moral condition of the 
patient, than those previously employed, the oc- 
currence is made a matter of notoriety, and 
equally to the disadvantage of the one, as to the 
credit of the other. The former is expected by 
the public to cure, and it is considered discredit- 
able for him to fail ; the latter is viewed as 
bmwing made a ironderful discovery, if he succeed 



but in a single case, and hb' kaowledge b np-' 
posed to have come br iaipiratioo, aa it coiM 
not have been derived from any other aowee. 
Another circumstance f uithar aenrea to coameiael 
the treatment advised by wrwDtific BMii,particalulj 
in large towns. The patient is caprickmayaDd kr 
friends are often equally nntaMe. If boefit ■ 
not received in a verj short tmie, the advkiif 
some one elsa ia oblaineri, tad befcn he on lit 
of any service, he also is dismiwed, and a liniii 
called in. Thus, from twenty to thirty pia^ 
titioners may be consulted without one ef ikm, 
having had a sufficient opnortuntty ef faliUJuia 
single intention of cure. Now, what is the eOHH- 

Sjuencel The patient resorts to tome wtiitAm 
ashionable empvic, who is informed of hm hm^ 
sufferings, and the want of sncoew of the gmM 
physicians in her case. He ia shrewd eBM|hla 
see at once the state of matters, and to ton thn 
both to his pecuniaiy advantage and to his eraiu 
He exaggerates the risk, thedimculty, and the ent 
sequences of the disease; refuses to nndarlaka Ihi 
case, unless at his own tenns^ whick he 
care to secure ; and he thus also seeuret the i 
tinuance of the patient undw his care, and even h« 
confidence, although he should fail in all 

63. From the dishonest acts of 
useful lessons may, however, be heoeitly 
When a physician is called to a nerve 
who has been under the care of other ^ 
instead of prescribing at once, and wiiliMl afci 
rence to this circwnstance, he should unMl 
her or her friends, that probably a sefinHl 
opportuni^ of afibrding relief had net hecaik 
lowed to those who had preceded him ^ thsl^ ii 
a member of an honourable profsssion, ht tft 
pects to be honourably dealt witfi, and thit h| 
will not compromise his reputation by presmbiil 
for the case, unless he be allowed time and $ft 
portunity — fully and drcumstantiaUy — far ii 
proper treatment. U nless these be conceded, ai 
m a spirit which will promise to secure their dM 
performance, it will be infinitely betterto relinipiib 
the case alto^ther, than to entor upon the tnii* 
ment of it, with the probability of disanMiataML 
When it is found that the physician mas W>^ 
his own reputation, respect and confidence ra hi 
accorded to him by the patient and her fnewk, 

64. There are various circumstances ia dift 
pathology of hysteria, which require strict attiB* 
tion in the treatment.— 1st. The partiealar km 
of the hysterical seizure, whether regular, ii 
or anomalous^ — ^2d. The condition of the 
system, particularly with reference to 
sensibility and irritability ; — 3d. The excil 
erethysm, vital turgescence, or other disordvif 
the uterine system, and tlieir influenoe by dirfd 
and reflex tumpothy ; — 4th. The stales of di 
vascular system, in connection with these, cifii' 
ally in respect of plethora, general orloalffd 
deficiency of blood; — and, 5th. The tumA/d 
or other disorder of the digestive canal. Of dl 
these, the most important is the state of eWii 
function ; for unless the symptoms connected aik 
the generative organs be carefully ascertaiasiitt 
far as is proper to inquire, and thedisofdtf ■ 
this quarter be caiefully inferred, the treataeetil 
often be unsuccessful ; and, even with the vMd 



exercise of professional acumen, 
more or less, owing to the 
mond and phyncal ctaiee of 







288 



HYSTERIA ^GmujkL Tbiatmsnt. 



suitable diet and regimen. The sulpkatuof iron, 
of zinc, and of quinint, are severally of use, in 
combination with small doses of camphor, or of 
ipeeacmtnha, and with extract of henbane, or of 
hop. If these should occasion headach, or in- 
crease the tenderness in the vicinity of the uterus, 
the infusion or decoction of cinchona, or the infu- 
sion of valerian with nitrate of potash, or hydros 
chlorate of ammonia, or carbonate of eodat may be 
prescribed. When the bowels require to be open- 
ed, the cooling aperients, as the bitartrate of pot- 
ash, with the nitrate, and the confection of senna, 
should be preferred. Moral and physical quietude, 
freauent reclining on a couch, and a digestible and 
cooling diet, ought also to be enforced. In more 
plethoric persons, these means are still more requi- 
site than in the preceding ; and, instead of chaly- 
beates and tomes, cooling diaphoretics, particularly 
weak camphor mixture, with solution ot the acetate 
of ammoma, nitrate of potash, and spirits of nitric 
aether, will be ofteo taken with benefit. Wherever 
utei ine tu igescence or erethysm is inferred , the treat- 
ment must be directed with reference to the statesof 
general or local plethora, and of nervous power, 
as hereafter insbted upon ; and hot spices, exciting 
articles of food, and stimulating beverages, should 
be avoided. Heating purgatives and irritating in- 
jections ought not to be employed. A separate 
sleeping apartment should be suggested. 

70. W hen the catamenia are disordered, the 
treatment must be directed with strict reference to 
the state of disorder, as explained in the article 
Messtrl'ation'. If they be excessive or too frequent, 
tonics and astringents, with refrigerants, and ano- 
dynes or narcotics, are generally requisite ; but the 
predominant use of either of these classes of reme- 
dies should depend upon the peculiarities of the case 
In these cases especially, advantage will accrue 
from cold sponging the loins, abdomen, and hips, 
every morninr^ with an astringent lotion, as with 
equal parts of rose water, solution of the acetate of 
ainmonia, and vinegar; from the occasional recourse 
to an enema of cold water, particularly when a seiz- 
ure is threatened, or to etnoUient and anodyne 
enemata on other oocasions ; and from rest in the 
horizontal posture. Tite ciild plunge or salt-toater 
bath, or shower bath, will often also be of service. 
In the other states of disordered menstruation, the 
treatment should be directed according to the prin- 
ciples stated above ($68, 69.). 

71. B, With reference to the state of nervous 
susceptibility and tone. — The increased suBcepti> 

' bility of the nervous system generally characteristic 
of hysteria is frequently a^'Sociated with more or 
loss debility, and increased irritability of the mov- 
ing fibre, — or in other words, with mobility of the 
muscular system ; and to this state, whatever may 
be other morbid conditions, should the treatment 
be in some mea'^ure directed. Yet the means 
which are the best calculated to correct this state 
are by no means obvious : for if it l)e associated 
with vascular turgcscence of the uterine s^'stem, 
or with general plethora, antispasmodics, chaly- 
beates, and other heating tonics may increase the 
complaint, although they will generally be of ser- 
vice in an opposite state of the vascular system. 
In general, therefore, the condition of the sensi- 
bility and irritability should be combated chiefly 
by frequent and regular exercise in the open air, by 
early rising, by sleeping in large airy apartments, 

by cold ortalt'water bathing or the shower bath, by 



cold sponging the surface of tlie bod^, by a proper 
condact and employment of the mind, aaa by a 
correct management of the paaswna. 

72. Dr. CuLiBN veiT justly remarks, thit 
tonics may be of service when the disease deptadi 
upon general debility ; but as a plethoric sisie, 
especially of the utemsy is more or lets joined with 
hysteria, the frequent or lone continued use of ikH 
may do harm. They should be confined to cini 
of pure mobility, particularly with a periodical nh 
currence of the seizttie ; and then the seledieD if 
them ought to be determined by the pecuiiaritiHW 
the case. In many such, the preparationaof em- 
chona or of valerian, with the nitrate of peUtA, 
or carbonate of soda ; the sulphate otquimm ar 
of tine, with small doses of camphor ; the 'ndmm 
of bark, or of rofti , with one of the wunerai mUt, 
and the tincture of the seequichlaride of tiw, «iO 
be most serviceable. In some cases, the uMm, 
to either of these medicines, of an antiepamett^ 
as of the compound spirit of sulphuric etkett Iki 
tincture oi valerian, &c. ; and of anaii«d:jriis,ash» 
bane, hydrocyanic acid, &c., according to theslkv 
substances selected, will be further advanla^ssta 
When hj^teria affects plethoric habits, and xsem^ 
nected with manifest signs of tureescence of tki 
generative organs, opium is injurious. Bat, ■ 
other circumstances, it is olien of service, partiei* 
larly when conjoined with camphor, aromatics, if 
with some of the substances just named, batsNi 
then it should only be occasionally emplo|rii 
When narcotics have not been previously resoilsl 
to, the preparations of hop will oe fouod nsdil,if 
general plethora be not present. 

73. C. With reference to the siaies tf the vett 
cular syttem, — The connection of bjrtferia in& 
vascular plethora, general or local, is often o^ 
vious ; and has been very judiciously viewed ^ 
Dr.CuLLEN. The usual practice of removing tte 
state by bloodletting, he remarks, is often prac>" 
nous ; for sometimes, instead of preventing, it will 
indirectly induce or increase vascular folneUi 
Besides, if depletion be carried too far, the cqb- 
piaint may be thereby increased. ''Vencseetioa 
therefore may either increase the plethora, or is* 
duce inanition ; and it is only to be used in rectal 
cases, and where there is manifestly a full habit" 
A spare diet and regular exerciee, particolarlj ii 
the 0{>en air and in the light of day, early ruufi 
and cnt>ling aperients, are the means upon whin 
the chief reliance ought to be placed in remorisg 
this state, and especially as they tend slso is 
strengthen the nervous system, and to prevent locil 
turgescence and irritation. The frequent associ- 
ation also of dyspepsia, and of gastro-inCestiosl 
disorder with hysteria, renders this regimes fl3 
more necessary. When depletion, however, ii 
indicated by the turgescence, or chronic infliMS 
tory state of the uterine organs, or by impsiifd ir 
obstructed menstruation, it should be practiNd ii 
the manner already advised (^68.). 

74. When the vascular system is deficiesl, 
rather than too full> of blood, and when thisfliid 
seems thin or poor (the Hysterim ekkretiet if 
SAuvAOEs),thenloni«s, especially the p u^ i sf im 
of iron and chalybeate mineral springs, will be HMrt 
beneficial; but they should be aided by airiii 
exercise, and the other means already sdviied fm 
improving nervous enei^(^ 71.}. The ulphM 
of iron with the extract of hop, or with the csa* 
pound galbanum, or with the coMpooad aMt 



1 



] 



\ 



290 



HYSTEBIA — TREATmKT of Irrbottlar akd Compucatbd Statu* 



resembling peritmitis ($21.)t the above treat- 
ment is more to be depended upon than any 
other. The warm epithem or embrocation should 
never be omitted. The enema just prescribed 
will seldom fail of emptying the large bowels, and 
of expelling tlie flatus which is a chief cause of 
the more painful symptoms. When the complaint 
assumes the form of hytlerical colic, the bowels 
being costive, these means arc usually eminently 
successful. They may require, however, to l^ 
repeated. If palpitations be present in these 
caser4, they depend upon, or are aggravated by, 
the Hatus which often rises up into the oeso- 
phagus, and, by distending a portion of this canal, 
embarrasses the auricles of the heart. Hence 
the benefit which results from the means which 
are most efficacious in expelling the 6atus, par- 
ticularly from those just named ; and from cal- 
cined magnesia, prescribed with antispasmodics 
and carminatives, or warm purgative tinctures. — 
For pain in the rcfrion of the tiver {§ 30.), the 
treatment here advised will be appropriate. In 
all these statesof the complaint, the bowels should 
be kept moderately open by mild or stomachic 
purgatives. 

81. «. When pain is seated behind, or just above 
the pubis ($20.), and particularly when it ex- 
tends to the sacrum, to the os coccygis, or when 
it implicates the urinary bladder, or its functions, 
irritation, or vascular turgescencc, or congestion 
of the uterus, may be inferred. Local depletions 
ought then to precede other means ; and the 
mode, amount, or repetition, of depletion, should 
depend entirely on the habit of body of the pa- 
tient, and the i»tate of the catamenia. After thosie 
have been prescribed, the bowels must be evacu- 
ated by mild or stomachic purgatives, and the 
circulation eiiualised by cooling diaphoretics and 
iinodyiies. Camphor mixture, almond emulsion, 
.solution of acetate of uminoiiia with nitrate of 

})otii.sli, spiiits of nitric .Tlhcr and tin<*ture of 
leiibune. are ^enemlly useful in these eases. ])ut 
if the pain still continue, the external means 
above advised, and the cnemata (§ 78, 79.), 
should be rc-^orted to. 

82. f. Pain in one or Itoth mamma (§ 29.) is 
sympailietio of irritation orturgescenceof the uterus 
or the ovuriii ; but it is sometimes associated with 
tenderness of one or two of the dorsal vertebra*. It 
is often removed by the trentincnt now prescribed. 
If there be sranty inenstruution, leeches may Ik; 
applied to the ninnimte ; but the tops of the thighs, 
and hypognsti'ium, are preferable situations. 1 
have found cooling diaphoretics with narcotics, 
as the solution of the uectate of nnimonia, ami 
cainplior julep, with the acetate of morphia and 
an aromatic spirit, very serviceable in this slate of 
disonler. In a co!>e of this kind, where there 
were remarkable tenderness and hardness of the 
left ntiimma, evidently depending upon uterine 
irritation and turgescence, and for which 1 was 
consulted by another practitioner, complete re- 
covery followed a short course of the solution of 
the iodide of potafisium in camphor mixture, to 
which the solution of pota*<h and henbane were 
added. If tenderness exist in any of the dorsal 
vcrtebraf', the treatment advised for this compli- 
cation (^ 85.) should also be pursued. 

83. g. In the mtrre acutelif painj'nl or neuralgic 
affections connecteil with uterine disorder, the 

effect of a plaster with the extract of belladonna 



and camphor may be tried. Bat when they u 
associated, as sometimes obBerved, with pain a 
tenderness in some portion of the spine, then tb 
other local means about to be noticed may b 
also employed. I have seen the most naika 
benefit result, in these more acute cases, fros 
half an ounce each of spirits of turpentine an 
castor oil, taken on the surface of nulk, and n 
})eated once or twice after the intervals of a du 
or two ; or from a full dose of the former msdb 
cine, followed by the enema already T*y»ntiftwi 
{§ 79.), or by any suitable purgative. Kqieaisi 
doses of turpentine, until either the kidnejs n 
aflTected, or the bowels are entirely evacmaHi 
and enemata containing a considenble qoaitiq 
of this substance, will be found the most cfia 
cious, when painful affections, connected will 
hysteria, are seated in, or extend to, the lom 
extremities. 

84. h. Pain in the regien of the Xctdiuyi, serfa 
the course of the ureters ($ 22.), is evideailf ■ 
extension of irritation from the uterus to OM 
organs by direct sympathy, — a considerable f» 
tion of the nerves of the generative and ariii^ 
organs belonging to the same ganglia. Tki 
treatment should, therefore, be chiefly dirededli 
the state of the uterine system. Local deplsMi 
will sometimes be requisite, especially if ihenM 
general or local plethora, and scanty BMSikfr 
ation. The fixed alkalies or the alkahoe Mik» 
bonates, with anodynes and the spirits of ■■§ 
ether or the compound spirits of juniper, «9, 
occaMonally be ot service, especially whea Al 
urine deposits a sediment of unc acid in thsfam 
of sand. Wlien the urine is higher coloBnd,tf 
deposits a pink or amorphous sediment, coBHlii| 
chiefly of the lithate of ammonia, the infuMi M 
decoction of cinchona with hydrochloric ted,€ 
the balsams taken in the form of pills with BSf* 
nesia, will be found beneficial. The digoM 
functions should receive due attention. A n)t»f 
facient, stimulating, or roborant plaster appliit 
on the loins, as the aromatic, cummin, pilch, • 
amrooniacum plaster, will often also adrnd MM 
relief. 

85. j. Pain in the spine (§ 23.) is nthtf I 
complication, than a form, of hysteria ; and ii Ml 
to be viewed as altogether, or always, dependm 
upon inflammatory action or irritation ; but rslhfl 
upon excited sensibility. There is no doubt thrf 
vascular excitement or congestion often exiikii 
these cases, especially where there is much M 
derness or prominence of one, two, or monof thi 
spinal processes, or pufhness around them, li 
these cases, especially, there is more or Icsi 01* 
tinued disorder of the uterine, or of the digcslii^ 
or of the respiratory functions, or evea of m 
of thcAe, according to the seat and extent of Al 
spinal afl'ection ; and occasionally the csnhri,' 
circulation becomes also deranged. To tbisiAB*- 
tion, Dahweli., Tlale, Tatf, Browk, m' 
Grikfin have directed particular attentkm,iil', 
the name of Spinal irritali*m, or, moie f^^ 
perly, irritation of the spine, and have ito^! 
mended for it local depletions and external irnuAj 
ice. Hut whoever confides in these aloa^f : 
even principally, will find himself disappoiBliiiti 
many, if not in the majority of cases, loey <M] 
however, are important parts of the treita^i 
especially if plethora, eeneral or local, or sM^ 
menstruation, exisu. In cases of this d fu i p ii ^' 



296 



JAUNDICE — Patbologt — Symftoki. 



Cachexia leterira, HoflTmano. Icterut, Boer- 
haave,Lianeus,Cullen, &c. ChoUlithia Jcterui, 
Young. Jcteroida, Fetlit Suffusio, Fellit 06- 
ttruetio, Icteritia, Auct var. Jaunisu, le- 
itre, Fr. Die Gelbsucht, Germ. Iterizia, Ci- 
trinezza, Ical. 

Classif. — 3. Clasi, Cachetic Diseases ; 
3. Order, Cutaoeous Diseases (Cm^^r). 

1. Clou, Diseases of Digestive Function ; 

2. Order, AflTcctiog the Viscera {Good), 
IV. Class, I. Obdek (Author, in Pre^ 

face), 

1. Defin. — YelUncneu of the eiiet and $kin, 
sometimes pastinf^ to a yellowitih'green hue, or even 
to a greenish brown ; the urine being of a taffron 
or deep colour, the stotUs generally paUf and the 
conrte of the bile obstructed , 

2. Iherc are few diseases, the nature and 
morbid relations of which have occasioned greater 
diversity of opinions than jaundice. By some it 
has been viewed as a symptom of derangement, or 
of organic lesion, of the biliary apparatus, more 
immc^diately dependent upon obstructed discharge, 
and upon absorption, of bile. Others have con- 
sidered it as independent of absorption of this se- 
cretion, and as the result of a morbid state of the 
capillary circulation. These, as well as other 
opinions, will be more fully noticed in the sequel ; 
and I shall then show that it cannot be considered 
merely as a symptom of the morbid states of the 
biliary apparatus, to which it lias commonly been 
attributed, although very often connected with, 
and sometimes originating in, these states. It oc- 
casionally appears in the course of bilious fevers, 
when there is no obstruction to the evacuation of 
bile. But the yellowness observed in the last 
stage of yellow and malignant fevers is not a 
syniptomatic jaundice, the change of colour de- 
pcnuin;^, in these maladies, upon the morbid state 
of the blood, and u]>on the change in the capillary 
vessels and circulation, independently of biliary 

bstruclion. 

3. Jaundice is generally sporadic ; but, accord- 
ngto Monro, Aliiiert, and others, it has assumed, 
on rare occasions, an epidemic character, particu- 
larly at the terminations of campaigns, and after, 
or during, very wet summers and autumns. It 
was thus said to have been epidemic in Cronstadt, 
in 1784 and 1785 ; and at Geneva, in 1814.— It 
is endemic in some places, particularly those in 
which, with a high range of temperature, the 
sources of malaria abound (see Endkmic and £pi- 
DKMic Inflvencka) ; but it is generally owing to 
the prevalence of biliary diseases and periodic 
fevers in these localities, that jaundice is also en- 
demic. 

4. I. Symptoms. — A, Precursory, — Jaundice 
generally approaches with languor, depression of 
spirits, slight chills or rigors, anorexia ; with un- 
easiness, tension, or weight at the prscordia ; with 
flatulence, sour eructations, sometimes nausea or 
vomiting, or other disordera of the stomach ; or 
with colicky pains, disturbed or irregular bowels, 
and headach. The stools are hard, ash-coloured, 
clayey, or whitish, indicating an absence of bile ; 
and sometimes relaxed, although the evacuations 
are pale or whitish. In rarer cases, the biliary, 
secretion is apparently more than usually profuse. 
The stools are commonly devoid of their usual 
odour, and are more or less offensive. There is 
an unpleasant taste in tlie mouth, with some thirst. 



The tongue is loaded at kflbtie. TbeikiBiidrf, 
and an itching or Hinging ii often Mt on the ns^ 
face. These aymptonu are oramlly of dbortdv- 
ation, and the afiection manifeata itaelf with Back 
celerity. 

5. B, The yeilaw timg$ generally begun in the 
eyes, and extends to the temples, brows, and (see; 
and thence to the neck, cbeit, and whole ndkee 
of the body. The colour is deepest in the wridkki 
and folds of the skin, and in the lines of the faei 
and hands. Sometimes it is distributed in deepv 
patches in one place than in another. It csa* 
mences in the superior parts of the body, appea 
latest on the inferior extremities, and depailsiitf 
from the parts where it commenced. The eolev 
varies from a light yellow or lemon-eoloiir, to i 
greenish brown ; the intermediate shades of pill 
yellow, deep yellow, and yellowish green, btif 
most common. With dryness of skin there isg^ 
nerally increased heat, particularly on the hah 
and feet. The itching and stinging are oAb 
also augmented, especially towaids the iii|l4 
and are most troublesome about the nostrils. Ii 
the more advanced stages, this symptom is dioh 
nished. The perspiration often then beconMs fiee^ 
particularly if the disease be attended by (ever; 
and in some cases so abundant as to wet Ik 
linen, and to tinge it of a deep yellow. SaflM^ 
times a desquamation of the cuticle, or a pMfr 
form eruption, follows these symptoms. 

6. The bowels are frequently costive, and the 
faeces clavey , pale, and scanty ; but in some esn 
they are loose, and have a peculiar fcetor. He 
urine is commonly high-coloured ; yellowiih lal 
limpid at the commencement, aflemrards deefmU 
fron-coloured or reddish, frothy, and thicL Sqb» 
times it is nearly black, depositing a brick-colnrBl 
sediment ; at other times a dark deposit. Alike 
disease subsides, the urine resumes its clear asd 
limpid ap))carance, unless dropsy supervene. 
The patient generally complains of a lereK, 
heavy, or lancinating headach, with a mom sf 
heat, particularly at the forehead ; and be ofbea 
falls into a state of despondency or mclancltolji 
or becomes morose. There is sometimes letbaiigy, 
and frequently watchfulness. The tongue uA 
palate are coated with a yellowish sordes, soda 
bitter taste is felt in the mouth. The appetite if 
extremely irregular ; sometimes being entirely l<K/tt 
at other times ravenous. Thirst is usually pre- 
sent. Pain, weight, or a dragging sensalioD, and 
tenderness, are often felt at the epigastrium; fre> 
quently with flatulence, acrid eructations, nimtt, 
difficult or painful digestion, and vomitiogvfa 
bitter, acrid, and sometimes dark, Huitl. In toae 
cases, acute ]iain runs in the course of thccoB- 
mon duct, and increases as it reaches the qitgif- 
trium, with more or less uneasiness in tlie regioi 
of the liver, and top of the right shoulder, or te- 
neath the right scapula, or between the shoolden- 
Violent pain is occasionally felt in the MnoA* 
with short fits of colic. The respiration ii rcidily 
accelerated, especially upon exertion ; aod tbeff 
are sometimes paroxysms of cough. The pebi 
varies exceedingly. At the commencemeot, it i* 
often hard and strong, but it is also freqaeidy 
feeble, particularly as the disease sdvaBceb 
When severe paroxysms of pain are complaioe^ 
of, the pulse generally becomes frequent, barf, 
or full ; but it is occasionally much slower tbu 
natural. Hsroorrhoids sometimes oocvr doii^ 



300 



JAUNDICE — PiniOLOGicAt Relatioks. 



various cavities are frecptently met with, and oc- 
casionally coincident lesbns in the heart, lung$, 
as well as in some one or more of the abdominal 
viscera. 

24. It should not be overlooked, that each, or 
several, of the foregoing lesions have often been 
present without jaundice, — a circumstance which 
nas led some pathologists to deny the origin of it 
in the presence of bile in the circulation ; and that 
jaundice has existed in patients, in whom no or- 
ganic lesion was detected after death,— an oc- 
currence which has led physicians, since the times 
of Hoffmann and Morgaoni, to impute the 
disease, in some cases, to spasm of the biliary 
ducts, and induced othera to view it as an occa- 
sional consequence of the accumulation in the 
blood of the materials of which bile is formed, 
owing to inaction of the liver. But there is every 
reason to suppose that undetected disease of the 
heart had existed in many of these, and had ob- 
structed the return of blood from the liver. 

25. In cases of jaundice, particularly in tho!«e 
of long standing, a yellow or greenish yellow tint, 
in different degrees, is usually observed in every 
texture and organ of the body, and in all the fluicjs 
and secretions, whether natural or morbid. The 
fat is usually of the deepest colour. The humours 
of the eye and the cornea are seldom or ever 
tinged. A case is, however, related in Horn's 
Archives (Fiir Praet. Medicin. b. vi. p. 341.), 
where they exhibited this change of colour. The 
yellow hue has rarely been detected cither in the 
cerebral structure, or in tlic medullary tissue of 
tlie nerves ; although instances have occurred to 
BARTiioi.rN, Morgaoni, and Portal, of its ap- 
pearance in the former. 

26. IV". Of the PATnoLooicAL Relations of 
Jaundice. — Jaundice is more or less intimately 
connected with one or other of the following pa- 
thological conditions: — 1. With an exuberant 
secretion of bile ; — 2. With inflammation and 
abscess of the liver ; — 3. With congestion of the 
liver and portal system ; — 4. With chronic al- 
terations of the structure of the liver ; — 5. With 
spasm, or temporary obstruction of the gall ducts ; 

— 6. With the pn-^sage or existence of gall-stones ; 

— 7. With inff animation, obliteration, or com- 
pression of the bilijiry ducts, or gall bladder; — 
8. With inflammation of the duodenum. 

27. i. Jaundice with Kxuherance pf Bile. — This 
variety was first contended for by JM. Portal, 
and afterwards by MM. Corn AC, Alidlrt, Ville- 
NKUVK, anil others. It has been referred to an 
excited state of the vital actions of the liver, par- 
ticularly to the predominance of its secreting 
function. It is sometimes met with in temperate 
climates, during summer ami autumn, especially 
tliOi>c which ajippoach nearest the tropics; but it 
occurs chiefly in warm or iuteitropical countries, 
and in those who live indolently and luxuriously 
or intempcrately, or who are of a bilious tempera- 
ment. It is generally preceded by supraorbitar 
hcadach, bitter taste in the mouth, loss of ap- 
petite, nausea, bilious vomiting, followed by a 
yellowi<ih, or greenish yellow tint of the skin. The 
chief characteristic of this form of the disease is 
the absence of constipation, and the prej<ence of 
bile in the evacuations, which are either natural, 
or more frequent than usual. I have seen it ac- 
comnaniefl with slight bilious diarrhoea, with 

/ebriie acUon, or with a full or strong pulse. It 



nay be presumed, that a portioii of the bile 
absorbed in this variety, donng its course thnni{ 
the biliary passages, or through the intestinal c 
nal, owing either to increased activity of theil 
sorbing vessels, to the state of the bile itself, or I 
partial obstructions in its course through either ( 
these parts. It is often complicated with dv 
sentery, hepatitis, and bilious fevers, particulur 
in miasmatous and intertrojucal countnes. 

28. ii. With Inflammation and Abtceu of tk 
J Aver — Hepatic Jaundice, Sauvaoes and Culld 
— Icteritia. Pyrerica, Alibert. — Jaundice roayac 
company any form of inflammation in this oi^ 
particularly when the internal structure is the «ai 
of the morbid action. Although inBammotioiisol 
the liver are so extremely frequent in India, yd 
jaundice is a comparatively rarer attendant oc 
them there, than in this country. In ContineDtal 
countries, this association of jaundice is very cmii< 
mon. The rare occurrence of jaundice, as i 
symptom of hepatitis, in India, is perhaps owing 
to tiic liberal use of calomel in the treatment 
of hepatic affections. But it is whenabscen 
forms in the liver, that we most frequently fiod 
jaundice supervene on hepatitis. In a rerjf 
large proportion of the cases of abscess of tlui 
viscus, detailed by M. Anoral (^CUmque MiS- 
cale, t. iv.), jaundice appeared;— and a rimilai 
frcfiuency of connection has occurred in my own 
practice. Out of six cases of abscess of tlte lirei 
to which I was called, in 1826 and 1827, in con- 
sultation, four had jaundice during some period 
of their progress, subsequently to the occurrence 
of the symptoms indicating the formation ol 
matter. 

29. In almost every case of jaundice from in- 
flammation or abscess of the liver, the nature d 
the disease is very readily recognised. Thesymptons 
of hepatitis are well marked, particularly the pain. 
uneasiness, and tumefaction in the right hypocbon- 
drium and epigastrium; the scanty, dark, or brownish 

urine; theory cough; the pain in the ri^lit shoulder, 
clavicle, and side of the neck, or under the right 
scapula, &c. ; and the full and frequent pulse, Ac. 
(See Liver — Injiammation of, and Ab$ceisof.) 

30. iii. Jaundice from Congestion of the Jjrff 
— Intcmjteries calida, of Sknnert — Jcttrui a 
Plethora, of F. HorrMANN. — The connection »i 
this state with jaundice has been admitted bj 
Sauvac'.fj, Grimaud, Hang, Portal, Cornac 
and IMakoury. It is generally observed inpfr- 
sons of the bilious and sangume temperaments 
who live luxuriously or intcmperately, and eithi*' 
pursue stilentary occupation, or are deprived o 
requisite exercise. It is chiefly to this ana the pr«' 
(reding pathological states, that we arc to refer tlic 
instances of jaundice, which take place from lh« 
suppression of the menses, or of accu8iome«l di* 
charges, particularly the ha?morrhoidal, and frwti 
the retrocession of gout and rheumatism. Activ< 
congestion of the portal vessels is connected wiir 
more or less plethora, and congestion, of all lh< 
vessels that convey blood into the vena ports. Iw 
bloofl circulates with difficulty through theli'f^ 
and the bile, which is formed, generally in grt* 
abundance, owing to the highly venous state p 
the blood, often is retarded and accumulated ii 
the ducts, during its course to the gall bladder o\ 
duodenum. Owing to this retardation or obstnij^ 
tion, a portion of it is absorbed, probably by ^ 
radicles of the hepatic veiiUy as toey pa» out ^ 



304 



JAUNDICE — Traumatic — IirrAMTiLE. 



comparatively rare. Mbnde lias sometimes re- 
marked it; and Ciieyne notices its infrequency. 
When it occurs during fevers, it may be imputed 
either to diminished excreting activity of the liver, 
and the rapidity of absorption of a portion of the 
secretion, or to obstruction m the way of the opening 
of the ducts into the duodenum, from a tumefied, 
congested, or inflamed state of its mucous surface. 
In some cases, both states may contribute ; whilst 
in otliers, the secretion takes place more rapidly 
than it is conveyed into the bowel, although its 
flow is in no respects impeded. The secretin]^ 
function of the or^n may also be much dimi- 
nished, — the constituents of bile being left in the 
blood. 

50. We occasionally also observe jaundice in 
connection with organic lesions of the heart, hys- 
teria, dropsy, me/at;ia, delirium tremens, apoplexy, 
palsy, and epilepsy. — When it is complicated with 
hysteria, the urine is usually very abundant and 
limpid, and tlie complication is of a much less 
serious nature, than with the other maladies just 
named, which more frcciuently terminate unfa- 
vourably, when thus associated. — When it occurs 
in consequence of interrupted circulation through 
the heart, dropsy* or hemorrhage, often also su- 
pervenes. We also not infrequently hear of it in 

^ connection with certain cachectic and malignant 
' affections of a chronic character. Several of the 
states, which are usually attributed to jaundice, in 
the last stages of these maladies, are not true jaun- 
dice, and do not proceed from the presence of bile, 
or of its constituents, in the circulation ; but from 
the absorption, and admixture with the blood, of 
a portion of the morbid matters formed in the 
seat of tlie local or malignant afTeclion, or of some 
of the morbid secretions retained in the digestive 
canal (i 54.). 

51. i). Jaundice sometimes follows the subsid- 
ence or suppression of other diseases, and is even 
removed by the reproduction of certain of them : 
it often appears after periodic fevers, and occa- 
sionally upon the sudden arrest of these fevers by 
large doses of cinchona or of sulphate of quinine, 
especially when these are exhibited before morbid 
secretions or accumulations have been evacuated. 
In such cases, tlie jaundice depends chiefly upon 
superinduced congestion or inflammation of the 
internal structure of the liver. The stoppage, 
also, of ha:morrhoidSf sometimes gives rise to jaun- 
dice, by inducinf]^ these morbid conditions of this 
oi^in ; the rc-t.>stablishment of thehsmonhoidal 
flux generally removing the con)]^tion, and fa- 
vouring resolution of the inflammatory action. A 
similar result occa»onally occurs from obstruction 
of the catamenia, and from suppression of dysen- 
tery .'diarrhoea, of gout, and of rheumadsm, es^peci- 
ally when morbid secretions, and collections in 
the digestive canal, have not been removinl. The 
relation of gout to several of the pathological 
stales which give rise to jaundice, and the con- 
version, in some instances, of the one into the 
other, have beoii remarked by several experienced 
physicians ; and a similar connection has been 
noticed between this latter and the other diseases 
just named. 

52. Vlil. TnArMATic Jaundice. — Jaundice 
sometimes occurs after concussion of the brain, and 

severe injuries of the head. The influence which 
ibe brain exercises on the functions of the Uver, baa 
been ofteaer the fiubjcct of remuk than o{ cxp\vi* 



ation. 
or 



ion. It has usually been inmited to lyiBptlhy • 
, in other words, the morbid relation has beai 
stated, and our ignoranoe of its nature admitted at 
the same time. Severe injuries, when they m- 
pend the energies of the brain, may also lowtr the 
secreting and excreting functions of the biliuy 
apparatus, by diminishing its nervous eoemr. ud 
placing it in a state whicn (^ 33.) favoun tae ib- 
sorption of bile into the circulation, independestly 
of any very obvious change in the stnicture of tW 
liver or ducts. There is, however, every resm 
to suppose that jaundice subsequent to severe i» 
juries, particularly of the head, sometimes lenhi 
from phlebitis, on^nating in the seat of injwy, m 
from the passage of purulent or other morW 
secretions thence into the circulation. In cite 
case, purulent collections will sometimes fona is 
the liver, and give rise to jaundice by preasf 
upon the hepatic ducts and veins. Severe mjarni 
in other situations than the head, — as compooad 
fractures, &c., — will sometimes also prodace the 
same results. That purulent collections fona is 
this viscus, under these circumstances, almost m 
freouently as in the lungs, is a fact fully ou- 
blished by the observation of the author, asd 
other pathologists ; and although jaundice ii ml 
a constant, yet it is a very general, attendant opiB 
them. — Injuries, wounds, 6lc^ which implinti 
any part of the biliary apparatus, occasioaillj 
producb jaundice, by tlie immediate change tky 
induce in the functions or structure of it; aod H 
is not unlikely that, in some of the instances where 
the injury seemed to have been inflicted on the 
head, the liver actually had sustained the chief 
injury, or had experienced a concussion, of whiflh 
jaundice was the consec^uence, either with, oi 
without, inflammatory action diffused throogk the 
substance of the organ. — When jaundice followi 
blows or injuries on the region or vicinity of tht 
liver, and especially if it be attended by a dull or 
aching pain, inflammation extending through the 
substance of the organ may be inferred to exist 

53. IX. Infantile Jaundicf. — Icterus Infen* 
turn — Icterus Neonatorum — Yellow Gum, — Jan- 
dice is usually slight during the infantile age. It 
is generally attended with languor, drowsiness, or j 
debility; and may be referred to the following i 
pathol(^ical states : — 1st. To the stagnant aad i 
altered blood contained in the umbilical vein, ^ 
changing the state or colour of the serum ;^^ i 
To a partial absorption, from retention of the nl^ ! 
conium ; — 3d. To saburrai accumulated in, and ^ 
absorbed partially from, the duodenum and HnaO 
intestines ; — 4th. To obstruction of the apertsR 
of the ducts from viscid meconium, and mDCOn 
sordes ; — 5th. To spasm of the excretory bifiaiy 
ducts (Beaumks) ; — 6th. To a superabundaocooif 
the biliary secretion : — and, 7th» To obstnictioB. 
or a paralysed state of the secreting structore of 
the liver. The flrst, second, and third of the 
above sources may so chanee, or deepen Ae 
colour of, the serum of the blood, independeotif 
of any absorption of bile, as to give rise to the 
yellow stale of the cutaneous surface frequeotij 
met with in infants. — Superabundance of tlN 
biliary secretion may exist in more than one le* 
spect ; — this fluid may be secreted in unossally 
large quantity, or it may have accumulated in the 
ducts and gall bladder during the period immiA- 
ale\^ axiVs^fideut to birth, or it may have flow^ 



308 



JAUNDICE — Tjieatment. 



treatment must be conducted os advised for this 
state of disease, in the article Livra. 

68. iii. Jaundice from Congestion of the Portal 
and Hepatic Veins often requires very nearly the 
same treatment, as just recommended for the 
siiglitcr states of the preceding variety ($ 66.). 
— Local bloodletting is generally sufficient ; and, 
unless in oases where the congestion depends 
upon dilatation of the cavities of the heart, the 
application of leeches to the anus is prefemble to 
cupping over the hypochondria. If the conges- 
tion is connected with a stoppage of the hemor- 
rhoidal flux, leeches are especially serviceable. 
AVhen congestion is chiefly in tlie hepatic veins, 
the circulation through the heart and lungs is 
often interrupted, and the congestion soon extends 
to the portal system, to the mesenteric veins, and 
the digestive mucous surface ; the early stage of 
jaundice being characterised by a bloated ap- 
pearance of tlie face, sometimes with lividity of 
the lips, and a deficiency, merely, of the bile in 
the stools. In these cases, the trea'ment should 
be chiefly directed to the primary complaint, and 
be modified according to the evidence furnished 
of the cause of obstruction. (See Heart — 
Organic T.esions of.) — When ha. morrhage (rom 
the digestive or nspiratnry mucous surface occurs 
in thib variety, as sometimes observed, cupjung 
from the sternum, or leeches applied to the anus, 
will be of service. In many cases of this kind, 
the liver is more or less enlarged, owing to the 
prolonged congestion ; and, altliough there can 
be but little expectation of a permanent restor- 
ation of this organ to its functions, whilst the 
obstruction to the circulation continues, deobstru- 
cnt and saline purgatives will generally be useful, 
csj)ecia11y mercurials, the bitartrate of potash 
with the sub -borate of soda and confection of 
senna, the preparations of taraxacum with soda, 
and the hot lurj)cntine cpitheiii placed on the abdo- 
men, &c. — Dropsicnl effxmnn Fometinirs lakes 
j>Iace in the advanced course of this form of 
jHunrlice, and rcnuircs diuretics, in addition to 
the decitled exhibition of the ine<licines just 
named. I'lie internnl and extornnl use of the 
spirits of turpentine ; the compound decoction of 
broom with llio ac«>tate of potash, or with carbon- 
ate of soda, and spirits of nitric aether; weak 
solutions of the hydrio<late of pota-^h, or tiie solu- 
tion of potash ; occasionally the more drastic or 
bydrogogue purgatives ; and a course of deob- 
struent niincnU tenters, such as those of the 
Beulah .Sua, of ('heltenliam, Pullua, Seidschutz, 
&c. ; will sometimes be of service. 

69. iv. Jaundice j'rtnn Chronic Organic Le- 
sions of the Liter requires a treatment modified 
according to the history of the case, and the signs 
furnished by a careful examination of the hv|)o- 
chondria, and even of the lower n?j:ions of^the 
thorax. If the patient have had attacks of acute 
or subacute hepatitis or dys<»ntery, or is subject 
to chronic <lysentery or diarrha'a, very probably 
the circulation through the extreme branches of 
the portal vein, and the passage of bile along the 
small ducts, arc obstructed by a deposit of albu- 
minous lymph from the inflamed v(^ssels in the 
nreolie or reticulations of the connecting cellular 
tissue of the organ, and by the jiressure on the^m 
vessels thereby occasioned. In ca<(;s of this kind, 
more or lew enlargement of the liver may be de- 
tectcd, especially in those which arc less chronic ; 



although, in the more protnu:ted, the liver miy 
have regained its former siie, or have become em 
smaller, its structure being dense, graoulaied, or 
otherwise changed. In these latter, the nutritioo 
of tlie organ, as well as its functions/, is impairad; 
and the deposits fomied in the substance of tiic 
organ become organised, or partially identified 
with it, and perpetuate the obstruction. In tUi 
variety, particularly in the less prolonged insunca 
of it, the exciting eautet of the hepatic disonkr 
should be avoidwl. — Diet and reginun will tot 
much assist the treatment. Stimulating food ssd . 
drink should be relinquished, and deohMtrutMiM ud j 
alteratives adopted. If any remains of infianuM- I 
tory action still exist, leechet should be applied H - 
the anus, or to the epigastrium. In any cJRsa* ^ 
stances, Plummeb's pi// should betaken regolulf * 
at bedtime, either alone, or with a little foo^SM *' 
extract of taraxacum (F. 503. 51 1 .),and the Mn^ 
trate rf potash, with the sub4tarate of toda^ in UJ > 
vehicle, or with other medicines, according to lb 
stat« of the bowels (F. 89. 96. 98.). 

70. I f evacuations of bUnd from the bovdi 
occur, the hydrargyrum cum cretd with ipeetn^ 
unha, enemata containing spirit of turpentiMtm' 
an occasional draught with this substance Hi 
castor oil, or the nitric or nitro-muriatie adds k* 
the simple infusion of roses, will be useful. la 
all cases, frequent^ ric/innf over the hypochoadni 
and epigastrium with an oleaginous and deobrtn* 
ent liniment (F. 297. 3 11.), or with thi8CoojfliiMi| 
with the mercurial Hniment, will be of tsioMi 
benefit. This variety, like the preceding, itv^j 
apt to become complicated with anaum m 
ascites^ or with both. In this case, the diciMj 
use of mercurials, the more drastic and hydrogsfll] 
jmrgativeSf the bitartrate of potash in Isige dNi 
with borax, diuretics, and the other mean^noMll 
above, ami advised for Dropsy, proceeding Am 
dibcase of the liver, will be requisite. Afli^, 
ous frictions of .the hypochondria and ibd^i 
men with liniments, particularly with the<«jidl 
mentioned, or with those containing tlie iodii^J 
potassiuuif and a course of deobstnient and pilf'i 
ative mineral waters ($68.), will sometioMihc 
of use. 

71. V. The more doubtful Si-urce of JaundiaM 
iipasm of the Ducts requires means which hiiel; 
stricter reference to the remote causes, andtsAij 
symptoms peculiar to the case, than to the 
ence of spasm. A large proportion of the 
usually attributed to this state, most 
would have been found, upon a more accMtf ; 
investigation, to belong either to coiigestiooofdij 
hepatic veins ; or to calculi lodged in the dodil 
or to obstruction of the mouth of the cobb* 
duct, arising from the states of the duodenum ; fli 
they consequently would have required a aaiv. 
treatment to th('se. The aflfection attributed tiAf;j 
ducts may have been almost entirely contiDcd 19 lb i 
duodenum ; the means found of service, as fldi^j 
alone, or with opifim, saline or other pm^iMl 
nntnlynes, emetics, &c., instead of acting npoalb 
former, actually removing the disorder of ^\ 
latter, or carrying ofl' mucous sordcs from illi 
face, or subduing vascular turgescence from ifV 
the o|>ening of the common duct. — When ibBi i 
any reason to suppose that the reputed ip''**] 
the ducts is actually a paralysed state flfwj 
oiganic nervous influence of the liver and dod^j 
restorative means will then be requiifd. "•] 



310 



JAUNDICE — Remedies recommended dt Autbobb. 



head, as being soroeUmes useful. A diaphoretic, 
as well as a deobstruent, effect is also produced by 
a combination of calomel with antiinoniuls and 
opium, or of calomel, CHmplior, and ouium ; and 
is often of great benefit in tue more imflaromatory 
varieties, after general or local depictions. 

79. C. Dcohitruentt and alttrutiies of various 
kinds arc much in^ted on by Lentin, Sn)i.i., 
and most modern writers. Several of these, 
suitable to the more chroric cases of jaundice, are 
prci^cribcd i.i the Appendix (F. 503. et seq.). — 
a. The deobstruent eth'Cts of mercurtf in this com- 
plaint arc much confided in by Disault, Tiio- 
MANV, and must recent writers; but there is lilOe 
agreement between them, as to the preparation 
which should hv. preferred, or as to the extent to 
which it kIiouUI be pushetJ. Gibbon and others 
prefer culomcif and give it until it produces sali- 
vation. In the more chronic cases especially, 1 
prefer PLUxiMkii's pill with «*up and Utraxucnm, 
occasionally aided by mercurial linimentSf or plat- 
ters, applied to tiie hypochondria. — h. Simple or 
medicated sintps are much piaiscd by some au- 
thors, and particularly by JJoyll, Stoeiu-k, Ra- 
Noic and (juakin. They are often very useful, 
either alone, or with taraxacum, mild mercunals, 
oxgall, asHafuL'tida, or with ammoniacum, or even 
with narcotics. The alkaline subcarbonates, and 
solution of potash, are also serviceable in similar 
combiuatiuns, and, as well as the soaps, are safe 
medicines in all >iates of the disease. — c, Taraxa- 
cum, in decoction or extract, has been much used 
in jaundice, since it was praised by Ranoic and 
QuAiiiN ; but it should be given in large doses, 
or be aided by other luediciues, as the alkalies, 
soap, neutral salts, &c. I have given it with 
small do»es uf ru/c/iicum, and in other combinations. 
(F. 7G, 77. 392.)— t/. The HoUmum dulcamara 
was recommended by hiNNAUS for jaundice, but 
it is rarely prescribed, although much used s an 
alterative in cutaneous eruptions depending upon, 
or connected with, biliaiy d!>order. It may be 
advaulageuu.-ly given in decoctiuu with tanixiicum 
and the alkaline .<^ubc4irboiiati>s, or with the other 
alteratives all eady noticed (F. 51).), Pli.mmi;u's 
pill being taken at night. — e, 1 am not aware that 
the prepuratiuiis of coUliicum have been reconi- 
memled for ttiis complaint by w/ncrs. I have, 
however, pi escribed it in several csises with 
marked beinJii, chietly iu conjunction with mild 
mercurials, or with &oap, alkalies, iS.c., or with 



ma^iK.'siu 



or neutral ^•alt^ 



according 



to circuin- 



st •uu'e<«. It should be given in small do-H.'?, be 
cuulinued lor a ciiu.-idi.rahle time, and carefully 
watched. 11" there be much deblity, or il it pio- 
tluce depiesMion, it situuld be given witii cainplu»r, 
or the nioie tonic sub.-tancc!» rccojumended for liie 
complaint, it olien mcieases the biliary sic.etion 
in th'.' cas<:s d:'[H'ndin- upon chronic inilami.iatory 
action, or enlarjri.menl oi the liver; ami pro!i;ute.s 
re olution of llie l«>im(r, and jliminution of the 
latter, morbid slate. — J. 1 have also given the 
preparations of .a »>///»« r<//n with advantage, in 
eunj auction with tliu liquor pota-^^T. 

I'.l). f. The internal u-e of nitric ttrid was ad- 
yUcil by FuANK. It is likely to be useiul in .-onic 
of the luon.'. chronic states. 'J'hc nitro muriatic 
acid was praised by Scon, A^N^^Ll:v, and others. 
J have founi\ it ilecidedly beneficial in stmne cases ; 
hut htvi', coiitTdry io tlie usual moilc, prcscrlWd i 
// inlurually u» ivtii ai> cAlcnially. It may V>v:\\»^' Wv.ulv \j\>v\v\\.'AM'\,ammou\Hcuii4 anjauuiitiu** 



employed as a warm foot-bath, or as a lotion, ap- 
pli«l warm or tepid, over the hypochondria and 
epigastrium. It is most serviceable in torpid states 
of the liver, and in the more chronic cases. It 
should not be employed when inBammatory actioB 
is present. •— ^. The chioraU of potash, or the cA(s» 
rinated soda, will be sometimes useful in the cir- 
cumstances or conditions of the disease in which 
these acids are indicated. The chlorate of putadi 
may be advantageously conjoined with the ear- 
bonate of soda, or with other substances. —A. The 
preparations of iotline are sometimes aL<oof Mrrioe, 
10 similar states of jaundice to those just allviU 
to, especially the hydriodate and tlie iodides ef 
mercurit. 'these may be given with amium or 
other narcotics, particularly where there b resMa 
to infer the existence of chronic obstruction, or 
malignant disease of the liver, or of adjoiiiia^ 
parts. — I. The liquor potass^ is also indicated ia 
such cases, and in similar combinatioDs. 

81. D. Diuretic deobstruents arc sometimes n^ 
scribed, but chiefly as adjuncts to aperients. Tb^ 
are noticed by IIiitocrates and Riedli!ii. Thi 
acetate of potash (F. 841.) is the mostuiefnlof 
this class; but the bitartrate is equal to itois 
diuretic, and even superior to it as a deobstnial 
in diseases of tlte liver, when given in large doM* 
so as to act upon the boweN, or when combiKd 
with the suh-ftoratt of uxla (F. 790.). Seven! of 
the foregoing medicines will be aided in thdr 
operation by emollient and mucilaginous dilieoUb 
as directed by Gilibert and others. 

82. E. Frictitms of the hypochondria tad 
up}>or regions of the abdomen with stunabtiag 
and deabitrueut liniments have received much IcM 
attention than they deser\'e. Indeed, theyhift 
hardly been noticed. When acute inflamnstoiy 
action is not present, they will be fouud of nuck 
service. Several of those contained in tlie Afptn- 
dix ( F. 297. 311., 6ni.) may be prescribed eiibcr 
alone, or with totlide of potassium, or the miwuriii 
liniment. Subse()uently the ammoniacal and mt* 
cuiial plaster may be kept applied to the side. 

83. F. Anmlune nntispusmt^iies and Harcctie* 
arc directed by Voglkr, Riciiter, HiriuyD* 
\'oori., J^iiANDis, and Conradi, chicHy on the 
supi>osition of jaundice being often a consequence 
ofspa<m; and ipecacuanha with opium is gcnC' 
rally adopted by them. As thi^ compla'uit often 
gnulually dis«pj)eur3 upon the ccssition or re- 
moval of the lemotc cause which occasioDcd itt 
much of the benefit, that seems to follow thcK 
sul><tances, probably de]x^nds upon this circtiin- 
stance. When the disonier proceeds from the 
ri.t( ntion of a calculus in the ducts, they arc pro- 
bably u-eful in relaxing the parts, and theftby 
facilitating the excretion of it. — (Jpiate* in full 
iloies are pre»cril)cd by Wi.xi)*i,stait, Vociis, 
TnoMANN, Dr. Chavk, &c. ; and belludoana, hy 
(iiiFniNG. In the states just named, and when 
severe i)ain is present, the advantiiges derived froR* 
tlicin aie un(|ue:>tioiiable, whether exhibited alonft 
or with calomel, or with alkaline subcarboQSte«» 
or with caniplior and cmollienbi. 

84. (i. C)( stimulating anti>pu»modia, the ip*' 
rit of t u rpcntine is the most deserving of notice. 1* 
isiecommemled by n(iLST,()niFU,and Dcrani*'' 
I have prescribed it with benefit in several va- 
rieties of the complaint, and in various mode*, ^ 
Alie-.vdv stated (^ 10.). — AiMfrtida is mcntioncA 



313 



ICHTHYOSIS — DrscniPTioK. 



the two first montlis, tbe cuticle becomes, ptrtici- 
larly in places, rough, thick, and of a greyidbor 
sallow hue. It may remain in this state for yein, 
or cveu during life, without proceediogfiirtiier; 
but the alteration ma^* increa&e until it is vtrj re- 
markable. — Ichthyosis sometimes does not ippesr 
until several months after birth. It is tbenoftn 
developed more rapidly, until the epidermii ia di- 
vided mto small irregular compartments, raeo- 
" i V. i ,..:«_.». J III , ,^^. , blinffthiit covering the legs of fowb, or the «cil« 
!!^f-r*«;Si.V„'L^.'-^s^a'?^i.lHl^^ I of ««riK.nt.. the ••icA.A,..« nacrif «rp.«.i»-.f 

sometimes linuted it 
the eitremtties. 
ou^ChTrurg. ifcv No. 47. v-XAi.'— Hrifihu in fJuy'i Ho*- Jt is then still more remarkabfy developed. and M- 
?iiiSSro7^i;«rfi^r aL J-fam^^^^^^^^ »"■>>«* Um appearance of a thick epMcnnic lay.,,- 

tical 'I'raaUM} nn the ManaKcment'and niirf^astn* uf C'tiil- of the bark of certain trees. In tucse cases, aim 
dren 
to 

AN 



Morbis, lib. vi. Do Uctenltonibui, par* HI. p. ?IH1.— 
.?. F. JL htahltndorff* l^e Iclera Uerol. 12ma IHIH — 
nil^nmir. Diet dcs .Sc. MM. t. xxiii. p. -"^Sd ; ct (iar- 
iifm, ill Ibid. L xxvlii. \\ 4<W. Pari., 181H.— 2'. Miih, 
An Inquiry lutotbe EHbcti produced in the Brain, Luni^M, 
and other VlkcerM, and on the Nervous Syitcm, by Di«. 
caies of the Liver. Loud. Svo. 1819. — C/t(*yNr, in Dub. 
Honi. llcp. vol. i. p. 273.-- Mar»k, in Ibid. vol. ili. i>. 2fi5. 
— Ffrrwjr, Diet, de Mcid. t xii. Pari*, W2X—n'eMfmeiffr, 
in Journ. dct Progr^ dei Sc. Med. t. v. p. 2/;7. — I^'uret, 
in Ibid. t. viiL p. iir>6. — O. limrnett, in Mcilical (Ja- 
lette, vol. v. \\ fiJl. — Cor/iin, in Journ. Couiplemenc t. 
xxxvii. p. 2U9. — Kochr, Diet, do Med. Prat. t. x. Paris 




ren, p. ifli. (^h? ai«o the Jiiiiiopraphif ami Rv/cuhcs ^Jj^ forc'oinjr. the epidermis is composed of a nu»- 

» the articles C0XrRKTION», — lJl LI AH-k ; (i %LL BlaDUER , ^f " ..n nnmMarlmonta nf irrocrular «liaM. 

xdDuctoj audLivEE-fflMo^tvy^r/.) ^^. ?' «">all compartments o! irregular sbapei, 

which are not imbricated , arc from two to thiM 



ICHTHYOSIS.— Syn. Perived from i^Swc 
pen. we?, a fish. Albarm nigra^ Aviocnna. 
Impetigo ei cortical Ira ; Lepra JchthijoAis, Sau- 
vages. Ichthyosis, Willan. LepidiMs Ichthtj- 
f»ii. Young, f.epidivis Ichihiiosis, GoojI, /rft- 
thyostt Fr. Fiichschuppeiwussatz, (ierin. /c- 
(ioiit, Ital. n^h Skin, Fish Skin Diteuse. 
Classif. — G. Class, Diseases of the Excer- 
ncnt Function ; 3. OrJer, Affecting' the 
Kxternal Surface (GiW). 2. OrWifr, Scaly 
Diseases ; 4. Genus ( Willmi'), IV. Ci-ts.-!, 
IV. OiiDFii (Author). 
1. Df.fi N. — i\]orhitl enUtrgement of tht* papilla' 
of the skin, and thickening of the lumcUa- of the 
epidermis, either in parts, or over the general sur- 
face, presenting irregular comjHirtments, and resem- 
bling in manu cases the scales of Jish, 



lines in diameter, but are often broad in propoitm 
ni they are Uiin. The morbid surface is genenlly 
^reyi.sh or sallow ; sometimes of a brownish hse ; 
but, in a few cu^es, it is shining or opalescent. It 
is so roujrh, that it feels like shagreen, or like tbs 
surfacoof a file, when the hand is pu<«edover it,— 
** Ichthifose nacrce cyprine" of Alibeht. — Is 
these states of the complaint, the epidermis is chidif 
altered ; and the scaler, excepting the largest, whieo 
ailhcre strongly, may be removed without cau4og 
much uneasioes:!. But, however detached, thcj 
arc soon reproduced. 

G. ii. J'tipi/Ztiri/ /c/»tfc_VMW, or that in which there 
is chiefly a remarkahle elongation of' the p«tpUUtS 
the skin, is a very rare variety. The firet ca.<c of 
this kind, wiiich was minutely descril»ed. was tbt 
of ii native of Sufifolk, who exhibitefl himself, ia 



2. Ichthtiosisis defined by \Vim..\n and Rati:- 1710, under the name of the /Jorcii/iiwenKiii. More 
MAN, to Ikj a papillary, indurated, and liorny con- | recently a family of the name of Lamiu.kt, affwted 
dition of the skin, to a greater or le<s extent. It ■ with this vdriely, weredescrilied by GiofinovSr. 
has been placed by them amoiit,' srjuainous diseases, ; Hii.T.Ainr., and others. About IBUO, 1 examined 
but more rt^cent writers h.ue ju-^tiy contended ! u very remarkable case, which was sseeii by many 
that it doc'S not belong to this order. It consi.«;U of of the medical men of the metropolis. In all lliwe 
a morbid enlar<;cinent and eloni'ation of the pa- 



pilla^ and a thickening of the epidermic. Horny 
peduncles are thus formed, wliieli >pread so an to 
a<'quirc broad irn'.jjuhir top.-*, an«l, underjroing par- 



instauce.^, the complaint was confined to the malrt 
of a family. The brothers Lam iii: in coul;! tiirt 
it baek throu;(h five gi-neiations, all of uhicii were 
attected with it. The alterati«m of the hkin api)eaT5 



tial exfoliation, sometimes resemble the scales of a ' to have been the same in all the c;ises, and nu-|Hi* 
fish. cal with that whi<!h I examineil. The /wf'/i'i* 

3. Thisaflreclioni.'.!::('«rrn/or/i)(M/,and//«'r^///Vrtr«/ were iimarkably hypcrlrophied and clon.jr:ueJi 
or accidental. When it is licredilary, it either is j over nearly the whole of the cutaneous surf*rti 
congenital, or it does not a[)pear until M)me months | exeeptinj; the prepuce. axilla\ groins, eycliils.-*oles 
after birth, i he local form is most frequently of the feet, ami palms of the hands. Ovf r ilif nf»t 
accidental, the more general affection is commonly ' of the body, the elongated napiihe pre^entnl il* 
congenital or hereditary. The states of the com- | form of short spines closely presse<l tci^fllief' 
plaint have been differently dividrd, and even de- i They were whilis,h or greyish when separalui, l>Bt 
scribwl, by writers. The divi-^ion and description blackish or brown on their exposed surface : awl 
of Dr. A. T. Tnu.MSos, are altO|:»ether incorrect, ! so hanl and elastic, that they produced a ncB« 
inasmuch as he confounds, as .M. Haakh has i when the hand was passed quickly over them, 
shown, n dix-ase of the cutaneous follicles with i These productions have genendly exuded a red* 
this affection, and n»ixes up a di.s<Tiption of both, [ dish brown serum, when divided cltm; to ibcff 
under the denomination of Fortuitous Irhthuofi^. 

4. I. Desciiii'TImn. — i. Ileriditarij Ichthuo:iis 



is commonly <:cuerai, affectinjj thoM« places chicfiy 
in which the skin is naturally thick and thee|)ider 



Tbef 



bases, and have soon been reproduced, 
could not be removed without pain. 

7. iii. Accidental and I Atca I Ichthuofis iS^^^ 
«li<'tinct form of the dis«'ase from the foregoing, aw 



mis rouijli, and being entirely wanting on ihp])re- ' i^ generally produced by pressure. It sonntimrt 
puce, eyelids, groins, axdhe, and on the palms of: occurs on the lower and anteiiorpart-* of the tliiiil** 
the hands and solos of tiic ft^t. NVhen the dis- of shoemakers ; and in ot I ler parts, where prt^mw 
ease is congenital, it is usually but little apj>aicnt ; is made, in various employments. It thus resen- 
but the skin, ini»tead of l>eing soft and smooth, is i bles corns in its mode of production. 
saUow, dry, and shngrcen-like. In the course of | 8. In the several forms of ichthyosis, the morW 



316 



IMPETIGINOUS AFFECTIONS — DjacHiPTiost. 



neck, face, shoulders, and extenial ears. This 
variety is most prevalent in autumn, continuing 
obstin-dtely throughout the wiuter, and disappear- 
ing only at the approach of summer. It has a 
greater tendency to pas.« into the chronic state 
than the last variety. Although it may develop 
itself on any part of the body, yet it affects more 
particularly the extremities, manifesting an espe- 
cial predilection for the legs, and in that situation 
becoming extremely troublesome and obstinate. 
Sometimes it confim^s itself to one spot alone; 
at others, it covers a whole limb, or even more 
tlian one at the same time. 

8. The pustules in impetigo spar$a are de- 
veloped in the same manner as in impetigo figu^ 
rata ; but here, instead of being collected together, 
they are scattered irregularly over the diseased 
surface, and accompanied with insupportable 
itching. The incrustations also, which follow 
the bursting of the pustules, are thicker and more 
friable, and not formed into so large plates as in 
impetigo ^figurata : the attendant inflammation is, 
however, more extensive ; and as they fall off and 
disappear, the surface of the limb becomes studded 
with ulcerations and fissures. (Edema is not an 
infrequent attendant or consequence of this va- 
riety of the di^^ase. 

9. In some cases, and estiecially in persons of 
advanced age, with enfeebled constitutions, the 
crusts attain a great thickness: they are of a 
yellowish brown colour, variously divided by deep 
fissures. They have been compared to the bark 
of a tree by Wii.lan, who calls this variety /m- 
petigo xcabida. It is, however, nothing more than 
a severer form of the Inst variety. Sometimes 
these crusts cover a whole limb, till it is cased 
with them, the motion of it becoming both diffi- 
cult and painful ; at the same time considerable 
heat and a tormenting itching exist. After a 
while, these crusts split ; and, when a portion of 
tliem is detached, a copious di<:ehar^c exudes 
from the excoriated surlace, quickly concretts, 
and fills up the vacuity. When this variety affects 
the lower oxtrennlie!<, and is vcrv severe, it some- 
times occasions (vdeniiituus infiltration and ulcer* 
ation, and even extends to the toes and secioting 
matrices of the nails — Onychia Impetigimnles, 
The cedcma and ulceration commonly appear 
about the ankles, particularly in aged, weakly, or 
broken-down constitutions. The ulcers are un- 
even ; and either discharge a sero-purulent fluid, 
or lire covered by yellowish crusts ; their edges 
being irregular, purplibh, or livid, and often 
crowned with !»mall sjin|»uineolent pu.<«tules. W hen 
this variety occurs in the upper extremities, it does 
nut differ from that already described, hut it is 
much less severe, and its chronic form more 
rarely associated with aideraa and ulceration, 
than that observed in the lower extremities. 
Acute impetigo hpnrsn of the face usually presents 
greenish yellow incrustations, disper^^ed over the 
checks or adhering to the beard in the adult. In 
children, the inflammation often extends to the 
no^^e, which swells, and is sometimes plugged up ; 
the disease then frequently becoming chronic. 

10. C Impetigo Favosa . — This variety is merely 
impetigo spnrsa affecting the necky eurs^ and hniry 
tcalp — the V or ri go favosa of VVii.i.an, and Tinea 

granulata of Alimkkt — especially of children, 

aoJ occ^aionvMy of adults. It occurs most ftc- 

quently ia the back parts of the head, but l\ie 



\ 



entire scalp may be implicated; and it ■ppeai 
as yellowish white pnatules, iiTegalBrly aeaitem 
over the hairy scalp, and attended by ioflam 
mation and pruritus, their centres being traversed 
by hairs. In from two to four days, the pustuJei 
pour out a fluid, which agglutinates the hair, sod 
dries into small brownish or greyish, rough, and 
irregular crusts or masses like candied sngv. 
These become friable and detached from the 
surface, but adhere to the hair, which ohtn seein 
filled with them ; a faint, sickly, or unpleasant 
smell being exhaled from the head, when cleanli- 
ness is neglected. Pediculi multiply rapidly, and 
swarm in the hair, which is not lost, but is oftea 
agglutinated or matted by the discharge. — Impetigo 
of the hairy scalp is not contagious, and does art 
implicate the piliferous bulbs, like ^mi or tm 
porrigp, 1 1 seldom 1 asts longer than some montls ; 
and it commonly is removed in the course of a 
few weeks, with proper treatment. When it be- 
comes chronic, the inflammation often extendi to 
the cellular tissue underneath, giving rise to small 
circumscribed a1>sces8e8. The lymphatic glaub 
of the neck are frequently enlarged and paiDfolw 
Raver and Grken consider that this aflectioi 
of the scalp is strictly a form of Impetiga ipam, 
and not a variety of the disease, to which Willjhi 
has applied the term Porrigo; and I am of tko 
same opinion. 

1 1. ii. Complicated Impetigo, — A. Impetigo Te- 
tematosa. — Impetigo is sometimes associated irith 
Eczema — Enema Impetiginodet. (Seeart.EczEHi, 
$ 5.) The eruption so fre([uent in infants dariaf 
suckling and teething, commonly called Crnji^ 
Isuciea, or Milk Scall, is evidently an associatioa 
of this kind, chiefly affecting the face, and extend- 
ing partially to the scalp ; the characters of ecieoa 
predominating in some infants, and those of im- 
petigo in others. Occasionally it assumes nesrly 
the (ippearance of impetigo figuraia. It ha.s Ixta 
variously arranged by writers on disea<e5 of tbe 
skin, who have, even to the present day, beea 
more desirous to point out, and even to feizn, 
distinctions, than to trace the changes wliieb 
these diseases undergo, and the connections trbirk 
subsist between them, or to show how fTeqoeDlIy 
the one runs into the other ; and has been terara 
Impetigo ^irivi/ii, !mf)etigo mitrcM, Tinea la(t» 
(Sai'vaces), Tinea henignot Tinea mueijiua (An* 
ntitr), Porrigo tactea, Porrigo /arra/i* (WiluS 
Ba'ikman), Lactumertt Eczema tactea^ ^c, "f" 
cording as it was supposed to be allied to Impetigft 
Porrigo^ or Eczema, This of itsi*lf is sufficient li 
show the very intimate relation of tlicse affection 
to each other, and to point out the neccssitrof 
considering them in their natural conditions, uA 
in connection with their particular seats, and «itk 
the states of vital action ; and not merely witk 
reference to certain artificial distinctions, which 
oi\en cannot be ascertained, and which sometino 
do not exist. The differences between rrticfei*" 
pustules, so much insisted on in the dassificitiooi 
usually adopted at the present time, often do oot 
exist, or exist not in such a manner as to hecm^ 
available to the practitioner. These, and nase- 
rous others, so implicitly received as mniterJ ■ 
belief, may be useful, as a part of the craft of the 
adept ; but they are of very minor importance ■ 
the estimation of the truly philosophic observer, 
and are valued by him for iust as much m th^ 
ma^ \>^ ^ov^Xi, \u ^^2ift \«:^Mular cases in ^m 



318 



IMPETIGINOUS AFFECTIONS — PnooNOsxs — Caoses— THEATaiE>*. 



most superficial observation will detect the veiy 
iTiar'iicd diifereace betweea acnelrosaeea and this 
coiuplnlnt. Mr. Dendy states that the internal 
use of the dcuto-ioduret of mercury often produrcs 
vesicles, followed by yellow or yellowish green 
scaly crusts, which may be easily miiitaken for 
those of impetigo and porrigo. 

15. III. PiioGNO&is. — This is more favourable 
iu impetigo than in lichen, lepra, psiyriasi$, eczema, 
and many other cutaneous eruptions. In what- 
ever part of the body the disease, in its acute state, 
be situated, it generally yields to medicine in two 
or three weeks. Its durati(m in the chrmiic ft»'m 
cannot be stated with precision ; as tlii*> necessarily 
depends on the constitution of thi* individual, the 
number of the eruptions, and the existence of 
other particular conditions, such as scrofula, 
pregnancy, amenorrlura, the change of life, &c. 
When chronic impetigo occurs on the head, on 
the upper lip, or any other region cover&l with 
Imir, It often proves a verj' obstinate and trouble- 
some disorder ; especiull v if the patient be of ad- 
vanced age, of a scrofulous diathesis, or a shat- 
terird constitution. Hut, under no circumstances, 
ran it be regarrlcd as attendctl by danger. 'J he 
puddun suppression of the more severe forms of 
the eruption, particularly those nflectiug the face 
and scalp of children, may, however, be produc- 
tive of most serious disease. 

16.1V'. Cavsks. — Impetigo is not communi- 
rated hy infection. It is most frequently obstrrved 
among the poor, ilModge<l, badly fed, and filthily 
disposed classes. Its exciting causes are, however, 
sometimes obscure. Individuals of a sanguineous 
or sanguinco-melancholic or lymphatic tem])era- 
ment, and scrofulous constitution, with a thin, 
soft skin, are most liable to it. In them it is 
occasionally excittjd by violent exercise, bv in- 
temperance of any kind, or by the depressing 
]>assi(m3 of the mind, as grief, disappointment, 
fear, &c. It is very often ureceiled by headarh, 
liinrjuor, and disorder of the alimentary eunal, 
imd cannot he traced to any other exciting cause 
than this disonler. — Infants at the brea<l, and 
children during teething, particularly the lym]»h- 
atie and vcrofulou^, are most liable to the vane- 
tie>J affecting the face and s<mlp. Voun.: persons 
vkilh fine skins arc sometimes attacked with that of 
the face, on exposure to a hot sun. Female*!, on 
the n])pj>earanee, and on the cessation, of the 
c itamenia, are nUo apt to be affected with this 
c Mnplaint. Several external causes niiiv, how- 
c.cr, excite ]>u>tules of impetigo, by acting di- 
fictly on the skin. Persons who handle irrilatinir 



17. V. Treatme.vt. — L Whatever be the vi- 
rict^ of simple impetigo, one mode ortreatmeBt ii 
indicated. In the commencement of the diieiie, 
W I I.I. AN and Dateman recommend the internal 
administration of sulphur, but not in lufficteot 
quantity to produce purging ; and if there is mnrli 
inflammatory irritation of the cuticle, tcda, nitre, 
or the bitartiate of ptttash, with which Mme of tlM 
wgelable ac'uU, as citric arid, or lime juice, mtj 
Im advantageously combined. The indiscrimimte 
employment of sulphur has, however, sometinci 
aggravated the symptoms, and favoured there^})- 
pearaiice of the eruption. I have prescribed, 
with marke<l licnefit. the sub-horate rf $oda n 
emollient vehicles, either with or without ismall 
doses of nitre, or of the bitartrate of potash.— 
Dlmul let lings, either general or local, hove tint 
propased in extensive attacks of impetigo figura^, 
and in plethoric individuals may be of iidvantRjie; 
but, in general, they are not productive of benefit, 
and in persons of a weak and scrofulous halitof 
body art: detrir.;enta1. If the eruption is atteiuM 
by much fever, calomel and antimoniali, or other 
mild mercurials, cooling taline tnhttioiis, and (fis- 
p/iort'/irx with diuretics, will be of service. 

18. Locally, emollient fomentations, sack v 
the decoction of mallows, digitalis, poppy headi, 
&c., and ablution with tepid water, are of the 
most essential service in the incipient stage of tlii 
disea«e, especially of the common saline mixtnre, 
with coitium, be given at the same time. At a 
later period, saturnine or alkaline lotions, and the 
application of the ointment of the acetate tf kid 
or niide of zinc, will accelerate the cure, and will 
be often sufhcient to effect it. 

19. ii. When this aflfcction occurs in childrrn it 
the period of dentition, simple cleanliness is fr^ 
quently all that is required. Here the eruption il 
occasionally accompr\nicd by a nsa^ife^t improTf* 
ment in tlie constitution, and it would be iiicfiY 
imprudent, and even injurious, to check or reif 1 it. 
If it occurs on the hairy scalp or face (^ 10.). 
the hair mu^t be removed, and emollient aupli- 
cations resulted to. Where there is much lc*>l 
inflnminnlion, or in plethoric children, IttAn 
ought to be applied behin<l the ears. 6'tf//* 
purtrntiics^ as the sulphate of soda, Mdpliate of 
magnesia, or tartrate of potash and sodn, iqot be 
given with advantage in these cases, in (lo<rt *f 
from two dnichms to half nn ounce daily. — IftI* 
disease, when ver occurring, jroves olistlnjte, it 
has been usually treated by an nltcratiic Ber* 
curial course, particularly Pthmmers pill, or ibe 
hutlrftrjiuntm cum creta, with the decoction rf 



p'd)>tances, as riw sugar, lime, or metallic «lust, *./r>/i/»«iri7/fi or cinchona ; but a more benifdii 
often have impetiginous eruptions on the hands, eflect ha«* been di-rived from the exhibition of fiw 
11a 1 1 MAX reuards the pustules, caused by the or six grains of oi/nwif/ at b<-dlimc. followed by • 
ointment of tai1aii<ed antimony, as a species of hri<i\i cnthartic the next morning, and a raodort 
this disease ; but they are of an entirely different I d<^se of the liijuar arsenicalis, taken three limcs« 
chamcter, and cannot be elasst-d innon«^' any of , day, in the decoction of elm hnrk, 
it< varieties. 1 believe, that disorder of the di- i 20. iii. As to Ux-al menus, almost every variety 



gestive organs, and accumulations of mucous ! has In^en tried in this di«ea«e. In some insttncfs 

Fordes and other s(;cietions in the prima via, more the patient cannot bear the most soothin^ «» 

rommonly occasion im|H'tij^o than u peiicrilly ! emollient applications; while, in others, the m** 

Mipposed. 1 scarcely have seen a ease, in which stimulant have betn employed with advanlMt 

this (h?rangcment was not manif(*t either bef(»re, . \Vh< re the irritation is insupportitble, the n«e« 

or in the course of, tn^atment ; and in whieh ihi^ the huiJrocunnic acid has been su?yw<ted bv Uf- 

eruption uas ijot evidently fiyn)])tomalie. of it. In A. T. I'iiomson, in the proi^ortion of one Ku»' 

r/i/s opinion 1 am .siipportcKl by Mr. DiNin, m^ ' ^\ttvc\\u\ Ui four fluid-ounc-cs of water, combnw 

/a/c roy/efl«:ue at the I ntirmary for (.!h\\dreu,'w\\tTe\vi\\\\ ow^ <\\^c\vki c\ qVcq\vo(« and sis or figk* 

r-a.-e* of tins kind c.'iinc frcoiicntlv litfoic us. \ ctwvtv?' o\ ucpV«\c oJ VmA •, vgA. v^srkq^m^ «T^ 



324 



IMPOTENCE AND STERILITY — 



by Dr. Duncan and Dr. Dkwefj, which appears 
to depend upon the fornaation of a naembranous 
aubsUnce ia the uterus, having a strong resem- 
blance tA the decldua, is very generallv productive 
of barrenness ; but this is only one of the several 
forma which subacute or chronic inBammation of 
the uterus assuoiea, either of which may occasion 
temporary or permanent sterility. 

22. There are other causes of temporary or 
relative sterility. Among these the moat common 
are too frequent, yet inefficient sexual intercourse, 
too early marriagcji, general ill-health, and debi- 
lity or exhaustion of the female organs, owing to 
premature or too frequent excitement. Variouscir- 
cumstances connected with sterility in prostitutes 
have, perhaps, thrown some light upon certain of 
the causes of this state ; and particularly the fact, 
that many of this class have had children after 
marriage, or af^er relinquisliing promiscuous inter- 
course. Numerous instances have occurred of 
females who, having been obliged to marry con- 
trary to their inclinations, have not conceived, and 
yet have had children froQi a second marriage. 
It is generally understood by 'females of all ranks 
in society, that indlffurenoe tiuring intercourse, or 
suppression of the orgasm will prevent impregna- 
tion ; and, although they are sometimes deceived 
in this respect, yet their inference is correct in 
the majority. This is one of the principal causes 
of the sterility of prostitutes, other circumstances, 
however, besides those just alluded to, combining 
with it, to produce this effect in them. 

23. III. Treatuent. The treatmentof impotence 
and stcritKy depends entirely upon the causes of 
either the one or the other, as far as they can be 
known. Many of these causes may be fully ascer- 
tained, and the consequences correctly antici- 
pated ; but as to the existence of others, iiiferences 
only can be drawn from a number of circum- 
stances, aad these inferences cannot be always 
fully confided in. JMost of the organic legions 
and deficiencies, enumerated above, cannot be re- 
medied, yet a few of them may be assisted by art, 
either temporarily or permanently. ])ut many of 
the functional and moral causes, and their cfTects, 
may be entirely removed. Absence of an organ 
or part essential to the function of generation in 
either sex is generally prcJuctive of impotence 
and sterility. Yet an imperfection only, and dis- 
ease, of one or more of tncsc organs occasioning 
cither inability in the male or barrenness in the 
female, may be remedied. Adhesions of the pre- 
puce to the glans penis, phymosis, strictures of the 
urethra, fistulous openings in the course of the 
urethra, some of the diseases of adjoining 
parts that prevent intercourse, paral^'tic and de- 
bilitated states of the penis, and the slighter in- 
juries of the testes, may be permanently removed, 
and their consequences disappear. Contractions of 
the vagina, and even constnetion or narrowncce of 
the OS uteri, occlusion of the entrance of the vagina 
by adhesions of the labia, or by a morbidly denee 
hymen, or by a false membrane, prolapsus or pro- 
citlentia of the uterus or vagina, uterine polypi, 
leucorrhea, difficult or painful menstruation, and 
inflammatory states of the uterus may be sevurally 
remedied, and, although sterility may not be al- 
wayi, li will be frequently, also removed. 

24. Ca>es of impotence and sterility from moral 
BDd fuactional causes are the most common ; and, 

Mkbough they require tjie most scientific and ')ud\« 



cious treatment, yet the menCaltis wdl is the phy- 
sical imbecility, that ofien chanctenwa then, 
brings them more freqaently ia the bands of ne« 
tenders and «inperics, than tn those of the qnauScd 
practitioner. The cases which proceed from then 
causes may be arranged into 1st. Those which de- 
pend upon exhaustion ; 2d. Those which proceed 
from disuse, or from an imperfect exertioB, of tke 
function ; and, 3d. Those which arise from ex- 
cessive mental and physical excitement, relstncly 
to the susceptibility and sensibility of the nenmi 
system.— a. When irapotency and steiihty p» 
ceed from exhaustioH, or from s prematuie dectf 
of the generative functions, owing to prematmc^ 
unnatural, or excessive excitement, the treatneit 
is nearly the same in both sexes, accerdinr ee 
either may be chiefly or solely affected. In thea 
cases the indications are, to restore — 1st. The 
energies of the constitution ; and 2d. The foadieM 
of the procreative organs. To attempt tiie seooid. 
without either previously or contemporaneooalf 
fulfilling the fiist indication, will generaUy befs- 
tile, and often injurious. Persons, -who aie thsi 
exhausted, sometimes perpetuate their infimity 
by having recourse to noxious excitants, and la 
the means advised by emperics. The scientiSe 
practitioner will be guided in the selectioo ol 
remedies, by the causes, circumstances, and phfr 
nomena, connected with the case 4 and he will 
find it necessary to associate a ukoral or amol 
regimen with the physical means which may te 
required. When the affection depends vpoo IB 
excited imagination, in connection with a d^ 
proved habit, the former part of the treatment fe 
the most necessary, but tne most unpleasant kt 
the physician to prescribe, and the most diffieA 
for Ine patient to adopt. In these cases the net* 
tal weakness has advanced, jtari poMu, with dtt 
constitutional and local infirmity, until the noi 
has become incapable of exerting its more refiocmf 
and moral powers. It will, Uierefore, be ^ita 
necessary to restore tlie energy of the oencM 
system by suitable diet, appropriate roediciieii 
regimen, occupation, and change of air, beftiretb 
moral part of the treatment will receive due atiei> 
tion from the patient. 

25. In other and slighter cases, the debilf^H 
principally local, the general health as wdlii 
the mental energies, remaining only partiallj V 
but little impaired. In these, the local, coostite- 
tional, and moral nraans of cure, will frequenll^ 
prove successful, especially -in the male, fntu 
sex, when the inability depends chiefly «^ 
weakness of the sexual muscles, invigoranif 
modes of treatment, general and local, asaiUf 
remove it, if its causes be avoided. In all tbd 
attention to the digestive and secreting functioiii 
vegetable or mineral tonics, especially the prepvi^ 
tions of iron, and chalybeate mineral waters, tbe 
shower bath, or the cold salt-water bath will) le* 
gular exercise ia the open air, mental occii|AM*» 
and early hours, will generally be most heat&ctL 
Where the patient is subject to discharges frp^ 
the urethra upon passing a stool, or on the eidH" 
mcnt of sexual desire, a turgid and irritable itti* 
of the prostate gland may be inferred. Wben hs 
is liable to frequent emissions during sleept ^ 
irritable condition of the testes, and of tbe rff* 
cula: seminales obviously exists. In thcie, th* 
more cooVmo \ot»fia «xtfil the more astringeat cki^ 



\ 



326 



INDIGESTION — Patiiolocy — DESCAiniosr. 



Ibid, vol xxi. 1x315. ->Jlla///aiMf, in Ibid. vol. %xw. p. 31. 
ycmon^ ill Ibid. vol. xxvii. p. 81. — Syme, in Ibid. vol. 
xxxii. p. L'lii. ; vol. xxxiii. p *J43. \ Ct vol. xxxvii. p. 3Si. 



NUM, FlATULVMCY, PTRCMnS, StOMlCH, Pah/>| 
affe.eiUtn»t and it\j(iammatitm of}, my obMnritioiii, 
at this place, will nccenarijy be confined to the 
simpler fornis of this diaorder. 

3. Indige$tioH is either primarji or metndmyr^ 
idiopathic or tymfitomatiCf timpU or eompliMtti, 
When it h complicated, it may have been cither 
the primary or the secondary afiectioD. Dr. 
Todd dLainguishes between symptonutic ud 
sympathetic dyspepsia ; and remarks that, " i 
iecondarif dyspepsia may be conveniently divided 



XX 

— Stttdmam, in Ibid. vol. xxxvii. \t. HiS. — Hoiutim, in 
Ibid. vol. xxxviil p 'Jlid — Turmbutlt in Ibid. vol. xxxix. 
u I'JS. — Kdwards. in IbiiL vol. xli. p. 4(1.*). — Par/«. 
Mcdlral JuriKpruucnrc, vol. i. p. 205. — Duekackef, and 
DrakCt in N'uw Yorlc Med. and Phy«. Journ. voL v. p. 44J. 

— ilusack. In Ihid. vol li. p. Id^/'. Mutt, in Ibid, 
vol. ii. p. 11». — M^yaugkton, in Ibid. vol. vi. p 2.VZ — 
AtouioHt in Amor. Journ. of Med. Science, vol. ii. p \VS. 
Aihwi'lt, in Ibid. vol. iv. p. l-IM. ^ WUIiams, in Ibid, 
vol. xi. it.AW. — IIoillcnun^ in Ibid, vol xv. p -Ki?. — 
Barret^ in Drake'n We»tcrn Mwi and Phyt. Journ. 

vol. iiL p. ilUfi. — jE>t>tMVjr, On the I>uieaiefl of Female*, — .t ~^-,-^|~.- — j 

p. *:». ; and in Otre'g .Medical MuMniin. vol. i. p. UV,. I imo $itmptomatic, formimr only a part of a moit 

— lAttcVi, Monthly Jounu of ForciKU Med. vol p 1«!». _-_^ ' i .i:-^«,„^ „,j «u_.^«fc«#;I. «Imi n—r. 

iniaumf! in Ibid. vol. L p. ;J7f,.- Unyward, in lUton | general disease, and «,vi"pa«*tlif, the cooseqneMC 

Med. Magai. vol. i. p. <u. ; and in Amer. Journ. of Med. ' of consent with the disorder of some Other orgta. 

Science, vol xiii. p. 7i«. — //umi7/i»/i. in iiMt. Mp«i.«»d xhe distinction is, in some respecU, wanting is 

tdirg. Journ. .vol. xi. p. I».l — /.fl»«Trr, in New tjijcland i » -. u j » • ^--- 

Jouni. vol ix. p ir>i. L ntipcch, in Med. chirurif. Hev. prccwion, but it may be preserved as beug m 

vol. xvii. p. 5SJ. — .4. V'Mtpert in Ibid. vol. xviil p .'Sft). usually recognii«ed. 

^ar/ur/niw. in ibid, vol xxiu p. ^K - H HamiUon, in 4 The win<riiesor/«irmiof indigealionhavebeM 

Transact, of the Royal Society of luiinhurKh, vol. ii. - , ., y , *, , . 

arta — .Varr, in Dirt, dei Science* MMicaltM, t xxiv. variously dcscnbed, named, anil arranged, Vf 

p. 17iK~//cifMfn, .Military Surgery. '2d edit. p. ."iUJ.— the numerous recent writers on this disorder ; ad 

Brctvsfcr, i-Aiinburich hjirvclii(>«tia, vol. i. p K'Jj.— . . pa e»r r rlianoailion haa been evinced h» llL 

n'iiMon, IxHriuriM (III the l^rinury and (Jeiiital Organs. * ™*?* ^^^^^ awposiuon lias ueen evincen oj au. 

p. 4(iK. .iiid 124. — chnnmait'M Journal, N. s. vol. iv. p. Jft. • to assign ncw terms, and to devise dtstmct patno- 

^&irWfc''f Morbid Anatomy, p;!7i.-- A'6^r/i;V Al^^^^ lopcal States, for each. In some inttaiMMa 

distinctions have been multiplied to an eiteit 



Review, vol. ii. p. :]*>t. — Iktrscy's .Surgery, vol. ii. p 3ft8. 
ii. I.Arc, EcclCkiastiiMl Ke[xirt!i, Apficndix, vol ii. p. ftSO. 
Jtaigc "' " ' " ■ 

vol 

Li'slon^ ill IxMid. Med. Oat. vol. vi. p. 2:'iS. — Earfc. in 



ige Detormct I >>(*<■ do Medicine, t. xii.'p. 74. ~ Afim- ■■ bewildering the inexperienced, and beyond iha 

. in Ijiicct, N. s. ytd ii. p 771.- A7//irf*iii, in Ibid. \ actual morbid manifesUtioDf of the orgam if- 

vm.. pj«.-.VVK^ar/««c.. i.i Ibid, vol.x. ,. .?Jl.- ^^^^^^ j^ ^.^ ^ ^^.j^ ^^^^^^ ,^^ jjfe. 




tcU, in Ibid. vol. xL p. 44.'i, — Arno/t, in Ibid. vol. xii. — i :„ . •\,:«i .k« m«<i«..i«- ««.»*•«•:!:«». :» > (nnrA 
T. E. Beatty. Cylc«n5. of Pract. Med. vol. ii. p ^M. _ »« « tn»ra. the muscular contractility; m a fonrtl, 




.'MidwiferjT, 

Obktctric Medicine, voL i. p. o\6. 

I N DIG KSTION.— S VN. ^ve-rrt-^^ia (from Juc tciih 
dijfictiltu, and trtTtrVf it//;;,'f>(),0pa8'yjri4»a,awj- 
4ia, (Jr. Concttctw tardUf Stomachi resnlutiOf 
Cniditiift Iinli^estio, Pusxio Stnmnchia, Auct. 



particular afTtctiMi 
disordera of th 
liver, or of the pancreas, or of the daodcoanr 
and not merely with these, but with othen ii 
remote organs. Yet these individual affvctinii 
even in their simpler or less complicate*! dtalef, 
will seldom be manifested by symptoms cnabliif 
the most trlose observer to determine, with pR" 



].ul. Aft'psia, Voirel..SM/rt, Linnaeus. Anoreaia, ] rision, which of them is the one actually pte«*. 
Sa{»ar. Braduprpsui, Sauva^es. Duspepsia, cither in n jsimplc or predoniii.ant forin. or Ihi 
Swctiiiiur, C'ulli;ri. I*arr. l)u>peiKsia -Siw/i/tj, cxnct associations to which it may have piven we. 
Youn?^. Lhiwsig Duspepsht, Good. Scliuerv '■ It will, therefore, be propt»r not to multiplydii- 
Verdamuig, I'tUfi Verdanuufr, Germ. /«i/i. ! linctions buvond those which will be found u«ial 
gfit'um, Fr. Ii,di:ieitwiu\h;x\, Bad digestiun, \ for praclicaf purposes. The disorder wliich pro- 
Sloiv di^i'it'wii, S'c, j ccfjls from a simple diminution of the functiowfli 

Ci.ASMF. — 2. Class, \ervou.«5 Disonses ; i|,e stomach, — from impaired secretion, wi'akeoe^ 
2. Order, Defect of Vital Kncrjzy {Cut- | orgRniccontn»ctility,nndIttnguidciroulation— fm 
len). 1. Cluss, Diseiu.cs of the J)igoj«tive asthenia of the orpnn, — will, with propriety, fon 



Function; 1. Order, AfTcctinj; the Ali- 
mentary Canal (f;«ii)</). 1, Cl.«ss, I. 
OiiDiu (Ant}wr,u\ Vref'ace), 

1. Dr.iiv. — Impaired or fastidious appetite; 
glow and difficnlt dii^fl>tiott ; sensations of discomfort 
referrihle to the stomach , and fri'i/itent hi costiveness. 

2. Dtisj)ept>ia or indif^estion hiK been employed 
ns the geni^ric di"yigiialioii of several disorders 



one variety of indigestion ; and that which <k 
}H'nds u|)on a state of erethysim, or vascular im 
tation, ap-)roaching, but not amountinjr to 
inflammation of the villous surface, will con^titnl 
another. This latter, especially, will pr«» 
certain modes, aeconlinrr as the sensibility, iIm 
villous inembnine, or the follicular apparato.*,! 
prominently affected. Those states of di?e*P 



ranged under it as species, by most modern j whic h are Vcnerallv consequent upon dv^pcpsi 
writers, and particularly by S.»i vagis and Cul- j althouijli son»etim«npix!ariiijr iiKle|»endeutlyofil 
LEX. VouNO and Gocjd have limited the mean- and which have been chisse*! by some wri'lffst 
ing of the term, by considerinjr some of those 1 .severer foims of this complaint, will be fo«»i 
disorders as ultOL^etlier distinct from it. Dr. Todd, j under the heads referred to above, 
however, in an able and comprehensive article on | 5. 1. Discription. — i. Simple .\sTnrfK 
the subject, has applitni tliis term to all the func- | Dyspfpm.^ ; — Stomachi Hesobitut,Ct.i^v*,''^^ 
tionul disorders of the ulimentury cniial. Ilavinjj | friditas Stomachi, Pkospku Ar.piM'S, — l>,«ir^ 
discussed tevenil of the aftections viewe.! by some ■ Idiopathica, CuLr.KN, — First Stape if h^ 
nritLTH as .<;wcies of indi-estion, in «^opanitc j rii,,,, \\ . Vuu.w, — sitonic Cwastrie ^Dvsp'pf^ 
ar//c7c% ncoor</jn;LMo their n.itures and scats l^see 1 F. J. Tom*, — i^i/jt/iepjin per Asthenii ^ 
arU'ck'S, Colcvm, ("olon, Comivlnlss, l)\:oi)t.\ rLstonuic, Ksto^sv/— l^u%vcvuo Apyrttiomi'' 



330 



INDIGESTION —Op certain Symptdmb oK 



17. e. Pain and tendernat at the epigastrium 
and region of the stomach have been much insisted 
upon by Dr. W. Pnii.ip, as indicative of the more 
inflammatory states of dyspepsia. But as I iiave 
shown elsewhere (see Stomach — Morbid Hensi- 
bilitif of ), the most severe pains in this organ are 
often felt without any inflammatory disposition. 
Tenderness upon pressure is a very common symp- 
tom in the slight or more functional states of in- 
digestion, as well as in the severe or more inflam- 
matory, especial If in thin and delicate persons. 
It is seldom wanting in irritative dyspepsia. The 
tendemcsA is often connected with f'ulneu in this 
region, and also in the hypochondria. But this 
latter symptom is generally owing to the distention 
caused by flatus, and by fcculeot and flatulent 
collections in the colon. When emaciation takes 
place in protracted cases, the fulness becomc8 
more apparent. 

18. d. The pu/(0, in dyspepua, is extremely vari- 
ous, but it is most commonly as 1 have described 
it. During the digestion of a full meal, it is 
usually accelerated, and somewhat harder or 
sharper than usual. The luirdncss insisted on by 
Dr. W. Philip, as indicative of the passage of 
functional into inflammatory dyspepsia, is seldom 
present. Sharpness and quick ne^^s arc more fre- 
quently observed, and are symptoms of irritation 
rather than of inflammation. The febrile symp- 
toms occasionally occurring, with soreness of the 
throat, high-coloured urine, and impaired secre- 
tions, are more probably occaraoned by the 
former, than by the latter pathological state. 

19. C. Of the itatex of the astociated viicera in 
dufpepsia, — It is obvious that indigestion will 
vary in form and severity, with the concomitance 
of disorder in any of the other digestive organs. 
— The functions of the Duodenum may be de- 
mn^^d, as shown in that article ; and, in this case, 
dyspepsia will present more or less of the ciiarac- 
tv.Ts there dc«tril)ed (^$ 2.). Other parts of the 
digestive oiinal may be deranged, the affection 
consisting either in impairment of function, or in 
nervous or va.sculnr irritation, and being; limited 
to the small intestines, or to the large bowuls, or 
even to ouc only of the latter. (See arts. Ca.ruM 
and Colon.) In such ca»cs, the physician will 
be guided by the slate of the evacuations, and by 
the symptoms detected on a careful examination 
of the abdomen. — It in not improbuble that the 

f)ancrcauc secrretion iKJComes dl^Drdered, particu- 
arly in protracted ca<eA ; but of this sutHcient 
proofs are seldom furnished : at best it can be 
only a probable inference. 'Jliat this secretion 
mav be diminished is not unlikely, inasmuch as 
there is sufficient evidence of the hiliary secretion 
l>eing deficient, retained, and altered, especially in 
the chronic states of indigestion ; and it is reason* 
able to infer, that, when one of the organs de- 
riving influence from the same part of the ner\'ous 
system is impaired in its functions, the other 
organs thus associated, a-? well as other^vise ana- 
tomically connecte<l, will Ik? similarly, if not co- 
ordinately, aflected. Indeed, every ex|)erienced 
practitioner must have noticed a more or less 
remarkable deficiency, or other disorder of the 
bile in d3'spepsia ; and not only of it, but also of 
the other secretions poure<l into the intestinal 
raaal. That the disorder originally induced in 
f/io stomach, often extends to the other digesUve 
organs, owing to various conconiiiant or coiibc- 



cutivc dreumstances, eaimot be donlited. It 
may be even apprehended, that the oonsecuiive 
disorder will become the most seriouf ia id 
nature and consequeoces, when theae mnm* 
stances are frequent or continued in their opera- 
tion ; and that it will thereby obscure or max tb 
original affection. In many cases of dytpepai, 
the functions of the biliai^ i^iparatua arenDpamd, 
in respect, not only of the quantity, bat alio af 
the qualities or properties of the secretion. Is 
some, more or las of retention or obstnictioB if 
bile actually takes place, as shown by the Hittrf 
the stools, rather than by the colour of the nrfM 
of the bodv. The remora of bile, aIflo,in the bilarr 
ducts and sail bladder, arising from impsiiM 
function of the stomach and torpor of the liver, nffl 
furtlier increase the morbid state of the evacuitioK 

20. D, Stfmpathetic affections of various vrgstL 
— Whilst an immense number of diseases orignM 
in neglected or protracted indigestion, vaiiM 
disorders are entirely sympathetic of it. DiMM 
of the urinary oigans, of the Uver and bowels 
gout, rheumatism, various painful, neuralpe,aai 
ncr\-ou8 affections, eruptbns on the skin, dJaorisM 
of the catamenia, and many others, oftea te 
arise. Dr. Webster, in a treatise publifbcd ii 
1793, endeavoured to show this, before the tp 
pearance of the writings of Mr. ABBawrniT m 
the subject ; but it had not been altogether a^ 
lected m the works of Whytt and others Tka 
excellent author very justly remarks, thatadti* 
cate state of the flr»t passages, or an unnitmil 
sensibility of their iier\'efl, not only disposn li 
many complaints in those parts, iMit the wUl 
nervous system is thereby rendered more liable H 
be aflfected by the slightest causes. " FaiotiBgi^ 
tremors, palpitations of the heart, convolrive ■•• 
tions, and great fearfulness, may be often oiri^ | 
more to the infirm state of the first passages, tbis 
to any fault either in the brain or lieart Tk 
powers which the alimentary canal, when iH 
nerves are disafifreeably aflected, must have ii 
producing disorders in the most distant part* ef 
the body, cannot be doubted by those who attesd 
to that wonderful and widely-extended svmptlbTi 
which obtains between it and almost tKe wholi 
system." 

21. a. The brain and organs of sense areofici 
much affected by indigestion. Headaek 'm ooi 
of the most common and severe affectioni, RV* 
pathetically excited by this complaint; but itiM 
received sufficient consideration in tlie article m 
its different forms. I'hc manifestations of aiMfi 
both intellectual and moral, are also often noit 
or less disordered, although but slightly or ilDpe^ 
ceptibly. Memory is somewhat impnured ; ittef 
tion is unsteady and cannot be long continnd; 
the disposition is more fickle, and the temper DOiv 
irritable than natural. There are often confusiai 
of thought, or of ideas, lowness of spirit*, desfwa- 
dency, and vertigo, particularly in severe or pre* 
tractcd cases. AI. Broussais has argued wtt 
much apparent jnsticc, that the functtonsl ^ 
order, thus sympathetically induced in the hniBf 
may, by its frequency or continuance. pa» ii*» 
organic change ; and several recent yrriten in Ikii 
countr)' have adopted the opinion. 

I 22. h. The organs of sense arc not less liabk* 
sympathetic disorder. — The sight become* »*k 
a.T\A 'v[id\9\\ivct \ the eyes impatient of lighter ini^ 



34 



INDIGESTION — Pathology. 



niach and related orgaDH, either of which may be I 
somewhat more prominent than the rest:— 1. 
Impaired organic nervous power of the stomach. ; 
2. Adeticient or disordered stateof the gastric juice, 
or a want of a due relation between the quantity and ; 
nature of this fluid and the ingeata. 3. Impaired ab- 
sorbing power of the stomach, rendering the diges- | 
tion of the fluid ingefcta more or less diiBcuIt, and 
weakening the gastric fluid. 4. Diminished mus- | 
cular energy of the stomach ; the motions and tonic 
vermicular actions of the organ being weakened, \ 
and the admixture of the gastric juice with the in- 
gesta being thereby impeded or delayed.* These 



• A« Dr. Combe otwenm, ihc^rtt requisite to digestion . 
ini an adequate fupply of gastric juice, and itf thbrough j 
.admixture with every {larticle of tiic foixl on whirh it is 
iu i>|icrate.i The ieeond it a htoady teiniieratiirc of atxiut 
i^^ or l(X/^ Fahr. 'I'he thfrd is the gentle and continued ' 
agitation of the alimentzurr mau in the' stomach during 
the digestive process. — Much light han been thrown 
upon the Ainction of digestion, and conMcquently upon 
disoniei* of this ftim'tion. by the experimenu of l>r. 
Urai.-mo.nt, of Aioerica, on St. Makiix, a strong young 
C^uailian, who was wounded in the left side, a fistulous 
opening into the stomach remaining without detriment 
to the general healtli. For some months after the wound, 
the food could be retained only by wearing a compress 
and bandage ; Init early in winter, a umall fold or dou. 
bling of the villous coat began to apfiear, which gradually 
increased till it filled the aperture and acted as a twi/vr, 
so as completely to prevent anv efllux fVom within, but 
to admit of being easily pushed back by the finger fVom 
withmit. 

Dr. Bbaunont describes the aperture in St. Martin's 
stomach as being situated about three inches to the left 
of the cardia, near the left or su|>erior termination of the 
great curvature. When the stomach was nearly empty, 
nc was able to examine its cavity, to the depth of five or 
six Inches by artificial diHtention. When it was entirely 
empty, the stomach was always contracted on itself, and 
the valve i^nerallv forced through the orifice, together 
with a jiortion of the mucous membrane, CMjual in bulk to 
a hen*s egg. After sleeping fur a few lituirs on the left 
side, the protruded p(>rtion became so much larger, as to 
spread over the Ineigbouring inti>gumeiits five or six 
inches in circumference, fairly exhibiting the natural 
rugip, villous membrane, and raucous coat, lining the 
gastric cavity. This appearance wan almoMt invariably 
exhibited in the morning l>efiire ^i^ing in bed. 

The first {loint which Dr. Bkai'mont cnnrlusively 
settled is, that the gUHtric juice does not continue to be 
secreted between the intervals of digestion, and does nut 
accumulate, to be ready for acting u])on the next nical. 
The next which he establi(>hi.tl is that in health, the 
gastric secretion always bears a direct relation to tlie 
quantity of aliment naturally required by the system ; so 
that if more than this be taken, there will lie too mn.ill 
a supi)ly of the Juice for the digestion of the whole. Dr. 
Braimont further ascertained that the gastric secretion, 
and the villous coat, undergo great changtm during dis. 
ease. In the course of hin attendance on St. Marti v. he 
had o)iportunities of trt'iMg what was actually going on 
in the organ, and of observing, that whenever a feverish 
Ktate was inducetl by olMitructetl |»crspiration, or by stimu- 
lating liqiiorx, or liy overloading the litomach ; and that 
when inlluenced by fear, anger, or other emotions, de- 
|ire«siiig or disturbing the ner\-ous s,\&tem, the villous 
coat iK'came sometimes n-d and dry. and at others, 
liale and moiNt, having lost its smooth and healthy ap- 
[learancc. As a noceiM-ary conseijuence, the secretions 
became vitiated. imiKiired, or suppre&setl ; and the fol- 
licles, «ecreting the mucuH whicli protects the surface of 
the villous coat. I>ecame flaccid, and no longer yieUIe<l 
this bland secretion. 'L'ho nervous and vascular jtapillae 
tlius deprived of tlieir defensive shield were then sub- 
jected to undue irritation. When these diseased appear- 
ances were considerable, the system sym|»athisec<, and 
dryncMof the mouth, thirst, quickenetl puUe,&c., showed 
themselves; and no gastric Juice could be procured or 
extracted, even on the application of the u^ual stimulus of 
fooil. The dry. irritate<l appearance of the villouM coat, and 
the absence of the healthy gastric secretion in the febrile 
state, as Dr. Combi£ has remarked, not only explain at 
once the want of apiK^tite, nausea, and unea.4ine«s gone- 
rally felt in the re(.Mon of the stomach ; but also show 
the fully of attenqiting to sustain strength, by forcing the 
IMtieiit tn eat, when the ftHxl cannot l>e digested, and 
when nature instinctively refusw to receive if. 

Tkr In/crencri, drawn from the experiments and 
oUicrratioaa of Dr. BcAUMo.vr and others, that more 



pathological conditioDt may be pn'mar 
may be conseeutice upon disease of thi 

immediately conrem the sutaject uoder coi 
may be stated as follows : — 

1. I'hat the processes of mtMetUkm, iHsai 
degtuUtivn are important, not merely as sul 
food tn the gastric juice in a state of due prej 
its action, hut also as allowing time for the r 
tra(*tion of the stomach upon each indivic 
conveyed into It, as well as transmitting the fi 
portions at a time, so as to prevent a too rapi 
sive, and injurious distention of ilie organ. — 

2. That the gastric juice is the agent of clr 
that it is secreted fWim vessels distinct from ' 
follicles ; that it is a clear tran»p«rent flu 
odour, a little salt, and percqitiUy acid ; and 
tains flrec hydrochloric acid, a little acetic aci 
other active chemical |trinciples. — 

^ That this julee is never found free in tl 
but is always excited to discharge itself by fo 
irritants 1 that it is seldom obtained pure. In 
mixed with mucus, and sometimes with saliv: 
when pure, it is capable of being kept for moi 
years 

4. That it Is a folvent of food, and alters itj 
that it checks the progress of putrefaction, om 
substances, coagulates albumen arxl milk, am 
dissolves the coagula ; and that it commenc 
onfbod^as soon as it comes in contact with it 

ii. Tliat it is ciquble of combining with a c 
qvantitjf of food; and when more is presci 
action than it will dissolve, indigestion will 
that its action is facilitated by the warmth . 
of the stomach, these motions 'taking plac 
two directions, transversely and longitudinall 

fit That the gastric juice is modified in q 
probably in its intimate constitution, so as 
kind of food | and hence the occurrence o 
on sudden alterations of the kinds, quality, n 
of food. 

7. 'I'hat the action of the stomach and o 
the same on all kinds of diet : and that th 
the stomach ]»roduce a constant ailinixture 
gastric Juice, and thereby facilitate digestion. 

A. That wlkl fooil, of a certain texture, 
digeittion than >ff/j</; that animat tnui /an. 
ments are more digestable than ocgctoin'r ; b 
ceptibility of digestion does not depend alto 
natural or chemical distinctions. — 

(i. That digestion is farilitatetl hy tniHHtn 
tion and tcntlcrmest ofjibre, and fctardeil 
qualities.—. 

](). That the ultimate principles of aliinciil 
the same, firom whatever frxnl they may Ih' ol 

11. 'i'hat chyme is homogenenus, but v.i 
coluur and consistence ; and that, toward 
stagi's of chymification, it iKcomes more acul 
lating. and ii.i»ses tnore rapidly from th(>>.ton 

12. That soiqts and other liquid Um*A di> 
play the muscular coat of the st(»ni:u-h ; ar 
gastric juice can act upon them, the fluid | 
aln>orbed and the mass thickene<1 to a profK r 
for undergoing the usual churning iiuktu>ti ; 
quently that thi* kii:d of foixl oAen givek ri^ 
particularly in weak states of the rtoin.ich. — 

!>. That, owing to the ada]>tatinn of thr- 
to the nature of the food, sudden or extrii 
from one kind of diet to another i^ injurii 
stomach has not had time to nKKiify its ^-ecre 
ently to meet the altereil dtan.-ind u'lxin it.-^ (n) 

14. That water, ardent spirits, .ind mtust > 
are not affected by the gastric juice, Init i> 
stomach soon after they have Ik-cii receivwl 
ing condiinenu are injurious to the he.iltl 
and that the u>ie of spirits always cause* di 
organ, if pcr^cvc^ed in. — 

13. 'Hiat bulk, as well as nutriment, is 
articles of diet ; and that digejttibility diKs 
U|>on the quantity vi nutrient principles ll 
contain. — 

\k\ That the quantity of fooil generally t. 
than the wants of the syvtem require; an 
excess, if pcr?evcrcd in, generally pro«lucc 
dwonler, and consecutively, organic di»(.'a«e. 

17. That oily fofid is dilHcult of digest ioi 
contain<i a large pri>|K>rtion of nutrient princi 

15. That hill' iii not usually found in the s 
is not nece»sary for the digestion of food ; bi 
oily food is useil, it assists digestion. — 

19. That gentle exercise faciiit.ite« digcKtlr 
the acetic, citric, aiut hydrochloric acidi* | 
process, iMrticiilarly if vegetables and indij 
sauces have been taken. — 

iX). That the time required for the stonucl 



336 INDIGESTION — Treatmsht. 

tulence u troublesome, the means already advised' the decoction or extract of tanncnm ; tht n\' 
may be prescribed, or those recommended in | phate of potash with rhubarb; the purified eitnei 
that article ($ 15.) may be employed. Friction . of aloes with castile soap, &c. — These and otfatf 
over the epigastrium, especially with a stimu- ' mild purgatives may be taken in other combin* 
lating liniment, will also give immediate relief ations, as draughts, mixtures, or pills, u pn- 
from both pain and flatulence. When headach j scribed in numerous and various fonni m dM 
is present, the treatment proposed for Dugpeptic . Appendixt and in the article Constipatiov. A 
HcADACH ($ 46.) should be directed. For the judicious combination of bitters with mild yai^ 
coitiv4neu so generally attendant upon this form : tives, as, of sulphate of quinine, or inspnnisd 
of indieestion, the medicines already noticed, or ! oxgall with aloes (F. 562. 675.); the infuaoDof 
those about to be prescribed, or a combination of . senna with any of the bitter infusions (F. 366.); 
mild aperients with tonics, deobstnients and al- '■ and the decoction of aloes, with soda and inTana 
teratives being given occasionally at night, will of columba, will generally be extremely anfid it 
prove of great service. > this state of the complaint. 

43. After an acute attack of dysperaia, particu- i 46. When chrome asthenic dyapepda ii tU 
larly when occasioned by errors of diet, it is ne- tended, not only by a torpid state of the liver, bat 
cessary to enjoin abstinence, and thus afford the also by incipient cachexia, or has given riie to 
stomach time for repose, until its organic sensibi- ! cutaneous eruptbns, &c., much benefit will malt 
lity and functions begin to return. After a while, from the simple preparations of sarza, with Uqiier 
a cup-full of mutton or veal broth, or of green ' potasas or Brandish 's alkaline solution, andci* 
tea, or of coffee without milk, may be given and , tract of taraxacum. If it have occasioned difBesk 
repeated ; or a wine-glass full of port-wine negus , or impaired menstruation, or a state of ineiptit 
may, in some cases, be allowed. But care should chlorosis, as often observed in females in Looik^ 
be taken in returning to a full diet ; and the in- j the preparations of iron, particularly the miitn 
junctions as to diet about to be stated ought to ferri composita, the decoction of aloes being tibi 
receive attention. In general, tonics and stoma- ; so as to act freely on the bowels ; or the pifah 
chics should not be prescribed until the functions ' ferri composita, conjoined either with the pL 
of the stomach are returning. aloes cum myrrha, or the pil. aloes compoaH; 

44. B. Having removed the more acute attack will generally remove all disorder, if suffiaolif 
of asthenic dyspepsia, with its urgent symptoms, i persisted in, and aided by change of air, diet, nl 
the remaining aisorder is in all respects the same | exercise. 

as the more itight and chronic ttntet of the com- i 47. In this form of dyspepsia, the leiti- 
plaint, and requires a similar treatment to them. ! ration of the digestive functions much depnii 
The third intention of cure ($38.) should now ' upon a healthy state of the * other eicRllif: 
be carried into effect ; and the organic nervous ; organs, as well as of the bowels. The foncMi 
energy, the secretions, and the muscular tone of of the kidneys and of the skin should be dilf 
the stomach be improved. This intention is to be ! promoted and corrected. The temperataro of ni 
effected chiefly by the diet and regimen hereafter general surface, and the exhalations from it, ooglft 
to be noticed; but a judicious recourse to medi- ; to be preserved, and the urine duly examiMi 
cine will also prove of great benefit. The iofusion . in order to ascertain, not only its appearancib 
of cinchona, of columba, of gentian, chamomile, but the general character of its chemical coi* 
cusparia, cuscarilla, will bo severally useful, stituents. As these vary, or, as certain of thM 
with the alkaline carbonates, and small doses of predominate, so should some of the most tSet' 
stomachic tinctures. Afterwardsthc metallic tonics, ^ cious medicines, prescribed in the complaint, bt 
as the tincture of thesesquichloride of iron, the sul- ; varied or altogether changed; so should tomei bl 
phate of iron, the sulphate of zinc, the trisnitrnte conjoined with alkalies or acids ; and apcrientsai 
of bismuth, and the mineral acids, will generally ' alteratives be given with absorbents or deobftnuolfc 
be of service. Several of these may be given with 48. ii. The irritative rariety of' du*peptia reqaiiW 
the extract or tincture of hop, or of hyoscyamus. very different means of cure from those jvit id- 
Lime water may be taken with aromutics, pnrti- vised ; but the removal of the exciting caua il 
cularly when the bowels are much relaxed ; and as necessary in the treatment of it as in tMl 
the aerated, or alkaline chalybeate waters may be of the foregoing. — a. In the more aeutt iMM 
used. When there U no complicution contra- of this variety, when pain, tenderness, heit, 
indicating cold bathing or the shower bath, it will ' or soreness is felt in the epigastrium, altho^ 
be advantageous to resort to them frequently ; the vascular disorder of the villous surface naf 
and when uneasiness at the epigastrium is often not amount, it nearly approaches to inflammitiaBi 
felt, a warm plaster will be worn in this situation and erethism, or vascular congestion, at lad, 
with benefit. exists, 'j'he application of leechet to the epigii- 

45. I'he most active or varied means employed trium then becomes necessary. In plethoric ptf- 
to restore the functions of the stomach will be sons, a bleeding from the arm should be prefenei 
frequently inefficacious, if the offices of the coUa- In those who have suffered from hcpmorrhoid^ tf 
titious viscera be imperfectly ()erformed. The obstructions of the liver, cupping on the kjp^ 
biliary tecretitm should therefore be promoted or chondrin, and in females, whose catamenii ill 
correcte<l by occasional doses of blue pill, or deficient, leeches to the groins may be prexrM 
Plummer's pill with soap: and the bowels pre-, Afterwards a large rubefacient plaster, fanfd 
served moderately open by mild purgatives, or by either of cnual parts of the compound pitch ni 
a combination of them with bitters and tonics. amrooniHcal plasters, or of seven parts of tli 
With this view, rhubarb may be conjoined with former with one of the cantharides plaster, ihi4 

aloeB, guuiacum, and ipecacuanha, or wiih mag- be apv^ied over the epigastrium. The blaep4 
neaia; the infusion of senna, with the inCusion o( OT\\^at^T^.e>im^xifi\ji&kVQ\i\K taken at bed-tw 
geatiau} the compound decoction of aJoeB, W\l\\ «iiid%m\^«i^>«»X'vBk^^\&an&^ 



940 



IXDIGESTIOX — Op the Diet ahv Reoxmsv. 



chiefly by the ioducement to excem in qutDtity, 
which the variety tifords, and by the incongruity 
of many of the articles. When ooly one dish is 



taking active exercise in the open air, the kknd 
may be somewhat shortened; but for ied«MHj 
persons, it may be much prolonged. Mich,Wv^ 



partaken of, Dr. Combe remarks, tliere is lcs» ever, should depend upon the appetite, wUik 
temptation to exceed the cjuaDtity, than when *' ' * ' '~ *^ ' ' 

several are tried. The first mtimatioos of a satis- 
lied appetite, are warnings to stop eating, which 
should never be neglected by dyspeptics. Ifthefie 
be passiid by, indigestion or an aggravation of it, 
where it is already present, will always result. 
The quantity of food should also have reference 
to the amount of exerciM. Wlien little or no 



ought to have returned some tiaac bclbrc diB«r ■ 
taken. According to this, the most laiiabkliMi 
for this meal, is about two o'clock. Ai «nf 
dyspeptics as well as otheim cannot diM «■ 
much later in the day, ought nothing tobt tikadi 
five, six, or seven o clock t or ought a light iifHI 
to be taken at one or two o'clock, and the tmlli 
be chiefly reserved for a aubstantial meilttl 



waste is excited by exercise, the supply should be much later hour? When dinner cannot btldai 
reroarkablv moderate, as well as digestible. Per- ' until eight or nine hours after breakfast, it will ki 
aons who nave removed from the country, where / necessary to have some refreshment in tbt m» 
ihey have enjoyed active exercise in the open nir, ' time; but it should be in relation to diethMthtf 
and have consequently digested well a full diet, ' will elapse until dinner, and to the exercise titak 
generally become dyspeptic wlien they have re- . For persons of sedentary habits, a bi*cnit wai I 
moved to large towns, and are subjected to very j gla^s of water will be suflicicnt ; botfortbeactiil 
diflerent circumstances, especially if they continue ! and the young, especially if the interval belMj;, 
the same Quantity of food, or if they increase it. | a more substantial Inncheon is necessary, ifi 
61. C. The timft of eating. In general, five or habit of resorting to pastry-cooks for refreslmi^ 
fix hours should elap.«e between one meal and and of taking wine with it, is generally prcjidical: 
another. Even in healthy persons, digestion of a ' and particularly in dyspepsia. When dinner M^l 
full meal is seldom over m less than four hours; ' nut be taken until a late nonr,it should ahvaji Ifi 
and in dyspeptics, it is seldom disposed of until a : postponed fur half an hour or an hour, naii*'] 
much longer period has pa^ised. The stomach, also, ', citementor fatigne has subsided. ^ 

requires an mterval of rest after the process is i 64. When the dinner is early — from on 11; 
finished, in order to enable it to enter upon the , three o'clock — a lipht meal of tea or eoAi ttl^ 
vigorous digestion of tiic next meal. If food be ; bread is necessary; but when the dinner blili, 11^ 
taken before the organ has recovered itself from < little exercise is taken after if, tea or coffee 
its previous exertion, the secretion of the gastric | be used merely as a diluent, and no food aafbtH 
juictrS, and the muscular contractions, will be im- I be eaten. Alter an early dinner, admitting Mlk"^ 
|)erfect. The whole of the gastric juice which the 



stomach can secrete in a given time being engaged 
in the digestion of the first meal, the one taken too 
closely upon it will be ins^ufliciently acted upon, 
and thereby undergo fermentation. The intcrvnls 
1)eiween meals should be in relation to the quan- 
tity eaten, and the habits of the individual is to 
air and exercise. When the latter are enjoyed, 
the periods may be much shorter than when the 
habits are sedentary. 

62. For dyspeptics, as well as for healthy 



for its digestion and a return of the appetite 
a late hour, a third meal, of Kght aliments, nikj 
moderate quantity, should be taken, jpartieslrif j 
by perrons engnged in the open air. nhenih^ 
temperance is practised by tne dyspeptic, puto ' 
lurl y when he lives actively, and retires to bed wMl 
an entirely empty stomach, he is quite as likfljtl 
have disturbed sleep and unpleasant dieami, hI 
he had his stoirarh loaded. Jle may erei W 
wakeful and irritable, or experience a frOK rf 
unpleasant emptiness or gnawing at the stonidk. 



]ierson8, tlie meals should be regulated according All these may bv removed by a basin ofuroa^ 
to the necessary occupations and habits of the ! root or sogo, about an hour before bedtime. A 



individual. For those, observes Dr. Combk, who 
work by day and sleep by night, an early breakfast, 
an early dinner, and an early evening meal, will 
l»e most conduci\e to health. Hut for those who, 



liffht supper may therefore be taken, when tkl 
dinner is early ; but it should be at least sa kov 
or t«o before retiring to rest. 

65. I), The ilyspeptic, as well as' other vtkts- 



ngainst the laws of nature, keep late hours, late | dinurians, inquire, What ought ve tB ^Hmkf k4 
breakfasts and dinners are prt^ferablc. — Per- : they rarely follow the question by tbe Mt 
sons who eat suppers ought not to breakfast till i important one. IVhfn khovld ue drink) Aadthcj 
one or two hours after rising ; but those who dine j never inquire as to the temperatvre at vhiek jkm 



late and eat nothing afterwards, require brci.kfn<-t 
sooner. As a general rule, breakfast about half 
an hour or an hour after rising will be found 
most beneficial. Those who are obligetl to rise 
very early, should take a cup of cofi'ee or tea with 



thou Id he taken, a. R(*spccting the Jint of iheK 
questions, it may be stated, that voter — either 
spring water, or toast-water, is the safest if it U 
taken only according to the dictates of thiilt* 
Whey, fresh small beer, soda water, and kIimt 



a biscuit soon after getting up, and a more sul>* water, aie c-f service in many case«, as will hv 
ftantial breakfast about three hours afterwanln. noticed hereafter; but fermented liqnori soA 
if exposure to cold, to the moining dews, or to wines require greater restrictions. The yosig 
unwholesdme air, or to any other cnu<e of infection (lys|:eptic ought never to drink any thing bii 
be incurred in the morning, the stomach should be | water, toast-water, or whey. The more ftioB- 
fortificd by cofl^ee or by breakfaf^t. The dyspeptic, = luting beverages will be prejudicial to hira, unlci' 



especially, ought never to travel, or to enter upon 
any exertion with an empty slumach, and never 
with an overloaded one. 

63. As a geneial rule, not more than five or six . „ ^ , _ 

houn $hould elupso from bfeukfast till dinner. I riety of indigestion. Some of the asthenic fUts of 
y^ yduth lad ct)nvkrc8ccnls> tiold f6i p«'twtii\^^^oTn^\i^\t>«i\^VsL«s«bca^ 



durin? states of debility, for which it mav be Vr 

cessary to prescribe them medicinally. Of w 

these, spirituous liquors are the mostinjuri(ni«,U" 

; ought never to be taken in any form, nor in sny vi« 



94*2 



INDIGESTIOX^O/ the Diet and Rcomtw. 



iVia state, particularly id respect of the brain and 
Viver. In dyspepsia, the desire for rent after a 
repast is great in proportion to the quantity eaten, 
the nervous energy being concentrated in the 
digestive vi:$ceni, in older to dispose (^ the ingcsta. 
The state of the mind has a powerful inAuence on 
digestion : hilarity and ease of mind promote this 
function ; whilKt care, anxiety, envy and dissatis- 
faction, impede it. Dr. Caldwell remarks, that 
dyspepsia commences perhaps as often in tite 
luam as in the stomach. It is almost exclu'^ivcly 
a complaint of the studious, the scitenung, the 
daring adventurer, the stock-jobber, and tliesfjecu- 
lator, and of those who, ovcr>exerting tlkeir brains, 
thereby injure tltem. 

69. ii. Of the Diet and Regimen with reference 
to the different itate$ of Dtt*pepsia. 'J he observ- 
ations of Dr. Todd a:) to tlie diet suitable to the 
different states of dyspepsia, are extremely just 
and precise; I shall, thercfure, avail myself of 
some of them. <■!. During the asthenic forms of 
indige>tionti\\e quantity of food sliouldbe reduced 
to the power of disposing of it ; such articles m 
are difficult of difrestiun and weiiken tin! stomach 
being altogether withdrawn. — «. I he patient should 
be confined to a spare diet of animal food, and to 
a restricte<l use of fluids. A bulky n>eul ought 
always to be avoide<l ; and wlien the appetite is 
impaired, abstinence will be frequently preferable 
to the use of Bton]achics. When tlie appetite 
does not fail, which is often tlie Ciise when dys- 
pepsia is produced by mental exertion, the patient 
should cease eatini; before the appetite is alto- 
gether allayed. The tea or coHee at breakfast 
should be taken with v(.-ry little milk and sugar, 
and vei7 little butter ought to be u^ed. An eg<T, 
lightly boiled, may lje eaten by those who take 
tuHicient exercise. 'J'he dinner t'hould consist of 
lean animal food, particularly mutton, poultry, 
game, and venisun, which ougl>^ to be roasted or 
broiled. Uulky ve;^ptubles should be avoided ; 
but mealy potatoes, yams, or rice, mixed with the 
gravy of the meat^ young summer turnip<«, cauli- 
tiower, or French bi-ans, may be taken spariujjfly. 
The least hurtful fruits are strawberries, morel 
cherries, and mulberries; but tlun' should bo enlen 
as n part of U)c luncheon, rather tlian after dinner. 
Fluids, even when theie l<> thiist.Wtould be taken 
slowly, and in small (|uantity, and always after a 
meal. If the digestion or habit rcquiic the sti- 
mulus of wine, old elierry or old port, with an 
equal part of water, should be jireferred ; but the 
quantity of either nr of both should not exceed two 
or three glasses. Twice-dressetl moat, rechuu flies, 
and made dishes, ought not to be eaten ; and the 
food should be masticated slowlv and thorouchly. 

tr ~ • 

70. fr. The kinds of food most injurious in this 
variety of dyspepsia, and therefore to be avoided, 
are sweet, mucilaginous, or acid fluids, and such 
as contain much milk ; puddings, compound 
dishes, and meat pies; new bread, or hoavy un- 
fefmented bread ; compact or fat dumplings, and 
pultaceous articles ; cream«. curds, custards, clwcse, 
and all preparations of milk ; fat meat. ])articu1arly 
pork or bacon, young meat, all (gelatinous parts of 
meat, and suited or Amoked meat ; the less di^^es. 
tible species of tish, and all shell-Hsh ; strong 
broths, gelatinous soups, or concentrated dishes ; 
melted butter, oil, sauces, spices, condiments, and 

pickles; bulky or flatulent vegetables, cspccVdWy 
ctbbage*, waxy polatoes ', pol-hcibs, beans, ]peas 



cucumbers, &c. ; most fmits, whether froh fp 
preserved ; currants, gooseberries, applciy plBO% 
melons, all kiufls of nuts or kernels, and pfcfenrei 
or jellies. Malt liquors, particulariy ale, niiTv 
cider, home-made wmes, punch, and shrub amU 
also be avoided. 

71. c. Regular exercise ought to be taken iatk 
open air ; and the kinds of exercise that bring th 
greatest number of muscles into moderate actJoa 
should be preferred. Crlsus very justly adriNi 
persons subject to stomach complaintSt to exercitt 
tlie upper extremities and parts of the bodj. 
TIkere are several amusements which have th« 
efiect, especially billiards, fencing, rowing, cridd, 
&(!. For females, singing, dancing, skipping, bit- 
tledorc, dumb-liclls, and the exercises recm* 
mended by Mr. D. Walker, will be found Toy 
scrvicx'able, especially when confined to the boMt 
by weather, or when exercise on horseback or M 
foot cannot be taken. 

72. D, The diet and regimen most suited far ik 
irritative states of indigestion differ conwdoaUy 
from those now recommended. In this varietr, 
bland, faiinaccous, and semi-fluid food, iasaiu 
or moilerate quantity, is the most appropmi^ 
until vascular disorder of the villous coat of tit 
stomach is removed by treatment. Sacchtriai^ [ 
farinaceous, feculent, mucilaginous, and acidakMi '. 
articles of food are most easily digested ia lUi 
condition of the organ. Gentle exercise, ugcH* * 
ation in a carriage or on horseback, sailing, swii^ 
iiig, and walking, is preferable to the more exdtioi 
kinds of exercise. After digestion is compIeK^' '* 
tepid or warm bat lung, and fnetions of the surfinii' 
arc generally benctieial. When vascular exflte" 
mcnt is removed, the patient may gradually adofl 
tite diet advised for the preceding variety, begii* 
ning with light chicken, mutton, or \eal brolkt 
with toast or rice ; and afterwards the more digeit- 
ible kinds of solid food may be used. 

73. (.-. 'i'hc wines and hererages heA suilsd (at 
indigestion arc old sherry or port diluted wilk 
etiual parts of water, the finer kinds of claret, 
hock, white hermitage, and Sauteme; buttbeK 
should not Ite taken in the irritative forms of (in* 
p<.-p.>ia until vascular excitement of the villons cost 
of the btomaoh is removed. The diluents BMMt 
beneficial are seltzer water with a small quantity of 
hock, or seltior water with milk or wltey, or iimC' 
water with milk or black tea, according to the 
peculiarities of the case. In the more irritable 
states of tlie stomach, whey, goat's whey, unsll 
quantities of selt/er water, or the imperial drink, 
should be preferred. Wlien the state of the urine 
indicates the im|>ropnety of using vegetable or 
mineral acids, the alkaline carbonates may be nb- 
stituted ; but, when indigestion has induced s 
torpid or disonlered state of the biliary organs, not 
connected wirh inflammation, beverages slightly 
acidulated with the nitro-hydrocldoric acids will 
be found serviceable. 

74. D. Several miueral voters, both natural 
and factitious, arc most excellent aids in the trett- 
ment of the several forms of indijjestion.^n.In 
the asthenic varielif, tl^ mineral springs of CiifloD, 
Malvern, Bath, and Tunbridge Wells, and the 
carbonated chalybeate waters of Spa, Pyrmooti 
Carl.-had, ^larienbad. Swelbach, and j-'.ger, oi 
the Continent ; or their imitations prepared bf 
\^T. $>A\vvvv.» arc generally beneficial. — *• I> 

\ \.\\e \rr\taVue Ua\e% q\ ^"^v^^i^ai^ the rpriogf of 



336 INDIGESTION — Treitmint. 

tulence u troublesome, the means already advised' the decoction or extract of tartncnm ; tbi al« 
nay be prescribed, or those recommended in ' phate of potash with rhubarb; the purified exlncl 
that article ($ 15.) may be employed. Friction | of aloes withcastile soap, &c. — These and g(kff 
over the epigastrium, especially with a stimu- ! mild purgatives may be taken in other combin* 
lating liniment, will also give immediate relief , ations, as draughts, mixtures, or pills, u pn> 
from both pain and flatulence. When headach , scribed in numerous and various tormi in tW 
is present, the treatment proposed for Dyspeptic Appendix, and in the article CoysriPATiox. A 
HcADACii ($ 46.) should be directed. For the judicious combination of bitters with mild mii|s> 
eattivfnea so generally attendant upon this form tives, as, of sulphate of quinine, or '"fpftirf 
of indigestion, the medicines already noticed, or '■ oxgall with aloes (F. 562. 575.) ; the infaiioDof 
those about to be prescribed, or a combination of ■ senna with an;^ of the bitter infunons (F. 206.); 
mild aperients with tonics, deobstruents and al- and the decoction of aloes, with soda and infHfloa 
teratives being given occasionally at night, will of columba, will generally be extremely usefid ia 
prove of great service. '■ this state of the complaint. 

43. After an acute attack of dyspepsia, particu- ! 46. When chronic asthenic dyspepsia ii it- 
larly when occasioned by errors of diet, it is ne- tended, not only by a torpid state of the liver, ImI 
cessary to enjoin abstinence, and thus afford the , also by incipient cachexia, or has given rise Ii 
stomach time for repose, until its organic scnsibi- : cutaneous eruptions, ficc, much benefit will mh 
lity and functions begin to return. After a while, i from the simple preparations of sarza, with liijiM 
a cup-full of mutton or veal broth, or of green ' potasaae or liraiidish's alkaline solution, tnd ei* 
tea, or of coffee without milk, may be ^iven and , tract of taraxacum. If it have occasioned difficsk 
repeated ; or a wine-glass full of nort-wine negus or impaired menstruation, or a state of iDcipint 
may, in some cases, be allowed. But care should ' chlorosis, as often observed in females in Loadoi, 
be taken in returning to a full diet ; and the in- ' the preparations of iron, particularly the mirtn 
junctions as to diet about to be stated ought to | ferri composita, the decoction of aloes being late 
receive attention. In general, tonics and stoma- : so as to act freely on the bowels ; or the pOdh 
chics should not be prescribed until the functions j ferri composita, conjoined either with the pL 
of the stomach are returning. aloes cum myrrha, or the pil. aloes compoiiii; 

44. B. Having removed the more acute attack will generally remove all disorder, if suffideillf 
of asthenic dyspepsia, with its urgent symptoms, persisted in, and aided by change of air, diet, ul 
the remuning aisorder is in all respects the same ; exercise. 

as the more tlight and chronic states of the com- j 47. In tliis form of dyspepsia, the nft^ 
plaint, and requires a similar treatment to them, ration of the digestive functions much depodi 
The third intention of cure ($38.) should now ' upon a healthy state of the * other eicKlii| 
be carried into effect ; and the organic nervous , organs, as well as of the bowels. The funcMi 
energy, the secretions, and the muscular tone of ' of the kidneys and of the skin should be di^ 
the stomach be improved. This intention is to be ! promoted and corrected. The temperature of 1v 
effected diiefly by the diet and regimen hereafter ! general surface, and the exhalations from it, oo^ 
to be noticed; but a judicious recourse to roedi- to be preserved, and the urine duly examiiMi 
cine will also prove of great benefit. The infusion ! in order to ascertain, not only its appeannc^ 
of cinchona, of columba, of gentian, chamomile, ' but the general character of its chemical cos* 
cusparia, CRScarillu, will be severally useful, : stituents. As these vary, or, as certain of thea 
with the alkaline carbonates, and small doses of predominate, so should some of the most efiei- 
stomachic tinctures. Afterwards the metallic tonics, rious medicines, prescribed in the coniplaint.be 
as the Unclure of the sesquichloride of iron, the sul- ; varied or altogether changed ; so should tomes be 
phate of iron, the sulphate of zinc, the trisnitrate conjoined witii alkalies or acids ; and apcrieDtsni 
of bismuth, and the mineral acids, will generally | alteratives be given with absorbents or dcobstraeolik 
be of service. Several of these may be given with 48. ii. 7^e irritative variety of duipepstann^wn 
the extract or tincture of hop, or of hyoscyamus. very different means of cure from those jnatsd- 
Lime water may be taken with aromutics, parti- vised ; but the removal of the exciting cauM ii 
cularly when the bowels arc much relaxed ; and as necessary in the treatment of it as in tbd 
the aifratcd, or alkaline chalybeate waters may be of the foregoing. — a. In the more acute stsM 
used. When there U no complication contra- of this variety, when pain, tenderness, beiti 
indicating cold bathing or the shower bath, it will ' or soreness is felt in the epigastrium, althoigb 
be advantageous to report to them frequently ; the vascular disorder of the villous surface autj 
and when uneasiness at the epigastrium is often not amount, it nearly approaches to inflammatioB; 
felt, a warm plaster will be worn in this situation and erethism, or vascular congestion, at leflt, 
with benefit. exists. The application of leeches to the epigaS' 

45. The most active or varied means employed trium then becomes nccessar)'. In plethoric per 
to restore the functions of the stomach will be sons, a bleeding from the arm should be piefencd 
frequently inefficacious, if the offices of the colla- In those who have suffered from hocmorrhoids,tt 
titious viscera be imperfectly performed. The obstructions of the liver, cupping on the hyp» 
biliarii secretion should therefore be promoted or chondiia, and in females, whose cataroenia an 
corrected by occasional doses of blue pill, or deficient, leeches to the groins may be prescribed 
Plummer*s pill with soap: and the bowels pre- Afterwards a large rubefacient plaster, fomuA 
served moderately open by mild pui^atives, or by either of e(iual parts of the compound |Htcb id 
a combination of them with bitters and tonics, ammoniacal plasters, or of seven parts of thi 
With this view, rhubarb may be conjoined with former with one of the cantharides plaster, shetU 

a/oetf, ^iiaiacum, and ipecacuanha, or wUVi ma^- \>eapuUcd over the epigastrium. Thebhiejiflf 

Desia; the infusion of senna, with ibe inCueioii o( OT\\^QLnLr^.c\iTucT^>k«in«LVi\K taken at bed-line^ 

geutitm; the compound decoction of a\oea, 'vnlVi a.uA a^ miXoL a.^>iwiV'v^^OMfc\aiqram^.^TA<MM i <»l 



351^ INFECTION — Tus EFPzen or. 

of the latter are frequently washed^ so as tu render ' choleni, dysentery, and vifceral dMeamirin lie* 
the air moist; the emanations from the healthy ! quently result, according to the eiisting dispoatioi 
as well as from the sick readily accumulate ' or states of those exposed to them, 
or acquire activity. Feven, dysentery, scurvy, | 24. JS.TheconiaminstingrflectsofunwhdlcaQM 
cryupelas, and even hospital gangrene or phage- [ kinds of food and drink frequently declare tha> 
denic ulceration and phlebitis, will thus be deve- j selves in specific fonna and modei. £rp)iira, 
loped or rendered prevalent. I gangrenous ergotism, scurvy, scorbutic dymitciT, 



21. /. Although there are various agents which 
infect the body in a certain determinate mode or 
medium, — as typhoid and czanthematous fevers, 



by the emanations proceeding from those affected causes concur with this in producing the effiecL 



adynamic dysentery, &c., are illaitrationiof iluk 
On many occasions, however, the ingests coni6- 
tute only one of the sources of infection, or ollMr 



by them floating in the air, — syphilis, by contact, 
— rabies, by inoculation, &c., — yet tiiere are 
others, as arranged a)>ove, which operate in more 
than one, or by all these modes. 1 here are some 
sources of infection respecting which we arc still 
insufficiently informed as to the seveial modes or 
media of their acti jn. A person on opening a ru- 
cent body that has died of peritonitis, may have a 
pustular or erysipelatous inflammation of the skin 
of his handi*, with smart fever produced, although 
there has been neither puncture nor abraMon of the 



Mucous, gastric, and putro-adynamic feven ul 
dysenteries, even when chiefly occasioned by le^ 
tic or di^icased articles of food, or by water coi* 
taining putrid animal matter, are o(\en aided ii 
their appearance by additional causes: wIm 
foul water is concerned in the production of teslic 
or adynamic maladies, animal or vegetable ezu!« 
ations, or both, and unwholesome food, fre(}aeadj 
co-operate with it. The fevers and dysenterisN 
generally developed in armies, in besieged tovai, 
^cc., seldom proceed from a single source of c«- 



cuticle, and if either has existed his life will be tamination only. When they assume h^lv i 
placed in the utmost jeopardy. Mr. Kiernan in- ; fectious and typhoid forms, it will generally U 
formsme that he ha« even seen, from the inspection ' found, that putrid end impure footl and fitter, 



of cases of this description, very severe constitutional 
disorder produced in those who had never touched 
the bodies which were examined. In these in- 
stances, the cfHuvium exhaled from the pcritoncul 
cavity or from other internal parts, upon 6rst ex- 
posing them, must have infected the system. 

22. III. The Effects, ok ihe Diseases, pro- 
duced BY Infection' vary with the sources and 
modes of infection, with the concentration orintcnsity 
of the infectious agents, and with the predisposition 
or susceptibility of the persons exposed to them. 
Certain of these agents produce adetcrmintite efTect, 
or a specific form of disease, paiticuliiily those 



exhalations from animal exuvia?, and from theio*' 
rounding soil containing numerous dead iMdiM 
imperfectly covered with the earth, famine, &• 
tigue, and the depressing passions, first conumiiMli 
the frame ; and that the exhalations from pemM 
confined in close plices, and from tho*« dnttt- 
fected by those causes, heighten still further tbi 
morbid effects, until a most malignant malady ii 
produced. It is extremely probable, that the ■ 
ofa place thus circumstanced, and especially ik 
moisture floating in it, may become so saluratd 
with noxious effluvia derived from these fonnti, 
as to assume a pestilential character ; the iofectioi 



rompris d under the third class. - A. It has been extending to nearly all who breathe it, but beccoh 
supposed, that the terrestrial miasms or mephitic in<; less n>niarkable, as the distance fiom tliefocii 
vapours, emitted by marshes and other .Hources of of in'ection increases. Hence it is, that in large 
malaria, produce only intermittent and remittent, crowded, or populous cities, particularly in $«asoDi 
fevers. Some writers, however, have contended j when the temperature is high and the air humid, 
that liue yellow fever, and even plapuc, also ] and is already contaminated l»y the circuniFtinit! 
spring from these sources, aided by the influence of . which nccetsHrily attach to them, and espjciallj 
high ranges of temperature anil an epidemic state . by exhalations from animal exuviae and bur}iB( 
of the air. That terrestrial mia>nis urc capable of ■ places, the infvctiou<« emanation.-! from the pt^rsoo: 
producing, under these circumstances, pernicious first attacked by the resulting febrile maladie 
or malignant forms of ffver, which assume either a ' heighten the existing aerial contamination, prp(lor< 
remittent, or a continued tyjie, accordinijto concur- . a more marked effect, and more readily spreaJth* 
ring c^iuncs and the state of the patient, I will . maludy in these places than in those differentlj 
readily admit; but that they o(:c.a>:ion either true ! circumstanced. l)uring the pestilence in Home 
yellow fever or plaj^ue, is an assumption founded durinjy 2()"2 and 26.'}, the air is stated by Ersrsici 
on preconceivcl and fall.u'iuus views, which every | and Ckdiienus to hjve been so contjnn'na><-d fcr 
circumstance connected with the orii:in and putho- 1 the emanations from the sick and dead, that tin 
logical relations of these maladies fully di-prove. ■ dew which fell in the mornings and evenings p* 
(See An. Pkstii ENCE^.) sented a sanious or putritl np{>«>arance on tti 

23. That malaria, however, produces a wider i surface of objects. It is chief! v owing to this cir» 
ran;;e of diseustid action, than has been lonj sup- cumstance that when an infectious di'senie l^eromrt 
>o-:eJ, I will allow ; for I agree with much that very destructive, or assumes a |>estilenlial form » 
lus been advanced by Dr. .Macculi.ocii on this crowded cites, it seldom spreuls extensively ii 
subject, and believe, that the less cimccntmted di-tricts far removed from them, althouiih it i*ef* 
states of terrestrial exhalation, particularly in low neially communicated to a greater or less exlrtt 
grades of atmospheric t'.Mnperature, will give risi to the healthy, by those who have left the sourf* 
to several diseu^ies usually imputed to other causes, of infection, and Uy J'nin'ite:^ ; for the circumstanoei 
— as to catarrh* or citarrhal fevers, rheumatism, favourable to the infection are there wanting, 
neur.ilgio affections, sc;iaiica, obstructions of };land- 25. That continued fevers of a low, adyas* 
uhir org;ins and premature decay. When terres- mic. typhoid, or putro-adynamic character. dyftfi- 
tria) exhalations are coneentrated or rendered more tcry, erysipela-*, hospital gangrene, phK»biti^. pow* 
Motive by a wnrm and humid air, bilious \nftam- \)eral fever, diffusive or disorganizing infiamiratiM 
matory remittBatB, gastric or mucouB (even, o( ciAWW ^^iV&^^xi'ivVA diseiaaes enumeratal it 



hii 



354 INFECTION — Development op its Effects. 

from a few hours to a few weuks, or perhaps to i ^- In pesliUntial cholera, the precunory period 
a few montlis, I have stated, that it may not con- I varies from one to sis days, according to my okh 
tinue beyond twenty- four hours in the worst forms { observations; and this agrees with the staiemcDts 
of these fever?, and tliat tlte moRt common dura- i of others. This period may, however, be Mcoe* 
tion is from three to fourteecn days. This agrees 1 what shorter or much longer than now sttted.— 
with some observations which I iiave lately had an True or malignant puerperal fever usually occvi 
opportunity of making^. Dr. Cikkgouy considers I from one to five days after infection, butitmiy 
that the medium duration of this period in these be delayed beyond this period, 
fcvern is ten days. 35. g. The time that the infection of eryaptlu 

.'J 1. r. The precursory or formative period in mea- takes to developo itself has not been accurately 
slci generally continues from seven or eight, to , determined. Dr. Williams thinks that it may 
fifteen or twenty tlnyn. Dr. Hatlman states it to | vary from two to fourteen day.4. In the inctaore 
vary from ten to fifteen days. Dr.GnKooRV from j above alluded to> and in some others that I ban 
eight to twcnly-oiie ilayn. Dr. \Vili.iams re- ' seen, the period was not longer than thirty-six 
marks, tliat the time which this poison might re- > hours. In the various forms of infection pro* 
main latent has l>«:Ln determiited to vary from ten | ceeding from the inoculation of morbid Tnstteiv,or 
to iiixtcen days. Thi.s figrucs with the observutions from injuries during the dissection of receatorof 



of Dr. HritF.Rnr.N and of Dr. HfE. — Dr. 1Io3ie, 
who first trietl the inoculation of mea^lcfi, observed 



putrid bodies, the constitutional cfTects arc usuiRy 
manifested within three days, sometime-^ ia tU 



that the eruption appeared on the sixth day after- courKof a few hours and very rarely after four dap. 



30'. h. The morbid secretions productive of tbe 
various fonns of venereal diseate evince their effect! 
at various periods, between one or t^vo days and im 
months. The gonorrharal affection generally ap> 
pears much earlier than the suphiliiic ; the fonner 
most frequently showing iti>elf fiom two or thra 
days to ten or twelve, — the latter from six of 
seven days to two or three weeks. 

37. /. The virus of rabies takes a longer time ii 
developing itself, than any other infectrous ag«it. 
There can be no doubt of the precursory pi^riod 
of this malady being sometimes prolonf>eil moek 
beyond what is generally believed, altiiough tka 
very long intervals stated to have ela()se!d in sooe 



wards. 'J'he ox|>eri]nents of inoculation in measles 
by Vor.EL, Monho, Tl^-ot, Ci'llkx, Si-iuanz v, 
anil others, furnish no additional information on this 
subject. — M. GuKnsKNT is of opinion that lukiping' 
cough n})pears livi* or six days after infection. I have 
stated that it is <jrenerally from five to nine days, 
orevcnlon;(cr. after exjM>su re to infection, that the 
cough conmience-f. 

32. t/. In scurlft fever , the formative period va- 
ries in duration from one, to twenty or twenty-five 
days. Dr. Williams consider^ that it continues 
from a few hours to about ten days. Dr. Ijinn.1 
uissigns two days a** the shortest period ; Dr. 
WiTiitniNCJ tliree or four days; and Dr. llibEn- 

i>KN and Dr. Frank five days; Dr.JlLACkiiuRN instances are quite apocryphal. There are, bow- 
believes tliat the period varies from four to seven ever, well attested cases of two years havinp 
ilays ; and Dr. AVillan, that it rarely continues passed from the insertion of the virus until tbe 
lonper than six days. The duration of this period ! appoarance of the malady. Instances of froni 
depentU much on t!ie eharact<i' of tho epideiiiio. four to twelve months havinif thus elapsed lire i'V" 
Dr. Maion ob'-ervr:d, in one epideinic. this stage ' no means rare. The .N/jcrlfjf pcrioil of pre moniurx 
nrolonaed to Iwcnlv-live or twenlv-.six days. In a 'in rabii.s maybe stated to be l-.vcntv-one tlav?. 
iiio.-«l maliLiiiint ca.-<i* of the d:><M«e, which 1 re- 1 In the greatest number of cases, the disia^' a[»- 
ceiilly attended, iiife-tion was produce<l by >:onie ' J^eared froni thirty-one to sixty-three day^ afltrS 
of the st'crction from the month (tf a ])alient liavin^f j the inoculation of the morbid secretion. 

been conveyed l)y llieliaiid to the glans peiii< of a | 38. ^tj'ier thf Jirft impression of an itifLciioa" 
dilleieiit person. .Mo.sl violent asthenic intlam- ! auent, until the devclopinent of its t-ffecl", *-■•' 
mation ami excoriation extended thence over the i during the whole of tliis percursory peritvl, tl»' 
genitals, to the i;ri)ins, abdomen, and inside of the j change produced in the economy present* rc: 
liiighs. • tain general features, which are of liie uliuO*tii^i 

33. f. In 5»l<l/^p^r, the dmation of the precur- , portauce to recognise, and to es'in-.atc ari'jl*^ 
sory p;:rio<l vaiies from six, to twenty or twenty- ! The»^e changes are not materially differciit iath« 
one clays. When the. «lis>eMS< ajjpearsin the natural difFerenl infectious maladies : lliey vary, li'jwvvc' 
way, or by tlie medium of the air, Dr. Ciiiiriditv in intt-n^ily as much as in duration ; but \\w\ o'l* f 
tiiinLs twelve days to be then the usual {>eriod. — ' |jossc.'Ss very nearly the suine diaracters wli'*^"*' 
When !jmall-])ox is ///i>f»//ii/fi/, tlie erujitivi* fever always manifest the production of a more or k?* 
commenec> seven days afterwards, but it may he , noxious (effect upon the economy — as deprc**:'^ 
driayed a diy or two lonj:er. ln<l< id, ca-^e* oeca- ofn«Tvous and mental cnertiV, and of a:i tfcc 
sionally aj)iMar, in uhieh this period is either manifestations of life. Tliese maniftslatiun-! 8-% 
shorter or loni'er than th:u now stated. j howi vor, j>everally depressed in ilifi'eren; dti;ref'. 

34. /'. In /</<r.'»< , llio ]Mccui-sory period may be in ilifl'erent maladies, during this perioil; s^i 
vcrysliorl. Sir I'isf'iki- I-'aii kmii ha< nu ntioned ; certain or^an-i cxperierice this t-ffeet more tLifl 
.••ojne ciKCs, in whii'h the attack seemed to follow others, as well as b»/tray a specific or pec'jliar 
nIn:o^t imme«Iiately, or uilhin a few hours, upon njode of aflection according to the nature ef tl* 
til.? iinpre<<sion of the infectious efllu^ium. Some , infectious agent. In tho*e distempers which pro* 
wiiter'^ ha\o stated this ])eriod to vary fr;:m two to ceed from the more intense or cuncealratel 
fil'teen tlnjs, five days bein;.^ its m'MJium duration, agents, and in whicli the precursory periods 
The disoai-e lias oceurred on tlie fourth day after short and severe, the effect prorlund ujwi'Jw 
its inoculation. — Tme ycH w feur usually ap- 1 nervous system is generally immediate arnl re- 

pcan from two to twelve days after infection ; but ' markable. i\ot only \irc the physical funrbosi 

itmny tukc plnve in a few hours after the "imptes- , deYt<i*?A;d and embarrassed, but the mental aid 

tfioa of the morbid effluvium, wlieu couccnimcd. \ moit^ v^yj^stiw^ i^\»»fi»yAl ^sK^iaLcncd or ncarlj 



356 



INFKCTION— MANStR of its Invasiov. 



any cause, during tbe precursory periorl, will not fluidst and elementary principles are given off, 
only accelerate the enects of infcotious agents, which have served their purp<Me« in the ecowmy. 
but also give rise to inflammation, or congestion, There is every reason to infer, that darino this pio- 
or ob!»tru(:tion of some vital organ. This often , ce«is, noxious matters floating in the air, ordis- 
occur<t in measles, scarlet and typhoid feversi • solved in the moisture of the atmosphere, produce 
hooi/mg-cou|;h, small-pox, 6:0. — Dr. Marsh a morbid impression upon the nerves supplying 
justly remarks, that a principal reason of the these surfaces, and upon the respiratory oi^dv 
danger and fatality of fever amongst medical ' tronenilly ; und that this impression is more or ks^ 
practitioners is, that, during the latent ncrioil, they . rapidly tranftmitted throughout the organic nerroas 
make an effort day after day to discharge their i system, — the other organs and general f\&tm% 
laborious duties, until at length they are re- ' of the IkkIv, more immediately dependent upon 
luctantlv compelled to yield; the disease having I this system j^ soon manifesting the efTect^ thuf pro- 
gathered strength in the same proportion as they '■, duced. At the same time, the noxious emani- 
havc made strong, but inencctual, eflbits to resist tions, thus conveyed to the lungs in thecoaneof 
it. A slight illnes^s may be prevented by a strong the respiratory functions, most probably affect tbe 
effort, but a severe one 'u thereby greatly, often ; condition of the circulating organs and of tiw 
fatally, a<rgravated, and this is not the cose mere* blood itself, — both these onlers of effects taking 
ly in resiMjcl of fever, but of every malady pro- 



duced by infection. The circumstances which 
retard or prtjvent the development of infection 
will be cousiderud hereafter, when the patholo- 
gical views here stated will be applied to practical 
purposes. 

44. VI. Tiir. JMannkr is m-hicii Iniictioks 

AND CONTACIONH INVADE: 1 HK Ec(»NO:viY, AND 
TIIHU IMMF.DIATK AND DiniXT EFFEnS, liaVC 

lately excittnl some discus>:ion. And let it not be 
supposed that the subject is devoid of importance. 
For correct views respecting it will lead to the 
adoption of means for the protection of the sys- 
e m, both at the time of exposure and in the pe- 
iod which more immediately follows it, that will 
often prove successful in counteracting its earlier 
effects, or in rendering the course of the disense 
more mild. — A. It is now about twenty years since 
I endeavoured to show, by anatomical connections, 
by functional relations, and by intimate observ- 
ation of the effects produced by the more energetic 
niorbiflc ngenls, that their impression is fir<^t made 
(hicllyiipoii the orfranic nervous sustcm, nUhoujih 



place co-ordinately, or either of them in a nwR 
or less special manner. That certain infecboas 
aironts impress the organic nervous 8)*4ea 
<lirecily and chiefly, is shown by the suddconw 
of the effects ; by the sensations experienced at 
the time of exposure to those agent«, especially to 
tiie emanations conveyed in the air ; by the *o«e 
of constriction and oppression produc^.'d In tbe 
client ; by the frequent and forcible efforts made to 
dilate ur fill the lungs, as if tbe impression <tf the 
infectious emanation had impaired the vital KS- 
liency of these organs ; by the offensive odoar 
frcfpienily perceived attlie time of infection ; by tbe 
sickness, fear, and alarm instantly aftcrwanlt fth; 
and by the other phenomena already enunientcd. 
46. B, Next to the impression and change in tbe 
nervous system of organic life, the alteration^ it 
the riiTulathig prgans andjluids, consequent upon 
infection, deserve attention. When infectionft 
effluvia ore inhaled into tbe lunn, tlie wvik. 
action of the heart soon indicates the depresBoa 
of this system. The impulse of the heart i> fwUf • 
slow, or irregular, and oppressed. The piiiwi* 



the chaii^^c or effect tluTcby productd, nece.-s.irily weak, •icift, comprcsj-ible, or small — soiueiimt? ir- 

soon extends to the vascular system, and even to rcirular. It indicates a want of tone; and whea 

the rin'uhuinjj liuids ; and that this takes phipij the infectious agent has acted with much iiitousit}'. 

when the infection^ agent is in-iertcd into a wound, ah.olutely or relatively, the .sen*ation inipaiictl 

as well as when it is inhaled into the lunffs with by the arler\' su.iije*ts the idea that the conL-Tnt- 

,. ., '11 IaI •I'l'l'' «• • 1 • 1 • ' 



the air. At the same time I on<lenvourcd to show 
that cerUiin agents may more espeeially affo<*t the 



ilily of the coals of the vessel is much impair- 
ed. From this defect of the contraetilitv au*i 



circulation by their iuihiliition or nhsiirjition into tone of the blood-vessels ari<<.'S, during the precuf- 
thc blo(Ml. This is mon3 especially the c«e4e when ; sory porictd of di*<'as<:s produced by the morv caf r- 
the infect ious agt lit is nceiveil into the alimentary getic iiilVtjtions, the remarkable tendency tu con- 
canal with the solid or lUiid in^estn, or when it I gestion of those part* of the circulating systtui. 
ennsivts of morbid secretions formed in an oi-gan ; smd of those vesseN, which are the most" reinnv»r<.l 
or part admitting of their pass;i'/e into the circu- ; from the influence of the heart's action. Heocc 
lution. Thnre can be no doubt of the re-piratory '. the conp.Lstions of the spleen, of the portal ve««l* 
or;;i!ns being i;rn« rally immediately affected by ; an<l hepatic veins, and of the sinuse> within the 
all tho-^i agents which arc <*onveyed through the ■ cranium ; and hence the retarded circulation 
iitediuui of the atmosphci-c. The cutaneous sur- j throut^h the lungs, and the fulm'ss of the aurieU*^ 
face is Rufliriently protected from the operation of innl sinuses of the heait, givinsj rise to the Pen* oi 
the imjjalpiible emanations constituting the most ' opj)re.-sion at the pra?cordia and in the chest, and 
common and the most numerous infectious accents, to the Iretjuent sighing and force«l intpinitiwn'S 
The diiieslive mucous membrane, although less attinding this stage ofdi<order. 
guarded than the cutaneous surface, is still le.-.s 4(j. The effects produced by infection on tl* 
evj.o-ed than it to their action. It is chiefly, hUhni ore not so immediately, or at le:ist not "^ 
therefore, throujih the medium of the resj.irat«»ry sensibly, evinced, as those induced in the funi.'li«'0' 
surfaces that these agents make their direct im- of organs aciuuletl by the organic nervous '.ysH'"* 
])jis;^:on. On tln'^^e *«iirfaces the air may be said ; The blood may, however, be nffecto<l without tk 
to underg'.)n]>rocess of digestion — certain elements alteration being j^erceptible to the »ea«*s; aw 
orportid. s of it entering in the circulation, ccmi- i changes in the appeiinincesof this fluid are usual'/ 
hininif f%,r u tiiuo with the circulating fluids, and ! visihie, before alterations in its constitution ran b' 
tfitmwtinf( their perfect sanguifaclion and a>s\uV\- I iVe.Ucicd by chemical tests or analysis. TIte p* 
tation; and from those surfaces ciTlaiu gaj^&o\i«\ v\\oW^\c^\ eoti^\>\Q\vh ^A^^\\Q^ during tbe earw 



358 INFECTION — Circumstances wincii favouh. 

and directly imprc»»ed, — that, in short, nervous > plications appear from these or other cimn- 
influence, which first experiences the morbid stances, nt the commencement, or during the 
change, in communicating this chan^^e to the vas- course, of infectious fevers. Amonpt theclian»es 
cular system and circulating fluids, soon undergoes induced in the soft solids by infectious acent^t, tiie 
a further alteration, owing to the clian^cs it litis most important, and evidently the most inlimattlj 
ibMiir produced in these fluids. In some mstances, dependent upon the state of vital manifestatioa 
however, and especially when putrid matters arc and the conditions of the circulating and secreted 
applied to a wound, a more rapid contamination of fluids, are the discolouration and the softenin« of 
the circulating fluids may l>e infcrrvil. When mcmbranous'and parenchymatous structures. Iht) 
these mutters, or when morbid secretions, or blood discolouration and sortcning, as observed moq 
in an arlvanced period of malignant or putrid (lis- aftrr death, are perfectly independent of incipiest 
cases, are injected into the cireulalion, it is but dissolution of the tissues, and are generally great 
rea.sonablo to infur that the effects will be more in proportion as the infectious or contap^ons nature 
immeiliate, and that they will be in most respects , of the agent is remarkable. The general loss of 
similar to the morbid conditions characterising; the vital cohesion of the tissues is often io grcit, 
tike advanced stages ot the mnlignant or putro-ady- that even the most firm and coherent stnu'taits 
namic maladies produced by seif-pcr[K'tuating are torn with ease; the substance of the heart. 
infections or contagions. The interesting cxperi- and muscular parts, also participating in the 
ments of Gaspaiid, MutNiuF, Lei'kit, and change. (Sec art. Ffvehs, § 527.) 
Hammond have fully established the truth of 51. Vll. The Circitmstancfs wnirii rAvniR 
these iuferciices, as shown in the article just refer- Inilction are numerous, and it is of importiLce 
red to. ' that they should be recognised and well uodcr- 

49. C. The morbid impression made upon the stood by the physician. 'I'hcse circum?taac«3 
Clonic nervous system, and the change induced may bo grouped — first, into those which are 
upon the circulatmg organs, by infectious agents, imnnsiCf which concern the individual, or are 
nec&sairWynffcct thesci^retions andexcret'ums. As proj>cr to the recipient ; — secondly, into tho« 
the secreting and excreting organs are actuated , which are extrinsic, or which concur or co-operate 
chiefly by the organic nervous system, and as the with the infvclious agent. — «. The circum- 
vital manifcjitations of this system are remarkably stances proper to the recipient of infection are 
depressed by infectious Hgont-*, the functions of ; numerous, but the chief only of them can li'*:« 
these organs must conseciuently be more or loss receive particular notice. There is a stiscefititni'tH 
impaired scon after infection. It is chiefly owing ' to infection from birth, which, in respect to ttmn 
to this circumstance, that the blood becomes infections, diminishes with age. or is entiri^ly a- 
altei'ed in the progress of infectious diseases, i hausicil or destroyed by the disease which it pro* 
In the article already noticed, T have fully i duces. This destruction of the susceptibility to 
shown that the imperfect performance of the infection is remarkable, as regards the exunthe* 
functions of depuration is a chief cau««o of the matic contagions, yellow fever, and hooping-couL'b; 
morbid states of the blooil ; and that, as these and, although it i» not universal, vet thcexwp- 
functions are impaired in proportion as viud power lions are very rare. Jn certain infectious maldio, 
is diniini«ilie(l, so must llio socretioiis and exere- as continued and typhoid fevers, the suscejitil.-ilitv 
tions be disordered both in the early and in the incieases with the projrress to pubeilv, anl Ji- 
advanced sljiges of infectious nialadics In the mini<hcsgraduallv from the iwenly-fiflhortwi'ity- 
form IT of these stagts, even the periiul (if preino- seventh year to old age. The danjer, huwovcr.ia- 
nition, the di-'order of then* functii)ns is often ' cic:iser^ with this diminution, if infection aeiurillv 
manifest, but they are diininishc<l rather than ' taki-s nl;u;c. Allliou^h typhoid feveis flo i. 'I ^a* 
vitiated. In the tidviinced st;ii;«.<, thvy are. j)ro- tiivly txlmust the siis^'cptibility to their iiilu'tioj, 
minently vitiatetl as well a-* diminishetl j nrul they manifestly weaken it. When a ]:irs.'«!i !»> 
Komelimes, even when the vitiation i-j most remark- escaped infection, upon the first or the r-irli-.r 
able, they are suriieiently abundant or even re- exposures to seveial infectious muladie-, !•«. «'■' 
markably copious. generally continue to poiset** an irnmuniiv, units* 

50. I). The alteniti.uis pr-duced in the Sift solids circumslaiu'es should occur to inercaM- his pit-i^- 
by infection jiie tlie latest in the procession of the • position ; for the infectious emanation proilaCfJ 
conse(|uent morbid phenomena, and vuiy remark- ' more sensible and marked eflx;et on the ceonoiuy.o:*. 
ably with the nature of the infect iou< agcut. Some the tir^t ocea»ioii of exposure to it, t!ii:ii suIn- 
of thoi«e agents pro«hiec certain determinate or (lucuily unless long intervals have ehip^nlbt-t^iV! 
specific eftecls upon the ti».>u«'S. Thus the efllii- the period? of exposure. It i.> thus that scuni! 
vium of sniiill-pox aflecls liie skin and naico-is members of the same family so often es'.ajH:-, ?i'-- 
surfaces especially; ■ that •)f searh-.t fever, the ' withstanding thereat are labouring nndtrinfocllou- 
throat, digestive mucous surface, skin, and the maladies, — the susceptibility to them dinjinisJiin? 
membranes of the biain ; — that of measles, the ■ with the freciuency of exposure, unlrs-* cotici:i;i!i'» 
respiratory and cutaneous surfaces, \c. ; — that causes or iu(Iuence« reinforce the infectiu, luent. 
of plague, the lyinphatic system and glandular 52. The kind of susceptibility, u^ich ili?;"--' 
orjjans; — that of cry>ipelas, the inte.;uinents an«l to infection, varies much with diflVrent iatVeji-'j' 
cellular tissue; — that of syphilis, the absorbent maladic*. In some, as typhoiil fevers, yuMi 2-J 
glands, the periosteum, the >kin, bones, and joints; the prime of life are predisposing circunr-siAnri?; 
sind so on, as respects most kind^ of inte<Mious and yet, fear of the disease, fatigue, exhau-ti-'^u. 
diseases. — These alterations are. lu)wever, much and other causes altogether of an opposite cm* 
inod/Zifd, or additionalle=ions are developed.by con- meter, have a similar influence, nnd concur »=i" 

Bvcutivti cliaw^cs or influences; by tUeten\\Hirvv\\\eui, it. In others, as yellow fever, the seasoairij;. |>er- 
pivdiupw^iitinn, or prcviou** disov<leT of lUe puVienV-, w'vevow"^, "^wSi wwXv^w^vA. <'Q\trs of warm cliti-atcSi 
or even by tho ta'atnjcnt, »-as whea cerlam com-\vuTsoTVA\\\\WY^xft^Q\\\\^,MA^\^>fcTM»X.«ho3t 



360 



INFECTION — Means op Protection rnoif — DinNrEcnoa. 



to huvc Ihc air and clothespin which tbeytn era* 
tincd, frequently reuewed,and the morbid efflnvim 
removed or counteracted, than to be subject to iti 
concentrated influence during the course of the mi- 
lady. 'Jo dilute, thereforo.orto destroy, the infccdsH 
(iuating in the air, or attached to any other me<fiaii, 
is a duty we owe both to the sick and to Uic hciltby. 
62. a. Amongst disinfecting means, a J^fi^ 
tion of pure drtf aii'f and the abbtractiou of iD 
sources of humidity, are the most univernlly fac- 
pcriod with reference to any infectious mahidy, neficial and apphcable. These alone picrcM 



itself, probably, loses the power of tninsmitting a 
malady, as soon us convalescence is so far esla- 
Mishcd lis to admit of free cxcicisein the o]M.'n air. 
Probably a fortnight after the commencement of 
recovery from most infectious maladies, the power 
of spreailing them has ceased. Where a disease 
hos been communicated at so late a period as this, 
there is every reason to suppo.?c that the clothes 
have been concerned in its communication. It 
however, most di/Hcult to assign a precipe 



IS 



as it!« duration will entirely depend upon the per- 
sonal liabits of the individual, upon the ventilation 



several maladies, particularly those which prKcel 
from the sources of infection, ranged under the fiot 



and means of purification resorted to during ill- , and second classes of these agents (§4.), frornim- 
ness as well as during' convaleACcncc, and upon the paguting themselves ; and when they can he nillf 
care taken with his cluthcH and person. Amongst , enforced, they prevent tlic cxtenuon of moft i 
the lower claisses, infection probably continues j those distempers, which always proceed from tp^ 
longer to attach itself to the person than the cific infection and contagion, uluitever maybe. 



|>eriod now nanieil, owing to circumstances 
peculiar to them ; and there is every reason to 
lM?lieve that it may continue in their apartments 
or dwellings even weeks and months alterwanls, 
unless disinfecting means be carefully employed. 
60. /i. In many situations, and in several dis- 
tempers, the chances of infection hti fomite$ arc 
much greater than by communication with the 
sick. — Articles of liedding, feathers, furs, body- 
clothes, bi.Q,t which have imbibed the eflluvium 
of the aiTected, readily transmit most of the in- 
fectious diseases of this country, as well as the 
jKistilential maladies of other countries, to very < 



the sources of the morbid effluvium or emanatioB, 
dilution by a free ventilation will either weaken er 
destroy it— at least, so far as to cause it to £ul it 
produce its usual effects. This result will In 
more certainly obtained when the air is dry. High 
ranges of temperature, by increasing the hamdi^ 
of the atmosphere, favour infection, if a very ro 
ventilation is not preserved ;nnd cold, although p» 
venting infection when there is a free circulaiia 
of air, often also promotes it, owing to the meui 
used to prevent currents of cohl air. This it fic- 
I quently evinced by the evolution or propagalioi 
; of infectious diseoses in the close words of li» 



I 



dltlunt parts. It is astonishing, how long woollen j pitals and other places, during winter and spring, 
and silken bed and body- clothes will retain the 63. b, Far/mis men if i have been resorted to ftr 



the destruction or ueutralisatimt of infecliaus r«» 
nations, especially during the prevalence ofd^ 
structive epidemics or pestilences. In tlic ddin 
to establish the efficacy of recently iutrodaad 
disinfectants, the older moans have been uodeseir- 
edly depreciatetl. Allhou-^h the former arv tbe 



eflluvium, so as to affect the healthy by it, when 
closely packed together, or excluded from venti- 
lation. The animal miasm, which the clothes 
worn in dissecting rooms have imbibed, will be 
seiihibly perceived many months afterwards, if 
they have been put in a cl(»se place, immediaiely 

lifter they were saturated with the foul air. The ' mo>t etficacious, yet it follows nut that the latkf 
necessity of subjecting these articles to ablution, ■ were devoid of all disinfecting powers. The ad- 
to free ventilation, and to other means of puritica- I vantages derived in former times from IvKii^itif* 
tion, is sufficiently obvious ; but, by the lower by camphor, benzoin, myrrh, tar, and terubiiuln* 
classes, and even by other pt'r.-^oiis, all precau- 
tionary measures, even those which merely con- 
sist of common cleanliness, are most HugitiouAJy 
neglecteil, althou<;h uinon^si them thos<; measures 
are tlie most recjuisiie. The crowdt^l, low, clos^c, 



and dirty state of their apartments, and the ne 
gleet of ventilation by tlieni in all circuiuhtnnces. 



nate substancL'S, and by numerous an>niai:c, fra- 
grant, and stimulating drugs, were owint; to men 
than one circumstance. These means not ou!r 
inspired those who used them with confitkacc, 
but also in some measure neutralised the up*.rJtico 
of the infectious emanation. The fuiik* iron 
them, and fiom other exeitinjr and fnu-PdiitMil" 
ande^iK-'cially diirinj* di.-cn<e, tleniandastricteren- I stances, often counteracted the imprcS'«ion n-auk 
fnreement of puriticalion, or disinfection, ainong>t i by the morbid emanation upon the nennus»}>tcm, 
them than clsewiiere. IJefore articles from tliem ' by pieventing the depression it would otlu-mJ* 
or other infected sources are introduced among>t I have produced. On tliis account they m:iy still 
henllhy j)redisposed person**, they should be sub- j he re»-orted to with advantage in M)me tinum- 
ject(.d to the disinfectincr agents about to be j stJinces, paitieularly in cases of casual or ^lhlIl 
noticed ; and to the perilalion of the air in suit- . exposure to infectious emanation^, or whiiiiti* 
able situations, or in places from which the public desired to counteract those which ore the k^ 
•nre exclndiul. | virulent and not generally difTused. When ju- 

61. C i)«iw/i'f//W. — During the continuance of dicioiiply employed, many of these substjnct.'S 
an infectious niiilady in a family or place, it is the aid the recovery of the sick, especially wlu-u the 
dutyofthcinmate<of the one, and of the authorities 



of the other, to put in force certain nietnures tf dis- 
infection; particularly when, owing to the general 
prevalence or nature of the malady, it may not 



disease is (ittended by much depression «>f vit^l 
power. Until the discovery of i-,Ai>.\niiAigrt'* 
disinfecting fluid, and of the uses of ihe chlon-Je . 
of lime, they were the chief means that could I* 



be deemed retpiisite to remove the sick to places employed in the chambers of the sick ; iKute 
suitable for their seclusion and tnmtment. In all which are next to be noticed, Ucing, fromllnar 
circumstance^, however, disinfecting means should acrimony, suiteil chiefly to uninhabited houses. 
Ife employed, ns tending, not only to protect the 04. c. Acids have long been in use fis di«n- 
healthy, but nlno to aid tlie infected. Vot \\ "is oV)- * feclvi\v; av;en^, under the impression that tl»«y 
v/ous, t/iat it is much to the advantage oCl\ieVaVUit\ ^osf^!«& vW \pco^\V<j q>\ 4d^<^a\^siog iafieclMV 



INFECTION— PaKArTJOK* j 



m 1NTI.AMMAT10X— I'MutiLM*. 

ulxxi.p.-^' UHl]:i..»vlmlxxxi. |i!>J— KlU'. En- sin. ]-il._ jr.OdPv.Chfninl uiI'PIiIIm 

n'W Mudoirti. li.lL BitL l"-.-!. — (;*/i,iri», ig Jmm. nuin'nilnzNitnuitlxt.hhKr. '|jinil.»i> I'll!, — i. a 

:<>ii.'r'.di'-M-.Mi-Lu.m.l\1iT.|>.-^— eiv.ff^iJ.D.rt. (,„•,■.« .VTnMV.Trj.l. .U'l M'>iH>.il.'<lf-iii(mcT|-AU'. 

<■ Ui"l. rrjl. [ V. V*r. I■'^^ — Ztr.-.-H.lif.nt Pu'-. df< ■■ci'vniir k'< ('nntHiiin^ n •I'm imHiT lii Pni. 

IfJ. i.J>.i. ii. l/iid. l-v;{, — J. /'.».«u«,liil.i>fTl, un... I>iii.. an.;t, \ .il »1. l>ir.'. funij hy H. lliU. 

'.II II.;- '-.i.:'i: -.Vait/m Mnl. «d. !)"•'. '■ !-.T.isi Ij.ikL •111. !■>•:.-.(■. .Vit.'r.lhKarkxiilhpNcrrw.l* 

::.— V-u'. ,-f-^,iii>I^.t.'li.ii[^ an: .l;ril,I- i.r '•- H-l Mi-ti:< irf •uiinrc-i' : ('• RMnimH rnvn. tjuid. 



X4. — .V,«i.v.,l"i. V. 5.11. \iv. — J A'.ii^, I h. «. rir.;. In.itimip. Kri.iiu l-iJ — J.: 
— (.-..rHiI *.K,j. I)e l|rj-vrvjii.JW rPL--.l.i.i-i i! 1].. II.«Tir.n<'r.tl>»l'''««-r Mli 









, IhlWr^u fj;n etj<«.k7ii» M<i!i.. ,ii, l-|-,_.( M f („«,,'.'. l:.i.i.itu>j!:i. ill- lAhnt. 

I'l^li.tiiliiB, ht. ^rf|^ M.i. l.-i ■iMAn.l.'liMkitonKrjiiJi.itrn lVv*p.-i'i I" l.— <irtt 

Xi^l..r'W. l^-wL*. -Ilk 1 '■■■r*' nru-h.-;.,-!.!- :li-r AiiXi-kiiklo KtuiLht-iltii uml ilj 

ili'Mjii iTli I'l dvr Z"il ihclVrtih'U ,„4|y. fi.lHr. Iti'riln. mil W'I J. 1'. XnW*, lectin t 

.ui.rU l-it tW hU^ ibl siL !».-. i_ Mi Uiin-iriiM-n » »l.i.«t iiT .V. (V«|* 



II !.( Uvr 



flirilllT ll.-tirjTOflllCl'ljfll.'. I. -_ -,-„-. -ILII ail r..ii.iii..i.H-.i ■■■ <M< . «.™ .~ .^....._-. . 

J.'^«... |li-.if"Iii; i:;il'r.-.iiJ..-awdrl».*tM,(.m. i,,„i ^, i«,-i_k.„r,. „i »,.„. rfs 'Hiilii. Iw.-- 

Ui E Jl.inilif in I'jl riBifc nr. IV, H-i I... — //. ,.u.. s. l-ln., n Jl.'h. Ili.i. p. s". in. p. I%T. — l'. 

fAVJj:. li.'iTiirhl ui>.[ lUil.i.r^vii, »w ^^-n Y'" •'''""' (l«W. TjIk'IWi-'Iic Allwi.Kini- Imrlwuiil nir V, 



r. II jr-" 



i.j.i, V...U t:^.,>. .^ . r.iiMJ. HE 



,1 1 .«._ d". IlA,s,i-iih He \..-fiiitf, lie .1 ,-. n „,j. !>-,. Hini...! junM lUiri-hiTniKm n^ 

!,(» i.mirf.n 111 A.ic >Ti«MiiiH..ii-i^v.:.-ai f,i,u,„„„.l pcmii Ai.-!r H. nnil llf.^. KMiil.hrB.iv 

111.. SJir-li ilfliiMii lYVv.M.il.. • .-UU- ,i,.,„. .,,1 vi"— /, I'.ir .. M..MI.1 lir Suit* K f 

SlaU Uiju.". »:.■ ri 1*> llnuOBiBkii -In. i^,„.fl,,, II „„~ti....... ^,. |^r,M;in,. ;«.|i.— '» J 



3fiB INFLAMMATION — PiiEM>ai.xi cokstitctixo Sthesic. 

ri^taliaa or the primary chinjie io the m^ntc ! >di1 of the colDniiDg g1aba]« into a Krin of 
ntrve-- of the part, — of ibit change, which in- ' veneli which rlJJ not formerlj admit them. The 
durei the vitaf eipansiun. or lurgocenee of the blood also, during the Mhenic itate of inSam- 
cnjiillary ymmIs, and the coniec|ucnl incrcaMd mntion, becomel Hmewhat moreflDridthan usual, 
iufliiiofbtood. The tnortfld sensation ii ■ftcnnir'U i in ihe eaaUttj reiseb. The redaes i* generallj 
Inrrea'eil loarlua' pniuby the ciicumstancea just , gresleil id the centre of the inSameJ part, or in 
itatMi (i T.)> and hj the'eiceuive expangon and , that spoi in which the irritation originated ; but it 
tension inking place in that part. It flilfifrs inMve- ' spreadi more or leu, and ii gradually hitt in the 



3TD IN'FIAUMATION — ConrmmcncjiL SmrToia or Snixic. 

ihit or wTi >ii'] \>tMinc pull. It U iocaaH- | lr,c ioRtintii liuDr. mi fiom ibe iwtllu^ ud 
dcrklik in iiUfWa, l.biu-iTdrliU^iiiiu-, a:id mkim- n^rhiDlcal obstruclioD thtrebj produced. 
Lbuisi, kf.d ii liirilly ajipimcit ucul lL« n.biud 10. 1 tie itir<V>nin; it coanfcicd wilh ihe ob- 
(ntiiin h i ClaliiiUtd' (of "itne lin.c. In ciillulai, ttnictioD lo tbe return of lilood, paiticularly (na 
Hiuchn-, kii'l pAruictivniilbiH li-ijtsthttn'tll.ii/ ine Mpaodtid canlianr*. ialo tLc veiiu. Il H tjlt- 
inruly >n-l<nn-id*nblt. In cutain (iiirt-,i> :ii •iLfi^iwUf wilti the pul^, ind ucaiuedby ibc in> 
ctllulu tj->iv: IkiiidiI duiin liy apobturoi.r ti- j^ciioD of blvol into the put on auh contiaelioD 
pui'liiii-i, ■!.•! in (he intKthkl «tru«iur« vl iirEaa/t i/( tiit left venlricle o( the heart. It iociBUKi 
■Bmiuhil'd bv libriiii* or unyiti'liTi; Hitn^naatt, aod iniiJcn tLe pain iiulsitile ] vbeo it occun it 
Uw -rti'liin:; ■• le-i, oi muir^nly dcteluj-ed ; an adiuuceJ »la^ ol inHatDmation, il i* luudij 
IbR pKVUK tnui oRTiiiaikadrHlniitiiD^ tiieelfu- HWDlaiioKcd by <nppuration. Ii it increaiedby a 
uun atfl tiid <:(}>aniibii ut llie cij^iUnei. Uul, dtyta-i.ae patiiian ut tl.t inflamed part, and bjr 
wfaKK tbs m'irljid actiun in inuti'^e, the pratiUK HbatettrcithcrabiitrucltlhtrclutDor blood TraM, 
pvtK riMita « UHnt iliirck^nK mitt of teo-wn, orfavourb ihel1o»oriita,ihai«alof diieate. 
Irtlemijiii tht funrliun> of the orpn, and Kime- r 31. B, Or iiiii LnciL AppEJiHA>ri> jima 
limM tiven ihu eirvulaliaii in i[, ihrrcby de- Dkath. — Cenain of the precedinfc local cba- 
Mrayinii itt vitality aiid occi»anini( dinolution. rHclcri of ioHaiDniatian necettanly dinppearwilh 
When tlie nubMaaee of iha bntn i* inliained, llie tctminalion of life : and the reft, af (vdncM 
the natiin; of tl« rircuUlion, tbe ^real divi^un and Hrellin^, either vanish, 'or temaia for tomt 
Rnd tcnuiiy of iu ea|iillatie<, ami the anyield- lime ufterwaidiv^Kednnt doe* not slniiyieaDtiDtie 
inn nalun: of iu surrouniling structures, coni- ■ after deaiii ; il* abrence, thenfore, ia no proof thai 
bine in prcd'Ot il from Lceoniin^ much (woUen. I inflammation had not elided during life. Iti 
Vet there i" every reuwn tu lielieve that mure > preience alM>. pott morltn, i> not lulKcieot eri. 
or le-w <>iirvllin:r actually orrun (KC art. Ari>- | dence of iti dependence upon lliia catite. Alas 
pli.xv.uihI llntiv — /H/JunwolidNof). and that - early ita^ of inflammaliiia. and before the capiU 
Ibf pte^iire nn the inllanied otnan. occaaioned ]aiie< have IotI tlieir vital tone or contractility, 
by the unyieMinK jiam 'umiundin!; it, put* lisr , and before much Krum or lymph haa been effuwd, 
to the niofp daniKniu-i *ymptom( ubwrveil in the redneu |!eneral1y diMpjiean alter death. Eita 
•dvaaei;(l|Ho^'rc<i<of llieili>eaije. ! when much elTuMnn of fluiil, and other cbaogef 

14. r. The J'ltHftiiiHi of an inflHined or^an, conwriuenl u]ion the niorbul vaacular action, bata 
ipwuH, or part, arci a* Mr. Miini;Ai ha>i rery ' taken place, ilie blnod may have entirely foiaaken 
justly ninli-mlr I, mnrc or Uu ■liM)r>lvTed : and I thu vesieiri befoic IIip parb have been examined, 
may aiUli that lln' diumdcr is nnr nf the euilieht i W here redneiu) actually eiiats, much diwriminalioB 
nlii-naiiwna lu- I'umqilui'til* nt tlie niorbkl action, ' i* neceiwry to iletvrmine, vliether or not it tu* 
iun;; UMiily cu-inmniui with llie changi^ in the [iroceeded from inllammalbn, ur from a dapend- 
tiTKaiiic UiTvciu- pufn^r, on wliirli lli!<< actioD de- enl pwiiuun, nr from tratundation of the colour- 
pemld, Tbe di-turliaiii-i- of tlie fiinction< it jje- r tn^ mailer of the blooil from tlie vecneU, or from 
nfially iti|ini|ii>rli<m tothe viiiluncriifth'' ili-<ea^e. ! ini^i|ncntilL-compii¥itiDn. It may ariiefmm eitlieroF 
If tin- infliiiiii'l ]i«il p-iforiiiKn •rcrrlini: function, ' then;. In mauv raw*, two or mora cunibme Id 
the H'l^'tiiiti ii vilhvT ihminisheil, iiiirrannl, or ; nruJuc- il : n 



372 



INFLAMMATION — Chavoes obsebved is toe Blood m SrHzmc. 



no Mgns of inflammation could be detected, and 
the internal viscera were quite bloodless. When, 
however, serous and fibrous structures are in- 
flamed, these states of the coagulum very gene- 
rally exist. During acute inflammation of cellular 
and mucous tissues, they are much less frequently 
observed. When compound or parenchymatous 
structures are inflamed, they are met with chiefly 
in certain stages and states of ttie disease. When 
an important or vital organ is inflamed, and espe- 
cially when the patient is plethoric, and the circu- 
lation oppressed, these appearances often do not 
take place until the vascular load and oppression 
are removed, and the circulation is rendered free. 
There are various other circumstances which affect 
the state of the coagulum in acute sthenic inflam- 
mations, but they are noticed in the article just 
referred to. It is chiefly in the venous blood that 
cupped and buffed appearances have been seen ; 
for the occasions of noticing tliem in arterial blood 
arc comparatively rare and unfavourable to their 
occurrence. Tliey have, however, been met witli 
in arterial blood by Gordon, Gendiiin, and 
others. 

26. The coagulation of the blood, and the origin 
of the buflV coat of the coagulum, have been so 
fully considered elsewhere (see art. Blood, and my 
Appendix to Rich era nd's illementt of Phyiiologii^ 
p. 638.), that I need adduce but little further on the 
subject, than to state the facts ascertained, and the in- 
ferences deduced, from my invcsUgations, and pub- 
lished in 1824, in the first edition of the Appendix 
just mentioned.—- The blood during life consists of 
serum, holding in suspension small regular and 
insoluble globules, each of which is composed of 
a central colourless spheroid corpuscle, and a 
coloured envelope. The latter always continues 
to surround the former during life; but, as life 
departs, and as the motion to whicii it gives rise 
ceases, the attraction between the central cor- 
puscles and their coloured envelopes no longer 
exists, the one completely se])urating from the 
other. The central corpuscles then obey the 
force which tends to unite thorn, and form a net- 
work in whose meshes the liberated colouring 
matter, now detached from those corpusclos, be- 
comes inclosed, and thus the coagulum is formed. 
These central corpuscles, in uniting into filaments, 
or other forms, constitute the fibrine, which, as 
respects its constitution, is probably only a modi- 
fieu or more highly animalised albumen, which 
abounds more or less in the serum. When the 
coagulum of the blood is exposed to a stream of 
water, the colouring matter, detached from the 
central corpuscles, is washed away, whilst the 
corpuscles themselves remain aggregated in the 
form of fibrinous filaments. It is the various 
forms assumed by the aggregation or mutual at- 
traction of the central corpuscles, in relation to 
the separation, deposition, or entanglement of the 
colouring matter, and to the ap}>earances of the 
serum in which these changes take place, which 
constitute the phenomena of coagulation, and give 
rise to the appearances of the blood characteristic 
of inflammatory action. In addition to these facts, 
the following inferenceSf as to the causes uf the 
phenomena of coagulation, may be abridged from 
my notes above referred to : — 
27, I, The globules of the blood possess a 
rotatory motion during life, this moliou conUnxxm^V < 
uutil shortly before coagulation takw v^aw, — %\ 



This motion is the consequence chiefly of (he (hw 
gimic nervous or vital influence which is exolid 
by the ganglionic system on the heart and blooi- 
vessels, ai^ which is partially imparted to the 
globules. —3. 'Hub influence thus preserves li« 
blood in a state of due fluidity. ^-4. The fluidity 
of the blood is hence a vital phenomenon, or pi»- 
perty tlerived from, and depending upon, the rittl 
conditions of the vessels in which, and the orga« 
through which, it circulates ; the vital condiSm 
of the vessels and organs depending, as shm 
elsewhere, chiefly upon the organic nervous inlia- 
ence. — 5. The cause of the coagulation of tte 
blood is not to be found in external agenciei, InC 
in the loss of the vital influence and motion of iki 
globules, proceedmg from the sources just taapei 
— the power exerted by the ganglionic upon ill 
vascular system.— 6. The presence of air,pulh 
cularly the oxygenous portion of it, and seTOil 
physical and chemical agents, hasten coagalatioi^ 
whilst others delayer altogether prevent it.— 7. 
When coagulation commences at anv point of ■ 
mass of blood, it is rapidly propagated ttirongliHl 
the whole : rest favouring coagulation ; whilst ■•• 
tion delays or prevents it. — 8. The heat of lift 
body and the strength of the circulation an Ml 
causes of the blood s fluidity, but are both reffhi 
of the same cause, namely, the vital energy of Iki; 
vessels, and vital endowment of the globnkiifj 
the blood : botli are co-ordinate ; and both, aivdl] 
as the phenomena connected wiiii coaguktiaikj 
are dependent on this source. — 9. CoagalitiMi 
occurs sooner in venous than in arterial blood ;i#| 
coagulation of arterial blood is still longer deU^j 
if it be prevented from leaving tlie arteries.— Nt 
Coagulation takes place the sooner after the bU i 
is removed from the vital sphere of the 8ysten,di j 
weaker the vital energy to which it was subjedrf 
whilst circulating in the system. -^11. The weito 
the vital energy, and consequently, the quidHr 
the coagulation, the more lax is the coa^ulia 
which is formed. — 12. Coagulation i$ more slav, 
and the coagulum more firm, the more eaerfttie 
the vital action of the vessels. — 13. As the ceaail 
corpuscles laso their coloured envelo{)es soon lAv 
their removal beyond the sphere of the \ital iufls* 
ence of the vessels, and as this is the first potflf 
the act of coagulation following the loss of niOW 
of the globules, so it may be inferred, ibit the 
colouring matter continues to surround the ccotnl 
corpuscles in consequence of the vitality enunii- 
iu^ from the interior of the ve&>els and eodowiiS 
the globules ; and that the separation of the ct- 
louring envelope from the central corpuscle is tke 
result of the loss of a portion or of the wboit 
of that vitality, and of the rotator}' (1.) nolios 
which it occasions; and, as the loss of vittlitf 
may be reasonably supposed to be quickest whrti 
it has existed in the lowes^t grade, the separatioBOt 
the coloured envelopes, and the attraction of ibt 
central corpuscles forming the fibrine, will he the 
quicker, the weaker the vital energy, aod im 
but the coagulum will be the rooreluo' 



verm 



imperfect, as shown by the facts already sutftl 
(10, ll.).->14. Although the loss of the nU^ 
tory motion and of the colouring envelopes of Afl 
globules disposes the central corpuscles to aitratf 
each oUier, yet the attraction is weak in propcnlioi 
to the depression of organic nervous or vital pow 
e.udov<\vis ihe vascular system at the time ito 
\.\i^\AQ^ \& ^%\x^\!^\ «a&ii \u lome inflaooi- 



374 



INFLAMMATION — Stubwic — CoMPLreAiioiw^TEiiinirjiTKnn. 



^ilar effect is fayourcd by parts which are na- 
tamlly va!«cular, and supplied abundantly with 
nerves, or endowed with high sensibility, and 
especially if they be placed near the centre of the 
circulation. On the other hand, the melancholic 
leucophlegmatic, and nervous temperaments, the 
acrofulous diRthe^is, an advanced perio<I of life, 
and the female ^cx, prolong; the progress of in- 
flammatory action, and cause it to assume, eitlicr 
primarilyor consecutively, a latent, lan^id, ormild 
and chronic, form. Structures cndow&l with little 
vascularity, and with a low grade of sensibility, as 
tendons, ligaments, fascia*, nnd bones; also part<i far 
remove<l from the centre of vitality and of circu- 
culation, as the extremities, are most prone to in- 
flammation of a slow and chronic character. 

34. The patient's habits of life have a remark- 
able influence in determining the character of 
inflammation from the commencement, — in fa- 
vouring the passage of the scute into chronic 
disease, and in disposin;; the lutter to assume the 
foritaer state. Full living, and the use of much 
animal food, or of exciting and intoxicating li- 
quors, have these eflects especially, nnrl not only 
prolong or aggravate the morbid action, Imt also 
cause its unfuvourahle termination. Similar re- 
sults arc also pro<liice<l by injudicious treatment ; 
by exposure to a close, miasmntoiK, foul, or un- 
healthy atmosphere ; by certain epidemic consti- 
tutions of the air, depending upon electrical 
conditions, or other circumstances; by mental 
anxieties and perturbations, and improper or pre- 
mature exercise or excitement of the functions of 
the part aflecte<l. These not only prolong or 
aggravate acute inflammation, but also render its 
terminations more unfavourable than they other- 
wise would have l>een ; and cause sli<!:ht or chronic 
inflammatory action to pass into the acute and 
active state. 

35. The circumstances just alluded to render 
the duration of sthenic inHammsiiions ipiite in- 
determinate. Tlie active and acuto states may 
continue but a sliort ]>eriotl, — but two or three 
days, or oven not so lonij, until one or other of tlio 
terminations about to be <ie'«cril»eil takes place : 
and the slight or chronic state niav endure mont!is, 
or even years. Between these extremes, every 
intcrme«liate term of duration, ns well as grade 
of action, may be seen. The «Iuraiion de]>ends 
chiefly uj)on the organ aflVrlc-d ; ucule inflamma- 
tion in vital parts, esjweially the stomach and 
bowi-ls, terruinatintr niost rapHllv. 

36. iv. The ('()>ii»r.ir.\rioNh of sthenic inflam- 
mations (les«;rve some notice, althou^ili hitherto the 
subject has received no attention from patholo^ir.i] 
and practical writer**, owinpr n);itiif<'»stly to tlie 
** verlni mff«,'/.Wr»V' the dictum of Hcmiu, — that 
two disease* cannot co-exist in tlie same frame. 
Thi^i, however, does not apply to inflammafions, 
and lianlly to other iliM'as<'s, not except iu^ evtm 
specific contagion'. 'I1ic one morbid action may 



freouently applies to inflammatioiis of the vtHM 
and urinary organs, of the cerebro-spiaal ismhi 
and of the digestive mucous surface ; and is fally 
illustrated in the articles Hr»TBRiA, Hypochosi- 
oniAsis, &c. 

37. When a vital organ is inflamed, citlKT 
acutely or chronically, other puts fympulUR 
more or less ; and when the inflammatory arun 
is slight, the affected organ may not manifest the 
disorder by characteristic phenomena, the fvnpt* 
thising parts actually presenting the chief &- 
turbance. Parts, also, which were at fint only 
sympathetically aflfected in their functions or m* 
sibility, may either, from the severity, or from thi 
continuance, of such afTeciion, become more vA 
more seriously diseased, until the structure ii 
changed ; and thus, what was merely a ^jp- 
tom, increases to a morbid association ; and, lasin, 
to a true complication; or even, ultimately, becomei 
the principal disease, the primary inflammation sab- 
siding, or entirely disappearing, as the consccanie 
complication is developed. Instances of this an 
not infrequent in respect of inflammations of tiw 
lungs, pleura, pericanlium, and heart; the (&• 
case originating in either, and extending to tie 
others ; the primary affection lieing ma«ked by tk 
consecutive disorder, and sometimes ultimtiely 
a1)sorbed by it. Such occurrences still more fre* 
quently take place when any one oi the abd** 
minal viscera is inflamed ; two or more of dm 
becoming consecutively affected, the disease ritber 
continuing for a time to co-exist in them, or din^ 
penring from the one as it is developed in the odxifc 

38. The complication of inflammations widi 
each other, or with nervous, spasmoflic, or coQ< 
vulsive disorders, or even with hapmorrhage. ii 
much more common than is usually supp(!>«d, 
— the latter often depending upon the fonutf, 
particularly when the inflammation is chrome, 
slight, or latent. In such cases, the pis- 
sage of the »li«ease into a more acute or artire 
form becomes an advantage, by disclo>in-: fl 
nature. Su**h complications are frequent in chiM- 
lioo<l, and in females particularly diirin? Ae 
puerjwral states. Many of the convuls-ive aS** 
lions of tlie former derive their origin, in a lir^ 
proi)Oition of cises, from intiaminatory action; 
and nio>*t of tlie nervou-, spa^moilic, painful, wd 
hysterical disorders of tlie latter, arise from in- 
flammatory action of a slight and chronic ionn 
in the uteruf«, ovarin, or urinary organs. 

3f). V. Tkuminatiovs and ('oN"jr.QLTENcr.*.— Ib* 
tlaiiirnation, correctly j«peaking, tenninate- onlyin 
(N-ciways : in ir.*olut ion, or the recovervoflhe hwBy 
state of action : nnd in g'iur;rtnCf or the ilfSlhof 
the inflamed part. The other iriorbid conJitioiA 
improperly ranked as terminations, are niertly 
consi'ijucnces of inflammation, the morbid va-^obr 
action giving rise to tlieni, still sub.sistinj; m most 
instance!*, in some one or other of it< forms. — •^' 
When inilaminatory action terminates in re*^^ 



mask or absorb the other; but the one that pre- tion, tlie phenomena subside very nearly in t!« 
dominates has its principal features somewhat mo- ' order in which they appeared. l*iiin cease*; ^ 
dified by the association. In cases of chronic redness and heat diminish ; the swelling sub**!** 
inflammation, particularly in feniales, ami in young 



or nervous subjei'ts, the ^ymjiaihetic di'*turban»'e 
produced by it, will ofllen attract the chief alten- 
tion of the patient, and also of the physician ; nnd 
A flitea^t', truly depending \\\hm\ \nHaw.w\Uuy 



•♦radually, and the functions slowly rctura. la 
many cases, however, the swelling continues wilb 
little diminution for a considerable time, and iIk 
functions of the part are restored with cqusl ^lo** 
V ue^«5 •, the recovery of the impaired lone of the c*r|l' 



ac'f/on, in some one of its grades,may\)ev'w^we.Ol asM;xr^' vt»wi\?.,wcv^\\\<i\x\»«it^lionofthesero-albom3h 
nervous, Mpasmodic, or funeliontil. T\us w^osX^ o^i>^^^3A^^^w«A\xv^^«t^«t^^^ ^C^^QaRM^/oei^ 



I 
378 INFLAMMATION— Ainrane— Craxictih. 

may be ^neially dcnrnninalcd ailhrnic, trom the | blood, npedally thit eirenUting: In Ibe put, ii 
want of or|[nnlc ncrvou<i energy, and Ihc liM of , atiureil. 

^Ul reai«lancG to ihe progrexa of (li«>rg!ini>wti(in, ' 56. c, Inrrtaitd tem/Mraliin it preaent chicAy 
which they UHually pre«enl, unlem i^ontrollcd at the cammennemenl of aalhsnie inflammitin, 
by judicixut Inntnienl. TFu>y harp alio bfen nnil when memlirnDoun tiwuea anil cirFuliting 
denominBteJ Ijiphmil, mihini. rriilhrmntir and Fru- yn«>lB nre attacked. Even in these caie*, at u 
•IfMliilmii ; tmt them ore rhicily specific Icrm«, ' early [leriail, the actual riae of temperature id the 
Iba generic appellation*, ipmilitig, diffiuiet, dii- alTcclnl pan n oflen not |;realrr than en Ihe nr- 
sfjpiiitiiit^fiOraitAeiiri:, being more appropriate. I fare of Ino body generally. Where the fcbtile 
H'i.Or AiirnENirlspi.iisiMATioMi, — ii, Oj'lhi dialuriianeu it ^at, the puW very nuick, and the 
Lon( jKlmlimt, in- CAararlrn. — a. I^ihniv leHW- ! tkin drv, Ihe heal oF the general nurface and of Um 
tIaii,ar;wia,!*thcevlieet,Biidnme^inu*(lu!n)o»t diwased part is very considerable; but il ■«■!» 
nfnirbil>le, aymplnm, pnrticnlarly when leraiu peculiar. b> obMrved in typhoid and tnal^nant 
membnne* or circnialinfr reuel^ are slleeled. ' tin'er* ; it aeeme to be greater than it rally ■^aod 
When the diwaiie i) caused by external injuiy, hy i> attended hy a .«lin^n<;. hanh, and unpleavDl 
the inooulalion of morbid mattcn. b> in |iunclarea npniition. At elTuriDn into the areolar tiane rf 
during dinectioa, the min ii often early and the part proceeds, and aa tbe iweltiog eilendi, 
acutely felt, even in cellular part*, although no little or no increaM of heat i> ueually o'wened ; 
other change has yet nppvared. In itervoua, *a*- and noinelimei the temperature of the part may 
neptible, and •rriikcned iicrnons, Ihe pain is so even he Inwer than that of the surface of the 
acuta aa'lo areelcratc or increase the nvIlesAnvHi trunk, or even lowt-rthan natural, 
or delirium consci|uent npon the constitutional i 57. d, SutHing a uoti«der«ble. nnd aome- 
qmiptnni-i. which are often remarkably severe, | limea very grcBl. when cellular or paienchy- 
comparcd with the apparent lunall eiteot of llie ' matoui ti«*ura are affected. It ia cauwd at iiiil 
local iliienM, enpecially when ceueed hy an ani- ', by the relainlinn of the vital tone of Ihe capillaries 
mal poison. I'nin, however, is frciincnlly not | nnd tissues, nnd by the injection of the fanner; 
very seven! in rcilain fonnB of asthenic inflam- ' hut consecutively, and chiefly, by the effusion of 
mabdn, pnrlicularty when parenchymatous orgiins ' serum from the (tiseased vessels. The swelling ■> 
■re their ftu, and when they arc con>ei)iicnl upon i alwayn diffused, is dbposed lo entend itself, and is 
•nme di«C4sp, which has lowered or eihausled or- ' never acuminntecl or convex. It is geDenlly soft, 
ganic nerrons power and sensibility. The inflani- 1 sometiniH Imcey or cedematnus, and never elastic 
tnttiona which complicnte or appear in tbe course ! or hard, unlei from Ibe tension oeca^ionrd by 
of eontinupd fever^ arc illustrations of this ; and ! aponeuroticj)r unyielding structures strvlched over 
the melnstnsis of rrv'ipelni, or the imnsrcrence of the swollen part,' In mucous and serous mem- 
inHammation fmm an cilcmal part to an internal | bmnr*, il is mncb less maniFest, although ciisliag 
orgnn, seldom gives rise to much pain. Tlic ! moro or leu; ami. in lliem. it is owing chiefly la 



886 INFLAMMATION — Coxstitutional and Fbsdiapouwg Cavui. 

mition, than that produced by mechanical obsta- 1 ative organs, at more advanced epochiflf eiiiteK, 
cles ; but attention to the relative situation of the \ and generally in the order in wiiich they art km 
congested part, especially with reference to a de- 1 enumerated. 

pending position and gravitation of the fluids, will ' 92. 6. Sex has but little inBoence in pni£ap» 
seoerally aid the observer. When congestion of | ing to inflammation. Males are more mqieady 
the capillaries is present, where gravitation could affected, chiefly because they are eipoaad noieikia 
not aiu in causing it, and when there is no mani- i females to other predisposing, and to ntany of Ike 
fest mechanical obstruction of the veins, it must . exciting, cause?. Females are most prodiipoKd Is 
be ascribed to inflammatory action, although the inflammation at the commenoement, during tibi 
usnal consequences of such action are absent, for continuance, and for some time after, the im* 
the inflammation may have been too recent to have ' appearance of the catamenia, and daring iha 
given rise to them. i puerperal states, especially after parturition. 

89. r. Redness from inhibition, or from the dye- ; 93. c. Of temperameatt and diathesu, the noit 
ing of the internal coats of vessels by the colour- , influential are the sangmneo-melaDchoIic lad 



irritable; the scrofulous, gouty, and rbeomaiie. 
It is chiefly owing to the descent of temperuMH 
and diathesis to the offspring, that ii ' 



iog matter of the blood is sufficiently discussed 
in the ardcle on Diseases of Arterils ($38.). 
It is of a scarlet red ; is limited to the lining mem- 
brane of the vessels ; and is unconnected with sometimes present an hereditary tendencyu 
any change in them, or with any capillary injec- 94. d. UabUs and modes of life dispose to i^ 
tion, or congestion of the vasa vasorum : whereas . flamraations of various organs. Persons wboare 
inflammatory redness in the internal surface of exposed to the open air, and to atmospheric i *' 



Yessels is less uniform than it ; is more dull or situdes, or who take active exercise in the air, m 
pink coloured ; extends to all the coats, although , liable to inflammation of the respiratoiy orgiM; 
in different degrees ; and is accompanied with j and inflammatory diseases generally assumt i i 
capillary injection, widi softening and opacity of sthenic or acute character in them. Those whsin i 
the inner membrane, with thickenmg, serous iniiU I indolent, sedentary, or confined to warm or dai 
tration, £cc. of all the tunics. I apartments, and unhealthy localities, are Mrt 

90. d. Injlammation sometimes leaves no marks j subject to inflammations oi the digestive, pii» 
tf Us eristence after death, — This occurs chiefly in ■ chymatous, and excreting viscera, particikrif 
the inflammatory affections of the skin, and in • the excreting organs in the abdomen ; the smW 
alight or incipient inflammation of serous mem- action very frequently assuming either astbeaietf 
branes. But the redness attendant upon the dis- : chronic forms. —The influence of modes e/'^tk 
case is more frequently diminisiied after death, than | predisposing to, and exciting, inflammatory Bil^ 
altogether banished. The inflammatory redness j dies, is fully shown in the article onAanui 
of the skin, and mucous and serous membranes, i Empi^ymknts. 

attending the exanthemata, and continued fevers, ' 95. e. Food and drink, — The liberal w ' 
often partially or wholly disappear after death : yet animal food favours the occurrence of every km 
these structures present appearances which may i of inflammatory- action, or generates an inflM- 
be inferred to have resulted from influnimation, and ; matory diathesis. It is even very probabkifal 
to have been associated with redness and vascular ceriuin kinds of animal food predispose to wM 
injection during life, even although the fact hod i vascular action in some structures in preferets 
not been demonstrated to the senses. W hen the to others. The frcciuent or habitual ue« of poik 
skin has been affected, it usually assumes n pur- seems to dispo:>e chiefly to inflammations of lit 
plish hue in the seat of affection, and the cohesion I glands, joints, and bowels; and aids in geD«nli|i? ' 
of the cuticle to the subsequent tissue is c;irly , a scrofulous diathesis. The laws of Mo«es, wJB 
diminished, so that it i^oon may be detached with | reference to animal food, have evidently badi 
ease. The vital cohesion also of mucous and salutary influence in rendering scrofulous, gosifi 1 
serous membranes is impaired more than is usu- ■ and iiitlammatory di-^easf^s less frequent taoef i 
ally observed, although all redness has (liinppeared, the Jews than in any other class of the comai' ^ 
and, in these parts, as well as in the skin, and , nity. In warm climates especially, the vset^ 
cellular tissue, decomna>iition makes a more rapid pork, and of the viscera and blood of aoimbi 
progress than in the healthy structures. A'oscu- i cannot fail of being prejudicial ; and there oi" 
lar mjection and retlness may have vanished more not be a doubt that the proneness to inflamnatioil 
or less, even in situations, nnd in forms of in- 1 among Kuropcans, in hut climates, arises chiefly' 
flammation, where some one of tiie usual eon- from the ({uantity of animal food and eiciiaf 
sequences of the disease is present. In this case, | liquors consumed by them. Persons who li^ 
however, there can be nu doubt of its nature. ] much upon tish arc liable to inflammatory i^ 
■ 91. V. Causes or Inflammations, — i. Consti- " tions of the skin and digestive mucous surtol 
TUTiONAL AND Prfuisposinc Cai:sks. — a. /];;(' ii.is | and, whilst flesh meats favour, in temper* 
considerable influence upon the production and ' climates, n sthenic form of inflammatory trtioii 
progress of inflammation. The disposition, par- living much on fish dis{)oscs chiefly to the toot 
ticularly to the more sthenic and acute forms asthenic and clironic states, 
of the disease, is greatest in childhood and youth. 96. Exciting or iutoiicating heteragti predi^ 
It may be said to diminish gradually from in- > pose to, and often directly excite, inflsmmatioit 
fancy to old age, whilst the more chronic and .'particularly of the digestive and urinary or|tai 
asthenic states become more frequent as age ad- The habitual use of these liquors frequently it- 
vances. The brain and membranes, the lungs duces and keeps up morbid vascular action, chie^ 
and mucous surfaces, the skin, the serous surfaces i of these parts, of a sub-acute or chronic kiss, 
within the thorax, and the glands, are the most generally passing into confirmed structural chaofe. 
irequenciy affected in children and young persons ; i 'J'hese effects most commonly follow the ratd 
MOii tbc aigestive, respiratory, uriaary, and guiL^T-W\vvc\VMQ>x^ Vv\\sac&') and, next to these, new vistf 






in, ,:t,K'i,!:.t'.ri!.'. i-.-J tif "Jt r.***- '.■ •,'. i.-'^T- f .in v:,:'^--/ f..:::. .TriTit v-y-Jy ■.:' o*^ii'>*::ra 

ibft ,i-r.>r. 'il ifiM'irt 1,-, ,i.|:anH.«'Ary li.-^^-^t n.ay oC i!a yin lit'.^i q-.-i.:. riUn.; ijirH.-;'y or ro'.Ht*-- 

l« (oftJ) tt.UiiiA , I'j' at tii<- 'l'!Mt'« ;/:ir'Aii':i tiitly ih-Cut'J, ll^ ilt'3£^c; fir'jLCLiIt l-i^.c; 

II* n.v--'. '.( i.ii.'f ■.! 'w: I'.p;m:.;( ' liSfi'.Vi-^. ■* i>iu«. — Vii-iir.t r- :u'i.-fti fo:i.ct:iut< 'fcj oj- 

•a.JI iw.H: •J.»'*v( )(•: ji-riaknl i-r Lw ii'''].;^ii|. (iT^bi.i'.' H |i'iit ii^ to pr>'ic£t it from mviErir.j 



390 



INFLAMMATION — Consecutxtb — Causes. 



position, and to the coDtinuance or intensity of the 
cause. When cold ia not protracted or intense, 
relatively to the constituUonal energy and predis- 
poBition of the individual, the internal functions, 
especially thoie of digestion, and of excretion, the 
unnary particularly, are increased, and inflam* 
matory action does not take place ; but when the 
internal determination is not relieved by augmented 
secretion, nor removed by a restoration of the cir- 
culation to the surface and extremities, inflam- 
mation of the predisposed organ is often the con- 
sequence. Sudden, continued, or frequent expo- 
sures to cold, vicissitudes of temperutu re, and par- 
tial exposure to currents of cold air, to humidity, 
&c., are the most common causes of internal in- 
flammation, and especially of the respirator}' organs. 
As respects these organs particularly, it is not the 
sedative influence of cold, acting upon exhaling 
surfiioes, the seat of active organic funclions, but 
the reaction consequent upon the removal of this 
influence, that occasions the inflammation ; the 
primary influence of cold only disposing the part 
to inflame, when reaction takes place, or modify- 
ing the reaction, so as to cause it to run on to in- 
flammation. Hence it is that persons, after going 
into a cold air from a warm apartment, generally 
escape inflammation of tlie air-passages, unless they 
be perspiring, or the predisposition to inflammation 
be strong, when they avoid a sudden return to a 
high temperature, by which reaction is liable to be 
morbidly increased; and hence the greater danger 
from exposure to much warmth after the prolonged 
or intense influence of cold, than from the culd 
without the subsequent injurious action of heat. 

111. 1). The specific causes of injiammation^ 
whereby the organic nervous sensibility, the vas- 
cular action, and all the vital conditions are truly 
morbidly altered, botli locally and {^cQenilly, com- 
prise all infectious, contagiouf),.&Dd contuniinnting 
matters, particularly when npplied to an ubnidcd 
surface or wound. INIo^t of the substances forniing 
the second and third classes q{ iufvcivms if^ents (see 
art. Infection, § 4.), and atrangcd aUo under 
the headof Animal Poisons (sec that niticle), pro- 
duce inflummution, presenting one or other of the 
local and general forms doscribeu under the a')- 
thenic species (§ 54. et seq.), Tiie secretions nnd 
fluids 01 one peri-on may excite inflammation when 
applied, as Just stated, to aiiotlier ; but the efTeit is 
more certainly pruducetl when these matters ore 
taken from the dead body, and e-ipecially when 
they are the product of iiiflaiiiniatorv or other dis- 
ease. The serous, puriform, saniowi, or soro-nuri- 
form fluids generated by s|)tMriH<! or constitutional 
maladies, and by difl'uscd inilaniinctioiis of tlie pe- 
ritoneum, or even of other serous ^ul•fac("J, ])o«spss 
the projierty of exciting the asihunic or difr»>ive 
forms of innamniRtory action iu u very rtmurkHble 
manner, 'i'he niosl dar)<;erou^ eiH^cts generally 
follow the inoculation of these iluids fiom the re- 
cently dead, or from the still warm body, or even 
the application of them to the skin, i'he next 
mo&t noxious eflecbi result fiom the introduction of 
animal matter in a very far advanced stacre of pu- 
trefaction. In both coiies, but in the former es- 
pecially, the constitutional nfl\.'(*tion is most severe 
(§ 59.). Even when the local injury is hardly 
to be perceived, as well as when it is more mani- 
/i?»^— vesicles or pustules arising in its vicinity — in- 
Hammation extends through the ceUular \\*swe. \u 
iJw course chiefiy of the lymphatics or veins, some* 



times implicating these vessels, and abeeaei farm 
under the muscles, particularly ander thepectml 
and other muscles of the chest ; a great psit of th 
cellular tissue on the trunk, and even the lemi 
surfaces underneath, becoming implicated ioths 
disease. Occasionally the inflammatioD proesli 
the characters of some one of the varieties of erjfA» 
]ielas ; the particular form of the local, as well of 
the general affiection, depending upon the coiHii> 
tution and previous health of the patieut, and apoa 
the nature or properties of the animal poison, lbs 
most virulent of the morbid pmsons seems to be the 
fluid efl'used in the large cavities, and paitiealarlj 
that found after puerperal peritonitis, in recently 
dead bodies. The recent brain, the substance of 
fungoid, carcinomatous, and medullary taDOvn, 
and the sanious fluids proceeding from diffanve, 
erysipelatous, and gangrenous inflammations, sre 
also frequently productive of most noxious effecti. 

95. Although tiie most dangerous form of in- 
flammation is caused by the fluids of tlie recent 
human subject, yet those of recently killed «n- 
muU produce no such effect. Thi^ probably ariM 
from death being caused in the former by diwsK; 
in the latter by bleeding, during a state of bealtk 
When, however, the fluids of animals which M 
either diseased or under the influence of inordioM 
excitement, or of its more immediate effects, in 
applied to a wound or denuded surface, the eftca 
are often severe, although not so dangerous as in iki 
former cases. (See arts. Infrciion, and Poison 
— Animal,^ 

112. iii. Consecutive IsFi.AM3iATi0KS.~.V#- 
hid maiten secreted by an organ, or circulating ts 
the hUh'df frequently produce inflammation cftithlt 
neighbouring or distant organs, — This if M 
important class of causes, and, like that iiiuM< 
diately prccetling, i^nerally occasions the aslbew 
or diffusive forms uf intlammation. When the na- 
tural secretions of an organ are rendered unusually 
morbid or iiritating, either from perverted action, 
or from the accuniulutiun of noxious elemeotiin 
the blood, the canals through which they pass tie 
often irritated and inflamed by them. The row- 
bid bile formed during affections of the liver, or in 
the course of gastric, bilious, remittent, and conO- 
nued fevers, often occasion the enteric or dy^n'ttic 
complications occurring iu these diseases. Infian- 
miition< of the colon nnd rectum also often srat 
from this cau.-c, as well as those of the pall-blaiWtf 
and bile-ducts. The secretions on the surface of 
the skin, especially when allowed to accumulate 
and reoiuin on it, ara the most frequent cau-^csof 
cutaneous inflaniniation ; and alteration^ of tbe 
urine often occa-ion inflammation of the urioaiy 
bhnldt:r. Indeed, most of the com pi ication* ap- 
pearing in the course of febrile diseases, arise etibtf 
from the morbid state of the secreted fluid*, ct 
fromthatof the bloo.l il'^ilf; the orpranic iiifiwroft 
bein;:^ remarkably 8usce])tible of thoir imprc*ion*. 
and the va«;cular system boinjr readilv cxeilcd by 
them to nn increa-ed action, devoid of power or 
healthy tone. When vital power or organic uerr- 
ous influence is exlreme'y deprefse*!, as in ady- 
namic, typhoid or exanthemnluus fevers, tiie parti 
with which di^^ea^ secretions come in contiiciare 
unable to resist the impression made by tliem, or 
to throw them off by means of a healthy secretion 
from their own surfaces, and by sthenic muscuhr 
AcUon. Hence, this imprcs-oion is soon foDovres 



392 



INFLAMMATION — Proonosh. 



mixes with it, and eontaminates it, thereby pro- sorfiBMses, but also in other orpns pnibnBng mu- 
ducing all the phenomena of adynamic or malign lar offices, as the kidneys, liver, &c This i^ 
oant fever. (See art. Veins — fnjiamtnation of,) j condaiy inflammation and ulceration of tbelufi 
117. d. Inflammations of parenchitmatout or\ bowels, kidneys, &c., often occur in the conns rf 
other viscera are often iecondarii or conseculice tubercular excavation and ulceration of the Inng^ 
upon primary inflammation of remote or external and of abcesses in the liver, 
parts. The brain, the lungs, liver, and kidneys! 121. VI. Prognosis^ — ^The prognosis of iafia» 
are most freciuently tlius remotely affected. In mation can be stated only in general terms. Tht 
these cases, tliere may be extensive inflammatory > more special circumstances connected with thim^ 
appearances without purulent collections ; but jcct must necessarily be considered in the sitidN 
most frequently one or more purulent collections, 



or distinct abscesH», or merely puriform inflU 
trations of the inflamed parts, arc observed. In 
some instances, the puriform collections and infil- 
trations are attended cither by very few marks of 
inflammatory action, or by almost none, so as to 
render it even doubtful, whether they have re 



devoted to the inflammations of particular orgw 
and textures ; for the result wilt mainly dnoi 
upon the organ affected, as well as upon the wi^ 
severity, and stage of the disease, and upon ths 
consequences wbich may have already tikn 
plac^. 

122. A. As to the organ or structure ejfectti,k 



suited from inflammation, or from a simple deposi- is unnecessary to state more tlian that \hd daagv 

tion, or separation, from the capillariesof the secon- of inflammations is great in proportion to the vfl 

darily diseased part, of the morbid fluids absorbed importance of the aflecled part. Acute iafluni» 

into and circulating with the blood. L believe, how- tions of the stomach, of the intestines of ll* 

ever, that, in these cases, the morbid matter in the lungs, of the heart, of the brain, of the liver, ai 

blood excites a suflicicnt degree of inflammator}- of tiie kidneys, are all attended by more or In 

irritation of the capillaries of this part, to form risk, owing to the disturbance of function tued^ 

the diseased secretion infiltrating it; and that, ing them, to the shock which the whole ffiM 
as in other instances where inflammation has 
unequivocally existed during life, the principal 
indications of it, in the anected tissues, have 



vanished soon after death. 

118. When secondary inflammation seizes upon a 
parenchymatous organ, remote from that prima> 
rily affected, it will generally be found that it is i 

owing to the passage uf the morbid fluids from the I thereby to infect, in a very dangerous mannfcr.ihi 
primary scat of inflammation into the blond, tlicse ' whole frame. — Inflammations of serous 



experiences from the attack, and to the 
quences and changes of structure, or the dia^^ 
guoisution, which they often occatiion. Vet iki' 
danger is still greater when the btcod'tmk, 
whether arteries or veins, are inflamed; fiwikii 
products of the morbid action are then liable W\ 
! mix with, and to contaminate, the blood. 



fluids consecutively inflaming tlie parts most pre- 
disposed. In some cases the secondary disease 
has been preceded by. and is associated with, phle- 
bitis ; in others, this complication cannot l>e de- 
tected. Even in cases of primary, as well as 



braiies, particularly at advanced stages, and ii 
unhealthy subjects, are always atten(ted by gnU 
risk of life; tor the fluids effused bythe'diKHl- 
either atMJumuIate to a fatal extent in the sWi 
cavities they form, if effusion be not early pf^ 



of consecutive phlebitis, secondary inflummutiuns vented or restrained; or agglutinate their opiMKiif 
of internal viscera, with punilcut cullections or .^urface<, so as to impede the functions of park 
infiltrations, arc very frequent. But this subject I and to occasion dangerous consecutive dueuu 



is fully discusseil in the articles Ansciss, and 

AVlNS*. 

119. e. Con<iocutivo inflammations of fuuovial 
capsules, and in senms surfaces, are observed chiefly 
in similar cases and circumstjinces to tho^e just de- 
scribed (§ 1 15. 1 18.), — when the blood contains 
morbid secretions, or when the veins are inflamed 
and the powers of life much reduced. The former 
of these structures are often nflected by the con- 
tamination of the fluids conse<)ucnt upon syphilis, 



INluch, al-so, of the risk attending inflanimalioD ol 
parenchymatous organs proceeds from the exinh 
sion of the disease to their serous surface?, ini 
from the efl'usion couset]uent thereon. — InfliB- 
mationa of mucous surfaces are much less dai^ 
ous than those already mentioned ; and chiefly 
because the secretions which they produce k^ 
vour a resolution of the morbid action, and M 
thrown off the diseased surface, — a source ofini- 
tation being thus removed. They often, howenTi 



and upon the subsidence of confluent smull-pox ; occiision great risk to life, by the extent of sorto 
the latter in the advancetl staj^es of diffusive in- 1 affected, and by the disturbance of the fur.cOfl* 
flammation of the cellular tissue, or of phlebitis,; performed by it, as in cases of universal broochilis 



or of inflammation of the lymphatics, particularly 
when either disease extends to the trunk. It also 



IS sometimes consctiuent upon extensive burns or 
scalds, especially when the surfaces over the large 
cavities are primarily inflamed by these accidents. 
120. J\ Mucous surfaces are secondarily in- 
flamed, both by the pasiage of the fluid pro<lucts 
of primary inflammation over them, us when 
laryngitis or bronchitis supervenes upon an ulcer- 
ated cavity in the lungs, and by the absorption of 1 14.) are always most dangerous, 
these products into the blood. Thcfsc surfaces,, 123. ]i. The form and severitu of the ipjfu^ 
especially those of the large bowels, perform an I mutton necessarily influence the'prtjgnosis.— !■ 
excreting, as well as a secreting function, and the general the asthenic forms are much more dao- 
morbid matters, in the course of their elimination gerou**, other circumstances bein? the fame, lta> 
from the circulation, excite inflammalory ac\M)iv,\ lUc »(/jewic. Vet u very acute sthenic state of tb 
generally of an asthenic form, nol ou\y iu xUesc \ 0^\sA«fic, «s^cva\\^ wS. \x\v«xu&l viscera, may be » 



where the changes produced by the air on tbi 
blood are impeded both by the disease, and by 
the morbid secretion produced by it. InfiamBA* 
tion may also extend from these surfaces to adjoii' 
ing structures ; the substance of vital organs, u^ 
even their serous envelopes, becoming extenwelf 
impli(Mtetl, and the danger proportionately ■» 
creased. — 'I'he cousrcutiref and particularly tk 
hecoudaru, injiammations described above ($11^ 



394 



INFLAMMATION— Theokt or Natuu or. 



of the extremities, by Weber and the author, 
in 1816 and 1817, and more recently by Rides 
and others ; and tlierc can be no doubt that they 
extend even to the capillaries, endowing these 
vessels with influence, and with the properties 
evinced by them in health and disease. 

129. The vital states which arteries anrl capilla- 
ries manifest, especially when influenced by stimu- 
lants, or depressants, are these: — 1st. Of turges* 
cencc, dilatation, or enlargement ; —2d. Of contrac- 
tion or constriction; and, 3d. Of healthy or natural 
tone. — The 6rst and second are anormal states, the 
third normal, and consistent with all the natural 
functions. It is to the ^first of these that atten- 
tion is principally to be directed in discussing the 
nature of ioflammation ; but, liefore this state is 
considered, a very few remarks may be oflTered on 
the others particularised. 

130. a. The constriction of arteries and capil- 
laries arises chiefly from agents, which increase the 
vital contractility of tissues. Many of these 
agents are of very opposite natures, and yet they 
act, paiticularly m certain grades of activity, and 
periods of operation, in definite modes. Cold, 
fear, and other depressing passions, severe in- 
juries, shocks to the system, &c., contract parts 
susceptible of organic contractility, especially the 
skin ; arterial, capillary, and venous canals; cel- 
lular and serous tissues, 6cc. &c. : but, if the oper- 
ation of these agents is intense, or long continued, 
the natural tone of the contractile tissues and 
vessels is impaired, and vital exhaustion or relax- 
ation ensues. A similar constriction of these 
parts follows the application of astringents and 
refrigerants ; the sudden diminution of the circu- 
lating fluids, as by hemorrhage or veniescction ; 
and the depression of vital power by whatever 
cause. The contraction of arteries and capil- 
laries soon after death depends chiefly upon the 
weakened injection of blood into these vessels, 
just before dissolution, and to the entire cessation 
of the action of the left ventricle. The organic 
or vital c^ntrnctility of arteries and capillaries is 
then no longer antagonised by tlie action of the 
ventricles u{K)n tlio column of blood they contain, 
and is consequently allowed to ndvance to the 
utmost permitted by the fibrous and cellular 
coats ; the arteries, and oven the capillaries, being 
con5ef[uontly found nearly empty and constricted 
after death. But as contractile parts lose their 
rigidity or tone with the incipient decomposition 
of the structures, the vessels afterwards relay, so 
as to allow a larger column of fluid to be injected 
through them than in the livin;:: state. 

131. h. In the henlthif or natural Uwe of con- 
trariilc ti-sue-*, thn arteries, rapillario^-*, and even the 
vein-;, fully participate. Still this natural state of the 
vessels is liable to various deviations or deflexions, 
either to the side of turjjcsccnce, or to that of 
constriction, without amounting to what consti- 
tutes a truly moibid condition. Numerous causes 
produce either constriction or turgescence, with- 
out reaching the pitch truly injurious. It is 
chiefly when the action of the causes is in- 
tense or continued ; or when they alter, by 
their primary and specific influence, the vital 
properties of the sentient system and contractile 
tissues ; that the eflect becomes truly morbid, and 
diiea^ed action is set up. Much, however, 

dopemln, in such cases, upon consUlul\oiia\ A\*- 
position, or the degree and kind of ausce^dVjxYvV-j 



existing at the time of exponiK to the 
Agents which produce no aerangement b nai 
persons, violently aflfect otben ; and the ■■§ 
cause, which was without effect at one time, Mf 
bo most injurious at another,— owing to yvfa^ 
states of organic nervous energy and snsceptibiiity; 

132. c. The state of turgueenee, di/al«riM, or 
enlargement of the smaller arteries and capiUuii^ 
although a part of the inflammatorj act, ooei lol 
alone constitute it. Something more is n ecaw j 

I to its unequivocal production. This iUte Mf 
take place without being at all morbid, — ii is w 
excitement of erectile parts, in the devclnpnt. 
of the uterus and mammas during pregDtBcj,i|. 
the enlargement of collateral vessels after iki^ 
obstruction of a large artery, in the act of kMj 
ing, and in the rapid growth or restoniioo rfj 
parts. It may even be morbid, or at kist 
souree of disorder, without constituting ii' 
mation. The acUve congestbns and 
ations of blood to particular organs, alt 
often passing into inflammation, yet ore 
different from it. In these vascular diMN 
more or less turgescence, or dUatstion, of A[| 
smaller arteries and capillaries, as well ascf f 
smaller veins, obviously exists ; but still tkiii 
is not attended by the same phenomena, sndi 
not give rise to the same conseonenocs, mi 
observed in the various forms of infianmnlij 
This state of tui^gesccnce of the capillaria cf ii 
flamed tissues has especially fixed the atteT^ 
of modem pathologists ; and the question, 
them, has been almost limited to the inqoiij,! 
to whether the increased diameter of the 
laries is to be imputed to relaxation or 
or to augmented action. The least material 
of the many, which should have fixed their i 
tion, has thus alone engaged the whole of it; 
whilst they have attributed every thing to 
other of these two conditions, they have e 
overlooked the fact, that they are both coobi 
or consecutive changes ; that either may 
according to the stage and form of the 
action ; and that the one as well as the otben 
be present quite independently of, and 
inflammatory action. 

133. The 5^i/e of the capillary ciretilatio» k 
flninmation has been agitated since the comi 
ment of the present century, and even at the | 
sent day, witn a parade of useless, deceptive, 
ill-conducted inquiry, dignified with the nan 
experiment. Numerous cold-blooded aod 
reptiles, and often animalsi very differently 
ganised from the higher species, have bceo K 
tured for evidence, whereupon an argument ni| 
be hung in behalf of preconceived hvpodicMl 
and crude and puerile observations Rsts * ^ 
made the basis of doctrines, which have 
of attracting notice, either from havio^ 
imperfectly understood, even by their 
ers, or from having been overlaid by the 
titude of words, in which attempts hafe tail 
made to convey them. Thus the author rfij 
recent work, entitled *' A Critical and Eip* 
mental Essay on the Circulation of the Btai.! 
&c., not only derives his inferences frea 
feet observations, made at similar sources ttf 
above, but also, because he observed so oiriltt 
motion of the blood in the aorta of a frif ■ 

' \^\Ti^ the vessel, jumps to the condosiQi ■ 
\ *' 'v\. "NQviNi^ ^.^-^Ritt iioEm^ c«itaitt thai lbs W 



from the surface whence they were produced. 

161. /. Consecutive ehanget in the itimit 
forms* — The succeaiive changes taking place m 
tlie couree of sthenic inflammatioiis aie oraCwa- 
able with the laws of the animal econonj. TVi 
excitement produced in the organic ncrroii 
tissue and capillRries of the part is ezhautted «ilh 
n rapidity, and to an extent, in proportbB to ii 

I the 



402 INFLAMMATION — PAiiiotofiY. 

the previous cxccWive excitement, before tlic in- ' clearly shown. Yet the moil vaienkrpaTtofihe 
creased artiun of the iicnrt has subsided. I newly organised false membrane may not betbt 

158. c Of the ilei eiipnient if new vessels in in- \ nearest the seat of inflammation^ — the Bew>ciNh 
Hnmtd juutu, — It in not only the vital turgc«cc nee foiming several anastomoses, and occaiiointty 
or expansion of the capillaries, so that those which becoming enlarged in some places at a " ' 
coulcl not admit ihe coloured globule.^of the blood 
in the healthy state readily admit them in nn in- 
flamed port, but also thedcvelopementof new ves- 
sel h that is often observed. But this latter event 
take<i place ciiiefly in serous membranot, and 
especially in albuminous exudations from the in- 
flamed surface. It possibly may also occur in 
other parts, to u more limited extent, although it 
duus not admit of so obvious a demonstration as in 
these. It can only occur in the various grades of 
sthenic inflammation, and it fully evinces that, 
although truly morbid in its nature, this form of 
the disease is characterised by vital activity, and 
by a deranged increase of the formative process 
in the afliicteil part. In asthenic inflammations, 
however much capillary canals may be enlarged 
so us to admit a greater column of bloo<l, no new 
ve.ssels arc developed, unless the asthenic be con- 
verted into the sthenic state. In the former state 
of disease, the expansion is the result of impaired 
vital tone and resistance, both of the capillaries 
and of the tissues afTected ; and the organic nerv- 
ous power of the part, and the action of the capil- 
laiies upon their contents, are incapable of form- 
ing either coaguluble lymph or new vessels. In 
the latter state, nervous power and vascular ac- 
tion arc capable of producing the one, and often 
also the other. 

I5f). When sthenic inflammation affects serous 
membranes, the morbid exudation thereby formed 
on their surfaces is sufliciently consistent to admit 
of the extension or growth of new vessels from 

those which had become enlarged in the early | nrction with the capillaries; the states of thwiii 
Rtnge.s of tht; intlnmniatory act, and to give tiiem the connected vessels, of the circulation thnafft 
support until they acquiie considerable develop- I them, of the blood, and of the diseased part, bcii| 
mcnt. Hut wiu>n the asthenic distea^e implicates i the effects which may either disappear befffcAi 
these membrunes, the secretion from their surfaces . vital resistance of the frame, or terminate io if 
is too watery or serous to furnish consistent canals ■ of the ways described above ($ 39, et leq.)* 
or channels in which the contents of the capilla- : 16*2. li. Of the Knture nf the Asthenic SUttn.-^ 
ries inny be convoyed bryoixl those which are i The remaiks which 1 have just oflfered ■■ 
moiiiidiy enlar«;e(l, withotil commingling^ with the ! especially refer to the nature of the witilW' 
rc-rt of the ellu-ed matter. In cases where new , injiammutionst and it is, therefore, newaaty* 
ve««sels form, the exuded lymph or albumen, into con>ider the circumstances in which the ul^ 
\\liicli they run, is not only to u certain extent | flate> dijj'cr from these. It has lieen shown ti* 
con:«i>iont, but also somewhat scanty, or at least these states proceed chiefly from conrtituti*' 
iKil veiy ubiindnnt ; but in cases where they can- '" ' * ^--.j^ 

not be toriiicd, the fluid eifused is generally both 
serous and copious. , 

lliO. The production of new vessels in parts stlicni- consequently, the tone or \itnl contraclilitj rfl^ 
rally intluitu-i.l.] articularly in exudation- of lymph, tissues and capillaries in ihpseatof tliedixaM.!* 
is ob-erved chiefly in youn^^ persons, nnd especially ' <pjickly exhausted or readily depressed, and •• 
in these who sire in the couise ot development. I become otherwise morbidly affected,— efW* 
Occnsionnljy ilu: new vessels are numerous and : softenimr, disorganisation, or gangrene, tiWf 
rljstinnt, even befoie the lymph had beconie at all ■ place with a rapidity in proportion lotheprii*J 
abundant or consi.Mient. In •iome very beautiful i vital depression, or to con^-equentexhauftioD.o^ll 
injected prepjuaiions by Mr. Kikrnan, the eini- I the nature of the impression made by thee««< 
nent pathologist, that he kindly nhowed n.e, this : cause;. Incases of asthenic inflaminatiDn, tfA* 
was must remarkably tiemonstmtcd ; as well ns there has been originally, or acquired, (frrtt^ 
the fact, ^^hich has been controverted by some bility or deficiency of the organic nenron? pc**' 
Tien' h pathologists, that the new vessels shoot ! or the assimilating and excreting funcliooite* 
out from the inn:mie<l suif.ice, if not from those been long disordered and imperfectly pet^inflii 
enlarpcd in the e.irly suigc of the inflammatory 
ant. Whi'U new vessels fonn in the fibrinous 
lymph exuded from serous membranes, they may 
oft&n }ic i/ijected, — the continuity of these vessels 
will those of tiio affected pail being \,\\cTCib^ 



intensity relatively to the powers o 
tution, and of the part affected ; and at thin* 
haustion proceeds, the tonicity of the extrm 
vessels and of the diseased tissue, as well if thi 
vital cohesion of both, is weakened, the circulriii 
through them retarded, ond the colour of Ai 
blood deepened. The eitent to which thn 
changes take place, in connection with the dcpa 
of general vascular action, and of constititiMl 
power, fully accounts for the lesions ch» 
quent upon sthenic inflammations. Wla 
phlegmasia arises from specific canses, the kill rf 
morbid excitement primarily indoced by tJMi 
will, according to their nature, more or leis maiff 
these changes, nnd give rise to csertain renhiii 
preference to others. We perceiTe this a Al 
exanthemata and in various inflammatory " 
Tiie tissue affected will also modify the 
ance and mode, as well as the consequeoM^' 
the morbid excitement. But there can bi 
doubt that the successive alterations in thei 
structures are merely consequences of the 
impressions made by the exciting causes ajWiii 
organic nervous tissue, particinarly in is eM* 



predisposition, or from previous or associttEdif 
onler, or from the nature of the exciting ci* 
In either case, the organic nervous inf)aeDce,Wi 



or the exciting cause has been of a poweifoHy ^ 
pressing or poisonous nature. Indeed, twOjOre'* 
all, of these circumstances may be conccmed.tfA 

more or less, in the production of someone or ^ 
\ olvVvft icvQ\b\d states of action compriied atticrtte 



404 



INFLAMMATION — PiiTHotooY. 



vessels, and accelerate the circulution through ! extends to the Teins — which not i&iifqiiBdy 
them. When the sub&tance of an organ is in- occurs when the constitutional powers are d^ 
flamed, the fibrinous lymph exuded at the point j pressed, or in the more asthenic forms of thi 
fint affected, often retards, by its pressure, the | disease. In such cases the local leaioostrer^ 
circulation in the vessels at this point ; and owing i markably increased, not only by the stasis of Uoal 
to this obstruction, the surroundiog vessels are the ■ in the capillaries, but also by the more copioH 
more readily developed, and more prone to be- [ morbid enfusion caused by the obstructed retan cf 
come morbidly tur>>escent. The lymph effused ' 



aldo affects the vitality of the part, either occa- 
sioning more or less irritation to the organic nerv- 
ous tissue, or perpetuating or modifymg the dis- 
order of thU tissue already existing, that caused 
its effusion. Muli.kr thinks that the lymph 
coagulates in the extreme capillaries, when the 
inflammation is seated in the substance of an 
organ ; but I believe that it is exuded in the 
areole of liie structure, thereby rendering the 
part more solid or dense ; the change thus pro- 
duced having been termed condensation, solidifi- 
cation, hepatisation, or splenification, according 
to the appearances assumed, and to the organ 
affected. It is only in the sthenic forms of in- 
flammation that the effused fluid gives rise to these 
changes, as shown al>ove. 

1G7. If the intensity of the morbid action in the 
spot first affected be so great as to exhaust its 
organic nervous power or its vitality, and to retard 
its circulation, or to stagnate the blood in the 
capillaries, not only do the surrounding vessels 
become more turgescent and developed, but the 
blood which has thus stagnated, and the tissue 
itself, undergo very material changes, as described 
above {i 156.). Hence very opposite states of the 
circulation generally exist in different parts of the 
seat of inflammation, especially when the disease 
is advanced. lu cases of injury, particularly of 
laceration, pressure, or other chungoS) the capil- 
lary circulation is often directly obstructed ; and 
either independently of lesion of IJje orpanic nerv- 
ous tissue and stmsibility, or aided by such lesion, 
distiased vascular turgescencc i"* thereby devolopecl 
around the scat of injury, — the eanillaries thus ob- 
structed, and tlic blouil contnincd in tliem, soun 
undergoing changes productive of suppuration, or 
ulceration, or gangron*;, wiiilst sthenic viiscular 
action is either proceeding in the surrounding 
turgescent vessels, or pa-rniug into exhaustion or 
into the asthenic comliliun, progressively from tlie 
point of injury, or from the spot first aflcctcd, 
according as the constitutional powers may reaist, 
or may favour, the cxien>.ion of the mischief. 

168. K. Ofthf Slate of the ^'enous Circulation 
t»i Inflamed Paitt. — Tliere is cver^' reason to be- 
lieve that the venou.) circuhition is locally more 
than usually active in the stlicnic and acute forms 
of inflammation ; but that it is more or less lan;:ui(l 
in the asthenic vaiieties. When the former, al'io, 
goes on to suppuration, and cs]>ccially to ulceration, 
the circulation in the veins, more immediately 
proceeding from the part, is generally somewhat 
retarded, the retardation increasing those changes. 
Ilenne the importance of favouring the return of 
blood from the part by positiim, when these ron- 
Sifcjuencea of inflammation have taken place. 
Whenever the venous circulation is obstructed, 
effusion and oedema increafe rapidly in the part 
affecte<l, and in its vicini'y ; and the consequent 
retardation or stagnation of the blood in the 
eapilini'ivti, induces or accelerates di>orgttnisation. 
This « observed very frequently in eT>f8iy»elus, 



blood. 

169. F. Of the Function of AbtorptinUAt 
Seat of Inflammation, — In the early «4a^itf 
sthenic inflammation especially, absorptioB fcen 
to be leas than usually active; but, wbeo ikt 
disease proceeds to ulceration, or even to tuppt* 
ration, and when it assumes asthenic forms, taa 
the absorbent action is often increased, althoagk 
there are ntimerous exceptions to this, abMqitioi 
sometimes being manifestly impaired. Whentk 
absorbents become inflamed, owing to the moiiiii 
nature of the cause, or of the matter formed miki 
primary seat of disease, then more or lev of ib- 
slruction results, and the function i« arrested, giHI 
tumefaction of the parts beyond the obstroctiN 
taking place, and increasing the local mischief bf 
pressure and by the contaminating influence of lb 
morbid secretion. In obstructed venous circalaMi 
the swelling increases rapidly, chiefly from Of 
mented effusion ; in impeded absorption it advaica 
with nearly equal rapidity, from the fluid bcaf 
undiminished by removaJ. In either ease tki 
effused fluid u ndergoes material changes darioffii 
retention, and becomes more and more haitAuli 
the tissues containing it, and more irritating to ihi 
vessels which may absoib it. 

170. It was supposed by John IIukt» aid 
others, that ulceration depends upon iocfemi 
activity of the absorbents of the part, wbeaii- 
flammation has reached a certain period of ill 
progress. But I believe that it is chiefly ovi^f 
to the superficial softening or loss of the vital os* 
hcsion at that part of the inflauicd tissue vheif 
the extreme vessels Imve lost their functioDf. i&d 
to the solution of the molecules of tlie tL«ue»ii 
the fluid effused from the disea-ed surface (\i 48.1. 
Absorption is probably also concerned io i\t 
process, and in vaiious degrees, according to tke 
seat of the inflammation, ami the slates ofor^aoic 
nervous or constitutional power and of vasoiiir 
action. 

1 7 1 . G . Of the States if the BLmhI in the Ctf/n'/ii- 
r/>s ii/' Inflamed Parts. — The blood oirculatingii 
inflamed parts presents vcr^" different appcoranets 
with the form and stage of the disease. Id i^ 
slhfMiic forms, and particularly in the early stages 
before any of the more unfavourable coajv* 
quences have supervened, the blood is floriii.snd 
partakes much of the characters of arterial I'lood; 
but in the a.>«tlienic forms, and less remarkahliia 
the advanced stages of the sthenic, it i* more if 
nous, or of ii daikerhuo. It is sometiinLsqain 
purplish, or blackish, paiiicularly when a tenJencjf 
to sphacelation or gangrene occurs. Abu, »tt 
circulates in the capillaries, the globules itttt, 
under the 'nlio^o^cope, grndunlly to move noK 
slowly, and to be attracted by the sides of the Te#» 
scl, or to stagnate in the capillary canaU. Tikii 
change seems to commence in the smallcrorrapS- 
lary veins, and to extend, especially in the asthenic 
states of inflammation, in the direction of ^ 
minute arteries the tem^ierature sinking »ith the 
deepening of the hue, and with the loss of motiai 



snj constantly when the inflammulory uc\\oii\ oi vW \A<yA ^^Wles. In other lespeds tbe 



408 



INFLAMMATION — Treatment op Sthenic -^Dloodleitino. 



tion. When tbcy are restored, then the chief j also render its institution or repctitioa iiji- 
object is attained, and no furlher Iobs of blood rious. 

should be inflicted on the patient; but if they | 191. The prevaiUng epidemic nmititutim, ot 
continue to be suspended or disordered, or if they the general character presented by epidemic aai 
nrc only partially restored or improved, local de- other diseases, should always be kept in reeol 



plctiuns, at least, arc required, especially if due : lection, especially as respects tlie empl^mait of 
time have been allowed for the Brst bleeding to ; bloodletting. The inflammations which oceir 
pioduce its effects. I in the puerperal states, erysipelas, and the in- 



187. The tongue furnishes important indications flammatory complications observed in the cosna 
as to the propriety of general or local bloodletting. . of exanthematous and continued fevcn, vuyr^ 
^Yhcn the papillas are distinct and erect, the ' markably in their particular characters, acconliof 
tongue being white or loaded, and inclined to be i to the prevading constitution. At the period i 
dry, or its edges or point, more or less red, vas- I change from one general conbtitution to another, 
cular depletions arc generally necessary. When > it is very diihcult at once to determine upoo ik 



tiie fur on the tongue is erect and white, and the 
sides and point rod, blood may be taken away, if 
no symptoms contra- indicate the practice. On the 



admissibility of bloodletting, particularly u i^ 
gards the diseases just named, and others alEei 
to them ; but clo^e observation of the aorW 



other hand, when the papUla: or the fur is flat, ' phenomena, and attention to the circumsunes 
and the tongue very moist or watery on its su- and considerations now enumerated, will leadtoa 
perior surface ; when it is broad, flabby, Assured, right determination as to this pracUce. Geoeiallf 
or lobulated ; when its edges are indented by, or , s])eaking, also, it will be found, that all ioBan* 
retain the impression of, itie teeth ; when it is ! malory diseases attended by a free state <d tli 
pule, especially at its point or edges ; when it is secretions; by copious fluid defluxioDS, puli' 
tremulous on l)eing held out; and when it is cularly from the seat of disease; by a molit « 
covered by a thick, dark mucus or fur; bleeding relaxed8kin,or irregularity and weakbess of pafac; 
is ^enerully inadmissible. by physical and mental depre^^n, and especiaU;f 

188. When the cutaneout surface is hot and by great despondency, unfavourable anticipatioai 



dry throughout, depletion will be of service ; but 
if it be cold, clammy, and shrunk, or if it be 
covered by a hot clammy perspiration, bloodlet- 
ting will be inappropriate, as the chief objects in- 
tended to be accomplished by bleeding are to 
lower general action and to produce relaxation, 
and the>ie are already attained. If the urive is 
high-coloured, scanty, and does not deposit a 
sediment, bloodletting may be practised, if other 
symptoms do not contra-indicate it ; but if the 
urine be pale, limpid, and copious, it will gene- 
rally be injurious. 

1H9. J besides these guiilcs to the institution and 



of the result, or inditference to objects of fonna 
or natural endearment; will either nut bcrelvred, 
or will be aggravated, by bloodletting. 

192. B, Local depletions arc often suflicieiuii 
many forms, states, or 6ta*i>es of inflammatioo, to 
accomplish the ends in view. The circum>4anca 
requiring local, in preference to general ^/amUiI* 
ting, are chiefly the following : — 1st, The dighvr 
slates of inflammatory action; — 2d, Forms Mtbi 
disease approaching to, or partakinjj of, the u* 
thenic condition ; — 3d, A stage of inflammatin 
too faradvanced to admit of, or to be benefilbl bj, 
j:<.neral depletion; — 4th, When vene-scction bai 



ropilition of vascular depiction, there are various | been carried so f.ir as not to admit of its rej»cli!ioB 
others, appertaining to the or^un aflccted, jkc, the disease being either unsubdued oroaiviuiu* 



'\^hl^]l should guide the physician; but thei^e do 
not come under consideration at this place. The 
n.';e, con!>titution, and diathesis of the patient, and 



^ated, and requiring to be aided by tliismean^;— 
5th, When it is desirable to derive from the sot 
of disease, as well iu> to deplete moderately \—^ 



t!ie other slates of predisi)Osition, as well as the ex- ] When it is wished to remove local congolioDcf 
citing causes, however, require some notice. The i the vessels, and to restore the sensibilities ud 



very youni^ (infants) and the aged should be de- 
f)leted wilh caution. Persons of a nervous or 
lymphatic temperument cannot benr so large losses 
of blood as those who are sanguine, irritable, or 
san>iuinco- melancholic. In the gouty and scrofu- 
lous, iu the previously diseased, in the dl-nourished. 



function> of the uflVcted part ; — and,7ih,>\ heaio- 
Hamniations occur in debilitated, neivou9. orddw 
cate constitutions, and as complications of febrile, 
or other disease^. 

193. The rmxles in which local depletion sheuU 
be performed also require aitcntion. Whea ■ 



in the very ol)Csc, and in person.- of a relaxed fibre, ' considerable (quantity of blood is to be abstnKted, 
or leucopiilegmntic or cacheclie habit of l>o<ly, and it is desirable to efft-ct a rapid derivalioQ I'W 
Kuch losses are generally injurious. the veat of disease, then cupping i^ to be preferred; 

190. 'i'he nature of the iwriting causes, and the but when the (jTiantity is to be small, and «it> 
i'lflui'/iccs, mrntal and p'liisirul, opci.itiug on the the application ol uurr.i fomentaiions ami pouiiiii' 



jhiliei.t tluring tiealuient, should greatly influence 
the amount of viLscular depletion. luHaniuiations 



to the part subsequently is likely to be scrviaablf, 
then leeches arc more appropriate. W here ^ 



ronsecjuent upon oclive excitement, or attending njorbid sensibility and situation of the parlipI^ 
vital leaclion, are niost brnefittd by this measure; , vent the having recourse to rupping, a large lofJ 
whilst those caused by septic, poisonous, infectious, j depletion being requisite, then a great numlicrfl 
or coutaniinating agents, are generally aggravated . leeches »hould be applied. In such cu?es llicft^ 
by il. All the depressing all'ections of mind, an mentations and pouUiceii used to promote it* 

11 1* 'Il >1 ^•ll • I* t^M 



I'ir loaiUd with mnlariu or paludal exhalations, 
the foul air of hospitals, and the condned atmo- 
sphere of lar;je to\\n<, j arlieularly in crowded 
dwellings, in low collars, in elo^e biiics or alleys, 
and in man u factories, fre(iuentl^' not only prevent 



bleeding will act beneficially in soothing W 
altered senMbility, upon which much of the dis- 
eased action depends. When the part iaflamw 
u<lmits of the direct application of lecches.it u 
often doubtful whether they should be plicrdupo 



the good tfTccts of bleeding from cnbuin^, \)>xl\\VoTiktt\.\^w\viwi\ii« constitutions the puJKturerf 



418 



INFLAMMATION— Treatment of Aitiiekic. 



or to restore the healthy BtHte of the circulating 
fluids, aad the crasis of the blood, by promoting 
the excreting or depurating functionB, and by 
other appropriate means;-— and, 3dly, Toa^sungc 
the urgent symptoms referrible either to the local 
malady or to tne constitutional affection. The 
means which most efficiently fulfil the J{r$t of 
these intentions, will generally also promote the 
attainment of the second and third ; and whatever 
has the effect of accomplishing the second, will 
also most materially advance the other indica- 
tions. 

239. A. The constitution will generally he en- 
ahled to resist the local progress of the malady, by 
whatever increases the tone or energy of the or^ 
ganic nervous system, through the medium either 
of the digestive canal, or of the respiratory organs, 
— by means of appropriate tonics and stimulants 
and by a dry, pure, and temperate air, duly re- 
newed. All asthenic inflammations have a ten- 
dency to spread or to extend themselves with a 
greater or less rapidity, and to terminate unfavour- 
ably, — the changes that successively arise, tending 
to gradual disorganisation, or to more immediate 
sphacelation. Unless under the influence of agents 
which rally the constitutional powers, they seldom 
or never show a disposition to spontaneous reso- 
lution, as often observed in sthenic phlegmasia. 
The only exceptions to this rule are met with in 
those asthenic inflammations which constitute a 
part of specific constitutional maladies ; and these 
are mere symptoms, or parts only, of these mala- 
dies, and are generally co-ordinate with and de- 
pendent upon them, in their rise, progress, and 
decline. This tendency to spread, and to give rise 
to a succesnon of unfavourable changes, consti- 
tutional as well as local, requires agents possessing 
powers of sufficient activity to meet the intensity 
of the disease. As this tendency depends upon 
depressed organic nervous energy, and deficient 
vascular tone, as shown tibove ($ 58.) ; and as 
the permanent fluidity of the effused fluids, and 
their infiltration, and contamination, of the sur- 
rounding tissues, depend upon these pathological 
states ; it is obviously re(|uisitc to employ such 
means, as attentive obs^ervation and enlightened 
experience have proved to be most efficient in re- 
moving them. All parts which are the scat of 



fluid part of the effused matter, and the pnpw 

of the local malaily may be more readily linitid. 

240. The principle of treatment in Ktbnie 

inflammations being established, tlie ■wm hf 

which it may be most successfully canied out ii 

practice will be readily found ; although tbc »> 

plication of these means, appropriately ts ill 

varying phases of individual cases, requires gnat 

discrimination and care. In the truly aitkaie 

forms of phlegmasia, the principle cooteodcd k 

must be acted upon with decision, aodwithort 

wavering or temporising. In the treatneot rf 

them, doubt or hesitation is fraught withdinm; 

and proceeding, as either generally does, mm 

ignorance of the true source and relations of Ai 

local malady, there will be every reason to fev 

that much of both positive and negative vn^ 

will be further perpctratetl. The ignorant m 

usually presuming ; and tlie half infurmed, riC> 

sufficient. In other professions and avocanooi^ 

the evils produced by both are compantifelf 

trivial; but, in the practice of medicine, ihv 

consequences are of fearful and immeannUi 

importance to humanity. I have seen nasMfM 

cases of asthenic inflammation die in suceesM^ 

without the occurrence of a single instance of i» 

cess to lull the suspicion that true prinriplarf 

practice had not been adopted ; and yet the «■ 

principles were blindly pursued in each sutiUM 

case. In a country where the most trivial i^ 

sion of the rights of property is visited by tbei 

condign punishment, human life may be sieri 

to an extent that more than rivals both the f^ 

tilence and the sword, by ignorant pretendeii II 

medical knowledge — by the totally uDcdocrirf 

as well as by the half instructed, — and notisMlf 

with perfect immunity from punishment, bit K* 

tually with the protection of the government, iW 

protection being virtually the most compile it 

those whose ignorance is the greatest I Thi* » 

orifice of human life, be it further recoHectedii 

! constant and unceasing — not occasional only,* 

at long intervals, as that caused by epideBii!^ 

pestilences, and wars. — It was said.upwanl** 

two hundred years ago, by a celebrated Arth* 

logist ^ir H, Spki.man), *• that wbiirt i^ 

tiling else had risen in nominal value in KnglM 

the life of man had become continually cheaptf' 



a.4thenic inflf^mmation rapidly lose their vital co- What would he have said, had he lived is til 



hesion or tone ; and this loss is participated in, not 
only by the extreme vessels, giving rise to a copious 
morbid effusion, but also by the tissues affected. 
The chief pathological conditions, from which all 
the consecutive changes have been shown to pro- 
ceed (^IGi.i'f^f^.), manifestly require an energetic 
recourse to those means which will enable the 
constitution to resist the progress of the local mis- 
chief. Where cellular or adipose tissues are im- 
plicated, the extension of disease, nn<l even of 
disorganisation, will be rapid, if organic nervous 
energy be not promoted, and if vascular action in 
the seat of inflammation be not changed, by suit- 
able remedies. In such cases, the constitution 
must be enabled, as John Hunter ably con- 
tende<l, to form congulable lymph, cither in, or 
around, the inflame<l part, — or, in other wonls, 
to change tiic fluid and often septic matter cffu'setl 
in the areolw of the ti'ssui^s, thut extends the mis- 
chief by iu/iltrating and c^nlam'inutm'^ vhcm, into 
coaga/abJc Jymph or albumen, wV\cTe\»'j V\\ewi 



present day ? 

241. The means, by which the indicatioi* 
practical principle above contended for is to h 
fulfilled, must necessarily vary with the airs"* 
stances of the case ; but the decoction ofcint^ 
or the infusions of cascarilla and of gentian, it 
with the alkaline carlnwates ( F. 381.385.3Pi 
388. 44.5. 869.), are generally beneficial, flf* 
cially when aided by warm aromatic tinctore** 
spirits. When the pulse i* very quick, wfi,^ 
weak, and when the patient is phywcill'** 
morally depressed, the chUn-atc of potatk, Hf^ 
taria, or other stimulants, mav be faddtd t« ■ 
above (F. 415--4I7. 437—439.). In I** 
cases, camphor in full doses, the preporatiois' 
ammonia, and caps-icum, or other spices • 
uromatics (F. 845. 852.), may likewise be p^" 
scribed. In all asthenic inflammations, the *• 
cretions, and the fluid eflu«ed in the discoM^ * 
sues, are more or less acid, — a state which ii ■** 
Ty;jLvi\\'^ cwvt^iVvid. b'j the alkaline carboniiei *••* 



mreoim may be rendered impervious lo iXve \\iOTt\\o\^^Ni\>i\\w»R&^\A«^KTOs^\^ VoLVtofi 



426 



INFLUENZA— Symptoms. 



— the two most severe visitations of the disease in 
this country upon record, and especially in Lomlon. 
In 1>oth these the distemper was either timple or 
compiicatfd, — A, The it'unple form of inilucnzn, 
was most fre(}uent in the young and uiiddlc-agcil, 
and the previously healthy ; and usuully com- 
menced with chilliness, rigors or horripilations, 
lassitude, general depression or anxiety, gravedo 
and headach, followed in some hour^ hy lieat of 
skin, coryza, sneezing, fulness and tenderness of 
the eyes, soreness of the throat, honrscnesH, cough, 
pain of the back and limbs, loss of sleep, and con- 
siderable fever. The cough was generally at- 
tended by more or less soreness of the chest, 
hurried re^iration, slight dyspnrea, either pain 
or a tenderne^ and bruised sensation at the dia* 
phragmatic margins of the ribs and epigastrium, 
and wandering pains in the trunk, especially about 
the sides. Nausea, loss of appetite, sometimes 
vomiting, costiveness, seldom diarrhoea, and a 
white, slightly coated, or mucous appearance of 
the tongue, were also present. These symptoms 
continued for 24, 36, or 48 hours ; the cough 
being dry, and aggravating the sense of sore- 
ness, and the pams about the chest. After- 
wards expectoration became more abundant 
and easy ; the skin softer and moister ; and the 
pain of the head or about the frontal sinuses, and 
in the chest, back, or limbs, less severe. The 
pulse was generally quick, sometimes a Utile 
sharp, usually soft and weak: but it was often 
irregular, or very changeable and uncertain. As 
the symptoms became mitigated, about the third, 
fourth, or fifth day, the perspiration became more 
abundant, and the urine deposited a copious sedi- 
ment : yet the cough fre(|uently continued severe 
and obstinate, and the consequent debility was 
much greater and more prolonged than the severity 
or duration of the di«cnse seemed to warrant. In 
the more severe cases, these symptoms were gene- 
rally very prominent, and the febrile phenomena 
fully developed, transient delirium even occurring; 
but in the hlightcr case*, several of them were not 
very remarkable. In this form of the dispuse, the 
chest sounded clear upon ])ercussiQn, and respir- 
ation was clear and vesicular, no moibid rfile being 
heard on auscuhation ; but, as the complaint 
proceeded, a slight mucous ndc was sometimes 
present. 

16. B. The Complication.*, or prominent af- 
fections of influenza, were ciiiefly — («) a peculiar 
inflummatory ctmdition of the throat and pharynx ; 
{h) severe gastric disorder; — (r) bronchitis; — (d) 
a specific pneumonia, or plenro- pneumonia ; — (e) 
tubercular phthisis; — (/') a form of nieuritis; — (/f) 
i!)'.:umatism ; — (h) di-^ease of the heart and peri- 
cardium ; — and, (i) severe adynamic or nervous 
fvyer. The frequency of the occurrence of these 
affections in a predominant fonn was nearly in the 
order in which I have enumerated them. — a. The 
inflammatory stJte rj/' the thrinit and pharym was 
very frequent, but sumetinies slight. It was 
always of what has been usually termed an ery- 
thematic or crys»j>elatous kind, but more correctly 
a>>thenic or sprt>ading; and attended, as it pro- 
cee<lo<l, by more or less of a fluid discharge, wliich 
servetl to incrca-ic the quantity of matter thrown 
off at ench fit of cough. In the severer cases, 
thin state of inflammatory iintnt'ion was accom- 
panied with some swcUins; and in man^ ca&es>,' 
the aifectiona of the bronchi, and of the up^T ^x- 



tion of the digestive mncoiu niifiMe, leened only 
the extension of the disorder of the thrati imI 
pharynx to these parts. This a£fectioo of tk 
throat generally subsided in two or three, or« 
most live or six, days, after a more or less eopiuw 
discharge from the afRicted surtece, and ^nmHiwei 
after the extension of disease to the guirie « 
bronchial surfaces — or rather, af^er the dinriicrif 
the latter had become more manifest. 

17. 6. Stvtre gattrle diwrder was indicated liy 
soreness and tenderness at the epigastrium ui 
under tlie lower end of the sternum, and by dihi 
and vomiting, sometimes with thirst. It wasoAa 
very early observed ; and when it and the pR- 
ceding anection were present in the Mune ctte,— 
which was not infrequent, — it wasdifficuh todi- 
termine which had been tlie first to appctr, ir 
whether they were coetaneous in origin. lodntf, 
tlicy seemed often to have been promioeot loal 
manifertations of the constitutional disease, aiiiii| 
nearly at the same time. Although reodenf 
the disease more or \ea& severe, increasing the de- 
bility and general depression, and prolonging ( 
valescencc, the gastric complication wai 
fatal, or even dangerous. It was sometimef i 
ciated with con^derable derangement of Uie biliirf 
functions and secretion, with slight cwtireoo^ 
and in some cases with diarrhcea; the irritslioaa 
these latter having seemed to extend along tto 
digestive raucous surface. 

18. c. Bronchitis was one of the mostfivqi 
and severe complications observed In the laN tf» , 
epidemics, especially in that of 1837. BstitMi 
different from the acute sthenic bronchitis oMrff i 
observed as a primary disease, or as occvrrii|ii 
previously healthy persons. It was attended k 
many cases with more marked vkal depreM 
with a more copious expectoration of a graviii 
viscid, ropy, and less frothy mucus, which oAn 
quickly piiss<Hl into a thin muco-purifora) malMr» 
than in idiop-Uhic bronchitis. In most of ik 
cases, both lungs were more or less affected, u' 
the disease seemed rapidly to extend aloi^tW 
larger bronchi to the smaller ramifications, anti, 
in the dangerous or fatal cases, tlic air-crlU thni* 
selves became implicatcnl. At tlie commeDreneol 
of tlic bronchial complication, the cough wasbii 
df}', and severe; but expectoration soon becazc 
abundant, — the wheezing from the accumahMe 
of the morbid secretion in the bronchi bein^ o^ 
r(!markal)ly loud. The cou^h and the qnaniitrif 
the sjmia were generally increased at nigbt, tk 
former being frequently so severe, and the tf- 
tendanl dyspnoea so urgent, as to prevent ita 
patient from lying down. When both lonpw 
gravely affected, the patient was obliged to sit' 
be shored up I>y pillows. In some ca$ej^ tb 
sputa were remarkably abundant, con<istiog of* 
very fluid mueo-punform matter, almost froa^ 
commencement. In most of the bronchial coV' 
plications, the dtjspntra was considersble, >■ 
e>tpecudly when expectoration was difficult uA 
the sputa copious ; still it was o(len gnat *^ 
the discharge from the respiratory passaf^ ** 
neither abundant nor ditticulL The rapid tt- 
tension of this asthenic form of bronchitis tbitxi^ 
out the lungs was most remarkable in the delict 
the aged, the cachectic, and those subject to e^ 
matic or bronchial disorder. In some iosiiocett 
v\\\\qV\^ fw^Titvivsieed a nervous or asthenic 1** 



43R 



IXSAMTY — Symptoms. 



Rgitation is observed, many patients vociferating | very justly remarkf, does not con6rm tin 16 
day nnd night, until tlicir voices become, in a short curacy of these assertions. l*h'a writer, «Ur 
time, so altered, that, in spite of their ciTorts, they experience is most extensive, and powenef dk- 
cannot be heard at tlie distance of a few paces = scrvation very great, states, that it is ceftn, ibl 
— aFpceie« of aphonia, peculiar to the maniac, the same partial delirium, in many paiieBti.e» 
Althou'^h thi4 aphonia is partly caused by tlie responds to opposite forms of the saniepsit of th 
eflbrts to cry, still it seems to be in some degree skull. In some religiously insane, he ui fnd 
owing to the state of nervous influence, for some : the superior and middle part of the cniUBaR' 
patients evince it from the very accession of their [ markably developed, whiUt, in others, the wn 
malady- Some maniacs present the peculiarity portion was much below the ordinary nia|Bitsdb 
of repeating all their actions, questions, or ex- The insane who suppose themselves king*, » 
pressions, or even their discourACS, a certain num- ' perors, piince*, &c., are far from premdi^ 
ber of times. The simple repetition of these acts , generally, a marked developmeut of the Rgi« 
or expressions has been i-cferred to n want of har- i of the organs of ambition, domination, vanity, la, 
nony in the action of both hemispheres of the as assigned to them in the system of Gall, bst k 
brain ; but the rej>ctition is sometime^ oftencr than often inferior in this respect to those who psH ii 
once. I whole day in sweeping or cleaning the eosri^ 

28. Amongst maniacs arc found instances of &c., or wn3 are most interested in the most mhI 
erotic excitement, of an exaltation of parental or j occupations. If there exist distinct orgiv k 
filial affection, or of the ties of fiicndship. Some I every faculty or propenuty, it is not Dccaear,!; 

ve a admit, that their development should be ltd, 



extraordinary, in order that irritation or inl» 
mation should excite their octivily, or oeoM. 
prominent or peculiar phenomena as respeeti thK i 
Uut it may be stated, at once, that we ofteoii( 



arc ferocious, others (quarrelsome, others ha^ 
propensity to murder, or to steal ; and many are 
remarkably cunning and deceitful. All large 
establishments contain maniacs of pride ; princes, 
sovereigns, great dignitarie;*, and even gods them- 
selves, are not rare. N'anity is observed in all \ in ca<ies of partial insanity, lesions aseitensmfli 
its extravagances, furnishing; the best lesson to the i in those where the mental disorder was j?^\\ 
vain fools who strut their hour on the stage of! and that we occasionally observe iDstasnii| 
modern society. Here are found patients a prey > partial delirium, that cannot be the remit of Al- 
to the most distressing imxiety, to the utmost I excessive, or of the irregular, exercM cf Mf\ 



fundamental faculty, or of vascular diiOftei> 
mitcd to any particular part of the braioito"*^ 



of a ])erson who believes himself tiansfonnedi 
a do;:, assumes his habit-s, barks like him,wi3i 
on all fours, biles, &c.? 

30. It may be truly said of partial iD«anilT,tVi 
whatever, in the course of a man's life, nay te 
to him an object of u particular resaid or pif 
pensity, of a distinct taste, of a ruling pa^ion— d 
the bizarre or fantastical ideas which hUmiolwy 
entertain, may, in a state uf disea:*e, becoiM*'' 
i subjects of his delirium or hallucinaiion; li* 



mental agony ; seeing in the present and in the 
future nothing but despair, imploring death, and 

deiiirous of inflicting it upon themselves, in order \ such partial affection may be referred, cm If 
to esca|>c from their miseries. Some dream of j those who espouse the doctrines in (|uatios. 1i| 
nothing but change, of distant journeys or voyages; <. the lesion of what fundamental faculty ^^j 
others have lust their memory of per«ons or of i insane notion of a man correspond, who bdinv! 
thin;^; and several, particularly during the ex- himself changed into a woman, et rife vfrnj^] 
acerbntiont of the disease, can no Ioniser sp<'ak 
their own lauiiuajre, but give utterance in.-tead to 
confused and fantastical sounds, delivered in the 
tone of a continued discourse. Painters, musicians, 
and arti.xLs of all kinds, ap])ear among those whose 
educatio!! has not been directed to the arts ; and 
even ])oets, or, at bnst, rhymers, spring up amongst 
tlio^e wiio even have not learnt to read. \'is!onaiics 
of all kinds abound ; some :ipply tliemselves in- 
ces««antly to tlie solution of liie greatest prolilems 

of nature, or of tlu most dilHcuU (|viestions in ' many delusions — many forms of partial in*is:ij^ 
meliiphyxic"*, religion, ])olitics, political economy, cannot really be referred to lesion of a ja^iff'* 
ivc, although uneducated ; nnd prophets, saints, ■ faculty, or of that portion of the bmia wliicij ta» 
and martyr* arc not uncommon. i been considered the origin of such focully:*' 
2}).()u;;lit ittobeinfernd from all these varieties, ■ that, in thort, where it np})enrs reasonable to K» 
a«5 regards the intellectual disturbance, that each i them to an alteration of this kind, atler.tirt e* 
of them is connected with an isolated nnd distinct ' mination of the conformation of the skyli i«^» 
lesion of a particular pait in the brain ? Ought we, ; in the majority of cases, from correspondin? * 
in tiic present state of our knowledge, to admit : the assertion* of the authors of the p«ycW<*?^ 
tliat the organ of the »mder»-tanding is composed of ■ svstem in ([ue^tion. It must not, llOWl'rt^'* 
an assemblage of paiticular and distinct or^^ansfor inferre<l from uhat has j\ist now been aHrtiM 
each pro|>ensity, j-nd for eacli endowment? Ought that attentive observation of the forms ofibf*'" 
we, in fart, to adopt, to its full extent, th(; j)sy- of the insane is of no use; on the conlB'Ji^i 
cholo|;ical system, arcording to whicli these ques- 
tions are answeicd in the afbirnativel It wouhl 
be out of place here to discuss the real value 
of a psychological sy-^tem ; but it becomes neces- 
sary to notice the assuitions of iho-e authors who , ..._ _. _-. .. 

maintain that, in partial insniiiiy, ])ariicular forms . only to the assumed seats of fundamental l>f 

of tli(^ skull correspond with the vari-.ties of the ties, exclusively or principally affected in ccW 

mental a/fecfion ; that they arc able even to trace patients. In short, the disorders of the iottltst^J 

the propensities, ilie talents, d\s\yos\i\o\\s, awiV i\o-\\t\V\\«i\wwveare partial or general, as regard** 

minant idcns of their patients. However, XmvvvT- \ V^V^WtcNxjaX \i\cv^V«*>'^i««^V'^ «q called. oA uK* 

tial observation of the insane, w M, yovvi.\,¥.\W\Mi\iviw.^tVQ\^&A'^wH«Ki^^s^^S«Ss^ 



regularly developed cranium, of a rca^onibtefi 
ought, cdteris ;>/in7ms. to assist an opinion, >*• 
the posMblc issue of the disease, very di^s^ 
fionj that inferred from a small, conline'l. ^ 
deformed skull. What has Iwen stated appi*» 



444 



INSANITY — Partial —Moral. 



67. III. Of THE flprciAL Forms of Insanity. — 
Id the above general descriptioD, I Imvc confined 
myself to the more obvious and fully developed 
states of mental di»}rder. It is necessary, however, 
that I should consider, in a more minute, yet suc- 
cinct, manner, the specific forms in which aberra- 
tions of mind pre«ent themselves in practice, and 
more particularly tho!<e slight, moral, and partial 



a. Mental Identitjr. — b. Time. — r. Power d 

Cauiatioii and truth — f. Right and wrong. — f. Kx- 
Utciicc of a Deity. —jf. IinTnortality of the loul. 
All thcfte are foldom injurious to health, but are 
oden beneficial in controlling the emotions and 
dcviret, in governing and directing the instinctive 
feelings, and in enabling the mind and body to resist 
the iuflucncc of injurious inipiessions and a'gentif. 

CLASS III. Moral Afprttioxs up Mind, in trhick 
Mome qf our Instinelire Fi'dinft*, a» well as qf our In- 
telUctnal PowerSf arefrfqucntly more or /<*ss engaged. 

OnDKR 1. The Irutfnetioc or simple Moral Emotions 
tlf yiindt often sudden and violent incentives to 
action. When strongly excited, or much indulged, 
they are amongst the most influential causes of both 
mental and corporeal disease. 

a. Anger, indignation, resentment, revenge — their 

elects uiKm health. — b. .Sympathy ~ its enlTtn r. 

Beauty, or deformity, — </. l/ove and hate, jealousy, 

domestic misery. ..«■. I'ride, vanity, and humility 

the liability of the former to lead to insanity. — /. 
(f ladness, regret, sadness, and grief : — Grief from 
lost ol^ects of affection — its efl'ccts — counteracted by 
progeny : — Grief from moral degradation the least 
^upportablc— 'Why ? ElTcfts of sudden shocks of grief 
on sensitive minds. Disapfiointments of the auec- 
lifms : —Grief from loss of fortune, &c. Influence of 
reiicated disapiwintment and losses — of harassing 
ditHcullir«. —' g. Hope and fear — their effects on 
health. Confidence. Various anticiitations — their 
effects. Anxiety ; — that of profesKions, particularly 
of mi'dicino. Anticipated h4i>iilnefs — etrects of the 
sudden arrest of, on scn»ifive minds, &r. Terror, 
fright, &c — olten productive ol nervous dise.ises, 
and sometimes of mental disorder. — A. Gratitude.— 

i. Wonder. l)e?irc of novelty. Mental languor. 

k. Sublimity and ludicrousru^s — / Ix>ve of appro- 
liation. — m. Desire of power and its related affoc- 
tions. Desire of Knowlixlge. Fame. Avarice. 

OitMER -. linii-mal Ktnotions of Mind, nrishifj out qf 
moral and religious OM/gations, often Mrong in- 
centives to action. 

(I. Itertitude, virtue, merit, and demerit, t\ith all 
the duties wu owe ourselvm, as nuirni .ind re 
8])onsibIc agent:*, and as tending to promote our 
intellectual and moral excellence and happiness. — 
b. Our \nr.ous duties, as ineinber8 of rucii'ty. — c. 
Our religious obligation.^, as immortal beings. I{e- 
inorse, or the coiifriousnc^s of having neglected 
one or more of the alK)vc duties and obligation^ — 
sometimci* productive of disorders of mind and body. 



i. IT.e influence of mental culture— intellcTtual and 
and moral — when duly directed in early life, upon 
the tein|)er«mcnt and constitution, — U]H)n mental 
and iHidily health, — in developing and in strength- 
ening both the mind and l)ody. 

ii. Tein|X"rament and conf>titution remarkably mmlify 
the operation of the afTections of mind upon health. 
Illustrations. 

iii. The Tofluence of mental nnd bodily occuiutions — 
1st, U|>on mind : Cnd, upon the body. 

iv. llleirects of want of orrui>ation—K'nnui— Hysteria — 
Hy|>ochondria&is — Melancholy— Insanity — Suicide. 
Ktfccts of solitary confinement. 

V. Dad consequences of improper orcn{)attons and 
amusementt, especially in firnalcK in early life. — 
Mental disMi>ation — its eirects, particularly in im- 
pairing— Ist, Mental vigour ; yd, Utdily health. 

vi. Consequences of habitual amu&cment«, sensual in- 
dulgences, and pleasurable excitements, on the nerv- 
ous »yKtem. These generate feelings calling for their 
reppntetl gratification, and for increaMtl excitement, 
until nervous energy and vital ^mwer are exhausted, 
and until moral and physical rum ensuc». 

vii. (tood elfet'tK of a well-reguliited and cheerful mind 
on health — of agreeable pursuitK, particularly tho.se 

exercising both the mind and the btniy. — T\\e w.Au. 

cnce of con fidence — of moderation — ot c»wIct\Vw«\\1 



States of disorder, to laliicb I have as yetven 
imperfectly adverted. 

68. i. Partial Insanity — the ttmpln ftrm 
and sUgh ter gradet of men tal disorder. — Most )•• 
thors have errc<I in viewing the more partial,* 
slighter forms of insanity, an coDsistins ci if 
rangement of one, or of a few, merely, of the 
intellectual or moral manifestations ; or of a fake 
perception, or delusioD, by which the niod m 
coni^tantly haunted, whilst the other facoltJes an 
unimpaired. I have already hinted {§ 3.) at ik 
inaccuracy of this view ; and stated that, although 
a single faculty or manifestatioo may be ]». 
minently disoniered, or a single train of ideal 
be almost exclusively entertained, the othef 
mental faculties are never in a healthy state, or 
very rarely retain their former energy. 'Coofuifr 
ably with this, the term, jyartial insanity^ ii mC 
so applicable to tiie states of disorder about It 
be considered, as one which would implj a 
slighter grade, or a simpler form, of alieuatioL 
Hut as the former has been already emplo)t4 
by recent authors ; and as it may be convenicDilf 
used, as implying slightncsa of grade, as well m 
an uncertain limitation as to extent ; I ikdl 
retain it, and employ it synonymously withtkM 
expressions. 

69. A, IVToRAL Insanity — the Mcnamaaiemi 
Dt'lire, or AT. instinctive, of M. Lsgciaoi.- 
This state of mental disorder may be dffinei H 
be a perversioH of the natural feelings, ajftctim, 
inclinations, temptr, habits, moral disptmism n 
impulses, withmtt antf illusion or hallueiiiatim,tk 
intellectual faculties being more or less Ktaktui 
tnr impaired. This state hns been noticed by 
IJFiNnoTii nnd CIuislain, ond more fully brDr. 
Mayo, M. Esqvirol, nnd Dr. Pricuard, ioibeir 
recent works. Its earlier or slighter grades, how- 
ever, hnvc not generally been viewed a»amoQ9U^ 
to in*>anity ; nnd, indeed, unlcfs cither the if 
ordered manifestntionfi, which 1 have ju»t enume- 
rated as constituting it, be remarkably promwBl, 
or the intellectual faculties be much utaUDcd 
or impaired, it cannot be really con^idcitJ m 
amounting to mental derangement. J)i. 3Uw 
has noticed, in his lltsay on the Kelaiiouptth 
Thioru of Morals to Inumifu, a certain v»rk!T 
of it as belonging to insanity, and given ii lie 
name of Bnitaliiii, IJut in n more recent n«i 
he rcmurk.s, ihnt further cousideiation hasrtii*' 
6cd him, that to claims it as such i.* loc«o sm 
unphilosnphical. ]Ie considers this as a Ji^irft 
form of mental dL^eacc* especially in ii.' fc'ij 
developed or strongly marked form, aod lo be 
altogether distinct from the moral symptom* of 
insanity that occur nl an early period ot ibed* 
case, and that often afford, at that tin:f. ii« 
only cltic to its exl-ilence. IJy Brutahty,'-^ 
the moral disposition to which this tirm luayk* 
applied, — he implies a destitution of prinrip-V; 
by Insanitif, a pcrveri^ion of tendencies ■Ddt>3:l 
ot ?(lf.»;onlr()l. In the latter case, the paw"' 
cannot henr the vcice of coii.«cicnce ; in the forrjcfi 
he has no coiiFcicnce to hear. 

70. The moral disorder, termed brutality l>» 
Dr. I\Ia\o, i*, however, only one of the »(■■'»■ 
fications ol moral insanity, comprised in the mw 
extended detii.ition which I have altera; ltd " 
^ss\^a to this species uf mental deranirtmeut. 



rnrc nr connuence — oi moaerauon — oi wimcTvui\«w\ \ _„_-_\.\-, ^\vv .v.. .vU,— -.■ r it ...^u 

—and of agrccvible and Uftefu\occuml\om,\u8ecvvTUAB\^^^*^^^^^^^ >N\V\\ V^ ^Vs^tvalions of llriMOT*. 
both the health and happiness of Vhcir \>o&tcs*oT«. \ Vjv\%\.xv^, wwi Vv\v,uk^\>\ *3bA. Vk wa vaoi 



\ 



460 



INSANITY— Dementia. 



exertion, jealousy, and passion. Physical cavset, 
— Hereditary disposition, parturition, disordered 
menstruation, the abuse of intoxicating licjuors, 
venereal excesses, masturbation, the critical periods 
of life, injuries of the head, insolation, fevers, the 
suppression and disappearance of cutaneous erup- 
tions and of accustomed discharges, the abuse of 
mercury, apoplexy, epilepsy ,'ficc., hypochondriasis, 
and melancholia, have been also enumerated as 
causes, but they are, when observed, the early 
or premonitory stage of the malady. (Sec GenC' 
ral View of the Causes o/' Insanity.) 

147. li. Dementia — Incoherence — Imltecility 
'— Amentia, Saw. \GE» — Incoherent Insunitu, PRi- 
cii A RD^Dewenctf , P inel — is a chronic form of in- 
sanity , characterised by impairment of the sensibility 
and of the will, by incoherence of the ideas, and by the 
loss of' the pavers of consciousness and of the under- 
standing. — A person thus mentally deranged is no 
longer able to perceive and apprehend matters 
correctly, to seize their relations, to compare them, 
or even to attend to them. lie cannot comprise, 
in his mind, an exact idea, or even a tolerable 
notion, of any one subject or object; but is occu- 
pied unceasingly with unconnected, incoherent 
thoughLs, and with emotions arising spontaneously, 
without association or aim. Pinel defines this 
state of mental disorder to be an incoherency of 
ideas, which have no relation to external objects ; 
a turbulent and incoercible mobility ; a rapid and 
instantaneous succession of ideas which seem to 
be develo|)ed in the mind, without any impression 
having been made upon the senses ; a continual 
and ridiculous flux and reflux of chimerical ideas 
and notions, which destroy each other almost as 
soon as produced, without intermission and with- 
out connection ; a similar incoherent but calm 
concurrence of the moral emotions, of the senti- 
ments of joy, sadness, or anger, which arise and ' 
disappear spontaneously, without leaving any ■ 
trace, and without evincing any correspondence 
with external impressions. 

148. a. An imbecile or demented person is de- 
prived of the power ol" adequately perceiving ob- 
jects or circumstances, of seeing tlieir relations, of 
comparing them, of preserving a complete recol- 
lection of them ; whence results the impossibility 
of reasoning or reflecting on them. lie is incapa- 
ble of forming any opinion or judgment, because 
external objects make too feeble an impression ; 
because the organs of transmission have lost a part 
of their energy, or because the brain itself has no 
longer sufficient power to receive and to retain the 
impression transmitted to it : hence the feebleness, 
obscurity, and incompleteness of the sensations and 
perceptions. Being unable to form a just idea of 
occurrences or objects, the demented person cannot 
compare them, or exercise abstraction or associ- 
ation of ideas ; his mind has not energy enough 
to exert attention, or any menlul operation neces- 
sary to the integrity of its functions. Hence the 
most incongruous ideas succeed each other, with- 
out dependence and without connection or order : 
hence he talks without being conscious of what 
he says; and he utters wonls and sentences with- 
out attaching to them any precise meaning. It 
seems as if unreal expressions were heard by him 
ifl his head, and as if he repeated them in obe- 
dience to some involuntary impu\se,\\^e tcsm\\o^ 

former habits, or fortuitous assoc'iaViou* w\\\\ o\i- 
Jects which strike his senses. 



149. A loss of the powers of perception, of 
attention, and of suggestion or assocntioo d 
ideas, and the consequent defect, or entire loM of 
memory — of the powers of consdoumctf acd 
of intellection (sec note, § 66.), — are maaifiHllj 
the earliest and fundamental changes coostitutiai 
dementia, whether in its primary , or in its rmiictk- 
tive forms ($150, 151.). Hence the want of «• 
quence or connection between the ideas, the irikl- 
lectual imbecility, and the assemblage of pbe» 
mena, which I have stated this disorder to pronL 
It must be obvious that, originating in the tuim 
of those fundamental powers, dementia will wy 
in grade, with the amount of such failure; andtkt 
the resulting effects, manifested by the h^ 
faculties and by the moral emotions, will iIn 
vary, not only in degree, but also in kind, accorf* 
ing to previous habits, disposition, £cc. — givif 
rise, at nist, to imbecility or to inco!terence,&tn 
slighter grades of dementia. 

150. Incoherency, imbecility or complete d^ 
mentia, appears either primarily, from toe opo^ 
ation of the predisposing and exciting caa«e3QpM 
the mind or cout^titution ; or conseeutivelp spis 
other disorders of the mind or brain, which, ^ 
their long duration, or their severity, affect ik 
alliance of the former with the latter, and theiiA- 
mate condition of structure of the brain more cffe- 
cially. When dementia occurs primarilt, i s 
usually caused by whatever overwhelms tfaeporai 
of the mind, or completely exhausts them,ai bh 
ordinate mental exertion, vehement emotio&i,p» 
tracted and inordinate anxiety ; and, as I wl 
have to point' out hereafter, it may thin appff 
primarily, not only as simple incoherency, bat iIm 
complicated with general paralysis or epilep^. 

151. Where dementia takes' place Kccxiv^ 
it is generally directly consccjuent upon prolrartrf 
mania, or upon partial insanity, or upon VG^ 
plexy, severe phreniti**, epilepsy, palsy, irpciOM 
gout, or fevers attended bv cerebral dtle^2i^ 
ation and severe or protracted delirium, lbs 
consecutive state of dementia has ken terac^ 
fatuity : it was confoundt-d with i^iiotcr, t&bl 
KsQi.iROL very ac^curately di«.tingui»btd btt«*ti 
them ; and showed that dementia is t.-xhau!U« 
or obliteration of an intellect which was owe 
sound, bv intense mental causes, or bv rtaiiiitil 
or other diseases ; whereas, idiotcy is a congcoiul 
stale of fciluily, or au original want of the intfl* 
lectual powers. The idiot, he remark?, has w^ 
possessed the faculties of the understanding r^ 
ciently developed for the dis])lay of reawD. Tfcs 
victim of dementia was once endowetl with iben, 
but has lost this possession. The former lirti 
neither in the past nor in the future ; the l3t!£r 
has some thoughts of times past, reuiini-^tort* 
which excite in him occasional gleams of lapt 
The idiot, in his habits and manners of existf •:('< 
evinces the semblance of childhood; the i* 
mented person preserves, in his conduct andaftS 
the characteristics of con-istcnt age, and bt** 
the impress derived from the anterior state of «• 
istencc. Idiots and Cretins have never poso^w 
memory, judgment, sentiments; scarcely do jK' 
present, in some instances, indications of aK3« 
instincts ; and their external conformatioo pl^^J 
indicates that their organisation is incapable <^ 

\^*X. '^\.'?A«vi\Yt.^\.\vw» dv&linguislicd thrtf i^ 



468 



INSANITY — Termisation in Recovebt.' 



tioDB instances of dementia in females which had 
continued from early youth, and had terminated 
on the appearance of the catamenia ; and others 
which had commenced at that period, and had 
recovered when the catamenia ceased. When the 
disease has followed the suppression of an erup- 
tion or of an accustomed aischarge, a cure may 
be hoped for, by re-establishing the suppressed 
evacuation or eruption, or by means which have a 
similar effect upon the constitution. 

192. d. The previous duration of the disease has 
a mariced influence upon the curability of it. The 
chance of recovery is very much greater in the 
early than in the advanced periods. Dr. Willis 
stated that 9 cases out of 10 were restored when 
they had been placed under his care within three 
months from the commencement of the attack ; 
and Dr. Finch has declared that 61 out of 69 
patients recovered who were received into his 
asylum within the same period from the appear- 
ance of the malady. Dr. Burrows, in his very 
excellent work, has reported 221 cures out of 242 
recent cases. Dr. Prichard remarks, that 7 out 
of 8, or even a larger proportion, of recent cases 
have terminated successfully in the Retreat near 
York. This is as favourable a view of the result 
in recent attacks as can be entertained ; and yet, 
when we consider that many recoveries from 
mental disorder take place in private practice 
without becoming known, and that the great 
majority of those cases which are admitted into 
institutions or asylums are either of some duration, 
or second or third attacks, or have withstood the 
treatment that had been adopted, it cannot be 
considered as being much too favourable as re- 
spects all very early states of this malady. 

193. M. PiNEL was the first, or amongst the 
first, to direct attention, by a memoir rend at the 
National Institute in 1800, to the degrees of pro- 
bability there existed of recovery at different 
periods of insanity. This eminent physician in- 
ferred, that a greater number of recoveries take 
place in the first than in any other succeeding 
month ; and that the mean duration of the malady, 
in cases of recovery, is from five to f>ix months. 
According, however, to M. Tuke and M. EfiQui- 
ROL, the mean duration of these cases is some- 
what under one year. 1 believe UiatlM. Pixel's 
conclusion is more correct as regards all instances 
of recovery, and especially as comprising recent 
cases, many of which arc not comprised in the 
accounts furnished by public institutions; whilst 
M. Esquiiiol's inference is applicable chiefly to 
these and similar institutions. This writer states, 
that of 2005 female lunatics, 604 were cured 
during the first year, 497 in the second, 86 in 
the third, and 41 in seven succeeding years. From 
the tables furnished by him, and by Mr. Hrrcrr, 
of the Gloucester Lunatic Asylum, to Dr. Pni- 
CHARD, as well as from other data, it may be truly 
inferred, that recovery is probable in proportion to 
the shortness of the duration of the malady. The 
importance of proper treatment at an early periol, 
and the impropriety of sending a patient hurriedly 
off to a house of confinement, with no assurance 
of a proper system of treatment beings persevered 
in, is very evident from these data, as well as from 
numerous other considerations. — A recent writer 



such cases have sometimes been overiooked orcne- 
cealed, there is too much reason to ranflcL la- 
stances are adduced by MM. Bcaumss, LsQviiOLt 
and Ciiambeyrov, in which recovery took place 
after madness liad continued for twenty jean, sr 
even longer, — especially upon the establUkiMottr 
a natural, or of a suppressed discharge, or of si^ 
puration, or some extensive coanter-irrilatna « 
evacuation. From Mr. Uitch's tables it would ap- 
pear, not only that the ereater number of caret cc- 
curred in recent cases, but that, in lome, reeoveiT 
took place in a short time after admission, aIibo«|i 
the disease had been of long anterior dorda. 
Of five patients, insane for ten years, one m 
cured in nine months, one in ten mooths, the tM 
in a year, and the other two in six months; ni 
one who had been insane forty years was cared ii 
four months. Three other cases recovered tha 
eleven, seventeen, and twenty years. TbeiefiNi 
are sufficient to prove that, from the longduntiN 
of the disease alone, recovery is not altogetkorb 
be despaired of. 

194. e. The complications of intanity verjrR- 
roarkably influence the terminations of it. Tbei» 
ciation of any of the forms of the disease with «inl 
or partial jmraiusit, and of dementia espedalljiii 
general palsy in any grade, is a most nnftvooiibfe 
circumstance, — recovery hardly ever taking phc^ 
as shown above ($ 168.), in any of these 
The complication with epilepsy, or ecumlmm, ■ 
also most unfavourable. VVhen mania ii 
quent upon severe attacks of epilepsy, or whes lb 
maniacal aflfiection is very violent in the intcmktf j 
these attacks, few or no hopes of recovery i ' 
be entertained. When, however, godivImi 
appear during the high excitement of inniBiii 
somewhat more favourable opinion of tbe eial 
may be formed. — The antecedence, ornpemi' 
lion, of apoplexy, or of coma, is a drcumstimeeii' 
milling of as few hopes as the preceding compliis- 
tion. — The occurrence of phthisical siimpUtrntH 
of obstinate c/iurr/ia-a, in the course of the mcsai 
disonier, especially when the latter is not foUosrf 
by amendment, generally indicates a moreorltf 
speedy termination in death. 

195. /*. The seasons have a slight influenoeooib 
issue of insanity. Mania is more frequently cud 
in summer and autumn. The month of 0(^ 
presents the greatest number of reooveri^i ^ 
month of February the fewest. Males are oM 
frequently cured in July and November, fcaita 
in October and May. Of 518 cures, M. &«ci- 
noL found, that 92 took place in winter, 123 ii 
spring, 145 in summer, and 158 in autumn. 

196. g. As to the prnjhjrtiontil number <^ vit^ 
veries in various countries and places, great dife* 
cnces are found to exist ; depending cliieflTsp^ 
the restrictions, or tlie latitude, observed in pobli' 
institution^!, as to the admission and retention (^f* 
tients. Dr. lUmnows states, that 240 cures «<•' 
affected, in his practice, in an aggregate of 296 
cases of various kinds ; 221 recovering oui of -^ 
n;cent cases, and 19 of 64 old cases, or Bl n 
100 of all cases, and 91 in 100 of those ^>oA 
were recent — a proportion much greater thaniJ* 
furnished by any other source ; but very DOnf 
agreeing with the statements of Dr. Wimii. ^' 
Jacodi considers that this high proportion cifl * 
explained only on the supposition that minrpt' 



justly remnrks, that cases are not wanting to prove, 

that the mind may recover even adet tn^n^ "^^w* Uxcnls were dismissed as cured upon the ^X 

have been passed in a itale of msamly *, aud v\vax\^'TOcv<i^ q\ '^xa^\)A\SL«n!L, or before recovery ^ 



478 



INSANITY — A PPEABANCES IS TBE BnAIK AFTSB Dunt. 



dura mtter, Beparation of its 6bres; effusion of 
scrum into the cavity of the arachnoid ; false 
membranes, organised or without organimtion ; 
oysts Hlled with blood in its two lamios ; simple 
hicmorrhagcs in the arachnoid; oedema of the 
meninges ; injections and thickenings oF the mem- 
branes ; vegetations of the pia mater, and develop- 
ment of irs vessels; adhesions between the pia 
mater and the convolutions ; diRappcarance of the 
grey substance; softening, induration, and dis- 
colouration of this substance ; hardening and in- 
jection of the white or fibrou«« structure ; redness 
and tumefnction of the ventricular villosities ; 
serous effusion into the ventricles; apoplectic 
cysts ; erosions of the convolutions ; softening of 
the brain, or of the spinal marrow. These changes 
are so various, and so far from uniform in occur- 
rence, that they cannot satisfactorily explain the 
results imputed to them. M. Calmf.il considers 
them all to be proofs of a chronic inflammation of 
the brain ; and in this, as well as in hU descriptions 
of many of the allcraUons, he agrees with M. 
FoviLLK. This latter writer states that, in luna- 
tics affected with gcnenil paralysis, he found the 
induration of the fibrous structure of the hcmi- 
ttpheresd escribed above {i 232.), wanting only in 
two cases, and in these the cerebral nerves, the 
annular protuberance, and the medulla oblongata 
presented extreme harrlness. He states further, 
that this induration of the fibrous structure of the 
brain has been found in old men, whose voluntary 
movements have become uncertain or vacillating ; 
but it has never 1)een seen in lunatics whose mus- 
cular powers had remained unimpaired. I have 
observed induration of the spinal cord, with effu- 
sion of serum between the membranes, and other 
changes, in two cases of general incomplete para- 
lysis unattended by insanity ; both patients, how- 
ever, having become dLlirioua shortly befori; death. 
*236. Tlie brain ha.s occasionally been so infil- 
tralcd with serum, that the fluid hns flowed from : fore, legitimately impute insanity, in all ciMi,1l 



that, although these lemons my be ipMl^ 
quite similar, and be followed by vkAj »■■ J 
results, in different cases or perHBi,}ctnyk 
state of vital power of mamfcMatioo, ia mfttt 
not only of the functions of the bnm,lNtikirf| 
the whole economy, differ remaiiablyiaeick^ 
ticulnr instance. It is well known tiMt dn iMtf j 
constituting, as well as consequeot vpoo, moli 
kinds of phl^masie — upon phl(^QBi,orflab 
sthenic inflammation, and upon erysipelimiflif 
forms of spreading or asthenic phlegDSM— Mdf 
resemble each other ; but they are aUeodedh|iif! 
different constitutional disorder; and t!liliiii^' 
pendently of grades of activity or iMnilj 
action. Besides, something should beito" ' 
in many cases, to the influence of the monl 
and to the consequent mental excitenot, 
the cerebral circulation, with reference BOt 
prolonged erethism or excitement of the 
ries distributed to the organ of mind, bit 
constitutional or vital power, and to ikc 
maladies of which the cerebral afifction 
only a symptom, or sympathetic disorder, 
know that, m other organs or parts, i p 
irritation or excitement of their cspiil 
agents which excite chiefly the nerves n[ 
them, will so determine the blood to then, 
enlarge and develop their vessels, is to gift 
to appearances which nearly resemble the 
queuces of inflammation. We find, bn 
that the most violent forms of mania and of 
liriuin, and the most fatal when not j 
treated, arc actually those in which i 
appearances are the least evinced, or ia 
states opposite to inflammatory really e»L 
find, also, lesions in the brain — whether i' 
maiory or not — equally extensive with 
observed in the most general and compGnMI 
casLS of insanity, and without any dtforlerf 
mind having existed during life. Canwe.tk» 

*i* 1*.* <!' * * * ll tm 



the surface of the incision^. Thi> infiltration has 
been so remarkable iu a few instances, as to con- 
btitute a true oedema of tlic brain. Much more 
inrely, as observed both by I^wuirol and by 
myself, a multitude of pores or small cavilics, con- 
taining a limpid scrum, have been found in the 
substance of the brain ; a section of the part thus 
changed resembling that of a porous cheese, lu 
these coses, the brain may be also somewhat in- 
durated and changed in colour. It is by no means 
determined, ns some suppose, that these pores or 
cavities are the sequela* of vascular extravasations. 
It is more probable that they arc the consequences 
of softening ; the pores being left by the removal 
of the molecules of tiie cerebral substance, which 
have lost their vital eohesion to the re>t of the 



these lesions? or may not these lesion? 1« jot* 
legitimately imputed to the insanity? lluni 
very probably a connection between them.iuBi* 
cases ; but neither the exact nature of U»c «► 
nection, nor the intimate lelations and ^oarcefl' 
the niorbiil alterations observed, have beea jtf 
fully ascertained. This is, however, no wrt 
wherefore we should altogether reject the coarfs* ; 
sions at which able and expericnceJ obserrtB " 
have arrived, until we obtain others upoowW 
more implicit reliance can be placed. 

238. The moibid changes in the enceplM , 
M. Fovii.LE infers to be the roulls of iafliP** 
tion : intense, diffused, and general rednc*;"; 
many cases, tumefaction ; and, in passio? to8t' 
chronic state, the formation of adhcflonsbe*"** 
the cortical substance of the convolution* ao^* 



structure, and filled by a serous effusion. ...^ „. ._.,„ „ ^. „.^ ^^„. 

2'37,f,T\\einfeiTucffuhirhvuivhedraunfrom contiguous menibmne : besides this, aillie**^* 
these reseniches deserve a biltf notice. It will be • the different planes, or layers of the cenrbral«^- 
seen from these, that iM. I'ovii.ii. ascribes the | stance, to eacli other, in a certain number of «* 
morbid appearances to inflammation ; and, in this, As the different traces of inflamm.^tion artE* 
agrees with Calm ML and others. But it will be 
remarked by many, and not the less by those who 
may have rend the article Imla.mmation in tliis 
work, that this term has been applied, and possi- 
bly is applicable, to several lesions, attended by 
changes in the state of capillary and vascular 
flctioo, each diflering more or less from the other, 



constant in the brain than in the rccnibrscei, * ^ 
Fovii.LE concludes that the essential cliancf f* 
nccte<l with insanity takes place in ibebnJD.tff 
that alterations of the membranes ore on'y*^^ 
dentally connected with it. Amongi«t the raw"* 
appearances in the brain, lesions of the gK? *"* 
ture are considered by him as the most coc-^[* 
connection with the mental disorder. AhW 



ani/ accompanied with different, or even o^^o%\\.e, I connection with the mental disorder. AhW 
conditions of organic nervous or v*\la\ ^onvw, ^n^\^\«Ck\.^ix\.v«^\sk!(:^^<clto uccibe loei rf"* 



480 



INSAXITV — Alterations in the Abdomikal VucimA. 



mental maDifestations. lie adds, that induration 
of the brain has been often observed by him, espe- 
cially in the porietes of the lateral ventricles, and 
in the rachidian bulb, or upper portion of the 
medulla oblongata .- that epileptic convulsions 
frequently attend it ; that convulsions are often 
also caused by organic lesions of the roen'branes, 
an J of the cincritious structure, but not constantly 
either by these, or by induration ; and that they 
may occur even without any visible change of 
tiiisue. He concludes, that absence of Organic 
alterations of the brain b indicated by the full 
possession of muscular action and motion, and 
that the existence of them is evinced by lesion of 
muscular motion and of sensibility — that sim- 
ple disorder or excitement of tlie mental faculties, 
without dementia or palsy, existjt independently 
of softening or compression of the brain ; and 
that dementia or extinction of the intellectual 
powers may depend — 1st, upon sanguineous en- 
gorgement of the brain; 2dly, upon effusion of 
serum between the membranes or in the ven- 
tricles; ddly, upon extravasation of blood be- 
tween the membranes or in the substance of the 
brain ; 4thly, upon softening of this organ ; 
5thly, on atrophy of it ; 6thly,on induration of it ; 
and, TtlilVf upon exhaustion of its vital influence. 
243. ii. Alterations in the Thoracic Vis- 
cera. — A, 'l\\Q lungs are diseased in a very 
lai^ proportion of the cases of insanity which 
terminate fatally. The propoiiion has been dif- 
ferently estimated by the writers already noticed. 
M. Georget declares that he has found organic 
changes in the lungs in at least three fourths of 
the cases which he had examined ; and phthisis 
to have been the cause of death in more than half 
the lunatics in Salpetriere. He describes the 
pulmonary disease as always chronic, and often 
60 obscure as not to be detected until the body is 
insi)ectcd. In tliese cases, the patient neither 
coughs nor expectorates, and he makes no com- 
plaint : he wastes, gets weak ; loosenes> or con- 
stipation succeeds ; he dies ; — these changes take 
place slowly. Vet, notwithstanding the absence 
of cough and expectoration, excavations arc found 
in the lungs after death. liut instances of latent 
phthisis occur inde|K;ndently of insanity. When, 
however, both maladies are associated, the latter 
is more frequently sympathetic, or dependent 
upon the coiitotitutional disturbance caused by the 
pulmonary disease, than is generally supposed ; 
and it then sometimes does not appear until the 
softened and absorbed tubercular matter has con- 
taminated the ciiculation, and thereby disturbed 
the functions of the brain. I have obAerved in 
persons predisposed to insanity, as well as in 
others, that, when tubercles arc developed in the 
lungs, and when softeninnr and ulceration follow 
without any communication having been made 
with a bronehuSj the pro<:ress of the disease is 
generally latent. The tubercular softened ■mattei 
undergoes changes during its retention ; causes 
thickening or condensation of the parietes of the 
cavity containing it, even whilst the cavity con- 
tinues to enlarge, and, if it be not evacuated by 
the bronchi, neither cough nor expectoration v>\\\ 
be present. But the constitutional disturbance 
caused by the accumulated matter, as well as by 
the organic lesion of the part containing it, and 
still more by the absorption ol' a poillon of it into 
the circulation, will so di6lUTbl\veoT^iviciv^i\o>]L% 



functions, as to occasion, fint, funetioiial ^aukt, 
and consecutively, even or;gaDic leaon of n^ 
organs as may be most prone to diaeaie bm 
either an original or an acquired predUpOiitiH. 

244. B, The heart is often cnan^ ia stn^ 
ture, in fatal cases of lunacy. lodcedi all ih 
lesions of which this organ is susceptible, kn 
been found in the bodies of the insane ; but hT|» 
trophy, passive dilatation, and softening, o) lb 
panetes of the cavities, seem to be the lMMfi^ 
quent. The proportion of cases in which oi|tK . 
alterations of the heart have been fonad, !■ 
been differently estimated by wTiters. Boxxnc ■ 
(Nasse's Archiv.f. Med. Erfahr. 1817.) befiml 
that five out of seven bodies present leoomofAi. 
organ; and M. Foville considered that fin i^jj 
of six display alterations either of it v 9iM\ 
great vessels. 

245. iii. Alterations in the 
Viscera. — A, The digeitivt mucous suifui 
frequently presents evidence of ioflj 
action, especially as respects certain of t&c< 
sequences of this state. M. S. Pinel net < 
indamroatorv ajppearances in this liluation iij 
out of 269 bodies of luoabcs; and of tbcier 
were only 13 of disease of the other si 
viscera. These appearances have beea ihi \ 
served in a number of cases by Paosr, 
civAL, and Guislain. — The frequency of i" 
menls of the cMon, first insisted upon by 
ROL, and especially with reference to melu 
has already been attended to (§ 119.); todi 
been remarked also by Deroian, McujcIi/ 
NESLEY, and GuisLAiN. In most oftk 
described by Esquirol, the disp]stedcolaB| 
sentcd none of tiie consequences of inflif 
In some of the instances observed by Pi 
aud Bergman, the colon was contraoedsri 
or less reduced in calibre through a great put < 
its length : in others, it was in parts dilated i 
contracted, as well as displaced. M. GfiilaB 
attributes both the displacement and tbecclun^; 
tions to inflammatory action; — the latter 
probably arises from this cause ; but the iuMti] 
cannot always thus be accounted for. Kn»l 
few instances which I have had an opportaiiicvi 
observing, and fiom the history of nanyoftba 
which I have seen recorded, it seems prubabklkt ' 
most of the changes observed in the cobnlM' 
been consequent upon asthenic inllanimalonr in^' 
tdtion, with diarrhcca, and occasionally with id^ 
scnteric or an irregular action of the bowels vm ' 
hud existed at some time or other during ihecMM 
of the mental disorder, and especialiyat ah*j| 
period of its progress. Ur. Piruv-il (l)flA'«fl*'i 
pital IhjK vol. i. p. 144.) obsei\cs, " tbal,«i"J' 
dissection of cases of insanity which have teniuB^J 
fatally from chronic diarrhoea, the iotestioci go^i 
rally exhibit an extensive mass of dtsea^ "^l 
n)ucous membrane is inHamed, thiekeDtJt i*| 
partially eroded, and the area of the cenaldi* 

j nibbed, often considerably, in the lower iate>wa 
The mesenteric glands are often found Oiore or W' 
enlarged and indurated. In additioa (o l** 
changes, ha>morrhoidal tumours and fiitulaioi 
are not rarely met \\ith in dissections. 

246. B. Although much importance »w^. 
merly attached to disorders of the /uwiocaBsaf 
insanity, yet th*i researches of recent wriiendft* 
tend to confirm the frequency of this eonsect* 



484 



INSANITY— >Predupos[mo CAUtu. 



M. EsQuxROL confirms this observatioD in respect 
of France ; and further states that, in the North of 
Europe, — in Germany, Denmaric, Norway, and 
Russia, — the proportion of male to female lunatics 
is as 3 to 2. l)r. Jacobi furnishes nearly the 
same results in regard of Prussia* In the United 
States of North America, the number of insane 
males is stated to be much greater than that of fe- 
male lunatics. In the States of New York, Penn- 
sylvania, and Connecticut, the proportion of the 
former to the latter is nearly 2 to 1. In summing 
up the results of his- inquiries obtained from va- 
rious parts of the civilised world, M. Esquirol 
finds that the general proportion of insane males 
to females is about 37 to 38. 

263. The occurrence of insanity among fe- 
males is partly owing to the nature and vices of 
their education ; to their greater sensibility and 
keener feelings ; to the restraints imposed upon 
their desires and emotions; to tlie crosses, cna- 
grin^, and disappointments to which they are 
liable ; to reading romances and noyels, and 
thereby exciting the imagination, without improv- 
ing the reasoning powers; to the addiction to music, 
and the want of salutary and invigorating occupa- 
tions ; and to the life of celibacy they are often 
doomed to lead. These, and various other moral 
causes, about to be noticed, contribute remaricably 
to the production of insanity among females. 

264. Tiie physical causes also operate ener- 
getically in producing insanity among this sex ; 
but they are chiefly disorders of the sexual organs. 
Irritation of the uterus, or of the nerves supply- 
ing it, and its appendages ; suppression, retention, 
or inordinate now of the menses; and various 
organic lesions of these parts ; have a very marked 
influence, sympatheticaUy, upon the functions of 
the brain. Many of the moral causes, and emo- 
tions of mind, have but little influence, until they 
have fint disordered the functions of the womb ; 
and as soon as this organ is disordered, it reacts 
upon the brain, and heightens the eflects of the 
moral emotions. In such cases, as well as in 
many other? common to both flexes, the moral 
causes are often insuflicieut to induce the mental 
disorder, until they have first occasioned physical 
disturbance in /some organ; which disturbance, 
from its sympathetic influence upon the brain, 
becomes an additional cause of the disorder. 
Females, however, are often so circumstanced as 
to experience very serious disorder of the circu- 
lation of the brain, from energetic mental emo- 
tions, occasioning an immediate eflect upon the 
manifestations of this organ, before any disorder 
can appear elsewhere. And, in some cases, tlie 
consequent disorder is produced almost simulta- 
neously in both the brain and the functions or 
state of the uterus. We observe this especially 
in the puerperal states, and, still more particularly, 
soon after delivery. 

265. M. EsQuiROL remarks, that females be- 
come insane at an earlier period of life, are more 
liable to lapse into dementia, and are more disposed 
to religious insanity and to erotic delirium, than 
males ; and that all varieties of insanity, in them, 
are generally complicated with hysteria. Males, 
on the other hand, are more liable to mania and 
violence ; they are more dangerous, and more diffi- 
cult to restrain : women are more noisy ; cry, and 
tmlk more ; are more dlssembVmg, and leaa readily 
coofide in those about tb^m. 



266. £. Agi.-^limmtf, ia the Imm vU 
have been described, ii nrelj obienelWn* 
the age of puberty. Imbecility and idiMoiai' 
always obeerved in childhood ; Vnt the iaMm^ . 
in which any form of true inauity hu oeevri 
at any epoch before puberty, are yery few. Tlty 
have, however, been recorded by J. Fbah, Dr. 
Haslam, M. Fodxrx, M. Esquiboi., Dr. Pii> 
CHARD, and one case occurred in invoira]nctti^ 
and that was caused by fright. Two cats b» 
tinned by M. Esquirol proceeded from tbe am 
cause. He met with one case of mclmeWlii 
complicated with marasmus, in a child dcm 
years of age, remarkable for his large htdwi 
mental precocity. Instances, however, bor f» 
quently occur of children beoomiog mehaeMi^ 
and even delirious, from jealousy and eafj,thB. 
is generally supposed. They tonetines tie thr] 
aflfected, although often only temporarily, bjM* 
the attentions of those to whom th«r tniMk 
tached, bestowed upon others ; and by bcii| 
stripped in obtaining distinctions at scbooL 

267. After fifteen years of age, ionailjfl 
to be a rare occurrence. About the period if 
berty, in females, or when the caCaroeniaaK ' 
to be established, melancholia and masa 
sionally appear, and especially if the g(s«lk 
rapid, and the catamenia are retained, so[ 
insuflicient, difficult, painful, or irrvgilirt^ 
these cases, and still more so at a Isler 
hysteria is generally attendant upon the 
d»>rder. During the first few years after 
in the male, mania and melancholia not 
quently occur ; the former generally htm tftt 
citement of sexual desires, the latter froa ~ 
turbation or venereal excesses. M. 
remarks, that mania, in all its forms of 
appears chiefly in early life ; melancholis, is 
die age ; and dementia, in the advanced epocb 
exbtence. In youlh, insanity assumes as irti 
an<l violent course, and often terminates bj a M* 
markable crisis: in middle age, it ismoRpMi 
to become chronic, and is ofiener compliinMi 
with disorder of the abdominal vUcen ; W ii 
sometimes resolved by hsmorrhage from the h^ 
morrhoidal vessels, or by diarrhcpa. AtaBa^_ 
vanced age, it is apt to pass into dementia, aid V * 
be complicated with paralysis, apoplexy, 6(e.;>d 
recovery is much less to be expected. Ho«c*Vi 
dementia may occur in the young ; and voy a|^ 
persons may be attacked by mania, and M^ 
from it, — but these are only exceptions 6m Ai 
rule just stated. 

268. The ages at which insanity nwit ^ 
quently appears, are — that between 30 aid 40; 
next, that from 20 to 30, and from 40 to 60. IL 
EsQvinoL, however, states, that the naai** 
number of admisNons of cases of iossaitT >■ 
place from SO to 35 years of age : that each N 
years, from 20 to 35, give nearly the laiae a^ 
ber : that the admissions of males are sMSt ai* 
merous from 25 to 30 ; and those of femakt.ft<i 
35 to 40 : that the periods from 30 to 36 dO* 
thereafter, for the men ; and from 40 to 45. fv* 
women : and that the admission of maks fns* 
to 25 yean of age occupy the third rank d *** 
quency; whilst \hoae of females hold oolf vi 
sixth rank. From this it follows, that iim 
is most frequent at an earlier age in men, thas ■ 
women. M. Esqdirol further states, ^ ^ 

\n«^>^'j <^<mma a.fe much earlier attacked"' 



498 



IKSANiry— Its Pm-sxoLooiCAL Patholoctp 



might have been navigated into t nfe kia. 
Uniil the philosophy of Btcov eztmded, it liii 
country » its influence to the icience of miid,bi( 
little care was taken to attend closely to iheiiii> 
mations of consciousness, and to inTSstigile lb 
nature, the extent, and the mutoal lehbosirf 
our faculties. The more predse attentioa vUek 
\iM recently been paid by some writen is llii 
country to the objects of consciousness, SBd tDth i 
origin and history of our ideas, whether iIh 
which are derived from our senses, or thsKBij 
suiting from reflection, will serve to gnk 
speculations to conclusions more correct, ssdi 
toinly more ennobling, than many of iboiti 
capable of accomplishing, that have bcei Ol 



one ascribing all vital and mental phenomena to 
organisation ; the other attributing it to a distinct 
principle — to vitality — allied to organisiation, in 
which state uf alliance only is it subjected to ob- 
servation, and made an object of investigation and 
of experience. Accordingly, the one class be- 
lieves that the range and power of intellect en- 
tirely result from organisation ; the other con- 
siders that organisation is only the medium or 
instrument of mental manifestation, whilst it con- 
tinues to be actuated by life — that the powers of 
mind are the result of the vital endowment of the 
brain. Although opinions on this subject may 
be thus cla^^sed, according to their general and 
fundamental principle*, yet they vary remarkably 

in their subordinate particulars — owing chiefly to > taincd in modem Ijmes. 
their discursions beyond the range of conscious- 332. B. The opiniont of the Amcienti 
ness and observation, and into the regions of ima- 
gination and wild speculation. 

331. The funciicms of the brain, in connection 
with the doctrine of life, have attracted the at- 
tention of philosophers from a very early period ; 
and, during the last century, they have engaged 
the researches of some of the most Acute inquirers 
who have '• interrogated nature." 'J'he progress 
of our kuowledji^c, however, in this very interest- 
ing but most diflicult fit-Id has'not been equal to 
the growing zenl with which it has been cultivated. 
This want of success is entirely owing to the cir- 
cumstances already alluded to, — to the obstacles 
which beset us when entenng upon investigations 
in which we encounter the mysterious union of 
mind with matter, and which relate to the more 
intimate states of both, and to their mutual influ- 
ences in diflerent and often in contradictory cir- 
cumstance-t and aspects. The o}>erutions oV the 
nervous system, pos^ssinp, as it does, so extended 
a connection with the mental powers on the one 
hand, and with the corporeal functions on the 
other, and rcciproc.illy receivin;^ and communi- 
cating inlluencc during' lienlih and disease, could 
not bo accurately timed, even in the more evi- 
dent pijcnonienn, without S(;ine reference to the 
sources and relations of vital and mental manifest- 
ations ; and hence have sprung up various and 
conflicting hypotheses, which have demonstrated 
little beyond the narrow limits of our knowledge 
ond of our powei^i. These humiliating consider- 
ations obtrude themselves, when we view the nu- 
merous speculation'* which have been entertained 
respectioi; life and oiiTani«;ation, and their relation** 
to mental manifestation, from the earlier dawn of 
philoso[)hy to the jire^ent time, when we con- 
sider the eonclu-iions to whicii many of them lead, 
and when we reflect upon the sniufl progress that 
has actually been made in thi<5 department of 
knowled^^o. Mow little has been added even to 
the physiolojy^ical part of the«;e researches, notwith- 
standing the self-felicitatiou'? of some recent in- 
quirers, since the writings of (iAi.rN ! how much 
of what has been supposed to have been disco- 
vered, still rem.'iins open to contradiction, cavil, 
and doubt ! and what has the science of mind 

gained tnnu the worU of iheir modern followers, I which originate either in sensation or n 
in addition to what aj)])ears in the discordant | !Some of their authors arranged the finl* 
theories of Plaio, AuixToii.r, and Ki'iccni's ! i life under three heads, — the vouCi t?"* ""^ 



ffii?id and the xntal phenomenm were ni 
vague ; and yet, when strictly examined, aoti 
more so than most of the views promalgwdJ 
modern times. Yv;(«,aniiiia, vital principlc,€r^ 
according to some, were employed by tbeii I 
press the cause of the vital actions; tbetcnil 
designaiiog the eflTect of that cause. Dsm 
Ericunus, and the Stoics considered the 
be corporeal, or material ; but difiered is V ' 
matter constituting it. Hippo maiDtsinidlhli 
was water ; Democritcs, that it wu fin; 
RACMTus, that it was a vapour, or eibabbHit 
the Stoics, that it was warm or iemtcd ~ 
those who believed the soul to be'ioe 
some considered it mortal, and otben tt 
immortal. Tiiai.is said that it was the 
motion, and always in nM>tion ; Fi 
that it was a self-moving monad ; Plato, Ml 
was conceivable only by the understaadiig; 
Aristott.e, that it was the first nnAiM